National and State-Level Place of Flu Vaccination among Vaccinated Adults in the United States, 2014–15 Flu Season

Data source: Behavioral Risk Factor Surveillance System (BRFSS)

Key Findings

  • Medical settings (57.7%) were the most common places for adult influenza (flu) vaccination in the 2014–15 season.
  • Doctor’s offices accounted for the majority (69.2%) of the flu vaccination in medical settings.
  • Nonmedical settings were also important places for flu vaccination for adults with 42.3% being vaccinated at a nonmedical setting.
  • Pharmacies/stores (22.2%) and workplaces (15.5%) were the two most commonly used nonmedical settings.
  • Among adults 18−64 years, workplaces were the most commonly used nonmedical place (21.3%) for receipt of flu vaccination.
  • By state, the percentage vaccinated at medical settings ranged from 42.8% in Rhode Island to 68.6% in California and the percentage vaccinated at nonmedical settings ranged from 31.4% in California to 57.2% in Rhode Island.

Figure 1.

Place of Flu Vaccination among Adults, United States, Behavioral Risk Factor Surveillance System (BRFSS), 2014-15 Flu Season

Influenza (flu) vaccination is an effective way to prevent flu and flu related complications (1,2). Annual flu vaccination has been recommended by the Advisory Committee on Immunization Practices (ACIP) for all persons 6 months and older since the 2010–11 season (3). New partnerships between public health agencies and medical and nonmedical vaccination providers formed during the 2009 influenza A pdm09 (H1N1) pandemic resulted in an increase in the number of vaccination providers and locations where flu vaccinations are delivered (4,5). Nonmedical settings, including stores (e.g., supermarkets or drug stores), have become popular places for flu vaccination of adults due to convenience and lower costs (4,6,7). This report summarizes place of flu vaccination for adults ≥18 years, overall and by age group, using the 2014–15 season Behavioral Risk Factor Surveillance System (BRFSS) data. State level place of flu vaccination estimates for adults are available on CDC FluVaxView.

National-Level Place of Flu Vaccination Overall and by Age Group

  • Medical settings were the most common place for receipt of flu vaccination for adults ≥18 years (57.7%). Adults ≥65 years were more likely to receive a flu vaccination at medical settings (61.8%) than adults 18−64 years (55.8%).
  • Approximately 40% of adults received their flu vaccination at a nonmedical setting. Adults ≥65 years were less likely to receive their flu vaccination at a nonmedical setting (38.2%) than adults 18−64 years (44.2%).
  • For adults ≥18 years, two common nonmedical settings for receipt of flu vaccination were pharmacies/stores (22.2%) and workplaces (15.5%).
    • Adults 18–49 years were more likely to receive their flu vaccination at a workplace than at a pharmacy/store (22.4% vs. 16.2%).
    • For adults ≥65 years, pharmacies/stores were the primary nonmedical setting for receipt of flu vaccination (31.3%).
    • Adults (18−64 years) were more likely to have received flu vaccination at a workplace compared with adults ≥65 years; adults ≥65 years were more likely to have received flu vaccination at a pharmacy/store compared with adults of younger age groups.
    • Adults 18−49 years were more likely to have received flu vaccination at a workplace compared with adults 50−64 years.
Table 1. Reported Place of Flu Vaccination among Adults ≥18 Years, by Age Group, United States, ‡ Behavioral Risk Factor Surveillance System (BRFSS) , 2014–15 Flu Season§
Age Group Unweighted Sample Size Medical Setting || Nonmedical Setting  Nonmedical Setting
Pharmacy/Store Workplace
%** ± 95% CI†† % ± 95% CI % ± 95% CI % ± 95% CI
≥18 years 94,142 57.7 ± 0.6 42.3 ± 0.6 22.2 ± 0.5 15.5 ± 0.5
18−64 years 51,293 55.8 ± 0.8 44.2 ± 0.8 18.1 ± 0.6 21.3 ± 0.7
18−49 years 22,675 55.8 ± 1.2 44.2 ± 1.2 16.2 ± 0.8 22.4 ± 1.0
50−64 years 28,618 55.9 ± 1.1 44.1 ± 1.1 21.0 ± 0.9 19.8 ± 0.9
≥65 years 42,849 61.8 ± 0.9 38.2 ± 0.9 31.3 ±0.9 2.3 ± 0.3

State-Level Place of Flu Vaccination

  • State-level place of flu vaccination estimates for adults for the 2014–15 flu season are available within the FluVaxView Interactive webpages at the following link FluVaxView.
  • Among states, the percentage vaccinated at a medical setting ranged from 42.8% in Rhode Island to 68.6% in California.
  • The percentage vaccinated at a nonmedical setting ranged from 31.4% in California to 57.2% in Rhode Island.
    • The percentage of adults vaccinated at a store/pharmacy ranged from 10.0% in North Dakota to 33.6% in Rhode Island.
    • The percentage of adults vaccinated at their workplace ranged from 10.4% in Florida to 22.9% in Wisconsin.

What Can Be Done?

Both medical and nonmedical settings were common and important places for adult flu vaccinations during the 2014–15 flu season. While the majority of adults reported receiving their flu vaccination in medical settings, approximately two of every five adults went to nonmedical settings for flu vaccination. The popularity of receiving flu vaccination in nonmedical settings suggests that while it is important to improve flu vaccination access in medical settings, extending efforts to also improve flu vaccination in nonmedical settings may help to increase flu vaccination coverage among adults and achieve the Healthy People 2020 target for flu vaccination (8,9). Strategies that allow nonmedical immunization providers to participate in state immunization information systems, allow medical  providers to verify patients who are vaccinated in other settings, and allow public health officials to track flu vaccination receipt could help promote flu vaccination in nonmedical settings (9).

