COVID-19 Vaccine Uptake in Immigrant, Refugee, and Nonimmigrant Children and Adolescents in Ontario, Canada

Julia Brandenberger; Raquel Duchen; Hong Lu; Susitha Wanigaratne; Eyal Cohen; Teresa To; Pierre-Philippe Piché-Renaud; Astrid Guttmann

doi:10.1001/jamanetworkopen.2023.25636

. 2023 Jul 26;6(7):e2325636. doi: 10.1001/jamanetworkopen.2023.25636

COVID-19 Vaccine Uptake in Immigrant, Refugee, and Nonimmigrant Children and Adolescents in Ontario, Canada

Julia Brandenberger ^1,^2,^3,⁴, Raquel Duchen ⁵, Hong Lu ⁵, Susitha Wanigaratne ^1,^4,⁵, Eyal Cohen ^1,^4,^5,^6,⁷, Teresa To ^4,^5,⁹, Pierre-Philippe Piché-Renaud ^7,⁸, Astrid Guttmann ^1,^4,^5,^6,^7,^9,^✉

¹Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada

²Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada

³Pediatric Emergency Department, University Hospital of Bern, Bern, Switzerland

⁴Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada

⁵ICES, Toronto, Ontario, Canada

⁶Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada

⁷Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada

⁸Division of Pediatric Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario, Canada

⁹Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

Accepted for Publication: June 13, 2023.

Published: July 26, 2023. doi:10.1001/jamanetworkopen.2023.25636

^✉

Corresponding Author: Astrid Guttmann, MDCM, MSc, ICES, 2075 Bayview Ave, V1 06, Toronto, ON M4N 3M5, Canada (astrid.guttmann@ices.on.ca).

Author Contributions: Drs Lu and Guttmann had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Brandenberger, Duchen, Cohen, Piché-Renaud, Guttmann.

Acquisition, analysis, or interpretation of data: Brandenberger, Duchen, Lu, Wanigaratne, To, Piché-Renaud, Guttmann.

Drafting of the manuscript: Brandenberger, Duchen, Guttmann.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Brandenberger, Lu.

Obtained funding: Guttmann.

Administrative, technical, or material support: Brandenberger, Duchen, Wanigaratne, Guttmann.

Supervision: Guttmann.

Conflict of Interest Disclosures: Dr Cohen reported serving as a member of the Committee to Evaluate Drugs, which advises Ontario’s Ministry of Health on public drug funding. Dr Piché-Renaud reported receiving grants from Pfizer outside the submitted work. Dr Guttmann reported receiving grants from the Edwin S.H. Leong Centre for Healthy Children during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care. Funding for the analyses was provided by the Edwin S.H. Leong Centre for Healthy Children, University of Toronto. Julia Brandenberger is funded through a research fellowship from the Edwin S.H. Leong Centre for Healthy Children and a 6-month exchange research grant from the Swiss National Fund. Astrid Guttmann and Teresa To are funded by the Canadian Institutes for Health Research as Tier 1 Canada Research Chairs. Pierre-Philippe Piché-Renaud is supported by a Clinician-Scientist Training Program and a Transplant and Regenerative Medicine Centre award from The Hospital for Sick Children.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.

Data Sharing Statement: See Supplement 2.

Additional Information: Parts of this material are based on data and/or information compiled and provided by Canadian Institute for Health Information, Ontario Ministry of Health, Ontario Health, Immigration, Refugees and Citizenship Canada, and Statistics Canada, 2016 Census. This work used data from the Toronto Community Health Profiles Partnership (Ontario Marginalization Index) and data adapted from Statistics, Canada, 2016 Census.

^✉

Corresponding author.

PMCID: PMC10372706 PMID: 37494039

Key Points

Question

What are the COVID-19 vaccination rates in immigrant and refugee children (5-11 years) and adolescents (12-17 years) in Ontario, Canada?

Findings

In this cohort study of 2.2 million minors, vaccine coverage was 53.1% for children (≥1 dose) and 79.2% for adolescents (≥2 doses), and uptake was higher in immigrants and lower in refugees compared with nonimmigrants. There was significant heterogeneity by region of origin in first- and second-generation immigrants and refugees, even after adjusting for immigration category and other sociodemographic factors.

Meaning

These findings suggest that precision public health approaches are warranted to increase vaccination in some immigrant, and particularly refugee, subgroups.

This cohort study examines characteristics associated with COVID-19 vaccination in immigrant, refugee, and nonimmigrant children and adolescents in Ontario, Canada.

Abstract

Importance

COVID-19 vaccinations are recommended for minors. Surveys indicate lower vaccine acceptance by some immigrant and refugee groups.

Objective

To identify characteristics in immigrant, refugee, and nonimmigrant minors associated with vaccination.

Design, Setting, and Participants

This retrospective cohort study used linked, population-based demographic and health care data from Ontario, Canada, including all children aged 4 to 17 years registered for universal health insurance on January 1, 2021, across 2 distinct campaigns: for adolescents (ages 12-17 years), starting May 23, 2021, and for children (ages 5-11 years), starting November 25, 2021, through April 24, 2022. Data were analyzed from May 9 to August 2, 2022.

Exposures

Immigrant or refugee status and immigration characteristics (recency, category, region of origin, and generation).

Main Outcomes and Measures

Outcomes of interest were crude rates of COVID-19 vaccination (defined as ≥1 vaccination for children and ≥2 vaccinations for adolescents) and adjusted odds ratios (aORs) with 95% CIs for vaccination, adjusted for clinical, sociodemographic, and health system factors.

Results

The total cohort included 2.2 million children and adolescents, with 1 098 749 children (mean [SD] age, 7.06 [2.00] years; 563 388 [51.3%] males) and 1 142 429 adolescents (mean [SD] age, 14.00 [1.99] years; 586 617 [51.3%] males). Among children, 53 090 (4.8%) were first-generation and 256 886 (23.4%) were second-generation immigrants or refugees; among adolescents, 104 975 (9.2%) were first-generation and 221 981 (19.4%) were second-generation immigrants or refugees, most being economic or family-class immigrants. Immigrants, particularly refugees, were more likely to live in neighborhoods with highest material deprivation (first-generation immigrants: 18.6% of children and 20.2% of adolescents; first-generation refugees: 46.4% of children and 46.3% of adolescents; nonimmigrants: 18.5% of children and 17.2% of adolescents) and COVID-19 risk (first-generation immigrants; 20.0% of children and 20.5% of adolescents; first-generation refugees: 9.4% of children and 12.6% of adolescents; nonimmigrants: 6.9% of children and 6.8% of adolescents). Vaccination rates (53.1% in children and 79.2% in adolescents) were negatively associated with material deprivation. In both age groups, odds for vaccination were higher in immigrants (children: aOR, 1.30; 95% CI, 1.27-1.33; adolescents: aOR, 1.10; 95% CI, 1.08-1.12) but lower in refugees (children: aOR, 0.34; 95% CI, 0.33-0.36; adolescents: aOR, 0.88; 95% CI, 0.84-0.91) compared with nonimmigrants. In immigrant- and refugee-only models stratified by generation, region of origin was associated with uptake, compared with the overall rate, with the lowest odds observed in immigrants and refugees from Eastern Europe (children: aOR, 0.40; 95% CI, 0.35-0.46; adolescents: aOR, 0.41; 95% CI, 0.38-0.43) and Central Africa (children: aOR, 0.24; 95% CI, 0.16-0.35; adolescents: aOR, 0.51,CI: 0.45-0.59) and the highest odds observed in immigrants and refugees from Southeast Asia (children: aOR, 2.68; 95% CI, 2.47-2.92; adolescents aOR, 4.42; 95% CI, 4.10-4.77). Adjusted odds of vaccination among immigrants and refugees from regions with lowest vaccine coverage were similar across generations.

