Racial, Ethnic, and Rural Disparities in U.S. Veteran COVID-19 Vaccine Rates

INTRODUCTION: Race-, ethnicity-, and rurality-related disparities in COVID-19 vaccine uptake have been documented in the U.S. We determined whether these disparities existed among patients at the Department of Veterans Affairs, the largest healthcare system in the U.S. METHODS: Using Department of Veterans Affairs Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least 1 primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race and ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on the 2019 home address at the ZIP code level. Our primary outcome was time to first COVID-19 vaccination between December 15, 2020 and June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or 1 outpatient International Classification of Diseases codes), service connection (any/none, using standardized Department of Veterans Affairs cut offs for disability compensation), and influenza vaccination in 2019–2020 (yes/no). RESULTS: Compared with unvaccinated patients, those vaccinated (n=3,238,532; 55.2%) were older (mean age in years vaccinated=66.3 [SD=14.4] vs unvaccinated=57.7 [18.0], p<0.0001). They were more likely to identify as Black (18.2% vs 16.1%, p<0.0001), Hispanic (7.0% vs 6.6%, p<0.0001), or Asian American Pacific Islander (2.0% vs 1.7%, p<0.0001). In addition, they were more likely to reside in urban settings (68.0% vs 62.8, p<0.0001). Relative to non-Hispanic White urban veterans, the reference group for whom race/ethnicity–urban/rural hazard ratios were reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native groups. Urban Black groups and rural Black groups were 12% (hazard ratio=1.12; 95% CI=1.12, 1.13) and 6% (hazard ratio=1.06; 95% CI=1.05, 1.06) more likely to receive a first vaccination than White urban groups. Urban Hispanic, Asian American Pacific Islander, and mixed groups were more likely to receive vaccination, whereas rural members of these groups were less likely (Hispanic: urban hazard ratio=1.17; 95% CI=1.16, 1.18, rural hazard ratio=0.98; 95% CI=0.97, 0.99; Asian American Pacific Islander: urban hazard ratio=1.22; 95% CI=1.21, 1.23, rural hazard ratio=0.86; 95% CI=0.84, 0.88). Rural White veterans were 21% less likely to receive an initial vaccine than urban White veterans (hazard ratio=0.79; 95% CI=0.78, 0.79). American Indian/Alaskan Native groups were less likely to receive vaccination regardless of rurality: urban hazard ratio=0.93 (95% CI=0.91, 0.95) and rural hazard ratio=0.76 (95% CI=0.74, 0.78). CONCLUSIONS: Urban Black, Hispanic, and Asian American Pacific Islander veterans were more likely than their urban White counterparts to receive a first vaccination; all rural race/ethnicity groups except Black patients had a lower likelihood for vaccination than urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution.