Summary
What is already known about this topic?
The Advisory Committee on Immunization Practices recommends that all adults receive
influenza and COVID-19 vaccines, and those aged ≥60 years may receive respiratory
syncytial virus (RSV) vaccine during the 2023–24 respiratory virus season.
What is added by this report?
By December 9, 2023, an estimated 42.2% and 18.3% of adults aged ≥18 years had received
influenza and updated 2023–2024 COVID-19 vaccine, respectively; 17.0% of adults aged
≥60 years had received RSV vaccine. Many adults who had not received the vaccines
reported being open to vaccination.
What are the implications for public health practice?
Strong provider recommendations for and offers of vaccination could increase influenza,
COVID-19, and RSV vaccination coverage. Immunization programs and vaccination partners
might benefit from using these within-season data to understand vaccination patterns
in their jurisdictions to strengthen vaccination activities.
Abstract
During the 2023–24 respiratory virus season, the Advisory Committee on Immunization
Practices recommends influenza and COVID-19 vaccines for all persons aged ≥6 months,
and respiratory syncytial virus (RSV) vaccine is recommended for persons aged ≥60
years (using shared clinical decision-making), and for pregnant persons. Data from
the National Immunization Survey-Adult COVID Module, a random-digit–dialed cellular
telephone survey of U.S. adults aged ≥18 years, are used to monitor influenza, COVID-19,
and RSV vaccination coverage. By December 9, 2023, an estimated 42.2% and 18.3% of
adults aged ≥18 years reported receiving an influenza and updated 2023–2024 COVID-19
vaccine, respectively; 17.0% of adults aged ≥60 years had received RSV vaccine. Coverage
varied by demographic characteristics. Overall, approximately 27% and 41% of adults
aged ≥18 years and 53% of adults aged ≥60 years reported that they definitely or probably
will be vaccinated or were unsure whether they would be vaccinated against influenza,
COVID-19, and RSV, respectively. Strong provider recommendations for and offers of
vaccination could increase influenza, COVID-19, and RSV vaccination coverage. Immunization
programs and vaccination partners are encouraged to use these data to understand vaccination
patterns and attitudes toward vaccination in their jurisdictions to guide planning,
implementation, strengthening, and evaluation of vaccination activities.
Introduction
Influenza, SARS-CoV-2, and respiratory syncytial virus (RSV) typically circulate in
the United States during the fall through early spring each year, causing epidemics
of respiratory illness, although patterns of influenza and RSV transmission shifted
during the COVID-19 pandemic (
1
–
3
). Certain groups, including older adults (those aged ≥65 years), persons with chronic
conditions, and racial and ethnic minority populations, have experienced disproportionate
influenza-, COVID-19–, and RSV-associated morbidity and mortality (
1
–
4
). Since 2010, the Advisory Committee on Immunization Practices (ACIP) has recommended
routine annual influenza vaccination for all persons aged ≥6 months who do not have
contraindications (
1
). On September 12, 2023, ACIP recommended updated 2023–2024 COVID-19 vaccination
for all persons aged ≥6 months to help protect against currently circulating SARS-CoV-2
variants (
2
). In June 2023, ACIP recommended that adults aged ≥60 years may receive a single
dose of RSV vaccine, using shared clinical decision-making, which is the first time
a vaccine for prevention of RSV-associated respiratory disease has been recommended*
(
3
). CDC monitors coverage with these vaccines and makes these data available during
the respiratory season for use in planning vaccination activities.
Methods
Data Collection
The National Immunization Survey-Adult COVID Module (NIS-ACM) is a random-digit–dialed
cellular telephone survey of adults aged ≥18 years in all 50 states, the District
of Columbia, and selected local areas and U.S. territories. Data are weighted to represent
the noninstitutionalized U.S. population.
†
The survey includes questions about receipt of COVID-19, influenza, and RSV vaccines,
vaccination intent, sociodemographic characteristics, and behavioral and social drivers
of COVID-19 vaccination. Respondents are asked if they have received a COVID-19 or
RSV vaccine or have received an influenza vaccine since July 1, 2023, and for affirmative
responses, the month and year of vaccination.
