COVID-19 vaccination coverage in deprived populations living in segregated colonies: A nationwide cross-sectional study in Hungary.

The segregated colonies (SCs) in Hungary are populated mainly but not exclusively by Roma. Their health care use is restricted in many respects. It has not been studied yet, whether fair COVID-19 vaccination coverage achieved in Hungary is accompanied with fair effectiveness in SCs. Using census data, the vaccination coverage in SCs and the complementary areas (CAs) in the same settlements of the country was determined. To describe the settlement level differences, the vaccination coverage (until June 30, 2021) in SCs were compared to those in CAs by age, sex, and eligibility for exemption certificate standardized measures. Aggregating settlement level data, the level of geographic discrimination in Hungary was also determined. According to nationwide aggregates, crude vaccination coverage was significantly lower in SCs (40.05%, 95% CI 39.87%-40.23%) than in CAs (65.42%, 95% CI 65.37%-65.46%). The relative standardized vaccination coverage was 0.643 (95% CI 0.639-0.647) in SCs. A total of 437 of the 938 investigated settlements showed significant local vaccination disparities. Hungarian citizens living in SCs, mainly of Roma ethnicity, are a distinct high-risk group. Special intervention adapted to SCs is needed to mitigate inequality in vaccination coverage and further consequences of the pandemic.

Introduction

The Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pathogen brought on a serious pandemic, which has been forecasted for a long time [1-3]. The echo of the concerned is reflected in the dramatic health, economic and social loss caused by the first three waves of the COVID-19 pandemic affecting all countries of the world [4]. The profound inequalities with respect to infection rate [5], mortality rate [6-11], and vaccination coverage are [12] among the dominant characteristics of this pandemic.

When and where COVID-19 vaccines became available, the vaccination programs’ target groups were determined by taking into consideration the susceptibility of individuals to lethal complications (e.g., elderly individuals, patients with chronic diseases) and to the personnel involved in COVID-19 patients’ health care [13].

The distinct (i.e., socioeconomic status independent) risk factor role of race/ethnicity has been demonstrated by investigations based on person-level race/ethnicity classification [14-16]. Studies, both on migrants by their country of birth [17] and geographical analyses of aggregated data on racial/ethnic composition and vaccination coverage [18-23], confirmed this observation. This evidence supports the case for strict monitoring of racial/ethnic inequalities in vaccination uptake/coverage, which is confirmed by published reports on successful interventions in this regard [24, 25]. To date, there are published reports on successful interventions aimed at diminishing racial/ethnic disparities in vaccination coverage [26-29].

These studies suggest that vaccination programs should consider racial/ethnic minorities as special high-risk groups that require minority-adapted, culturally appropriate approaches (complementing the main programs designed for the majority) to diminish the consequences of the vaccine-preventable COVID-19 infections pandemic in the forthcoming wave(s) of the pandemic.

Central and Eastern European (CEE) countries are home to 10–12 million Roma (many of them in segregated colonies, SC) who are the largest ethnic minority in Europe. In spite of some positive European experiences on Roma specific monitoring [30], there are no socioeconomic status (SES) or ethnic minority-specific monitoring programs either for COVID-19 health impacts or COVID-19 vaccination effectiveness in CEE countries. Although it seems probable that the CEE Roma are similar to the Black populations in the US and UK as well as to the Native Americans in the US with respect to health care use, the lack of monitoring prevents even planning targeted pandemic intervention [31-33]. Taking into consideration disadvantaged SES and the health status of Roma in CEE countries with limited access to health care [34], the COVID-19 vaccination coverage among this people group needs to be evaluated.

In Hungary, the last census in 2011 classified 315,583 persons as Roma (3.18% of the total population) by self-declaration. This approach (due to the negative historical experiences of ethnic minorities in governmental registration) seriously underestimates the number of Roma people. A special survey used the active contribution of the local municipalities estimated their number to be 870,000 (8.75% of the Hungarian population) [35, 36].

The poorer health status of the Roma living in Hungary is well documented [37, 38]. Approximately one-quarter of them [39] with a critical health status live in SCs. To improve the effectiveness of interventions targeting this high-risk population, a governmental decree (314/2012) defines the SCs utilizing census data. It establishes the production of indicators by which the needs can be explored and interventions can be elaborated for SCs, as well as the effectiveness of implemented SC-specific programs can be assessed.

Roma comprised 94% of the inhabitants in SCs in 2005 [9]. Although the Roma characteristics of SCs have weakened due to social changes over the last two decades, there have been no new investigations on the proportion of Roma inhabitants in SCs.

The free-of-charge voluntary COVID-19 vaccination program has been organized by the government in Hungary and it started on 26 December 2020. By the time our dataset was generated on 30 June 2021, Hungarian vaccination coverage was at 58.89% among adults, the 2nd highest in Europe according to the European Centre for Disease Prevention and Control [40].

Our investigation utilized the special opportunity of the Hungarian health statistical system (e.g., its ability to produce SC-specific indicators), to describe COVID-19 vaccination coverage in Hungary’s SCs in relation to the nonsegregated part of the same settlements to determine whether the population living in SCs dominated by Roma should be a distinct target group for vaccination programs.

Methods

Setting

This cross-sectional investigation encompassed the whole country. All COVID-19 vaccinations registered before 30 June 2021 were used in this study. The government organized a free-of-charge vaccination program using the Oxford/AstraZeneca COVID-19 vaccine, Janssen Ad26.COV2.S COVID-19 vaccine, Moderna COVID-19 (mRNA-1273) vaccine, Pfizer-BioNTech COVID-19 mRNA vaccine, Sinopharm COVID-19 vaccine, and the Sputnik V vaccine. The National Health Insurance Fund (NHIF) registered all vaccinations.

Mapping the segregated colonies

A governmental decree defines SCs as within settlement (within towns and within villages) clustering of residents 18–59 years old with not higher than primary level education and a lack of work-related income. The Hungarian Central Statistical Office determines the cluster or clusters as SCs and the complementary areas (CA) of the same settlements not belonging to any SC for all Hungarian settlements. Each Hungarian household is classified in this system as either an SC or a CA, in a mutually exclusive manner.

With the addresses of the adults the NHIF can define populations living in certain SCs or CAs. Therefore, all Hungarian adults can be classified as inhabitants living in an SC or living in a CA.

