Influenza vaccination coverage among adults by nativity, race/ethnicity, citizenship, and language of the interview - United States, 2012-2013 through 2017-2018 influenza seasons.

BACKGROUND: Approximately 20,000 people died from influenza in the US in the 2019-2020 season. The best way to prevent influenza is to receive the influenza vaccine. Persons who are foreign-born experience disparities in access to, and utilization of, preventative healthcare, including vaccination. METHODS: National Health Interview Survey data were analyzed to assess differences in influenza vaccination coverage during the 2012-2013 through 2017-2018 influenza seasons among adults by nativity, citizenship status of foreign-born persons, race/ethnicity, and language of the interview. RESULTS: Influenza vaccination coverage increased significantly during the study period for US-born adults but did not change significantly among foreign-born racial/ethnic groups except for increases among foreign-born Hispanic adults. Coverage for foreign-born adults, those who completed an interview in a non-English language, and non-US citizens, had lower vaccination coverage during most influenza seasons studied, compared with US-born, English-interviewed, and US-citizen adults, respectively. CONCLUSIONS: Strategies to improve influenza vaccination uptake must consider foreign-born adults as an underserved population in need of focused, culturally-tailored outreach. Achieving high influenza vaccination coverage among the foreign-born population will help reduce illness among the essential workforce, achieve national vaccination goals, and reduce racial and ethnic disparities in vaccination coverage in the US.

Hepatitis B Vaccination Among Adults With Diabetes Mellitus, U.S., 2018.

INTRODUCTION: Hepatitis B vaccination is routinely recommended for adults with diabetes mellitus aged <60 years and for those aged ≥60 years at the discretion of their healthcare provider. The purpose of this study is to assess hepatitis B vaccination coverage among adults with and without diabetes mellitus. METHODS: Data from the 2014-2018 National Health Interview Survey were analyzed in 2020 to determine hepatitis B vaccination series completion (≥3 doses) among adults aged 18-59 and ≥60 years with diabetes mellitus. Multivariable logistic regression analysis was conducted to identify the factors independently associated with hepatitis B vaccination among adults aged 18-59 and ≥60 years with diabetes mellitus. RESULTS: In 2018, among adults aged 18-59 years with diabetes mellitus, 33.2% had received hepatitis B vaccination (≥3 doses), an increase of 9.7 percentage points from 2014 (p<0.05). Among adults aged ≥60 years with diabetes mellitus, coverage was 15.3% in 2018 and did not increase during 2014-2018. Coverage was not significantly different among adults with diabetes mellitus compared with those without diabetes mellitus, even after controlling for the assessed factors. Among adults with diabetes mellitus aged 18-59 and ≥60 years, younger age, having some college or college education, having been tested for HIV, being healthcare personnel, or having traveled to hepatitis B virus-endemic areas were independently associated with an increased likelihood of vaccination. CONCLUSIONS: Self-reported hepatitis B vaccination coverage among adults with diabetes mellitus remains suboptimal. Healthcare providers should assess patients' diabetes status, recommend and offer needed vaccinations to patients, or refer them to alternate sites for vaccination.

Surveillance of Vaccination Coverage Among Adult Populations -United States, 2018.

