Vaccine Coverage Across the Life Course in Michigan During the COVID-19 Pandemic: January‒September 2020

Abstract

Objectives. To assess the impact of the COVID-19 pandemic on immunization services across the life course.

Methods. In this retrospective study, we used Michigan immunization registry data from 2018 through September 2020 to assess the number of vaccine doses administered, number of sites providing immunization services to the Vaccines for Children population, provider location types that administer adult vaccines, and vaccination coverage for children.

Results. Of 12 004 384 individual vaccine doses assessed, 48.6%, 15.6%, and 35.8% were administered to children (aged 0–8 years), adolescents (aged 9–18 years), and adults (aged 19‒105 years), respectively. Doses administered overall decreased beginning in February 2020, with peak declines observed in April 2020 (63.3%). Overall decreases in adult doses were observed in all settings except obstetrics and gynecology provider offices and pharmacies. Local health departments reported a 66.4% decrease in doses reported. For children, the total number of sites administering pediatric vaccines decreased while childhood vaccination coverage decreased 4.4% overall and 5.8% in Medicaid-enrolled children.

Conclusions. The critical challenge is to return to prepandemic levels of vaccine doses administered as well as to catch up individuals for vaccinations missed. (Am J Public Health. 2021;111(11):2027–2035. https://doi.org/10.2105/AJPH.2021.306474)

The pandemic spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, exploded onto the global stage in early December 2019 in Wuhan, China.¹ The first confirmed case of COVID-19 in the United States was reported on January 20, 2020,² and community transmission was detected in February 2020. By mid-March, all 50 states, the District of Columbia, and all 4 US territories had reported cases of COVID-19.³ Michigan reported its first case on March 10, 2020, and, soon thereafter, on March 13, 2020, the United States declared a national state of emergency to control the pandemic spread of the virus.⁴ As of April 27, 2021, more than 918 000 cases and 17 400 deaths have been recorded in Michigan, and more than 31.9 million cases and more than 569 700 deaths have been reported across the United States.³

Public health response measures were implemented across the nation to mitigate the pandemic, centering on social distancing and quarantine policies, including shelter-in-place and stay-at-home orders. Michigan declared a state of emergency⁵ and implemented executive orders to suspend in-person operations that were not critical to sustain or maintain life, disrupting access to routine health services.^6,7 Michigan reopened using a tiered approach on June 22, 2021. Public schools, kindergarten through grade 12, also opened for the 2020–2021 academic year through a combination of in-person, online, and hybrid learning.

Core preventive services, including immunizations, were dramatically interrupted resulting in declines in vaccination coverage leaving communities at risk for vaccine-preventable diseases (VPDs) and associated complications.^8,9 With interruptions of immunization services, concerns about outbreaks of disease, particularly measles, which requires an estimated immunity level of at least 92% to 94% to reach the herd immunity threshold and prevent outbreaks, were of primary concern.¹⁰ Reductions in measles coverage and coverage of other routinely recommended vaccines (e.g., diphtheria, mumps, pertussis, polio, varicella, and rubella) threaten herd immunity, particularly in areas where unvaccinated persons are in close proximity and introductions of cases through travel are more likely. The critical challenge for Michigan and other states across the nation is to ensure a return to prepandemic levels of doses administered while ensuring catch-up doses are administered to individuals who have fallen behind on complying with the Advisory Committee on Immunization Practices (ACIP) routine immunization schedules.¹¹

To do this, states rely on programs like the Vaccines for Children (VFC) program, a federal safety net that seeks to ensure that all children have access to vaccines without financial barriers. Children eligible for the VFC program include those who are Medicaid-eligible, uninsured, and American Indian or Alaska Native. In addition, children with health insurance that does not cover vaccination (underinsured) can get free vaccines at federally qualified health centers.¹² Furthermore, all states including Michigan utilize pharmacists and pharmacies as vaccinators and sites of service. Pharmacies offer the convenience of extended hours outside of those for a traditional medical clinic, including holidays, expanding access points for routine vaccination services, particularly for adults who value the convenience pharmacies offer.¹³ In this retrospective study, we used the Michigan Care Improvement Registry (MCIR; the state’s immunization information system [IIS]) and assessed vaccine doses administered across the life course during the COVID-19 pandemic. We also assessed routine vaccination coverage for children aged 19 to 35 months.¹⁴

METHODS

The study period for this retrospective analysis of doses reported to MCIR for individuals aged 0 through 105 years was from January 1, 2018, through September 30, 2020. We compared monthly dose administrations from January through September 2020 with January through September 2018–2019 averages. We chose a 2-year average as a representative baseline to account for data fluctuations that may occur in a given year, beginning in 2018, because administration of the 2-dose herpes zoster vaccine began in earnest in 2018, after the November 2017 ACIP recommendation, as supply constraints limited initial vaccinations.^15–17 The analysis of vaccination coverage for children aged 19 to 35 months included coverage in September 30, 2020, compared with coverage in September 30, 2019, as point estimates.