Conclusions and Relevance

In this cohort study using a population-based sample in Canada, nonrefugee immigrants had higher vaccine coverage than nonimmigrants. Substantial heterogeneity by region of origin and lower vaccination coverage in refugees persisted across generations. These findings suggest that vaccine campaigns need precision public health approaches targeting specific barriers in identified, undervaccinated subgroups.

Introduction

COVID-19 is the eighth leading cause of death in minors in the US¹ and has negatively affected pediatric populations worldwide.^2,3,4,5 Vaccination of children can mitigate risk of complications from SARS-CoV-2 infections⁶ and support their uninterrupted access to education and healthy psychosocial development.^7,8,9 US and Canadian public health guidance strongly recommends COVID-19 vaccinations for minors.^10,11

Despite adequate supply and accessibility, studies report parents are less likely to vaccinate their children than themselves.^12,13,14 Factors associated with parents’ willingness to vaccinate children include older age of parents or guardians, good access to scientific information, and acceptance of routine and influenza vaccinations.¹⁵ A systematic review and meta-analysis of 44 cross-sectional surveys described that while 60.1% of parents intended to vaccinate their children against COVID-19, the range was very wide (25.6%-92.2%).¹⁵ Diverse cultural and religious beliefs, education, and experiences with the health system may be important factors, especially in countries with large immigrant populations. A systematic review on vaccination determinants among migrants in Europe showed undervaccination among adults was associated with geographic origin.¹⁶ It is unclear whether these trends persist in migrants living in other countries, with different immigration selection criteria, social supports, and public health practices. North American surveys describing parental intention to vaccinate minors against COVID-19 have highlighted higher vaccine hesitancy in racialized populations, such as individuals identifying as Arab, Black, Hispanic, or Latin American.^17,18,19 To our knowledge, there have been few empirical or population-based studies on COVID-19 vaccine coverage in minors²⁰ and none have explored vaccination in immigrant and refugee populations in North America.

Health Canada authorized a COVID-19 vaccine for persons aged at least 16 years in December 2020, for adolescents (ages 12-15 years) in May 2021²¹ and for children (ages 5-11 years) in November 2021^22,23,24 (eFigure 1 in Supplement 1). Adolescents were part of an initial campaign; however high-risk populations, such as health care workers and older individuals, were initially prioritized. The campaign had a strong focus on vaccine equity. With constraints in vaccine availability during the first month of the adolescent vaccination campaign, 50% of available vaccines were allocated to 30% of neighborhoods that had high rates of COVID-19–related hospitalizations²⁵ and were made up of highly racially and ethnically diverse populations, many of whom were immigrants and essential workers.²⁶ The $1.5 billion campaign, mainly funded by the provincial government,²⁷ leveraged numerous community-led approaches that were culturally and linguistically tailored to reduce barriers,^28,29 including mobile clinics and door-to-door campaigns.^30,31 The children’s vaccination campaign had less focus on high-risk communities³²; however, vaccine supply was adequate by that time.

Ontario is Canada’s largest province (40% of the total population), with a racially and ethnically diverse population, with 2.9% identifying as Indigenous,³³ and 30% identifying as immigrants, of whom approximately 70% are racialized.³⁴ Canada’s immigration system primarily selects economic immigrants with high levels of education, language ability, and work experience. However, immigration pathways exist for family members, resettled refugees, and asylum seekers. Like nonimmigrants, all successful asylum seekers and refugees receive provincial health insurance coverage. In Ontario, nonrefugee immigrants become eligible 3 months after arrival, and refugees are immediately insured either through the provincial insurance (resettled refugees) or a temporary federal program (asylum seekers). Undocumented migrants are not covered but have access to some free primary care through community health centers.³⁵ All Ontario residents are entitled to free COVID-19 vaccinations.

This study capitalized on linked, population-based health care and demographic data to analyze vaccination in minors in Ontario across the 2 distinct campaigns, focusing on immigrants and refugees. Given the stronger equity focus in the adolescent campaign,²⁵ we hypothesized that COVID-19 vaccination coverage would be higher and more homogenous across socioeconomic and immigrant characteristics in adolescents than in younger children. We also postulated that there would be significant differences between immigrant and refugee groups once disaggregated by immigration category and region of origin, but that these associations would be moderated in the second generation, associated with acculturation, as described by others.¹⁶

Methods

Study Design

This retrospective population-based cohort study used encoded data from multiple, linked data sets, including the provincial health insurance registry, the COVID-19 vaccine registry, and the federal immigration permanent resident files (eTable 1 in Supplement 1), accessed at ICES.³⁶ ICES is an independent, nonprofit research institute whose legal status under Ontario’s health information privacy law allows collection and analysis of health care data, without consent, for health system evaluation. The use of data in this project was authorized under section 45 of Ontario’s Personal Health Information Protection Act, thus not requiring research ethics board approval. The study followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and Reporting of Studies Conducted Using Observational Routinely-Collected Health Data (RECORD) reporting guidelines.

This study included all children aged 4 to 17 years living in Ontario, Canada, on January 1, 2021, and registered in the universal Ontario Health Insurance Program³⁷ for at least 1 year. The cohort was stratified to reflect the 2 distinct vaccine campaigns in 2021, beginning May 23 for adolescents²³ and November 25 for children.²² Each participant was assigned an individual eligibility date based on their birthday (ie, children aged 4 years became eligible on their fifth birthday) and followed until the end of the observation window (April 24, 2022) (eFigure 1 in Supplement 1).

Outcome Measures and Exposures

Vaccination was defined as receipt of at least 1 dose of a COVID-19 vaccine for children (ages 5-11 years) and at least 2 doses for adolescents (ages 12-17 years) (eTable 1 and eTable 2 in Supplement 1). We used 1 dose for children as there were only 5 months between the start of their campaign and study end. Additionally, there were recommendations to delay doses at least 3 months after SARS-CoV-2 infection.³⁸ While SARS-CoV-2 polymerase chain reaction testing in Ontario was limited due to overwhelming case volumes after November 2021,^39,40 surveillance studies from other Canadian jurisdictions suggest high pediatric infection rates during that time.⁴¹

Main exposures of interest were immigration characteristics: category (economic or family-sponsored immigrant, resettled refugee [fulfilling the United Nations High Commissioner for Refugees definition prior to arrival in Canada], or protected person [refugee who successfully applied for asylum through the in-country immigration pathway) (eTable 3 in Supplement 1), time since immigration, region of origin, and generation. First-generation immigrants and refugees were identified by the immigration database. Linked maternal- or birthing parent–infant hospital delivery records were used to assign the immigration characteristics of mothers and birthing parents to their second-generation children (eTable 1 and eTable 2 in Supplement 1). All others were categorized as nonimmigrant minors.

Covariates

Baseline characteristics were recorded on January 1, 2021 (eTable 1 in Supplement 1). Individual-level covariates hypothesized to be associated with vaccination included age, sex, having a pediatric chronic condition, influenza vaccination in 2019 or 2020, primary care model (family practice, pediatrician, community health center, or no regular primary care practitioner), and history of SARS-CoV-2 infection. Socioeconomic characteristics have been reported to be associated with vaccination and are potential mediators between immigrant or refugee status and vaccination.⁴² We used the material deprivation construct from the census-based Ontario Marginalization Index,⁴³ which includes income and education information on a neighborhood level to capture socioeconomic disparities, and previously derived deciles of neighborhood COVID-19 risk⁴⁴ based on COVID-19 cases from the beginning of the pandemic until March 23, 2021 (eTable 2 in Supplement 1).²⁵

Statistical Analysis

We compared baseline characteristics of both generations of immigrants and refugees with nonimmigrants using standardized differences (>0.1 signified important differences).⁴⁵ Given the size of the cohort, we did not test differences in crude rates but commented on clinically important differences.

