In 1996, influenza and pneumonia were the fifth leading cause of death among persons aged greater than or equal to 65 years in the United States (1). A national health objective for 2000 is to increase influenza and pneumococcal vaccination levels to greater than or equal to 60% among persons at high risk for complications, including those aged greater than or equal to 65 years (2). To monitor states' progress toward achieving this objective, data from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. This report summarizes the BRFSS findings, which indicate the influenza vaccination objective was exceeded by 45 states and by the 50 states and the District of Columbia (DC) combined, but the pneumococcal vaccination objective was not reached by any state.

The BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of U.S. noninstitutionalized civilian adults aged greater than or equal to 18 years. In 1997, 52 reporting areas (50 states, DC, and Puerto Rico) participated in the survey. Overall vaccination level estimates were based on combined data from the 51 reporting areas that included the 50 states and DC. Data from Puerto Rico were included in the area-specific analysis. Responses for two questions related to adult vaccination were analyzed: "During the past 12 months, have you had a flu shot?" and "Have you ever had a pneumonia vaccination?" Of all 133,321 participants, 26,469 were aged greater than or equal to 65 years. Respondents who did not report or did not know their vaccination status were excluded from the analysis (2% of respondents for the influenza vaccination question and 5% of respondents for the pneumococcal vaccination question). Previously published vaccination data from the 1995 BRFSS included in the denominator those respondents who did not report or did not know their vaccination status (3); for comparisons in this study, this group was excluded from the 1995 data. Data for racial/ethnic groups other than non-Hispanic whites, non-Hispanic blacks, and Hispanics were too small for analysis. Data were weighted by age and sex to reflect each state's most recent adult population estimate. SUDAAN was used to calculate point estimates and 95% confidence intervals (CIs).

During 1997, among persons aged greater than or equal to 65 years, 65.5% (95% CI=64.6%-66.4%) reported receiving influenza vaccine during the preceding year, and 45.4% (95% CI=44.4%-46.3%) reported ever receiving pneumococcal vaccine (Table_1). Both percentages were higher than in 1995, when 58.7% (95% CI=57.6%-59.7%) and 36.9% (95% CI=35.9%-38.0%) reported receiving influenza and pneumococcal vaccine, respectively.

Among the 52 reporting areas, 45 had influenza vaccination levels greater than or equal to 60%, and nine had levels greater than or equal to 70% (range: 41.5% in Puerto Rico to 74.4% in Colorado) (Table_2). From 1995 to 1997, 48 of 50 states showed improvement in influenza vaccination levels (median percentage point difference: 6.1; range: -4.1 to 23.2).

Although all states reported pneumococcal vaccination levels less than 60% among persons aged greater than or equal to 65 years, levels were greater than or equal to 50% in 17 states; levels ranged from 32.2% in Louisiana to 59.4% in Arizona. All but four states showed improvement in the levels of pneumococcal vaccination from 1995 to 1997 (median percentage point difference: 8.8; range: -6.7 to 20.9).

Overall, persons aged 65-74 years were significantly less likely than persons aged greater than or equal to 75 years to report receipt of influenza (63.2% compared with 69.1%) or pneumococcal (41.7% compared with 51.3%) vaccines (Table_1). Among persons aged greater than or equal to 65 years in different racial/ethnic groups, non-Hispanic whites were more likely to report receipt of influenza (67.2%) and pneumococcal (47.3%) vaccines than Hispanics (57.9% and 34.1%, respectively) and non-Hispanic blacks (50.2% and 29.7%, respectively). Influenza and pneumococcal vaccination levels in all racial/ethnic groups increased from 1995 to 1997 (for influenza, 6.6 percentage points for non-Hispanic whites, 7.0 for Hispanics, and 10.4 for non-Hispanic blacks, and for pneumococcal, 8.3 for Hispanics, 8.5 for non-Hispanic whites, and 9.1 for non-Hispanic blacks). Men had slightly higher coverage levels than women for influenza vaccine; pneumococcal vaccination levels did not differ by sex.

Other factors correlated with vaccination levels were level of education, length of time since last check-up, and self-reported index of health (Table_1). As level of education increased and as self-reported health declined, vaccination levels increased for both vaccines. Persons reporting having had a routine check-up within the previous 12 months (86.3% of all respondents aged greater than or equal to 65 years) were more likely to report receipt of influenza and pneumococcal vaccines than persons reporting a longer interval since their last check-up.

