Noninfluenza Vaccination Coverage Among Adults — United States, 2011

Vaccinations are recommended throughout life to prevent vaccine-preventable diseases and their sequelae. Adult vaccination coverage, however, remains low for most routinely recommended vaccines (1) and well below Healthy People 2020 targets.* In October 2012, the Advisory Committee on Immunization Practices (ACIP) approved the adult immunization schedule for 2013 (2). Apart from influenza vaccination, which is now recommended for all adults, other vaccines recommended for adults target different populations based on age, certain medical conditions, behavioral risk factors (e.g., injection drug use), occupation, travel, and other indications (2). To assess adult (aged ≥19 years) vaccination coverage for select vaccines, CDC analyzed data from the 2011 National Health Interview Survey (NHIS). This report summarizes the results of that analysis for pneumococcal vaccine, tetanus toxoid–containing vaccines (including tetanus and diphtheria toxoid [Td] with acellular pertussis vaccine [Tdap]), and hepatitis A, hepatitis B, herpes zoster (shingles), and human papillomavirus (HPV) vaccines, by selected characteristics (age, race/ethnicity,† and vaccination target criteria). Influenza vaccination coverage estimates for the 2011–12 influenza season have been published separately (3). Compared with 2010 (1), the data indicate modest increases in Tdap vaccination among persons aged 19–64 years and HPV vaccination among women, but only little improvement in coverage for the other vaccines among adults in the United States. Coverage for tetanus vaccination (with any tetanus toxoid–containing vaccine) during the past 10 years was unchanged. Substantial increases in vaccination coverage are needed to reduce the occurrence of vaccine-preventable diseases among adults. The Community Preventive Services Task Force and other authorities have recommended that health-care providers incorporate vaccination needs assessment, recommendation, and offer of vaccination into routine clinical practice for adult patients (4,5).

NHIS collects information about the health and health care of the noninstitutionalized, civilian population in the United States using nationally representative samples. Interviews are conducted in respondents' homes by the U.S. Census Bureau for CDC's National Center for Health Statistics. Questions about receipt of recommended vaccinations for adults are asked of one randomly selected adult within each family in the household. The presence of high-risk conditions,§ as defined by ACIP for each vaccine, was determined by responses to questions in the NHIS (2). The final sample adult component response rate for the 2011 NHIS was 66.3%. Weighted data¶ were used to produce national estimates. Point estimates and estimates of corresponding variances were calculated using statistical software to account for the complex sample design. Statistical significance was defined as p<0.05.

Pneumococcal Vaccination Coverage

Pneumococcal vaccination coverage among adults aged 19–64 years at high risk was 20.1% overall, a 1.6 percentage point increase from 2010 (Table 1). Coverage among whites aged 19–64 years at high risk was higher (20.1%) compared with Hispanics (18.3%) and Asians (12.0%), but coverage was not significantly different for other racial/ethnic groups. Among adults aged ≥65 years, coverage was 62.3% overall, a 2.6 percentage point increase from 2010. Coverage among whites aged ≥65 years increased from 2010 (by 3.0 percentage points to 66.5%) and was higher compared with Asians (40.3%), Hispanics (43.1%), and blacks (47.6%).

Tetanus Vaccination Coverage

In 2011, the proportion of adults receiving any tetanus toxoid–containing vaccination (i.e., Td or Tdap) during the past 10 years was 64.5% for adults aged 19–49 years, 63.9% for adults aged 50–64 years, and 54.4% for adults aged ≥65 years (Table 1). The proportion of adults receiving tetanus vaccination during the past 10 years across all age groups did not change compared with 2010 (1). Whites had higher coverage across all age groups compared with Asians, Hispanics, and blacks.

Among adults aged 19–64 years for whom Tdap vaccination specifically could be assessed, Tdap coverage increased compared with 2010 (a 4.3 percentage point increase to 12.5%) (Table 1). Tdap coverage was estimated after excluding from the 25,783 respondents all those without a "yes" or "no" response for tetanus vaccination status in the past 10 years (n = 1,118 [4.3%]) or tetanus vaccination status during 2005–2011 (n = 803 [3.1%]), and those who reported tetanus vaccination during 2005–2011 but were not told (n = 5,501 [21.3%]) or did not know the vaccine type (n = 881 [3.4%]) (Td or Tdap). Among 9,805 respondents who received a tetanus vaccination during 2005–2011, 55.9% reported that they were not informed of the vaccination type, and 8.9% could not recall what type of tetanus vaccination they had received (Table 2). Of the remaining 35.2% of respondents who reported they knew what type of tetanus vaccine they received, 61.1% reported receiving Tdap.

