Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes

Abstract

Objectives:

This study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs).

Design:

Retrospective cohort study.

Setting and Participants:

We included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons.

Methods:

Our comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs.

Results:

The study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons.

Conclusions and Implications:

Our analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.

Influenza disproportionately affects nursing home (NH) residents, who experience an increased risk of severe illness following infection due to their advanced age, multimorbidity, and frailty.¹ Nonetheless, the proportion of NH residents vaccinated against influenza has stagnated.² The inertia exists despite the Healthy People 2020 goal of achieving 90% vaccination among NH residents and regulations that require vaccines to be offered.³ Although this goal was not included in Healthy People 2030, increasing vaccination will remain an important yet unachieved goal without new opportunities for improvement. Disparities in vaccination between marginalized Black NH residents and more privileged White residents may be one unaddressed source of stagnation in vaccine uptake.^4–6 In addition to being a moral wrong that there is an obligation to address, disparities also offer new opportunities to improve overall vaccination rates.⁷

Health disparities embody inequities in the provision of health services and inequities in adverse health outcomes across socially privileged and marginalized groups.⁸ Racial health disparities often manifest locally in small geographic areas.⁹ These disparities likely differ in magnitude across small geographic areas as a consequence of localized structural racism: the systemic and mutually reinforcing societal policies and practices that foster discrimination of marginalized groups.^10,11 Studies have suggested that racial disparities in influenza vaccination among NH residents exist nationally and between NHs.^4,5,12 A prior study revealed differences in disparities in influenza vaccination between Hispanic and non-Hispanic White NH residents across smaller area geographic units including hospital referral regions (HRRs)¹³; however, the geographic distribution of these disparities between Black and White NH residents remains unknown. Identifying small-area disparities between Black and White NH residents is important for intervening to reduce disparities. State and local interventions and policies are likely to have just as large, if not larger, effects on the elimination of health disparities as national interventions and policies.¹⁴

Therefore, we identified the geographic distribution of influenza vaccination among Black and White NH residents and racial disparities in vaccination between these populations at the state and HRR levels. Both short-stay (post-acute care) and long-stay (long-term care) NH populations were examined not only because of each population’s unique care needs but because tailored interventions to each of these groups may be necessary to increase vaccination and reduce disparities.¹⁵

Methods

Study Design and Data Sources

This was a nationally representative retrospective cohort study of NH residents between October 1, 2011, and March 31, 2018. We linked the Medicare Beneficiary Summary File (MBSF) and Medicare claims to Minimum Data Set (MDS) version 3.0 clinical assessment records and Certification and Survey Provider Enhanced Reports (CASPER). The MBSF includes beneficiary enrollment information and demographics.¹⁶ The MDS is a federally mandated assessment for all nursing facilities certified by the Centers for Medicare and Medicaid Services (CMS) that documents resident demographics and vaccination.¹⁷ Facility location and hospital ownership were obtained from CASPER, which includes facility-level information collected by state survey agencies.¹⁸ We employed a validated residential history algorithm to characterize residents’ timing and location of health services utilization, as well as to identify their type of stay.¹⁹ The need for informed consent was waived because of the use of deidentified data.

Study Population

Eligible residents were Traditional Medicare beneficiaries aged 65 and older residing in non–hospital-based NHs with at least 1 MDS assessment identified between the 2011–2012 and 2017–2018 influenza seasons. The study period included 7 distinct influenza seasons, with each season starting on October 1 and ending on March 31 of the following year. These dates were chosen because influenza activity is empirically the highest throughout this period.²⁰ Residents were included if any part of their NH stay occurred during an influenza season. Residents with <100 days in the same NH were considered short-stay and those with ≥100 consecutive days with no more than 10 days outside of a NH were considered long-stay.¹⁹ Only the first NH stay identified per influenza season was included; however, residents could be represented across multiple seasons.

