Influenza and Tdap Vaccination Coverage Among Pregnant Women - United States, April 2020.

Vaccination of pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can decrease the risk for influenza and pertussis among pregnant women and their infants. The Advisory Committee on Immunization Practices (ACIP) recommends that all women who are or might be pregnant during the influenza season receive influenza vaccine, which can be administered at any time during pregnancy (1). ACIP also recommends that women receive Tdap during each pregnancy, preferably during the early part of gestational weeks 27-36 (2,3). Despite these recommendations, vaccination coverage among pregnant women has been found to be suboptimal with racial/ethnic disparities persisting (4-6). To assess influenza and Tdap vaccination coverage among women pregnant during the 2019-20 influenza season, CDC analyzed data from an Internet panel survey conducted during April 2020. Among 1,841 survey respondents who were pregnant anytime during October 2019-January 2020, 61.2% reported receiving influenza vaccine before or during their pregnancy, an increase of 7.5 percentage points compared with the rate during the 2018-19 season. Among 463 respondents who had a live birth by their survey date, 56.6% reported receiving Tdap during pregnancy, similar to the 2018-19 season (4). Vaccination coverage was highest among women who reported receiving a provider offer or referral for vaccination (influenza = 75.2%; Tdap = 72.7%). Compared with the 2018-19 season, increases in influenza vaccination coverage were observed during the 2019-20 season for non-Hispanic Black (Black) women (14.7 percentage points, to 52.7%), Hispanic women (9.9 percentage points, to 67.2%), and women of other non-Hispanic (other) races (7.9 percentage points, to 69.6%), and did not change for non-Hispanic White (White) women (60.6%). As in the 2018-19 season, Hispanic and Black women had the lowest Tdap vaccination coverage (35.8% and 38.8%, respectively), compared with White women (65.5%) and women of other races (54.0%); in addition, a decrease in Tdap vaccination coverage was observed among Hispanic women in 2019-20 compared with the previous season. Racial/ethnic disparities in influenza vaccination coverage decreased but persisted, even among women who received a provider offer or referral for vaccination. Consistent provider offers or referrals, in combination with conversations culturally and linguistically tailored for patients of all races/ethnicities, could increase vaccination coverage among pregnant women in all racial/ethnic groups and reduce disparities in coverage.

Vaccination differences among U.S. adults by their self-identified sexual orientation, National Health Interview Survey, 2013-2015.

INTRODUCTION: Very few studies have explored the associations between self-identified sexual orientation and comprehensive vaccination coverage. Most of the previous studies that reported health disparities among lesbian, gay and bisexual populations were not based on a nationally representative sample of U.S. adults, limiting the generalizability of the findings. Starting in 2013, the National Health Interview Survey (NHIS) included questions to ascertain the adult's self-identified sexual orientation that allowed national level vaccination estimation by sexual orientation. This study examined associations of self-reported vaccination coverage for selected vaccines among U.S. adults by their sexual orientation. METHODS: We analyzed combined data from 2013-2015 NHIS, a nationally representative probability-based health survey of the noninstitutionalized U.S. population ≥18 years. For vaccines other than influenza, weighted proportions were calculated. Influenza coverage was calculated using the Kaplan-Meier procedure. Multivariable logistic regression models were used to calculate adjusted prevalence differences for each vaccine overall and stratified by sexual orientation and to identify factors independently associated with vaccination. RESULTS: Significant differences were observed by sexual orientation for self-reported receipt of human papillomavirus (HPV), hepatitis A (HepA), hepatitis B (HepB), and influenza vaccination. Bisexual females (51.6%) had higher HPV coverage than heterosexual females (40.2%). Gay males (40.3% and 53.6%, respectively) had higher HepA and HepB coverage than heterosexual males (25.4% and 32.6%, respectively). Bisexual females (33.9% and 58.5%, respectively) had higher HepA and HepB coverage than heterosexual females (23.5% and 38.4%, respectively) and higher HepB coverage than lesbian females (45.4%). Bisexual adults (34.1%) had lower influenza coverage than gay/lesbian (48.5%) and heterosexual adults (43.8%). Except for the association of having self-identified as gay/lesbian orientation with greater likelihood of HepA, HepB, and influenza vaccination, sexual orientation was not associated with higher or lower likelihood of vaccination. Health status or other behavioral characteristics studied had no consistent relationship with vaccination among all populations. CONCLUSION: Differences were identified in vaccination coverage among the U.S. adult population by self-reported sexual orientation. This study is the first to assess associations of sexual orientation with a comprehensive list of vaccinations. Findings from this study can serve as a baseline for monitoring changes over time. All populations could benefit from improved vaccination.

Influenza Vaccination Coverage Among Pregnant Women in the U.S., 2012-2015.