Compared with 2010, Tdap coverage increased among all racial/ethnic groups except Asians. For white and black respondents, coverage increased by 4.7 and 3.6 percentage points, respectively, to 13.8% and 11.0%. For Hispanic respondents, coverage increased by 2.9 percentage points to 7.7% (Table 1). The largest increase occurred among adults aged 19–64 years who indicated a race other than Asian, black, or white, and non-Hispanic ethnicity (a 11.3 percentage point increase to 19.7%). Increases compared with 2010 also occurred among persons with and without household contact with an infant aged <1 year** (a 10.9 percentage point increase to 21.5%, and a 4.0 percentage point increase to 12.1%, respectively). However, reported Tdap coverage among persons aged 19–64 years remained low overall. Whites had higher Tdap coverage (13.8%) compared with blacks (11.0%) and Hispanics (7.7%).

During 2005–2011, Tdap vaccination of health-care personnel (HCP) (26.8%) was 6.5 percentage points higher than the 2010 estimate (Table 3). White HCP had higher Tdap coverage (27.2%) compared with black HCP (21.7%). Compared with 2010, Tdap coverage increased for Hispanic HCP (by 16.3 percentage points to 30.1%) and was similar to that of white HCP.

Among persons aged 19–64 years who received a tetanus vaccination, HCP were more likely to report receipt of Tdap (66.8%) than non-HCP (59.7%) (Table 2).

Hepatitis A Vaccination Coverage

Compared with 2010, overall hepatitis A vaccination coverage (≥2 doses) increased among adults aged 19–49 years (by 1.8 percentage points to 12.5%) but remained low. Vaccination coverage was higher (20.1%) among adults aged 19–49 years who had traveled outside the United States since 1995 to a country of high or intermediate endemicity than among respondents who had traveled only to countries of low endemicity (8.4%) (Japan, Australia, New Zealand, Canada, and the countries of Europe). Vaccination coverage among adult travelers to highly endemic countries increased by 3.5 percentage points from 2010 to 2011 (Table 1). Coverage was higher for Asians (19.1%) and adults aged 19–49 years who indicated a race other than Asian, black, or white and non-Hispanic ethnicity (21.1%) than for other groups. Coverage among those with chronic liver conditions (17.1%) was similar to the estimate for 2010.

Hepatitis B Vaccination Coverage

In 2011, information on high-risk status for hepatitis B virus infection was not collected. Overall hepatitis B vaccination coverage (≥3 doses) among all adults aged 19–49 years was 35.9% (2.1 percentage points higher than the 2010 estimate) (Table 1). Vaccination coverage was lower for blacks (33.0%) and Hispanics (28.9%) compared with whites (37.8%). Vaccination coverage for persons with diabetes was 26.9% for those aged 19–59 years and 12.4% for those aged ≥60 years, similar to the estimates for 2010. Overall, hepatitis B vaccination coverage among HCP was 63.8%, similar to the estimate for 2010. Coverage for black HCP (57.1%) and Hispanic HCP (59.4%) was lower compared with white HCP (65.1%), but coverage for Asian HCP (70.4%) was higher than that for white HCP (Table 3).

Herpes Zoster Vaccination Coverage

In 2011, 15.8% of adults aged ≥60 years reported receiving herpes zoster vaccination to prevent shingles, similar to the estimate for 2010 (Table 1). Whites aged ≥60 years had higher herpes zoster vaccination coverage (17.6%) compared with blacks (7.9%), Hispanics (8.0%), and Asians (14.0%). Coverage for blacks and Hispanics aged ≥60 years increased by more than 3 percentage points compared with herpes zoster vaccination coverage estimates in 2010.

HPV Vaccination Coverage

In 2011, 29.5% of women aged 19–26 years reported receipt of ≥1 dose of HPV vaccine, an increase from the 20.7% reported for 2010 (Table 1) (1), and a further increase from the 17.1% reported for 2009 (1). Coverage was 43.1% among women aged 19–21 years and 21.5% among those aged 22–26 years. Among women aged 19–26 years, Hispanics had lower coverage (20.2%) compared with whites (32.5%), but coverage across racial/ethnic groups otherwise did not differ. Compared with 2010, receipt of ≥1 dose of HPV vaccine increased among males aged 19–26 years (by 1.5 percentage points to 2.1%). Coverage was 2.8% for males aged 19–21 years and 1.7% for those aged 22–26 years.

