Vaccination Coverage among Adults in the United States, National Health Interview Survey, 2022

At a glance

Data from the 2022 National Health Interview Survey (NHIS) indicates vaccination coverage among U.S. adults was low for most vaccines.

Summary

Adults are at risk of illness, hospitalization, disability, and death from vaccine-preventable diseases (VPDs). The Centers for Disease Control and Prevention (CDC) recommends vaccinations for adults based on age, health conditions, prior vaccinations, and other considerations to prevent morbidity and mortality from VPDs. Updated CDC vaccination recommendations for adults are published annually. Despite the burden and consequences of VPDs and recommendations to get vaccinated, vaccination coverage among U.S. adults remains low for most vaccines. In addition, large disparities in adult vaccination coverage by race and ethnicity and other demographic factors have remained mostly unchanged over the last several years.

To assess vaccination coverage among adults aged ≥19 years, CDC analyzed data from the National Health Interview Survey (NHIS). The NHIS is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. Interviews are conducted over the course of the year in a probability sample of households, and data are compiled and released on an annual basis. For this report, adult receipt of influenza, pneumococcal, herpes zoster (including any type of herpes zoster and recombinant zoster vaccine [RZV]), tetanus and diphtheria [Td], tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], human papillomavirus [HPV], and COVID-19 vaccines were assessed using the data collected in 2022. A composite adult vaccination quality measure, which tracks vaccines routinely recommended for all adults (tetanus toxoid-containing and influenza vaccine) or indicated among adults based on age (herpes zoster and pneumococcal vaccines), was assessed using 2022 data. Recent trends in adult vaccination were examined using data from 2017–2022.

Coverage for all vaccines differed by race and ethnicity with generally lower coverage among Black and Hispanic adults compared with White adultsA. Coverage for the age-appropriate composite measure (including influenza vaccination) among adults aged ≥19 years was low (22.8%) and ranged from 14.7% among those aged 50–64 years to 26.2% among those aged ≥65 years. Adults without health insurance or a usual place for health care were less likely to be vaccinated than those with insurance and a usual place for health care for all vaccines. Linear trend tests since 2017 indicated that coverage increased for any type of herpes zoster vaccination among adults aged ≥60 years, remained stable for pneumococcal vaccination among adults aged 19–64 years at increased risk of disease, and decreased for pneumococcal vaccination among adults aged ≥65 years. While the overall trend for influenza vaccination (aged ≥19 years and aged ≥19 years with high-risk conditions) reveals increased coverage, coverage was statistically similar for the 2020–21 and 2021–22 seasons. Coverage with ≥2 doses of RZV among adults aged ≥50 years increased from 1.1% in 2018, when RZV was first recommended, to 18.1% in 2022.

A majority of adults had not received age-appropriate vaccinations based on the composite measure. Substantial improvement in adult vaccination uptake is needed to reduce the burden of VPDs nationally. Increasing the proportion of adults who receive recommended age-appropriate vaccines and ensuring equitable access to and uptake of recommended vaccines is a high-priority public health issue.

Methods

The NHIS is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population conducted by the U.S. Census Bureau for CDC's National Center for Health Statistics1. The objectives of the NHIS are to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors2. Non-institutionalized adults aged ≥19 years with interviews conducted during August 2021–June 2022 (for influenza vaccination) and January 2022–December 2022 (for pneumococcal, herpes zoster, Td/Tdap, HPV, and COVID-19 vaccination) were included in this analysis. The total sample of persons aged ≥19 years was 27,376 in 2022. The final sample adult core response rate was 47.7% for the 2022 NHIS. Questions about receipt of vaccinations recommended for adults are asked of one randomly selected adult within each family in the household.

