Diversity and COVID-19 vaccine rollout: we can’t fix what we can’t see

GLOBALLY, as of 15 February 2021, there have been over 109 million confirmed cases of COVID-19 and over 2.4 million deaths. In Australia, the total number of cases is 28 900 with 909 deaths.

These staggering figures indicate the scale of the COVID-19 pandemic. Although Australia has avoided widespread transmission through concerted public health efforts, many individuals, families and communities have been severely affected by school closures, job losses, cancellation of non-emergency health care, travel restrictions and border closures.

In many settings culturally and linguistically diverse (CALD) communities have been disproportionately affected by COVID-19. In the US, Black and Latinx people were almost twice as likely to be infected with COVID-19, about four times as likely to be hospitalised, and nearly three times as likely to die compared with white people. Similarly, in the UK, the risk of death due to COVID-19 was 25–56% higher in ethnic minority groups compared with white adults. It is important to note that race, culture and ethnicity are social, and not biological, categories and as such these disparities highlight underlying societal conditions that affect the health of CALD communities, including socio-economic status, access to care, and exposure to infection in relation to occupation.

While comprehensive CALD-related data are not publicly available in Australia, evidence provided to the Victorian COVID-19 contact tracing inquiry indicates that 50% of people who acquired COVID-19 during the Victorian outbreak, which comprises the majority of Australia’s locally acquired cases, were born outside of Australia – significantly higher than expected as a proportion of the population. Many individuals from CALD backgrounds remain at higher risk of contracting COVID-19 due to structural factors such as insecure high risk employment or living in high density households.

Given the considerable impacts of COVID-19, the newly developed COVID-19 vaccines have been in high demand. Countries with the incentives and resources to procure priority doses have rapidly commenced intensive COVID-19 vaccination efforts administering more than 130 million COVID-19 vaccine doses worldwide across 73 countries to date. Meanwhile Australia, which has been in the fortunate position to carefully consider the evidence and the options, is set to begin vaccinating its population against COVID-19 in late February.

Concerningly, early data on COVID-19 vaccination from the US and UK shows lower rates of vaccination among some CALD communities, raising early warning flags about the potential for disparities in access to and uptake of the vaccine.

Existing studies tell us that, in Australia, there are disparities in vaccinations rates; for example, the uptake of childhood vaccinations depending on the mother’s country of birth. A study of over 1.9 million Australian children reported lower vaccination uptake among infants with a mother who was born overseas (who constituted 34.6% of the cohort) compared with infants of mothers born in Australia. Related research also highlighted the existence of different patterns of vaccine uptake among different CALD communities, indicating that some communities require additional support.

Potential reasons for disparities in vaccine coverage among some CALD communities include differing attitudes to vaccinations and levels of trust in the health care system. Individuals from CALD backgrounds can experience barriers to health care access due to language, transport options, cost, discrimination, competing priorities or lack of culturally appropriate care. Furthermore, asylum seekers and undocumented migrants may be afraid to access health services.

Pockets of undervaccination have previously been associated with outbreaks of vaccine-preventable diseases. It is not yet clear whether current COVID-19 vaccines will be able protect communities through herd immunity. However, if the vaccine is able to protect against infection, it is likely that high coverage is required to achieve herd immunity, given the infectiousness of the virus causing COVID-19. Therefore, timely access to high quality data (including CALD data) is critical to identifying any gaps and inequities in vaccine uptake to inform responsive vaccination strategies and communications.

While Australia has a comprehensive system for registering vaccinations (the Australian Immunisation Register), we do not collect CALD-related data such as country of birth or preferred language. Existing evidence on disparities in immunisation among CALD communities has relied on linkage of immunisation data with other health and administrative datasets – a process that involves nine approval and regulatory bodies and can take more than 2 years. The lack of CALD-related data on immunisation is indicative of the larger systemic health data gap that exists in Australia, which significantly limits our ability to identify, report and monitor health disparities among CALD communities.

What can be done to support COVID-19 vaccination efforts? Here are some thoughts:

• Mandate comprehensive and quality collection of data on cultural, ethnic and linguistic diversity as part of existing routine data collection systems, particularly the National Notifiable Diseases Surveillance System (which includes COVID-19 and other notifiable diseases) and the Australian Immunisation Register, and ensure that timely data are readily available to local public health and health care providers to inform actions to mitigate the impact of COVID-19 on CALD communities.
• Ensure that CALD communities are engaged as active and equal participants in COVID-19 pandemic preparedness, response, recovery and evaluation.
• Fund, develop and implement culturally competent COVID-19 education and prevention campaigns, including effective messaging to counter racial prejudice and discrimination, working in partnership with CALD communities.
• Improve access to culturally safe health and government services, including COVID-19 vaccination.
• Ensure that COVID-19 recovery strategies actively reduce inequalities caused by the wider social determinants of health, such as housing and employment conditions, to create long term sustainable change.

In Australia, we have an opportunity to learn from what is occurring internationally to ensure our own COVID-19 vaccine rollout does not exacerbate health disparities. In order to protect those at greatest risk, we need better data to ensure vaccines are reaching those who need it the most. Rapid changes in order to record CALD data at the point of vaccination have already been made in other settings. It is encouraging that the government has taken some steps, including the establishment of a CALD Communities COVID-19 Health Advisory Group, the development of a CALD communities implementation plan, ensuring free access to all visa holders and allocation of $1.3 million for peak multicultural organisations to help reach CALD communities. However, accurate collection and availability of CALD data are essential to evaluate the success of these measures in ensuring equitable vaccine uptake, and provide an opportunity to ensure health equity across the health system more broadly.

Dr Jocelyn Chan is an epidemiologist, public health registrar and PhD candidate with the Murdoch Children’s Research Institute.

Dr Mandy Truong is a Research Fellow with the School of Nursing and Midwifery, at Monash University, and a Senior Project Officer at the Menzies School of Health Research.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.