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COVID Vaccination Disparities in Racial and Ethnic Groups

Robert Ogden

School of Nursing and Health Science, University of San Diego

HCIN 540 – Introduction to Health Care Informatics

Dr. Klimpel

3/25/2022
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Abstract

The White House National Strategy for the COVID-19 Response and Pandemic Preparedness made

vaccine equity for Americans a primary goal in the Biden Administration’s response to the pandemic. To

assess progress towards the goal and the impact on health, this paper looked at COVID vaccinations

amongst racial and ethnic groups and sampled states with high and low-vaccination rates to compare

mortality rates using data drawn from the CDC COVID Data Tracker. Broadly, the United States achieved

or exceeded COVID vaccination equity for Hispanics/Latinos, Asians, Native Americans/Alaskan Natives,

and Hawaiian/Pacific Islanders. Notably, Hispanics/Latinos, who lagged White non-Hispanics with only

one-third of the vaccinations in March 2021, ended March 2022 with 19.8% of the overall vaccinations

though representing just 17.2% of the U.S. population. On the other hand, Black non-Hispanics

continued to lag in vaccination rates, with only 10.1% of the vaccinations despite representing 12.4% of

the general population. In a sampling of states, states with among the lowest vaccination rates and large

representations of Black non-Hispanics collectively had a 35% higher mortality rate in early 2021 when

compared to the three states with the highest vaccination rates and relatively small Black non-Hispanic

populations. This disparity grew to 39% in early 2022, indicating possible disparities in health outcomes

for the Black non-Hispanic community. However, further research is needed to associate the higher

mortality rate with specific racial or ethnic groups.

Keywords: COVID, Racial Equity, Disparities, Vaccinations

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COVID Vaccination Disparities in Racial and Ethnic Groups

The White House National Strategy for the COVID-19 Response and Pandemic Preparedness,

published in January 2021, made vaccine equity for high-risk groups a primary goal in the Biden

Administration’s response to the COVID pandemic (White House, 2021). This strategy, coming on the

heels of the release of the first COVID vaccines, sought to accord priority to groups disproportionately

impacted by the COVID pandemic. These high-risk groups included minority racial and ethnic

populations. The White House strategy indicated that some minority and ethnic groups were about four

times more likely to be hospitalized and nearly three times more likely to die from COVID-19 infections

(White House, 2021). Two minority groups, American Indians and Alaska Natives in the 18 to 49-year-old

range, saw hospitalizations about 4 to 10 times higher than the same age groups of other races (Hicks et

al., 2022).

Despite an early government strategy to increase vaccination equity across high-risk groups,

vaccination rates in minority racial and ethnic groups lagged the non-Hispanic White population for the

first part of 2021 (Hughes et al., 2021). For example, data from March 2021 indicated that vaccination

rates for the non-Hispanic White population was 2.9 times higher than that among the Hispanic

population, and, in May 2021, about 50% of COVID hospitalizations where among minority groups

(COVID-NET, 2020). Statistics like this indicate that the strategy was much needed to increase equity

across racial and ethnic groups. To assess the progress in achieving the national strategy and determine

whether there is a need to adjust the national approach, this paper conducts a review of recent data.

Data will be drawn from the CDC COVID-NET website, using information on COVID-associated

hospitalizations, deaths, and vaccinations.

Literature Review

The COVID pandemic laid bare the health disparities in minority and ethnic populations

compared to the non-Hispanic White population. Using the CDC’s social vulnerability index to examine
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vaccination rates in counties across the United States, regions with a low vulnerability (often, those

regions with high percentage of minorities) showed a nearly 2% higher vaccination rate than regions

with high vulnerability scores (Hughes et al., 2021). Hughes et al. (2021) showed that only two states

had a higher vaccination rate amongst higher vulnerability groups when compared to low vulnerability

groups, demonstrating a seemingly successful localized achievement of one of the goals laid out in the

national strategy (White House, 2021). Hughes concluded that the two states, Arizona and Montana,

achieved success by early prioritization of minority groups, community collaboration, and making

vaccination sites readily accessible (Hughes et al., 2021).

Despite the demonstrated success of the two states, other states failed to achieve equity

amongst higher vulnerability groups. Hughes et al. (2021) did not provide reasons for most states not

achieving the goal, instead suggesting that public health officials should investigate potential causes and

concluding that states needed to do more to reach those most affected by COVID.

Findings months later showed that states continued to struggle with achieving race-equity in

vaccinations. In the April 2021 Issue Brief, the U.S. Department of Health and Human Services (2021)

concluded that “Black and Hispanic populations consistently make up a disproportionately lower share

of the vaccinated population” and “Black and Hispanic populations are also being vaccinated at a lower

rate than expected given their prevalence in priority vaccination groups” (2021, p. 6). HHS (2021)

concluded that the two main factors were likely vaccine hesitancy and vaccine accessibility.