INTRODUCTION: Pregnant women are at increased risk for severe illness from influenza and influenza-related complications. Vaccinating pregnant women is the primary strategy to protect them and their infants from influenza. This study aims to assess influenza vaccination coverage during three influenza seasons (2012-2015) from a national probability-based sampling survey and evaluate potential factors that influence vaccination uptake among pregnant women. METHODS: Data from the 2012 through 2015 National Health Interview Surveys were analyzed in 2017. Pregnant women aged 18-49 years were included in the analysis. The Kaplan-Meier survival analysis procedure was used for vaccination coverage in each season. Bivariate and multivariable logistic regression analyses were performed to examine factors associated with vaccination. Adjusted vaccination coverage and adjusted prevalence ratios are reported with corresponding 95% CIs. RESULTS: In the 2012-2013, 2013-2014, and 2014-2015 influenza seasons, 40.4%, 45.4%, and 43.1% of pregnant women were vaccinated, respectively. Multivariable analysis indicated that factors independently associated with a lower likelihood of vaccination included having only a high school education, having three or less provider visits, and having no usual place of care (p<0.05). Less than half of women with ten or more visits were vaccinated (48.6%). CONCLUSIONS: Vaccination coverage among pregnant women from this nationally representative sample was suboptimal during recent influenza seasons. Vaccination coverage was lower among certain sociodemographic, access-to-care subgroups. Multifactorial vaccination barriers may exist. Interventions, such as assessing vaccination history at every visit and implementing reminder-recall systems, standing orders, and addressing vaccination hesitancy, are needed to increase vaccination uptake among pregnant women.

Influenza Vaccination Coverage Among English-Speaking Asian Americans.

INTRODUCTION: English-speaking non-Hispanic Asians (Asians) in the U.S. include populations with multiple geographic origins and ethnicities (e.g., Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese). Health behaviors and outcomes can differ widely among Asian ethnicities, and highlight the importance of subgroup analysis. Aggregating Asians may mask differences in influenza vaccination across various ethnicities. METHODS: Combined data from 2013 to 2015 Behavioral Risk Factor Surveillance System, a population-based, telephone survey of the non-institutionalized, U.S. population aged ≥18years, were analyzed in 2017 to assess influenza vaccination among Asians. Weighted proportions were calculated. Multivariable logistic regression was used to determine independent associations between sociodemographic factors and receipt of influenza vaccination. RESULTS: Influenza vaccination varied widely among Asian ethnicities, both nationally and by state. Overall, 42.1% of Asians reported having received an influenza vaccine, similar to vaccination among whites (42.4%). Coverage ranged from 36.1% among Koreans to 50.9% among Japanese. Factors independently associated with influenza vaccination among some or all Asian ethnicities included age (≥50 years), female, never married, high school or higher education, annual household income ≥$75,000, possession of medical insurance and personal healthcare provider, routine checkup in the previous year, and presence of certain chronic conditions. CONCLUSIONS: Though Asians and whites had similar overall influenza vaccination coverage, differences existed between Asian ethnicities, both nationally and by state. This information may help community-based, state-level, and national-level public health agencies to support targeted approaches for outreach to these populations, such as improving cultural and linguistic access to care, to improve influenza vaccination.

Knowledge of influenza vaccination recommendation and early vaccination uptake during the 2015-16 season among adults aged ≥18years - United States.

BACKGROUND: Since 2010, the Advisory Committee on Immunization Practices (ACIP) has recommended that all persons aged ≥6months receive annual influenza vaccination. METHODS: We analyzed data from the 2015 National Internet Flu Survey (NIFS), to assess knowledge and awareness of the influenza vaccination recommendation and early influenza vaccination coverage during the 2015-16 season among adults. Predictive marginals from a multivariable logistic regression model were used to identify factors independently associated with adults' knowledge and awareness of the vaccination recommendation and early vaccine uptake during the 2015-16 influenza season. RESULTS: Among the 3301 respondents aged ≥18years, 19.6% indicated knowing that influenza vaccination is recommended for all persons aged ≥6months. Of respondents, 62.3% indicated awareness that there was a recommendation for influenza vaccination, but did not indicate correct knowledge of the recommended age group. Overall, 39.9% of adults aged ≥18years reported having an influenza vaccination. Age 65years and older, being female, having a college or higher education, not being in work force, having annual household income ≥$75,000, reporting having received an influenza vaccination early in the 2015-16 season, having children aged ≤17years in the household, and having high-risk conditions were independently associated with a higher correct knowledge of the influenza vaccination recommendation. CONCLUSIONS: Approximately 1 in 5 had correct knowledge of the recommendation that all persons aged ≥6months should receive an influenza vaccination annually, with some socio-economic groups being even less aware. Clinic based education in combination with strategies known to increase uptake of recommended vaccines, such as patient reminder/recall systems and other healthcare system-based interventions are needed to improve vaccination, which could also improve awareness.

