COVID-19 Booster Dose Vaccination Coverage and Factors Associated With Booster Vaccination Among Adults, United States, March 2022

Peng-jun Lu; Anup Srivastav; Kushagra Vashist; Carla L. Black; Jennifer L. Kriss; Mei-Chuan Hung; Lu Meng; Tianyi Zhou; David Yankey; Nina B. Masters; Hannah E. Fast; Hilda Razzaghi; James A. Singleton

Disclosures

Emerging Infectious Diseases. 2023;29(1):133-140.

Abstract and Introduction

Abstract

The Centers for Disease Control and Prevention recommends a COVID-19 vaccine booster dose for all persons ≥18 years of age. We analyzed data from the National Immunization Survey–Adult COVID Module collected during February 27–March 26, 2022 to assess COVID-19 booster dose vaccination coverage among adults. We used multivariable logistic regression analysis to assess factors associated with vaccination. COVID-19 booster dose coverage among fully vaccinated adults increased from 25.7% in November 2021 to 63.4% in March 2022. Coverage was lower among non-Hispanic Black (52.7%), and Hispanic (55.5%) than non-Hispanic White adults (67.7%). Coverage was 67.4% among essential healthcare personnel, 62.2% among adults who had a disability, and 69.9% among adults who had medical conditions. Booster dose coverage was not optimal, and disparities by race/ethnicity and other factors are apparent in coverage uptake. Tailored strategies are needed to educate the public and reduce disparities in COVID-19 vaccination coverage.

Introduction

A COVID-19 vaccine booster dose is intended to boost the immune system for better, long-lasting protection when the primary vaccine response decreases over time. Studies have shown that a booster increased the immune response in trial participants who completed a Pfizer-BioNTech (https://www.pfizer.com) or Moderna (https://www.modernatx.com) primary series 6 months earlier or who received a Johnson & Johnson/Janssen (https://www.jnj.com) single-dose vaccine 2 months earlier.^[1,2]

With an increased immune response, booster doses provide additional protection against both Delta and Omicron variants for clinical COVID-19 emergency department visits and hospitalization even for those persons who have received an initial vaccine series.^[1,3] For example, the mRNA vaccine effectiveness (VE) against emergency room visits during the period of Delta predominance was 76%–86% after the second initial dose and 94% after a booster dose; estimates of VE during Omicron variant predominance were 38%–52% after the second initial dose and 82% after a booster dose. VE against hospitalizations during the period of Delta predominance was 81%–90% after the second initial dose and 94% after a booster dose, and estimates of VE for during Omicron variant predominance were 57%–81% after the second initial dose and 90% after a booster dose.^[3]

The Centers for Diseases Control and Prevention (CDC) first recommended booster doses for select populations in September 2021 and on November 29, 2021, recommended that all persons ≥18 years of age should get a booster dose when eligible.^[1,2] By March 2022, approximately 84% of American adults were fully vaccinated with the COVID-19 primary vaccine series; primary vaccine series completion rates varied by some social–demographic characteristics.^[4] Receiving a COVID-19 booster dose is useful both to prevent COVID-19-related illness and death and slow the spread of COVID-19 in the United States. The objective of this study was to assess COVID-19 booster dose vaccination coverage by demographics and behaviors and experiences toward vaccination among fully vaccinated adults by using data from the National Immunization Survey–Adult COVID Module (NIS-ACM).^[5]

