Abstract
Adults with disabilities are at increased risk for severe coronavirus disease 2019 (COVID-19). Using data across 9 states during Delta- and Omicron-predominant periods (June 2021–September 2022), we evaluated the effectiveness of the original monovalent COVID-19 messenger RNA vaccines among 521 206 emergency department/urgent care encounters (11 471 [2%] in patients with a documented disability) and 139 548 hospitalizations (16 569 [12%] in patients with a disability) for laboratory-confirmed COVID-19 illness in adults (aged ≥18 years). Across variant periods and for the primary series or booster doses, vaccine effectiveness was similar in those with and those without a disability. These findings highlight the importance of adults with disabilities staying up to date with COVID-19 vaccinations.
Keywords: COVID-19, disabilities, test-negative design, vaccine effectiveness
Graphical Abstract
The Centers for Disease Control and Prevention (CDC) defines a disability as any condition of the body or mind that makes it more difficult for the person with the condition to do certain activities or interact with the world around them [1]. It is estimated that approximately 1 billion people globally and >60 million adults in the United States had a disability in 2022 [2].
People with disabilities may be more susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection owing to exposure risks such as residence in congregate settings or inability to socially distance, wear masks, or acquire protection through vaccines because of barriers in accessing healthcare [3, 4]. Compared with adults without disabilities, those with disabilities are at higher risk of critical coronavirus disease 2019 (COVID-19)–associated outcomes, including invasive mechanical ventilation or death [4]. Some disabilities may also be associated with multiorgan manifestations that both increase risk for severe COVID-19 and could further affect COVID-19 vaccine effectiveness (VE) [5].
Using data from the multisite VISION Network [6], we evaluated whether COVID-19 VE against emergency department/urgent care (ED/UC) encounters or COVID-19–associated hospitalizations differed between adults (aged ≥18 years) with and those without disabilities. Among adults with disabilities, we further evaluated 3 disability groups with condition-specific subtypes defined by the Centers for Medicaid and Medicare Services (CMS) Chronic Data Warehouse [7], including developmental disabilities, sensory disabilities, and mobility-related disabilities.
METHODS
Study Design, Settings, and Participants
The VISION Network is a multistate collaboration between the CDC and healthcare systems with integrated medical, laboratory, and vaccination records. VISION performs serial assessments of VE using the test-negative case-control design [8]. Seven VISION sites from 9 states contributed data for this analysis.
We included adults ≥18 years of age with a COVID-19–like illness (CLI) and SARS-CoV-2 molecular testing during an ED/UC encounter or hospital admission (≥24 hours duration) during site-specific Delta (June–December 2021) or Omicron (December 2021 to September 2022) predominance periods. Variant predominance periods were defined using site-specific dates from local sequencing data when the variant prevalence was ≥50%. The Omicron period continued through the end date for this analysis (ie, 5 September 2022), which corresponded with authorization for updated bivalent COVID-19 booster vaccines [9]. Hence, the analyses focused on original monovalent doses only.
CLI was defined using International Classification of Disease, Tenth Revision (ICD-10) discharge diagnosis codes for acute respiratory clinical diagnoses (eg, pneumonia or respiratory failure) or COVID-19–related signs or symptoms (eg, shortness of breath or cough) [6]. VISION uses an encounter-based design: A unique individual could contribute ≥1 hospitalization if admission dates were >30 days apart or ED/UC encounter if visits were >24 hours apart. Repeat ED or UC encounters within a 24-hour period or hospitalizations within 30 days were considered a single event.
Information on patients’ baseline characteristics, including demographic characteristics and underlying medical conditions for the index encounter, was obtained through ICD-10 discharge codes. This analysis examined individuals with any defined disability as well as 3 categories of disability, including developmental, sensory, and mobility-related disabilities. Individual conditions and categories of conditions were defined by the CMS Chronic Data Warehouse [4, 7], with included ICD-10 codes within each category detailed in Supplementary Table 1. To compare VE estimates with those in a population without documented disabilities, we also included individuals with CLI-associated encounters and SARS-CoV-2 test results who did not have a disability-related discharge code.
Patient vaccination status was determined using electronic health record, local immunization information system, and claims data and was categorized as unvaccinated (no documented vaccine receipt), primary series vaccination only (receipt of 2 mRNA vaccine doses ≥14 days before the index date), or primary series and any number of booster doses (receipt of ≥3 mRNA vaccine doses ≥7 days before the index date). Encounters were excluded if (1) the patient had a likely immunocompromising condition [10]; (2) an mRNA vaccine dose was received before it was authorized [11]; (3) the patient received ≥1 dose of a non–mRNA vaccine product; or (4) the patient received ≥1 mRNA vaccine dose but had not completed a primary 2-dose series [11].
