Adult Vaccination Disparities Among Foreign-Born Populations in the U.S., 2012

Published:October 06, 2014DOI:


      Foreign-born persons are considered at higher risk of undervaccination and exposure to many vaccine-preventable diseases. Information on vaccination coverage among foreign-born populations is limited.


      To assess adult vaccination coverage disparities among foreign-born populations in the U.S.


      Data from the 2012 National Health Interview Survey were analyzed in 2013. For non-influenza vaccines, the weighted proportion vaccinated was calculated. For influenza vaccination, Kaplan–Meier survival analysis was used to assess coverage among individuals interviewed during September 2011–June 2012 and vaccinated in August 2011–May 2012.


      Overall, unadjusted vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents: influenza, age ≥18 years (40.4% vs 33.8%); pneumococcal polysaccharide vaccine (PPV), 18–64 years with high-risk conditions (20.8% vs 13.7%); PPV, ≥65 years (62.6% vs 40.5%); tetanus vaccination, ≥18 years (65.0% vs 50.6%); tetanus, diphtheria, and acellular pertussis (Tdap), ≥18 years (15.5% vs 9.3%); hepatitis B, 18–49 years (37.2% vs 28.4%); shingles, ≥60 years (21.3% vs 12.0%); and human papilloma virus (HPV), women 18–26 years (38.7% vs 14.7%). Among the foreign born, vaccination coverage was generally lower for non-U.S. citizens, recent immigrants, and those interviewed in a language other than English. Foreign-born individuals were less likely than U.S.-born people to be vaccinated for pneumococcal (≥65 years), tetanus, Tdap, and HPV (women) after adjusting for confounders.


      Vaccination coverage is lower among foreign-born adults than those born in the U.S. It is important to consider foreign birth and immigration status when assessing vaccination disparities and planning interventions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Grieco E.M.
        • Acosta Y.D.
        • de la Cruz G.P.
        • et al.
        The foreign born population in the United States, 2010..
        U.S. Census Bureau, 2012
        • Malone N.
        • Baluja K.F.
        • Costanzo J.M.
        • Davis C.J.
        The foreign born population in the United States, 2000..
        US Census Bureau, 2003
      1. Pew Hispanic Center. Statistical portrait of the foreign born population in the United States, 2011. Washington DC: Pew Hispanic Center.

        • Bacaner N.
        • Stauffer B.
        • Boulware D.R.
        • Walker P.F.
        • Keystone J.S.
        Travel medicine considerations for North American immigrants visiting friends and relatives.
        JAMA. 2004; 291: 2856-2864
        • Ioannou G.N.
        Hepatitis B virus in the United States: infection, exposure, and immunity rates in a nationally representative survey.
        Ann Intern Med. 2011; 154: 319-328
        • Buelow V.H.
        • Van Hook J.
        Timely immunization series completion among children of immigrants.
        J Immigr Minor Health. 2008; 10: 37-44
        • Alagappan K.
        • Donohue B.
        • Guzik H.
        • Silverman R.
        Seroprevalence for tetanus antibodies among immigrants over age 50: comparison to an age matched US born population.
        Ann Emerg Med. 2004; 44: S126-S127
        • CDC.
        Plan and operation of the Third National Health and Nutrition Examination Survey, 1988–94. Series 1: programs and collection procedures, no 32..
        DHHS, Hyattsville MD1994
        • Weinberg M.
        • Hopkins J.
        • Farrington L.
        • Gresham L.
        • Ginsberg M.
        • Bell B.P.
        Hepatitis A in Hispanic children who live along the United States-Mexico border: the role of international travel and food-borne exposures.
        Pediatrics. 2004; 114: e68-e73
        • Reynolds M.A.
        • Kruszon-Moran D.
        • Jumaan A.
        • Schmid D.S.
        • McQuillan G.M.
        Varicella seroprevalence in the U.S.: data from the National Health and Nutrition Examination Survey, 1999-2004.
        Public Health Rep. 2010; 125: 860-869
        • Bridges C.B.
        • Coyne-Beasley T.
        Advisory Committee on Immunizaiton Practices. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older—United States, 2014.
        MMWR Morb Mortal Wkly Rep. 2014; 63: 110-112
        • CDC.
        Non-influenza vaccination coverage among adults—United States, 2011.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 66-72
        • CDC.
        Non-influenza vaccination coverage among adults—United States, 2012.
        MMWR MOrb Mortal Wkly Rep. 2014; 63: 95-102
        • CDC.
        Global routine vaccination coverage, 2011.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 883-885
      2. Healthy People 2020. Topics & objectives—immunization and infectious diseases. Washington DC: DHHS, Office of Disease Prevention and Health Promotion.

