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Influenza Vaccination Coverage Among Pregnant Women — 2011–12 Influenza Season, United States

Pregnant women and their newborns are at elevated risk for influenza-associated hospitalization and death (1). The Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists (ACOG) have recommended influenza vaccination for all women who are or will be pregnant during the influenza season, regardless of trimester (1,2). To estimate influenza vaccination coverage among pregnant women for the 2011–12 influenza season, CDC analyzed data from an Internet panel survey (3) conducted April 3–17, 2012, among women pregnant at any time during the 4-month period October 2011–January 2012. Among 1,660 survey respondents, 47.0% reported they had received influenza vaccination; 9.9% were vaccinated before pregnancy, 36.5% during pregnancy, and <1.0% after pregnancy. Overall, 43.7% of women reported receipt of both a health-care provider recommendation and offer of influenza vaccination; these women had higher vaccination coverage (73.6%) than women who received only a recommendation but no offer of vaccination (47.9%) and women who received neither a recommendation nor an offer (11.1%). Continued efforts are needed to encourage providers of medical care to routinely recommend and offer influenza vaccination to women who are pregnant or who might become pregnant.

To provide timely end-of-season estimates of influenza vaccination coverage and information on knowledge, attitudes, and behaviors related to influenza vaccination among women pregnant during the 2011–12 influenza season, CDC conducted an Internet panel survey during April 3–17, 2012 that was similar to a survey conducted in April 2011 (3). Women aged 18–49 years who were pregnant at any time since August 2011 were recruited from a SurveySpot panel operated by Survey Sampling International.* Of 7,485 women who visited the Internet survey site during the study period, 2,223 were determined to be eligible for the survey based on the timing of their pregnancies; of those, 2,096 (94%) completed the online survey. Data were weighted to reflect the age group, racial/ethnic, and geographic distribution of the total U.S. population of pregnant women during 1995–2005.The same questions used to determine pregnancy status in the April 2011 survey (3) were used in this survey. In addition, women pregnant since August 2011 but no longer pregnant at the time of their response were asked to provide the start and end months of pregnancy. For this analysis, the study population was limited to 1,660 women reporting pregnancy any time during the usual peak influenza vaccination period of October 2011–January 2012.

Survey respondents were asked questions about their knowledge and attitudes regarding influenza and influenza vaccination; their vaccination status before, during, and after pregnancy; their physician's practices regarding influenza vaccination, place of vaccination, and reasons for not receiving influenza vaccination. Weighted analyses were conducted. Because opt-in Internet panels are not random samples, statistical measures such as compilation of confidence intervals and tests of differences cannot be performed.§

Of the 1,660 women pregnant at any time during October 2011–January 2012, 47.0% reported influenza vaccination since August 1, 2011: 9.9% were vaccinated before pregnancy; 36.5% during pregnancy; and 0.6% after pregnancy (Table 1). By trimester of pregnancy, the percentages vaccinated were similar (10.1%, 12.6%, and 11.8% during the 1st, 2nd, and 3rd trimester, respectively). Women aged 18–24 years had lower vaccination coverage (42.3%) than women aged 25–49 years (49.4%). Non-Hispanic black women had lower vaccination coverage (39.8%) than Hispanic women (48.8%), non-Hispanic white women (47.9%), and other non-Hispanic women (53.7%). Vaccination coverage estimates varied by U.S. Census regions from 43.9% in the south to 49.7% in the northeast (Table 1). Women with education beyond a college degree had higher coverage (61.3%) than those with a college degree (49.4%) or less than a college degree (42.8%). Women with private or military medical insurance had higher vaccination coverage (50.2%) than those without medical insurance (36.9%) (Table 1).

Of women in the April 2012 survey, 39.8% reported having received influenza vaccination for the 2010–11 influenza season. Among these women, vaccination coverage for the 2011–12 season was 86.5%, compared with 20.7% for those who did not receive vaccination for the 2010–11 season (Table 1).

