Cholera Outbreak - Haiti, September 2022-January 2023: Weekly / Vol. 72 / No. 2 January 13, 2023

Morbidity and Mortality Weekly Report
Weekly / Vol. 72 / No. 2 January 13, 2023
Cholera Outbreak — Haiti, September 2022–January 2023

Denisse Vega Ocasio, PhD1,2; Stanley Juin, MD3; David Berendes, PhD1; Kristen Heitzinger, PhD1; Graeme Prentice-Mott, MSPH1; Anne Marie Desormeaux, MD3;
Phaimyr D. Jn Charles, MD3; Jonas Rigodon, MD3; Valerie Pelletier, MD3; Reginald Jean Louis, MD3; John Vertefeuille, MD4; Jacques Boncy, MD5;
Gerard Joseph, MD5; Valusnor Compère5; Donald Lafontant, MD6; Lesly L. Andrecy, MD6; Edwige Michel, MD6; Katilla Pierre, MSc6; Evenel Thermidor, MSc7;
David Fitter, MD4; Yoran Grant-Greene, PhD3; Matthew Lozier, PhD1; Samson Marseille, MD6; CDC Haiti Cholera Response Group
On September 30, 2022, after >3 years with no confirmed Epidemiologic Investigation
cholera cases (1), the Directorate of Epidemiology, Laboratories On September 30, 2022, DELR was alerted about a pedi-
and Research (DELR) of the Haitian Ministry of Public atric patient with acute watery diarrhea in Haiti’s Ouest
Health and Population (Ministère de la Santé Publique et de Department,† who was treated at a health center operated
la Population [MSPP]) was notified of two patients with acute, by Doctors Without Borders (Médecins Sans Frontières
watery diarrhea in the metropolitan area of Port-au-Prince. [MSF]). The patient was from the Carrefour Feuille area in
Within 2 days, Haiti’s National Public Health Laboratory Port-au-Prince, had been seen at an MSF health clinic on
confirmed the bacterium Vibrio cholerae O1 in specimens from September 29, 2022, and died shortly after arrival. Also, on
the two patients with suspected cholera infection, and an out- September 29, MSF reported a fatal case of acute, watery diar-
break investigation began immediately. As of January 3, 2023, rhea from Cité Soleil, a densely populated commune of the
>20,000 suspected cholera cases had been reported throughout metropolitan area of Port-au-Prince. On October 2, Haiti’s
the country, and 79% of patients have been hospitalized. The National Public Health Laboratory confirmed these two sus-
moving 14-day case fatality ratio (CFR) was 3.0%. Cholera, pected cholera cases, both in the greater Port-au-Prince area,
which is transmitted through ingestion of water or food con-
taminated with fecal matter, can cause acute, severe, watery † Haiti is divided into 10 departments, which are further divided into
diarrhea that can rapidly lead to dehydration, shock, and death 42 arrondissements and 145 communes.
if not treated promptly (2). Haiti is currently facing ongoing
worsening of gang violence, population displacement, social INSIDE
unrest, and insecurity, particularly in the metropolitan area of 26 Vaccination Coverage with Selected Vaccines and
Port-au-Prince, including Belair, Bas-Delmas, Centre-Ville, Exemption Rates Among Children in Kindergarten —
Martissant, Cité Soleil, Croix-des Bouquets, and Tabarre, creat- United States, 2021–22 School Year
ing an environment that has facilitated the current resurgence 33 Vaccination Coverage by Age 24 Months Among
of cholera (3). This report describes the initial investigation, Children Born During 2018–2019 — National
ongoing outbreak, and public health response to cholera in Immunization Survey–Child, United States,
Haiti. Cholera outbreak responses require a multipronged, 2019–2021
multisectoral approach including surveillance; case manage- 39 Safety Monitoring of Bivalent COVID-19 mRNA
ment; access to safe water, sanitation, and hygiene (WASH) Vaccine Booster Doses Among Children Aged
services; targeted oral cholera vaccine (OCV) campaigns; risk 5–11 Years — United States, October 12–
communication; and community engagement. This activity January 1, 2023
was reviewed by CDC and was conducted consistent with 44 QuickStats
applicable federal law and CDC policy.*
Continuing Education examination available at
* Sect. 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); https://www.cdc.gov/mmwr/mmwr_continuingEducation.html
5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
to be V. cholerae O1 (El Tor biotype) of the Ogawa serotype The highest proportion of suspected cholera cases (20%) and
by culture and seroagglutination. Subsequent sequencing of deaths (17%) occurred among children aged 1–4 years (4,009
one of these patients’ stool samples revealed the strains to be and 48, respectively).
very similar to the strain that caused the cholera epidemic in The epicenter of the outbreak was the greater Port-au-Prince
Haiti in 2010, suggesting the resurgence of cholera in Haiti (4). area, located in Ouest Department; as of January 3, based on
MSPP defined a suspected case of cholera as the occurrence Haiti’s case-based surveillance system, Port-au-Prince metro-
of acute, watery diarrhea, with or without vomiting or dehy- politan area had reported 63% of all suspected cases (12,695)
dration, in a person of any age. Confirmed cases were defined and 51% of all deaths (144) in the country. The peak in sus-
as any suspected case with a positive culture for V. cholerae pected cases occurred on November 8, after which case counts
or with an epidemiologic link with a confirmed case. Not all have steadily declined. However, V. cholerae transmission
suspected cases undergo confirmatory testing. As of January 3, continues to occur throughout the country. As of January 3,
2023, MSPP had reported 280 institutional (health care facil- MSPP had reported confirmed cases in nine of 10 departments
ity) deaths and 177 community deaths through the daily alert- (all except Nord-Est), and suspected cases have been reported
based reporting system§ (a system through which surveillance in all 10 departments (Figure 2). The actual number of inci-
officers obtain daily counts of cases and deaths from the report- dent cases is likely substantially higher than that reported,
ing facilities); the moving 14-day CFR was 3.0% (Figure 1). given that incidence** to date has closely mirrored reporting
As of January 3, Haiti’s case-based surveillance system¶ had from cholera treatment centers, and 79% of all patients with
detected 20,262 suspected cases, 1,332 (7%) of which were suspected cholera have been hospitalized. This indicates that
culture-confirmed; 16,019 (79%) patients had been hospital- occurrence of community-based surveillance is limited, which
ized. Among reported patients with suspected cholera, 11,580 could hinder the ability to detect cholera cases that can propa-
(57%) are males, and the median age is 21 years (ranging gate transmission.
from <1 to 100 years). Approximately one third (36%) of
patients with suspected cholera are aged <10 years (Table). ** Cases per 100,000 persons.
§ From alert-based reporting.

¶ From case-based surveillance reporting.
The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2023;72:[inclusive page numbers].
Centers for Disease Control and Prevention
Rochelle P. Walensky, MD, MPH, Director
Debra Houry, MD, MPH, Acting Principal Deputy Director
Jennifer Layden, MD, PhD, Acting Deputy Director for Public Health Science and Surveillance
Rebecca Bunnell, PhD, MEd, Director, Office of Science
Leslie Dauphin, PhD, Director, Center for Surveillance, Epidemiology, and Laboratory Services
MMWR Editorial and Production Staff (Weekly)

Charlotte K. Kent, PhD, MPH, Editor in Chief Martha F. Boyd, Lead Visual Information Specialist Ian Branam, MA,
Jacqueline Gindler, MD, Editor Alexander J. Gottardy, Maureen A. Leahy, Acting Lead Health Communication Specialist
Tegan K. Boehmer, PhD, MPH, Guest Science Editor Julia C. Martinroe, Stephen R. Spriggs, Tong Yang, Kiana Cohen, MPH, Symone Hairston, MPH,
Paul Z. Siegel, MD, MPH, Associate Editor Visual Information Specialists Leslie Hamlin, Lowery Johnson,
Mary Dott, MD, MPH, Online Editor Quang M. Doan, MBA, Phyllis H. King, Health Communication Specialists
Terisa F. Rutledge, Managing Editor Terraye M. Starr, Moua Yang, Dewin Jimenez, Will Yang, MA,
Teresa M. Hood, MS, Lead Technical Writer-Editor Information Technology Specialists Visual Information Specialists
Leigh Berdon, Glenn Damon,
Tiana Garrett-Cherry, PhD, MPH,
Stacy Simon, MA, Morgan Thompson, Suzanne Webb, PhD
Technical Writer-Editors
MMWR Editorial Board
Timothy F. Jones, MD, Chairman
Matthew L. Boulton, MD, MPH David W. Fleming, MD Patricia Quinlisk, MD, MPH
Carolyn Brooks, ScD, MA William E. Halperin, MD, DrPH, MPH Patrick L. Remington, MD, MPH
Jay C. Butler, MD Jewel Mullen, MD, MPH, MPA Carlos Roig, MS, MA
Virginia A. Caine, MD Jeff Niederdeppe, PhD William Schaffner, MD
Jonathan E. Fielding, MD, MPH, MBA Celeste Philip, MD, MPH Morgan Bobb Swanson, BS
22 MMWR / January 13, 2023 / Vol. 72 / No. 2 US Department of Health and Human Services/Centers for Disease Control and Prevention
Public Health Response Discussion

CDC is working closely with MSPP, the U.S. Agency for The first cholera outbreak in Haiti was reported in October 2010,
International Development, and implementing partners 10 months after the catastrophic earthquake that killed >200,000
(including MSF and the Pan American Health Organization) persons and displaced >1 million. The 2010 outbreak resulted in
to further expand epidemiologic and laboratory surveillance to >820,000 cases and approximately 10,000 deaths (1,2). Nearly
guide ongoing response needs. These include improving data 12 years after the outbreak began, Haiti was declared cholera-free
collection and ensuring that a sufficient number of cholera on February 4, 2022, after 3 years without a confirmed case (1).
treatments centers, beds for patient care, and oral rehydra- Haiti is currently experiencing a resurgence of cholera that affects
tion points are available, to reduce morbidity and mortality. all parts of the country. The ongoing social unrest has negatively
Support is also being provided to departmental health director- affected public health infrastructure, creating an environment
ates to implement local investigations and response activities that has facilitated the current resurgence and associated high
to contain cholera in areas of high transmission. Efforts are mortality across the country. In addition, recent fuel shortages
underway to improve access to WASH services and to support have hindered water treatment efforts and other cholera response
risk communication and community engagement nationwide activities nationwide. These factors have reduced the supply of safe
to interrupt community transmission of cholera throughout drinking water, forcing an increasing number of residents to rely
Haiti. Support was also provided to launch an OCV campaign on unsafe sources and untreated water, substantially worsening
in mid-December in high-transmission areas. the cholera outbreak and hindering the response (5,6).
FIGURE 1. Date of notification of suspected cholera cases* and 14-day case fatality ratio† — Haiti, September 2022–January 2023
100
500
4
14-day CFR
400
Incident suspect cases
3
300
14-day CFR
2
200
100 1
0 0
18 25 2 9 16 23 30 6 13 20 27 4 11 18 25 1
Sep Oct Nov Dec Jan
2022 2023
Date of notification
Abbreviation: CFR = case fatality ratio.
* From case-based surveillance reporting.
† From alert-based reporting.
US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / January 13, 2023 / Vol. 72 / No. 2 23
TABLE. Characteristics of cholera outbreak cases — Haiti, September Cholera outbreaks, especially in the setting of a complex
2022–January 2023* humanitarian crisis, can spread rapidly, result in many deaths,
No. (%) and quickly become a public health crisis. Mild cases that are
Characteristic Suspected cholera cases† Cholera deaths not seen in health care facilities can propagate transmission;
Age group, yrs thus, their detection is critical for monitoring and controlling
<1 376 (1.9) 2 (0.7) transmission. Prompt and effective treatment for patients with
1–4 4,009 (19.8) 48 (16.8)
5–9 2,890 (14.3) 30 (10.5) cholera can reduce mortality rates from >50% to <1% (6,7).
10–14 1,383 (6.8) 13 (4.6) Primary treatment includes rehydration therapy (prompt
15–19 1,041 (5.1) 9 (3.2)
20–29 2,970 (14.7) 31 (10.9)
restoration of lost fluids and salts); antibiotic treatment is
30–39 2,803 (13.8) 26 (9.1) recommended for severe cholera cases only (8). A CFR of <1%
40–49 1,931 (9.5) 39 (13.7) is the goal for case management interventions. Recent peaks
50–59 1,378 (6.8) 31 (10.9)
60–69 879 (4.3) 26 (9.1)
in the 14-day CFR at the beginning of December and January
70–79 441 (2.2) 19 (6.7) might be elevated because of recent receipts of large numbers
≥80 161 (0.8) 11 (3.9) of backlogged death reports and because of safety and security
Sex
Female 8,682 (42.8) 109 (38.2)
concerns making community-based surveillance challenging,
Male 11,580 (57.2) 176 (61.8) thereby limiting the detection of less severe cases of cholera.
Department Efforts to control the outbreak and reduce CFRs should
Ouest 14,176 (70.0) 170 (59.6) include a combination of surveillance, WASH services, risk
Artibonite 3,134 (15.5) 66 (23.2)
Centre 1,250 (6.2) 0 (—) communication and community engagement, timely treatment
Nippes 517 (2.6) 7 (2.5) of illness, and OCVs. According to WHO’s position paper on
Nord-Ouest 490 (2.4) 16 (5.6)
Grand’Anse 254 (1.3) 9 (3.2)
cholera vaccines, OCVs should be used in humanitarian crises
Sud-Est 185 (0.9) 10 (3.5) with high risk for cholera, during a cholera outbreak, and in
Nord 155 (0.8) 2 (0.7) places with endemic cholera, always in conjunction with other
Sud 95 (0.5) 5 (1.8)
Nord-Est 6 (<1.0) 0 (—)
cholera prevention and control strategies (9).
The resurgence of cholera in Haiti and the complexity of the
* From case-based surveillance reporting.
† Department was missing for two suspected cases. response present significant challenges. However, the existing
FIGURE 2. Rolling 14-day cholera incidence (cases per 100,000 population), by department — Haiti, October 2022–January 2023
Oct 9 Nov 20 Jan 1
Nord-Ouest Nord-Ouest Nord-Ouest
Nord Nord Nord

Nord-Est Nord-Est Nord-Est
Artibonite Artibonite Artibonite
Centre Centre Centre
Grande’Anse Grande’Anse Grande’Anse

Nippes Nippes Nippes
Ouest Ouest Ouest
Sud Sud-Est Sud Sud-Est Sud Sud-Est
>50
10−49
5−9
2−4
0−1
No case reports
Corresponding author: Denisse Vega Ocasio, rhq1@cdc.gov.