Using logistic regression, we first modeled the association of immigrant category (with nonimmigrants as the reference group) with vaccination in the full study population and included all covariates. To understand the associations among immigration characteristics, we did a subgroup analysis of first- and second-generation immigrants and refugees, stratified by generation, as we hypothesized different associations by generation. We included key mediators, like socioeconomic characteristics (material deprivation quintile) but did not include influenza vaccination and previous SARS-CoV-2 infection, as these models were intended to test which intersecting sociodemographic and immigration characteristics were most strongly associated with vaccination. We compared differences within each generation using 95% CIs of adjusted odds ratios (aORs). To explore if associations between the exposures and vaccine hesitancy were different than those for vaccine uptake, we performed a secondary analysis using time-to-event models to calculate hazard ratios (HRs) associated with first doses. Individuals with missing or suppressed data were merged to the most appropriate category or excluded from the final models (eTable 2 in Supplement 1). Statistical analyses were conducted using SAS statistical software, Enterprise Guide version 7.1 (SAS Institute). Data were analyzed from May 9 to August 2, 2022.

Results

Approximately 2.2 million Ontario minors were included in the study, with nearly equal numbers of children (1 098 749 children; mean [SD] age, 7.06 [2.00] years; 563 388 [51.3%] males) and adolescents (1 142 429 adolescents; mean [SD] age, 14.00 [1.99] years; 586 617 [51.3%] males) (eFigure 2 in Supplement 1). Of the children’s cohort, 53 090 children (4.8%) were first-generation immigrants or refugees and 256 886 children (23.4%) were second-generation immigrants or refugees. In adolescents, 104 975 adolescents (9.2%) were first-generation immigrants or refugees and 221 981 adolescents (19.4%) were second-generation immigrants or refugees. In both cohorts, regions of origin of immigrants and refugees were mostly South Asia (15 931 children [30.0%]; 25 209 adolescents [24.0%]) and the Middle East (12 732 children [24.0%]; 22 503 adolescents [21.4%]). Second-generation minors most frequently had mothers or birthing parents originating from South Asia (Table 1). Immigrants, and particularly refugees, were more likely than nonimmigrants to live in neighborhoods with highest material deprivation (first-generation immigrants: 18.6% of children and 20.2% of adolescents; first-generation refugees: 46.4% of children and 46.3% of adolescents; nonimmigrants: 18.5% of children and 17.2% of adolescents) (Table 1; eTable 4 in Supplement 1).

Table 1. Baseline Characteristics of Immigrants, Refugees, and Nonimmigrant Children and Adolescents in Ontario on January 1, 2021^a .

