DeSalvo et al. BMC Pediatrics(2024) 24:570
https://doi.org/10.1186/s12887-024-05039-9

BMC Pediatrics

RESEARCH

Open Access

COVID-19 immunization status in children
compared to their parents: a retrospective
review at an upstate NY medicine/pediatrics
practice
Katelyn DeSalvo1†, Arun Sitsabeshon1†, Annamaria Walden1†, Vivian Vu1†, Ashar Ata2 and Danielle P. Wales3,4*
Abstract
Background This study aimed to investigate the relationship between parent and child COVID-19 immunization
series completion using vaccine records.
Methods A cross-sectional chart review was performed on parent and child patients at the Albany Medical Center
Internal Medicine and Pediatrics practice. Patient and parent demographic data, COVID-19 immunization status, andhealth care worker status was collected. Patient data was further separated into 2 cohorts to account for vaccine
eligibility among child age groups, with 5–11 years and 6 months-4 years cohorts. Chi square or Fisher’s exact test wasused where appropriate.
Results Across both cohorts, 371 child patients were identified and cross-matched with corresponding parents.
Neither cohort offered evidence linking child immunization series completion with the child’s race, ethnicity, or
county of residence. However, rates of series completion were higher for children with private insurance versus
public options in both the 5–11 years and 6 months-4 years cohorts (both p < 0.001). Children were more likely to
be immunized against COVID-19 if their parents were fully immunized against COVID-19 (both p < 0.05). Children
aged 6 months-4 years were more likely to be immunized against COVID-19 if their parent was a health care worker(p = 0.038).
Conclusions This study demonstrates a significance between child insurance status, as well as between parental
vaccination status and child vaccination status. Only children under 5 years were more likely to be vaccinated against
COVID-19 if their parent was a health care worker.
Keywords COVID-19, Immunization, Vaccination†

Katelyn DeSalvo, Arun Sitsabeshon, Annamaria Walden and Vivian
Vu are Co-first authors.
*Correspondence:
Danielle P. Wales
walesd@amc.edu

1Albany Medical College, Albany, NY, USA
Albany Medical Center Department of Surgery, Albany, NY, USA
3
Albany Medical Center Division of Internal Medicine and Pediatrics, 1019
New Loudon Road, Cohoes, NY 12047, USA
4
University at Albany School of Public Health, Rensselaer, NY, USA
2© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation
or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://
creativecommons.org/licenses/by-nc-nd/4.0/.

DeSalvo et al. BMC Pediatrics(2024) 24:570

Background
During the COVID-19 Omicron wave, children aged 0–4
years experienced the largest increase in hospitalization
rates [1]. COVID-19 ranked eighth among all cases ofdeath in U.S. persons ages 0–19 years, and first in deaths
caused by infectious or respiratory diseases in 2021–2022[2]. Despite the risk of COVID-19 to young children, as
of May 2023, only about 13% of children ages 6 months
through 4 years had received 1 dose of COVID-19 vaccine across the United States. Among children ages 5–11
years, 39% of US children had received at least 1 dose of
COVID-19 vaccine, with 32% of children completing the
2-dose series [3]. Children ages 6 months through 4 years
who receive 2 doses of mRNA COVID vaccine reduced
their risk of hospitalization by 40% [4].
Our study seeks to establish a link between parental
COVID-19 immunization status and the immunization status of their children, aged 6 months through 11
years. Previous studies investigating factors associatedwith child COVID-19 immunization uptake have reliedon data from self-reported surveys. One nationwide
cohort study found that when the COVID-19 vaccine
was approved for children, parents who had previously
been immunized against COVID-19 were more likely toalready have immunized their children or to have immediately immunized them compared to unvaccinatedpeers. Amongst immunized parents, only 10% reported
they would not immediately vaccinate their children [5].
Another survey from Nguyen, et al. found that vaccinated parents were almost 8 times more likely to reportthat their children (ages 5–11 years) were also vaccinatedagainst COVID-19 [6].
There are currently no published studies reviewing thelink between parent and child COVID-19 immunization
status that use actual records as a data source. However,there are many studies analyzing the varied factors that
contribute to immunization rates of children. In one
2015 study, it was found that one of many the determinants of childhood immunization was “personal, family
and/or community members’ experience with immunization, including pain,” meaning that parents based theirdecision to vaccinate their children on their own experience with immunization [7]. While the current researchsuggests that there is a correlation between a parent’s
immunization status and their willingness to vaccinate
their children, there seems to also be other factors that
could come into play [8]. Health care professionals areoften a positive influence on childhood immunization,
however studies looking at the effect of having a healthcare worker as a parent are in their infancy [9]. Strictly
using immunization records, our study seeks to establish
the role a parent’s COVID-19 immunization status for
COVID-19 plays concerning the vaccination decisions of
their children.

