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Reasons Reported by Medicare Beneficiaries for Not Receiving Influenza and Pneumococcal Vaccinations -- United States, 1996

In the United States, influenza causes an average of 20,000 deaths per year; 90% of these death are among persons aged greater than or equal to 65 years (1). Pneumococcal disease accounts for more deaths than any other vaccine-preventable bacterial disease (2). Annual influenza vaccination and one dose of pneumococcal polysaccharide vaccine can prevent complications from these infections among persons aged greater than or equal to 65 years (1,3). In 1997, 65% of adults aged greater than or equal to 65 years reported receiving influenza vaccination during the previous 12 months and 45% reported ever receiving pneumococcal vaccination (4). This report presents an analysis of responses to the 1996 Medicare Current Beneficiary Survey (MCBS) to describe self-reported vaccination status and reasons for not receiving influenza and pneumococcal vaccinations reported by Medicare beneficiaries aged greater than or equal to 65 years; the findings indicate that most persons who had never received pneumococcal vaccination did not think they needed it, and those who had not received influenza vaccine did not know of the need for influenza vaccination and had misconceptions about its safety and efficacy.

MCBS is an ongoing, nationally representative, multistage, longitudinal survey of approximately 16,000 Medicare beneficiaries (5). Participants are interviewed in person every 4 months even if they have changed residences or live in long-term-care facilities. In the autumn of each year, respondents are asked, "Did you have a flu shot for last winter?" and "Have you ever had a shot for pneumonia?" During 1996, beneficiaries were asked for the first time why they had not been vaccinated for each vaccination they reportedly had not received. Beneficiaries were not provided with a response list. Interviewers assigned each reported reason to one of 23 categories that were created to accommodate all responses. Proxy respondents were used for persons who were incapacitated. Responses from 14,590 Medicare beneficiaries aged greater than or equal to 65 years were weighted to represent the Medicare population in 1996. SUDAAN software was used to calculate prevalence estimates, 95% confidence intervals (CIs), and adjusted odds ratios (ORs) from multivariate logistic regression analyses. Multivariate logistic regression analyses were used to assess the association of the most commonly reported reasons for nonvaccination with race/ethnicity, controlling for age, income, education, region, vaccination status, health status, degree of debility, and presence of vaccine-indicated medical conditions.

Overall, 65.2% (95% CI=64.1%-66.4%) of beneficiaries reported receiving influenza vaccination for the winter of 1995-1996 and 45.1% (95% CI=43.8%-46.4%) reported ever having received pneumococcal vaccination; 39.3% (95% CI=38.1%-40.5%) of beneficiaries reported receiving both vaccinations and 29.1% (95% CI=28.5%-29.7%) reported receiving neither vaccination; 25.9% (95% CI=25.3%-26.5%) reported receiving only the influenza vaccination and 5.7% (95% CI=5.5%-6.0%) reported receiving only pneumococcal vaccination; of non-Hispanic whites, 67.9% (95% CI=66.7%-69.0%) received influenza vaccinations and 47.6% (95% CI=46.3%-49.0%) received pneumococcal vaccinations. Of non-Hispanic blacks, 45.8% (95% CI=42.6%-49.0%) received influenza vaccinations and 25.2% (95% CI=22.5%-27.8%) received pneumococcal vaccinations. Of Hispanics, 52.9% (95% CI=51.8%-53.9%) and 35.9% (95% CI=32.0%-39.8%) received influenza and pneumococcal vaccinations, respectively. Among other racial/ethnic groups (Asians/Pacific Islanders, American Indians/Alaska Natives, and others*) 58.9% (95% CI=52.5%-65.2%) received influenza and 35.6% (95% CI=29.3%-41.9%) received pneumococcal vaccinations.

Not knowing vaccination was needed was the most commonly reported reason for not receiving influenza (19%) or pneumococcal (57%) vaccination (Table 1). Cost of vaccination and difficulty reaching vaccinators were cited by less than 2% of beneficiaries. For both vaccines, 10%-15% of unvaccinated beneficiaries reported not thinking of, or missing, vaccination. Approximately 40% of beneficiaries who reported not receiving recent influenza vaccination cited concerns about the vaccine, including thinking it could cause influenza, could have side effects, or would not prevent influenza. Of beneficiaries reporting not having received pneumococcal vaccination, 13% cited lack of a doctor's recommendation as a reason.

