Abstract
Background
Seasonal influenza vaccination is recommended for all asthma patients. Persons with work-related asthma may have more severe disease than those with non–work-related asthma and may particularly benefit from receiving influenza vaccination.
Purpose
To determine if influenza vaccination coverage differs among individuals aged 18–64 years with work-related and non–work-related asthma.
Methods
Data from the 2006–2009 Behavioral Risk Factor Surveillance System Asthma Call-Back Survey collected in 38 states and the District of Columbia were analyzed in 2013. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with influenza vaccination among respondents aged 18–64 years with work-related asthma.
Results
Among adults aged 18–64 years with current asthma, an estimated 42.7% received influenza vaccination in the past 12 months. Although influenza vaccination coverage was significantly higher among adults with work-related asthma than those with non–work-related asthma (48.5% vs 42.8%), this association became non-significant after adjustment for demographic and clinical characteristics (prevalence ratio=1.08, 95% CI=0.99, 1.20). Among individuals with work-related asthma, receiving the influenza vaccine was associated with being 50–64 years old, being unemployed in the prior year, and seeking urgent treatment for worsening asthma symptoms.
Conclusions
Among persons with work-related and non–work-related asthma, less than half received influenza vaccination in the prior year, both below the Healthy People 2010 target of 60%. These results suggest the need for strengthening current vaccination interventions to meet the updated Healthy People 2020 objective of achieving at least 70% influenza vaccination coverage.
Introduction
In 2010, an estimated 18.7 (8.2%) million U.S. adults had asthma.1 Asthma was the most frequently reported comorbid condition among patients hospitalized with 2009 H1N1 influenza.2 Annual influenza vaccination is the most effective method for preventing infection with influenza virus, preventing infection-associated complications, and reducing work absenteeism.3–6 In 2006–2009, annual influenza vaccination was recommended for adults with asthma.4,7–11
Work-related asthma (WRA) is asthma that is caused or exacerbated by work-related factors.12 We previously reported that among adults with current asthma, 9% were diagnosed with WRA and an additional 38% describe their asthma as caused or worsened by workplace exposures (possible WRA).13 Persons with WRA have lower SES and may have more severe disease than those with non-WRA.13–15 Therefore, persons with WRA may be at higher risk for severe asthma exacerbation associated with influenza virus infection than those with non-WRA.16,17
Although previous studies have examined influenza vaccination coverage in persons with asthma, no information is available for those with WRA. 18–20 Data from the 2006–2009 Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-Back Survey (ACBS) were analyzed to determine influenza vaccination coverage differences among individuals with WRA and non-WRA.
Methods
A detailed description of the survey methods is available else-where.21–23 Classification of asthma, asthma-related healthcare utilization, asthma outcomes, and asthma control were based on previously used definitions.13–15 Participants with current asthma were classified as having WRA (diagnosed), possible WRA, and non-WRA (referent group). Influenza vaccine recipients were those who received an influenza vaccine injection or nasal spray. Number of physician contacts for asthma in the past 12 months was calculated based on information on the number of doctor's visits for routine asthma checkup, urgent treatment of worsening asthma symptoms, or an asthma episode or attack, as well as the number of asthma-related emergency room visits.
Statistical Analysis
Analyses were performed in 2013 following previously used methods using SAS, version 9.3 (SAS Institute Inc., Cary NC) and SUDAAN, Release 10.0.1 (Research Triangle Institute, Research Triangle Park NC).15,23 We restricted analyses to adults aged 18–64 years with current asthma because of the age- and condition-specific recommendations for influenza vaccinations during 2006–2009.4,7–10
Results
A total of 55,105 adults aged ≥18 years ever diagnosed with asthma participated in ACBS in 2006–2009; of these a total of 28,809 (representing an estimated annual average of 14.4 million) adults with current asthma aged 18–64 years were included in this analysis. The median response rates among the 38 states and District of Columbia providing data for this report ranged from 47.5% to 51.4% for BRFSS and 47.2% to 54.3% for ACBS.21,22
Of all adults aged 18–64 years with current asthma, an estimated annual average 42.7% received influenza vaccination during 2006–2009 (range: 25.8% for persons with no health insurance to 60.3% for those who stayed overnight in a hospital) (Table 1). Although coverage was higher among adults with WRA than those with non-WRA (48.5% vs 42.8%, respectively), the association between WRA status and vaccination coverage was not significant after adjusting for covariates (adjusted prevalence ratio=1.08; 95% CI=0.98, 1.20).