Pneumococcal Vaccination Among Medicare Beneficiaries Occurring After the Advisory Committee on Immunization Practices Recommendation for Routine Use Of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine for Adults Aged ≥65 Years.

On September 19, 2014, CDC published the Advisory Committee on Immunization Practices (ACIP) recommendation for the routine use of 13-valent pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years, to be used in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) (1). This replaced the previous recommendation that adults aged ≥65 years should be vaccinated with a single dose of PPSV23. As a proxy for estimating PCV13 and PPSV23 vaccination coverage among adults aged ≥65 years before and after implementation of these revised recommendations, CDC analyzed claims for vaccination submitted for reimbursement to the Centers for Medicare & Medicaid Services (CMS). Claims from any time during a beneficiary's enrollment in Medicare Parts A (hospital insurance) and B (medical insurance) since reaching age 65 years were assessed among beneficiaries continuously enrolled in Medicare Parts A and B during annual periods from September 19, 2009, through September 18, 2016. By September 18, 2016, 43.2% of Medicare beneficiaries aged ≥65 years had claims for at least 1 dose of PPSV23 (regardless of PCV13 status), 31.5% had claims for at least 1 dose of PCV13 (regardless of PPSV23 status), and 18.3% had claims for at least 1 dose each of PCV13 and PPSV23. Claims for either type of pneumococcal vaccine were highest among beneficiaries who were older, white, or with chronic and immunocompromising medical conditions than among healthy adults. Implementation of the National Vaccine Advisory Committee's standards for adult immunization practice to assess vaccination status at every patient encounter, recommend needed vaccines, and administer vaccination or refer to a vaccinating provider might help increase pneumococcal vaccination coverage and reduce the risk for pneumonia and invasive pneumococcal disease among older adults (2).

Surveillance of Vaccination Coverage among Adult Populations - United States, 2015.

PROBLEM/CONDITION: Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults is low. PERIOD COVERED: August 2014-June 2015 (for influenza vaccination) and January-December 2015 (for pneumococcal, tetanus and diphtheria [Td] and tetanus and diphtheria with acellular pertussis [Tdap], hepatitis A, hepatitis B, herpes zoster, and human papillomavirus [HPV] vaccination). DESCRIPTION OF SYSTEM: The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. The survey objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. RESULTS: Compared with data from the 2014 NHIS, increases in vaccination coverage occurred for influenza vaccine among adults aged ≥19 years (a 1.6 percentage point increase compared with the 2013-14 season to 44.8%), pneumococcal vaccine among adults aged 19-64 years at increased risk for pneumococcal disease (a 2.8 percentage point increase to 23.0%), Tdap vaccine among adults aged ≥19 years and adults aged 19-64 years (a 3.1 percentage point and 3.3 percentage point increase to 23.1% and to 24.7%, respectively), herpes zoster vaccine among adults aged ≥60 years and adults aged ≥65 years (a 2.7 percentage point and 3.2 percentage point increase to 30.6% and to 34.2%, respectively), and hepatitis B vaccine among health care personnel (HCP) aged ≥19 years (a 4.1 percentage point increase to 64.7%). Herpes zoster vaccination coverage in 2015 met the Healthy People 2020 target of 30%. Aside from these modest improvements, vaccination coverage among adults in 2015 was similar to estimates from 2014. Racial/ethnic differences in coverage persisted for all seven vaccines, with higher coverage generally for whites compared with most other groups. Adults without health insurance reported receipt of influenza vaccine (all age groups), pneumococcal vaccine (adults aged 19-64 years at increased risk), Td vaccine (adults aged ≥19 years, 19-64 years, and 50-64 years), Tdap vaccine (adults aged ≥19 years and 19-64 years), hepatitis A vaccine (adults aged ≥19 years overall and among travelers), hepatitis B vaccine (adults aged ≥19 years, 19-49 years, and among travelers), herpes zoster vaccine (adults aged ≥60 years), and HPV vaccine (males and females aged 19-26 years) less often than those with health insurance. Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting one or more physician contacts in the past year compared with those who had not visited a physician in the past year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts within the past year, depending on the vaccine, 18.2%-85.6% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was higher than that among foreign-born adults, with few exceptions (influenza vaccination [adults aged 19-49 years and 50-64 years], hepatitis A vaccination [adults aged ≥19 years], and hepatitis B vaccination [adults aged ≥19 years with diabetes or chronic liver conditions]). INTERPRETATION: Coverage for all vaccines for adults remained low but modest gains occurred in vaccination coverage for influenza (adults aged ≥19 years), pneumococcal (adults aged 19-64 years with increased risk), Tdap (adults aged ≥19 years and adults aged 19-64 years), herpes zoster (adults aged ≥60 years and ≥65 years), and hepatitis B (HCP aged ≥19 years); coverage for other vaccines and groups with vaccination indications did not improve. The 30% Healthy People 2020 target for herpes zoster vaccination was met. Racial/ethnic disparities persisted for routinely recommended adult vaccines. Missed opportunities to vaccinate remained. Although having health insurance coverage and a usual place for health care were associated with higher vaccination coverage, these factors alone were not associated with optimal adult vaccination coverage. HPV vaccination coverage for males and females has increased since CDC recommended vaccination to prevent cancers caused by HPV, but many adolescents and young adults remained unvaccinated. PUBLIC HEALTH ACTIONS: Assessing factors associated with low coverage rates and disparities in vaccination is important for implementing strategies to improve vaccination coverage. Evidence-based practices that have been demonstrated to improve vaccination coverage should be used. These practices include assessment of patients' vaccination indications by health care providers and routine recommendation and offer of needed vaccines to adults, implementation of reminder-recall systems, use of standing-order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. For vaccination coverage to be improved among those who reported lower coverage rates of recommended adult vaccines, efforts also are needed to identify adults who do not have a regular provider or insurance and who report fewer health care visits.