Reported by

Walter W. Williams, MD, Peng-Jun Lu, MD, PhD, Stacie Greby, DVM, Carolyn B. Bridges, MD, Faruque Ahmed, MD, PhD, Immunization Services Div; Jennifer L. Liang, DVM, Tamara Pilishvili, MPH, Div of Bacterial Diseases; Craig Hales, MD, Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Walter W. Williams, www1@cdc.gov, 404-718-8734.

Editorial Note

In 2011, noninfluenza adult vaccination coverage in the United States was similar to 2010, except for modest increases in Tdap vaccination overall and HPV vaccination among women, with little or no improvements in coverage for the other vaccines recommended for adults. Many adults have not received one or more recommended vaccines. Vaccination coverage estimates for the three vaccines in this report that are included in Healthy People 2020 (pneumococcal, herpes zoster, and hepatitis B [for HCP] vaccines) are well below the respective target levels of 90% for persons aged ≥65 years and 60% for persons aged 18–64 years at high risk (pneumococcal vaccine [objectives IID 13.1 and IID 13.2, respectively]), 30% (herpes zoster vaccine [IID 14]), and 90% (hepatitis vaccine for HCP [IID 15.3]). These data indicate little progress was made in improving adult coverage in the past year and highlight the need for continuing efforts to increase adult vaccination coverage.

Since 2006, ACIP has recommended that adults aged 19–64 years receive a single dose of Tdap to replace a dose of Td for active booster vaccination against tetanus, diphtheria, and pertussis if they received their most recent dose of Td ≥10 years earlier (6). In October 2010, ACIP recommended expanded use of Tdap, indicating that adults aged ≥65 years who have or who anticipate having close contact with an infant aged <1 year, and who previously have not received Tdap, should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission. ACIP also recommended that Tdap, when indicated, be administered regardless of the interval since the most recent tetanus or diphtheria toxoid–containing vaccine was received (6). Information on Tdap vaccination of adults aged ≥65 years was not collected in the 2011 NHIS but is being collected starting in 2012. In February 2012, ACIP recommended that all adults aged ≥19 years who have not yet received a dose of Tdap should receive a single dose regardless of the interval since the most recent tetanus or diphtheria toxoid–containing vaccine was received.†† These recommendations supersede previous Tdap recommendations regarding adults aged ≥65 years. Health-care providers should not miss an opportunity to vaccinate persons aged ≥19 years who have not received Tdap previously.

In June 2012, ACIP recommended routine use of 13-valent pneumococcal conjugate vaccine (PCV13) in series with the 23-valent pneumococcal polysaccharide vaccine (PPSV23) for adults aged ≥19 years with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants.§§ Given the high burden of invasive pneumococcal disease caused by serotypes in PPSV23 but not in PCV13, ACIP noted that broader protection might be provided through use of both pneumococcal vaccines. Current ACIP recommendations call for use of PPSV23 in adults aged 19–64 years with chronic conditions that are not immunocompromising, such as chronic heart disease or diabetes, at the time of diagnosis of the high-risk condition (6). All adults are eligible for a dose of PPSV23 at age 65 years, regardless of previous PPSV23 vaccination; however, a minimum interval of 5 years between PPSV23 doses should be maintained. The 2012 NHIS cannot estimate the proportion of pneumococcal vaccinations by type (PCV13 versus PPSV23).

The findings in this report provide baseline estimates of hepatitis B vaccination coverage of adults with diabetes. The ACIP-recommended administration of hepatitis B vaccine to unvaccinated adults with diabetes aged 19–59 years (category A recommendation) or aged ≥60 years (category B recommendation) in December 2011 (6). The recommendations were based on available information about risk for contracting acute hepatitis B among persons with diabetes, morbidity and mortality, available vaccines, age at diagnosis of diabetes, and cost-effectiveness (6).

The percentage of age-eligible females administered HPV vaccine has increased steadily during 2009–2011 but is still low. The largest increase in 2011 (14.9 percentage points) was reported among women aged 19–21 years. This finding might reflect the knowledge, attitude, and practices of the health-care providers of young women (7); the social norms of young women and the perceptions and vaccination intentions of peers (8); or receipt of vaccine when eligible for the Vaccines for Children Program (age <18 years) but aged ≥19 years when interviewed (7). The percentage of age-eligible adult males administered HPV vaccine increased by 1.5 percentage points but remained very low. The ACIP recommendation for routine use of HPV vaccine in females age 11–26 years was made in 2006, whereas use in males aged 11–21 years and males aged 22–26 years at high risk was recommended in October 2011 (6). Thus, coverage levels for males in 2011 would not reflect this new recommendation. The primary target group for HPV vaccine is girls and boys aged 11–12 years.

