To examine the relationship between political county-level partisanship and COVID-19 and flu vaccination uptake in the United States following the 2020 and 2024 presidential elections.
Design
Ecological, cross-sectional analysis utilizing public datasets.
Setting
All 3224 US counties and county equivalents.
Sample
Data includes 3224 counties; 3192 had complete COVID-19 vaccination data, and 3125 had complete flu vaccination data.
Measures
Dependent variables were county-level flu and full COVID-19 vaccination rates. Independent variables included 2020 and 2024 GOP vote share, median household income, education, healthcare access, and county-level health indicators.
Analysis
Spearman correlation, independent t-tests, and multivariate linear regressions.
Results
GOP vote share is strongly negatively correlated with COVID-19 vaccination (r = −.699, P < .001) and moderately with flu vaccination (r = −.427, P < .001). Counties in the highest GOP quartile had significantly lower vaccination rates than Democratic quartile counties (COVID-19: 45% vs 60%, t = −39.64, P < .001; flu: 35% vs 46%, t = −23.10, P < .001). Each percentage-point increase in GOP vote share is associated with a 0.45% decrease in COVID-19 uptake in 2024 (β = −.449, P < .001) and a 0.13% decrease in flu uptake (β = −.128, P < .001), independent of socioeconomic controls.
Conclusions
Partisan alignment has become a significant determinant of vaccination, with the divide persisting between 2020 and 2024. Findings underscore the need for localized, depoliticized public health strategies.
WHO. COVID-19 and the Social Determinants of Health and Health Equity: Evidence Brief. WHO: Geneva, Switzerland; 2021.
2.
LundonDJMohamedNLantzAGoltzHHKellyBDTewariAK. Social determinants predict outcomes in data from a multi-ethnic cohort of 20,899 patients investigated for COVID-19. Front Public Health. 2020;8:571364.
3.
NiedzwiedzCLO’DonnellCAJaniBD, et al.Ethnic and socioeconomic differences in SARS-CoV-2 infection: prospective cohort study using UK biobank. BMC Med. 2020;18:160. doi:10.1186/s12916-020-01640-8
4.
MuhsenKNa’aminhWLapidotY, et al. A nationwide analysis of population group differences in the COVID-19 epidemic in Israel, February 2020-February 2021. Lancet Reg Health Eur. 2021;7:100130. doi:10.1016/j.lanepe.2021.100130
5.
XieWShiLLiuMYangJMaMSunG. Disparities and effectiveness of COVID-19 vaccine policies in three representative European countries. Int J Equity Health. 2024;23:16. doi:10.1186/s12939-024-02110-w
6.
WangQHuSDuF, et al.Mapping global acceptance and uptake of COVID-19 vaccination: a systematic review and meta-analysis. Commun Med. 2022;2:113. doi:10.1038/s43856-022-00177-6
7.
SalmonDADudleyMZBrewerJ, et al.COVID-19 vaccination attitudes, values and intentions among United States adults prior to emergency use authorization. Vaccine. 2021;39:2698-2711. doi:10.1016/j.vaccine.2021.03.034
8.
MooneyC. The Republican War on Science. Hachette UK: London, UK; 2007.
9.
GauchatG. Politicization of science in the public sphere: a study of public trust in the United States, 1974 to 2010. Am Sociol Rev. 2012;77:167-187. doi:10.1177/0003122412438225
10.
JoslynMRSylvesterSM. The determinants and consequences of accurate beliefs about childhood vaccinations. Am Polit Res. 2019;47:628-649.
11.
SweeneyC. Poll Finds Public Support for School-based Vaccination, but Limited Trust in Vaccine Safety and Public Health Agencies. Cambridge, MA: Harvard T.H. Chan School of Public Health; 2019.
12.
YangYT. The perils of RFK Junior’s anti-vaccine leadership for public health. Lancet. 2025;405:122. doi:10.1016/S0140-6736(24)02603-5
13.
Ortiz-PradoESuárez-SanguchoIAVasconez-GonzalezJ, et al.Pandemic paradox: how the COVID-19 crisis transformed vaccine hesitancy into a two-edged sword. Hum Vaccines Immunother. 2025;21:2543167. doi:10.1080/21645515.2025.2543167
14.
DuboisEMinaeianSPaquet-LabelleABeaudryS. Who to trust on social media: how opinion leaders and seekers avoid disinformation and echo chambers. Soc Media Soc. 2020;6:2056305120913993. doi:10.1177/2056305120913993
15.
LunPGaoJTangB, et al.A social ecological approach to identify the barriers and facilitators to COVID-19 vaccination acceptance: a scoping review. PLoS One. 2022;17:e0272642. doi:10.1371/journal.pone.0272642
16.
NagaseM. Factors associated with vaccine hesitancy against COVID-19 among adults in Europe: a descriptive study analysis applying socio-ecological framework. BMC Res Notes. 2024;17:84. doi:10.1186/s13104-024-06739-2
17.
MadanayFMcDevittRCUbelPA. Hydroxychloroquine for COVID-19: variation in regional political preferences predicted new prescriptions after president Trump’s endorsement. J Health Polit Policy Law. 2022;47:429-451.
18.
NeelonBMutisoFMuellerNTPearceJLBenjamin-NeelonSE. Associations between governor political affiliation and COVID-19 cases, deaths, and testing in the U.S. Am J Prev Med. 2021;61:115-119. doi:10.1016/j.amepre.2021.01.034
19.
