Influenza Vaccination Coverage Among Pregnant Women — United States, 2016–17 Influenza Season

Helen Ding, MD; Carla L. Black, PhD; Sarah Ball, ScD; Rebecca V. Fink, MPH; Walter W. Williams, MD; Amy Parker Fiebelkorn, MSN, MPH; Peng-Jun Lu, MD, PhD; Katherine E. Kahn, MPH; Denise V. D'Angelo, MPH; Rebecca Devlin, MA; Stacie M. Greby, DVM

Disclosures

Morbidity and Mortality Weekly Report. 2017;66(38):1016-1022. 

In This Article

Abstract and Introduction

Introduction

Pregnant women and their infants are at increased risk for severe influenza-associated illness,[1] and since 2004, the Advisory Committee on Immunization Practices (ACIP) has recommended influenza vaccination for all women who are or might be pregnant during the influenza season, regardless of the trimester of the pregnancy.[2] To assess influenza vaccination coverage among pregnant women during the 2016–17 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28–April 7, 2017. Among 1,893 survey respondents pregnant at any time during October 2016–January 2017, 53.6% reported having received influenza vaccination before (16.2%) or during (37.4%) pregnancy, similar to coverage during the preceding four influenza seasons. Also similar to the preceding influenza season, 67.3% of women reported receiving a provider offer for influenza vaccination, 11.9% reported receiving a recommendation but no offer, and 20.7% reported receiving no recommendation; among these women, reported influenza vaccination coverage was 70.5%, 43.7%, and 14.8%, respectively. Among women who received a provider offer for vaccination, vaccination coverage differed by race/ethnicity, education, insurance type, and other sociodemographic factors. Use of evidence-based practices such as provider reminders and standing orders could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.*

Since 2011, an Internet panel survey has been conducted for CDC by Abt Associates, Inc. (Cambridge, Massachusetts) at the beginning of each April to provide end-of-season estimates of influenza vaccination coverage among pregnant women and assess factors associated with vaccination. The Internet panel and survey methodology have been described previously.[3] The 2016–17 survey was conducted during March 28–April 7, 2017, among women aged 18–49 years who reported being pregnant at any time since August 1, 2016. Among 10,734 women who entered the survey site, 2,399 were eligible and 2,319 completed the survey (a cooperation rate of 96.7%).§ Data were weighted to reflect the age, race/ethnicity, and geographic distribution of the total U.S. population of pregnant women. A woman was considered to be vaccinated for the 2016–17 season if she reported receiving vaccination before or during her most recent pregnancy since July 1, 2016. Analysis was limited to 1,893 women who reported being pregnant any time during the peak influenza vaccination period (October 2016–January 2017). A difference was noted as an increase or decrease when a ≥5 percentage-point difference occurred between any values being compared.

Influenza vaccination coverage among pregnant women in 2016–17 was similar to coverage during the previous four seasons (Figure). Among women pregnant during the 2016–17 influenza season, 53.6% reported receiving influenza vaccination before (16.2%) or during (37.4%) pregnancy since July 1, 2016 (Table 1). Coverage among women aged 18–24 years (41.7%) was lower than coverage among women aged 25–34 years (58.4%) and 35–49 years (58.5%). Coverage among Hispanic women (61.2%) was higher than that among non-Hispanic white (white) women (55.4%) and non-Hispanic black (black) women (42.3%); these differences were not observed during the 2015–16 season. Higher vaccination coverage was found among women with higher level of education, married women, women with private or military insurance, working women, women at or above poverty level, women with a high-risk condition, women with positive attitude toward vaccination effectiveness or safety, and women who were concerned about influenza infection, similar to the 2015–16 season.

Figure.

Prevalence of provider recommendation for and offer of influenza vaccination* and influenza vaccination coverage† among women pregnant any time during October–January — Internet panel survey, United States, 2010–11 through 2016–17 influenza seasons
*Among women who reported having at least one visit to a provider since July.
Vaccination coverage estimates for the 2012−13 through 2016−17 influenza seasons were based on vaccination given from July to mid-April; coverage estimates for the 2010−11 and 2011−12 influenza seasons were based on vaccination given from August to mid-April.

