COVID-19 Vaccination Coverage and Demographic Characteristics of Infants and Children Aged 6 Months–4 Years — United States, June 20–December 31, 2022

Bhavini Patel Murthy, MD^1,2; Hannah E. Fast, MPH^1,2; Elizabeth Zell, MStat^1,2,3; Neil Murthy, MD^1,3; Lu Meng, PhD²; Lauren Shaw, MS^1,2; Tara Vogt, PhD^1,2; Kevin Chatham-Stephens, MD^2,4; Tammy A. Santibanez, PhD^1,2; Lynn Gibbs-Scharf, MPH^1,2; LaTreace Q. Harris, MPH^1,2 (View author affiliations)

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Summary

What is already known about this topic?

Although severe COVID-19 hospitalization and death occur more commonly among adults, young children are also affected.

What is added by this report?

As of December 31, 2022, coverage with ≥1 COVID-19 vaccine dose among young children (those aged 6 months–4 years) was 10.1%, and 5.1% had completed the primary series. Coverage among young children varied by jurisdiction, urbanicity, race, and ethnicity. Five months after the COVID-19 vaccines became available to young children, their vaccination coverage is substantially lower than that in older children.

What are the implications for public health practice?

Enhanced evidence-based practices are needed to decrease barriers to vaccination and increase parental COVID-19 vaccine confidence to improve COVID-19 vaccination coverage among young children to reduce associated morbidity and mortality.

Although severe COVID-19 illness and hospitalization are more common among older adults, children can also be affected (1). More than 3 million cases of COVID-19 had been reported among infants and children aged <5 years (children) as of December 2, 2022 (2). One in four children hospitalized with COVID-19 required intensive care; 21.2% of cases of COVID-19–related multisystem inflammatory syndrome in children (MIS-C) occurred among children aged 1–4 years, and 3.2% of MIS-C cases occurred among infants aged <1 year (1,3). On June 17, 2022, the Food and Drug Administration issued an Emergency Use Authorization (EUA) of the Moderna COVID-19 vaccine for children aged 6 months–5 years and the Pfizer-BioNTech COVID-19 vaccine for children aged 6 months–4 years. To assess COVID-19 vaccination coverage among children aged 6 months–4 years in the United States, coverage with ≥1 dose* and completion of the 2-dose or 3-dose primary vaccination series^† were assessed using vaccine administration data for the 50 U.S. states and District of Columbia submitted from June 20 (after COVID-19 vaccine was first authorized for this age group) through December 31, 2022. As of December 31, 2022, ≥1-dose COVID-19 vaccination coverage among children aged 6 months–4 years was 10.1% and was 5.1% for series completion. Coverage with ≥1 dose varied by jurisdiction (range = 2.1% [Mississippi] to 36.1% [District of Columbia]) as did coverage with a completed series (range = 0.7% [Mississippi] to 21.4% [District of Columbia]), respectively. By age group, 9.7 % of children aged 6–23 months and 10.2% of children aged 2–4 years received ≥1 dose; 4.5% of children aged 6–23 months and 5.4% of children aged 2–4 years completed the vaccination series. Among children aged 6 months–4 years, ≥1-dose COVID-19 vaccination coverage was lower in rural counties (3.4%) than in urban counties (10.5%). Among children aged 6 months–4 years who received at least the first dose, only 7.0% were non-Hispanic Black or African American (Black), and 19.9% were Hispanic or Latino (Hispanic), although these demographic groups constitute 13.9% and 25.9% of the population, respectively (4). COVID-19 vaccination coverage among children aged 6 months–4 years is substantially lower than that among older children (5). Efforts are needed to improve vaccination coverage among children aged 6 months–4 years to reduce COVID-19–associated morbidity and mortality.

Data on COVID-19 vaccine administration in the United States are reported to CDC by jurisdictions, pharmacies, and federal entities through immunization information systems (IISs),^§ the Vaccine Administration Management System (VAMS),^¶ or through direct data submission.** Children aged 6 months–4 years residing in one of 50 states or the District of Columbia who received ≥1 COVID-19 vaccine dose as of December 31, 2022, and whose data were reported to CDC by February 9, 2023, were included in this analysis.^††

Daily and cumulative numbers of children initiating COVID-19 vaccination were calculated. Receipt of ≥1 COVID-19 vaccine dose and series completion among children aged 6 months–4 years were calculated overall and by age group^§§ (6–23 months and 2–4 years), sex (male and female), and jurisdiction (50 states and the District of Columbia). Population size by age group and sex were obtained for the 50 states and District of Columbia from the U.S. Census Bureau’s 2020 Population Estimates Program (4). Vaccination coverage with the first dose and series completion was calculated. Tests for statistical significance were not conducted because these data reflect the U.S. population and were not based on population samples.