Reported by the following BRFSS coordinators: J Cook, MBA, 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; C Mitchell, District of Columbia; S Hoecherl, Florida; LM Martin, MS, Georgia; A Onaka, PhD, Hawaii; J Aydelotte, MA, Idaho; B Steiner, MS, Illinois; K Horvath, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; RB Jiles, PhD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, Mississippi; T Murayi, PhD, Missouri; P Feigley, PhD, Montana; M Metroka, Nebraska; E DeJan, MPH, Nevada; L Powers, MA, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; TA Melnick, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; P Pullen, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; Y Cintron, MPH, Puerto Rico; J Hesser, PhD, Rhode Island; D Shepard, South Carolina; M Gildmaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; C Roe, MS, Vermont; L Redman, MPH, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. SM Greby, DVM, Association of Schools of Public Health, Atlanta, Georgia. Adult Vaccine-Preventable Diseases Br, Epidemiology and Surveillance Div, and Statistical Analysis 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: The findings in this report indicate that in 1997, influenza and pneumococcal vaccination rates overall, by state, and by racial/ethnic group continued to increase from levels in 1995. The national health objective for influenza vaccination was exceeded by 45 states and by the 50 states and DC combined. No state met the national health objective for pneumococcal vaccination, but if state-specific coverage continues to increase at rates observed from 1995 to 1997, 28 states would reach or exceed the 60% coverage goal by 2000.

Vaccination rates varied substantially by state. Possible reasons for these differences include state differences in demographic distribution, provision of adult vaccination programs, physician practice patterns, and patient attitudes.

In the 50 states and DC combined, several factors were independently associated with self-reported receipt of influenza and pneumococcal vaccines. Racial/ethnic disparities in vaccination levels among Hispanics and non-Hispanic blacks continued and were not explained by differences in age, sex, education level, health-care access, or perceived health status. To understand reasons for disparity in vaccination by race/ethnicity, CDC and other federal agencies have implemented a national Eliminating Racial and Ethnic Disparities Initiative, with the goal of eliminating by 2010 disparities in infant mortality, diabetes, cancer screening and management, heart disease, human immunodeficiency virus infection/acquired immunodeficiency syndrome, and child and adult vaccinations.

Persons aged 65-74 years were less likely than persons aged greater than or equal to 75 years to report receipt of influenza and pneumococcal vaccines, and this was not explained by differences in race/ethnicity, sex, education level, health-care access, or perceived health status. Increasing age may represent increased opportunity for encounters with the health-care system by patients, increased offers for vaccination by providers, and increased perception of need for vaccination by both patients and providers. Awareness of the need for routine vaccination should be increased among all persons aged greater than or equal to 65 years.

Although most persons aged greater than or equal to 65 years had had a routine check-up during the previous year, many were not vaccinated against influenza and pneumococcal disease. Routine check-ups provide an ideal opportunity to review a patient's need for clinical preventive services and

1. provide pneumococcal vaccine to those not previously vaccinated or not documented to be vaccinated and 2) to recommend influenza vaccination or provide it if the check-up occurs during the influenza vaccination season usually beginning in September. A doctor's recommendation for vaccination services can have a strong influence on the patient's decision to be vaccinated (4-6).

The findings in this study are subject to at least two limitations. First, self-reports about vaccination status were not validated. However, in one study, the predictive value and accuracy of self-report of influenza vaccination within the previous year was up to 91% when vaccination status was validated by record review (7). Accuracy of recall of pneumococcal vaccination is under investigation by CDC. Second, persons residing in nursing homes and in households without telephones are not included in this survey, therefore results may not reflect vaccination levels in these groups.

Although the BRFSS was not designed to produce national estimates, overall vaccination levels from previous years have been similar to estimates from the National Health Interview Survey (NHIS) (in 1995, the BRFSS estimate was 0.8 percentage points higher for influenza vaccination and 4.5 percentage points higher for pneumococcal vaccine) (8). The NHIS is used to monitor progress toward the national 2000 objective.

