GAO-22-105079, COVID-19: Federal Efforts to Provide Vaccines to Racial and Ethnic Groups

Report — GAO-22-105079, COVID-19: Federal Efforts to Provide Vaccines to Racial and Ethnic Groups, dated 2021-09-04, issued by Government Accountability Office.

Full text

COVID-19
Federal Efforts to
Provide Vaccines to
Racial and Ethnic
Groups

Report to Congressional Committees
February 2022

GAO-22-105079

United States Government Accountability Office

 United States Government Accountability Office
Highlights of GAO-22-105079, a report to
congressional committees
February 2022
COVID-19
Federal Efforts to Provide Vaccines to Racial and
Ethnic Groups
What GAO Found
In February 2021, the Centers for Disease Control and Prevention (CDC), the
Health Resources and Services Administration (HRSA), and the Federal
Emergency Management Agency (FEMA) each launched COVID-19 vaccine
programs to supplement state and jurisdictional vaccination efforts. Through
these three programs, the agencies took steps to provide COVID-19 vaccines to
underserved and historically marginalized racial and ethnic groups, such as by
using population data on race and ethnicity when selecting vaccination sites.
CDC, HRSA, and FEMA data—although limited in completeness—suggest that
the agencies’ COVID-19 vaccine programs vaccinated varying shares of racial
and ethnic groups. GAO’s analysis of data from CDC’s retail pharmacy program,
the largest of the programs, suggests that, among those with identified race and
ethnicity, 43 percent of people vaccinated through the program were from racial
and ethnic groups other than non-Hispanic White, as of September 4, 2021. (See
figure.)
Percentage of People Vaccinated against COVID-19 through CDC’s Retail Pharmacy Program
by Race and Ethnicity, as of September 4, 2021
CDC exceeded its goal to administer at least 40 percent—the approximate
percent of the U.S. population comprised of racial and ethnic groups other than
non-Hispanic White—of COVID-19 vaccines through its retail pharmacy program
to persons from these groups. However, comparisons between program
vaccination data and U.S. population percentages suggest that some racial and
ethnic groups, such as non-Hispanic Black persons, represented a smaller share
of persons vaccinated through each of the three federal vaccine programs
relative to their population size. For example, non-Hispanic Black persons make
up roughly 12 percent of the U.S. population, but account for about 9 percent of
persons vaccinated through CDC’s retail pharmacy program with identified race
and ethnicity, as of September 4, 2021. These findings should be interpreted with
caution due to the rate of missing race and ethnicity program data, which may
account for some, or even all, of the differences in comparisons.
View GAO-22-105079. For more information,
contact Alyssa M. Hundrup at (202) 512-7114
or HundrupA@gao.gov.
Why GAO Did This Study
COVID-19 continues to have
devastating effects on public health,
serious economic repercussions, and
has disproportionately affected some
racial and ethnic groups. Ensuring all
racial and ethnic groups have fair
access to the COVID-19 vaccine is
critical to reducing severe COVID-19
health outcomes and saving lives.
The CARES Act includes a provision
for GAO to report on its ongoing
oversight efforts related to the COVID-
19 pandemic. This report describes,
among other things, the actions CDC,
HRSA, and FEMA have taken through
their programs to provide COVID-19
vaccines to underserved and
historically marginalized racial and
ethnic groups, and the extent to which
these programs vaccinated various
racial and ethnic groups.
GAO analyzed CDC, HRSA, and
FEMA vaccine administration data
through September 2021; interviewed
agency officials and reviewed agency
documentation on COVID-19 vaccine
programs and published literature on
vaccine administration; interviewed
health officials from four selected
states and representatives from six
selected stakeholder groups based on
several criteria, such as states’ racial
and ethnic population distributions; and
compared the agencies’ vaccine
administration data to 2020 U.S.
Census Bureau population counts.
GAO provided a draft of this report to
the Department of Health and Human
Services (HHS), including CDC and
HRSA, and FEMA. HHS and FEMA
provided technical comments, which
GAO incorporated as appropriate.

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GAO-22-105079  COVID-19
Letter

1
Background
6
Actions CDC, HRSA, and FEMA Took to Provide COVID-19
Vaccines to Underserved and Historically Marginalized Racial
and Ethnic Groups
13
CDC, HRSA, and FEMA Program Vaccination Among Various
Racial and Ethnic Groups, and Comparison to Shares of
Population
23
CDC, HRSA, and FEMA Collected and Monitored Data to Inform
Program Efforts to Vaccinate Racial and Ethnic Groups
29
Agency Comments
31
Appendix I
Scope and Methodology
35

Appendix II
Coronavirus Disease 2019 Indicators by Race and Ethnicity
37

Appendix III
Additional Efforts That HHS and FEMA Have Taken to Provide
COVID-19 Vaccines to Underserved and Historically Marginalized
Racial and Ethnic Groups
41

Appendix IV
GAO Contact and Staff Acknowledgments
49

Table
Table 1: Race and Ethnicity Data Completeness for Indicators of
COVID-19 Burden, as Reported by GAO
37

Figures
Figure 1: Selected CDC, HRSA, and FEMA COVID-19 Vaccine
Programs
7
Figure 2: Percentage of People Fully Vaccinated Against COVID-
19 by Race and Ethnicity, Compared to Share of U.S.
Population, as of January 9, 2022
10
Figure 3: Factors That Could Affect COVID-19 Vaccination Rates
for Various Racial and Ethnic Groups
12
Contents

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GAO-22-105079  COVID-19
Figure 4: Example of Spanish Language Interpreter Assisting at a
FEMA Vaccination Center Pilot Program Site
18
Figure 5: Example of Pop-up Retail Pharmacy Vaccination Event
20
Figure 6: HRSA-Funded Health Center Staff Administer Vaccines
at a Church
21
Figure 7: Example of FEMA Vaccination Center Pilot Program
Mobile Site
22
Figure 8: Percentage of People Fully Vaccinated against COVID-
19 through CDC’s Retail Pharmacy Program by Race
and Ethnicity, Compared to Share of U.S. Population, as
of September 4, 2021
24
Figure 9: Percentage of People Fully Vaccinated against COVID-
19 through HRSA’s Health Center Vaccine Program by
Race and Ethnicity Reported through Survey Data,
Compared to Share of U.S. Population, as of August 27,
2021
26
Figure 10: Percentage of COVID-19 Vaccine Doses Administered
through FEMA’s Vaccination Center Pilot Program by
Race and Ethnicity, Compared to Share of County
Population, as of June 20, 2021
28
Figure 11: Example of a CDC Communication Toolkit Poster
about COVID-19 Vaccines
44

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GAO-22-105079  COVID-19

Abbreviations

CDC

Centers for Disease Control and

Prevention
COVID-19

Coronavirus Disease 2019
FEMA

Federal Emergency Management

Agency
health center vaccine program
Health Center COVID-19 Vaccine

Program
HHS

Department of Health and Human

Services
HRSA

Health Resources and Services

Administration
retail pharmacy program

Federal Retail Pharmacy Program

for COVID-19 Vaccination
SVI

Social Vulnerability Index
vaccination center pilot program
Community Vaccination Center Pilot

Site and Mobile Vaccination

Program

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GAO-22-105079  COVID-19
441 G St. N.W.
Washington, DC 20548
February 7, 2022
Congressional Committees
Coronavirus Disease 2019 (COVID-19) continues to have devastating
effects on public health and serious economic repercussions. Such
effects have been uneven, disproportionately affecting certain racial and
ethnic groups, highlighting health disparities—preventable differences in
the burden of disease—in the United States.1 Data from the Centers for
Disease Control and Prevention (CDC) suggest that some racial and
ethnic groups have experienced worse health outcomes related to
COVID-19.2 For example, between March 2020 and January 2022,
available CDC data indicated that Hispanic or Latino persons and non-
Hispanic Black persons were hospitalized due to COVID-19 at a rate 2.4
and 2.5 times more than non-Hispanic White persons, respectively, after
adjusting for age.3
Available data on persons vaccinated against COVID-19 also suggest
some racial and ethnic disparities in vaccination rates. Nationwide, about
67 percent of the U.S population eligible for vaccination (those 5 years
and older)—about 208 million individuals—had been fully vaccinated as

1According to CDC, health disparities are preventable differences in the burden of
disease, injury, violence, or in opportunities to achieve optimal health experienced by
socially disadvantaged racial, ethnic, and other population groups and communities. We
previously reported on racial and ethnic health disparities, including for COVID-19. See
GAO, Health Care Capsule: Racial and Ethnic Health Disparities, GAO-21-105354
(Washington, D.C.: September 23, 2021).
2For more information, see GAO, COVID-19: Federal Efforts Could Be Strengthened by
Timely and Concerted Actions, GAO-20-701 (Washington, D.C.: September 21, 2020) and
COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second Year,
GAO-21-387 (Washington, D.C.: March 31, 2021). Research studies have also shown that
some racial and ethnic groups have experienced worse health outcomes related to
COVID-19. For example, see M. L. Wang, et al., “Addressing Inequities in COVID-19
Morbidity and Mortality: Research and Policy Recommendations,” Translational
Behavioral Medicine (2020) and Selden T. M. and Berdahl T. A., “COVID-19 and
Racial/Ethnic Disparities in Health Risk, Employment, and Household Composition,”
Health Affairs vol. 39, no. 9 (2020).
3CDC data on COVID-19 hospitalizations are from select counties in 14 states,
representing 10 percent of the U.S. population. It includes data from hospitals in select
counties in California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan,
Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah.
Letter

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GAO-22-105079  COVID-19
of January 9, 2022, according to CDC.4 However, vaccination rates vary,
including for certain racial and ethnic groups. For example, although 22.9
percent of data made available by CDC on fully vaccinated persons were
missing race and ethnicity information, CDC data show that across the
total U.S. population, 46 percent of non-Hispanic White persons were fully
vaccinated against COVID-19, compared with 38 percent of non-Hispanic
Black persons as of January 9, 2022.5
Given the identified disparities and the importance of COVID-19 vaccines
in preventing more severe outcomes such as hospitalizations and deaths,
ensuring vaccine equity—when all people have fair access to COVID-19
vaccinations—is critical to saving lives and reducing severe COVID-19
health outcomes for all Americans. Additionally, ensuring vaccine equity
continues to be critical as variants emerge, children become eligible for
COVID-19 vaccines, and those already vaccinated may need booster
shots to sustain sufficient immunity against the virus.6
The January 2021 National Strategy for the COVID-19 Response and
Pandemic Preparedness and related executive orders call for the federal
government to help ensure equity in the response to COVID-19.7 To help
ensure vaccine equity, in February 2021, the CDC, the Health Resources
and Services Administration (HRSA), and the Federal Emergency
Management Agency (FEMA) each established a program in part to

4Data are from CDC’s COVID Data Tracker, https://covid.cdc.gov/covid-data-
tracker/#vaccinations_vacc-total-admin-rate-total, accessed January 10, 2022. For the
purposes of this report, fully vaccinated persons are persons who received two doses on
different days (regardless of time interval) of the two-dose mRNA series (Pfizer or
Moderna) or received one dose of a single-dose vaccine (Johnson & Johnson).
5As of January 9, 2022, 22.9 percent of data made available by CDC on fully vaccinated
persons were missing race and ethnicity information, so there may be limitations with any
conclusions that can be drawn with available CDC data. CDC does not make available
data on the proportion of eligible persons (which was expanded to include persons aged 5
years and older as of October 29, 2021) who have been vaccinated in each racial and
ethnic group.
6As of January 2022, the U.S. Food and Drug Administration had authorized the
emergency use of the Pfizer-BioNTech COVID-19 vaccine for the prevention of COVID-19
in individuals aged 5 and older. According to CDC, a booster dose is a dose of vaccine
administered when the initial sufficient immune response to a primary vaccine series is
likely to have waned over time.
7The White House, National Strategy for the COVID-19 Response and Pandemic
Preparedness (Jan. 21, 2021). See also Exec. Order No. 13994, 86 Fed. Reg. 7,189 (Jan.
21, 2021) and Exec. Order No. 13995, 86 Fed. Reg. 7,193 (Jan. 21, 2021).