Data sources

Data were provided by the NHIF to which reporting COVID-19 vaccinations is compulsory. The NHIF updated their database day-by-day. In this study, vaccinations until 30 June 2021 were included.

The NHIF characterized all patients by their age, sex and eligibility for an exemption certificate (deprived patients with chronic disease are supported by an exemption certificate which is released by the local municipality based on the recommendation of the patient’s GP), and prepared the age group-, sex-, and eligibility for an exemption certificate-aggregated tables for each SC and CA based on the administration of the first and second COVID-19 vaccination doses.

The NHIF provided the target population data in the same structure. The age- (5-year bands), sex-, and possession of exemption certificate-specific numbers of vaccinations and populations were provided for each SC and CA.

Statistical analysis

People who have received both doses of the vaccine are defined as ‘vaccinated’ in this analysis. The crude vaccination coverage (cVC) was calculated for each SC and CA. The different vaccine types were not distinguished. Age, sex, and eligibility for exemption certificate-specific reference vaccination ratios for the whole population of Hungary were calculated and used in indirect standardization. Age, sex, and exemption certificate standardized vaccination coverage (sVC) was computed for each SC and CA.

The settlement-specific sVC was evaluated by comparing to the local reference value of settlement-specific sVC in CAs. Relative standardized vaccination coverage (RsVC), the ratio of sVCs for the SC to sVCs for the CA of the same settlement, along with the corresponding 95% confidence interval (95% CI), were calculated. (In the settlements where more than one SC was located, settlement-specific aggregated SC measures were computed by summarizing the observed number of vaccinations, populations, and the expected number of vaccinations.) The excess number of vaccinations was calculated as the difference between the observed and the expected number of vaccinations. The proportion of vaccinations attributable to segregation (attributable risk) was computed as the ratio of excess and observed number of vaccinations.

SPSS version 20 (IBM Corporation, New York, NY, USA) was used for the data analysis.

Ethical permission

Data provided by the Hungarian NHIF were used in this study. All data processed in our secondary analyses were geographically aggregated. Because individual information was not used, ethical approval and written informed consent were not required according to the Hungarian legal framework. The protocol to produce segregation-specific indicators was approved by the Office of the Commissioner for Fundamental Rights (AJB-3147/2013), the general director of the NHIF (E0101/215-3/2014), and the Hungarian National Authority for Data Protection and Freedom of Information (NAIH/2015/826/7N). Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the (S1 Checklist).

Results

There are 2006 SCs in Hungary belonging to 938 settlements. A total of 4,987,661 persons (60.7% of the Hungarian adult population) lives in settlements with SCs, and276,879 (5.6%) of them live in SCs. This proportion was higher in the 18-59-year-old age group (6.6%) than in the older age group (3.45%), reflecting the poor life expectancy in SCs. Younger adults were overrepresented, and elderly adults were underrepresented in the SC population. (Fig 1) The proportion of adults who were eligible for an exemption certificate was 6.43% (N = 17,814) in SCs and 2.39% (N = 112,700) in CAs, showing a higher level of deprivation in the SC population (p<0.001 by the chi square test).

Fig 1

Demographic structure of the populations living in segregated colonies and complementary areas of the settlements with segregated colonies in Hungary.

The overall cVC was 64.0% (3,192,457 vaccinations). According to nationwide aggregates, cVC was significantly lower in SCs (40.05%, 95% CI 39.87%-40.23%) than in CAs (65.42%, 95% CI 65.37%-65.46%). The difference was much larger in the 18- to 59-year-old age group than in the older than 60 age group (Table 1).

Table 1

Crude COVID-19 vaccination ratios among adults in segregated colonies and in the complementary part of the settlements with segregated colonies (Hungary, as 30 June 2021).

Age groups	Number of observed cases in the segregated colonies	Target group in the segregated colonies	Vaccination coverage in the segregated colonies*	Number of observed cases in the complementary areas	Target group in the complementary areas	Vaccination coverage in the complementary areas*
18–59 years	75,567	219,156	34.48% [34.28%-34.68%]	1,888,229	3,094,472	61.02% [60.97%-61.07%]
60+ years	35,324	57,723	61.20% [60.80%-61.59%]	1,193,337	1,616,310	73.83% [73.76%-73.90%]
18+ years	110,891	276,879	40.05% [39.87%-40.23%]	3,081,566	4,710,782	65.42% [65.37%-65.46%]

*with 95% confidence interval.

The sVC proved to be significantly lower in SCs (0.653, 95% CI 0.650–0.657) than in CAs (1.017, 95% CI 1.016–1.018). The RsVC was 0.643 (95% CI 0.639–0.647), associated with 58,807.9 missing vaccinations in SCs. Living in a SC accounted for 53% of the missing vaccinations. The difference was mainly generated in the 18-59-year-old age group, but it was significant in the older than 60-year-old age group as well (Table 2).

Table 2

Standardized COVID-19 vaccination coverage among adults in the segregated colonies and in the complementary part of the settlements with segregated colonies (Hungary, as 30 June 2021).

Age groups	Standardized vaccination coverage in segregated colonies*	Standardized vaccination coverage in complementary areas*	Relative standardized vaccination coverage in segregated colonies*	Number of excess cases in segregated colonies	Attributable risk in segregated colonies
18–59 years	0.593 [0.589–0.597]	1.026 [1.024–1.027]	0.578 [0.574–0.582]	-51,882.7	-68.7%
60+ years	0.836 [0.827–0.845]	1.003 [1.001–1.005]	0.833 [0.825–0.842]	-6,925.2	-19.6%
18+ years	0.653 [0.650–0.657]	1.017 [1.016–1.018]	0.643 [0.639–0.647]	-58,807.9	-53.0%

*with 95% confidence interval.

The SC-specific RsVCs showed a wide distribution among adults (mean±SD: 0.771±0.251). The mean RsVC was lower for the 18-59-year-old age group (0.740±0.262) than for the older than 60-year-old adults (0.884±0.217). The majority of SCs had lower local reference sVCs compared to CAs (Fig 2).

Fig 2

Vaccination coverage among adults in segregated colonies compared to the complementary area of the settlements with segregated colonies in Hungary.

Mapping the SCs, where local interventions were established by sVC were significantly lower than the sVCs in the CAs in the corresponding settlement; the spatial distribution proved to be highly uneven (Fig 3A–3C).

