Abstract
Background/Objectives: This study examines trends in county-level vaccination coverage before, during, and after the COVID-19 pandemic among children aged 2-3 and 4-6 years in Tennessee, with a focus on rurality; Methods: Data from the Tennessee Immunization Information System (January 2017 to September 2023) were analyzed for vaccination coverage in children in both age groups. The study categorized the COVID-19 pandemic into three periods: pre-pandemic (P1: January 2017 to December 2019), stay-at-home (P2: January 2020 to May 2021), and reopening (P3: June 2021 to September 2023). Vaccination trends were stratified by vaccine type, rurality, sex, race and ethnicity; Results: During P1, there were no significant changes in trends of vaccination coverage percentages in both rural and urban counties for both age groups. However, vaccination coverage declined significantly during P2 and P3 compared to P1 for most vaccines, except for influenza, which initially increased but later declined. Rural counties experienced a more pronounced decline compared to urban counties during P2 and P3 for both age groups. Within rural and urban counties, vaccination coverage was higher among white children compared to black children, and among non-Hispanic compared to Hispanic children. There were higher coverage percentages in age group 4-6 for all vaccines, except for influenza, compared to 2-3 year group; Conclusions: The COVID-19 pandemic has exacerbated disparities in childhood vaccination coverage, particularly in rural areas. These findings highlight the need for targeted public health interventions to address barriers to vaccination and ensure equitable access to vaccines for all children.