Factors Related to Pertussis and Tetanus Vaccination Status Among Foreign-Born Adults Living in the United States.

Pertussis is a common vaccine-preventable disease (VPD) worldwide. Its reported incidence has increased steadily in the United States, where it is endemic. Tetanus is a rare but potentially fatal VPD. Foreign-born adults have lower tetanus-diphtheria-pertussis (Tdap) and tetanus-diphtheria (Td) vaccination coverage than do U.S.-born adults. We studied the association of migration-related, socio-demographic, and access-to-care factors with Tdap and Td vaccination among foreign-born adults living in the United States. The 2012 and 2013 National Health Interview Survey data for foreign-born respondents were analyzed. Multivariable logistic regression was conducted to calculate prevalence ratios and 95% confidence intervals, and to identify variables independently associated with Tdap and Td vaccination among foreign-born adults. Tdap and Td vaccination status was available for 9316 and 12,363 individuals, respectively. Overall vaccination coverage was 9.1% for Tdap and 49.8% for Td. Younger age, higher education, having private health insurance (vs. public insurance or uninsured), having visited a doctor in the previous year, and region of residence were independently associated with Tdap and Td vaccination. Among those reporting a doctor visit, two-thirds had not received Tdap. This study provides further evidence of the need to enhance access to health care and immunization services and reduce missed opportunities for Tdap and Td vaccination for foreign-born adults in the United States. These findings apply to all foreign-born, irrespective of their birthplace, citizenship, language and years of residence in the United States. Addressing vaccination disparities among the foreign-born will help achieve national vaccination goals and protect all communities in the United States.

Surveillance of Vaccination Coverage Among Adult Populations - United States, 2014.

