Marked Disparities in COVID-19 Vaccination among US Children and Adolescents by Racial/Ethnic, Socioeconomic, Geographic, and Health Characteristics, United States, December 2021 – April 2022

2.1. Data

We used pooled data from five consecutive samples of the US Census Bureau’s Household Pulse Survey (HPS) conducted between December 2021 and April 2022. The five independent HPS samples that included information for vaccination among children aged 5-11 and 12-17 years were: Week 40, December 1-13, 2021; Week 41, December 29, 2021–January 10, 2022; Week 42, January 26–February 7, 2022; Week 43, March 2–14, 2022; and Week 44, March 30–April 11, 2022.18 The HPS is a national sample household survey in which data on socioeconomic, demographic, physical and mental health, food insecurity, childcare, and healthcare characteristics, including health insurance coverage, COVID-19 diagnosis and vaccination, and access to telehealth during the COVID-19 pandemic are collected in near real-time via email and internet. The survey was developed as a rapid response survey in order to track the social and economic impacts of COVID-19 pandemic on American households on a weekly or bi-weekly basis in partnership with several federal statistical agencies.19,20 Information collected in the survey is based on self-reports by respondents aged 18 years and older. The HPS uses a systematic sample design and is representative of the civilian non-institutionalized population of the US. Substantive and methodological details of the survey are available elsewhere.18–20

2.2. Measurement of Childhood COVID-19 Vaccination and Covariates

The binary outcome variable, the receipt of COVID-19 vaccine in children, was derived from the question, “Have any of the children living in your household received at least one dose of a COVID-19 vaccine?” with children receiving the vaccine coded as 1 and those not receiving the vaccine coded as 0. The pooled sample size from December 1, 2021 to April 11, 2022 HPS was 86,335 for children aged 5-17 years for whom the vaccination status was available.18

Based on previous research and the social determinants of health framework, we selected the following parental or household covariates: parental age, gender, race/ethnicity, marital status, region or metropolitan statistical area (MSA) of residence, educational attainment, household income, housing tenure, employment status, health insurance status, and prior COVID-19 diagnosis, and COVID-19 vaccination status.6,9,18,21 Except for age, no other demographic characteristics for children were available. The covariates were measured as shown in Tables 1 and 2.

2.3. Statistical Methods

Multivariate logistic regression was used to model vaccination disparities among children after controlling for parental or household socioeconomic, demographic, and health characteristics. The Chi-square statistic was used to test the overall association between each covariate and vaccination prevalence, whereas the two-sample t-test was used to test the difference in prevalence between any two groups or geographic areas. To account for the complex sample design of the HPS, SUDAAN software was used to conduct all statistical analyses, including the logistic modeling procedure RLOGIST.22

3.1. Disparities in COVID-19 Vaccination among US Children Aged 5-17 by Social Determinants

During December 2021–April 2022, an estimated 40.1 million, or 57.2% of US children aged 5-17 years received COVID-19 vaccination (Table 1). The child vaccination rate varied 2-fold across the parental age range, from a low of 34.9% for parents aged 25-34 to 69.2% for parents aged 45-54 years (Table 1). Adjusted for covariates, children of parents aged 18-24 and 45-54 had, respectively, 115% and 69% higher odds of vaccination, and children of parents aged 25-34 had 45% lower odds, compared with children of parents aged ≥75 (Table 1).

Female adults, non-Hispanic Blacks, other and multiple-race adults, divorced/separated, widowed, and single individuals, adults with lower education and household income levels, renters, not-employed or uninsured individuals, adults with prior COVID-19 diagnoses, and adults without COVID-19 vaccination reported significantly lower rates of vaccination for their children aged 5-17 (Table 1). Controlling for sociodemographic and health characteristics, Asian and Hispanic children had, respectively, 134% and 47% higher odds of receiving vaccination than their non-Hispanic White counterparts (Table 1). Compared with children of parents with at least a master’s degree, children of parents with a high school education, some college, or bachelor’s degree had, respectively, 47%, 39%, and 23% lower adjusted odds of receiving a vaccination (Table 1). Children with household income <$25,000 had 48% lower adjusted odds of receiving vaccination than those with household income ≥$200,000 (Table 1). Children of uninsured parents had 25% lower adjusted odds of receiving vaccination than children whose parents had health insurance.

Parental COVID-19 diagnosis and parental vaccination status were strong predictors of children’s vaccination status (Table 1). Controlling for covariates, children of parents who had a prior COVID-19 diagnosis had 27% lower odds of vaccination than children of parents without a COVID-19 diagnosis. Children whose parents had not received COVID-19 vaccination themselves had 95% lower odds of receiving COVID-19 vaccination than children whose parents received COVID-19 vaccination, controlling for other factors.

3.2. Disparities in COVID-19 Vaccination among US Children Aged 5-11 and Adolescents Aged 12-17

During December 2021–April 2022, an estimated 19.9 million or 47.7% of US children aged 5-11 received COVID-19 vaccination (Table 2). During the same period, 29.1 million, or 66.1% of US adolescents aged 12-17 received COVID-19 vaccination (Table 2). Parents aged 45-54 reported the highest vaccination rates for their children aged 5-11 (58.5%) and adolescents aged 12-17 (75.1%), whereas parents aged 25-34 reported the lowest vaccination rate for their children aged 5-11 (29.9%) and adolescents aged 12-17 (50.6%).