§
Those reporting receipt of any COVID-19 vaccine since September 14, 2023, are considered
to be vaccinated with the updated 2023–2024 COVID-19 vaccine, because this was the
only COVID-19 vaccine authorized in the United States after that date.
Data Analysis
Data collected during September 24–December 9, 2023, are included in this analysis.
¶
Estimates of coverage (percentage of the population vaccinated) with influenza, COVID-19,
and RSV vaccines were calculated for weekly data collection periods using a nondecreasing
composite estimation procedure that uses data from completed interviews from the current
week combined with data from all previous weeks (
5
). Estimates for vaccination intent are based on interviews conducted each respective
week and are adjusted to the cumulative vaccination coverage estimate for that week.
Influenza and COVID-19 vaccination coverage is estimated among adults aged ≥18 years,
and RSV vaccination coverage estimates are restricted to respondents aged ≥60 years.
Differences among estimates were determined using t-tests with p<0.05 considered statistically
significant. This activity was reviewed by CDC, deemed not research, and was conducted
consistent with applicable federal law and CDC policy.**
Results
Overall Vaccination Coverage and Intent
As of December 9, 2023, estimated influenza and updated COVID-19 vaccination coverage
among adults aged ≥18 years was 42.2% and 18.3%, respectively; estimated RSV vaccination
coverage among all adults aged ≥60 years was 17.0% and among those with chronic health
conditions
††
was 21.4% (Figure 1) (Supplementary Table, https://stacks.cdc.gov/view/cdc/136452).
From September 24 through December 9, the percentage of adults who reported being
unvaccinated, but who definitely will get vaccinated, decreased over time as vaccination
coverage increased, from 33.2% to 9.4% for influenza and from 28.2% to 14.1% for COVID-19
vaccines. The decrease was less for RSV vaccine (from 20.9% to 14.1%). Throughout
the study period, the proportion of adults who were unvaccinated and reported they
probably or definitely would not get vaccinated was lowest for RSV, whereas the proportion
who were unvaccinated and reported they probably would get vaccinated or were unsure
was highest for RSV.
FIGURE 1
Weekly influenza (A), updated COVID-19 (B), and respiratory syncytial virus (C) vaccination
status* and vaccination intent
†
among adults
§
— National Immunization Survey-Adult COVID Module, United States, September 24–December
9, 2023
Abbreviation: RSV = respiratory syncytial virus.
* Estimates of vaccination coverage were calculated for December 3–9, 2023 using a
nondecreasing composite estimation procedure that uses data from all completed interviews
during September 24–December 9, 2023: influenza (168,899), COVID-19 (168,669), and
RSV (62,816).
† Estimates for vaccination intent are based on interviews conducted during December
3–9, 2023, and were adjusted to the cumulative vaccination coverage estimate for that
week: influenza (14,562), COVID-19 (14,539), and RSV (5,258). Estimates for vaccination
intent are not shown for groups with sample size <30.
§ Estimates for influenza and COVID-19 vaccination coverage and vaccination intent
are among adults aged ≥18 years. Estimates for RSV vaccination coverage and intent
are among adults aged ≥60 years.
This figure is a bar chart illustrating the weekly influenza, updated COVID-19, and
respiratory syncytial virus vaccination status and vaccination intent among adults
from the National Immunization Survey-Adult COVID Module in the United States during
September 24–December 9, 2023.
