ACIP Evidence to Recommendations for Use of Moderna COVID-19 Vaccine

About

The Evidence to Recommendations (EtR) frameworks describe information considered in moving from evidence to ACIP vaccine recommendations.

Summary

Question: Should vaccination with the Moderna COVID-19 vaccine (Spikevax, 2-dose primary series) be recommended for persons 18 years of age and older?

Population: Persons 18 years of age and older

  • Symptomatic laboratory-confirmed COVID-19
  • Hospitalization due to COVID-19
  • Death due to COVID-19
  • Asymptomatic SARS-CoV-2 infection
  • Serious Adverse Events (SAEs) (including myocarditis and anaphylaxis)
  • Reactogenicity (proportion with grade 3 or worse reactions)

Background

The emergence of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), in late 2019 has led to a global pandemic with dramatic societal and economic impact on individual persons and communities. In the United States, more than 76 million cases and more than 900,000 COVID-19-associated deaths have been reported as of February 7, 2022. Persons of all ages are at risk for infection and severe disease. However, the risk for severe illness from COVID-19 is higher in people aged ≥65 years, those living in long-term care facilities, and those with chronic medical conditions. Additionally, there is a disproportionate burden of COVID-19 infections and deaths among racial and ethnic minority communities. Non-Hispanic Black, Hispanic/Latino (Hispanic) and American Indian/Alaska Native persons have experienced higher rates of disease, hospitalization and death compared with non-Hispanic White persons. This is likely related to inequities in social determinants of health that put racial and ethnic minority groups at increased risk for COVID-19, including overrepresentation among essential workers who have higher risk of exposure to COVID-19, lower incomes, reduced access to healthcare, or higher rates of comorbid conditions.

In the United States, the first vaccines to prevent COVID-19 received Food and Drug Administration (FDA) Emergency Use Authorizations (EUA): Pfizer-BioNTech on December 11, 2020, for persons aged 16 years and older, Moderna on December 18, 2020, for adults aged 18 years and older, and Janssen on February 27, 2021, for adults aged 18 years and older. On August 23, 2021, the FDA approved a Biologics License Application (BLA) for use of the Pfizer-BioNTech COVID-19 vaccine in persons aged 16 years and older; and on January 31, 2022, the FDA approved a BLA for use of the Moderna COVID-19 vaccine in persons aged 18 years and older.

Additional background information supporting the ACIP recommendation on the use of Moderna COVID-19 vaccine can be found in the relevant publication of the recommendation referenced on the ACIP website.

Problem

Criteria Work Group Judgements Evidence Additional Information
Is the problem of public health importance? Yes COVID-19 is a major global public health threat that dramatically disrupted all sectors of society worldwide. In the United States, COVID-19 has important associated morbidity and mortality.
Incidence:
As of February 7, 2022, there were 76,782,002 COVID-19 cases reported in the United States for an incidence of 23,425 cases per 100,000 population.1
Hospitalization:
Among sites participating in population-based surveillance for laboratory-confirmed COVID-19-associated hospitalizations, the overall cumulative hospitalization rate between March 1, 2020 and January 29, 2022 was 898 per 100,000 population. Among those hospitalized, 23.5% required care in an intensive care unit and 13.5% died.2,3
COVID-19-associatiated hospitalization rates were 12-17 times higher in unvaccinated adults compared to fully vaccinated adults.4
Mortality:
As of February 7, 2022, there were 903,038 COVID-19-associated deaths reported in the United States.5
 ICU Capacity:
As of February 3, 2022, 29 states had over 80% intensive care unit (ICU) beds occupied.6
Vaccination:
As of February 8, 2022, more than 540 million doses of COVID-19 vaccines had been administered in the United States. However, 25.6% of people ≥18 years of age were not fully vaccinated.7 Vaccination coverage varies by geography and age. Older adults ≥18 had a higher proportion of individuals receiving ≥1 dose (95% in 65-74 years) compared to younger persons 12-17 (66.7%).8
Variants of Concern:
As of February 5, 2022, the Omicron variant is the dominant circulating variant in the United States and spreads more easily than the original virus that causes COVID-19 and the Delta variant.9,10