This study was reviewed and approved by institutional review boards at participating sites or under reliance agreement with Westat and was conducted consistently with applicable federal law and CDC policy (45 CFR part 46; 21 CFR part 56). All data were collected through electronic health records, and informed consent was not required.
Analysis
The VE methods in VISION have been described elsewhere [6, 8]. Briefly, VISION uses a test-negative case-control design, comparing the odds of testing positive for SARS-CoV-2 between vaccinated (or boosted) and unvaccinated individuals. VE was estimated as [1 – adjusted odds ratio] × 100%, using multivariable logistic regression with inverse-propensity-to-be-vaccinated weights and adjusting for site, calendar time, age, local virus circulation, and any variable not considered balanced after the propensity score (ie, with standardized mean difference >0.2).
Separate models were used for the primary vaccination series and the primary vaccination series with any number of boosters, compared with unvaccinated status (referent). VE was estimated for ED/UC encounters and for hospitalizations. Separate analyses were conducted by variant-predominant period (Delta or Omicron), for groups defined by disability status (any or none), and by disability subgroup (developmental disability, sensory disabilities, and mobility-related impairments). Each VE model used its own set of propensity-to-be-vaccinated weights. Estimates with a 95% confidence interval (CI) width >50% were not presented owing to poor precision. Estimates with nonoverlapping CIs were considered significantly different. Analyses were conducted using R software (version 4.2.1; R Foundation).
RESULTS
Overall, there were 521 206 eligible ED/UC encounters during the study period. Of these, 11 471 (2.2%) were in patients with ≥1 documented disability, including 1969 (17.2%) COVID-19 case patients and 9502 (82.8%) test-negative controls (Table 1, Supplementary Table 2). For encounters in patients with a documented disability, 5572 patients (48.6%) had a developmental disability, 2484 (21.7%) a sensory disability, and 4296 (37.5%) a mobility-related disability. The most common disabilities included mobility impairment (3462 [30.2%]), epilepsy (3441 [30.0%]), and deafness or hearing impairment (2167 [18.9%]). Compared with the 509 735 (97.8%) encounters among patients without a disability, those with a disability were more likely to be ≥65 years of age (46.2% with a disability vs 20.2% without) and male (52.4% vs 39.4%) and had more underlying medical conditions (median, 4 vs 1) (Supplementary Table 3). During the Delta period, among adults with disabilities 49.5% had completed a primary vaccine series only, compared with 47.2% in those without disabilities. Booster rates were low in both groups owing to boosters being authorized late in the Delta period [12]. During the Omicron period, among adults with disabilities 34.9% had completed a primary series only and 17.7% ≥1 vaccine booster dose, compared with 33.4% and 18.4%, respectively, in those without disabilities.