Summary
1Division of Foodborne, Waterborne, and Environmental Diseases, National
What is already known about this topic?
Center for Emerging and Zoonotic Infectious Diseases, CDC; 2Epidemic
The first cholera outbreak in Haiti was reported in October 2010. Intelligence Service, CDC; 3CDC Haiti Country Office; 4Global Immunization
Haiti was declared cholera-free in February 2022, after 3 years Division, Center for Global Health, CDC; 5National Public Health Laboratory,
with no confirmed cases. Ministère de la Santé Publique, Port-au-Prince, Haiti; 6Directorate of
Epidemiology of Laboratory Research, Ministère de la Santé Publique, Port-
What is added by this report? au-Prince, Haiti; 7Direction Nationale de l’Eau Potable et de l’Assainissement,
On October 2, 2022, two cases of Vibrio cholerae O1 infection Port-au-Prince, Haiti.
were confirmed in the greater Port-au-Prince area. As of All authors have completed and submitted the International
January 3, 2023, >20,000 suspected cholera cases had been Committee of Medical Journal Editors form for disclosure of potential
reported throughout the country. conflicts of interest. No potential conflicts of interest were disclosed.
What are the implications for public health practice?
Multiple factors, including social unrest, have affected public References
health infrastructure and facilitated cholera resurgence. 1. DAI. Haiti declared free of Cholera. Bethesda, MD: DAI; 2022. https://
Although cases have declined, a multipronged approach, www.dai.com/news/haiti-declared-free-of-cholera
including sufficient and timely case management, strengthened 2. CDC. Cholera - Vibrio cholerae infection: general information. Atlanta,
surveillance, emergency water treatment, and targeted oral GA: US Department of Health and Human Services, CDC; 2022. Accessed
cholera vaccination campaigns are urgently needed. December 19, 2022. https://www.cdc.gov/cholera/general/index.html
3. United Nations. Haiti: UN sounds alarm over worsening gang violence
across Port-au-Prince. New York, New York: United Nations; 2022.
technical capacity in Haiti, which was built during the previous https://www.ungeneva.org/es/news-media/news/2022/07/haiti-un-
sounds-alarm-over-worsening-gang-violence-across-port-au-prince
cholera response, has provided valuable experience and staffing 4. Rubin DHF, Zingl FG, Leitner DR, et al. Reemergence of cholera in
resources to combat cholera. Lessons learned about how to Haiti. N Engl J Med 2022;387:2387–9. PMID:36449726 https://doi.
treat and prevent cholera from the previous response should be org/10.1056/NEJMc2213908
5. Doctors Without Borders. Haiti: shortages of fuel, water and
leveraged to aggressively respond to this outbreak and ensure transportation threaten medical care. Toronto, Canada: Doctors
effective public health actions. Although cases have declined, Without Borders; 2022. https://www.doctorswithoutborders.ca/article/
a multipronged approach including strengthened surveillance, haiti-shortages-fuel-water-and-transportation-threaten-medical-care
timely case management, targeted OCV campaigns, risk com- 6. World Health Organization. Disease outbreaks news: cholera–Haiti.
Geneva, Switzerland: World Health Organization; 2012. https://www.
munication, community engagement, and access to safe WASH who.int/emergencies/disease-outbreak-news/item/2022-DON415
services and emergency water treatment are urgently needed. 7. Harris JB, LaRocque RC, Qadri F, Ryan ET, Calderwood SB. Cholera.
Lancet 2012;379:2466–76. PMID:22748592 https://doi.org/10.1016/
Acknowledgments S0140-6736(12)60436-X
8. CDC. Cholera - Vibrio cholerae infection: treatment. Atlanta, GA: US
The Haitian government, implementing partners, and staff Department of Health and Human Services, CDC; 2022. Accessed
members who are responding to the cholera outbreak. November 30, 2022. https://www.cdc.gov/cholera/treatment/index.html
9. World Health Organization. Cholera vaccines: WHO position paper–
CDC Haiti Cholera Response Group August 2017. Geneva, Switzerland: World Health Organization; 2017. http://
apps.who.int/iris/bitstream/10665/258764/1/WER9234-477-498.pdf
Ashley Andujar, CDC; Alondra Baez-Nieves, CDC; Lucy Breakwell,
CDC; Sara Breese, CDC; Joan Brunkard, CDC; Mushtaq Dualeh, CDC;
Thomas Handzel, CDC; Christine Lee, CDC; Andrea Martinsen, CDC;
Taylor Osborne, CDC; David Shih, CDC; Amanda Tiffany, CDC;
Maryann Turnsek, CDC.
Please note: This report has been corrected. An erratum has been published.
Vaccination Coverage with Selected Vaccines and Exemption Rates Among