Benefits and Harms

Criteria Work Group Judgements Evidence Additional Information
How substantial are the desirable anticipated effects? Large In the Phase III randomized controlled trial (RCT), the Moderna COVID-19 vaccine demonstrated efficacy up to 5 months after vaccination. The overall efficacy* against symptomatic laboratory-confirmed COVID-19 was 92.7 (95% confidence interval [CI]  90.4–94.4%)) (Table 3a). For hospitalization due to COVID-19, 25 events occurred, 24 in the placebo group and 1 in the vaccine group. Vaccine efficacy against hospitalization due to COVID-19 was 95.9% (95% CI 69.5–99.4%) (Table 3b). Deaths due to COVID-19 were uncommon, zero in the vaccine group and three in the placebo group (vaccine efficacy: 100%) (Table 3c).1
The pooled vaccine effectiveness estimates from the observational studies demonstrated that the Moderna COVID-19 vaccine reduced symptomatic COVID-19 when compared to no vaccination (pooled vaccine effectiveness: 89.2%, 95% CI 82.0–93.6%; based on 11 studies). The pooled vaccine effectiveness against hospitalization due to COVID-19 was 94.8% (95% CI 93.1–96.1%), based on 14 studies. The pooled vaccine effectiveness for prevention of death due to COVID-19 was 93.8% (95% CI 91.5–95.4%), based on five studies. The pooled vaccine effectiveness against asymptomatic SARS-CoV-2 infection was 69.8% (95% CI 60.9–76.7%), based on three studies.1
 Thirty-three publications, which reported data on 31 studies or surveillance systems, were included in the evidence synthesis and GRADE evidence assessment. Data were reviewed from five RCTs publications including two publications from the Phase I trial, one publication from a Phase II trial, and two publications from the Phase III trial. Data were reviewed from 26 vaccine effectiveness studies.
How substantial are the undesirable anticipated effects? Small In the Phase III RCT, numbers of serious adverse events (SAEs)§§ were comparable between the vaccine group and the placebo group across the two RCTs (Phase III: 268/15,184 (1.8%) vs. 292/15,164 (1.9%); Phase II: 0/200 (0.0%) vs. 0/200 (0.0%)); there were no cases of vaccine-associated enhanced disease or vaccine-related deaths (Table 3e). Grade ≥3 reactions** generally were not uncommon and occurred more frequently in the vaccine than placebo groups (Table 3f).1

Observational data on serious adverse events were reviewed. A rapid cycle analysis from Vaccine Safety Datalink (VSD) evaluated chart-reviewed cases of myocarditis occurring among persons aged 18–39 years in a 7-day risk interval following dose 2 of the Moderna COVID-19 vaccine versus a 22–42 day comparison interval resulting in an adjusted rate ratio of 18.8 (95% CI 6.7–64.9) (Table 3e). Data from Vaccine Adverse Event Reporting System showed an elevated ratio of observed to expected myocarditis cases in the 7-day interval following vaccination among females aged 18–29 years and among males aged 18–49 years, with higher observed/expected ratios in males than females. A rapid cycle analysis of data from VSD evaluated chart-reviewed cases of anaphylaxis among all vaccinated persons aged ≥18 years. Based on events occurring in a 0–1 day risk interval after vaccination, the estimated incidence of confirmed anaphylaxis was 5.1 (95% CI 3.3–7.6) per million doses.1

 Safety data showed an acceptable safety profile.
Two vaccine safety surveillance systems, VSD and VAERS, included data for SAEs, including myocarditis and anaphylaxis.1 In post-authorization safety monitoring, myocarditis and anaphylaxis were rare but more common following vaccination.
Do the desirable effects outweigh the undesirable effects? Favors intervention The Work Group felt that the desirable effects of the Moderna COVID-19 vaccine outweigh the undesirable effects.
What is the overall certainty of this evidence for the critical outcomes? High to moderate For the critical outcomes, the certainty of evidence was high for prevention of symptomatic laboratory-confirmed COVID-19, moderate for prevention of hospitalizations due to COVID-19, and moderate for serious adverse events. For important outcomes, the certainty of evidence was moderate for prevention of death due to COVID-19, high for prevention of asymptomatic infection, and high for reactogenicity.1

