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.

Results

From 2009–10 through 2021–22 (excluding 2020–21), age-adjusted influenza-associated hospitalization rates per 100,000 population among adults, by race and ethnicity were as follows: Black, 78.2; AI/AN, 54.6; Hispanic, 50.3; White, 43.0; and Asian or Pacific Islander (API), 34.5 (Figure 1). Compared with age-adjusted rates among White adults, rates were higher among Black (RR = 1.8), AI/AN (RR = 1.3), and Hispanic adults (RR = 1.2) (Supplementary Table, https://stacks.cdc.gov/view/cdc/121713) with some variation by influenza season. During most influenza seasons, age-adjusted hospitalization rates were highest among Black adults, ranging from 1.5 to 2.4 times the rates among White adults. During the 2011–2012 and 2021–22 seasons, the highest influenza-associated hospitalization rates were among AI/AN adults, with age-adjusted rates 2.7 times those in White adults. Age-adjusted hospitalization rates among Hispanic adults were 2.1 times those among White adults in 2009–10 and 2021–22 (Figure 2) (Supplementary Table, https://stacks.cdc.gov/view/cdc/121713). In every season except 2011–12, API adults had the lowest hospitalization rates among all racial and ethnic groups, from 60% to 90% of those among White adults.

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Figure 1.

Age-adjusted Influenza-associated hospitalization rates* among adults aged ≥18 years, by race and ethnicity — Influenza-Associated Hospitalization Surveillance Network, United States, 2009–10 through 2021–22^†
Abbreviations: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander; NH = non-Hispanic.
*Hospitalizations per 100,000 population.
^†Excluding 2020–21 season.

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Figure 2.

Age-adjusted Influenza-associated hospitalization rates among adults, by race and ethnicity and influenza season — Influenza-Associated Hospitalization Surveillance Network, United States, 2009–10 through 2019–20 and 2021–22*
Abbreviations: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander; NH = non-Hispanic.
*Data for 2020–21 season are not included.

Overall vaccination coverage in the 2021–22 influenza season was 49.4% among adults aged ≥18 years and varied by race and ethnicity. Coverage was higher among White adults (53.9%) than among AI/AN (40.9%), Hispanic (37.9%), Black (42.0%), and multiracial and adults of other races (42.6%) and was similar to that among Asian adults (54.2%) (Table). From the 2010–11 through 2021–22 seasons, overall adult influenza vaccination coverage increased from 40.5% to 49.4% and increased within all racial and ethnic groups except AI/AN adults (Figure 3). Between the 2020–21 and 2021–22 seasons, coverage decreased among all adults by 0.8 percentage points and among White adults by 1.6 percentage points. In all other racial and ethnic groups, coverage was stable during the 2018–19 through 2021–22 influenza seasons. Since the 2010–11 influenza season, coverage has been consistently higher among White and Asian adults compared with that among Black and Hispanic adults.

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Figure 3.

Influenza vaccination coverage among adults aged ≥18 years, by race and ethnicity and influenza season — Behavioral Risk Factor Surveillance System, United States, 2010–11 through 2021–22
Abbreviations: AI/AN = American Indian or Alaska Native; NH = non-Hispanic.

During the 2021–22 influenza season, vaccination coverage among all racial and ethnic groups was higher among adults aged ≥65 years than among younger adults and among the following groups: those with medical insurance compared with those without medical insurance; those who had a personal health care provider compared with those without a personal health care provider; and those who had had a routine medical checkup in the past year compared with those who had not. However, compared with White adults, Hispanic adults were less likely to have medical insurance, and Hispanic, AI/AN, and multiracial and adults of other races were less likely to have a personal health care provider and a medical checkup in the past year. In addition, among adults with medical insurance, a personal health care provider, and a routine medical checkup in the past year, and in most age and education strata, influenza vaccination coverage was higher among White adults than among Black, Hispanic, AI/AN, and multiracial and adults of other races (Table).

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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