Characteristic	First-generation immigrants and refugees					Second-generation immigrants and refugees^b						Nonimmigrants
	No. (column %)			Standardized difference^c		No. (column %)			Standardized difference^c			No. (column %)	Standardized difference^c
	Immigrants^d	Refugees^e	Protected persons^f	Refugees	Protected persons	Immigrants	Refugees	Protected persons	Immigrants	Refugees	Protected persons	No. (column %)	Standardized difference^c
Children
Total, No.	36 584	10 144	6362	NA	NA	218 093	14 800	23 993	NA	NA	NA	788 773	NA
Age, y
Mean (SD)	7.55 (1.92)	7.51 (1.86)	7.83 (1.79)	0.017	0.153	7.01 (2.00)	6.85 (2.01)	6.90 (2.00)	0.275	0.352	0.328	7.04 (2.00)	0.258
4-7	16 524 (45.2)	4762 (46.9)	2532 (39.8)	0.036	0.109	123 868 (56.8)	8859 (59.9)	14 181 (59.1)	0.234	0.297	0.282	443 300 (56.2)	0.222
8-10	20 060 (54.8)	5382 (53.1)	3830 (60.2)	0.036	0.109	94 225 (43.2)	5941 (40.1)	9812 (40.9)	0.234	0.297	0.282	345 473 (43.8)	0.222
Sex
Female	17 868 (48.8)	4973 (49.0)	3202 (50.3)	0.004	0.030	106 089 (48.6)	7280 (49.2)	11 780 (49.1)	0.004	0.007	0.005	384 169 (48.7)	0.003
Male	18 716 (51.2)	5171 (51.0)	3160 (49.7)	0.004	0.030	112 004 (51.4)	7520 (50.8)	12 213 (50.9)	0.004	0.007	0.005	404 604 (51.3)	0.003
Material deprivation quintile
1 (Least deprived)	8649 (23.6)	730 (7.2)	697 (11.0)	0.468	0.34	49 956 (22.9)	2940 (19.9)	3668 (15.3)	0.017	0.092	0.212	201 221 (25.5)	0.043
2	7604 (20.8)	1023 (10.1)	865 (13.6)	0.299	0.191	46 471 (21.3)	2643 (17.9)	3895 (16.2)	0.013	0.074	0.117	173 353 (22.0)	0.029
3	6858 (18.7)	1528 (15.1)	878 (13.8)	0.098	0.134	41 056 (18.8)	2261 (15.3)	4001 (16.7)	0.002	0.092	0.054	142 164 (18.0)	0.019
4	6674 (18.2)	2160 (21.3)	1311 (20.6)	0.077	0.06	38 719 (17.8)	2286 (15.4)	4604 (19.2)	0.013	0.075	0.024	125 941 (16.0)	0.06
5 (Most deprived)	6799 (18.6)	4703 (46.4)	2611 (41.0)	0.621	0.506	41 891 (19.2)	4670 (31.6)	7825 (32.6)	0.016	0.303	0.326	146 094 (18.5)	0.002
Region of origin
Central Africa	174 (0.5)	88 (0.9)	122 (1.9)	0.048	0.133	715 (0.3)	304 (2.1)	743 (3.1)	0.023	0.142	0.199	NA	NA
Western Africa	1194 (3.3)	49 (0.5)	423 (6.6)	0.206	0.156	4678 (2.1)	246 (1.7)	1277 (5.3)	0.069	0.103	0.102	NA	NA
East Africa	312 (0.9)	937 (9.2)	677 (10.6)	0.390	0.430	4996 (2.3)	1599 (10.8)	3356 (14.0)	0.116	0.435	0.518	NA	NA
Southern Africa	344 (0.9)	120 (1.2)	47 (0.7)	0.024	0.022	916 (0.4)	8 (0.1)	75 (0.3)	0.063	0.126	0.08	NA	NA
Middle East	4157 (11.4)	7120 (70.2)	1455 (22.9)	1.494	0.309	15 456 (7.1)	3189 (21.5)	1547 (6.4)	0.148	0.277	0.173	NA	NA
North Africa	1056 (2.9)	482 (4.8)	360 (5.7)	0.097	0.137	3845 (1.8)	458 (3.1)	410 (1.7)	0.075	0.012	0.079	NA	NA
Central America	637-643	1-5	105 (1.7%)	0.180	0.007	3867 (1.8)	1099 (7.4)	960 (4.0)	0.002	0.274	0.135	NA	NA
South America	868 (2.4)	29 (0.3)	269 (4.2)	0.180	0.104	9915 (4.5)	336 (2.3)	1787 (7.4)	0.119	0.007	0.237	NA	NA
Caribbean	1000 (2.7)	1-5	141-146	0.230	0.029	13 006 (6.0)	20 (0.1)	1953 (8.1)	0.159	0.220	0.240	NA	NA
North America	3424 (9.4)	26 (0.3)	418 (6.6)	0.440	0.103	4496 (2.1)	87 (0.6)	113 (0.5)	0.318	0.412	0.420	NA	NA
East Asia	2793 (7.6)	6 (0.1)	302 (4.7)	0.400	0.120	31 159 (14.3)	60 (0.4)	2834 (11.8)	0.214	0.374	0.141	NA	NA
Australasia, Oceania, and Asia unspecified	270-275	0	1-5	0.120	0.108	572 (0.3)	9 (0.1)	8 (0.0)	0.069	0.109	0.115	NA	NA
Southeast Asia	2642 (7.2)	214 (2.1)	25 (0.4)	0.244	0.363	26 998 (12.4)	1168 (7.9)	256 (1.1)	0.174	0.025	0.313	NA	NA
South Asia	14 326 (39.2)	575 (5.7)	1030 (16.2)	0.877	0.531	66 084 (30.3)	3091 (20.9)	6081 (25.3)	0.187	0.407	0.299	NA	NA
Eastern Europe	1080 (3.0)	42 (0.4)	482 (7.6)	0.198	0.208	18 068 (8.3)	1738 (11.7)	1877 (7.8)	0.233	0.342	0.217	NA	NA
Europe other	2301 (6.3)	448 (4.4)	498 (7.8)	0.083	0.060	13 322 (6.1)	1387 (9.4)	714 (3.0)	0.008	0.115	0.158	NA	NA
Not stated or missing	0	0	0	NA	NA	0	1-5	1-5	NA	0.012	0.013	NA	NA
Adolescents
Total, No.	75 665	14 085	15 225	NA	NA	192 512	11 542	17 927	NA	NA	NA	815 473	NA
Age, y
Mean (SD)	14.32 (1.99)	13.99 (1.99)	14.30 (1.96)	0.170	0.012	13.86 (1.96)	13.91 (1.99)	13.77 (1.94)	0.236	0.208	0.281	14.01 (1.99)	0.159
11-14	37 861 (50.0)	8121 (57.7)	7785 (51.1)	0.153	0.022	116 838 (60.7)	6826 (59.1)	11 237 (62.7)	0.216	0.184	0.257	466 377 (57.2)	0.144
15-17	37 804 (50.0)	5964 (42.3)	7440 (48.9)	0.153	0.022	75 674 (39.3)	4716 (40.9)	6690 (37.3)	0.216	0.184	0.257	349 096 (42.8)	0.144
Sex
Female	36 175 (47.8)	6862 (48.7)	7468 (49.1)	0.018	0.025	93 345 (48.5)	5652 (49.0)	8871 (49.5)	0.014	0.023	0.034	397 439 (48.7)	0.019
Male	39 490 (52.2)	7223 (51.3)	7757 (50.9)	0.018	0.025	99 167 (51.5)	5890 (51.0)	9056 (50.5)	0.014	0.023	0.034	418 034 (51.3)	0.019
Material deprivation quintile
1 (Least deprived)	17 008 (22.5)	1146 (8.1)	1829 (12.0)	0.406	0.28	41 313 (21.5)	2296 (19.9)	2681 (15.0)	0.025	0.063	0.194	216 415 (26.5)	0.095
2	15 560 (20.6)	1604 (11.4)	1847 (12.1)	0.252	0.230	41 638 (21.6)	2117 (18.3)	2973 (16.6)	0.026	0.056	0.102	185 474 (22.7)	0.053
3	14 022 (18.5)	1988 (14.1)	2274 (14.9)	0.120	0.096	38 199 (19.8)	1944 (16.8)	3155 (17.6)	0.033	0.044	0.024	147 650 (18.1)	0.011
4	13 807 (18.2)	2826 (20.1)	3111 (20.4)	0.046	0.055	34 772 (18.1)	1855 (16.1)	3533 (19.7)	0.005	0.058	0.037	125 300 (15.4)	0.077
5 (Most deprived)	15 268 (20.2)	6521 (46.3)	6164 (40.5)	0.577	0.453	36 590 (19.0)	3330 (28.9)	5585 (31.2)	0.030	0.203	0.253	140 634 (17.2)	0.075
Region of origin
Central Africa	253 (0.3)	285 (2.0)	314 (2.1)	0.157	0.159	351 (0.2)	140 (1.2)	564 (3.1)	0.030	0.100	0.216	NA	NA
Western Africa	1607 (2.1)	95 (0.7)	1061 (7.0)	0.124	0.234	3595 (1.9)	199 (1.7)	886 (4.9)	0.018	0.029	0.153	NA	NA
East Africa	882 (1.2)	1682 (11.9)	1407 (9.2)	0.446	0.370	4596 (2.4)	1342 (11.6)	3290 (18.4)	0.093	0.438	0.605	NA	NA
Southern Africa	388 (0.5)	96 (0.7)	105 (0.7)	0.022	0.023	826 (0.4)	10-15	9-14	0.012	0.072	0.082	NA	NA
Middle East	11 090 (14.7)	9266 (65.8)	2147 (14.1)	1.222	0.016	12 463 (6.5)	1447 (12.5)	1172 (6.5)	0.269	0.062	0.266	NA	NA
North Africa	2399 (3.2)	346 (2.5)	442 (2.9)	0.043	0.016	3201 (1.7)	494 (4.3)	390 (2.2)	0.098	0.059	0.062	NA	NA
Central America	837 (1.1)	12 (0.1)	457 (3.0)	0.133	0.134	3519 (1.8)	1272 (11.0)	546 (3.0)	0.060	0.425	0.136	NA	NA
South America	1772 (2.3)	123 (0.9)	598 (3.9)	0.117	0.091	9280 (4.8)	281 (2.4)	1231 (6.9)	0.134	0.006	0.217	NA	NA
Caribbean	3560 (4.7)	7 (0.0)	835 (5.5)	0.309	0.035	13 536 (7.0)	22 (0.2)	626 (3.5)	0.099	0.295	0.061	NA	NA
North America	5836 (7.7)	7 (0.0)	2153 (14.1)	0.405	0.207	3605 (1.9)	55-60	31-36	0.276	0.369	0.394	NA	NA
East Asia	5567 (7.4)	15 (0.1)	966 (6.3)	0.390	0.04	24 929 (12.9)	47 (0.4)	1685 (9.4)	0.186	0.366	0.074	NA	NA
Australasia, Oceania, and Asia unspecified	428 (0.6)	0	11 (0.1)	0.107	0.088	580 (0.3)	16-21	1-5	0.040	0.068	0.100	NA	NA
Southeast Asia	11 477 (15.2)	365 (2.6)	89 (0.6)	0.453	0.562	21 628 (11.2)	1098 (9.5)	199 (1.1)	0.116	0.173	0.532	NA	NA
South Asia	21 127 (27.9)	1334 (9.5)	2748 (18.0)	0.487	0.236	61 882 (32.1)	2088 (18.1)	5268 (29.4)	0.092	0.235	0.032	NA	NA
Eastern Europe	3654 (4.8)	262 (1.9)	1021 (6.7)	0.166	0.081	15 781 (8.2)	1713 (14.8)	1333 (7.4)	0.137	0.341	0.109	NA	NA
Europe other	4788 (6.3)	190 (1.3)	871 (5.7)	0.261	0.026	12 736 (6.6)	1307 (11.3)	687 (3.8)	0.012	0.177	0.114	NA	NA
Not stated or missing	0	0	0	NA	NA	1-5	1-5	0	0.006	0.019	NA	NA	NA

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Abbrevation: NA, not applicable.

^{^a}

Small cells (<6) suppressed, and in the case of nonmissing data other cells may be reported as ranges without percentage to reduce risk of reidentification in accordance with ICES policy.

^{^b}

Immigrant-related characteristics of second generation immigrants and refugees are those of their mother or birthing parent.

^{^c}

Standardized differences compared with first-generation immigrants.

^{^d}

Immigrants include economic immigrants and sponsored family immigrants.

^{^e}

Resettled refugees include privately sponsored and government-assisted refugees.