To assist local planners in targeting public health programs to reach undervaccinated groups, states can expand the BRFSS survey or use local surveys to capture information on reasons for vaccination and nonvaccination, provider recommendations for vaccination, and accessibility of vaccination services. Because older adults have a high rate of reported routine medical care and because provider recommendation can influence a patient's decision to be vaccinated, strategies to improve vaccination directed at practitioners can have a large impact (9). Interventions, such as standing orders for vaccination, using provider and patient recalls and reminders, and feedback on vaccination levels, have been effective in increasing adult vaccination levels (9). Guidelines and tools for implementing these interventions are available through Put Prevention Into Practice, a national campaign to improve delivery of clinical preventive services (10). In addition, opportunities for vaccination outside of traditional health-care settings should be increased to reach healthy elderly persons who do not routinely access traditional health-care settings.

References

1. National Center for Health Statistics. Health, United States, 1998, with socioeconomic status and health chartbook. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Health Statistics, 1998:217.

2. 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.

3. CDC. Pneumococcal and influenza vaccination levels among adults aged greater than or equal to 65 years -- United States, 1995. MMWR 1997;46:913-9.

4. CDC. Adult immunization: knowledge, attitudes, and practices -- DeKalb and Fulton counties, Georgia, 1988. MMWR 1988;37:657-61.

5. Ballard JE, Liu J, Uberuagua D, Mustin HD, Sugarman JR. Assessing influenza immunization rates in Medicare managed care plans: a comparison of three methods. Journal on Quality Improvement 1997;23: 434-42.

6. Fiebach NH, Viscoli CM. Patient acceptance of influenza vaccination. Am J Med 1991;91:393-400.

7. 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.

8. Greby SM, Singleton JA, Strikas RA, Williams WW. Influenza and pneumococcal vaccination -- progress toward Healthy People 2000 goals {Abstract}. In: Abstracts from the 32nd National Immunization Conference. Atlanta, Georgia: 32nd National Immunization Conference, 1998.

9. Gyorkos TW, Tannenbaum TN, Abrahamowicz M, et al. Evaluation of the effectiveness of immunization delivery methods. Can J Public Health 1994;85:S14-S30.

10. Agency for Health Care Policy and Research. Implementing preventive care. World-Wide Web site http://www.ahcpr.gov/ppip/handbkiv.htm. Accessed September 4, 1998.

TABLE 1. Percentage of persons aged >=65 years in the 50 states and the District of
Columbia who reported receiving influenza or pneumococcal vaccine, by selected
characteristics -- Behavioral Risk Factor Surveillance System, 1997
========================================================================================================
                                        Influenza                            Pneumococcal
                             -----------------------------------  ------------------------------------
                                                       % point                               % point
                                                      difference                            difference
                                                       from 2000                             from 2000
Characteristic                %       (95% CI*)        objective   %      (95% CI)           objective
------------------------------------------------------------------------------------------------------
Mean                         65.5    (64.6-66.4)           5.5    45.4   (44.4-46.3)           -14.6

Age group (yrs)
  65-74                      63.2    (62.0-64.3)           3.2    41.7   (40.4-42.9)           -18.3
   >=75                      69.1    (67.8-70.5)           9.1    51.3   (49.8-52.8)           - 8.7

Race/Ethnicity
  Non-Hispanic white         67.2    (66.3-68.1)           7.2    47.3   (46.3-48.3)           -12.7
  Non-Hispanic black         50.2    (46.5-53.9)         - 9.8    29.7   (26.2-33.2)           -30.3
  Hispanic                   57.9    (52.0-63.8)         - 2.1    34.1   (28.6-39.6)           -25.9
  Other+                     64.2    (56.8-71.7)           4.2    42.6   (34.3-50.9)           -17.4

Sex
  Men                        67.0    (65.6-68.4)           7.0    45.1   (43.5-46.6)           -14.9
  Women                      64.4    (63.3-65.6)           4.4    45.6   (44.4-46.8)           -14.4

Education level
  Less than high school      60.1    (58.4-61.9)           0.1    40.1   (38.3-41.9)           -19.9
  High school                65.0    (63.5-66.5)           5.0    45.0   (43.5-46.6)           -15.0
  More than high school      69.5    (68.1-70.9)           9.5    49.1   (47.6-50.7)           -10.9

Time since last checkup
  1-12 months                68.8    (67.9-69.8)           8.8    48.3   (47.3-49.3)           -11.7
    >1 year                  47.2    (44.6-49.7)         -12.8    29.3   (26.9-31.7)           -30.7

