Influenza Vaccination in Health Centers during the COVID-19 Pandemic—United States, November 7–27, 2020

Abstract Background Influenza vaccination is the most effective way to prevent influenza and influenza-associated complications including those leading to hospitalization. Resources otherwise used for influenza could support caring for patients with Coronavirus Disease 2019 (COVID-19). The Health Resources and Services Administration (HRSA) Health Center Program serves 30 million people annually by providing comprehensive primary health care, including influenza vaccination, to demographically diverse and historically underserved communities. As racial and ethnic minority groups have been disproportionately impacted by COVID-19, the objective of this analysis was to assess disparities in influenza vaccination at HRSA-funded health centers during the COVID-19 pandemic. Methods The Centers for Disease Control and Prevention (CDC) and HRSA analyzed cross-sectional data on influenza vaccinations from a weekly, voluntary Health Center COVID-19 survey after addition of an influenza-related question covering November 7-27, 2020. Results During the three-week period, 1,126 (81%) of 1385 health centers responded to the survey. Most of the 811,738 influenza vaccinations took place in urban areas and in the Western US Region. There were disproportionately more health center influenza vaccinations among racial and ethnic minorities in comparison with county demographics, except among Non-Hispanic Blacks and American Indian/Alaska Natives. Conclusions HRSA-funded health centers were able to quickly vaccinate large numbers of mostly racial or ethnic minority populations, disproportionately more than county demographics. However, additional efforts might be needed to reach specific racial populations and persons in rural areas. Success in influenza vaccination efforts can support success in SARS-CoV-2 vaccination efforts.

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Introduction
With the exception of the 2020-2021 influenza season, every year, it is estimated that tens of millions of people in the United States become ill with seasonal influenza, resulting in hundreds of thousands of hospitalizations and tens of thousands of deaths (1). Signs and symptoms of influenza resemble those of Coronavirus Disease 2019 (COVID- 19), including fever, chills, cough, difficulty breathing, fatigue, sore throat, runny or stuffy nose, body aches, and headache. As a result, it is challenging to differentiate between the diseases based on symptoms alone without diagnostic testing (2). Both influenza and COVID-19 can lead to serious complications. Some populations are at increased risk for serious influenzarelated complications (e.g., pneumonia, myocarditis, encephalitis, multiple organ failure).
This includes those 65 years or older, those with certain chronic medical conditions (e.g., asthma, diabetes, heart disease), pregnant women, and individuals younger than 5 years of age (3). Further, co-infection with influenza virus and SARS-CoV-2, the virus that causes COVID-19, can result in poorer outcomes than with SARS-CoV-2 infection alone (4).
Influenza vaccination is the most effective way to prevent influenza, reduce influenza severity, limit influenza-associated complications, and to reduce the burden on the healthcare system, allowing for utilization of medical resources to care for patients with COVID-19. Nationally, influenza vaccinations in the 2019-2020 influenza season prevented an estimated 7.5 (5.8-9.4) million cases of influenza, 3.7 (2.8-4.6) million influenzaassociated medical visits, 105,000 (59,000-160,000) influenza-associated hospitalizations, and 6,300 (2,800-11,400) influenza-associated deaths (1). Influenza vaccination is associated with improved health due to the prevention of influenza-related complications for people A c c e p t e d M a n u s c r i p t 5 with pre-existing heart disease, chronic lung disease, diabetes, and for those who are pregnant (5)(6)(7)(8). Additionally, influenza vaccination of pregnant people can prevent influenza in their newborns for several months after birth (9). While CDC recommends that all people aged ≥6 months in the United States get an influenza vaccine by the end of October each year, there are still benefits of late-season vaccination into January or later, for as long as influenza viruses typically circulate (10).
The Health Resources and Services Administration (HRSA) Health Center Program (HCP) serves 30 million people annually by providing comprehensive primary health care, including influenza vaccination, to demographically diverse and historically underserved populations.
The HCP supports 1,385 health centers that provide comprehensive primary health care (e.g., medical, dental, vision, behavioral health, and enabling services), including influenza vaccination, through 14,000 service delivery sites across the United States. "Health center" refers to both Federally Qualified Health Centers (FQHCs) and HCP Look-Alikes (which meet all HCP requirements but do not receive Section 330 award funding). During the COVID-19 pandemic, HRSA provided one-time COVID-19 funding to health centers to purchase, administer, and expand capacity for SARS-CoV-2 testing and to monitor COVID-19 response related activities, which included influenza vaccination efforts to avoid concomitant outbreaks of influenza during the COVID-19 pandemic.
Health centers serve diverse populations, many of whom are at high risk for many diseases or disease complications associated with poverty(11.) However, it was unknown how influenza vaccinations were reaching populations served by health centers during the A c c e p t e d M a n u s c r i p t 6 COVID-19 pandemic. Moreover, identifying successes achieved in influenza vaccination reach could support success in SARS-CoV-2 vaccination, which was not yet available during the analysis period. The objective of this analysis was to assess successes and disparities in influenza vaccination at HRSA-funded health centers during the COVID-19 pandemic.