Children in Kindergarten — United States, 2021–22 School Year
Ranee Seither, MPH1; Kayla Calhoun, MS1; Oyindamola Bidemi Yusuf, PhD1,2; Devon Dramann, MPH1,3; Agnes Mugerwa-Kasujja, MD1,2;
Cynthia L. Knighton1; Carla L. Black, PhD1
State and local school vaccination requirements protect students has been a nearly complete return to in-person learning after
and communities against vaccine-preventable diseases (1). This COVID-19 pandemic-associated disruptions, immunization
report summarizes data collected by state and local immunization programs continued to report COVID-19–related impacts on
programs* on vaccination coverage and exemptions to vaccination vaccination assessment and coverage. Follow-up with undervac-
among children in kindergarten in 49 states† and the District cinated students and catch-up campaigns remain important for
of Columbia and provisional enrollment or grace period status increasing vaccination coverage to prepandemic levels to protect
for kindergartners in 27 states§ for the 2021–22 school year. children and communities from vaccine-preventable diseases.
Nationwide, vaccination coverage with 2 doses of measles, mumps As mandated by state and local school entry requirements, par-
and rubella vaccine (MMR) was 93.0%¶; with the state-required ents provide children’s vaccination or exemption documentation
number of diphtheria, tetanus, and acellular pertussis vaccine to schools, or schools obtain records from state immunization
(DTaP) doses was 92.7%**; with poliovirus vaccine (polio) was information systems. Federally funded immunization programs
93.1%††; and with the state-required number of varicella vaccine work with departments of education, school nurses, and other
doses was 92.8%.§§ Compared with the 2020–21 school year, school personnel to assess vaccination and exemption status of
vaccination coverage decreased 0.8-0.9 percentage points for all children enrolled in public and private kindergartens and to report
vaccines. Although 2.6% of kindergartners had an exemption unweighted counts, aggregated by school type, to CDC via a web-
for at least one vaccine,¶¶ an additional 4.4% who did not have based questionnaire in the Secure Access Management system, a
an exemption were not up to date with MMR. Although there federal, web-based system that provides authorized personnel with
secure access to public health applications operated by CDC. CDC
* Federally funded immunization programs are located in 50 states and the District uses these counts to produce state- and national-level estimates
of Columbia, five cities, and eight U.S territories and freely associated states. of vaccination coverage among children in kindergarten. During
Two cities reported data, which were also included in data submitted by their
state, to CDC. State-level data were used to calculate national estimates and the 2021–22 school year, 49 states and the District of Columbia
medians. Immunization programs in territories reported vaccination coverage reported coverage with all state-required vaccines and exemption
and exemptions; however, these data were not included in national calculations. data for public school kindergartners; 48 states and the District of
† Montana did not report school vaccination data.
§ Arkansas, California, Colorado, Florida, Georgia, Hawaii, Idaho, Iowa, Columbia reported coverage with all state-required vaccines and
Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New exemption data for private school kindergartners.*** Data from
Mexico, New York, North Carolina, Ohio, South Carolina, Tennessee, Texas, cities were included with their state data. State-level coverage and
Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming
reported data on the number of students within a grace period or provisionally national and median coverage with the state-required number
enrolled at the time of assessment. of DTaP, MMR, polio, and varicella vaccine doses are reported.
¶ All states require 2 doses of a measles-containing vaccine. Seven states (Alaska,
Georgia, New Jersey, New York, North Carolina, Oregon, and Virginia) require
Hepatitis B vaccination coverage is not included in this report but
only 1 dose of rubella vaccine. Alaska, New Jersey, and Oregon require only is available at SchoolVaxView (2). Twenty-seven states reported
1 dose of mumps vaccine; mumps vaccine is not required in Iowa. the number of kindergartners who were attending school under a
** Nebraska requires 3 doses of DTaP, Maryland and Wisconsin require 4 doses,
and all other states require 5 doses, unless dose 4 was administered on or after grace period (attendance without proof of complete vaccination or
the fourth birthday. The reported coverage estimates represent the percentage exemption during a set interval) or provisional enrollment (school
of kindergartners with the state-required number of DTaP doses, except for attendance while completing a catch-up vaccination schedule). All
Kentucky, which requires 5 doses of DTaP by age 5 years but reported 4-dose
coverage for kindergartners. counts were current as of the time of the assessment.††† National
†† Two states (Maryland and Nebraska) require only 3 doses of polio vaccine; all other
estimates, medians, and summary measures include only U.S. states
states require 4 doses unless the last dose was given on or after the fourth birthday.
§§ Five states require 1 dose of varicella vaccine; 44 states and the District of and the District of Columbia.
Columbia require 2 doses.
¶¶ Colorado, Illinois, Minnesota, and Missouri did not report the number of *** Twelve states reported coverage and exemption data for at least some
kindergartners with an exemption but instead reported the number of homeschooled kindergartners, either separately or included with data from
exemptions for each vaccine, which could have counted some children more public or private schools.
than once. For these states, the percentage of kindergartners exempt from the ††† Assessment date varied by state and area. Three states assessed schools on the
vaccine with the highest number of exemptions by exemption type (the lower first day of school; 10 states assessed schools by December 31; 18 states and the
bound of the potential range of exemptions) was included in the national and District of Columbia assessed schools by some other date, ranging from
median exemption rates. October 15, 2021, to June 23, 2022; and 18 states assessed schools on a
rolling basis.
Vaccination coverage and exemption estimates were Nationally, 2-dose MMR coverage was 93.0% (range =
adjusted on the basis of survey type and response rate.§§§ 78.0% [Alaska] to ≥98.6% [Mississippi]), with coverage of
National estimates measure coverage and exemptions among ≥95% reported by 14 states and <90% by nine states and
all kindergartners, whereas medians indicate the midpoint of the District of Columbia (Table). DTaP coverage was 92.7%
state-level coverage, irrespective of population size. During (range = 78.0% [Alaska] to ≥98.6% [Mississippi]); coverage
the 2021–22 school year, immunization programs reported of ≥95% was reported by 15 states and of <90% by 12 states
3,835,130 children enrolled in kindergarten in 49 states and and the District of Columbia. Polio vaccination coverage was
the District of Columbia.¶¶¶ Reported estimates are based on 93.1% (range = 77.1% [Alaska] to ≥98.6% [Mississippi]), with
3,536,546 (92.2%) children who were surveyed for vaccination coverage of ≥95% reported by 14 states and <90% by 10 states
coverage, 3,686,775 (96.1%) surveyed for exemptions, and and the District of Columbia. Varicella vaccination coverage
2,527,578 (65.9%) surveyed for grace period and provisional nationally was 92.8% (range = 76.1% [Alaska] to ≥98.6%
enrollment status. Potentially achievable coverage with MMR [Mississippi]), with 13 states reporting coverage ≥95% and nine
(the sum of the percentage of children who were up to date states and the District of Columbia reporting <90% coverage.
with 2 doses of MMR and those not up to date but with no Coverage decreased in most states for all vaccines compared
documented vaccination exemption) was calculated for each with the 2020–21 school year (Supplementary Figure, https://
state. Nonexempt students include those who were provision- stacks.cdc.gov/view/cdc/123205).
ally enrolled in kindergarten, in a grace period, or otherwise Overall, 2.6% of kindergartners had an exemption (0.2%
without documentation of complete vaccination. SAS software medical and 2.3% nonmedical§§§§) for one or more required
(version 9.4; SAS Institute) was used for all analyses. This vaccines (not limited to MMR, DTaP, polio, and varicella
activity was reviewed by CDC and was conducted consistent vaccines) in 2021–22 (range = 0.1% [Mississippi, New York,
with applicable federal law and CDC policy.**** and West Virginia] to 9.8% [Idaho]), compared with 2.2%
Vaccination assessments varied by state because of differ- reported during the 2020–21 school year (Supplementary
ences in required vaccines and required numbers of doses, Table 2, https://stacks.cdc.gov/view/cdc/123204). Among
vaccines assessed, methods of data collection, and data 27 states reporting data on provisional kindergarten enrollment
reported (Supplementary Table 1, https://stacks.cdc.gov/view/ or grace period attendance, 2.4% of children were so enrolled
cdc/123203). Kindergartners were considered up to date with (range = <0.1% [Hawaii] to 8.5% [Wisconsin]).
a given vaccine if they received all doses required for school Nationally, MMR coverage for both the 2020–21 and 2021–
entry, except in eight states†††† that reported kindergartners 22 school years was lower than that reported since 2013–14
as up to date for any vaccine only if they had received all doses (Figure 1). Nationwide, 4.4% of kindergarten students were
of all vaccines required for school entry. States were asked to not fully vaccinated and not exempt. Among the 35 states
report any COVID-19–related impact on kindergarten vac- and the District of Columbia with MMR coverage <95%, all
cination measurement and coverage through a combination but four could potentially achieve ≥95% MMR coverage if all
of structured responses and open-ended questions. nonexempt kindergartners who were within a grace period,
provisionally enrolled, or otherwise enrolled in school without
§§§ Immunization programs that used census or voluntary response provided documentation of vaccination were vaccinated (Figure 2).
CDC with data aggregated at the state or local (city or territory) level. Twenty-three states reported COVID-19–related impacts on
Estimates based on these data were adjusted for nonresponse using the
inverse of the response rate, stratified by school type (public, private, and data collection including lower response rates from schools,
homeschool, where available). Programs that used complex sample surveys data collection extensions and delays, and incomplete data
provided CDC with data aggregated at the school or county level for from schools that did respond; 30 states reported lingering
weighted analysis. Weights were calculated to account for sample design
and adjusted for nonresponse. COVID-19–related impacts on vaccination coverage, mostly
¶¶¶ These totals are the summations of the kindergartners surveyed among
related to reduced access to vaccination appointments and local
programs reporting data for coverage, exemptions, grace periods, and
provisional enrollment. Data from cities and territories were not included
or school level extensions of grace period or provisional enroll-
in these totals. ment policies (CDC, School Vaccination Coverage Report,
**** 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 unpublished data, 2022).
U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
†††† Alabama, Florida, Georgia, Iowa, Mississippi, New Hampshire, New Jersey,
and Wisconsin considered kindergartners up to date only if they had §§§§ Washington was unable to deduplicate data for students with both religious
received all doses of all vaccines required for school entry. In Kentucky, and philosophical exemptions; therefore, the nonmedical exemption type
public schools reported numbers of children up to date with specific vaccines with the highest number of kindergartners (the lower bound of the potential
and most private schools reported numbers of children who received all range of nonmedical exemptions) was included in the national and median
doses of all vaccines required for school entry. exemption rates for nonmedical exemptions.
TABLE. Estimated* coverage† with measles, mumps, and rubella; diphtheria, tetanus, and acellular pertussis; poliovirus; and varicella vaccines;
grace period or provisional enrollment§; and any exemption¶,** among kindergartners, by immunization program — United States,†† 2021–22
school year
Percentage
Grace period or point change in
Kindergarten 2 Doses 5 Doses 4 Doses 2 Doses provisional Any any exemption,
Immunization program population§§ Surveyed,¶¶ % MMR,*** % DTaP,††† % polio,§§§ % VAR,¶¶¶ % enrollment, % exemption, % 2020–2021
National estimate**** 3,835,130 92.2 93.0 92.7 93.1 92.8 2.4 2.6 0.4
Median**** — — 92.9 92.0 92.7 92.6 1.9 2.7 0.2
U.S. jurisdictions
Alabama††††,§§§§ 60,332 100.0 ≥94.9 ≥94.9 ≥94.9 ≥94.9 NP 1.7 0.4
Alaska§§§§,¶¶¶¶ 9,790 76.2 78.0 78.0 77.1 76.1 NR 4.6 0.6
Arizona***** 83,463 97.0 90.6 90.5 90.9 94.6 NR 6.8 1.3
Arkansas††††† 39,358 96.3 92.5 91.3 91.4 91.9 7.5 2.5 0.5
California§§§§,*****,††††† 512,144 98.4 96.3 95.7 96.2 96.0 1.2 0.2 −0.3
Colorado 66,900 97.5 88.4 89.1 88.8 87.6 ≥0.6 ≥3.2 −1.0
Connecticut††††,§§§§ 35,451 100.0 95.7 96.0 96.0 95.5 NP 2.3 −0.3
Delaware§§§§,††††† 11,181 9.5 96.4 96.4 97.1 95.7 NR 1.2 −1.2
District of Columbia ††††,§§§§ 8,959 100.0 82.0 82.2 84.7 81.0 NR 0.5 0.2
Florida§§§§,§§§§§ 229,432 97.8 ≥91.7 ≥91.7 ≥91.7 ≥91.7 4.3 3.9 0.8
Georgia††††,§§§§ 118,742 100.0 ≥83.2 ≥83.2 ≥83.2 ≥83.2 0.4 4.7 1.8
Hawaii§§§§ 13,368 6.7 94.3 92.5 93.2 90.2 <0.1 3.4 0.6
Idaho 23,854 99.6 83.9 83.5 84.0 83.4 1.8 9.8 1.6
Illinois††††,§§§§ 137,699 100.0 92.1 91.9 91.9 91.8 NR ≥1.7 NA
Indiana§§§§,§§§§§ 83,198 75.1 92.1 84.0 89.3 91.7 NR 2.4 0.5
Iowa††††,§§§§ 40,111 100.0 ≥90.6 ≥90.6 ≥90.6 ≥90.6 5.4 2.4 0.2
Kansas§§§§,†††††,§§§§§,¶¶¶¶¶ 36,526 29.5 91.1 90.0 92.2 90.4 NR 2.3 0.3
Kentucky§§§§,†††††,§§§§§ 59,233 91.5 ≥86.5 ≥87.1 ≥87.8 ≥85.6 NR 1.3 0.3
Louisiana†††† 66,518 100.0 93.7 96.2 97.6 91.4 NP 1.1 0
Maine 12,881 91.6 96.7 96.3 96.5 95.5 NR 1.8 −2.7
Maryland§§§§,††††† 53,866 98.4 93.9 88.6 94.8 92.7 NR 1.5 0.6
Massachusetts††††,§§§§,††††† 65,582 100.0 96.2 96.1 96.0 95.7 NP 1.0 −0.1
Michigan†††† 114,251 100.0 93.6 94.1 94.8 93.6 0.7 4.5 0.8
Minnesota 69,403 98.7 89.0 89.0 89.3 88.7 NR ≥3.7 0.9
Mississippi††††,§§§§,***** 36,524 100.0 ≥98.6 ≥98.6 ≥98.6 ≥98.6 1.0 0.1 0
Missouri††††,§§§§ 71,034 100.0 91.6 91.5 91.9 91.2 NR ≥3.0 0.5
Montana NR NA NR NR NR NR NR NR NA
Nebraska§§§§,††††† 25,018 99.5 96.2 96.6 97.6 95.5 1.9 2.5 0.3
Nevada§§§§ 36,855 99.2 92.7 91.5 92.2 92.1 3.1 4.8 0.4
New 12,157 100.0 ≥88.7 ≥88.7 ≥88.7 ≥88.7 5.2 3.4 0.6
Hampshire††††,§§§§,§§§§§
New Jersey††††,§§§§,§§§§§ 104,240 100.0 ≥94.1 ≥94.1 ≥94.1 ≥94.1 1.3 2.6 0.4
New Mexico††††,§§§§ 20,736 100.0 94.3 94.0 94.3 93.6 0.4 1.4 0.5
New York (including 195,377 99.3 98.0 97.3 97.4 97.4 2.0 0.1 0
New York City)§§§§,*****
New York City§§§§,***** 82,938 99.8 97.3 96.5 96.4 96.7 1.7 0.1 0
North Carolina§§§§,†††††,§§§§§ 118,191 78.5 96.1 96.0 96.1 95.9 1.1 1.9 0.4
North Dakota 10,755 96.6 91.5 91.4 91.7 91.2 NR 5.3 1.1
Ohio 139,077 91.9 88.3 88.5 88.9 87.9 7.4 3.0 0.5
Oklahoma††††† 54,042 84.3 90.9 91.1 91.9 95.5 NR 3.5 1.1
Oregon††††,††††† 41,538 100.0 93.0 92.0 92.3 94.7 NR 7.0 1.6
Pennsylvania 139,558 94.9 95.0 95.4 95.1 94.8 NR 3.3 0.6
Rhode Island§§§§,†††††,§§§§§ 11,002 96.9 97.3 97.0 97.1 97.0 NR 1.2 0.2
South Carolina§§§§,¶¶¶¶¶ 58,276 27.2 92.7 91.0 91.9 92.4 3.4 3.4 1.0
South Dakota††††,§§§§ 12,251 100.0 93.7 93.2 93.6 91.9 NR 3.5 0.1
Tennessee††††,§§§§,§§§§§ 79,120 100.0 95.8 95.2 95.4 95.4 1.9 2.4 0.5
Texas (including 389,037 99.3 94.0 93.7 94.0 93.5 1.8 2.9 0.6
Houston)†††††,§§§§§
Houston†††††,§§§§§ 40,123 99.3 88.2 88.3 88.3 87.8 1.2 1.5 0.2
Utah†††† 48,995 100.0 90.0 89.6 90.0 92.8 2.0 7.4 2.3
Vermont††††,§§§§ 6,126 100.0 93.4 92.9 93.1 92.6 6.8 3.3 0.1
Virginia§§§§,¶¶¶¶¶ 95,996 2.8 95.5 98.3 94.7 94.9 NR 1.8 0.3
Washington§§§§§ 87,256 97.3 92.5 91.4 91.9 91.3 1.3 3.7 0.4
West 18,070 85.5 96.5 96.5 96.6 98.0 3.8 0.1 NA
Virginia§§§§,*****,§§§§§,†††††
Wisconsin††††† 64,275 96.8 ≥82.6 ≥82.6 ≥82.6 ≥82.6 8.5 6.3 1.1
Wyoming††††,§§§§ 7,382 100.0 92.9 92.5 93.8 93.6 2.1 3.9 0.9
See table footnotes on the next page.
TABLE. (Continued) Estimated* coverage† with measles, mumps, and rubella; diphtheria, tetanus, and acellular pertussis; poliovirus; and
varicella vaccines; grace period or provisional enrollment§; and any exemption¶,** among kindergartners, by immunization program —
United States,†† 2021–22 school year
Percentage
Grace period or point change in
Kindergarten 2 Doses 5 Doses 4 Doses 2 Doses provisional Any any exemption,
Immunization program population§§ Surveyed,¶¶ % MMR,*** % DTaP,††† % polio,§§§ % VAR,¶¶¶ % enrollment, % exemption, % 2020–2021
Territories and freely associated states
American Samoa†††† 630 100.0 90.0 94.3 97.0 76.8 NR 0 NA
Federated States of 1,884 100.0 85.4 78.1 82.5 Nreq NR NR NA
Micronesia††††
Guam§§§§ 2,236 96.8 91.5 89.8 90.9 Nreq NR 0.2 NA
Marshall Islands†††† 1,003 100.0 97.7 93.2 97.3 Nreq NR NR NA
Northern Mariana Islands†††† 914 100.0 94.4 85.0 90.8 93.5 NR 0 0
Palau NR NR NR NR NR NR NR NR NA
Puerto Rico§§§§ 27,591 8.0 85.2 92.6 91.2 86.0 NR 1.8 NA
U.S. Virgin Islands NR NR NR NR NR NR NR NR NA
Abbreviations: DTaP = diphtheria, tetanus, and acellular pertussis vaccine; DTP = diphtheria and tetanus toxoids and pertussis vaccine; MMR = measles, mumps, and
rubella vaccine; polio = poliovirus vaccine; NA = not available; NP = no grace period or provisional policy; NR = not reported to CDC; Nreq = not required;
VAR = varicella vaccine.
* Estimates adjusted for nonresponse and weighted for sampling where appropriate.
† Estimates based on a completed vaccination series (i.e., not vaccine specific) use the “≥” symbol. Coverage might include history of disease or laboratory evidence
of immunity. In Kentucky, public schools reported numbers of children up to date with specific vaccines, and most private schools reported numbers of children
who received all doses of all vaccines required for school entry.
§ A grace period is a set number of days during which a student can be enrolled and attend school without proof of complete vaccination or exemption. Provisional
enrollment allows a student without complete vaccination or exemption to attend school while completing a catch-up vaccination schedule. In states with one
or both of these policies, the estimates represent the number of kindergartners who were within a grace period, were provisionally enrolled, or were in a
combination of these categories.
¶ Some programs did not report the number of children with exemptions, but instead reported the number of exemptions for each vaccine, which could count
some children more than once. Lower bounds of the percentage of children with any exemptions were estimated using the individual vaccines with the highest
number of exemptions. Estimates based on vaccine-specific exemptions use the “≥” symbol.
** Exemptions, grace period or provisional enrollment, and vaccine coverage status might not be mutually exclusive. Some children enrolled under a grace period or
provisional enrollment might be exempt from one or more vaccinations, and children with exemptions might be fully vaccinated with one or more required vaccines.
†† Includes five territories and three freely associated states.
§§ The kindergarten population is an approximation provided by each program.
¶¶ The number surveyed represents the number surveyed for coverage. Exemption estimates are based on 29,010 kindergartners for Kansas, 58,276 for South
Carolina, and 92,265 for Virginia.
*** Most states require 2 doses of MMR; Alaska, New Jersey, and Oregon require 2 doses of measles, 1 dose of mumps, and 1 dose of rubella vaccines. Georgia, New
York, New York City, North Carolina, and Virginia require 2 doses of measles and mumps vaccines and 1 dose of rubella vaccine. Iowa requires 2 doses of measles
vaccine and 2 doses of rubella vaccine.
††† Pertussis vaccination coverage might include some DTP doses if administered in another country or by a vaccination provider who continued to use DTP after
2000. Most states require 5 doses of DTaP for school entry, or 4 doses if the fourth dose was received on or after the fourth birthday; Maryland and Wisconsin
require 4 doses; Nebraska requires 3 doses. The reported coverage estimates represent the percentage of kindergartners with the state-required number of
DTaP doses, except for Kentucky, which requires ≥5 but reports ≥4 doses of DTaP.
§§§ Most states require 4 doses of polio for school entry, or 3 doses if the fourth dose was received on or after the fourth birthday; Maryland and Nebraska require
3 doses. The reported coverage estimates represent the percentage of kindergartners with the state-required number of polio doses, except for Kentucky, which
requires ≥4 but reports ≥3 doses of polio.
¶¶¶ Most states require 2 doses of VAR for school entry; Alabama, Arizona, New Jersey, Oklahoma, and Oregon require 1 dose. Reporting of VAR status for kindergartners
with a history of varicella disease varied within and among states; some kindergartners were reported as vaccinated against varicella and others as medically exempt.
**** National coverage estimates and medians were calculated using data from 49 states (i.e., do not include Montana) and the District of Columbia. National grace period
or provisional enrollment estimates and median were calculated using data from the 27 states that have either a grace period or provisional enrollment policy and
reported relevant data to CDC. National exemption estimate and median were calculated from data from 49 states (i.e., did not include Montana) and the District of
Columbia. Other jurisdictions excluded were Houston, New York City, American Samoa, Guam, Marshall Islands, Federated States of Micronesia, Northern Mariana
Islands, Palau, Puerto Rico, and the U.S. Virgin Islands. Data reported from 3,536,546 kindergartners were assessed for coverage, 3,686,775 for exemptions, and 2,527,578
for grace period or provisional enrollment. Estimates represent rates for populations of coverage (3,835,130), exemptions (3,835,130), and grace period or provisional
enrollment (2,604,872).
†††† The proportion surveyed is reported as 100% but might be <100% if based on incomplete information about the actual current enrollment.
§§§§ Philosophical exemptions were not allowed.
¶¶¶¶ Reported public and homeschool school data only.
***** Religious exemptions were not allowed.
††††† Counted some or all vaccine doses received regardless of Advisory Committee on Immunization Practices recommended age and time interval; vaccination
coverage rates reported might be higher than those for valid doses.
§§§§§ Did not include certain types of schools, such as kindergartens in child care facilities, online schools, correctional facilities, or those located on military bases or
tribal lands.
¶¶¶¶¶ Vaccination coverage data were collected from a sample of kindergartners; exemption data were collected from a census of kindergartners.
Discussion formally or informally during the 2020–21 school year, and

