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COVID-19 vaccine uptake in immigrant, refugee, and nonimmigrant children and adolescents in Ontario, Canada


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

Objective — To identify characteristics in immigrant/refugee and non-immigrant minors associated with vaccination, across two distinct campaigns: for adolescents (12-18 years) starting May 23rd, 2021, and for children (5-11 years) starting November 25th, 2021, through April 24, 2022.

Design — A retrospective cohort study using linked, population-based, demographic and healthcare data.

Setting — Ontario/Canada.

Participants — All children aged 4-17 registered for universal health insurance on January 1st, 2021.

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

Main Outcome(s) and Measure(s) — Crude rates of COVID-19 vaccination (children ≥1 vaccination; adolescents ≥2 vaccinations) and odds ratios with 95% confidence intervals (CI) adjusted for clinical, sociodemographic and health system factors.

Results — Among the 2.2 million study cohort, 4.8% (53,090/1,098,749) of children and 9.2 (104,975/1,142,429) of adolescents were first generation, and 23.4% (256,886/1,098,749) and 19.4%(221,981/1,142,429) second generation immigrants/refugees, the majority being economic/family class immigrants. Immigrants, particularly refugees, were more likely to live in neighbourhoods with highest material deprivation (first generation children/adolescents: immigrants 18.6%/20.2%, refugees 46.4%/46.3%, non-immigrants 18.5%/17.2%) and COVID-19 risk (first generation children/adolescents: immigrants 20.0%/20.5%, refugees 9.4%/12.6%, non-immigrants 6.9%/6.8%). Vaccination rates (53.1% in children and 79.2% in adolescents) were negatively associated with material deprivation. In both age groups, adjusted odds [aOR] for vaccination were higher in immigrants (children: aOR=1.30, CI: 1.27-1.33; adolescents: aOR=1.10, CI: 1.08-1.12) but lower in refugees (children: aOR=0.34, CI: 0.33-0.36; adolescents: aOR=0.88, CI: 0.84-0.91) compared to non-immigrants. In immigrant/refugee-only models stratified by generation, region of origin was associated with uptake (compared to the overall average) (lowest: Eastern Europe (children aOR=0.40, CI: 0.35-0.46; adolescents aOR=0.41, CI: 0.38-0.43) and Central Africa (children aOR=0.24, CI: 0.16-0.35; adolescents aOR=0.51,CI: 0.45-0.59); highest: Southeast Asia (children aOR=2.68, CI: 2.47-2.92; adolescents aOR=4.42, CI: 4.1-4.77)). Adjusted ORs of regions with lowest vaccine coverage were similar across generations.

Conclusions — In this Canadian study, non-refugee immigrants had higher vaccine coverage than non- immigrants. Substantial heterogeneity by region of origin and lower vaccination coverage in refugees persisted across generations. Vaccine campaigns need precision public health approaches targeting specific barriers in identified, undervaccinated subgroups.



Brandenberger J, Duchen R, Lu H, Wanigaratne S, Cohen E, To T, Piche-Renaud PP, Guttmann A. JAMA Netw Open. 2023; 6(7):e2325636. Epub 2023 Jul 26.

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