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Major global and national vaccine allocation guidelines urge planners to allocate vaccines in ways that recognize, and ideally reduce, existing societal inequities within countries. However, allocation plans of the US will be determined individually by each of the CDC’s 64 jurisdictions (states, the District of Columbia, five cities, and territories). We analyzed whether jurisdictions have incorporated novel approaches to reduce inequity, based on plans published by the CDC in early November 2020 (63 summaries [98% of all jurisdictions] and 47 full guidance documents [73% of all, including all 50 states]).

Eighteen states adopted a novel proposal to use a disadvantage index to allocate vaccines more equitably, for five types of equity goals: 1) to prioritize disadvantaged groups directly, 2) to define priority groups in phased systems, 3) to plan tailored outreach and communication, 4) to plan the location of dispensing sites and 5) to monitor uptake. Yet just over a third of all states, and only half of the 16 states with the largest shares of disadvantaged populations—where reducing inequity would be most urgent—pursue such goals.

While allocation frameworks are still evolving, the plans we analyzed mark important historical and practical benchmarks, and could become firm policy when COVID-19 vaccines are authorized and delivered. Vaccine roll-out poses unprecedented logistical and practical challenges. To minimize the risk that ethics and social justice falls by the wayside in the busy months to come, planners at the federal, state and local levels should carefully consider on what grounds they decline to adopt equity measures that other planners deem important and feasible for defining priority populations, designing allocation quotas, and just as critical, enabling, and monitoring, uptake.