During the 2021–22 school year, coverage with MMR, this expansion continued to a lesser extent during the 2021–22
DTaP, polio, and varicella vaccines among kindergarten chil- school year, even as most schools returned to in-person classes.
dren was approximately 93% nationwide for each vaccine, States continued to report COVID-19–related impacts on
lower than the 94% coverage reported during the 2020–21 vaccination coverage and assessment activities.
school year, and the 95% coverage reported during the The findings in this report are subject to at least five limita-
2019–20 school year, when children were vaccinated before tions. First, comparisons among states are limited because of
the pandemic (2,3). Coverage with all four vaccines declined variation in states’ requirements such as which vaccines are
in most states. National MMR coverage among kindergarten required, the number of doses required, the date required, and
students remained below the Healthy People 2030 target of the type of documentation accepted; data collection methods;
95% (4) for the second consecutive year. These findings are allowable exemptions; and definitions of grace period and
consistent with those of continuing declines in routine child- provisional enrollment. Second, representativeness might be
hood and adolescent vaccine administration through March negatively affected by data collection methods that assess vac-
2021 (5). MMR coverage of 93.0% translates to approximately cination status at different times or miss some schools or stu-
250,000 kindergartners who are potentially not protected dents, such as those who are homeschooled. Third, vaccination
against measles; clusters of unvaccinated and undervaccinated coverage, exemption rates, or both, might be underestimated
children can lead to outbreaks of vaccine-preventable diseases. or overestimated because of inaccurate or absent documenta-
The overall percentage of children with an exemption tion or missing schools. Fourth, national coverage estimates
remained low during the 2021–22 school year at 2.6%, for the 2021–22 school year include only 49 of 50 states and
although the percentage of children with exemptions increased the District of Columbia and use lower bound estimates for
in 38 states and the District of Columbia. Nationwide, 4.4% of eight states; exemption estimates include 49 states and the
kindergarten students were not fully vaccinated with MMR and District of Columbia and use lower bound estimates for five
not exempt, and this percentage increased in most states com- states, and grace period or provisional enrollment estimates
pared with 2020–21. Nonexempt undervaccinated students include only 27 states. Finally, states continued to report that
often attend school while in a grace period or are provisionally the COVID-19 pandemic response created various barriers that
enrolled; in many states, these policies were expanded either limited the amount and quality of student vaccination data
collected and reported by local health departments.
FIGURE 1. Estimated national coverage with 2 doses of measles, mumps, and rubella vaccine among kindergartners — United States, 2013–14
to 2021–22 school years
100
90
Vaccination coverage (%)
80
20
Target MMR coverage (95%)

MMR, 2 doses
10
0
2013–14 2014–15 2015–16 2016–17 2017–18 2018–19 2019–20 2020–21 2021–22
School year
Abbreviation: MMR = measles, mumps, and rubella vaccine.
FIGURE 2. Potentially achievable coverage*,† with measles, mumps, and rubella vaccine among kindergartners, by state — United States,
2021–22 school year
MMR coverage MMR not UTD and no exemption Target coverage = 95%
Idaho
Utah
Arizona
Oregon
Wisconsin
Georgia
North Dakota
Nevada
Alaska
Michigan
Florida
Minnesota
Wyoming
South Dakota
New Hampshire
Hawaii
Pennsylvania
Oklahoma
Colorado
Missouri
Washington
South Carolina
Vermont
Ohio
State
New Jersey
Texas
Arkansas
Tennessee
Iowa
Indiana
Nebraska
Connecticut
Kansas
Virginia
Illinois
Alabama
Maryland
New Mexico
Kentucky
Delaware
Maine
Louisiana
Rhode Island
Massachusetts
District of Columbia
North Carolina
California
Mississippi
West Virginia
New York
0 20 40 60 80 100
Percent coverage
Abbreviations: MMR = measles, mumps, and rubella vaccine; UTD = up to date.

* States are ranked from lowest to highest potentially achievable coverage. Potentially achievable coverage is estimated as the sum of the percentage of students
with UTD MMR and the percentage of students without UTD MMR and without a documented vaccine exemption.
† The exemptions used to calculate the potential increase in MMR coverage for Alaska, Arizona, Arkansas, Colorado, Delaware, District of Columbia, Idaho, Illinois,
Maine, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South
Carolina, Texas, Utah, Vermont, Washington, Wisconsin, and Wyoming are the number of children with exemptions specifically for MMR. For all other states, numbers
are based on an exemption to any vaccine.
References
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All authors have completed and submitted the International

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conflicts of interest. No potential conflicts of interest were disclosed.
Vaccination Coverage by Age 24 Months Among Children Born During

