key: cord-1014801-qzhg0s7f
authors: Moreland, Ashley; Gillezeau, Christina; Alpert, Naomi; Taioli, Emanuela
title: Assessing influenza vaccination success to inform COVID‐19 vaccination campaign
date: 2021-10-11
journal: J Med Virol
DOI: 10.1002/jmv.27368
sha: aade4eb2f06128839b496e66827e88c45a51b1d9
doc_id: 1014801
cord_uid: qzhg0s7f

Given recent downward trends in daily rates of COVID‐19 vaccinations, it is important to reassess strategies to reach those most vulnerable. The success and efficacy of vaccination campaigns for other respiratory illnesses, such as influenza, may help inform messaging around COVID‐19 vaccinations. This cross‐sectional study examines the individual‐level factors associated with, and the spatial distribution of, predictors of COVID‐19 severity, and uptake of influenza and hepatitis B (as a negative control) vaccines across NYC. Data were obtained from the 2018 Community Health Survey (CHS), including self‐reported influenza and hepatitis B vaccine uptake, diabetes, asthma, hypertension, body mass index (BMI), age, race/ethnicity, educational attainment, borough, and United Hospital Fund (UHF) neighborhood of residence. A CDC‐defined COVID‐19 severity risk score was created with variables available in the CHS, including diabetes, asthma, hypertension, BMI ≥ 30 kg/m(2), and age ≥65 years old. After adjustment, there was a significant positive association between COVID‐19 severity risk score and influenza vaccine uptake (1: OR(adj) = 1.49, 95% CI 1.28–1.73; 2: OR(adj) = 1.99; 95% CI: 1.65–2.41; 3+: OR(adj) = 2.89; 95% CI: 2.32–3.60, compared to 0). Hepatitis B vaccine uptake was significantly inversely associated with COVID‐19 severity risk score (1: OR(adj) = 0.67; 95% CI: 0.57–0.79; 2: OR(adj) = 0.54; 95% CI: 0.44–0.66; 3+: OR(adj) = 0.45; 95% CI: 0.36–0.56, compared to 0). The influenza vaccination campaign template is effective at reaching those most at risk for serious COVID‐19 and, if implemented, may help reach the most vulnerable that have not yet been vaccinated against COVID‐19.

points to a need to improve the campaign and messaging around COVID-19 vaccinations, as the grim reality of COVID-19 hospitalizations and deaths may not be sufficient to motivate the hesitant pockets of the population. COVID-19 vaccine hesitancy and acceptance vary across racial and ethnic groups, 9 and reasons for having not yet received a vaccine include virus skepticism, a desire to get more information and see how things play out, a perceived lack of time or monetary resources, and distrust in the healthcare system. 10 Understanding the uptake of the influenza vaccine, another contagious respiratory illness, could help provide insight into the features of vaccination campaigns that are successful in reaching those most vulnerable to severe illness, given that many of the risk factors for influenza severity overlap with the risk factors for COVID-19 severity, including age ≥65 years of age, chronic health conditions (asthma, heart disease, kidney disease, liver disease, and diabetes), high body mass index (BMI), immunosuppression, and pregnancy. [11] [12] [13] [14] [15] [16] [17] NYC Health + Hospitals has an ongoing "Fight the Flu!" campaign, offering information and free influenza vaccines at locations across the city. 18 In 2020, preceding the onset of the COVID-19 pandemic, the NYC Department of Health launched an influenza campaign that ran on public transport and social media with the main message, "This year's flu vaccination could be the most important one you ever get." 19 If influenza vaccination campaigns in previous years were successful in reaching the most vulnerable and at-risk demographics, similar strategies could be adopted for COVID-19 vaccines, and may provide a template for better reaching individuals who have yet to be vaccinated against COVID-19.

To understand if the influenza vaccine uptake in NYC was successful in reaching the most vulnerable, and how the results can be applied to COVID-19 specifically, we set the following objectives for this analysis: (1) identify the spatial distribution of COVID-19 severity risk scores and influenza vaccine uptake according to United Hospital Fund (UHF) neighborhood across NYC; (2) assess the independent associations of influenza vaccine uptake with COVID-19 severity risk score, race/ethnicity, education, and borough; and (3) as a negative control, assess the independent associations of the listed factors with hepatitis B vaccine uptake, a disease that has different transmission modality and risk factors. We hypothesize that COVID-19 severity risk will be associated with influenza vaccine uptake, but not with hepatitis B vaccine uptake. This study used data from the 2018 CHS (n = 10,076). The primary outcomes of interest were self-reported influenza and hepatitis B vaccine uptake. Information on other variables of interest, including self-reported diabetes, asthma, high blood pressure, body mass index (BMI), age at interview, race/ethnicity, highest level of education attained, borough of residence, and United Hospital Fund (UHF) neighborhood of residence were extracted from the survey. A summary of the included variables can be found in Table S1. 2.2 | COVID-19 severity risk score As previously published, 15,21 a risk score for severe COVID-19 was defined based on a count of individual risk factors identified by the Centers for Disease Control and Prevention (CDC) 11 as predictors of COVID-19 severity, and available in the CHS. These included diabetes, asthma, high blood pressure, BMI ≥ 30 kg/m 2 , and age ≥65 years old. Risk index scores ranged from 0 to 5 and were collapsed into categories 0, 1, 2, and 3+, with 0 indicating least risk and 3+ indicating greatest risk of severe COVID-19.