Page 2 of 7

Methods
A retrospective chart review was performed on patientsof the Albany Medical Center Internal Medicine andPediatrics practice. Records of immunizations wereaccessed through the electronic health record, Altera
Touchworks® version 22.1, which also pulls immunization data from the state immunization registry, NYSIIS(New York State Immunization Information System),for patients who received the vaccine outside of thepractice. New York State Public Health Law Sect. 2168
requires that all immunizations given to patients underage 19 years in New York to be reported to NYSIIS [10].
Subjects were patients 6 months through 11 years of age
and their parents. FDA approval of COVID-19 vaccination for 5–11 years was October 29, 2021, and for 6
months-4 years was June 17, 2022. Clinics for COVID
vaccination at the practice started on November 12,2021 for 5–11-year-olds, and July 1, 2022 for ages 6
months-4 years. Chart reviews were conducted from
October 2022 – April 2023 for the 5–11 years cohortand from February 2023 – May 2023 for the 6 months-4
years cohort.
Children ages 5–11 years were considered fully vaccinated if they received 2 doses of the primary mRNA
COVID-19 vaccine series (Pfizer BNT162b2 or ModernamRNA-1273). Children ages 6 months through 4 years
were considered fully vaccinated if they received 2 dosesof mRNA-1273 vaccine or 3 doses of BNT162b2 vaccine.
Parents were considered fully vaccinated if they received
2 doses of a COVID-19 mRNA vaccine (BNT162b2 or
mRNA-1273) or 1 dose of a replication-incompetentrecombinant adenovirus type 26 viral vector (Janssen
ChAdOx1 nCoV-19 vaccine). These definitions are congruent with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization
Practices (ACIP) recommendations at the time of thestudy. Over 90% of the patients in both cohorts received
these immunizations at the Internal Medicine and Pediatrics practice.
When data for two parents was available, the parent
identified as a health care worker was used for analysis.
A parent was identified as a health care worker if they
fit the definition as specified by the World Health Organization (WHO) definition of a health worker, which
includes if they fell into the following categories: healthprofessionals, health associate professionals, personalcare workers in health services, health management
and support personnel, and other health service providers not otherwise classified [11]. If two parents wereidentified as health care workers, the guarantor wasused for analysis. Similarly, for two parent families with
one parent with a completed COVID-19 immunization
series, the parent with the completed immunization
series was used for analysis. None of the subjects had

DeSalvo et al. BMC Pediatrics(2024) 24:570

Page 3 of 7

Table 1 Demographics of children

1st child
2nd childRace/Ethnicity
Non Hispanic white
Non Hispanic black
Asian
Hispanic or Latino
Other
Unknown
County of Residence
AlbanyRensselaer
Saratoga
Schenectady
Other
Insurance
PrivateManaged Medicaid
Medicaid
Total

Table 2A Demographic Variables Versus COVID Immunization
Status, 5–11 years

Number (%)
5–11 years
163 (78.7)
44 (21.3)