Values

Criteria Work Group Judgements Evidence Additional Information
Does the target population feel that the desirable effects are large relative to undesirable effects? Large In 63 national surveys among U.S. adults conducted between December 2020 and January 2022, for the scenario that a vaccine would be or had been approved in the United States, acceptability was moderate overall. The proportion intending to receive the COVID-19 vaccine ranged across the surveys between 47%-84%.1 Vaccination intent over time has been relatively stable. A survey conducted from January 2 – 8, 2022 reported 84.7% of adults ages 18 years and older are vaccinated or definitely will get vaccinated.2 
A survey of the American general population conducted on unvaccinated adults ages 18 years and older between January 7 – 10, 2022, inquired if the discovery of the Omicron variant would make them more or less likely to get the COVID-19 vaccine. The majority (72%) of respondents expressed that it makes no difference.3 Furthermore, when unvaccinated adults were asked what, if anything, would convince them to get vaccinated for COVID-19, about half (48%) said nothing would convince them to get a COVID-19 vaccine.4
Initial data indicated that following the FDA’s full approval of the Pfizer-BioNTech COVID-19 vaccine, the United States saw a slight uptick (17%) in the average number of Americans getting their first COVID-19 vaccine. In the week prior to full approval, an average of about 404,000 Americans were initiating vaccination each day. Following approval, approximately 473,000 Americans were getting their first dose each day. Although not a rapid surge in vaccinations in the days immediately following approval, full approval may have been enough to convince some to finally get vaccinated.5
 Knowledge and attitudes may change with time, and intentions may not reflect uptake. The survey sample populations may not be representative, limiting the generalizability of the results to all adults in the U.S. Most surveys used convenience sampling, had limited representation of minority and priority populations (such as healthcare workers or essential workers), and low or unknown response rates.
Is there important uncertainty about or variability in how much people value the main outcomes? Probably important uncertainty or variability In a recent ongoing survey to assess vaccination intention of unvaccinated Americans in response to the FDA’s Biologics License Application for the Moderna COVID-19 vaccine, only 5% of unvaccinated respondents said they would get a COVID-19 vaccine as soon as they could if the Moderna vaccine received full approval from the FDA. Moreover, 20% said they would continue waiting to see if COVID vaccines were safe and effective, and 52% said they would definitely not get vaccinated or would only do so if it were required.6
As it pertains to time to vaccination in response to a Moderna FDA Biologics License Application, 11% of unvaccinated respondents who were open to or unsure about getting vaccinated said they would wait a few more weeks and an additional 11% said they would wait more than a year to get a COVID vaccine after the Moderna vaccine received full FDA approval.6
Common concerns or factors associated with vaccine hesitancy included vaccine side effects or general mistrust of COVID-19 vaccines.6
 During the data collection period (January 27 – January 31, 2022), 29% of unvaccinated respondents thought the Moderna COVID-19 vaccine had already received full approval from the FDA.6
The Work Group determined that whereas there might be variability and uncertainty in how all populations value the vaccine, for most populations, the desirable effects probably outweigh the undesirable effects.

Acceptability

Criteria Work Group Judgements Evidence Additional Information
Is the intervention acceptable to key stakehold-ers? Yes Pandemic vaccination response planning requires collaboration among a wide range of public- and private-sector partners. COVID-19 vaccination has been implemented in a variety of settings, including state and local health departments, healthcare sites and hospitals, mass vaccination clinics, Long Term Care Facilities, and retail pharmacies. As of February 9, 2022, more than 205 million doses have been administered.1 Vaccination with the Moderna COVID-19 vaccine was already highly acceptable to stakeholders under FDA EUA and ACIP interim recommendation, and vaccination may be more acceptable to stakeholders under full FDA approval and a standard ACIP recommendation.

