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Pneumococcal and Influenza Vaccination Levels Among Adults Aged greater than or equal to 65 Years -- United States, 1995

In 1995, pneumonia and influenza together ranked sixth among the 10 leading causes of death in the United States (1). An estimated 90% of deaths caused by these illnesses occur among adults aged greater than or equal to 65 years (2). In addition, pneumococcal infections are the most common cause of bacterial pneumonia requiring hospitalization and account for an estimated 40,000 deaths annually in the United States (3). A national health objective for 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) (4). To estimate state-specific pneumococcal and influenza vaccination levels for persons aged greater than or equal to 65 years, CDC analyzed data from the 1995 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the BRFSS findings, which indicate sustained increases in self-reported coverage levels for pneumococcal and influenza vaccination among persons aged greater than or equal to 65 years; compares these findings with data from the 1993 BRFSS; and assesses progress toward the 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. It can be used to determine the prevalence of behaviors and practices related to the leading causes of death (5). To assess state-specific vaccination levels, responses to two questions about pneumococcal and influenza vaccinations were analyzed from the 1995 BRFSS; all 50 states participated (the District of Columbia did not participate). Race/ethnicity-specific data are presented only for non-Hispanic blacks, non-Hispanic 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. Software for Survey Data Analysis (SUDAAN) was used to calculate 95% confidence intervals (CIs). In 1995, weighted responses were available from 22,639 adults aged greater than or equal to 65 years (14,636 {64.7%} women and 8003 {35.4%} men) who were interviewed throughout the year as part of state BRFSS surveys. Respondents were asked, "Have you ever had a pneumonia vaccination?" and "During the past 12 months, have you had a flu shot?"

During 1995, a total of 35.6% of respondents reported ever having received pneumococcal vaccine and 58.1% reported receiving influenza vaccine during the preceding 12 months (Table_1). These were substantial increases over 1993 (6).

During 1993-1995, overall pneumococcal vaccination levels increased by 6.9 percentage points (from 28.7% to 35.6%). Pneumococcal vaccination levels increased in all states except three. The largest state-specific increase occurred in New Hampshire (from 19.1% to 37.7%), and the largest decrease occurred in New Jersey (from 21.9% to 11.4%). State-specific levels ranged from 11.4% (New Jersey) to 46.6% (Arizona) (median: 36.8%) (Table_2). In 1995, pneumococcal vaccination levels were greater than or equal to 40% in 12 states, compared with one state in 1993.

During 1993-1995, overall receipt of influenza vaccination increased by 7.7 percentage points (from 50.4% to 58.1%); in addition, influenza vaccination levels increased in 45 states and decreased in five. The largest state-specific increase occurred in Tennessee (17 percentage points, from 46.0% to 63.0%), and the largest decrease occurred in New Jersey (7.6 percentage points, from 53.0% to 45.6%). State-specific levels ranged from 44.2% (Alabama) to 70.0% (Utah) (median: 59.2%). Influenza vaccination levels were greater than or equal to 60% in 23 states (an increase from five states in 1993) and greater than or equal to 50% in 45 states (an increase from 24 states in 1993).

During 1995, reported sex-specific pneumococcal and influenza vaccination levels were similar to the overall mean level (Table_1), and non-Hispanic whites were more likely to report ever receiving pneumococcal vaccine (37.4%) than either Hispanics (24.2%) or non-Hispanic blacks (19.7%). In addition, non-Hispanic whites were substantially more likely to report having received influenza vaccine during the preceding 12 months (60.1%) than Hispanics (50.0%) or non-Hispanic blacks (39.3%) (Table_1). Both pneumococcal and influenza vaccination levels were lowest among non-Hispanic blacks (19.7% and 39.3%, respectively). Compared with 1993, race/ethnicity-specific levels for both vaccines in 1995 were higher for all racial/ethnic groups analyzed (except for blacks for pneumococcal vaccine) and were substantially higher for non-Hispanic whites.

Because self-reported vaccination levels were consistently lower for non-Hispanic blacks and Hispanics than for non-Hispanic whites and because race-specific levels varied among the states, census data were examined to determine whether the size and distribution of these groups affected overall state vaccination levels. However, there was no clear association between overall state-specific pneumococcal and influenza vaccination levels and either size or vaccination levels of minority populations aged greater than or equal to 65 years in states. State-specific variations persisted when crude pneumococcal and influenza vaccination rates were adjusted for race/ethnicity. The percentage point difference between the crude and adjusted rates was calculated to assess the effect of adjusting for race/ethnicity in each state. For pneumococcal vaccination, adjusted rates for 35 (70%) of the 50 states were within 5 percentage points of the crude rates (range: -8.8% to 26.2%). For influenza vaccination, adjusted rates for 40 (80%) of the 50 states were within 5 percentage points of the crude rates (range: -15.8% to 9.8%).

