New Study: Low Vaccination Rates Across States Suggest COVID-19 Vaccine Distribution Requires Stronger Federal Support and Partnership

The successful national rollout of a future COVID-19 vaccination program will depend on high rates of vaccine uptake, but many states are likely to face serious challenges in distributing the vaccine without strong federal support and partnership, a new Commonwealth Fund study shows.

Although COVID-19 is more contagious and more lethal than influenza, experience with past vaccination efforts is still relevant, the researchers say. Their study finds that adult vaccination rates for seasonal influenza in calendar year 2019 and for the H1N1 flu pandemic in 2009–2010 fell well below the 70 percent threshold that is believed to be necessary to reach herd immunity. The rates for both vaccination programs were low in many states with higher COVID-19 case counts and large Black, Latino, and American Indian populations, whose communities have been among the hardest hit by the pandemic.

Among the study findings:

• Adult vaccination rates for the seasonal flu and H1N1 pandemic varied significantly across states and never met their goals. In calendar year 2019, adult seasonal flu vaccination rates in all 51 U.S. states and jurisdictions fell well below the population goal of 70 percent, with no state achieving a rate above 51 percent and some reaching only half that rate. During the 2009–2010 H1N1 pandemic, when government agencies had more direct control over allocation and distribution, vaccine uptake still averaged only about 23 percent. Many of the same states with lower seasonal flu vaccination rates also reported low adult uptake during H1N1.
• Racial inequities in vaccination rates persist. Annual influenza data reveal racial inequities in adult vaccinations across virtually every state. Georgia, Texas, and Maryland, home to some of the nation’s largest Black communities, report some of the highest racial gaps in adult vaccination rates. Data from the 2009–2010 H1N1 pandemic vaccination program also show significant racial disparities among adults.
• Nearly all states report wide seasonal flu vaccination gaps between white and Latino adults. The vaccination gap for Latino adults, who already face greater barriers to obtaining insurance coverage and accessing care than other groups, is extremely wide within many states. Seventeen states report gaps of at least 15 percentage points; in six of those states, the gap is at least 20 points.
  
  Among the five states with the largest Latino populations — California, Texas, Florida, New York, and Arizona — all but New York report vaccination rate gaps exceeding 10 points.

Policy Implications

The authors note that, although recently released 2019–2020 data from the Centers for Disease Control and Prevention (CDC) show improvement in last season’s flu vaccination rates, no state comes close to achieving target adult vaccination rates. Even worse, cumulative COVID-19 case rates are higher in many states with poor vaccination rates.

A successful U.S. pandemic response depends on effective state and local responses with the partnership and support of the federal government, the authors say. This involves:

• An enhanced federal role in COVID-19 vaccination. While states have a primary role in public health actions, particularly during disease outbreaks, the federal government can guide state allocation strategies and monitor vaccination progress. It also can expand state funding to bolster vaccination capacity, assist distribution to states by operating centralized storage and administration facilities, and sponsor and support state and local vaccine awareness campaigns.
• Prioritizing racial and ethnic equity in vaccine allocation. Communities of color have been hit hardest by COVID-19 and are less likely to get vaccinated, reflecting wide-ranging racial and ethnic inequities within health care, housing, and economic opportunity. States can work with the CDC to design a vaccination plan that accounts for these inequities and prioritizes distribution to at-risk populations. States also can move to reduce financial barriers and other impediments to vaccine access while partnering with community organizations to maximize vaccination rates.
• A robust media campaign. Given vaccine safety concerns, a strong information and awareness campaign will be critical to building public trust and reaching target vaccination levels.
• Eliminating vaccine cost-sharing. Even though the federal government will have purchased an initial supply of the vaccine, cost-sharing for additional services, such as dose administration, may vary by type of health insurance. Removing these costs will likely be critical to achieving high levels of vaccination and equity in participation.