Racial and Ethnic Differences in COVID-19 Vaccination Coverage Among Children and Adolescents Aged 5–17 Years and Parental Intent to Vaccinate Their Children

National Immunization Survey-Child COVID Module, United States, December 2020-September 2022

Madeleine R. Valier, MPH; Laurie D. Elam-Evans, PhD; Yi Mu, PhD; Tammy A. Santibanez, PhD; David Yankey, PhD; Tianyi Zhou, MPH; Cassandra Pingali, MPH, MS; James A. Singleton, PhD


Morbidity and Mortality Weekly Report. 2023;72(1):1-8. 

In This Article

Abstract and Introduction


Some racial and ethnic groups are at increased risk for COVID-19 and associated hospitalization and death because of systemic and structural inequities contributing to higher prevalences of high-risk conditions and increased exposure.[1] Vaccination is the most effective prevention intervention against COVID-19–related morbidity and mortality*; ensuring more equitable vaccine access is a public health priority. Differences in adult COVID-19 vaccination coverage by race and ethnicity have been previously reported,[2,3] but similar information for children and adolescents is limited.[4,5] CDC analyzed data from the National Immunization Survey–Child COVID Module (NIS-CCM) to describe racial and ethnic differences in vaccination status, parental intent to vaccinate their child, and behavioral and social drivers of vaccination among children and adolescents aged 5–17 years. By August 31, 2022, approximately one third (33.2%) of children aged 5–11 years, more than one half (59.0%) of children and adolescents aged 12–15 years, and more than two thirds (68.6%) of adolescents aged 16–17 years had received ≥1 COVID-19 vaccine dose. Vaccination coverage was highest among non-Hispanic Asian (Asian) children and adolescents, ranging from 63.4% among those aged 5–11 years to 91.8% among those aged 16–17 years. Coverage was next highest among Hispanic or Latino (Hispanic) children and adolescents (34.5%–77.3%). Coverage was similar for non-Hispanic Black or African American (Black), non-Hispanic White (White), and non-Hispanic other race or multiple race (other/multiple race) children and adolescents aged 12–15 and 16–17 years. Among children aged 5–11 years, coverage among Black children was lower than that among Hispanic, Asian, and other/multiple race children. Enhanced public health efforts are needed to increase COVID-19 vaccination coverage for all children and adolescents. To address disparities in child and adolescent COVID-19 vaccination coverage, vaccination providers and trusted messengers should provide culturally relevant information and vaccine recommendations and build a higher level of trust among those groups with lower coverage.

NIS-CCM is a nationally representative random-digit–dialed mobile telephone survey of households with children and adolescents aged 6 months–17 years. NIS-CCM interview data collected from 94,838 respondents during September 26, 2021–September 30, 2022,§ were used to assess racial and ethnic differences in COVID-19 vaccination coverage, parental intent to vaccinate, and behavioral and social drivers of vaccination among children and adolescents aged 5–17 years. Survey respondents were those who reported being knowledgeable about the child's or adolescent's vaccination status (parent). Interviews with parents of an unvaccinated child or adolescent, or a child or adolescent who received ≥1 COVID-19 vaccine dose during December 2020–September 2022 were included. White persons were designated as the referent group for most racial and ethnic comparisons because this group has the largest population size and the most social advantage.[6]

Kaplan-Meier estimation methods were used to calculate cumulative ≥1-dose COVID-19 vaccination coverage as of August 31, 2022.** First-dose vaccination month and year were hot deck imputed†† for 20.2% of children and adolescents with parent-reported vaccination but without a vaccination date.[7] Differences in ≥1-dose coverage were assessed by race and ethnicity and stratified by sociodemographic subgroups. Pairwise comparisons were conducted to assess differences in ≥1-dose estimates for all races and ethnicities. Survey data during July 1–September 30, 2022,§§ (26,961) were pooled to calculate proportions of children and adolescents who 1) were unvaccinated, but parental intent to vaccinate was ascertained, 2) initiated COVID-19 vaccination (received ≥1 dose), 3) completed the primary series (received ≥2 doses), 4) received a monovalent booster (≥3 doses),¶¶ or 5) had an assessment of behavioral and social drivers of vaccination.*** For all analyses, p-values <0.05 were considered statistically significant. Analyses were performed using SAS (version 9.4; SAS Institute) and SAS-callable SUDAAN (version 11.0.3; Research Triangle Institute). Survey weights were used to adjust to the noninstitutionalized U.S. population of children and adolescents and to calibrate to CDC vaccine administration data. The cumulative Council of American Survey Research Organizations (CASRO) response rate††† was 18.1%. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§§§