PROBLEM/CONDITION: Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults is low. REPORTING PERIOD: August 2013-June 2014 (for influenza vaccination) and January-December 2014 (for pneumococcal, tetanus and diphtheria [Td] and tetanus and diphtheria with acellular pertussis [Tdap], hepatitis A, hepatitis B, herpes zoster, and human papillomavirus [HPV] vaccination). DESCRIPTION OF SYSTEM: The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. The survey objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. RESULTS: Compared with data from the 2013 NHIS, increases in vaccination coverage occurred for Tdap vaccine among adults aged ≥19 years (a 2.9 percentage point increase to 20.1%) and herpes zoster vaccine among adults aged ≥60 years (a 3.6 percentage point increase to 27.9%). Aside from these modest improvements, vaccination coverage among adults in 2014 was similar to estimates from 2013 (for influenza coverage, similar to the 2012-13 season). Influenza vaccination coverage among adults aged ≥19 years was 43.2%. Pneumococcal vaccination coverage among high-risk persons aged 19-64 years was 20.3% and among adults aged ≥65 years was 61.3%. Td vaccination coverage among adults aged ≥19 years was 62.2%. Hepatitis A vaccination coverage among adults aged ≥19 years was 9.0%. Hepatitis B vaccination coverage among adults aged ≥19 years was 24.5%. HPV vaccination coverage among adults aged 19-26 years was 40.2% for females and 8.2% for males. Racial/ethnic differences in coverage persisted for all seven vaccines, with higher coverage generally for whites compared with most other groups. Adults without health insurance were significantly less likely than those with health insurance to report receipt of influenza vaccine (aged ≥19 years), pneumococcal vaccine (aged 19-64 years with high-risk conditions and aged ≥65 years), Td vaccine (aged ≥19 years), Tdap vaccine (aged ≥19 years and 19-64 years), hepatitis A vaccine (aged ≥19 years overall and among travelers), hepatitis B vaccine (aged ≥19 years, 19-49 years, and 19-59 years with diabetes), herpes zoster vaccine (aged ≥60 years and 60-64 years), and HPV vaccine (females aged 19-26 years and males aged 19-26 years). Adults who reported having a usual place for health care generally were more likely to receive recommended vaccinations than those who did not have a usual place for health care, regardless of whether they had health insurance. Vaccination coverage was significantly higher among those reporting one or more physician contacts in the past year compared with those who had not visited a physician in the past year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended either for all persons or for those with some specific indication. Overall, vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents with few exceptions (influenza vaccination [adults aged 19-49 years], hepatitis A vaccination [adults aged ≥19 years], hepatitis B vaccination [adults with diabetes aged ≥60 years], and HPV vaccination [males aged 19-26 years]). INTERPRETATION: Overall, increases in adult vaccination coverage are needed. Although modest gains occurred in Tdap vaccination coverage among adults aged ≥19 years and herpes zoster vaccination coverage among adults aged ≥60 years, coverage for other vaccines and risk groups did not improve, and racial/ethnic disparities persisted for routinely recommended adult vaccines. Coverage for all vaccines for adults remained low, and missed opportunities to vaccinate adults continued. Although having health insurance coverage and a usual place for health care are associated with higher vaccination coverage, these factors alone do not assure optimal adult vaccination coverage. PUBLIC HEALTH ACTIONS: Assessing associations with vaccination is important for understanding factors that contribute to low coverage rates and to disparities in vaccination, and for implementing strategies to improve vaccination coverage. Practices that have been demonstrated to improve vaccination coverage should be used. These practices include assessment of patients' vaccination indications by health care providers and routine recommendation and offer of needed vaccines to adults, implementation of reminder-recall systems, use of standing-order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. For vaccination to be improved among those least likely to be up-to-date on recommended adult vaccines, efforts also are needed to identify adults who do not have a regular provider or insurance and who report fewer health care visits.

Meeting the Challenges of Immunizing Adults.

The overall burden of illness from diseases for which vaccines are available disproportionately falls on adults. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations. Updated vaccine recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Vaccine use among U.S. adults is low. Although receipt of a provider (physician or other vaccinating healthcare provider) recommendation is a key predictor of vaccination, more often consumers report not receiving vaccine recommendations at healthcare provider visits. Although providers support the benefits of vaccination, they also report several barriers to vaccinating adults, including the cost of providing vaccination services, inadequate or inconsistent payment for vaccines and vaccine administration, and acute medical care taking precedence over preventive services. Despite these challenges, a number of strategies have been demonstrated to substantially improve adult vaccine coverage, including patient and provider reminders and standing orders for vaccination. Providers are encouraged to incorporate routine assessment of their adult patients' vaccination needs during all clinical encounters to ensure patients receive recommendations for needed vaccines and are either offered needed vaccines or referred for vaccination.

Racial and ethnic disparities in vaccination coverage among adult populations in the U.S.

INTRODUCTION: Reducing racial/ethnic disparities in immunization rates is a compelling public health goal. Disparities in childhood vaccination rates have not been observed in recent years for most vaccines. The objective of this study is to assess adult vaccination by race/ethnicity in the U.S. METHODS: The 2012 National Health Interview Survey was analyzed in 2014 to assess adult vaccination by race/ethnicity for five vaccines routinely recommended for adults: influenza, tetanus, pneumococcal (two vaccines), human papilloma virus, and zoster vaccines. Multivariable logistic regression analysis was performed to identify factors independently associated with all adult vaccinations. RESULTS: Vaccination coverage was significantly lower among non-Hispanic blacks, Hispanics, and non-Hispanic Asians compared with non-Hispanic whites, with only a few exceptions. Age, sex, education, health insurance, usual place of care, number of physician visits in the past 12 months, and health insurance were independently associated with receipt of most of the examined vaccines. Racial/ethnic differences narrowed, but gaps remained after taking these factors into account. CONCLUSIONS: Racial and ethnic differences in vaccination levels narrow when adjusting for socioeconomic factors analyzed in this survey, but are not eliminated, suggesting that other factors that are associated with vaccination disparities are not measured by the National Health Interview Survey and could also contribute to the differences in coverage. Additional efforts, including systems changes to ensure routine assessment and recommendations for needed vaccinations among adults for all racial/ethnic groups, are essential for improving vaccine coverage.