Fig 3

a. Settlements with local intervention requirements in Hungarian counties established by low relative standardized vaccination coverage among 18- to 59-year-old adults. (black square: standardized vaccination coverage in segregated colonies less than the complementary area’s reference; white circle: standardized vaccination coverage in segregated colonies not deviating from the complementary area’s reference). b. Settlements with local intervention requirements in Hungarian counties established by low relative standardized vaccination coverage among 60+ adults. (black square: standardized vaccination coverage in segregated colonies less than the complementary area’s reference; white circle: standardized vaccination coverage in segregated colonies not deviating from the complementary area’s reference). c. Settlements with local intervention requirements in Hungarian counties established by low relative standardized vaccination coverage among 18+ adults. (black square: standardized vaccination coverage in segregated colonies less than the complementary area’s reference; white circle: standardized vaccination coverage in segregated colonies not deviating from the complementary area’s reference).

Altogether, the number of SCs with significantly lower sVCs was 437, with 208,494 inhabitants, of which 80,065 were vaccinated. The number of missing vaccinations was 47,494.5. Most of the missing vaccinations were connected to the 18-59-year-old age group. In the 60+ age group, there were much fewer missing vaccinations (Table 3).

Table 3

Impact of segregation on COVID-19 vaccination coverage in high-risk segregated colonies (HRSC*).

Age groups	Number of HRSC	Population in HRSC	Number of vaccinations in HRSC	Number of excess cases in HRSC	Attributable risk in HRSC
18–59 years	412	159,433	52,578	-40,091.4	-76.3%
60+ years	85	14,455	7,705	-2,862.6	-37.2%
18+ years	437	208,494	80,065	-47,494.5	-59.3%

*standardized vaccination coverage in the settlement’s segregated colony significantly lower than that in complementary part of the same settlement.

Discussion

Main findings

Our study shows that COVID-19 vaccination coverage is significantly lower in SCs than in CAs according to both cVC (40.05% vs. 65.42%) and sVC (0.653 vs. 1.017). This demonstrates that the Hungarian COVID-19 vaccination program did not avoid geographic inequality, which has a strong ethnic dimension. This observation confirms the reported experiences from other countries about the inequality-generating characteristics of COVID-19 vaccination programs [17-23].

The cVC was much higher and vaccination inequality was much less pronounced among elderly individuals older than 60 years, compared to adults in the 18–59 age range. Organizational efforts were much more intensive and started earlier among elderly adults than among younger adults. The aim of public health authorities is not only to reduce of the epidemic’s intensity (reduction of susceptible population) but also to prevent serious complications, especially the infection of elderly individuals who were at higher risk. Personal motivation was also larger among elderly individuals for the same reasons.

By the time of our investigation, a total of 165,988 adults (9.24% of the sensitive population) were from the SCs and 1,629,216 from CAs. If the vaccination coverage in SCs were equal to that in CAs, then there would be only 95,758 susceptible inhabitants in SCs. It would be reflected in 3.91% decrease of the number of susceptible adults in the studied population, and in the 5.55% of the susceptible inhabitants would be from SCs. Consequently, although, the pandemic related future health loss could be prevented basically by the elevation of the vaccination in the CAs, a not negligible risk reduction could be achieved by the enforced/adapted vaccination project in the SCs.

Our investigation described the huge variability of settlement-specific RsVC. SC-related under-vaccination was generated by 437 SCs, where the number of adult inhabitants was 208,494 and the number of missing vaccinations was 47,494.5. The capacities required to make up the missing vaccinations seem to be small, given that in Hungary, 4,746,822 adults have been vaccinated at the time of our study.

It is probable that the vaccination inequality demonstrated by our study will increase the intensity of the fourth wave of the pandemic and result in health losses in Hungary, as it was observed in the second wave as area deprivation related COVID-19 mortality inequality [41].

Strengths and limitations

This investigation covered the entire country, which prevented selection bias. Because vaccination registration is compulsory in Hungary, misclassification of the vaccination status was also avoided.

The unique feature of the Hungarian health statistical system is that the segregated colonies populated mainly by Roma are defined in the census data, and health indicators can be computed for these geographical units. Since, the registration of ethnicity in Hungarian health care administration is prohibited as it is in other European countries as well; the main strength of our study design was that it could avoid the violation of personal rights by utilizing SC related opportunity.

The living place of adults could be misclassified if the registered residential address was in a SC but the real residential address was in a CA (or vice versa). The extent of this residential place misclassification is not known. Therefore, the potential dilution of the observed RsVC could not be quantified. Consequently, the real difference between SCs and CAs is underestimated by the observed RsVC = 0.643 (i.e. the real RsVC is less than 0.643). Furthermore, it must be acknowledged that this misclassification could be strong in certain SCs, where the segregation effect could be seriously underestimated. Therefore, there could be nonidentified high-risk SCs. Altogether, the segregation effect suggested by an RsVC of 0.643 is valid, and the identified high-risk SCs are real high-risk populations.

In this study, calculations for cVC, sVC and RsVC were made with the assumption that SC localization has not changed from the last Hungarian census collection. Since the most recent, census took place in 2011, both geographic boundaries and demographic composition of SCs and CAs may have changed due to internal migration. This effect can be evaluated having the data from the next census, which will be implemented in 2022.

Taking into consideration that SCs are dominated but not exclusively inhabited by Roma, and about three quarters of the Roma population does not reside in SCs, our findings of SC vaccination inequality cannot be extrapolated to characterize Roma vaccination inequality in general.

This study was not able to collect data on many factors that can affect vaccination coverage apart from age, sex, and exemption certificate eligibility [42]. A detailed exploration on the background of SC-specific vaccination’s variability needs further study. The social, cultural, economic and/or environmental differences between settlements with vaccination inequalities in SCs and those without inequality could be confounding variables in the rates of vaccination in these communities. Thus, there must be further understandings of the ethnic makeup and social determinants of health in Hungarian SCs.

Implications

The detected inequality demonstrates the necessity of special intervention programs targeting SCs in Hungary. Clearly, the general program was not as effective in SCs. The general program considered elderly individuals, patients with chronic disease, and health care personnel as high-risk groups. It appears that the population living in SCs, comprised dominantly of Roma, is also a high-risk group. Therefore, the population living in SCs should be considered high-risk target groups, where the general vaccination program should be adapted.

Extending the high-risk group definition in Hungary could help to mitigate the impacts of the epidemic on disadvantaged, mainly Roma minority of SCs. Although, there are obvious differences between Hungarian SC inhabitants and the ethnic minorities of the United States and the United Kingdom, this reconsideration is supported by published positive experiences and elaborated methodologies in these countries where vaccination organizations and monitoring are adapted to racial/ethnic minorities [6, 43–48].

