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This study examined the impact of the COVID-19 pandemic on adult vaccination uptake, specifically recombinant zoster vaccine (RZV), influenza (FLU), and pneumococcal vaccines (PnV), and explored factors influencing COVID-19 vaccine receipt in US adults.
Methods
We conducted a retrospective analysis of nationally representative cross-sectional data from the 2019 and 2022 Behavioral Risk Factor Surveillance Systems (n=777,807). Multivariable regression models assessed vaccination status for COVID-19, RZV, FLU, and PnV, adjusting for sociodemographic factors, geography, and healthcare coverage.
Results
Among insured adults, RZV vaccination increased from 31.9% in 2019 to 41.5% in 2022, and FLU vaccination increased from 42.7% to 45.0%. Among uninsured individuals, FLU vaccination rates declined 3.2%, while RZV remained unchanged. PnV rates remained stable among the insured but decreased by 15.4% among the uninsured. Individuals with healthcare coverage were 2.9 times more likely (95% confidence interval, 2.6–3.2) to have received ≥1 dose of the COVID-19 vaccine. Minorities reported higher uptake for 1 to 2 doses of the COVID-19 vaccine but lower uptake for FLU, RZV, and PnV than non-Hispanic Whites, who had higher rates of >4 doses of COVID-19 vaccine.
Conclusion
Despite free access to the COVID-19 vaccine, healthcare coverage significantly influenced its uptake. Increases in RZV and FLU vaccination among the insured, in contrast to minimal changes or decreases among the uninsured, highlight the critical role of healthcare access. While RZV and FLU uptake improved post-pandemic, PnV uptake remained stable. We found no evidence that COVID-19 vaccine safety affected RZV, FLU, and PnV vaccination rates.
Vaccine uptake is essential for community protection against infectious diseases. However, it is hindered by a complex interplay of psychological, accessibility, and sociocultural factors [1]. Vaccine uptake and hesitancy are recognized as complex phenomena influenced by factors such as perceptions of low disease risk, heightened concerns regarding vaccine side effects, negative past experiences, personal attitudes, lack of knowledge, perceived control over behavior, complacency, barriers to vaccine access, and a lack of confidence in vaccination. Additionally, socioeconomic factors and education level have been linked to vaccine uptake, whereas incompatibility with religious beliefs has been associated with vaccine hesitancy [2-9].
The coronavirus disease 2019 (COVID-19) pandemic intensified the public debate on vaccine safety and efficacy, while also disrupting routine immunization services globally. Notably, global vaccine hesitancy was already a growing concern prior to the pandemic [10]. Consequently, the pandemic intensified the public debate on vaccine safety and efficacy, fueled by widespread media coverage and tensions between public health mandates and personal freedoms [8,11]. This disruption also extended to routine healthcare access, contributing to global declines in pediatric immunization rates [11-14].
Historically, vaccination rates among the American adult population have frequently lagged behind Healthy People targets [15,16]. This is particularly concerning for older adults, who are more vulnerable to severe illness, hospitalization, and death from vaccine-preventable diseases. The extent to which the COVID-19 pandemic and the related public discourse on vaccination have affected the uptake of routine adult vaccines remains unclear [17].
To address this gap in our understanding, this study aimed to compare the immunization uptake of three key adult vaccines: recombinant zoster vaccine (RZV), seasonal influenza (FLU), and pneumococcal vaccines (PnV). A concurrent assessment between the pre-pandemic year of 2019 and the post-acute pandemic year of 2022 allowed for a comprehensive evaluation of the differential impact of the pandemic on these routine vaccinations. Second, we sought to identify the key factors associated with any observed changes. This novel approach provides insights into vaccine equity and potential co-vaccination behaviors by investigating the receipt of routine adult vaccines and the uptake of COVID-19 vaccines.