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; 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; T Murayi, 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; K Passaro, PhD, 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; D Shepard, MD, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; J Stones, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin; M Futa, Wyoming. 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: Vaccination levels against pneumococcal infection and influenza in the United States increased steadily during 1973-1993 (6,7). Based on the findings in this report, in 1995 state-specific self-reported pneumococcal and influenza vaccination levels for persons aged greater than or equal to 65 years were the highest ever. Self-reported vaccination levels for the 1995 BRFSS varied by state and race/ethnicity, and the variation is consistent with previous reports (6-8). Even after adjusting for race/ethnicity, variations persisted in crude pneumococcal and influenza vaccination rates, suggesting that state-specific variations reflected other factors in addition to race/ethnicity distribution (e.g., regional variations in physician practice patterns, education, income level, insurance coverage, the prevalence of specific risk factors in target groups, and varying patient attitudes toward aspects of medical care {6,9,10}).

An important limitation of this study is that data about vaccination status were self-reported and were not validated; therefore, the vaccination levels may not be precise. However, the predictive value and accuracy of self-reported influenza vaccination was 91% when vaccination status was validated by record review (11); no similar data are available for validation of pneumococcal vaccination levels. In addition, although this study documents the highest overall levels ever of pneumococcal and influenza vaccination in the United States among persons aged greater than or equal to 65 years, vaccination levels were low among non-Hispanic blacks and among Hispanics.

Strategies to improve delivery of these vaccines to all persons at risk should include continued 1) assessment of factors accounting for differential state-specific and race/ethnicity-specific vaccination rates, particularly physician practice patterns and patient attitudes; 2) collaboration between public and private organizations to improve awareness about the need for these vaccines; 3) changes in clinical practice to improve vaccine delivery; 4) expansion of pneumococcal and influenza vaccination services by working with private, medical, and community groups to limit cost and remove accessibility constraints; 5) collaboration of public and private medical providers with Health Care Financing Administration Quality Improvement Organizations (formerly Peer Review Organizations) to increase vaccination levels among Medicare beneficiaries; and 6) encouragement of local health departments to enroll as Medicare providers, implement pneumococcal and influenza vaccination programs, and file claims for pneumococcal and influenza vaccination services, which are reimbursable by Medicare. In addition, timely reporting and collection of surveillance data on vaccination coverage (e.g., through BRFSS) and disease are necessary to assess the effectiveness of vaccination programs and assist in targeting efforts to improve programs and vaccination levels.

References

  1. Rosenberg HM, Ventura SJ, Maurer JD, Heuser RL, Freedman MA. Births and deaths: United States, 1995. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Health Statistics, 1996. (Monthly vital statistics report; vol 45, no. 3, suppl 2).

  2. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(no. RR-9).

  3. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(no. RR-8).

  4. 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; DHHS publication no. (PHS)91-50212.

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

  6. CDC. Pneumococcal and influenza vaccination levels among adults aged greater than or equal to 65 years -- United States, 1993. MMWR 1996;45:853-9.

  7. 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.

  8. CDC. Race-specific differences in influenza vaccination levels among Medicare beneficiaries -- United States, 1993. MMWR 1995;44:24-7,33.

  9. 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.

  10. Pilote L, Califf RM, Sapp S, et al. Regional variation across the United States in the management of acute myocardial infarction. N Engl J Med 1995;333:565-72.

  11. 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.

+------------------------------------------------------------------- ----+ | Errata: Vol. 46, No. 39 | |             | | In the report, "Pneumococcal and Influenza Vaccination Levels | | Among Adults Aged greater than or equal to 65 Years -- United States, | | 1995," an error appears in the footnotes of Tables 1 and 2 on pages | | 915-917. In the second sentence of the **** footnote of Table 1 and | | of the *** footnote of Table 2, the word "weighted" should be | | deleted before the words "sample size." | |             | +------------------------------------------------------------------- ----+
Table_1
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TABLE 1. Percentage of persons aged >=65 years who reported receiving pneumococcal* or influenza+ vaccine, by sex and race/ethnicity&, 1995, and
percentage point difference in vaccination coverage levels from 1993 to 1995 -- United States, Behavioral Risk Factor Surveillance System (BRFSS) @
==============================================================================================================================================================
                                                     Pneumococcal vaccine                                          Influenza vaccine
                                          -------------------------------------------------       ------------------------------------------------------------
                                                                         % Point difference                                                % Point difference
Characteristic       Sample size            %                  (95% CI)  from 1993 to 1995          %               (95% CI**)           from 1993 ti 1995
--------------------------------------------------------------------------------------------------------------------------------------------------------------
Sex
 Men                        8,003           34.1           (32.1%-35.8%)         5.9                58.4          (56.6%-60.2%)                   9.6
 Women                     14,636           36.6           (35.4%-37.9%)         7.5                58.0          (56.7%-59.2%)                   6.5