It is also urgent to expand these methods in Hungary to reduce COVID-19 vaccination inequalities. If it is successful, then the approach could be used as a template for other inequality reductions. Otherwise, if a special intervention program is not implemented and applied, the lesson by the end of the pandemic will be that the COVID-19 epidemic (and other problems) can be managed without considering ethnic inequalities and accepting the associated additional health loss.

One of the seven objectives of the European Union is to “Increase effective equal access to adequate desegregated housing and essential services” showing that segregation is among the most important characteristics of European Roma. It is highly probable that segregated colonies of Roma in other European countries face similar problems demonstrated in Hungary [34]. Moreover, our observations could help to characterize inequities occurring in similarly segregated groups around the world. For example, in the United States, Native American populations on reservations closely resemble the geographic and ethnic isolation patters exhibited by the Roma in Hungary [49]. Thus, understanding vaccination discrimination in the Roma-populated SCs parallels the in access to healthcare and vaccination disparities of minority populations in the United States [50, 51].

Conclusions

The COVID-19 vaccination program was less effective in Hungarian SCs, populated mainly by Roma, than in the nonsegregated part of the settlements with SCs. Accordingly, the population of SCs can be considered a distinct high-risk group with respect to vaccination coverage. This inequality was weaker but significant among elderly individuals. On the other hand, there was not detectable disparities in all settlements, demonstrating that there were effective COVID-19 vaccination protocols in Hungary, which avoided SC related geographical inequality which can be an indicator of Roma vs. non-Roma discrimination.

Our findings suggest that within the SC population, elderly individuals, patients with chronic disease, and healthcare personnel should be considered as distinct target groups with adapted vaccination programs. The required adapted methodology could be based on the benchmarking of good practice by which vaccination rate disparities were avoided in many Hungarian settlements and on the experiences reported in other countries. The need for SC-adapted methodology should be as clear as the need for a special vaccination program for healthcare personal.

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15 Nov 2021

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15 Dec 2021

Dear Editor and Reviewers,

Thank you very much for the careful review of our manuscript. Please find enclosed the revised version of the manuscript “COVID-19 vaccination coverage in deprived populations living in segregated colonies: a nationwide cross-sectional study in Hungary” by János Sándor, et al.

Each comment and suggestion has been considered. The corresponding changes and refinements made in the revised paper are summarized in our response after considering each of your suggestion. Answers along with the modifications we made are summarized below (comments/questions of Yours are in capitals).

Sincerely yours, Janos Sandor (on behalf of the authors)

Answers/reflections to the comments of the Editor:

1. The title page and the main text have been corrected according to the PLOS ONE style templates.

2. Reference list has been updated according to the corrections. New references were added (see answers to the specific comments to the reviewers), and the numbering of references has been updated.

3. We completed the PLOS’ questionnaire on inclusivity in global research. It has been uploaded as Supporting Information (S1 Checklist.docx). The suggested subsection has been added to the Methods section: “Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist)”

4. The correct information on funding is the following:

"This study was carried out in the framework of the “ Routine monitoring for the health status and health care use in the Hungarian segregated colonies” program (BM/6327-3/2021, FEIF/951/2021-ITM), supported by the Deputy State Secretariat for Social Inclusion, Ministry of Interior. (https://2010-2014.kormany.hu/en/ministry-of-interior)

JS, FV, LK, KK, RÁ received grant from that program.

The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Please, modify the statement in the on-line submission system.

5. The Funding section of our manuscript has been deleted.

6. Because, we would like to respect the PLOS Data policy, the database of the investigation with the segregated colony and complementary area specific observed and expected number of completed vaccinations had been archived in the figshare repository.

This file can be downloaded without any restriction. All the indicators reported in our manuscript can be produced from this dataset. The name of settlements have been replaced with serial numbers in the dataset, because the identification of a settlement is not allowed: the Hungarian law on statistical data reporting (2016. évi CLV. törvény a hivatalos statisztikáról; Act on Official Statistics 2016) and related decrees prohibit the report of statistical data with less than or equal to 5 number of observed cases, and there are many observed number of cases meeting this criterion in the dataset. (The ’data.xlsx’ file is available searching for ’covid-19 vaccination’ and applying the following filters: Licence CC BY 4.0; Item Type dataset; Source figshare.com; Category Preventive Medicine.)

7. Files with figures had been uploaded to the PACE. The original figures had been revised according to this list:

Figure1.tiff: Resolution is changed to 300 PPI. Dimensions are adjusted to 2.63in W x 2.63in H TIFF file is converted to a valid TIF file.

Figure2.tiff: Resolution is changed to 300 PPI. TIFF file is converted to a valid TIF file.

Figure3a.tif: Compression is set to LZW. Resolution is changed to 300 PPI Dimensions are adjusted to 7.5in W x 3.91in H TIF file is converted to a valid TIF file.

Figure3b.tif: Compression is set to LZW. Resolution is changed to 300 PPI Dimensions are adjusted to 7.5in W x 3.91in H TIF file is converted to a valid TIF file.

Figure3c.tif: Compression is set to LZW. Resolution is changed to 300 PPI Dimensions are adjusted to 7.5in W x 3.91in H TIF file is converted to a valid TIF file.

The original files have been replaced with the PACE-revised versions in the on-line submission system.

Answers/reflections to the comments of Reviewer-1:

1.

THE AUTHORS, THROUGH A CROSS-SECTIONAL STUDY, PROVIDE EVIDENCE OF ETHNIC INEQUALITIES IN VACCINATION COVERAGE IN HUNGARY. THE MANUSCRIPT IS SUPPORTED BY EMPIRICAL EVIDENCE COLLECTED AT NATIONAL LEVEL; THE CONCLUSIONS ARE BASED ON THE DATA PRESENTED. THE AUTHORS STATE THAT RESTRICTIONS WILL APPLY IN THE AVAILABILITY OF DATA UNDERPINNING THIS STUDY.

