Vital Signs

Influenza Hospitalizations and Vaccination Coverage by Race and Ethnicity

United States, 2009-10 Through 2021-22 Influenza Seasons

Carla L. Black, PhD; Alissa O'Halloran, MSPH; Mei-Chuan Hung, PhD; Anup Srivastav, PhD; Peng-jun Lu, MD, PhD; Shikha Garg, MD; Michael Jhung, MD; Alicia Fry, MD; Tara C. Jatlaoui, MD; Elizabeth Davenport, MPH; Erin Burns, MA

Disclosures

Morbidity and Mortality Weekly Report. 2022;71(43):1366-1373.

Abstract and Introduction

Abstract

Introduction: CDC estimates that influenza resulted in 9–41 million illnesses, 140,000–710,000 hospitalizations, and 12,000–52,000 deaths annually during 2010–2020. Persons from some racial and ethnic minority groups have historically experienced higher rates of severe influenza and had lower influenza vaccination coverage compared with non-Hispanic White (White) persons. This report examines influenza hospitalization and vaccination rates by race and ethnicity during a 12–13-year period (through the 2021–22 influenza season).

Methods: Data from population-based surveillance for laboratory-confirmed influenza-associated hospitalizations in selected states participating in the Influenza-Associated Hospitalization Surveillance Network (FluSurv-NET) from the 2009–10 through 2021–22 influenza seasons (excluding 2020–21) and influenza vaccination coverage data from the Behavioral Risk Factor Surveillance System (BRFSS) from the 2010–11 through 2021–22 influenza seasons were analyzed by race and ethnicity.

Results: From 2009–10 through 2021–22, age-adjusted influenza hospitalization rates (hospitalizations per 100,000 population) were higher among non-Hispanic Black (Black) (rate ratio [RR] = 1.8), American Indian or Alaska Native (AI/AN; RR = 1.3), and Hispanic (RR = 1.2) adults, compared with the rate among White adults. During the 2021–22 season, influenza vaccination coverage was lower among Hispanic (37.9%), AI/AN (40.9%), Black (42.0%), and other/multiple race (42.6%) adults compared with that among White (53.9%) and non-Hispanic Asian (Asian) (54.2%) adults; coverage has been consistently higher among White and Asian adults compared with that among Black and Hispanic adults since the 2010–11 season. The disparity in vaccination coverage by race and ethnicity was present among those who reported having medical insurance, a personal health care provider, and a routine medical checkup in the past year.

Conclusions and Implications for Public Health Practice: Racial and ethnic disparities in influenza disease severity and influenza vaccination coverage persist. Health care providers should assess patient vaccination status at all medical visits and offer (or provide a referral for) all recommended vaccines. Tailored programmatic efforts to provide influenza vaccination through nontraditional settings, along with national and community-level efforts to improve awareness of the importance of influenza vaccination in preventing illness, hospitalization, and death among racial and ethnic minority communities might help address health care access barriers and improve vaccine confidence, leading to decreases in disparities in influenza vaccination coverage and disease severity.

Introduction

Influenza is a contagious respiratory disease that can lead to serious illness, hospitalization, and death. CDC estimates that influenza resulted in 9–41 million illnesses, 140,000–710,000 hospitalizations, and 12,000–52,000 deaths annually during 2010–2020.^[1,2] Annual vaccination against seasonal influenza is recommended for all persons aged ≥6 months except when contraindicated.^[3] Vaccination provides important protection from influenza illness and its potential complications. For example, during the 2019–20 season, influenza vaccination prevented an estimated 7.5 million influenza illnesses, 105,000 influenza-associated hospitalizations, and 6,300 influenza-associated deaths.^[4] Persons from some racial and ethnic minority groups experience higher rates of severe influenza and have lower influenza vaccination coverage rates compared with White persons.^[5,6] This report presents 1) influenza hospitalization rates by race and ethnicity from the 2009–10 through 2021–22 seasons; 2) trends in influenza vaccination coverage by race and ethnicity from the 2010–11 through 2021–22 seasons; and 3) influenza vaccination coverage stratified by race and ethnicity and health care access variables for the 2021–22 season and possible reasons for observed disparities.