Feasibility

Criteria Work Group Judgements Evidence Additional Information
Is the intervention feasible to implement? Yes There are a variety of barriers that are likely to limit the feasibility of implementing the Moderna COVID-19 vaccine including:
  • Complexity of recommendations
  • Vaccine storage and handling requirements
  • Financial barriers
The Moderna COVID-19 vaccine will be the second COVID-19 vaccine that has an FDA approved Biologics License Application (BLA). Furthermore, the BLA has only been issued for some indications, which may add complexity to current recommendations. For example, the BLA has been issued for a primary series for those ages 18 years and older, whereas an Emergency Use Authorization (EUA) has been issued for an additional dose in immunocompromised people for those ages 18 years and older as well as a booster dose in persons ages 18 years and older who completed a primary series ≥5 months ago. Moreover, recommendations made under Emergency Use Instructions (EUI) are only allowed for vaccines with a BLA, which will allow these recommendations to extend to the Moderna COVID-19 vaccine as well as include recommendations for additional/booster vaccination of people who received their primary series overseas or as part of a clinical trial.
Vaccine storage and handling requirements also influence feasibility. Moderna COVID-19 multiple-dose vials are stored frozen -50oC to -15oC (-58o to 5oF). The vaccine should not be stored on dry ice or below -50oC (-58oF) and the vaccine must be stored in the original carton to protect the vials from light. Vials can be refrigerated between 2oC to 8oC (36o to 46oF) for up to 30 days prior to first use. After the first dose has been withdrawn, the vial should be held between 2oC to 25oC (36o to 77oF), and vials should be discarded 12 hours after the first puncture.1
Financial barriers to receiving the Moderna COVID-19 vaccine will be reduced because the vaccine is being provided free of charge to the U.S. population. However, health systems or health departments could incur costs for COVID-19 vaccine implementation, clinics, outreach, and education. Furthermore, financial hardship may arise if vaccine recipients need to take time off to receive the vaccine or experience post-vaccination reactogenicity that prevents them from working.
Vaccine supply in the United States is sufficient for implementation of the intervention. As of February 9, 2022, over 205 million doses of Moderna COVID-19 vaccine have been administered in the United States, demonstrating that the vaccine is feasible to implement broadly.2
 The Work Group determined that the Moderna COVID-19 vaccine is feasible to implement.

Resource Use

Criteria Work Group Judgements Evidence Additional Information
Is the intervention a reasonable and efficient allocation of resources? Yes A recent study estimated that preventable COVID-19 hospitalizations among unvaccinated adults in the United States cost over $13 billion from June to November in 2021.1 An effective vaccine combined with a successful vaccination program would be expected to reduce costs associated with COVID-19 disease outcomes and other COVID-19 mitigation activities.
Vaccine doses purchased with U.S. taxpayer funds will be given to people living in the United States at no cost.2 Several published modeling studies have found that COVID-19 vaccinations are likely to be of a reasonable economic value and may also be cost-saving under many circumstances.3-6 

Equity

Criteria Work Group Judgements Evidence Additional Information
What would be the impact of the intervention on health equity? Probably no impact As of January 22, 2022, cumulative COVID-19-associated hospitalizations in the United States illustrated that rates (per 100,000 population) were higher among American Indian/Alaska Native, Black, and Hispanic populations compared to White and Asian/Pacific Islanders.1
As of February 2, 2022, the percentage of people ages 18 years and older who received at least one dose of the COVID-19 vaccine was highest among American Indian/Alaska Natives (69.3%), followed by Asians (64.4%), Native Hawaiian or Other Pacific Islanders (63.1%), Hispanic/Latino (59.3%) and White populations (52.4%).  Black populations had the lowest percentage (45.9%) of people who received at least one dose of the COVID-19 vaccine. Further analysis indicates that American Indian/Alaska Native populations have consistently had the highest percentage among those who have received at least one dose of the COVID-19 vaccine over time.2
COVID-19 vaccination coverage also varies by geography. Additional analysis of an integrated, county view of vaccination coverage in the United States illustrates that 50-70% of the population ≥18 years of age are fully vaccinated, which consists of 58% of U.S. counties.3 Further analysis highlights disparities in vaccine intent by geographic location. Vaccine uptake lags in adults living in rural and suburban areas compared with urban areas. As of November 21, 2021, eight in ten urban residents (79%) say they have received at least one dose of a COVID-19 vaccine, compared to seven in ten suburban adults and 67% of rural adults. Moreover, one in five (21%) of those living in rural areas and one in six (16%) of those living in suburban areas say they will “definitely not” get a COVID-19 vaccine, at least twice the share of urban residents who say the same (8%).4
COVID-19 vaccination coverage also varies by sexual orientation and gender identity. During August 29 – October 30, 2021, data from the National Immunization Survey Adult COVID Module (NIS-ACM) was analyzed to assess COVID-19 vaccination coverage in COVID-19 vaccines among lesbian, gay, bisexual, and transgender (LGBT) adults ages 18 years and older. By sexual orientation, gay or lesbian adults reported higher vaccination coverage overall (85.4%) than heterosexual adults (76.3%). Furthermore, among gay or lesbian adults and bisexual adults, vaccination coverage was lower among women (80.5% and 74.2%, respectively) than among men (88.9% and 81.7%, respectively). There were no significant differences in vaccination coverage among persons based on gender identity. However, vaccination coverage was lowest among non-Hispanic Black LGBT persons across all categories of sexual orientation and gender identity.5
 The Work Group determined a standard ACIP recommendation for Moderna COVID-19 vaccine would probably have no impact on equity.