Methods
Publicly available, de-identified data from 2019 (pre-COVID) and 2022 (post-COVID) Behavioral Risk Factor Surveillance System (BRFSS) surveys were used to assess vaccination rates for RZV, FLU, PnV, and COVID-19. The BRFSS is a state-based initiative assisted by the Centers for Disease Control and Prevention (CDC) and is the largest continuously conducted national survey of health-risk behaviors, clinical preventive services, and healthcare access in the United States. The survey methodology provides nationally representative estimates of the noninstitutionalized US population. Despite median response rates of 49.4% in 2019 and 45.1% in 2022, data weighting of demographic characteristics reduced bias and increased the representativeness of the estimates [18].
The BRFSS uses a disproportionately stratified random sampling design with accompanying weights to ensure that the survey sample is representative of adults in the US population. This methodological approach minimizes non-response bias and error within the estimates. Respondents were weighted by age, sex, race/ethnicity, education level, marital status, property ownership, and telephone ownership. The final weight variable (LLCPWT) was used for the analysis. In total, 436,918 and 470,791 respondents participated in the 2019 and 2022 surveys, respectively (total number=907,709). Our final analytical sample included adults who provided valid response data for at least one vaccine of interest (n=777,807).
The selected vaccines and age groups were based on the CDC vaccine recommendations for routine adult vaccination and the limitations of the BRFSS survey questions. For FLU, the CDC recommends annual vaccination for all persons aged ≥6 months. To determine influenza vaccination, BRFSS respondents were asked “During the past 12 months, have you had a flu shot or flu vaccine sprayed into your nose?” For RZV, the RZV is recommended for all adults ≥aged 50 years and for adults with immunosuppression aged ≥18 years. Our RZV analysis was limited to respondents aged ≥50 years because the BRFSS only inquired the general question “Have you ever received the shingles vaccine?” and did not inquire regarding immunosuppression status. Therefore, to adhere to the most general CDC recommendations, an age range of ≥50 years was used. Similarly, due to age limitations and data availability, only participants aged ≥65 years were included in the PnV analysis. The survey question used to determine PnV vaccination was “Have you ever had a pneumonia shot? This vaccine is also called a pneumococcal vaccine.”
For our analysis of COVID-19 vaccinations, following the emergency use authorization of the Food and Drug Administration (FDA) and subsequent recommendations from the Advisory Committee on Immunization Practices, all adults were recommended for receipt after the initial FDA emergency use authorization. Therefore, our analysis of COVID-19 vaccination included all individuals aged ≥18 years [19,20].
Primary sociodemographic characteristics of interest included age at the time of the survey, sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, or other non-Hispanic races including multiracial), and marital status (married/living with partner, divorced/widowed/separated, or never married). Additional characteristics of interest included healthcare coverage, smoking status, and location.
Participants were categorized by location using the National Center for Chronic Disease Prevention and Health Promotion Regions (Figure 1) [21] and the Metropolitan Statistical Area (MSA). MSAs are defined by the Census Bureau as areas that include a city with >50,000 residents, an urbanized area, and a total metropolitan population of >100,000. In this study, the term “urban” refers to those living within the center city of an MSA. The term “suburban” refers to those living outside the center city of an MSA but inside the county containing the center city, or those within the commuting county of an MSA. The term “rural” refers to those not residing in an MSA or suburban county [22].
Categorical variables were summarized using participant counts and weighted prevalence estimates along with 95% Wald confidence intervals (95% CIs). Variances were estimated using the Taylor series linearization method to account for the complex sampling design of the survey. Differences in vaccination rates across subgroups were assessed using Rao-Scott adjusted chi-square statistics. Multivariable binary logistic regression models were constructed to assess the independent effects of the primary predictors on vaccination status. Covariates included age, sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and others), marital status, access to healthcare, and income. Backward elimination with a retention threshold of P<0.05 was used to reach the final reduced model. Odds ratios (ORs) and adjusted odds ratios (aORs) with 95% CIs were estimated. Missing data were treated as missing and no attempts were made to impute the data. Statistical significance was defined at P<0.05. All analyses were conducted using the complex samples package of the IBM SPSS Statistics ver. 25.0 software (IBM Corp.).
