Disparities in COVID-19 Vaccination Status, Intent, and Perceived Access for Noninstitutionalized Adults, by Disability Status

National Immunization Survey Adult COVID Module, United States, May 30-June 26, 2021

A. Blythe Ryerson, PhD; Catherine E. Rice, PhD; Mei-Chuan Hung, PhD; Suchita A. Patel, DO; Julie D. Weeks, PhD; Jennifer L. Kriss, PhD; Georgina Peacock, MD; Peng-Jun Lu, MD; Amimah F. Asif, MPH; Hannah L. Jackson, PhD; James A. Singleton, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2021;70(39):1365-1371.

Abstract and Introduction

Introduction

Estimates from the 2019 American Community Survey (ACS) indicated that 15.2% of adults aged ≥18 years had at least one reported functional disability.^[1] Persons with disabilities are more likely than are those without disabilities to have chronic health conditions^[2] and also face barriers to accessing health care.^[3] These and other health and social inequities have placed persons with disabilities at increased risk for COVID-19–related illness and death, yet they face unique barriers to receipt of vaccination.^[4,5] Although CDC encourages that considerations be made when expanding vaccine access to persons with disabilities,* few public health surveillance systems measure disability status. To describe COVID-19 vaccination status and intent, as well as perceived vaccine access among adults by disability status, data from the National Immunization Survey Adult COVID Module (NIS-ACM) were analyzed. Adults with a disability were less likely than were those without a disability to report having received ≥1 dose of COVID-19 vaccine (age-adjusted prevalence ratio [aPR] = 0.88; 95% confidence interval [CI] = 0.84–0.93) but more likely to report they would definitely get vaccinated (aPR = 1.86; 95% CI = 1.43–2.42). Among unvaccinated adults, those with a disability were more likely to report higher endorsement of vaccine as protection (aPR = 1.29; 95% CI = 1.16–1.44), yet more likely to report it would be or was difficult to get vaccinated than did adults without a disability (aPR = 2.69; 95% CI = 2.16–3.34). Reducing barriers to vaccine scheduling and making vaccination sites more accessible might improve vaccination rates among persons with disabilities.

Data from noninstitutionalized adults aged ≥18 years were collected in the NIS-ACM by telephone interview during May 30–June 26, 2021 using a random-digit–dialed sample of cellular telephone numbers, stratified by locality.^† Although the current U.S. Department of Health and Human Services (HHS) minimum standard for measuring disability in surveys relies on six questions,^[6] during the COVID-19 emergency response, data collection opportunities were limited. To assess COVID-19 vaccination status for this demographic group, CDC added a single question to the NIS-ACM: "Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, or communicating?" Respondents who answered "yes" were considered to have a disability, and those who answered "no" were categorized as having no disability. Among all respondents (56,749; 18.9% final response rate), 5,361 (9.4%) reported having a disability, and 51,253 (90.3%) reported no disability. Disability status was missing for 135 (0.2%) respondents, and these respondents were excluded from all analyses. Respondents were also asked a series of questions on perceived COVID-19 risk, current COVID-19 vaccination status, and attitudes and perceived barriers to getting vaccinated.^§

All percentages were weighted to represent the noninstitutionalized U.S. adult population. Survey weights were calibrated to state-level vaccine administration data reported to CDC as of June 15, 2021.^¶ T-tests were performed to detect differences in percentages between groups. Unadjusted and age-adjusted vaccination prevalence ratios (PRs) comparing percentages of adults with a disability with those without a disability were calculated using logistic regression and predictive marginals. T-tests and PRs were considered statistically significant if p-values were <0.05. All analyses were performed using SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0.3; Research Triangle Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.**

Among all respondents, 9.4% reported having a disability. In age-adjusted analyses, adults with a disability were less likely than were those without a disability to report having received ≥1 dose of a COVID-19 vaccine (aPR = 0.88; 95% CI = 0.84–0.93) (Table) but more likely to report they would definitely get vaccinated (aPR = 1.86; 95% CI = 1.43–2.42) (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/109902). Among unvaccinated adults, those with a disability were more likely than those without a disability to report they were very or moderately concerned about getting COVID-19 (aPR = 1.61; 95% CI = 1.37–1.89), thought the vaccine is very or somewhat important for protection (aPR = 1.29; 95% CI = 1.16–1.44), reported many or almost all friends and family members as vaccinated (aPR = 1.19; 95% CI = 1.03–1.38), and had a health care provider recommend the vaccine (aPR = 1.27; 95% CI = 1.08–1.51) (Figure 1) (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/109903).

