Federal Retail Pharmacy Program Contributions to Bivalent mRNA COVID-19 Vaccinations Across Sociodemographic Characteristics — United States, September 1, 2022–September 30, 2023

Discussion

During September 1, 2022–September 30, 2023, FRPP partners administered 40.5 million bivalent COVID-19 doses, representing more than two thirds (67.7%) of all bivalent COVID-19 doses administered across the United States and its territories and freely associated states. In comparison, previous data show that FRPP partners administered 45% of monovalent doses during February 11, 2021–January 31, 2022 (2). Factors that might have contributed to the higher proportion of bivalent compared with monovalent COVID-19 vaccines doses administered by FRPP partners include a higher level of awareness of COVID-19 vaccine availability at pharmacies, ease of accessibility (e.g., extended hours of operation, walk-in and scheduled appointments, and geographically convenient locations), and fewer COVID-19 mass vaccination clinics during this period compared with the time when the original monovalent vaccine first became available (2). Although FRPP partners were effective in making COVID-19 vaccines widely accessible, differences in use of FRPP partner vaccination services was observed across age groups, racial and ethnic groups, sex, and urbanicity.

Despite the availability of COVID-19 vaccines through FRPP partners and from other vaccine providers, overall U.S. bivalent vaccination coverage was substantially lower than that of completed monovalent primary COVID-19 vaccination series. Data from CDC’s COVID Data Tracker reveal that as of May 11, 2023 (the end date of the public health emergency), 17% of the U.S. population had received the bivalent vaccine,^§§ compared with 69.5% who had completed a primary series. Among persons considering bivalent vaccination, commonly reported barriers to receipt of bivalent COVID-19 vaccine have included being too busy or forgetting to get vaccinated and having concerns related to side effects, whereas the main concerns reported by persons reporting no intent to receive a bivalent vaccine were more often related to trust, belief that vaccination was not necessary, and concerns about safety. However, the results of surveys conducted in March and April 2023 indicate that fewer than 5% of respondents reported access issues of time or costs as concerns, suggesting that access was not a substantial contributor to low vaccination rates (4).

FRPP vaccinations were reported for all evaluated demographic groups, including all age groups. However, FRPP partners administered the highest proportion of bivalent vaccine doses to adults, with similar percentages of doses administered to adults in all age groups (range = 69.3%–70.6%). FRPP partners administered a lower proportion of bivalent doses to children aged 5–11 years (33.6%) and 6 months–4 years (5.9%). This difference in percentages of doses administered to adult and pediatric recipients is not unexpected: historically, more adults than children have received annual influenza vaccination at pharmacies (5). Surveys conducted during September 2021 found that parents reported a higher level of trust when vaccinating their child at their regular clinic (63%), compared with vaccination at 1) a local pharmacy (34%), 2) a clinic different from their regular one (30%), 3) school with the parent present (25%), 4) temporary mass vaccination clinic (25%), and 5) school without the parent present (15%) (6). Pharmacy administration of COVID-19 vaccination to children was possible in part because of the Public Readiness and Preparedness Act, which lowered the age at which children could be vaccinated at pharmacies to 3 years in all states, making COVID-19 vaccination accessible for some age groups not typically vaccinated at pharmacies in many states (7). Although FRPP helped during this public health emergency, pediatricians, health departments and federally qualified health centers were needed to ensure that young children had adequate access to COVID-19 vaccines.

FRPPs administered a large proportion of COVID-19 bivalent doses to most racial and ethnic groups. However, the proportion was lower for AI/AN persons, a group that might have relied more on Indian Health Service facilities or other vaccine providers.

The FRPPs’ contribution to COVID-19 bivalent doses was higher among urban than rural counties. Possible reasons for this difference are the potential higher accessibility of pharmacies in urban areas, as well as the fact that independent pharmacies in rural areas might have been less likely to partner with the FRPP. In addition, factors such as the availability of bivalent COVID-19 vaccines in primary care settings or other settings could have affected the proportion of COVID-19 bivalent doses administered by FRPP partners located in urban versus rural areas (8,9). Further evaluations are needed to understand the factors contributing to differences in pharmacy provider vaccination among urban and rural residents.

Limitations

The findings in this report are subject to at least four limitations. First, COVID-19 vaccination coverage estimates were not possible using data from this analysis because unique persons vaccinated could not be identified. Second, the age groups used to describe COVID-19 vaccination among younger children include those aged 6 months–4 years. However, FRPP data only include vaccinated children aged ≥3 years, unlike the all-provider data, which included vaccinations administered to children and infants as young as age 6 months. Third, the higher number and percentage of records with race and ethnicity reported as unknown in the FRPP data compared with those in the all-provider data might have resulted in less accurate representation and potential underestimation of FRPP contributions for some racial and ethnic groups. Finally, the National Center for Health Statistics Urban-Rural Classification was developed in 2013, and the urban-rural designations used likely affected these analyses. Several counties classified as rural in 2013 might no longer be rural. In addition, a larger percentage of records were removed from the all-provider data (15.0%) than from the FRPP data (0.2%) because of the lack of matching urban–rural classification. Both factors might have skewed the overall pharmacy contribution, particularly in examining the percentage of urban and rural doses administered by FRPP partners.

Implications for Public Health Practice

FRPP partners were critical in ensuring access to bivalent COVID-19 vaccination services throughout the United States. This partnership could serve as a model to address vaccination services needs for administration of routinely recommended vaccines and potential future responses to vaccine-preventable disease emergencies. Further strategies to support improvement in race and ethnicity data collection and reporting, particularly in pharmacy settings, are needed to help guide public health practices. Although the public health emergency has ended, the need to ensure that the U.S. population has equitable access to all recommended vaccines, including COVID-19 vaccines, remains. FRPP demonstrated that partnering with pharmacies, in addition to other vaccine providers, can help accelerate vaccine access provision across the United States and address other potential infectious diseases-related public health emergencies.