Vaccination Coverage and Intent by Demographic Characteristics and Jurisdiction
Coverage with all vaccines was lowest among uninsured persons. Coverage and intent
to be vaccinated increased with age and were higher among adults living in urban and
suburban areas compared with those living in rural areas (Figure 2). Influenza vaccination
coverage was higher among non-Hispanic White (White) and non-Hispanic Asian (Asian)
adults than among most other racial and ethnic groups. However, the percentage of
persons reporting that they probably or definitely will not get an influenza vaccination
was similar among White adults (32.2%) and Black or African American (Black) adults
(32.2%) and was lower among Hispanic or Latino (Hispanic) adults (24.0%). Updated
COVID-19 and RSV vaccination coverage was higher among White adults than among most
other racial and ethnic groups. However, a higher percentage of White adults reported
that they probably or definitely will not receive a COVID-19 vaccine (43.2%) than
did Black (31.3%) and Hispanic (34.7%) adults. Similarly, a higher percentage of White
adults reported that they probably or definitely will not receive an RSV vaccine (32.5%)
than did Black (15.3%) and Hispanic (19.3%) adults. Coverage with all vaccines varied
by jurisdiction, ranging from 15.6% to 54.8% for influenza vaccine, from 2.4% to 35.6%
for updated COVID-19 vaccine, and from 1.9% to 32.4% for RSV vaccine (Table).
FIGURE 2
Influenza (A), updated COVID-19 (B), and respiratory syncytial virus (C) vaccination
status* and vaccination intent
†
among adults,
§
by demographic characteristics
¶
— National Immunization Survey-Adult COVID Module, United States, December 3–9, 2023
Abbreviations: AI/AN = American Indian or Alaska Native; NH/OPI = Native Hawaiian
or other Pacific Islander; RSV = respiratory syncytial virus.
* Estimates of vaccination coverage were calculated for December 3–9, 2023 using a
nondecreasing composite estimation procedure that uses data from all completed interviews
during September 24–December 9, 2023: influenza (168,899), COVID-19 (168,669), and
RSV (62,816).
† Estimates for vaccination intent are based on interviews conducted during December
3–9, 2023, and were adjusted to the cumulative vaccination coverage estimate for that
week: influenza (14,562), COVID-19 (14,539), and RSV (5,258). Estimates for vaccination
intent are not shown for groups with sample size <30.
§ Estimates for influenza and COVID-19 vaccination coverage and vaccination intent
are among adults aged ≥18 years. Estimates for RSV vaccination coverage and intent
are among adults aged ≥60 years.
¶ Persons of Hispanic or Latino (Hispanic) origin might be of any race but are categorized
as Hispanic; all racial groups are non-Hispanic.
This figure is a bar chart illustrating the influenza, updated COVID-19, and respiratory
syncytial virus vaccination status and vaccination intent among adults, by demographic
characteristic, from the National Immunization Survey-Adult COVID Module in the United
States during December 3–9, 2023.
TABLE
Coverage with influenza, updated COVID-19, and respiratory syncytial virus vaccines
among adults,* by jurisdiction — National Immunization Survey-Adult COVID Module,
