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Did prioritizing essential workers help to achieve racial/ethnic equity in early COVID‐19 vaccine distribution? The LA pandemic surveillance cohort study

Abstract Background Most US states and counties prioritized essential workers for early access to COVID‐19 vaccines due to their heightened occupational risk. Racial/ethnic groups most impacted by COVID‐19 are overrepresented among essential workers. This study estimates the effects of prioritizing essential workers on racial/ethnic equity in COVID‐19 vaccination. Methods Survey data were collected from 5500 Los Angeles County adult residents in March and April 2021. Multivariate regression models were used to assess marginal changes in probabilities of vaccination attributable to essential worker status by race/ethnicity. These probabilities were multiplied by population proportions of essential workers in each racial/ethnic group to estimate the effects of prioritizing essential workers on vaccine equity in the population. Results While Latinos (24.9%), Blacks (22.4%), and Asians (21.4%) were more likely to be prioritized essential workers than Whites (14.3%), their marginal gains in vaccine uptake due to their essential worker status did not significantly differ from that of Whites. At the population‐level, prioritizing vaccines for essential workers increased the probabilities of vaccination by small and similar amounts among Asians (5.3%; 95% confidence interval [CI]: 3.3%, 7.5%), Blacks (4.0%; 95% CI: 1.7%, 6.5%), Latinos (3.7%; 95% CI: 2.3%, 5.1%), and Whites (2.9%; 95% CI :1.9%, 3.9%). Conclusions Prioritizing essential workers did not provide proportionally greater early vaccine uptake benefits to racial/ethnic groups that were disproportionately affected by COVID‐19. Early prioritization of essential workers during vaccine campaigns is an important but insufficient strategy for reducing racial/ethnic disparities in early vaccine uptake. Additional strategies addressing access and trust are needed to achieve greater equity in vaccine distribution.


| INTRODUCTION
In states and counties across the United States, the emergency authorization of potentially lifesaving vaccines against SARS-CoV-2 sparked considerable debate about how to prioritize sub-groups of the population for early vaccine access. Studies using pre-pandemic data alone or in combination with early COVID-19 case data found that workers in occupations involving direct patient care were at greatest risk of infection. 1,2 Epidemiological data showed that Black, Latino, Native American, and Pacific Islander individuals were suffering disproportionately from serious illness and death due to COVID-19, with a projected 40% increase in the Black-White life expectancy gap and a virtual elimination of the Latino life expectancy advantage over Whites. [3][4][5][6][7] Researchers seeking to explain these racial/ethnic inequities to inform mitigation efforts began to examine more closely the racial/ethnic composition of workers in essential occupations and the exposure risks faced by these workers. 8 The Department of Homeland Security (DHS) issued guidance defining categories of essential workers during the COVID-19 response, although their definition was based on job functions and not risk of infectious disease transmission. 9 The National Bureau of Economic Research translated the DHS categories into the North American Industry Classification System and identified a subset of "frontline" essential occupations for which working from home was much less feasible-a crude proxy measure for exposure risk. 10 These frontline workers had lower wages, were less educated, and were more likely to belong to racial/ ethnic minority groups than the broader DHS-defined essential worker categories. 11 Among specific frontline occupations, Blacks were overrepresented among health care support and public safety workers, Latinos were overrepresented among food related and janitorial/custodial workers, and Asians were overrepresented among health care practitioners.
A study using the Medical Expenditure Panel Survey to explore racial/ethnic disparities in COVID-19-related health and occupational risk-again defined by ability to work from home-reported similar findings, with Blacks and Asians overrepresented among health care workers overall, Latinos overrepresented among food related workers, and Blacks overrepresented among public safety workers. 12 The authors concluded that occupational exposures may be more important than personal health risk factors in explaining racial/ethnic disparities in COVID-19 outcomes.
Other studies used occupational codes from death certificates to identify occupational and racial/ethnic groups with higher COVID-19 mortality rates. In Massachusetts, the occupational categories with the highest mortality rates from March through July of 2020 were healthcare support, transportation, food related, and janitorial/custodial. Within each of those occupations, Black and Latino workers had higher mortality rates than White workers. 13 A California study of excess COVID-19-related mortality by occupation and race/ethnicity found that overall mortality from March through October of 2020 was 22% higher compared to the pre-pandemic period. The highest relative increase was among food and agricultural workers (39% higher), transportation workers (28%), and facility maintenance workers (27%). Latino food and agriculture workers experienced a 59% increase in mortality, and Asian health care workers experienced a 40% increase in mortality. The relative increase among health care workers (19%) was lower than the overall figure and the number of excess deaths among health care workers was half to twothirds less than among the three hardest hit occupational groups. 14 In their study of disparities in COVID-19-related occupational risk, Goldman et al. used a detailed set of questions from the US Department of Labor's Occupational Information Network to characterize exposure risk among occupations not able to be performed from home. 15 While some of these questions had been used in earlier studies that did not examine racial/ethnic disparities, 1,2 Goldman et al. added occupational standing-the percent of persons in an occupation who have completed at least 1 year of college-to their analysis. They describe occupational standing as a proxy measure for access to workplace risk mitigation strategies, which are used less frequently in lower-wage non-healthcare settings. 16,17 After stratifying occupations by occupational standing, they found that Whites and Asians were overrepresented in high-standing high-risk occupations, while Blacks and Latinos were overrepresented in low-standing high-risk occupations.
In late December 2020, Los Angeles County (LAC), in alignment with state and national guidelines, 18 began implementing a COVID-19 vaccine distribution strategy that prioritized essential workers, people aged 65+, and people with qualifying health conditions for early access to the vaccine. The purpose of the current study was to examine the extent to which prioritizing essential workers improved vaccine equity, a key strategy for reducing racial/ethnic disparities in disease burden.
To address this study question, we analyzed survey data from a large representative sample of LAC residents. The surveys were administered just as the county was transitioning from its priority-group based vaccine distribution strategy to universal eligibility and included questions about essential worker status, vaccination status, and a variety of sociodemographic characteristics.