Self-reported health
  Poor                       71.0    (68.3-73.6)          11.0    54.5   (51.4-57.6)           - 5.5
  Fair                       66.7    (64.7-68.7)           6.7    48.3   (46.2-50.5)           -11.7
  Good                       66.4    (64.9-67.9)           6.4    44.9   (43.3-46.5)           -15.1
  Very good or excellent     62.9    (61.5-64.4)           2.9    42.2   (40.7-43.8)           -17.8
------------------------------------------------------------------------------------------------------
* Confidence interval.
+ Numbers from other racial/ethnic groups were too small for meaningful analysis.
========================================================================================================

TABLE 2. Percentage of persons aged >=65 years in the 50 states, the District of
Columbia, and Puerto Rico who reported receiving influenza or pneumococcal vaccine,
by reporting area -- Behavioral Risk Factor Surveillance System (BRFSS), 1997
===============================================================================================================================
                                             Influenza                                         Pneumococcal
                             ---------------------------------------------      ---------------------------------------------
                                                      % Point difference                                 % Point difference
                                                     ---------------------                              ---------------------
                                                                  1997 to                                            1997 to
                                                     1995 to       2000                                 1995 to       2000
Reporting area                %       (95% CI*)       1997+      objective       %       (95% CI)        1997+      objective
-----------------------------------------------------------------------------------------------------------------------------
Alabama                      62.6    (57.6-67.5)       17.5          2.6        47.5    (42.3-52.6)       14.3        -12.5
Alaska                       58.3    (46.9-69.7)        8.5        - 1.7        39.2    (28.2-50.3)       -6.7        -20.8
Arizona                      72.9    (67.5-78.3)        7.6         12.9        59.4    (53.4-65.5)       10.2        - 0.6
Arkansas                     61.1    (55.8-66.3)        0.1          1.1        39.1    (33.7-44.4)        1.9        -20.9
California                   65.5    (61.7-69.3)        5.5          5.5        49.8    (45.8-53.9)        5.5        -10.2
Colorado                     74.4    (69.0-79.9)        7.7         14.4        53.3    (47.2-59.5)        6.7        - 6.7
Connecticut                  67.2    (62.2-72.3)        4.7          7.2        43.0    (37.6-48.4)        4.8        -17.0
Delaware                     68.6    (64.4-72.8)       11.4          8.6        52.6    (47.9-57.3)       11.1        - 7.4
District of Columbia         54.3    (47.2-61.3)        NA&        - 5.7        32.3    (25.6-38.9)         NA        -27.7
Florida                      62.3    (58.9-65.8)        0.7          2.3        45.5    (42.0-49.0)        6.0        -14.5
Georgia                      58.5    (52.7-64.3)       11.5        - 1.5        48.5    (42.8-54.2)        8.9        -11.5
Hawaii                       71.1    (65.9-76.3)        8.8         11.1        51.7    (45.8-57.7)        8.8        - 8.3
Idaho                        66.4    (62.9-69.9)        2.3          6.4        50.2    (46.5-54.0)       10.0        - 9.8
Illinois                     67.8    (61.3-74.3)        9.9          7.8        44.7    (38.1-51.3)       15.8        -15.3
Indiana                      62.5    (57.3-67.8)        3.3          2.5        38.0    (32.7-43.4)        3.9        -22.0
Iowa                         69.7    (66.3-73.1)        6.1          9.7        51.5    (47.6-55.3)        6.6        - 8.5
Kansas                       61.5    (56.3-66.7)       -0.7          1.5        43.7    (38.4-49.0)       -1.0        -16.3
Kentucky                     61.2    (57.5-64.9)        7.8          1.2        38.6    (34.8-42.3)       13.3        -21.4
Louisiana                    58.4    (52.3-64.5)        6.2        - 1.6        32.2    (26.4-38.1)        6.3        -27.8
Maine                        72.1    (66.7-77.4)        7.5         12.1        50.0    (44.3-55.7)       14.5        -10.0
