Influenza and Pneumococcal Vaccination Levels Among Adults Aged ≥65 Years— United States, 1997 FREE

MMWR. 1998;47:797-802

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IN 1996, influenza and pneumonia were the fifth leading cause of death among persons aged≥65 years in the United States.¹ A national health objective for 2000 is to increase influenza and pneumococcal vaccination levels to≥60% among persons at high risk for complications, including those aged≥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≥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≥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 status³; 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≥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. 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≥60%, and nine had levels≥70% (range: 41.5% in Puerto Rico to 74.4% in Colorado). 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 <60% among persons aged ≥65 years, levels were≥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≥75 years to report receipt of influenza (63.2% compared with 69.1%) or pneumococcal (41.7% compared with 51.3%) vaccines. Among persons aged≥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. 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≥65 years) were more likely to report receipt of influenza and pneumococcal vaccines than persons reporting a longer interval since their last check-up.

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.

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≥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≥65 years.

Although most persons aged≥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 vaccinate.^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 10 available.

MMWR. 1998;47:749-751

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EACH YEAR, approximately three million cases of sexually transmitted diseases (STDs) occur among teenagers,¹ and approximately one million become pregnant.² Human immunodeficiency virus (HIV) infection is the sixth leading cause of death among persons aged 15-24 years in the United States.³ Unprotected sexual intercourse and multiple sex partners place young persons at risk for HIV infection, other STDs, and pregnancy. To determine trends in sexual risk behaviors among high school students, CDC analyzed data from the Youth Risk Behavior Survey (YRBS) for the years 1991, 1993, 1995, and 1997. This report summarizes the results of this analysis, which indicate that, from 1991 to 1997, the percentage of U.S. high school students who had ever had sexual intercourse decreased, and the prevalence of condom use among currently sexually active students increased.

The YRBS, a component of CDC's Youth Risk Behavior Surveillance System, measures the prevalence of health-risk behaviors among adolescents through representative national, state, and local surveys conducted biennially. The 1991, 1993, 1995, and 1997 national surveys used independent, three-stage cluster sampling to obtain representative cross-sectional samples of students in grades 9-12 in the 50 states and the District of Columbia. In 1991, 1993, 1995, and 1997, the sample sizes were 12,272, 16,296, 10,904, and 16,262, respectively; school response rates were 75%, 78%, 70%, and 79%, respectively; student response rates were 90%, 90%, 86%, and 87%, respectively; and overall response rates were 68%, 70%, 60%, and 69%, respectively.

For each of the four cross-sectional surveys, students completed a self-administered questionnaire that included questions about sexual intercourse, number of sex partners, and condom use. The wording of these questions was identical in each biennial survey. Sexual experience was defined as ever having had sexual intercourse, multiple sex partners as having had four or more sex partners during one's lifetime, current sexual activity as having had sexual intercourse during the 3 months preceding the survey, and condom use as having used a condom at last sexual intercourse among currently sexually active students. Data are presented only for non-Hispanic black, non-Hispanic white, and Hispanic students because the numbers of students from other racial/ethnic groups were too small for meaningful analysis.

Data were weighted to provide national estimates, and SUDAAN was used to calculate 95% confidence intervals and to conduct trend analyses. The relative percent change in behavior from 1991 to 1997 was calculated as the 1997 prevalence minus the 1991 prevalence divided by the 1991 prevalence and multiplied by 100. Secular trends were analyzed by using logistic regression analyses that controlled for sex, grade, and race/ethnicity and simultaneously assessed linear, higher order (i.e., quadratic and cubic), and overall time effects. Additional logistic regression models included significant time effects and their interactions with sex, grade, and race/ethnicity. For interactions that were significant (p <0.05), posthoc analyses were used to examine subgroup differences.

Compared with 1991, the prevalence of sexual experience in 1997 decreased 11%. Logistic regression analysis indicated a significant linear decrease overall and among male students and white and black students (p ≤0.01). Among male students, sexual experience decreased 15% (from 57.4% to 48.8%); sexual experience among female students did not show a significant linear decrease. Sexual experience decreased 13% (from 50.0% to 43.6%) among white students and 11% (from 81.4% to 72.6%) among black students; sexual experience among Hispanic students did not show a significant linear decrease.

The prevalence of multiple sex partners decreased significantly overall (14%) (from 18.7% to 16.0%) and among male students (p <0.01). The prevalence of multiple sex partners among male students decreased 25% (from 23.4% to 17.6%); multiple sex partners among female students did not show a significant linear decrease. The overall trend did not differ among grade or racial/ethnic subgroups.

The proportion of students who reported current sexual activity did not change significantly over time. Among currently sexually active students, condom use increased 23%, a significant linear increase (p ≤0.001). The overall trend in condom use did not differ among sex, grade, or racial/ethnic subgroups.

Div of Adolescent and School Health and Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of HIV/AIDS Prevention-Intervention, Research, and Support, Div of HIV/AIDS Prevention-Surveillance and Epidemiology, and Div of Sexually Transmitted Diseases Prevention, National Center for HIV, STD, and TB Prevention, CDC.

The findings in this report indicate that fewer high school students are engaging in behaviors that place them at risk for HIV infection, other STDs, and pregnancy. The decrease in sexual experience represents a reversal of the increasing trend in sexual intercourse rates among adolescents that occurred during the 1970s and 1980s.⁴

These survey findings are consistent with other national data that have shown stable rates of sexual experience and increasing use of condoms among adolescents during the 1990s.^4- 5 These behavioral changes also are consistent with recent reports describing national decreases in related health outcomes among adolescents. During 1993-1996, gonorrhea rates decreased 35% among males and 11% among females aged 15-19 years.⁶ During 1992-1995, pregnancy rates among females aged 15-19 years declined in all 43 states with available data.⁷ The decrease in sexual risk behaviors among high school students during 1991-1997 also corresponds to an increase in the percentage of high school students who received HIV/AIDS education in school (from 83.3% in 1991 to 91.5% in 1997) (CDC, unpublished data, 1998).

The findings in this report are subject to at least three limitations. First, these data apply only to adolescents who attend high school. In 1996, 5% of persons aged 14-17 years were not enrolled in school.⁸ These adolescents are more likely to be sexually experienced and to have had multiple sex partners than those adolescents who are enrolled in school.⁹ Second, the extent of underreporting or overreporting cannot be determined, although the survey questions demonstrate good test-retest reliability.¹⁰ Finally, the survey provides no information on socioeconomic status and other variables that might explain subgroup differences.

The decreases in sexual risk behaviors and the corresponding improvements in reproductive health outcomes among adolescents are the result of broad efforts by parents and families; schools; community-based organizations; the religious community; the media; federal, state, and local government agencies; and adolescents. The dual approach of delaying first intercourse among all adolescents and increasing condom use among those who are sexually active has succeeded in reducing overall risk through improvements in both behaviors. Despite these findings, decreases in sexual experience and multiple sex partners were not found among all subgroups of students, and the percentage of currently sexually active students remained stable. Many adolescents remain at risk for HIV, other STDs, and unintended pregnancy. Expanded efforts are required of families, schools, and other social institutions that affect adolescents to achieve continued reductions in risk.