PROBLEM/CONDITION: Adults are at risk for illness, hospitalization, disability and, in some cases, death from vaccine-preventable diseases, particularly influenza and pneumococcal disease. CDC recommends vaccinations for adults on the basis of age, health conditions, 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 remains low. REPORTING PERIOD: August 2017-June 2018 (for influenza vaccination) and January-December 2018 (for pneumococcal, herpes zoster, tetanus and diphtheria [Td]/tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], hepatitis A, hepatitis B, 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. NHIS's 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. Adult receipt of influenza, pneumococcal, herpes zoster, Td/Tdap, hepatitis A, hepatitis B, and at least 1 dose of HPV vaccines was assessed. Estimates were derived for a new composite adult vaccination quality measure and by selected demographic and access-to-care characteristics (e.g., age, race/ethnicity, indication for vaccination, travel history [travel to countries where hepatitis infections are endemic], health insurance status, contacts with physicians, nativity, and citizenship). Trends in adult vaccination were assessed during 2010-2018. RESULTS: Coverage for the adult age-appropriate composite measure was low in all age groups. Racial and ethnic differences in coverage persisted for all vaccinations, with lower coverage for most vaccinations among non-White compared with non-Hispanic White adults. Linear trend tests indicated coverage increased from 2010 to 2018 for most vaccines in this report. Few adults aged ≥19 years had received all age-appropriate vaccines, including influenza vaccination, regardless of whether inclusion of Tdap (13.5%) or inclusion of any tetanus toxoid-containing vaccine (20.2%) receipt was measured. Coverage among adults for influenza vaccination during the 2017-18 season (46.1%) was similar to the estimate for the 2016-17 season (45.4%), and coverage for pneumococcal (adults aged ≥65 years [69.0%]), herpes zoster (adults aged ≥50 years and aged ≥60 years [24.1% and 34.5%, respectively]), tetanus (adults aged ≥19 years [62.9%]), Tdap (adults aged ≥19 years [31.2%]), hepatitis A (adults aged ≥19 years [11.9%]), and HPV (females aged 19-26 years [52.8%]) vaccination in 2018 were similar to the estimates for 2017. Hepatitis B vaccination coverage among adults aged ≥19 years and health care personnel (HCP) aged ≥19 years increased 4.2 and 6.7 percentage points to 30.0% and 67.2%, respectively, from 2017. HPV vaccination coverage among males aged 19-26 years increased 5.2 percentage points to 26.3% from the 2017 estimate. Overall, HPV vaccination coverage among females aged 19-26 years did not increase, but coverage among Hispanic females aged 19-26 years increased 10.8 percentage points to 49.6% from the 2017 estimate. Coverage for the following vaccines was lower among adults without health insurance compared with those with health insurance: influenza vaccine (among adults aged ≥19 years, 19-49 years, and 50-64 years), pneumococcal vaccine (among adults aged 19-64 years at increased risk), Td vaccine (among all age groups), Tdap vaccine (among adults aged ≥19 years and 19-64 years), hepatitis A vaccine (among adults aged ≥19 years overall and among travelers aged ≥19 years), hepatitis B vaccine (among adults aged ≥19 years and 19-49 years and among travelers aged ≥19 years), herpes zoster vaccine (among adults aged ≥60 years), and HPV vaccine (among males and females aged 19-26 years). 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 ≥1 physician contact during the preceding year compared with those who had not visited a physician during the preceding year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts during the preceding year, depending on the vaccine, 20.1%-87.5% 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 significantly higher than that of foreign-born adults, including influenza vaccination (aged ≥19 years), pneumococcal vaccination (all ages), tetanus vaccination (all ages), Tdap vaccination (all ages), hepatitis B vaccination (aged ≥19 years and 19-49 years and travelers aged ≥19 years), herpes zoster vaccination (all ages), and HPV vaccination among females aged 19-26 years. Vaccination coverage also varied by citizenship status and years living in the United States. INTERPRETATION: NHIS data indicate that many adults remain unprotected against vaccine-preventable diseases. Coverage for the adult age-appropriate composite measures was low in all age groups. Individual adult vaccination coverage remained low as well, but modest gains occurred in vaccination coverage for hepatitis B (among adults aged ≥19 years and HCP aged ≥19 years), and HPV (among males aged 19-26 years and Hispanic females aged 19-26 years). Coverage for other vaccines and groups with Advisory Committee on Immunization Practices vaccination indications did not improve from 2017. Although HPV vaccination coverage among males aged 19-26 years and Hispanic females aged 19-26 years increased, approximately 50% of females aged 19-26 years and 70% of males aged 19-26 years remained unvaccinated. Racial/ethnic vaccination differences persisted for routinely recommended adult vaccines. Having health insurance coverage, having a usual place for health care, and having ≥1 physician contacts during the preceding 12 months were associated with higher vaccination coverage; however, these factors alone were not associated with optimal adult vaccination coverage, and findings indicate missed opportunities to vaccinate remained. PUBLIC HEALTH ACTIONS: Substantial improvement in adult vaccination uptake is needed to reduce the burden of vaccine-preventable diseases. Following the Standards for Adult Immunization Practice (https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html), all providers should routinely assess adults' vaccination status at every clinical encounter, strongly recommend appropriate vaccines, either offer needed vaccines or refer their patients to another provider who can administer the needed vaccines, and document vaccinations received by their patients in an immunization information system.

