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


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

In This Article


Racial and ethnic disparities in influenza-associated hospitalizations were consistently observed among Black, AI/AN, and Hispanic adults compared with White adults, with hospitalization rates an average of 1.2 to 1.8 times those in White adults during the past 13 seasons. Similar disparities have been observed for COVID-19 hospitalizations.[8] The reasons for these disparities in severe respiratory disease are likely multifactorial. Influenza vaccination coverage continues to be lower among Black, AI/AN, and Hispanic adults compared with coverage among White and Asian adults. Distrust of the medical system, misperceptions about vaccine safety, and higher levels of concern about side effects have contributed to lower coverage.[9] Members of racial and ethnic minority groups might face barriers to affordable, quality health care, including access to health insurance, transportation to health providers, and child care; therefore, they might have fewer opportunities for preventive health care and increased vulnerability to chronic medical conditions.[10] Higher prevalences of chronic medical conditions have been independently associated with more severe influenza outcomes,[11,12] and downstream effects of structural racism have been demonstrated to affect economic stability, housing, and education.[10,13,14] In addition, poverty, crowded housing, and community exposure to respiratory diseases are associated with more severe influenza disease.[15,16]

In contrast to the decline in influenza vaccination observed among children during the COVID-19 pandemic,[6] recent coverage among adults has not decreased compared with prepandemic estimates. However, longstanding disparities in coverage by race and ethnicity remain. The finding that adults of some minority racial and ethnic groups were less likely than White adults to have medical insurance and a personal health care provider suggests that access to influenza vaccination likely plays a role in lower coverage among these groups. Racial and ethnic disparities in COVID-19 vaccination coverage that were evident early in the COVID-19 vaccination program have decreased or been eliminated over time, likely related to efforts by immunization programs to provide equitable access to COVID-19 vaccination, such as making vaccines available free of charge at varied and nontraditional locations.[17,18] However, disparities in COVID-19 booster vaccination are now evident, and differences in influenza vaccination coverage within most socioeconomic and access-to-care strata suggest that in addition to access limitations, other factors contributed to disparities in coverage. A provider recommendation and offer of vaccination is strongly associated with vaccination.[19] BRFSS does not collect information on receipt of provider recommendations or offers of vaccination; however, variables such as having a medical checkup in the past year and having a personal health care provider can serve as proxies for these data. Overall, adults who reported having a medical checkup in the past year were twice as likely to be vaccinated as those who did not. Hispanic, AI/AN, and multiracial and adults of other races were less likely than were White adults to report having a personal health care provider and a routine medical checkup in the past 12 months. Moreover, even among Black, Hispanic, AI/AN, and multiracial and adults of other races who reported a recent medical checkup, influenza vaccination coverage was <50% and was also lower than coverage among White adults with a recent medical checkup, suggesting that missed opportunities for influenza vaccination occurred during these visits. Following the standards for adult immunization practice, providers should assess patient vaccination status at all medical visits and offer (or provide a referral for) all recommended vaccines.[20] Meeting this standard in a culturally responsive manner could help reduce observed disparities in vaccination coverage.

Programmatic efforts and communication campaigns, such as Partnering for Vaccine Equity: Equity in Adult vaccination, that have brought COVID-19 vaccines to communities through nontraditional settings (local libraries, local businesses [e.g., barber shops/salons, thrift stores, restaurants, and grocery stores], and school-based events) likely contributed to decreased disparities in COVID-19 vaccination and might also decrease disparities in influenza vaccination.§§ Surveys collected after 2 years of a tailored vaccination campaign¶¶ collaboratively led by the Ad Council, the American Medical Association, and CDC indicated that concerns about influenza vaccine risks or side effects were reduced from 43% to 33% among Black adults and from 41% to 32% among Hispanic adults.

The findings in this report are subject to at least seven limitations. First, because FluSurv-NET surveillance is conducted in selected counties within the United States, findings might not represent the entire U.S. population. Second, influenza-associated hospitalizations reported to FluSurv-NET are identified by clinician-directed testing; hospitalization rates might be underestimated, as they have not been adjusted for testing practices, which differ by surveillance site, age group, and timing during influenza seasons[2] and might also vary by race and ethnicity. Third, within FluSurv-NET data, approximately 17% of persons were missing ethnicity and were classified based only on their reported race; 7% were missing race. Fourth, weighting adjustments for BRFSS survey data used to assess influenza vaccination coverage might not eliminate all possible bias from incomplete sample frame because households with no telephones are excluded. Fifth, survey response rates were low, and influenza vaccination coverage might differ between survey respondents and nonrespondents; survey weighting adjustments might not adequately control for these differences. Sixth, influenza vaccination status was self-reported and subject to recall error and social desirability bias. Finally, errors in BRFSS data from incomplete sample frame, nonresponse, and accuracy of reported influenza vaccination status might change over time, which could lead to inaccurate assessment of trends in vaccination coverage.

The findings in this report highlight persistent disparities in influenza disease severity among adults in some racial and ethnic minority groups during 2009–2022, as well as continued disparities in influenza vaccination coverage among adults during the same period. Increasing influenza vaccination coverage among racial and ethnic minorities could reduce disparities in the risk for severe disease. National, state, and community-level efforts to build trust, increase access to vaccination services, and combat misinformation among racial and ethnic minority communities are important actions for increasing vaccination coverage in these groups. Interventions that support and promote partnerships at the community level to effectively reduce racial and ethnic disparities in influenza vaccination include creating and training (or partnering with) a network of local community trusted messengers reflecting the communities served; using trusted messengers to address misinformation and promote accurate, culturally responsive vaccine messages, including through social media; and working with culturally competent health care providers to provide a strong recommendation for influenza vaccination. National, tailored influenza vaccination campaigns can reinforce local efforts to increase awareness of the importance of influenza vaccination among target audiences to encourage increased vaccination coverage among these groups.