Combating COVID-19 Vaccine Inequity During the Early Stages of the COVID-19 Pandemic

Durham County is a single-city county in the central region of North Carolina, U.S. The demographics of Durham County residents have shifted dramatically over the last two decades. Since 2000, Durham County’s population has grown over 21% to 326,126 in 2020, according to U.S. Census Bureau data [12]. Estimates from 2020 show that non-Hispanic Black or African Americans and non-Hispanic whites make up 35.9% and 43.4% of Durham’s population, respectively. Hispanic or Latinos are an estimated 13.8% of the county population, while AIAN, Asian and multiracial individuals make up another 9.5%. In 2020, the proportion of residents who spoke a language other than English at home was 18.4%. In 2021, 7.3% of the population over five years of age spoke English less than well [13]. Of Durham County’s residents, 11.7% of met the threshold for poverty. By comparison, the U.S. population is 58.1% non-Hispanic white, 11.8% non-Hispanic Black or African American, 18.8% Hispanic or Latino, and 5.7% AIAN and other Asianic multiracial individuals. The percentage of residents who speak another language that is not English at home is slightly higher nationally (21.6%) than in Durham County, while 12.8% of Americans nationally meet the threshold for poverty [13].

The U.S. Food and Drug Administration (FDA) approved an emergency use authorization (EUA) for the Pfizer/BioNTech vaccine for those aged 16 years and older on December 11, 2020 [14], and the first vaccine in the U.S. was delivered in New York on December 14, 2020 [15]. The EUA for the Moderna vaccine for individuals 18 years and older soon followed on December 18, 2020 [16], and by the end of the year, 2.8 million people in the U.S. had received an initial dose of the COVID-19 vaccine [17].

Due to limited supply of the vaccine, populations were prioritized in groups based on level of vulnerability. Based on Center for Disease Control and Prevention (CDC) recommendations, between January and April 2021 North Carolina prioritized populations designated to receive the vaccine into the following groups: Group 1: health care workers and long-term care staff and residents; Group 2: adults 65 years and older; Group 3: frontline essential workers; Group 4: adults 16–64 years old at high risk for exposure and increased risk of severe illness, and Group 5: everyone else who did not fall into one of the previous groups [18]. Once vaccine providers completed priority groups that aligned with federal priorities, NC DHHS allowed flexibility to move to the next group. Prioritization of vulnerable groups were adjusted periodically throughout the first quarter of 2021, but race and ethnicity were not considered factors in the decision-making process.

DCoDPH made the COVID-19 vaccine available to all community members on April 7, 2021 [19]. By this time, inequities in vaccination rates among the BIPOC population, compared to non-Hispanic whites, were already apparent. As the FDA issued COVID-19 vaccine EUAs for age groups 12–15 in May 2021 [20] and 5–11 in October 2021 [21], DCoDPH saw similar discrepancies in vaccine uptake by race and ethnicity among younger residents. The initial barrier to vaccination was eligibility. Because prioritization for vaccination was at first given to healthcare workers, staff and residents at long-term care facilities, essential workers, those over the age of 65, and adults with chronic medical conditions, not everyone was initially eligible for vaccination.

There were a number of issues that contributed to inequities in vaccination for those who were vaccine-eligible. Despite being known as the “City of Medicine,” Durham has a well-documented history of racial segregation that has led to historical health disparities [22, 23]. Inequities in access to healthcare for populations of color and historical mistrust of the public health system due to structural racism likely contributed to vaccine-eligible individuals not getting vaccinated [24]. Another potential factor may have been lack of internet access. As areas of Durham County with lower rates of internet access also have lower levels of household income [25, 26], populations already socioeconomically vulnerable are at a higher risk of lacking internet access, making it difficult to schedule online vaccine appointments. Vaccine providers with limited interpretation services and challenges in communicating to the wider community about available vaccinations were also likely factors. Not having access to a trusted primary care physician was another problem, primarily among the Hispanic or Latino community. According to the 2020 Durham County Community Health Assessment survey, while 77% of survey respondents county-wide could identify one person whom they considered a personal doctor or healthcare provider, including 82.9% of African American and white respondents, only 50.8% of Hispanic or Latino respondents could identify a primary care physician [23].