Race and ethnicity data were available for 71.4% of children aged 6 months–4 years and were analyzed by the following categories: Black, Hispanic, non-Hispanic American Indian or Alaska Native, non-Hispanic Asian (Asian), non-Hispanic Native Hawaiian or other Pacific Islander, non-Hispanic White (White), and non-Hispanic multiple races or other (multiracial/other). The percentage of children aged 6 months–4 years receiving the first dose of COVID-19 vaccine was calculated by race and ethnicity.

To investigate disparities in vaccination coverage by urban-rural environment, first-dose coverage was also calculated by two- and six-level urban-rural classifications according to the 2013 National Center for Health Statistics (NCHS) urban-rural classification scheme (6). To dichotomize counties as urban versus rural, four of these six categories (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) were combined and considered urban areas, and two (micropolitan and noncore) were combined and considered as rural areas (6). Eight counties in California with <20,000 residents were excluded from the analysis because of data-sharing restrictions on county-level information reported to CDC. All analyses were conducted using SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^¶¶

As of December 31, 2022, a total of 1,755,596 (10.1%) children aged 6 months–4 years had received ≥1 dose of a COVID-19 vaccine (Table), and approximately 39% of these children received the first dose within 1 month of vaccine authorization (Supplementary Figure, https://stacks.cdc.gov/view/cdc/124660). Overall, 5.1% of children in this age group completed the series during the study period (Supplementary Table, https://stacks.cdc.gov/view/cdc/124661). Among those who received their first dose of Pfizer-BioNTech vaccine by September 4, 2022, or of Moderna vaccine by October 23, 2022, approximately 70% had completed the vaccination series.*** COVID-19 vaccination coverage with ≥1 dose varied by jurisdiction (range = 2.1% [Mississippi] to 36.1% [District of Columbia]), as it did for series completion (0.7% [Mississippi] to 21.4% [District of Columbia]), with lower coverage in the southeastern United States (Figure 1). Coverage was slightly higher among children aged 2–4 years (10.2% for ≥1 dose; 5.4% for series completion) than among those aged 6–23 months (9.7% for ≥1 dose; 4.5% for series completion). Coverage was similar among males and females.

Among vaccinated children aged 6 months–4 years, race and ethnicity were known for 71.4%. Among those with known race and ethnicity who received at least the first dose, 7.0% were Black, and 19.9% were Hispanic, whereas these groups account for 13.9% and 25.9%, respectively, of the U.S. population of children aged 6 months–4 years. In contrast, 55.3% of vaccine recipients were White, and 13.4% were Asian children; these groups account for 48.4% and 5.7% of the U.S. population of children aged 6 months–4 years, respectively (4) (Figure 2). Race and ethnicity were unknown or not reported for 501,899 (28.6%) children, either because race and ethnicity had not been recorded (24.5%), was reported as “other” (3.6%), or was not reported (0.5%) because of jurisdictional policy or law (Vermont and eight counties in California).

COVID-19 vaccination coverage with ≥1 dose was lower among children aged 6 months–4 years residing in rural counties (3.4%) than among those residing in urban counties (10.5%), according to the two-level urban-rural classification (Table). The six-level classification indicated that coverage was highest (12.5%) among children residing in large metro areas and declined as areas became more rural, with the lowest coverage (2.7%) among children residing in noncore (i.e., most rural) areas. Overall, coverage in 41 jurisdictions was higher in urban counties, in two jurisdictions (Arizona and Wyoming) was higher in rural counties, and in four jurisdictions (Louisiana, Michigan, Mississippi, and Nevada) coverage was similar (i.e., within two percentage points) in urban and rural counties. Coverage comparisons could not be made for four jurisdictions (Delaware, District of Columbia, New Jersey, and Rhode Island) that have only urban counties.