Table 1. Characteristics of adults aged 18–64 years with current asthma and influenza vaccination coveragea.
| Characteristics | n in sampleb | Population %c (95% CI) | Influenza vaccination coverage | |
|---|---|---|---|---|
| %d (95% CI) | PRe (95% CI) | |||
| Age group (years) | ||||
| 18–49 | 13,956 | 70.1 (69.0, 71.1) | 36.3 (34.5, 38.2) | 1.00 (ref) |
| 50–64 | 14,853 | 29.9 (28.9, 31.0) | 57.5 (55.9, 59.1) | 1.52 (1.43, 1.61) |
| Gender | ||||
| Male | 7,525 | 37.9 (36.4, 39.4) | 38.9 (36.3, 41.5) | 1.00 ref |
| Female | 21,284 | 62.1 (60.6, 63.6) | 45.0 (43.5, 46.5) | 1.13 (1.05, 1.21) |
| Race/ethnicity | ||||
| White, non-Hispanic | 23,191 | 74.1 (72.8, 75.5) | 44.4 (42.9, 46.0) | 1.00 ref |
| Black, non-Hispanic | 1,721 | 9.0 (8.2, 9.8) | 34.5 (30.3, 38.7) | 0.81 (0.71, 0.92) |
| Hispanic | 1,446 | 9.6 (8.6, 10.6) | 37.0 (31.6, 42.4) | 0.94 (0.82, 1.09) |
| Other, non-Hispanic | 2,271 | 7.3 (6.5, 8.1) | 42.1 (36.5, 47.8) | 1.01 (0.89, 1.15) |
| Education level | ||||
| ≤High school | 9,462 | 34.3 (32.9, 35.8) | 39.7 (37.0, 42.4) | 0.98 (0.91, 1.06) |
| >High school | 19,331 | 65.7 (64.2, 67.5) | 44.3 (42.7, 45.9) | 1.00 ref |
| Household income ($) | ||||
| <50,000 | 14,911 | 51.0 (49.5, 52.4) | 38.4 (36.4, 40.4) | 1.00 ref |
| ≥50,000 | 11,564 | 49.0 (47.6, 50.5) | 47.0 (45.0, 48.9) | 1.13 (1.06, 1.21) |
| Health insurance | ||||
| Yes | 25,327 | 85.9 (84.8, 87.1) | 45.5 (44.0, 46.9) | 1.00 ref |
| No | 3,383 | 14.1 (12.9, 15.2) | 25.8 (21.6, 30.0) | 0.64 (0.54, 0.75) |
| Employment statusf | ||||
| Employed | 17,538 | 64.0 (62.6, 65.4) | 41.3 (39.6, 43.0) | 1.00 ref |
| Not employed | 11,271 | 36.0 (34.6, 37.4) | 45.3 (42.9, 47.7) | 1.04 (0.96, 1.12) |
| Work-related asthma | ||||
| Work-related asthma | 3,003 | 8.9 (8.3, 9.6) | 48.5 (44.7, 52.4) | 1.08 (0.98, 1.20) |
| Possible work-related asthma | 11,421 | 36.9 (35.5, 38.2) | 41.1 (39.0, 43.3) | 0.98 (0.92, 1.05) |
| Non–work-related asthma | 14,226 | 54.2 (52.8, 55.6) | 42.8 (40.8, 44.8) | 1.00 ref |
| Other chronic diseaseg | ||||
| Yes | 6,170 | 15.3 (14.5, 16.1) | 53.4 (50.7, 56.1) | 1.16 (1.08, 1.24) |
| No | 22,372 | 84.7 (83.9, 85.5) | 40.8 (39.2, 42.3) | 1.00 ref |
| Ability to see a doctor for asthma if neededf | ||||
| Yes | 25,442 | 87.7 (86.7, 88.6) | 44.6 (43.1, 46.0) | 1.27 (1.12, 1.46) |
| No | 3,213 | 12.3 (11.4, 13.3) | 29.8 (26.3, 33.3) | 1.00 ref |
| Routine checkup for asthmaf | ||||
| Yes | 24,559 | 86.5 (85.5, 87.5) | 42.9 (41.4, 44.4) | 1.02 (0.92, 1.13) |
| No | 3,965 | 13.5 (12.5, 14.5) | 41.1 (37.4, 44.8) | 1.00 ref |
| Physician contactsh | ||||
| None | 11,567 | 42.5 (41.1, 43.9) | 32.1 (30.2, 34.0) | 1.00 ref |