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Figure 1.

Age-adjusted prevalence ratios* of COVID-19 vaccine attitudes, perceptions, and recommendations^† among adults aged ≥18 years with a disability^§ compared with adults without a disability, by COVID-19 vaccination status^¶ — National Immunization Survey Adult COVID Module, United States, May 30–June 26, 2021
Abbreviation: aPR = age-adjusted prevalence ratio.
*95% confidence intervals indicated with error bars.
^†Prevalence ratio p<0.05 for all groups except "unvaccinated: thinks a COVID-19 vaccine is completely/very safe."
^§Disability was defined as an affirmative response to the following survey item: "Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, or communicating?"
^¶Respondents were considered vaccinated if they reported having received at least 1 dose of any of the approved COVID-19 vaccines (Pfizer-BioNTech, Moderna, or Janssen [Johnson & Johnson]).

Overall, adults with a disability were more likely than were those without a disability to report that it would be or was somewhat or very difficult to get vaccinated (aPR = 1.19; 95% CI = 1.05–1.36), and this observation was more pronounced among the unvaccinated (aPR = 2.69; 95% CI = 2.16–3.34) (Figure 2). Among unvaccinated adults, those with a disability were more likely than were those without a disability to report having the following difficulties associated with getting the vaccine: getting an appointment online (aPR = 2.14; 95% CI = 1.48–3.10), not knowing where to get vaccinated (aPR = 1.95; 95% CI = 1.36–2.79), getting to vaccination sites (aPR = 3.43; 95% CI = 2.53–4.67), and vaccination sites not being open at convenient times (aPR = 1.69; 95% CI = 1.23–2.33).

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Figure 2.

Age-adjusted prevalence ratios* of experiences and difficulties with getting the COVID-19 vaccine^† among adults aged ≥18 years with a disability^§ compared with adults without a disability, by COVID-19 vaccination status^¶ — National Immunization Survey Adult COVID Module, United States, May 30–June 26, 2021
Abbreviation: aPR = age-adjusted prevalence ratio.
*95% confidence intervals indicated with error bars.
^†Prevalence ratio p<0.05 for all groups except "vaccinated: getting to vaccination sites."
^§Disability was defined as an affirmative response to the following survey item: "Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, or communicating?"
^¶Respondents were considered vaccinated if they reported having received at least 1 dose of any of the approved COVID-19 vaccines (Pfizer-BioNTech, Moderna, or Janssen [Johnson & Johnson]).

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Abstract and Introduction
Discussion
References
Sidebar

*COVID-19 Vaccine Recommendations and Guidelines of the Advisory Committee on Immunization Practices, CDC. https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html
^†The NIS-ACM cellular telephone sample was stratified by state, the District of Columbia, five local jurisdictions (Bexar County, Texas; Chicago, Illinois; Houston, Texas; New York City, New York; and Philadelphia County, Pennsylvania), and Guam, Puerto Rico, and the U.S. Virgin Islands.
^§ https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-ACM-Questionnaire-Q2-2021_508.pdf
^¶Additional information about the NIS-ACM is available at https://www.cdc.gov/vaccines/imz-managers/nis/about.html#current-surveys.
**45 C.F.R. part 46; 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