Vaccination questions included in the 2022 NHIS were as follows:

  • for influenza vaccination, respondents were asked if they had received an influenza shot or nasal spray during the preceding 12 months and, if so, in which month and year;
  • for pneumococcal vaccination, respondents were asked if they had ever had a pneumonia shot;
  • for herpes zoster vaccination, respondents were asked if they had ever received a shingles vaccine and, if yes, if they ever had RZV (Shingrix), number of vaccine doses received, and timing of vaccine receipt;
  • for tetanus-containing vaccine, respondents were asked if they had received a tetanus shot in the past 10 years, and, if yes, they were asked if their most recent shot included the pertussis or whooping cough vaccine (Tdap);
  • for HPV, respondents were asked if they had ever received the HPV shot or cervical cancer vaccine and, if yes, how old they were when they received their first HPV shot; and,
  • for COVID-19 vaccine, respondents were asked if they had ever received at least one dose of a COVID-19 vaccination.

Weighted data were used to produce national vaccination coverage estimates. For non-influenza adult vaccination coverage estimates, the weighted proportion of respondents who reported receiving selected vaccinations was calculated. To better assess season-specific influenza vaccination coverage, the Kaplan-Meier survival analysis procedure was used3. Race and ethnicity were categorized into five mutually exclusive groups as follows: White, Black, Hispanic, Asian, and other. In this report, persons were included in White, Black, Asian, or other race categories if they did not report Hispanic ethnicity. Persons who reported Hispanic ethnicity were classified as Hispanic in the analyses regardless of reported race. Other race was defined as non-Hispanic persons reporting American Indian, Alaska Native, Native Hawaiian, Pacific Islander, or any other race and persons who reported multiple races.

For the adult vaccination composite measure4, data from the 2022 NHIS were analyzed to determine estimates of vaccination coverage for select vaccines routinely recommended for all adults aged ≥19 years (tetanus toxoid-containing and influenza vaccine) or indicated based on age (herpes zoster: all adults age ≥50; pneumococcal vaccine: all adults ≥65 years). Respondents had to have received all vaccines appropriate for their age group to be considered up-to-dateB. Estimates for composite measures were calculated with and without influenza vaccination in the past 12 months. Point estimates and 95% confidence intervals (CIs) were calculated using SUDAAN software (Research Triangle Institute, Research Triangle Park, NC, version 11.0.1) to account for the complex sample design. Differences were measured as the simple difference between 2021 and 2022 for pneumococcal, and herpes zoster vaccination coverage, and between 2019 and 2022 for Td/Tdap and HPV vaccination coverage due to the NHIS survey question rotation every 3 years for these two vaccines. T-tests were used for comparisons between data years and for comparisons of each level of each respondent characteristic to a chosen referent level (e.g., for race and ethnicity, White was the reference group). Statistical significance was defined as p<0.05. Coverage estimates are not reported for small sample size (n<30) or large relative standard errors (standard error/estimate >0.3). Only statistically significant comparisons are noted in the text. Logistic regression under the predictive marginal was used to compare vaccination with each vaccine between adults with and without health insurance and with and without a usual place for health care. Trends in adult vaccination were assessed from 2017 through 2022 for influenza, pneumococcal, and herpes zoster vaccinations using weighted linear regression of annual estimates using inverse of estimated variances of the estimates as weights.

Results

  • Pneumococcal vaccination coverage overall (≥1 dose of any type of pneumococcal vaccination) among adults aged 19–64 years at increased risk for pneumococcal disease was 23.0% in 2022, similar to the estimate for 2021.
    • Coverage among White adults aged 19–64 years at increased risk was higher (24.0%) compared with Hispanic (19.5%) adults.
  • Coverage with ≥1 dose of any type of pneumococcal vaccine among adults aged ≥65 years was 64.0%, similar to the estimate for 2021.
    • Coverage among White adults aged ≥65 years (69.1%) was higher compared with Black (53.5%), Hispanic (41.7%), Asian (50.2%), and other race (54.0%) adults.