The proportion of women who reported receiving a provider recommendation for and offer** of vaccination was 67.3% in the 2016–17 season, similar to that during the past four seasons (Figure). During both the 2015–16 and 2016–17 seasons, women who reported receiving both a provider recommendation for and offer of influenza vaccination had higher vaccination coverage (63.4% [2015–16] and 70.5% [2016–2017]) compared with women who reported receiving a provider recommendation but no offer†† (37.5% and 43.7%) and women who reported receiving no recommendation for vaccination§§ (12.8% and 14.8%) (Table 1); this pattern was observed among all age groups, racial/ethnic groups, levels of education, marital status, some level of insurance coverage, poverty status, number of health care visits, presence or absence of a high-risk condition, attitudes regarding efficacy and safety of influenza vaccine, and concern about influenza infection (Table 2). An increased number of provider visits since July 2016 was associated with both an increase in women's report of receiving a provider recommendation and an increase in vaccination coverage estimates (65.7% [1–5 visits]; 70.9% [6–10 visits]; 72.1% ["10 visits]). Women in the following subgroups reported receiving a provider recommendation for and offer of vaccination less frequently than did women in the reference category of each stratum: aged 18–24 years, with a college degree, without medical insurance, without a high-risk condition other than pregnancy, with a negative attitude toward influenza vaccination effectiveness or safety, or not concerned about influenza infection (Table 2).

Vaccination coverage differed within some subgroups that reported similar proportions of receipt of a provider recommendation for and offer of vaccination. For example, although 68%–69% of insured women reported being offered vaccination, coverage was 74.7% among women with private or military insurance and 63.9% among women with public insurance. Differences in coverage among women who were offered vaccination were also observed between white and black women and women with more than a college degree and those with a college degree or less (Table 2). Among insured women who were offered vaccination, a higher proportion of publically insured women were younger (18–24 years), black, had less than a college degree, and lived below the poverty threshold compared with privately insured women.

Among the 221 (11.9%) women who reported that their provider recommended but did not offer vaccination, 114 (51.0%) received a referral¶¶ to go somewhere else to be vaccinated; 36.7% of the women receiving a referral were vaccinated, compared with only 12.5% of women who received a provider recommendation but no offer or referral.

*Guide to Community Preventive Services: Vaccination; https://www.thecommunityguide.org/topic/vaccination.
Additional information on the online survey and incentives for participants is available at https://www.surveysampling.com.
§An opt-in Internet panel survey is a nonprobability sampling survey. The denominator for a response rate calculation cannot be determined because no sampling frame with a selection probability is involved at the recruitment stage. Instead, the survey cooperation rate is provided.
Additional information on obstacles to inference in nonprobability samples is available at http://www.aapor.org/Education-Resources/Reports/Non-Probability-Sampling.aspx.
**"Recommendation and offer" is based on a "yes" response to the question "Since July 2016, during any of your visits to a doctor, nurse, or medical professional, did any of these medical professionals offer to give you a flu vaccination during a visit?"
††"Recommendation but no offer" is based on a "yes" response to the question "Since July 2016, during any of your visits to a doctor, nurse, or other medical professional, did any of these medical professionals recommend that you get a flu vaccination or tell you that you needed a flu vaccination?" and a "no" response to the question "Since July 2016, during any of your visits to a doctor, nurse, or medical professional, did any of these medical professionals offer to give you a flu vaccination during a visit?"
§§"No recommendation" is based on a "no" response to the questions "Since July 2016, during any of your visits to a doctor, nurse, or other medical professional, did any of these medical professionals recommend that you get a flu vaccination or tell you that you needed a flu vaccination?" and "Since July 2016, during any of your visits to a doctor, nurse, or medical professional, did any of these medical professionals offer to give you a flu vaccination during a visit?"
¶¶Referral is defined based on a "yes" response to the question "Did any doctor, nurse, or medical professional suggest that you go someplace else to get the flu vaccination?"

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