^{^f}

Protected persons include successful asylum seekers and their dependents.

COVID-19 Vaccine Coverage

A total of 583 160 children (53.1%) and 905 131 adolescents (79.2%) were vaccinated by study end (Table 2). Vaccine coverage was significantly different by immigration category. There were higher or similar rates of vaccination in immigrants compared with nonimmigrants (children: 60.2% vs 54.3%; adolescents: 79.1% vs 79.2%), but across age groups and generations, resettled refugees had lower vaccine coverage compared with immigrants and nonimmigrants (refugee children: 27.7%; refugee adolescents: 74.2%). Vaccination varied significantly by region of origin, with the lowest rates in immigrants and refugees from Eastern Europe (children: 20.6%; adolescents: 59.3%) and Central Africa (children: 20.6%; adolescents: 59.3%) and the highest rates in immigrants and refugees from Southeast Asia (children: 74.2%; adolescents: 92.8%). Vaccination rates increased with age (Table 2).

Table 2. Vaccine Coverage by Characteristics of First- and Second-Generation Immigrants and Refugees and All Nonimmigrant Children and Adolescents on April 24, 2022.

Characteristic	Children (age 4-10 y)				Adolescents (age 11-17 y)
	No. (row %)		Total, No	P value	No. (row %)			Total, No.	P value
	Unvaccinated	≥1 Dose	Total, No	P value	Unvaccinated	1 Dose	≥2 Doses	Total, No.	P value
Total, No.	515 589 (46.9)	583 160 (53.1)	1 098 749	NA	212 504 (18.6)	24 794 (2.2)	905 131 (79.2)	1 142 429	NA
Age, y
4-7	310 950 (50.6)	303 076 (49.4)	614 026	<.001	NA	NA	NA	NA	<.001
8-10	204 639 (42.2)	280 084 (57.8)	484 723		NA	NA	NA	NA
11-14	NA	NA	NA		134 338 (20.5)	15 416 (2.4)	505 291 (77.1)	655 045
15-17	NA	NA	NA		78 166 (16.0)	9378 (1.9)	399 840 (82.0)	487 384
Sex
Female	250 568 (46.8)	284 793 (53.2)	535 361	.013	99 122 (17.8)	11 580 (2.1)	445 110 (80.1)	555 812	<.001
Male	265 021 (47)	298 367 (53)	563 388	.013	113 382 (19.3)	13 214 (2.3)	460 021 (78.4)	586 617	<.001
Immigration category
First generation
Immigrants^a	14 545 (39.8)	22 039 (60.2)	36 584	<.001	14 521 (19.2)	1286 (1.7)	59 858 (79.1)	75 665	<.001
Resettled refugees^b	7335 (72.3)	2809 (27.7)	10 144		2550 (18.1)	1086 (7.7)	10 449 (74.2)	14 085
Protected persons and others^c	4045 (63.6)	2317 (36.4)	6362		3049 (20.0)	656 (4.3)	11 520 (75.7)	15 225
Second generation
Immigrants	104 038 (47.7)	114 055 (52.3)	218 093		33 301 (17.3)	4017 (2.1)	155 194 (80.6)	192 512
Resettled refugees	10 230 (69.1)	4570 (30.9)	14 800		2737 (23.7)	450 (3.9)	8355 (72.4)	11 542
Protected persons and others	14 796 (61.7)	9197 (38.3)	23 993		3563 (19.9)	613 (3.4)	13 751 (76.7)	17 927
Nonimmigrants	360 600 (45.7)	428 173 (54.3)	788 773		152 783 (18.7)	16 686 (2.0)	646 004 (79.2)	815 473
Recency of immigration^d
Recent (0 to ≤5 y)	17 833 (51.9)	16 529 (48.1)	34 362	<.001	4456 (15.3)	1426 (4.9)	23 150 (79.7)	29 032	<.001
Intermediate (>5 to ≤10 y)	7962 (43.3)	10 439 (56.7)	18 401		7227 (19.0)	991 (2.6)	29 899 (78.4)	38 117
Long-term (>10 y)	130 (39.8)	197 (60.2)	327		8437 (22.3)	611 (1.6)	28 778 (76.1)	37 826
Region of origin^e
Central Africa	1728 (80.5)	418 (19.5)	2146	<.001	607 (31.8)	123 (6.4)	1177 (61.7)	1907	<.001
Western Africa	4,793 (60.9)	3,074 (39.1)	7867		1506 (20.2)	326 (4.4)	5611 (75.4)	7443
East Africa	8421 (70.9)	3456 (29.1)	11 877		3004 (22.8)	735 (5.6)	9460 (71.7)	13 199
Southern Africa	617 (40.9)	893 (59.1)	1510		274 (19.0)	34 (2.4)	1133 (78.6)	1441
Middle East	20 999 (63.8)	11 925 (36.2)	32 924		8067 (21.5)	1454 (3.9)	28 064 (74.7)	37 585
North Africa	4423 (66.9)	2188 (33.1)	6611		1583 (21.8)	208 (2.9)	5481 (75.4)	7272
Central America	3796 (56.9)	2878 (43.1)	6674		1629 (24.5)	129 (1.9)	4885 (73.5)	6643
South America	6080 (46.0)	7124 (54.0)	13 204		2048 (15.4)	261 (2.0)	10 976 (82.6)	13 285
Caribbean	11 466 (71.1)	4662 (28.9)	16 128		5988 (32.2)	717 (3.9)	11 881 (63.9)	18 586
North America	3969 (46.3)	4595 (53.7)	8564		3446 (29.5)	226 (1.9)	8021 (68.6)	11 693
East Asia	11 635 (31.3)	25 519 (68.7)	37 154		4061 (12.2)	385 (1.2)	28 763 (86.6)	33 209
Australasia, Oceania, and Asia unspecified	366 (42.2)	501 (57.8)	867		252 (24.2)	18 (1.7)	771 (74.1)	1041
Southeast Asia	9388 (30.0)	21 915 (70.0)	31 303		2455 (7.0)	400 (1.1)	32 001 (91.8)	34 856
South Asia	39 077 (42.9)	52 110 (57.1)	91 187		10 893 (11.5)	2020 (2.1)	81 534 (86.3)	94 447
Eastern Europe	17 198 (73.9)	6089 (26.1)	23 287		8585 (36.1)	605 (2.5)	14 574 (61.3)	23 764
Europe other	11 030 (59.1)	7640 (40.9)	18 670		5323 (25.9)	467 (2.3)	14 789 (71.9)	20 579
Rural residence
Yes	60 085 (53.2)	52 867 (46.8)	112 952	<.001	26 523 (23.9)	2946 (2.7)	81 665 (73.5)	111 134	<.001
No	454 263 (46.2)	529 554 (53.8)	983 817		185 133 (18.0)	21 797 (2.1)	822 003 (79.9)	1 028 933
Missing	1241 (62.7)	739 (37.3)	1980		848 (35.9)	51 (2.2)	1463 (61.9)	2362
Material deprivation quintile
1 (Least deprived)	97 066 (36.2)	170 795 (63.8)	267 861	<.001	37 674 (13.3)	3722 (1.3)	241 292 (85.4)	282 688	<.001
2	98 909 (41.9)	136 945 (58.1)	235 854		39 167 (15.6)	4083 (1.6)	207 963 (82.8)	251 213
3	94 853 (47.7)	103 893 (52.3)	198 746		38 614 (18.5)	4306 (2.1)	166 312 (79.5)	209 232
4	95 790 (52.7)	85 905 (47.3)	181 695		39 647 (21.4)	4761 (2.6)	140 796 (76.0)	185 204
5 (Most deprived)	128 971 (60.1)	85 622 (39.9)	214 593		57 402 (26.8)	7922 (3.7)	148 768 (69.5)	214 092
Neighborhood COVID-19 risk decile^e
1 (Most at risk)	69 524 (56.7)	53 025 (43.3)	122 549	<.001	27 605 (21.3)	3648 (2.8)	98 639 (75.9)	129 892	<.001
2	54 538 (49.6)	55 379 (50.4)	109 917		22 651 (19.1)	2572 (2.2)	93 590 (78.8)	118 813
3	54 925 (50.1)	54 680 (49.9)	109 605		22 421 (19.6)	2497 (2.2)	89 584 (78.2)	114 502
4	53 666 (49.5)	54 803 (50.5)	108 469		22 828 (20.4)	2605 (2.3)	86 648 (77.3)	112 081
5	49 630 (44.6)	61 634 (55.4)	111 264		19 592 (17.2)	2229 (2.0)	92 006 (80.8)	113 827
6	48 649 (44.2)	61 523 (55.8)	110 172		21 061 (18.3)	2291 (2.0)	91 855 (79.7)	115 207
7	42 211 (41.2)	60 264 (58.8)	102 475		18 291 (17.2)	1801 (1.7)	86 552 (81.2)	106 644
8	45 749 (41.0)	65 759 (59.0)	111 508		18 735 (16.0)	1935 (1.7)	96 547 (82.4)	117 217
9	48 671 (44.0)	61 956 (56.0)	110 627		19 657 (17.4)	2542 (2.3)	90 547 (80.3)	112 746
10 (Least at risk)	48 009 (47.0)	54 122 (53.0)	102 131		19 658 (19.4)	2674 (2.6)	79 137 (78.0)	101 469
Previous SARS-CoV-2 infection
No	499 210 (46.8)	567 582 (53.2)	1 066 792	<.001	208 950 (18.8)	23 917 (2.2)	878 113 (79.0)	1 110 980	<.001
Yes	16 379 (51.3)	15 578 (48.7)	31 957	<.001	3554 (11.3)	877 (2.8)	27 018 (85.9)	31 449	<.001
Has a pediatric chronic condition
No	485 254 (47.0)	547 905 (53.0)	1 033 159	<.001	173 027 (19.8)	19 063 (2.2)	680 578 (78.0)	872 668	<.001
Yes	30 335 (46.2)	35 255 (53.8)	65 590	<.001	39 477 (14.6)	5731 (2.1)	224 553 (83.2)	269 761	<.001
Primary care access model
Community health center	12 750 (53.9)	10 887 (46.1)	23 637	<.001	4390 (18.8)	902 (3.9)	18 063 (77.3)	23 355	<.001
Rostered to a primary health care practitioner	319 888 (44.2)	404 306 (55.8)	724 194		127 281 (15.3)	16 978 (2.0)	687 209 (82.7)	831 468
Pediatrician	28 786 (36.6)	49 909 (63.4)	78 695		4982 (11.0)	660 (1.5)	39 610 (87.5)	45 252
Noncomprehensive care	81 999 (50.2)	81 229 (49.8)	163 228		20 008 (16.3)	3500 (2.9)	99 103 (80.8)	122 611
No regular health care practitioner	72 166 (66.2)	36 829 (33.8)	108 995		55 843 (46.6)	2754 (2.3)	61 146 (51.1)	119 743
Influenza vaccination in 2019-2020
No	486 412 (50.1)	484 753 (49.9)	971 165	<.001	209 465 (19.3)	24 004 (2.2)	849 460 (78.4)	1 082 929	<.001
Yes	29 177 (22.9)	98 407 (77.1)	127 584	<.001	3039 (5.1)	790 (1.3)	55 671 (93.6)	59 500	<.001