Conceptual Framework

We constructed a causal directed acyclic graph (DAG) informed by the literature and subject matter knowledge to guide our analyses (Figure 1).^{10,11,21–26} Descriptions of all nodes in Figure 1 can be found in Supplementary Text 1. Common determinants of vaccination, such as comorbidities and NH characteristics, were considered to be mediators of the relationship between racial group and influenza vaccination. Because our study included NH residents who met eligibility criteria, part of the relationship between racial group and influenza vaccination may occur through collider stratification via pathways operating through age and sex.^27,28 We standardized our analyses by age and sex to minimize the impact of this nonrandom selection, which may mask or underestimate disparities in vaccination.²⁹

Fig. 1.

Causal DAG encoding subject matter knowledge regarding the relationship between racial group and influenza vaccination. The figure represents an encoding of our assumptions about distinct variables (nodes) and the relationships between them that are reflected by single-direction arrows. The figure is read from left to right, encoding temporality, wherein each node that is an antecedent (a node with an arrow emanating from it) of another also precedes it in time. Our comparison group of interest is represented by the node “Membership in a marginalized vs privileged racial group,” which is operationalized as being Black vs White race in our analyses. Descriptions of each node can be found in Supplementary Text 1.

Comparison: Membership in a Marginalized vs Privileged Racial Group

We define race as a social construct, not a biological one.³⁰ In our study, Black race was considered a marginalized racial group, and White race was considered a privileged racial group.¹⁰ We obtained race information from the MBSF using the validated Research Triangle Institute race/ethnicity variable to identify non-Hispanic White and non-Hispanic Black residents.³¹ Residents who were identified as Hispanic, Asian/Pacific Islander, American Indian/Alaska Native, and Other were excluded because we were explicitly interested in disparities between White and Black residents, who account for most NH residents and between whom the difference in privilege is among the largest.^10,32

Outcome: Influenza Vaccination

Vaccination status was determined via the immunization supplement of the MDS using a previously described algorithm that documents whether influenza vaccination was offered to residents and theiracceptanceorrefusal.³³ MDS assessments from October 1 through June 30 were leveraged to determine vaccination status in a given season to allow for sufficient time for vaccination to be documented in the MDS.¹⁷ Residents were considered vaccinated if any assessment during this period indicated receipt of vaccination in or outside the NH.

Covariates

Residents’ age and sex were obtained from the MBSF. Age was categorized into the following groups according to their index date in each season, defined as the date of admission for short-stay and 100^th day of stay for long-stay: 65–69, 70–74, 75–79, 80–84, and ≥85 years.

Statistical Analyses

Unit of analysis

We conducted our analyses at “resident-season” level, whereby each resident could contribute multiple influenza seasons to the study. Resident-season measures, including vaccination status, were ascertained for each person in each season and aggregated across seasons to generate summary measures of the distribution of age, sex, and race among states and HRRs.

Measurement of disparities

We calculated the proportion of vaccinated White and Black resident-seasons at the state and HRR levels. HRRs represent regional hospital catchment areas with a minimum population of 120,000.³⁴ HRRs are notably not restricted by state boundaries, which may more accurately reflect the geographic patterns of health care utilization that result in the admission of residents to NHs and serve as a viable geographic unit targetable by interventions to reduce disparities. Disparities were measured as the percentage point (pp) difference in the proportion of individuals vaccinated between Black and White NH residents among states and HRRs; positive differences indicate the presence of a disparity. By definition, disparities can only arise from differences that favor privileged groups.⁸

Nonparametric G-formula

To calculate age- and sex-standardized estimates of vaccination within states and HRRs, we used the nonparametric g-formula using a fully saturated linear regression model, including interactions between race and all other variables (see Supplementary Text 2 for a full list of other variables).^35–37 To obtain stable estimates, we restricted our analyses to geographic units with at least 100 resident-seasons per covariate strata per racial group.