| 1 | 5,127 | 18.7 (17.5, 19.9) | 49.8 (46.1, 53.5) | 1.40 (1.27, 1.54) |
| 2–3 | 5,434 | 18.7 (17.7, 19.7) | 48.6 (45.7, 51.5) | 1.40 (1.28, 1.52) |
| 4–9 | 4,683 | 14.0 (13.1, 14.8) | 52.4 (49.1, 55.7) | 1.42 (1.30, 1.55) |
| ≥10 | 1,898 | 6.1 (5.5, 6.7) | 50.7 (45.7, 55.6) | 1.48 (1.30, 1.69) |
| Asthma control | ||||
| Well controlled | 13,817 | 50.6 (49.2, 52.1) | 40.3 (38.4, 42.3) | 1.00 ref |
| Not well controlled | 7,438 | 27.1 (25.8, 28.4) | 43.1 (40.3, 45.9) | 1.10 (1.02, 1.19) |
| Very poorly controlled | 7,543 | 22.2 (21.2, 23.3) | 47.7 (45.1, 50.3) | 1.16 (1.07, 1.25) |
| Adverse asthma outcomesf | ||||
| Asthma attack | ||||
| Yes | 15,653 | 53.0 (51.6, 54.5) | 44.4 (42.5, 46.3) | 1.08 (1.01, 1.15) |
| No | 12,902 | 47.0 (45.5, 48.4) | 40.7 (38.6, 42.8) | 1.00 ref |
| Urgent treatment for worsening asthma | ||||
| Yes | 7,251 | 23.4 (22.4, 24.5) | 49.2 (46.6, 51.7) | 1.18 (1.10, 1.26) |
| No | 21,155 | 76.6 (75.5, 77.6) | 40.3 (38.7, 41.9) | 1.00 ref |
| Asthma-related emergency room visit | ||||
| Yes | 3,578 | 12.2 (11.3, 13.1) | 45.0 (41.1, 48.9) | 1.08 (0.97, 1.20) |
| No | 25,083 | 87.8 (86.9, 88.7) | 42.1 (40.7, 43.6) | 1.00 ref |
| Overnight stay in hospital because of asthma | ||||
| Yes | 1,120 | 3.2 (2.7, 3.7) | 60.3 (53.5, 67.0) | 1.28 (1.11, 1.45) |
| No | 27,531 | 96.8 (96.3, 97.3) | 41.9 (40.5, 43.3) | 1.00 ref |
| Total | 28,809 | 42.7 (41.3, 44.1) | ||
Note: Boldface indicates significance.
Data were collected in 38 states (Alaska, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Texas, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin) and the District of Columbia during 2006–2009.
Unweighted sample size (the numbers may not add up to the total because of missing values)
Distribution presented as weighted average annual estimate
Proportion presented as weighted average annual estimate
Adjusted for age, gender, race/ethnicity, annual household income, health insurance, and chronic disease. For each model, the outcome variable was influenza vaccination.
In the past 12 months
Diabetes or cardiovascular disease
Includes doctor's visits for routine asthma checkup, doctor's visits for urgent treatment of worsening asthma symptoms or an asthma episode or attack, and emergency room visits because of asthma in the past 12 months
PR, prevalence ratio
Influenza vaccination coverage and multivariate logistic regression results for influenza vaccination by WRA status are shown in Table 2. Influenza vaccination coverage among persons with non-WRA (an estimated 7.7 million) ranged from 26.1% among persons with no health insurance to 61.2% among those who stayed overnight in a hospital because of asthma in the past 12 months.
