Caregiver COVID-19 vaccine status and its influence on pediatric vaccination decisions in a US cohort

Despite availability of safe and effective COVID-19 vaccines for children, uptake of this vaccine remains low in the United States. Caregiver attitudes and behaviors play a key role in child vaccine decisions, yet little is known about the reasons for vaccine refusal within families or the relationship between COVID-19 vaccine and routine childhood immunization refusal. This study examined 1) associations between caregiver and child COVID-19 vaccination status, 2) alignment of reasons for vaccine non-acceptance between the caregiver themselves and for their child, and 3) associations between COVID-19 vaccine non-acceptance and refusal or delay of routine childhood vaccinations.

We analyzed data from 6395 families in the NIH ECHO Cohort with self-reported caregiver and child COVID-19 vaccination status between December 2021 and August 2023. Generalized estimating equations were used to assess associations while accounting for cohort clustering.

Of the 6395 families, 25% of caregivers had not accepted the COVID-19 vaccine for themselves, and 59% had not accepted the vaccine for any of their children. Children were more likely to be unvaccinated when their caregivers were unvaccinated (OR: 13.2, 95% CI: 10.3-16.9). Among unvaccinated caregiver-child pairs, reasons for vaccine refusal showed strong concordance. The predominant concern among vaccinated caregivers with unvaccinated children was a belief that the COVID-19 vaccine had not been well tested in children (OR: 3.7, 95% CI: 2.3-6.0). Caregivers who refused the COVID-19 vaccination for themselves were more likely to have delayed or refused routine vaccines for their child (child unvaccinated for COVID-19: OR: 1.8, 95% CI: 1.4-2.1); caregiver unvaccinated for COVID-19: OR 2.8, 95% CI: 2.2-3.4).

COVID-19 vaccine status among caregivers was strongly associated with child COVID-19 vaccine uptake and broader vaccine behaviors. Addressing shared safety concerns and building caregiver trust in vaccines is essential for improving pediatric vaccination coverage.