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.

Methods

FluSurv-NET

The Influenza-Associated Hospitalization Surveillance Network (FluSurv-NET) has been previously described.^[5,7] Briefly, FluSurv-NET conducts all-age, population-based surveillance for laboratory-confirmed influenza-associated hospitalizations in selected states representing approximately 8%–9% of the U.S. population. Persons met the FluSurv-NET case definition if they resided in the FluSurv-NET catchment area,* were admitted to a hospital during October 1–April 30^† and received a positive influenza test result ≤14 days before hospitalization or during hospitalization. Cases in persons aged <18 years and cases from the 2020–21 season were excluded from this analysis because case counts during this season were too low to calculate rates by race and ethnicity.

Population denominators used for rate estimation were obtained from the National Center for Health Statistics.^§ Unadjusted rates, stratified by age group (18–49, 50–64, 65–74, and ≥75 years), race and ethnicity,^¶ and influenza season were calculated by dividing the number of hospitalizations by the total catchment population. Unadjusted rates by race, ethnicity, and age group were multiplied by the age distribution of the total FluSurv-NET catchment population to obtain age-adjusted rates; the age groups referenced previously were used for the age adjustment. For rates and rate ratios (RRs), 95% CIs were calculated assuming a simple random sample design and a normal distribution via the SAS STDRATE procedure. All analyses were conducted using SAS software (version 9.4; SAS Institute).

Influenza Vaccination Coverage

The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based random-digit–dialed cellular and landline telephone survey that collects information on various health conditions and risk behaviors from one randomly selected adult aged ≥18 years in a household.** BRFSS data for adults aged ≥18 years were analyzed to estimate influenza vaccination coverage for the 2010–11 through 2021–22 influenza seasons. The analysis includes data collected from interviews completed during September–June of each season and vaccine doses received during July–May. Respondents were asked if they had received an influenza vaccine in the past 12 months, and if so, in which month and year. Vaccination coverage estimates were calculated using Kaplan-Meier survival analysis, as previously described.^[6] For the 2021–22 season, for which more detailed data stratified by race and ethnicity and access to care variables are presented, vaccination coverage estimates are based on 291,839 completed interviews; 28,007 respondents were excluded from the analysis because there was no information on whether they had received an influenza vaccine in the past 12 months. The median state BRFSS response rate for a complete or partially complete interview was 42.5% for September–December 2021 and 45.4% for January–June 2022. All estimates were weighted and analyzed using SAS (version 9.4; SAS Institute) and SAS-callable SUDAAN (version 11.0.3; RTI International) statistical software to account for the complex survey design. Differences between estimates were determined using t-tests with p-values <0.05 considered statistically significant.

For each data system, activities were reviewed by CDC and were conducted consistent with applicable federal law and CDC policy.^†† Sites participating in FluSurv-NET obtained approval from their respective state and local institutional review boards, as applicable. The requirement for informed consent was waived per 45 CFR 46.

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*Emerging Infections Program sites include selected counties in California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee, and FluSurv-NET sites include selected counties in Idaho (2009–10 to 2010–11 only), Iowa (2009–10, 2012–13, 2020–21, and 2021–22 only), Michigan and North Dakota (2009–10 only), Ohio (2010–11 to 2021–22), Oklahoma (2009–10 to 2010–11 only), Rhode Island (2010–11 to 2012–13 only), South Dakota (2009–10 only) and Utah (2010–11 to 2021–22). Across these seasons, approximately 25–29 million persons (8%–9% of the U.S. population) were in the FluSurv-NET catchment area.
^†Period for the 2009–10 season was April 15, 2009, through April 30, 2010, and the period for 2021–22 was October 1, 2021, through June 11, 2022.
^§ https://www.cdc.gov/nchs/nvss/bridged_race.htm
^¶For FluSurv-NET data, race and ethnicity were categorized using the National Center for Health Statistics categories as non-Hispanic White, non-Hispanic Black, Hispanic or Latino, non-Hispanic Asian or Pacific Islander, and non-Hispanic American Indian or Alaska Native. Persons of more than one race or of unknown race were excluded from the FluSurv-NET analysis because population denominators were not available for these groups. Persons of any race (including unknown race) but of Hispanic ethnicity were classified as Hispanic. In 17% of included persons (across all seasons), ethnicity was unknown, but race was known; these persons were assumed to be of non-Hispanic ethnicity. In the 2017–18 season, race and ethnicity were collected on a stratified random sample of hospitalized adult influenza patients aged ≥50 years, so sampling weights were used to calculate the weighted number of hospitalizations by race and ethnicity that season. For BRFSS data, race and ethnicity were categorized similarly in the vaccination coverage analyses with two exceptions: 1) non-Hispanic persons reporting more than one race were categorized along with persons reporting Native Hawaiian/Other Pacific Islander and "other" race into a "Non-Hispanic other/multiple race" category; and 2) persons of unknown ethnicity or race were excluded from the analysis (2.8% of BRFSS respondents in the 2021–22 season).
**https://www.cdc.gov/brfss
^††45 CFR. part 46.102[l][2], 21 CFR part 56; 42 USC Sect. 241[d]; 5 USC Sect. 552a; 44 USC Sect. 3501 et seq.

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