Table 3.

Factors Affecting Equitable Vaccine Allocation for NH. This table, adapted from NASEM for the NH context, shows challenges associated with early pandemic COVID-19 vaccine allocation, and how these factors affected equitable vaccine allocation [13].

Features of Early Pandemic Vaccine Allocation	Implications for Equity
Uncertain number and timing of available vaccine doses	● The inability to commit to vaccine allocation in advance likely disproportionately negatively impacted persons who qualified for equity doses, because they often require more time to plan and access vaccine than those who do not (e.g., finding childcare, arranging transportation, planning day off work) ● Messaging that described tentative vaccination availability could undermine already fragile trust in government public health systems among populations requiring equitable distribution, particularly among historically marginalized populations
Uncertain vaccine efficacy, especially for vulnerable populations	● Community partners sometimes expressed preference for the more operationally feasible but less efficacious single-dose Johnson and Johnson / Janssen vaccine, which may have resulted in disproportionate allocation for transient and high-need populations (e.g., migrant, incarcerated, homeless and homebound) ● Differences in feasibility/efficacy required careful balance between public demand and public benefit, including the decision to not direct only one vaccine product based on logistical considerations (e.g., challenges with reaching transient populations for second doses)
Vaccine safety, overall and in different populations	● Communicating incomplete vaccine safety data may have increased vaccine hesitancy, which was initially higher among populations requiring equitable distribution, particularly among historically marginalized populations ● Development of clear messaging regarding safety was delayed for certain populations, particularly those requiring non-English and plain language messaging
Extreme cold chain requirements for the mRNA vaccines	● Some groups requested specific vaccine based on ease of handling and storage capacities. Sites serving lower resource communities were less likely to have the logistical capability to handle all storage and handling requirements, resulting in less vaccine access to the highest need populations ● Unanticipated resources were required to maintain cold chain, including appropriate refrigerators/freezers and dedicated mobile providers
Social, economic, and legal contexts	● Considerable resources were required to balance and communicate differential risk that resulted in the prioritizing of some populations over others ● Equitable allocation practices should incorporate a public input process, including a mechanism for requests for prioritization, and transparency of final decisions and the decision-making process