The proportion of adults receiving their flu vaccination at a pharmacy/store increased to 22% for the 2014−15 season, compared with 5%, 6%, 6%, 18%, and 20% for the1998−99, 2001−02, 2004−05, 2010−11, and 2011−12 seasons, respectively (4,7,10). More states allowing pharmacists to administer flu vaccinations to adults, more programs existing for training pharmacists to immunize, and more pharmacies offering on-site flu vaccinations might have contributed to this increase (4,11). By June 2009, all 50 states allowed pharmacists to administer flu vaccinations to adults (4,11). As a nontraditional setting, a pharmacy/store not only provides extended access, convenience, and a low cost option for adults to receive their annual flu vaccination, but could also be an effective source for flu vaccination during a flu pandemic (12,13).

Workplaces were the second most common nonmedical place (15.5%) for flu vaccination among adults ≥18 years, and were the most popular nonmedical place (21.3%) for adults 18−64 years. Offering flu vaccination services in the workplace is convenient for working adults and is particularly important for those who do not regularly access the healthcare system (14,15).

The state variability in the proportion of adults vaccinated in medical and nonmedical settings was noted in this report. This variation might be associated with vaccination delivery factors among states (e.g., medical-care delivery infrastructure, population norms, availability of nonmedical settings and workplace vaccination) (15-17).

This report will be updated every three years as the place of flu vaccination questions rotate in the BRFSS core survey. Continued monitoring of place of vaccination will benefit flu vaccination programs by helping identify trends in the use of services, identify potential new partnerships, and improve the focus and effectiveness of flu immunization programs. Increasing access to flu vaccination services in both medical and nonmedical settings should be considered an important approach for increasing flu vaccination coverage among adults.

Data Sources and Methods

Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed to estimate place of flu vaccination among vaccinated adults ≥18 years. BRFSS interviews from January through June 2015 were used to represent the 2014–15 flu season.

The BRFSS is a continuous, population-based monthly telephone survey which collects information on health conditions and risk behaviors from randomly selected people ≥18 years among the U.S. population. Data are weighted by age, sex, and in some states, race/ethnicity, to reflect the adult population distribution in the United States. In the 2015 BRFSS, respondents were asked if they had received a flu vaccine in the past 12 months, and if so, in which month and year and at what type of place. This information was self-reported and not verified by medical records. Individuals with missing place of flu vaccination (n = 122, 0.13 %), those who reported receiving their vaccinations in Canada or Mexico (n = 33, 0.03%), those who reported that they did not know where they received their vaccination (n = 252, 0.27 %), and those who declined to answer the question (n = 51, 0.05 %) were excluded from the analysis. The final dataset included a total of 94,142 adults ≥18 years. The median state 2015 BRFSS response rate using the standard set by the American Association of Public Opinion Research (AAPOR) was 47.2% (10). Starting in 2011, BRFSS methods changed by adding persons in households with only cellular telephone service and improving weighting procedures; these changes were reflected in the 2011–12 and subsequent flu vaccination coverage estimates (18).

The definition of medical versus nonmedical settings of vaccination in this report is the same as described in the 2011 MMWR report (4). Weighted percentage estimates with 95% confidence intervals (CI) of place of flu vaccination were calculated using SUDAAN to account for the complex survey design. Differences between groups were determined using t-tests with significance at p<0.05. Differences mentioned in this report were statistically significant.

Limitations

The estimates in this report are subject to the following limitations. First, flu vaccination status and place of flu vaccination estimates were based on self-reported data and were not verified by medical records, thus might be subject to recall bias. Second, the 2015 BRFSS only covered households with landline and cellphones and did not include households with no telephone service. In addition, the BRFSS survey had a low median state AAPOR response rate (47.2%) (19). Nonresponse bias can result if respondents and nonrespondents differ in their place of vaccination, and if these differences are not accounted for fully by survey weights that include adjustments for nonresponse. Finally, the BRFSS did not ask about reasons why respondents were vaccinated at a particular setting, and did not collect data on the distribution of vaccination providers by state or geography, thus whether place of flu vaccination is driven by personal preference as opposed to accessibility issues was unknown.

Authors

Yusheng Zhai, 1 MSPH; Tammy A. Santibanez,2 PhD; Alissa O’Halloran, 2 MSPH; Katherine E. Kahn, 1 MPH; Peng-Jun Lu, 2 MD, PhD; Walter W. Williams, 2 MD, MPH; Stacie M. Greby, 2 DVM, MPH.

1Leidos Inc.

2Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention

Related Links

Behavioral Risk Factor Surveillance System (BRFSS):

NIS-Flu/BRFSS vaccination coverage reports:

FluVaxView Interactive for State Level Place of Flu Vaccination Estimates:

Footnotes

* “Pharmacy/Store” includes pharmacies or drugstores and local supermarkets or grocery stores.

“Other Place” includes military-related places, other schools such as trade schools, residences, and other unspecified nonmedical places.

Excludes U.S territories.

§ Estimates based on interviews conducted January through June 2015 and reported vaccinations from July 2014 through May 2015.

|| “Medical setting” includes doctor’s office/HMO, hospital/emergency department, clinic/health center, health department.

“Non-medical setting” includes pharmacy/store, workplace, senior/recreation/community center, school, and others.

** Percentage of vaccinated adults who received their vaccination at this place. Percentages are weighted to the U.S. population. Adults with missing place of vaccination are excluded from the denominator.

†† Confidence interval (CI) half-widths.

References

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