FIT FOR PURPOSE IN ACTION: DESIGN, IMPLEMENTATION, AND EVALUATION OF THE NATIONAL INTERNET FLU SURVEY.

Researchers strive to design and implement high-quality surveys to maximize the utility of the data collected. The definitions of quality and usefulness, however, vary from survey to survey and depend on the analytic needs. Survey teams must evaluate the trade-offs of various decisions, such as when results are needed and their required level of precision, in addition to practical constraints like budget, before finalizing the design. Characteristics within the concept of fit for purpose (FfP) can provide the framework for considering the trade-offs. Furthermore, this tool can enable an evaluation of quality for the resulting estimates. Implementation of a FfP framework in this context, however, is not straightforward. In this article, we provide the reader with a glimpse of a FfP framework in action for obtaining estimates on early season influenza vaccination coverage estimates and on knowledge, attitudes, behaviors, and barriers related to influenza and influenza prevention among civilian noninstitutionalized adults aged 18 years and older in the United States. The result is the National Internet Flu Survey (NIFS), an annual, two-week internet survey sponsored by the US Centers for Disease Control and Prevention. In addition to critical design decisions, we use the established NIFS FfP framework to discuss the quality of the NIFS in meeting the intended objectives. We highlight aspects that work well and other survey traits requiring further evaluation. Differences found in comparing the NIFS to the National Flu Survey, the National Health Interview Survey, and Behavioral Risk Factor Surveillance System are discussed via their respective FfP characteristics. The findings presented here highlight the importance of the FfP framework for designing surveys, defining data quality, and providing a set a metrics used to advertise the intended use of the survey data and results.

Trends in place of early-season influenza vaccination among adults, 2014-15 through 2018-19 influenza seasons-The importance of medical and nonmedical settings for vaccination.

BACKGROUND: Annual vaccination is the most effective strategy for preventing influenza. We assessed trends and demographic and access-to-care characteristics associated with place of vaccination in recent years. METHODS: Data from the 2014-2018 National Internet Flu Survey were analyzed to assess trends in place of early-season influenza vaccination during the 2014-15 through 2018-19 seasons. Multivariable logistic regression was conducted to identify factors independently associated with vaccination settings in the 2018-19 season. RESULTS: Among vaccinated adults, the proportion vaccinated in medical (range: 49%-53%) versus nonmedical settings (range: 47%-51%) during the 2014-15 through 2018-19 seasons were similar. Among adults aged ≥18 years vaccinated early in the 2018-19 influenza season, a doctor's office was the most common place (34.4%), followed by pharmacies or stores (32.3%), and workplaces (15.0%). Characteristics significantly associated with an increased likelihood of receipt of vaccination in nonmedical settings among adults included household income ≥$50,000, having no doctor visits since July 1, 2018, or having a doctor visit but not receiving an influenza vaccination recommendation from the medical professional. CONCLUSIONS: Place of early-season influenza vaccination among adults who reported receiving influenza vaccination was stable over 5 recent seasons. Both medical and nonmedical settings were important places for influenza vaccination. Increasing access to vaccination services in medical and nonmedical settings should be considered as an important strategy for improving vaccination coverage.

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.

Influenza vaccination coverage among adults with diabetes, United States, 2007-08 through 2017-18 seasons.

BACKGROUND: Diabetes is associated with higher risk of hospitalization, morbidity, and mortality from influenza. We assessed influenza vaccination coverage among adults aged ≥ 18 years with diabetes during the 2007-08 through 2017-18 influenza seasons and identified factors independently associated with vaccination during the 2017-18 season. METHODS: We analyzed data from the 2007-2018 National Health Interview Surveys, using Kaplan-Meier survival analysis to estimate season-specific influenza vaccination coverage. Multivariate logistic regression was conducted to examine whether diabetes was independently associated with self-reported influenza vaccination in the past 12 months and identify factors independently associated with vaccination among adults with diabetes using the 2017-18 data. RESULTS: During the 2007-08 through 2017-18 influenza seasons, influenza vaccination coverage among adults aged ≥ 18 years with diabetes ranged from 62.6% to 64.8%. In the 2017-18 influenza season, coverage was significantly higher among adults with diabetes (64.8%) compared with those without diabetes (43.9%). Having diabetes was independently associated with an increased prevalence of vaccination after controlling for other factors. Among adults with diabetes, living at or above poverty level, having more physician contacts, having usual place for health care, and being unemployed were independently associated with increased prevalence of vaccination; being 18-64 years and non-Hispanic black were independently associated with decreased prevalence of vaccination. CONCLUSIONS: Despite specific recommendations for influenza vaccination among people with diabetes, more than one-third of adults with diabetes are unvaccinated. Targeted efforts are needed to increase influenza vaccination coverage among adults with diabetes.