        • Strine T.W.
        • Barker L.E.
        • Mokdad A.H.
        • Luman E.T.
        • Sutter R.W.
        • Chu S.Y.
        Vaccination coverage of foreign-born children 19 to 35 months of age: findings from the National Immunization Survey, 1999-2000.
        Pediatrics. 2002; 110 (e15)
        • Poethko-Müller C.
        • Ellert U.
        • Kuhnert R.
        • Neuhauser H.
        • Schlaud M.
        • Schenk L.
        Vaccination coverage against measles in German-born and foreign-born children and identification of unvaccinated subgroups in Germany.
        Vaccine. 2009; 27: 2563-2569
        • Van der Wal M.F.
        • Diepenmaat A.C.
        • Pel J.M.
        • Hirasing R.A.
        Vaccination rates in a multicultural population.
        Arch Dis Child. 2005; 90: 36-40
        • Rodríguez-Rieiro C.
        • Hernández-Barrera V.
        • Carrasco-Garrido P.
        • de Andres A.L.
        • Jiménez-García R.
        Vaccination against 2008/2009 and 2009/2010 seasonal influenza in Spain: coverage among high risk subjects, HCWs, immigrants and time trends from the 2005/2006 campaign.
        Vaccine. 2011; 29: 6029-6034
        • Greenaway C.
        • Dongier P.
        • Boivin J.F.
        • Tapiero B.
        • Miller M.
        • Schwartzman K.
        Susceptibility to measles, mumps, and rubella in newly arrived adult immigrants and refugees.
        Ann Intern Med. 2007; 146: 20-24
        • Canavati S.
        • Plugge E.
        • Suwanjatuporn S.
        • Sombatrungjaroen S.
        • Nosten F.
        Barriers to immunization among children of migrant workers from Myanmar living in Tak province, Thailand.
        Bull World Health Organ. 2011; 89: 528-531
        • Kiros G.E.
        • White M.J.
        Migration, community context, and child immunization in Ethiopia.
        Soc Sci Med. 2004; 59: 2603-2616
        • Kusuma Y.S.
        • Kumari R.
        • Pandav C.S.
        • Gupta S.K.
        Migration and immunization: determinants of childhood immunization uptake among socioeconomically disadvantaged migrants in Delhi, India.
        Trop Med Int Health. 2010; 15: 1326-1332
        • Ayers J.W.
        • Juon H.S.
        • Lee S.
        • Park E.
        Hepatitis B vaccination prevalence and its predictors among Asian, Pacific Islander, Native American, and multiracial adults in the National Health and Nutrition Examination Survey.
        J Immigr Minority Health. 2010; 12: 847-852
      3. California Health Interview Survey. Ask CHIS gives you the answers. Los Angeles CA: UCLA Center for Health Policy Research.

        • Vlahov D.
        • Bond K.T.
        • Jones K.C.
        • Ompad D.C.
        Factors associated with differential uptake of seasonal influenza immunizations among underserved communities during the 2009-2010 influenza season.
        J Community Health. 2012; 37: 282-287
      4. New York City Department of Health and Mental Hygiene. The health of immigrants in New York City. June 2006.

