U.S. COVID Vaccination: Rural vs. Urban

Alaska, West Virginia, New Mexico, and Connecticut are 4 of the top states that have the largest share of vaccinated citizens. Alabama, Kansas, Iowa, and Missouri are the bottom four. The 4 top states with the highest vaccination administration rates include North Dakota, New Mexico, West Virginia, and Montana, while the 4 states with the lowest rates include Rhode Island, Kansas, Alaska, and Alabama.
Reasons for the disparity in vaccination rates have been attributed to some states opting out of the distribution partnership with CVS and Walgreens, levels involved in decision-making, number of vaccination sites, and states holding out vaccines for the second round of vaccination. The reasons suggested for the differences in vaccine administration (actual inoculation) rates include attitudes towards the COVID-19 vaccine, different distribution strategies, storage requirements, as well as barriers to healthcare in rural areas.
Findings from the CDC, the Kaiser Family Foundation (KFF), Becker’s Hospital Review, Fortune, The Conversation, and Brookings form the bulk of the findings in this brief, and they all suggest that rural states are vaccinating their residents at a faster rate than the more urban and suburban states.

Vaccination Rates Per State

  • Pulling data from the Centers for Disease Control and Prevention (CDC), Fortune lists the percentage of vaccinated populations per state (from highest to lowest) as follows: Alaska(13.4%), West Virginia (10.9%), New Mexico (10.4%), Connecticut (10.3%), North Dakota (9.5%), Oklahoma (9.4%). District of Columbia (9.2%), Delaware (9.1%), South Dakota, Vermont, Virginia (8.9%), Oregon (8.6%), Arkansas, Wyoming (8.5%), Louisiana (8.3%), Colorado, Florida, Hawaii, Maine, Michigan, North Carolina (8.2%), Washington, Kentucky (8.1%), New York (8.0%), New Jersey, Wisconsin (7.9%), Montana (7.8%), California, Georgia, Indiana, Nevada, New Hampshire, Utah (7.7%), Arizona, Minnesota, Ohio, South Carolina (7.6%), Mississippi, Maryland (7.5%), Massachusetts, Nebraska, Pennsylvania, Texas (7.2%), Rhode Island (7.0%), Illinois, Tennessee (6.8%), Alabama, Kansas (6.6%), Iowa (6.3%), and Missouri (6.1%).
  • Based on the US Census Bureau’s data from 2010, Stacker lists Maine, Vermont, West Virginia, Mississippi, Montana, Arkansas, South Dakota, Kentucky, Alabama, and North Dakota as the states with the highest rural population. West Virginia, North Dakota, South Dakota, Vermont, Arkansas, Maine, and Kentucky have population vaccination rates between 8% and 11%. This represents 7 out of 10, or 70%.
  • The states identified with the lowest rural population include California, New Jersey, Nevada, Massachusetts, Hawaii, Florida, Rhode Island, Utah, Arizona, and Illinois. Using the same range (8-11% of population vaccination rates), only Florida and Hawaii appear, representing 2 out of 10, or 20%. The remaining 8 states have population vaccination rates between 7 and 8%.

Vaccination Distribution and Administration Rates

  • The number of vaccines distributed, the number of vaccines administered, and percentage rates per state can be found on this spreadsheet. The data is curated from CDC’s Data Tracker and is as recent as 8th February 2021.
  • Using the same top 10 states with the highest rural population- Maine, Vermont, West Virginia, Mississippi, Montana, Arkansas, South Dakota, Kentucky, Alabama, and North Dakota- the research team found that 8 out of these ten states, or 80%, had vaccination administration rates of above 70%. The highest was North Dakota at 96.35%
  • In contrast, only 4 out of the 10 states (40%) with the lowest rural population had vaccination administration rates of above 70%. These are Utah (81.11%), Nevada (78.09%), New Jersey (72.58%), and Hawaii (71.12%)