6mo-4 years
164 (100)n/a

153 (73.9)
14 (6.8)
7 (3.4)4 (1.9)16 (7.7)
13 (6.3)

117 (71.3)
8 (4.88)0(0)5 (3.0)7 (4.3)27 (16.5)

115 (55.5)
29 (14.0)30 (14.5)
32 (15.5)
1 (0.5)104 (63.4)
15 (9.1)
25 (15.2)
18 (11)2 (1.2)150 (72.5)
55 (26.6)
2 (0.9)207

98 (59.8)
64 (39.0)
2 (1.2)
164

data for two parents where both parents were healthcare workers with differences in immunization completion status. Charts were reviewed to determine which
parents were health care workers. If the chart did notprovide this information, the primary care physicianof the parent was queried directly by the study teamregarding parental occupation.
5–11 Years

Each child was cross matched with a corresponding parent. In this age group, there were 44 families that had
more than 1 child established at our practice. When 2children in the same family were identified, child 1 was
the child earlier in alphabetical order in relation to theirfirst (given) name. Each child was analyzed separately inorder to match with the available parent in the data set.
Data is presented first for the 5–11-year cohort as thisdata was analyzed first.
6 months-4 Years

As above, each child was cross matched with a corresponding parent. No siblings (or second children) were inthis analysis.
Data Analysis

Data analysis was conducted using Stata version 17.0.
Chi square or Fisher’s exact test was used whereappropriate. Logistic regression was used to estimate
odds ratio.

VariableNChild 1, Race/ethnicity
Non-Hispanic white115
Non-Hispanic black
6
Asian
7
Hispanic/Latino
4
Other
15
Unknown
10Child 2, Race/ethnicity
Non-Hispanic white38
Non-Hispanic black
2
Other
1
Unknown
3Child 1, County of Residence
Albany96Saratoga
22
Schenectady
24
Rensselaer
20
Other
1
Child 2, County of Residence
Albany19Saratoga
8
Schenectady
8
Rensselaer
9

Unimmunized/underimmunized(%)

Fully immunized
(%)

P
value

51 (44.3)0 (0)4 (57.1)
2 (50)
8 (53.3)
8 (80)

64 (55.7)
6 (100)3 (42.9)2 (50)
7 (46.7)
2 (20)

0.517

19 (50)1 (50)0 (0)1 (33.3)

19 (50)1 (50)
1 (100)2 (66.7)

0.969

42 (43.8)
7 (31.8)
13 (54.2)
11 (55)0 (0)54 (56.2)
15 (68.2)
11 (45.8)
9 (45)
1 (100)0.400

7 (36.8)
5 (62.5)
2 (25)
6 (66.7)

12 (63.2)
3 (37.5)
6 (75)
3 (33.3)

0.213

Results
5–11 Years

Of the 207 children in this cohort, 73.9% identified as
non-Hispanic White, 55.5% resided in Albany County,
and 72.5% had private insurance (Table 1). Immunization series completion was not found to be statisticallysignificant when comparing ethnicity or race, and countyof residence (Table 2A). Immunization series completion
was found to be statistically significant when comparing
insurance type. Twenty-eight percent (n = 46) of Managed Medicaid patients were found to be fully vaccinatedwhile 60.9% (n = 115) of privately insured patients were
found to be up to date (p < 0.001) (Table 3). The relationship between child 2 COVID immunization status andinsurance was not found to be statistically significant(p = 0.064), but this group has a smaller sample size.
Among parents who completed their primary COVID
immunization series, 59% of children in the child 1 groupalso were fully vaccinated with the COVID-19 immunization series (p = 0.001) (Table 4). Table 5 shows the resultsof the analysis where parent vaccination status was compared to child vaccination status when both child 1 andchild 2 were combined in the same analysis. The results
were not significant, again with a smaller sample size.