1 2 3 4

Next Section

Abstract and Introduction
Methods
Results
Discussion
References

Table 1. COVID-19 booster dose vaccination coverage for fully vaccinated adults (all ages) by demographic, confidence, or behavior characteristics, National Immunization Survey-Adult COVID Module, United States, February 27–March 26, 2022*
Characteristic	No.	COVID-19 booster dose vaccination coverage, % (95% CI)
Characteristic	No.	Persons >18 y of age, n = 63,072	Persons 18–49 y of age, n = 29,084	Persons 50–64 y of age, n = 17,414	Persons >65 y of age, n = 15,527
Total	63,072	63.4 (62.5–64.3)	53.6 (52.3–54.9)	66.4 (64.7–68.1)†	79.5 (78.0–80.9)†
Sex
M‡	30,699	61.6 (60.3–62.9)	50.2 (48.3–52.0)	66.2 (63.6–68.6)†	81.2 (79.1–83.1)†
F	31,853	64.9 (63.7–66.1)§	56.8 (55.0–58.6)§	66.7 (64.3–68.9†	78.2 (76.0–80.2)†§
Race/ethnicity
Non-Hispanic White‡	41,878	67.7 (66.7–68.8)	57.6 (56.0–59.2)	70.0 (68.0–71.8)†	80.2 (78.4–81.8)†
Non-Hispanic Black	6,080	52.7 (50.2–55.2)§	40.1 (36.6–43.7)§	56.2 (51.6–60.7)†§	73.2 (68.7–77.3)†§
Hispanic	7,423	55.5 (52.8–58.1)§	47.5 (44.2–50.9)§	63.1 (57.3–68.5)†§	82.6 (76.5–87.3)§
Non-Hispanic Asian	2,754	74.6 (70.8–78.1)§	72.8 (68.6–76.7)§	77.9 (64.3–87.4)	89.6 (81.8–94.3)†§
Non-Hispanic AI/AN	723	56.6 (47.8–64.9)§	45.2 (32.6–58.4)	64.4 (50.9–75.9)§	76.2 (60.7–86.9)§
Native Hawaiian/Pacific Islander	296	45.4 (30.2–61.5)§	40.5 (24.2–59.2)	38.6 (15.3–68.7)§	83.3 (54.3–95.5)†
Non-Hispanic other/multiple races	2,076	54.1 (48.3–59.9)§	46.3 (39.1–53.7)§	53.2 (40.7–65.4)§	83.2 (76.0–88.6)†
Urbanicity
MSA, principal city‡	22,652	6.5 (62.0–65.0)	56.2 (54.1–58.2)	66.5 (63.2– 69.7)†	79.5 (76.5–82.2)†
MSA, nonprincipal city	28,757	63.9 (62.7–65.2)	52.9 (51.0–54.7)§	68.0 (65.7–70.2)†	80.4 (78.3–82.3)†
Non-MSA	11,663	60.8 (58.5–63.0)§	46.6 (43.0–50.2)§	60.0 (55.7, 64.2)†§	76.7 (73.1–79.9)†
SVI of county of residence¶
Low‡	19,979	68.2 (66.8–69.6)	59.8 (57.6–61.9)	70.8 (68.3–73.3)†	81.8 (79.3, 84.1)†
Moderate	21,573	64.8 (63.3– 66.2)§	54.8 (52.7–56.9)§	68.4 (65.5–71.3)†	80.6 (78.1, 83.0)†
High	15,158	59.3 (57.5–61.2)§	49.1 (46.4–51.7)§	62.0 (58.4–65.5)†§	78.2 (75.1, 81.1)†
Household income
Below poverty‡	5,216	51.6 (48.2–54.9)	43.6 (39.1–48.2)	51.9 (45.3–58.4)†	69.5 (62.7–75.6)†
Above poverty, <$75k	19,645	59.8 (58.2–61.4)§	46.9 (44.6–49.2)	63.3 (59.9–66.5)†§	79.9 (77.6–82.1)†§
Above poverty, >$75k	24,821	70.4 (69.1–71.7)§	62.9 (60.9–64.8)§	73.5 (71.1–75.7)†§	85.3 (82.8–87.4)†§
Unknown	13,390	61.5 (59.6–63.5)§	51.5 (48.4–54.5)§	61.6 (57.5–65.5)†§	75.8 (72.5–78.9)†
Education level
High school graduate or less‡	14,975	53.4 (51.6–55.1)	39.7 (37.2–42.3)	56.4 (53.2–59.6)†	73.9 (71.0–76.6)†
Some college	17,487	61.3 (59.6–62.9)§	49.8 (47.5–52.2)§	66.4 (63.2–69.5)†§	78.9 (76.0–81.5)†§
College graduate	28,929	75.7 (74.6–76.8)§	69.7 (68.0–71.3)§	78.3 (76.0–80.4)†§	87.2 (85.4–88.9)†§
Health insurance
