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Stalled COVID-19 Booster Rollout Reveals New Hurdles for Vaccine Equity in Cities

empty pharmacy lit from within

October 5, 2023

When the updated COVID-19 booster was made available last month, many of us lined up immediately to get the shot, in hopes of heading off the uptick in infection rates that began in the U.S. over the summer. But here in Philadelphia, some of us were told that we would have to pay out of pocket – up to $190 – because insurance companies hadn’t yet updated their billing codes to cover the boosters. Others were turned away at pharmacies not in their networks or had their appointments canceled due to shipping delays. Philadelphia wasn’t alone in this: People across the U.S. experienced similar complications in getting the new COVID-19 booster.

This shortage in vaccines led to the Philadelphia Department of Health to ask low-risk residents to delay getting boosted, so that people at higher risk of COVID-19 complications can be prioritized. But will that be enough to ensure that the residents with the highest need get vaccinated?

COVID-19 Booster Access Remains a Structural Issue

Vaccine access is often determined by social structures, not individual choice, as explained by Drs. Alina Schnake-Mahl and Usama Bilal in an invited commentary published last summer in the American Journal of Epidemiology.

“Once vaccines were authorized, the pandemic of the unvaccinated dominated common discourse. … This framed vaccination as an individual choice, ignoring the role of policies (e.g., paid sick leave, vaccination center distribution decisions) and social and economic factors (e.g., lack of trust in government, residential segregation) in creating structural barriers to vaccination. This shift from structural factors towards a dominant individualistic narrative will only make COVID-19 control harder, and disparities more evident.”

Now that vaccine access will be determined by private businesses, as opposed to the federal government, this commentary’s warning about profit-seeking actions undermining confidence in public health and pandemic precautions seems prescient.

“I think the big impact of shifting distribution from the Fed to providers is about changes in, and more limitations to, access,” Dr. Schnake-Mahl recently told us. “We know that the U.S. health care system is highly inequitable. I worry that when we depend on the pharmacy and health care system, without the role of the government, we risk exacerbating inequities in access challenges.

“The federal government (at times) and states (some states) have played an important role in actively working to ensure access to vaccines in communities that experience the worst access to health care services, via targeted vaccine locations, outreach, campaigns, etc. Without that continued government activity to target populations with poor access to care for vaccination, I do worry we'll see exacerbated challenges with vaccine access.”

Adding to these challenges is federal funding drying up for state and local COVID-19 programs, due to the public health emergency ending last May. Public health departments may no longer be able to support vaccination programs that target certain communities.

“When vaccines are difficult to access as it is now with the boosters, it may drive those that were thinking of getting vaccinated to postpone that decision,” Dr. Bilal added. “This is especially important in communities that have historically had lower access to vaccines because of lack of healthcare access, lack of pharmacies (pharmacy deserts), or targeted misinformation in social media."

Vaccine Equity in Philadelphia: Taking a Neighborhood View

As urban health researchers, the UHC has closely tracked inequities in factors related to COVID-19 throughout the pandemic. Although there is less data available for tracking recent positivity and vaccination rates, our work has revealed which Philadelphia neighborhoods experienced higher rates of COVID-19 infection, hospitalization, and death. We also observed significant racial/ethnic and neighborhood disparities in COVID-19 outcomes, especially test positivity and odds of hospitalization. These disparities tended to be worse for racial/ethnic minorities living in neighborhoods with higher social vulnerability.

A data brief from a team led by Dr. Sharrelle Barber provided detailed maps of Philadelphia’s COVID-19 inequities by neighborhood, and explains how historic and current racial residential segregation created structural characteristics that increased the risk of exposure, transmission, and mortality. These same structures can also make it difficult for residents to access vaccines.

Ensuring that Philadelphia’s highest risk populations get boosted will likely take more than consumers holding off on making appointments. According to Dr. Schnake-Mahl, “What we actually need are more social policy-based solutions, like paid sick leave. Even if you make vaccines available, that’s not enough, because access and availability are two different things. They are connected systems, and we’re looking at them in isolation.

“We’re also looking at vaccination as the single intervention we’re willing to continue do at this point. That’s well and good, but, again, we have to think about the larger structures that determine vaccine availability in addition to individuals’ ability get vaccinated.”