Maryland                     63.4    (59.0-67.8)        5.2          3.4        41.0    (36.6-45.4)        7.4        -19.0
Massachusetts                66.0    (60.1-72.0)        6.7          6.0        52.7    (46.4-59.0)       20.3        - 7.3
Michigan                     63.6    (58.5-68.6)        6.8          3.6        45.6    (40.4-50.8)        5.7        -14.4
Minnesota                    69.0    (65.7-72.2)        5.7          9.0        48.3    (44.8-51.8)        8.2        -11.7
Mississippi                  61.1    (55.6-66.6)        4.1          1.1        45.9    (39.9-51.9)        6.5        -14.1
Missouri                     70.3    (65.3-75.3)        3.7         10.3        44.3    (38.6-50.0)       12.1        -15.7
Montana                      68.4    (63.0-73.7)        4.4          8.4        50.8    (45.0-56.7)       15.9        - 9.2
Nebraska                     65.8    (61.7-69.9)        1.4          5.8        49.8    (45.4-54.2)       13.8        -10.2
Nevada                       56.5    (46.3-66.7)        4.0        - 3.5        53.5    (43.1-64.0)       13.3        - 6.5
New Hampshire                64.6    (58.4-70.8)        8.7          4.6        49.6    (43.1-56.1)        9.1        -10.4
New Jersey                   60.7    (55.9-65.5)       12.7          0.7        33.9    (29.3-38.6)       20.9        -26.1
New Mexico                   72.8    (67.9-77.7)        3.8         12.8        50.1    (44.5-55.8)       10.6        - 9.9
New York                     64.5    (60.3-68.7)        8.5          4.5        38.9    (34.5-43.4)       12.8        -21.1
North Carolina               64.6    (60.8-68.4)       12.0          4.6        50.6    (46.7-54.6)       19.4        - 9.4
North Dakota                 64.8    (60.0-69.6)        7.4          4.8        40.8    (36.0-45.7)        7.6        -19.2
Ohio                         65.4    (61.3-69.5)        2.4          5.4        38.5    (34.0-43.1)       -2.2        -21.5
Oklahoma                     69.3    (65.1-73.5)        8.2          9.3        40.4    (36.1-44.6)        3.2        -19.6
Oregon                       69.8    (65.8-73.9)        2.9          9.8        55.9    (51.5-60.2)       10.0        - 4.1
Pennsylvania                 65.8    (62.0-69.6)        7.2          5.8        47.1    (42.9-51.2)        8.6        -12.9
Puerto Rico                  41.5    (36.2-46.8)         NA        -18.5        33.7    (28.5-38.8)         NA        -26.3
Rhode Island                 67.7    (62.4-73.0)        1.1          7.7        43.0    (37.4-48.6)       12.2        -17.0
South Carolina               74.3    (70.1-78.5)       23.2         14.3        41.6    (36.8-46.4)       15.1        -18.4
South Dakota                 65.6    (61.0-70.1)        5.5          5.6        40.6    (36.1-45.2)        9.1        -19.4
Tennessee                    69.1    (65.0-73.2)        5.9          9.1        45.0    (40.5-49.5)       15.1        -15.0
Texas                        68.0    (62.9-73.2)       11.3          8.0        44.4    (38.8-50.0)       -0.3        -15.6
Utah                         66.1    (60.5-71.8)       -4.1          6.1        48.5    (42.3-54.8)        5.8        -11.5
Vermont                      69.5    (65.4-73.5)        5.4          9.5        51.6    (47.1-56.2)       15.7        - 8.4
Virginia                     67.7    (62.8-72.5)       15.2          7.7        53.6    (48.0-59.2)       14.1        - 6.4
Washington                   70.3    (66.3-74.2)        3.6         10.2        51.6    (47.1-56.1)        5.5        - 8.4
West Virginia                58.2    (53.7-62.6)        5.0        - 1.8        41.3    (36.9-45.6)        4.3        -18.7
Wisconsin                    66.1    (60.7-71.4)        9.1          6.1        42.6    (36.9-48.3)        6.8        -17.4
Wyoming                      72.4    (67.6-77.2)        5.6         12.4        50.9    (45.5-56.2)        7.0        - 9.1

Range                     41.5-74.4                                          32.2-59.4
Median                       65.9                                               45.8
-----------------------------------------------------------------------------------------------------------------------------
* Confidence Interval.
+ Percentage point difference from 1995 to 1997 excluded don”t know and unknown responses.
& Not available. Puerto Rico and District of Columbia did not participate in the 1995 BRFSS.
===============================================================================================================================

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