RuizJBBellRA. Predictors of intention to vaccinate against COVID-19: results of a nationwide survey. Vaccine. 2021;39:1080-1086. doi:10.1016/j.vaccine.2021.01.010
20.
ViswanathKBekaluMDhawanDPinnamaneniRLangJMcLoudR. Individual and social determinants of COVID-19 vaccine uptake. BMC Public Health. 2021;21:818. doi:10.1186/s12889-021-10862-1
21.
MillerJDAckermanMSLaspraBPolinoCHuffakerJS. Public attitude toward Covid-19 vaccination: the influence of education, partisanship, biological literacy, and coronavirus understanding. FASEB J. 2022;36:e22382. doi:10.1096/fj.202200730
22.
CowanSKMarkNReichJA. COVID-19 vaccine hesitancy is the new terrain for political division among Americans. Socius. 2021;7:23780231211023657. doi:10.1177/23780231211023657
23.
LiuRNagaoHHatungimanaWZhangJJKennedyJJ. The politics of flu vaccines: international collaboration and political partisanship. Jpn J Polit Sci. 2024;25:61-74. doi:10.1017/S1468109924000021
24.
MeschGSSchwirianKP. Social and political determinants of vaccine hesitancy: lessons learned from the H1N1 pandemic of 2009-2010. Am J Infect Control. 2015;43:1161-1165. doi:10.1016/j.ajic.2015.06.031
25.
CarrollDRConroySJVamosiuA. The importance of political and religious affiliation in explaining county-level COVID-19 vaccine hesitancy. Health Econ Rev. 2025;15:29. doi:10.1186/s13561-025-00605-y
26.
PerrySLWhiteheadALGrubbsJB. Culture wars and COVID-19 conduct: Christian nationalism, religiosity, and Americans’ behavior during the coronavirus pandemic. J Sci Stud Relig. 2020;59:405-416. doi:10.1111/jssr.12677
27.
ViskupičFWiltseDLStenvigTE. Nurses’ attitudes about RSV vaccination for pregnant women and infants: evidence from a cross-sectional survey. PLoS One. 2025;20:e0331326. doi:10.1371/journal.pone.0331326
28.
vonElm EAltmanDGEggerM, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61:344-349. doi:10.1016/j.jclinepi.2007.11.008
AkogluH. User’s guide to correlation coefficients. Turk J Emerg Med. 2018;18:91-93. doi:10.1016/j.tjem.2018.08.001
41.
LaCourMBellZ. Attitudes towards COVID-19 vaccines may have “spilled over” to other, unrelated vaccines along party lines in the United States. Harv Kennedy Sch Misinformation Rev. 2024. doi:10.37016/mr-2020-148
42.
HeidtALedfordH. Vaccine sceptic RFK Jr is now a powerful force in US science: what will he do?Nature. 2025. doi:10.1038/d41586-025-00439-y
43.
SylvesterSMottaMTrujilloKLCallaghanT. Vaccinating across the aisle: using co-partisan source cues to encourage COVID-19 vaccine uptake in the ideological right. J Behav Med. 2023;46:311-323.
44.
RosenbluthT. Texas Measles Outbreak, Signs of a Riskier Future for Children. NY Times; 2025.
MazzeiP. Florida Moves to End Vaccine Mandates for Schoolchildren. NY Times; 2025.
47.
StoeckelFCarterCLyonsBAReiflerJ. The politics of vaccine hesitancy in Europe. Eur J Publ Health. 2022;32:636-642. doi:10.1093/eurpub/ckac041
48.
YudinaTFedorovskayaV. German vaccine discourse: changes over time and polarization. Vestnik of Saint Petersburg University Language and Literature. 2023;20:362-379. doi:10.21638/spbu09.2023.210
49.
NogaraGPierriFCresciS, et al.Misinformation and polarization around COVID-19 vaccines in France, Germany, and Italy. In: Proceedings of the 16th ACM Web Science Conference. Stuttgart, Germany: Association for Computing Machinery; 2024:119-128.
50.
WollebækDFladmoeASteen-JohnsenKIhlenØ. Right-wing ideological constraint and vaccine refusal: the case of the COVID-19 vaccine in Norway. Scand Polit Stud. 2022;45:253-278. doi:10.1111/1467-9477.12224
CabralSItoNPongeluppeL. The disastrous effects of leaders in denial: evidence from the COVID-19 crisis in Brazil. SSRN. 2021, 3836147.
53.
LeungJPriceDMcClure-ThomasC, et al.Motivation and hesitancies in obtaining the COVID-19 vaccine—A cross-sectional study in Norway, USA, UK, and Australia. Vaccines. 2023;11:1086.
54.
XieYJTianLDengY, et al.Use of the PRECEDE-PROCEED model in piloting vaccine promotion and infection self-protection: Intervention development and effectiveness examination. Vaccines (Basel). 2024;12:979. doi:10.3390/vaccines12090979
55.
PourrazaviSFathiBFathifarZNadrianHAllahverdipourH. Leveraging Ottawa charter strategies to enhance COVID-19 vaccination: a systematic review of global health promotion approaches. Health Promot Perspect. 2025;15:9-22. doi:10.34172/hpp.025.43752
56.
Munoz-LavanderosCOluyomiARosalesOHernandezNMensah-BonsuNBadrH. Development, implementation, and evaluation of three outreach events to improve COVID-19 vaccine uptake among racial and ethnic minority communities in Houston, Texas, 2022. Publ Health Rep. 2024;139:71s-80s. doi:10.1177/00333549231213848
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