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GAO-22-105079  COVID-19
provide COVID-19 vaccines to underserved and historically marginalized
racial and ethnic groups, among other groups. These federal programs
are in addition to the vaccines the federal government made available to
the 50 states and other jurisdictions to further distribute to health care
providers in their jurisdictions.
The CARES Act includes a provision for us to monitor and oversee the
authorities and funding provided to address the COVID-19 pandemic and
the effect of the pandemic on the health, economy, and public and private
institutions of the United States.8 This report, which is part of our body of
work related to the CARES Act, describes:
1. actions CDC, HRSA, and FEMA have taken through their COVID-19
vaccine programs to provide vaccines to underserved and historically
marginalized racial and ethnic groups;
2. the extent to which CDC, HRSA, and FEMA’s programs have
vaccinated various racial and ethnic groups; and
3. monitoring by CDC, HRSA, and FEMA on the extent to which their
programs have vaccinated underserved and historically marginalized
racial and ethnic groups.
To conduct this work, we focused our review on three of the agencies’
COVID-19 vaccine programs:

CDC’s Federal Retail Pharmacy Program for COVID-19 Vaccination
(retail pharmacy program),

HRSA’s Health Center COVID-19 Vaccine Program (health center
vaccine program),9 and

8Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). We have regularly issued
government-wide reports on the federal response to COVID-19. For the latest report, see
GAO, COVID-19: Significant Improvements Are Needed for Overseeing Relief Funds and
Leading Responses to Public Health Emergencies, GAO-22-105291 (Washington, D.C.:
January 27, 2022). Our next government-wide report will be issued in April 2022 and will
be available on GAO’s website at https://www.gao.gov/coronavirus. This report also
responds, in part, to a request from the Chairman of the House Committee on Homeland
Security, which included a specific question for GAO related to FEMA’s and HHS’s
COVID-19 response for racial and ethnic groups.
9CDC coordinated with HRSA on the health center vaccine program, but for the purposes
of this report, we refer to this program as a HRSA-operated vaccine program since HRSA
was the primary agency responsible for implementing the program.

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GAO-22-105079  COVID-19

FEMA’s Community Vaccination Center Pilot Site and Mobile
Vaccination Program (vaccination center pilot program).10
To describe the actions CDC, HRSA, and FEMA have taken to provide
COVID-19 vaccines to underserved and historically marginalized racial
and ethnic groups as well as efforts by the agencies to monitor program
vaccination rates by race and ethnicity, we reviewed CDC, HRSA, and
FEMA guidance and documents, such as monitoring reports and surveys
used to collect information on the administration of COVID-19 vaccine
doses. We interviewed or received written responses from CDC, HRSA,
and FEMA officials about their COVID-19 vaccine programs’ efforts to
vaccinate various racial and ethnic groups, how they monitored race and
ethnicity data, and how, if at all, they used these data to inform program
efforts. We also interviewed health officials from four selected states and
representatives from six selected stakeholder groups. We selected these
states and groups based on several criteria, such as states’ racial and
ethnic population distributions and groups involved in COVID-19 vaccine
administration or representation of a racial or ethnic group. Lastly, we
reviewed selected literature published between 2007 and 2021 to
summarize examples of factors that have been identified as potentially
affecting COVID-19 vaccine administration for various racial and ethnic
groups and actions that could advance equity in vaccine administration.
To determine the extent to which CDC, HRSA, and FEMA’s COVID-19
vaccine programs have vaccinated various racial and ethnic groups, we
obtained and analyzed aggregated data on vaccines administered
through each program by race and ethnicity beginning in February 2021.
For context, we compared each agency’s vaccine administration data to
population data from the U.S. Census Bureau. Specifically, for CDC and
HRSA, we analyzed data on the number of persons fully vaccinated
through the agencies’ vaccine administration programs, by race and
ethnicity, along with data on the share of the general U.S. population the
racial and ethnic groups represent. For FEMA, we analyzed data on
vaccine doses administered through the agency’s vaccine administration
program by race and ethnicity, along with data on the size of these racial

10CDC coordinated with FEMA on the vaccination center pilot program, but for the
purposes of this report, we refer to this program as a FEMA-operated vaccine program
since FEMA was the primary agency responsible for implementing the program.

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and ethnic groups across the 39 counties with FEMA pilot sites.11 We
compared FEMA vaccination data to population data only from the
counties with FEMA pilot sites because, relative to the CDC and HRSA
data, there were fewer FEMA pilot sites, and these sites were located in
areas with population demographics that were less similar to the
aggregate U.S. population. We analyzed FEMA vaccination data
cumulatively by race and ethnicity from the beginning of program
administration through June 20, 2021, when FEMA’s program ended.
Additionally, we analyzed the FEMA vaccination data cumulatively by
race and ethnicity and by FEMA site type: hubs (large stationary
vaccination sites) and spokes (smaller sites that also include mobile
vaccination units). The population data we used reflect the population of
all ages.12 As of the date of our analysis of program data, only persons
aged 12 and older were eligible for vaccination.13
To assess the reliability of the CDC, HRSA and FEMA data sources, we
interviewed agency officials and reviewed related agency documentation.
We also checked the data for obvious errors, and took steps to ensure
consistency in race and ethnicity categories across data sources. Race
and ethnicity information were missing for 22.9 percent of CDC’s national
data on people vaccinated, 26.1 percent of CDC’s retail pharmacy
vaccine program data, 13.6 percent of HRSA’s health center vaccine
program data, and 18.6 percent of FEMA’s vaccination center pilot
program data. According to CDC, some groups may have a higher

11Data represent vaccine doses administered, and may reflect one dose of a two-dose
COVID-19 vaccine series or one dose of the single-shot Johnson & Johnson COVID-19
vaccine. FEMA stated the agency collects data on vaccine doses administered rather than
persons vaccinated in an effort to leave out personally identifiable information.
Comparisons between the distribution of FEMA administered vaccine doses and the
population by race and ethnicity should be interpreted with caution as there could be
variation in the extent to which racial and ethnic groups received a two-dose or one-dose
vaccine.
12The U.S. Census Bureau does not provide population estimates by race and ethnicity for
the specific population subgroup aged 12 and older in the 2020 Decennial Census data
files. Since there may be differences in the distribution of age groups across various racial
and ethnic groups (i.e., some groups may have larger numbers of children under 12, who
at the time of analysis were not eligible for COVID-19 vaccines), we conducted additional
analyses to assess the extent to which the lack of data on subgroups age 12 or older
affected our analysis of program data. We compared program data to the total population
(of all ages) and to the population 18 and over, based on data availability, and found that
there were no differences in our overall findings.
13The U.S. Food and Drug Administration expanded the emergency use authorization for
the Pfizer-BioNTech COVID-19 vaccine to include adolescents 12 through 15 years of age
on May 10, 2021, and on October 29, 2021, it expanded the emergency use authorization
for the Pfizer-BioNTech COVID-19 vaccine to include children 5 through 11 years of age.

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likelihood of having missing race and ethnicity data, and the percentage
of unknown race and ethnicity data may account for some, or even all, of
the differences between shares of vaccinations and of the population by
race and ethnicity. Therefore, results of our analyses should be
interpreted with caution. To assess the reliability of Census Bureau
population data, we reviewed documentation related to the relevant data
sources and reviewed the data elements for obvious errors,
inconsistencies, or missing data. On the basis of these steps, we
determined that the data with known race and ethnicity and population
data were sufficiently reliable for the purposes of our reporting objectives.
See appendix I for more information on our scope and methodology.
We conducted this performance audit from March 2021 to February 2022
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
When COVID-19 vaccination began in December 2020, the federal
government provided the majority of available vaccine doses to the 50
states and other jurisdictions to distribute to health care providers located
in their jurisdictions.14 In February 2021, CDC, HRSA, and FEMA initiated
specific programs to supplement states’ and jurisdictions’ vaccination
efforts, in part, to focus on vaccinating higher-risk populations who might
experience worse health outcomes associated with COVID-19, according
to federal officials. CDC’s retail pharmacy program goal was to expand
access to vaccines for people living in socially vulnerable areas; HRSA’s
health center vaccine program goal was to help ensure underserved
communities and those disproportionately affected by COVID-19 are
equitably vaccinated; and FEMA’s vaccination center pilot program goal
was to promote equitable access to COVID-19 vaccines to underserved
and historically marginalized groups. In our prior work we found that as of

14A total of 62 jurisdictions—including all 50 states, the District of Columbia, three major
cities (Chicago, New York City, and Philadelphia), and eight territories (American Samoa,
Guam, the Marshall Islands, the Federated States of Micronesia, the Northern Mariana
Islands, Palau, Puerto Rico, and the U.S. Virgin Islands)—received weekly allocations of
COVID-19 vaccine doses. Although there are 64 jurisdictions implementing COVID-19
vaccination and receiving federal funding for these efforts, allocations of vaccine doses
were made to 62 jurisdictions because two major cities considered jurisdictions—Houston
and San Antonio—had their allocations consolidated with Texas.
Background

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August 2021, the majority of vaccine doses were being distributed
nationwide through CDC’s retail pharmacy program.15 See figure 1.
Figure 1: Selected CDC, HRSA, and FEMA COVID-19 Vaccine Programs

15For more information, see GAO, COVID-19 HHS Agencies’ Planned Reviews of Vaccine
Distribution and Communication Efforts Should Include Stakeholder Perspectives,
GAO-22-104457 (Washington, D.C.: November 4, 2021). For example, between April and
July 2021, the proportion of vaccine doses distributed through states and other
jurisdictions decreased from 62 percent in early April 2021, to 6 percent in mid-July 2021.
During that same time, the proportion of vaccine doses distributed through CDC’s retail
pharmacy program increased from 29 percent to 92 percent, according to our analysis.