| Study design and vaccine distribution context
The survey was administered as part of the LAC COVID-19 Pandemic Surveillance Cohort Study (PSCS) which includes survey data as well as blood sample collection to monitor and study population trends in SARS-CoV-2 antibody status in relation to symptoms, testing and vaccination status, sociodemographic characteristics, and health-related behaviors. 19 The PSCS is an ongoing longitudinal study of a representative sample of

| Measures
Frontline essential worker status was measured based on responses to the question "Since the COVID-19 pandemic began, did you work as an Essential Worker in any of these categories?" Response choices came from a master list of essential occupation categories. Only those categories corresponding to occupations prioritized for early vaccine access in LAC were coded as essential for analysis purposes.
Those who responded, "health care or providing direct care to patients," or "worker in group setting (long term care facility, nursing home, assisted living facility, correctional facility, homeless shelter)" were coded as health care essential workers. Those who responded, "food supply or retail," "public safety," "education or childcare," or "janitorial/sanitation" were coded as non-health care essential workers. Respondents were also asked how they commuted to their work location and those who answered "work from home" were categorized as non-essential regardless of their response to the essential worker question. The only transportation workers eligible for early vaccine access in LAC were public transit drivers/operators, but the essential worker survey response choice, "transportation, including delivery" elicited responses from a broad range of transportation and delivery related jobs not related to public transit. Since we could not identify public transit drivers specifically, this response choice was coded as non-prioritized essential worker. All "other/ specify" free text responses to the essential worker question that were not accompanied by "work from home" were manually reviewed. Responses indicating any of the prioritized health care or non-health care essential worker categories described above were re-coded into those categories. Responses not indicating any prioritized essential worker category were re-coded as either nonprioritized essential worker or non-essential worker/not working.
Vaccination status was coded as "yes" if the respondent reported having received at least one vaccine dose when the survey was completed. Data on gender, age, educational attainment, household income, health status, and prior positive COVID-19 test results were also captured in the survey. Based on LAC COVID-19 vaccine surveillance data we hypothesized that all these sociodemographic and health-related variables would also be associated with vaccine uptake.

| Statistical analyses
Descriptive, bivariate, and multivariate analyses were conducted using SAS ® 9.4, copyright © 2016, SAS Institute, including the % margins macro for estimating adjusted marginal effects of covariates.
Multivariate logistic regression models predicting vaccine uptake for each major racial ethnic group included all covariates hypothesized to influence vaccine uptake. These models yielded adjusted odds of vaccination for essential workers in each racial/ethnic group and adjusted marginal changes in probability of vaccination attributable to essential worker status. These probabilities were multiplied by the proportion of each racial/ethnic group that were essential workers to estimate the effects of vaccine prioritization of essential workers on vaccine uptake in the population, by race/ethnicity.