      5. CDC. 2012 National Health Interview Survey public use data release: NHIS survey description. Hyattsville MD: CDC, 2012.

      6. U.S. Census Bureau. Poverty thresholds.

        • Shah B.
        • Barnwell B.
        • Bieier G.
        SUDAAN user’s manual, release 10.1.
        Research Triangle Park NC: Research Triangle Institute. 2010;
        • Lu P.J.
        • Santibanez T.A.
        • Williams W.W.
        • et al.
        Surveillance of influenza vaccination coverage—United States, 2007-08 through 2011-12 influenza seasons.
        MMWR Surveill Summ. 2013; 62: 1-28
        • Walker P.F.
        • Barnett E.D.
        An introduction to the field of refugee and immigrant healthcare.
        in: Walker P.F. Barnett E.D. Immigrant medicine. Saunders Elsevier, Philadelphia2007
      7. Mexico adult immunization schedule. Secretaría de Salud.

      8. Vaccination schedule. Wikipedia.

      9. WHO. WHO vaccine-preventable diseases: monitoring system. 2014 global summary.

      10. UNICEF. Immunization.

        • Derose K.P.
        • Escarce J.J.
        • Lurie N.
        Immigrants and health care: sources of vulnerability.
        Health Aff. 2007; 26: 1258-1268
        • Alegría M.
        • Cao Z.
        • McGuire T.G.
        • et al.
        Health insurance coverage for vulnerable populations: contrasting Asian Americans and Latinos in the United States.
        Inquiry. 2006; 43: 231-254
        • Lu P.J.
        • Williams W.W.
        • Li J.
        • et al.
        Human papillomavirus (HPV) vaccine initiation and HPV and vaccine awareness: U.S. young men in the 2010 National Health Interview Survey..
        Am J Prev Med. 2013; 44: 330-338
        • Cheng E.M.
        • Chen A.
        • Cunningham W.
        Primary language and receipt of recommended health care among Hispanics in the United States.
        J Gen Intern Med. 2007; 22: 283-288
        • DuBard C.A.
        • Gizlice Z.
        Language spoken and differences in health status, access to care, and receipt of preventive services among U.S. Hispanics..
        Am J Public Health. 2008; 98: 2021-2028
        • Haviland A.M.
        • Elliott M.N.
        • Hambarsoomian K.
        • Lurie N.
        Immunization disparities by Hispanic ethnicity and language preference.
        Arch Intern Med. 2011; 171: 158-165
        • Farmer G.C.
        • Papachristou T.
        • Gotz C.
        • Yu F.
        • Tong D.
        Does primary language influence the receipt of influenza and pneumococcal immunizations among community-dwelling older adults?.
        J Aging Health. 2010; 22: 1158-1183
        • Graham E.A.
        • Jacobs T.A.
        • Kwan-Gett T.S.
        • Cover J.
        Health services utilization by low-income limited English proficient adults.
        J Immigr Minor Health. 2008; 10: 207-217
        • Fiscella K.
        • Franks P.
        • Doescher M.P.
        • Saver B.G.
        Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample.
        Med Care. 2002; 40: 52-59
        • Leng J.F.
        • Changrani I.
        • Gany F.M.
        Language discordance and influenza vaccination.
        J Immigr Refug Stud. 2009; 7: 101-105
        • Mac Donald R.
        • Baken L.
        • Nelson A.
        • Nichol K.L.
        Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients.
        Am J Prev Med. 1999; 16: 173-177
        • Zimmerman R.K.
        • Raymund M.
        • Janosky J.E.
        • Nowalk M.P.
        • Fine M.J.
        Sensitivity and specificity of patient self-report of influenza and pneumococcal polysaccharide vaccinations among elderly outpatients in diverse patient care strata.
        Vaccine. 2003; 21: 1486-1491
        • Mangtani P.
        • Shah A.
        • Roberts J.A.
        Validation of influenza and pneumococcal vaccine status in adults based on self-report.
        Epidemiol Infect. 2007; 135: 139-143
        • Shenson D.
        • DiMartino D.
        • Bolen J.
        • Campbell M.
        • Lu P.J.
        • Singleton J.A.
        Validation of self-reported pneumococcal vaccination in behavioral risk factor surveillance surveys: experience from the sickness prevention achieved through regional collaboration (SPARC) program.
        Vaccine. 2005; 23: 1015-1020
        • Rolnick S.J.
        • Parker E.D.
        • Nordin J.D.
        • et al.
        Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors?.
        Vaccine. 2013; 31: 3928-3935
      11. U.S. Census Bureau: News Room. International migration is projected to become primary driver of U.S. population growth for first time in nearly two centuries.