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Abstract and Introduction
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Table. Influenza vaccination coverage, by race and ethnicity and demographic and access-to-care variables — Behavioral Risk Factor Surveillance System, United States, 2021–22 influenza season*
Characteristic	Race or ethnicity^†
	Overall		White		Black		Hispanic		Asian		AI/AN		Other/Multiple races
	Sample no. (weighted %)	Influenza vaccination coverage % (95% CI)	Sample no. (weighted %)	Influenza vaccination coverage, % (95% CI)	Sample no. (weighted %)	Influenza vaccination coverage, % (95% CI)	Sample no. (weighted %)	Influenza vaccination coverage, % (95% CI)	Sample no. (weighted %)	Influenza vaccination coverage, % (95% CI)	Sample no. (weighted %)	Influenza vaccination coverage, % (95% CI)	Sample no. (weighted %)	Influenza vaccination coverage, % (95% CI)
Overall	319,846 (100.0)	49.4 (49.0–49.9)	239,619 (63.6)	53.9 (53.4–54.4)	25,046 (12.2)	42.0 (40.6–43.6)^§	25,032 (15.6)	37.9 (36.3–39.5)^§	8,035 (4.1)	54.2 (51.5–57.0)	5,250 (1.1)	40.9 (37.0–45.1)^§	9,095 (3.4)	42.6 (39.8–45.5)^§
Age group, yrs
18−49	116,719 (52.9)	37.1 (36.5–37.8)^¶	75,723 (45.1)	39.6 (38.9–40.4)^¶	9,969 (55.5)^§	29.4 (27.5–31.3)^§,¶	16,024 (72.5)^§	32.0 (30.2–33.9)^§,¶	5,212 (78.9)^§	52.1 (48.9–55.4)^§,¶	2,279 (56.5)^§	32.5 (27.5–38.1)^§,¶	4,750 (68.4)^§	37.1 (33.5–40.9)^¶
50−64	85,144 (24.6)	52.4 (51.5–53.3)^¶	64,980 (26.7)	54.2 (53.2–55.3)^¶	7,319 (26.6)	50.5 (47.8–53.2)^§,¶	5,559 (18.4)^§	47.0 (43.5–50.7)^§,¶	1,506 (14.2)^§	55.5 (49.6–61.5)^§	1,692 (27.7)	40.5 (34.2–47.4)^§,¶	2,156 (18.1)^§	45.5 (40.7–50.6)^§,¶
≥65 (Ref)	117,983 (22.5)	73.9 (73.1–74.8)	98,916 (28.2)	75.7 (74.8–76.5)	7,758 (17.9)^§	67.8 (64.4–71.1)^§	3,449 (9.1)^§	65.2 (60.5–69.9)^§	1,317 (7.0)^§	79.4 (74.4–84.0)	1,279 (15.8)^§	76.4 (65.7–85.8)	2,189 (13.5)^§	68.8 (62.6–74.8)^§
High-risk condition (among persons aged 18–64 yrs)**
Yes (Ref)	53,244 (24.4)	50.4 (49.3–51.6)	37,567 (25.1)	52.6 (51.2–53.9)	5,189 (28.2)^§	47.0 (43.7–50.4)^§	4,852 (21.5)^§	46.6 (43.1–50.3)^§	1,001 (12.7)^§	53.6 (46.6–60.9)	1,398 (32.2)^§	43.8 (36.1–52.3)^§	2,039 (26.3)^§	46.0 (40.4–52.0)^§
