key: cord-0761879-7xi7weda
authors: Gao, David X; Fisher, Lloyd D; Miller, Donald R; Geller, Alan C
title: Inequities in COVID-19 vaccination rates among adolescents in Massachusetts: a cross-sectional study
date: 2022-02-13
journal: Clin Infect Dis
DOI: 10.1093/cid/ciac123
sha: 70abfe83b46c2a110c7aff450a87fe7d85af412d
doc_id: 761879
cord_uid: 7xi7weda

BACKGROUND: The COVID-19 pandemic has disproportionately affected more socioeconomically disadvantaged persons and areas. We sought to determine how certain sociodemographic factors were correlated to adolescents’ COVID-19 vaccination rates in towns and cities (“communities”) in the Commonwealth of Massachusetts. METHODS: Data on COVID-19 vaccination rates were obtained over a 20-week period from March 30, 2021 to August 10, 2021. Communities’ adolescent (ages 12-19) vaccination rates were compared across quintiles of community-level income, COVID-19 case rate, and proportion of non-Hispanic Black or Hispanic individuals. Other variables included population density and earlier COVID-19 vaccination rates of adolescents and adults, averaged from March 30 to May 11 to determine their effects on vaccination rates on August 10. Linear and logistic regression was used to estimate individual effects of variables on adolescent vaccination rates. RESULTS: Higher median household income, lower proportion of Black or Hispanic individuals, higher early adolescent COVID-19 vaccination rates, and higher early adult COVID-19 vaccination rates were associated with higher later adolescent COVID-19 vaccination rates. Income per $10,000 (adjusted odds ratio=1.01 [95% confidence interval=1.01-1.02]), proportion of Hispanic individuals (1.33 [1.13-1.56]), early adolescent COVID-19 vaccination rates (5.28 [4.67-5.96]), and early adult COVID-19 vaccination rates (2.31 [2.02-2.64]) were associated with higher adolescent COVID-19 vaccination on August 10, while proportion of Black individuals approached significance (1.26 [0.98-1.61]). CONCLUSIONS: Vaccination efforts for adolescents in Massachusetts should focus on boosting vaccination rates early in communities with the lowest incomes and greatest proportion of Hispanic individuals and consider targeting communities with a greater proportion of Black individuals.

M a n u s c r i p t INTRODUCTION As of January 20 , 2022, 10 .6 million US children tested positive for COVID-19, making vaccination of this population a crucial goal [1] [2] . Among adults, COVID-19 has disproportionately affected lower-income communities that have also seen lower vaccination rates [3] [4] . According to the Centers for Disease Control and Prevention, counties that rank high on the Social Vulnerability Index (SVI) have lower vaccination rates than counties that rank lower on this index. Median household income is one component of the SVI [5] .

Herein, in Massachusetts towns and cities (communities), we examined the relationship between community level median household income, population density, race/ethnicity, COVID-19 case rates, early adolescent COVID-19 vaccination rates, and adult COVID-19 vaccination rates on rates of adolescent COVID-19 vaccination as of August 10, 2021 . We anticipated that this analysis could uncover lessons to be learned for the rest of the country, where vaccination rates remain relatively low for 12-to 19-year-olds. This analysis could also deepen the understanding of structural barriers in vaccinating the 28 million children ages 5 to 11, an initiative which began nationally in early November 2021.

-Adolescents‖ were defined as individuals ages 12-19 years old and -adults‖ ages ≥20 years. COVID-19 vaccination rates were analyzed for adolescents receiving at least one dose and for adults fully vaccinating against COVID-19, which at the time of this investigation, meant receiving two COVID-19 vaccinations. At the inception of this investigation, many adolescents would have had the opportunity to be vaccinated only once whereas most adults would have had an opportunity for two shots.

A c c e p t e d M a n u s c r i p t 5 We focused our analysis on Massachusetts for several reasons. vaccination data for adolescents were released weekly by the Massachusetts Department of Public Health (MDPH) for 335/351 towns and cities (henceforth termed -communities‖) beginning March 30, 2021 and then specified by age (12-15, 16-19 years) beginning May 20 and ending August 10, 2021. Data discussed herein will generally refer to the combined vaccination data of adolescents (individuals ages 12-19 years old), although we do note vaccination rates of the 12-15-and 16-19-year-old subgroups in Table I These two race and ethnicity groups were analyzed independently because of the disproportionate impact of COVID-19 amongst these groups [8] . To obtain these quintiles, Statistical analyses were conducted in R-4.0.3, with significance determined at P<0.05 [9] . Chi square testing was used for comparing differences in weekly vaccination rates between income, case rate, and race/ethnicity groups; Mann-Kendall Trend Test for detecting trends in vaccination rates; and two-sample t-test to detect differences in increases in vaccination rates. Linear regression was also performed to determine how individual communities' median income, population, race/ethnicity, COVID-19 case rates, and early COVID-19 vaccination rates of adolescents and adults (obtained as average COVID-19 vaccination rates between March 30, 2021 and May 11, 2021) were associated with A c c e p t e d M a n u s c r i p t 7 adolescent vaccination rates on August 10, 2021. Multivariable logistic regression analysis was performed and provided crude odds ratios (OR) and adjusted odds ratios (aOR) with corresponding 95% confidence intervals (95% CI) for each of the aforementioned variables.