Race/Ethnicity
 White,non-Hispanic        20,133           37.4           (36.3%-38.5%)         7.6                60.1          (59.0%-61.2%)                   7.9
 Black,non-Hispanic         1,302           19.7           (16.7%-22.7%)        -5.3                39.3          (35.6%-43.1%)                   6.2
 Hispanic ++                  590           24.2           (18.9%-29.4%)         3.2                50.0          (43.7%-56.3%)                   2.4
 Other                        552           36.0           (25.0%-46.0%)        17.3                58.5          (48.6%-68.5%)                  18.8

Total                      22,639  &&       35.6           (34.5%-36.6%)         6.9                58.1          (57.1%-59.2%)                   7.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------
*  Ever during their lifetimes.
+  During the preceding 12 months.
&  Numbers for racial/ethnic groups other than blacks, whites, and Hispanics were too small for meaningful analysis.
@  All 50 states participated in the 1995 BRFSS (the District of Columbia did not participate). Weighted sample size=22,639.
** Confidence interval.
++ Persons of Hispanic origin can be of any race.
&& Some persons (n=62) answered the vaccination question but refused to answer the question about race/ethnicity.
==============================================================================================================================================================

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Table_2
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TABLE 2. Percentage of persons aged >=65 years who reported receiving pneumococcal* or influenza+ vaccine, by state, 1995, and percentage point
difference in vaccination coverage from 1993 to 1995 -- United States, Behavioral Risk Factor Surveillance System (BRFSS) &
===================================================================================================================================================
                                       Pneumococcal vaccine                                          Influenza vaccine
                         ---------------------------------------------------            ----------------------------------------------------
                                                          % Point difference                                            % Point difference
State                       %                (95% CI)       from 1993 to 1995            %               (95% CI@)      from 1993 to 1995
---------------------------------------------------------------------------------------------------------------------------------------------------
Alabama                   31.2            (26.1%-36.3%)            6.2                  44.2           (38.5%-49.8%)            4.2
Alaska                    41.1            (25.2%-57.0%)           10.0                  49.4           (33.4%-65.4%)           -3.9
Arizona                   46.6            (40.5%-52.8%)           15.9                  64.7           (58.8%-70.5%)           -1.6
Arkansas                  35.8            (30.6%-40.9%)            8.6                  60.5           (55.5%-65.5%)            8.7
California                42.7            (38.0%-47.3%)            7.0                  59.4           (54.6%-64.2%)            5.0
Colorado                  44.6            (28.6%-50.5%)            4.6                  65.9           (60.4%-71.5%)            2.0
Connecticut               36.9            (31.3%-42.4%)           18.1                  62.3           (56.6%-67.9%)            8.9
Delaware                  39.9            (35.2%-44.6%)            4.3                  57.2           (52.1%-62.2%)            2.2
Florida                   38.4            (34.8%-42.1%)           13.2                  61.3           (57.7%-64.9%)           15.0
Georgia                   37.8            (33.3%-42.4%)           10.1                  46.6           (41.7%-51.5%)            2.2
Hawaii                    40.5            (35.0%-46.0%)            2.7                  62.1           (57.0%-67.6%)            5.5
Idaho                     38.8            (34.4%-43.2%)            5.7                  64.2           (59.7%-68.6%)           -0.2
Illinois                  28.3            (22.7%-34.0%)            5.2                  57.6           (51.4%-63.8%)           12.4
Indiana                   33.2            (28.8%-37.6%)            6.5                  58.8           (54.0%-63.5%)           11.8
Iowa                      43.6            (39.8%-47.3%)           11.2                  62.8           (59.2%-66.3%)           13.1
Kansas                    41.4            (36.3%-46.4%)           18.3                  58.7           (53.6%-63.8%)            6.3
Kentucky                  24.1            (20.4%-27.9%)           -0.1                  52.1           (47.7%-56.4%)            7.6
Louisiana                 25.9            (20.3%-30.6%)            7.0                  52.0           (45.8%-58.1%)           15.8
Maine                     34.8            (28.3%-41.2%)           14.4                  64.5           (58.2%-71.0%)           15.3