No	145,674 (75.6)	39.4 (38.8–40.1)^¶	101,444 (74.9)	42.6 (41.9–43.3)^¶	11,829 (71.8)^§	32.2 (30.4–34.1)^§,¶	16,274 (78.5)^§	32.3 (30.5–34.2)^§,¶	5,545 (87.3)^§	52.5 (49.4–55.7)^§	2,497 (67.8)^§	31.7 (27.2–36.7)^§,¶	4,734 (73.7)	36.8 (33.1–40.7)^§,¶
Education level
High school or less	98,563 (39.8)	40.4 (39.5–41.2)^¶	67,326 (35.0)	43.8 (42.8–44.9)^¶	9,455 (45.3)^§	38.5 (36.1–41.0)^§,¶	12,796 (58.9)^§	32.9 (30.9–35.0)^§,¶	1,379 (21.4)^§	50.1 (43.5–57.0)	2,273 (50.9)^§	36.6 (31.2–42.7)^§,¶	2,976 (38.8)^§	32.5 (28.2–37.2)^§,¶
Some college or technical school	88,077 (23.8)	47.5 (46.6–48.4)^¶	66,866 (24.2)	50.2 (49.2–51.1)^¶	7,082 (25.3)^§	43.7 (40.6–46.8)^§	5,850 (21.0)^§	41.6 (38.0–45.3)^§,¶	1,482 (16.8)^§	49.5 (43.5–55.8)^¶	1,724 (29.1)^§	43.8 (37.2–51.0)	2,970 (28.1)^§	42.0 (36.7–47.7)^§,¶
College (Ref)	132,098 (36.5)	60.2 (59.5–60.9)	104,892 (40.8)	64.6 (63.8–65.4)	8,425 (29.4)^§	46.0 (43.7–48.3)^§	6,232 (20.0)^§	47.2 (44.1–50.3)^§	5,122 (61.8)^§	57.1 (53.7–60.5)^§	1,237 (20.0)^§	49.2 (39.7–59.6)^§	3,122 (33.1)^§	55.2 (50.5–59.9)^§
U.S. Census Bureau Region^††
Northeast (Ref)	68,359 (19.4)	55.5 (54.4–56.6)	52,959 (19.9)	60.2 (58.9–61.6)	3,791 (17.2)^§	45.0 (41.4–48.7)^§	5,869 (18.3)^§	43.4 (40.4–46.5)^§	1,935 (25.5)^§	55.4 (51.2–59.8)^§	412 (10.9)^§	43.5 (29.8–60.1)^§	1,538 (14.7)^§	56.5 (48.8–64.4)
Midwest	84,306 (22.9)	51.3 (50.5–52.2)^¶	69,655 (27.8)	54.1 (53.2–55.1)^¶	4,427 (16.8)^§	42.3 (39.0–45.7)^§	3,828 (10.7)^§	38.9 (35.4–42.5)^§	1,222 (16.6)^§	53.3 (48.0–58.7)	1,793 (20.9)^§	45.9 (37.4–55.4)	1,704 (18.8)^§	38.2 (32.6–44.5)^§,¶
South	93,057 (38.8)	45.5 (44.7–46.3)^¶	63,694 (35.5)	50.5 (49.6–51.4)^¶	15,506 (58.8)^§	41.5 (39.6–43.5)^§	6,649 (40.7)^§	33.8 (31.3–36.5)^§,¶	1,510 (26.4)^§	52.7 (46.3–59.4)	1,132 (40.7)^§	35.2 (29.1–42.0)^§	2,366 (36.2)	37.3 (32.6–42.5)^§,¶
West	74,124 (19.0)	49.4 (48.3–50.5)^¶	53,311 (16.9)	53.8 (52.6–55.0)^¶	1,322 (7.1)^§	37.3 (31.4–44.0)^§,¶	8,686 (30.3)^§	40.4 (37.4–43.5)^§	3,368 (31.4)^§	54.7 (49.7–60.0)	1,913 (27.5)^§	45.4 (39.0–52.2)^§	3,487 (30.3)^§	46.9 (42.4–51.7)^§,¶
Medical insurance
Yes (Ref)	291,594 (91.5)	52.7 (52.2–53.2)	223,925 (95.2)	56.2 (55.7–56.8)	22,374 (91.9)^§	44.3 (42.7–45.9)^§	18,676 (75.4)^§	43.5 (41.7–45.5)^§	7,314 (95.4)	57.0 (54.1–59.9)	4,636 (90.8)^§	44.8 (40.4–49.4)^§	8137 (91.6)^§	45.6 (42.6–48.7)^§
