State-Specific Influenza Vaccination Coverage Among Adults — United States, 2006-07 Influenza Season

PJ Lu, PhD; GL Euler, DrPH; GT Mootrey, DO; F Ahmed, MD, PhD; KG Wooten, MA

Disclosures

Morbidity and Mortality Weekly Report. 2008;57(38):1033-1039. 

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Adult groups included in the 2008 Advisory Committee on Immunization Practices (ACIP) recommendation[1] for annual influenza vaccination include all persons aged ≥50 years, women who will be pregnant during the influenza season, persons aged 18-49 years with high-risk conditions,* and other persons at increased risk for complications from influenza. Health-care personnel and household contacts and caregivers of persons at high risk also should receive annual influenza vaccination, as should adults who want to reduce their risk for becoming ill with influenza or for transmitting it to others. Healthy People 2010 influenza vaccination coverage targets are 90% among all persons aged ≥65 years and 60% among persons aged 18-64 years who have one or more high-risk conditions.[2] Data from the 2006 and 2007 Behavioral Risk Factor Surveillance System (BRFSS) surveys indicate that influenza vaccination coverage among adults for the 2006-07 season increased significantly compared with the 2005-06 season, reaching 35.1% among persons aged 18-49 years with high-risk conditions, 42.0% among all persons aged 50-64 years, and 72.1% among all persons aged ≥65 years. However, vaccination coverage remained well below Healthy People 2010 targets. Increasing influenza vaccination coverage among adults in the United States will require more cooperation among health-care providers, professional organizations, vaccine manufacturers, and public health departments to raise public awareness about influenza vaccination and to ensure continued distribution and administration of available vaccine throughout the vaccination season.

BRFSS is an ongoing, annual state-based telephone survey that collects information from approximately 400,000 randomly selected noninstitutionalized U.S. civilian adults aged ≥18 years on health risk behaviors, preventive health practices, and health-care use. Data are collected monthly in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam, and weighted by age, sex, and race/ethnicity to reflect each area's adult population. To determine influenza vaccination coverage, respondents were asked, "During the past 12 months, have you had a flu shot?" and "During the past 12 months, have you had a flu vaccine that was sprayed in your nose?" Each year, BRFSS also solicits information regarding identified high-risk conditions; influenza-related high-risk conditions in the 2006 and 2007 surveys were diabetes, asthma, myocardial infarction, and coronary heart disease. To better approximate vaccination coverage, analysis was restricted to respondents interviewed during February-August of each survey year, thereby excluding vaccinations received during previous and subsequent seasons. The median state response rate, based on guidelines set by the Council of American Survey and Research Organization (CASRO), was 50.6% (range: 26.9%-65.4%) in 2007 and 51.4% (range: 35.1%-66.0%) in 2006. Unweighted sample sizes from the interviews conducted during February-August were 249,336 in 2007 and 210,335 in 2006. Respondents who reported unknown influenza vaccination status (0.42% in 2007 and 0.46% in 2006) were excluded from the analysis. T-tests were performed to test the percentage-point significant differences (p<0.05) among racial/ethnic populations and between influenza seasons.

Among adults aged 18-49 years, influenza vaccination coverage for the 2006-07 season was 35.1% among persons with identified high-risk conditions and 23.4% among those without these conditions. Coverage among persons with identified high-risk conditions was significantly higher for non-Hispanic whites (37.1%, 95% confidence interval [CI] = ±1.7) compared with the other racial/ethnic groups combined (31.6%, CI = ±3.1). Among these other racial/ethnic groups, coverage was 34.0% (CI = ±4.9) for non-Hispanic blacks, 36.5% (CI = ±13.6) for Asians, 43.9% (CI = ±10.0) for American Indians/Alaska Natives, and 28.2% (CI = ±4.9) for Hispanics. Coverage among those with identified high-risk conditions ranged from 22.3% in Florida to 54.0% in Tennessee (median: 37.6%) ( Table 1 ). The median change in vaccination coverage among states and areas from the 2005-06 to 2006-07 seasons among persons aged 18-49 years with identified high-risk conditions was 6.2 percentage points (range: -5.3 to 22.0) ( Table 2 ). Vaccination coverage increased significantly in four of the nine regions§ and 11 states or areas.

Among adults aged 50-64 years, influenza vaccination coverage during the 2006-07 season was 42.0%, ranging from 34.0% in Florida to 53.7% in Minnesota (median: 43.6%) ( Table 1 ). Coverage among those with identified high-risk conditions was 54.2% (CI = ±1.4) and 37.9% (CI = ±0.8) among those without these conditions. Coverage was significantly higher for non-Hispanic whites (44.1%, CI = ±0.6) compared with other racial/ethnic groups (35.8%, CI = ±1.9). Among these other racial/ethnic groups, coverage was 35.2% (CI = ±2.3) for non-Hispanic blacks, 39.5% (CI = ±8.4) for Asians, 43.6% (CI = ±6.8) for American Indians/Alaska Natives, and 34.0% (CI = ±3.4) for Hispanics. Among states and areas, the median percentage-point difference in vaccination coverage from 2005-06 to 2006-07 among persons aged 50-64 years with identified high-risk conditions was 4.8 (range: -11.4 to 18.4) and among those without these conditions was 4.9 (range: -3.8 to 10.8) ( Table 2 ).

Among adults aged ≥65 years, influenza vaccination coverage was 72.1% for the 2006-07 season, ranging from 60.8% (Nevada) to 81.0% (Rhode Island) (median: 73.3%) ( Table 1 ). Coverage was significantly higher for non-Hispanic whites (74.2%) compared with other racial/ethnic groups (63.2%) as a whole. Coverage was 57.1% (CI = ±2.9) for non-Hispanic blacks, 83.3% (CI = ±8.8) for Asians, 63.1% (CI = ±7.4) for American Indians/Alaska Natives, and 61.4% (CI = ±4.9) for Hispanics. Compared with the 2005-06 season, the greatest racial/ethnic percentage-point increase was seen among Asians (19.3), with a smaller increase (2.3) among whites.[3] Overall, among states and areas, the median percentage-point difference in vaccination coverage from 2005-06 to 2006-07 among persons aged ≥65 years was 2.7 (range: -2.8-9.2). Increases in coverage were statistically significant in four regions and 13 states ( Table 2 ).

Influenza vaccination coverage has trended upward since the 1992-93 season, except for a drop in 2004-05 caused by an influenza vaccine shortage.[4] By the 2006-07 season, coverage had nearly returned to 2003-04 levels (Figure 1). Among adults aged 50-64 years without identified high-risk conditions, 2006-07 vaccination coverage increased 16.1 percentage points over the 2004-05 level, but was still 4.6 percentage points below the 2003-04 level. In comparison, vaccination coverage for adults ≥65 years had increased to within 1.4 percentage points of the 2003-04 level, and coverage for adults aged 18-49 years with identified high-risk conditions was 1.7 percentage points below the 2003-04 level.

Estimated influenza vaccination coverage among persons aged >18 years, by age and risk group -- United States, Behavioral Risk Factor Surveillance System (BRFSS), 1992-93 to 2006-07 influenza seasons*

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