BQ Journal Vol 47 - Q2 2022 - 32

Morbidity and Mortality Weekly Report
TABLE 3. COVID-19 vaccine series completion* and receipt of booster or additional dose among eligible population,† by urban-rural
classification§ - United States, December 14, 2020-January 31, 2022
No. (%)
Characteristic
Completed
series*
Overall
199,221,855
(64.2)
Eligible for
booster dose† 151,089,493
Received booster or additional dose
Yes
75,983,349
(50.3)
No
75,106,144
(49.7)
Large central
metropolitan
66,993,451
(70.5)
49,090,381
24,689,986
(50.3)
24,400,395
(49.7)
Large fringe
metropolitan
52,606,393
(67.2)
Six-level urban-rural classification
Medium
Small
metropolitan
40,925,558
(62.8)
metropolitan Micropolitan Noncore
16,107,552
(57.0)
13,783,465
(53.6)
8,805,436
(50.0)
Urban
176,632,954
(66.2)
Rural
22,588,901
(52.1)
39,909,203 32,033,567 12,472,784 10,892,636 6,690,922 133,505,935 17,583,558
20,439,141
(51.2)
19,470,062
(48.8)
15,878,242
(49.6)
16,155,325
(50.4)
6,244,751
(50.1)
6,228,033
(49.9)
5,343,170
(49.1)
5,549,466
(50.9)
3,388,059
(50.6)
3,302,863
(49.4)
67,252,120
(50.4)
66,253,815
(49.6)
8,731,229
(49.7)
8,852,329
(50.3)
* Persons aged ≥5 years who received a single dose of Janssen (Johnson & Johnson) vaccine or 2 doses of an mRNA vaccine (Pfizer-BioNTech or Moderna). This includes
those who received the same vaccine type for both mRNA vaccine doses, as well as those who received heterologous products for the first and second dose (e.g.,
Pfizer-BioNTech for first dose and Moderna for the second dose, or vice versa). Excludes doses with state of residence reported as a territory, freely associated state,
or county of residence in California with population <20,000. Completeness of county data varied by jurisdiction.
† Eligible population is defined as persons aged ≥12 years who completed a primary COVID-19 vaccination series and were eligible to receive a booster or additional
primary dose by the end of the analysis period, January 31, 2022. For Pfizer-BioNTech and Moderna, the primary series must have been completed by August 31,
2021 (i.e., ≥5 months earlier); for Janssen recipients, 1 dose must have been received by December 1, 2021 (i.e., ≥2 months earlier). Excludes residents in Texas and
persons aged <18 years from Idaho.
§ Doses of COVID-19 vaccine were 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 (https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf). To further classify counties into two categories (urban versus rural),
four of these six categories were combined into urban areas (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan),
and two were combined into rural areas (micropolitan and noncore).
Receipt of booster or additional doses among those eligible was
similar between urban (50.4%) and rural counties (49.7%).
Discussion
Across the United States, COVID-19 vaccination coverage
was lower in rural counties than in urban counties, and this
disparity persisted across sex and age groups. 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
(persons aged ≥5 years) for vaccination have increased overall
and across sex and age groups, despite increased availability
and access to COVID-19 vaccines (5). During December 14,
2020-April 10, 2021, urban-rural differences in first-dose
COVID-19 vaccination coverage among adults aged ≥18 years
were 6.8 percentage points (5); this gap has increased more
than twofold to 16.9 percentage points in the current analysis
among persons aged ≥5 years.
Various factors might have contributed to these increasing
disparities. First, access to health care remains challenging in
rural counties. Before the pandemic, persons in rural areas were
more likely to report not having enough health care providers
or hospitals to serve the community compared with persons
living in urban areas, which might pose access issues for rural
Americans seeking COVID-19 vaccination (6). Second, variations
in views regarding the seriousness of COVID-19 infection
338
MMWR / March 4, 2022 / Vol. 71 / No. 9
and intention to implement COVID-19 prevention strategies
exist and are often shaped by sociocultural identities and
political ideologies that vary across the urban-rural continuum
(7). Third, vaccine hesitancy has been historically higher in
rural††† than urban areas for routinely recommended vaccines
and continues to drive lower COVID-19 vaccination coverage
in rural areas. Adults in rural areas were nearly three times as
likely to report that they " definitely won't " get a COVID-19
vaccine than were those in urban areas (8). Targeted efforts
are critical to increase vaccine confidence to address gaps in
vaccination coverage between urban and rural communities.
Similar factors have also affected pediatric COVID-19 vaccination
coverage. Parents in rural communities were approximately
twice as likely to state that their child will " definitely
not " get a COVID-19 vaccine compared with those in urban
communities (8). Notably, 76% of parents in rural areas indicated
that their trusted source of vaccination information for
their children is their health care provider. However, nearly
40% of rural parents reported that their child's pediatrician
did not recommend a COVID-19 vaccine, compared with
only 8% of parents in urban communities (8). Health care
providers remain a trusted source of information for parents,
and vaccine recommendations from a health care provider are
strong predictors of COVID-19 vaccination (9). This reported
††† https://www.ruralhealthinfo.org/rural-monitor/increasing-vaccination-rates/
Two-level urban-rural
classification
US Department of Health and Human Services/Centers for Disease Control and Prevention
Diagnostics I Pharmaceuticals I DxRx Solutions I Continuing Education I News
32
A Henry Schein Publication
https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf https://www.ruralhealthinfo.org/rural-monitor/increasing-vaccination-rates/
BQ Journal Vol 47 - Q2 2022

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