DeSalvo et al. BMC Pediatrics(2024) 24:570

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Table 2B Demographic Variables Versus COVID Immunization
Status, Age 6 months – 4 years

Table 5 Parental vaccine status versus child 1 and child 2 age
5–11 years

VariableAge 5–11 years, Child 1 + Child 2
N Neither
At least 1child fully
child fully
immunized
immunized
Parent31 7 (53.9)
1 (7.7)
immunized
Parent13 12 (38.7)
1 (3.2)
unimmunizedN

Race/Ethnicity
Non Hispanic white
Non Hispanic black
Other
Hispanic/Latino
Unknown
County of Residence
AlbanySaratoga
Schenectady
Rensselaer
Other

Unimmunized/underimmunized(%)

Fully immunized
(%)

P
value

117
8
7
5
27

96 (82.1)
8 (100)7 (100)3 (60)
23 (85.2)

21 (18.0)
0 (0)
0 (0)
2 (40)
4 (14.8)

0.266

104
25
18
15
2

83 (79.8)
21 (84)16 (88.9)
15 (100)
2 (100)21 (20.2)
4 (16)
2 (11.1)
0 (0)
0 (0)

0.433

InsuranceN

6 months – 4 years
PrivateManaged Medicaid
Medicaid
5 to 11 years Child 1
PrivateManaged Medicaid
Medicaid
5 to 11 years Child 2
PrivateManaged Medicaid
Medicaid

Unimmunized/underimmunized(%)

Fully immunized(%)

P value98
64
2

72 (73.5)
63 (98.4)
2 (100)26 (26.5)
1 (1.6)0< 0.001115
46
2

45 (39.1)
33 (71.7)
1 (50)

70 (60.9)
13 (28.3)
1 (50)< 0.0013590

14 (40)7 (77.8)
021 (60)2 (22.2)
0

0.064

N

Age 6 months-4 years
Parent immunized133
Parent unimmunized 31
Age 5–11 years, Child 1
Parent immunized
124
Parent unimmunized 39
Age 5–11 years, Child 2
Parent immunized
31
Parent unimmunized 13

Age 6 mo – 4 years
HCW
46
Non-HCW
118
Age 5–11 years
HCW
35
Non-HCW
128

UnimmuFully
nized, under- immunizedimmunized
(%)

P
value

107 (80.5)
30 (96.8)

26 (19.6)
1 (3.2)0.027

51 (41.1)
28 (71.8)

73 (58.9)
11 (28.2)

0.001

13 (41.9)
8 (61.5)

18 (58.06)
5 (38.5)

0.235

0.376

18 (58.1)

Unimmunized orunderimmunized(%)

Fully immunized (%)

P
value

3 (6.5)28 (23.7)

43 (93.5)
90 (76.3)

0.011

2 (5.7)37 (28.9)

33 (94.3)
91 (71.1)

0.004

Table 7 Parental health care worker (HCW) status versus child
immunization status
N

Table 4 Parental vaccination status versus child vaccination
statusP
value

Table 6 Parental health care worker status versus parent COVID
vaccination status
N

Table 3 Insurance versus COVID immunization status

Both children fully
immunized
5 (38.5)

Child unimmunized
or underimmunizedAge 6 months – 4 years
HCW
46
34 (73.9)
Non-HCW
118
103 (87.3)
Age 5–11 years, Child 1
HCW
35
16 (45.7)
Non-HCW
128
63 (49.2)
Age 5–11 years, Child 2HCW
93 (33.3)
Non-HCW
35
18 (51.4)

Child
immunizedPvalue

12 (26.1)
15 (12.7)

0.038

19 (54.3)
65 (50.8)

0.713

6 (66.7)
17 (48.6)

0.462

a COVID-19 primary immunization series (p = 0.004)(Table 6). Children of health care workers were not more
likely to be vaccinated when compared to children of
non-health care workers (p = 0.713 for child 1, p = 0.462
for child 2) (Table 7). When child 1 and child 2 were combined, there was no significant difference between child
immunization status and parental health care worker status (p = 0.671) (Table 8).
6 mo–4 Years