Because, we would like to respect the PLOS Data policy, the database of the investigation with the segregated colony and complementary area specific observed and expected number of completed vaccinations had been archived in a public available site of the University of Debrecen:

https://nepegeszseg.unideb.hu/data/

This file can be downloaded without any restriction. All the indicators reported in our manuscript can be produced from this dataset. The name of settlements have been replaced with serial numbers in the dataset, because the identification of a settlement is not allowed: the Hungarian law on statistical data reporting (2016. évi CLV. törvény a hivatalos statisztikáról; Act on Official Statistics 2016) and related decrees prohibit the report of statistical data with less than or equal to 5 number of observed cases, and there are many observed number of cases meeting this criterion in the dataset.

2.

THIS STUDY IS A VERY RELEVANT PIECE OF RESEARCH, ESPECIALLY IN THE CONTEXT OF MULTICULTURAL SOCIETIES, WHERE DISADVANTAGED MINORITY ETHNIC GROUPS EXPERIENCE GROWING HEALTH INEQUALITIES, WHICH HAVE BEEN FURTHER DEEPENED BY THE COVID-19 PANDEMIC.

Thank you very much for this evaluation!

3.

I CANNOT COMMENT ON STATISTICAL ANALYSIS AS MY EXPERTISE IS IN QUALITATIVE DATA COLLECTION/ANALYSIS, RATHER THAN QUANTITATIVE METHODOLOGIES.

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4.

THIS MANUSCRIPT REQUIRES SUBSTANTIAL COPYEDITING TO IMPROVE READABILITY, CLARITY AND ACCURACY OF THE CONTENTS/STATEMENTS. THE UPLOADED PDF DOCUMENT CONTAINS NOTES WITH ADDITIONAL COMMENTS, AND SENTENCES HIGHLIGHTED IN YELLOW WHERE IMPROVEMENT MIGHT BE NECESSARY.

The text has been edited by the American Journal Expert (certificate uploaded to the on-line submission system).The highlighted texts with comments are reflected point by point as below:

Line 22:

THIS SENTENCE SHOULD BE REFORMULATED. “WHETHER FAIR COVID-19 VACCINATION COVERAGE HAS BEEN ACHIEVED IN HUNGARY IS ACCOMPANIED WITH FAIR EFFECTIVENESS IN SCS, HAS NOT YET BEEN STUDIED.”

Corrected version:

It has not been studied yet, whether fair COVID-19 vaccination coverage achieved in Hungary is accompanied with fair effectiveness in SCs.

Line 32:

THIS SENTENCE SHOULD BE REFORMULATED. “HUNGARIAN SCS POPULATED MAINLY BY ROMA ARE A DISTINCT HIGH-RISK GROUP WITH RESPECT TO COVID-19 VACCINATION.”

Thank you for this suggestion!

Corrected version:

Hungarian citizens living in SCs, mainly of Roma ethnicity, are a distinct high-risk group.

Line 38:

IT WOULD BE ADVISABLE TO SPELL OUT THE MEANING OF THIS ACRONYM (SARS-COV-2) THE FIRST TIME IT IS MENTIONED IN THE MANUSCRIPT.

Full name of the virus has been inserted.

Corrected version:

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2)

Line 43:

I THINK THE WORD “AND” IS NOT NEEDED HERE; IT SEEMS TO MISLEAD THE CORRECT MEANING OF THIS SENTENCE.

The “and” has been deleted. Thank you for this suggestion!

Corrected version:

“When and where COVID-19 vaccines became available, the vaccination programs’ target groups were determined by taking into consideration the susceptibility of individuals to lethal complications …”

Line 52:

THIS REMARK IS VERY IMPORTANT, HOWEVER, THE WAY IT IS WRITTEN IS MORE SUITABLE AS A RECOMMENDATION FROM STUDY FINDINGS. THIS SENTENCE AND THE NEXT COULD BE MERGED AS FOLLOWS: "THIS EVIDENCE SUPPORTS THE CASE FOR STRICT MONITORING OF RACIAL/ETHNIC INEQUALITIES IN VACCINATION UPTAKE/COVERAGE, WHICH IS CONFIRMED BY PUBLISHED REPORTS ON SUCCESSFUL INTERVENTIONS IN THIS REGARD."

Thanks for the suggested reformulation!

Corrected version:

“This evidence supports the case for strict monitoring of racial/ethnic inequalities in vaccination uptake/coverage, which is confirmed by published reports on successful interventions in this regard.”

Line 53:

REFERENCES SHOULD BE PLACED BEFORE FULL STOP THROUGHOUT THE MANUSCRIPT.

Correction:

All the references have been placed before full stop.

Line 55:

CULTURALLY APPROPRIATE?

The suggested completion has been accepted.

Corrected version:

“… that require minority-adapted, culturally appropriate approaches …”

Line 57:

THIS SENTENCE COULD END LIKE THIS "....VACCINE-PREVENTABLE COVID-19 INFECTIONS"

Corrected version:

“… to diminish the consequences of the vaccine-preventable COVID-19 infections in the forthcoming wave(s) of the pandemic.”

Line 59:

"....WHO ARE THE LARGEST ETHNIC MINORITY IN EUROPE"?

Corrected version:

“… home to 10-12 million Roma (many of them in segregated colonies, SC) who are the largest ethnic minority in Europe.”

Line 60:

IN HUNGARY OR IN CEE?

There is specific monitoring neither in CEE nor in Hungary.

Corrected version:

“There are no socioeconomic status (SES) or ethnic minority-specific monitoring programs either for COVID-19 health impacts or COVID-19 vaccination effectiveness in CEE countries”.

(see further modification of this sentence by the Line62 comments)

Line 62:

IT MAY BE WORTH MENTIONING HOW IN OTHER EUROPEAN COUNTRIES NGOS SUPPORTING THE RIGHTS TO HEALTH OF ROMA HAVE BEEN ADVOCATING FOR 'ETHNIC IDENTIFIER' IN COVID-19 HEALTH IMPACT. THIS MAY STRENGTHEN THE ARGUMENTS PUT FORWARD IN THIS MANUSCRIPT.

SEE HERE: HTTPS://WWW.PAVEEPOINT.IE/STAY-SAFE-FROM-CORONAVIRUS-COVID-19/

AND ALSO RECOMENDATION N.10 IN THE FOLLOWING REPORT: HTTPS://WWW.PAVEEPOINT.IE/WP-CONTENT/UPLOADS/2015/04/VACCINE-IMPLEMENTATION.PDF

Thank you very much for these suggestions! It really adds to the paper! One of the proposed references has been inserted. (Fay R, Kavanagh L, Amin N. COVID-19 and Irish travellers: Interim responses, reflections and recommendations. Available from: https://www.paveepoint.ie/wp-content/uploads/2015/04/COVIDREPORTWEB.pdf Accessed at 24/11/2021)

Corrected version:

“In spite of some positive European experiences on Roma specific monitoring [REF], there are no socioeconomic status (SES) or ethnic minority-specific monitoring programs either for COVID-19 health impacts or COVID-19 vaccination effectiveness in CEE countries.”

