As of 2022, the United States has reported approximately ​​1,050,426 deaths due to COVID-19. Over the past two years, the U.S. has rapidly expanded vaccine coverage, consistently rolling out booster shots to control the spread of new variants. Most recently, the emergent XBB.1.5 variant has caused the majority of COVID-19 cases and the demand for vaccines to slow the spread and reduce hospitalizations has persevered. The U.S. first authorized the administration of COVID-19 vaccines produced by Pfizer on December 17, 2020. As of September 2022, the country had achieved 68% full vaccination (received both doses in the COVID-19 vaccine series) against the virus.

Despite over half of the nation having received full vaccination against COVID-19, this coverage is not equitable across the United States, a demographically diverse country contending with disparities between and within states. Previous articles from this series of “Pandemic and Inequities” have addressed broad structural and social determinants as well as barriers, including misinformation, that contribute to a lack of equity in vaccine coverage. However, it is just as important to evaluate the geographic disparities in vaccine coverage and why certain states and regions in the U.S. have disproportionately lower coverage of COVID-19 vaccination. Thus, this article seeks to outline the specific geographic disparities, the reasons behind such disparities, and potential solutions that can close the geographic disparities. 

Before delving into the specific geographic disparities in vaccine coverage, it is important to define geographic disparities in the context of vaccine access. In the context of healthcare and vaccine access, geographic disparities include not only the physical lack of access to vaccines but also “differences in demography, attitudes, lifestyle factors, and cultural practices in regional and rural settings” that impact the tendency for one to seek out the COVID-19 vaccine. With this definition in mind, this article will consider geographic disparities not just in the context of distance but also in the context of the factors that define a region, such as the political affiliation of the state, poverty levels, and access to education. 

In a study published in the Lancet on December 14, 2022, researchers found that “regions including the Rocky Mountains, the Gulf Coast, the lower Atlantic region, and the Midwest” had populations with disproportionately lower COVID-19 vaccination rates. Specific areas with low COVID-19 vaccination rates were concentrated among 17 states (Nev, Mont, Wyo, N.D, S.D, Neb, N.M, Okla, Miss, Ala, Ark, La, Tenn, Ky, Kan, Ind, and Ohio). In examining the states and regions closer at a county level, the lowest-vaccination areas, or “coldspots,” were in rural areas. It is particularly salient to explore why rural areas in the Midwest, South, and Southwest regions carry the majority of unvaccinated individuals against COVID-19.  

There is a significant correlation between regions that contain the most coldspots and the quality of healthcare in that region. Specifically, factors such as reduced healthcare infrastructure, a small healthcare provider workforce, lack of healthcare funding, and lower investment in preventive care are all common characteristics in regions with low vaccination rates. In fact, the 17 states with the lowest COVID-19 vaccination rates are also ranked lowest in terms of healthcare quality and access. There is a physical lack of access in such regions to vaccination clinics and healthcare workers that can administer such vaccines if there are significantly fewer funds dedicated to delivering quality healthcare and providing access to healthcare workers.

There is often a general lack of access to healthcare in rural areas, with “65.6% of Primary Care Health Professional Shortage Areas” located in rural areas as of 2022. This affects access to COVID-19 vaccines. Lower access to healthcare and healthcare workers is directly correlated to reduced access to testing, vaccines, and treatment supplies. When health systems are more restricted in terms of resources and workers, it becomes especially difficult to build an effective and robust healthcare system that routinely delivers vaccines and booster shots and runs vaccine campaigns in a timely manner.  

Knowing the specific geographic disparities in healthcare access across the U.S., strategies can be developed to close gaps in COVID-19 vaccine coverage. Federal funding towards expanding health clinics in rural areas and increasing the distribution of COVID-19 vaccines to rural health programs can increase accessibility. Specifically, the Rural Health Clinic COVID-19 Vaccine Distribution Program provides certification to healthcare practices in low-resource rural areas and distributes COVID-19 vaccines directly to such rural clinics. Additionally, clinics can receive a one-time allocation of funds to expand and strengthen the healthcare infrastructure in their area. 

As COVID-19 has become endemic in the United States, it has revealed underlying social and regional inequities that must be addressed to achieve equitable access to disease treatments and prevention. Vaccines have the ability to reduce the spread and incidence of severe hospitalizations, yet marginalized groups in the United States still lack access to this critical innovation. In focusing attention on geographic disparities in COVID-19 vaccine coverage, greater efforts should be made to center intervention strategies around groups that are disproportionately impacted. 

Image courtesy of the Centers for Disease Control and Prevention as seen in The New York Times.