Atlanta, GA—Providing COVID-19 vaccines apparently has been a very different experience for pharmacists working in urban areas compared with those located in primarily rural locations. The difference is the level of demand.

A report from the CDC points out that, among most United States jurisdictions analyzed, COVID-19 vaccination coverage was lower overall, among all age groups, and among men and women in rural compared with urban counties.

The article in the Morbidity & Mortality Weekly Report notes that data from 49 states and the District of Columbia indicates that, through April 10, 2021, COVID-19 vaccination coverage was lower in rural counties, at about 39%, compared with about 46% in urban counties. 

Vaccination rates among adults aged 18 to 64 years were 29.1% rural versus 37.7% urban; adults aged 65 years and older, 67.6% rural versus 76.1% urban; women, 41.7% rural versus 48.4%; and men 35.3% rural versus 41.9% urban. 

The CDC authors advise that coverage among adults aged 65 years and older was higher than among younger adults in both rural and urban areas, possibly because that group was prioritized early for vaccines.

Vaccination coverage for women was higher than that for men in both urban and rural areas. The report posits that could be because women, in general, are more likely to seek preventive care and that they also are more likely to be working in economic sectors prioritized for early vaccination, such as healthcare and education.

But the authors expressed concern as to how the overall urban-rural vaccination gap would affect the battle to end the pandemic, writing, “Because residents of rural communities are at increased risk for severe COVID-19–associated illness and death, vaccination disparities between urban and rural areas might hinder efforts to reduce morbidity and mortality from COVID-19 nationally.”

Approximately 60 million U.S. residents live in rural counties, representing 19.3% of the population, according to the CDC. In September 2020, the authors add, COVID-19 incidence in rural counties surpassed that in urban counties. Complicating matters is that rural communities often have a higher proportion of residents who lack health insurance, live with comorbidities or disabilities, are age 65 years or older, and have limited access to healthcare facilities with intensive-care capabilities, raising the risk of COVID-19–associated morbidity and mortality.

Accessibility was deemed to be a significant issue, even for the more than 90% of Americans live within 5 miles of a community pharmacy. The researchers evaluated travel outside the county of residence as a marker of potential vaccine access difficulties. Their analysis determined that a higher percentage of persons in the most rural counties traveled to nonadjacent counties for vaccination versus those in the most urban counties.

The authors said that “might be related to challenges with vaccine access and the dearth of pharmacies in some rural areas. In addition, more persons in suburban (i.e., large fringe metropolitan) areas traveled outside their county of residence for vaccination; the reasons for this are unclear.”

Accessibility issues didn’t explain all of the gap, however.

“Vaccine hesitancy in rural areas is a major barrier that public health practitioners, health care providers, and local partners need to address to achieve vaccination equity,” the CDC authors write. “In March 2021, a poll by the Kaiser Family Foundation found that vaccine hesitancy was highest in rural communities, with 21% of rural residents stating that they would 'definitely not' get a vaccine compared with 10% of urban residents.”

That poll showed much higher hesitancy among younger adults, those aged 18 to 64 years, than those aged 60 to 69 years. Among rural respondents, 45% of younger adults responded that they would “definitely not” get a vaccine compared with 8% of the older adults.

Rural residents who reported that they would “definitely not” get a vaccine were more likely to report not having a college degree and earning less than $40,000 per year, according to the Kaiser Family Foundation.

The CDC authors suggest that one way to reach that group might be through established outpatient healthcare system in rural areas.

“Disparities in COVID-19 vaccination between urban and rural communities can hinder progress toward ending the pandemic,” the researchers conclude. “Public health practitioners should continue collaborating with health care providers, pharmacies, community-based organizations, faith leaders, and local employers to address vaccine hesitancy and ensure equitable vaccine access and distribution, particularly in rural areas. These focused, multi-partner efforts can help increase nationwide vaccination coverage and reduce morbidity and mortality from COVID-19.”

“We remain committed to listening and to reaching out to communities in every corner of the United States in our work to narrow these differences and make sure that vaccine coverage is equitable regardless of whether you are live in rural or urban areas,” said CDC Director Rochelle Walensky, MD, at a White House briefing.

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