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Abstract

Mass COVID-19 vaccination, as the last resort to bring society to a new normal, has been rapidly rolled out in the US. However, because of the lifting of international travel restrictions, amid the many uncertainties induced by the emerging B.1.1.529 variant, it remains unclear about the timeline of reaching herd immunity and when our daily life will return to normalcy. Since access to a vaccine is an important predicate to the achievement of herd immunity, we articulate the vaccine access issue as the degree of fit between patients and the healthcare system in five dimensions: availability, accessibility, accommodation, affordability, and acceptability. These five dimensions can be adopted in existing health practice and policy to elucidate effective strategies for raising COVID-19 vaccination rates and improving vaccine equity in the fight against the new variant.
Journal Pre-proofs
Commentary
On the rise of the new B.1.1.529 variant: Five dimensions of access to a
COVID-19 vaccine
Xiang Chen, Hui Wang
PII: S0264-410X(21)01596-6
DOI: https://doi.org/10.1016/j.vaccine.2021.11.096
Reference: JVAC 23592
To appear in: Vaccine
Received Date: 25 March 2021
Revised Date: 27 November 2021
Accepted Date: 30 November 2021
Please cite this article as: X. Chen, H. Wang, On the rise of the new B.1.1.529 variant: Five dimensions of access
to a COVID-19 vaccine, Vaccine (2021), doi: https://doi.org/10.1016/j.vaccine.2021.11.096
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On the rise of the new B.1.1.529 variant: Five dimensions of access to a COVID-19 vaccine
Xiang Chen1, 2, Hui Wang3,*
1. Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of
Connecticut, Storrs, CT 06269 USA
2. Department of Geography, University of Connecticut, Storrs, CT 06269 USA
3. Institute for Modeling Collaboration and Innovation, University of Idaho, Moscow, ID 83844
USA
Corresponding author: Dr. Hui Wang, E-mail: huiwang@uidaho.edu Phone: +1 (208)-874-4690
Present address:
Institute for Modeling Collaboration and Innovation, 875 Perimeter Drive, MS-1122, Moscow, Idaho,
USA 83844
Abstract
Mass COVID-19 vaccination, as the last resort to bring society to a new normal, has been rapidly
rolled out in the US. However, because of the lifting of international travel restrictions, amid the many
uncertainties induced by the emerging B.1.1.529 variant, it remains unclear about the timeline of
reaching herd immunity and when our daily life will return to normalcy. Since access to a vaccine is an
important predicate to the achievement of herd immunity, we articulate the vaccine access issue as the
degree of fit between patients and the healthcare system in five dimensions: availability, accessibility,
accommodation, affordability, and acceptability. These five dimensions can be adopted in existing
health practice and policy to elucidate effective strategies for raising COVID-19 vaccination rates and
improving vaccine equity in the fight against the new variant.
Keywords: COVID-19; vaccine; B.1.1.529; vaccine acceptance; health inequity
On the rise of the new B.1.1.529 variant: Five dimensions of access to a COVID-19 vaccine
Abstract
Mass COVID-19 vaccination, as the last resort to bring society to a new normal, has been
rapidly rolled out in the US. However, because of the lifting of international travel restrictions,
amid the many uncertainties induced by the emerging B.1.1.529 variant, it remains unclear about
the timeline of reaching herd immunity and when our daily life will return to normalcy. Since
access to a vaccine is an important predicate to the achievement of herd immunity, we articulate
the vaccine access issue as the degree of fit between patients and the healthcare system in five
dimensions: availability, accessibility, accommodation, affordability, and acceptability. These
five dimensions can be adopted in existing health practice and policy to elucidate effective
strategies for raising COVID-19 vaccination rates and improving vaccine equity in the fight
against the new variant.
Keywords: COVID-19; vaccine; B.1.1.529; vaccine acceptance; health inequity
1. Introduction
The rapid rise and diffusion of the coronavirus disease 2019 (COVID-19) have prompted
unprecedented global health adversities, economic downturns, and massive societal impacts. In
the US, with infection cases nearing 50 million and deaths surpassing 770 thousand as of
November 2021 [1], simply containing the virus spread through social distancing is of little avail
in ending the pandemic. Vaccination, as the last resort to bring society to a new normal, has been
rapidly implemented in the US over the past year. Guided by the Centers for Disease Control and
Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP), vaccinations were
implemented in multiple phases, with the initial phases prioritizing healthcare personnel, long-
term care facility residents, and elderly with medical conditions [2]. Subsequent phases saw
vaccines offered to other age groups in reverse chronological order. As of late November 2021,
more than 196 million or 59.1% of people received full vaccination, including Johnson &
Johnson’s single-dose vaccine or Pfizer-BioNTech and Moderna’s two-dose series [1].
The vaccination effort has been approved to be effective as new cases started to dwindle.
However, the emerging B.1.1.529 variant, firstly reported from South Africa on November 24,
2021 [3], posed new challenges to ending the pandemic. The B.1.1.529 variant manifests heavy
mutations found in existing variants and can even evade the immunity gained from vaccines [3].
Because of the new variant, amid the lifting of travel restrictions for fully vaccinated foreign
travelers in early November 2021 [4], there is a likelihood of seeing a new wave in the months to
come. While the pathway to herd immunity rests on effective vaccines, the actual disease
landscape that vaccination shapes is predicated on how readily accessible and culturally
acceptable vaccines are to those yet to be vaccinated. This issue can be further articulated by
examining the different dimensions of access to a vaccine.
While “access” is an important concern in evaluating the effectiveness of health policy
and services, it is often loosely defined and used interchangeably with other terms, such as
accessibility and availability. Penchansky and Thomas [6], by defining access as the degree of fit
between patients and the healthcare system, further specify it in five dimensions: availability,
accessibility, accommodation, affordability, and acceptability. These five dimensions can be
adopted in existing health practice and research agenda to elucidate effective strategies for
vaccine distribution and promotion in fighting the emerging variant.
2. Five dimensions of vaccine access
Availability is defined as the volume and type of healthcare services in meeting patients’
demands. At the early vaccination phase, because of the relative shortage of vaccine production,
amid the hurdles of fulfilling Pfizer-BioNTech and Moderna’s two-dose requirements, there has
been a debate about the vaccination schedule in the US. Although ACIP has proposed the general
guidelines, every state has its own plan in terms of priority groups and timelines. The lack of
consistency and sudden change of criteria over different phases could obfuscate the public’s
perception of eligibility [7]. Also, vaccination priorities based on age, occupation, and health
conditions overlooked racial inequities. Specifically, racial minorities, especially African
Americans and Latinos, were comparatively victimized in the pandemic in terms of the highest
case rates [8]. However, these two populations had considerably lower vaccination rates [9].
With increased vaccine production and continuing vaccination efforts, vaccine availability has
become a minor issue. However, in future vaccination efforts, such as the implementation of the
booster shot and a new vaccine against the variant, it is advisable to refer to a comprehensive
social metric, such as the Social Vulnerability Index [11], to aid communities at the highest risk
of spreading the disease.
Accessibility, defined as the physical access to healthcare services, depends on the
geographical distribution of healthcare facilities, patients’ residential locations, and their
transportation resources (e.g., car ownership, access to public transit). Healthcare accessibility
has been long evaluated using various spatial measures, including the density of services,
proximity to healthcare centers, and more complex spatial interaction models [12]. While
vaccination practice is underway, a promising research agenda is to explore the spatial
complementarity between vaccine supply and demand from a geographical perspective, such as
evaluating if the distribution of vaccination clinics and allocations of doses can accommodate the
unequal disease landscape and if vaccination gaps exist in certain high-risk communities (e.g.,
neighborhoods of color). This identification can rely on classical accessibility models, such as
the two-step floating catchment area (2SFCA) method [12]. Understanding this spatial
complementarity helps to identify regional pockets where vaccination coverage is devoid.