Reasons for Differences in Vaccination Rates

Opting Out of the State Distribution Plan

  • Brookings, a nonprofit public policy organization, posits that some states with the highest vaccination rates have opted out of the federal distribution plan with CVS and Walgreens, relying on their own distribution strategy.
  • West Virginia, with the second-highest vaccination rate at 10.9%, opted out of the state distribution plan and instead used its network of 250 small and independent pharmacies across the state to distribute the vaccines.
  • Becker’s Hospital Review observes that these pharmacies already had data on many of the targeted vaccine recipients, thus made it easy to schedule appointments, “secure consent forms, and match doses to eligible patients”. These are some of the issues that seem to be “confounding the vaccine roll-out” efforts in other states.
  • Brookings adds that these local pharmacies not only serve both remote areas and larger population centers, but they also enjoy preexisting relationships with these facilities Thus, they are privy to “extensive information” and had formed “relationships of trust” with the long-term facilities and their residents. The Kaiser Family Foundation’s (KFF) survey supports this, as it found that 86% of rural Americans trust their local doctor or healthcare provider to provide reliable information about the COVID-19 vaccine, compared to only 55% who said they trust government officials.
  • Claire Hanna, Executive Director of the Association of Immunization Managers, notes that while other states have to contend with the bureaucracy that comes with national chains such as CVS and Walgreens, West Virginia has “more direct control” over its vaccination efforts to long-term care facilities. CVS and Walgreens asserted that they would be on track to complete vaccinations in long-term facilities by January 25, 2021, but Becker’s Hospital Review notes that they would be lagging behind West Virginia by almost a month.
  • About 58% of North Dakota’s long-term care facilities opted out too, making the state distribute the vaccines through its public health department, independent pharmacies, and in the long-term care facilities themselves for “immediate vaccination“. At 9.5%, North Dakota’s rate of vaccination is the 5th highest in the nation.

Levels of Decision-making

  • Brookings postulates that part of West Virginia’s success in vaccination roll-out is as a result of decision-making at the state level by its governor. This, Brookings continues to note, has aided in “eliminating confusion and competition” among localities.
  • In contrast, decision-making in Maryland has been relegated to the counties which, according to Brookings, have different priority lists and facilities, thereby “impeding vaccine delivery“. Maryland’s population vaccination rate stands at 7.5%.
  • With the decisions left to the counties of Maryland, residents have received “a bewildering maze” of information from hospitals, counties, and other providers, creating confusion.
  • Brookings further notes that distribution decisions made by governors in some states are “not fully” transparent, suggesting that political pressures may have influenced their decisions.

Number of Vaccination Sites

  • Another commentary by Brookings suggests that the number of vaccination sites may also explain the differences in vaccination rates. It gives an example of Massachusetts that only has 65 vaccination locations meant to serve about 6.9 million residents when Burleigh County in North Dakota opened 54 sites for about 100,000 residents.
  • Brookings also pits West Virginia side by side with its larger counterpart Pennsylvania. According to the policy research firm, West Virginia operates 250 vaccination sites while Pennsylvania has 274 vaccination sites. At approximately 12.8 million, Pennsylvania’s population is 711% larger than West Virginia’s population (approximately 1.8 million).
  • Reuters reports that officials in counties with the most successful vaccination efforts have been able to quickly set up temporary vaccination sites with “little bureaucratic red tape“. These measures have been “hard to duplicate” in big cities, Reuters notes.

Holding Out for Second Round of Vaccinations

  • Brookings also notes that some of the states that seem to be slower in vaccination administration may be holding onto vaccinations for the second round of vaccination required for complete dosage.
  • CDC reports that of the almost 50 million vaccines distributed, only about 31 million have been administered. CDC posits that many of the remaining 20 million vaccines “are being held” for second doses.