Sensitivity analyses

We estimated crude estimates of disparities among the national long-stay and short-stay populations in each influenza season to assess for changes in disparities over time. We also evaluated an alternative approach to standardization to determine the robustness of our results to different analytic decisions. Because we restricted to geographic units with a minimum number of observations, we assessed whether the distributions of age, sex, and vaccination status among resident-seasons in excluded geographic units were comparable to those of included units. In addition, we were concerned that standardizing to the overall population might produce estimates that differ substantially from those that would be obtained from standardizing to the covariate distributions of Black NH residents.³⁸ We used direct standardization, which is mathematically equivalent to nonparametric g-formula, to a marginalized (Black) population reference standard. Finally, to assess the impact of standardization by age and sex and stratification by geographic unit, we compared the median standardized difference in vaccination across states and HRRs to the crude national difference among all residents and the standardized national difference. We estimated the standardized national difference by using the nonparametric g-formula to standardize the national Black and White resident populations to the overall population age and sex distributions (ie, this model did not include geographic unit).

Software

Data were analyzed using SAS version 9.4 (SAS Institute, Inc.), Stata version 16 (StataCorp LLC), and ArcMap 10.8 (ESRI).

Results

Study Cohort and Influenza Vaccination

The study cohort consisted of 7,807,187 short-stay resident-seasons from 14,889 NHs and 7,308,111 long-stay resident-seasons from 14,885 NHs (Supplementary Figure 1). Among short-stay resident-seasons, 7,002,108 (89.7%) were White and 805,079 (10.3%) were Black. Of the long-stay population, 6,335,373 (86.7%) were White and 972,738 (13.3%) were Black (Table 1). The crude proportions of short-stay resident-seasons vaccinated against influenza were 64.0% among White resident-seasons and 51.5% among Black resident-seasons, for a national disparity of 12.5 pps. The crude national disparity among long-stay resident-seasons was 7.7 pps (81.8% White resident-seasons vaccinated, 74.1% Black resident-seasons vaccinated).

Table 1.

Characteristics of Short-Stay (Post-acute Care) and Long-Stay (Long-Term Care) NH Residents, 2011—2018 Influenza Seasons

Resident-Season-Level* Characteristic	Short-Stay/Post-Acute Care n = 7,807,187		Long-Stay/Long-Term Care n = 7,308,111
	n or mean	% or SD	n or mean	% or SD
Race, n (%)
White non-Hispanic	7,002,108	89.7	6,335,373	86.7
Black non-Hispanic	805,079	10.3	972,738	13.3
Age,† y, mean (SD)	81.4	8.4	84	8.7
Age group, y, n (%)
65–69	888,488	11.4	565,920	7.7
70–74	1,120,278	14.3	754,733	10.3
75–79	1,337,592	17.1	983,304	13.5
80–84	1,578,022	20.2	1,346,861	18.4
85+	2,882,807	36.9	3,657,293	50
Sex, n (%)
Male	3,015,646	38.6	2,152,139	29.4
Female	4,791,541	61.4	5,155,972	70.6

Note: Influenza seasons were defined as starting on October 1 of one year and ending on March 31 of the following year based on historical influenza activity from the Centers for Disease Control and Prevention. Vaccination status leveraged data through June 30 to allow for sufficient time for vaccination status to be documented by nurses during resident assessments.

^*Because a resident could be represented across multiple influenza seasons, we conducted our analyses at “resident-season" (also commonly referred to as “person- period") level, whereby each resident could contribute multiple influenza seasons to the study, each of which is a resident-season. Resident-season-level information refers to measures that could be ascertained for each person in each season and that could vary between seasons.

^†Age was assigned at index date, defined for short-stay (post-acute care) residents as the date of admission to the NH and for long-stay (long-term care) residents as the 100^th day of a NH stay in alignment with the definitions of short-stay and long-stay commonly used by the Centers for Medicare and Medicaid Services.

State Analyses

The proportion of Black resident-seasons vaccinated against influenza at the state level ranged from 29% to 87%, compared with 41% to 89% among White resident-seasons across both short-stay and long-stay populations (Supplementary Figure 2). The median state-level crude disparity in vaccination among the short-stay population was 10.5 pps and 6.1 pps among long-stay resident-seasons. After standardizing by age and sex, the median disparity among short-stay resident-seasons was 10.1 pps and 5.3 pps among long-stay resident-seasons (Table 2). Illinois had the largest disparity among short-stay and long-stay populations at 23.2 (95% CI, 22.7–23.7) and 16.6 (95% CI, 16.1–17.0) pps, respectively. Maryland had the largest difference in disparities between short-stay and long-stay resident-seasons, a difference of 15.5 (95% CI, 15.0–16.0) pps among short-stay and 6.1 (95% CI, 5.6e6.6) pps among long-stay residents-seasons (Figure 2).