Shingles Vaccination of U.S. Adults Aged 50-59 Years and ≥60 Years Before Recommendations for Use of Recombinant Zoster Vaccine.

INTRODUCTION: In 2006, zoster vaccine live was recommended for adults aged ≥60 years. In 2011, zoster vaccine live was approved for use but not recommended for adults aged 50-59 years. This study assessed zoster vaccine live coverage among adults aged 50-59 years and ≥60 years. METHODS: Data from the 2013-2017 National Health Interview Surveys were analyzed in 2019 to estimate national zoster vaccine live coverage among adults aged ≥50 years. State-specific zoster vaccine live coverage among adults aged ≥50 years was assessed using 2017 Behavioral Risk Factor Surveillance System data. RESULTS: Among adults aged 50-59 years, zoster vaccine live coverage was 5.7% in 2017, ranging from 4% to 6% during 2013-2017 (test for trend, p>0.05). Zoster vaccine live coverage among adults aged 50-59 years ranged from 5.8% in Pennsylvania to 14.7% in South Dakota. By 2017, zoster vaccine live was received by 34.9% of adults aged ≥60 years, a significant increase from 24.2% in 2013. Zoster vaccine live coverage among adults aged ≥60 years in 2017 ranged from 26.0% in Mississippi to 51.8% in Vermont. In 2017, major characteristics significantly associated with increased likelihood of zoster vaccine live vaccination among adults aged 50-59 years and ≥60 years were older age, having 4 to 9 physician contacts in the past 12 months, and having a usual place for health care. CONCLUSIONS: This study provides an assessment of zoster vaccine live coverage among adults aged ≥50 years before the newly recommended recombinant zoster vaccine came into widespread use. Providers should routinely assess adults' vaccination status and strongly recommend or offer needed vaccines to their patients.

Seasonal Influenza Vaccination Coverage Trends Among Adult Populations, U.S., 2010-2016.

INTRODUCTION: Influenza is a major cause of morbidity and mortality among adults. The most effective strategy for preventing influenza is annual vaccination. However, vaccination coverage has been suboptimal among adult populations. The purpose of this study is to assess trends in influenza vaccination among adult populations. METHODS: Data from the 2010-2016 National Health Interview Survey were analyzed in 2018 to estimate vaccination coverage during the 2010-2011 through 2015-2016 seasons. Trends of vaccination in recent years were assessed. Vaccination coverage by race/ethnicity within each group was examined. Multivariable logistic regression and predictive marginal models were conducted to identify factors associated with vaccination, and interactions between race/ethnicity and other demographic and access-to-care characteristics were assessed. RESULTS: Vaccination coverage among adults aged ≥18 years increased from 38.3% in the 2010-2011 season to 43.4% in the 2015-2016 season, with an average increase of 1.3 percentage points annually. From the 2010-2011 through 2015-2016 seasons, coverage was stable for adults aged ≥65 years and changed by -0.1 to 9.9 percentage points for all other examined subgroups. Coverage in 2015-2016 was 70.4% for adults aged ≥65 years, 46.4% for those aged 50-64 years, and 32.3% for those aged 18-49 years; 47.9% for people aged 18-64 years with high-risk conditions; 64.8% for healthcare personnel; and 50.3% for pregnant women. Among adults aged ≥18 years for the 2015-2016 season, coverage was significantly lower among non-Hispanic blacks and Hispanics compared with non-Hispanic whites. CONCLUSIONS: Overall, influenza vaccination coverage among adults aged ≥18 years increased during 2010-2016, but it remained below the national target of 70%. Vaccination coverage varied by age, risk status, race/ethnicity, healthcare personnel, and pregnancy status. Targeted efforts are needed to improve coverage and reduce disparities.

