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Pneumococcal and Influenza Vaccination Levels Among Adults Aged Greater Than or Equal to 65 Years -- United States, 1993

In 1993, pneumonia and influenza ranked sixth among the 10 leading causes of death in the United States, and approximately 90% of the deaths caused by these illnesses occurred among adults aged greater than or equal to 65 years. A national health objective for the year 2000 is to increase pneumococcal and influenza vaccination levels to greater than or equal to 60% for persons at high risk for complications from pneumococcal disease and influenza, including those aged greater than or equal to 65 years (objective 20.11) (1). To estimate state-specific influenza and pneumococcal vaccination levels for persons aged greater than or equal to 65 years, CDC analyzed data from the 1993 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the BRFSS findings, which indicate substantial increases in coverage levels for influenza and pneumococcal vaccines among persons aged greater than or equal to 65 years, and assesses progress toward the year 2000 objective.

BRFSS is a population-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged greater than or equal to 18 years and can be used to determine the prevalence of behaviors and practices related to the leading causes of death (2). To assess state-specific vaccination levels, two questions about influenza and pneumococcal vaccination were added to the 1993 BRFSS; 49 states and the District of Columbia participated. Race/ethnicity-specific data are presented only for blacks, whites, and Hispanics because numbers for other racial/ethnic groups were too small for meaningful analysis. Data were weighted by age and sex to reflect each state's most recent adult population estimate and by the probability of the respondent's selection. SUDAAN was used to calculate 95% confidence intervals (CIs).

In 1993, weighted responses were available from 19,761 adults aged greater than or equal to 65 years (12,862 {65.1%} and 6899 {34.9%} men) who were interviewed throughout the year as part of state BRFSS surveys. Respondents were asked, "During the past 12 months, have you had a flu shot?" and "Have you ever had a pneumonia vaccination?" A total of 50.4% of respondents reported receiving influenza vaccine during the preceding 12 months, and 28.7% reported ever having received pneumococcal vaccine (Table_1).

Self-reported vaccination levels varied by race/ethnicity and state for both influenza and pneumococcal vaccines. Reported vaccination levels were low but similar among men and women (Table_1). Coverage levels varied by race/ethnicity. Non-Hispanic white respondents were significantly more likely to report receiving influenza vaccine during the preceding 12 months (52.2%) than were non-Hispanic black respondents (33.1%) and respondents of other racial/ethnic groups (39.7%). Non-Hispanic whites also were more likely to report ever receiving pneumococcal vaccine (29.8%) than either Hispanics (21.0%) or persons of other racial/ethnic groups (18.7%) (Table_1).

State-specific rates for self-reported influenza vaccination ranged from 28.7% (District of Columbia) to 66.2% (Arizona) (median: 49.9%); rates for pneumococcal vaccination ranged from 18.5% (Louisiana) to 40.0% (Colorado) (median: 27.4%) (Table_2). For reported influenza vaccination, coverage levels were greater than or equal to 60% in five states and greater than or equal to 50% in 24 states.

Reported by the following BRFSS coordinators: J Durham, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; J Cooper, MA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Asher, Kentucky; R Meriwether, MD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; S Loyd, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, New Mexico; T Melnik, DrPH, New York; G Lengerich, VMD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; J Ferguson, DrPh, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; J Stones, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin. Adult Vaccine Preventable Diseases Br, Epidemiology and Surveillance Div, and Assessment Br, Data Management Div, National Immunization Program; Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: During 1972-1991, influenza caused an estimated 20,000 excess deaths during each of 10 U.S. epidemics (3). Pneumococcal infections are the most common cause of bacterial pneumonia requiring hospitalization and cause an estimated 40,000 deaths annually in the United States (4). Despite the continuing morbidity and mortality caused by influenza and pneumococcal disease among adults, coverage levels remained low during 1973-1993 for influenza vaccine and during 1984-1993 for pneumococcal vaccine (5) (Figure_1). However, the findings in this report indicate that, in 1993, state-specific self-reported coverage levels for both influenza and pneumococcal vaccines were at the highest levels ever reported for persons aged greater than or equal to 65 years. Previous estimates indicate that self-reported influenza and pneumococcal vaccination levels among persons aged greater than or equal to 65 years increased steadily during 1987-1993 (3,6) (Figure_1). In addition, preliminary estimates from the 1994 National Health Interview Survey indicate overall influenza and pneumococcal vaccination levels for persons aged greater than or equal to 65 years were 55% and 30%, respectively (CDC, unpublished data, 1996).

