Body Politic: The Political Divide in Vaccine Uptake. A County-Level Analysis of COVID-19 and Flu Vaccination Rates Across the United States

Abstract

Purpose

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.

Keywords

vaccine hesitancy partisanship and vaccination politics and vaccine uptake COVID-19 vaccine uptake flu vaccine uptake

Get full access to this article

View all access options for this article.

References

WHO . COVID-19 and the Social Determinants of Health and Health Equity: Evidence Brief. WHO: Geneva, Switzerland; 2021.

Lundon

Mohamed

Lantz

Goltz

Kelly

Tewari

. 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.

Niedzwiedz

O’Donnell

Jani

, 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

Muhsen

Na’aminh

Lapidot

, 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

Xie

Shi

Liu

Yang

Sun

. 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

Wang

, 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

Salmon

Dudley

Brewer

, 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

Mooney

. The Republican War on Science. Hachette UK: London, UK; 2007.

Gauchat

. 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.

Joslyn

Sylvester

. The determinants and consequences of accurate beliefs about childhood vaccinations. Am Polit Res. 2019;47:628-649.

11.

Sweeney

. 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.

Yang

. 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-Prado

Suárez-Sangucho

Vasconez-Gonzalez

, 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.

Dubois

Minaeian

Paquet-Labelle

Beaudry

. 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.

Lun

Gao

Tang

, 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.

Nagase

. 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.

Madanay

McDevitt

Ubel

. 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.

Neelon

Mutiso

Mueller

Pearce

Benjamin-Neelon

. 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.

Ruiz

Bell

. 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.

Viswanath

Bekalu

Dhawan

Pinnamaneni

Lang

McLoud

. Individual and social determinants of COVID-19 vaccine uptake. BMC Public Health. 2021;21:818. doi:10.1186/s12889-021-10862-1

21.

Miller

Ackerman

Laspra

Polino

Huffaker

. 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.

Cowan

Mark

Reich

. COVID-19 vaccine hesitancy is the new terrain for political division among Americans. Socius. 2021;7:23780231211023657. doi:10.1177/23780231211023657

23.

Liu

Nagao

Hatungimana

Zhang

Kennedy

. The politics of flu vaccines: international collaboration and political partisanship. Jpn J Polit Sci. 2024;25:61-74. doi:10.1017/S1468109924000021

24.

Mesch

Schwirian

. 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.

Carroll

Conroy

Vamosiu

. 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.

Perry

Whitehead

Grubbs

. 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.

Viskupič

Wiltse

Stenvig

. 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.

von

Elm E

Altman

Egger

, 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

29.

County Health Rankings & Roadmaps. https://www.countyhealthrankings.org/ (2024, accessed February, 20 2025).

30.

National Center for Health Statistics. https://www.cdc.gov/nchs/index.html (2023, accessed February, 20 2025).

31.

The Behavioral Risk Factor Surveillance System (BRFSS). https://www.cdc.gov/brfss/index.html (2023, accessed February, 20 2025).

32.

The American Community Survey . Washington DC: US Census Bureau; 2020.

33.

US Religion Census. https://www.usreligioncensus.org/ (2020, accessed January 3 2026).

34.

County Health Rankings & Roadmaps. https://www.countyhealthrankings.org/ (2022, accessed January 3 2026).

35.

Leip

. David Leip’s Atlas of US Presidential Elections, Datasets. https://uselectionatlas.org/ (2025).

36.

NYT.

See How Vaccinations are Going in your County and State . 2023. https://www.nytimes.com/interactive/2020/us/covid-19-vaccine-doses.html (accessed 20 November 2024).

37.

County Health Rankings & Roadmaps. https://www.countyhealthrankings.org/ (2025, accessed January 3 2026).

38.

IBM Corp . IBM SPSS Statistics for Windows. Version 31.0.0.0. Armonk, NY: IBM Corp, 2025.

39.

RStudio . 2026.01.0+392 ed. Boston, MA, US: Posit PBC; 2026.

40.

Akoglu

. User’s guide to correlation coefficients. Turk J Emerg Med. 2018;18:91-93. doi:10.1016/j.tjem.2018.08.001

41.

LaCour

Bell

. 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.

Heidt

Ledford

. 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.

Sylvester

Motta

Trujillo

Callaghan

. 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.

Rosenbluth

. Texas Measles Outbreak, Signs of a Riskier Future for Children. NY Times; 2025.

45.

Kearney

Sparks

Hamel

, et al. KFF Tracking Poll on Health Information and Trust. KFF: San Francisco, California, US; 2025. https://www.kff.org/health-information-trust/kff-covid-19-vaccine-monitor-maga-republicans-relationship-with-covid-19-vaccines/ (accessed 4 September 2025).

46.

Mazzei

. Florida Moves to End Vaccine Mandates for Schoolchildren. NY Times; 2025.

47.

Stoeckel

Carter

Lyons

Reifler

. The politics of vaccine hesitancy in Europe. Eur J Publ Health. 2022;32:636-642. doi:10.1093/eurpub/ckac041

48.

Yudina

Fedorovskaya

. 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.

Nogara

Pierri

Cresci

, 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.

Wollebæk

Fladmoe

Steen-Johnsen

Ihlen

. 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

51.

Ricard

Medeiros

. Using misinformation as a political weapon: COVID-19 and Bolsonaro in Brazil. Harv Kennedy Sch Misinformation Rev. 2020;1, April 28, 2021. https://misinforeview.hks.harvard.edu/article/using-misinformation-as-a-political-weapon-covid-19-and-bolsonaro-in-brazil/

52.

Cabral

Ito

Pongeluppe

. The disastrous effects of leaders in denial: evidence from the COVID-19 crisis in Brazil. SSRN. 2021, 3836147.

53.

Leung

Price

McClure-Thomas

, 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.

Xie

Tian

Deng

, 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.

Pourrazavi

Fathi

Fathifar

Nadrian

Allahverdipour

. 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-Lavanderos

Oluyomi

Rosales

Hernandez

Mensah-Bonsu

Badr

. 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

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.41 MB

0.00 MB