Data Source

As of September 2020, MCIR contained more than 153 million provider-verified immunization records for more than 11 million individuals, including 2 693 310 children and adolescents aged younger than 19 years and 8 772 125 adults. Duplicate doses, doses from individuals who opted out of the registry, nonvaccine products (e.g., tuberculin skin tests and immunoglobulins), and other doses (e.g., historical doses, not administered by the reporting MCIR provider—rather, reported based on vaccine documentation) were excluded. Doses were limited to 1 vaccine type (based on vaccine administration code) per day per person (e.g., only 1 hepatitis B included per person per day). Influenza vaccinations were excluded because of the seasonality of vaccine administration and because the study period ended before the start of the 2020–2021 influenza season. Travel and counterbioterrorism vaccines were included; however, they accounted for less than 1% of vaccine doses. Immunization providers are required to report vaccinations administered to persons less than 20 years of age to the MCIR within 72 hours, unless the parent, guardian, or person in loco parentis of the child who received the vaccine objects by written notice.¹⁸ According to annual data reported to the Centers for Disease Control and Prevention, a majority of doses are reported electronically within 24 hours.

Study Population

The following study cohorts were created to assess doses administered in 2020 compared with the monthly average of the 2 previous years (2018–2019) for the months of January to September: young children (aged 0 to < 2 years), children (aged 2 to 8 years), adolescents (aged 9 to 18 years), and adults (aged 19 to 105 years). First, pediatric and adolescent doses administered were reported by programmatic variables: by VFC Program status and whether the doses were administered at a VFC site. Second, doses administered were reported by ACIP-recommended age groups, for adolescents and adults respectively: human papillomavirus; tetanus, diphtheria, and acellular pertussis (Tdap) or tetanus‒diphtheria (Td); and meningococcal serogroup A, C, W, Y (MenACWY) vaccines for adolescents aged 11 through 18 years; and Tdap or Td (adults aged 19 years and older), herpes zoster (for adults aged 50 years and older), and pneumococcal polysaccharide vaccine‒23 valent (PPSV23, for adults aged 65 years and older) for adults. Lastly, doses administered for adults were reported by 10 MCIR facility types (i.e., site of service) that most frequently report administering adult vaccinations.

Vaccination coverage (up-to-date status) for children aged 19 to 35 months was also reported. This includes the percentage of children (19‒35 months) fully immunized with 4 or more doses of diphtheria, tetanus, and acellular pertussis (DTaP); 3 or more doses of polio; 1 or more dose of measles, mumps, and rubella; 3 or more doses of Haemophilus influenzae type b (3 or 4 doses depending on vaccine product), 3 or more doses of hepatitis B, 1 or more dose of varicella, and 4 or more doses of pneumococcal conjugate.¹⁴ We also assessed the change in vaccination coverage in Medicaid-enrolled children and the number of children enrolled in Medicaid during the same 1-year time period.

We analyzed data by using SAS version 9.4 (SAS Institute Inc, Cary, NC).

RESULTS

Of the 12 004 384 provider-verified doses in the study sample, 48.6% were administered to children aged 0 to 8 years, 15.6% to adolescents aged 9 to 18 years, and 35.8% to adults aged 19 years and older. Total doses administered in each age group increased in January 2020 compared with the average during the same time period in 2018 and 2019, with the largest increase in adults aged 19 through 105 years (32.3%), primarily driven by increased administrations of a newly licensed¹⁵ and ACIP-recommended¹⁶ 2-dose herpes zoster vaccine (Figure 1). The greatest decreases across all age groups were observed in April 2020, with the largest percentage decrease of 85.6% observed among adolescents (2018‒2019 average = 46 295; 2020 = 6678), followed by a 82.7% decrease in children aged 2 through 8 years (2018‒2019 average = 37 890; 2020 = 6571), a 82.2% decrease in adults (2018‒2019 average = 128 383; 2020 = 22 865), and a 34.9% decrease in children aged younger than 2 years (2018‒2019 average = 147 456; 2020 = 95 998).