2018–2019 — National Immunization Survey–Child, United States, 2019–2021
Holly A. Hill, MD, PhD1; Michael Chen, PhD1; Laurie D. Elam-Evans, PhD1; David Yankey, PhD1; James A. Singleton, PhD1
Millions of young children are vaccinated safely in the Persistent disparities by health insurance status indicate the
United States each year against a variety of potentially dan- need to improve access to vaccines through the Vaccines for
gerous infectious diseases (1). The Advisory Committee on Children (VFC) program.¶ Providers should review children’s
Immunization Practices (ACIP) recommends routine vaccina- histories and recommend needed vaccinations during every
tion against 14 diseases during the first 24 months of life* (2). clinical encounter and address parental hesitancy to help
This report describes vaccination coverage by age 24 months reduce disparities and ensure that all children are protected
using data from the National Immunization Survey–Child from vaccine-preventable diseases.
(NIS-Child).† Compared with coverage among children born NIS-Child is a random-digit–dialed survey of households
during 2016–2017, coverage among children born during that includes children aged 19–35 months. Parents or guard-
2018–2019 increased for a majority of recommended vaccines. ians complete a telephone survey,** and consent to contact
Coverage was >90% for ≥3 doses of poliovirus vaccine (93.4%), the child’s vaccination providers is requested. With parental
≥3 doses of hepatitis B vaccine (HepB) (92.7%), ≥1 dose of or guardian consent, identified providers are mailed a ques-
measles, mumps, and rubella vaccine (MMR) (91.6%), and tionnaire to obtain vaccination information, which is synthe-
≥1 dose of varicella vaccine (VAR) (91.1%); coverage was sized to create the child’s comprehensive vaccination history.
lowest for ≥2 doses of hepatitis A vaccine (HepA) (47.3%). Children born during 2018–2019 were identified from data
Vaccination coverage overall was similar or higher among collected during 2019–2021, resulting in 29,598 children with
children reaching age 24 months during March 2020 or later adequate provider data†† for analysis. The 2021 household
(during the COVID-19 pandemic) than among those reaching response rate§§ was 22.9%, and adequate provider data were
age 24 months before March 2020 (prepandemic); however, obtained from 51.5% of households with completed inter-
coverage with the combined 7-vaccine series§ among children views. Vaccination coverage by age 24 months was estimated
living below the federal poverty level or in rural areas decreased using Kaplan-Meier techniques, except for the birth dose of
by 4–5 percentage points during the pandemic (3). Among ¶ Eligible children include those aged ≤18 years who are Medicaid-eligible,
children born during 2018–2019, coverage disparities were uninsured, American Indian or Alaska Native, or insured by health plans that
observed by race and ethnicity, poverty status, health insurance do not fully cover routine immunization (if vaccination is received at a
status, and Metropolitan Statistical Area (MSA) residence. Federally Qualified Health Center or a rural health clinic). https://www.cdc.
gov/vaccines/programs/vfc/
Coverage was typically higher among privately insured children ** NIS-Child used a landline-only sampling frame during 1995–2010. During
than among children with other insurance or no insurance. 2011–2017, the survey was conducted using a dual-frame design, with both
mobile and landline sampling frames included. During 2018, NIS-Child returned
to a single-frame design, with all interviews conducted by mobile telephone.
* Vaccination against COVID-19 was recommended for children aged †† Children with at least one vaccination reported by a provider and those who
6 months–4 years in June 2022 (https://www.cdc.gov/vaccines/acip/recs/grade/ had received no vaccinations were considered to have adequate provider data.
covid-19-moderna-pfizer-children-vaccine-etr.html). Children in this report “No vaccinations” indicates that the vaccination status is known because the
were either aged >4 years during June 2022 (some were eligible for COVID-19 parent or guardian indicated there were no vaccinations and the providers
vaccine at age ≥5 years, but vaccine history was not ascertained past age returned no immunization history forms or returned them indicating that no
35 months), or data on vaccine histories were collected before 2022. vaccinations had been administered.
† Estimates for U.S. Department of Health and Human Services regions, states, §§ The Council of American Survey Research Organizations (CASRO) household
selected local areas, and the territories of Guam and Puerto Rico can be found response rate is calculated as the product of the resolution rate (percentage
online (https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/ of the total telephone numbers called that were classified as nonworking,
data-reports/index.html). Certain local areas that receive federal Section 317 nonresidential, or residential), screening completion rate (percentage of known
immunization funds are sampled separately and included in the NIS-Child households that were successfully screened for the presence of age-eligible
sample every year (Chicago, Illinois; New York, New York; Philadelphia County, children), and the interview completion rate (percentage of households with
Pennsylvania; Bexar County, Texas; and Houston, Texas). National estimates one or more age-eligible children that completed the household survey). The
in this report exclude territories. CASRO household response rate is equivalent to the American Association for
§ The combined 7-vaccine series (4:3:1:3*:3:1:4) includes ≥4 doses of diphtheria Public Opinion Research type 3 response rate (https://www-archive.aapor.org/
and tetanus toxoids and acellular pertussis vaccine; ≥3 doses of poliovirus AAPOR_Main/media/publications/Standard-Definitions20169theditionfinal.
vaccine; ≥1 dose of measles-containing vaccine; ≥3 or ≥4 doses (depending pdf ). CASRO response rates and the proportions of children with household
upon product type) of Haemophilus influenzae type b conjugate vaccine; ≥3 doses interviews that had adequate provider data for survey years 2015–2020 are
of hepatitis B vaccine; ≥1 dose of varicella vaccine; and ≥4 doses of pneumococcal available online. https://www.cdc.gov/vaccines/imz-managers/nis/downloads/
conjugate vaccine. NIS-PUF20-DUG.pdf
HepB¶¶ and rotavirus vaccine.*** Coverage with ≥2 doses of assessed using z-tests; p-values <0.05 were considered statisti-
HepA was also estimated by age 35 months (the maximum cally significant. Analyses used weighted data and were per-
age available).††† Significance of coverage differences was formed using SAS (version 9.4; SAS Institute) and SUDAAN
(version 11; RTI International). This activity was reviewed by
¶¶ The birth dose of HepB is measured as the proportion of children who CDC and was conducted consistent with applicable federal
received a dose of HepB by age 3 days.
*** Rotavirus is assessed at age 8 months to reflect the maximum age at law and CDC policy.§§§
administration recommended by ACIP.
††† Children waiting 12–18 months to receive the second dose of HepA might receive §§§ 45 C.F.R. part 46.102(l)(2); 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5
it during the beginning of the catch-up period, which starts at age 24 months. U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
TABLE 1. Estimated vaccination coverage by age 24 months,* among children born during 2016–2017 and during 2018–2019 for selected
vaccines and doses — National Immunization Survey–Child, United States, 2017–2021
% (95% CI)
Birth year† Percentage point difference
Vaccine and dose 2016–2017 2018–2019 (2016–2017 to 2018–2019)
DTaP§
≥3 doses 93.2 (92.6 to 93.7) 94.2 (93.6 to 94.8) 1.0 (0.2 to 1.9)¶
≥4 doses 80.6 (79.7 to 81.6) 81.9 (80.9 to 82.8) 1.3 (−0.1 to 2.6)
Poliovirus (≥3 doses) 92.0 (91.4 to 92.6) 93.4 (92.8 to 94.0) 1.4 (0.5 to 2.2)¶
MMR (≥1 dose)** 90.6 (89.9 to 91.3) 91.6 (90.9 to 92.3) 1.1 (0.1 to 2.0)¶
Hib††
Primary series 92.4 (91.7 to 93.0) 93.6 (93.0 to 94.1) 1.2 (0.3 to 2.1)¶
Full series 79.6 (78.6 to 80.6) 80.0 (79.0 to 81.0) 0.4 (−1.0 to 1.8)
HepB
Birth dose§§ 76.4 (75.4 to 77.4) 79.8 (78.8 to 80.8) 3.4 (2.0 to 4.8)¶
≥3 doses 91.2 (90.6 to 91.9) 92.7 (92.0 to 93.3) 1.4 (0.5 to 2.3)¶
VAR (≥1 dose)** 90.1 (89.4 to 90.8) 91.1 (90.3 to 91.8) 1.0 (0 to 2.0)
PCV
≥3 doses 91.7 (91.0 to 92.3) 93.3 (92.7 to 93.9) 1.7 (0.8 to 2.5)¶
≥4 doses 81.2 (80.2 to 82.1) 83.5 (82.6 to 84.4) 2.3 (1.0 to 3.7)¶
HepA
≥1 dose 85.6 (84.8 to 86.4) 88.3 (87.5 to 89.1) 2.7 (1.5 to 3.8)¶
≥2 doses¶¶ 45.2 (44.0 to 46.4) 47.3 (46.0 to 48.5) 2.1 (0.3 to 3.8)¶
≥2 doses (by age 35 mos)¶¶ 76.8 (75.6 to 78.1) 79.6 (78.0 to 81.0) 2.7 (0.8 to 4.7)¶
Rotavirus (by age 8 mos)*** 74.6 (73.5 to 75.6) 77.1 (76.1 to 78.2) 2.6 (1.1 to 4.1)¶
Influenza (≥2 doses)††† 57.5 (56.3 to 58.6) 63.9 (62.7 to 65.0) 6.4 (4.8 to 8.0)¶
Combined 7-vaccine series§§§ 69.8 (68.6 to 70.9) 70.1 (68.9 to 71.2) 0.3 (−1.3 to 1.9)
No vaccinations¶¶¶ 1.3 (1.1 to 1.5) 0.9 (0.7 to 1.1) −0.4 (−0.7 to −0.1)¶
Abbreviations: DTaP = diphtheria, tetanus toxoids, and acellular pertussis vaccine; HepA = hepatitis A vaccine; HepB = hepatitis B vaccine; Hib = Haemophilus influenzae
type b conjugate vaccine; MMR = measles, mumps, and rubella vaccine; PCV = pneumococcal conjugate vaccine; RV5 = pentavalent rotavirus vaccine; VAR = varicella vaccine.
* Includes vaccinations received by age 24 months (before the day the child turns age 24 months), except for the HepB birth dose, rotavirus vaccination, and
≥2 HepA doses by age 35 months. For all vaccines except the HepB birth dose and rotavirus vaccination, the Kaplan-Meier method was used to estimate vaccination
coverage to account for children whose vaccination history was ascertained before age 24 months (age 35 months for ≥2 HepA doses).
† Data for the 2016 birth year are from survey years 2017, 2018, and 2019; data for the 2017 birth year are from survey years 2018, 2019, and 2020; data for the 2018
birth year are from survey years 2019, 2020, and 2021; data for the 2019 birth year are considered preliminary and are from survey years 2020 and 2021 (data from
survey year 2022 are not yet available).
§ Includes children who might have received diphtheria and tetanus toxoids vaccine or diphtheria, tetanus toxoids, and pertussis vaccine. Healthy People 2030
target for ≥4 doses of DTaP is 90%. https://health.gov/healthypeople/objectives-and-data/browse-objectives/vaccination
¶ Statistically significantly different from 0 at p<0.05.
** Includes children who might have received measles, mumps, rubella, and varicella combination vaccine. Healthy People 2030 target for ≥1 dose of MMR is 90.8%.
https://health.gov/healthypeople/objectives-and-data/browse-objectives/vaccination
†† Hib primary series: receipt of ≥2 or ≥3 doses, depending on product type received; full series: primary series and booster dose, which includes receipt of ≥3 or
≥4 doses, depending on product type received.
§§ One dose HepB administered from birth through age 3 days.
¶¶ Before 2020, first dose of HepA was recommended at age 12–23 months, with second dose administered 6–18 months after the first, depending upon the product
type received. During 2020, recommendation was revised to 2 doses between ages 12 and 23 months, ≥6 months apart. Because children in this analysis were
vaccinated under both recommendations, coverage estimates for both <24 months and <35 months are provided.
*** Includes ≥2 doses of Rotarix monovalent rotavirus vaccine or ≥3 doses of RotaTeq RV5. If any dose in the series is either RV5 or unknown, the default is a 3-dose
series. The maximum age for the final rotavirus dose is age 8 months, 0 days.
††† Doses must be ≥24 days apart (4 weeks with a 4-day grace period); doses could have been received during two influenza seasons.
§§§ The combined 7-vaccine series (4:3:1:3*:3:1:4) includes ≥4 doses of DTaP, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, the full Hib series
(≥3 or ≥4 doses, depending on product type), ≥3 doses of HepB, ≥1 dose of VAR, and ≥4 doses of PCV.
¶¶¶ Healthy People 2030 target for children who get zero recommended vaccines by age 2 years is 1.3%. https://health.gov/healthypeople/objectives-and-data/
browse-objectives/vaccination
National Vaccination Coverage Vaccination by Selected Sociodemographic

Among children born during 2018–2019, vaccination cov- Characteristics and Geographic Locations
erage by age 24 months increased compared with that among Among children born during 2018–2019, coverage among
children born during 2016–2017 for a majority of vaccines those who were uninsured and those insured by Medicaid or
(Table 1). Coverage was >90% for ≥3 doses of poliovirus vac- other insurance¶¶¶ was lower than that among privately insured
cine (93.4%), ≥1 dose of MMR (91.6%), ≥3 doses of HepB children for all vaccines except the HepB birth dose, which
(92.7), and ≥1 dose of VAR (91.1%). The only vaccines for was lower among uninsured children only (Table 2). The pro-
which coverage was <70% were ≥2 doses of HepA (47.3%) portion of children who were unvaccinated by age 24 months
and ≥2 doses of influenza vaccine (63.9%). The proportion was eight times higher for uninsured compared with privately
of children who received no vaccinations by age 24 months insured children. Compared with non-Hispanic White chil-
decreased from 1.3% among those born during 2016–2017 to dren, coverage with a majority of vaccines was lower among
0.9% among those born during 2018–2019. Coverage by birth non-Hispanic Black or African American (Black) children, and
year during 2011–2019 was stable for a majority of vaccines, coverage with ≥1 MMR dose, ≥1 VAR dose, rotavirus vaccine,
with increases during recent years for the HepB birth dose,
¶¶¶ “Other insurance” includes the Children’s Health Insurance Program, military
rotavirus vaccine, ≥2 influenza vaccine doses, and ≥2 HepA
insurance, coverage via the Indian Health Service, and any other type of
doses by age 35 months (Figure). health insurance not mentioned elsewhere.
FIGURE. Estimated vaccination coverage with selected individual vaccines*,†,§,¶,**,†† and a combined vaccine series§§ by age 24 months,¶¶ by
birth year 2011–2019*** — National Immunization Survey–Child, United States, 2012–2021
100
95 ≥4 DTaP
≥3 Poliovirus
90
≥1 MMR
Percentage vaccinated
85 Hib full series

≥3 HepB
80
HepB birth dose
75 Rotavirus
≥2 Influenza
70
Combined
65 7-vaccine series
≥1 VAR
60
≥4 PCV
55 ≥2 HepA (35 mos)
50
2011 2012 2013 2014 2015 2016 2017 2018 2019
(preliminary)
Birth year
type b conjugate vaccine; MMR = measles, mumps, and rubella vaccine; PCV = pneumococcal conjugate vaccine; VAR = varicella vaccine.
* Four or more DTaP includes children who might have received diphtheria and tetanus toxoids vaccine or diphtheria, tetanus toxoids, and pertussis vaccine.
† One or more MMR includes children who might have received measles, mumps, rubella, and varicella combination vaccine.
§ Hib full series: primary series and booster dose, which includes receipt of ≥3 or ≥4 doses, depending on product type received.
¶ HepB birth dose = 1 dose HepB administered from birth through age 3 days.
** Rotavirus vaccination includes ≥2 doses of Rotarix monovalent rotavirus vaccine or ≥3 doses of RotaTeq pentavalent rotavirus vaccine. The maximum age for the
final rotavirus dose is 8 months, 0 days.
†† Influenza vaccine doses must be administered ≥24 days apart (4 weeks with a 4-day grace period); doses could have been received during two influenza seasons.
§§ The combined 7-vaccine series (4:3:1:3*:3:1:4) includes ≥4 doses of DTaP, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, the full series of
Hib (≥3 or ≥4 doses, depending on product type), ≥3 doses of HepB, ≥1 dose of VAR, and ≥4 doses of PCV.
¶¶ Includes vaccinations received before age 24 months, except for the HepB birth dose, rotavirus vaccination, and ≥2 HepA doses by age 35 months. For all vaccines
except the HepB birth dose and rotavirus vaccination, the Kaplan-Meier method was used to estimate vaccination coverage to account for children whose
vaccination history was ascertained before age 24 months (35 months for ≥2 HepA doses).
*** Children born in 2011 are included in survey years 2012, 2013, and 2014; children born in 2012 are included in survey years 2013, 2014, and 2015; children born
in 2013 are included in survey years 2014, 2015, and 2016; children born in 2014 are included in survey years 2015, 2016, and 2017; children born in 2015 are
included in survey years 2016, 2017, and 2018; children born in 2016 are included in survey years 2017, 2018, and 2019; children born in 2017 are included in
survey years 2018, 2019 and 2020; children born in 2018 are included in survey years 2019 and 2020, and 2021; data for children born in 2019 are considered
preliminary and are included in survey years 2020 and 2021 (data from survey year 2022 are not yet available).
≥2 influenza vaccine doses, and the 7-vaccine series was lower by jurisdiction (Supplementary Table 3, https://stacks.cdc.
among Hispanic or Latino (Hispanic) children (Supplementary gov/view/cdc/123208), especially coverage with ≥2 influenza
Table 1, https://stacks.cdc.gov/view/cdc/123206). Coverage vaccine doses, which ranged from 39.7% (Alabama) to 84.0%
was lower among children living below the poverty level than (Rhode Island).
among those living at or above the poverty level for all vac-
cines except the HepB birth dose (Supplementary Table 2, **** MSA status was determined based on household reported city and county
https://stacks.cdc.gov/view/cdc/123207). Coverage with all of residence and was grouped into three categories: MSA principal city,
vaccines except for the HepB birth dose was lower among MSA nonprincipal city, and non-MSA. MSAs and principal cities were as
defined by the U.S. Census Bureau (https://www.census.gov/programs-
children living in a non-MSA**** compared with those in surveys/metro-micro.html). Non-MSA areas include urban populations
an MSA principal city. Vaccination coverage varied widely not located within an MSA and completely rural areas.
TABLE 2. Estimated vaccination coverage by age 24 months* among children born during 2018–2019,† by selected vaccines and doses and
health insurance status§ — National Immunization Survey–Child, United States, 2019–2021
Health insurance status, % (95% CI)
Private only (Ref) Any Medicaid Other insurance Uninsured
Vaccine and dose (n = 16,629) (n = 10,200) (n = 2,168) (n = 601)
DTaP¶
≥3 doses 96.9 (96.4–97.4) 92.3 (91.2–93.2)** 92.7 (90.3–94.7)** 85.5 (80.6–89.7)**
≥4 doses 88.6 (87.6–89.6) 77.1 (75.4–78.8)** 78.9 (75.3–82.3)** 57.0 (49.1–65.0)**
Poliovirus (≥3 doses) 96.1 (95.5–96.6) 91.4 (90.3–92.5)** 91.9 (89.4–94.1)** 84.8 (79.7–89.1)**
MMR (≥1 dose)†† 95.1 (94.4–95.7) 89.2 (87.9–90.4)** 90.0 (87.2–92.5)** 79.7 (73.0–85.6)**
Hib§§
Primary series 96.7 (96.1–97.1) 91.3 (90.2–92.4)** 92.4 (90.0–94.4)** 83.4 (77.9–88.2)**
Full series 86.2 (85.0–87.3) 75.6 (74.0–77.3)** 76.8 (73.2–80.3)** 57.8 (50.0–65.9)**
HepB
Birth dose¶¶ 80.6 (79.1–81.9) 79.8 (78.2–81.4) 77.4 (74.1–80.5) 69.9 (61.7–77.1)**
≥3 doses 94.6 (93.9–95.3) 91.4 (90.3–92.4)** 91.2 (88.7–93.3)** 84.6 (79.4–89.0)**
VAR (≥1 dose)†† 94.3 (93.6–95.0) 89.1 (87.7–90.3)** 88.8 (85.9–91.4)** 76.8 (69.9–83.1)**
PCV
≥3 doses 96.2 (95.6–96.8) 91.3 (90.2–92.4)** 91.1 (88.6–93.3)** 83.9 (78.6–88.5)**
≥4 doses 90.0 (89.0–91.0) 78.8 (77.2–80.3)** 80.6 (77.3–83.7)** 62.3 (54.9–69.7)**
HepA
≥1 dose 91.3 (90.4–92.2) 86.3 (84.9–87.7)** 87.0 (84.4–89.4)** 73.2 (66.1–79.8)**
≥2 doses*** 49.6 (47.9–51.3) 46.3 (44.3–48.3)** 45.4 (41.2–49.7) 27.9 (21.5–35.8)**
≥2 doses (by age 35 mos)*** 84.9 (83.0–86.7) 76.2 (73.6–78.7)** 79.1 (73.9–83.8)** 43.4 (34.9–52.9)**
Rotavirus (by age 8 mos)††† 85.1 (83.9–86.2) 71.1 (69.3–72.8)** 72.0 (67.8–75.8)** 63.8 (56.4–70.7)**
Influenza (≥2 doses)§§§ 77.1 (75.7–78.4) 52.6 (50.6–54.5)** 63.5 (59.4–67.6)** 40.1 (33.0–48.0)**
Combined 7-vaccine series¶¶¶ 78.0 (76.6–79.4) 64.2 (62.3–66.1)** 67.4 (63.4–71.2)** 45.2 (37.8–53.3)**
No vaccinations 0.7 (0.5–0.9) 0.9 (0.6–1.3) 1.0 (0.6–1.7) 6.0 (3.2–10.0)**
type b conjugate vaccine; MMR = measles, mumps, and rubella vaccine; PCV = pneumococcal conjugate vaccine; Ref = referent group; VAR = varicella vaccine.
* Includes vaccinations received by age 24 months (before the day the child turns 24 months), except for the HepB birth dose, rotavirus vaccination, and ≥2 HepA
doses by 35 months. For all vaccines except the HepB birth dose and rotavirus vaccination, the Kaplan-Meier method was used to estimate vaccination coverage
to account for children whose vaccination history was ascertained before age 24 months (35 months for ≥2 HepA doses).
† Data for the 2018 birth year are from survey years 2019, 2020, and 2021; data for the 2019 birth year are considered preliminary and are from survey years 2020
and 2021 (data from survey year 2022 are not yet available).
§ Children’s health insurance status was reported by parent or guardian. “Other insurance” includes the Children’s Health Insurance Program, military insurance,
coverage via the Indian Health Service, and any other type of health insurance not mentioned elsewhere.
¶ Includes children who might have received diphtheria and tetanus toxoids vaccine or diphtheria, tetanus toxoids, and pertussis vaccine.
** Statistically significant (p<0.05) difference compared with Ref.
†† Includes children who might have received MMR and VAR combination vaccine.
§§ Hib primary series: receipt of ≥2 or ≥3 doses, depending on vaccine product type received; full series: primary series and booster dose, which includes receipt of
≥3 or ≥4 doses, depending on vaccine product type received.
¶¶ One dose HepB administered from birth through age 3 days.
*** Before 2020, first dose of HepA recommended at age 12–23 months, with second dose administered 6–18 months after the first, depending upon the vaccine
product type received. During 2020, recommendation revised to 2 doses between ages 12 and 23 months, ≥6 months apart. Because children in this analysis
were vaccinated under both recommendations, coverage estimates for both <24 months and <35 months are provided.
††† Includes ≥2 doses of Rotarix monovalent rotavirus vaccine, or ≥3 doses of RotaTeq pentavalent rotavirus vaccine. If any dose in the series is either RotaTeq or
unknown, the default is a 3-dose series. The maximum age for the final rotavirus dose is 8 months, 0 days.
§§§ Doses must be ≥24 days apart (4 weeks with a 4-day grace period); doses could have been received during two influenza seasons.
¶¶¶ The combined 7-vaccine series (4:3:1:3*:3:1:4) includes ≥4 doses of DTaP, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, the full series of
Hib (≥3 or ≥4 doses, depending on product type), ≥3 doses of HepB, ≥1 dose of VAR, and ≥4 doses of PCV.
pandemic, providing a more complete assessment of trends in