Insured	57,161	65.3 (64.4–66.2)§	55.8 (54.4–57.1)§	67.8 (66.0–69.5)†§	79.9 (78.4–81.3)†§
Not insured‡	4,229	41.2 (37.6–44.9)	37.2 (33.0–41.6)	51.7 (44.3–59.0)†	58.1 (39.5–74.6)†
Foreign born status
Foreign born	7,707	63.1 (60.6–65.6)	55.8 (52.5–59.1)	68.5 (63.2–73.4)†	81.9 (76.7–86.0)†
US born‡	52,546	63.9 (62.9–64.9)	53.7 (52.2–55.1)	66.5 (64.6–68.3)†	79.9 (78.3–81.4)†
Frontline and essential workers#
Essential healthcare	6,580	67.4 (64.8–69.9)§	62.5 (59.2–65.6)§	72.6 (67.5–77.1)†§	85.4 (77.3–91.0)†§
School and childcare	2,321	68.2 (63.3–72.8)§	68.3 (62.1–73.9§	66.2 (56.7–74.5)	83.8 (73.4–90.6)†
Other frontline worker	3,870	52.2 (48.5–55.9)	45.1 (40.4–49.9)	64.5 (58.1–70.3)†	75.6 (64.9–83.8)†
Other essential worker‡	6,228	52.0 (49.1–54.9)	42.9 (39.3–46.7)	64.2 (59.0–69.1)†	73.4 (64.1–81.0)†
Persons not essential workers	43,658	65.4 (64.3–66.4)§	54.3 (52.6–55.9)§	66.2 (64.1–68.3)†	79.6 (78.0–81.1)†
Disability**
Yes (any)	6,122	62.2 (59.4–64.9)	43.8 (38.2–49.5)§	56.8 (51.5–61.9)†§	76.1 (72.5–79.4)†§
No‡	56,807	63.5 (62.6–64.5)	54.2 (52.8–55.5)	67.6 (65.8–69.4)†	80.3 (78.7–81.9)†
Ever had COVID-19
Yes	21,202	50.9 (49.3–52.5)§	44.8 (42.7–46.8)§	53.2 (50.2–56.3)†§	69.8 (65.9–73.5)†§
No‡	41,058	69.5 (68.4–70.5)	59.4 (57.7–61.1)	72.4 (70.4–74.4)†	82.1 (80.5–83.6)†
Received any vaccine that was not a COVID-19 vaccine in the past 2 y
Yes	37,874	73.6 (72.6–74.6)§	65.5 (63.8–67.1)§	75.8 (73.8–77.7)†§	83.0 (81.3–84.6)†§
No‡	24,836	46.4 (44.9–48.0)	39.5 (37.5–41.5)	49.2 (46.2–52.2)†	68.4 (64.9–71.8)†
Reported medical conditions
Yes	19,165	69.9 (68.4–71.3)§	59.4 (56.5–62.3)§	67.9 (65.1–70.5)†	80.9 (78.8–82.8)†
No‡	43,274	60.4 (59.3–61.5)	52.2 (50.7–53.7)	65.4 (63.2–67.6)†	78.7 (76.5–80.7)†
Concerned about getting COVID-19
Not at all/a little‡	37,362	58.1 (56.9–59.3)	49.1 (47.4–50.7)	61.8 (59.4–64.1)†	75.7 (73.5–77.8)†
Moderately/very	25,456	70.1 (68.8–71.4)§	60.5 (58.4–62.6)§	71.5 (68.9–74.0)†§	83.5 (81.4–85.3)†§
Thinks COVID-19 vaccine is important
Not at all/a little‡	10,815	22.8 (20.4–25.3)	16.9 (14.5–19.7)	26.0 (21.2–31.4)†	41.7 (33.9–49.9)†
Very/completely	51,384	67.8 (66.9–68.7)§	58.9 (57.5–60.2)§	70.2 (68.5–71.9)†§	82.0 (80.5–83.4)†§
Thinks COVID-19 vaccine is safe
Not at all/somewhat‡	17,737	39.8 (37.9–41.7)	30.5 (28.1–33.0)	42.1 (38.6–45.5)§	62.5 (58.3–66.6)†
Very/completely	42,063	71.8 (70.8–72.7)§	62.9 (61.4–64.3)§	75.4 (73.4–77.2)†§	84.3 (82.7–85.7)†§
Friends and family vaccinated
No/some family or friends‡	12,740	42.5 (40.2–44.8)	31.2 (28.1–34.5)	47.0 (42.5–51.6)†	60.9 (56.1–65.5)†
Many/almost all family or friends	49,514	67.0 (66.0–67.9)§	57.5 (56.1–58.9)§	69.9 (68.0–71.7)†§	82.6 (81.1–84.0)†§
Difficulty getting a COVID-19 vaccine
Very/somewhat‡	7,848	73.0 (70.7–75.1)	62.5 (58.7–66.2)	72.6 (68.3–76.6)†	88.0 (85.1–90.4)†
A little/not at all	54,901	61.9 (60.9–62.9)§	52.4 (51.0–53.8)§	65.5 (63.6–67.3)†§	77.8 (76.1–79.4)†§

