National and state-specific estimates of settings where adults received influenza, updated COVID-19, and RSV vaccinations, 2023-2024 respiratory virus season, United States

Summary

Receiving influenza (flu), COVID-19, and respiratory syncytial virus (RSV) vaccinations are important to prevent disease-related morbidity and mortality (1–3). Flu, COVID-19, and RSV vaccination coverage have been reported for the 2023–2024 respiratory virus season (4, 5). The objective of this report was to assess settings where vaccinations were received, overall and by demographic characteristics among adult populations.

CDC analyzed data from the National Immunization Survey-Adult COVID Module (NIS-ACM) collected during January 2–March 31, 2024. Overall, among vaccinees, 42.7% and 23.8% of adults aged ≥18 years received flu and updated COVID-19 vaccinations, and 16.9% of adults aged ≥60 years received RSV vaccinations in medical settings versus 57.3%, 76.2%, and 83.1% in nonmedical settings, respectively. Pharmacies or drug stores were the most common settings for flu (48.0%), updated COVID-19 (71.5%), and RSV vaccinations (81.7%); this was followed by a doctor’s office (23.4%) for flu, clinics or health centers (9.2%) for updated COVID-19, and a doctor’s office (7.9%) for RSV vaccinations. By state, reported flu vaccination in nonmedical settings ranged from 35.7% in North Dakota to 68.5% in Florida, for updated COVID-19 from 33.4% in North Dakota to 88.1% in Florida, and for RSV from 49.2% in North Dakota to 94.1% in New Jersey.

This study demonstrated that large proportions of adults received flu, updated COVID-19, and RSV vaccinations at pharmacies or drug stores. While pharmacies and stores are important settings for vaccine access, vaccine access in other locations, including medical offices, remain critical.  Ensuring access to vaccination services in medical and nonmedical settings that provide vaccination in convenient and trusted settings remains an important strategy for improving vaccination coverage.

Methods

The NIS-ACM data used in this report were collected by telephone interview from January 2–March 31, 2024, among adults aged ≥18 years using a random-digit-dialed sample of cell telephone numbers. This survey collected information about flu, COVID-19, and RSV vaccinations and settings of vaccination among the non-institutionalized U.S. adult population, including all 50 states, Washington DC, and Puerto Rico (6). The response rate for the data set was 23.8%, and the total sample size was 184,011.

For adults who received flu, COVID-19, or RSV vaccinations, respondents were asked “At what kind of place did you get your most recent flu vaccination/most recent COVID-19 vaccination/RSV vaccination?” The following categories were listed for responses: 1) doctor’s office, 2) health department, 3) clinic or health center, 4) hospital, 5) other medically related place, 6) mass vaccination site, 7) pharmacy or drug store, 8) workplace, 9) high school, college, or university, and 10) other nonmedically-related place. For place of COVID-19 vaccination, analysis was limited to respondents who reported receipt of an updated 2023–2024 COVID-19 vaccine, and for flu, those who reported receipt of a flu vaccination since July 1, 2023; a total of 95,596 and 47,587 adults aged ≥18 years who reported their most recent flu and updated COVID-19 vaccination setting, respectively, and a total of 17,500 adults aged ≥60 years who reported their RSV vaccination settings, were included in the analysis.

Responses to the question on settings of vaccinations were divided into medical and nonmedical settings. Medical settings were doctor’s office, health department, clinic or health center, hospital, and other medically related place. Nonmedical settings were mass vaccination site, pharmacy/drug store, workplace, high school/college/university, and other nonmedically-related place. Medical and nonmedical settings were stratified by selected covariates including age group, sex, race and ethnicity, urbanicity status, Social Vulnerability Index (SVI) of county of residence, educational level, annual household income, health insurance status, foreign-born status, disability status, and reported medical conditions.

Data were analyzed using SAS (version 9.4) and SUDAAN (version 11.0.1; Research Triangle Institute). All percentages were weighted to represent the non-institutionalized U.S. adult population. Statistical significance was set at p<0.05. This activity was reviewed by the CDC and was conducted consistent with applicable federal law and CDC policy (45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq).

Results

Settings where adults (aged ≥18 years) received flu vaccination:

• Overall, among adult vaccinees aged ≥18 years, 42.7% received their most recent flu vaccination in medical settings and 57.3% in nonmedical settings (Table 1).
  • Pharmacies or drug stores were the most common vaccination settings (48.0%), followed by a doctor’s office (23.4%), clinics or health centers (9.5%), hospitals (7.6%), and workplace (6.5%). Pharmacies or drug stores were also the most common settings of vaccination among each age group (Table 1).
• A greater proportion of adults aged 50–64 years (56.0%) and adults aged ≥65 years (63.4%) received vaccination in nonmedical settings compared with younger adults aged 18–49 years (53.2%) (Table 1).
• Among adults aged ≥18 years, those who were non-Hispanic Black (47.6%), Hispanic (44.5%), non-Hispanic Asian (56.9%), non-Hispanic American Indian/Alaska Native (AI/AN) (40.7%), and non-Hispanic other or multiple races (47.6%) were less likely to receive vaccination in nonmedical settings compared with those who were non-Hispanic White (62.1%) (Table 4).
• Vaccination in nonmedical settings by state ranged from 35.7% in North Dakota to 68.5% in Florida, with a median of 56.7% (Table 5).

