COVID-19, Social EM

COVID-19 Vaccine Equity and Distribution in Emergency Departments

Social EMpathy is a working group of medical students, residents, and faculty interested in social emergency medicine working together to organize initiatives in social EM topics.

As part of Social EMpathy’s first roundtable, we aimed to explore the topic of vaccine equity and distribution in the ED. Vaccine equity has been a major area of concern particularly when it comes to COVID-19. The most recent CDC data shows that among the vaccinated population, 60% were white, 9% were Black, 15% were Hispanic, 6% were Asian, 1% were American Indian or Alaska Native, and <1% were Native Hawaiian or other Pacific Islander.1 Ultimately these data show that proportionally, marginalized groups continue to be underrepresented in COVID-19 vaccinations. Even the data being collected to ask questions about racial equity in distribution is lacking.2

Given the pressing nature of these disparities, both in COVID-19 vaccines and others, we gathered three leaders in vaccine equity from around the country who shared their experiences with COVID vaccine administration in their respective communities. Each speaker shared tactical, tangible advice surrounding their efforts toward achieving greater vaccine equity.

Meet the Experts

  • Evan Rusoja, MD, PhD, is the current Quality and Safety Innovations Fellow as well as an attending emergency physician at Alameda Health System in Oakland, CA. Dr. Rusoja has applied his expertise in global health to vaccine equity by leading efforts to bring the vaccine to patients directly in their own communities as well as administering the vaccine to patients in the ED.
  • Morgan Hutchinson, MD, is the Medical Director for Vulnerable Communities and Assistant Medical Director of the emergency department at Thomas Jefferson University Hospital in Philadelphia. Dr. Hutchinson’s current work around vaccine equity focuses on partnering with community clinics to vaccinate Philadelphia’s immigrant and refugee populations along with administering the Johnson and Johnson vaccine in the emergency department.
  • Amita Sudhir, MD, is an attending emergency physician and Program Director of the EM residency at the University of Virginia. In addition to authoring multiple articles on vaccine equity, Dr. Sudhir has spearheaded the recent effort to vaccinate patients in the emergency department at the University of Virginia, many of whom come from rural areas or are undocumented workers with poor access to health care.

Logistics of Distributing Vaccines
Because several clinic locations already had COVID testing labs, a few of them were able to be converted to vaccine distribution sites as well. Incorporating a mobile vaccine element and distributing vaccines at school and church parking lots also proved to be beneficial. Having this mobile distribution arm helped reach vulnerable communities and eliminated any traveling or access barriers.

Stakeholder buy-in is also key. At one speaker’s institution, a vaccine task force was created that had representatives from stakeholders, department heads, and others. This team was willing and ready to make timely and well-informed decisions to help with rapid vaccine distribution which accelerated various efforts during a tumultuous time in distributing vaccines. 

Regarding vaccine logistics, the current vaccine vials have five doses in each vial, so the timing of vaccine distribution is critical in order to make sure that no vaccine is wasted. Funding can be a challenge to obtain, and departments often purchase the vaccines while clinic staff members volunteer to support operations. City grants may also be available to help fund operations in particularly vulnerable communities. Medical students have been helpful volunteers for staffing the clinic and helping with education efforts in the community. Also, trusted messengers from a variety of cultural and linguistic backgrounds were educated about the vaccine and helped establish trust with communities that might be hesitant about receiving the vaccine. 

Challenges in Vaccine Distribution
Obtaining buy-in from stakeholders was initially a labor-intensive and time-consuming challenge. Lack of clarity about priority groups and perceptions on distribution were some of the many hurdles. Engaging stakeholders in the conversation early, performing background research, and maintaining persistence are key to success. Cost may be mitigated by use of volunteer clinicians and medical students. City grant funding may also be available to support ED vaccination efforts.

Other challenges include barriers to patients obtaining the vaccine. Addressing patient fears and concerns in a clear and non-judgmental way is incredibly important when discussing vaccination. Consideration of factors beyond general vaccine hesitancy is equally important, however. Often patients who are labeled as noncompliant or hesitant in fact have concrete barriers to care, such as incarceration, lack of transportation, financial constraints, or fear of the repercussions of documentation. Recognizing and addressing the unique challenges of patients instead of making assumptions is an essential part of the vaccination effort.

Success Metrics
In order to create more effective vaccine distribution programs, targets need to be defined and outcomes need to be measured. Defining success can be challenging, however, when the goal is not simply to increase the number of vaccines delivered, but to increase access and equity as well. Focusing solely on the number of vaccines administered can bias providers from trying to provide access to those who may be harder to reach (e.g. elderly, patients with language barriers, limited access to tech, uninsured/don’t want to share SSN, patients with disabilities). As a result, it is important to measure demographic data and identify barriers faced by patients who receive the vaccine. Demographic data on vaccine recipients can be compared to peer institutions and departments and serve as a proxy measure for increasing access and equity.

In addition, while it is important to collect data on those who receive the vaccine, it is equally important to collect data on those who do not. Providers should document when they offer the vaccine and when patients decline for example, through the use of EPIC smart-phrases. Data on demographics of individuals who decline the vaccine and reasons for declining can be used to target future educational campaigns and outreach initiatives. While outstanding progress has been made in vaccine distribution, continued work is needed to define and measure success with a focus on access and equity.

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  1. Ndugga N, Hill L, Artiga S, Haldar S. Latest Data on COVID-19 Vaccinations by Race/Ethnicity. Kaiser Family Foundation. Feb 2022.
  2. Hwang C, McEachern E. Nonprofit health plan CMOs: Data sharing needed to drive vaccine equity. HealthcareDive. June 7, 2021.

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