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Brief Report
September 9, 2020

Sociodemographic Disparities in Influenza Vaccination Among Adults With Atherosclerotic Cardiovascular Disease in the United States

Author Affiliations
  • 1Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland
  • 2Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
  • 3Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
  • 4Center for Outcomes Research, The Houston Methodist Research Institute, Houston, Texas
  • 5Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas
  • 6Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
  • 7Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
  • 8Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
  • 9Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
  • 10Baylor College of Medicine, Houston, Texas
  • 11Department of Medicine, Houston Methodist Hospital, Houston, Texas
  • 12Yale Institute of Global Health, New Haven, Connecticut
  • 13Yale School of Nursing, New Haven, Connecticut
  • 14Department of Internal Medicine (Infectious Diseases), Yale School of Medicine, New Haven, Connecticut
  • 15Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
  • 16Division of Cardiology, Yale University, New Haven, Connecticut
JAMA Cardiol. 2021;6(1):87-91. doi:10.1001/jamacardio.2020.3978
Key Points

Question  What are the prevalence of and sociodemographic differences in influenza vaccination among a nationally representative sample of individuals with atherosclerotic cardiovascular disease?

Findings  In this cross-sectional study of 19 793 US adults with atherosclerotic cardiovascular disease, 32.7% lacked influenza vaccination with statistically significant higher proportions observed among high-risk groups based on younger age, non-Hispanic Black race/ethnicity, low family income, lack of insurance, lower level of education, and lack of usual source of care.

Meaning  Many US adults with established atherosclerotic cardiovascular disease lack influenza vaccination with significant disparities existing based on high-risk sociodemographic characteristics.


Importance  Atherosclerotic cardiovascular disease (ASCVD) remains a leading cause of death and disability in the US and worldwide. Influenza vaccination has shown to decrease overall morbidity, mortality, severity of infection, and hospital readmissions among these individuals. However, national estimates of influenza vaccination among individuals with ASCVD in the US are not well studied.

Objective  To evaluate the prevalence of and sociodemographic disparities in influenza vaccination among a nationally representative sample of individuals with ASCVD.

Design, Setting, and Participants  Pooled Medical Expenditure Panel Survey data from 2008 to 2016 were used and included adults 40 years or older with ASCVD. Participants’ ASCVD status was ascertained via self-report and/or International Classification of Diseases, Ninth Revision diagnosis of coronary heart disease, peripheral artery disease, and/or cerebrovascular disease. Analysis began April 2020.

Main Outcomes and Measures  Prevalence and characteristics of adults with ASCVD who lacked influenza vaccination during the past year. Covariates including age, sex, race/ethnicity, family income, insurance status, education level, and usual source of care were assessed.

Results  Of 131 881 adults, 19 793 (15.7%) had ASCVD, corresponding to 22.8 million US adults annually. A total of 7028 adults with ASCVD (32.7%), representing 7.4 million adults, lacked influenza vaccination. The highest odds of lacking vaccination were observed among individuals aged 40 to 64 years (odds ratio [OR], 2.32; 95% CI, 2.06-2.62), without a usual source of care (OR, 2.00; 95% CI, 1.71-2.33), without insurance (OR, 2.05; 95% CI, 1.63-2.58), with a lower education level (OR, 1. 25; 95% CI, 1.12-1.40), with a lower income level (OR, 1.14; 95% CI, 1.01-1.27), and of non-Hispanic Black race/ethnicity (OR, 1.24, 95% CI, 1.10-1.41). A stepwise increase was found in the prevalence and odds of lacking influenza vaccination among individuals with increase in high-risk characteristics. Overall, 1171 individuals (59.7%; 95% CI, 55.8%-63.5%) with 4 or more high-risk characteristics and ASCVD (representing 732 524 US adults annually) reported lack of influenza vaccination (OR, 6.06; 95% CI, 4.88-7.53).

Conclusion and Relevance  Despite current recommendations, a large proportion of US adults with established ASCVD lack influenza vaccination, with several sociodemographic subgroups having greater risk. Focused public health initiatives are needed to increase access to influenza vaccinations for high-risk and underserved populations.