Table. COVID-19 vaccination status* of adults aged ≥18 years, by respondent characteristic and disability status ^† — National Immunization Survey Adult COVID Module, United States, May 30–June 26, 2021
Respondent group/Characteristic	With a disability^†		Without a disability		Prevalence ratio^§ (95% CI)
Respondent group/Characteristic	No.	%^¶ Vaccinated* (95% CI)	No.	%^¶ Vaccinated* (95% CI)	Unadjusted	Age-adjusted
Total	5,345	66.7 (63.9–69.3)	51,106	64.5 (63.5–65.4)	1.03 (0.99–1.08)	0.88 (0.84–0.93)**
Age group, yrs
18–24 (Ref)	198	33.5 (23.8–44.7)	5,015	46.4 (43.9–49.0)	0.72 (0.52–0.99)**	NA
25–29	162	35.5 (22.9–50.6)	4,203	49.8 (46.7–52.9)	0.71 (0.48–1.07)	NA
30–39	372	48.8 (40.2–57.5)^††	8,817	52.9 (50.8–55.0)^††	0.92 (0.77–1.11)	NA
40–49	559	54.4 (46.2–62.3)^††	8,050	60.8 (58.4–63.1)^††	0.89 (0.77–1.04)	NA
50–64	1,783	62.8 (57.6–67.7)^††	14,246	71.9 (70.1–73.6)^††	0.87 (0.80–0.95)**	NA
65–74	1,260	82.7 (77.4–87.0)^††	7,069	88.6 (86.6–90.4)^††	0.93 (0.88–0.99)**	NA
≥75	953	88.2 (83.7–91.6)^††	2,827	90.0 (87.5–92.1)^††	0.98 (0.93–1.03)	NA
Sex
Male (Ref)	2,542	66.4 (62.2–70.5)	25,297	61.9 (60.6–63.2)	1.07 (1.00–1.15)**	0.91 (0.85–0.99)**
Female	2,747	67.3 (63.6–70.7)	25,457	67.0 (65.7–68.3)^††	1.00 (0.95–1.06)	0.86 (0.80–0.92)**
Race/Ethnicity^§§
White (Ref)	2,993	69.0 (65.4–72.4)	30,871	66.6 (65.5–67.7)	1.04 (0.98–1.09)	0.88 (0.82–0.94)**
Hispanic	822	67.2 (59.8–73.7)	6,613	61.8 (59.2–64.3)^††	1.09 (0.97–1.22)	0.94 (0.84–1.05)
Black	726	60.1 (52.8–67.1)^††	5,748	56.3 (53.6–58.9)^††	1.07 (0.94–1.22)	0.84 (0.73–0.97)**
AI/AN	105	38.2 (23.6–55.2)^††	538	39.2 (31.8–47.1)^††	0.97 (0.81–1.56)	0.85 (0.56–1.30)
Asian	127	74.7 (46.5–90.9)	3,015	85.5 (81.5–88.8)^††	0.87 (0.64–1.19)	0.86 (0.67–1.12)
NHPI	113	71.1 (27.8–94.0)	974	59.1 (47.0–70.2)	1.20 (0.68–2.13)	0.78 (0.32–1.91)
Multiple race/Other	294	55.6 (43.0–67.6)^††	1,797	49.2 (43.9–54.5)^††	1.13 (0.88–1.45)	0.85 (0.62–1.18)
Urbanicity^¶¶
MSA, principal city (Ref)	1,387	68.7 (62.8–74.0)	14,609	68.0 (66.2–69.7)	1.01 (0.93–1.10)	0.88 (0.79–0.97)**
MSA, nonprincipal city	2,697	67.4 (63.7–70.9)	26,796	65.1 (63.9–66.3)^††	1.04 (0.98–1.10)	0.89 (0.84–0.95)**
Non-MSA	1,261	61.4 (55.4–67.2)	9,701	54.4 (52.0–56.7)^††	1.13 (1.02–1.26)	0.88 (0.77–1.01)
SVI of county of residence***
Low (Ref)	1,225	68.0 (62.3–73.2)	14,066	69.9 (68.2–71.6)	0.97 (0.89–1.06)	0.84 (0.76–0.93)**
Moderate	1,687	68.6 (63.6–73.2)	17,064	65.1 (63.5–66.6)^††	1.05 (0.98–1.14)	0.90 (0.83–0.99)**
High	1,520	64.8 (59.8–69.4)	11,864	60.4 (58.6–62.2)^††	1.07 (0.99–1.16)	0.89 (0.82–0.98)**
Poverty status and household income^†††
Above poverty, ≥$75k (Ref)	798	78.0 (70.3–84.1)	19,539	72.5 (71.0–73.9)	1.08 (0.98–1.17)	0.97 (0.87–1.07)
Above poverty, <$75k	1,911	68.9 (64.5–73.1)^††	15,528	61.1 (59.4–62.7)^††	1.13 (1.05–1.21)**	0.94 (0.86–1.03)
Below poverty	1,137	55.5 (49.4–61.5)^††	4,410	48.6 (45.6–51.7)^††	1.14 (1.01–1.30)**	0.95 (0.83–1.07)
Unknown income	1,499	66.6 (61.3–71.4)^††	11,629	64.3 (62.4–66.2)^††	1.03 (0.95–1.12)	0.89 (0.81–0.98)**
Education level
College graduate (Ref)	1,338	80.2 (74.6–84.9)	23,844	79.2 (78.0–80.5)	1.01 (0.95–1.08)	0.89 (0.81–0.99)**
Some college	1,652	66.0 (61.2–70.5)^††	13,590	62.2 (60.5–63.9)^††	1.06 (0.98–1.14)	0.94 (0.87–1.03)
High school graduate or less	2,175	62.6 (58.4–66.6)^††	12,231	53.8 (52.1–55.5)^††	1.16 (1.08–1.25)**	0.93 (0.86–1.01)
Health insurance
Insured (Ref)	4,803	69.4 (66.5–72.1)	45,472	67.6 (66.6–68.6)	1.03 (0.98–1.07)	0.88 (0.83–0.93)**
Not insured	363	40.2 (31.7–49.3)^††	4,205	42.1 (39.2–45.1)^††	0.95 (0.76–1.20)	0.87 (0.72–1.05)
Mental health
Excellent, very good, or good (Ref)	3,866	70.7 (67.4–73.7)	46,379	64.8 (63.9–65.8)	1.09 (1.04–1.11)**	0.92 (0.86–0.98)**
Fair or poor	1,398	56.5 (51.2–61.7)^††	4,405	61.5 (58.2–64.6)^††	0.92 (0.83–1.02)	0.79 (0.72–0.88)**
Comorbidities^§§§
No (Ref)	2,087	62.2 (57.8–66.4)	37,054	60.2 (59.2–61.3)	1.03 (0.96–1.11)	0.89 (0.83–0.96)**
Yes	3,120	71.0 (67.5–74.3)^††	13,577	76.6 (74.9–78.2)^††	0.93 (0.88–0.98)**	0.82 (0.77–0.88)**
Ever had COVID-19
No (Ref)	4,496	68.6 (65.6–71.5)	43,223	68.1 (67.1–69.1)	1.01 (0.96–1.06)	0.86 (0.81–0.91)**
Yes	776	59.1 (52.3–65.5)^††	7,234	49.1 (46.9–51.4)^††	1.20 (1.06–1.96)**	1.05 (0.93–1.18)
Received any vaccine that was not a COVID-19 vaccine in the past 2 years
Yes (Ref)	3,224	81.1 (78.0–83.9)	29,282	80.7 (79.6–81.7)	1.01 (0.97–1.05)	0.90 (0.85–0.95)**
No	2,078	48.1 (43.8–52.4)^††	21,534	47.5 (46.2–48.8)^††	1.01 (0.92–1.11)	0.86 (0.78–0.95)**