Among women who received a health-care provider recommendation to be vaccinated, 81.6% were offered vaccination during a provider visit. Among women who received both a health-care provider recommendation and offer for influenza vaccination, 73.6% received influenza vaccination, which was substantially higher than for women whose health-care provider recommended but did not offer vaccination (47.9%) and for women who did not receive either a provider recommendation or offer (11.1%) (Table 1).

Among the 87.7% of women participants who indicated that they had visited a provider since August 2011, 62.9% received a provider recommendation for influenza vaccination (Table 2).Within each of the categories, the subgroups with lower percentages reporting receipt of a provider recommendation were non-Hispanic black (54.1%), having no medical insurance (46.4%), underweight before pregnancy (55.0%), not vaccinated for the previous season (48.6%), and visited a provider because of pregnancy five times or fewer (52.3%) (Table 2). The subgroups with a higher percentage receiving a provider recommendation were women with more than a college degree (71.9%), women who were vaccinated for the previous season (83.7%), and those with more than 10 pregnancy-related provider visits (76.0%) (Table 2).

Most women who received influenza vaccination received it at their obstetrician's or midwife's office (41.4%), at a non-obstetrician health-care provider's office (20.7%), or a hospital, clinic or health center (17.5%). Other locations for vaccination included pharmacy/drug or grocery store (8.0%); health department (4.1%); and workplace, school, or others (8.3%).

Among unvaccinated women who received a health-care provider recommendation and offer of vaccination, when the main reason for nonvaccination was asked, the top three most common answers were 1) concern that the vaccination would cause influenza (25.6%); 2) concern about the safety risk to the baby (13.1%); and 3) not believing the vaccination was effective (12.5%) (Table 3). Among women reporting no provider offer for influenza vaccination, the same three answers for not being vaccinated were most frequently cited (Table 3).

Reported by

Deborah K. Walker, EdD, Sarah Ball, ScD, Sara Donahue, DrPH, David Izrael, MS, Abt Associates Inc., Cambridge Massachusetts. K.P. Srinath, PhD Abt SRBI, New York, New York. Helen Ding, MD, Gary L. Euler, DrPH, Walter W. Williams, MD, Stacie M. Greby, DVM, James A. Singleton, PhD, Peng-Jun Lu, MD, Erin D. Kennedy, DVM, Carolyn B. Bridges, MD, Immunization Service Div, Lisa A. Grohskopf, MD, Influenza Div, National Center for Immunization and Respiratory Diseases; Denise J. Jamieson, MD, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributors: Gary L. Euler, gle0@cdc.gov, 404-639-8742; Helen Ding, hding@cdc.gov, 404-639-8513.

Editorial Note

In previous years, estimates of annual influenza vaccination levels among pregnant women were consistently lower than 30% through the 2007–08 season, according to data from the National Health Interview Survey (4) and Behavioral Risk Factor Surveillance System (BRFSS) (5). During the 2009–10 influenza A (H1N1) pdm09 season, estimates increased to 32% (National 2009 H1N1 Flu Survey) (6) and 47% (Pregnancy Risk Assessment Monitoring System) (5). During the 2010–11 influenza season, estimates were 38%, according to BRFSS data (5) and 49%, based on the previous Internet panel survey (3). The findings in this report indicate that the level of influenza vaccination among pregnant women achieved during the two preceding seasons (3) was sustained during the 201112 season.

Women who received a health-care provider recommendation for influenza vaccination continued to be more likely to be vaccinated (5,6); in addition, women who received both a provider recommendation and an offer for influenza vaccination were more likely to be vaccinated than women who only received a provider recommendation. In this study, 81.6% of women with a recommendation to be vaccinated were offered vaccination during a visit with their provider. Among women in this group, vaccination coverage was 73.6%, nearly reaching the Healthy People 2020 target of 80% for pregnant women, regardless of provider recommendations or offers.