By August 31, 2022, 33.2%, 59.0%, and 68.6% of persons aged 5–11, 12–15, and 16–17 years, respectively, had received ≥1 COVID-19 vaccine dose (Table 1). Coverage among Asian persons was higher than that among persons of other races and ethnicities, ranging from 63.4% (aged 5–11 years) to 91.8% (16–17 years), followed by Hispanic persons, with coverage ranging from 34.5% to 77.3% (Figure). Coverage was similar for Black, White, and other/multiple race persons aged 12–15 and 16–17 years. Coverage in Black children aged 5–11 years was 4.0 to 33.6 percentage points lower than that among Asian, Hispanic, and other/multiple race children of the same age (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/122810).


COVID-19 vaccination coverage estimates,* by race and ethnicity, among persons aged 5–11 years (A), 12–15 years (B), and 16–17 years (C) during December 2020–August 2022 — National Immunization Survey–Child COVID Module, United States, September 26, 2021–September 30, 2022
Abbreviations: Black = Black or African American; Hispanic = Hispanic or Latino.
*≥1 dose coverage; Kaplan-Meier survival analysis was used to estimate vaccination coverage based on the month and year of first dose receipt; estimates reflect the cumulative percentage vaccinated as of the end of each month.
Race and ethnicity were reported by the parent or guardian. Children and adolescents identified as Asian, Black, White, or other or multiple races were reported by the parent or guardian as non-Hispanic. Children and adolescents identified as being of other or multiple races had more than one race category selected or were identified as American Indian or Alaska Native, or Native Hawaiian or other Pacific Islander. Children and adolescents identified as Hispanic might be of any race.

Coverage with ≥1 COVID-19 vaccine dose by August 31, 2022, was higher among children and adolescents aged 12–17 years, those whose mothers had obtained a college degree, who lived in a household with yearly income ≥$75,000, who always or often wore a mask in public during the previous 7 days, and who had received ≥1 influenza vaccine dose (Table 1). Coverage among Asian and Hispanic children and adolescents was higher in most sociodemographic subgroups compared with coverage among White children and adolescents. Black, White, and other/multiple race children and adolescents had the largest variation in coverage by sociodemographic and behavioral characteristics.

Data collected during July 1–September 30, 2022, indicate that overall, 47.2% of children and adolescents received ≥1 COVID-19 vaccine dose; 43.3% completed the primary series (≥2 doses) (Table 2). Among children and adolescents aged 5–17 years, primary series coverage was highest among Asian persons. Monovalent booster dose coverage was low overall (14.7%) and was highest among Asian children and adolescents (22.4%) and lowest among Black children and adolescents (9.3%). Parents of White children and adolescents of all ages reported the highest level of reluctance¶¶¶ (40.3%) to have their child vaccinated.

Parents of vaccinated children and adolescents reported high levels of confidence in the importance (93.1%) and safety (78.8%) of vaccination overall and by race and ethnicity (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/122811). Confidence in vaccine importance remained high (76.7%), but confidence in vaccine safety was considerably lower (40.2%) among parents of unvaccinated children and adolescents who might get their child vaccinated (reachable children****). Parents of reluctant and reachable children and adolescents reported substantially lower percentages of friends and family had vaccinated their children and adolescents (reflection of social norms) (6.4%–21.2%) and reported having received a provider recommendation (27.9%–35.9%) for vaccination compared with parents of vaccinated children (72.9% and 61.8%, respectively). The magnitude of these differences was similar by race and ethnicity.