Some of these barriers to vaccination were combated by acknowledging some of the historical health inequities and disenfranchisement that affected and excluded certain populations within Durham County, including historical segregation of healthcare access and challenges of tuberculosis screening campaigns due to skepticism of the healthcare system among the African American community [22]. DCoDPH’s initial vaccine campaign communication was primarily conducted online through a registration scheduling waitlist for those in eligible groups. DCoDPH also provided an appointment scheduling hotline and had a specified email address for organizations to schedule group employee appointments. Local pharmacies provided online only registration options.

To reduce barriers to vaccine access, DCoDPH public health team staff met community members where they were, organizing and participating in vaccination events in the community during 2021. These outreach events were organized with trusted community partners with whom DCoDPH had existing relationships, in familiar locations such as churches and grocery stores, and communication occurred through credible messengers such as faith leaders. Outreach was tailored to be culturally appropriate, and events in neighborhoods with large Hispanic or Latino populations had bilingual staff and interpreters available with materials in Spanish. Lastly, DCoDPH focused on data to drive decision-making and determine how best to allocate resources.

The areas in Durham County with higher totals of households without broadband or internet access are mostly located near central City of Durham. Percentages of households in these census tracts without internet or broadband range from 14.6 to 24.4% (Fig. 1). The same census tracts also have higher rates of poverty and populations of color, which impacts internet access. Research has shown that older Americans, those with less income, lower education levels or populations of color are less likely to go online [27].

Quickly after the first cases of COVID-19 infection were diagnosed in Durham County, in April 2020 DCoDPH established a “Durham County Coronavirus Data Hub” [28] to provide residents of Durham County access to the most up-to-date COVID-19 information as the pandemic progressed. The initial data hub was built using data provided by the NCDHHS and the North Carolina Electronic Disease Surveillance System COVID-19 module (NCCOVID). This system has the ability to track COVID-19 infection cases, and later vaccine data was incorporated from the COVID-19 Vaccine Management System (CVMS). Data from healthcare providers in Durham County and pharmacies was collected, cleaned, and transformed prior to publication. The data hub has evolved throughout the COVID-19 pandemic based on community feedback, observations of how other communities are presenting their COVID-19 data, and as the COVID-19 vaccines were approved for younger age groups.

DCoDPH used data to tailor its approach to vaccine distribution for populations most impacted. Once COVID-19 vaccine data became available from the NCDHHS in January 2021, DCoDPH created systems for the collection and analysis of the data. COVID-19 vaccine data was obtained from the CVMS vaccine portal on a weekly basis through an uploaded Excel spreadsheet of Durham County resident data, which is HIPAA secure through login and password access with permissions granted to a limited number of health department staff. This data required significant cleaning and transformations before it was usable. The data received from NCDHHS was curated based on DCoDPH’s request, for two weekly large files, one containing vaccine data from health care providers and another for pharmacy providers. The DCoDPH Data Scientist processes the data in an ETL (Extract, Transform, Load) process to a Power BI dashboard. Data is stored in a SQL database and new data is retrieved weekly. Python scripts clean and transform the data and the process for cleaning is completed in Power BI.

In response to public and stakeholder requests, DCoDPH added vaccination data to its existing public facing COVID-19 dashboard in February 2021. Vaccine data included total number of vaccines delivered, vaccinations by date, partial and full vaccination rates for Durham County, provider sites and vaccinations by zip code. The vaccine portion of the dashboard disaggregated data by demographics such as age and gender, including an interactive component to allow users to parse vaccinations by race and ethnicity.