Table 1.
Characteristics of Emergency Department or Urgent Care Encounters and Hospitalizations in Adults Aged ≥18 Years With a Disability—VISION Network, June 2021 to September 2022
| ED/UC Encountersa | Hospitalizationsa | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall, No. (Col %) | SARS-CoV-2 Positive, No. (Col %) | SMDb | Unvaccinated, No. (Row %) | Primary Series, No. (Row %) | Primary Series + 1 Booster Dose, No. (Row %) | Primary Series + 2 Booster Doses, No. (Row %) | SMDb | Overall, No. (Col %) | SARS-Cov-2 Positive, No. (Col %) | SMDb | Unvaccinated, No. (Row %) | Primary Series, No. (Row %) | Primary Series + 1 Booster Dose, No. (Row %) | Primary Series + 2 Booster Doses, No. (Row %) | SMDb | |
| All encounters | 521 206 (100.0) | 115 735 (100.0) | 260 070 (49.9) | 207 057 (39.7) | 52 115 (10.0) | 1964 (0.4) | 139 548 (100.0) | 31 170 (100.0) | 72 581 (52.0) | 53 538 (38.4) | 12 848 (9.2) | 581 (0.4) | ||||
| Among encounters for individuals with any disability | ||||||||||||||||
| Any disability | 11 471 (2.2) | 1969 (1.7) | 0.046 | 5559 (48.5) | 4683 (40.8) | 1181 (10.3) | 48 (0.4) | 0.013 | 16 569 (11.9) | 2734 (8.8) | 0.129 | 8006 (48.3) | 6849 (41.3) | 1631 (9.8) | 83 (0.5) | 0.068 |
| Variant period | ||||||||||||||||
| Delta | 4656 (40.6) | 679 (34.5) | 0.152 | 2327 (50.0) | 2306 (49.5) | 23 (0.5) | 0 (0.0) | 0.817 | 7389 (44.6) | 1062 (38.8) | 0.140 | 3681 (49.8) | 3669 (49.7) | 39 (0.5) | 0 (0.0) | 0.880 |
| Omicron | 6815 (59.4) | 1290 (65.5) | 3232 (47.4) | 2377 (34.9) | 1158 (17.0) | 48 (0.7) | 9180 (55.4) | 1672 (61.2) | 4325 (47.1) | 3180 (34.6) | 1592 (17.3) | 83 (0.9) | ||||
| Age group, y | ||||||||||||||||
| 18–49 | 3738 (32.6) | 591 (30.0) | 0.114 | 2128 (56.9) | 1264 (33.8) | 345 (9.2) | 1 (0.0) | 0.521 | 4177 (25.2) | 614 (22.5) | 0.097 | 2534 (60.7) | 1318 (31.6) | 321 (7.7) | 4 (0.1) | 0.485 |
| 50–64 | 2430 (21.2) | 375 (19.0) | 1258 (51.8) | 922 (37.9) | 236 (9.7) | 14 (0.6) | 3831 (23.1) | 601 (22.0) | 1948 (50.8) | 1483 (38.7) | 384 (10.0) | 16 (0.4) | ||||
| ≥65 | 5303 (46.2) | 1003 (50.9) | 2173 (41.0) | 2497 (47.1) | 600 (11.3) | 33 (0.6) | 8561 (51.7) | 1519 (55.6) | 3524 (41.2) | 4048 (47.3) | 926 (10.8) | 63 (0.7) | ||||
| Sex | ||||||||||||||||
| Male | 6010 (52.4) | 1101 (55.9) | 0.085 | 2987 (49.7) | 2393 (39.8) | 608 (10.1) | 22 (0.4) | 0.085 | 8747 (52.8) | 1514 (55.4) | 0.062 | 4357 (49.8) | 3504 (40.1) | 844 (9.6) | 42 (0.5) | 0.065 |
| Female | 5461 (47.6) | 868 (44.1) | 2572 (47.1) | 2290 (41.9) | 573 (10.5) | 26 (0.5) | 7822 (47.2) | 1220 (44.6) | 3649 (46.7) | 3345 (42.8) | 787 (10.1) | 41 (0.5) | ||||
| Race | ||||||||||||||||
| White | 8392 (73.2) | 1468 (74.6) | 0.08 | 3776 (67.9) | 3645 (77.8) | 926 (78.4) | 45 (93.8) | 0.442 | 11987 (72.3) | 2017 (73.8) | 0.059 | 5454 (45.5) | 5223 (43.6) | 1238 (10.3) | 72 (0.6) | 0.289 |
| Black | 1795 (15.6) | 278 (14.1) | 1109 (19.9) | 579 (12.4) | 105 (8.9) | 2 (4.2) | 2436 (14.7) | 384 (14.0) | 1401 (57.5) | 835 (34.3) | 195 (8.0) | 5 (0.2) | ||||