Studies of health-care providers have suggested that they are more likely to discuss influenza vaccination with their patients when they understand the vaccination guidelines for pregnant women, are vaccinated themselves, or provide vaccination at their practice (7–8). However, providers also might be more likely to recommend influenza vaccination to women who appear to be in favor of influenza vaccination. A previous study found that providers' who did not recommend vaccination were more likely influenced by patient preference than the providers' continuing education (9).

Even among the 288 women in the sample with more than 10 pregnancy-related provider visits, about one fourth reported they did not receive a provider recommendation for influenza vaccination. Providers might have administrative and financial barriers to routine offering of influenza vaccination, such as working in a solo practice, concern about the up-front cost of ordering vaccines, high costs of storing and maintaining vaccine inventory, and other logistical challenges of vaccine administration (10). In this study, women without medical insurance of any type or with less frequent provider visits related to pregnancy were less likely to receive a provider recommendation. Health-care providers should use every opportunity to recommend and offer vaccination if appropriate, and women who are pregnant or who might become pregnant should ask about influenza vaccination at their provider visits, and if necessary, make a visit just for influenza vaccination.

Among unvaccinated women, 25.6% who received a provider offer and recommendation indicated that the main reason they chose not to receive an influenza vaccination was concern that the vaccination would give them influenza; another 13.1% said they were concerned about the safety risk to their baby. Tailored education messages on vaccination safety delivered through multiple means including social media and text messaging might help change negative attitudes and false beliefs about vaccination.

The findings in this report are subject to at least four limitations. First, the survey was self-administered and not validated by medical record review. Second, the results were weighted to the distribution of pregnant women in the U.S. population, but the study sample did not include women without Internet access. Therefore, it might not be a representative sample of pregnant women and findings might not be generalizable to all pregnant women in the United States. Third, estimates might be biased if the selection processes for entry into the Internet panel and a woman's decision to participate in this particular survey were related to receipt of vaccination. Comparing estimates, the Internet panel survey estimates for women pregnant at any time during October–January was 9 percentage points higher than the BRFSS estimate for women who were pregnant at interview during December–February for the 2010–11 influenza season (5) and 4 percentage points higher for the 2011–12 season (CDC, unpublished data, 2012). Additional comparisons with BRFSS and other available data sources over multiple seasons are needed to determine whether the more timely Internet panel survey estimates, despite sampling differences, provide valid assessments of trends. Finally, the results from these surveys might be subject to multiple sources of error, including but not limited to sampling error, coverage error, and measurement error.

Health-care provider recommendation and offer of influenza vaccination were associated with higher vaccination levels among pregnant women. Efforts to enhance provider practices are needed. Messages to pregnant women from providers should more strongly emphasize the safety and effectiveness of maternal influenza vaccination and the risk from influenza to mother and infants without maternal vaccination. Increasing knowledge among pregnant women regarding influenza risks and influenza vaccination safety might also increase opportunities for provider recommendations and offers to vaccinate.

Acknowledgments

John Boyle, PhD, Rachel Martonik, and Faith Lewis, Abt SRBI, Silver Spring, Maryland.

References

  1. CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR 2010;59(No. RR-8).
  2. American Congress of Obstetricians and Gynocologists Committee on Obstetric Practice. ACOG committee opinion no. 468: influenza vaccination during pregnancy. Obstet Gynecol 2010;116:1006–7.
  3. CDC. Influenza vaccination coverage among pregnant women—United States, 2010–11 influenza season. MMWR 2012;60:1078–82.
  4. Lu P, Bridges CB, Euler GL, Singleton JA. Influenza vaccination of recommended adult populations, U.S., 1989–2005. Vaccine 2008;26:1786–93.
  5. Kennedy ED, Ahluwalia IB, Ding H, Lu PJ, Singleton JA, Bridges CB. Monitoring seasonal influenza vaccination coverage among pregnant women in the United States. Am J Obstet Gynecol 2012;207(3 Suppl):S9–16.
  6. Ding H, Santibanez TA, Jamieson DJ, et al. Influenza vaccination coverage among pregnant women—National 2009 H1N1 Flu Survey (NHFS). Am J Obstet Gynecol 2011;204(6 Suppl 1):S96–106.
  7. Silverman NS, Greif A. Influenza vaccination during pregnancy. Patients' and physicians' attitudes. J Reprod Med 2001;46:989–94.
  8. Panda B, Stiller R, Panda A. Influenza vaccination during pregnancy and factors for lacking compliance with current CDC guidelines. J Matern Fetal Neonatal Med 2011;24:402–6.
  9. McNeil S, Halperin B, MacDonald N. Influenza in pregnancy: the case for prevention. Adv Exp Med Biol 2009;634:161–83.
  10. Kissin DM, Power ML, Kahn EB, et al. Attitudes and practices of obstetrician-gynecologists regarding influenza vaccination in pregnancy. Obstet Gynecol 2011;118:1074–80.