This retrospective study was approved by the Womack Army Medical Center Human Research Protections Program Office for applicability of human subjects’ protection regulations. Due to the retrospective nature of the study and the use of anonymized data, the project was determined to be exempt from Institutional Review Board as the research does not involve human subjects in accordance with 32 CFR 219.102(e)(1). The project number is 24-20620 and the reference number is 978085.
Results
Respondent characteristics
Data from 777,807 respondents were included in this study, representing a weighted estimate of approximately 228 million adults in the non-institutionalized US population. The sample was divided evenly between 2019 (n=379,796) and 2022 (n=398,011). There were no significant differences in distributions of sex, age, race, or marital status between the two survey periods. However, data from 2022 revealed a significant shift toward urban residency, with corresponding decreases in suburban (–4.0%) and rural areas (–1.3%) (P<0.001). Reported healthcare coverage significantly increased from 87.7% (95% CI, 87.4–87.9) in 2017 to 91.7% (95% CI, 91.5–91.9) in 2022 (P<0.001).
Among the total sample of respondents, 48.7% were males (n=359,266; 95% CI, 48.5–49.0) and 51.3% were females (n=418,541; 95% CI, 51.0–51.5). Most participants reported living in urban areas (n=539,865; 83.9%; 95% CI, 83.8–84.0), whereas only 7.7% (n=76,745; 95% CI, 7.6–7.8) and 8.4% (n=144,371; 95% CI, 8.3–8.5) reported living in suburban or rural counties, respectively. The overall respondent characteristics of the sample, stratified by data collection year, are presented in Table 1.
Overall, the distributions of age, race, and marital status showed minimal sex differences (r²<0.01), whereas health insurance coverage varied significantly by sex (P<0.001). Specifically, females were more likely than males to report having health insurance, with an OR of 1.3 (95% CI, 1.1–1.7), independent of age. Notably, racial disparities in healthcare coverage were observed. Hispanics demonstrated the lowest rates, with 25.3% (95% CI, 24.7–26.0) reporting no healthcare coverage. In contrast, non-Hispanic Whites had the highest coverage rates, with only 6.5% (95% CI, 6.4–6.7) reporting a lack of coverage.
Changes in routine vaccine uptake (2019–2022)
Table 2 presents vaccination rates by year and health coverage type. Yearly adult FLU vaccinations increased among individuals with health insurance from 42.7% (95% CI, 42.4–43.0) in 2019 to 45.0% (95% CI, 44.7–45.3) in 2022. However, among those without healthcare coverage, rates fell from 19.0% (95% CI, 18.1–19.9) in 2019 to 15.8% (95% CI, 14.9–16.8) in 2022 (P<0.001). Among respondents aged ≥65 years with healthcare coverage, PnV vaccination rates remained unchanged from 71.3% (95% CI, 70.3–72.4) in 2019 to 70.3% (95% CI, 69.7–70.9) in 2022. A decline similar to FLU vaccination rates was observed in PnV vaccination rates for individuals without healthcare coverage; PnV vaccination rates declined from 46.6% (95% CI, 41.7–51.5) to 31.2% (95% CI, 23.5–40.2) (P<0.001). Notably, RZV uptake among adults aged ≥50 years significantly increased among individuals with healthcare coverage from 31.9% (95% CI, 30.4–33.4) in 2019 to 41.5% (95% CI, 40.3–42.8) in 2022. However, no significant difference was observed in RZV vaccination rates among individuals without healthcare coverage from 2019 (10.1%; 95% CI, 6.9–14.7) to 2022 (10.2%; 95% CI, 7.0–14.6) (P=0.98).