United States, September 24–December 9, 2023
Jurisdiction
Influenza
COVID-19
RSV
Cumulative unweighted no.
% Vaccinated (95% CI)†
Cumulative unweighted no.
% Vaccinated (95% CI)†
Cumulative unweighted no.
% Vaccinated (95% CI)†
Alabama
4,015
39.1 (35.4–42.8)
4,010
11.4 (9.3–13.4)
1,740
12.1 (8.4–15.7)
Alaska
2,079
39.7 (35.3–44.2)
2,075
16.0 (13.0–19.0)
734
21.3 (16.1–26.6)
Arizona
5,023
41.0 (37.5–44.5)
5,017
17.7 (15.4–20.1)
2,129
22.0 (17.4–26.6)
Arkansas
2,599
42.2 (37.0–47.3)
2,591
14.5 (11.1–17.8)
1,037
14.7 (9.7–19.8)
California
4,232
44.9 (40.6–49.2)
4,227
20.0 (16.8–23.1)
1,300
16.4 (10.5–22.3)
Colorado
3,686
49.1 (45.0–53.3)
3,680
25.7 (22.3–29.2)
1,308
32.4 (25.9–39.0)
Connecticut
1,235
47.0 (39.2–54.8)
1,233
23.6 (16.1–31.0)
212
24.1 (11.1–37.1)
Delaware
2,530
51.2 (43.9–58.6)
2,527
23.1 (17.7–28.6)
1,194
17.2 (12.6–21.8)
District of Columbia
4,307
52.9 (49.2–56.5)
4,304
35.6 (32.2–38.9)
1,291
20.7 (16.3–25.2)
Florida
2,045
36.0 (30.0–41.9)
2,043
10.9 (7.8–14.1)
733
20.7 (13.0–28.4)
Georgia
1,132
33.3 (25.3–41.3)
1,132
11.2 (5.1–17.3)
222
9.4 (5.2–13.7)
Hawaii
3,323
46.1 (42.0–50.1)
3,319
20.1 (17.2–22.9)
1,421
19.2 (14.9–23.5)
Idaho
1,474
34.8 (29.7–39.9)
1,472
16.5 (12.9–20.2)
502
21.0 (13.9–28.2)
Illinois
7,190
48.0 (44.9–51.2)
7,175
24.6 (22.0–27.2)
2,662
20.3 (16.7–23.8)
Indiana
2,678
39.5 (35.7–43.3)
2,671
16.8 (13.9–19.6)
1,003
14.5 (11.2–17.9)
Iowa
1,510
46.1 (38.3–53.9)
1,509
26.8 (18.7–34.9)
583
22.9 (7.3–38.5)
Kansas
2,875
44.7 (39.6–49.7)
2,871
20.0 (16.1–23.8)
960
22.4 (15.0–29.8)
Kentucky
2,290
39.6 (32.6–46.7)
2,287
14.8 (8.8–20.7)
804
22.9 (7.7–38.2)
Louisiana
3,719
36.8 (33.0–40.5)
3,713
10.1 (8.0–12.1)
1,542
13.8 (10.4–17.2)
Maine
4,291
49.2 (42.6–55.9)
4,287
28.8 (22.7–34.8)
1,949
18.0 (11.7–24.4)
Maryland
2,263
46.7 (41.2–52.2)
2,261
24.7 (17.7–31.7)
471
29.3 (17.2–41.3)
Massachusetts
4,696
50.7 (47.5–54.0)
4,689
28.4 (25.8–31.0)
1,764
23.9 (18.7–29.1)
Michigan
1,080
43.6 (35.4–51.7)
1,079
18.1 (12.2–23.9)
226
13.8 (5.2–22.4)
Minnesota
3,154
48.0 (44.6–51.4)
3,149
31.5 (28.4–34.5)
1,316
19.3 (15.2–23.4)
Mississippi
2,663
32.2 (27.9–36.5)
2,663
7.3 (4.9–9.8)
1,106
10.8 (6.0–15.6)
Missouri
1,211
43.3 (34.9–51.7)
1,213
21.1 (14.4–27.7)
315
14.1 (2.8–25.3)
Montana
3,301
39.4 (34.8–44.0)
3,292
20.9 (16.9–24.8)
1,510
17.1 (12.0–22.2)
Nebraska
1,990
47.9 (40.7–55.2)
1,986
18.7 (12.5–24.9)
715
20.7 (10.4–31.0)
Nevada
4,243
34.6 (31.7–37.4)
4,234
14.9 (12.9–16.9)
1,678
19.7 (15.9–23.5)
New Hampshire
4,620
51.0 (47.4–54.7)
4,619
27.6 (24.6–30.7)
2,276
17.6 (14.6–20.7)
New Jersey
3,780
45.7 (41.6–49.9)
3,770
19.1 (16.2–22.0)
1,350
14.6 (9.3–19.8)
New Mexico
4,041
44.5 (40.9–48.1)
4,034
19.8 (17.3–22.2)
1,596
23.3 (19.3–27.3)
New York
5,101
43.0 (39.7–46.2)
5,093
16.3 (14.3–18.4)
1,419
10.8 (8.2–13.5)
North Carolina
4,240
43.9 (40.3–47.4)
4,234
18.3 (15.6–21.0)
1,618
16.0 (12.4–19.6)
North Dakota
1,880
43.9 (39.5–48.2)
1,877
17.7 (14.6–20.8)
684
16.8 (10.4–23.2)
Ohio
1,148
44.1 (36.5–51.7)
1,148
17.5 (12.2–22.7)
206
19.9 (9.3–30.5)
Oklahoma
4,872
39.8 (36.7–42.9)
4,866
13.6 (11.7–15.5)
1,938
17.3 (13.9–20.8)
Oregon
3,080
40.8 (37.1–44.5)
3,078
25.0 (21.6–28.5)
1,200
20.3 (15.8–24.7)
Pennsylvania
