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Influenza and Pneumococcal Vaccination Levels Among Persons Aged >65 Years --- United States, 1999

Annual influenza epidemics have resulted in an average of >18,000 deaths and 48,000 pneumonia and influenza hospitalizations among older persons in the United States (1). In 1998, an estimated 3400 older persons died from bacteremic pneumococcal pneumonia, a common complication of influenza, or from other forms of invasive pneumococcal disease (2). A 2000 national health objective included increasing influenza and pneumococcal vaccination levels to >60% among noninstitutionalized, high-risk persons, including those aged >65 years (3). To assess progress toward this objective, data were analyzed from the 1999 Behavioral Risk Factor Surveillance System (BRFSS) for persons aged >65 years. This report summarizes the results of that analysis, which indicated that prevalence of influenza vaccination during the 1998--99 influenza season exceeded the objective nationally and in 48 of 52 reporting areas; however, influenza vaccination levels may have reached a plateau. Prevalence among older persons who had ever received pneumococcal vaccination exceeded the national objective in only eight states. To reach the 2010 national objective of >90% influenza and pneumococcal vaccination among this population, new strategies and additional resources to implement adult vaccination activities may be needed.

BRFSS is an ongoing, state-based, random-digit--dialed telephone survey of noninstitutionalized civilian adults aged >18 years. Questions about having received an influenza vaccination ("During the past 12 months, have you had a flu shot?") and pneumococcal vaccination ("Have you ever had a pneumonia vaccination?") were asked in odd-numbered years starting in 1993. In 1999, 30,668 of 159,989 respondents reported they were aged >65 years. Respondents who reported an unknown influenza (2%) or pneumococcal (4%) vaccination status were excluded from analysis. Overall vaccination levels were estimated for the 50 states and the District of Columbia; data for Puerto Rico were reported in area-specific results only. Data were weighted by age, sex, and, in some states, by race/ethnicity, to reflect each area's estimated adult population. SUDAAN was used to calculate point estimates and 95% confidence intervals (CI), and to conduct multivariate logistic regression to calculate odds ratios (OR) and test associations of vaccination status with age, race/ethnicity, sex, education level, length of time since last check-up, self-reported health, and diabetes status.

During 1999, 66.9% (95% CI=66.0%--67.8%) of respondents reported having received an influenza vaccination during the preceding year (Table 1), compared with 65.5% (95% CI=64.6%--66.4%) in 1997 (4). Estimated influenza vaccination levels exceeded 60% in 48 of 52 reporting areas; in 33 of 48, the lower limit of the 95% CI also exceeded 60% (Table 2). In three of four areas with point estimates of influenza vaccination below 60%, the 95% CI included 60%. Estimated influenza vaccination levels increased in 31 areas from 1997 to 1999, compared with increases in 48 areas from 1995 to 1997. In the 52 reporting areas, the median percentage point difference from 1997 to 1999 was 1.6 (range: --5.0--9.0), compared with a median difference of 6.0 (range: --4.1--23.2) from 1995 to 1997.

The proportion of respondents reporting having ever received a pneumococcal vaccination increased from 45.4% (95% CI=44.4%--46.3%) in 1997 to 54.1% (95% CI=53.2%--55.1%) in 1999 (Table 1). Estimated prevalence of pneumococcal vaccination was >50% in 45 states and >60% in eight states (Table 2). In one of the eight states with point estimates >60%, the lower 95% CI also exceeded 60%. In 16 of 44 areas with estimated prevalence <60%, the 95% CI included 60%. From 1997 to 1999, pneumococcal vaccination prevalence estimates increased in 49 areas (median percentage point difference among the 52 reporting areas: 8.4; range: --12.0--21.1).