Factors associated with vaccine uptake
While RZV vaccination rates increased across all health insurance types, the most substantial increase was observed among those covered by Tricare, the Veterans Health Administration, and the Civilian Health and Medical Program of the Department of Veterans Affairs (P<0.001). Adults aged ≥65 years were significantly more likely to report receiving annual FLU (OR, 3.2; 95% CI, 3.1–3.2) and RZV (OR, 3.2; 95% CI, 2.9–3.5) vaccines. Notably, multivariable logistic regression analyses revealed a significant interaction between age and time (pre/post-COVID-19; P<0.001). Specifically, adults aged ≥65 years showed a greater increase in FLU vaccination rates from 2019 to 2022 than those aged 18 to 64 years (P<0.001). Similarly, adults aged ≥65 years exhibited a greater increase in RZV vaccination rates than those aged 50 to 64 years (P<0.001).
Females were more likely than males to report prior vaccination for PnV (OR, 1.3; 95% CI, 1.7–1.4), RZV (OR, 1.1; 95% CI, 1.0–1.2), and FLU (OR, 1.3; 95% CI, 1.3–1.4). Married individuals or those living with a partner had the highest vaccination rates, whereas those who were never married and did not live with a partner had the lowest rates for FLU, PnV, and RZV vaccination. This association remained significant in the multivariate analysis, independent of sex and race/ethnicity (P<0.001).
Analysis of race/ethnicity revealed significant disparities in vaccination rates. In bivariate analyses, non-Hispanic White adults exhibited higher vaccination rates for all three vaccines than non-Hispanic Black, Hispanic, and individuals identifying as other races (all P<0.001). In multivariable analyses, after controlling for sex and age, non-Hispanic White adults continued to have significantly higher vaccination rates compared to minorities for PnV (P<0.001). FLU and RZV vaccination rates were significantly lower in non-Hispanic Blacks and Hispanics than in non-Hispanic Whites (both P<0.001). In contrast, no statistically significant differences were observed between non-Hispanic Whites and individuals identifying as other races (both P>0.05). Table 3 presents the FLU rates for 2019 and 2022 according to the National Center for Chronic Disease Prevention and Health Promotion region (Figure 1). Although regions D, F, and G showed a decrease in vaccination rates, these changes were not statistically significant. Region E showed the largest improvement over time with a 5% increase, followed by Region A (both P<0.001). Regions B, H, I, and J also showed significant increases over time (P<0.05). However, after adjusting for other variables, no statistically significant geographic pattern influencing FLU vaccine uptake was identified (P>0.05).
COVID-19 vaccination and associated factors
Finally, we analyzed self-reported COVID-19 vaccination status, defined as the receipt of at least 1 dose of the COVID-19 vaccine. Among all adult respondents, those who received a FLU vaccine within the past 12 months were 10.9 times more likely (95% CI, 10.0–11.8) to have also received at least 1 dose of the COVID-19 vaccine. Specifically, 95.4% of FLU vaccine recipients also reported COVID-19 vaccination, while only 4.6% (95% CI, 4.3–4.9) of FLU vaccine recipients did not. In contrast, among adults who did not receive a FLU vaccine in the 12 months preceding the survey, only 65.6% (95% CI, 64.8–66.3) reported COVID-19 vaccination. Adults aged ≥50 years who received RZV were 4.8 times more likely (95% CI, 3.7–6.3) to report receiving a COVID-19 vaccine. Despite efforts to improve access and reduce financial barriers, in an unadjusted analysis, individuals reporting current healthcare coverage were 2.9 times more likely (95% CI, 2.6–3.2) to report receiving at least 1 dose pf the COVID-19 vaccine. This relationship was further explored in subanalyses adjusted for age, sex, race/ethnicity, and marital status. In these analyses, health insurance coverage demonstrated an independent effect on COVID-19 vaccination rates for receipt of at least 1 vaccine dose (aOR, 2.8; 95% CI, 2.5–3.1), as well as for 3 (aOR, 2.3; 95% CI, 1.9–2.9) and 4 doses (aOR, 3.5; 95% CI, 2.2–5.4), but not for 2 doses (aOR, 1.1; 95% CI, 0.87–1.3).
