Reimagining COVID Vaccine Distribution: Reflecting on Waste and Equity
Authors: Greenhalgh Scott , Alva Maria L. , Phuong Jim 
Published: October 2024

ABSTRACTImportanceEfficient distribution and administration of vaccines are critical to preventing unnecessary morbidity and mortality. We assess the distribution, uptake, and wastage of COVID-19 vaccine doses across the U.S., providing insights for optimizing future vaccination distribution strategies.ObjectiveWe evaluate the distribution, uptake, and wastage of COVID-19 vaccine doses in the U.S. Specifically, we quantify the impact of limiting vaccine wastage and illustrate incidence and deaths averted under two targets set by the Global Alliance for Vaccines and Immunization (GAVI).Design and SettingWe obtained COVID-19 vaccine doses administered by location and wastage data from jurisdictions, pharmacies, and federal entities from the Centers for Disease Control and Prevention through a Freedom of Information Act. From this data, a retrospective analysis covering the period from December 2020 to October 2022 involving 761 million vaccine doses distributed across all counties and states in the U.S. We estimate the proportion of vaccines wasted, and then incidence and deaths averted had adherence to GAVI waste targets occurred to inform on the quality of the national vaccination effort and identify potential regions for improvement.ExposureVaccine uptake and waste vary substantially across states, as measured by doses administered per capita. GAVI targets of 25% and 15% vaccine waste serve as benchmarks for assessing the impact of potential improvements in vaccine distribution and acceptance.Main outcomes and measuresThe identification of within and across-state variation in COVID-19 vaccine waste relative to GAVI targets and their implications on morbidity and mortality.ResultsAmong the 761 million distributed doses, only 600 million were administered, resulting in a national average of 1.8 doses per capita. Substantial regional disparities were observed, with the District of Columbia reaching 2.5 doses per capita and Alabama lagging at 1.3 doses per capita. Thirty states exceeded the GAVI 15% vaccine waste target, corresponding to 64.2 million unused doses. Meeting the 15% target would have averted 29,669,318 incidences and 6,468 deaths.Conclusion and relevanceAddressing the causes of county-level variations and targeting states with below-average vaccine hesitancy and above-target vaccine waste would likely maximize future vaccine distribution efforts and minimize wastage-related losses. This strategy highlights an avenue for improving future vaccine distribution policy.KEY POINTSQuestionIn what areas of domestic vaccine allocation could improvements be made to reduce vaccine waste? What impact could reducing vaccine waste have had on lowering both COVID-19 incidence rates and mortality rates?FindingsBetween December 2020 and October 2022, the U.S. wasted approximately 25.4 million COVID-19 vaccine doses. Reducing waste to under 25% could have averted 1.3 million COVID-19 cases and an estimated 1,570 deaths over that period. Waste was associated with hesitancy, rurality, and prevalent political affiliation.MeaningThis counterfactual exercise underscores the importance of addressing vaccine wastage to mitigate COVID-19 incidence and its associated fatalities.