Flu vaccination rates could foreshadow health-equity and acceptance challenges ahead

By Jitinder Kohli, managing director, and Carla Andrews, senior manager, Deloitte Consulting LLP

In a recent blog post, our colleague Dr. Asif Dhar outlined the importance of getting a flu shot as we enter the colder winter months and face a powerful second wave of COVID-19 infections. He also explained why some members of certain populations—particularly Black Americans—are often reluctant to get vaccines. One or more safe and effective COVID-19 vaccines could be approved soon. However, unless we remove barriers that keep people from getting inoculated, our chances of defeating this disease could be grim.

Before COVID-19 emerged in late 2019, the Centers for Disease Control and Prevention (CDC) was already looking for ways to improve influenza vaccination rates among racial and ethnic minorities experiencing disparities. During the 2019-2020 flu season, 53% of white adults received the vaccine, while just 38% of Latinx and Hispanic adults, and 41% of Black adults, got a shot.¹ Moreover, during the 2019-2020 flu season, Black adults had the highest rates of flu-related hospitalizations. Health disparities between Black and white persons are most pronounced in rural and southern areas, yet disparities are also widening in urban locations. In September 2020, the CDC provided funding through the Racial and Ethnic Approaches to Community Health program to 31 REACH community organizations to help equip influential messengers, increase vaccination opportunities, and enhance provider partnerships with the goal of increasing flu vaccination confidence and coverage among racial and ethnic minorities experiencing disparities.

On October 6, the CDC announced it had teamed up with the Ad Council and the American Medical Association to launch the No One Has Time for Flu—a campaign aimed at encouraging all Americans to get vaccinated against flu.

The racial divide is growing

Structural racism has been a root cause of many issues including economic inequality, limited access to health care, and poor nutrition. Such health disparities have made certain ethnic and minority populations more susceptible to influenza and other illnesses that can be prevented through vaccination. For example, vaccination rates between Black and white adults for Hepatitis A, Hepatitis B, and tetanus have been widening for the past decade. There are a number of reasons that certain populations have lower vaccination rates than the general population. Such disparities are often driven by limited access to, or scarce availability of, vaccines.

As Asif mentioned in his blog, experiences with structural racism—including the Tuskegee Syphilis Study, which ended in 1972—continue to drive significant distrust in vaccines and in the health care system that recommends them. This distrust could be further magnified by personal experiences, rumors, or traditions. In addition, a fear of side-effects—particularly among people who already view vaccines as being ineffective, or who believe they are at low risk for the disease—could be a significant deterrent. Health care professionals who are trusted in the community could help to dispel inaccurate information and encourage vaccination.

Many Americans are already skeptical

COVID-19 has hit some racial and ethnic minorities particularly hard. Black Americans are 4.7 times more likely than white Americans to be hospitalized for COVID-19 and are 2.1 times more likely to die from it.

Black Americans are more likely than other ethnic or racial groups to have jobs that have been deemed as essential during the pandemic, and those jobs can place workers at higher risk of infection.² Black Americans also have disproportionately high rates of diabetes, obesity, and hypertension, all of which are risk factors for severe COVID-19.³ However, just 29% of Black Americans said they would be willing to get a COVID-19 vaccine once one becomes available, according to an October survey, conducted by the Public Policy Institute of California. By contrast, 70% of Asian Americans and 62% of white Americans said they would be willing to get a COVID-19 vaccine.⁴ There is an understandable level of anxiety about a newly developed vaccine. Public health officials and health care stakeholders should try to work collectively with communities to encourage all populations to get inoculated once a safe and effective vaccine is approved and made available. Our colleagues Sarah Thomas and Greg Szwartz recently published a blog that discusses some strategies to help build confidence in the new vaccines.