Consistent with prior research, marital status and sex were significantly associated with COVID-19 vaccination rates (P<0.001). Females were approximately 20% more likely to be vaccinated than males (aOR, 1.2; 95% CI, 1.1–1.3). After adjusting for age, sex, and marital status, all minorities (non-Hispanic Black, Hispanic, and individuals identifying as other races) exhibited higher COVID-19 vaccination rates (for at least 1 dose) compared to non-Hispanic White individuals (all P<0.001). For 3 doses of the COVID-19 vaccine, the uptake rates among non-Hispanic White were comparable to those of other racial/ethnic groups (P>0.05), and for ≥4 doses, non-Hispanic White individuals had the highest uptake rates (P<0.05).
Discussion
Our findings align with several trends observed in previous studies on vaccine uptake during the COVID-19 pandemic. Previous studies have highlighted declines in routine vaccination rates across various age groups in the United States during the pandemic [17,23,24]. While our study also observed the impact of the pandemic on vaccination rates, particularly the influence of healthcare coverage, we found that RZV and FLU uptake increased post-pandemic, suggesting some recovery in adult vaccination rates. However, similar to the findings of other studies, we identified disparities in vaccine coverage. For example, a previous study noted more pronounced disparities among Black and Hispanic children than among White and Asian children, and our study found disparities in COVID-19, FLU, RZV, and PnV vaccine uptake among racial/ethnic groups [23]. Furthermore, some studies have mentioned decreased pro-vaccine attitudes; while our study did not directly measure attitudes, the persistently lower uptake in certain groups despite free vaccine access suggests that factors beyond financial barriers, such as trust and access to care, play a significant role in vaccine uptake [23,25].
Overall, FLU and RZV uptake increased in 2022 than in 2019, whereas PnV uptake remained statistically unchanged. This addresses our first objective and suggests that concerns regarding COVID-19 vaccine safety did not negatively affect its uptake in our cohort. However, healthcare coverage analysis revealed a complex relationship. RZV uptake significantly improved among insured individuals, while uninsured individuals experienced declines in FLU (–3.2%) and PnV (–14.3%) vaccination rates in 2022, with RZV uptake remaining unchanged at 10%. Out-of-pocket costs and access to care are likely contributors to these disparities. However, cost barriers alone do not explain the nearly three-fold difference in COVID-19 vaccine uptake, as it was provided free to the public in 2022. This finding suggests that other influencing factors are associated with healthcare coverage. Less tangible benefits include outreach, education, promotion, reminder systems, and patient-provider relationships. As trusted resources, providers offer personalized counseling, which has been shown to be a primary determinant of vaccine acceptance [14].
The COVID-19 vaccine uptake rates varied according to race and the number of doses received. For 1 to 2 doses, non-Hispanic Blacks, Hispanics, and individuals identified as other races exhibited higher vaccination rates than non-Hispanic White individuals. However, the same groups showed lower uptake rates for the established FLU, RZV, and PnV vaccines. Notably, for 3 doses of the COVID-19 vaccine, uptake rates among non-Hispanic White individuals were comparable to those of other racial/ethnic groups, and for ≥4 doses, non-Hispanic White individuals had the highest uptake rates. Subanalyses indicated that insurance coverage was not significantly correlated with COVID-19 vaccination rates (P=0.39), suggesting that the effect was not attributable to socioeconomic differences. This finding contrasts with the typical patterns of lower vaccine uptake among minority groups during routine adult vaccinations.