Maryland                  32.2            (28.8%-35.6%)           -1.5                  57.3           (53.7%-61.0%)            8.7
Massachusetts             30.8            (25.2%-36.3%)            9.3                  58.9           (53.0%-64.8%)            9.2
Michigan                  38.5            (33.8%-43.2%)           13.9                  56.7           (52.0%-61.5%)            9.0
Minnesota                 39.2            (35.6%-42.7%)           13.0                  62.9           (59.1%-66.5%)           12.0
Mississippi               38.7            (33.0%-44.3%)           11.1                  56.7           (50.8%-62.5%)           14.3
Missouri                  30.6            (24.6%-36.6%)            0                    66.5           (60.4%-72.5%)           11.7
Montana                   34.6            (28.3%-40.9%)            0.8                  63.8           (57.4%-70.1%)            1.4
Nebraska                  35.0            (30.4%-39.5%)            7.6                  63.9           (59.2%-68.5%)           10.7
Nevada                    38.8            (32.9%-44.5%)            7.4                  51.7           (45.8%-57.6%)            8.1
New Hampshire             37.7            (31.1%-44.2%)           18.6                  53.4           (46.7%-60.1%)            3.8
New Jersey                11.4            ( 6.9%-15.9%)          -10.5                  45.6           (38.1%-53.1%)           -7.6
New Mexico                38.5            (31.4%-45.7%)           6.8                   68.5           (61.6%-75.5%)            7.7
New York                  25.7            (21.0%-30.3%)           3.6                   55.9           (50.6%-61.2%)           10.6
North Carolina            30.7            (27.2%-34.2%)           4.4                   52.2           (48.4%-56.1%)            1.3
North Dakota              32.1            (27.4%-36.8%)          12.3                   56.9           (51.9%-61.7%)            8.0
Ohio                      39.8            (33.0%-46.6%)          11.9                   62.7           (56.2%-69.2%)           12.6
Oklahoma                  36.8            (32.3%-41.3%)           7.7                   60.8           (56.0%-65.5%)            2.3
Oregon                    44.7            (40.3%-49.1%)          10.0                   67.0           (62.9%-71.0%)           11.2
Pennsylvania              36.5            (31.7%-41.3%)          11.5                   57.7           (53.3%-62.1%)            9.1
Rhode Island              29.2            (24.0%-34.5%)           9.1                   65.6           (60.2%-71.0%)           14.4
South Carolina            25.8            (21.1%-30.6%)           6.4                   49.6           (44.1%-55.0%)            2.3
South Dakota              31.1            (26.3%-36.0%)           4.5                   59.9           (55.0%-64.9%)           12.2
Tennessee                 29.5            (24.7%-34.3%)           4.1                   63.0           (57.7%-68.4%)           17.1
Texas                     42.7            (35.9%-49.6%)           5.5                   56.4           (49.6%-63.2%)           -0.7
Utah                      41.9            (36.5%-47.4%)           6.6                   70.0           (65.2%-74.8%)           15.8
Vermont                   34.9            (30.2%-39.6%)           6.2                   63.5           (58.6%-68.4%)            6.4
Virginia                  38.7            (31.5%-45.8%)           4.5                   52.5           (45.6%-59.4%)            6.7
Washington                44.4            (39.5%-49.2%)          12.3                   66.4           (61.8%-71.0%)           13.0
West Virginia             36.1            (31.7%-40.5%)           7.6                   53.0           (48.6%-57.4%)            3.3
Wisconsin                 34.8            (29.3%-40.3%)           7.4                   56.7           (50.9%-62.6%)            7.7
Wyoming                   43.1            (37.9%-48.1%)            NA**                 66.5           (61.6%-71.5%)             NA

Range                   11.4-46.6                                                    44.2-70.0
Median                    36.8                                                          59.2
Overall mean              35.6            (34.5%-36.6%)                                 58.1           (57.1%-59.2%)
---------------------------------------------------------------------------------------------------------------------------------------------------
*  Ever during their lifetimes.
+  During the preceding 12 months.
&  All 50 states participated in the 1995 BRFSS (the District of Columbia did not participate). Weighted sample size=22,639; 14,636 (64.7%)
   women and 8003 (35.4%) men.
@  Confidence interval.
** Not applicable (Wyoming did not participate in the 1993 BRFSS).
===================================================================================================================================================

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