Background: Childhood immunization is one of the most effective public health strategies for reducing morbidity and mortality from vaccine-preventable diseases. Although overall vaccination coverage in the United States remains high, disparities persist across socioeconomic and healthcare access groups. Understanding these disparities is particularly important in the post-COVID-19 era, when increased vaccine hesitancy may threaten progress in maintaining equitable coverage.
Materials and Methods: We analyzed data from the National Immunization Survey–Child (NIS-Child), focusing on U.S. children aged 19–35 months in 2023, corresponding to cohorts reaching this age during or after the COVID-19 pandemic. The primary outcome was receipt of the up-to-date combined 7-vaccine series (4:3:1:3:3:1:3: ≥4 doses of DTaP, ≥3 doses of polio, ≥1 dose of measles-containing vaccine, full Hib series, ≥3 doses of hepatitis B, ≥1 dose of varicella, and ≥3 doses of PCV). Logistic regression models were used to estimate associations between vaccination coverage and key explanatory variables: household income-to-poverty ratio, maternal education, health insurance type, and provider facility type, controlling for demographic and regional covariates. Disparities were quantified using concentration indices (CIs).
Results: Among children in the analytic sample, overall coverage for the 7-vaccine series was only 78.5%. Nonetheless, disparities were evident. Children from households with lower income-to-poverty ratios (<1 × FPL: OR = 0.44, 95% CI = 0.37–0.53; 100–200%: OR = 0.66, 95% CI = 0.56–0.79), those covered by Medicaid (OR = 0.54, 95% CI = 0.45–0.64), other insurance (OR = 0.48, 95% CI = 0.37–0.61), or uninsured (OR = 0.27, 95% CI = 0.18–0.42), and those whose mothers had lower educational attainment (<12 years: OR = 0.35, 95% CI = 0.28–0.44) had significantly lower odds of being up-to-date. Similar associations were observed across specific vaccines. Unadjusted CIs for income-to-poverty ratio (0.04,
p < 0.01), maternal education (0.04,
p < 0.01), health insurance (0.03,
p < 0.01), and provider type (0.03,
p < 0.01) decreased but remained statistically significant after adjustment (0.02, 0.02, 0.01, and 0.02, respectively; all
p < 0.01). No significant disparities were found by census region or race/ethnicity.
Discussion: Despite relatively high overall vaccination coverage among U.S. children born during and after the COVID-19 pandemic, disparities by socioeconomic and healthcare access factors persisted. However, the absolute magnitude of these disparities was very small (concentration indices ≤ 0.04). These findings suggest that while inequities remain statistically measurable, their scale is limited in absolute terms. Targeted efforts to address income, insurance, maternal education, and provider-related barriers will be important to sustain equitable immunization coverage in the post-pandemic era.
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