ATrain Education


Continuing Education for Health Professionals

Influenza 2018–2019

Module 6

The Goal of Universal Vaccination

It has been well-established that influenza vaccination reduces influenza-associated illness. CDC estimates that tens of thousands of hospitalizations are averted because of vaccination each year and that vaccination prevents millions of influenza-related illnesses. This is despite that fact that fewer than half of those over the age of 6 months are vaccinated each year. Higher vaccination rates almost certainly would prevent a substantial number of additional cases and hospitalizations.


CDC flu vaccination benefits infographic

The estimated number of flu illnesses prevented by flu vaccination during the 2016–2017 season: 5.3 million, about the population of the Atlanta metropolitan area.


In the United States, goals for improving influenza vaccination rates are outlined in Healthy People 2020 (see table below). Since 2010 CDC has recommended that all people 6 months of age and older receive annual influenza vaccination. Despite substantial gains in the number of people vaccinated each year, we have yet to come close to the goal of universal influenza vaccination.


Source: CDC, 2018a; CDC, 2018e; Black et al., 2018.

Influenza Vaccination Coverage 2017–2018 Season

Age group

2017–18 rates

2020 goals

All people (≥6 months)



Adults (≥18 years)



Children (6 months – 17 years)



Adults 65 and older



Healthcare personnel




Flu Vaccination Coverage Among Adults by Age Group and Season
United States 2010–2018

chart of adult vaccination coverage by age group and season

Source: CDC.


The College of Physicians of Philadelphia provides a fascinating look at the issues associated with vaccines on their History of Vaccines website ( It is well worth the time to look over this website and explore “the ways in which vaccines, toxoids, and passive immunization work, how they have been developed, and the role they have played in the improvement of human health.”

Vaccination Rates Among Adults

During the 2017–2018 season, flu vaccination coverage among adults was 37.1%, a decrease of 6.2% from the previous flu season. Vaccination coverage varied by age group and state, and coverage decreased in all age groups and in most states. However, interpretation of these results should take into account limitations of the survey, including reliance on self-report of vaccination status and decreasing response rates (CDC, 2018f).


Flu Vaccination Coverage Among Adults by Season, United States 2010–2018

chart of adult vaccination coverage by season

Source: CDC.


During the 2016–2017 flu season, more than 53% of Americans did not receive a flu vaccination. The lowest rate of vaccination occurred in Nevada (36.1%) and the highest in South Dakota (53.9%). Vaccination rates increased slightly among adults compared to the previous influenza season but remained much the same for children (Black et al., 2017).

The same trends have been noted in European countries where surveys from five countries have shown consistently low coverage rates in the general population. During the 2009 H1N1 pandemic, vaccination campaigns were adopted in many countries; however, low acceptance of a vaccine or uptake rates against pandemic influenza were reported in many studies (25% among health workers in Beijing, 17% among a French adult population, and 8.9% among pregnant women in Turkey) (Wu et al., 2013).


Vaccination Rates Decline as Clinic Day Progresses

A retrospective, quality-improvement study of 11 primary care practices at the University of Pennsylvania Health System from September 1, 2014, to March 31, 2017 yielded interesting results. Researchers found that influenza vaccination rates significantly declined as the clinic day progressed.

Offering an “active choice” intervention in which medical assistants were prompted to make decisions on whether to template vaccinations orders in patients’ electronic health record for clinicians to review was associated with a significant increase in vaccination rates. Importantly, the active choice intervention was associated with a significant increase in influenza vaccination rates that were similar in magnitude throughout the day.

Source: Kim et al., 2018.


Vaccination Rates Among Children

Influenza-associated deaths in children (less than 18 years) were added as a nationally notifiable condition in 2004. Of particular interest, for children in the United States, influenza vaccination rates are fairly high in young children but decrease with increasing age:

  • 6–23 months: 76.3%
  • 2–4 years: 66.2%
  • 5–12 years: 59.9%
  • 13–17 years: 48.8% (Black et al., 2017)

CDC analyzed data from the National Immunization Survey—Flu to estimate flu vaccination coverage for the U.S. population of children 6 months through 17 years during the 2017–2018 flu season. Receipt of flu vaccination was determined by parental report. Vaccination coverage with more than 1 dose of flu vaccine was 57.9%, a decrease of 1.1 percentage point from the previous flu season. Vaccination coverage varied by state and age group (CDC, 2018g).

During the 2017-2018 flu season, 180 lab-confirmed pediatric deaths were reported; for children eligible for vaccination and for whom vaccination status is known, 74% were not vaccinated. Common reasons parents give for not having their child receive a flu vaccination include: the child is unlikely to get the flu or get very sick from the flu, the child is not in a high risk group, and concern about side effects from the vaccine (CDC, 2018g).