| Asian | 204 (1.8) | 43 (2.2) | 78 (1.4) | 89 (1.9) | 37 (3.1) | 0 (0.0) | 231 (1.4) | 44 (1.6) | 98 (42.4) | 105 (45.5) | 27 (11.7) | 1 (0.4) | ||||
| Otherc | 317 (2.8) | 64 (3.3) | 162 (2.9) | 122 (2.6) | 32 (2.7) | 1 (2.1) | 484 (2.9) | 83 (3.0) | 266 (55.0) | 175 (36.2) | 41 (8.5) | 2 (0.4) | ||||
| Unknown | 763 (6.7) | 116 (5.9) | 434 (7.8) | 248 (5.3) | 81 (6.9) | 0 (0.0) | 1431 (8.6) | 206 (7.5) | 787 (55.0) | 511 (35.7) | 130 (9.1) | 3 (0.2) | ||||
| Ethnicity | ||||||||||||||||
| Non-Hispanic | 9585 (83.6) | 1636 (83.1) | 0.016 | 4518 (47.1) | 4020 (41.9) | 1001 (10.4) | 46 (0.5) | 0.253 | 13 711 (82.8) | 2225 (81.4) | 0.050 | 6440 (47.0) | 5830 (42.5) | 1363 (9.9) | 78 (0.6) | 0.216 |
| Hispanic | 1397 (12.2) | 245 (12.4) | 737 (52.8) | 513 (36.7) | 145 (10.4) | 2 (0.1) | 1841 (11.1) | 316 (11.6) | 987 (53.6) | 673 (36.6) | 179 (9.7) | 2 (0.1) | ||||
| Unknown | 489 (4.3) | 88 (4.5) | 304 (62.2) | 150 (30.7) | 35 (7.2) | 0 (0.0) | 1017 (6.1) | 193 (7.1) | 579 (56.9) | 346 (34.0) | 89 (8.8) | 3 (0.3) | ||||
| UMCs | ||||||||||||||||
| Any UMC | 10 866 (94.7) | 1891 (96.0) | 0.075 | 5257 (48.4) | 4459 (41.0) | 1105 (10.2) | 45 (0.4) | 0.036 | 16 294 (98.3) | 2712 (99.2) | 0.090 | 7846 (48.2) | 6754 (41.5) | 1611 (9.9) | 83 (0.5) | 0.104 |
| Any respiratory UMC | 5698 (49.7) | 1170 (59.4) | 0.238 | 2767 (48.6) | 2380 (41.8) | 531 (9.3) | 20 (0.4) | 0.094 | 10 442 (63.0) | 1942 (71.0) | 0.204 | 5047 (48.3) | 4318 (41.4) | 1023 (9.8) | 54 (0.5) | 0.016 |
| Any cardiovascular UMC | 7359 (64.2) | 1287 (65.4) | 0.031 | 3408 (46.3) | 3177 (43.2) | 738 (10.0) | 36 (0.5) | 0.153 | 12 421 (75.0) | 2032 (74.3) | 0.018 | 5706 (45.9) | 5391 (43.4) | 1253 (10.1) | 71 (0.6) | 0.217 |
| Any cerebrovascular UMC | 2867 (25.0) | 405 (20.6) | 0.127 | 1409 (49.1) | 1170 (40.8) | 276 (9.6) | 12 (0.4) | 0.021 | 4866 (29.4) | 660 (24.1) | 0.141 | 2399 (49.3) | 1988 (40.9) | 447 (9.2) | 32 (0.7) | 0.086 |
| Any neurological or muscular UMC | 8080 (70.4) | 1332 (67.6) | 0.073 | 3949 (48.9) | 3296 (40.8) | 805 (10.0) | 30 (0.4) | 0.086 | 12 308 (74.3) | 1949 (71.3) | 0.081 | 5963 (48.4) | 5082 (41.3) | 1206 (9.8) | 57 (0.5) | 0.049 |
| Any hematological UMC | 642 (5.6) | 132 (6.7) | 0.056 | 268 (41.7) | 296 (46.1) | 76 (11.8) | 2 (0.3) | 0.056 | 1053 (6.4) | 221 (8.1) | 0.081 | 520 (49.4) | 438 (41.6) | 91 (8.6) | 4 (0.4) | 0.038 |
| Any endocrine/metabolic UMC | 7024 (61.2) | 1228 (62.4) | 0.028 | 3214 (45.8) | 3080 (43.8) | 693 (9.9) | 37 (0.5) | 0.201 | 11 951 (72.1) | 2003 (73.3) | 0.030 | 5504 (46.1) | 5171 (43.3) | 1209 (10.1) | 67 (0.6) | 0.183 |
| Any renal disease UMC | 2697 (23.5) | 475 (24.1) | 0.017 | 1161 (43.0) | 1259 (46.7) | 264 (9.8) | 13 (0.5) | 0.107 | 4533 (27.4) | 751 (27.5) | 0.003 | 1926 (42.5) | 2086 (46.0) | 492 (10.9) | 29 (0.6) | 0.174 |
| Any GI or hepatic UMC | 603 (5.3) | 112 (5.7) | 0.023 | 314 (52.1) | 220 (36.5) | 68 (11.3) | 1 (0.2) | 0.078 | 1080 (6.5) | 176 (6.4) | 0.004 | 569 (52.7) | 401 (37.1) | 105 (9.7) | 5 (0.5) | 0.040 |