The lower uptake of FLU, RZV, and PnV vaccines among non-Hispanic Black, Hispanic, and other racial groups in our study aligns with previous research highlighting persistent disparities in routine adult vaccination, likely influenced by historical events [2,26,27]. Distrust toward medical personnel regarding vaccinations among minority groups may be partly attributable to the predominance of White healthcare providers [28,29]. However, the initially higher uptake of 1 to 2 doses of the COVID-19 vaccine in these groups deviates from this trend. This may reflect heightened awareness of the disproportionate impact of COVID-19 on these communities and the potential influence of targeted early vaccination efforts. The subsequent convergence and lower uptake of subsequent COVID-19 doses suggest that the factors influencing vaccination behavior are dynamic and context-specific, warranting further investigation into the socioeconomic effects and evolving perceptions and barriers associated with COVID-19 vaccination across different racial and ethnic groups.
The observed higher COVID-19 vaccine uptake among individuals receiving FLU or RZV vaccines may indicate that the copromotion of established vaccines could enhance the acceptability of newer vaccines. Alternatively, this association may simply reflect the higher health-seeking behaviors in this group. Among individuals who did not receive the FLU vaccine, the strongest predictors were a lack of health insurance, smoking, and lower educational levels. Notably, the ≥65 years cohort exhibited the greatest increase in FLU vaccine uptake, potentially due to the shared respiratory nature of influenza and COVID-19 and the heightened risk of severe illness in this age group for both diseases. The COVID-19 pandemic may also have increased overall disease prevention behaviors [7,14,28,30].
Regional variations in vaccine uptake are anticipated and potentially influenced by distinct regional factors. We expected urban-rural disparities and socioeconomic status to play a significant role, with densely populated urban areas potentially benefiting from increased healthcare access and awareness. Conversely, rural populations were expected to encounter greater barriers owing to limited healthcare resources and information dissemination. Despite small regional variations in FLU uptake, our multivariable analysis did not reveal statistically significant geographical differences when accounting for other variables.
This study had several limitations. First, the data relied on self-reported vaccination status, which may introduce recall bias, in addition to potential response bias. Second, we did not capture the differences in COVID-19 vaccination schedules, which could be relevant given the variations in the primary series requirements. Third, the retrospective design limited the types of data available. Notably, mandatory COVID-19 vaccination for certain occupations (e.g., healthcare workers and military personnel) may have influenced the overall uptake, and we could not ascertain individual motivations for vaccination. Finally, the cross-sectional nature of the data prevented assessment of individual changes in vaccine acceptance or hesitancy over time.
Although this study provides valuable insights into vaccine uptake within our specific cohort of American adults, the generalizability of these findings may be limited to populations with similar demographic and healthcare access characteristics. Further research is required to determine the applicability of these results to other populations, particularly those with differing socioeconomic disparities and healthcare systems.
This study underscores the multifaceted nature of vaccine uptake and elucidates the factors influencing vaccination behavior among diverse demographic groups. Overall, we found no significant negative effect of the COVID-19 pandemic on the uptake of RZV, FLU, or PnV vaccines. Conversely, improvements in uptake were observed, particularly among the insured. Although healthcare coverage has emerged as a significant factor in vaccine acceptance, vaccination disparities persist. To effectively address vaccine inequities, a multifaceted approach is needed. Based on our findings, we recommend that policymakers and clinicians prioritize strategies that combine strengthening provider-patient relationships with expanding community-based outreach, particularly among uninsured individuals. This could involve empowering providers to become vaccine champions within their practice and supporting community health initiatives that provide vaccine education and services directly to underserved populations. Further research on the non-monetary benefits of health coverage may identify strategies for increasing vaccine equity across racial and socioeconomic groups.
Notes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
The authors would like to thank Laurie A. Housel and Christina Spooner for their contributions to this effort. The views expressed in this presentation are those of the authors and do not necessarily represent the official policy or position of the Army, Defense Health Agency (DHA), Department of Defense (DOD), or any other US government agency.
Funding
None.
Data availability
The data supporting the findings of this study are available from the National Health and Nutrition Examination Survey at https://www.cdc.gov/nchs/nhanes.
Author contribution
Conceptualization: TAB. Acquired the data: TAB. Formal analysis: TAB. Interpretation of the results: CSB, SMR, BKM. Writing–original draft: TAB. Writing–review & editing: CSB, SMR, BKM. Final approval of the manuscript: all authors.