Summary
vaccination coverage during the pandemic.
Vaccination coverage declined for children living below the
The Advisory Committee on Immunization Practices recom- federal poverty level or in rural areas during the pandemic,
mends routine vaccination against 14 diseases during the first
24 months of life.
and substantial variation in coverage by sociodemographic
characteristics persists. As observed elsewhere (4), estimated
What is added by this report?
coverage was highest among Asian children and lowest among
Vaccination coverage among young children has remained high
Black children. Lower coverage was found among children
and stable for most vaccines, although disparities persist. The
National Immunization Survey–Child identified no decline living below the federal poverty level, without private health
overall in routine vaccination coverage associated with the insurance, and in rural (non-MSA) areas.
COVID-19 pandemic among children born during 2018–2019, If equity is to be achieved in the national childhood vac-
although declines were observed among children living below cination program, a number of obstacles must be overcome.
the federal poverty level and in rural areas. Parents and other caregivers must have the willingness and the
What are the implications for public health practice? means to get children vaccinated. A recent report estimated
Additional efforts, such as providers reviewing children’s that 6.5%–31.3% of nonvaccination among children could
immunization histories during every clinical encounter, be attributed to parental hesitancy, depending upon the vac-
recommending needed vaccinations, and addressing parental
cine (5). CDC has developed a Vaccinate with Confidence
hesitancy, are warranted to reduce disparities so that all
children can be protected from vaccine-preventable diseases. strategy for identifying activities designed to bolster vaccine
confidence and prevent outbreaks of vaccine-preventable
diseases (6). Several additional evidence-based approaches
Discussion
to increasing vaccination coverage include strong health care
U.S. coverage with most recommended childhood vaccines provider recommendations, advocating for vaccines at every
has remained high and stable for many years. Increases in cover- health care encounter, use of reminder and recall notices and
age by age 24 months were observed for most vaccines when standing orders, and the presence of state and local immuniza-
comparing children born during 2018–2019 with those born tion information systems to provide consolidated immuniza-
during 2016–2017. Approximately 70% of children born in tion histories (7).
recent years (2016–2019) were up to date with the 7-vaccine Logistical and financial barriers also must be addressed. The
series by age 24 months, with coverage >70% for all other VFC program covers the cost of all recommended vaccines for
vaccines except for ≥2 influenza vaccine doses and ≥2 doses of eligible children; it is imperative that this program retain an
HepA. The proportion of children completely unvaccinated by adequate supply of participating vaccination providers and that
age 24 months was 0.9% for children born during 2018–2019, families in need are aware of how to access it. Establishment
meeting the Healthy People 2030†††† objective of <1.3%. of alternative vaccination settings such as pharmacies, emer-
This report did not identify any overall decline in vaccina- gency departments, hospitals, and outpatient subspecialty
tion coverage associated with the COVID-19 pandemic among clinics might help address accessibility issues for underserved
all children. The youngest children were born in 2019. These communities (8).
children reached age 12 months in 2020 and 24 months in The findings in this report are subject to at least three limi-
2021; therefore, many of these children had vaccine doses tations. First, the possibility of selection bias exists because
recommended after the pandemic was declared in March 2020. of the low household interview response rate (ranging from
In a more detailed analysis, coverage with the combined 21%–26% during survey years 2017–2021) and the avail-
7-vaccine series by age 24 months decreased 4–5 percentage ability of adequate provider data for 49%–54% of those who
points among children living below the federal poverty level or completed interviews in survey years 2017–2021. Second,
in rural areas (3). In addition, MMR coverage was 10 percent- although the data were weighted to account for nonresponse
age points lower for children reaching age 13 months during and households without telephones, some bias could remain.
April–May 2020 compared with those reaching age 13 months Finally, coverage estimates could be incorrect if some vaccina-
before and after this time frame, but coverage reached prepan- tion providers did not return questionnaires or if administered
demic levels by age 19 months (3). Similar decreases in coverage vaccines were not documented accurately. Total survey error (9)
were observed in other data sources (4). The 2022 NIS-Child for the 2021 survey year data was assessed and demonstrated
will include more children born shortly before or during the that coverage was underestimated by 3.1 percentage points for
≥1 dose of MMR, 4.4 percentage points for the HepB birth
†††† https://health.gov/healthypeople/objectives-and-data/browse-objectives/ dose, and 8.7 percentage points for the combined -vaccine
vaccination
series. An analysis of change in bias of vaccination coverage 3. CDC. Childhood vaccination coverage before and during the
estimates from 2020 to 2021 determined that a meaningful COVID-19 pandemic among children born January 2017–May 2020,
National Immunization Survey-Child (NIS-Child), 2018–2021. Atlanta,
change was unlikely.§§§§ GA: US Department of Health and Human Services, CDC; 2022.
At the national level, coverage with most routine childhood https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/
vaccines is high; however, this high coverage is not distributed pubs-presentations/nis-child-pandemic-effects-2018-2021.html
4. DeSilva MB, Haapala J, Vazquez-Benitez G, et al. Association of the
uniformly: coverage is lower among Black and Hispanic chil- COVID-19 pandemic with routine childhood vaccination rates and
dren, those of lower socioeconomic status, and those living in proportion up to date with vaccinations across 8 US health systems
rural areas. Recent measles outbreaks¶¶¶¶ and the diagnosis in the Vaccine Safety Datalink. JAMA Pediatr 2022;176:68–77.
PMID:34617975 https://doi.org/10.1001/jamapediatrics.2021.4251
of a case of polio (10) serve as reminders that pockets of sus- 5. Nguyen KH, Srivastav A, Vaish A, Singleton JA. Population
ceptibility can and do exist, even in a largely well-vaccinated attributable fraction of nonvaccination of child and adolescent vaccines
society. Parents and providers must remain vigilant to ensure attributed to parental vaccine hesitancy, 2018–2019. Am J Epidemiol
that all children are up to date with their routine vaccinations 2022;191:1626–35. PMID:35292806 https://doi.org/10.1093/aje/
kwac049
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vaccine confidence in the United States. Pediatrics 2020;145:e20200390.
§§§§ https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-PUF21- PMID:32461260 https://doi.org/10.1542/peds.2020-0390
DUG.pdf 7. Stokley S, Kempe A, Stockwell MS, Szilagyi PG. Improving pediatric
¶¶¶¶ https://www.cdc.gov/measles/cases-outbreaks.html vaccination coverage in the United States. Acad Pediatr 2021;21(4S):S1–2.
PMID:33958085 https://doi.org/10.1016/j.acap.2021.03.004
Corresponding author: Holly A. Hill, hhill@cdc.gov, 404-639-8044. 8. Hofstetter AM, Schaffer S. Childhood and adolescent vaccination in
alternative settings. Acad Pediatr 2021;21(4S):S50–6. PMID:33958093
1Immunization Services Division, National Center for Immunization and https://doi.org/10.1016/j.acap.2021.02.001
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All authors have completed and submitted the International J Am Stat Assoc 1991;86:839–55. PMID:12155391 https://doi.org/1
0.1080/01621459.1991.10475122
Committee of Medical Journal Editors form for disclosure of potential 10. Link-Gelles R, Lutterloh E, Schnabel Ruppert P, et al.; 2022 U.S.
conflicts of interest. No potential conflicts of interest were disclosed. Poliovirus Response Team. Public health response to a case of paralytic
poliomyelitis in an unvaccinated person and detection of poliovirus
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mm7006a1
Safety Monitoring of Bivalent COVID-19 mRNA Vaccine Booster Doses Among