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Abbreviation: NA, not applicable or not available.

^{^a}

Immigrants include economic immigrants and sponsored family immigrants.

^{^b}

Resettled refugees include privately sponsored and government-sponsored refugees.

^{^c}

Protected persons include successful asylum seekers and their dependents.

^{^d}

Recency is only reported for first-generation immigrants and refugees.

^{^e}

Vaccination rates not reported in missing categories with small cells.

Vaccination in Immigrants and Refugees and by Generation

Compared with nonimmigrants, immigrants had higher odds of being vaccinated, an association that persisted after adjustment (children: aOR, 1.30; 95% CI, 1.27-1.33; adolescents: aOR, 1.10; 95% CI, 1.08-1.12) (Figure 1) and for immigrant adolescents across generation. Conversely, resettled refugees had lower odds of being vaccinated compared with nonimmigrants (children: aOR, 0.34; 95% CI, 0.33-0.36; adolescents: aOR, 0.88; 95% CI, 0.84-0.91). Odds for protected-person children were lower (aOR, 0.55; 95% CI, 0.52-0.58), whereas adolescent protected persons had similar odds of uptake compared with nonimmigrants (aOR, 0.99; 95% CI, 0.95-1.03). The lower odds of vaccination in resettled refugees persisted across generations for both cohorts, whereas there was an attenuation of difference in the odds in second-generation immigrant children (aOR, 0.98; 95% CI, 0.97-0.99) (eTable 5 in Supplement 1). Vaccination coverage was lower with increasing material deprivation for all minors, but the association with neighborhood COVID-19 risk decile was less consistent, particularly in adolescents (Figure 1). Individuals with chronic conditions had higher odds of vaccination compared with healthy peers, especially among adolescents (children: aOR, 1.13; 95% CI, 1.11-1.14; adolescents: aOR, 1.30; 95% CI, 1.28-1.32). While having no primary health care practitioner was strongly associated with lower odds of vaccination, children and adolescents with a pediatrician had higher odds of vaccination (Figure 1).

Figure 1. — Children were considered vaccinated if they had received at least 1 vaccine dose; adolescents, at least 2 vaccine doses. NA indicates not applicable.

^aFor children, the reference age group was 8 to 10 years, and data are given for children aged 4 to 7 years.

The analysis by immigrant or refugee generation showed a strong association between vaccination and region of origin after adjustment for other sociodemographic factors. Compared with the overall vaccination rate for all immigrants and refugees, odds were lowest for children and adolescents from Eastern Europe (children: aOR, 0.40; 95% CI, 0.35-0.46; adolescents: aOR, 0.41; 95% CI, 0.38-0.43) and Central Africa (children: aOR, 0.24; 95% CI, 0.16-0.35; adolescents: aOR, 0.51; 95% CI, 0.45-0.59) and highest for children and adolescents from Southeast Asia (children: aOR, 2.68; 95% CI, 2.47-2.92; adolescents: aOR, 4.42; 95% CI, 4.10-4.77) (Figure 2; eTable 6 and eTable 7 in Supplement 1). For almost all regions of origin with low vaccination rates, the adjusted odds were similarly low in the second generation. Socioeconomic inequities were present in the immigrant- and refugee-only model but less pronounced than in the model including all Ontario minors (eTables 5-7 in Supplement 1).

Figure 2. — Children were considered vaccinated if they had received at least 1 vaccine dose; adolescents, at least 2 vaccine doses. NA indicates not applicable.

^aFirst-generation immigrants are the reference group for other first-generation individuals; second-generation immigrants, other second-generation individuals.

^bThe full cohort of first-generation immigrants and refugees are the reference group for first-generation immigrants and refugees by region of origin; the full cohort of second-generation immigrants and refugees, second-generation immigrants and refugees by region of origin.

Time to First Vaccination

The time-to-event analyses showed similar patterns to the logistic regression models (Table 3). There was earlier uptake of the first COVID-19 vaccine dose in immigrants compared with nonimmigrants (adjusted HR, 1.05; 95% CI, 1.04-1.06). In the immigrant- and refugee-only model, wide ranges in the time to vaccination existed among different regions of origin, with faster uptake seen in regions with higher vaccine coverage. An exception was observed among children and adolescents from South America, with a relatively slow vaccine uptake (adjusted HR, 0.69; 95% CI, 0.68-0.71) paired with an vaccination rate higher than the overall rate (immigrant children: aOR, 2.37; 95% CI, 2.10-2.68) (Table 3; eTable 6 in Supplement 1).

