2009 H1N1 and Seasonal Flu and African American Communities: Questions and Answers

February 17, 2010, 3:30 PM ET

Since April 2009, the 2009 H1N1 influenza virus has been spreading from person-to-person worldwide, affecting all racial and ethnic groups. This 2009 H1N1 and Seasonal Flu and African American Communities: Questions and Answers document summarizes current understanding of the impact of 2009 H1N1 and seasonal influenza virus on African Americans, describes some of the barriers to uptake of 2009 H1N1 and seasonal influenza vaccines, and outlines potential strategies for improving health and increasing vaccine coverage in African American communities.

2009 H1N1 and seasonal influenza materials for all individuals are available at Flu.gov and CDC.gov.

What impact is 2009 H1N1 having on African American communities?

2009 H1N1 and seasonal flu data on racial and ethnic groups have been taken from a wide range of sources and geographic areas and show differing results. For instance:

• Behavioral Risk Factor Surveillance System data show self-reported influenza-like illness and having sought medical care for that illness was similar among racial/ethnic groups.¹
• From April 15-August 31, 2009, 35 percent of people hospitalized with 2009 H1N1 in 13 metropolitan areas of 10 states were non-Hispanic black. Only 16 percent of the catchment area population studied, however, was non-Hispanic black.²
• Non-Hispanic black children less than 5 years old had higher seasonal influenza-associated hospitalization rates (1.2/100,000) than non-Hispanic white children of the same age (0.5/100,000) in university medical centers serving Rochester, Nashville and Cincinnati.³
• Black children younger than 18 years of age account for 16.6% of 210 reported influenza-associated deaths in 2009.⁴ Their representation in the U.S. population is 16.8%.⁵

Because the geographic spread of influenza varies over time, findings may vary depending on when and where data were collected. However, any influenza-associated hospitalization or death is tragic. It is important to better understand the causes and take steps to prevent these hospitalizations and deaths.

What factors contribute to 2009 H1N1’s impact on African American communities?

Many medical conditions are associated with an increased risk of serious complications from influenza. Disparities in underlying medical conditions, such as asthma and diabetes, may contribute to the impact of 2009 H1N1 on African American communities.

From April 2009 — September 2009:

• Almost one-third of people hospitalized with complications from 2009 H1N1 influenza were persons with asthma. Asthma-related hospitalization and mortality rates from all causes, not just influenza, are approximately two to three times higher among non-Hispanic blacks compared with non-Hispanic whites.⁶
• Approximately 10 percent of people hospitalized with complications from 2009 H1N1 influenza have been diabetic. Among adults 20 years of age and older, diabetes is more prevalent among non-Hispanic blacks (12%) compared with non-Hispanic whites (7%).⁷

Some African-Americans may also face barriers to accessing health care, such as lack of insurance or transportation. There is no epidemiological or clinical evidence that suggests that African Americans are more susceptible to either 2009 H1N1 or seasonal influenza, or to poorer health outcomes by virtue of their race alone.  Therefore, further investigation is essential to more clearly elucidate factors that might contribute to the disproportionate influenza-associated hospitalization among non-Hispanic blacks.

What can we do to prevent 2009 H1N1 and seasonal flu?

CDC recommends a three-step approach for everyone to fight the flu,

• Get vaccinated;
• Take everyday preventive actions, including covering coughs and sneezes, frequent hand washing, and staying home when sick; and
• Use antiviral drugs correctly if your doctor recommends them.

Although the most effective way to prevent both 2009 H1N1 and seasonal influenza and their complications is to be vaccinated, overall 2008-2009 seasonal influenza vaccination coverage was low across racial and ethnic groups. Further, many non-Hispanic blacks were less likely than non-Hispanic whites to receive influenza vaccination (Figure1).

Click graph to enlarge

*Respondents who have diabetes, heart disease, or asthma.

However, non-Hispanic blacks at high-risk for complications in the 18-49 year old age group received vaccine at levels above their white counterparts, but rates were suboptimal for both racial populations in this and other groupings.⁸  Similarly, in the 2008 National Health Interview survey 33% of non-Hispanic blacks in the 19-49 year old high-risk group reported receiving seasonal influenza vaccine compared to 30% of non-Hispanic whites.⁹

What perceptions affect the uptake of 2009 H1N1 and seasonal vaccine?