Possible reasons for the increase in self-reported influenza vaccination levels include 1) greater acceptance of preventive medical services by practitioners, 2) increased delivery and administration of vaccine by health-care providers and sources other than physicians (e.g., visiting nurse and home-health agencies), and 3) the initiation of Medicare reimbursement for influenza vaccination in 1993 (5). In conjunction with the increase in coverage levels for influenza vaccine, net doses of influenza vaccine distributed nationwide also increased, from 24 million doses of vaccine distributed in 1989 to 40.9 million doses in 1993 (Figure_2).

Although pneumococcal vaccination levels increased during 1989-1993, self-reported coverage levels in 1993 were substantially lower than those for influenza vaccine. Distribution of pneumococcal vaccine increased from 1.2 million doses in 1989 to 3.6 million doses in 1993, consistent with increasing self-reported vaccination levels (Figure_2). Coverage may be lower because many providers and patients are not routinely reminded about the need for pneumococcal vaccination among persons aged greater than or equal to 65 years; in comparison, influenza vaccination campaigns are conducted annually before each influenza season. Intensified efforts are needed to improve knowledge among health-care providers and the public about the benefits of pneumococcal vaccination and current recommendations for this vaccine (e.g., simultaneous administration of influenza and pneumococcal vaccines for those who require both vaccines).

Lower levels for influenza vaccination coverage among non-Hispanic blacks and pneumococcal vaccination coverage among Hispanics have been previously reported (5). Compared with vaccination levels for non-Hispanic whites, these racial/ethnic variations may reflect differences in multiple factors, including education, income, insurance coverage, culture and behavior, and the prevalence of specific risk factors (7,8), and emphasize the need for programs aimed at increasing vaccination levels among these groups.

The 1993 BRFSS documents substantial state-specific variation in influenza and pneumococcal vaccination levels. Some of these differences probably are related to racial/ethnic variations in population density and vaccination levels. In addition, medical practice patterns vary regionally because of differences in health-reimbursement plans, physician practice patterns, and patient attitudes toward different aspects of medical care (9). These variations probably are determinants for administration of influenza and pneumococcal vaccines.

The findings in this report are subject to at least two limitations. First, because BRFSS data were self-reported without validation of vaccination status, these findings may underestimate vaccination levels; however, a validation study among a different sample indicated 91% of persons who had reported receiving influenza vaccine actually received the vaccine (10). Second, some medical conditions increase the risk for complications or death from influenza and pneumococcal disease, and providers may be more likely to administer vaccine to patients with these conditions; however, BRFSS did not collect data about medical conditions of respondents.

To achieve the year 2000 objective for influenza and pneumococcal vaccination levels, additional efforts should be directed toward high-risk populations, including all persons aged greater than or equal to 65 years. Measures for increasing coverage require 1) continuing collaboration between public and private organizations to improve awareness about the need for these vaccines; 2) changes in clinical practice to improve vaccine delivery; 3) vaccine delivery mechanisms that limit cost and remove accessibility constraints; and 4) timely surveillance data, such as those collected by BRFSS, to assess the progress of current and future programs. States can expand influenza and pneumococcal vaccination services for the elderly by building coalitions with private, medical, and community groups; collaborating with Health Care Financing Administration Peer Review Organizations to increase vaccination levels among Medicare beneficiaries; and encouraging local health departments to enroll as Medicare providers and to file claims for influenza and pneumococcal vaccination services, which are covered benefits under Medicare. BRFSS and other state-specific data can assist states in targeting expanded vaccination programs for the elderly.


  1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:122-3; DHHS publication no. (PHS)91-50213.

  2. CDC. Behavioral Risk Factor Surveillance, 1991: monitoring progress towards the nation's year 2000 health objectives. In: CDC surveillance summaries (August). MMWR 1993;42(no. SS-4):1-21.