| Any obesity UMC | 2148 (18.7) | 408 (20.7) | 0.061 | 983 (45.8) | 924 (43.0) | 229 (10.7) | 12 (0.6) | 0.092 | 3840 (23.2) | 726 (26.6) | 0.094 | 1795 (46.7) | 1632 (42.5) | 399 (10.4) | 14 (0.4) | 0.074 |
| Any clinical underweight UMC | 1030 (9.0) | 184 (9.3) | 0.015 | 533 (51.7) | 411 (39.9) | 81 (7.9) | 5 (0.5) | 0.052 | 2262 (13.7) | 338 (12.4) | 0.046 | 1128 (49.9) | 904 (40.0) | 209 (9.2) | 21 (0.9) | 0.116 |
| Payer | ||||||||||||||||
| Medicaid | 3132 (27.3) | 482 (24.5) | 0.086 | 1830 (58.4) | 1057 (33.7) | 239 (7.6) | 6 (0.2) | 0.367 | 4461 (26.9) | 662 (24.2) | 0.080 | 2611 (58.5) | 1521 (34.1) | 322 (7.2) | 7 (0.2) | 0.424 |
| Disability typed | ||||||||||||||||
| Developmental disability | 5572 (48.6) | 890 (45.2) | 0.082 | 2793 (50.1) | 2166 (38.9) | 589 (10.6) | 24 (0.4) | 0.031 | 7464 (45.0) | 1222 (44.7) | 0.008 | 3722 (49.9) | 2961 (39.7) | 752 (10.1) | 29 (0.4) | 0.103 |
| Sensory disability | 2484 (21.7) | 602 (30.6) | 0.25 | 1019 (41.0) | 1192 (48.0) | 263 (10.6) | 10 (0.4) | 0.111 | 3908 (23.6) | 833 (30.5) | 0.188 | 1649 (42.2) | 1825 (46.7) | 407 (10.4) | 27 (0.7) | 0.173 |
| Mobility-related disability | 4296 (37.5) | 608 (30.9) | 0.167 | 2157 (50.2) | 1709 (39.8) | 415 (9.7) | 15 (0.3) | 0.094 | 6743 (40.7) | 875 (32.0) | 0.217 | 3344 (49.6) | 2734 (40.5) | 629 (9.3) | 36 (0.5) | 0.045 |
| Disability conditionsd | ||||||||||||||||
| Developmental | ||||||||||||||||
| ADHD, conduct disorders, and hyperkinetic syndrome | 1095 (9.5) | 172 (8.7) | 0.034 | 577 (52.7) | 402 (36.7) | 111 (10.1) | 5 (0.5) | 0.032 | 1302 (7.9) | 200 (7.3) | 0.024 | 700 (53.8) | 469 (36.0) | 129 (9.9) | 4 (0.3) | 0.086 |
| Autism spectrum disorders | 328 (2.9) | 61 (3.1) | 0.017 | 157 (47.9) | 128 (39.0) | 43 (13.1) | … (…) | 0.098 | 278 (1.7) | 56 (2.0) | 0.033 | 144 (51.8) | 96 (34.5) | 38 (13.7) | 0 (0.0) | 0.087 |
| Cerebral palsy | 392 (3.4) | 67 (3.4) | 0.001 | 182 (46.4) | 157 (40.1) | 52 (13.3) | 1 (0.3) | 0.046 | 564 (3.4) | 89 (3.3) | 0.010 | 239 (42.4) | 244 (43.3) | 78 (13.8) | 3 (0.5) | 0.054 |
| Epilepsy | 3441 (30.0) | 530 (26.9) | 0.082 | 1781 (51.8) | 1324 (38.5) | 321 (9.3) | 15 (0.4) | 0.069 | 4954 (29.9) | 787 (28.8) | 0.029 | 2458 (49.6) | 2005 (40.5) | 469 (9.5) | 22 (0.4) | 0.056 |
| Intellectual disabilities and related conditions | 561 (4.9) | 113 (5.7) | 0.046 | 242 (43.1) | 242 (43.1) | 75 (13.4) | 2 (0.4) | 0.045 | 904 (5.5) | 184 (6.7) | 0.064 | 410 (45.4) | 378 (41.8) | 112 (12.4) | 4 (0.4) | 0.035 |
| Learning disability | 131 (1.1) | 19 (1.0) | 0.021 | 67 (51.1) | 51 (38.9) | 12 (9.2) | 1 (0.8) | 0.033 | 195 (1.2) | 27 (1.0) | 0.022 | 106 (54.4) | 68 (34.9) | 21 (10.8) | 0 (0.0) | 0.066 |
| Other developmental delay | 103 (0.9) | 18 (0.9) | 0.002 | 54 (52.4) | 38 (36.9) | 10 (9.7) | 1 (1.0) | 0.040 | 125 (0.8) | 18 (0.7) | 0.014 | 67 (53.6) | 48 (38.4) | 10 (8.0) | 0 (0.0) | 0.057 |
| Spina bifida and other congenital anomalies of the nervous system | 296 (2.6) | 33 (1.7) | 0.074 | 122 (41.2) | 122 (41.2) | 52 (17.6) | … (…) | 0.121 | 326 (2.0) | 33 (1.2) | 0.071 | 166 (50.9) | 127 (39.0) | 33 (10.1) | 0 (0.0) | 0.075 |
| Sensory | ||||||||||||||||