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 US-Mexico land border crossers: 2009 H1N1 pandemic and 2011-2012 influenza season.

BACKGROUND: The high volume of US-Mexico land border crossings can facilitate international dissemination of influenza viruses. METHODS: We surveyed adult pedestrians crossing into the United States at two international land ports of entry to assess vaccination coverage during the 2009H1N1 influenza pandemic and 2011-2012 influenza season. RESULTS: Of 559 participants in 2010, 23.4% reported receipt of the 2009H1N1 vaccine. Of 1423 participants in 2012, 33.7% received the 2011-2012 influenza vaccine. Both years, those crossing the border ≥8 times per month had lower vaccination coverage than those crossing less frequently. US-border residents had lower H1N1 coverage than those in other locations. Vaccination coverage was higher for persons age ≥65 years and, in 2010 only, those with less than high school education. Although most participants believed it is important to get vaccinated, only half believed the influenza vaccine was safe and effective. The main reasons for not receiving the influenza vaccine were beliefs of low risk of disease, time constraints, and concerns about vaccine safety (in 2010) or efficacy (in 2012). CONCLUSIONS: International land border crossers are a large and unique category of travelers that require targeted binational strategies for influenza vaccination and education.

Influenza vaccination among adults living with persons at high-risk for complications from influenza during early 2016-17 influenza season.

BACKGROUND: The Advisory Committee on Immunization Practices (ACIP) recommends all persons aged ≥6 months get vaccinated for influenza annually, placing particular emphasis on persons who are at increased risk for influenza-related complications and persons living with or caring for them. METHODS: Data from the 2016 National Internet Flu Survey (NIFS), a nationally representative, probability-based Internet panel survey of the noninstitutionalized U.S. civilian population aged ≥18 years, was used to compare influenza vaccination coverage among adults who live with household members at high-risk for complications from influenza with those who do not. Logistic regression was used to evaluate the difference in the adjusted vaccination coverage prevalence between persons living with and without high-risk household members. RESULTS: From the 2016 NIFS (n = 4,113), we estimated that 29.2% of noninstitutionalized U.S. adults had at least one household member at increased risk for influenza-related complications. Unadjusted influenza vaccination coverage was significantly higher for adults with a high-risk household member compared with those without (46.7% vs 38.6%, respectively). After adjustment for demographic and access-to-care factors, adults with high-risk household members were more likely to be vaccinated than those without (adjusted prevalence difference = 5.3 [0.3, 10.3]). Among vaccinated respondents with high-risk household members, 88.7% reported that protection of their family and close contacts was one of the reasons they were vaccinated. CONCLUSION: Approximately half of adults living with someone at increased risk of complications from influenza did not report receiving an influenza vaccination. Vaccination reminder/recall for persons at increased risk should include reminders for their household contacts.

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.

Influenza Vaccination Coverage Among Health Care Personnel - United States, 2017-18 Influenza Season.

The Advisory Committee on Immunization Practices (ACIP) recommends that all health care personnel receive an annual influenza vaccination to reduce influenza-related morbidity and mortality among health care personnel and their patients and to reduce absenteeism among health care personnel (1-4). CDC conducted an opt-in Internet panel survey of 2,265 U.S. health care personnel to estimate influenza vaccination coverage among these persons during the 2017-18 influenza season. Overall, 78.4% of health care personnel reported receiving influenza vaccination during the 2017-18 season, similar to reported coverage in the previous four influenza seasons (5). As in previous seasons, coverage was highest among personnel who were required by their employer to be vaccinated (94.8%) and lowest among those working in settings where vaccination was not required, promoted, or offered on-site (47.6%). Health care personnel working in long-term care settings, the majority of whom work as assistants or aides, have lower influenza vaccination coverage than do health care personnel working in all other health care settings, which puts the elderly in long-term settings at increased risk for severe complications for influenza. Implementing workplace strategies shown to improve vaccination coverage among health care personnel, including vaccination requirements and active promotion of on-site vaccinations at no cost, can help ensure health care personnel and patients are protected against influenza (6). CDC's long-term care web-based toolkit* provides resources, strategies, and educational materials for increasing influenza vaccination among health care personnel in long-term care settings.

Influenza and Tdap Vaccination Coverage Among Pregnant Women - United States, April 2018.

