Background In the USA, Covid-19 exposed deep social, racial and ethnic inequities—but policy makers also deployed a major novel tool to promote equity within, and likely beyond, the pandemic, by modifying allocation frameworks with disadvantage indices (DIs, ie: place-based measures integrating census variables such as income, education or housing-situation, enabling ranking geographic areas as small as neighborhoods).

Objective To assess to what extent DIs have been adopted, and what their potential is to improve equity in, and beyond, Covid-19 allocation-decisions.

Methods A) structured review of US states’ use of DIs in the initial vaccine roll-out, (Schmidt et al. ‘Equitable allocation…’ Nature Medicine (27) 2021), C) literature scoping review of use of dominant DI (Pubmed/Embase/WebSc), D) Conceptual analysis.

Results In an unprecedented, rapid, and widespread effort, a majority of US states (n=34) added disadvantage indices in Covid-19 vaccine allocation plans. The dominant model is the CDC’s Social Vulnerability Index (SVI), developed for natural disaster response efforts (mapping well onto a conceptualization in the philosophical literature: Wolff/De-Shalit, ‘Disadvantage’, OUP 2007, as well as public preferences: Schmidt et al. ‘US adults’ preferences…’ JME, 2021). Main DI uses: planning dispensing site locations, targeted outreach/communication, increasing vaccine quantities, and monitoring uptake/course-correcting. Adapted forms were also used for tests and antiviral treatment allocation. The scoping review of SVI uses is ongoing at the time of submission; preliminary findings are that around 50% of N=119 publications use DIs ‘off-label’, ie in non-emergency settings, indicating an unmet need. Emergent themes include: budgetary allocations, healthcare service access planning, targeted prevention.

Discussion In Spring 2020, the dominant theme in Covid-19 allocation frameworks was maximizing overall benefits—often risking exacerbating existing inequities. The rapid and widespread DI adoption opened a major new chapter, holds major potential to improve equity in allocation beyond Covid-19, and should be explored further.