Children Aged 5–11 Years — United States, October 12–January 1, 2023
Anne M. Hause, PhD1; Paige Marquez, MSPH1; Bicheng Zhang, MS1; John R. Su, MD, PhD1; Tanya R. Myers, PhD1; Julianne Gee, MPH1;
Sarada S. Panchanathan, MD2; Deborah Thompson, MD2; Tom T. Shimabukuro, MD1; David K. Shay, MD1
On October 12, 2022, the Food and Drug Administration findings from the first 11 weeks of bivalent booster vaccination
(FDA) issued Emergency Use Authorizations (EUAs) for biva- among children aged 5–11 years are reassuring. Compared with
lent (mRNA encoding the spike protein from the SARS-CoV-2 the low risk of serious health effects after mRNA COVID-19
ancestral strain and BA.4/BA.5 Omicron variants) formulations vaccination, the health effects of SARS-CoV-2 infection include
of Pfizer-BioNTech and Moderna mRNA COVID-19 vaccines death and serious long-term sequalae (6). ACIP recommends that
for use as a single booster dose ≥2 months after completion of all persons aged ≥6 months receive an age-appropriate bivalent
primary series or monovalent booster vaccination for children mRNA booster dose ≥2 months after completion of a COVID-19
aged 5–11 years (Pfizer-BioNTech) and 6–17 years (Moderna); primary series or receipt of a monovalent booster dose.¶
on December 8, 2022, FDA amended the EUAs to include A parent or guardian with a v-safe account can register a
children aged ≥6 months (1,2). The Advisory Committee on child aged <15 years and complete health surveys on behalf
Immunization Practices (ACIP) recommends that all persons of the child.** Health surveys sent daily during the week
aged ≥6 months receive an age-appropriate bivalent mRNA after vaccination ask questions about local injection site and
booster dose (3). The safety of bivalent mRNA booster doses systemic reactions and health impacts experienced; registrants
among persons aged ≥12 years has previously been described can provide additional information about these reactions or
(4). To characterize the safety of bivalent mRNA booster doses health impacts via free text responses. CDC’s v-safe call center
among children aged 5–11 years after receipt of bivalent Pfizer- personnel contact registrants who report receiving medical care
BioNTech and Moderna booster doses, CDC reviewed adverse to request further information; registrants are also encouraged
events and health impacts reported to v-safe,* a voluntary, to complete a VAERS report, if indicated.
smartphone-based U.S. safety surveillance system established by VAERS accepts reports of postvaccination adverse events
CDC to monitor adverse events after COVID-19 vaccination, from health care providers, vaccine manufacturers, and
and to the Vaccine Adverse Event Reporting System (VAERS), members of the public.†† Providers in the CDC COVID-19
a U.S. passive vaccine safety surveillance system co-managed Vaccination Program are required to file VAERS reports for
by CDC and FDA† (5). During October 12–January 1, 2023, observed adverse events after vaccination and for vaccination
a total of 861,251 children aged 5–11 years received a bivalent errors. Signs, symptoms, and diagnoses reported to VAERS are
Pfizer-BioNTech booster, and 92,108 children aged 6–11 years assigned Medical Dictionary for Regulatory Activities preferred
received a bivalent Moderna booster.§ Among 3,259 children terms (MedDRA PTs) by VAERS personnel.§§ Death certifi-
aged 5–11 years registered in v-safe who received a bivalent cates and autopsy reports are requested for any reported death.
booster dose, local (68.7%) and systemic reactions (49.5%) were
commonly reported in the week after vaccination. Approximately ¶ https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-
99.8% of reports to VAERS for children aged 5–11 years after vaccines-us.html (Accessed January 1, 2023).
bivalent booster vaccination were nonserious. There were no ** Text message reminders are sent to parents or guardians to complete online
health surveys for their child on days 0–7 after vaccination; then weekly
reports of myocarditis or death after bivalent booster vaccination. through 6 weeks after vaccination; and then 3, 6, and 12 months after
Eighty-four percent of VAERS reports were related to vaccina- vaccination. Previously registered persons can report receipt of a COVID-19
tion errors, 90.5% of which did not list an adverse health event. booster dose, and new registrants can enter information about all doses
received; registrants can also indicate whether any other vaccines were
Local and systemic reactions reported after receipt of a bivalent administered during the same visit. Parents and guardians use the following
booster dose are consistent with those reported after a monova- definitions to describe the severity of a child’s symptoms: mild (noticeable,
but not problematic), moderate (limit normal daily activities), or severe (make
lent booster dose; serious adverse events are rare. Vaccine provid- daily activities difficult or impossible).
ers should provide this information when counseling parents or †† Under EUA, and as enrolled providers in the CDC COVID-19 Vaccination
guardians about bivalent booster vaccination. Preliminary safety Program, health care providers are required to report certain adverse events after
COVID-19 vaccination to VAERS, including death (https://vaers.hhs.gov/faq.
html). VAERS forms ask for patient, vaccine, administration, and adverse event
* https://vsafe.cdc.gov/en information. https://vaers.hhs.gov/docs/VAERS%202.0_Checklist.pdf
† https://vaers.hhs.gov §§ Each VAERS report might be assigned more than one MedDRA PT. A
§ https://covid.cdc.gov/covid-data-tracker/#vaccination-demographic (Accessed MedDRA-coded event does not indicate a medically confirmed diagnosis.
January 1, 2023). https://www.meddra.org/how-to-use/basics/hierarchy
A bivalent booster dose in v-safe was defined as adminis- parents or guardians reported seeking medical care for their
tration of an age-appropriate mRNA COVID-19 vaccine child after bivalent booster vaccination, most commonly in an
dose on or after October 12, 2022, to a registrant who had outpatient clinic (37; 1.1%); no children received hospital care.
completed at least a primary vaccination series (2 doses of Of the 64 reports of medical care sought, 37 had additional
Pfizer-BioNTech or Moderna vaccine). In this report, local information available; parents or guardians of 35 children
and systemic reactions and health impacts reported during reported that seeking care was unrelated to vaccination.
the week after vaccination were described for v-safe registrants
Review of VAERS Data
aged 5–11 years who received a bivalent booster dose during
October 12–January 1, 2023. VAERS adverse event reports During October 12–January 1, 2023, VAERS received and
were described by serious and nonserious classification, demo- processed 922 reports of adverse events among children aged
graphic characteristics, and MedDRA PTs. Reports of serious 5–11 years (Table 3).††† The median recipient age was 9 years
events to VAERS were reviewed by CDC physicians to form
††† Processed VAERS reports are those that have been coded using MedDRA,
a consensus on clinical impression based on available data.¶¶ deduplicated, and undergone standard quality assurance and quality
Possible cases of myocarditis, a rare adverse event that has been control review.
associated with mRNA COVID-19 vaccines, were identified
using selected MedDRA PTs (6). All analyses were conducted TABLE 1. Demographic and vaccination characteristics reported to
using SAS software (version 9.4; SAS Institute). These sur- v-safe for children aged 5–11 years* who received a bivalent Pfizer-
veillance activities were reviewed by CDC and conducted BioNTech or Moderna COVID-19 vaccine booster dose † —
United States, October 12–January 1, 2023
consistent with applicable federal law and CDC policy.***
No. (%), by vaccine
Review of v-safe Data Pfizer-
BioNTech Moderna Total
During October 12–January 1, 2023, a total of 3,259 Characteristic (n = 2,647) (n = 612) (N = 3,259)
v-safe registrants aged 5–11 years received an age-appropriate Sex
bivalent booster dose (Table 1); 2,647 (81.2%) received Female 1,296 (49.0) 300 (49.0) 1,596 (49.0)
Male 1,338 (50.6) 310 (50.7) 1,648 (50.6)
Pfizer-BioNTech, and 612 (18.8%) received Moderna biva- Unknown 13 (0.5) 2 (0.3) 15 (0.5)
lent booster doses. Approximately 20.6% (670) of registrants Age range, yrs (median) 5–11 (8) 6–11 (8) 5–11 (8)
received at least one other vaccination at the same visit as biva- Ethnicity
lent booster vaccination; among these, 649 (96.9%) received Hispanic or Latino 298 (11.3) 51 (8.3) 349 (10.7)
Non-Hispanic or Latino 2,293 (86.6) 549 (89.7) 2,842 (87.2)
an influenza vaccine. Unknown 56 (2.1) 12 (2.0) 68 (2.1)
On ≥1 day during the week after receipt of the bivalent Race
booster dose, local injection site reactions were reported for American Indian or Alaska Native 7 (0.3) 2 (0.3) 9 (0.3)
Asian 131 (5.0) 27 (4.4) 158 (4.9)
1,740 (65.7%) Pfizer-BioNTech recipients and 470 (76.8%) Black or African American 99 (3.7) 16 (2.6) 115 (3.5)
Moderna recipients (Table 2); systemic reactions were reported Native Hawaiian or other 5 (0.2) 0 (—) 5 (0.2)
for 1,215 (45.9%) Pfizer-BioNTech recipients and 379 Pacific Islander
White 2,033 (76.8) 489 (79.9) 2,522 (77.4)
(61.9%) Moderna recipients. The most commonly reported Multiracial 245 (9.3) 58 (9.5) 303 (9.3)
adverse reactions after receipt of either vaccine were injection Other 71 (2.7) 8 (1.3) 79 (2.4)
Unknown 56 (2.1) 12 (2.0) 68 (2.1)
site pain (2,146; 65.9%), fatigue (1,076; 33.0%), and headache
Total no. of COVID-19 vaccine doses received
(745; 22.9%). Most reported reactions were mild in severity 3 1,055 (39.9) 119 (19.4) 1,174 (36.0)
(noticeable, but not problematic). Reactions were most fre- 4 1,588 (60.0) 493 (80.6) 2,081 (63.9)
quently reported the day after vaccination; reporting frequency 5 4 (0.1) 0 (—) 4 (0.1)
Vaccine co-administration§
decreased in the days that followed. At least 1 day during the Yes 565 (21.3) 105 (17.2) 670 (20.6)
week after bivalent booster vaccination, 469 (14.4%) children No 2,082 (78.7) 507 (82.8) 2,589 (79.4)
were reported to be unable to attend school, and 447 (13.7%) * On October 12, 2022, the Food and Drug Administration authorized bivalent
were unable to complete daily activities. Sixty-two (1.9%) (mRNA encoding the spike protein from the SARS-CoV-2 ancestral strain and
BA.4/BA.5 Omicron variants formulations of Pfizer-BioNTech and Moderna
¶¶ VAERS reports are classified as serious (based on FDA C.F.R. Title 21) if mRNA COVID-19 vaccines for use as a single booster dose ≥2 months after
completion of primary series or monovalent booster vaccination for children
any of the following are reported: hospitalization, prolongation of
aged 5–11 years and 6–17 years, respectively. A bivalent booster dose in v-safe
hospitalization, life-threatening illness, permanent disability, congenital
was defined as an age-appropriate mRNA vaccine dose administered on or
anomaly or birth defect, or death. https://www.accessdata.fda.gov/scripts/ after October 12, 2022, for registrants who had completed at least a primary
cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr series (2 doses of Pfizer-BioNTech or Moderna vaccine).
*** 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. † Includes registrants who completed at least one survey during postvaccination
552a; 44 U.S.C. Sect. 3501 et seq. days 0–7.
§ Other vaccines administered during the same visit.
(range = 5–11 years), and 459 (49.8%) reports were for females. Reports assigned the MedDRA PTs “incorrect dose admin-
Approximately 13.4% (124) of registrants received at least one istered,” “incorrect product formulation administered,” or
other vaccination during that same visit; of those, 115 (92.7%) “product administered to patient of inappropriate age” often
received an influenza vaccine. Among all 922 VAERS reports, represented situations in which a child received an adult
920 (99.8%) were classified as nonserious, 845 (99.8%) after bivalent booster dosage or a bivalent booster dose instead
Pfizer-BioNTech and 75 (100%) after Moderna bivalent of the appropriate monovalent primary series dose. Reports
booster vaccination. assigned the MedDRA PT “product preparation issue” often
The most common events reported (775; 84.2%) were
vaccination errors (e.g., incorrect dose administered [303;
TABLE 3. Events* reported to the Vaccine Adverse Event Reporting
39.1%], incorrect product formulation administered [207; System for children aged 5–11 years† after receipt of a bivalent
26.7%], product preparation issue [177; 22.8%], and product Pfizer-BioNTech or Moderna COVID-19 vaccine booster dose —
administered to patient of an inappropriate age [126; 16.3%]). United States, October 12–November 20, 2022
No. (%) reporting, by vaccine
Pfizer-
TABLE 2. Adverse reactions and health impacts reported to v-safe BioNTech Moderna Total
for children aged 5–11 years* who received a bivalent Pfizer- Adverse events (n = 847) (n = 75) (N = 922)
BioNTech or Moderna COVID-19 vaccine booster dose, by vaccine —
Serious reports§
United States, October 12–January 1, 2023
Total serious reports 2 (0.2) 0 (—) 2 (0.2)
No. (%) reporting reaction or health impact
after vaccination§ Nonserious reports
Pfizer-BioNTech Moderna Total Total nonserious reports 845 (99.8) 75 (100) 920 (99.8)
Event† (n = 2,647) (n = 612) (N = 3,259)
Reports of vaccination error¶ 726 (85.9) 49 (65.3) 775 (84.2)
Any injection site reaction 1,740 (65.7) 470 (76.8) 2,210 (67.8) Error without adverse health event 661 (91.0) 40 (81.6) 701 (90.5)
Pain 1,683 (63.6) 463 (75.7) 2,146 (65.9) Error with adverse health event** 65 (9.0) 9 (18.4) 74 (9.5)
Swelling or hardness 229 (8.7) 64 (10.5) 293 (9.0) Reports not specifying 119 (14.1) 26 (34.7) 145 (15.8)
Redness 211 (8.0) 64 (10.5) 275 (8.4) vaccination error††
Itching 123 (4.7) 21 (3.4) 144 (4.4) Fever 13 (10.9) 8 (30.8) 21 (14.5)
Any systemic reaction 1,215 (45.9) 379 (61.9) 1,594 (48.9) Syncope 17 (14.3) 3 (11.5) 20 (13.8)
Fatigue 798 (30.2) 278 (45.4) 1,076 (33.0) Vomiting 10 (8.4) 8 (30.8) 18 (12.4)
Headache 534 (20.2) 211 (34.5) 745 (22.9) Nausea 12 (10.1) 5 (19.2) 17 (11.7)
Fever 512 (19.3) 198 (32.4) 710 (21.8) Dizziness 12 (10.1) 2 (7.7) 14 (9.7)
Myalgia 353 (13.3) 145 (23.7) 498 (15.3) Fall 11 (9.2) 1 (3.9) 12 (8.3)
Chills 247 (9.3) 103 (16.8) 350 (10.7) Fatigue 6 (5.0) 5 (19.2) 11 (7.6)
Nausea 208 (7.9) 89 (14.5) 297 (9.1) Headache 5 (4.2) 6 (23.1) 11 (7.6)
Abdominal pain 182 (6.9) 56 (9.2) 238 (7.3) Loss of consciousness 11 (9.2) 0 (—) 11 (7.6)
Vomiting 115 (4.3) 39 (6.4) 154 (4.7) Cough 7 (5.9) 2 (7.7) 9 (6.21)
Joint pain 106 (4.0) 41 (6.7) 147 (4.5) Urticaria 7 (5.9) 2 (7.7) 9 (6.21)
Diarrhea 74 (2.8) 15 (2.5) 89 (2.7)
Abbreviations: MedDRA PT = Medical Dictionary for Regulatory Activities
Rash 37 (1.4) 8 (1.3) 45 (1.4)
preferred term; VAERS = Vaccine Adverse Event Reporting System.
Any health impact 506 (19.1) 196 (32.0) 702 (21.5) * Signs and symptoms in VAERS reports are assigned MedDRA PTs by VAERS
Unable to attend school 355 (13.4) 114 (18.6) 469 (14.4) staff members. Each VAERS report might be assigned more than one MedDRA
Unable to perform normal 298 (11.3) 149 (24.4) 447 (13.7) PT, which can include normal diagnostic findings. A MedDRA PT does not
daily activities indicate a medically confirmed diagnosis.
Needed medical care 49 (1.9) 13 (2.1) 62 (1.9) † On October 12, 2022, the Food and Drug Administration authorized bivalent
Outpatient clinic 30 (1.1) 7 (1.1) 37 (1.1) (mRNA encoding the spike protein from the SARS-CoV-2 ancestral strain and
Telehealth 10 (0.4) 4 (0.7) 14 (0.4) BA.4/BA.5 Omicron variants) formulations of Pfizer-BioNTech and Moderna
Other 12 (0.5) 3 (0.5) 15 (0.5) mRNA COVID-19 vaccines for use as a single booster dose ≥2 months after
Emergency department 4 (0.1) 0 (—) 4 (0.1) completion of primary series or monovalent booster vaccination for children
visit aged 5–11 years and 6–17 years.
§ The most common MedDRA PTs among reports of vaccination error included
Hospitalization 0 (—) 0 (—) 0 (—)
incorrect dose administered (303; 39.1%), incorrect product formulation
* On October 12, 2022, the Food and Drug Administration authorized bivalent administered (207; 26.7%), product preparation issue (177; 22.8%), and
(mRNA encoding the spike protein from the SARS-CoV-2 ancestral strain and product administered to patient of inappropriate age (126; 16.3%).
BA.4/BA.5 Omicron variants) formulations of Pfizer-BioNTech and Moderna ¶ The most common adverse health events MedDRA PTs for reports with
mRNA COVID-19 vaccines for use as a single booster dose ≥2 months after nonserious vaccination errors included fever (24; 32.4%), pain in extremity
completion of primary series or monovalent booster vaccination for children (20; 27.0%), fatigue (14; 18.9%), headache (11; 14.9%), and pain (eight; 10.8%).
aged 5–11 years and 6–17 years, respectively. A bivalent booster dose in v-safe ** Excluding reports of vaccination error. Includes the top 10 most frequently
was defined as an age-appropriate mRNA vaccine dose administered on or coded MedDRA PTs among nonserious reports.
after October 12, 2022, for registrants who had completed at least a primary †† VAERS reports are classified as serious if any of the following are reported:
series (2 doses of Pfizer-BioNTech or Moderna vaccine). hospitalization, prolongation of hospitalization, life-threatening illness,
† Events reported are not mutually exclusive. permanent disability, congenital anomaly or birth defect, or death. Serious
§ Percentage of registrants reported a reaction or health impact at least once reports to VAERS were reviewed by CDC physicians to form a clinical
during postvaccination days 0–7. impression. https://www.meddra.org/how-to-use/basics/hierarchy
Reports to v-safe of systemic and injection site reactions after

