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Adult Immunization: Knowledge, Attitudes, and Practices -- DeKalb and Fulton Counties, Georgia, 1988

Vaccine-preventable diseases are a major problem in adults (1). In particular, influenza and pneumococcal disease account for approximately 60,000 deaths each year among persons greater than or equal to 65 years of age. Many of these deaths could be prevented through appropriate vaccination, but most adults are not immunized (1).

In July 1988, the DeKalb County Board of Health, Fulton County Health Department, Georgia Department of Human Resources, and CDC surveyed persons greater than or equal to 65 years of age who lived in DeKalb and Fulton counties, Georgia. This survey assessed knowledge, attitudes, and practices regarding influenza and pneumococcal immunizations. Interviews were conducted by telephone or in person using the same questionnaire. In DeKalb and Fulton counties, respectively, 13 and 50 housing communities for older adults who lived independently were identified. Seven communities (five in DeKalb County and two in Fulton County) participated in the in-person interviews. For all the remaining communities in DeKalb County and half of those remaining in Fulton County, telephone numbers for interviews were selected from a reverse telephone directory. On a Wednesday evening, telephone calls were made to every other residence. The following day, interviewers conducted voluntary personal interviews of residents passing through lobbies of the housing in the seven previously identified communities.

The data were combined for this report because the same questionnaire was used for the telephone and in-person surveys in both counties, county-specific results were similar, and results from telephone and in-person interviews were similar.

A total of 867 interviews were completed -- 486 (26%) of 1851 telephone numbers called, 380 (26%) in-person interviews of the estimated 1452 residents, and one of unknown type. Because influenza and pneumococcal vaccines are recommended for all persons aged greater than or equal to 65 years (2-5), this analysis is restricted to responses from the 716 (83%) residents who were in this age group and who identified their county of residence as DeKalb County (354 (49%)) or Fulton County (362 (51%)). Of these persons, 609 (85%) were female, 594 (83%) were white, and 122 (17%) were black. The median age was 78 years. For comparison, county-specific demographic data are shown in Table 1.

Six hundred forty-two (90%) of the respondents reported that they were aware of influenza vaccine. Of these, 355 (55%) reported receiving it within the past year. Fifty-nine percent of white respondents and 37% of black respondents reported receiving influenza vaccine in the past year (Table 2) (prevalence ratio (PR) = 1.6, 95% confidence interval (CI) 1.3, 2.0). No difference was found in vaccination status by sex.

Of factors that might be associated with influenza vaccination status, including race and gender, the most important was a recommendation for vaccination by a health-care provider. Seventy-five percent (447) of the 596 respondents who were aware of influenza vaccine and responded to the question reported that their health-care provider had recommended influenza vaccination. Seventy-five percent of persons to whom immunization had been recommended reported being vaccinated within the last year, compared with 7% of those who had not had a recommendation (Table 2) (PR = 11.2; 95% CI 8.1, 15.5). This association of recommendation and vaccination was present for both races.

Of the 642 respondents who were aware of the influenza vaccine, 466 (73%) reported negative attitudes toward it (i.e., that influenza vaccine itself causes illness, does not protect against influenza, or is unnecessary). Fifty percent of those with a negative attitude who responded to the question reported being vaccinated within the last year. Seventy percent of respondents with positive attitudes reported being vaccinated (PR = 0.7, 95% CI 0.6, 0.8). Of respondents with negative attitudes whose health-care provider had or had not recommended vaccination, 70% and 7%, respectively, had been vaccinated (Table 2) (PR = 10.8, 95% CI 7.3, 16.0). Of respondents with positive attitudes whose health-care provider had or had not recommended immunization, 87% and 8%, respectively, had been vaccinated (PR = 11.3, 95% CI 6.3, 20.3).

Three hundred eighty-one (53%) of respondents were aware of a vaccine to prevent pneumococcal disease, and 146 (38%) of these reported having received it. There was no association between race or gender and pneumococcal vaccination status.

The most important factor associated with pneumococcal vaccination status, as with influenza vaccination status, was vaccine recommendation by a health-care provider. Of persons who were aware of the pneumococcal vaccine and responded to the question, 169 (53%) reported that the vaccine had been recommended to them by a health-care provider. Seventy-six percent of the 169 persons were vaccinated, compared with 6% of persons who did not report receiving a recommendation (table 2) (PR = 12.5, 95% CI 8.4, 18.6). The association of vaccination and recommendation was present for both races.