Non-Hispanic black and Hispanic respondents were significantly less likely than non-Hispanic white respondents to report vaccination against influenza (blacks: OR=0.41; 95% CI=0.35--0.48, and Hispanics: OR=0.68; 95% CI=0.53--0.88) or pneumococcal disease (blacks: OR=0.44; 95% CI=0.37--0.53, and Hispanics: OR=0.43, 95% CI=0.34--0.56) based on the logistic regression analysis (p<0.05). These differences were not explained by variations in age, sex, education level, length of time since last check-up, self-reported health, or diabetes status. A significant change in vaccination coverage from 1997 to 1999 among racial/ethnic populations was an increase in pneumococcal vaccination among non-Hispanic whites (Table 1).

Other factors independently associated with vaccination status based on the logistic regression analysis were age, education level, length of time since last check-up, and health status (p<0.05). Persons aged >75 years were more likely to report influenza or pneumococcal vaccination than persons aged 65--74 years (Table 1). Persons with diabetes were more likely to report vaccination, compared with those who did not have diabetes. Coverage increased as education level increased, self-reported health declined, and length of time since last check-up decreased.

Reported by the following BRFSS coordinators: S Reese, MPH, Alabama; P Owen, Alaska; B Bender, MBA, Arizona; G Potts, MBA, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; I Bullo, District of Columbia; S Hoecherl, Florida; L Martin, MS, Georgia; F Reyes-Salvail, MS, Hawaii; J Aydelotte, MA, Idaho; B Steiner, MS, Illinois; L Stemnock, Indiana; J Davila, MS, Iowa; C Hunt, Kansas; T Sparks, Kentucky; B Bates, MSPH, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Feigley, PhD, Montana; L Andelt, PhD, Nebraska; E DeJan, MPH, Nevada; L Powers, MA, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; C Baker, New York; Z Gizlice, PhD, North Carolina; L Shireley, MPH, North Dakota; P Pullen, Ohio; K Baker, MPH, Oklahoma; K Pickle, MPH, Oregon; L Mann, Pennsylvania; Y Cintron, MPH, Puerto Rico; J Hesser, PhD, Rhode Island; M Wu, MD, South Carolina; M Gildmaster, South Dakota; D Ridings, Tennessee; K Condon, MS, Texas; K Marti, Utah; C Roe, MS, Vermont; K Carswell, MPH, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; K Pearson, Wisconsin; M Futa, MA, Wyoming. A Poel, Association of Schools of Public Health, Atlanta, Georgia. Statistical Analysis Br, Data Management Div, and Adult Vaccine-Preventable Diseases Br, Epidemiology and Surveillance Div, National Immunization Program, CDC.

Editorial Note:

The findings in this report indicate that by 1999 coverage levels among persons aged >65 years approached or exceeded the 2000 national objective for influenza vaccination in all states and for pneumococcal vaccination in 24 states. Pneumococcal vaccination coverage increased linearly from 1993 to 1999; the rate of increase for influenza vaccination coverage was lower from 1997 to 1999 than from 1993 to 1997 (Figure 1). Similar findings were observed in the 1993--1998 National Health Interview Surveys (NHIS), which monitors progress toward the national health objectives (5; CDC, unpublished data, 2000). Self-reported influenza vaccination in the 1999 BRFSS mainly reflected vaccinations received for the 1998--99 influenza season. Vaccination coverage for subsequent seasons will be monitored using BRFSS and NHIS to determine whether influenza vaccination coverage for this population reached a plateau by the 1999--2000 season and the effect of delays in influenza vaccine supply during the 2000--01 season and projected for 2001--02. Preliminary NHIS estimates of influenza vaccination coverage among older adults were 66.6% for those interviewed during the first 6 months of 1999 and 68.1% for the first 6 months of 2000 (

In addition to increasing influenza and pneumococcal vaccination to >90% among persons aged >65 years by 2010, another national health objective is to eliminate health disparities among diverse populations (6). Racial/ethnic disparities continued in vaccination levels from 1997 to 1999. Influenza vaccination levels were lower among persons with less than a high school education or aged 65--74 years than among persons with higher education levels or older age.