Concurrent with the lower rates of vaccination rates, racial and ethnic groups continue to show

higher rates of hospitalization and death, with Hispanics having the greatest disproportionate

hospitalization rate when compared to non-Hispanic Whites (Romano et al., 2021). Romano et al. (2021)

show that racial and ethnic minority group hospitalization rates in the months prior to vaccine

availability were up to five times higher than for non-Hispanic Whites (Romano et al., 2021). Following

vaccine availability, the online CDC COVID-NET tracking tool demonstrated that the disparity in
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hospitalizations continued. However, the findings also showed that disparities were less pronounced

over time. Like Hughes et al., Romano et al. (2021) points to a need for an investigation into the

potential causes of disparities. Findings by Romano et al. (2021) were highly disconcerting, as an article

published in the Journal of American Medical Association Data shows that up to half the individuals who

are hospitalized by COVID “experience prolonged work absence, financial difficulty, or emotional

effects” (Prescott et al., 2021, p. 1511).

Catheters (2020) findings published in the Journal of Internal Medicine showed that the

disparity in deaths extended across different age groups when compared to White Non-Hispanics in the

same age groups. In particular, in the younger age group (25-34 years old) where death rates are

generally low for COVID-infected patients, African Americans and Hispanics were still 6.4 and 4.3 times

more likely to die from COVID-19 than in White non-Hispanic Americans. These disparities, Catheters

suggests, are predominantly driven by socioeconomic and health-related factors.

The research above highlights the significantly disproportionate impact COVID has had on

minorities and ethnic groups. A review of recent data will tell us whether we have closed the gap in

equity or whether an adjustment to the current approach is necessary to ensure that the goal of the

national strategy is achieved. Together, vaccination and hospitalization rates will provide us a good

measure of whether we are closing the vaccination equity gap and, most importantly, if it is having the

desired effects on the health of minority and ethnic groups.

Methods

This paper examines the progress in closing COVID-19 vaccination disparities in historically

underserved racial and ethnic groups compared to the non-Hispanic White group. The first metric used

data from The Centers for Disease Control and Prevention’s (CDC) COVID-19 tracking website. The

comparison begins with the U.S. Department of Health and Human Services (HHS) Assistance Secretary

for Planning and Evaluation (ASPE) Issue Brief conclusions that “vaccine coverage was approximately 2.1
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and 2.9 times higher for the White population relative to the Black and Hispanic populations,

respectively” (ASPE, 2021). Data was then drawn from CDC COVID Data Tracker from March 31, 2022,

providing the most recent quarterly vaccination coverage those fully vaccinated. To evaluate whether

disparities continue, the data was processed and cleaned to identify the percentage of the U.S.

population made up of a given racial/ethnic group demographic and the percentage of that population

(as a percentage of the entire U.S. population) that was fully vaccinated. Sample population size (those

reporting race or ethnicity when vaccinated) was 168,401,861. Notably, this data excluded nearly 50

million people for whom race/ethnicity was not available. Additionally, while data from seven racial and

ethnic groups (Hispanic/Latino, Native American Non-Hispanic, Asian Non-Hispanic, Black Non-Hispanic,

Hawaiian/Pacific Islander Non-Hispanic, White Non-Hispanic, Multiple/Other Non-Hispanic) was used,

results for Multiple/Other Non-Hispanic is not presented in the findings of this paper.

The second metric used in this study was the mortality rate in states with high and low

vaccination rates. Data source was obtained from the CDC’s COVID Tracker website, using the

race_ethnicity_of_people_fully_vaccinated and statewide-covid-19-cases-deaths-demographics dataset

(CDC, 2022). Data on COVID-19 vaccination coverage and the mortality rate from three states with high

vaccination rate was compared to the three states with low vaccination rates. Data was cleaned to

include only COVID-19-confirmed deaths. The data from each group of three states (high-vax states and

low-vax states) was averaged to give a nominal mortality rate. Where deaths from COVID were probable

or unknown, the data was excluded. Furthermore, to get the best comparison of the disparate impact

vaccination rates continue to have on vaccine-underserved populations, mortality data was aggregated

into two quarters: 1st quarter of 2021 (when vaccination roll-out began in earnest) was compared to

data from the 1st quarter of 2022 (when the majority of the population had already been fully

vaccinated). Though this metric was not specifically focused on race and ethnicity, three of the five
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least-vaccinated states (AL, MS, LA) have a proportionally large Black Non-Hispanic population, while all

three of the most-vaccinated states (ME, VT, RI) have a relatively small percentage.