Balance of consequences

Desirable consequences clearly outweigh undesirable consequences in most settings.

Is there sufficient information to move forward with a recommendation? Yes.

Policy options for ACIP consideration

ACIP recommends the intervention

Draft recommendation (text)

The Moderna COVID-19 vaccine is recommended for people 18 years of age and older under FDA’s Biologics License Application.

Final deliberation and decision by the ACIP

Final ACIP recommendation

ACIP recommends the intervention.

The Moderna COVID-19 vaccine is recommended for persons 18 years of age and older in the U.S. population under the FDA’s Biologics License Application.

*Overall vaccine efficacy was calculated at ≥14 days after second dose of vaccine among persons without evidence of prior SARS-CoV-2 infection.

†Asymptomatic SARS-CoV-2 infection is defined as (1) positive serology (non-spike protein), and (2) no prior SARS-CoV-2 positive PCR or COVID-19 symptoms during the study. Seroconversion to a non-spike protein can distinguish between natural infection and vaccine-induced immunity.

**Grade 3 reactions are defined as: pain at injection site or axillary swelling/tenderness that prevents daily activity, redness > 10 cm, and swelling > 10 cm; fever 102.1-104.0°F (39°C–40°C); vomiting that requires intravenous hydration; or headache, fatigue/tiredness, new or worsened muscle pain, or new or worsened joint pain that prevents daily routine activity; grade 4 reactions are defined as: requires emergency room visit or hospitalization, fever >104°F (40°C).

§§Serious adverse events defined as any untoward medical occurrence that results in death, is life-threatening, requires inpatient hospitalization or prolongation of existing hospitalization, or results in persistent disability/incapacity.

References

Problem:

  1. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#trends_totalcases_totalcasesper100k. Accessed: February 9, 2022.
  2. COVID-NET A Weekly Summary of U.S. COVID-19 Hospitalization Data, preliminary cumulative rates. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://gis.cdc.gov/grasp/COVIDNet/COVID19_3.html. Accessed: February 9, 2022.
  3. COVID-NET A Weekly Summary of U.S. COVID-19 Hospitalization Data, characteristics of COVID-19-associated hospitalizations. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://gis.cdc.gov/grasp/COVIDNet/COVID19_5.html. Accessed: February 9, 2022.
  4. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#covidnet-hospitalizations-vaccination. Accessed February 9, 2022.
  5. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#trends_dailydeaths. Accessed: February 9, 2022.
  6. HHS Protect Public Data Hub. Washington, D.C.: US Department of Health and Human Services, 2022. https://protect-public.hhs.gov/pages/hospital-utilization. Accessed: February 3, 2022.
  7. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total. Accessed: February 9, 2022.
  8. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends. Accessed: February 9, 2022.
  9. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#variant-proportions. Accessed February 9, 2022.
  10. Omicron Variant: What You Need to Know. Coronavirus Disease 2019 (COVID-19) | COVID-19 | CDC Accessed: February 9, 2022.