| Blindness and visual impairment | 348 (3.0) | 60 (3.0) | 0.001 | 167 (48.0) | 157 (45.1) | 24 (6.9) | 0 (0.0) | 0.110 | 482 (2.9) | 76 (2.8) | 0.009 | 232 (48.1) | 207 (42.9) | 42 (8.7) | 1 (0.2) | 0.049 |
| Deafness and hearing impairment | 2167 (18.9) | 544 (27.6) | 0.255 | 857 (39.5) | 1056 (48.7) | 244 (11.3) | 10 (0.5) | 0.153 | 3484 (21.0) | 761 (27.8) | 0.192 | 1435 (41.2) | 1648 (47.3) | 375 (10.8) | 26 (0.7) | 0.197 |
| Mobility-related | ||||||||||||||||
| Mobility impairments | 3462 (30.2) | 495 (25.1) | 0.136 | 1731 (50.0) | 1392 (40.2) | 328 (9.5) | 11 (0.3) | 0.097 | 5575 (33.6) | 749 (27.4) | 0.162 | 2734 (49.0) | 2279 (40.9) | 533 (9.6) | 29 (0.5) | 0.022 |
| Multiple sclerosis and transverse myelitis | 50 (0.4) | 9 (0.5) | 0.004 | 22 (44.0) | 20 (40.0) | 8 (16.0) | 0 (0.0) | 0.044 | 86 (0.5) | 14 (0.5) | 0.001 | 38 (44.2) | 36 (41.9) | 12 (14.0) | 0 (0.0) | 0.046 |
| Muscular dystrophy | 105 (0.9) | 27 (1.4) | 0.053 | 48 (45.7) | 42 (40.0) | 15 (14.3) | 0 (0.0) | 0.058 | 150 (0.9) | 24 (0.9) | 0.003 | 72 (48.0) | 60 (40.0) | 18 (12.0) | 0 (0.0) | 0.053 |
| Spinal cord injury | 834 (7.3) | 95 (4.8) | 0.122 | 429 (51.4) | 322 (38.6) | 79 (9.5) | 4 (0.5) | 0.032 | 1232 (7.4) | 120 (4.4) | 0.152 | 650 (52.8) | 481 (39.0) | 92 (7.5) | 9 (0.7) | 0.078 |
Abbreviations: ADHD, attention-deficit hyperactive disorder; ED/UC, emergency department/urgent care; GI, gastrointestinal; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; SMD, standardized mean or proportion difference; UMC, underlying medical condition.
aED/UC encounters and hospitalizations with a discharge code consistent with coronavirus disease 2019 (COVID-19)–like illness were included. COVID-19–like illness diagnoses included acute respiratory illness, respiratory signs or symptoms, and febrile or non-respiratory signs or symptoms using diagnosis codes from the International Classification of Diseases, Tenth Revision. Clinician-ordered molecular assays (eg, real-time reverse-transcription polymerase chain reaction) for SARS-CoV-2 occurring betweent ≤14 days before to <72 hours after the encounter date were included.
bAn absolute SMD >0.20 indicates a nonnegligible difference in variable distributions between encounters for vaccinated versus unvaccinated patients or for patients with positive versus patients with negative SARS-CoV-2 test results. For messenger RNA COVID-19 vaccination status, a single SMD was calculated by averaging the absolute SMDs obtained from pairwise comparisons of each vaccinated category versus unvaccinated. Specifically, it was calculated as the average of the absolute value of the SMDs for (1) vaccinated with primary series versus unvaccinated, (2) vaccinated with primary series and 1 booster dose versus unvaccinated, and (3) vaccinated with primary series and 2 booster doses versus unvaccinated.
cOther race includes Asian, Hawaiian or other Pacific Islander, American Indian or Alaska Native, other not listed, and multiple races. Because of small numbers, these categories were combined.
dIndividuals may appear in >1 disability group or have >1 disability.