  3. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996;45(no. RR-5).

  4. CDC. Pneumococcal polysaccharide vaccine. MMWR 1989;38:64-8,73-6.

  5. CDC. Influenza and pneumococcal vaccination coverage levels among persons aged greater than or equal to 65 years -- United States, 1973-1993. MMWR 1995;44:506-7,513-5.

  6. CDC. Influenza vaccination levels in selected states -- Behavioral Risk Factor Surveillance, 1987. MMWR 1989;38:124,129-33.

  7. Tsai C, Strikas RA, Baughman AL, Williams WW. Racial differences in 1993 United States influenza vaccination levels among older persons (greater than or equal to 65 years): relationship to access to care {Abstract no. P3-32}. Presented at Options for the Control of Influenza III, Cairns, North Queensland, Australia, May 4-9, 1996.

  8. Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income on mortality and use of services among Medicare beneficiaries. N Engl J Med 1996;335:791-9.

  9. Detsky AS. Regional variation in medical care. N Engl J Med 1995;333: 589-90.

  10. Hutchison BG. Measurement of influenza vaccination status of the elderly by mailed questionnaire: response rate, validity and cost. Can J Public Health 1989;80:271-5.

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TABLE 1. Percentage of persons aged >= 65 years who reported receiving influenza * or
pneumococcal + vaccine, by sex and race/ethnicity & -- United States, Behavioral Risk
Factor Surveillance System (BRFSS), 1993
                            Influenza              Pneumococcal
                       --------------------    --------------------
Characteristic          %      (95% CI **)      %       (95% CI)
  Men                  48.8   (47.1%-50.5%)    28.2   (26.7%-29.7%)
  Women                51.5   (50.2%-52.8%)    29.1   (27.9%-30.3%)

  White, non-Hispanic  52.2   (51.1%-53.3%)    29.8   (28.8%-30.8%)
  Black, non-Hispanic  33.1   (29.5%-36.7%)    25.0   (19.3%-30.7%)
  Hispanic             47.6   (40.9%-54.3%)    21.0   (14.5%-27.5%)
  Other                39.7   (30.8%-48.5%)    18.7   (15.6%-21.8%)

Total                  50.4   (49.3%-51.5%)    28.7   (27.7%-29.7%)
 * During the preceding 12 months.
 + Ever during their lifetimes.
 & Numbers for racial/ethnic groups other than blacks, whites, and Hispanics were too small
   for meaningful analysis.
 @ Forty-nine states and the District of Columbia participated in the 1993 BRFSS. Weighted
   sample size=19,761: 12,862 (65.1%) women and 6899 (34.9%) men.
** Confidence interval.

