Characterization of Post-Vaccination COVID-19 Cases Among School-Aged Children in Georgia: An Exploration by Urbanicity Open Access

Abstract

Background

The vulnerability of pediatric populations to COVID-19 infections and geographic trends of

COVID-19 infections in the United States shifted after the emergence of new variants and

emergency-use authorization of mRNA COVID-19 vaccines. Nationally, and in Georgia, children

became more susceptible to severe infections, and the burden of disease shifted from urban

counties towards rural counties. The purpose of this thesis is to characterize breakthrough infection

burden among school-aged children in Georgia and examine the relationship between urbanicity

and breakthrough infections during major variant periods of the COVID-19 pandemic between

June 1, 2021, and December 31, 2022.

Methods

Surveillance data on vaccinated COVID-19 cases between the ages of 5-17 years in Georgia were

used in this analysis. Cases were classified as residing in a rural or urban county, and as residing

in Metropolitan Atlanta or Non-Metropolitan Atlanta using the 2013 National Center for Health

Statistics Urban-Rural Classification Scheme for Counties. Poisson regression was used to

determine associations between residence classification and breakthrough infections by school age

group during the entire study period and for each variant period, stratified by race, ethnicity, and

political affiliation of the counties.

Results

The risk of breakthrough infection among children who lived in urban or Metropolitan Atlanta

counties was significantly higher than that of children who lived in rural or Non-Metropolitan

Atlanta counties. While urbanicity analyses had limited significant differences, the Metropolitan

Atlanta analyses indicated significant differences across each stratification of race, ethnicity, and

political affiliation for each age group. The incidence density ratios of the urbanicity and

metropolitan variant analyses peaked during the Omicron BA.2 period, with more dramatic

increases in the metropolitan analyses. Results demonstrated a stepwise inverse relationship

between breakthrough risk and age group, with the oldest age group (14-17 years) having the

smallest risk, and the youngest age group (5-10 years) having the highest risk.

Conclusion

Promoting primary vaccination series will raise the herd immunity of the pediatric population and

lower the risk of infection among each age group. Booster vaccinations must be promoted among

highly vaccinated populations to prevent mass waning immunity events that increase the risk of

breakthrough infections during prolonged pandemic events.

Table of Contents

INTRODUCTION ........................................................................................................................1

METHODS .................................................................................................................................4

Study Design .............................................................................................................................4

Source Population, Study Population, and Ethical Considerations ..................................................6

Data Sources ..............................................................................................................................7

Data Analysis .............................................................................................................................7

RESULTS ....................................................................................................................................7

Descriptive Results .....................................................................................................................7

Overall Breakthrough Analyses ...................................................................................................10

COVID-19 Variant Impact Analysis ..............................................................................................13

DISCUSSION .............................................................................................................................24

CONCLUSION ...........................................................................................................................28

SUPPLEMENT ...........................................................................................................................29

REFERENCES ............................................................................................................................30

About this Master's Thesis

Rights statement

• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health
Keyword	Pediatrics Urbanicity Vaccine Breakthrough Infection COVID-19
Committee Chair / Thesis Advisor	Chamberlain, Allison, Emory University

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