| RESULTS
Sample characteristics and available comparison data for the LA County adult population are provided in Table 1. While the sample was younger and more educated than the LAC population, the racial/ ethnic and household income distribution was very similar to that of the LAC adult population in 2019. 20 The distribution of self-reported health status in the sample was similar to that of adult respondents to the most recent LAC Health Survey. 21 The percentages of respondents reporting at least one vaccine dose (62.5%) and a prior positive COVID-19 test result (14.6%) were similar to the respective percentages of LAC adults as of April 25th, 2021 (61.0% and 13.0%). 22 Using 2020 Bureau of Labor Statistics (BLS) data, The United Way estimated 43.5% of California workforce members were essential workers (LAC data not available). 23 The BLS also estimated that in 2020 approximately 63% of the LAC population aged 16+ was in the labor force. 24 Applying this LAC labor force participation rate to the percentage of essential workers in California yields an estimated 27.4% essential workers in the total LAC population. This is slightly lower than the 29.4% in the study sample who reported being essential workers (Table 1), but the sample was limited to adults aged 18+ whose labor force participation is likely a little higher than that of the 16+ population used by the BLS. While we don't know if our sample represents the proportion of LAC essential workers by race/ ethnicity, it does represent the racial/ethnic makeup of the county overall, and several other studies cited in this paper corroborate our estimates of higher proportions of non-White groups in essential occupations compared to Whites. 8,11,15     %margins macro, data from the logistic regression models in Table 5 were used to estimate the adjusted marginal effects of essential worker status on vaccination uptake for each racial/ethnic group (Table 6). These effects can be interpreted as the absolute differences in the probability of vaccination between essential workers and non-essential workers after controlling for all covariates. The smallest 3.3%, 7.5%) among Asians (Table 6).

| DISCUSSION
To the authors' knowledge, this is the first study of racial/ethnic disparities in COVID-19 vaccine uptake to consider the effects of prioritizing essential workers during the early rollout of the vaccine.
By surveying a large representative sample of LAC adults at the time when the public health department was shifting from a priority group-based distribution strategy to universal eligibility, this study was able to explore the effects of essential worker prioritization on vaccine uptake among the largest racial/ethnic groups. These analyses exclude the 29 respondents who indicated they were unsure of their vaccination status. b Non-Essential/Not Working is the reference group for odds ratios. c Includes those working in food and agriculture, education and childcare, public safety, and janitorial and maintenance occupations. d Includes those working in health care and group living facilities, including nursing homes, homeless shelters, and jails. *p < 0.05; **p < 0.01; ***p < 0.001; ****p < 0.0001.

NICHOLAS ET AL.
| 237 distribution strategy with no prioritization of essential workers, we estimate that Whites, Blacks, Latinos and Asians experienced small and similar increases in population-level vaccine uptake following essential worker prioritization. While Blacks, Latinos, and Asians had significantly greater proportions of prioritized essential workers compared to Whites, they did not experience significantly greater marginal gains in vaccine uptake from their essential worker status compared to Whites (Table 6).
This may be partly explained by racial/ethnic disparities in the proportions of health care workers among all prioritized essential workers ( Table 2). Whites (48.5%) and Asians (61.1%) had higher proportions of health care workers than Blacks (42.8%) and Latinos (34.5%), and health care workers-likely because they were prioritized first-had higher vaccination rates than other prioritized essential workers regardless of race/ethnicity. Given that almost two thirds of Black and Latino prioritized essential workers were not If one of the goals of prioritizing essential workers was to achieve proportionally greater gains in early vaccine uptake among Blacks and Latinos due to the greater burden of COVID-19 in these communities, then the answer to the question posed in the title of this paper is no. While larger proportions of non-Whites groups were among the essential workers prioritized for early vaccine access, a lack of significant racial/ethnic differences in the marginal effects of essential worker status on early vaccine uptake muted any potential equity gains from this vaccine prioritization strategy. Nevertheless, while prioritizing essential workers did not achieve proportionally greater gains in early vaccine uptake among Blacks and Latinos-a laudable equity goal given the disproportionate burden of COVID-19 in these communities-this strategy likely prevented a further widening of racial/ethnic disparities in vaccine uptake.

CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest.

DISCLOSURE BY AJIM EDITOR OF RECORD
John Meyer declares that he has no conflict of interest in the review and publication decision regarding this article.

ETHICS APPROVAL AND INFORMED CONSENT
This study was reviewed and approved by the Institutional Review Board of the Los Angles County Department of Public Health.
Written informed consent was obtained from all study participants.

AUTHOR CONTRIBUTIONS
Will

DATA AVAILABILITY STATEMENT
Research data are not shared at this time.