Abbreviations: AI/AN = American Indian or Alaska Native; CI = confidence interval; MSA = metropolitan statistical area; NA = not applicable; NHPI = Native Hawaiian or Other Pacific Islander; Ref = referent group; SVI = social vulnerability index.
*At least 1 dose of any of the approved COVID-19 vaccines (Pfizer-BioNTech, Moderna, or Janssen [Johnson & Johnson]).
^†Disability was defined as an affirmative response to the following survey question: "Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, or communicating?"
^§Prevalence ratio comparing vaccination rates among persons with a disability with rates among persons without a disability.
^¶Weighted percentage. Respondents missing either vaccination or disability status were excluded (298).
**p<0.05 for prevalence ratio.
^††p<0.05 by t-test for comparisons of proportions with the indicated reference level.
^§§ White, Black, AI/AN, Asian, NHPI, and multiple-race persons were non-Hispanic; Hispanic persons could be of any race.
^¶¶Urbanicity derived based on the centroid of the zip code of residence.
***CDC and Agency for Toxic Substances and Disease Registry Social Vulnerability Index use 15 U.S. Census variables to help officials identify communities that might need support before, during, or after disasters. https://www.atsdr.cdc.gov/placeandhealth/svi/index.htm
^†††Household income is derived from the number of persons reported in the household, the reported household income, and the 2020 U.S. Census poverty thresholds.
^§§§Based on response to the question, "Do you have a health condition that may put you at higher risk for COVID-19?"