Table 2.

Crude and Standardized Incidence of and Differences in Influenza Vaccination Between Non-Hispanic White and Black Short-Stay (Post-acute Care) and Long-Stay (Long-Term Care) NH Residents, by State and HRR, 2011—2018 Influenza Seasons

	Crude			Age/Sex-Standardized
	White Vaccination (%)	Black Vaccination (%)	Percentage Point Difference	White Vaccination (%)	Black Vaccination (%)	Percentage Point Difference
State
Long-Stay (n = 35)
Mean	81.94	75.16	6.77	81.85	75.54	6.31
SD	4.62	6.11	3.42	4.62	6.12	3.43
Median	82.89	76.90	6.13	82.83	77.19	5.32
Q1,Q3	80.19, 84.22	72.64, 79.52	4.66, 8.08	80.15, 84.11	72.94, 79.98	4.13, 7.64
Min, Max	64.79, 88.72	60.56, 87.21	1.51, 17.10	64.72, 88.65	60.96, 87.49	1.16, 16.57
Short-Stay (n = 34)
Mean	64.82	54.06	10.76	64.73	54.28	10.45
SD	7.83	8.91	3.71	7.83	8.93	3.70
Median	65.41	54.28	10.45	65.35	54.47	10.11
Q1,Q3	62.65, 69.64	49.20, 60.48	8.23, 12.44	62.44, 69.56	49.36, 60.72	7.91, 12.10
Min, Max	40.41, 76.74	29.66, 68.51	5.17, 23.49	40.04, 76.63	29.81, 68.71	4.91, 23.20
HRR
Long-Stay (n = 110)
Mean	80.79	74.93	5.87	80.67	75.21	5.46
SD	5.51	6.93	3.58	5.51	6.95	3.59
Median	81.98	76.46	5.41	81.94	76.67	4.95
Q1,Q3	79.02, 84.42	71.87, 79.86	3.60, 7.47	78.68, 84.31	72.09, 80.17	3.20, 7.10
Min, Max	58.12, 89.96	53.77, 87.49	−1.81, 20.94	57.81, 89.87	53.93, 87.76	−2.20, 20.71
Short-Stay (n = 106)
Mean	62.12	52.47	9.65	62.00	52.70	9.32
SD	9.60	9.95	4.85	9.60	9.97	4.83
Median	64.64	52.41	8.88	64.47	52.61	8.58
Q1,Q3	57.02, 69.25	45.90, 61.28	6.69, 12.48	56.83, 69.16	46.15, 61.47	6.26, 12.10
Min, Max	28.88, 76.21	23.81, 68.24	−6.23, 26.60	28.57, 76.13	24.02, 68.53	−6.37, 26.19

Max, maximum; Min, minimum; Q1, Quartile 1; Q3, Quartile 3.

Note: Influenza seasons were defined as starting on October 1 of one year and ending on March 31of the following year based on historical influenza activity from the Centers for Disease Control and Prevention. Vaccination status leveraged data through June 30 to allow for sufficient time for vaccination status to be documented by nurses during resident assessments. Standardized estimates were calculated via nonparametric g-formula using a fully saturated linear regression model. Calculations of marginal quantities were completed by using predicted probabilities summed to a weighted average reflecting the age and sex distribution in the overall population. Percentage point differences are calculated as the proportion ofWhite race residents vaccinated minus the proportion of Black race residents vaccinated, such that positive differences indicate the presence of a disparity.

Fig. 2.

