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What is already known about this topic?
COVID-19 incidence and mortality are higher in rural than in urban communities. Disparities in COVID-19 vaccination coverage between urban and rural communities have been recognized.
What is added by this report?
COVID-19 vaccination coverage with the first dose of the primary vaccination series was lower in rural (58.5%) than in urban counties (75.4%); disparities have increased more than twofold since April 2021. Receipt of booster or additional doses was similarly low in both rural and urban counties.
What are the implications for public health practice?
Addressing barriers to vaccination in rural areas is critical to achieving vaccine equity, reducing disparities, and decreasing COVID-19–related illness and death in the United States.
Higher COVID-19 incidence and mortality rates in rural than in urban areas are well documented (1). These disparities persisted during the B.1.617.2 (Delta) and B.1.1.529 (Omicron) variant surges during late 2021 and early 2022 (1,2). Rural populations tend to be older (aged ≥65 years) and uninsured and are more likely to have underlying medical conditions and live farther from facilities that provide tertiary medical care, placing them at higher risk for adverse COVID-19 outcomes (2). To better understand COVID-19 vaccination disparities between urban and rural populations, CDC analyzed county-level vaccine administration data among persons aged ≥5 years who received their first dose of either the BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna) COVID-19 vaccine or a single dose of the Ad.26.COV2.S (Janssen [Johnson & Johnson]) COVID-19 vaccine during December 14, 2020–January 31, 2022, in 50 states and the District of Columbia (DC). COVID-19 vaccination coverage with ≥1 doses in rural areas (58.5%) was lower than that in urban counties (75.4%) overall, with similar patterns across age groups and sex. Coverage with ≥1 doses varied among states: 46 states had higher coverage in urban than in rural counties, one had higher coverage in rural than in urban counties. Three states and DC had no rural counties; thus, urban-rural differences could not be assessed. COVID-19 vaccine primary series completion was higher in urban than in rural counties. However, receipt of booster or additional doses among primary series recipients was similarly low between urban and rural counties. Compared with estimates from a previous study of vaccine coverage among adults aged ≥18 years during December 14, 2020–April 10, 2021, these urban-rural disparities among those now eligible for vaccination (aged ≥5 years) have increased more than twofold through January 2022, despite increased availability and access to COVID-19 vaccines. Addressing barriers to vaccination in rural areas is critical to achieving vaccine equity, reducing disparities, and decreasing COVID-19–related illness and death in the United States (2).
Data on COVID-19 vaccine doses administered in the United States are reported to CDC by jurisdictions, pharmacies, and federal entities through immunization information systems (IISs),* the Vaccine Administration Management System (VAMS),† or through direct data submission.§ Persons aged ≥5 years with a valid county of residence in one of the 50 states or DC who received their first dose of a COVID-19 vaccine¶ during December 14, 2020–January 31, 2022, and whose deidentified data were reported to CDC were included in the analysis.** Urban-rural comparisons could not be made for three states (Delaware, New Jersey, and Rhode Island) and DC because they only had urban counties. In addition, eight counties in California with population size <20,000 were excluded because they have data-sharing restrictions on county-level information reported to CDC. Vaccine doses administered to persons residing in U.S. territories and freely associated states were also excluded because jurisdictional divisions could not be mapped to urban-rural classifications at the county level.
Receipt of the first dose of COVID-19 vaccine was matched by county of residence to one of six urban-rural categories according to the 2013 National Center for Health Statistics Urban-Rural Classification Scheme (3). To further classify counties into two categories (urban versus rural), four of these six categories (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) were combined into an urban category, and two (micropolitan and noncore) were combined into a rural category (3).
Vaccination coverage for persons aged ≥5 years who received ≥1 doses of a 2-dose COVID-19 primary vaccination series or a single dose of the Janssen COVID-19 vaccine was calculated overall and by age group (5–11, 12–17, 18–64, and ≥65 years), sex, jurisdiction, and urban-rural classification (two- and six-level). Population size was obtained by county, age group, and sex from the U.S. Census Bureau’s 2020 Population Estimates Program (4). Because only the first dose of a 2-dose primary vaccination series or the single dose for Janssen vaccine was analyzed, the total number of doses per county was capped at the county’s population size.†† Primary series completion§§ was also calculated and stratified by urban-rural classification. Among those aged ≥12 years who had completed their primary COVID-19 vaccination series, the proportions eligible for a booster dose and with sufficient time to receive it,¶¶ as well as the proportions of eligible persons who did and did not receive a booster dose, were calculated and stratified by urban-rural classification. Tests for statistical significance were not conducted because the data represent the U.S. population (excluding eight counties in California) and were not based on population samples. All analyses were conducted using SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.***
Overall, during December 14, 2020–January 31, 2022, rural counties had lower first-dose vaccination coverage (58.5%) than did urban counties (75.4%) (Table 1). Females and males had lower first-dose coverage in rural counties (61.4% and 55.7%, respectively) than in urban counties (77.6% and 73.2%, respectively). Among all age groups, vaccination coverage with ≥1 doses was lower in rural counties, with the largest absolute difference (26.2 percentage points) among those aged 12–17 years (38.7% rural, 64.9% urban) and the largest relative difference among those aged 5–11 years (14.7% rural, 30.5% urban). Across jurisdictions, vaccination coverage with ≥1 doses varied by urban-rural classification. Among jurisdictions for which the urban-rural classification could be calculated, 46 jurisdictions had higher coverage in urban than rural counties, and one jurisdiction (Arizona) had higher coverage in rural than urban counties (Table 2). Primary series completion was lower in rural counties (52.1%) than in urban counties (66.2%) (Table 3). Receipt of booster or additional doses among those eligible was similar between urban (50.4%) and rural counties (49.7%).
Créditos: Comité científico Covid