*Values are percentages (95% CIs). Percentages are weighted. AI/AN, non-Hispanic American Indian/Alaska Native; MSA, metropolitan statistical area; SVI, Social Vulnerability Index. †p<0.05 by t-test for comparisons of vaccination coverage within age groups using adults 18–49 y as the reference level. ‡Reference level for comparisons of vaccination coverage within each variable. §p<0.05 by t-test for comparisons of vaccination coverage within each variable with the indicated reference level. ¶Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry SVI uses 15 US census variables to help officials identify communities that might need support before, during, or after disasters. #Essential worker groups were categorized as essential healthcare personnel (including healthcare, social service, and death care workers), school and childcare (including preschool or daycare, K–12 school, and other schools and instructional settings), other frontline (including first response [e.g., police or fire protection], correctional facility, food and beverage store, agriculture, forestry, fishing, or hunting, food manufacturing facility, nonfood manufacturing facility, public transit, and US Postal Service), other essential (including other essential that are not listed above), and not a frontline or essential worker (including those who were not employed). **Defined as an affirmative response to the following survey question: "Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, or communicating?"

Table 2. Logistic model of associations between COVID-19 booster dose vaccination and characteristics among fully vaccinated adults, National Immunization Survey-Adult COVID Module, United States, February 27–March 26, 2022*
Characteristic	PR (95% CI)	aPR (95% CI) demographic variables	aPR (95% CI) demographic and behavior variables
Age group, y
18–49	Referent	Referent	Referent
50–64	1.24 (1.20–1.28)†	1.18 (1.14–1.22)†	1.15 (1.11–1.19)†
>65	1.48 (1.44–1.53)†	1.38 (1.33–1.42)†	1.32 (1.28–1.36)†
Sex
M	Referent	Referent	Referent
F	1.05 (1.02–1.08)†	1.00 (0.98–1.03)	0.99 (0.97–1.02)
Race/ethnicity
Non-Hispanic White	Referent	Referent	Referent
Non-Hispanic Black	0.78 (0.74–0.82)†	0.89 (0.85–0.93)†	0.88 (0.84–0.92)†
Hispanic	0.82 (0.78–0.86)†	1.00 (0.96–1.05)	0.99 (0.94–1.03)
Non-Hispanic Asian	1.10 (1.05–1.16)†	1.14 (1.08–1.1)†	1.12 (1.06–1.19)†
Non-Hispanic AI/AN	0.84 (0.72–0.97)†	0.98 (0.87–1.10)	0.99 (0.88–1.12)
Native Hawaiian/Pacific Islander	0.67 (0.47–0.96)†	1.03 (0.87–1.21)	1.08 (0.89–1.30)
Non-Hispanic other/multiple races	0.80 (0.72–0.89)†	0.94 (0.85–1.03)	0.95 (0.87–1.04)
Urbanicity