VE against laboratory-confirmed COVID-19–associated ED/UC encounters for a primary mRNA series during the Delta period was similar among individuals with and those without a disability (79% [95% CI, 75%–83%] vs 82% [82%–83%], respectively; median time since second dose, 184 vs 167 days) [Figure 1]. Booster dose VE during the Delta period was not estimated in individuals with a disability because there were few boosted individuals during this period. During the Omicron period, among individuals with a disability, VE for the primary series was 45% (95% CI, 36%–52%; median time since second dose, 325 days) and VE for the primary series with a monovalent mRNA booster was 58% (45%–67%; median time since last dose, 111 days). Among those without a disability during the Omicron period, VE for the primary series was slightly lower (31% [95% CI, 29%–32%]; median time since second dose, 297 days) and comparable for the primary series plus a monovalent mRNA booster (59% [58%–61%;] median time since last dose, 120 days). Within variant periods, VE estimate precision was limited across the 3 disability subgroups, with some differences in point estimates but generally overlapping 95% CIs (Supplementary Figure 1). During the Delta period, primary series VE point estimates ranged from 68% to 86% across disabilities categories. During the Omicron period, primary series VE point estimates ranged from 35% to 65%, and VE for the primary series plus ≥1 booster doses ranged from 46% to 65%.
Figure 1.
Coronavirus disease 2019 (COVID-19) vaccine effectiveness (VE) against laboratory-confirmed COVID-19–associated emergency department and urgent care (ED/UC) encounters and hospitalizations among adults aged ≥18 years with or without a disability (VISION Network, June 2021 to September 2022). VE was estimated as (1 – adjusted odds ratio) × 100%, using multivariable logistic regression with inverse-propensity-to-be-vaccinated weights and adjusting for site, calendar time (days since 1 January 2021), age, local virus circulation (percentage of positive severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] test results from testing within the counties surrounding the facility on the date of the encounter), and any variable not considered balanced after the propensity score (ie, with standardized mean difference >0.2. Dashes (missing values) indicate that the estimated VE had a confidence interval (CI) width ≥50%. Estimates with CI widths ≥50% are not shown here because of imprecision, and the associated data are also omitted. Abbreviations: IQR, interquartile range; mRNA, messenger RNA; NA, not applicable; Ref, referent group.
Overall, there were 139 548 eligible CLI-associated hospitalizations. Of these, 16 569 (11.9%) were in patients with a disability, including 2734 (16.5%) COVID-19 case patients and 13 835 (83.5%) test-negative controls (Table 1). Among encounters for those with a documented disability, 7464 (45.0%) had a developmental disability, 3908 (23.6%) had a sensory disability, and 6743 (40.7%) had a mobility-related disability. The most common disabilities among hospitalizations included mobility impairment (n = 5575 [33.6%]), epilepsy (n = 4954 [29.9%]), and deafness or hearing impairment (n = 3484 [21.0%]). Compared with the 122 979 (88.1%) hospitalizations among patients without a disability, hospitalized patients with a disability were similar in age distribution but had more underlying medical conditions (median, 5 vs 2 in patients without disabilities). During the Delta period, among patients with disabilities, 49.7% had completed a primary vaccine series only, compared with 43.5% in those without disabilities. During the Omicron period, among adults with disabilities 34.6% had completed a primary series only and 18.2% had received ≥1 vaccine booster dose, compared with 32.7% and 18.2%, respectively, in those without disabilities.
VE against laboratory-confirmed COVID-19–associated hospitalizations for primary mRNA series during the Delta period was slightly lower among individuals with a disability than in those without a disability (79% [5% CI, 76%–83%] vs 87% [86%–87%], respectively; median time since second dose, 182 vs 179 days). Booster dose VE was not estimated during the Delta period because there were few boosted individuals. During the Omicron period, among individuals with a disability VE for the primary series was 45% (95% CI, 8%–52%; median time since last dose, 337 days) and VE for primary series with a mRNA booster was 64% (55%–71%; median time since last dose, 109 days). Among those without a disability during the Omicron period, VE for the primary series was similar (45% [95% CI, 43%–48%]; median time since last dose, 326 days) and slightly higher but with overlapping CIs for the primary series with an mRNA booster (71% [68%–73%]; median time since last dose, 114 days). Within variant periods, VE point estimates varied somewhat by disability category but with limited precision and generally overlapping CIs (Supplementary Figure 1).