Line 64:

The same NGOs have also published evidence of targeted COVID-19 pandemic mitigation interventions for Travellers and Roma in Ireland which may be worthwhile mentioning here as good practice in other European countries: https://journals.sagepub.com/doi/full/10.1177/1757975921994075

Thank you very much for this suggestion! Because this paper is about Roma specific interventions, citation of this paper is really important. But, the sentence “To date, there are published reports on successful interventions aimed at diminishing racial/ethnic disparities in vaccination coverage.”, therefore this reference has been added to the references for this sentence.

Villani J, Daly P, Fay R, Kavanagh L, McDonagh S, Amin N. A community-health partnership response to mitigate the impact of the COVID-19 pandemic on Travellers and Roma in Ireland. Glob Health Promot. 2021; 28(2):46-55. doi: 10.1177/1757975921994075

Correction:

Reference has been added.

Line 75:

THIS SENTENCE NEEDS TO BE REFORMULATED. “THIS ESTABLISHES THE PRODUCTION OF SC-SPECIFIC INDICATORS BY WHICH THE NEEDS’ EXPLORATION AND THE ELABORATION OF INTERVENTIONS, AS WELL AS AN ASSESSMENT OF THE INTERVENTIONS’ EFFECTIVENESS CAN BE CARRIED OUT.”

Corrected version:

“It establishes the production of indicators by which the needs can be explored and interventions can be elaborated for SCs, as well as the effectiveness of implemented SC-specific programs can be assessed.

Line 84:

ANY REFERENCE AVAILABLE TO SUPPORT THIS STATEMENT?

The ECDC regularly updates a downloadable dataset of the country specific indicators of vaccination.

Corrected version:

A new reference has been added as:

European Centre for Disease Prevention and Control: Download COVID-19 datasets; https://www.ecdc.europa.eu/en/covid-19/data Accessed at 30/09/2021

Line 87:

IT WAS NEVER EXPLAINED BEFORE THAT THERE IS A NONSEGREGATED PART OF THE SETTLEMENTS. PERHAPS THIS COULD BE EXPLAINED FOR READERS WHO ARE NOT FAMILIAR WITH THE ROMA SETTLEMENTS IN HUNGARY.

Corrected version:

“… in relation to the nonsegregated part of the same settlements …”

Line 90:

WHILE THE TITLE OF THE MANUSCRIPT REFLECTS THE STUDY DESIGN (I.E. CROSS-SECTIONAL STUDY), THIS IS NOT MENTIONED EXPLICITLY IN THE MANUSCRIPT. THIS COULD BE SPECIFIED IN THE TEXT, ALONG WITH A REFERENCE OF SIMILAR STUDIES USING THE SAME DESIGN. THIS WILL STRENGTHEN THE METHODOLOGICAL UNDERPINNINGS OF THE STUDY.

Thank you for this suggestion! The design has been inserted into the main text, into the first sentence of the Setting section.

Corrected version:

This cross-sectional investigation encompassed the whole country.

Line 99:

THIS PARAGRAPH REQUIRES EDITING. THE DEFINITIONS OF SC AND CA ARE VERY IMPORTANT FOR THE PURPOSE OF THIS PAPER, AND THEY SHOULD BE DEFINED MORE CLEARLY. THIS WILL HELP READERS WHO ARE NOT FAMILIAR WITH THE HUNGARIAN ENVIRONMENT. FOR EXAMPLE, LATER ON IT IS EXPLAINED THAT IN A 'SETTLEMENT' THERE COULD BE SEVERAL SCS. PLEASE DEFINE WHAT A 'SETTLEMENT' IS.

Corrected version:

A governmental decree defines SCs as within settlement (within towns and within villages) clustering of residents 18-59 years old with not higher than primary level education and a lack of work-related income. The Hungarian Central Statistical Office determines the cluster or clusters as SC(s) and the complementary areas (CA) of the same settlements not belonging to any SC for all Hungarian settlements.

Line 123:

Nationality?

Not. But, this misleading sentence has been modified.

Corrected version:

Age, sex, and eligibility for exemption certificate-specific reference vaccination ratios for the whole population of Hungary were calculated and used in indirect standardization.

Line 130:

DEFINITION OF 'SETTLEMENT' IS REQUIRED.

The term settlement as the aggregated concept for villages and towns has been explained before (see the answer to the Line 99 comment)

This sentence has not been modified.

Line 149

THIS SENTENCE CAN BE MERGED WITH THE PREVIOUS ONE: "..."

Corrected version:

A total of 4,987,661 persons (60.7% of the Hungarian adult population) live in settlements with SCs, and 276,879 (5.6%) of them live in SCs.

Line 226:

REFERENCE?

New references had been added. References cited in the Introduction (references 17-23) have been cited here again.

Line 236:

THE INTENT OF THE AUTHORS TO DEMONSTRATE INEQUALITIES IN VACCINATION COVERAGE IS CLEAR HERE. HOWEVER, THIS PARAGRAPH REQUIRES EDITING TO MAKE THE SENTENCES CLEARER AND ITS CONTENT STRONGER AND MORE READABLE.

Corrected version:

By the time of our investigation, a total of 165,988 adults (9.24% of the sensitive population) were from the SCs and 1,629,216 from CAs. If the vaccination coverage in SCs were equal to that in CAs, then there would be only 95,758 susceptible inhabitants in SCs. It would be reflected in 3.91% decrease of the number of susceptible adults in the studied population, and in the 5.55% of the susceptible inhabitants would be from SCs. Consequently, although, the pandemic related future health loss could be prevented basically by the elevation of the vaccination coverage in the CAs, a not negligible risk reduction could be achieved by the enforced/adapted vaccination project in the SCs.

Line 293:

'THE POPULATION LIVING IN SCS SHOULD BE CONSIDERED HIGH RISK TARGET GROUPS'

Thank you for this suggestion!

Corrected version:

“Therefore, the population living in SCs should be considered high risk target groups, where the general vaccination program should be adapted.”