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Notes: In December 2020, the federal government also initiated CDC’s Pharmacy Partnership for
Long-Term Care Program. Under this program, CDC worked with selected pharmacy partners to
vaccinate residents and staff at participating nursing homes and other long-term care facilities. CDC
coordinated with HRSA on the health center program and with FEMA on the vaccination center pilot
program, but for the purposes of this report, we refer to these programs as HRSA- and FEMA-
operated vaccine distribution programs since these agencies were the primary agencies responsible
for implementing these programs. The federal government allocated and distributed vaccine doses to
five federal entities (the Bureau of Prisons, Department of Defense, Department of State, Indian
Health Service, and the Veterans Health Administration). The federal government also allocated
vaccine doses to the Department of Health and Human Services/National Institutes of Health for a
small program managing doses allocated to federal departments and agencies for administration to
critical infrastructure personnel and made a one-time allocation of vaccine doses to the Federal
Dialysis Center Program to distribute to participating dialysis centers to administer vaccines to
patients and health care personnel.
aAccording to CDC, social vulnerability refers to the potential negative effects on communities caused
by external stresses on human health, such as natural or human-caused disasters or disease
outbreaks.
bFederally supported health centers generally receive Health Center Program grants from HRSA
under section 330 of the Public Health Service Act (42 U.S.C § 254b) and provide primary care
services in medically underserved areas. Some health centers meet all program requirements but do
not receive federal grant funding through the section 330 program. However, these centers, which are
known as “look-alikes,” receive other benefits, such as higher reimbursement rates from the Medicare
and Medicaid programs and may receive grants through other federal programs. The term “federally
supported health centers” in this report refers to both “look-alikes” and those health centers that
receive grants under section 330 of the Public Health Service Act.
cAlthough FEMA’s vaccination center pilot program ended June 20, 2021, the agency continued to
support community vaccination centers managed and operated by states and other jurisdictions
(using doses allocated to states and jurisdictions) by providing federal personnel, funding, and
material, such as medical equipment and supplies, according to agency officials.

As the nation’s health protection agency, CDC collects and makes
national data available on COVID-19 vaccinations, including by race and
ethnicity.16 These data are collected from a variety of sources, such as
health care providers, pharmacies, and state and jurisdictional health
departments, and include data from the CDC, HRSA, and FEMA COVID-
19 vaccine programs.
Our prior work has highlighted gaps in race and ethnicity data reported to
CDC on COVID-19 vaccinations.17 We reported that as of March 8, 2021,
data collected from states and jurisdictions on race and ethnicity for
COVID-19 vaccine recipients were missing for almost half (46.7 percent)
of recipients who received at least one vaccine dose. We recommended
that CDC take steps to help ensure more complete reporting of race and
ethnicity information for recipients of COVID-19 vaccines. CDC neither
agreed nor disagreed with our recommendation, but officials stated that
they are taking steps to implement this recommendation, such as

16For more information, see https://covid.cdc.gov/covid-data-tracker/.
17GAO-21-387.
Data Availability on
COVID-19 Vaccination by
Race and Ethnicity

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requiring providers that participate in CDC’s COVID-19 Vaccination
Program to report the race and ethnicity of vaccine recipients.18 For
additional information on data availability and racial and ethnic disparities
for COVID-19 indicators, see appendix II.
As of January 9, 2022, according to national data reported to CDC from
states and jurisdictions, 207,662,071 people were fully vaccinated against
COVID-19, including 66.5 percent of those eligible for vaccination (i.e.,
aged 5 and older) as of the same date. Race and ethnicity information
were available for approximately 77.1 percent of fully vaccinated people.
Our analysis of CDC’s national data shows that among those with known
race and ethnicity data, 42.8 percent of fully vaccinated people belonged
to racial and ethnic groups other than non-Hispanic White.19 When
compared to the U.S. population, our analysis suggests some racial and
ethnic disparities in vaccination rates. For example, when compared to
their respective shares of the U.S. population, a greater share of non-
Hispanic Asian persons were fully vaccinated against COVID-19, while a
disproportionately smaller share of non-Hispanic Black persons were fully
vaccinated against COVID-19.20 However, results should be interpreted
with caution because the percentage of unknown race and ethnicity data
may account for some, or even all, of the differences in vaccination rates.
See figure 2.

18GAO-21-387.
19Racial and ethnic groups other than non-Hispanic White include non-Hispanic American
Indian/Alaska Native, non-Hispanic Asian, non-Hispanic Black, Hispanic or Latino, non-
Hispanic Multiracial/Other, and non-Hispanic Native Hawaiian or Other Pacific Islander
persons.
20Disparities in persons vaccinated by race and ethnicity may also be observed at the
state or jurisdictional level. For example, see Centers for Disease Control and Prevention,
“COVID-19 Vaccine Administration, by Race and Ethnicity — North Carolina, December
14, 2020–April 6, 2021,” Morbidity and Mortality Weekly Report, vol. 70, no. 28 (July 16,
2021).

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Figure 2: Percentage of People Fully Vaccinated Against COVID-19 by Race and
Ethnicity, Compared to Share of U.S. Population, as of January 9, 2022

Notes: Data represent the percentage of fully vaccinated people (who have received the second dose
in a two-dose COVID-19 vaccine series or one dose of the single-shot Johnson & Johnson COVID-19
vaccine) by race and ethnicity. Asian, Black, and White persons were non-Hispanic. Hispanic or
Latino persons may be of any race. Data for racial and ethnic groups that represented less than 6
percent of vaccinated persons are not shown and therefore, percentages may not add to 100. We
calculated population distributions using the 2020 Decennial Census population counts by race and
ethnicity for the United States and Puerto Rico and applied the race and ethnicity distributions from
the 2010 Decennial Census to Census’ International Database 2021 population projections for Guam,
Commonwealth of the Northern Mariana Islands, American Samoa, and United States Virgin Islands.
Comparisons between agency and U.S. Census Bureau percentages should be interpreted with
caution due to missing race and ethnicity data for vaccinations (22.9 percent), which may account for
some, or even all, of the differences in comparisons. At the time of this analysis, only those aged 5
and older were eligible for vaccination, although population data reflect the population of all ages.
Vaccination data reflect a combination of all vaccinations administered in the United States including
federal, state, and local efforts. CDC noted that these vaccination data represent the geographic
areas that contributed data and therefore may not be representative of the entire vaccinated
population in the U.S. In addition, the jurisdictions reporting data may vary in terms of populations
prioritized for vaccination over time; thus, the aggregated national estimates are not generalizable to
the entire U.S. population.

We previously reported that unvaccinated persons may include people
who desire to be vaccinated but face access barriers, such as lacking
transportation to a vaccination site.21 Others may be uncertain or reluctant
to be vaccinated (sometimes referred to as vaccine hesitancy) for
different reasons, such as having concerns about the safety of COVID-19
vaccines or believing vaccination is unnecessary because COVID-19 is

21GAO-22-104457.
Factors That Could Affect
Vaccination Rates

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not a serious threat to their health.22 Factors such as limited access to
health care and COVID-19 vaccine registration challenges could affect
vaccination administration for various racial and ethnic groups, according
to selected literature we reviewed and selected state officials and
stakeholder groups we interviewed. See figure 3.

22While different models exist for categorizing attitudes toward vaccination, a common
conception is that these attitudes run along a continuum that ranges from full acceptance
of vaccines on one end to full opposition to vaccines on the other. The term “vaccine
hesitancy” has been used to refer to a delay in acceptance of vaccines, including the
COVID-19 vaccine, despite the availability of vaccination services. An individual’s level of
vaccine hesitancy can vary by vaccine and over time. See National Academies of
Sciences, Engineering, and Medicine, The Critical Public Health Value of Vaccines:
Tackling Issues of Access and Hesitancy: Proceedings of a Workshop (Washington, D.C.:
2021).

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Figure 3: Factors That Could Affect COVID-19 Vaccination Rates for Various Racial and Ethnic Groups

Note: We interviewed state health officials from four selected states and representatives from six
selected stakeholder groups based on several criteria, including their representation of entities
involved in COVID-19 vaccine administration or representation of a racial or ethnic group. We also

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conducted a review of selected literature published from 2007 to 2021 to identify factors that can
affect COVID-19 vaccine administration for various racial and ethnic groups.

Through interviews with agency officials and our review of agency
documentation, we found that CDC, HRSA, and FEMA took several
actions to provide COVID-19 vaccines to underserved and historically
marginalized racial and ethnic groups in implementing their COVID-19
vaccine programs beginning in February 2021. Below are examples of
actions taken by these agencies to help ensure equity in the
administration of COVID-19 vaccines through their programs. See
appendix III for examples of additional efforts that the Department of
Health and Human Services (HHS) and FEMA have taken to help ensure
equity in the administration of COVID-19 vaccines.
CDC, HRSA, and FEMA used population data on race and ethnicity
when selecting vaccination sites. CDC, HRSA, and FEMA considered
population data on communities’ racial and ethnic makeup when deciding
on the location of program vaccination sites. Using data on race and
ethnicity can help inform decisions to allocate vaccines to certain
communities, such as those disproportionately affected by the pandemic,
according to literature we reviewed and interviews with selected state
health officials and stakeholder groups.23

CDC Retail Pharmacy Program. According to CDC officials, CDC
worked with states, jurisdictions, and territories at the launch of the
retail pharmacy program in February 2021 to identify initial pharmacy
partners to start the program in their communities based on a number
of factors, including the ability to reach socially vulnerable
communities. CDC officials told us that retail pharmacy partners used
criteria including CDC’s Social Vulnerability Index (SVI)—which takes
into account an area’s racial and ethnic composition and factors such
as poverty, transportation, and housing—when selecting retail

23For example, see Thoumi, A., H. Tewarson, and K. Johnson. “Prioritizing Equity in
COVID-19 Vaccinations: Promising Practices from States to Reduce Racial and Ethnic
Disparities.” Washington, DC: Duke-Margolis Center for Health Policy and National
Governors Association Center for Best Practices (2021).
Actions CDC, HRSA,
and FEMA Took to
Provide COVID-19
Vaccines to
Underserved and
Historically
Marginalized Racial
and Ethnic Groups

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locations to receive and administer vaccines.24 According to CDC
officials, during the start of the program when vaccine supply was
limited, pharmacy partners considered SVI when deciding on
additional store locations to administer vaccines. Additionally, our
review of agency documentation shows that in April 2021, CDC
conducted a gap analysis using SVI data to identify vulnerable areas
where a large share of the population does not reside within a 5-mile
radius of a vaccination site. CDC then worked with FEMA and
jurisdictions to increase access in these areas, for example, by
working to engage existing local pharmacies not yet providing
vaccines in vaccine administration. According to CDC officials,
approximately 50 percent of retail pharmacy program sites were
located in areas with high social vulnerability as of September 8,
2021. According to CDC officials, pharmacy partners also considered
SVI when planning weekly vaccine allocations across pharmacy
locations. According to CDC, as the retail pharmacy program
expanded and vaccine supply became more readily available,
pharmacy partners increased the number of vaccines available in
areas with higher social vulnerability.