Participants were excluded from analyses if they were missing information about self-reported influenza vaccination or information for any variable used to define the COVID-19 severity risk score.

The distribution of self-reported influenza vaccine uptake, hepatitis B vaccine uptake, and COVID-19 risk index scores were mapped according to UHF using ArcGIS, v10.8.

the previous year were compared on all demographic and risk factor variables using χ 2 tests. Multivariable logistic regression analysis was performed to assess the independent association of the COVID-19 severity risk score with self-reported influenza vaccine uptake, adjusting for race/ethnicity, education, and borough of residence.

Among participants with definitive information about whether they had ever received the hepatitis B vaccine, a similar model was run to assess the association with hepatitis B vaccine uptake, as a negative control. Correlations between individual risk factors and influenza vaccine uptake were assessed to identify factors most associated with vaccine uptake. Multivariable models were run on the subset of participants with complete data. All analyses were performed using SAS software, version 9.4 (SAS Institute). All analyses used the suite of "survey" procedures in SAS to account for the complex sampling design of the CHS. All presented results represent weighted values.

There were 9,740 CHS respondents in 2018 with complete information on influenza vaccination and variables contained in the COVID-19 severity risk score; 47% of whom reported receiving the influenza vaccine within the last year (Table 1) . Those with an influenza vaccine were significantly more likely to report having diabetes (14.9% vs. 7.4%; p < 0.0001), asthma (6.0% vs. 3.1%; p < 0.0001), high blood pressure (31.5% vs. 21.2%; p < 0.0001), and to be ≥65 years old (20.7% vs.10.6%; p < 0.0001) than those who had not received influenza vaccine. Those who received the influenza vaccine had significantly (p < 0.0001) higher COVID-19 severity risk scores (11.7% vs. 5.7% for scores ≥3). There was also a statistically significant difference by race (p = 0.0427), with those who received an influenza vaccine more likely to be non-Hispanic white (NHW) (37.2% vs. 33 .8%) and less likely to be non-Hispanic Black (NHB) (20.4% vs.

23.9%). There was a significant association between influenza vaccination status and educational attainment (p = 0.0116), with greater numbers of college graduates among those who were vaccinated than those who were not (36.5% vs. 33.5%). Those who received an CI 0.62-0.92, respectively) ( Table 2 ). When we studied the individual components of the COVID-19 risk score, we observed a statistically significant positive association between influenza vaccine uptake and self-reported diabetes (ρ = 0.12, p < 0.0001), high blood pressure (ρ = 0.12, p < 0.0001), and age ≥65 years old (ρ = 0.14, p < 0.0001).

After adjusting for all covariates, diabetes (OR adj = 1.68; 95% CI: 

To the best of our knowledge, this is the first analysis to incorporate CDC-defined risk factors for COVID-19 severity, racial and ethnic composition, education, and borough to predict influenza vaccine uptake across NYC at the individual level. Here we identify that influenza vaccine uptake was highest among residents with higher COVID-19 severity risk scores, NHW residents, and residents of Manhattan borough. In comparison, residents that had higher COVID-19 severity risk scores had decreased hepatitis B vaccine uptake, whereas hepatitis B vaccine uptake was highest among NHB residents, Hispanic residents, residents with higher levels of education, and residents of Manhattan. These findings support our hypothesis that COVID-19 severity risk would be associated with influenza vaccine uptake, due to the shared risk factors for severity of both, but not associated with hepatitis B vaccine uptake.

These findings suggest that the campaign for influenza vaccination uptake has been successful, as influenza vaccine uptake was highest among residents most vulnerable to severe complications from influenza. 37, 38 In the present analysis, we found that COVID-19 severity risk had an inverse relationship with hepatitis B vaccine uptake, which suggests that vaccine uptake is not allinclusive of every vaccine but dependent on the specific one in question.

Due to the survey sampling methodology of the data used in this analysis, data for adults in households without any telephone service and adults living in group settings (e.g., college dormitories, nursing facilities) could not be obtained. 39 

To the best of our knowledge, this is the only study using individuallevel data on risk factors for COVID-19 severity and influenza vaccine uptake at the UHF level in NYC. 

The authors declare that there are no conflict of interests. 

Individual-level count data used for this analysis was obtained by the New York City Department of Health and Mental Hygiene's 2018

Community Health Survey with a signed data access agreement. The data dictionary for this data is publicly available at the following website: https://www1.nyc.gov/assets/doh/downloads/pdf/episrv/ chs2018-codebook.pdf.

https://orcid.org/0000-0002-9097-6749

Emanuela Taioli https://orcid.org/0000-0001-5734-4806

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Assessing influenza vaccination success to inform COVID-19 vaccination campaign