        • Poland G.A.
        • Shefer A.M.
        • McCauley M.
        • et al.
        Standards for adult immunization practice.
        Am J Prev Med. 2003; 25: 144-150
      12. Guide to Community Preventive Services.

        • Lu P.J.
        • Nuorti J.P.
        Uptake of pneumococcal polysaccharide vaccination among working-age adults with underlying medical conditions, United States, 2009.
        Am J Epidemiol. 2012; 175: 827-837
        • Lu P.J.
        • Byrd K.K.
        • Murphy T.V.
        • Weinbaum C.
        Hepatitis B vaccination coverage among high-risk adults 18-49 years, U.S., 2009.
        Vaccine. 2011; 29: 7049-7057
        • Lu P.J.
        • Singleton J.A.
        • Rangel M.C.
        • Wortley P.M.
        • Bridges C.B.
        Influenza vaccination trends among adults 65 years or older in the U.S., 1989–2002.
        Arch Intern Med. 2005; 165: 1849-1856
        • Williams W.W.
        • Lu P.J.
        • Saraiya M.
        • et al.
        Factors associated with human papillomavirus vaccination among young adult women in the United States.
        Vaccine. 2013; 31: 2937-2946
        • National Vaccine Advisory Committee.
        Recommendations from the National Vaccine Advisory Committee: standards for adult immunization practice.
        Public Health Rep. 2014; 129: 115-123
        • National Foundation for Infectious Diseases and National Coalition for Adult Immunization.
        A report on reaching underserved ethnic and minority populations to improve adolescent and adult immunization rates..
        National Foundation for Infectious Diseases, Bethseda MD2002
      13. Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub. L. No. 104–193, 110 Stat. 2105 (Aug 22, 1996).

      14. Illegal Immigration Reform and Immigrant Responsibility Act of 1996 , enacted as Division C of the Defense Department Appropriations Act, 1997, Pub. L. No. 104–208, 110 Stat. 3008 (Sept 30, 1996).

        • Broder T.
        • Blazer J.
        Overview of immigrant eligibility for federal programs.
        National Immigration Law Center. 2011;
      15. U.S. Citizenship and Immigration Services. Immigration and Nationality Act.

      16. CDC. Technical instructions for panel physicians civil surgeons.

        • U.S. Department of Homeland Security.
        Yearbook of immigration statistics: 2011.
        U.S. Department of Homeland Security, Office of Immigration Statistics, Washington DC2012
      17. 111th Congress. An act entitled the Patient Protection and Affordable Care Act. Pub. Law No. 111–148, 124 Stat. 119, H.R. 3590 (Mar 23, 2010).

      18. Kenney GM, Huntress M. The Affordable Care Act: coverage implications and issues for immigrant families. Washington DC: DHHS, 2012.

        • Riccardo F.
        • Dente M.G.
        • Kojouharova M.
        • et al.
        Migrant׳s access to immunization in Mediterranean Countries.
        Health Policy. 2012; 105: 17-24
      19. PROMOVAX—promote vaccinations among migrant populations in Europe.