Logistic regression analysis indicated racial/ethnic differences in three of the eight reasons cited by greater than or equal to 10% of the nonvaccinated beneficiaries (Table 1). Hispanics and persons of other racial/ethnic groups were more likely than non-Hispanic whites to cite not being aware of the need for pneumococcal vaccination as a reason for nonvaccination (61% versus 55% [adjusted OR=1.8, 95% CI=1.3-2.4] and 66% versus 55% [adjusted OR=2.2, 95% CI=1.3-3.7]), respectively. Hispanics also were less likely than non-Hispanic whites to cite lack of a doctor's recommendation as a reason for not receiving pneumococcal vaccination (8% versus 13% [adjusted OR=0.5, 95% CI=0.2-0.9]). Non-Hispanic blacks were less likely than non-Hispanic whites to report thinking influenza vaccination could cause side effects as a reason for nonvaccination (11% versus 16% [adjusted OR=0.7, 95% CI=0.5-0.9]).

Reported by: D Drociuk, School of Public Health, Univ of South Carolina, Columbia, South Carolina. Office of Strategic Planning, Health Care Financing Administration, Baltimore, Maryland. Adult Vaccine-Preventable Diseases Br, Epidemiology and Surveillance Div, National Immunization Program, CDC.

Editorial Note:

This study is the first nationally representative survey to assess Medicare beneficiaries' reasons for not receiving vaccinations. In 1996, the influenza vaccination level reported by Medicare beneficiaries aged greater than or equal to 65 years exceeded 60%, the national objective for 2000 (objective 20.2). Although influenza and pneumococcal vaccinations are available at no charge to Medicare beneficiaries, approximately half had not received pneumococcal vaccination, and nearly one third reported receiving neither vaccination. Self-reported influenza and pneumococcal vaccination levels from the 1996 MCBS were consistent with estimates reported by the 1997 Behavioral Risk Factor Surveillance System and higher than levels reported by the 1995 National Health Interview Survey (4). This report also documents lower vaccination levels among racial/ethnic minority groups than among non-Hispanic whites; however, observed differences in reasons for nonvaccination cited by non-Hispanic whites compared with persons in other racial/ethnic groups were relatively small and may be unimportant when planning interventions to improve vaccination levels for specific racial/ethnic groups.

The reasons reported by this national sample of Medicare beneficiaries for not receiving influenza or pneumococcal vaccination were consistent with previously reported data that indicated a lack of knowledge, misconceptions about vaccines and vaccine-associated illnesses, and lack of recommendations from physicians (6-8). In 1996, lack of knowledge and lack of physician recommendations were the predominant reasons cited by Medicare beneficiaries for not receiving pneumococcal vaccination; 57% of beneficiaries who reported not receiving pneumococcal vaccination, i.e., 31% of the total 1996 Medicare population aged greater than or equal to 65 years, were unaware that this vaccination was recommended.

Because physicians provide the greatest proportion of vaccinations to Medicare beneficiaries (Health Care Financing Administration, unpublished data, 1999), the 26% of beneficiaries who received influenza but not pneumococcal vaccination indicates that physicians miss opportunities to vaccinate older persons during office visits. Because physicians' recommendations for influenza and pneumococcal vaccination are accepted by patients even when they have negative perceptions about the vaccinations (7), health-care providers should include patient education with vaccination recommendations during scheduled appointments.

The findings in this study are subject to at least three limitations. First, reasons reported for nonvaccination may differ depending on how questions were asked (i.e., if respondents had been provided with a response list, the frequency of responses in different categories, such as lack of physician recommendation for vaccination, may have changed). Second, self-reports of influenza vaccination may be more reliable than self-reports of pneumococcal vaccination (9). Third, survey responses were not validated by medical record review.

For 2010, the proposed national objective for influenza and pneumococcal vaccination levels for high-risk persons is 90%, a 30% increase from the 2000 level (**). To achieve this level, public, private, and community health-care providers must increase awareness of the need for vaccination and must reduce missed opportunities among older persons. The Initiative to Eliminate Racial and Ethnic Disparities in Health by 2010, which includes adult vaccination activities (, has been implemented by CDC and other federal agencies. Effective mechanisms to improve vaccination of adults should be implemented, including physician and patient education coupled with provider and patient reminders and recalls, standing orders for vaccination, and feedback to providers on vaccination levels (10). Local public health planners should seek guidance from national survey data such as those from the MCBS and design surveys to identify interventions that address the reasons why older adults in their communities are not vaccinated.