Figure. 1.
National Center for Chronic Disease Prevention and Health Promotion Regions. From Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion regions [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2025 Jan 14]. Available from: https://www.cdc.gov/nchs/hus/sourcesdefinitions/geographic-region.htm [21].
Values are presented as % (95% confidence interval). From Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion regions [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2025 Jan 14].
a)Does not include data for Guam, Puerto Rico, or U.S. Virgin Islands.
b)Regions correspond to U.S. Department of Health and Human Services (HHS) regions: Region A (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont New Jersey, New York); Region B (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia); Region C (Florida, Georgia, North Carolina, South Carolina); Region D (Alabama, Kentucky, Mississippi, Tennessee); Region E (Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin); Region F (Arkansas, Louisiana, New Mexico, Oklahoma, Texas); Region G (Iowa, Kansas, Missouri, Nebraska); Region H (Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming); Region I (Arizona, California, Hawaii, Nevada); Region J (Alaska, Idaho, Oregon, Washington).
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Vaccine uptake pre- and post-COVID-19 in American adults: a retrospective observational study using the Behavioral Risk Factor Surveillance System
Figure. 1. National Center for Chronic Disease Prevention and Health Promotion Regions. From Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion regions [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2025 Jan 14]. Available from: https://www.cdc.gov/nchs/hus/sourcesdefinitions/geographic-region.htm [21].
Graphical abstract
Figure. 1.
Graphical abstract
Vaccine uptake pre- and post-COVID-19 in American adults: a retrospective observational study using the Behavioral Risk Factor Surveillance System
Characteristic
No. of patients
Weighted estimate % (95% CI)
2019
2022
Sex
Male
359,266
48.6 (48.3–48.9)
48.9 (48.5–49.2)
Female
418,541
51.4 (51.1–51.7)
51.1 (50.8–51.5)
Age category (y)a)
20–29
72,354
17.0 (16.7–17.3)
16.8 (16.5–17.1)
30–39
90,931
17.8 (17.5–18.1)
17.6 (17.3–17.8)
40–49
99,294
15.7 (15.5–16.0)
15.9 (15.7–16.2)
50–59
132,706
17.6 (17.3–17.8)
16.4 (16.1–16.6)
60–69
168,180
16.3 (16.1–16.5)
16.6 (16.4–16.9)
70–79
136,999
10.8 (10.6–10.9)
11.6 (11.4–11.8)
≥80
65,299
4.8 (4.7–4.9)
5.1 (5.0–5.3)
Race/ethnicity
White, non-Hispanic
593,148
63.8 (63.4–64.1)
60.3 (59.9–60.6)
Black, non-Hispanic
58,065
11.1 (10.9–11.3)
11.2 (11.0–11.4)
Hispanic
70,827
16.9 (16.6–17.2)
17.9 (17.6–18.2)
Non-Hispanic, other race
55,767
8.3 (8.1–8.5)
10.6 (10.4–10.9)
Marital statusb)
Married or member of unmarried couple
429,182
55.5 (55.2–55.8)
55.2 (54.9–55.6)
Widowed, divorced, or separated
208,599
20.3 (20.0–20.5)
19.9 (19.6–20.1)
Never married
134,205
24.2 (23.9–24.5)
24.9 (24.6–25.2)
County locationc)
Urban
539,865
81.2 (81.0–81.4)
86.5 (86.3–86.7)
Suburban
76,745
9.7 (9.6–9.9)
5.7 (5.6–5.8)
Rural
144,371
9.1 (9.0–9.2)
7.8 (7.7–7.9)
Have any health care coveraged)