Over the ensuing months, DCoDPH added pediatric data for ages 12–18 years, 5–11, and under 5 age groups, as each age cohort was approved for the vaccine. DCoDPH created a “Vaccinations by Populations of Color” interactive map from a biweekly vaccine equity meeting between DCoDPH, a local health provider and a social justice non-profit organization. DCoDPH shared the vaccination map and additional data regarding the pace of vaccination in these communities at each meeting. Partners suggested the data would be helpful to the entire community. The Vaccinations by Populations of Color map has assisted DCoDPH partners in prioritizing vaccination events, outreach, and communications in African American and Hispanic or Latino communities that had lower COVID-19 vaccine uptake.

DCoDPH worked to ensure all people had access to accurate vaccine information but prioritized reaching Black or African American and Hispanic or Latino populations since these groups were underrepresented in vaccination rates. Through geocoded vaccine data stratified by race and ethnicity, DCoDPH identified areas of low uptake for specific races and ethnicities by census tract and focused efforts and resources io increase vaccinations in BIPOC communities. Collaboration and support between DCoDPH, partners, and community members dedicated to these efforts made an impact in increasing vaccination rates.

Offering timely, clear communication in English and Spanish about vaccine importance and safety, as well as the facts and dangers about low vaccination rates among historically excluded communities helped DCoDPH convey to partners the importance of their role in ensuring the safety of the communities we all worked to reach. In collaboration with organizations serving Black or African American and Hispanic or Latino communities, DCoDPH listened to specific concerns and worked to address them within BIPOC populations, while collaborating with representatives from these communities to develop messaging. For example, working with prominent Hispanic or Latino doctors when speaking to Spanish-speaking communities was prioritized to ensure that messaging was being provided by a trusted source with firsthand knowledge and experience with these populations.

Using social media to host virtual town halls to answer community questions, DCoDPH shared infographics explaining how vaccines work or how to be vaccinated and provided links to accurate sources of information. Social media also became a listening tool to monitor common questions and concerns and combat misinformation, which helped determine what resources to create and distribute. Additional media platforms utilized to increase COVID-19 vaccine uptake among communities of color included television and radio ads, print documents, billboards with accurate information often targeting common vaccine concerns and misconceptions, and a video describing what to expect when arriving to DCoDPH the day of vaccination.

In May 2021, DCoDPH worked with partners who could reach the populations that data showed experienced vaccine inequities, often by ensuring that community partners had access to COVID-19 vaccines and could either vaccinate their own community members, or DCoDPH offered to vaccinate through outreach teams. As a result, DCoDPH held joint in-person events and outreach at locations such as local churches, grocery stores, barber shops, schools, universities, and community organizations with a variety of local partners such as the African American COVID-19 Task Force (AACT +), Latinx Advocacy Team & Interdisciplinary Network for COVID-19 (LATIN-19), Black fraternities at local universities, non-profit organizations, Hispanic or Latino businesses, in addition to medical providers from area pediatrics offices and hospitals. Over 60 of these events were completed throughout 2021, generally either targeting or hosted by Black or African American and Hispanic or Latino organizations, although some events were hosted to feature more general topics such as vaccinations for children.

Lastly, DCoDPH participated in a pilot program operated by the NCDHHS, which began in May 2021 and provided $25 “Summer Cards” to individuals getting a COVID-19 vaccination, to offset the time and transportation costs of getting vaccinated [29]. This was later increased to $100 Summer Cards in August 2021 for anyone 18 years or older who had yet to receive their first COVID-19 vaccine dose, as well as $25 Cards for their drivers [30]. In the initial days following the offering of $100 Cards, DCoDPH saw an increase in vaccinations (Fig. 2).

Did these engagement and vaccine outreach efforts increase vaccination rates among the most targeted groups, particularly the Black or African American and Hispanic or Latino populations? According to the data, the largest impact was seen in the Black or African American community. On April 1, 2021, while 54.8% of non-Hispanic whites had received one and 23.4% had received two COVID-19 vaccine doses, only 32.0% of Black or African Americans had received one dose and 14.0% two doses (Table 1). Vaccination rates for other BIPOC groups were even lower. Only 21.0% of Hispanic or Latinos had received one and 6.6% two COVID-19 vaccine doses (Table 2). The AIAN population had the lowest vaccination rate, with only 17.7% receiving one dose and 7.0% receiving two COVID-19 doses as of April 1, 2021.