Vaccinating pregnant women with influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines can reduce the risk for influenza and pertussis for themselves 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 any time during pregnancy (1). The ACIP also recommends that women receive Tdap during each pregnancy, preferably from 27 through 36 weeks' gestation (2). To assess influenza and Tdap vaccination coverage among women pregnant during the 2017-18 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 10, 2018. Among 1,771 survey respondents pregnant during the peak influenza vaccination period (October 2017-January 2018), 49.1% reported receiving influenza vaccine before or during their pregnancy. Among 700 respondents who had a live birth, 54.4% reported receiving Tdap during their pregnancy. Women who reported receiving a provider offer of vaccination had higher vaccination coverage than did women who received a recommendation but no offer and women who did not receive a recommendation. Reasons for nonvaccination included concern about effectiveness of the influenza vaccine and lack of knowledge regarding the need for Tdap vaccination during every pregnancy. Provider offers or referrals for vaccination in combination with patient education could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.

U.S. clinicians' and pharmacists' reported barriers to implementation of the Standards for Adult Immunization Practice.

BACKGROUND: The Standards for Adult Immunization Practice (Standards), revised in 2014, emphasize that adult-care providers assess vaccination status of adult patients at every visit, recommend vaccination, administer needed vaccines or refer to a vaccinating provider, and document vaccinations administered in state/local immunization information systems (IIS). Providers report numerous systems- and provider-level barriers to vaccinating adults, such as billing, payment issues, lower prioritization of vaccines due to competing demands, and lack of information about the use and utility of IIS. Barriers to vaccination result in missed opportunities to vaccinate adults and contribute to low vaccination coverage. Clinicians' (physicians, physician assistants, nurse practitioners) and pharmacists' reported barriers to assessment, recommendation, administration, referral, and documentation, provider vaccination practices, and perceptions regarding their adult patients' attitudes toward vaccines were evaluated. METHODS: Data from non-probability-based Internet panel surveys of U.S. clinicians (n = 1714) and pharmacists (n = 261) conducted in February-March 2017 were analyzed using SUDAAN. Weighted proportion of reported barriers to assessment, recommendation, administration, referral, and documentation in IIS were calculated. RESULTS: High percentages (70.0%-97.4%) of clinicians and pharmacists reported they routinely assessed, recommended, administered, and/or referred adults for vaccination. Among those who administered vaccines, 31.6% clinicians' and 38.4% pharmacists' submitted records to IIS. Reported barriers included: (a) assessment barriers: vaccination of adults is not within their scope of practice, inadequate reimbursement for vaccinations; (b) administration barriers: lack of staff to manage/administer vaccines, absence of necessary vaccine storage and handling equipment and provisions; and (c) documentation barriers: unaware if state/city has IIS that includes adults or not sure how their electronic system would link to IIS. CONCLUSION: Although many clinicians and pharmacists reported implementing most of the individual components of the Standards, with the exception of IIS use, there are discrepancies in providers' reported actual practices and their beliefs/perceptions, and barriers to vaccinating adults remain.

Promoting Adult Immunization Using Population-Based Data for a Composite Measure.

INTRODUCTION: A composite adult immunization status measure is currently under consideration for adoption into the Healthcare Effectiveness Data and Information Set. This paper complements the Healthcare Effectiveness Data and Information Set health plan-level measure testing efforts by examining use of survey-based self-reported vaccination data to assess composite adult immunization coverage and identify limitations to using survey data to measure progress. METHODS: The 2015 National Health Interview Survey data were used in 2017 to calculate estimates for a composite of selected vaccines routinely recommended for adults aged ≥19 years, overall and in three age groups: 19-59, 60-64, and ≥65 years for tetanus and diphtheria toxoids (Td); tetanus toxoid; reduced diphtheria toxoid; and tetanus, diphtheria, acellular pertussis vaccine (Tdap); and herpes zoster, pneumococcal, and influenza vaccines. RESULTS: Composite coverage for adults aged ≥19 years including receipt of Tdap in the past 10 years and influenza vaccination was 11.9%, ranging from 6.3% in adults aged 60-64 years to 13.7% in adults aged 19-59 years. Excluding influenza, composite coverage was 20.7%, ranging from 8.1% (adults aged 60-64 years) to 25.2% (adults aged 19-59 years). In a composite including any Td-containing vaccine in the past 10 years, coverage including influenza vaccination for adults aged ≥19 years was 23.4%, ranging from 12.6% (adults aged 60-64 years) to 25.7% (adults aged 19-59 years). Excluding influenza, composite coverage was 51.4%, ranging from 15.8% (adults aged 60-64 years) to 63.0% (adults aged 19-59 years). CONCLUSIONS: Survey-based vaccination data may under- or over-estimate coverage, but most adults require at least one additional vaccination by any metric. A composite measure provides a single focal point to promote adherence to standards of care.

