Oni Blackstock is a primary care and HIV physician and founder and executive director of Health Justice. Alexandra Skinner is a research fellow at Boston University School of Public Health. Julia Raifman, an assistant professor at Boston University School of Public Health, leads the Covid-19 U.S. State Policy database.
Now, a new inequity may be emerging: While vaccines remain effective for reducing cases and severe disease for everyone, vaccinated Black, Latino and Pacific Islander people appear more likely to experience breakthrough infections.
It is hard to fully evaluate breakthrough cases due to a lack of complete data. This is unacceptable. Public health agencies must do better to track these infections to inform an effective and equitable response.
The little data that we do have on breakthrough cases show concerning racial and ethnic inequities. For example, data from King County, Wash., suggest that hospitalization rates among fully vaccinated people are higher for Black, Indigenous and Pacific Islander residents than their White peers. These data likely underestimate breakthrough inequities because age-specific rates within each race and ethnicity are not reported, and White populations are older than populations of other races and ethnicities.
That there would be potential racial and ethnic inequities in covid-19 outcomes among vaccinated people should be no surprise. Historical and present-day policies, driven by structural racism, have created striking racial and ethnic inequities in wealth, health, education, work, housing and medical care. Non-White Americans are thus more likely to hold front-line jobs, less likely to be able to work from home and more likely to live in crowded homes or neighborhoods. These factors increase the risk of coronavirus exposure regardless of vaccination status.
On top of the elevated risk of exposure, the impact of weathering — the physiological toll of ongoing exposure to racism — and inequities in access to high-quality health care contribute to higher rates of comorbidities that increase the risk of hospitalization or death due to covid-19. Vaccines reduce that risk, but they cannot eliminate the structural drivers that lead to these inequities.
Despite the importance of data to understand patterns in covid-19 breakthroughs, the Centers for Disease Control and Prevention stopped reporting most breakthrough cases in May. Instead, the CDC now reports only severe breakthrough cases that result in hospitalization or death, which are not publicly available divided by race or ethnicity. As a result, there is minimal information about whether the protection vaccines confer differs by race or ethnicity and no data to guide potential policies to address inequities. This lack of publicly available data by the CDC runs counter to its declaration of racism as a public health crisis earlier this year.
Meanwhile, 38 states and Washington, D.C., report breakthrough cases publicly in some capacity, but only four states and D.C. report these data by race and ethnicity. Furthermore, state-level data on such cases often lack detail about whether they result in hospitalization or death. The numbers of breakthrough cases are likely higher than reported, as surveillance data may miss cases that arise from asymptomatic infections or are captured by home testing.
High levels of covid-19 transmission mean that breakthrough infections are not rare. These cases may carry less risk, but some may result in hospitalization or several months of recovery from long covid. Additionally, breakthrough infections can be transmitted to others.
Complete data on breakthrough infections could allow for early identification of variants for which the vaccines may be less effective. When disaggregated by race, ethnicity and age group and presented over time, these data can then help to describe whether there is variability in vaccine response due to modifiable factors such as workplace safety standards.
Vaccines have not been enough to control the spread of the delta variant, nor will they eliminate racial inequities in covid-19 outcomes. Without explicitly addressing how structural forces perpetuate these inequities, no single intervention can be effective. Centering equity in data collection and reporting is a key step to informing policies that will reach and serve Black, Latino, Pacific Islander and Indigenous communities — those who have faced the greatest burden of covid-19, bereavement, parental loss and economic precarity throughout the pandemic.
We call on the CDC, as well as state and local health departments, to provide comprehensive breakthrough data by race, ethnicity and age group.
Earlier in the pandemic, as vaccines were just starting to be made available to the public, younger Black Americans were dying from covid-19 at rates similar to White Americans 10 years older. This should be evidence enough that policymakers must center equity in our country’s pandemic response, especially as we begin to roll out boosters and vaccinations for young children. Without the full picture, booster implementation and subsequent vaccine-related efforts could exacerbate existing covid-19 inequities, putting an end to the pandemic even further out of reach.