Line 296:

'...ON DISADVANTAGE ETHNIC MINORITIES'?

Corrected version:

“… to mitigate the impacts of the epidemic on disadvantaged ethnic minorities.”

Line 310:

IT WOULD BE RECOMMENDED TO INTRODUCE THE EXAMPLE OF NATIVE AMERICANS, AND RELATED REFERENCES, IN THE INTRODUCTION ALONG WITH BLACKS IN US AND UK (LINES 62-64), AS THIS IS THE FIRST TIME WHERE NATIVE AMERICANS ARE MENTIONED IN THE MANUSCRIPT, AT THE VERY END OF THE MANUSCRIPT. GENERALLY THE DISCUSSION DOES NOT INTRODUCE NEW CONCEPTS OR TOPICS.

Mention of Native Americans has been added to the sentence suggested with a new reference.

Cromer KJ, Wofford L, Wyant DK. Barriers to Healthcare Access Facing American Indian and Alaska Natives in Rural America. J Community Health Nurs. 2019;36(4):165-187. doi: 10.1080/07370016.2019.1665320

Corrected version:

“Although it seems probable that the CEE Roma are similar to the Black populations in the US and UK as well as to the Native Americans in the US with respect to health care use [REF], …”

Line 315:

FINALLY, THE MANUSCRIPT REQUIRES SIGNIFICANT PROOFREADING AND COPYEDITING AS SEVERAL PARAGRAPHS THROUGHOUT THE TEXT ARE NOT CLEAR. THE AUTHORS COULD SEEK EDITORIAL HELP BEFORE SUBMITTING A REVISION.

Thank you very much for the careful reviewing! The criticized texts have been modified (as it is reported above). We hope that these reflections are acceptable. (The text has been edited by the American Journal Expert -certificate uploaded to the on-line submission system.)

5.

ALL IN ALL IT IS AN INTERESTING AND RELEVANT PIECE OF RESEARCH. A THOROUGH EDITING WOULD GREATLY IMPROVE THE QUALITY OF THIS MANUSCRIPT.

Thank you for this general evaluation! The required editing has been completed as detailed above.

Answers/reflections to the comments of Reviewer-2:

Line 62:

PLEASE ELABORATE FURTHER ON HOW THE SIMILARITY BETWEEN CEE ROMA AND BLACK POPULATIONS IN THE US AND UK (WITH RESPECT TO HEALTH CARE USE) ARE PROBABLE? BASED ON WHAT ASSUMPTIONS, OR RESEARCH? BASED ON THE SOCIAL, ENVIRONMENTAL AND OTHER DETERMINANTS OF HEALTH? OR IS IT SOMETHING ELSE?

As it is stated in the sentence, the restricted health care availability is the common characteristic of the mentioned minorities. (The paper is about the restricted access to a special health care service – COVID-19 vaccination. The paper is not about the mechanisms behind the inequality.) To support this statement two references had been added to the text.

Williams DR, Rucker TD. Understanding and Addressing Racial Disparities in Health Care. Health Care Financ Rev. 2000; 21(4):75–90.

Fiscella K, Sanders MR. Racial and Ethnic Disparities in the Quality of Health Care. Annu Rev Public Health. 2016;37:375-94. doi: 10.1146/annurev-publhealth-032315-021439

Correction:

New references added.

Line 227:

REPORTED EXPERIENCES FROM OTHER COUNTRIES ABOUT THE INEQUALITY-GENERATING CHARACTERISTICS OF COVID-19 PROGRAMS ARE NOT SUPPORTED BY REFERENCE.

The same was requested by the Reviewer-1 also. References cited in the Introduction (references 17-23) have been cited here again. These papers are about the observed inequalities.

Correction:

New references added.

Line 263:

LACKS THOSE ROMA THAT MIGHT BE WITHOUT VALID ID DOCUMENTS AND/OR REGISTERED ADDRESS.

Because the study base of this investigation was adults with registered residential place (it is accompanied with valid ID) in settlements with at least one segregated colony, people belong to other part of the Hungarian population, even being at high-risk in the respect of omitting COVID-19 vaccination, were not scrutinized.

No correction in the text.

Line 272:

I FIND THE ASSUMPTION OF SC LOCALISATION NOT HAVING CHANGED FROM THE LAST HUNGARIAN CENSUS COLLECTION (2011) VAGUE.

The limitation caused by the not updated segregation boundaries is explicitly acknowledged in the paragraph (4th paragraph in the Strengths and limitations section).

No correction in the text.

Line 289:

SCS ARE TO BE TARGETED WITH INTERVENTIONS PROGRAMS REGARDLESS OF ETHNICITY, AS DUE TO THE LACK OF DATA ON ETHNICITY, WE DON'T KNOW THE REAL NUMBER OF THE ROMA POPULATION LIVING THERE. USING GEOGRAPHICAL UNITS AS INDICATORS MIGHT NOT BE ACCURATE.

This limitation is also acknowledged in the paragraph of Line 277-280: “Taking into consideration that SCs are dominated but not exclusively inhabited by Roma, and about three quarters of the Roma population does not reside in SCs, our findings of SC vaccination inequality cannot be extrapolated to characterize Roma vaccination inequality in general.” We did not (over-)interpret our results as Roma specific findings.

No correction in the text.

Line 298:

ALL REFERENCES REFER TO BLACK AND/OR ASIAN COMMUNITIES, AND THE SECTION LACKS A DEEPER DISCUSSION ON HOW THEIR CHALLENGES MIGHT BE SIMILAR TO THOSE OF THE ROMA OR WHY THEY ARE RELEVANT.

It was not among the objectives of our investigation to explore the background of SC-related inequality in COVID-19 vaccination in Hungary. The reliable description of this inequality was aimed to be demonstrated. The purpose with reference to similar inequality in other countries was to demonstrate that the Hungarian finding is not exceptional according to the international experiences.

No correction in the text.

Line 310:

THE STATEMENT THAT USA NATIVE AMERICAN POPULATIONS ON RESERVATIONS CLOSELY RESEMBLE THE GEOGRAPHIC AND ETHNIC ISOLATION PATTERNS EXHIBITED BY THE ROMA IN HUNGARY LACKS A REFERENCE, AND SUGGESTS THAT THIS STATEMENT IS BASED ON SUBJECTIVE ASSUMPTIONS. IT SHOULD BE EITHER SUPPORTED BY SCIENTIFIC SOURCES AND DISCUSSED IN MORE DETAILS, OR SHOULD BE REMOVED FROM THE TEXT.

