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PAVEing a path towards equitable access and use of Covid-19 vaccines

By: Robert F Breiman, MD, Chief Science Officer, Global Health Crisis Coordination Center (GHC3)

At the beginning of this Covid-19 crisis, some thought that the pandemic would affect everyone equally. After all, the word pandemic literally means “affecting all” and “universal.”

But now, we know that this pandemic has not affected all people equally. While the reasons are not fully characterized, the disproportionate risk of infection and death due to Covid-19 in Blacks, Hispanics/Latinos, and Indigenous Americans in the U.S. seems to be most principally due to systemic differences in living and working circumstances.

A primary driver for public health is to identify and to eliminate disparities while improving the health and well-being of all people. With unprecedented “warp-speed”, a panoply of covid-19 vaccine candidates have entered the scene. However, if we don’t consider the massive inequities associated with Covid-19, a vaccination program could exacerbate the disparities.

If we thoughtfully engage communities around the U.S. with reciprocal, informative and adaptive messaging, safe and effective vaccines will level the very uneven playing field we find ourselves on. This requires accessible, culturally relevant, transparent and interpretable information about safety profiles and effectiveness in both preventing illness and reducing transmission of the virus. “Information equity” combined with pathways to get immunized will be the ingredients for assuring that people in communities that are marginalized and traditionally underserved can make informed decisions about getting vaccinated and are not left-behind in benefitting from these new vaccines.

As immunization expert Walt Orenstein says, “Vaccines don’t save lives, vaccinations do.” Used optimally, immunization will shorten the time to get to the end of the pandemic, save many lives, and accelerate progress towards getting the economy, and educational development through in-person learning, back on track. Getting to optimal and equitable use of vaccines will not be easy. Hurdles include:

  • getting vaccine doses to places that are easily accessible by those who are prioritized for immunization

  • keeping track of who has received one dose of vaccine so that they can be reminded to return to an immunization site one month later to receive the same vaccine

  • people who are at disproportionate risk of severe outcomes from Covid-19 may have perspectives that make them unlikely to seek or accept Covid-19 immunization;

  • at least one of the vaccines that will constitute a substantial proportion of the initial supply will require extremely cold temperatures for storage and remain stable for only a short period of time after being thawed; and

  • active, functional surveillance for adverse events following immunizations will be required to detect relatively rare adverse events.

With Microsoft providing technical resources, the Global Health Crisis Coordination Center (GHC3) developed a tool to help health departments and companies receiving limited allotments of vaccines to think through and address some of the key hurdles. The Priority-based use of Allocated Vaccines Estimator (PAVE) provides a conceptual framework and calculator to plan for the distribution of vaccines, consider communities disproportionately affected, and ultimately get vaccines into the arms of prioritized recipients.

There are simple steps for using PAVE, which will aid in determining how to best provide equitable access to Covid-19 vaccines. Because of the complexities involved with these vaccines, the tool supports the development of strategies and scenarios for use by immunization program managers to potentially land on the most practical, locally relevant approach given the limited number of vaccines currently available.

PAVE offers the priority ordering of categories recommended by NASEM and by as options to select - in which case the categories will be listed in the order that either NASEM or ACIP (if there are differences) provides: health care workers taking care of COVID patients, first responders, essential workers, long-term care facility/skilled-nursing facility residents, other elderly patients, and people with high-risk comorbidities.

Further, an immunization manager will have the option to prioritize calculations based on local contingencies. An immunization manager can accept a default entry or enter the percent expected for vaccine uptake (willingness to be immunized) among each of the immunization categories, as well as the expected proportion of first-dose recipients expected to return for a second dose. The user can then run the calculation to see how many people in each category can potentially be immunized with the available number of doses of vaccine.

Entries and calculations can be stored within the tool, so when a second allotment is scheduled, the target number of people in each category will be adjusted when considering how to use the number of vaccines anticipated.

The introduction of safe and highly effective Covid-19 vaccines is one of the fastest biomedical achievements in history and represents a paragon of 21st century technical advances. Immunizing people who are high-risk will be a highly complex endeavor – and requires partnership and cooperation with a vast array of disparate entities and stakeholders.


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