TABLE 1. Estimated proportion of adults aged ≥19 years who ever received pneumococcal vaccination by age, increased-risk status and race and ethnicity — National Health Interview Survey, United States, 2022

  • Overall, herpes zoster vaccination coverage (≥1 dose of any type of herpes zoster vaccination) in 2022 was 34.4% among all adults aged ≥19 years with an indication for vaccination (adults aged ≥50 years or adults aged ≥19 years with weakened immune system).
    • White adults aged ≥19 years with an indication had higher coverage compared with Black, Hispanic, and other race adults.
  • Coverage with ≥1 dose of any type of herpes zoster vaccination was 36.0% among adults aged ≥50 years and 43.8% among adults aged ≥60 years, higher than estimates for 2021.
    • White adults aged ≥50 and ≥60 years had higher coverage compared with Black and Hispanic adults.
  • RZV coverage (≥1 dose) was 25.6% among adults aged ≥50 years: 18.3% among adults aged 50–59 years, 27.6% among adults aged 60–64 years, and 30.3% among adults aged ≥65 years, all higher than estimates for 2021.
    • Coverage was 29.5% among adults aged ≥60 years, higher than the estimate for 2021.
  • RZV coverage (≥2 doses) was 17.1% among adults aged ≥19 years and 18.1% among adults aged ≥50 years, including 11.9% among adults aged 50–59 years, 19.8% among adults aged 60–64 years, and 22.0% among adults aged ≥65 years, all higher than estimates for 2021.

TABLE 2. Estimated proportion of adults aged ≥50 years or adults aged ≥19 years with weakened immune system who ever received herpes zoster vaccination, by age and race and ethnicity — National Health Interview Survey, United States, 2022

  • In 2022, the proportion of adults reporting having received any tetanus toxoid–containing vaccination during the past 10 years was 59.2% overall for adults aged ≥19 years: 59.4% for adults aged 19–49 years, 61.2% for adults aged 50–64 years, and 56.7% for adults aged ≥65 years. Coverage among adults aged ≥19 years and aged 19–49 years was lower compared with the estimates for 2019.
    • Overall, White adults had higher coverage compared with Black, Hispanic, and Asian adults.
  • Among adults aged ≥19 years for whom Tdap vaccination could be assessed specifically, overall coverage was 28.6%, similar to the estimate for 2019. Tdap coverage was 30.1% among adults aged 19–64 years, lower than estimate for 2019.
    • Tdap coverage for Black (17.8%), Hispanic (21.2%), and Asian (28.9%) adults aged ≥19 years was lower compared with White (32.6%) adults.

TABLE 3. Estimated proportion of adults aged ≥19 years who in the past 10 years received any tetanus vaccination and Tdap vaccination, by race and ethnicity and overall, by age group — National Health Interview Survey, United States, 2022

  • In 2022, 22.8% of adults aged ≥19 years had received all age-appropriate vaccines (including influenza vaccination) included in the composite measure.
  • Coverage with all age-appropriate vaccines in the composite measure was low in all age groups, ranging from 14.7% among adults aged 50–64 years to 26.2% among adults aged ≥65 years.
    • Low coverage with herpes zoster vaccine was the primary driver of lower coverage among adults aged 50–64 years compared with the other age groups.
  • Coverage with all age-appropriate vaccines in the composite adult vaccination measure (including influenza vaccination) was lower among Black (12.1%) and Hispanic (17.0%) adults compared with White (26.1%), Asian (26.2%) and other race (24.5%) adults aged ≥19 years.