(A–D) Standardized disparities in influenza vaccination between non-Hispanic White and Black short-stay (post-acute care) and long-stay (long-term care) NH residents, by state and hospital referral region, 2011–2018 influenza seasons. (B) and (D) include HRR boundaries in black and state boundaries in gray. Alaska, Hawaii, and Puerto Rico are not pictured as none met the minimum number of observations set by the eligibility criteria in any of the analyses. Influenza seasons were defined as starting on October 1 of one year and ending on March 31 of the following year based on historical influenza activity from the Centers for Disease Control and Prevention. Vaccination status leveraged data through June 30 to allow for sufficient time for vaccination status to be documented by nurses during resident assessments. Standardized estimates were calculated via nonparametric g-formula using a fully saturated linear regression model. Calculations of marginal quantities were completed by using predicted probabilities summed to a weighted average reflecting the age and sex distribution in the overall population. Percentage point differences are calculated as the proportion in White race residents vaccinated minus the proportion in Black race residents vaccinated, such that positive differences indicate the presence of a disparity.

HRR Analyses

At the HRR level, the proportion of Black resident-seasons vaccinated against influenza ranged from 24% to 87%, compared with 29% to 90% among White resident-seasons across both short-stay and long-stay populations (Supplementary Figure 3). The median crude disparity in vaccination among short-stay resident-seasons was 8.9 pps and 5.4 pps among long-stay resident-seasons. The median standardized disparity among short-stay resident-seasons was 8.6 pps and 5.0 pps among long-stay resident-seasons (Table 2). HRRs with the largest disparities were concentrated around urban centers in the US Midwest, including HRRs surrounding Chicago, IL (short-stay, 26.2; 95% CI, 25.0–27.4 pps), Gary, IN (long-stay, 20.7; 95% CI, 18.6–22.8 pps), and Detroit, MI (short-stay, 22.6; 95% CI, 21.5–23.7 pps) (Figure 2).

Sensitivity Analyses

Crude national disparities in vaccination were largely consistent and may have increased slightly across influenza seasons for both populations (Supplementary Table 1). The distributions of age, sex, and vaccination status among resident-seasons in excluded geographic units were comparable to those of included units (Supplementary Tables 2 and 3). Disparities estimated by directly standardizing using a standard population represented by only Black NH resident-seasons did not change inferences about which geographic units had the largest disparities in vaccination (Supplementary Table 4). We did find that median standardized disparities across states and HRRs were somewhat smaller compared with national estimates (Supplementary Table 5).

Discussion

In this nationally representative cohort study of NH residents from 2011 to 2018, we used nonparametric g-formula to estimate how racial disparities in influenza vaccination vary across states and HRRs. Our results suggest that, across geographic areas, the magnitude of disparities may range from no disparity in vaccination to disparities in excess of 25 pps. These disparities were most dramatic among short-stay NH residents and HRRs. The largest disparities were typically found in areas with the lowest vaccination among Black NH resident-seasons (Supplementary Figures 2 and 3). These analyses reveal that disparities measured at the state level may mask more dramatic disparities at smaller geographic units. More importantly, a focus at the national and state levels obscures an important opportunity to intervene locally and increase the magnitude of effect that interventions or policies might exert. For example, the standardized difference among short-stay resident-seasons in Texas was 8.0 (95% CI, 7.5–8.4) pps; however, the standardized difference among HRRs in Texas ranged from 2.8 (95% CI, 1.9–3.6) to 11.3 (95% CI, 10.3–12.3) pps (Figure 2).

Our results concord with estimates from national surveillance of NH resident influenza vaccination that reveal a concerning decline in influenza vaccination (approximately 3 pps among NH residents during our study period).³⁹ Despite declines in vaccination for both Black and White NH residents, we also found that disparities persisted at the national level over time, which is similar to prior work.⁴ Future efforts are needed to (1) improve influenza vaccination uptake for all NH residents and (2) reduce racial disparities in influenza vaccination. These findings also coincide with prior research that estimated the geographic distribution of disparities in influenza vaccination between Hispanic and non-Hispanic White NH residents among states and HRRs during the same time period.¹³ Disparities in vaccination between Black and White NH residents were larger in our study and concentrated in different geographic areas. For example, the largest disparity estimated between Hispanic and non-Hispanic White short-stay residents in prior work was 19.2 pps in Florida, compared with the largest disparity of 26.2 pps between Black and White short-stay residents in the HRR associated with Chicago, IL. These differences are likely influenced by the geographic distribution of non-Hispanic Black and Hispanic NH resident populations, as well as differences in how structural racism has influenced knowledge and beliefs on vaccines and other individual-level characteristics between these populations.⁴⁰