Pneumococcal vaccination coverage lagged behind influenza vaccination coverage and was <60% even among persons most likely to visit a health-care provider (e.g., those reporting a check-up within the preceding 12 months, poor health, or diabetes). Health-care providers should use every opportunity to assess the vaccination status of patients and offer indicated vaccines. Annual influenza vaccination provides such an opportunity; influenza and pneumococcal vaccines can be administered concurrently at different sites without increasing side effects, and pneumococcal vaccine should be administered to patients who are uncertain about their vaccination history (5).

The findings in this report are subject to at least two limitations. First, vaccination status was self-reported and not validated; self-report of influenza vaccination may be more reliable than self-report of pneumococcal vaccination (7). In addition, recall of pneumococcal vaccination may be more accurate for persons aged 65--74 years than for those aged >75 years (8). Second, BRFSS excludes nursing-home residents and other institutionalized populations and households without telephones or with only cellular phones; however, vaccination coverage among older adults estimated from the 1997 NHIS increased only slightly when households without telephones were excluded (from 63.2% to 64.1% for influenza and from 42.4% to 43.0% for pneumococcal) (CDC, unpublished data, 2000).

Multiple factors underscore the need to assess local, state, and national adult vaccination programs (9), including a possible plateau in influenza vaccination levels among older adults, failure nationally and in most states to meet the 2000 objective for pneumococcal vaccination, racial/ethnic and socioeconomic disparities in vaccination coverage, delays in the distribution of the influenza vaccine reported during the 2000--01 season (1,5), and projected delays during 2001--02 ( To achieve and sustain >90% vaccination among these populations, public, private, and community partners must collaborate to improve vaccine use among older persons and to strengthen the influenza vaccine supply. When supply problems are anticipated, delivery of the first available vaccine should target older persons and others at high risk; for the 2001--02 season, providers should target vaccine available in September and October to these groups and to health-care workers. Physicians can improve coverage using strategies such as provider reminder/recall, assessment and feedback, and standing orders (10); however, methods are needed to identify and increase the number of health-care providers using these strategies. Even with such strategies, providers may be unable to achieve the 2010 objective among older patients during October--November, the optimal period for influenza vaccination. Providers should continue to vaccinate through December and as long as vaccine is available. Other interventions include increasing community demand for vaccinations using client reminder/recall and education campaigns (10), enhancing access to vaccination services by reducing out-of-pocket costs (10), and offering vaccination in community settings such as senior centers and drug stores.


  1. CDC. Updated recommendations from the Advisory Committee on Immunization Practices in response to delays in supply of influenza vaccine for the 2000--01 season. MMWR 2000;49:888--92.
  2. Robinson KA, Baughman W, Rothrock G, et al. Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995--1998. JAMA 2001;285:1729--35.
  3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives---healthy people 2000 review 1998--1999. Washington, DC: US Department of Health and Human Services, Public Health Service, 1999; DHHS publication no. (PHS)99-1256.
  4. CDC. Influenza and pneumococcal vaccination levels among adults aged >65 years---United States, 1997. MMWR 1998;47:797--802.
  5. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2001;50(no. RR-4).
  6. US Department of Health and Human Services. Healthy people 2010 (conference ed., 2 vols). Washington, DC: US Department of Health and Human Services, 2000.
  7. MacDonald R, 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.
  8. Long C, Kouides R, Peer S, LaForce F, Whitney C, Bennett N. Accuracy of self-report of pneumococcal vaccine status in older adults. Abstracts of the 127th American Public Health Association Meeting, November 7--11, 1999. Chicago, Illinois: American Public Health Association, 1999.
  9. Guyer B, Smith DR, Chalk R. Calling the shots: immunization finance policies and practices. Executive summary of the report of the Institute of Medicine. Am J Prev Med 2000;19(3S):4--12.
  10. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18(1S):92--6.

Table 1

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Figure 1

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Table 2

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