Yes
675,632
87.7 (87.4–87.9)
91.7 (91.5–91.9)
Overweight or obesee)
Yes
499,289
66.7 (66.4–67.0)
67.7 (67.4–68.0)
Current smokerf)
Yes
100,287
15.2 (14.9–15.4)
12.6 (12.4–12.8)
Group
Influenza
Pneumonia
Zoster
2019
2022
2019
2022
2019
2022
Total sample
37.9 (37.5–38.2)
39.1 (38.8–39.5)
71.2 (70.7–71.8)
69.6 (69.0–70.2)
29.9 (28.6–31.4)
40.0 (38.8–41.2)
Total without healthcare coverage
19.0 (18.1–19.9)
15.8 (14.9–16.8)
46.6 (41.7–51.5)
31.2 (23.5–40.2)
10.1 (6.9–14.7)
10.2 (7.0–14.6)
Total with healthcare coverage
42.7 (42.4–43.0)
45.0 (44.7–45.3)
71.3 (70.3–72.4)
70.3 (69.7–70.9)
31.9 (30.4–33.4)
41.5 (40.3–42.8)
Purchased plan or provided by employer
42.5 (41.6–43.5)
44.5 (44.1–45.0)
68.0 (65.1–70.8)
64.6 (63.1–66.0)
23.0 (20.9–25.2)
35.1 (33.2–37.0)
Medicare, Medicaid, Medigap, CHIP
50.6 (49.6–51.6)
52.1 (51.5–52.6)
72.2 (71.0–73.4)
71.4 (70.7–72.0)
41.6 (39.3–43.8)
46.8 (45.1–48.5)
Tricare, VA healthcare, CHAMP
39.9 (36.0–44.0)
51.9 (50.2–53.6)
67.3 (59.7–74.0)
70.3 (67.1–73.3)
31.7 (24.6–39.7)
48.5 (42.5–54.6)
Year
Regionb)
A
B
C
D
E
F
G
H
I
J
2019
46.9 (46.1–47.7)
48.1 (47.3–49.0)
40.2 (39.3–41.2)
41.3 (40.4–42.2)
41.9 (41.3–42.6)
40.6 (39.4–41.9)
46.9 (46.1–47.8)
44.6 (43.9–45.3)
40.7 (39.7–41.7)
44.8 (39.7–41.7)
2022
51.6 (50.9–52.3)
49.6 (48.6–50.5)
41.5 (40.4–42.5)
40.2 (39.2–41.3)
46.9 (46.2–47.5)
39.6 (38.6–40.7)
46.3 (45.4–47.1)
46.5 (45.7–47.3)
44.3 (43.1–45.4)
46.3 (45.6–47.0)
Table 1. Respondent characteristics (n=777,807)
CI, confidence interval.
Age (n=767,763) due to non-response.
Marital status (n=771,986) due to non-response.
County location (n=760,981) due to non-response.
Health care coverage (n=723,918) due to non-response.
Overweight or obese (n=728,501) due to non-response.
Smoking status (n=772,547) due to non-response.
Table 2. Vaccination rates by healthcare coverage type and year
Values are presented as % (95% confidence interval).
CHIP, Children’s Health Insurance Program; VA, U.S. Department of Veterans Affairs ; CHAMP, Civilian Health and Medical Program.
Table 3. Seasonal influenza vaccination rates by geographical regiona)
Values are presented as % (95% confidence interval). From Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion regions [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2025 Jan 14].
Available from: https://www.cdc.gov/nchs/hus/sourcesdefinitions/geographic-region.htm [21].
Does not include data for Guam, Puerto Rico, or U.S. Virgin Islands.
Regions correspond to U.S. Department of Health and Human Services (HHS) regions: Region A (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont New Jersey, New York); Region B (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia); Region C (Florida, Georgia, North Carolina, South Carolina); Region D (Alabama, Kentucky, Mississippi, Tennessee); Region E (Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin); Region F (Arkansas, Louisiana, New Mexico, Oklahoma, Texas); Region G (Iowa, Kansas, Missouri, Nebraska); Region H (Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming); Region I (Arizona, California, Hawaii, Nevada); Region J (Alaska, Idaho, Oregon, Washington).