Table 2. Influenza vaccination coverage and multivariate logistic regression results for influenza vaccination by work-related asthma statusa.
| Characteristics | Work-related asthma | Possible work-related asthma | Non–work-related asthma | ||||||
|---|---|---|---|---|---|---|---|---|---|
| n in sampleb | Influenza vaccination coverage | n in sampleb | Influenza vaccination coverage | n in sampleb | Influenza vaccination coverage | ||||
| % (95% CI)c | PRc,d (95% CI) | %c (95% CI) | PRc,d (95% CI) | %c (95% CI) | PRc,d (95% CI) | ||||
| Age group (years) | |||||||||
| 18–49 | 1,206 | 42.0 (36.3, 47.6) | 1.00 (ref) | 5,351 | 33.9 (31.0, 36.7) | 1.00 (ref) | 7,340 | 37.1 (34.6, 39.7) | 1.00 (ref) |
| 50–64 | 1,797 | 57.2 (52.3, 62.1) | 1.36 (1.15, 1.61) | 6,070 | 56.5 (54.1, 59.0) | 1.48 (1.36, 1.62) | 6,886 | 58.5 (60.3, 65.4) | 1.56 (1.44, 1.69) |
| Gender | |||||||||
| Male | 936 | 46.9 (40.4, 53.3) | 1.00 ref | 3,020 | 37.7 (33.5, 42.0) | 1.00 ref | 3,522 | 38.3 (34.5, 42.0) | 1.00 ref |
| Female | 2,067 | 49.5 (44.7, 54.3) | 1.08 (0.91, 1.29) | 8,401 | 43.4 (41.1, 45.6) | 1.05 (0.93, 1.17) | 10,704 | 45.4 (43.1, 47.6) | 1.19 (1.07, 1.32) |
| Race/ethnicity | |||||||||
| White, non-Hispanic | 2,318 | 48.4 (44.0, 52.8) | 1.00 ref | 9,051 | 44.4 (42.0, 46.7) | 1.00 ref | 11,707 | 43.9 (41.6, 46.1) | 1.00 ref |
| Black, non-Hispanic | 224 | 36.6 (25.0, 48.3) | 0.77 (0.55, 1.08) | 733 | 35.6 (29.0, 42.2) | 0.84 (0.68, 1.02) | 745 | 33.2 (27.0, 39.4) | 0.80 (0.65, 0.97) |
| Hispanic | 155 | 58.6 (45.1, 72.2) | 1.22 (0.92, 1.62) | 582 | 28.4 (21.5, 35.3) | 0.77 (0.62, 0.96) | 698 | 38.9 (31.0, 46.9) | 1.00 (0.81, 1.24) |
| Other, non-Hispanic | 290 | 52.9 (40.7, 65.2) | 1.01 (0.78, 1.32) | 979 | 35.8 (26.4, 45.1) | 0.89 (0.70, 1.12) | 989 | 45.3 (38.0, 52.5) | 1.12 (0.94, 1.34) |
| Education level | |||||||||
| ≤High school | 1,084 | 42.7 (36.3, 49.1) | 0.87 (0.72, 1.05) | 3,930 | 36.3 (32.5, 40.2) | 0.94 (0.85, 1.05) | 4,384 | 41.6 (37.5, 45.7) | 1.03 (0.93, 1.15) |
| >High school | 1,919 | 52.4 (47.6, 57.2) | 1.00 ref | 7,486 | 44.0 (41.4, 46.6) | 1.00 ref | 9,831 | 43.3 (41.0, 45.5) | 1.00 ref |
| Household income ($) | |||||||||
| <50,000 | 1,851 | 46.7 (41.5, 51.9) | 1.00 ref | 6,536 | 36.1 (33.1, 39.1) | 1.00 ref | 6,441 | 38.5 (35.6, 41.4) | 1.00 ref |
| ≥50,000 | 946 | 51.8 (45.4, 58.3) | 1.07 (0.91, 1.27) | 4,008 | 48.6 (45.4, 51.7) | 1.19 (1.07, 1.32) | 6,559 | 45.4 (42.8, 48.0) | 1.11 (1.01, 1.23) |
| Health insurance | |||||||||
| Yes | 2,558 | 50.9 (46.8, 55.0) | 1.00 ref | 9,817 | 45.1 (42.8, 47.3) | 1.00 ref | 12,818 | 44.8 (42.7, 46.9) | 1.00 ref |
| No | 437 | 37.0 (26.4, 47.6) | 0.72 (0.52, 1.00) | 1,565 | 23.1 (16.9, 29.4) | 0.58 (0.45, 0.76) | 1,356 | 26.1 (19.4, 32.7) | 0.67 (0.52, 0.85) |