The findings in this report are subject to at least five limitations. First, the NHIS sample excludes persons in the military and those residing in institutions, which might result in underestimation or overestimation of vaccination coverage levels. Second, the response rate was 66.3%. A low response rate can result in sampling bias if the nonresponse is unequal among the participants regarding vaccination. Third, the determination of vaccination status and identification of high-risk conditions in NHIS were not validated by medical records. Self-report of vaccination is subject to recall bias and overestimation of rates. However, adult self-reported pneumococcal vaccination status has been shown to be sensitive and specific (9). Fourth, the Tdap estimate is subject to considerable uncertainty. Many respondents were excluded from estimations of Tdap coverage, creating a potential for bias. All respondents who reported a tetanus vaccination during 2005–2011 but were unable to say whether Td or Tdap was used, were excluded. Sensitivity calculations were conducted to assess the magnitude of potential bias. Depending on what proportion of excluded respondents actually received Tdap, actual Tdap coverage could fall within the range of 8.0%–36.4%. Comparisons of Tdap coverage across years within subgroups might be affected by bias resulting from excluding persons who did not report the type of tetanus vaccine they received. Finally, age at vaccination is not known for vaccines adults reported having "ever" received (e.g., HPV and hepatitis B vaccines), so it is not clear for younger adults whether vaccination occurred as an adult or was given as part of a child or adolescent vaccination program.

Vaccination coverage levels among adults are unacceptably low. Substantial improvement in adult vaccination is needed to reduce the health consequences of vaccine-preventable diseases among adults. Successful vaccination programs combine 1) education of potential vaccine recipients and publicity to promote vaccination; 2) increased access to vaccination services in medical and complementary settings, such as workplaces and commercial establishments (e.g., pharmacies); and 3) use of practices shown to improve vaccination coverage, including reminder-recall systems, efforts to remove administrative and financial barriers to vaccination, use of standing order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members (5). Health-care provider recommendations for vaccination are associated with patient vaccination (10). Routine assessment of adult patient vaccination needs, recommendation, and offer of needed vaccinations for adults should be incorporated into routine clinical care of adults (4,5). The adult immunization schedule (2), updated annually, provides current recommendations for vaccinating adults and a ready resource for persons who provide health-care services for adults in various settings.

References

1. CDC. Adult vaccination coverage—United States, 2010. MMWR 2012;61:66–72.
2. CDC. Advisory Committee on Immunization Practices (ACIP) recommended immunization schedules for persons aged 0 through 18 years and adults aged 19 years and older—United States, 2013. MMWR 2013;62(Suppl 1).
3. CDC. Flu vaccination coverage, United States, 2011–12 influenza season. National Immunization Survey and Behavioral Risk Factor Surveillance System, August 2011 through May 2012. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/flu/professionals/vaccination/coverage_1112estimates.htm.
4. Poland GA, Shefer AM, McCauley M, et al. Standards for adult immunization practices. Am J Prev Med 2003;25:144–50.
5. Community Preventive Services Task Force. The guide to community preventive services. Increasing appropriate vaccination: universally recommended vaccinations. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.thecommunityguide.org/vaccines/universally/index.html.
6. CDC. Advisory Committee on Immunization Practices (ACIP) recommendations. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cdc.gov/vaccines/pubs/acip-list.htm.
7. Taylor LD, Hariri S, Sternberg M, Dunne EF, Markowitz LE. Human papillomavirus vaccine coverage in the United States, National Health and Nutrition Examination Survey, 2007–2008. Prev Med 2011;52:398–400.
8. Allen JD, Mohllajee AP, Shelton RC, et al. Stage of adoption of the human papillomavirus vaccine among college women. Prev Med 2009;48:420–5.
9. Shenson D, DiMartino D, Bolen J, Campbell M, Lu PJ, Singleton JA. Validation of self-reported pneumococcal vaccination in behavioral risk factor surveillance surveys: experience from the sickness prevention achieved through regional collaboration (SPARC) program. Vaccine 2005;23:1015–20.
10. Winston CA, Wortley PM, Lees KA. Factors associated with vaccination of Medicare beneficiaries in five U.S. communities: results from the racial and ethnic adult disparities in immunization initiative survey, 2003. J Am Geriatr Soc 2006;54:303–10.