TABLE 4. Vaccination coverage estimates using an age-appropriate composite adult vaccination quality measure and individual component measures, by age group — National Health Interview Survey, United States, 2022

TABLE 4_1. Vaccination coverage estimates using an age-appropriate composite adult vaccination quality measure and individual component measures, by race and ethnicity — National Health Interview Survey, United States, 2022

  • In 2022, HPV vaccination coverage (reported receipt of ≥1 dose) was 57.7% among females 19–26 years overall, and within age strata 58.9% among females 19–21 years, and 57.0% among females 22–26 years, similar to the estimates for 2019.
    • Among females aged 19–26 years, White females had higher coverage compared with Black females.
  • In 2022, HPV vaccination coverage (≥1 dose) was 34.8% among males 19–26 years overall, and within age strata 39.8% among males 19–21 years, and 32.1% among males 22–26 years, similar to the estimate for 2019.
  • HPV vaccination (≥1 dose) among females aged 19–26 years who had not received HPV vaccination prior to age 19 years was 9.4%, similar to the estimate for 2019. Among males aged 19–26 years who had not received HPV vaccination prior to age 19 years, HPV vaccination coverage was 3.5%, similar to the estimate for 2019.

TABLE 5. Estimated proportion of adults aged 19–26 years who received at least one dose of human papillomavirus (HPV) vaccination, by age group, sex, and race and ethnicity — National Health Interview Survey, United States, 2022

  • In 2022, COVID-19 vaccination coverage (ever received ≥1 dose of COVID-19 vaccination) was 79.7% among adults aged ≥19 years overall and within age strata, 73.7% among adults aged 19–49 years, 82.9% among adults aged 50–64 years, and 89.8% among adults aged ≥65years.
    • Overall, White adults had higher coverage compared with Black adults and lower coverage than Asian adults.

TABLE 6. Estimated proportion of adults aged ≥19 years who received at least one dose of COVID-19 vaccination, by age and race and ethnicity — National Health Interview Survey, United States, 2022

  • Overall, vaccination coverage was generally lower among adults without health insurance compared with those with health insurance, with prevalence ratios ranging from 0.1 for both pneumococcal (aged ≥65 years) and herpes zoster vaccine to 0.7 for tetanus and COVID-19 vaccine.
  • Overall, adults without a usual place for health care were less likely to report having received recommended vaccinations than those who have a usual place for health care, with prevalence ratios ranging from 0.3 for pneumococcal (aged 19–64 years at increased risk) vaccine to 0.8 for tetanus, HPV (females aged 19–26 years), and COVID-19 vaccines.

TABLE 7. Vaccination coverage among adults aged ≥19 years, by age group, increased-risk status, health insurance status, and usual place for health care status — National Health Interview Survey, United States, 2022

  • Trends in coverage from 2017–2022 with selected vaccines recommended for adults are shown in Figure 1.
  • Increases in coverage from 2017–2022 were observed for influenza vaccination among all adults aged ≥19 years (annual average percentage point increase: 1.0%, 95% CI: 0.2, 1.7) and influenza vaccination among adults aged ≥19 years at high risk (annual average percentage point increase: 1.1%, 95% CI: 0.4, 1.8).
    • However, coverage was statistically similar between the 2020–21 and 2021–22 seasons for all adults aged ≥19 and adults aged ≥19 years at high risk.
  • Increases in coverage from 2017–2022 were observed for any herpes zoster vaccination among adults aged ≥60 years (annual average percentage point increase: 2.0%, 95% CI: 1.6, 2.3).
    • Coverage with ≥2 doses RZV among adults ≥50 years increased from 1.1% in 2018, the first year of the RZV recommendation, to 18.1% in 2022.
  • Decreases in coverage were observed for pneumococcal vaccination among adults aged ≥65 years (annual average percentage point decrease: -1.0%, 95% CI: -1.3, -0.6), but coverage for pneumococcal vaccination among adults aged 19–64 years at increased risk remained stable from 2017 to 2022.

Figure 1. Estimated proportion of adults aged ≥19 years who received selected vaccines, by age group and risk status — National Health Interview Survey, United States, 2017–2022 [XLS – 20 KB]

Discussion

NHIS data from 2022 indicate that many adults in the United States remained unprotected against VPDs. A majority of adults had not received age-appropriate vaccinations based on the composite measure. Overall vaccination trends indicated that, for the years assessed, influenza and herpes zoster vaccination coverage increased, although influenza vaccination coverage plateaued for the 2020–21 and 2021–22 seasons; and pneumococcal vaccination coverage remained stable among adults aged 19–64 years at increased risk of disease and decreased among adults aged ≥65 years.