| Employment statuse | |||||||||
| Employed | 1,635 | 43.1 (38.1, 48.1) | 1.00 ref | 6,995 | 38.2 (35.5, 40.8) | 1.00 ref | 8,811 | 43.2 (40.8, 45.6) | 1.00 ref |
| Not employed | 1,368 | 55.6 (49.9, 61.3) | 1.44 (1.20, 1.73) | 4,426 | 47.2 (43.7, 50.7) | 1.08 (0.95, 1.22) | 5,415 | 42.0 (38.5, 45.6) | 0.93 (0.83, 1.04) |
| Other chronic diseasef | |||||||||
| Yes | 848 | 51.8 (44.4, 59.2) | 1.07 (0.87, 1.31) | 2,631 | 46.3 (52.5, 60.1) | 1.25 (1.13, 1.39) | 2,647 | 51.5 (47.2, 55.8) | 1.10 (0.99, 1.23) |
| No | 2,125 | 47.3 (42.7, 51.9) | 1.00 ref | 8,657 | 38.2 (35.8, 40.7) | 1.00 ref | 11,479 | 41.4 (39.2, 43.7) | 1.00 ref |
| Ability to see a doctor for asthma if needede | |||||||||
| Yes | 2,433 | 50.8 (46.5, 55.1) | 1.08 (0.84, 1.40) | 9,746 | 44.4 (42.0, 46.8) | 1.28 (1.07, 1.55) | 13,178 | 43.7 (41.6, 45.8) | 1.37 (1.09, 1.71) |
| No | 563 | 40.9 (31.6, 50.2) | 1.00 ref | 1,640 | 26.0 (21.6, 30.4) | 1.00 ref | 999 | 30.8 (24.7, 36.9) | 1.00 ref |
| Routine checkup for asthmae | |||||||||
| Yes | 2,636 | 49.1 (45.1, 53.2) | 1.18 (0.87, 1.60) | 9,745 | 41.6 (39.3, 43.9) | 1.07 (0.88, 1.31) | 12,050 | 42.7 (40.5, 44.8) | 0.97 (0.86, 1.09) |
| No | 332 | 42.7 (29.4, 55.9) | 1.00 ref | 1,579 | 37.7 (31.6, 43.8) | 1.00 ref | 2,043 | 43.2 (38.3, 48.2) | 1.00 ref |
| Physician contactsg | |||||||||
| None | 952 | 39.5 (32.5, 46.5) | 1.00 ref | 4,330 | 27.9 (25.1, 30.8) | 1.00 ref | 6,240 | 33.7 (31.1, 36.4) | 1.00 ref |
| 1 | 410 | 50.0 (39.8, 60.2) | 1.32 (1.02, 1.71) | 1,924 | 50.1 (44.6, 55.6) | 1.58 (1.32, 1.90) | 2,778 | 49.7 (44.5, 54.9) | 1.33 (1.19, 1.49) |
| 2–3 | 574 | 53.1 (44.0, 62.2) | 1.39 (1.09, 1.78) | 2,256 | 46.3 (41.9, 50.7) | 1.45 (1.27, 1.66) | 2,579 | 49.8 (45.6, 54.0) | 1.38 (1.22, 1.56) |
| 4–9 | 704 | 56.3 (49.0, 63.5) | 1.48 (1.17, 1.87) | 2,028 | 53.0 (47.7, 58.3) | 1.61 (1.40, 1.85) | 1,908 | 50.3 (45.3, 55.3) | 1.29 (1.12, 1.48) |
| ≥10 | 353 | 50.0 (38.5, 61.4) | 1.33 (1.00, 1.77) | 854 | 53.5 (46.9, 60.1) | 1.71 (1.44, 2.03) | 671 | 48.8 (39.7, 57.8) | 1.43 (1.14, 1.81) |
| Asthma control | |||||||||
| Well controlled | 1,137 | 46.8 (40.6, 53.1) | 1.00 ref | 4,848 | 37.2 (34.0, 40.4) | 1.00 ref | 7,766 | 41.1 (38.5, 43.8) | 1.00 ref |
| Not well controlled | 763 | 45.4 (38.1, 52.7) | 1.05 (0.85, 1.30) | 3,167 | 43.5 (39.3, 47.8) | 1.15 (1.01, 1.31) | 3462 | 42.6 (38.5, 46.7) | 1.08 (0.97, 1.21) |
| Very poorly controlled | 1,102 | 52.9 (46.4, 59.3) | 1.20 (0.99, 1.46) | 3,403 | 45.2 (41.4, 48.9) | 1.16 (1.03, 1.30) | 2996 | 48.6 (44.4, 52.7) | 1.15 (1.01, 1.30) |
| Adverse asthma outcomesd | |||||||||
| Asthma attack | |||||||||