About 77.3% of Asian children aged 5-11 had received COVID-19 vaccination, compared with 40.5% of Black children, 45.2% of non-Hispanic White children, and 49.5% of Hispanic children aged 5-11. About 91.9% of Asian adolescents aged 12-17 had received COVID-19 vaccination, compared with 63.2% of Black adolescents and 62.6% of non-Hispanic White adolescents, and 70.3% of Hispanic adolescents (Table 2). Controlling for covariates, Asian children aged 5-11 had 142% higher odds of vaccination, and Asian adolescents aged 12-17 had 287% higher odds of vaccination compared with their non-Hispanic White counterparts. Hispanic children aged 5-11 had 45% higher adjusted odds of vaccination and Hispanic adolescents aged 12-17 had 54% higher adjusted odds of vaccination than their non-Hispanic White counterparts.

Marked education and income gradients in vaccination rates were found for children aged 5-11 and adolescents 12-17. Compared with children aged 5-11 whose parents had at least a master’s degree, children aged 5-11 whose parents had a high school education, some college, or bachelor’s degree had, respectively, 48%, 44%, and 30% lower adjusted odds of receiving a vaccination. Compared with adolescents aged 12-17 whose parents had at least a master’s degree, adolescents aged 12-17 whose parents had a high school education, some college, or bachelor’s degree had, respectively, 52%, 43%, and 19% lower adjusted odds of receiving a vaccination.

3.3. Disparities in Childhood COVID-19 Vaccination among 15 Largest US Metropolitan Areas

Rates of COVID-19 vaccination among children aged 5-17 ranged from a low of 49.6% in Atlanta MSA, Georgia, and 52.1% in Detroit MSA, Michigan to a high 82.6% in San Francisco-Oakland MSA, California (Figure 1). Parental age, race/ethnicity, education, household income, and prior parental COVID-19 diagnosis and vaccination status were independent and significant predictors of COVID-19 vaccination in metropolitan areas (data not shown). After controlling for covariates, the odds of vaccination for all MSAs, except for Boston MSA, Massachusetts, were significantly lower than those for San Francisco-Oakland MSA. For example, compared with San Francisco-Oakland MSA, the adjusted odds of receiving COVID-19 vaccination among children aged 5-17 were 68% lower (OR=0.32; 95% CI=0.23-0.45) in Atlanta MSA, 58% lower (OR=0.42; 95% CI=0.30-0.59) in Detroit MSA, and 34% lower (OR=0.66; 95% CI=0.49-0.90) in Washington, DC metropolitan area (Figure 1).

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Figure 1

Prevalence1 and Adjusted2 Odds Ratios for COVID-19 vaccination among children aged 5-17 years in 15 largest Metropolitan Statistical Areas (MSAs), United States, December 2021 - April 2022 (N=28,156). 1Prevalence rates of childhood COVID-19 vaccination for all MSAs were significantly lower than the rate for San Franciso-Oakland MSA at p<0.01. 2Adjusted by logistic regression for age, gender, race/ethnicity, marital status, education, household income, recent household job loss, employment status, insurance status, and COVID-19 diagnosis, and COVID-19 vaccination status. The adjusted odds ratio for Boston MSA was not statistically significant at p<0.01. All other MSAs had significantly lower odds ratios, indicating lower adjusted vaccination prevalence compared with San Francisco-Oakland MSA. Source: Data derived from December 2021 – April 2022 Household Pulse Survey

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Rates of COVID-19 vaccination among children aged 5-11 ranged from a low of 40.4% in Detroit MSA, Michigan, and 40.8% in Riverside-San Bernardino MSA, California to a high 77.7% in San Francisco-Oakland MSA, California. Rates of COVID-19 vaccination among adolescents aged 12-17 ranged from a low of 57.9% in Atlanta MSA, Georgia, and 62.7% in Dallas-Fort Worth MSA, Texas to a high 87.7% in San Francisco-Oakland MSA, California (Figure 2).

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Figure 2

Unadjusted prevalence of COVID-19 vaccination among children aged 5-11 years and adolescents aged 12-17 years in 15 largest Metropolitan Statistical Areas, United States, December 2021 - April 2022. Prevalence rates of COVID-19 vaccination among children aged 5-11 years for all MSAs were significantly lower than the rate for San Francisco-Oakland MSA at p<0.01. Prevalence rates of COVID-19 vaccination among adolescents aged 12-17 years for all MSAs were significantly lower than the rate for San Francisco-Oakland MSA at p<0.05 except for Boston (p=0.41). Source: Data derived from December 2021-April 2022 Household Pulse Survey

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4.1. Limitations

This study has some limitations. First, racial/ethnic detail in the HPS public use file is limited as we are unable to identify American Indians and Alaska Natives and specific Asian/Pacific Islander and Hispanic subgroups as well as immigrant children and non-English speakers who may have lower rates of COVID-19 vaccination.18 These groups are not identified in the public-use HPS file because of the small sample size and confidentiality reasons.18 Second, the HPS lacks data for several other priority groups such as children living in rural areas, those experiencing homelessness, or those with special healthcare needs such as developmental disabilities, all of whom may have a higher likelihood of not getting vaccinated and who may therefore be at substantially increased risk for severe illness from COVID-19.9,23 Indeed, data on child characteristics other than child’s age, such as child’s gender, COVID-19 diagnosis status, or physical, mental or behavioral health status are not available in HPS. Third, the respondents in HSP are more likely to be women and non-Hispanic Whites and have higher education, compared with the American Community Survey.30 This might have resulted in an underestimate of the magnitude of racial/ethnic and socioeconomic disparities in childhood vaccine coverage. However, we addressed disproportionate sampling of demographic characteristics by using survey weights, which rake the demographics of the interviewed persons to education attainment/sex/age distributions and ethnicity/race/sex/age population distributions.19