FIGURE 1—

Percent Change in Vaccine Doses Administered, by Age Group and Month: Michigan Care Improvement Registry, January‒September 2020 vs January‒September 2018–2019 Average

Only 1 age group and time point showed a percentage increase during the pandemic. Specifically, in June 2020, children aged younger than 2 years received 5.7% more vaccines compared with the average in June 2018 and 2019. However, the increase was not sustained, as doses administered in July through September declined, compared with July through September 2018–2019 averages, by 3.5%, 8.6%, and 2.8%, respectively (Figure 1).

Vaccination Sites of Services for Children

The total number of sites reporting vaccines to the MCIR for children aged 0 through 18 years declined 36.2% from March to April 2020; the number of sites reporting VFC and non-VFC doses declined from 1123 and 1634 sites to 718 and 1040 sites, respectively, between March and April 2020. The number of sites reporting doses has somewhat recovered; however, the total number of sites reporting doses remain below 2018–2019 averages (9384 in 2020 relative to 10 738 in 2018–2019 for VFC sites and 14 899 in 2020 relative to 17 825 in 2018–2019 for non-VFC sites). In addition, the number of VFC doses reported (775 736) was lower than non-VFC doses (1 041 055) reported during the study period.

Doses Administered to Adolescents

Total doses of routinely recommended adolescent vaccines administered declined, with the greatest decrease occurring in 11 through 18-year-old adolescents in April 2020 (Figure 2). Decreases were observed in all routinely recommended adolescent vaccines relative to the same month average during 2018 and 2019 with the peak decline in April: 85.8% decrease in human papillomavirus (from 14 388 to 2043), 86.2% decrease in MenACWY (from 121 156 to 1675), and an 82.6% decrease in Tdap (from 7337 to 1273). Only MenACWY is required for school entry at this age.¹⁹

FIGURE 2—

Doses Administered of Select Vaccine Types, by Month, to Adolescents Aged 11 Through 18 Years: Michigan Care Improvement Registry, January‒September 2020 vs January‒September 2018–2019 Average

Note. HPV = human papillomavirus; MenACWY = meningococcal serogroup A, C, W, Y; Tdap = tetanus, diphtheria, and acellular pertussis.

Doses Administered to Adults

Dramatic decreases were also observed in the routinely recommended adult vaccines evaluated in April: 89.6% decrease in PPSV23 (from 6905 to 716), 85.5% decrease in herpes zoster (from 22 262 to 3229), and 67.5% decrease in Tdap or Td (from 38 802 to 12 616; Figure 3). Doses of herpes zoster and PPSV23 administered during June through September 2020 exceeded doses administered in the same time period (June through September) 2018–2019 averaged.

FIGURE 3—

Doses of Routinely Recommended Adult Vaccines Administered, by Month: Michigan Care Improvement Registry, January‒September 2020 vs January‒September 2018–2019 Average

Note. PPSV23 = pneumococcal polysaccharide vaccine‒23 valent; Td = tetanus‒diphtheria; Tdap = tetanus, diphtheria, and acellular pertussis.

The sites of service where adults received vaccines did not change during the pandemic relative to before the pandemic (Table 1). The largest proportion of doses administered to adults aged 50 through 64 years and adults aged 65 years and older were reported by family practice and pharmacy locations (44.0% and 55.8%, respectively); doses administered to adults aged 19 through 49 years (37.8%) were most often reported by family practice sites and hospitals (37.8%). The greatest decreases were observed in doses reported by local health departments for adults aged 19 through 49 years (70.3%) and adults aged 50 through 64 years (66.1%). Obstetrics and gynecology provider sites and pharmacies were the only locations that reported percentage increases in doses administered to adults during 2020 (11.1% and 0.4%, respectively). Any remaining types were defined as “other” (Table 1).

TABLE 1—

Adult Vaccine Doses Administered and Percent Change, by Site of Service and Age Group: Michigan Care Improvement Registry, January‒September 2020 vs January‒September 2018–2019 Average

	Adults Aged 19–49 y			Adults Aged 50–64 y			Adults Aged ≥ 65 y			Total, Adults Aged ≥19 y
Facility Site of Service	2018–2019 (n = 475 156), No. (%)	2020 (n = 315 577), No. (%)	Percent Change	2018–2019 (n = 318 501), No. (%)	2020 (n = 294 370), No. (%)	Percent Change	2018–2019 (n = 391 236), No. (%)	2020 (n = 346 945), No. (%)	Percent Change	2018–2019 (n = 1 184 893), No. (%)	2020 (n = 956 892), No. (%)	Percent Change
Family practice	188 276 (39.6)	132 499 (27.9)	−29.6	127 439 (26.8)	123 131 (25.9)	−3.4	115 513 (24.3)	94 024 (19.8)	−18.6	431 227 (36.4)	349 654 (36.5)	−18.9
Pharmacy	32 549 (6.9)	20 365 (4.3)	−37.4	75 505 (15.9)	85 954 (18.1)	13.8	168 267 (35.4)	171 033 (36.0)	1.6	276 320 (23.3)	277 352 (29.0)	0.4
Hospital	56 310 (11.9)	47 020 (9.9)	−16.5	23 259 (4.9)	18 454 (3.9)	−20.7	27 085 (5.7)	21 729 (4.6)	−19.8	106 653 (9.0)	87 203 (9.1)	−18.2
Internal medicine	26 319 (5.5)	17 615 (3.7)	−33.1	28 675 (6.0)	28 425 (6.0)	−0.9	40 605 (8.5)	32 059 (6.7)	−21.0	95 598 (8.1)	78 099 (8.2)	−18.3
Othera	25 296 (5.3)	13 825 (2.9)	−45.3	15 127 (3.2)	12 232 (2.6)	−19.1	13 043 (2.7)	11 290 (2.4)	−13.4	53 465 (4.5)	37 347 (3.9)	−30.1
Local health department	60 296 (12.7)	17 934 (3.8)	−70.3	26 097 (5.5)	8 853 (1.9)	−66.1	14 959 (3.1)	7 298 (1.5)	−51.2	101 352 (8.6)	34 085 (3.6)	−66.4
Obstetrician/gynecologist	26 384 (5.6)	29 467 (6.2)	11.7	255 (0.1)	240 (0.1)	−5.9	160 (0.0)	61 (0.0)	−61.8	26 799 (2.3)	29 768 (3.1)	11.1
Pediatrics	17 267 (3.6)	13 267 (2.8)	−23.2	7 371 (1.6)	8 734 (1.8)	18.5	5 451 (1.1)	5 229 (1.1)	−4.1	30 089 (2.5)	27 230 (2.8)	−9.5
Urgent care	10 545 (2.2)	8 509 (1.8)	−19.3	5 087 (1.1)	3 979 (0.8)	−21.8	3 193 (0.7)	2 403 (0.5)	−24.7	18 825 (1.6)	14 891 (1.6)	−20.9
College or university	15 756 (3.3)	8 609 (1.8)	−45.4	3 455 (0.7)	2 220 (0.5)	−35.7	2 170 (0.5)	1 555 (0.3)	−28.3	21 381 (1.8)	12 384 (1.3)	−42.1
Corporate	16 160 (3.4)	6 467 (1.4)	−60.0	6 234 (1.3)	2 148 (0.5)	−65.5	793 (0.2)	264 (0.1)	−66.7	23 187 (2.0)	8 879 (0.9)	−61.7

^aOther includes specialty clinic, travel clinic, correctional clinic, tribal health center, migrant health center, adolescent health center, school-based health center, adult-only clinic, adolescent-only clinic, long-term care, sexually transmitted disease center, family planning clinic, and Veterans Affairs hospital.

Childhood Vaccination Coverage

Recommended vaccination coverage for children aged 19 through 35 months for the complete doses of the combined 7-vaccine series to prevent 13 diseases was 70.3% as of September 30, 2020, a decrease of 4.4% from September 30, 2019. Coverage for completion of individual vaccines also declined; specifically, coverage with DTaP was 72.9% (a 4.4% decrease from 2019). Vaccination coverage and respective declines for the completion of individual vaccines was 79.3% for pneumococcal conjugate (3.9%); 82.4% for measles, mumps, and rubella (3.6%); 81.4% for varicella (3.4%); 83.9% for Haemophilus influenzae type b (3.1%); 85.2% for hepatitis B (2.2%); and 84.7% for polio (1.6%). From September 30, 2019, to September 30, 2020, the number of Medicaid-enrolled children aged 19 through 35 months in MCIR increased 4.3%, from 71 798 to 74 837, while vaccination coverage for the complete series of the combined 7-vaccine series of Medicaid-eligible children decreased 5.8%, from 73.1% in 2019 to 67.3% in 2020. Vaccination coverage for the individual vaccines also decreased in Medicaid-eligible children with the largest decrease in DTaP vaccination of 5.6% (69.6% in 2020 vs 75.2% in 2019).