Table 3. Hazard of First Vaccination in Full Cohort and Immigrants and Refugees Among Adolescents and Children on April 24, 2022.

Parameter	Adjusted HR (95% CI)
Parameter	Full cohort (N = 2 236 799)	First and second generation immigrants/refugees (n = 635 868)
Age group, y
4-7	0.39 (0.39-0.39)	0.30 (0.30-0.30)
8-10	0.53 (0.52-0.53)	0.40 (0.40-0.40)
11-14	0.80 (0.79-0.80)	0.76 (0.76-0.77)
15-17	1 [Reference]	1 [Reference]
Male sex (vs female)	0.96 (0.95-0.96)	0.96 (0.95-0.96)
Immigration category
Nonimmigrants	1 [Reference]	NA
First generation
Immigrants^a	1.05 (1.04-1.06)	1 [Reference]
Resettled refugees^b	0.67 (0.66-0.68)	0.72 (0.71-0.74)
Protected persons and others^c	0.82 (0.80-0.83)	0.85 (0.83-0.87)
Second generation
Immigrants^a	0.96 (0.96-0.97)	0.95 (0.94-0.96)
Resettled refugees^b	0.63 (0.62-0.64)	0.68 (0.67-0.70)
Protected persons and others^c	0.77 (0.76-0.78)	0.82 (0.81-0.83)
Recency of immigration
Recent (0 to ≤5 y)	NA	1.04 (1.03-1.06)
Intermediate (>5 to ≤10 y)	NA	0.97 (0.96-0.98)
Long-term (>10 y)	NA	1 [Reference]
Region of origin (Ref Southeast Asia)
Australasia & Oceania & Asia unspecified	NA	0.67 (0.64-0.71)
Caribbean	NA	0.35 (0.35-0.36)
Central Africa	NA	0.33 (0.32-0.35)
Central America	NA	0.57 (0.56-0.59)
East Africa	NA	0.5 (0.49-0.51)
East Asia	NA	0.91 (0.90-0.92)
Eastern Europe	NA	0.32 (0.32-0.33)
Europe other	NA	0.50 (0.50-0.51)
Middle East	NA	0.51 (0.50-0.52)
North Africa	NA	0.49 (0.48-0.50)
North America	NA	0.57 (0.56-0.58)
South America	NA	0.69 (0.68-0.71)
Southeast Asia	NA	1 [Reference]
South Asia	NA	0.80 (0.79-0.81)
Southern Africa	NA	0.76 (0.73-0.80)
Western Africa	NA	0.48 (0.47-0.49)
Rural (vs urban)	0.80 (0.80-0.81)	0.71 (0.68-0.73)
Material Deprivation Quintile
1 (Least deprived)	1 [Reference]	1 [Reference]
2	0.91 (0.90-0.91)	0.96 (0.95-0.97)
3	0.81 (0.81-0.81)	0.88 (0.87-0.89)
4	0.73 (0.72-0.73)	0.83 (0.82-0.84)
5 (Most deprived)	0.61 (0.60-0.61)	0.76 (0.75-0.77)
Neighborhood COVID-19 risk decile
1 (Most at risk)	0.92 (0.91-0.92)	0.88 (0.85-0.90)
2	1.00 (0.99-1.01)	0.92 (0.90-0.95)
3	0.92 (0.91-0.92)	0.84 (0.82-0.87)
4	0.93 (0.92-0.93)	0.85 (0.83-0.88)
5	0.99 (0.98-0.99)	0.89 (0.87-0.92)
6	1.00 (0.99-1.00)	0.89 (0.86-0.91)
7	0.99 (0.98-1.00)	0.88 (0.86-0.90)
8	1.01 (1.00-1.02)	0.90 (0.88-0.93)
9	0.99 (0.99-1.00)	0.86 (0.83-0.89)
10 (Least at risk)	1 [Reference]	1 [Reference]
No influenza vaccination in 2019-2020	0.54 (0.54-0.54)	0.64 (0.63-0.65)
Has a pediatric chronic condition	1.10 (1.09-1.10)	1.11 (1.10-1.12)
Primary care access model
Rostered	1 [Reference]	1 [Reference]
Community health center	0.94 (0.93-0.95)	1.01 (0.99-1.03)
Pediatrician	1.15 (1.14-1.16)	1.10 (1.08-1.11)
Noncomprehensive care	0.92 (0.92-0.93)	0.99 (0.98-1.00)
No regular care practitioner	0.49 (0.49-0.49)	0.43 (0.43-0.44)
No previous COVID-19 infection	1.00 (0.99-1.01)	0.91 (0.90-0.93)

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Abbreviation: NA, not applicable or not available.

^{^a}

Immigrants include economic immigrants and sponsored family immigrants.

^{^b}

Resettled refugees include privately sponsored and government sponsored refugees.

^{^c}

Protected persons and others include successful asylum seekers and their dependents.

Discussion

In this population-based cohort study, COVID-19 vaccination coverage was 53.1% in children and 79.2% in adolescents in Ontario, Canada. Vaccination rates were higher for immigrants and lower for refugees, compared with nonimmigrants. There was significant variation within subgroups of immigrants and refugees by region of origin, with relative differences frequently persisting across generations. Odds of vaccination increased with age, higher socioeconomic status, and lower neighborhood COVID-19 risk. Similar associations were found when analyzing time to first vaccination.

Vaccine acceptance is complex,⁴⁶ as recently summarized in the 5C model: besides vaccine confidence, complacency (not perceiving diseases as high risk), constraints (structural or psychological barriers), calculation (engagement in extensive information searching), and collective responsibility were identified as important factors associated with vaccine acceptance.^47,48 For migrants, a systematic review on routine and COVID-19 vaccination named language, vaccine literacy, and vaccination benefits as additional factors.⁴⁹ All of these factors likely contributed to our results.

Our findings of higher vaccine coverage in immigrants is consistent with a study of adolescents and adults from Alberta, Canada, which found higher vaccine coverage (78% vs 76%) in immigrants compared with nonimmigrants. However, it did not distinguish immigrants and refugees, assess generations, or include children.⁵⁰ In our study, refugees, and particularly refugee children, were more likely to be undervaccinated, which is consistent with data on routine and COVID-19 immunizations in European refugees.¹⁰ While potential explanations include different countries of origin or socioeconomic status in refugees compared with other immigrants, we adjusted for both, suggesting an independent association between refugee status and undervaccination. Educational attainment is higher in protected persons than in resettled refugees⁵¹ and may explain differences within refugee groups in our study. Although evidence on parental education and vaccination acceptance is not universal,^52,53,54 studies from North America, New Zealand, and Europe have reported a positive association.^{55,56,57,58,59} Other explanations may be limited language ability or health literacy and lower confidence in vaccine information from the media.⁵⁹