* Additional information available at http://www.surveysampling.com.

The sample of pregnant women was weighted to reflect the age group, racial/ethnic and geographic distribution of total pregnant women in the United States during 1995–2005. Source: CDC. Estimated pregnancy rates for the United States, 1990–2005: an update. Natl Vital Stat Rep 2009;58(4).

§ Additional information available at http://www.aapor.org/opt_in_surveys_and_margin_of_error1.htm.

Additional information available at http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23.


What is already known on this topic?

Pregnant women are at increased risk for influenza-associated complications and are recommended to receive inactivated influenza vaccination regardless of trimester. Vaccination coverage among pregnant women was estimated at 32% (National 2009 H1N1 Flu Survey) and 47% (Pregnancy Risk Assessment Monitoring System) for the 2009–10 season and 38% (Behavioral Risk Factor Surveillance System) and 49% (Internet panel survey) for the 2010–11 influenza season.

What is added by this report?

Approximately 47% of pregnant women in the Internet panel survey reported being vaccinated for influenza for the 2011–12 influenza season; 9.9% were vaccinated before pregnancy; 36.5% during pregnancy; and <1.0% after pregnancy. Women who received both health-care provider recommendations and offers to vaccinate had substantially higher vaccination coverage (73.6%) compared with other women (47.9% for those with recommendations but no offers, and 11.1% for those with neither).

What are the implications for public health practice?

Continued efforts are needed to encourage health-care providers to educate their patients about the safety and effectiveness of vaccination and continually recommend and offer influenza vaccination to their pregnant patients. To overcome their concerns and fears, messages to pregnant women should emphasize the safety and effectiveness of maternal influenza vaccination for both the mother and baby.


TABLE 1. Percentage vaccinated among women pregnant at any time during October 2011–January 2012, by selected characteristics — Internet panel surveys, United States, 2011–12 influenza season

Characteristic

Unweighted no. of participants

Unweighted %

Weighted %

Weighted % vaccinated

Percentage point change from 2010–11 survey*

Vaccinated

802

48.3

47.0

-2.0

Before pregnancy

165

9.9

9.9

-1.8

During pregnancy

625

37.7

36.5

4.3

1st trimester

172

10.4

10.1

2nd trimester

218

13.1

12.6

3rd trimester

200

12.1

11.8

After pregnancy

12

0.7

0.6

-4.5

Unvaccinated

858

51.7

 

53.0

Age group (yrs) 