Meeting the Challenges of Immunizing Adults.

The overall burden of illness from diseases for which vaccines are available disproportionately falls on adults. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations. Updated vaccine recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Vaccine use among U.S. adults is low. Although receipt of a provider (physician or other vaccinating healthcare provider) recommendation is a key predictor of vaccination, more often consumers report not receiving vaccine recommendations at healthcare provider visits. Although providers support the benefits of vaccination, they also report several barriers to vaccinating adults, including the cost of providing vaccination services, inadequate or inconsistent payment for vaccines and vaccine administration, and acute medical care taking precedence over preventive services. Despite these challenges, a number of strategies have been demonstrated to substantially improve adult vaccine coverage, including patient and provider reminders and standing orders for vaccination. Providers are encouraged to incorporate routine assessment of their adult patients' vaccination needs during all clinical encounters to ensure patients receive recommendations for needed vaccines and are either offered needed vaccines or referred for vaccination.

Racial and Ethnic Disparities in Vaccination Coverage Among Adult Populations in the U.S.

INTRODUCTION: Reducing racial/ethnic disparities in immunization rates is a compelling public health goal. Disparities in childhood vaccination rates have not been observed in recent years for most vaccines. The objective of this study is to assess adult vaccination by race/ethnicity in the U.S. METHODS: The 2012 National Health Interview Survey was analyzed in 2014 to assess adult vaccination by race/ethnicity for five vaccines routinely recommended for adults: influenza, tetanus, pneumococcal (two vaccines), human papilloma virus, and zoster vaccines. Multivariable logistic regression analysis was performed to identify factors independently associated with all adult vaccinations. RESULTS: Vaccination coverage was significantly lower among non-Hispanic blacks, Hispanics, and non-Hispanic Asians compared with non-Hispanic whites, with only a few exceptions. Age, sex, education, health insurance, usual place of care, number of physician visits in the past 12 months, and health insurance were independently associated with receipt of most of the examined vaccines. Racial/ethnic differences narrowed, but gaps remained after taking these factors into account. CONCLUSIONS: Racial and ethnic differences in vaccination levels narrow when adjusting for socioeconomic factors analyzed in this survey, but are not eliminated, suggesting that other factors that are associated with vaccination disparities are not measured by the National Health Interview Survey and could also contribute to the differences in coverage. Additional efforts, including systems changes to ensure routine assessment and recommendations for needed vaccinations among adults for all racial/ethnic groups, are essential for improving vaccine coverage.

Impact of health insurance status on vaccination coverage among adult populations.

INTRODUCTION: Underinsurance is a barrier to vaccination among children. Information on vaccination among adults aged ≥18 years by insurance status is limited. This study assesses vaccination coverage among adults aged ≥18 years in the U.S. in 2012 by health insurance status and access to care characteristics. METHODS: The 2012 National Health Interview Survey data were analyzed in 2014 to estimate vaccination coverage among adults aged ≥18 years by health insurance status for seven routinely recommended vaccines. RESULTS: Influenza vaccination coverage among adults aged ≥18 years without or with health insurance was 14.4% versus 44.3%, respectively; pneumococcal vaccination coverage among adults aged 18-64 years with high-risk conditions was 9.8% versus 23.0%; tetanus and diphtheria toxoid (Td) coverage (age ≥18 years) was 53.2% versus 64.5%; tetanus, diphtheria, and acellular pertussis (Tdap) coverage (age ≥18 years) was 8.4% versus 15.7%; hepatitis A (HepA) coverage (age 18-49 years) was 16.6% versus 19.8%; hepatitis B (HepB) coverage (age 18-49 years) was 27.5% versus 38.0%; shingles coverage (age ≥60 years) was 6.1% versus 20.8%; and human papillomavirus (HPV) coverage (women aged 18-26 years) was 20.9% versus 39.8%. In addition, vaccination coverage differed by insurance type, whether respondents had a regular physician, and number of physician contacts. CONCLUSIONS: Overall, vaccination coverage among adults aged ≥18 years is lower among uninsured populations. Implementation of effective strategies is needed to help improve vaccination coverage among adults aged ≥18 years, especially those without health insurance.

Vaccination coverage among adults, excluding influenza vaccination - United States, 2013.