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TABLE 2. Number of persons aged >= 65 years who reported receiving influenza * or
pneumococcal + vaccine and percentage vaccination coverage, by state -- United
States, Behavioral Risk Factor Surveillance System (BRFSS), 1993&
                                      Influenza               Pneumococcal
                       No.       --------------------     --------------------
State                persons      %      (95% CI @)        %       (95% CI)
Alabama                490       40.0   (35.4%-44.7%)     25.1   (20.9%-29.2%)
Alaska                 141       53.3   (42.2%-64.5%)     31.2   (21.2%-41.2%)
Arizona                384       66.2   (59.8%-72.7%)     30.7   (24.7%-36.7%)
Arkansas               427       51.8   (46.3%-57.3%)     27.2   (22.6%-31.7%)
California             630       54.4   (50.0%-58.8%)     35.6   (31.4%-39.9%)
Colorado               268       64.0   (57.5%-70.4%)     40.0   (33.4%-46.6%)
Connecticut            345       53.4   (47.6%-59.1%)     18.8   (14.5%-23.1%)
Delaware               395       55.0   (49.6%-60.3%)     35.6   (30.6%-40.7%)
District of Columbia   225       28.7   (21.8%-35.7%)     22.2   (14.9%-29.4%)
Florida                788       46.3   (42.6%-50.1%)     25.2   (21.9%-28.5%)
Georgia                391       44.4   (38.8%-50.0%)     27.8   (23.0%-32.6%)
Hawaii                 299       56.6   (49.2%-64.0%)     37.8   (31.1%-44.6%)
Idaho                  355       64.4   (58.5%-70.3%)     33.1   (27.3%-38.9%)
Illinois               470       45.2   (40.0%-50.4%)     23.1   (18.8%-27.4%)
Indiana                438       47.0   (41.9%-52.2%)     26.7   (22.2%-31.2%)
Iowa                   430       49.7   (44.6%-54.8%)     32.3   (27.6%-37.0%)
Kansas                 258       52.4   (45.9%-59.0%)     23.1   (17.8%-28.5%)
Kentucky               581       44.5   (40.1%-48.9%)     24.2   (20.3%-28.1%)
Louisiana              318       36.2   (30.3%-42.1%)     18.5   (13.8%-23.2%)
Maine                  287       49.2   (42.9%-55.6%)     20.3   (15.2%-25.4%)
Maryland               749       48.6   (44.6%-52.7%)     33.8   (30.0%-37.5%)
Massachusetts          289       49.7   (43.5%-56.0%)     21.5   (16.4%-26.6%)
Michigan               401       47.8   (42.4%-53.2%)     24.7   (20.2%-29.1%)
Minnesota              660       50.9   (46.9%-54.9%)     26.1   (22.6%-29.7%)
Mississippi            302       42.4   (35.9%-48.9%)     27.6   (22.0%-33.2%)
Missouri               337       54.8   (48.9%-60.6%)     30.6   (25.0%-36.2%)
Montana                244       62.4   (55.8%-69.0%)     33.8   (27.1%-40.4%)
Nebraska               426       53.2   (48.1%-58.3%)     27.4   (22.9%-31.9%)
Nevada                 278       43.6   (37.0%-50.1%)     31.4   (24.9%-37.8%)
New Hampshire          256       49.6   (42.8%-56.3%)     19.1   (13.9%-24.4%)
New Jersey             265       53.2   (46.6%-59.9%)     21.9   (16.5%-27.3%)
New Mexico             226       60.9   (54.0%-67.8%)     31.8   (25.6%-38.0%)
New York               438       45.3   (40.1%-50.5%)     22.1   (18.0%-26.2%)
North Carolina         443       50.9   (45.9%-55.9%)     26.3   (21.7%-30.9%)
North Dakota           423       48.9   (43.9%-53.9%)     19.8   (15.8%-23.8%)
Ohio                   324       50.1   (44.0%-56.2%)     27.9   (22.4%-33.4%)
Oklahoma               355       58.4   (52.7%-64.1%)     29.1   (24.4%-33.8%)
Oregon                 593       55.8   (51.4%-60.2%)     34.7   (30.3%-39.1%)
Pennsylvania           544       48.7   (44.1%-53.2%)     25.0   (21.2%-28.8%)
Rhode Island           356       51.2   (45.4%-57.0%)     20.1   (15.8%-24.5%)
South Carolina         400       47.3   (41.6%-53.0%)     19.4   (14.9%-23.9%)
South Dakota           401       47.7   (42.6%-52.8%)     26.6   (22.1%-31.1%)
Tennessee              578       46.0   (41.6%-50.4%)     25.5   (21.6%-29.3%)
Texas                  376       56.8   (50.9%-62.6%)     36.9   (31.4%-42.4%)
Utah                   284       54.3   (47.7%-60.9%)     35.3   (28.7%-41.9%)
Vermont                318       57.0   (51.2%-62.9%)     28.7   (23.4%-34.0%)
Virginia               287       45.8   (39.2%-52.3%)     34.2   (28.0%-40.4%)
Washington             394       53.4   (48.1%-58.6%)     32.1   (27.2%-37.0%)
West Virginia          592       49.8   (45.3%-54.2%)     28.5   (24.5%-32.5%)
Wisconsin              302       49.1   (42.8%-55.3%)     27.4   (21.7%-33.1%)

Range                141-788   28.7-66.2                18.5-40.0
Median                           49.9                     27.4
* During the preceding 12 months.
+ Ever during their lifetimes.
& Forty-nine states and the District of Columbia participated in the 1993 BRFSS. Weighted sample
  size=19,761:12,862 (65.1%) women and 6899 (34.9%) men.
@ Confidence interval.

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