HRSA Health Center Vaccine Program. In February 2021, HRSA
used internal data from 2019 to identify health centers that serve high
proportions of low-income patients and patients from racial and ethnic
groups other than non-Hispanic White to participate in the health
center vaccine program.25 According to HRSA, when vaccine supply
was limited, HRSA also prioritized health centers that serve a large
volume of public housing residents, migrant or seasonal agricultural
workers, patients with limited English proficiency, individuals

24CDC’s SVI takes into account various factors including socioeconomic status, household
composition, racial and ethnic group status, and housing type/transportation for each U.S.
county and Census tract. According to CDC, socially vulnerable populations are especially
at risk during public health emergencies due to these types of factors. SVI is generated for
each U.S. county and Census tract as a percentile rank, with higher percentiles indicating
greater vulnerability. CDC and retail pharmacy partners used CDC’s Equitable Distribution
Index, which approximates SVI at the ZIP code level (SVI is calculated at the census tract
and county levels) to allow for more granular assessment of an area’s socioeconomic
conditions.
25There are three provider types recognized by Centers for Medicare & Medicaid Services
as Federally Qualified Health Centers: those that receive Health Center Program funding,
look-alike health centers that do not receive Health Center Program funding, and
outpatient health programs or facilities operated by a tribe or tribal/Indian organizations.
HRSA Health Center Program awardees receive federal funding to improve the health of
underserved and vulnerable populations in areas where economic, geographic, or cultural
barriers limit access to affordable health care. Each year, HRSA Health Center Program
awardees and look-alikes are required to report a core set of information, including data
on patient characteristics, as part of a standardized reporting system.

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experiencing homelessness, and individuals with low income, which
may disproportionately reflect racial and ethnic groups other than non-
Hispanic White. In March 2021, HRSA also invited health centers
operating Tribal/Urban Indian Health Programs serving American
Indian/Alaska Native persons to participate in the program. According
to the agency’s website, as vaccine supply increased, HRSA
expanded its program to invite all of its nearly 1,500 health centers
nationwide, which includes both Health Center Program awardees
and look-alike health centers, to participate beginning in April 2021.

FEMA Vaccination Center Pilot Program. According to FEMA officials,
the agency determined vaccination center pilot program site locations
and sizes in partnership with state, jurisdiction, and local officials as
well as its Civil Rights Advisory Group. To make these determinations,
FEMA officials told us they took U.S. county population size and SVI
into consideration to target populations most in need. FEMA officials
stated that they considered counties with SVI in the top half of ranked
counties. However, agency officials stated that they preferred placing
sites in counties with higher SVI (top third), for example, those with
higher poverty or less access to transportation. Our analysis of
vaccination center pilot program site locations in relation to SVI found
that nearly all (92.3 percent) vaccination centers were located in
counties in the top half in social vulnerability rankings, and a majority
(66.7 percent) were located in counties in the top third.26
CDC, HRSA, and FEMA conducted community outreach and offered
translation services. According to CDC, HRSA, and FEMA, these
agencies and their program partners targeted communications about
COVID-19 vaccines to various racial and ethnic groups through outreach
to trusted community partners and offered translation services for those
with limited English proficiency. According to literature we reviewed and
interviews with selected state health officials and stakeholder groups,
partnering with trusted local, community-based, and faith-based
organizations, such as historically Black colleges and universities, can
increase vaccine administration in some communities.27 Additionally,
selected state health officials and stakeholder groups told us that

26We analyzed FEMA vaccination center pilot program locations in relation to SVI
because FEMA considered SVI when placing vaccination sites. We did not similarly
analyze CDC and HRSA sites in this manner because these agencies did not use a
specific SVI threshold for their site selection.
27For example, see National Academies of Sciences, Engineering, and Medicine. “Critical
Findings on COVID-19.” (March 2021).

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preparing culturally competent and accessible communication materials
that are translated in applicable languages can help ensure factual
information about vaccines reaches targeted communities.28

CDC Retail Pharmacy Program. CDC officials stated that from the
beginning of the retail pharmacy program, participating pharmacy
partners conducted outreach to community and national
organizations, faith groups, and community centers to promote
vaccine administration to different racial and ethnic groups. CDC
officials also noted that pharmacy partners in the retail pharmacy
program translated materials into multiple languages to help provide
educational information about the COVID-19 vaccine to persons with
limited English proficiency.

HRSA Health Center Vaccine Program. HRSA officials told us they
partnered with other federal government agencies to promote vaccine
administration for various racial and ethnic groups. For example, in
May 2021, HRSA partnered with the Department of Housing and
Urban Development to conduct outreach to promote COVID-19
vaccination among Department of Housing and Urban Development-
assisted households, which are disproportionately Black. According to
HRSA, beginning in May 2021, HRSA also worked with CDC and the
Food and Drug Administration, as well as with its National Training
and Technical Assistance Partners, to conduct outreach to migratory
and seasonal agricultural workers to increase vaccinations for these
populations, which are disproportionately Hispanic or Latino.29

FEMA Vaccination Center Pilot Program. According to FEMA,
beginning in February 2021, FEMA’s Office of Equal Rights deployed
civil rights advisors to all its regions to assist vaccination center pilot
program sites in ensuring equity in the administration of COVID-19

28See also U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, National Center for Immunization and Respiratory Diseases, A Guide for
Community Partners: Increasing COVID-19 Vaccine Uptake Among Members of Racial
and Ethnic Minority Communities (April 6, 2021).
29HRSA’s National Health Center Training and Technical Assistance Partners are national
organizations that provide training and technical assistance to health centers to help
increase access to high quality, comprehensive primary care services for special and
underserved populations.

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GAO-22-105079  COVID-19
vaccines.30 Civil rights advisors collaborated with community and
faith-based organizations by conducting and participating in
roundtable events and state equity task forces. FEMA’s Office of
Equal Rights also developed and published a checklist of civil rights
considerations for COVID-19 vaccination center pilot program sites at
the start of the program in February 2021. The checklist included
items on promoting effective communication and language access as
well as developing outreach mechanisms to engage with community
organizations that serve persons with limited English proficiency and
persons from various racial and ethnic groups. Additionally, FEMA
officials told us that they provided language translation services at
vaccination center pilot program sites, as well as translations of
outreach and public awareness information related to COVID-19. See
figure 4.

30Civil rights advisors, led by FEMA’s Office of Equal Rights, are assigned to FEMA
regional offices to provide guidance, technical assistance, compliance, and enforcement
regarding FEMA’s civil rights obligations. FEMA stated that staff from the Office of Equal
Rights visited 90 percent of COVID-19 vaccination center pilot program sites and met with
state emergency management and public health officials to offer recommendations to
enhance accessibility and equitable administration of COVID-19 vaccines.

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Figure 4: Example of Spanish Language Interpreter Assisting at a FEMA
Vaccination Center Pilot Program Site

CDC, HRSA, and FEMA extended vaccination hours and used pop
up clinics and mobile sites to administer vaccines. CDC, HRSA, and
FEMA also took actions to help certain populations, including various
racial and ethnic groups, access COVID-19 vaccines, such as extending
the hours of vaccination sites and using mobile vaccination sites.
According to literature we reviewed, some racial and ethnic groups may
experience systemic inequalities, such as not having transportation
options to reach COVID-19 vaccination sites. As suggested by literature
we reviewed and selected state health officials and stakeholder groups
we interviewed, mobile or pop up COVID-19 vaccination sites can

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supplement mass COVID-19 vaccination sites to better serve people who
do not have access to transportation.31

CDC Retail Pharmacy Program. According to CDC officials,
participating pharmacies in the retail pharmacy program extended
their appointment times after 6 p.m. and on the weekends and
established walk-in hours to improve vaccine accessibility. CDC
officials also stated that they hold biweekly calls with participating
pharmacies to monitor their community-based efforts, including
pharmacies’ pop-up or mobile vaccine clinics held outside of
traditional pharmacy stores. See figure 5. CDC stated that pharmacy
partners also provided on site vaccinations in places such as
churches in order to help vaccinate members of certain racial and
ethnic groups. According to CDC officials, as of August 22, 2021,
participating pharmacies have cumulatively administered 3,203,104
vaccine doses at 11,449 mobile clinics across the country.

31For example, Thoumi, A., H. Tewarson, and K. Johnson. “Prioritizing Equity in COVID-
19 Vaccinations: Promising Practices from States to Reduce Racial and Ethnic
Disparities.” Duke-Margolis Center for Health Policy and National Governors Association
Center for Best Practices (Washington, DC; 2021).

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Figure 5: Example of Pop-up Retail Pharmacy Vaccination Event


HRSA Health Center Vaccine Program. According to HRSA, the
agency invited health centers that were using mobile vans to deliver
services to participate in the health center vaccine program in March
2021, when vaccine supply was still limited, to help provide vaccines
to underserved communities and those disproportionately impacted by
COVID-19. Some federally supported health centers also held pop-up
vaccination sites, such as at churches, to administer vaccines to
various racial and ethnic groups. See figure 6. From May 14 through
September 24, 2021, health centers reported administering vaccines
at 8,565 mobile van clinics, 18,451 pop-up clinics, and 3,660 school-
based clinics to enhance access to vaccination sites.32 Additionally,
we previously reported that health centers participating in HRSA’s
program were able to schedule vaccination appointment times on

32HRSA began collecting data on community-based vaccination events, including mobile
van clinics, pop-up sites, and school-based clinics, on May 14, 2021.

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weekends or evenings to provide more equitable access to
vaccination sites.33
Figure 6: HRSA-Funded Health Center Staff Administer Vaccines at a Church


FEMA Vaccination Center Pilot Program. FEMA officials told us
vaccination center pilot program sites included smaller satellite sites
and mobile clinics, known as spokes. According to officials, FEMA
used spoke sites to bring vaccines closer to people by addressing
factors including work schedules and lack of transportation that may
make it difficult for high-risk populations, including certain racial and
ethnic groups and essential workers, to access vaccines. Some of
these sites were on wheels (for example, inside of a trailer) while
others were pop-up sites that could easily be set up and taken down
(for example, in community and faith-based centers). See figure 7. As
of the close of FEMA’s vaccination center pilot program on June 20,
2021, FEMA reported that 449,763 vaccine doses had been
administered at its spoke sites. According to agency officials, FEMA

33GAO-22-104457.

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also advised vaccination center pilot program sites to expand their
hours of operation to ensure that underserved communities had
access to vaccines. We previously reported that some vaccination
center pilot program sites extended their hours to include early
mornings, evenings, and Saturdays, allowing them to administer
additional vaccines.34
Figure 7: Example of FEMA Vaccination Center Pilot Program Mobile Site

34GAO-22-104457.

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Although available data are limited, our analysis of CDC, HRSA, and
FEMA COVID-19 vaccine program data suggest that the percentage of
people vaccinated through these programs by race and ethnicity varied.35
Our analysis suggests that while the programs vaccinated a greater share
of some racial and ethnic groups compared to their shares of the
population, disparities exist for other racial and ethnic groups, such as
non-Hispanic Black persons. However, according to CDC, some groups
may have a higher likelihood of having missing race and ethnicity data,
and the percentage of unknown race and ethnicity data may account for
some, or even all, of the differences observed in comparing vaccinations
among various racial and ethnic groups to their shares of the U.S.
population.36
CDC Retail Pharmacy Program. Our analysis of CDC retail pharmacy
program data found that participating pharmacies fully vaccinated
51,554,294 people from February 11, 2021, through September 4,
2021.37 However, we found that 26.1 percent of people fully vaccinated
through CDC’s program as of those dates were missing race and ethnicity
information. Our analysis suggests that, among people fully vaccinated
with known race and ethnicity, 43.3 percent (16,484,240 out of
38,085,142 people) were from racial and ethnic groups other than non-
Hispanic White, though vaccinations varied by racial and ethnic group.38
Though comparisons between CDC data and U.S. population
percentages should be interpreted with caution due to the rate of missing
race and ethnicity data for vaccinated persons, our analysis suggests that
the retail pharmacy program fully vaccinated a greater share of non-
Hispanic Asian and Hispanic or Latino persons compared to their shares
of the U.S. population. In contrast, our analysis suggests that non-

35For the purposes of this report, fully vaccinated persons are persons who received two
doses on different days (regardless of time interval) of the two-dose mRNA series (Pfizer
or Moderna) or received one dose of a single-dose vaccine (Johnson & Johnson).
36Missing race and ethnicity data may include unreported data, as well as data for persons
who declined to provide their race and ethnicity.
37Data provided by CDC on persons vaccinated through the retail pharmacy program
includes all persons vaccinated at pharmacies, and may contain persons vaccinated using
doses distributed through states and other jurisdictions, in addition to CDC’s retail
pharmacy program.
38Racial and ethnic groups other than non-Hispanic White include non-Hispanic American
Indian/Alaska Native, non-Hispanic Asian, non-Hispanic Black, Hispanic or Latino, non-
Hispanic Multiracial, non-Hispanic Native Hawaiian or Other Pacific Islander, and non-
Hispanic Other persons.
CDC, HRSA, and
FEMA Program
Vaccination Among
Various Racial and
Ethnic Groups, and
Comparison to
Shares of Population

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Hispanic Black and non-Hispanic White persons represented a smaller
share of persons fully vaccinated through the retail pharmacy program
relative to their population shares. See figure 8.
Figure 8: Percentage of People Fully Vaccinated against COVID-19 through CDC’s
Retail Pharmacy Program by Race and Ethnicity, Compared to Share of U.S.
Population, as of September 4, 2021

Notes: Data represent the percentage of fully vaccinated people (who have received the second dose
in a two-dose COVID-19 vaccine series or one dose of the single-shot Johnson & Johnson COVID-19
vaccine) by race and ethnicity. Asian, Black, and White persons were non-Hispanic. Hispanic or
Latino persons may be of any race. Data for racial and ethnic groups that represented less than 5
percent of vaccinated persons are not shown and therefore, percentages may not add to 100. We
calculated population distributions using the 2020 Decennial Census population counts by race and
ethnicity for the United States and Puerto Rico and applied the race and ethnicity distributions from
the 2010 Decennial Census to Census’ International Database 2021 population projections for Guam,
Commonwealth of the Northern Mariana Islands, American Samoa, and United States Virgin Islands.
Comparisons between CDC and U.S. Census Bureau percentages should be interpreted with caution
due to missing race and ethnicity data for vaccinations (26.1 percent), which may account for some,
or even all, of the differences in comparisons. At the time of this analysis, only those aged 12 and
older were eligible for vaccination, although population data reflect the population of all ages.
Because there may be differences in the age distributions for different racial and ethnic groups, we
conducted additional analyses using population data for those aged 18 and older, based on data
availability, and found that these did not affect identified differences.

CDC established a program target to administer 40 percent of COVID-19
vaccines through the retail pharmacy program to persons from racial and
ethnic groups other than non-Hispanic White combined because
approximately 40 percent of the total U.S. population comprises racial
and ethnic groups other than non-Hispanic White. CDC officials noted
that while 40 percent is the minimum threshold, the agency aimed to
achieve at least 50 percent of vaccine doses administered through the
retail pharmacy program to persons from racial and ethnic groups other
than non-Hispanic White. According to CDC, the retail pharmacy program
surpassed the 40 percent threshold in mid-April 2021.

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HRSA Health Center Vaccine Program. Our analysis of HRSA health
center vaccine program data collected through HRSA’s biweekly COVID-
19 survey of health centers found that the program fully vaccinated
3,238,100 people as of August 27, 2021. We found that 13.6 percent of
people fully vaccinated as reported through health center survey data
were missing race and ethnicity data as of August 27, 2021.39 Our
analysis suggests that, among people fully vaccinated with known race
and ethnicity, 73.6 percent (2,058,030 out of 2,797,714 people) belonged
to racial and ethnic groups other than non-Hispanic White, though
vaccinations varied by racial and ethnic group.40
Though comparisons between HRSA data and U.S. population
percentages should be interpreted with caution due to the rate of missing
race and ethnicity data for vaccinated persons, our analysis suggests that
the health center vaccine program fully vaccinated a greater share of non-
Hispanic Asian and Hispanic or Latino persons, among those with known
race and ethnicity, compared to their shares of the U.S. population. In
contrast, our analysis suggests that the program fully vaccinated a
disproportionately smaller share of non-Hispanic Black and non-Hispanic
White persons compared to their shares of the U.S. population.41 See
figure 9.

39Participating health centers are required to respond to an addendum to the survey that
requests the race and ethnicity of vaccine recipients as a condition of program
participation. HRSA stated the average response rate for the survey addendum capturing
participating health center data from the start of the health center vaccine program
through August 27, 2021, was 90.4 percent.
40Racial and ethnic groups other than non-Hispanic White include non-Hispanic American
Indian/Alaska Native, non-Hispanic Asian, non-Hispanic Black, Hispanic or Latino, non-
Hispanic Multiracial, and non-Hispanic Native Hawaiian or Other Pacific Islander persons.
41According to HRSA, nearly 63 percent of patients served by HRSA-funded health
centers belong to racial or ethnic groups other than non-Hispanic White, which may
explain the relatively low vaccination rate among non-Hispanic White persons compared
to their share of the U.S. population.

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Figure 9: Percentage of People Fully Vaccinated against COVID-19 through HRSA’s Health Center Vaccine Program by Race
and Ethnicity Reported through Survey Data, Compared to Share of U.S. Population, as of August 27, 2021

Notes: Data represent the percentage of fully vaccinated people (who have received the second dose
in a two-dose COVID-19 vaccine series or one dose of the single-shot Johnson & Johnson COVID-19
vaccine) by race and ethnicity. Asian, Black, and White persons were non-Hispanic. Hispanic or
Latino persons may be of any race. Data for racial and ethnic groups that represented less than 5
percent of vaccinated persons are not shown and therefore, percentages may not add to 100.
According to HRSA, vaccination data are from HRSA’s biweekly COVID-19 survey of health centers.
Participating health centers are required to respond to an addendum to the survey that requests the
race and ethnicity of vaccine recipients as a condition of program participation. HRSA stated the
average response rate for the survey addendum capturing participating health center data from the
start of the health center vaccine program through August 27, 2021 was 90.4 percent. We calculated
population distributions using the 2020 Decennial Census population counts by race and ethnicity for
the United States and Puerto Rico and applied the race and ethnicity distributions from the 2010
Decennial Census to Census’ International Database 2021 population estimates for Guam,
Commonwealth of the Northern Mariana Islands, American Samoa, and United States Virgin Islands.
Comparisons between HRSA and U.S. Census Bureau percentages should be interpreted with
caution due to missing race and ethnicity data for vaccinations (13.6 percent), which may account for
some, or even all, of the differences in comparisons. At the time of this analysis, only those aged 12
and older were eligible for vaccination, although population data reflect the population of all ages.
Because there may be differences in the age distributions for different racial and ethnic groups, we
conducted additional analyses using population data for those aged 18 and older, based on data
availability, and found that these did not affect identified differences.

FEMA Vaccination Center Pilot Program. Our analysis of FEMA
vaccination center pilot program data found that the program
administered 5,651,094 vaccine doses as of the end of the program on
June 20, 2021.42 However, we found that 18.6 percent of vaccine doses
administered were missing race and ethnicity data. Among doses with

42Data represent vaccine doses administered, and may reflect one dose of a two-dose
COVID-19 vaccine series or one dose of the single-shot Johnson & Johnson COVID-19
vaccine. FEMA stated the agency collects data on vaccine doses administered rather than
persons vaccinated in an effort to leave out personally identifiable information.

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GAO-22-105079  COVID-19
available race and ethnicity data, our analysis shows that 58.1 percent of
doses administered through the program (2,674,224 of 4,602,689 doses)
were to people belonging to racial and ethnic groups other than non-
Hispanic White, though vaccinations varied by racial and ethnic group.43
Comparisons between FEMA data and population percentages should be
interpreted with caution due to the rate of missing race and ethnicity data
for vaccinations and because FEMA data represent vaccine doses
administered and not persons vaccinated. Among doses administered to
people with known race and ethnicity, the vaccination center pilot
program administered vaccine doses to a larger share of non-Hispanic
Asian persons and non-Hispanic White persons compared to their shares
of the population across counties with pilot sites.44 However, our analysis
suggests that non-Hispanic Black persons received fewer vaccine doses
compared to their share of the population across these counties, among
doses administered to people with known race and ethnicity as of the end
of the program. Additionally, Hispanic or Latino persons received fewer
vaccine doses compared to their share of the population across these
counties. See figure 10.

43Racial and ethnic groups other than non-Hispanic White include non-Hispanic American
Indian/Alaska Native, non-Hispanic Asian, non-Hispanic Black, Hispanic or Latino, non-
Hispanic Multiracial, non-Hispanic Native Hawaiian or Other Pacific Islander, and non-
Hispanic Other persons. We calculated the total number of doses administered to people
with known race and ethnicity as the sum of the number of doses administered to each
racial and ethnic group.
44We compared FEMA vaccination data to population data only from the counties with
FEMA pilot sites because, relative to the CDC and HRSA data, there were fewer FEMA
pilot sites, and these sites were located in areas with population demographics that are
less similar to the aggregate U.S. population. Pilot sites may provide doses to populations
in multiple surrounding counties.

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Figure 10: Percentage of COVID-19 Vaccine Doses Administered through FEMA’s
Vaccination Center Pilot Program by Race and Ethnicity, Compared to Share of
County Population, as of June 20, 2021

Notes: Data represent vaccine doses administered, and may reflect one dose of a two-dose COVID-
19 vaccine series or one dose of the single-shot Johnson & Johnson COVID-19 vaccine. Asian,
Black, and White persons were non-Hispanic. Hispanic or Latino persons may be of any race. Data
for racial and ethnic groups that represented less than 5 percent of vaccinated persons are not shown
and therefore, percentages may not add to 100. We calculated the total number of doses
administered to people with known race and ethnicity as the sum of the number of doses
administered to each racial and ethnic group. We compared FEMA’s vaccination center pilot program
data to population data from counties with FEMA pilot sites, using the 2020 Decennial Census
population counts by race and ethnicity, as there are relatively few pilot sites and the surrounding
population is not necessarily representative of the U.S. population. Pilot sites may provide doses to
populations in multiple surrounding counties. Comparisons between FEMA and U.S. Census Bureau
percentages should be interpreted with caution due to missing race and ethnicity data for
vaccinations (18.6 percent), which may account for some, or even all, of the differences in
comparisons. At the time of this analysis, only those aged 12 and older were eligible for vaccination,
although population data reflect the population of all ages. Because there may be differences in the
age distributions for different racial and ethnic groups, we conducted additional analyses using
population data for those aged 18 and older, based on data availability, and found that these did not
affect identified differences. FEMA’s vaccination center pilot program ended on June 20, 2021.

FEMA also used spoke vaccination center pilot program sites, including
mobile and pop-up sites, in addition to its mass vaccination centers to
bring vaccines closer to populations for whom transportation or proximity
to a site may be a barrier to vaccination, including various racial and
ethnic groups. Our analysis of FEMA vaccination center pilot program
data suggests that spokes administered a higher percentage of doses to
Hispanic or Latino persons (39.1 percent), among doses administered to
people with known race and ethnicity, than FEMA’s larger vaccination
centers (24.2 percent) through the end of the program.

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Our review of agency documentation and interviews with agency officials
found that CDC, HRSA, and FEMA collected and monitored data on the
race and ethnicity of individuals vaccinated through their programs. The
agencies did this to adjust operations as needed to meet agency goals to
vaccinate underserved and historically marginalized groups, including
various racial and ethnic groups.
CDC Retail Pharmacy Program. CDC officials stated the agency
collected and maintained data on COVID-19 vaccine recipients by race
and ethnicity for the retail pharmacy program. CDC developed weekly
monitoring reports to assess the percentage of COVID-19 vaccines
administered by race and ethnicity, among other things. Officials said they
used these reports to assess the extent to which COVID-19 vaccines
were administered in higher risk communities, such as those with higher
percentages of people from various racial and ethnic groups, as well as
missing race and ethnicity data.45 Officials said they closely monitored
race and ethnicity information to help inform how the retail pharmacy
program could better administer vaccines to various racial and ethnic
groups, such as by encouraging pharmacy collaboration with community-
based organizations to advertise vaccine appointment locations within
communities and assist with appointment scheduling. CDC officials stated
they also worked with pharmacy partners when reviewing race and
ethnicity data to understand any reporting difficulties or challenges
reaching various racial and ethnic groups in their communities.
HRSA Health Center Vaccine Program. HRSA officials told us that
since February 2021, the agency has conducted a biweekly survey of
health centers participating in the health center vaccine program to track
any challenges and successes for the program. Participating health
centers are required to respond to the survey as a condition of program
participation, which captures data on program vaccine administration by
race and ethnicity, among other things.46 HRSA stated the response rate

45CDC and retail pharmacy partners used CDC’s Equitable Distribution Index, which
approximates SVI at the ZIP code level to allow for more granular assessment of an
area’s socioeconomic conditions, to identify high risk communities.
46As a condition of participation in this program, health centers identified for participation
in the Health Center COVID-19 Vaccine Program are required to complete both the Health
Center COVID-19 Biweekly Survey and additional questions outlined in an addendum to
the survey. Prior to July 2, 2021, the survey was conducted weekly.
CDC, HRSA, and
FEMA Collected and
Monitored Data to
Inform Program
Efforts to Vaccinate
Racial and Ethnic
Groups

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GAO-22-105079  COVID-19
for the survey capturing participating health center vaccine administration
data is generally above 90 percent.47
HRSA stated that the agency regularly reviewed the biweekly survey
data, which includes the number of vaccinations administered biweekly by
race and ethnicity, to monitor health center capacity and the effect of
COVID-19 on health center operations, patients and staff, as well as to
better understand training and technical assistance, funding, and other
health center resource needs. HRSA officials told us they developed a
public dashboard to provide information on COVID-19 vaccinations by
race and ethnicity through the health center vaccine program.48 HRSA
shared the dashboard with federal and non-federal partners to inform
vaccination planning and technical assistance activities for vaccinating
racial and ethnic groups other than non-Hispanic White. Additionally,
HRSA officials stated they worked with CDC to analyze vaccine
administration data to assess the program’s effect and to evaluate the
program to inform future vaccination efforts.
FEMA Vaccination Center Pilot Program. Prior to the program ending
in June 2021, FEMA collected race and ethnicity data for vaccine doses
administered through its vaccination center pilot program. FEMA’s
vaccination center pilot program sites requested that each jurisdiction
where sites were located gather data on the following five key data
elements: race, ethnicity, age, sex, and disability status. To help ensure
FEMA vaccinated socially vulnerable communities, FEMA officials told us
that staff analyzed the collected data, regularly communicated findings
with jurisdictions, and when necessary, FEMA worked with jurisdictions to
make alterations to their vaccination plans. For example, officials said that
at one vaccination center pilot program site, FEMA’s data showed that the
majority of people vaccinated at the site during the first few days of
operation were non-Hispanic White rather than the Black population that
the site was intended to serve. After reviewing this data, FEMA staff told
us they adapted their approach to reach the non-Hispanic Black
community by adjusting the hours of site operation and the requirements
for a vaccination appointment as well as partnering with local community

47Survey response rates may differ from week to week. Between February 26 and August
27, 2021, the Health Center COVID-19 Survey addendum response rate ranged from 86
to 96 percent.
48See HRSA’s Health Center COVID-19 Vaccination Dashboard at
https://data.hrsa.gov/topics/health-centers/covid-vaccination, accessed November 16,
2021.

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GAO-22-105079  COVID-19
organizations. Following the end of the vaccination center pilot program,
FEMA officials told us that they could no longer track the same level of
demographic data for sites that continued to operate under state or
jurisdictional leadership.49
Although CDC, HRSA, and FEMA have taken these efforts to collect and
monitor data on race and ethnicity for COVID-19 vaccine programs, gaps
remain in data on vaccine administration by race and ethnicity across all
three programs.50 Specifically, race and ethnicity information is
incomplete in national vaccination data as well as data from the three
agency programs, as described above. As noted, all vaccine
administration data—including data from these three programs—are
reported to CDC. CDC told us that it is working to ensure more complete
reporting of race and ethnicity information for recipients of COVID-19
vaccinations, such as by requiring providers to report the race and
ethnicity of vaccine recipients, and reaching out to states and jurisdictions
to improve demographic data completeness. Having more complete data
will help federal agencies identify any disparities in vaccination rates
among various racial and ethnic groups, monitor the extent to which their
COVID-19 vaccine programs have helped to reduce these disparities, and
adjust program operations as needed to meet program goals.
We provided a copy of this draft report to HHS, including CDC and HRSA,
and FEMA. HHS and FEMA provided technical comments, which we
incorporated as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Administrator of FEMA and the Secretary of HHS, and
other interested parties. The report is also available at no charge on
GAO’s website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at 202-512-7114 or HundrupA@gao.gov. Contact points for our

49Community vaccination centers managed and operated by states and other jurisdictions
continue to operate as COVID-19 vaccination sites and are overseen by state or
jurisdictional officials.
50In our prior work, CDC stated that information on race and ethnicity for COVID-19
vaccine recipients is missing for a variety of reasons, including a lack of consistent
collection and reporting of this information by physicians and pharmacists and challenges
with transmitting data to CDC. Additionally, we reported that it can be challenging to
collect this information when administering COVID-19 vaccinations because recipients
may refuse to provide their race and ethnicity at the time of vaccination, among other
things. See GAO-21-387.
Agency Comments

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GAO-22-105079  COVID-19
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in appendix IV.

Alyssa M. Hundrup
Director, Health Care

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GAO-22-105079  COVID-19
List of Committees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives

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GAO-22-105079  COVID-19
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard E. Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives

Appendix I: Scope and Methodology

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GAO-22-105079  COVID-19
This appendix provides additional details regarding our data analysis of
national COVID-19 vaccination by race and ethnicity. We also provide
information on the methodologies used to select health officials and
stakeholder groups for interviews and for reviewing research on COVID-
19 vaccine equity. To provide background information on potential
disparities for various racial and ethnic groups, we compared national
COVID-19 vaccination data to the race and ethnicity distribution using
population data from the U.S. Census Bureau.1 To assess the reliability of
the CDC vaccine administration data, we reviewed agency documents,
interviewed agency officials from CDC, and tested the data we received
from CDC for missing data and obvious outliers and errors. Although a
notable share of these vaccination data were missing information on race
and ethnicity, we determined the data with known race and ethnicity were
sufficiently reliable for the purposes of generally describing vaccination
trends in the United States and comparing to U.S. population data to
identify potential disparities.
To provide additional information on all of our objectives, we interviewed
state health officials from four states that we selected based on criteria,
such as selecting states from different Census regions and whether
states report race and ethnicity data for COVID-19 vaccine recipients on
their state public health websites as of October 2021. We also
interviewed representatives from the National Medical Association,
National Hispanic Medical Association, National Indian Health Board,
Association of State and Territorial Health Officials, National Association
of County and City Health Officials, and National Association of
Community Health Centers. In selecting these stakeholders, we
considered several criteria, including their representation of entities
involved in COVID-19 vaccine administration or representation of a racial
or ethnic group, to capture a variety of perspectives.
To identify examples of actions that could potentially advance equity in
vaccine administration during pandemics and factors that can affect
COVID-19 vaccine administration for various racial and ethnic groups, we
conducted a review of selected research articles published between 2007
and 2021, in addition to information gathered from state health officials
and stakeholder interviews. Our review of the research on COVID-19

1We calculated population distributions using the 2020 Decennial Census population
counts by race and ethnicity for the United States and Puerto Rico and applied the race
and ethnicity distributions from the 2010 Decennial Census to Census’ International
Database 2021 population estimates for Guam, Commonwealth of the Northern Mariana
Islands, American Samoa, and United States Virgin Islands.
Appendix I: Scope and Methodology

Appendix I: Scope and Methodology

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GAO-22-105079  COVID-19
vaccines included peer-reviewed articles, government reports, books, and
publications from associations, nonprofit organizations, and think tanks.

Appendix II: Coronavirus Disease 2019
Indicators by Race and Ethnicity

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GAO-22-105079  COVID-19
The Centers for Disease Control and Prevention (CDC) plays a key role
in collecting and making available nationwide data on indicators of
Coronavirus Disease 2019 (COVID-19) burden, including testing positivity
rates, cases, hospitalizations, and deaths. While race and ethnicity
information is incomplete for some of these reported data and thus should
be interpreted with caution, available data suggest racial and ethnic
disparities in COVID-19 indicators. This appendix discusses data
availability and suggested disparities in these COVID-19 indicators.
CDC data on race and ethnicity continue to be limited. In our prior
work on COVID-19, we found that gaps exist in data on COVID-19
indicators by race and ethnicity.1 While the proportions of cases,
hospitalizations, and deaths with known race and ethnicity have
increased since we first reported on this issue in September 2020,
available data on COVID-19 indicators by race and ethnicity continue to
be limited. See table 1.
Table 1: Race and Ethnicity Data Completeness for Indicators of COVID-19 Burden, as Reported by GAO
COVID-19 indicator
Percentage missing race
and ethnicity dataa
As of date
Percentage missing
race and ethnicity data
As of date
Testing
N/Ab
67.2c
January 19, 2022
Casesd,e
Case report forms
52.6
July 31, 2020
33.8
January 9, 2022
Total cases
63.8
July 31, 2020
47.9
January 9, 2022
Hospitalizationsf
6.4
August 1, 2020
1.5
January 8, 2022
Deathsd,g
Case report forms
16.6
July 13, 2020
14.6
January 9, 2022
Total deaths
35.4
July 31, 2020
27.1
January 9, 2022
Death certificate
reportingh
<1.0
August 7, 2020
<1.0
January 6, 2022
Source: GAO analysis of Centers for Disease Control and Prevention (CDC) data. | GAO-22-105079
1Our prior work highlighted gaps in race and ethnicity data reported to CDC on COVID-19
indicators including test positivity rates, cases, hospitalizations, deaths, and vaccination
rates. We made five recommendations to CDC such as taking steps to help ensure more
complete reporting of race and ethnicity information for COVID-19 indicators. For more
information, see GAO, COVID-19: Federal Efforts Could Be Strengthened by Timely and
Concerted Actions, GAO-20-701 (Washington, D.C.: September 21, 2020); COVID-19:
Urgent Actions Needed to Better Ensure an Effective Federal Response, GAO-21-191
(Washington, D.C.: November 30, 2020); and COVID-19: Sustained Federal Action Is
Crucial as Pandemic Enters Its Second Year, GAO-21-387 (Washington, D.C.: March 31,
2021).
Appendix II: Coronavirus Disease 2019
Indicators by Race and Ethnicity

Appendix II: Coronavirus Disease 2019
Indicators by Race and Ethnicity

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GAO-22-105079  COVID-19
aFor more information, see GAO, COVID-19: Federal Efforts Could Be Strengthened by Timely and
Concerted Actions, GAO-20-701 (Washington, D.C.: September 21, 2020).
bCDC did not publicly report data on COVID-19 test results by race and ethnicity when we first
reported on COVID-19 disparities in September 2020.
cFor more information, see Department of Health and Human Services, Centers for Disease Control
and Prevention, Report to Congress on Paycheck Protection Program and Health Care Enhancement
Act Disaggregated Data on U.S. Coronavirus Disease 2019 (COVID-19) Testing, 20th 30-Day Update
(January 2022).
dFor more information, see CDC’s COVID Data Tracker
(https://covid.cdc.gov/covid-data-tracker/#demographics).
eCDC officials reported that the number of cases with case report forms received by CDC is less than
the total number of reported cases because there is generally a 2-week lag from when total cases are
reported by state and jurisdictional health departments to when CDC receives the case report forms.
Total cases reported by CDC include both probable and confirmed cases as reported by states or
jurisdictions. A probable case does not have confirmatory laboratory evidence, but meets certain
other criteria, such as clinical symptoms and epidemiological linkage (i.e., exposure).
fCDC’s COVID-19-Associated Hospitalization Surveillance Network (COVID-NET)
(https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covid-net/purpose-methods.html) collects
data on COVID-19 hospitalizations that are confirmed by laboratory testing from select counties in 14
states, representing 10 percent of the U.S. population. It includes data from hospitals in select
counties in California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New
Mexico, New York, Ohio, Oregon, Tennessee, and Utah. In addition to COVID-NET, HHS also
collects national hospitalization data through its HHS Protect Public Data Hub,
https://protect-public.hhs.gov/, accessed December 8, 2021; however, HHS does not make data
available on COVID-19 hospitalizations by race and ethnicity through this website.
gCDC officials noted that the number of deaths with case report forms it has received is less than the
total number of reported deaths through case reporting because there is generally a 2-week lag from
when total deaths are reported by state and jurisdictional health departments to when CDC receives
case report forms noting deaths.
hCDC also makes data available on COVID-19 deaths from death certificate data through its National
Center for Health Statistics’ National Vital Statistics System
(https://www.cdc.gov/nchs/nvss/covid-19.htm).

CDC data, though incomplete, continue to show disparities by race
and ethnicity. We have previously reported that certain racial and ethnic
groups have been disproportionately affected by the pandemic. Though
limited, available data from CDC continues to suggest racial and ethnic
disparities in COVID-19 indicators.

Testing. As of January 19, 2022, 246,844,030 COVID-19 diagnostic
test results reported to CDC from laboratories in the United States
had available race and ethnicity information, representing 32.8
percent of total test results. The percent of tests that were positive for
each racial and ethnic group was: 12.4 percent for Hispanic or Latino
persons, 11.9 percent for non-Hispanic American Indian/Alaska
Native persons, 11.6 percent for non-Hispanic Black persons, 10.9
percent for non-Hispanic Native Hawaiian or Other Pacific Islander

Appendix II: Coronavirus Disease 2019
Indicators by Race and Ethnicity

Page 39
GAO-22-105079  COVID-19
persons, compared to 10.3 percent for non-Hispanic White persons
and 9.1 percent among all persons tested for COVID-19.2

Cases. CDC race and ethnicity data on COVID-19 cases, while
incomplete, demonstrate that certain racial and ethnic groups have
been disproportionately affected. Among the 31,032,445 cases with
known race and ethnicity reported to CDC through case reporting as
of January 9, 2022 (representing 52.1 percent of total cases):

1.0 percent were among non-Hispanic American Indian/Alaska
Native persons (compared to 0.7 percent of the U.S. population),

3.3 percent were among non-Hispanic Asian persons (compared
to 5.9 percent of the U.S. population),

12.1 percent were among non-Hispanic Black persons (compared
to 11.9 percent of the U.S. population),

24.0 percent of cases were among Hispanic or Latino persons
(compared to 19.5 percent of the U.S. population),

0.3 percent were among non-Hispanic Native Hawaiian or Other
Pacific Islander persons (compared to 0.2 percent of the U.S.
population), and

55.3 percent were among non-Hispanic White persons (compared
to 57.2 percent of the U.S. population).
Available data suggest that racial and ethnic disparities in COVID-19
cases have decreased over time. For example, among those with known
race and ethnicity, the proportion of cases representing non-Hispanic
Black persons has decreased from 19.8 percent as of July 31, 2020 to
12.1 percent as of January 9, 2022. Additionally, the proportion of cases
representing Hispanic or Latino persons has decreased from 31.9 percent
to 24.0 percent as of the same dates.

Hospitalizations. CDC data indicate that certain racial and ethnic
groups are disproportionately hospitalized with COVID-19 in the

2Department of Health and Human Services, Centers for Disease Control and Prevention.
Report to Congress on Paycheck Protection Program and Health Care Enhancement Act
Disaggregated Data on U.S. Coronavirus Disease 2019 (COVID-19) Testing, 20th 30-Day
Update (January 2022). CDC data represent viral COVID-19 laboratory test results from
laboratories in the United States, including commercial and reference laboratories, public
health laboratories, hospital laboratories, and other testing locations from all jurisdictions.
The data represent total laboratory tests, not individual people, and exclude antibody and
antigen tests. We did not compare these testing data to previously reported data, as CDC
did not publicly report data on COVID-19 test results by race and ethnicity when we first
reported on COVID-19 disparities in September 2020.

Appendix II: Coronavirus Disease 2019
Indicators by Race and Ethnicity

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GAO-22-105079  COVID-19
selected hospitals included in CDC’s COVID-19 hospitalization
surveillance system. According to CDC’s analysis of these data,
between March 1, 2020 and January 8, 2022, when adjusting for age:

non-Hispanic American Indian/Alaska Native persons were
hospitalized with COVID-19 at a rate 3.2 times that of non-
Hispanic White persons,

non-Hispanic Black persons were hospitalized with COVID-19 at a
rate 2.5 times higher than non-Hispanic White persons,

and Hispanic or Latino persons were hospitalized at a rate 2.4
times higher than non-Hispanic White persons.
COVID-19-associated hospitalization rates among these racial and ethnic
groups have decreased relative to the hospitalization rate among non-
Hispanic White persons since we first reported these data in September
2020, suggesting a reduction in disparities.3

Deaths. As of November 15, 2021, National Center for Health
Statistics data show that non-Hispanic American Indian/Alaska Native
persons died of COVID-19 at a rate 2.2 times higher than non-
Hispanic White persons, when adjusting for age. Non-Hispanic Black
persons died of COVID-19 at a rate 1.9 times higher than non-
Hispanic White persons, and Hispanic or Latino persons died at a rate
2.1 times higher than non-Hispanic White persons, when adjusting for
age.4

3We previously reported that between March 1, 2020, and August 1, 2020, non-Hispanic
American Indian/Alaska Native persons were hospitalized with COVID-19 at a rate 5.2
times that of non-Hispanic White persons (compared to 3.2 times as of January 8, 2022),
and non-Hispanic Black and Hispanic or Latino persons were hospitalized at a rate 4.7
times that of non-Hispanic White persons (compared to 2.5 times and 2.4 times,
respectively, as of January 8, 2022) when adjusting for age.
4We did not compare these data on COVID-19-related deaths to previously reported data,
as the data we reported in September 2020 reflected deaths per 100,000 population
rather than age-adjusted rate ratios as provided in this report.

Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

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GAO-22-105079  COVID-19
Throughout the pandemic, the Department of Health and Human Services
(HHS) and its operating divisions and the Federal Emergency
Management Agency’s (FEMA) took additional actions aside from its
Coronavirus Disease 2019 (COVID-19) vaccine programs to provide
COVID-19 vaccines to underserved and historically marginalized racial
and ethnic groups.1 Below are examples of additional actions that HHS
and FEMA took as of November 2021 to help ensure COVID-19 vaccine
equity for various racial and ethnic groups. We identified these examples
through interviews with agency officials, a review of agency
documentation, and information obtained through HHS and FEMA
websites.
Department of Health and Human Services. In April 2021, the U.S.
Department of Health and Human Services (HHS) announced additional
measures to encourage vaccinations and increase vaccine confidence as
part of the next phase of its COVID-19 public education campaign. These
include the launch of the COVID-19 Community Corps—a nationwide,
grassroots network of local voices and trusted community leaders to
encourage vaccinations. This effort mobilized health professionals,
scientists, community organizations, faith leaders, businesses, rural
stakeholders, civil rights organizations, sports leagues and athletes, and
Americans from all walks of life to become leaders within their own
communities to help get friends, family, and neighbors vaccinated. The
program provides resources and fact-based public health information
through HHS in partnership with CDC.
Additionally, HHS aired both English and Spanish language TV
advertisements across the country to encourage vaccination among key
groups currently eligible to receive vaccinations. In addition to general
market broadcast and cable advertising, HHS has also made multi-million
dollar ad buys in Black and Spanish-language media, as well as in outlets
that reach Asian American and Pacific Islanders and Tribal populations,
to add an additional layer of outreach and messaging to hard-hit
communities.