Vaccinations are recommended throughout life to prevent vaccine-preventable diseases and their sequelae. Adult vaccination coverage, however, remains low for most routinely recommended vaccines and below Healthy People 2020 targets. In October 2014, the Advisory Committee on Immunization Practices (ACIP) approved the adult immunization schedule for 2015. With the exception of influenza vaccination, which is recommended for all adults each year, other adult vaccinations are recommended for specific populations based on a person's age, health conditions, behavioral risk factors (e.g., injection drug use), occupation, travel, and other indications. To assess vaccination coverage among adults aged ≥19 years for selected vaccines, CDC analyzed data from the 2013 National Health Interview Survey (NHIS). This report highlights results of that analysis for pneumococcal, tetanus toxoid-containing (tetanus and diphtheria vaccine [Td] or tetanus and diphtheria with acellular pertussis vaccine [Tdap]), hepatitis A, hepatitis B, herpes zoster (shingles), and human papillomavirus (HPV) vaccines by selected characteristics (age, race/ethnicity,† and vaccination indication). Influenza vaccination coverage estimates for the 2013-14 influenza season have been published separately. Compared with 2012, only modest increases occurred in Tdap vaccination among adults aged ≥19 years (a 2.9 percentage point increase to 17.2%), herpes zoster vaccination among adults aged ≥60 years (a 4.1 percentage point increase to 24.2%), and HPV vaccination among males aged 19-26 years (a 3.6 percentage point increase to 5.9%); coverage among adults in the United States for the other vaccines did not improve. Racial/ethnic disparities in coverage persisted for all six vaccines and widened for Tdap and herpes zoster vaccination. Increases in vaccination coverage are needed to reduce the occurrence of vaccine-preventable diseases among adults. Awareness of the need for vaccines for adults is low among the general population, and adult patients largely rely on health care provider recommendations for vaccination. The Community Preventive Services Task Force and the National Vaccine Advisory Committee have recommended that health care providers incorporate vaccination needs assessment, recommendation, and offer of vaccination into every clinical encounter with adult patients to improve vaccination rates and to narrow the widening racial/ethnic disparities in vaccination coverage.

Adult vaccination disparities among foreign-born populations in the U.S., 2012.

BACKGROUND: Foreign-born persons are considered at higher risk of undervaccination and exposure to many vaccine-preventable diseases. Information on vaccination coverage among foreign-born populations is limited. PURPOSE: To assess adult vaccination coverage disparities among foreign-born populations in the U.S. METHODS: Data from the 2012 National Health Interview Survey were analyzed in 2013. For non-influenza vaccines, the weighted proportion vaccinated was calculated. For influenza vaccination, Kaplan-Meier survival analysis was used to assess coverage among individuals interviewed during September 2011-June 2012 and vaccinated in August 2011-May 2012. RESULTS: Overall, unadjusted vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents: influenza, age ≥18 years (40.4% vs 33.8%); pneumococcal polysaccharide vaccine (PPV), 18-64 years with high-risk conditions (20.8% vs 13.7%); PPV, ≥65 years (62.6% vs 40.5%); tetanus vaccination, ≥18 years (65.0% vs 50.6%); tetanus, diphtheria, and acellular pertussis (Tdap), ≥18 years (15.5% vs 9.3%); hepatitis B, 18-49 years (37.2% vs 28.4%); shingles, ≥60 years (21.3% vs 12.0%); and human papilloma virus (HPV), women 18-26 years (38.7% vs 14.7%). Among the foreign born, vaccination coverage was generally lower for non-U.S. citizens, recent immigrants, and those interviewed in a language other than English. Foreign-born individuals were less likely than U.S.-born people to be vaccinated for pneumococcal (≥65 years), tetanus, Tdap, and HPV (women) after adjusting for confounders. CONCLUSIONS: Vaccination coverage is lower among foreign-born adults than those born in the U.S. It is important to consider foreign birth and immigration status when assessing vaccination disparities and planning interventions.

Seasonal influenza vaccination coverage among adult populations in the United States, 2005-2011.

The most effective strategy for preventing influenza is annual vaccination. We analyzed 2005-2011 data from the National Health Interview Survey (NHIS), using Kaplan-Meier survival analysis to estimate cumulative proportions of persons reporting influenza vaccination in the 2004-2005 through 2010-2011 seasons for persons aged ≥18, 18-49, 50-64, and ≥65 years, persons with high-risk conditions, and health-care personnel. We compared vaccination coverage by race/ethnicity within each age and high-risk group. Vaccination coverage among adults aged ≥18 years increased from 27.4% during the 2005-2006 influenza season to 38.1% during the 2010-2011 season, with an average increase of 2.2% annually. From the 2005-2006 season to the 2010-2011 season, coverage increased by 10-12 percentage points for all groups except adults aged ≥65 years. Coverage for the 2010-2011 season was 70.2% for adults aged ≥65 years, 43.7% for adults aged 50-64 years, 36.7% for persons aged 18-49 years with high-risk conditions, and 55.8% for health-care personnel. In most subgroups, coverage during the 2010-2011 season was significantly lower among non-Hispanic blacks and Hispanics than among non-Hispanic whites. Vaccination coverage among adults under age 65 years increased from 2005-2006 through 2010-2011, but substantial racial/ethnic disparities remained in most age groups. Targeted efforts are needed to improve influenza vaccination coverage and reduce disparities.