8,446
43.4 (40.8–46.0)
8,432
19.8 (17.8–21.7)
3,217
14.4 (10.3–18.6)
Puerto Rico
4,742
28.3 (25.8–30.8)
4,735
5.3 (4.2–6.4)
1,911
4.1 (2.3–6.0)
Rhode Island
894
44.4 (36.6–52.2)
895
27.0 (19.1–35.0)
138
10.9 (2.0–19.7)
South Carolina
2,951
42.5 (36.6–48.3)
2,955
16.7 (11.9–21.4)
1,285
10.1 (7.3–12.9)
South Dakota
3,794
49.4 (45.5–53.3)
3,790
20.0 (17.4–22.6)
1,711
15.5 (12.2–18.9)
Tennessee
855
35.6 (27.7–43.4)
853
11.4 (5.8–17.0)
183
8.8 (2.4–15.3)
Texas
9,153
40.1 (34.9–45.4)
9,136
15.2 (11.0–19.4)
2,964
14.6 (10.2–19.0)
U.S. Virgin Islands
1,782
15.6 (12.5–18.6)
1,784
2.4 (1.5–3.3)
876
1.9 (0.9–2.9)
Utah
854
41.2 (33.7–48.7)
852
15.0 (9.7–20.3)
175
19.9 (4.4–35.4)
Vermont
831
54.8 (44.9–64.8)
831
32.0 (24.9–39.0)
164
21.8 (10.5–33.0)
Virginia
5,900
47.5 (45.0–50.1)
5,890
22.4 (20.5–24.3)
2,034
18.5 (15.5–21.5)
Washington
1,445
41.5 (35.0–48.0)
1,440
21.7 (15.9–27.6)
278
20.2 (12.0–28.4)
West Virginia
1,886
44.8 (35.9–53.7)
1,888
16.4 (9.6–23.2)
771
7.7 (5.5–10.0)
Wisconsin
2,690
46.4 (41.8–51.0)
2,684
23.7 (20.1–27.3)
1,054
14.3 (10.3–18.2)
Wyoming
3,080
35.6 (32.3–38.8)
3,076
14.9 (12.7–17.0)
1,341
16.6 (12.8–20.5)
Range across jurisdictions
—
15.6–54.8
—
2.4–35.6
—
1.9–32.4
Abbreviation: RSV = respiratory syncytial virus.
* Estimates presented for influenza and COVID-19 vaccination are among adults aged
≥18 years. Estimates for RSV vaccination are among adults aged ≥60 years. Estimates
of vaccination coverage were calculated for December 3–9, 2023 using a nondecreasing
composite estimation procedure, which uses data collected from all completed interviews
during September 24–December 9, 2023: influenza (168,899), COVID-19 (168,669), and
RSV (62,816).
† Weighted percentage.
Discussion
As of December 9, 2023, self-reported coverage with influenza, updated COVID-19, and
RSV vaccines among U.S. adults was low, particularly for updated COVID-19 and RSV
vaccines. RSV vaccination coverage was low even among persons with chronic conditions
who are at highest risk for severe RSV disease and might benefit from vaccination.
As of mid-November, influenza vaccination coverage was approximately 2.5 percentage
points lower than it was at the same time during the 2022–23 influenza season (
6
). Approximately 41% of all adults and 53% of adults aged ≥60 years were unvaccinated
but reported that they definitely or probably plan to receive or are unsure about
receiving updated COVID-19 and RSV vaccines, respectively, suggesting they are open
to vaccination. A health care provider recommendation for and offer of vaccination
are strongly associated with vaccination (
7
). A previous report found that unvaccinated adults who were open to receiving a bivalent
COVID-19 vaccine had not yet done so mainly because of concerns about side effects,
being too busy, or just had not gotten around to getting vaccinated (
8
). Making vaccination available in provider offices, pharmacies, workplaces, and other
convenient locations at convenient times, along with a strong provider recommendation
for vaccination, could increase vaccination coverage, particularly for RSV, which
is recommended on the basis of shared clinical decision-making between a patient and
provider (
3
).