Our results can be leveraged by NH staff and administrators as well as state and local public health officials, local boards of health, and policymakers to develop and implement interventions targeted to NHs within states and HRRs with the largest disparities. For example, CMS Quality Improvement Organizations, which partner with local NHs to improve patient safety, have had documented success in increasing influenza vaccination, particularly among minority NH resident populations.⁴¹ Additional research is needed to determine whether interventions associated with increased vaccine uptake, such as educational toolkits for providers such as The Immunization Champions, Advocates, and Mentors Program, centralized influenza vaccination coverage tracking systems, and mobile immunization clinics, can also be used to reduce vaccination disparities.^42–44 The results of this study (and other similar studies) could be directly embedded into educational resources for providers and would likely be most useful for areas with the greatest disparity (ie, for providers to know that NHs in their area have some of the highest disparities).

The magnitude of the disparities we detected also highlights the need for additional research into the complex and multidimensional sources of geographic racial disparities in influenza vaccination. Prior work identified several contributors to racial/ethnic disparities in influenza vaccination in NHs. Yet, some contributors are not sufficiently feasible targets for intervention (eg, NH racial/ethnic composition) and most influenza vaccination disparities are explained by factors that cannot be measured using secondary data.⁵ Qualitative research is necessary into additional factors, such as NH staff and resident knowledge and beliefs on vaccines, and the extent to which they may contribute to these disparities. Medical distrust and differences in reasons given for not receiving an influenza vaccination have been documented among community-dwelling adults, including concerns of vaccine-induced infection and side effects^45,46; however, the reasoning behind NH resident declination of vaccination when offered, which largely contributes to the disparities we detected, have not been fully elucidated. The role of influenza vaccination among NH health care personnel also remains unexplored, yet the reporting of which was recently required for NHs during the 2022–2023 influenza season to the Centers for Disease Control and Prevention’s National Healthcare Safety Network.⁴⁷

Limitations

Several limitations merit discussion. First, by limiting our analyses to geographic units with a minimum number of observations, our results may not generalize to all states or HRRs. However, the results from our sensitivity analyses showed that excluded geographic units were comparable to those of included units. In addition, Black Americans are not equally or randomly distributed across the United States., and our analyses included states and HRRs from which most Black Americans reside.⁴⁸

Second, our analyses were restricted to beneficiaries aged 65 and older and our results may also not be generalizable to younger NH residents with disabilities or those who enroll in Medicare through entitlements other than age.

Third, because we did not have measured data for all nodes in our DAG (eg, no measure of other individual-level characteristics), we were unable to minimize the selection effect potentially operating through obtaining estimates within geographic units or restricting to geographic units with sufficient sample sizes. It is unclear whether the inability to minimize this selection effect disadvantaged the Black population with respect to influenza vaccination.⁴⁹

Finally, we found that national disparities were largely consistent across the seasons included in our study, suggesting future minimal changes are likely to have occurred. Nevertheless, additional studies using data from more recent influenza seasons are needed to assess how influenza vaccination uptake and disparities may have changed in more recent seasons, particularly during the COVID-19 pandemic.

Conclusions and Implications

Our results reveal substantial small-area geographic variation of racial disparities in influenza vaccination among short- and long-stay NH residents across both states and HRRs, demonstrating a rigorous methodological approach to estimating health disparities between racially diverse subpopulations across geographic units. Local interventions and policies targeted to NHs in high-disparity geographic areas may have the largest effects on increasing vaccination. These results can be leveraged by local policymakers and other stakeholders to address localized disparities and meaningfully improve progress toward achieving health equity in vaccination, an important national objective and one that combats the long-standing effects of structural racism.