Whereas vaccination rates from the first metric will show whether the government achieved its

goal of vaccine equity, the second metric demonstrates whether the goal had the intended effect—that

is, reducing the health impact of the COVID pandemic in high-risk groups.

Results

As of March 31, 2022, the analysis of data showed that the United States has made significant

progress in addressing inequities in vaccination rates across racial and ethnic groups. The

Hispanic/Latino population along with Native Americans and Hawaiian Pacific Islanders reached parity or

greater with White non-Hispanics while Black non-Hispanics partially closed the gap but continued to lag

in vaccination rates.

Figure 1 in the reference section shows the vaccination rates for six racial/ethnic groups as of

March 31, 2022, from a sample population size of 168,401,861. As can be seen, Hispanic/Latinos as a

group achieved rates of vaccination well above national averages. This group makes up 17.2% of the

population but has a disproportionately large percentage (19.8%) of the overall vaccinated population,

with an extrapolated rate of 58.8% of this demographic group fully vaccinated. Native Americans and

Asian Americans also showed large representative vaccinated population. Black non-Hispanics remain

underrepresented, with 12.4% of the population accounting for 10.1% of the vaccinations, with a rate of

41.5% overall vaccination in this demographic group. Notably, White non-Hispanic, who account for

61.2% of the U.S. population, were also underrepresented in vaccinations, with 56.2% of the

vaccinations in the sample group for an estimated 46.9% of the total vaccinated U.S. population.

It is important to note that the percentage of vaccinations for each demographic population is

higher than indicated since nearly fifty million fully vaccinated were not included in the calculations due

to the absence of race and ethnicity data. For example, only 94,650,691 White non-Hispanics were
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indicated in this study as being fully vaccinated, whereas the actual number would include that fraction

of the fifty million people who were not counted.

Figure 2 introduced a baseline graph to magnify the vaccination progress made or challenges for

racial and ethnic groups. A group that is vaccinated at a rate equal to their ratio of the U.S. population

would be at the baseline, 0%. Hence, if equity existed across all groups, no groups would extend above

or below the baseline. This chart shows that Hispanic/Latino’s and Native Americans exceeded equity by

15% and 13% for their demographic population group, while Black Non-Hispanics are significantly under-

represented within their group, with a nearly 20% delta from the baseline, and White Non-Hispanic are

under-represented by 8%.

As shown in Figure 3, the mortality rate in the top three states with highest vaccination rates

was compared against the three least vaccinated states. Importantly, the top three states with the

highest vaccination rates also had relatively small Black non-Hispanics whereas the three at or near the

bottom of the vaccination rates had amongst the highest Black non-Hispanic percentage of state

population. While mortality rates for both groups of states declined significantly over the year, the

death rate in states with the low-vaccination rates remained significantly higher than that in high

vaccination states. In fact, the disparity increased over the year, with a 35% higher death rate in the first

quarter of 2021 compared to 39% higher one year later. While the data does not specifically look at race

and ethnicity, the higher mortality rates in states with relatively large Black non-Hispanic percentages

points to the possibility that successfully addressing vaccination disparities may not have had the

desired effect of closing health outcome disparities in racial and ethnic groups affected by COVID-19.

Discussion and Future Recommendations

As the primary goal of the National Strategy for the COVID-19 Response and Pandemic

Preparedness was to bring vaccine equity to minority groups (White House, 2021), this study concludes

that the strategy mostly achieved its objective with respect to vaccinating racial and ethnic minority
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groups. However, further effort is needed to achieve vaccine equity in the Black non-Hispanic

community. A study to determine which states had the greatest success in achieving the objectives of

the national strategy and the methods these states used would be beneficial to help poorly performing

states or regions achieve the same results.

Notwithstanding the positive progress in vaccination rates, significant differences were seen in

death rates, with the mortality rate significantly higher in a sample of states with large Black non-

Hispanic populations when compared to states with very low minority representation. The findings

indicated that states with higher vaccination rates were likely to see a more pronounced drop in

mortality rates than states with the lowest vaccination rates.