Table 1. Reported place of influenza vaccination* among adults by age group- National Immunization Survey-Adult COVID Module, January 2–March 31, 2024, United States

Settings where adults (aged ≥18 years) received updated COVID-19 vaccination:

• Overall, among adult vaccinees aged ≥18 years, 23.8% received updated COVID-19 vaccination in medical settings and 76.2% in nonmedical settings (Table 2).
  • Among adults aged ≥18 years, pharmacies or drug stores were the most common vaccination settings (71.5%), followed by a doctor’s office (9.2%), clinic or health center (7.6%), hospitals (4.9%), and workplace (2.1%). Pharmacies or drug stores were also the most common settings of vaccination among each age group (Table 2).
• A greater proportion of adults aged 50–64 years (75.6%) and adults aged ≥65 years (79.9%) received vaccination in nonmedical settings compared with younger adults aged 18–49 years (72.3%) (Table 2).
• Among adult vaccinees aged ≥18 years, those who were non-Hispanic Black (68.5%), Hispanic (62.2%), non-Hispanic Asian (73.6%), non-Hispanic AI/AN (38.8%), and non-Hispanic other or multiple races (63.6%) were less likely to receive vaccination in nonmedical settings compared with those who were non-Hispanic White (80.6%) (Table 4).
• Vaccination in nonmedical settings by state ranged from 33.4% in North Dakota to 88.1% in Florida, with a median of 77.2% (Table 5).

Table 2. Reported place of COVID-19 vaccination* among adults by age group – National Immunization Survey-Adult COVID Module, January 2–March 31, 2024, United States

Abbreviations: CI=confidence interval.
* Individuals reported place where they received their most recent COVID-19 vaccination.
^† p<0.05 by t test for comparisons between age groups with those aged 18–49 years as the reference group.
^‡Estimate is not reliable due to small sample size (n<30) or relative standard error (standard error/estimate) >0.3.

Settings where adults (aged ≥60 years) received RSV vaccination:

• Overall, among adult vaccinees aged ≥60 years, 16.9% received their RSV vaccination in medical settings and 83.1% in nonmedical settings (Table 3).
  • Among adults aged ≥60 years, pharmacies or drug stores were the most common vaccination settings (81.7%), followed by a doctor’s office (7.9%), clinic or health center (4.6%), and hospitals (3.0%). Pharmacies or drug stores were also the most common settings of vaccination among both age groups (Table 3).
• A greater proportion of adults aged ≥65 years (84.0%) received vaccination in nonmedical settings compared with younger adults aged 60–64 years (78.6%) (Table 3).
• Among adult vaccinees aged ≥60 years, those who were non-Hispanic Black (73.0%), Hispanic (69.8%), non-Hispanic AI/AN (51.3%), and non-Hispanic other or multiple races (73.2%) were less likely to receive vaccination in nonmedical settings compared with those who were non-Hispanic White (85.7%) (Table 4).
• Vaccination in nonmedical settings by state ranged from 49.2% in North Dakota to 94.1% in New Jersey, with a median of 83.0% (Table 5).

Table 3. Reported place of RSV vaccination* among adults aged ≥60 years by age group – National Immunization Survey-Adult COVID Module, January 2–March 31, 2024, United States

Abbreviations: CI=confidence interval.
*Among individuals reported receiving a RSV vaccination.
^† p<0.05 by t test for comparisons between age groups with those aged 60–64 years as the reference group.
^‡Estimate is not reliable due to small sample size (n<30) or relative standard error (standard error/estimate) >0.3.

Table 4. Percentage of adults receiving influenza, COVID-19, and RSV vaccinations in medical and nonmedical settings, by selected characteristics – National Immunization Survey-Adult COVID Module, January 2-March 31, 2024, United States

Abbreviations: RSV=respiratory syncytial virus; CI=confidence interval; NA=not applicable; AI/AN=American Indian/Alaska Native; MSA=metropolitan statistical area.
* Doctor’s office, hospital, clinic/health center, health department, or other medically-related place.
^† Pharmacy or drug store, mass vaccination site, workplace, school, or other nonmedically-related place.
^‡ Weighted percent.
^§ Reference level.
^|| p<0.05 by t test for comparisons within each variable with the indicated reference level.
^¶ Estimate is not reliable due to small sample size (n<30) or relative standard error (standard error/estimate) >0.3.
**CDC/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI) uses 15 U.S. census variables to help officials identify communities that may need support before, during, or after disasters: CDC/ATSDR Social Vulnerability Index (CDC/ATSDR SVI).
^†† Disability was defined as an affirmative response to the following survey question: “Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, or communicating?”
^‡‡ Self-reported health conditions included report of any of the following chronic conditions: chronic lung disease, diabetes, heart conditions, kidney disease, liver disease, cancer, weakened immune system, sickle cell disease, organ and blood transplant, stroke and cerebrovascular disease, dementia and other neurological conditions, HIV infection, or other conditions that may put them at higher risk for getting very sick from COVID-19.