Summary
bivalent booster vaccination among children aged 5–11 years
were similar in frequency to those reported after monovalent
After CDC’s October 2022 recommendation for bivalent Pfizer-BioNTech booster vaccination (7). Consistent with pre-
COVID-19 booster vaccination for children aged 5–11 years,
children in this age group received approximately 953,359
vious descriptions of reactogenicity after mRNA COVID-19
bivalent booster doses during October 12, 2022–January 1, 2023. vaccination (8), reactions and health impacts were reported
What is added by this report?
more frequently for children who received Moderna than for
those who received Pfizer-BioNTech bivalent booster vaccina-
Early safety findings from v-safe and the Vaccine Adverse Event
Reporting System (VAERS) for bivalent booster vaccination in tion. Most reports to v-safe of children who received medical
children aged 5–11 years are similar to those described for care after bivalent booster vaccination indicated that care was
monovalent booster vaccination. Most VAERS reports represented not related to vaccination.
vaccine errors rather than adverse events. Neither myocarditis nor After administration of >950,000 doses of bivalent booster
death were reported after bivalent booster vaccination. vaccine to children aged 5-11 years, only two serious VAERS
What are the implications for public health practice? reports have been received. Approximately 99.8% of reports
These preliminary safety findings should be provided when to VAERS for children aged 5–11 years after bivalent booster
counseling parents or guardians about bivalent booster vaccination were deemed nonserious; most (85.0%) reports
vaccination. All eligible persons should receive a bivalent
were related to vaccination errors. Many vaccination errors
booster dose.
represented children receiving an incorrect bivalent booster
dose for their age or an incorrectly reconstituted dose. Most
represented situations in which vaccine was incorrectly recon- reports of vaccination error did not include an adverse health
stituted. Among 775 reports of vaccination errors related to event; those with an event were consistent with expected
bivalent booster vaccination, 74 (9.5%) reports indicated that reactions after an mRNA COVID-19 vaccination. Among
an adverse health event had occurred. events reported to VAERS, vaccination errors were reported
After excluding vaccination error reports, 145 (15.8%) of the with a similar frequency among children aged 5–11 years after
920 nonserious reports remained. Commonly reported events monovalent (71%) or bivalent (84%) booster vaccination (7).
included fever (21; 14.5%), syncope (20; 13.8%), vomiting Vaccination errors represented a smaller proportion of events
(18; 12.4%), nausea (17; 11.7%), and dizziness (14; 9.7%). (35%) reported among persons aged ≥12 years who received
Two serious reports were for children who received Pfizer- bivalent booster vaccination (4). CDC provides updated clini-
BioNTech vaccine; one for a child who developed symptoms cal guidance, educational materials, and training opportunities
consistent with Miller Fisher syndrome, a rare, acquired neu- after each update to COVID-19 vaccine recommendations.¶¶¶
rologic condition considered to be a variant of Guillain-Barré Public health officials should continue to provide training
syndrome§§§; verification based on medical record review materials for vaccine administrators to help reduce vaccination
is pending. The other one was for a child hospitalized with errors among children.
urticaria and arthritis. No reports of myocarditis or death after The findings in this report are subject to at least four limita-
bivalent booster vaccination were received. tions. First, v-safe is a voluntary program, and data might not
Discussion be representative of the vaccinated population. Second, v-safe
does not directly identify whether a vaccine is monovalent or
This report provides findings from v-safe and VAERS data bivalent; therefore, misclassification might occur among chil-
collected during the first 11 weeks of bivalent Pfizer-BioNTech dren who aged into this population without having completed
and Moderna mRNA booster dose administration among a 3-dose primary series. Third, VAERS is a passive surveillance
children aged 5–11 years; during this period, approximately system and subject to reporting biases and underreporting,
953,359 booster doses were administered to children in this especially of nonserious events (5). Finally, conclusions drawn
age group. The findings in this report are generally consistent from these data are limited by the 11-week surveillance period;
with those from postauthorization vaccine safety surveillance safety monitoring will continue during the bivalent booster
of monovalent mRNA COVID-19 booster vaccination in this vaccination program.
age group (7). ACIP recommends that all persons aged ≥6 months receive
an age-appropriate bivalent mRNA booster dose ≥2 months
§§§ https://www.ninds.nih.gov/health-information/disorders/miller-fisher-
after completion of a COVID-19 primary series or receipt of a
syndrome#:~:text%20=%20Miller%20Fisher%20syndrome%20is%20
a,preceded%20by%20a%20viral%20illness ¶¶¶ https://www.cdc.gov/vaccines/covid-19/index.html
monovalent booster dose. Preliminary safety findings from the 3. Rosenblum HG, Wallace M, Godfrey M, et al. Interim recommendations
first 11 weeks of bivalent booster vaccination among children from the Advisory Committee on Immunization Practices for the use of
bivalent booster doses of COVID-19 vaccines—United States, October
aged 5–11 years are reassuring. Compared with the low risk of 2022. MMWR Morb Mortal Wkly Rep 2022;71:1436–41.
serious health effects after mRNA COVID-19 vaccination, the PMID:36355612 https://doi.org/10.15585/mmwr.mm7145a2
health effects of SARS-CoV-2 infection include death and serious 4. Hause AM, Marquez P, Zhang B, et al. Safety monitoring of bivalent
COVID-19 mRNA vaccine booster doses among persons aged
long-term sequalae (6). Immunization with bivalent vaccines ≥12 years—United States, August 31–October 23, 2022. MMWR Morb
provides significant additional protection against symptomatic Mortal Wkly Rep 2022;71:1401–6. PMID:36327162 https://doi.
SARS-CoV-2 infection (9). CDC and FDA will continue to org/10.15585/mmwr.mm7144a3
5. Shimabukuro TT, Nguyen M, Martin D, DeStefano F. Safety monitoring
monitor vaccine safety and will provide updates as needed to in the Vaccine Adverse Event Reporting System (VAERS). Vaccine
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vaccine.2015.07.035
Acknowledgments 6. Block JP, Boehmer TK, Forrest CB, et al. Cardiac complications after
SARS-CoV-2 infection and mRNA COVID-19 vaccination—PCORnet,
Charles Licata, Isaac McCullum. United States, January 2021–January 2022. MMWR Morb Mortal Wkly
Corresponding author: Anne M. Hause, voe5@cdc.gov. Rep 2022;71:517–23. PMID:35389977 https://doi.org/10.15585/
mmwr.mm7114e1
1CDC COVID-19 Emergency Response Team; 2Food and Drug Administration,
7. Hause AM, Baggs J, Marquez P, et al. Safety monitoring of Pfizer-
Silver Spring, Maryland. BioNTech COVID-19 vaccine booster doses among children aged
All authors have completed and submitted the International 5–11 years—United States, May 17–July 31, 2022. MMWR Morb Mortal
Wkly Rep 2022;71:1047–51. PMID:35980875 https://doi.org/10.15585/
Committee of Medical Journal Editors form for disclosure of potential mmwr.mm7133a3
conflicts of interest. No potential conflicts of interest were disclosed. 8. Hause AM, Baggs J, Marquez P, et al. Safety monitoring of COVID-19
vaccine booster doses among adults—United States, September 22,
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QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Percentage* of Adults Aged ≥18 Years Who Have Ever Had Hepatitis,† by Age
Group and Sex — National Health Interview Survey,§ United States, 2021
100
Total 18–44 yrs 45–64 yrs ≥65 yrs
6
Percentage
0
Total Men Women
Sex
* With 95% CIs indicated by error bars.

† Based on an affirmative response to the survey question, “Have you ever been told by a doctor or other health
professional that you had hepatitis?” All types and causes of hepatitis could be reported by the respondent.
§ Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population.
In 2021, 1.6% of adults aged ≥18 years reported having ever had hepatitis. The prevalence of hepatitis was lowest among adults
aged 18–44 years (0.6%) and highest among adults aged ≥65 years (2.7%). Prevalence increased with age for both men and
women. The percentage of adults who ever had hepatitis was higher in men than women aged 45–64 years (2.7% versus 1.9%)
and ≥65 years (3.2% versus 2.3%), but was similar in adults aged 18–44 years (0.5% versus 0.6%).
Source: National Center for Health Statistics, National Health Interview Survey, 2021. https://www.cdc.gov/nchs/nhis.htm
Reported by: Julie D. Weeks, PhD, jweeks@cdc.gov, 301-458-4562; Nazik Elgaddal, MS.
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ISSN: 0149-2195 (Print)

Cholera Outbreak - Haiti, September 2022-January 2023: Weekly / Vol. 72 / No. 2 January 13, 2023

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Cholera Outbreak - Haiti, September 2022-January 2023: Weekly / Vol. 72 / No. 2 January 13, 2023

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Morbidity and Mortality Weekly Report

Weekly / Vol. 72 / No. 2 January 13, 2023

Cholera Outbreak — Haiti, September 2022–January 2023

U.S. Department of Health and Human Services

§ From alert-based reporting.

MMWR Editorial and Production Staff (Weekly)

Public Health Response Discussion

Oct 9 Nov 20 Jan 1

Nord-Ouest Nord-Ouest Nord-Ouest

Nord Nord Nord

Grande’Anse Grande’Anse Grande’Anse

Sud Sud-Est Sud Sud-Est Sud Sud-Est

Corresponding author: Denisse Vega Ocasio, rhq1@cdc.gov.

Morbidity and Mortality Weekly Report

Vaccination Coverage with Selected Vaccines and Exemption Rates Among

Discussion formally or informally during the 2020–21 school year, and

Target MMR coverage (95%)

Abbreviations: MMR = measles, mumps, and rubella vaccine; UTD = up to date.

All authors have completed and submitted the International

Vaccination Coverage by Age 24 Months Among Children Born During

National Vaccination Coverage Vaccination by Selected Sociodemographic

85 Hib full series

pandemic, providing a more complete assessment of trends in

Safety Monitoring of Bivalent COVID-19 mRNA Vaccine Booster Doses Among

Reports to v-safe of systemic and injection site reactions after

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Total 18–44 yrs 45–64 yrs ≥65 yrs

* With 95% CIs indicated by error bars.

ISSN: 0149-2195 (Print)

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