Reasons for Differences in Vaccination Administration Rates

Attitudes Towards the COVID-19 Vaccine

  • KFF’s survey of 1,676 Americans found that rural residents are among the most “vaccine-hesitant” groups. 35% said they will either probably not get it or definitely not get it, compared to 26% and 27% of urban and suburban residents with the same views respectively.
  • According to the survey, about 50% of rural residents said that the seriousness of the coronavirus has been “generally exaggerated” compared to 27% and 37% of urban and suburban residents respectively.
  • Only 36% of rural Americans believe that getting vaccinated is “part of everyone’s responsibility” compared to 55% and 47% of urban and suburban residents.
  • About 39% of rural residents admit to not worrying that they or someone in their family will get infected by the coronavirus. This is in comparison to 23% and 30% of urban and suburban residents who feel the same way respectively. KFF concludes its report noting that vaccine hesitancy among rural residents is “much more than just partisanship” but is also strongly tied to their views on the virus as well as their reasons for getting vaccinated.

Different Distribution Strategies

  • In addition to opting out of the vaccine distribution partnership with CVS and Walgreens, some states also deviated from other original federal recommendations. For instance, North and South Dakota “departed” from federal guidelines when it included populations aged 65 and up (not the recommended group of 75 years and above), as well as individuals with at least 2 high-risk conditions and frontline workers in schools and child care in its second phase of vaccinations. West Virginia similarly extended its age bracket to 80 years and above.
  • North Dakota launched a “robust provider education program” to help prepare its healthcare system for efficient vaccine administration. This was done in conjunction with the North Dakota State University Center for Immunization, Research, and Education. In a statement to Becker’s Hospital Review, North Dakota’s health department said, “Healthcare providers were trained regarding the COVID-19 vaccines before they were authorized for use in the United States, which allowed for vaccines to be administered immediately”.
  • Further, North Dakota also operates a state warehouse that stores vaccines and helps the state break down vaccine batches into smaller shipments for smaller localities. This warehouse not only distributes the vaccines to hospitals and health systems but also to all healthcare providers statewide. “We are able to break down COVID-19 vaccine shipments into smaller quantities to get vaccines to rural areas of the state, where many healthcare providers are located,” North Dakota’s health department says.
  • KFF gives a robust state-by-state breakdown of COVID-19 vaccine prioritization and phase of distribution here. It was last updated on January 29, 2021.

Storage Requirements

  • The Conversation, an independent source of news and views from the academic and research community, asserts that Pfizer’s shipment of 975 doses poses a challenge for small rural hospitals to distribute quickly. It attributes this to the difficulty of finding enough patients. Hospitals and healthcare systems in urban areas, however, can quickly mobilize the required number of patients.
  • The Conversation also posits that small rural hospitals are less likely to have the expensive freezers required to properly store the Pfizer and Moderna vaccines. Pfizer’s vaccine must be stored in minus 94 degrees Fahrenheit and minus 4 degrees Fahrenheit for Moderna’s vaccine.

Barriers to Healthcare

  • Bennet Daughty, Clinical Assistant Professor, Pharmacy Practice, Binghamton University, State University of New York, and Pamela Stewart Fahs, Professor of Rural Nursing, Binghamton University, State University of New York, both remark that rural America has fewer healthcare providers despite catering to a more “geographically diverse” population. Further, both practitioners note the “alarming rate” at which rural hospitals are being shut down.
  • Other barriers identified include distance and geography such as mountain roads in rural areas. According to Daughty and Fahs, these may prove an impediment to the distribution and administration of the COVID-19 vaccine.
  • Daughty and Fahs also posit that rural counties “don’t seem to have specific plans” on how to inform their residents. They write, “While some rural counties have started getting the word out, many don’t seem to have specific plans on how to inform their residents about how and when each person can get the vaccine, let alone specific plans for actually giving it. They often rely just on local press releases that many residents never see.”
Glenn is the Lead Operations Research Analyst at The Digital Momentum with experience in research, statistical data analysis and interview techniques. A holder of degree in Economics. A true specialist in quantitative and qualitative research.

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