Twenty-one percent of the 163 parents were classified as health care workers. Parents identified as healthcare workers were more likely to be fully vaccinated with

Of the 164 children identified in this age group, 71% identified as Non-Hispanic White, 63.4% resided in Albany
County, and 59.8% had private insurance (Table 1).
Immunization series completion was not found to bestatistically significant when comparing age groups, ethnicity or race, and county of residence (Table 2B). Immunization status was found to be statistically significant

DeSalvo et al. BMC Pediatrics(2024) 24:570

Page 5 of 7

Table 8 Parent health care worker (HCW) status versus child 1
and child 2, 5–11 years
Age 5–11 years, Child 1 + Child 2
N Neither
One childchild fully
fully
immunized
immunized
HCW
9 3 (33.3)
0 (0)Non-HCW 35 16 (45.7)
2 (5.7)

Both children fully
immunized
6 (66.7)
17 (48.6)

P
value
0.671

when comparing insurance type. Under 3% of Medicaid
insured patients were found to be fully vaccinated against
COVID-19 while 26.5% of privately insured patients were
found to be fully vaccinated (p < 0.001) (Table 3).
Parents fully vaccinated against COVID-19 were more
likely to have their children vaccinated against COVID19 (p = 0.027) (Table 4). Additionally, amongst all parents
identified in this cohort, 81% of parents were up to datewith COVID-19 primary immunization series. These
results also yielded a odds ratio of 7.29 (95% confidence
interval 0.95 to 55.9), indicating vaccinated parents wereover 7 times more likely to vaccinate their children in thissample.
The trends identified in parents listed as health care
workers were much more significant in this cohort. 28%of the 164 parents identified in this sample were classified as health care workers. Parents who were health care
workers were more likely to have completed the COVID19 immunization primary series (p = 0.011) (Table 6). 14%of parents who were not identified as health care workers
completed a full vaccination regimen for their children
while 28% of parents who were identified as health care
workers completed a full vaccination regimen for theirchildren (p = 0.038) (Table 7). Additionally, the odds ratio
for these percentages was 2.42 (95% confidence intervalof 1.03 to 5.68), therefore health care workers were morethan twice as likely to vaccinate their children in thissample.

Discussion
Parents are the driving force behind their children’s
health care; therefore, it is important to understand theirreasons for immunizing their children against COVID19. It is estimated that the average well child visit in the
US is 18 min; physicians use over half this time addressing immunization in families expressing hesitancy orrefusal— detracting from other essentials of primary care[12]. One previous study evaluating parental perspectives
on childhood immunization relied on a cross-sectional
survey [13]. Surveys of attitudes have, however, threemain limitations. First, they may be subject to participant bias. Second, factors other than parental attitudes
may affect whether the child gets immunized. Third, dataon actual immunization is not collected. A retrospective