Factors associated with human papillomavirus vaccination among young adult women in the United States.

BACKGROUND: Human papillomavirus (HPV) vaccination is recommended to protect against HPV-related diseases. OBJECTIVE: To estimate HPV vaccine coverage and assess factors associated with vaccine awareness, initiation and receipt of 3 doses among women age 18-30 years. METHODS: Data from the 2010 National Health Interview Survey were analyzed to assess associations of HPV vaccination among women age 18-26 (n=1866) and 27-30 years (n=1028) with previous HPV exposure, cervical cancer screening and selected demographic, health care and behavioral characteristics using bivariate analysis and multivariable logistic regression. RESULTS: Overall, 23.2% of women age 18-26 and 6.7% of women age 27-30 years reported receiving at least 1 dose of HPV vaccine. In multivariable analyses among women age 18-26 years, not being married, having a regular physician, seeing a physician or obstetrician/gynecologist in the past year, influenza vaccination in the past year, and receipt of other recommended vaccines were associated with HPV vaccination. One-third of unvaccinated women age 18-26 years (n=490) were interested in receiving HPV vaccine. Among women who were not interested in receiving HPV vaccine (n=920), the main reasons reported included: not needing the vaccine (41.3%); concerns about safety of the vaccine (12.5%); not knowing enough about the vaccine (11.9%); not being sexually active (8.2%); a doctor not recommending the vaccine (7.6%); and already having HPV (2.7%). Among women with health insurance, 10 or more physician contacts within the past year and no contraindications, 74.5% reported not receiving HPV vaccine. CONCLUSIONS: HPV vaccination coverage among women age 18-26 years remains low. Opportunities to vaccinate are missed. Healthcare providers can play an important role in educating young women about HPV and encouraging vaccination. Successful public health and educational interventions will need to address physician attitudes and practice patterns and other factors that influence vaccination behaviors.

Influenza vaccination coverage among adults--National Health Interview Survey, United States, 2008-09 influenza season.

In the United States, annual influenza epidemics typically occur during the late fall through early spring. During these epidemics, rates of serious illness and death are highest among adults aged ≥65 years, children aged <2 years, and persons of any age who have medical conditions that increase their risk for complications from influenza. Adults aged 50-64 years who have underlying medical conditions have a substantially increased risk for hospitalization during the influenza season. Influenza illness among healthy adults aged 18-64 years typically is not as severe as the illness among adults aged ≥65 years, pregnant women, or persons with chronic medical conditions and less frequently results in hospitalization. However, influenza among healthy adults aged 18-49 years is an important cause of outpatient medical visits and worker absenteeism. An economic analysis estimated an annual average of approximately 5 million illnesses, 2.4 million outpatient visits, 32,000 hospitalizations, and 680 deaths from influenza among adults aged 18-49 years who did not have a medical condition that increased their risk for influenza complications. In this analysis, adults aged 18-49 years accounted for 10% of the total economic cost from influenza, or approximately $8.7 billion.

Impact of four urban perinatal hepatitis B prevention programs on screening and vaccination of infants and household members.

During 1992-2000, the authors studied compliance with perinatal hepatitis B prevention recommendations, including vaccination of household contacts, at four metropolitan sites in Connecticut, Georgia, Texas, and Michigan. Demographic and hepatitis B-related knowledge, attitudes, practices, and barrier data were collected on pregnant women testing positive for hepatitis B surface antigen and on their infants, children, and household and sexual contacts. Generalized estimating equations with repeated measures in a multivariable model were used to obtain adjusted relative risks of household noncompliance. In 1,458 households studied, 1,490 infants and 3,502 other contacts were identified. Among infants, vaccination start/finish rates were 92%/72%, and 73% were serotested postvaccination. Prevaccination serotesting rates among contacts were 22% preenrollment and 47% postenrollment. Among 2,519 contacts whose immunity status was susceptible or unknown, the vaccination start/finish rate was 45%/41%. Site-specific adjusted relative risks of household noncompliance compared with Texas were 2.14 (Michigan), 1.96 (Georgia), and 1.30 (Connecticut). Mother's birth in the United States increased the relative risk of household noncompliance (1.32). Home visits, implemented only in Texas, most likely account for higher compliance rates in that state. Findings may indicate that many perinatal programs could achieve higher overall rates of infant and contact identification; pre- and postvaccination serologic testing in contacts and infants, respectively; and contact hepatitis B vaccination.