We found a high degree of variation by region of origin (the range of differences in rates was 29.5 percentage points for second generation immigrant and refugee adolescents and 53.6 percentage points for immigrant and refugee children). Associations between regions of origin and vaccination were not attenuated after adjustment for socioeconomic and demographic factors. Low rates in immigrants and refugees from Eastern Europe and Central Africa were consistent with other literature,¹⁶ and low uptake has also been documented for citizens in the corresponding home countries.⁶⁰ While cross-national frameworks for research on immigrant health are complex and causes for health behaviors highly context-specific,^60,61 low vaccine coverage in Eastern European immigrants and refugees is well documented.^62,63,64 A study on routine vaccine hesitancy in Eastern Europe elucidated potential factors, including conspiracy theories and reduced confidence in medical science and institutions, particularly if combined with low objective vaccine knowledge⁶⁵; these factors likely to contribute to undervaccination observed in Eastern European immigrants in our study. However for Central African immigrants, structural racism⁶⁶ and systemic discrimination against Black individuals in Canada might have catalyzed the spread of disinformation and mediated undervaccination, as described in a 2023 qualitative study by Kemei et al.⁶⁷ Distinguishing factors associated with vaccine hesitancy can help to better tailor public health campaigns.⁶⁵ A 2021 study by Ganczak et al⁶⁸ found Ukrainian refugees were more willing to receive COVID-19 vaccinations in countries other than their own, considering the host country’s health system more trustworthy. For Black individuals in Canada, strategies like town-hall events organized by the Black Scientists’ Task Force on Vaccine Equity were associated with successfully decreasing vaccine hesitancy.²⁸ Our finding of high vaccine coverage in immigrants and refugees from Southeast Asia correspond with current evidence⁶⁰ describing high confidence in vaccinations and health experts in these regions.⁶⁹ Contrary to our hypotheses, associations by region of origin, especially in regions with low vaccination, were remarkably stable across generations, suggesting that cultural background influences vaccination decisions over longer periods of time than expected. While there is little comparable literature, this is consistent with a 2019 US study,⁷⁰ in which self-reported influenza vaccine coverage was similar across first- and second-generation Arab immigrants.

We found lower material deprivation was associated with higher vaccination coverage. This is consistent with a systematic review by Wang et al⁷¹ reporting higher adult COVID-19 vaccination rates in higher-income households. A 2021 Canadian survey study¹⁹ described similar disparities, with lower-income parents being less likely to accept COVID-19 vaccinations for their children. The negative association of COVID-19 neighborhood risk decile and vaccination was less pronounced in adolescents compared with children, likely reflecting a mitigating effect of the adolescent COVID-19 vaccine campaign that specifically targeted high-risk neighborhoods.⁷² The undervaccination of individuals without a primary health care practitioner aligns with a 2022 Canadian mixed-methods analysis by Kholina et al⁷³ describing primary care practitioners as key drivers of vaccine uptake, highlighting the importance of primary care for vaccine equity.

Other findings of our study correlate with survey data. Vaccination was higher with each incremental age increase, which was anticipated by parental surveys from Asia, the Middle East, North America, and Europe.^{74,75,76,77,78,79} Lower perceived risk of developing severe COVID-19, combined with less confidence in the relatively new COVID-19 vaccine for younger children, were the main reasons reported for vaccine hesitancy.^{74,75,76,77,78,79} Lower effectiveness of COVID-19 vaccinations in younger age groups may also contribute to reduced vaccine confidence.^79,80

Limitations

This study has some limitations. The use of administrative data and the retrospective design limited our ability to measure potentially important variables, including individual household income, parent or guardian education, language preference and proficiency, routine vaccine uptake, sources of information about COVID-19, peer group influence, and trust in the health system. As testing criteria for SARS-CoV-2 infections changed over time, this variable was limited to infections prior to vaccine eligibility. We had no data on immigrants or refugees who intended to arrive in another province, were undocumented migrants, or were asylum seekers awaiting their hearings, limiting generalizability of our findings to these groups. Additionally, the research took place in a context where publicly funded, equity-focused COVID-19 vaccination campaigns existed, where pediatric vaccination was recommended and promoted, and with distinct immigration policies. While resettled refugees in Canada may be similar to those in other countries, protected persons and immigrants may have different attributes than in other jurisdictions.

Conclusions

In this Canadian population-based cohort study, nonrefugee immigrant minors had higher vaccine coverage than nonimmigrants. The substantial heterogeneity by region of origin and lower vaccination coverage in refugees persisted across generations. Precision public health approaches should target specific barriers in the identified, undervaccinated subgroups in ongoing vaccine campaigns.

Supplement 1.

eTable 1. List of Databases Used in the Study

eTable 2. List of Variables Used in the Study

eTable 3. Relevant Immigration Pathways in Canada and Context-Specific Definitions

eReferences.

eTable 4. Additional Baseline Characteristics of Immigrants, Refugees, Second-Generation Immigrants, Refugees, and All Nonimmigrant Children and Adolescents in Ontario on January 1, 2021

eTable 5. Crude and Adjusted Odds Ratios of Being Vaccinated (Full Cohorts) on April 24, 2022

eTable 6. Adjusted Odds Ratios of Being Vaccinated Among First- and Second-Generation Immigrant and Refugee Children on April 24, 2022

eTable 7. Adjusted Odds Ratios of Being Vaccinated Among First- and Second-Generation Immigrant and Refugee Adolescents on April 24, 2022

eFigure 1. Study Population Inclusion Flowchart

eFigure 2. Milestones of the Ontario Vaccination Campaign in Relation to the Study Timeline

Click here for additional data file.^{(653.8KB, pdf)}

Supplement 2.

Data Sharing Statement

Click here for additional data file.^{(16.8KB, pdf)}

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable 1. List of Databases Used in the Study

eTable 2. List of Variables Used in the Study

eTable 3. Relevant Immigration Pathways in Canada and Context-Specific Definitions

eReferences.

eTable 4. Additional Baseline Characteristics of Immigrants, Refugees, Second-Generation Immigrants, Refugees, and All Nonimmigrant Children and Adolescents in Ontario on January 1, 2021

eTable 5. Crude and Adjusted Odds Ratios of Being Vaccinated (Full Cohorts) on April 24, 2022

eTable 6. Adjusted Odds Ratios of Being Vaccinated Among First- and Second-Generation Immigrant and Refugee Children on April 24, 2022

eTable 7. Adjusted Odds Ratios of Being Vaccinated Among First- and Second-Generation Immigrant and Refugee Adolescents on April 24, 2022

eFigure 1. Study Population Inclusion Flowchart

eFigure 2. Milestones of the Ontario Vaccination Campaign in Relation to the Study Timeline

Click here for additional data file.^{(653.8KB, pdf)}

Supplement 2.

Data Sharing Statement

Click here for additional data file.^{(16.8KB, pdf)}

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PERMALINK

COVID-19 Vaccine Uptake in Immigrant, Refugee, and Nonimmigrant Children and Adolescents in Ontario, Canada

Julia Brandenberger, MD, PhD

Raquel Duchen, MPH

Hong Lu, PhD

Susitha Wanigaratne, PhD

Eyal Cohen, MD, MSc

Teresa To, PhD

Pierre-Philippe Piché-Renaud, MD

Astrid Guttmann, MDCM, MSc

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Study Design

Outcome Measures and Exposures

Covariates

Statistical Analysis

Results

Table 1. Baseline Characteristics of Immigrants, Refugees, and Nonimmigrant Children and Adolescents in Ontario on January 1, 2021a .

COVID-19 Vaccine Coverage

Table 2. Vaccine Coverage by Characteristics of First- and Second-Generation Immigrants and Refugees and All Nonimmigrant Children and Adolescents on April 24, 2022.

Vaccination in Immigrants and Refugees and by Generation

Figure 1. Adjusted Odds Ratios (aORs) for Being Vaccinated Among Children and Adolescents in Ontario, Canada, by April 24, 2022.

Figure 2. Adjusted Odds Ratios (aORs) for Being Vaccinated Among First- and Second-Generation Immigrant Children and Adolescents in Ontario, Canada, by April 24, 2022.

Time to First Vaccination

Table 3. Hazard of First Vaccination in Full Cohort and Immigrants and Refugees Among Adolescents and Children on April 24, 2022.

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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Links to NCBI Databases

Table 1. Baseline Characteristics of Immigrants, Refugees, and Nonimmigrant Children and Adolescents in Ontario on January 1, 2021^a .