Pneumococcal vaccination coverage among adults aged ≥65 years decreased, especially during the COVID-19 pandemic period. A separate analysis of adults in NHIS who reached age 65–70 years and became eligible for pneumococcal conjugate vaccination (PCV) after the start of the COVID-19 pandemic in 2020, as well as similar analysis of data from the Behavioral Risk Factor Surveillance System, showed a pandemic effect on pneumococcal vaccination coverage and suggested a modest decrease in pneumococcal vaccination among older adults, which might be associated with COVID-19-related reductions in persons accessing vaccination services (56, CDC unpublished data). Pneumococcal vaccination recommendations for older adults also changed around this same time7. Importantly, the NHIS does not distinguish between PCV and polysaccharide 23 valent (PPSV23) vaccines and PPSV23 was recommended for all adults aged ≥65 years through 2020; after 2020, providers had several options for pneumococcal vaccination of patients. At all times during the COVID-19 pandemic, some form of the pneumococcal vaccine was recommended for adults ≥65 years7.

This report estimated COVID-19 vaccine coverage for one or more doses received any time before the interview date through 2022. Although CDC recommended bivalent COVID-19 vaccination for adults in September 20228, coverage with bivalent vaccine was not specifically assessed in the 2022 NHIS.

Racial and ethnic differences in vaccination coverage persisted for all vaccines, with generally lower coverage among Black and Hispanic adults compared with White adults. Coverage for the age-appropriate composite measure was low in all age groups and in all race and ethnicity groups.

For all vaccines, adults without health insurance were less likely to be vaccinated than those with health insurance. Differences were most pronounced for pneumococcal and zoster vaccination, where adults with health insurance were 3-10 times more likely to be vaccinated compared to those without health insurance. By contrast, the difference between insured and uninsured adults in coverage with COVID-19 vaccines, which were provided free of charge by the U.S. government, was smaller. Expansion of adult vaccination benefits and elimination of out-of-pocket expenses by the Inflation Reduction Act (IRA) for recommended adult vaccines covered under Medicare and Medicaid may contribute to increasing coverage among insured persons in the coming years; however, vaccine access remains challenging for uninsured persons9. Additionally, our results showed that adults without a usual place for health care were less likely to be vaccinated than those with a usual place for health care. Having a usual place for health care and routine physician contact can provide important opportunities for providers to educate their patients about VPDs, as well as strongly recommend and offer vaccination. The Standards for Adult Immunization Practice recommend that providers assess vaccination status at every patient visit, offer needed vaccines or refer patients to other vaccination sites if vaccines are not available10, and use evidenced-based interventions such as provider reminder systems and standing orders to improve vaccination coverage11.

Limitations

The estimates in this report are subject to several limitations. First, all data rely on respondent self-report and were not validated with medical records. However, adult self-reported vaccination status has been shown to be ≥70% sensitive in one or more studies for influenza, pneumococcal, and herpes zoster vaccines and ≥70% specific in one or more studies121314. Adults might not be able to recall accurately vaccines received as adolescents and as a result, coverage levels for HPV might be substantially underestimated. Additional studies are needed to determine accuracy of recall for vaccinations that adults might have received as children or adolescents. Second, the NHIS response rate was 47.7% in 2022. Nonresponse bias can result if respondents and non-respondents differ in their vaccination behaviors and if survey weighting does not fully correct for this. Finally, the NHIS sample excludes persons in the military and those residing in institutions, which might result in underestimation or overestimation of adult vaccination coverage levels.

Conclusion

Coverage of routinely recommended vaccines among adults remains low. Disparities in vaccination coverage by race and ethnicity, health insurance, and usual place for health care were seen for all vaccines assessed. Ensuring equitable access to and increasing uptake of recommended vaccines is needed to maximally reduce the burden of vaccine preventable diseases.