Methods
In April 2020, HRSA instituted a voluntary weekly survey to collect information on SARS-CoV-2 testing and related activities in health centers (12). During the week ending November 13, 2020, HRSA added a question about seasonal influenza vaccination ("By race and ethnicity, how many flu vaccinations did your health center administer in the last week?") about seasonal influenza vaccination . In this cross-sectional analysis, CDC and HRSA analyzed data from health centers reporting on the total number of influenza vaccinations during  [13]), and the percentage of the population served (obtained from the 2019 HCP Uniform Data System annual patient population [14]).    Many HRSA-funded health centers already have policies to address some social risk factors and to ensure that services provided are culturally responsive for the communities served(16). Health centers provide high-quality, patient-centered, comprehensive primary health care services regardless of patients' ability to pay. These services include supporting patients to stay up to date on vaccinations, following recommendations of CDC's Advisory Committee on Immunization Practices (ACIP) (17), and leveraging best practices. To support vaccinations for uninsured patients, health centers collaborate with state and local public health departments to provide vaccinations at little to no cost to health center patients.

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Online scheduling, walk-in services, and drive-through vaccinations are offered to increase access. Health center staff review data to see who is being vaccinated and who is not, so that they can offer targeted services, outreach, and frequent prompts for current patients to encourage vaccination and completion of vaccination series. Messaging to patients is A c c e p t e d M a n u s c r i p t 11 culturally responsive, based on assessments of patients' health beliefs and barriers. Health center staff are trained in trauma-informed care, and motivational interviewing to address patient barriers and to support staff resiliency. Standing orders for vaccinations are used to facilitate health centers' ability to vaccinate patients without requiring physician approval for each encounter and to enhance team-based care. Some health centers are also using dedicated vaccination rooms to increase patient and staff safety. This analysis has implications for the provision of SARS-CoV-2 vaccinations, which will be ongoing at HRSA-funded health centers for many more months in 2021 and possibly into 2022. These health centers serve millions of racial and ethnic minorities who have been identified to be at high risk for SARS-CoV-2 infection and COVID-19 disease (18). COVID-19 incidence has been consistently higher than in Non-Hispanic White persons among Native Hawaiian/Pacific Islander, non-Hispanic American Indian or Alaska Native, and Hispanic/Latino persons (18). There is also elevated SARS-CoV-2 vaccine hesitancy among US racial/ethnic minorities, particularly among Blacks (19). Recently, $6 billion was awarded through the American Rescue Plan Act to HRSA-funded health centers for SARS-CoV-2 testing, vaccination, and treatment, and for expansion of operational capacity, including adding of mobile units (20).  * County population data was obtained from the American Community Survey for the counties in which health centers were located that responded to the survey. The number of influenza vaccinations administered by HRSA-funded Health Centers in US states, excluding 6,678 in the US territories, during the period was 805,060. Patients having unknown race and ethnicity data (6% of vaccinations, n=49,469) were excluded from the displayed percentages (new N=755,591). Non-Hispanics with unreported race were included within the Multiracial category for comparison purposes. Percentages may not equal 100% due to rounding.
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