Despite disparities in vaccination coverage by race and ethnicity, when responses
indicating the person is open to vaccination are included, the potential vaccination
coverage that could be achieved for Hispanic, Black, and Asian adults is similar to
or higher than that for White adults. Programmatic measures that helped reduce disparities
in coverage with the primary series of COVID-19 vaccine, such as making vaccines available
free of charge, use of trusted messengers, and bringing vaccines into communities
through nontraditional settings (e.g., local libraries and local businesses such as
barber shops and restaurants)
§§
(
4
,
9
), might increase equitable access to vaccination and decrease disparities for these
currently recommended vaccines.
CDC is partnering with community-based organizations, health care providers, and other
trusted messengers to build vaccine confidence and awareness, including through the
Partnering for Vaccine Equity program.
¶¶
CDC is also working to expand COVID-19 vaccine access to all through the Bridge Access
Program, which provides COVID-19 vaccines for adults without health insurance and
adults whose insurance does not cover all COVID-19 vaccine costs. Public health safety
net and pharmacy locations offering influenza and COVID-19 vaccines, including COVID-19
vaccines through the Bridge Access Program, are available at https://www.vaccines.gov.
Communication campaigns,*** such as the “Wild to Mild” and “Get My Flu Shot” influenza
vaccine campaign and the “Everything” broad respiratory virus communication initiative,
include various materials and resources to promote vaccination, including to persons
who are disproportionately affected by disease. Finally, CDC has developed health
care provider toolkits to empower providers with knowledge to confidently recommend
vaccination.
†††
CDC makes vaccination coverage estimates rapidly available during the respiratory
virus season.
§§§
,
¶¶¶
In addition to data from the NIS-ACM, vaccination data are available from multiple
sources and include coverage among children, pregnant persons, Medicare beneficiaries,
and national projected vaccination in pharmacies and medical offices. Jurisdiction-level
estimates of COVID-19 vaccination coverage and intent stratified by demographic factors,
behavioral and social drivers of vaccination, and barriers to vaccination are available.****
CDC’s COVID-19 Vaccination Geographic Information System Mapping Tool, designed with
feedback from several local health departments, provides web maps where jurisdiction-level
data including demographic characteristics and social determinants of health can be
displayed along with vaccine confidence and vaccination coverage.
††††
End-of-season influenza vaccination coverage estimates for children and adults since
the 2010–11 influenza season, nationally and by state, are available on FluVaxView.
§§§§
Limitations
The findings in this report are subject to at least three limitations. First, response
rates for NIS-ACM were relatively low (<25%). Data were weighted to mitigate possible
bias resulting from incomplete sample frame (i.e., exclusion of households with no
phone service or only landline telephones) or nonresponse, but some selection bias
might persist. Second, all responses were self-reported; vaccination receipt, and
month and year of receipt of most recent dose might be subject to recall or social
desirability bias. Nonresponse and social desirability bias could result in overestimation
of coverage. Third, the survey sampled noninstitutionalized U.S. adults; therefore,
adults who were incarcerated or who live in long-term care facilities
¶¶¶¶
might not be represented in the sample.
Implications for Public Health Practice
Although influenza, updated COVID-19, and RSV vaccination has slowed for the 2023–24
respiratory season, vaccination is recommended to continue while viruses are circulating
(
1
–
3
), and many unvaccinated persons continue to report intent to be vaccinated. Health
care provider recommendations for and offers of vaccination are important to increasing
vaccination coverage (
7
). Immunization programs and vaccination partners are encouraged to use CDC developed
dashboards and tools, as well as other data sources available to them, such as immunization
information systems, to identify undervaccinated populations and better understand
vaccination patterns, attitudes and behaviors, and systemic barriers to vaccination
in their jurisdiction to help tailor vaccination activities to improve coverage and
health equity.