Many African Americans are concerned about the safety of influenza vaccines. For example, in a recent survey of 1500 registered voters in California, 17% of survey respondents felt that there was a strong chance that the 2009 H1N1 vaccine was unsafe. However, this concern was twice as high among African Americans.¹⁰

According to a University of Michigan study, despite recommendations emphasizing the importance of vaccinating children against 2009 H1N1, only 40% of parents intended to have their children vaccinated. Broken down by racial background, 52% percent of Hispanic parents, 38% of white parents, and 30% of black parents were planning to have their children vaccinated against 2009 H1N1.

What are some strategies for increasing 2009 H1N1 and seasonal vaccine coverage in African American communities?

Promotion of 2009 H1N1 and seasonal influenza vaccination among African Americans recommended for these vaccines is a key part of the response. Vaccination campaigns should be inclusive and transparent, engaging all stakeholders in the African American community in order to more effectively address community concerns, and to inform and educate the public.¹²

Improve the collection and use of data.

It is important to continue to improve our ability to collect, analyze, and disseminate race/ethnicity data on influenza-associated hospitalizations, deaths, and influenza vaccine coverage.

Better understand beliefs about influenza immunization.

African American communities’ historical experiences with health care and public health may impact perceptions of the safety and utility of vaccination. Tailored outreach, sensitive to these issues, is critical. For example, focus groups about seasonal influenza immunization beliefs among older African Americans revealed the following:¹³

• Participants who did not intend to receive influenza vaccination believed that they had gotten sick from the flu shot or knew someone else who became sick after receiving the flu shot. 
• Some participants expressed a distrust of the government, physicians, and pharmaceutical companies. Trusted influenza spokespeople included physicians or other health professionals, peers, family members and, for men, their wives.
• The concept of “protecting others” by getting the flu shot resonated well with the participants.

Communicate what is known about vaccine safety and effectiveness.

Vaccine coverage will improve with increased awareness that:

• Both the 2009 H1N1 and seasonal influenza vaccines are safe.
• The 2009 H1N1 vaccine is made the same way as the seasonal vaccine that has been used safely and successfully for many years.
• The benefits of vaccination with the 2009 H1N1 influenza vaccine outweigh the risks.

Increase the number, accessibility, and use of vaccination sites.

As more vaccine becomes available, it will also be important to continue to increase the number, accessibility of, and use of vaccination sites, particularly within underserved communities.

References

1. CDC. Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2009. Unpublished data.
2. CDC. Emerging Infections Program. Unpublished data.
3. CDC. New Vaccine Surveillance Network. Unpublished data.
4. CDC. Nationally Notifiable Disease Surveillance System. Surveillance for Influenza-Associated Pediatric Mortality, 2009. Unpublished data.
5. U.S. Census Bureau, Population Division. Table 4: Annual Estimates of the Black or African American Alone or in Combination Resident Population by Sex and Age for the United States: April 1, 2000 to July 1, 2008
6. Moorman JE, Rudd RA, Johnson CA, King M, Minor P, Bailey C, Scalia MR, Akinbami LJ. National surveillance for asthma—United States, 1980–2004. Morb Mortal Wkly Rep. CDC Surveill Summ 2007; 56:1–13.
7. American Diabetes Association. 2007 National Diabetes Fact Sheet. Accessed 28 November 2009.
8. CDC. Influenza Vaccination Coverage Among Children and Adults --- United States, 2008--09 Influenza Season. Morb Mortal Wkly Rep. 2009 Oct 9;58(39):1091-5.
9. Schiller, JS and Euler GL. NCHS Health E-Stat. Vaccination coverage estimates from the National Health Interview Survey: United States, 2008. Accessed 28 November 2009.
10. Hennessy-Fiske, M. Times/USC poll finds majority of California's registered voters have no plans to get H1N1 vaccine. Los Angeles Times. Accessed 6 November 2009.
11. C.S. Mott Children’s Hospital. National Poll on Children’s Health. Vol. 8 Issue 1. September 24, 2009. Accessed 28 November 2009.
12. Hutchins SS, et al.  Protection of Racial and Ethnic Minority Populations during an Influenza Pandemic. Am J Public Health 2009; Suppl: S261-S270.   
13. Sapsis, K and Janssen, A. Influenza and Pneumococcal Immunization: A Qualitative Assessment of the Beliefs of Physicians and Older Hispanic and African Americans. Final Report December 2002. Accessed 28 November 2009.