18–24

428

25.8

33.8

42.3

-1.3

25–49

1,232

74.2

66.2

49.4

-2.4

Race/Ethnicity

Hispanic

234

14.1

23.5

48.8

-4.4

White, non-Hispanic

1,179

71.0

54.2

47.9

1.4

Black, non-Hispanic

132

8.0

17.2

39.8

-7.3

Other, non-Hispanic

115

6.9

5.2

53.7

-10.1

Census regions

Region 1: Northeast

273

16.5

17.4

49.7

-4.5

Region 2: Midwest

420

25.4

21.2

48.5

-6.1

Region 3: South

591

35.7

35.2

43.9

-0.5

Region 4: West

373

22.5

26.2

48.1

0.9

Education

Less than college degree

845

50.9

55.5

42.8

-0.6

College degree only

603

36.3

34.3

49.4

-5.5

More than college degree

186

12.8

10.2

61.3

-5.6

Married

Yes

1,161

69.9

64.3

49.1

-4.5

No

499

30.1

35.7

43.1

0.8

Medical coverage

Any public

555

33.4

37.4

44.0

-2.2

Private/Military only

1,000

60.2

55.9

50.2

-3.9

None reported

105

6.3

6.7

36.9

1.9

Working status

Working

816

49.2

47.5

47.9

-6.7

Not working

843

50.8

52.5

46.2

1.6

Income§

<$50,000

814

49.5

53.0

44.8

1.3

≥$50,000

832

50.6

47.0

49.7

-4.5

High-risk condition

Yes

602

36.3

37.4

52.4

-5.8

No

1,058

63.7

62.6

43.8

-1.9

Vaccinated for previous influenza season

Yes

691

41.7

39.8

86.5

3.0

No

968

58.4

60.2

20.7

-0.2

Provider recommendation/Offer

Recommended and offered

744

44.8

43.7

73.6

2.7

Recommended with no offer

181

10.9

9.9

47.9

15.1

No recommendation and no offer

413

24.9

26.4

11.1

2.6

Unknown status for recommendation and offer

243

14.6

15.0

30.9

1.8

Did not visit a provider since August 2011

79

4.8

5.0

50.5

5.7

* Source: CDC. Influenza vaccination coverage among pregnant women—United States, 2010–11 influenza season. MMWR 2011;60:1078–82 .

Those who were employed for wages and the self-employed were grouped as working. Those who were out of work, homemakers, students, retired, or unable to work were grouped as not working.

§ For those who only reported a range for income, the mid-point of the range was used for the actual household income.

Conditions associated with increased risk for serious medical complications from influenza, including chronic asthma, a lung condition other than asthma, a heart condition, diabetes, a kidney condition, a liver condition, obesity, or a weakened immune system caused by a chronic illness or by medicines taken for a chronic illness.


TABLE 2. Percentage vaccinated among women pregnant at any time during October 2011–January 2012 who reported at least one visit to a health-care provider since August 2011, by health-care provider recommendation and offer status* and selected characteristics — Internet panel survey, United States, 2011–12 influenza season

Characteristic

Received health-care provider recommendation

% vaccinated

Recommended and offered

Recommended with no offer

No recommendation

No.

%

No.

%

No.

%

No.

%

Total

1,356

62.9

693

73.8

167

48.5

380

11.0

Age group (yrs)