DISCUSSION

As Michigan and the entire country emerged from stringent lock-down measures imposed in spring 2020, adults have resumed work in congregate settings; students, to varying degrees, have physically returned to schools and universities; and individuals have returned to popular community settings, like the gym, bars, and restaurants. In our study, we found dramatic decreases in (1) doses administered across the life course; (2) adult dose administration across the majority of provider settings, particularly in local health departments; and (3) vaccination coverage for the complete doses of the combined 7-vaccine series in children aged 19 to 35 months in 2020 compared with previous data.

As we strive to achieve pre‒COVID-19 levels of doses administered for routinely recommended vaccines, it is vital to ensure catch-up vaccination of doses missed throughout the pandemic to stem outbreaks of VPDs (e.g., measles). Decreasing coverage can lead to resurgences of all VPDs. Because measles is the most contagious of the VPDs, measles may be the first such disease to increase.¹⁰ This study also showed a decrease in pediatric immunization provider sites, particularly those dedicated to caring for more vulnerable populations, like Medicaid-insured children; this will complicate the ability to reach prepandemic rates quickly with fewer access points for vaccination and, in some cases, fewer appointment options.

To reach prepandemic levels of vaccination coverage and to ensure catch-up vaccination on doses missed since the onset of the pandemic, it is critical to take steps to ensure both adult and pediatric providers identify and target their patients for catch-up doses.^20–22 The IIS can help with this effort, as a supplement to provider electronic health records for doses that are not captured by a provider’s electronic health records to identify those indicated for vaccination and to contact them to schedule appointments. Additional clinic hours and appointment times can also be a useful strategy to support efforts. At every encounter, providers can ensure that the immunization status of every individual is assessed, vaccines are strongly recommended, and individuals are vaccinated or referred for vaccination.²³ While the rate of decrease in doses administered has slowed since April 2020 (Figure 1), decreases in preventive care during the pandemic are cause for concern. This concern stems from the potential for missed diagnoses that may increase infectious disease susceptibility coupled with health care practices, particularly small, private practices, which continue to struggle to survive in the wake of the COVID-19 pandemic, changing health care patterns of access and utilization.^24–26

August is often associated with back-to-school vaccinations, and this study confirmed increased doses administered in August 2020 (Figure 2); however, up-to-date vaccination coverage is a more accurate reflection of protection against VPDs, and this will take longer to rebound. While providers and some families appear to be seeking catch-up vaccinations, lower coverage among Medicaid-covered children is concerning.⁸ Increases in Medicaid enrollment from the previous year, most likely attributable to COVID-19‒ induced economic-related insurance coverage shifts, means more children are shifting from other insurance types onto Medicaid coverage and eligibility for the VFC program, shifting the costs of vaccination onto public programs. The marginal increase already observed in this study may signal an ongoing potential for increases in Medicaid enrollment, particularly as the long-term economic impact of the pandemic is yet to be fully realized; therefore, monitoring changes in VFC immunization provider sites will be important for ensuring access to vulnerable populations and at-risk communities. Changes in practice patterns may be a result of pay cuts, staff layoffs because of low patient volume, and the consequences of adhering to public health guidelines related to social distancing (e.g., fewer appointments, fewer people in the office).

Dramatic declines in doses administered have yet to translate to dramatic declines in vaccination coverage as the full impact on coverage levels at specific ages (i.e., 19–35 months), as young children aged 2 years and younger who missed doses have yet to age into the 19- through 35-month age cohort assessed by the National Immunization Survey.¹⁴ For example, a child aged 6 months who missed multiple vaccinations throughout the pandemic would not be included in the coverage assessment. The decreases in this study reflect preliminary decreases in coverage, which can be alarming if children are not caught up on recommended vaccines.