MSA, principal city	Referent	Referent	Referent
MSA, nonprincipal city	1.01 (0.98–1.04)	0.97 (0.94–1.00)	0.98 (0.95–1.01)
Non-MSA	0.96 (0.92–1.00)	0.91 (0.87–0.95)†	0.95 (0.91–0.99)†
SVI of county of residence‡
Low	Referent	Referent	Referent
Moderate	0.95 (0.92–0.98)†	0.97 (0.95–1.00)	0.98 (0.96–1.01)
High	0.87 (0.84–0.90)†	0.95 (0.92–0.99)†	0.98 (0.95–1.01)
Household income
Below poverty	Referent	Referent	Referent
Above poverty, <$75k	1.16 (1.08–1.24)†	1.06 (1.00–1.13)	1.05 (0.99–1.11)
Above poverty, >$75k	1.37 (1.28–1.46)†	1.15 (1.08–1.22)†	1.13 (1.06–1.20)†
Unknown	1.19 (1.11–1.28)†	1.09 (1.02–1.17)†	1.09 (1.03–1.17)†
Education level
High school graduate or less	Referent	Referent	Referent
Some college	1.15 (1.10–1.20)†	1.09 (1.05–1.13)†	1.06 (1.02–1.10)†
College graduate	1.42 (1.37–1.47)†	1.27 (1.22–1.32 †	1.19 (1.15–1.23)†
Health insurance
Insured	1.58 (1.45–1.73)†	1.11 (1.04–1.19)†	1.13 (1.06–1.20)†
Not insured	Referent	Referent	Referent
Foreign born status
Foreign born	0.99 (0.95–1.03)	1.04 (0.99–1.09)	1.02 (0.98–1.07)
US born	Referent	Referent	Referent
Frontline and essential workers§
Essential healthcare	1.30 (1.21–1.39)†	1.13 (1.07–1.20)†	1.11 (1.05–1.17)†
School and childcare	1.31 (1.20–1.43)†	1.13 (1.04–1.22)†	1.10 (1.02–1.18)†
Other frontline worker	1.00 (0.92–1.10)	1.08 (1.01–1.15)†	1.06 (1.00–1.13)
Other essential worker	Referent	Referent	Referent
Persons who are not essential workers	1.26 (1.19–1.33)†	1.07 (1.02–1.12)†	1.04 (0.99–1.08)
Disability¶
Yes (any)	0.98 (0.93–1.02)	0.93 (0.88–0.97)†	0.94 (0.90–0.99)†
No	Referent	Referent	Referent
Ever had COVID-19
Yes	0.73 (0.71–0.76)†	0.81 (0.78–0.83)†	0.85 (0.82–0.87)†
No	Referent	Referent	Referent
Received any vaccine that was not a COVID-19 vaccine in the past 2 y
Yes	1.59 (1.53–1.64)†	1.35 (1.31–1.40)†	1.27 (1.23–1.31)†
No	Referent	Referent	Referent
Reported medical conditions
Yes	1.16 (1.13–1.19)†	1.06 (1.02–1.09)†	1.02 (0.99–1.05)
No	Referent	Referent	Referent
Concerned about getting COVID-19
Not at all/a little	Referent	NA	Referent
Moderately/very	1.21 (1.17–1.24)†		1.06 (1.03–1.09)†
Thinks COVID-19 vaccine is important
Not at all/a little	Referent	NA	Referent
Very/completely	2.98 (2.67–3.31)†		1.54 (1.42–1.69)†
Thinks COVID-19 vaccine is safe
Not at all/somewhat	Referent	NA	Referent
Very/completely	1.80 (1.72–1.89)†		1.30 (1.25–1.36)†
Friends and family vaccinated
No/some family or friends	Referent	NA	Referent
Many/almost all family or friends	1.58 (1.49–1.67)†		1.14 (1.09–1.19)†
Difficulty getting a COVID-19 vaccine
Very/somewhat	Referent	NA	Referent
A little/not at all	0.85 (0.82–0.88)†		0.93 (0.90–0.96)†