18–24

329

56.6

162

70.5

—§

107

6.1

25–49

1,027

65.9

531

75.2

138

52.1

273

14.0

Race/Ethnicity

Hispanic

186

61.8

96

76.8

57

11.8

White, non-Hispanic

986

65.1

505

74.1

128

48.2

265

12.0

Black, non-Hispanic

94

54.1

44

66.3

36

8.1

Other, non-Hispanic

90

69.4

48

77.0

Education

Less than college degree

654

61.0

329

71.7

74

40.1

197

7.8

College degree only

510

62.4

267

74.4

60

50.1

137

14.5

More than college degree

172

71.9

87

79.5

31

68.1

43

16.3

Married

Yes

982

64.3

509

75.1

124

51.1

262

11.7

No

374

60.0

184

71.1

43

42.5

118

9.7

Medical coverage

Any public

428

63.2

227

72.9

52

38.1

122

9.9

Private/Military only

858

64.2

440

75.1

108

56.2

230

12.1

None reported

70

46.4

Working status

Working

735

63.0

335

75.8

93

52.6

191

12.4

Not working

721

62.7

358

72.0

74

43.2

189

9.7

Poverty status**

Below poverty

264

59.9

130

74.2

32

22.5

74

7.3

At or above poverty

1,064

63.5

547

74.0

131

57.5

299

12.4

Pre-pregnancy weight††

Underweight

76

55.0

36

66.6

Normal weight

734

61.5

365

73.4

98

41.7

198

9.8

Overweight

242

67.8

128

70.0

32

63.3

65

5.6

Obese

267

64.0

144

78.1

N/A

80

15.5

High-risk conditions§§

Yes

492

67.6

273

76.8

55

52.9

125

11.6

No

864

60.0

420

71.6

112

46.1

255

10.7

Vaccinated for previous season

Yes

581

83.7

410

94.7

70

89.5

71

51.2

No

774

48.6

283

45.7

97

20.8

309

2.4

No. of provider visits related to pregnancy

≤5 visits

487

52.3

205

70.7

52

43.7

180

7.8

6–10 visits

530

64.4

272

72.9

74

48.8

137

13.4

>10 visits

288

76.0

182

79.0

35

49.5

53

18.5

* The women were asked two questions: "Since August 2011, during your visits to the doctor/medical professional, did your doctor or other health professional personally recommend that you get a flu vaccination?" and "Since August 2011, during your visits to the doctor/medical professional, did your doctor or other health professional offer the flu vaccination to you?" A total of 243 women with unknown response regarding provider recommendation and offer were excluded.

Weighted percentage.

§ Sample size <30.

Those who were employed for wages and the self-employed were grouped as working. Those who were out of work, homemakers, students, retired, or unable to work were grouped as not working.

** Below poverty was defined as a total family income of <$22,811 for a family of four with two minors as of 2011, as categorized by the U.S. Census Bureau (http://www.census.gov/hhes/www/poverty/data/threshld/index.html). For those who only reported a range for income, the mid-point of the range was used for the actual household income.

†† Based on body mass index (weight [kg] / height [m]2). Underweight = <8.5; normal weight = 18.5–24.9; overweight = 25–29.9; obese = ≥30.0.

§§ Conditions associated with increased risk for serious medical complications from influenza, including chronic asthma, a lung condition other than asthma, a heart condition, diabetes, a kidney condition, a liver condition, obesity, or a weakened immune system caused by a chronic illness or by medicines taken for a chronic illness.


TABLE 3. Main reasons offered for not receiving influenza vaccination among nonvaccinated women pregnant at any time during October 2011–January 2012*, by health-care provider recommendation and offer status — Internet panel survey, United States, 2011–12 influenza season

Reason

Total

Recommendation and offer

No offer

No.

%§

No.

%

No.

%

Total

815

100

179

28

434

72

Concerned vaccination would give me the flu

145

20.0

43

25.6

70

18.3

Concerned about the safety risk to my baby

131

15.8

26

13.1

72

17.1

Don't think the vaccination is effective in preventing flu

93

10.7

21

12.5

53

11.2

Do not need the vaccination

66

8.4

12

7.8

36

8.8

The flu will not make me very sick/can get medication to treat

61

7.6

5

3.0

41

9.0

Concerned about the safety risks to myself

52

5.5

16

6.4

21

4.3

Afraid of needle/shots

38

5.4

13

10.6

14

3.3

Concerned about side effects

39

5.2

2

1.7

22

4.9

Don't trust it

43

4.6

11

5.6

25

4.9

Not covered by medical insurance/costs too much

35

4.3

7

2.5

19

5.4

Don't have time/don't know where to go/who to call

31

3.7

5

3.2

20

4.5

Allergic/contraindication

22

2.4

6

2.5

6

1.6

Other reason

59

6.4

12

5.5

35

6.7

* Main reason data were missing for 43 women.

The women were asked two questions: "Since August 2011, during your visits to the doctor/medical professional, did your doctor or other health professional personally recommend that you get a flu vaccination?" and "Since August 2011, during your visits to the doctor /medical professional, did your doctor or other health professional offer the flu vaccination to you?" Data regarding provider recommendation and offer were missing for 202 women.

§ Weighted percentage.


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