Table 5. Settings of adults aged ≥18 years receiving influenza, updated COVID-19, and RSV vaccination by state – National Immunization Survey-Adult COVID Module, January 2-March 31, 2024, United States

Abbreviations: RSV=respiratory syncytial virus; CI=confidence interval.
* Doctor’s office, hospital, clinic/health center, health department, or other medically-related place.
^† Pharmacy or drug store, mass vaccination site, workplace, school, or other nonmedically-related place.
^‡ Weighted percents.
^§ Estimate is not reliable due to small sample size (n<30) or relative standard error (standard error/estimate) >0.3.

Discussion

Findings from this study indicated that nonmedical settings, specifically pharmacies and drug stores, were the most common settings for COVID-19, flu, and RSV vaccinations during the 2023-2024 respiratory virus season. The COVID-19 pandemic provided evidence of the vital role pharmacists can play in administering vaccinations. During the COVID-19 pandemic, amendments to the Public Readiness and Emergency Preparedness (PREP) Act expanded the authority of pharmacists, pharmacy technicians, and interns to administer vaccines, and those efforts made great contributions to COVID-19 vaccination uptake (7, 8). While pharmacies and stores are important settings for vaccine access, vaccine access in other locations, including medical offices, remain critical. Ensuring access to vaccination services in medical and nonmedical settings that provide vaccination in convenient and trusted settings remains an important strategy for improving vaccination coverage.

Prior to the COVID-19 pandemic, medical offices were the most common setting for receiving flu vaccination among adults, though the shift in place of flu vaccination away from the medical setting into pharmacies began before the pandemic. Previous reports showed that during the 2014–15 and the 2018–19 flu seasons, 24.3% and 32.3% of vaccinated adults received their flu vaccination at a pharmacy, respectively, and this percentage increased to 38.5% in the 2020–21 season during the COVID-19 pandemic; during the 2014–15 and the 2018–19 flu seasons, 50.8% and 48.8% of vaccinated adults received their flu vaccination at medical settings, respectively, and this percentage was 48.8% in the 2020–21 season during the COVID-19 pandemic (9, 10).

Current data in this report from the 2023–24 flu season showed that 48.0% and 42.7% of all vaccinated adults received their flu vaccine in a pharmacy, and medical setting, respectively. However, medical settings remained the most common vaccination setting among some demographic subgroups, including Black, Hispanic, and American Indian or Alaskan Native adults, adults with a disability, uninsured adults, and those living in poverty.

Most adults aged ≥60 years who received RSV vaccine were vaccinated in pharmacies (83%), likely because RSV vaccine is covered by Medicare Part D (11), which is a pharmacy benefit and makes reimbursement more difficult when given in medical clinics. RSV vaccine is recommended based on shared clinical decision making between a patient and provider, which, along with 2023-24 being the first year for RSV vaccine availability for adults, may have resulted in lower uptake (3).

Limitations

The findings in this study are subject to several limitations. First, flu, COVID-19, and RSV vaccination status and settings of vaccination were based on self-reported data and were not verified by medical records, so might be subject to recall or social-desirability bias. Second, healthcare personnel vaccinated in medical settings might have reported they were vaccinated at their workplace; therefore, the percentage of vaccinations in nonmedical settings might be overestimated. Third, data were weighted to mitigate possible bias resulting from incomplete sample frame (i.e., exclusion of households with no phone service or only landline telephones) or nonresponse, but some selection bias might persist. Finally, the survey sampled non-institutionalized U.S. adults and thus, adults who were incarcerated or who were nursing home residents might not be represented in the sample.

Conclusion

This study demonstrated that large proportions of adults received their flu, updated COVID-19, and RSV vaccination at pharmacies or drug stores. Pharmacies or drug stores provide extended access, and convenience for adults to receive annual routine vaccination and can be an effective source for vaccination during a pandemic (8, 12). However, medical offices remain a vital place of vaccination, especially given the demonstrated benefit of healthcare provider recommendations in increasing vaccine uptake (13, 14). Moreover, in a separate survey, adults reported that a doctor’s office was their most preferred place to receive a vaccination, followed by a pharmacy or store (15). In order to improve adult vaccination coverage, it will be important that medical offices continue to stock and recommend vaccination, especially those that serve rural and lower income adults and racial and ethnic minorities.

Authors: Peng-jun Lu, MD, PhD¹; Anup Srivastav, PhD^1,2; Mei-Chuan Hung, PhD^1,2; Jennifer L. Kriss, PhD¹; Carla L. Black, PhD¹; Tianyi Zhou, MPH^1,2; Sean Hu, MD, DrPH¹; James A. Singleton, PhD¹

¹Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC

²Eagle Health Analytics, LLC

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