Beyond the measure of physical access, another area of equal importance is to elucidate the
perceived accessibility of unvaccinated individuals, as the difficulty in reaching a clinic may not
be a result of spatial separation but could be a lack of transport resources and knowledge to
schedule or fulfill an appointment. Supporting evidence can be found in a recent study, which
showed that the vaccination rates in the elderly were significantly correlated with education
attainment [9]. Thus, improving vaccine accessibility for socioeconomically disadvantaged
populations in terms of onsite scheduling and at-home vaccination services will be a promising
approach to improving vaccine accessibility.
Accommodation can be defined as the organization of healthcare services in fulfilling
patients’ needs. A drastic shift in healthcare accommodation during the pandemic manifests in
the rise of telehealth services (through videoconferences, emails, text messages, and wearable
devices). Due to the compliance with social distancing, telehealth services have been rapidly
approved and adopted for screening, triaging, and consultation. Evidence-based research shows
that telehealth services help to decrease the chance of virus transmission for both clinicians and
patients and play an indispensable role in psychiatric treatment and providing social support [14].
The digital transformation comes with the concern of possibly violating patients’ privacy in
virtual care, an area currently uncovered by either the Health Insurance Portability and
Accounting Act (HIPAA) or the Food and Drug Administration (FDA) [15]. Another issue
arising from the new care form is the existence of the digital divide, referred to as the inequity of
access to technology between different social groups. The digital divide has further catalyzed
health inequity, as those most vulnerable to the epidemic exposure (e.g., the elderly, immigrants,
and populations of color) experience considerable challenges in utilizing technology. Similar to
COVID-19 testing, telehealth has been ubiquitously adopted for vaccination registration and
relevant medical intervention. How to leverage telehealth to improve vaccination
accommodation while bridging the digital divide, such as retaining field support for physically or
technologically disadvantaged patients, needs urgent assessments and practices.
Affordability is the pricing of healthcare services in relation to patients’ ability to pay. In
the US, the financing mechanism of a vaccine can be divided into two pathways—conventional
vaccines (e.g., influenza, and hepatitis) are supported by federal and state healthcare programs
(e.g., Medicare, the Affordable Care Act (ACA), and the Section 317 Immunization Program),
while non-conventional vaccines for countering abrupt public health crises are purchased by the
federal government and provided to care providers at no cost [16]. The payment model for
COVID-19 vaccines undoubtedly follows the second financial pathway with the federal
government fully reimbursing providers, even for uninsured patients (which will be covered by
the Health Resources and Services Administration’s Provider Relief Fund) [17]. Because of the
pervasive support, it is unlikely that affordability will become an issue for COVID-19 vaccinees.
Acceptability refers to patients’ attitudes towards healthcare services and providers.
Research on individuals’ perception of COVID-19 vaccines shows that vaccine acceptability is
largely dictated by the trust in vaccine efficacy and safety and is moderated by the severity of
outbreaks in individuals’ residential neighborhoods [18]. As the pandemic continued to evolve,
there have been many transitions in vaccine acceptance—a biweekly longitudinal survey on over
8,000 adults in the US showed that the percentage of respondents willing to get a COVID-19
vaccine significantly declined in early December 2020 (56%) compared to the early outbreak
(74%) [19]. Another study in early January 2021 reported that 20% of adults in the US had a
strong reluctance to receive a vaccine [20]. There was also a significantly lower acceptance
within certain groups, including African Americans and individuals with low education
attainment [18, 19, 21], and these populations were found to have higher infection and mortality
rates [8]. This lack of vaccine confidence was palpably a trust issue, and was historically rooted
in marginalized populations experiencing medical exploitation and education deprivation. To this
end, Volpp et al. [21] propose behaviorally informed strategies where such trust can be rebuilt,
including increasing the physical access to and the visibility of vaccination, making vaccination
conditional and less compulsory in non-essential settings, increasing vaccine publicity with the
voice of trusted opinion leaders, prioritizing vaccine access to people with early sign-up,
promoting vaccination as a public act. At the forefront of these strategies is the assurance of
integrity in the vaccine efficacy and the approval process. While the COVID-19 booster shot is
quickly rolling out, a concurrent need exists in building a national promotion program to induce
behavioral changes among populations with vaccine resistance.
3. Conclusions
These five dimensions of vaccine access are subject to various degrees of uncertainty.