| Yes | 1,983 | 49.8 (45.1, 54.5) | 1.05 (0.88, 1.26) | 6,865 | 43.5 (40.7, 46.3) | 1.13 (1.01, 1.27) | 6,721 | 43.7 (40.8, 46.7) | 1.06 (0.97, 1.16) |
| No | 999 | 45.9 (39.1, 52.7) | 1.00 ref | 4,458 | 37.7 (34.2, 41.2) | 1.00 ref | 7,387 | 41.7 (39.0, 44.5) | 1.00 ref |
| Urgent treatment for worsening asthma | |||||||||
| Yes | 1,054 | 55.0 (48.6, 61.4) | 1.25 (1.06, 1.48) | 3,202 | 49.4 (45.7, 53.1) | 1.23 (1.12, 1.36) | 2,929 | 47.3 (43.2, 51.3) | 1.11 (1.00, 1.23) |
| No | 1,905 | 45.4 (40.6, 50.3) | 1.00 ref | 8,046 | 37.7 (35.1, 40.4) | 1.00 ref | 11,127 | 41.2 (38.9, 43.5) | 1.00 ref |
| Asthma-related emergency room visit | |||||||||
| Yes | 555 | 49.9 (41.5, 58.3) | 1.09 (0.91, 1.32) | 1,627 | 47.2 (41.1, 53.4) | 1.19 (1.01, 1.40) | 1,376 | 41.1 (35.4, 46.9) | 1.00 (0.84, 1.14) |
| No | 2,428 | 48.5 (44.2, 52.9) | 1.00 ref | 9,751 | 39.9 (37.6, 42.1) | 1.00 ref | 12,786 | 42.6 (40.5, 44.7) | 1.00 ref |
| Overnight stay in hospital because of asthma | |||||||||
| Yes | 212 | 57.0 (42.0, 72.0) | 1.15 (0.81, 1.63) | 489 | 60.7 (50.1, 71.4) | 1.30 (1.11, 1.53) | 408 | 61.2 (50.7, 71.6) | 1.29 (1.03, 1.61) |
| No | 2,775 | 48.2 (44.2, 52.2) | 1.00 ref | 10,880 | 40.2 (38.0, 42.3) | 1.00 ref | 13,749 | 42.1 (40.0, 44.1) | 1.00 ref |
Note: Boldface indicates significance.
Data were collected in 38 states (Alaska, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Texas, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin) and the District of Columbia during 2006–2009.
Unweighted sample size (the numbers may not add up to the total because of missing values)
Proportion presented as weighted average annual estimate
Adjusted for age, gender, race/ethnicity, annual household income, health insurance, and other chronic disease. For each model, the outcome variable was influenza vaccination.
In the past 12 months
Diabetes or cardiovascular disease
Includes doctor's visits for routine checkup for asthma, doctor's visits for urgent treatment of worsening asthma symptoms or an asthma episode or attack, and emergency room visits because of asthma in the past 12 months
PR, prevalence ratio
On multivariate analysis, among persons with non-WRA, vaccination coverage was significantly higher in subgroups similar to those for all adults with current asthma. Influenza vaccination coverage among persons with WRA (an estimated 1.3 million) ranged from 36.6% among non-Hispanic blacks to 58.6% among Hispanics and was significantly associated with age 50–64 years, lack of employment, and receiving urgent treatment for worsening asthma. Overall, vaccination coverage was significantly higher among asthmatics with a history of at least one physician contact in the previous year compared with those with no contact (Table 2).