Hepatitis B vaccination coverage among adults aged ≥18 years traveling to a country of high or intermediate endemicity, United States, 2015.

BACKGROUND: Persons from the United States who travel to developing countries are at substantial risk for hepatitis B virus (HBV) infection. Hepatitis B vaccine has been recommended for adults at increased risk for infection, including travelers to high or intermediate hepatitis B endemic countries. PURPOSE: To assess hepatitis B vaccination coverage among adults ≥18 years traveling to a country of high or intermediate endemicity from the United States. METHODS: Data from the 2015 National Health Interview Survey (NHIS) were analyzed to determine hepatitis B vaccination coverage (≥1 dose) and series completion (≥3 doses) among persons aged ≥18 years who reported traveling to a country of high or intermediate hepatitis B endemicity. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with hepatitis B vaccination. RESULTS: In 2015, hepatitis B vaccination coverage (≥1 dose) among adults aged ≥18 years who reported traveling to high or intermediate hepatitis B endemic countries was 38.6%, significantly higher compared with 25.9% among non-travelers. Series completion (≥3 doses) was 31.7% and 21.2%, respectively (P < 0.05). On multivariable analysis among all respondents, travel status was significantly associated with hepatitis B vaccination coverage and series completion. Other characteristics independently associated with vaccination (≥1 dose, and ≥3 doses) among travelers included age, race/ethnicity, educational level, duration of US residence, number of physician contacts in the past year, status of ever being tested for HIV, and healthcare personnel status. CONCLUSIONS: Although travel to a country of high or intermediate hepatitis B endemicity was associated with higher likelihood of hepatitis B vaccination, hepatitis B vaccination coverage was low among adult travelers to these areas. Healthcare providers should ask their patients about travel plans and recommend and offer travel related vaccinations to their patients or refer them to alternate sites for vaccination.

Hepatitis B vaccination coverage among adults aged ≥ 18 years traveling to a country of high or intermediate endemicity, United States, 2015.

BACKGROUND: Persons from the United States who travel to developing countries are at substantial risk for hepatitis B virus (HBV) infection. Hepatitis B vaccine has been recommended for adults at increased risk for infection, including travelers to high or intermediate hepatitis B endemic countries. PURPOSE: To assess hepatitis B vaccination coverage among adults ≥ 18 years traveling to a country of high or intermediate endemicity from the United States. METHODS: Data from the 2015 National Health Interview Survey (NHIS) were analyzed to determine hepatitis B vaccination coverage (≥1 dose) and series completion (≥3 doses) among persons aged ≥ 18 years who reported traveling to a country of high or intermediate hepatitis B endemicity. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with hepatitis B vaccination. RESULTS: In 2015, hepatitis B vaccination coverage (≥1 dose) among adults aged ≥ 18 years who reported traveling to high or intermediate hepatitis B endemic countries was 38.6%, significantly higher compared with 25.9% among non-travelers. Series completion (≥3 doses) was 31.7% and 21.2%, respectively (P < 0.05). On multivariable analysis among all respondents, travel status was significantly associated with hepatitis B vaccination coverage and series completion. Other characteristics independently associated with vaccination (≥1 dose, and ≥ 3 doses) among travelers included age, race/ethnicity, educational level, duration of U.S. residence, number of physician contacts in the past year, status of ever being tested for HIV, and healthcare personnel status. CONCLUSIONS: Although travel to a country of high or intermediate hepatitis B endemicity was associated with higher likelihood of hepatitis B vaccination, hepatitis B vaccination coverage was low among adult travelers to these areas. Healthcare providers should ask their patients about travel plans and recommend and offer travel related vaccinations to their patients or refer them to alternate sites for vaccination.