chart review is better reflective of actual immunization
decisions.
The overall trend found in vaccine literature showschildhood immunization completion is strongly determined by their parents’ immunization status. Yet even so,
parents’ readiness to immunize themselves is consistently
higher than for their children [14]. This is reinforced inour study— in the 5–11 years cohort, parents who completed a full COVID-19 vaccine series had a 58.9% rate ofchild COVID-19 immunization whereas parents who did
not complete the series had a 28.2% rate of child COVID19 immunization (p = 0.001) (Table 4).
We found that, if parents were health care workers,
their children were more likely to be immunized against
COVID-19 if they were in the 6 months-4 years cohort,
but not if they were in the 5–11-year cohort. Parental
perception of risk of younger children from COVID-19
may play a role [13]. An online survey in 2022 suggested
that the two main concerns for parents were side effects
and the notion that the vaccines were “too new” [15]. One
could also speculate that parental concern of myocarditis
in the older cohort from the vaccine may be a reason thatthe older cohort was not immunized, despite the fact that
COVID-19 itself is more likely to cause myocarditis thanthe vaccine [16]. Interestingly, in a recent survey of healthcare workers and COVID-19 vaccine hesitancy, Kainth etal. found that there was greater vaccine hesitancy whenhealth care worker had children under age 5 in the home[17]. It should be noted that this study did not look at
immunization records from children in this age group.
Further studies should examine this discrepancy between
vaccine hesitancy and COVID-19 vaccine uptake.
This study has several limitations. First, it is crosssectional, and parents may have subsequently decided
to immunize their children. Second, it takes place at one
academic primary care site in Northeastern New Yorkand may not be externally generalizable to all populations. Third, all data was collected through Altera Touchworks®, which queried NYSIIS. Altera Touchworks will
only query NYSIIS for immunization records the nightprior to an appointment. If the patient was immunizedoffsite and was not seen in the time frame of the study
for a routine well-child check or follow-up visit, we may
not know that they received any COVID-19 immunization, therefore underestimating the number of completed
vaccination series.
This study opens future research opportunities
regarding family influences on vaccination rates, suchas grandparent vaccination rates, extended family
vaccination rates, and other familial factors, such asa relative with a history of an adverse event to a vaccine, that may contribute to the decision for a parent
to vaccinate their child. It should be noted that most,
if not all, electronic health records (EHRs) do notDeSalvo et al. BMC Pediatrics(2024) 24:570

analyze data by families, but rather at the individuallevel. EHRs may consider adding this functionality tobetter answer these research questions. Furthermore,other studies have suggested that COVID-19 vaccine hesitancy among health professionals can varyby employment type [18]. Future studies may examine
vaccination records of children stratified by their parents’ employment type.

Conclusions
Our study adds to the growing body of literature showing that children are more likely to be fully immunizedagainst COVID-19 if their parents are also fully immunized. It is also found that immunization of children was
more likely in both cohorts if they had private, rather
than public, insurance, and more likely in the younger
cohort if one or both parents were health care workers.
These findings present opportunities for the informing
public health efforts to immunize children, especially ina pandemic scenario. Future studies should also analyze
best practices to improve COVID-19 immunization rates
in children 6 months-11 years.
Abbreviations
ACIP	Advisory Committee on Immunization Practices
CDC	Centers for Disease Control and Prevention
EHR	Electronic Health Record
FDA	Federal Drug Administration
mRNA	messenger RNA
NYSIIS	New York State Immunization Information System
U.S.	United States

Supplementary Information

The online version contains supplementary material available at https://doi.
org/10.1186/s12887-024-05039-9.
Supplementary Material 1
Acknowledgements
The authors would like to thank Dr. Paul Sorum, MD, PhD, for his review of thismanuscript prior to journal submission. We would also like to thank Liz Irish for
her help in the journal selection process.
Author contributions
KD contributed to initial study planning, data entry, analysis, and manuscript
production. AS contributed to data entry, analysis and manuscript production.
AW contributed to data entry, analysis, and manuscript production.
VV contributed to data entry, analysis, and manuscript production. AA
contributed to data analysis and manuscript review. DW contributed to study
conceptualization, data entry and analysis, manuscript production. All authors
approved the final manuscript as submitted and agree to be accountable for
all aspects of the work. No learned language artificial intelligence was used in
the production of this manuscript.
Funding
Financial support for publication of this article was provided by a grant fromthe Department of Pediatrics at Albany Medical Center.
Data availability
All data analyzed during this study are included in this published article orprovided to the reviewers.

Page 6 of 7

Declarations
Ethical approval
This protocol was approved by the Albany Medical College Institutional
Review Board.
Consent for publication
n/a.
Competing interests
DW previously received salary support from Gilead for Project FOCUS, ahepatitis C screening project. This relationship ended in 2021. All other authors
declare that they have no competing interests.
Received: 20 April 2024 / Accepted: 28 August 2024

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