Authors

Mei-Chuan Hung, MPH, PhD1,2; Anup Srivastav, B.V.Sc.&A.H., MPVM, PhD1,2; Peng-jun Lu, MD, PhD1; Carla L. Black, PhD1; Megan C. Lindley, MPH1; James A. Singleton, PhD1

1Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC2 Eagle Health Analytics, Inc, Atlanta, GA

Print
Content Source:
National Center for Immunization and Respiratory Diseases
  1. *In this report, persons identified as White, Black, Asian, or other race are non-Hispanic. Persons identified as Hispanic might be of any race. “Other” includes American Indian/Alaska Native, Native Hawaiian, Pacific Islander, or any other race and persons who identified multiple races. The five racial/ethnic categories are mutually exclusive.
  2. †To be considered up-to-date based on age recommendations, adults aged ≥19–49 years had to have received an influenza vaccine in the past year and a tetanus toxoid-containing vaccine in the past 10 years; adults aged 50–64 years had to have received an influenza vaccine in the past year and a tetanus toxoid-containing vaccine in the past 10 years, plus ever received a herpes zoster vaccine; and adults ≥65 years had to have received an influenza vaccine in the past year and a tetanus toxoid-containing vaccine in the past 10 years, plus ever received a herpes zoster vaccine and a pneumococcal vaccine.
  1. National Center for Health Statistics. Survey description, National Health Interview Survey, 2022. Hyattsville, Maryland. 2022. Available at: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2022/srvydesc-508.pdf.
  2. National Center for Health Statistics. Public-use data file and documentation. Available at: https://www.cdc.gov/nchs/nhis/about_nhis.htm.
  3. Lu PJ, Santibanez TA, Williams WW, Zhang J, Ding H. et al. Surveillance of influenza vaccination coverage—United States, 2007-08 through 2011-12 influenza seasons. MMWR Surveill Summ. 2013 Oct 25;62(4):1-28.
  4. Shen AK, Williams WW, O’Halloran AC, et al. Promoting adult immunization using population-based data for a composite measure. Am J Prev Med 2018; 55:517–23.
  5. CDC. Pneumococcal vaccination among adults 65–70 years of age before and during the COVID-19 pandemic— United States, 2021. Available at https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/pandemic-impact-on-ppv.html)
  6. Czeisler MÉ, Marynak K, Clarke KEN, et al. Delay or avoidance of medical care because of COVID-19–related concerns—United States, June 2020. MMWR Morb Mortal Wkly Rep 2020;69(36):1250–1257.
  7. CDC. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2019;68:1068–1075.
  8. CDC. Use of updated COVID-19 vaccines 2023–2024 formula for persons aged ≥6 months: Recommendations of the Advisory Committee on Immunization Practices — United States, September 2023. MMWR 2023; 72(42);1140–1146.
  9. Centers for Medicare & Medicaid Services. Anniversary of the Inflation Reduction Act: Update on CMS implementation. Available at: https://www.cms.gov/newsroom/fact-sheets/anniversary-inflation-reduction-act-update-cms-implementation.
  10. CDC. Standards for adult immunization practice. Available at: https://www.cdc.gov/vaccines-adults/hcp/imz-standards/index.html.
  11. Community Preventive Services Task Force. The Guide to Community Preventive Services: what works to promote health? Available at: http://www.thecommunityguide.org/index.html.
  12. Rolnick SJ, Parker ED, Nordin JD, et al. Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors? Vaccine 2013;31(37):3928–3935.
  13. Donald RM, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients. Am J Prev Med. 1999; 16:173–177.
  14. Zimmerman RK, Raymund M, Janosky JE, et al. Sensitivity and specificity of patient self-report of influenza and pneumococcal polysaccharide vaccinations among elderly outpatients in diverse patient care strata. Vaccine. 2003; 21:1486–1491.