*AI/AN, non-Hispanic American Indian/Alaska Native; aPR, adjusted prevalence ratio; MSA, metropolitan statistical area; NA, not applicable; PR, prevalence ratio; SVI, Social Vulnerability Index. †p<0.05 by t-test for comparison within each covariate category with the indicated reference level. ‡The Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry SVI uses 15 US census variables to help officials identify communities that might need support before, during, or after disasters. §Essential worker groups were categorized as essential healthcare personnel (including healthcare, social service, and death care workers), school and childcare (including preschool or daycare, K–12 school, and other schools and instructional settings), other frontline (including first response [e.g., police or fire protection], correctional facility, food and beverage store, agriculture, forestry, fishing, or hunting, food manufacturing facility, nonfood manufacturing facility, public transit, and US Postal Service), other essential (including other essential that are not listed above), and not a frontline or essential worker (including those who were not employed). ¶Defined as an affirmative response to the following survey question: "Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, or communicating?"

Table 3. Characteristics of persons who were fully vaccinated but did not receive booster dose vaccination, National Immunization Survey-Adult COVID Module, February 27–March 26, 2022*
Characteristic	Persons >18 y of age, n = 16,790	Persons 18–49 y of age, n = 9,378	Persons 50–64 y of age, n = 4,394	Persons >65 y of age, n = 2,767
Confidence, behavior, experience, provider recommendation, and requirement for adults fully vaccinated but who did not receive booster dose†
Concerned about getting COVID-19, strongly or moderately	36.8 (35.3–38.4)	34.1 (32.2–36.1)	41.6 (38.4–44.9)‡	41.1 (37.2–45.2)‡
Thinks COVID-19 vaccine is safe, completely or mostly	60.6 (59.0–62.1)	60.5 (58.4–62.5)	59.5 (56.2–62.6)	64.4 (60.4–68.3)
Thinks COVID-19 vaccine is needed for protection, mostly or somewhat	80.5 (79.2–81.8)	78.9 (77.1–80.6)	82.5 (80.1–84.8)‡	84.4 (81.3–87.1)‡
Had friends/family who were vaccinated, almost all or many	77.6 (76.3–78.9)	78.6 (76.9–80.2)	76.6 (73.8–79.2)	74.4 (70.6–77.8)‡
Work or school requires COVID-19 vaccine	31.9 (30.4–33.4)	39.7 (37.7–41.7)	24.5 (21.8–27.4)‡	8.3 (6.3–10.8)‡
Provider recommendation of the COVID-19 vaccine	47.9 (46.3–49.4)	46.5 (44.5–48.5)	50.7 (47.4–53.9)‡	49.9 (45.9–54.0)
Difficulty for adults fully vaccinated but did not receive booster dose§
Getting vaccinated, mostly or somewhat	9.9 (9.1–10.9)	9.5 (8.3–10.7)	11.2 (9.4–13.3)	9.6 (7.7–11.9)
Getting an appointment online	9.5 (8.6–10.5)	8.7 (7.6–9.8)	10.5 (8.7–12.7)	11.1 (8.6–14.2)
Not knowing where to get vaccinated	5.3 (4.7–6.1)	5.3 (4.4–6.3)	5.5 (4.3–7.0)	4.9 (3.7–6.5)
Getting to vaccination sites	4.2 (3.6–4.9)	4.3 (3.5–5.2)	4.0 (3.0–5.2)	3.9 (2.6–5.7)
Vaccination sites are not open at convenient times	5.1 (4.5– 5.7)	5.6 (4.8–6.7)	4.4 (3.5–5.5)	3.5 (2.6–4.6)‡

*Values are percentages (95% CIs). Percentages are weighted. †Questions were asked about COVID-19 vaccination generally and not specifically about COVID-19 booster dose vaccination.
‡p<0.05 by t-test for comparisons with adults 18–49 y of age as the reference level. §Questions were asked about difficulty getting a COVID-19 vaccination and did not ask specifically about difficulty getting a booster vaccine.