Overall, reluctant parents expressed less favorable attitudes and opinions regarding vaccination than did parents of vaccinated and unvaccinated but reachable children. Among all reluctant parents, those of Black and Hispanic children and adolescents reported the highest levels of concern about their child getting COVID-19 and expressed the most confidence in the importance of the vaccine.

*CDC's Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Pfizer-BioNTech COVID-19 vaccine for persons aged ≥16 years on December 12, 2020, 12–15 years on May 12, 2021, and 5–11 years on November 2, 2021. ACIP recommended use of an additional homologous primary dose of Pfizer-BioNTech vaccine after an initial series in immunocompromised persons aged ≥12 years on August 13, 2021. ACIP recommended monovalent booster doses for persons aged 16–17 years on December 9, 2021, 12–15 years on January 5, 2022, and 5–11 years on May 19, 2022.
Race and ethnicity of the child or adolescent were reported by the parent or guardian and were available for all study participants. Asian, Black, White, or other/multiple race children and adolescents were reported by the parent or guardian to be non-Hispanic. Other/multiple race children and adolescents had more than one race category selected, or were identified as American Indian or Alaska Native, or Native Hawaiian or other Pacific Islander. Hispanic children and adolescents might be of any race.
§Respondents interviewed during September 26, 2021–September 30, 2022, were included; month and year of vaccination occurred during December 2020–September 2022.
Assessed by response to the question, "Has [child's name] received at least one dose of a COVID-19 vaccine?" Month and year of first dose was assessed by asking, "During what month and year did [child's name] receive [his/her] first COVID-19 vaccine?"
**Kaplan-Meier estimation methods were used to calculate estimated cumulative vaccination coverage as of the end of each month from December 2020 through August 2022 using data from interviews conducted during September 26, 2021–September 30, 2022, in which the event was defined as the month and year of receipt of first dose of COVID-19 vaccine and was censored by date of interview. Vaccination status was assigned as of the end of the month before the interview.
††Data were imputed using hot deck imputation (replacing missing values with observed values from a respondent with similar characteristics) from donor pools matched for month of interview, age group, region, and race and ethnicity.
§§Interview data were restricted to the previous 3 months (July 1–September 30, 2022) to provide the most current assessment of vaccination coverage, parental intent, and behavioral and social drivers of vaccination. Estimates of vaccination coverage represent the cumulative percentage of children and adolescents vaccinated as of approximately the midpoint of this interview period (mid-August 2022), and estimates of coverage with ≥1 dose might differ from the Kaplan-Meier estimates as of August 31, 2022.
¶¶Information on whether the child or adolescent was immunocompromised was not ascertained in NIS-CCM; thus, booster dose coverage estimates might include immunocompromised children and adolescents who received 3 primary COVID-19 vaccine doses.
***Assessed by responses to six questions covering 1) concern about the child or adolescent getting COVID-19, 2) confidence in COVID-19 vaccine safety, 3) confidence in COVID-19 vaccine importance, 4) percentage of friends and family who had vaccinated their children (social norms), 5) health care provider recommendation for COVID-19 vaccination, and 6) school COVID-19 vaccination requirements. https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-CCM-Questionnaire-Q3-2022.pdf
†††The CASRO response rate is the product of three rates: 1) the proportion of telephone numbers that can be identified as either for business or residence (resolution rate), 2) the proportion of qualified households that complete the screening process (screening rate), and 3) the proportion of contacted eligible households for which a completed interview is obtained (cooperation rate).
§§§45 C.F.R. part 46.102(l)(2), 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.
¶¶¶Unvaccinated children and adolescents whose parents responded that they definitely or probably will not vaccinate their child (reluctant).
****Unvaccinated children and adolescents whose parents responded that they definitely, probably will, or are unsure if they will vaccinate their child (reachable).