Specifically, it is not difficult to estimate availability, as current vaccine development and
production have projected timelines. Accessibility, accommodation, and affordability, as
relatively objective measures, could be illuminated by health policy legislation and targeted
medical funding. However, acceptability, as a subjective, perceptual dimension, is dictated by
individuals’ risk perceptions and health education, and could be moderated by political ideology
[22]. Increasing the vaccination acceptability in high-risk regions and among those showing
strong resistance is worthy of policy intervention.
It should be noted that although the five dimensions of access are articulated in a US
context, they can be substantiated in a different country given the local disease progression,
vaccination policy, and available medical resources. While there are still many uncertainties
about the vaccine effectiveness towards the new B.1.1.529 variant, the five dimensions of
vaccine access must be evaluated and substantiated in synchrony with new vaccine development.
These combined efforts can help to elucidate potential obstacles in vaccine distribution, reduce
health inequity, and pave the pathway to a new normal.
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Highlights
Vaccine access is the degree of fit between patients and the healthcare system.
Access to a COVID-19 vaccine is articulated in five dimensions.
Increasing vaccination acceptance is worthy of policy intervention.
Funding Source
This research was supported by pilot grant funding from the Institute for Collaboration on
Health, Intervention, and Policy (InCHIP) at the University of Connecticut.
Authors’ Contributions
XC contributed towards conceptualization of the study and writing the manuscript. HW critically
revised the manuscript for important intellectual content. Both authors have read and agreed to
the published version of the manuscript.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal
relationships that could have appeared to influence the work reported in this paper.
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The recent decade has witnessed a new wave of development in the place-based accessibility theory, revolving around the two-step floating catchment area (2SFCA) method. The 2SFCA method, initially serving to evaluate the spatial inequity of health care services, has been further applied to other urban planning and facility access issues. Among these applications, different distance decay functions have been incorporated in the thread of model development, but their applicability and limitations have not been thoroughly examined. To this end, the paper has employed a place-based accessibility framework to compare the performance of twenty-four 2SFCA models in a comprehensive manner. Two important conclusions are drawn from this analysis: on a small analysis scale (e.g., community level), the catchment size is the most critical model component; on a large analysis scale (e.g., statewide), the distance decay function is of elevated importance. In sum, this comparative analysis provides the theoretical support necessary to the choice of the catchment size and the distance decay function in the 2SFCA method. Justification of model parameters through empirical evidence (e.g., field surveys about local travel activities) and model validation through sensitivity analysis are needed in future 2SFCA applications for various urban planning, service delivery, and spatial equity scenarios.
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Background Coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020. Several prophylactic vaccines against COVID-19 are currently in development, yet little is known about people’s acceptability of a COVID-19 vaccine. Methods We conducted an online survey of adults ages 18 and older in the United States (n=2,006) in May 2020. Multivariable relative risk regression identified correlates of participants’ willingness to get a COVID-19 vaccine (i.e., vaccine acceptability). Results Overall, 69% of participants were willing to get a COVID-19 vaccine. Participants were more likely to be willing to get vaccinated if they thought their healthcare provider would recommend vaccination (RR=1.73, 95% CI: 1.49–2.02) or if they were moderate (RR=1.09, 95% CI: 1.02–1.16) or liberal (RR=1.14, 95% CI: 1.07–1.22) in their political leaning. Participants were also more likely to be willing to get vaccinated if they reported higher levels of perceived likelihood getting a COVID-19 infection in the future (RR=1.05, 95% CI: 1.01–1.09), perceived severity of COVID-19 infection (RR=1.08, 95% CI: 1.04–1.11), or perceived effectiveness of a COVID-19 vaccine (RR=1.46, 95% CI: 1.40–1.52). Participants were less likely to be willing to get vaccinated if they were non-Latinx black (RR=0.81, 95% CI: 0.74–0.90) or reported a higher level of perceived potential vaccine harms (RR=0.95, 95% CI: 0.92–0.98). Conclusions Many adults are willing to get a COVID-19 vaccine, though acceptability should be monitored as vaccine development continues. Our findings can help guide future efforts to increase COVID-19 vaccine acceptability (and uptake if a vaccine becomes available).