  1. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(no. RR-4).
  2. Gardner P, Schaffner W. Immunization of adults. N Engl J Med 1993;328:1252-8.
  3. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(no. RR-8).
  4. CDC. Influenza and pneumococcal vaccination levels among adults aged greater than or equal to 65 years--United States, 1997. MMWR 1998;47:797-802.
  5. Adler GS. A profile of the Medicare Current Beneficiary Survey. Health Care Financing Rev 1994;15:153-63. Available at Accessed September 8, 1999.
  6. CDC. Vaccination levels among Hispanic and non-Hispanic whites aged greater than or equal to 65 years--Los Angeles County, California, 1996. MMWR 1997;46:1165-8.
  7. CDC. Adult immunization: knowledge, attitudes, and practices--DeKalb and Fulton counties, Georgia, 1988. MMWR 1988;37:657-61.
  8. CDC. Influenza vaccination status of persons aged 65-79 years--Allegheny County, Pennsylvania, February-March 1997. MMWR 1998;47:1094-7.
  9. MacDonald RM, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients. Am J Prev Med 1999;16:173-7.
  10. CDC. Vaccine-preventable diseases: improving vaccination coverage in children, adolescents, and adults. A report on recommendations of the Task Force on Community Preventive Services. MMWR 1999;48(no. RR-8).

Table 1

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TABLE 1. Percentage of Medicare beneficiaries* in the Medicare Current Beneficiary Survey aged >=65 years who reported reasons for not receiving influenza vaccination during winter 1995-1996 and for not ever receiving pneumococcal vaccination -- United States, 1996



(95% CI)

Reasons for not receiving influenza vaccination (n=4503)


  "I did not know the flu shot was needed."



  "Did not think of/missed it."



  "Thought the flu shot could cause the flu."



  "Thought the flu shot could have side effects."



  "Didn't think it would prevent the flu."


( 9.8%-12.5%)

  "Thought I was not at risk of catching the flu."


( 5.8%- 7.7%)

  "Don't like shots or needles."


( 4.9%- 6.8%)

  "Doctor recommended against the flu shot."


( 4.7%- 6.7%)

  "Doctor did not recommend the flu shot."


( 4.5%- 6.6%)

  "Unable to get to the location."


( 1.8%- 2.8%)

  "Had the flu shot before, did not need it again."


( 0.5%- 1.1%)

  "Cost of the shot not worth the money."


( 0.1%- 0.4%)

Reasons for not receiving pneumococcal vaccination** (n=6926)


  "I did not know the pneumonia shot was needed."



  "Doctor did not recommend the pneumonia shot."



  "Did not think of it/missed it."


( 9.3%-13.2%)

  "Did not think it would prevent pneumonia."


( 3.6%- 5.1%)

  "Thought I was not at risk of catching pneumonia."


( 3.6%- 5.0%)

  "Don't like shots or needles."


( 2.1%- 3.2%)

  "Thought the pneumonia shot could have side effects."


( 1.9%- 2.9%)

  "Thought the pneumonia shot could cause pneumonia."


( 1.9%- 2.8%)

  "Doctor recommended against the pneumonia shot."


( 0.7%- 1.3%)

  "Unable to get to the location."


( 0.4%- 0.8%)

  "Cost of the shot not worth the money."


( 0.1%- 0.5%)

* n=14,590, weighted to reflect the 1996 Medicare beneficiary population.
† At least one reason for not receiving influenza vaccination was reported by 91% of those who reported not receiving influenza vaccination; at least one reason for not receiving pneumococcal vaccination was reported by 87% of those who reported not receiving pneumococcal vaccination.
Confidence interval.
Multiple responses were possible for not receiving the influenza vaccination and accounted for 9% of the total responses.
** Multiple responses were possible for not receiving the pneumococcal vaccination and accounted for 17% of the total responses.
†† Logistic regression analysis indicated significant differences by racial/ethnic group.

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