Four goals for boosting inoculation rates

In the early part of the 20^th century, thousands of people died each year from whooping cough, polio, measles, smallpox, and other diseases that are now prevented by vaccines.⁵ Even small reductions in vaccination coverage can lead to disproportionately large increases in the number of infectious disease outbreaks. Case in point: If just 5% fewer children were inoculated against the measles, mumps, and rubella, cases of those childhood diseases would triple, according to researchers at the Stanford University School of Medicine and Baylor College of Medicine.⁶ Here are four strategies that could help reduce racial disparities in vaccination rates among racial and ethnic minority populations: 

• Identify priority areas and populations: A foundational step in reducing racial disparities in vaccination coverage is to identify geographic areas or communities that have the highest disparities in vaccination rates. Data from the US Centers for Medicare and Medicaid (CMS), other insurers, hospitals and health systems, or state and local governments could be used to create vaccination coverage maps. These maps could help identify high-disparity communities and specific demographics within each community.
• Equip influential messengers: Trusted voices in community can be influential. Black Americans are more likely than white Americans to distrust physicians and might rely on more informal sources of information such as radio stations and community or spiritual leaders. Partnering with influential national groups could help educate certain populations about the benefits and safety of a vaccine. Organizations that are trusted in the community might include colleges and universities (and fraternities and sororities), professional sports leagues, local hospitals and health systems, pharmacists, radio stations, local shop owners, and faith leaders.^7,8,9 Trusted messengers in a community can be educated and trained in how to support vaccination efforts at the local level, especially in areas where negative sentiments toward vaccination are prevalent. Empowering influential and trusted sources with actionable knowledge and education could help improve support of public health efforts around vaccination. This strategy has been effective in combating stigma and disseminating critical information around the HIV/AIDS epidemic.^{10, 11, 12}
• Increase vaccination opportunities: It is important to meet members of the community where they live. Moreover, it might be less costly to administer vaccines en masse or in pharmacy settings than during scheduled physician visits. In some cases, the location of the site (e.g., church, community event) can add to the reputation of the vaccination being offered. This, in turn, might persuade people from certain racial and ethnic groups—who might initially be more skeptical—to be vaccinated. Mobile vaccination clinics or community vans could bring vaccinations into high-disparity areas. Mobile clinics can offer a potentially sizable return on investment in dollars saved from unnecessary emergency department visits.
• Incentivize immunization: Incentives, such as quality measures or payment-model reforms, might encourage health care professionals to help reduce disparities in vaccine take up. CMS has implemented a number of value-based models aimed at specific health issues (e.g., end-stage renal disease, hospital readmissions, and hospital-acquired conditions). These models show that certain health outcomes can be improved through payment models, metrics, and performance indicators or goals. For example, providers might be rewarded for increasing vaccination coverage in populations where vaccine confidence is lower, or for decreasing disparities. Such incentives could include risk adjustment, differential benchmarks, or rewards for improved vaccination rates.

If the barriers that keep certain populations from getting a flu shot can be removed, mass inoculation against COVID-19 will be more likely, and the effectiveness of a vaccine will likely be much greater, allowing our society to thrive without the omnipresent worry of infection. Moreover, strategies developed to reduce health disparities for vaccines could provide valuable lessons learned more broadly to help reduce disparities in mortality and morbidity.  

Endnotes

^{1.  Flu Disparities Among Racial and Ethnic Minority Groups, CDC, October 23, 2020}

^{2.  COVID-19 deaths among Black essential workers linked to racial disparities}

^{3.  ‘I won’t be used as a Guinea pig for white people’, The New York Times, October 7, 2020}

^{4.  Will Californians trust a COVID-19 vaccine?, California Health Care Foundation, October 26, 2020}

^{5. What Would Happen If We Stopped Vaccinations?, CDC, July 29, 2018}

^{6.  Small drop in measles vaccinations would have outsized effect, Stanford Medicine News Center, July 24, 2017}

^{7.  Barbershops as venues to assess and intervene in HIV/STI risk among young, heterosexual African American men, American Journal of Men’s Health, March 7, 2012}

^{8. Talking About Fighting Prostate Cancer—in the Barber Shop!, American Journal of Men’s Health, Montclair State University, August 16, 2007}

^{9.  Pandemics and health equity: lessons learned from the H1N1 response in Los Angeles County, Journal of Public Health Management and Practice, January 2011}

^{10. Structural interventions for HIV prevention in the United States. Journal of Acquired Immune Deficiency Syndromes, 1999}

^{11. Improving community support for HIV and AIDS prevention through national partnerships. Public Health Reports, 1991}

^{12. HIV in the African American Community: Progress, But Our Work Is Far From Over, HIV.gov, February 7, 2018}

Return to the Health Forward home page to discover more insights from our leaders.