Flu Vaccination Coverage by Age Group and Season
Children 6 Months–17 years, United States 2010–2018

chart of vaccination coverage of children by age group and season

Source: CDC.


Vaccination Rates Among Healthcare Workers

The overall influenza vaccination coverage estimate among healthcare personnel was 78.4% during the 2017–2018 influenza season, a 15% increase since the 2010–2011 season, but similar to coverage during the previous four seasons. As in past seasons, the highest coverage was associated with workplace vaccination requirements. Reported coverage was consistently higher among healthcare personnel working in hospital settings than among those working in other settings; healthcare personnel working in hospital settings were also the most likely to report workplace vaccination requirements (Black et al., 2018).

Influenza vaccination coverage was higher among healthcare personnel with vaccination available at or promoted in their workplace than among those without any type of employer promotion of vaccination; however, coverage achieved through vaccine availability and promotion was still suboptimal in the absence of requirements. Neither vaccination coverage nor prevalence of employer vaccination requirements or promotion differed in the 2017–2018 season compared with the previous season, despite the severity of the 2017–2018 influenza season (Black et al., 2018).

Influenza vaccination coverage among healthcare personnel working in long-term care settings, the majority of whom work as assistants and aides, continues to be consistently lower than that among healthcare personnel working in all other healthcare settings. Influenza vaccination among healthcare personnel in long-term care settings is especially important because influenza vaccine efficacy is generally lowest among elders, who are at increased risk for severe disease (Black et al., 2018).

In contrast to healthcare personnel working in hospitals, a much lower proportion of survey respondents working in long-term care settings reported having a requirement for vaccination, and 23.5% reported that their employer did not require, make available on-site at no cost, or promote vaccination in any way. Implementing workplace vaccination programs that have been successful in increasing coverage in hospital settings, including vaccination requirements, could increase coverage in long-term care and other settings with historically lower vaccination coverage (Black et al., 2018).

Did You Know. . .

Workplace vaccination programs that have been successful in increasing coverage in hospital settings could be implemented in long-term care and other settings with lower vaccination coverage.

Employers can use the long-term care web-based toolkit developed by CDC and the National Vaccine Program Office to access resources, strategies, and educational materials for increasing influenza vaccination among healthcare personnel in long-term care settings (Black et al., 2017).

These low rates are certainly at least partly related to high staff turnover; it is not uncommon for a long-term facility’s staff to turn over completely every few years. Newly hired managers may not adhere to existing policies related to vaccinations, or they may decide to discard such policies and implement new ones (AHRQ, 2014).


poster: All Healthcare Workers Need Flu Vaccines

Source: Morbidity and Mortality Weekly Report, 2018.


Vaccination Rates by Healthcare Occupation

During the 2016–2017 season (earliest available statistics), flu vaccination coverage was highest among physicians (95.8%) and lowest among assistants and aides (69.1%), and highest overall among healthcare personnel who were required by their employer to be vaccinated (96.7%) (Black et al., 2017).

Among healthcare personnel working in settings where vaccination was neither required, promoted, nor offered onsite, vaccination coverage continued to be low (45.8%). An increased percentage of healthcare personnel reporting a vaccination requirement or onsite vaccination availability compared with earlier influenza seasons might have contributed to the overall increase in vaccination coverage during the past seven influenza seasons (Black et al., 2017).

Vaccination Rates by Healthcare Setting

Not surprisingly, vaccination rates among healthcare providers vary by work setting. During the 2016–2017 season, vaccination coverage continued to be higher among healthcare personnel working in hospitals (92.3%) and lower among healthcare personnel working in ambulatory (76.1%) and long-term care settings (68%) (Black et al., 2017).

Coverage was highest among physicians, nurse practitioners/physician assistants, nurses, pharmacists, and healthcare personnel working in hospital settings. Coverage was lowest among assistants and aides and personnel working in long-term care settings. Employer vaccination requirements and offering vaccination at the workplace at no cost were associated with higher vaccination coverage (Black et al., 2017).

Why is it so important to increase vaccination rates among healthcare personnel?

Because of their close proximity to sick patients, healthcare providers are more likely to get influenza and to pass it on, with more significant consequences than for any other group of workers. Paradoxically, when a healthcare provider gets sick, several studies have shown that more than 75% continue to work despite being infected with influenza (Riphagen-Dalhuisen et al., 2013).

A recent study conducted among nursing home workers in France suggest low rates of influenza vaccination there as well. Management and working environment appear to play a strong role and the authors suggest that: “To overcome vaccine ‘hesitancy,’ specific communication tools may be required to be adapted to the various NH professionals to improve influenza prevention” (Elias et al., 2017).

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