Benefits and harms:

  1. Centers for Disease Control and Prevention (CDC). Grading of Recommendations, Assessment, Development, and Evaluation (GRADE): Moderna COVID-19 Vaccine. 2022. www.cdc.gov/acip/grade/bla-covid-19-moderna-vaccine.html

Values:

  1. Oliver, S. Evidence to Recommendation Framework: Moderna COVID-19 vaccine, Spikevax. Presentation to ACIP. February 4, 2022. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2022-02-04/07-COVID-Oliver-508.pdf
  2. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#vaccine-confidence. Accessed January 21, 2022.
  3. Axios/Ipsos Poll. January 2022. https://www.ipsos.com/en-us/news-polls/axios-ipsos-coronavirus-index. Accessed January 19, 2022
  4. KFF COVID-19 Vaccine Monitor: Early Omicron Update (Dec 15 – 20, 2021). https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-early-omicron-update/. Accessed January 19, 2022
  5. ABC news. August 31, 2021. More Americans getting vaccinated following full FDA approval of Pfizer COVID vaccine. https://abcnews.go.com/Health/americans-vaccinated-full-fda-approval-pfizer-covid-vaccine/story?id=79750505
  6. CDC and University of Iowa/RAND survey, unpublished

Acceptability:

  1. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total. Data as February 9, 2022.

Feasibility:

  1. Moderna. Storage & Handling. https://eua.modernatx.com/covid19vaccine-eua/providers/storage-handling. Accessed January 18, 2022.
  2. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total. Accessed: February 9, 2022.

Resource use:

  1. Peterson-KFF Health System Tracker. December 22, 2021. Unvaccinated COVID-19 hospitalizations cost billions of dollars. https://www.healthsystemtracker.org/brief/unvaccinated-covid-patients-cost-the-u-s-health-system-billions-of-dollars/
  2. CDC COVID-19. COVID-19 Vaccines Are Free to the Public. www.cdc.gov/coronavirus/2019-ncov/vaccines/expect.html. Updated November 3, 2021.
  3. Padula WV, Malaviya S, Reid NM, et al. Economic value of vaccines to address the COVID-19 pandemic: a U.S. cost-effectiveness and budget impact analysis. J Med Econ. 2021 Jan-Dec;24(1):1060-1069. doi: 10.1080/13696998.2021.1965732.
  4. Bartsch SM, Ferguson MC, McKinnell JA. The potential health care costs and resource use associated with COVID-19 in the United States. Health Aff. 2020:39:927-35. DOI: 10.1377/hlthaff.2020.00426.
  5. Gupta S, Cantor J, Simon KI, et al. Vaccinations Against COVID-19 May Have Averted Up To 140,000 Deaths In The United States. Health Aff . 2021 Sep;40(9):1465-1472. doi: 10.1377/hlthaff.2021.00619.
  6. Kohli M, Maschio M, Becker D, Weinstein M. The Potential Public Health and Economic Value of a Hypothetical COVID-19 Vaccine in the United States: Use of Cost-Effectiveness Modeling to Inform Vaccination Prioritization. Vaccine 2021 Feb 12; 39(7): 1157–1164.

Equity:

  1. COVID-NET Laboratory-confirmed COVID-19 hospitalizations. https://covid.cdc.gov/covid-data-tracker/#covidnet-hospitalization-network. Accessed February 3, 2022.
  2. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends. Accessed February 3, 2022.
  3. CDC COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=all_states&list_select_county=all_counties&data-type=Vaccinations&metric=Administered_Dose1_Pop_Pct. Accessed February 3, 2022.
  4. KFF COVID-19 Vaccine Monitor: Differences in Vaccine Attitudes Between Rural, Suburban and Urban Areas. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-vaccine-attitudes-rural-suburban-urban/. Accessed January 18, 2022.
  5. McNaghten A, Brewer NT, Hung M, et al. COVID-19 Vaccination Coverage and Vaccine Confidence by Sexual Orientation and Gender Identity — United States, August 29–October 30, 2021. MMWR Morb Mortal Wkly Rep 2022;71:171–176. DOI: http://dx.doi.org/10.15585/mmwr.mm7105a3

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Content Source:
National Center for Immunization and Respiratory Diseases (NCIRD)