We observed age-related differences in adult vaccines as doses administered of PPSV23 and herpes zoster have rebounded to pre‒COVID-19 levels. The rebound in doses administered for PPSV23 may reflect a concern for other respiratory pathogens amid SARS-CoV-2 cocirculation. Undoubtedly, resolution of persistent supply issues for herpes zoster and an ACIP-preferential recommendation for a 2-dose zoster vaccine¹⁶ have contributed to increased doses administered, as the previous zoster vaccine was only a single dose.¹⁷ By contrast, younger adults may not feel as much of a need to seek health care, or they may have difficulties related to appointment availability, causing them to change where they get immunizations, particularly as providers may have decreased appointment “slots.” Some special populations such as pregnant women were prioritized as a priority population for appointments (Table 1). Even as providers consider different adult populations and pandemic-associated changes in vaccination-seeking behaviors, it is important that even those not offering, or no longer offering, vaccinations continue to promote the importance of vaccination.²³

Pharmacies have increasingly become a vital vaccination resource in communities. Michigan has observed an increase in the number of pharmacy sites and the number of doses reported to the MCIR. There has been an increase in electronic reporting by pharmacies, which play a critical role in administering vaccinations, particularly to older adults (Table 1).^23,27,28 Ensuring individuals are vaccinated, particularly as other respiratory pathogens (e.g., influenza, Streptococcus pneumoniae), are circulating during the COVID-19 pandemic, has been a priority.²⁹ While this study period ended before influenza vaccinations began in earnest, efforts to vaccinate for routinely recommended vaccines are important, particularly in adults aged 65 years and older, as this cohort is a vulnerable population accounting for a disproportionate number of seasonal influenza-related deaths, an estimated 70% to 85%, and a high proportion of influenza-related hospitalizations.³⁰ This same population accounts for 8 of every 10 confirmed COVID-19‒reported deaths in the United States.^31,32

Limitations

Vaccination coverage is the traditional metric and gold standard used to assess vaccine utilization, a population’s level of protection from disease, and immunization program performance; however, doses administered and reported to an IIS represent timely and available proxy measures. One well-established limitation in the use of IIS data, particularly in the adolescent and adult population, is denominator inflation.^33,34 Denominator inflation occurs when IIS client totals exceed population estimates, which can skew population coverage estimates, for example, because of multiple records for 1 individual. This inflation may underestimate coverage rates. Overestimates of coverage estimates occur when a population estimate is used for the denominator. We attempted to account for this by conducting manual checks to deduplicate data and limiting coverage calculations to childhood vaccinations.

Another limitation is that adult immunization reporting is not required in Michigan; therefore, completeness of reporting for adults is lower than for children. It is possible that some of the changes noted in the number of reported adult immunizations in 2020 were attributable to reductions in reporting rather than changes in administration. In responding to the pandemic, we suspect that providers may have had less time because of competing priorities to report all administered doses to the registry.

A third limitation is that the classification of MCIR facility types is performed by MCIR regional staff, who are best positioned to know the populations served by the facilities in their regions; however, these classifications are not routinely verified and updated after enrollment.

Lastly, at the time of this analysis, race and ethnicity data, which can be useful in understanding the health disparities and health care utilization patterns of care in vulnerable communities, were incomplete across the life course.

Public Health Implications

After a 2020 summer lull in daily COVID-19 case counts, cases began to rise exponentially, with unprecedented record metrics (e.g., hospitalizations) associated with the pandemic in November 2020.³ Diligence in monitoring vaccination rates and provider site availability will be critical to returning to prepandemic levels of coverage as well as catching up cohorts of individuals for vaccinations. It will also be critical for all providers to be astute in considering VPD diagnoses in their diagnostic assessments moving forward. As vaccination coverage has dropped, susceptible populations are accumulating, which could lead to outbreaks of VPDs not seen in recent times. Given that measles is the most contagious of the VPDs, outbreaks of measles may be the first evidence of resurgences in VPDs. The susceptibility gap for all of the VPDs needs to be closed as soon as possible.

Since May 2021, COVID-19 vaccination programs are now widely available across all jurisdictions in the United States. As a result of increased capability to report race and ethnicity data for adults, as required for COVID-19 vaccine, Michigan and other jurisdictions now have enhanced tools to address under- and unvaccinated populations. As society shifts to a new normal, recalibrating to a world where SARS-CoV-2 is endemic, COVID-19 vaccines will certainly transition onto the routine immunization schedule in some form. It is critical to ensure the immunization delivery system supports timely, accessible, and reliable access to routinely recommended vaccines across the nation, sustaining historical high coverage in children and strengthening increasing coverage for adolescents and adults.