Thank you very much for this comment! A comprehensive health status evaluation of Native American community is presented in this report: Indian Health Service. Trends in Indian health - 2014 edition.

Available from https://www.ihs.gov/sites/dps/themes/responsive2017/display_objects/documents/Trends2014Book508.pdf Accessed at 24/11/2021

Correction:

New reference has been added.

General remarks 1:

DATA BASED ON HEALTH INDICATORS OF GEOGRAPHICAL UNITS, EVEN IF THESE UNITS ARE MAINLY POPULATED BY ROMA MIGHT RESULT IN BIAS AS MANY ROMA DON'T LIVE IN THESE AREAS ACROSS HUNGARY. THUS, THE RESEARCH REVEALS DATA AND INFORMATION ON THE POPULATIONS OF THE SCS AND CAS, REGARDLESS OF THEIR ETHNIC BACKGROUND.

This remark is true. But, it was not the aim of our investigation to describe the vaccination among Roma compared with the vaccination among non-Roma in general. To demonstrate that we did not over-interpret the presented results, we explicitly stated it in the text (5th paragraph in Strengths and limitations section) that: “Taking into consideration that SCs are dominated but not exclusively inhabited by Roma, and about three quarters of the Roma population does not reside in SCs, our findings of SC vaccination inequality cannot be extrapolated to characterize Roma vaccination inequality in general.”

No correction in the text.

General remarks 2:

FURTHERMORE, THE RESEARCH DOES NOT TAKE NON-GOVERNMENTAL INITIATIVES INTO CONSIDERATION IN TERMS OF VACCINATION CAMPAIGNS, THAT WERE CARRIED OUT MAINLY IN THE MOST DEPRIVED AND SEGREGATED AREAS OF HUNGARY.

This paper is not about the evaluation of the background of the vaccination inequality. It is a descriptive paper about the demonstration of within settlement inequality. The last paragraph of the Strengths and limitations section is about the future research needs: “This study was not able to collect data on many factors that can affect vaccination coverage apart from age, sex, and exemption certificate eligibility [36]. A detailed exploration on the background of SC-specific vaccination’s variability needs further study. The social, cultural, economic and/or environmental differences between settlements with vaccination inequalities in SCs and those without inequality could be confounding variables in the rates of vaccination in these communities. Thus, there must be further understandings of the ethnic makeup and social determinants of health in Hungarian SCs.”

No correction in the text.

Submitted filename: Response to Reviewers 2.docx

Click here for additional data file.

31 Jan 2022

2 Feb 2022

Dear Editor and Reviewer,

Thank you very much for the careful second review of our manuscript. Please find enclosed the revised version of the manuscript “COVID-19 vaccination coverage in deprived populations living in segregated colonies: a nationwide cross-sectional study in Hungary” by János Sándor, et al.

Both comments have been considered. The corresponding changes made in the revised paper are summarized in our response after considering each of your suggestion. Answers along with the modifications we made are summarized below (comments/questions of Yours are in capitals).

Sincerely yours, Janos Sandor (on behalf of the authors)

Answers/reflections to the comments of the Editor:

1.

THERE IS A DISCREPANCY BETWEEN THE FIRST LINES OF THE ABSTRACT AND THE REST OF THE TEXT OF THE RESEARCH. ALTHOUGH IT IS FURTHER ELABORATED WITHIN THE TEXT LATER, THE ABSTRACT DOES NOT SUPPORT THE ABOVE STATEMENTS. PLEASE REPHRASE YOUR ABSTRACT ACCORDINGLY, AS THE TEXT CURRENTLY SUGGESTS THAT THIS RESEARCH FOCUSES ON THE ROMA ETHNIC MINORITY (LIVING IN SCS AND CAS).

Thank you for this comment. The misleading sentences have been modified accordingly.

Original text:

“The largest ethnic minority in Hungary is Roma, comprising 8.7% of the population. A quarter of them live in segregated colonies (SCs). Their health care use is restricted in many respects.”

Corrected version:

“The segregated colonies (SCs) in Hungary are populated mainly but not exclusively by Roma. Their health care use is restricted in many respects.”

2.

FURTHERMORE, WITH REGARDS TO LINE 298 NO REFERENCE OR SCIENTIFIC EVIDENCE HAS BEEN ADDED TO SUPPORT THE STATEMENT THAT ROMA AND BLACK/ASIAN COMMUNITIES FACE THE SAME CHALLENGES AND OBSTACLES IN TERMS OF THEIR ACCESS TO HEALTH SERVICES. IN MY OPINION THIS PART SHOULD BE EITHER EXTENDED, OR REPHRASED.

As it is acknowledged in the paper our investigation could not investigate the background of SC-related inequality in COVID-19 vaccination in Hungary. The demonstration of this inequality was aimed.

We referred the successful experiences with monitoring based interventions in the field of racial inequalities’ management in order to demonstrate that the basic discipline of public health is working in practice.

We could not undertake a deeper analysis of similarities and differences between racial minorities in the USA/UK and Hungarian segregated colonies populated mainly by Roma.

To clarify this intention, the paragraph has been rephrased.

Original text:

“Extending the high-risk group definition could help to mitigate the impacts of the epidemic on disadvantaged ethnic minorities. This reconsideration is supported by published positive experiences and elaborated methodologies in countries where vaccination organizations and monitoring are adapted to racial/ethnic minorities [6,43-48].”

Corrected version:

“Extending the high-risk group definition in Hungary could help to mitigate the impacts of the epidemic on disadvantaged, mainly Roma minority of SCs. Although, there are obvious differences between Hungarian SC inhabitants and the ethnic minorities of the United States and the United Kingdom, this reconsideration is supported by published positive experiences and elaborated methodologies in countries where vaccination organizations and monitoring are adapted to racial/ethnic minorities [6,43-48].”

Submitted filename: Response to Reviewer 2.docx

Click here for additional data file.

9 Feb 2022

COVID-19 vaccination coverage in deprived populations living in segregated colonies: a nationwide cross-sectional study in Hungary

PONE-D-21-32644R2

Dear Dr. Sándor,

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

18 Feb 2022

PONE-D-21-32644R2

COVID-19 vaccination coverage in deprived populations living in segregated colonies: a nationwide cross-sectional study in Hungary

Dear Dr. Sándor:

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