One hundred thirty-seven (36%) of the 381 respondents who were aware of the pneumococcal vaccine reported negative attitudes toward it (i.e., that the vaccine would not prevent pneumonia or that the vaccine would make them sick). Thirty-three percent of respondents with negative attitudes who answered the question and 44% of those with positive attitudes reported being vaccinated (PR = 0.8, 95% CI 0.6, 1.0). Respondents with negative attitudes who reported that the vaccine was recommended by a health-care provider were more likely to report being vaccinated (64%) than were those who did not report receiving a recommendation (5%) (PR = 12.5, 95% CI 5.9 26.6). Eighty-four percent of persons with positive attitudes who received vaccination recommendations from health-care providers reported being vaccinated, compared with 7% of those with positive attitudes who did not receive a recommendation (Table 2) (PR = 12.3, 95% CI 7.7, 19.6).

Reported by: AJ Sievert, MD, Div of Physical Health, GN Bohan, MD, DeKalb County Board of Health; WR Elsea, MD, Fulton County Health Dept; RK Sikes, DVM, State Epidemiologist, Georgia Dept of Human Resources. Div of Field Svcs, Epidemiology Program Office; Div of Immunization, Center for Prevention Svcs; EIS Class of 1988, CDC.

Editorial Note

Editorial Note: As many as 20,000 influenza-associated deaths occur during typical influenza epidemics, and approximately 40,000 deaths associated with pneumococcal infections occur each year. Many of the deaths are in persons at high risk for serious complications from these illnesses, particularly persons ages greater than or equal to 65 years (1). Although safe, effective, and inexpensive vaccines are available for these diseases, only about 22% of persons greater than or equal to 65 years of age receive influenza vaccine annually; only 10% have ever received pneumococcal vaccine (1). Limited data have suggested that lack of awareness of the availability and benefits of safe, effective vaccines and unfounded concerns about adverse reactions among both physicians and patients contribute to low levels of adult immunization (1). Many of the DeKalb County and Fulton County residents interviewed were unaware of the availability of vaccines against influenza (10%) and pneumococcal disease (47%), and many expressed negative attitudes toward the safety and effectiveness of these vaccines. Other factors influencing vaccinations in this group need to be identified.

These data have several important limitations. The survey addressed a limited segment of the population at high risk for complications from influenza and pneumococcal infections in metropolitan Atlanta. Persons less than 65 years of age with high-risk conditions such as cardiopulmonary disease, those who do not live in residential centers, and those living in chronic-care facilities were not included. Of persons who were surveyed, 85% were women, a disproportionately high percentage compared with the percentages of women greater than or equal to 65 years of age living in DeKalb (64%) and Fulton (65%) counties. The racial distributions of respondents from both DeKalb and Fulton counties also differed from that of the reference populations (Table 1). Selection bias may have been introduced into this survey because residential centers voluntarily participated in the survey, and randomization was not possible. In addition, the analysis is potentially complicated by the lack of information on the number of respondents seen by health-care providers. Those not seen by providers are unlikely to have received vaccination recommendations. Also, responses concerning immunization status were not verified. However, in previous surveys on the use of influenza vaccine, respondents correctly recalled receiving a "flu shot" within the previous year (CDC, unpublished data, 1988).

Despite these limitations, findings in this survey were similar to others (1) in demonstrating that recommendations for vaccination from health-care providers markedly influenced the decision to be vaccinated, even among those with negative attitudes toward immunization. Health- care providers can promote adult immunization by increasing awareness of vaccine availability, safety, and effectiveness and by recommending and offering vaccines to all adults, whenever indicated. Providers often miss opportunities to immunize adults during routine contacts in offices, clinics, and hospitals (1); such opportunities can be used to review the immunization status of adult patients and, when indicated, provide influenza and pneumococcal vaccines as well as other appropriate vaccines (diphtheria and tetanus toxoids, measles-mumps-rubella, and hepatitis B vaccines) (2,3). Many persons are candidates for both influenza and pneumococcal vaccines, and these vaccines can be given simultaneously (4,5). Education of health-care providers should therefore emphasize increasing awareness of not only vaccine recommendations but also the provider's role in promoting adult immunization.


  1. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.

  2. ACIP. Adult immunization: recommendations of the Immunization Practices Advisory Committee. MMWR 1984:33(suppl 1S).

  3. Committee on Immunization. Guide for adult immunization. Philadelphia: American College of Physicians, Council of Medical Societies, 1985.

  4. ACIP. Prevention and control of influenza. MMWR 1988;37:361-4, 369-73.

  5. ACIP. Update: pneumococcal polysaccharide vaccine usage -- United States. MMWR 1984;33:273-6,281.

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