By August 10, 2021, across 335 Massachusetts communities, 63% of adolescents had received at least one dose, and 73% of adults were fully vaccinated (Table I) . 

vaccinations were lower among adolescents in communities most impacted by COVID-19 compared to those communities less impacted, particularly those communities in the quintile with the lowest case rates of COVID-19 (54% rate of vaccinations for communities with highest COVID-19 case rates vs. 82% for lowest COVID-19 case rates) (P<0.001). A similar pattern was seen for adults, whose COVID-19 vaccination rates were lowest in the highest vs. (Figures 2-3 ). In particular, by August 10, 2021, although vaccination rates were approximately equal amongst the four quintiles of communities with the lowest proportion of Black (ranging from 68% to 73%) or Hispanic individuals (69% to 76%), only 55% and 54% of adolescents in the quintile of communities with the highest proportion of Black or Hispanic individuals, respectively, were vaccinated against COVID-19. Adolescent COVID-19 vaccination rates among Black or Hispanic individuals also increased more slowly (from 3% to 55% and 3% to 54%, respectively) than that of non-Hispanic White (5% to 71%) and Asian (4% to 67%) individuals (P<0.001).

In the linear regression, with the community as the unit of analysis, median income (Table II) . There was no independent effect of population or total population case rate on adolescent COVID-19 vaccination rates.

With the national rollout of the COVID-19 vaccine for children ages 5-11 currently ongoing, it is important to draw lessons from the earlier, separate rollouts for 12-15-and 16-

19-year-olds. Among noteworthy findings, we found that communities with higher COVID-19 vaccination rates for adolescents and adults soon after the vaccine became available had adolescent COVID-19 vaccination rates that were greater many months later. Therefore, prior to the actual roll-out of a COVID-19 vaccination program, planners should lay the groundwork in communities with lower income and higher proportion of Hispanic and Black individuals [10] . For the 2020-2021 school year 93.8% of children had received all the required vaccinations prior to kindergarten entry and 88.2% prior to 7 th grade entry [11] [12] . One vaccine that is typically associated with decreased vaccination rates is the human papilloma virus (HPV) [13] . In this study, as of August 2021, rates of COVID-19 vaccinations of adolescents (63%) lagged behind vaccination rates in 2020 of individuals ages 13-17 years old who had completed the HPV series (73%) [14] . Similar to our findings, vaccination rates tend to lag in communities of decreased socioeconomic status and in Black children, making these communities important targets [13] .

There are limitations to this study. Our analysis is limited to one state, and we do not have information on all potential confounding factors, such as family size. More generally, this analysis was based on community-level data, and we do not have the actual measures for each adolescent in the community; information that is not available from the Department of Public Health. Thus, in our ecologic analysis, there may have been some error in estimating the effects of measures on COVID-19 vaccination rates.

It is also worth noting that approval for the Pfizer-BioNTech COVID-19 vaccine for 16-to-19-year-olds began in December 2020 and was available as of April 19, 2021; the vaccine became available for 12-to-15-year-olds on May 10, 2021. However, because adolescents with co-morbidities were able to get the vaccine at the same time as adults, the MDPH began reporting vaccinations for children ages 0 to 19 in March 2021. We noted that disparities in vaccine utilization by income of the community were apparent soon after the -age by community-specific rates‖ were first reported for adolescents.

Concentrating efforts in low-income communities represent opportunities to increase COVID-19 vaccination equity for adolescents. Vaccines were available during this period in who have yet to be vaccinated [15] .

Lessons learned from this attempt to successfully vaccinate adolescents may provide valuable lessons for vaccinating the next wave of younger children. In particular, federal agencies and state planners must embark on a broad-scale public service campaign highlighting parents, pediatricians, and the aforementioned sub-groups to motivate the nearly two-thirds of parents who have initial hesitancy about vaccinating against COVID-19 their children ages 5 to 11 [16] . There has been much confusion over current messaging about COVID-19 vaccine safety and efficacy. However, the data are clear that regardless of age and medical history, the risk of severe adverse effects from COVID-19 vaccination, particularly for those ages five and older, is always lower than complications from the virus itself. The messaging needs to be simple, clear, and widespread such that nearly all parents will want to choose vaccination for their child. A c c e p t e d M a n u s c r i p t 20 

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