As above, extensive vaccination outreach events began in May 2021, and by mid-June 2021, more COVID-19 vaccinations were being given to Black or African Americans (44.6%) than non-Hispanic whites (32.1%), and the percent given to the Hispanic or Latino population had increased as well (23.3%). From mid-June until September 2021, COVID-19 vaccinations were given at a rate of 2:1 to Black or African American individuals compared to non-Hispanic white individuals (Fig. 2). In two priority communities with a large Black or African American population, after a community outreach event Durham County saw the vaccination rate for the Black or African American Community increase 3% over the course of one week, and 12% over the course of six weeks. In relation to other geographically similar Durham communities the vaccination rate only rose 1% and 5% respectively. Durham County COVID-19 vaccinations for the Black or African American population was higher than all but one North Carolina peer county in 2021 (Fig. 3).

Interestingly, the largest uptake of COVID-19 vaccinations among the AIAN population in Durham County occurred during the initial months of the vaccine rollout between March and June of 2021 (Table 1 and Fig. 4). While this high uptake was prior to the majority of the vaccine outreach that was provided to priority communities in Durham County, it aligns with findings among other AIAN communities across the USA. In response to a high number of COVID-19 infection early on in the COVID-19 pandemic, AIAN communities across the U.S. mounted very effective vaccination campaigns in the initial months of the vaccine rollout, leading to AIAN having higher vaccination rates than other priority groups early in the COVID-19 pandemic [31].

The type of vaccine outreach efforts that had born such success over the summer of 2021 continued through the Fall and Winter of 2021 and well into 2022. Unfortunately, by October 2021 the vaccine inequities noted early in the COVID-19 pandemic began to appear again, with Black or African Americans and Hispanic or Latinos receiving fewer COVID-19 booster doses than non-Hispanic whites (Fig. 5). This trend persisted across all age groups and was particularly evident for the Hispanic or Latino population. By the end of December 2021, the Native Hawaiian and Other Pacific Islander population in Durham County had the highest fully vaccinated rate at 77.24%, compared to 73.27% of Asians, 59.14% of Hispanic or Latinos, 58.65% of non-Hispanic whites, 46.94% of Black or African Americans, and 30.82% of AIAN’s. Thus, while gains were made to vaccinate members of the BIPOC population, disparities still existed after the first year of DCoDPH COVID-19 vaccination campaign.

Throughout the COVID-19 vaccine rollout in 2021, DCoDPH addressed multiple challenges to vaccine uptake among populations disproportionately impacted by COVID-19 infection, such as vaccine mistrust, language barriers, and access to and inequities in the healthcare system. Perhaps the most important intervention was collaborating with trusted members of these communities to meet members of the Durham County community where they were at, out in the community. In addition, DCoDPH rolled out an easy-to-use dashboard to communicate vaccine data to the community and disseminated COVID-19 messaging to the public on different media platforms, all while getting public and stakeholder buy-in throughout the community.

While gains were made to vaccinate members of the BIPOC population, disparities still existed after one year of COVID-19 vaccinations. One of the key lessons learned is that transparency is key, and DCoDPH worked diligently to ensure that reliable and accurate data was being disseminated to Durham County residents. In a future pandemic, DCoDPH hopes to compile up-to-date information on its Data Hub from many sources, which will allow real-time data to help identify areas in the community that need more outreach efforts. In addition, collecting data on social determinants of health will further enable better collaboration with the Durham County community as disparities in social determinants of health are often such significant causes of health inequities. Vaccine data and vaccine equity will play a pivotal role in future investigations, including from Mpox and other vaccine-preventable disease. Taking a measured approach to address the root causes of vaccine inequities allowed DCoDPH to better prepare to address future pandemics, disasters, or other public health crises.