No	16,195 (8.5)	17.6 (16.2–19.1)^¶	7,985 (4.8)	13.9 (12.4–15.5)^¶	1,401 (8.1)^§	18.1 (14.5–22.5)^¶	5,130 (24.6)^§	21.2 (18.5–24.2)^§,¶	285 (4.6)	22.0 (14.7–32.2)^¶	381 (9.2)^§	8.7 (5.2–14.4)^§,¶	541 (8.4)^§	17.8 (8.2–36.0)^¶
Personal health care provider
Yes (Ref)	278,538 (82.8)	54.8 (54.2–55.3)	214,307 (87.0)	58.3 (57.8–58.9)	21,966 (84.2)^§	45.9 (44.2–47.5)^§	17,730 (67.4)^§	46.1 (44.1–48.1)^§	6,499 (77.7)^§	59.2 (56.1–62.4)	4,174 (77.5)^§	45.1 (40.4–50.0)^§	7,542 (78.9)^§	48.3 (45.3–51.4)^§
No	38,567 (17.2)	23.9 (22.8–24.9)^¶	23,624 (13.0)	24.9 (23.7–26.1)^¶	2,856 (15.8)^§	21.9 (18.5–25.8)^¶	7,004 (32.6)^§	20.7 (18.4–23.1)^§,¶	1,365 (22.3)^§	36.9 (32.1–42.2)^§,¶	1,001 (22.5)^§	25.9 (19.9–33.3)^¶	1,453 (21.1)^§	23.4 (16.8–32.1)^¶
Yrs since last routine checkup
<1 (Ref)	251,361 (76.1)	56.6 (56.0–57.1)	190,656 (77.1)	61.2 (60.6–61.8)	21,124 (82.2)^§	46.2 (44.6–48.0)^§	17,388 (69.9)^§	46.1 (44.1–48.1)^§	5,775 (70.5)^§	60.6 (57.3–64.0)	3,929 (73.2)^§	48.7 (43.8–53.8)^§	6,643 (71.4)^§	49.7 (46.3–53.2)^§
≥1	62,589 (23.9)	28.4 (27.6–29.3)^¶	45,183 (22.9)	30.8 (29.9–31.8)^¶	3,572 (17.8)^§	23.0 (20.1–26.3)^§,¶	6,810 (30.1)^§	21.7 (19.6–24.1)^§,¶	1,998 (29.5)^§	39.9 (35.2–45.0)^§,¶	1,177 (26.8)^§	23.8 (17.8–31.3)^§,¶	2,239 (28.6)^§	27.6 (22.6–33.3)^¶

Abbreviations: AI/AN = American Indian or Alaska Native; Ref = referent group.
*Data from respondents interviewed during September 2021–June 2022 were analyzed to estimate influenza vaccination received during July 2021–May 2022. Influenza vaccination coverage estimates are based on a sample size of 291,839; 28,007 respondents were excluded from analyses of vaccination coverage because of missing influenza vaccination status.
^†White, Black, Asian, AI/AN, and other/multiple race persons are non-Hispanic; Hispanic persons could be of any race.
^§p<0.05 when compared with non-Hispanic White (column comparisons).
^¶p<0.05 when compared with referent category (row comparisons).
**Includes people with asthma, diabetes, heart disease, chronic obstructive pulmonary disease, or cancers other than skin cancer.
^††https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf