As states get the first 2.9 million doses of COVID-19 vaccines, some are turning to a planning tool used for natural disasters to make sure their most vulnerable residents aren’t overlooked.

Because of the limited supply of doses, at least 26 states and Washington, D.C., will rely on what’s known as the Social Vulnerability Index, or SVI, to determine who should be immunized. The SVI tries to account for social, economic, racial and ethnic factors, and it might help health-care officials figure out whom to prioritize for vaccination.An advisory committee to the Centers for Disease Control and Prevention suggested that health-care workers and nursing-home residents get shots first, followed by those with pre-existing medical conditions.

The thinking is that because ethnic and racial minorities are overrepresented in those groups, the plan will be equitable. But health-care experts and government officials, including President-elect Joe Biden, say that plan will miss too many people who are poor, Black, Latino or members of other minority or disadvantaged groups.

“Even if just 10% of states decide to use the index, it makes a big difference,” said Harald Schmidt, assistant professor of medical ethics and health policy in the University of Pennsylvania, who recently co-authored an analysis of equitable vaccine allocation. “Everybody is still trying to figure out this equity piece, and I’m hopeful we will see quite a bit of change.”

Black and Latino populations have had higher rates of infections and deaths from COVID-19, and have been hit harder by unemployment. Pre-existing medical conditions tend to make them more vulnerable to the virus. Many work in essential businesses or live in crowded multigenerational housing, where the virus is easily transmitted. Even before the pandemic, many were either uninsured or underinsured, while others feared deportation, keeping them away from hospitals when they got sick.

The question many states now face is how exactly to ensure that these group are accounted for in immunization plans. The National Academies of Sciences, Engineering, and Medicine is among the organizations recommending use of the SVI.


So far, several states are following that advice. Schmidt’s analysis found that as of early November, 18 states were planning to use the SVI, though several others have since announced plans to adopt it. Some, such as Ohio, will use it to allocate vaccines and to monitor the rollout, while Arizona will use it to design communication plans that encourage people to get vaccinated. Tennessee has one of the clearest plans: Following a National Academies suggestion, it will use the SVI to reserve and distribute 10% of the vaccines it receives in the most vulnerable geographic areas, mostly rural counties. New Hampshire also will follow that advice.

Schmidt’s study also identified 17 states that didn’t mention using the SVI in their draft plans for vaccine distribution. Several of these states when contacted by Bloomberg said they were either thinking of using the index or have since added it to their vaccination plans. Minnesota officials said they would use it, as will Virginia, along with some other metrics. Connecticut has also added the index to its broader distribution plan, while Oklahoma plans to use it to establish distribution maps. Iowa said it will “soon” decide on the matter and Texas is considering how to use the index after the very first phases of vaccination. Utah doesn’t plan to include it, but will stick to its own risk model.

Not using the SVI does not mean states won’t strive for equitable vaccine distribution. As of early November, 23 states planned to use Tiberius, a software program developed by Palantir Technologies Inc. that can include the SVI if local officials request it. Nebraska has in fact incorporated the index in its software, although representatives said they may make modifications to meet specific state needs. Maryland is considering doing the same.

Other states plan to use different metrics: California will deploy a health-equity measure initially created for the reopening of the state and Illinois will use something called the Community Vulnerability Index, which also is recommended by the National Academies. Missouri said it is working on its vaccination plan and will consider all options.Kansas and West Virginia either didn’t respond or couldn’t be reached for comment on their plans for distributing vaccines.

This would be the first time the SVI is used on such a broad scale. Created in 2011 by the CDC, its main purpose has been to help coordinate delivering aid in the case of major natural catastrophes such as hurricanes or floods. The difference is those events tend to affect just one state or region of the country.

The index uses 15 measures, including household composition, disability, minority status, housing type, English fluency, minority-group identification and employment status.

“People are starting to understand the connection between equity and the SVI,” said Ruqaiijah Yearby, a professor at Saint Louis University School of Law who has focused on equity in health care. “But I hope it will go beyond the vaccine and be connected to our overall response.