The fact that the states with the lowest vaccination rates also had among the highest proportion

of Black non-Hispanics provides some evidence that higher death rates may continue to exist along

racial and ethnic lines. However, as the study did not specifically break out racial and ethnic groups in

these states, the connection is weak. Indeed, it is plausible that other factors may be contributing to the

higher mortality rates in these states, such as social determinants of health, co-morbidities, political

factors, or even historically-based distrust in government health programs. It is also plausible that racial

or ethnic groups in these states may fair as well or better than the White non-Hispanic population. To

resolve this ambiguity in the study, research is recommended to assess state trends in vaccination and

mortality rates by racial and ethnic groups and determine causal factors for the disparities.
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References

Carethers, J.M. (2020). Insights into Disparities Observed with COVID-19. Journal of Internal Medicine.

https://doi.org/10.1111/joim.13199

Centers for Disease Control and Prevention. (2022, March 13). Race Ethnicity of People Fully Vaccinated

[Data set]. https://covid.cdc.gov/covid-data-tracker/#vaccine-delivery-coverage

Centers for Disease Control and Prevention. (2022, March 13). Statewide COVID-19 Cases Deaths

Demographics [Data set]. https://data.cdc.gov/Case-Surveillance/COVID-19-Case-Surveillance-Public-

Use-Data-with-Ge/n8mc-b4w4

COVID-NET. (n.d.). Characteristics of COVID-19-Associated Hospitalizations [Data set].

https://gis.cdc.gov/grasp/COVIDNet/COVID19_5.html

Hicks, J.T., Burnett, E., Matanock, A., Khalil, G., English K., Doman, B., Murphy, T. (2022). Hospitalizations

for COVID-19 Among American Indian and Alaska Native Adults (≥ 18 Years Old) — New Mexico,

Journal of Racial and Ethnic Health Disparities, March–September 2020.

https://doi.org/10.1007/s40615-021-01196-0

Hughes, M. M., Wang, A., Grossman, M. K., Pun, E. Whiteman, A., Deng, L., Hallisey, E., Sharpe, J. D.,

Ussery, E. N., Stokley, S., Musial, T., Weller, D. L., Murthy, B. P., Reynolds, L. Gibbs-Scharf, L.,

Harris, L., Ritchey, M. D., Toblin, R. L. (2021). County-Level COVID-19 Vaccination Coverage and

Social Vulnerability – United States, December 14, 2020—March 1, 2021. Morbidity and

Mortality Weekly Report, 70. https://doi.org/10.15585/mmwr.mm7012e1

Prescott, H.C. (2021). Outcomes for Patients Following Hospitalization for COVID-19. The Journal of the

American Medical Association. 325(15), 1511-1512. https://doi:10.1001/jama.20213430

Romano, S. D., Blackstock, A. J., Taylor, E.V., Felix, S. E. B., Adjei, S. Singleton, C. Fuld, J Bruce, B. B.,

Boehmer, T. K. (2021). Trends in Racial and Ethnic Disparities in COVID-19 Hospitalizations by

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Region – United States. Morbidity and Mortality Weekly Report, 70(15), March—December

2020. https://www.cdc.gov/mmwr/volumes/70/wr/mm7015e2.htm

U.S. Department of Health and Human Services. (n.d.) Disparities in COVID-19 Vaccination Rates across

Racial and Ethnic Minority Groups in the United States. Assistant Secretary for Planning and

Evaluation. https://aspe.hhs.gov/reports/disparities-covid-19-vaccination-rates-across-racial-

ethnic-minority-groups-united-states

Whitehouse. (2022). National-Strategy-for-the-COVID-19-Response-and-Pandemic-Preparedness.

https://www.whitehouse.gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-

19-Response-and-Pandemic-Preparedness.pdf
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Figures

Figure 1

Vaccination Rates for Select Race/Ethnic Groups

% Fully Vaccinated % of Population

70
61.2
60 56.2

50
Population (%)

40

30
19.8
20 17.2
12.4
10.1
10 6.8 5.8
0.9 0.8 0.3 0.3
0
White Non- Black Non- Hispanic/Latino Native American Asian Non- Hawaiian/Pacific
Hispanic Hispanic Non-Hispanic Hispanic Islander Non-
Hispanic
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Figure 2

Baseline Comparison of Vaccination Rates as a Percentage of the Representative Population

0%
17%
13%
15%
-19%
-8%

-25% -20% -15% -10% -5% 0% 5% 10% 15% 20%

Hawaiian/Pacific Islander Non-Hispanic Asian Non-Hispanic

Native American Non-Hispanic Hispanic/Latino
Black Non-Hispanic White Non-Hispanic
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Figure 3

Mortality Rate in High vs. Low Vaccination States

2.5%

2.18%

2.0%

1.67%
1.61%
Mortality Rate

1.5%
1.24%
1.14%

1.0%
0.70% 0.67%
0.59% 0.64%
0.46%
0.5%

0.0%
1st Qtr 2021 2nd Qtr 2021 3rd Qtr 2021 4th Qtr 2021 1st Qtr 2022

Low Vax Region High Vax Region Average