DISCUSSION
In a multisite study spanning multiple SARS-CoV-2 variant periods, we examined the effectiveness of mRNA vaccines against COVID-19–associated ED/UC encounters and hospitalizations in adults with disabilities. A substantial number of adults are living with disabilities, which may affect the risk of SARS-CoV-2 infection or severe COVID-19–associated outcomes [13, 14]. For example, one study in CMS beneficiaries conducted from January 2020 to November 2021 found an approximately 50% higher rate of COVID-19–associated hospitalization among beneficiaries with disabilities compared with age-eligible beneficiaries without a disability [13]. Reassuringly, we found similar mRNA COVID-19 VE among adults with or without documented disabilities, even though individuals with disabilities were generally older and had more underlying medical conditions. These findings were consistent across SARS-CoV-2 variant periods, with primary series as well as primary series plus booster dose completion, and across care settings. Notably, a substantial proportion of patients with disabilities had not received COVID-19 vaccination despite the increased risk of severe COVID-19 that has been observed, highlighting a need to further reduce barriers to access and promote vaccine acceptance [15].
This analysis was subject to limitations. First, disability was defined based on diagnosis codes associated with the index encounter and was likely undercaptured. Second, we had a modest sample size of adults with specific diagnoses, limiting our ability to generate precise VE estimates in more granular disability subgroups. Third, we did not capture medication data, residence in congregate settings, other exposure risk factors or behaviors such as mask use that could affect VE. Furthermore, we captured only medically attended illness and did not assess VE that did not result in medical encounters or account for at-home testing.
These results highlight the importance of ensuring that populations with disabilities stay up to date with COVID-19 vaccination. Future studies should continue to evaluate VE among individuals with disabilities, given changes in vaccination policies, population-level immunity, and emergence of new SARS-CoV-2 variants or variant sublineages.
Supplementary Material
Acknowledgments
VISION Network sites that contributed data for this analysis included Baylor Scott & White Health (Texas), Columbia University Irving Medical Center (New York), HealthPartners (Minnesota and Wisconsin), Intermountain Healthcare (Utah), Kaiser Permanente Center for Health Research (Oregon and Washington), Regenstrief Institute (Indiana), and the University of Colorado (Colorado).
Disclaimer. The findings and conclusions of this report are those of the authors and do not necessarily reflect the official position of the Centers for Disease Control and Prevention.
Financial support. This work was supported by the Centers for Disease Control and Prevention though (contracts 75D30120C07986 to Westat and 75D30120C07765 to Kaiser Foundation Hospitals).
Contributor Information
Palak Patel, Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Kristin E Schrader, Department of Clinical Research, Westat, Rockville, Maryland, USA.
Catherine E Rice, Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Elizabeth Rowley, Department of Clinical Research, Westat, Rockville, Maryland, USA.
Robyn A Cree, Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Malini B DeSilva, Department of Research, Health Partners Institute, Minneapolis, Minnesota, USA.
Peter J Embi, Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Manjusha Gaglani, Section of Pediatric Infectious Diseases, Department of Pediatrics, Baylor Scott & White Health, Temple, Texas, USA; Department of Medical Education, Texas A&M University College of Medicine, Temple, Texas, USA.
Shaun J Grannis, Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA; School of Medicine, Indiana University, Indianapolis, Indiana, USA.
Toan C Ong, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
Edward Stenehjem, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA.
Allison L Naleway, Department of Science Programs, Kaiser Permanente Center for Health Research, Portland, Oregon, USA.
Sarah Ball, Department of Clinical Research, Westat, Rockville, Maryland, USA.
Karthik Natarajan, Department of Biomedical Informatics, Columbia University Irving Medical Center, NewYork, New York, USA; Medical Informatics Services, NewYork-Presbyterian Hospital, NewYork, New York, USA.
Nicola P Klein, Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California Division of Research, Oakland, California, USA.
Katherine Adams, Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Anupam Kharbanda, Department of Emergency Medicine, Children’s Minnesota, Minneapolis, Minnesota, USA.
Caitlin Ray, Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Ruth Link-Gelles, Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Mark W Tenforde, Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Supplementary Data
Supplementary materials are available at Open Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.
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