1HHS’s operating divisions include the Administration for Children and Families,
Administration for Community Living, Agency for Healthcare Research and Quality,
Agency for Toxic Substances and Disease Registry, Centers for Disease Control and
Prevention, Centers for Medicare & Medicaid Services, Food and Drug Administration,
Health Resources and Services Administration, Indian Health Service, National Institutes
of Health, and Substance Abuse and Mental Health Services Administration.
Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

Page 42
GAO-22-105079  COVID-19
HHS’s Office of Minority Health partnered with CDC to launch the Minority
Health SVI. The Minority Health SVI is an extension of the CDC SVI that
combines the 15 social factors included in the original CDC SVI with
additional factors known to be associated with COVID-19 outcomes.
These factors were developed using 5-year estimates of demographic
data from the U.S. Census Bureau’s American Community Survey, and
are organized into six themes: 1) socioeconomic status; 2) household
composition and disability; 3) minority status and language; 4) housing
type and transportation; 5) health care infrastructure and access; and 6)
medical vulnerability. The Minority Health SVI can be used to apply a
health equity lens to research, strategic planning, program design, and
evaluation related to response and recovery for COVID-19 and other
public health emergencies. Among other things, the Minority Health SVI
databases and dashboard can be used to plan targeted and equitable
COVID-19 testing, vaccine and treatment distribution, and vaccine
administration efforts.
In June 2020, the Office of Minority Health also launched the National
Infrastructure for Mitigating the Impact of COVID-19 within Racial and
Ethnic Minority Communities, a 3-year project designed to work with
community-based organizations across the nation to deliver education
and information on resources to help fight the pandemic. As part of this
program, the Office of Minority Health awarded $40 million to the
Morehouse School of Medicine to coordinate a strategic network of
national, state, territorial, tribal, and local organizations to deliver COVID-
19-related information such as testing and vaccinations to communities
hardest hit by the pandemic, including certain racial and ethnic groups
and socially vulnerable communities.
Centers for Disease Control and Prevention. The Centers for Disease
Control and Prevention (CDC) developed a COVID-19 Data Tracker
Health Equity Landing Page that catalogs current equity-related data on
COVID-19 indicators, such as vaccinations, by race and ethnicity.2 As
part of the COVID-19 Data Tracker, CDC has a COVID-19 Vaccine Equity
web page that provides county-level vaccination coverage and SVI.3 CDC
also developed a web page on COVID-19 vaccine equity for racial and
ethnic groups that includes culturally specific communication and
educational resources to build vaccine confidence and raise awareness

2For more information, see COVID-19 Vaccine Equity for Racial and Ethnic Minority
Groups.
3For more information, see CDC COVID Data Tracker.

Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

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GAO-22-105079  COVID-19
about the benefits of the COVID-19 vaccine. Some of the resources
include a guide for community organizations to increase vaccine uptake
for certain racial and ethnic groups and a COVID-19 prevention and
vaccine communication toolkit that includes messaging for public health
professionals, health care providers, and community organizations to
reach communities that speak languages other than English. See Figure
11.

Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

Page 44
GAO-22-105079  COVID-19
Figure 11: Example of a CDC Communication Toolkit Poster about COVID-19
Vaccines

Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

Page 45
GAO-22-105079  COVID-19
Additionally, CDC worked with national, state, tribal, territorial, local, and
community partners to promote COVID-19 vaccination among Black and
Hispanic or Latino people. To support these partnerships, CDC provided
funding for organizations that reach certain racial and ethnic groups. For
example, in April 2021, CDC awarded $3 billion to 64 jurisdictions to
support local health departments and community-based organizations in
launching new programs and initiatives to increase vaccine access,
acceptance, and uptake in communities disproportionately affected by
COVID-19.
CDC officials also told us they conducted community outreach efforts to
increase vaccine uptake among various racial and ethnic groups. For
example, in June 2021, CDC hosted a webinar titled “Motivate to
Vaccinate: National Month of Action for COVID-19 Vaccinations” to
increase the number of vaccinated persons in non-Hispanic Black and
Hispanic or Latino communities. The webinar included organizations such
as the Black Coalition against COVID-19, Latinx COVID-19 Task Force,
and the National Resource for Refugees, Immigrants, and Migrants.
These organizations provided information on successes, challenges, and
strategies used to increase vaccine education, awareness, and uptake. In
September 2020, CDC began a series of listening sessions to hear
concerns from different partners and organizations serving communities
that have been disproportionately affected by COVID-19. CDC stated that
the goal of these listening sessions was to collect qualitative data to
expand CDC’s communication, outreach, and partnership efforts to
ensure minority groups and rural populations receive accurate, timely,
and culturally responsive COVID-19 outreach messages and resources
for prevention and control.
Food and Drug Administration. To better understand and address the
needs of various racial and ethnic communities, the Food and Drug
Administration conducted several efforts to boost vaccine confidence,
such as:

holding listening sessions with diverse health professional
organizations and other stakeholders to learn more about the gaps
and needs of various racial and ethnic communities and to share
information on COVID-19 activities;

building awareness about clinical trial diversity (clinical trials are how
medical products like vaccines get to the market);

supporting the development and translation of information for the
COVID-19 Multilingual Resources web page that features a growing

Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

Page 46
GAO-22-105079  COVID-19
collection of educational materials in more than 20 languages
including Spanish, simplified Chinese, Korean, and Vietnamese.
These educational materials provide information and details on
pertinent COVID-19 topics such as social distancing, diagnostic
testing, vaccine development;

launching a COVID-19 Bilingual (English/Spanish) Social Media
Toolkit. This toolkit allows stakeholders to have ready to use
messages that can be shared with their community to ensure accurate
and consistent messaging;

releasing videos in English and Spanish that talk about the
importance of getting vaccinated; and

hosting a webinar on the vaccine approval process aimed at reaching
various racial and ethnic groups.
Health Resources and Services Administration. In June 2021, the
Health Resources and Services Administration (HRSA) awarded $125
million in American Rescue Plan Act of 2021 funding to 14 non-profit
private or public organizations to reach underserved communities in all 50
states and the District of Columbia, Puerto Rico, Guam, and the Freely
Associated States to develop and support a community-based workforce
that will engage in locally tailored efforts to build vaccine confidence and
bolster COVID-19 vaccinations.4 For example, organizations supported
with this funding will answer individual questions, help make vaccine
appointments, and assist with transportation and other needs. In July
2021, an additional $121 million was awarded to 127 organizations
to support trusted voices in local communities in sharing information
about vaccines, building vaccine confidence, and addressing barriers to
vaccination for individuals in underserved communities.
Indian Health Service. The Indian Health Service provides health
services, including COVID-19 vaccinations, to American Indians and
Alaska Natives. According to Indian Health Service officials, facilities
operated by the Indian Health Service, tribal health programs, and urban
Indian organizations have distributed COVID-19 vaccine doses to over
350 facilities in 36 states. The Indian Health Service also developed
educational materials to provide information and address concerns
regarding COVID-19 vaccines that reflect diverse environments where
American Indian and Alaska Native people live. In November 2020, the
Indian Health Service released its COVID-19 Pandemic Vaccine Plan that
detailed how its health care system prepares for and operationalizes

4See Pub. L. No. 117-2, § 2501, 135 Stat. 4, 42.

Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

Page 47
GAO-22-105079  COVID-19
COVID-19 vaccine distribution. This plan provides important guidance for
all Indian Health Service Direct Service facilities and Tribal health
programs and Urban Indian Organizations that choose to receive COVID-
19 vaccine coordinated through the Indian Health Service. In September
2020, Indian Health Service approved a COVID-19 Vaccine Task Force to
lead the Agency’s COVID-19 vaccine activities and distribution efforts.5 In
April through May 2021, the Indian Health Service partnered with FEMA
to provide mobile COVID-19 vaccination services to 13 communities in
North Dakota and South Dakota. The mobile vaccination sites were able
to provide up to 250 shots a day and did not require preregistration.
National Institutes of Health. The National Institutes of Health
developed the COVID-19 Prevention Network that enrolled thousands of
volunteers in large-scale clinical trials to test a variety of investigational
vaccines and monoclonal antibodies intended to protect people from
COVID-19. Through stakeholder and community engagement, the
COVID-19 Prevention Network engages the participation of priority
populations, such as racial and ethnic groups that have been hardest hit
by the pandemic.
In September 2020, the National Institutes of Health developed the
Community Engagement Alliance Against COVID-19 Disparities.6 The
Community Engagement Alliance Against COVID-19 Disparities provides
trustworthy, science-based information through active community
engagement and outreach to the people hardest-hit by the COVID-19
pandemic. The goal is to build long-lasting partnerships as well as
improve diversity and inclusion in the National Institutes of Health’s
research response to COVID-19.
Federal Emergency Management Agency. Funding under FEMA’s
Public Assistance program included community engagement and
information dissemination to promote vaccination availability, scheduling,
and accessibility, as well as reimbursement for activities to increase
public confidence in and uptake of COVID-19 vaccines. This funding was
available to state, local, tribal, and territorial governments and eligible
private and non-profit medical facilities carrying out vaccination

5The Indian Health Service Vaccine Task Force is comprised of broad clinical federal
employee representation and is established in accordance with the Federal Advisory
Committee Act.
6For more information, see Community Engagement Alliance (CEAL) Against COVID-19
Disparities | Community Engagement Alliance.

Appendix III: Additional Efforts That HHS and
FEMA Have Taken to Provide COVID-19
Vaccines to Underserved and Historically
Marginalized Racial and Ethnic Groups

Page 48
GAO-22-105079  COVID-19
administration activities. Eligible expenses included communication and
outreach (advertising campaigns and public service announcements);
vaccination information sharing (call centers, websites); accessible
communication (translation and interpretation services; the provision of
auxiliary aid); and transportation.7
FEMA analyzed community demographics to determine communication
needs and to mobilize translation and interpretation services. FEMA
worked to provide translations of outreach and public awareness
information related to COVID-19 response including vaccinations.
Additionally, FEMA provided interpretation and language services at
federally supported vaccine centers.

7Under the direction of the current administration, FEMA funded 100 percent of eligible
costs associated with COVID-19 response efforts through December 31, 2021, which
included funding for COVID-19 booster shots. Additionally, FEMA was also directed to
fund 100 percent of eligible National Guard costs under Title 32 authorities for COVID
response efforts, including the cost for COVID-19 booster shots, through December 31,
2021.

Appendix IV: GAO Contact and Staff
Acknowledgments

Page 49
GAO-22-105079  COVID-19
Alyssa M. Hundrup, (202) 512-7114 or HundrupA@gao.gov.
In addition to the contact named above, Rebecca Rust Williamson
(Assistant Director), Courtney Liesener (Analyst-in-Charge), Alison
Granger, and Rachel Weingart made key contributions to this report. Also
contributing were Sam Amrhein, Sonia Chakrabarty, Diona Martyn,
Ethiene Salgado-Rodriguez, Amber Sinclair, and Sirin Yaemsiri.
Appendix IV: GAO Contact and Staff
Acknowledgments
GAO Contact
Staff
Acknowledgments
(105079)

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