Discussion
In this population-based study, the estimated annual average influenza vaccination coverage during 2006–2009 in adults aged 18–64 years was 48.5% in those with WRA and 42.8% in those with non-WRA. These rates were higher than those of the general age-matched U.S. adult population during the 2006–2007 season (39.9%) but less than the Healthy People 2010 target of 60%.19,24 These results are similar to other studies showing that vaccine uptake in adults is suboptimal.19,20,25–27 The notable vaccination coverage difference among adults with WRA was the increased likelihood of vaccination among the unemployed. This may reflect the association between severity of WRA and job loss.28,29
Barriers to vaccination include lack of knowledge about these vaccines among adult patients and healthcare providers, the perception of feeling healthy, vaccine safety concerns, vaccination costs, lack of health insurance, and lack of financing mechanisms.25,30 Low influenza vaccination coverage among employed adults and those with routine asthma checkups may indicate missed opportunities for vaccination.
Also, contrary to previous reports,27,31 among all asthma patients with at least one physician visit, influenza vaccination coverage did not increase with increasing number of physician contacts.9 No data were available in the ACBS to examine potential factors (e.g., vaccine availability, vaccination policies, public and clinician knowledge and practices, person's belief that they were in a high-risk group) that would explain why vaccination opportunities have been missed.8,30,32 The use of electronic health records with clinical decision support and physician prompts may improve influenza vaccination rates.33
Additionally, influenza vaccination coverage may be increased by offering and improving vaccination in workplaces.34 Blank et al.30 reported that the most important motivating factors for receiving influenza vaccine in the U.S. were media advertising, physician's advice, and advice from family, friends, or relatives. The authors concluded that improvement in vaccine coverage rates can be achieved by accurate communication of health information, particularly by physicians. Similar results have been reported by others.32,35,36
Across all analyzed groups, the lowest influenza vaccination coverage was noted among persons without health insurance. In the coming years, access to medical care and preventive services, including influenza vaccination, is expected to improve owing to passage of the Patient Protection and Affordable Care Act of 2010.27,37
Information on asthma and influenza vaccination was not validated; thus, estimates may be subject to misclassification. However, previous studies have found self-report of adult influenza vaccination to be reliable compared with reviews of medical records.38,39 This analysis used combined data years and influenza vaccination reported in the past 12 months rather than influenza season– specific coverage, which may produce different vaccination prevalence (http://cdc.gov/flu/fluvaxview/index.htm).
The cross-sectional design of BRFSS does not allow for examination of causal associations between adverse asthma outcomes and receiving influenza vaccination. For example, it is not clear whether influenza vaccination occurred before, during, or after unscheduled asthma treatment. Also, during 2006–2009, persons who resided in households that lacked a landline telephone and those who only used cellular telephones were not interviewed, likely resulting in vaccination coverage overestimatation.40 Finally, estimates are limited to the 38 states and District of Columbia and do not represent the entire U.S. population.
Conclusions
More effective influenza vaccination and communication strategies are needed to meet the updated Healthy People 2020 goal of increasing annual influenza vaccination coverage among adults aged ≥18 years to 70%.41
Acknowledgments
We thank the Behavioral Risk Factor Surveillance System state coordinators for their assistance in collecting the data used in this analysis. We thank Dr. Peng-jun Lu, National Center for Immunization and Respiratory Diseases, CDC, and Dr. Paul Garbe, National Center for Environmental Health, CDC, for their helpful comments.
Footnotes
The findings and conclusions in this report are those of authors and do not necessarily represent the views of the CDC.
No financial disclosures were reported by the authors of this paper.
Contributor Information
Jacek M. Mazurek, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, CDC, Morgantown, West Virginia.
Gretchen E. White, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, CDC, Morgantown, West Virginia.
Jeanne E. Moorman, National Center for Environmental Health, CDC, Atlanta, Georgia.
Eileen Storey, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, CDC, Morgantown, West Virginia.
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