Att B - MMWR Weekly Sample

Morbidity and Mortality Weekly Report
Weekly / Vol. 62 / No. 4

February 1, 2013

Ciguatera Fish Poisoning — New York City, 2010–2011
During August 2010–July 2011, the New York City
Department of Health and Mental Hygiene (DOHMH)
received reports of six outbreaks and one single case of ciguatera
fish poisoning (CFP), involving a total of 28 persons. CFP
results from consumption of certain large, predatory, tropical
reef fish that have bioaccumulated ciguatoxins (CTX). CFP is
characterized by various gastrointestinal, cardiovascular, and
neurologic symptoms. A prolonged period of acute illness can
result, and the neurologic symptoms can last months, with
variable asymptomatic and symptomatic periods. The first
two outbreaks and the single case, involving 13 persons, were
reported during August 6–September 13, 2010. DOHMH
distributed a health alert in November 2010 requesting healthcare providers be alert for CFP signs and symptoms. The health
alert resulted in identification of 11 more cases that month
and an additional two outbreaks involving four persons in July
2011. In comparison, only four CFP outbreaks, involving 21
persons total, had been reported in New York City (NYC)
during the preceding 10 years (2000–2009). DOHMH’s
investigation revealed that 13 persons became ill after eating
barracuda, and 15 became ill after eating grouper. Although
specific and highly sensitive laboratory analyses can detect
and confirm CTX in fish, no practical field tests are available
for fish monitoring programs. CFP prevention depends on
educating the public, seafood suppliers, and distributors about
known CFP endemic areas and high-risk fish species. Traceback
investigations of fish associated with outbreaks provide valuable
information regarding fishing areas associated with CFP. Not
all fish from CFP endemic areas are ciguatoxic, but persons
who eat fish from endemic regions are at higher risk for CFP.
If an illness is suspected to be CFP, public health authorities
should be notified and informed of the case history for possible
investigation and intervention measures.
On August 6, 2010, an adolescent female aged 16 years,
and her mother aged 47 years went to a hospital emergency
department (ED) with diarrhea, light-headedness, and perioral
tingling after eating barracuda purchased at a fish market in

Queens, New York. Hours later, an additional four family
members (three males and one female) who had eaten the same
fish, reported tingling in their extremities. Two of the four
also visited the ED. Later, the four who had gone to the ED
experienced abdominal cramps, dizziness, headache, faintness,
nausea, and vomiting. Hypotension and bradycardia persisted,
despite volume resuscitation with normal saline. The treating
physician suspected a link between the barracuda consumption and neurologic and gastrointestinal symptoms (Table 1),
subsequently diagnosed CFP,* and contacted the NYC Poison
Control Center (PCC). The PCC reported the incident to
DOHMH, and a DOHMH inspector collected samples of
barracuda from the fish market and the patients’ home. The
inspector also embargoed barracuda sale at the fish market.
Samples were analyzed for CTX at the Gulf Coast Seafood
Laboratory of the Food and Drug Administration (FDA) using
methods developed by FDA to confirm CFP cases. These
methods included an in vitro mouse neuroblastoma cell assay
for sodium channel toxins to provide a semiquantitative measure of composite ciguatoxicity in fish (1). Extracts that were
* Additional information on CFP signs and symptoms available at http://www.
nyc.gov/html/doh/downloads/pdf/cd/2010/10md25.pdf.

INSIDE
66 Noninfluenza Vaccination Coverage Among Adults
— United States, 2011
73 Notes from the Field: Multistate Outbreak of Human
Salmonella Typhimurium Infections Linked to
Contact with Pet Hedgehogs — United States,
2011–2013
74 Announcement
75 QuickStats
Continuing Education examination available at
http://www.cdc.gov/mmwr/cme/conted_info.html#weekly.

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention

Morbidity and Mortality Weekly Report

positive by this method were subsequently analyzed by liquid
chromatography–tandem mass spectrometry for unequivocal
confirmation of ciguatoxins (1). One meal remnant was confirmed to contain Caribbean CTX-1 and -2 at a toxicity level of
1.1 µg/kg total C-CTX-1 equivalents, more than 10 times the
FDA guidance level of 0.1 µg/kg total C-CTX-1 equivalents.
The patients reported that some of their neurologic symptoms
persisted for 2–5 months (Table 1).
During August–September 2010, an additional seven CFP
cases were reported to DOHMH. These consisted of two
outbreaks (outbreaks 2 and 3; Table 1) and a single case. All
patients experienced symptoms consistent with CFP after eating barracuda purchased from fish markets in three different
NYC boroughs and one restaurant (Table 2). On the evening
of November 19, 2010, after reading the health alert about
CFP, a physician reported a suspected CFP outbreak in Queens
(outbreak 4). This new outbreak involved 11 persons from
three families who had eaten fish labeled as grouper that was
purchased from a Queens supermarket. Five hours after eating
the fish, one family member visited the ED with vomiting, nausea, hypotension, and leg cramping. Shortly thereafter, other
members of the family reported experiencing numbness and
tingling, and two had bradycardia diagnosed several days after
fish consumption. In contrast with previously reported cases,
four patients experienced tooth pain or paradoxical dysesthesias

(Table 1). New York State Department of Agriculture and
Markets completed their traceback investigation and identified
the same distributor involved in the barracuda-related CFP
outbreak reported earlier that year.
On July 12, 2011, two separate outbreaks and an additional four cases that were associated with eating grouper at
Manhattan restaurants were reported to DOHMH. One of the
patients was a physically active man who swam >2 miles per
day before his illness. After the onset of acute CFP symptoms,
he had difficulty walking that persisted for several months.
A sample of leftover fish was confirmed by FDA to contain
1.9 µg/kg total C-CTX-1 equivalents, exceeding the FDA
guidance level by almost 20 times. Before this most recent
outbreak, the implicated vendor was inspected by FDA and
issued a warning letter detailing violations.
Reported by

Nathan Graber, MD, Faina Stavinsky, MS, Robert Hoffman,
MD, Jessica Button, Nancy Clark, MA, New York City Dept of
Health and Mental Hygiene; Scott Martin, MD, Stony Brook
Univ Medical School, Stony Brook, New York. Alison Robertson,
PhD, Food and Drug Administration. John Hustedt, MPH,
Public Health Prevention Svc, CDC. Corresponding contributor:
John Hustedt, [email protected], 212-788-4290.

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30333.
Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2013;62:[inclusive page numbers].

Centers for Disease Control and Prevention

Thomas R. Frieden, MD, MPH, Director
Harold W. Jaffe, MD, MA, Associate Director for Science
James W. Stephens, PhD, Director, Office of Science Quality
Denise M. Cardo, MD, Acting Deputy Director for Surveillance, Epidemiology, and Laboratory Services
Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office

MMWR Editorial and Production Staff

Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series
Maureen A. Leahy, Julia C. Martinroe,
John S. Moran, MD, MPH, Deputy Editor, MMWR Series
Teresa F. Rutledge, Managing Editor, MMWR Series
Stephen R. Spriggs, Terraye M. Starr
Douglas W. Weatherwax, Lead Technical Writer-Editor
Visual Information Specialists
Donald G. Meadows, MA, Jude C. Rutledge, Writer-Editors
Quang M. Doan, MBA, Phyllis H. King
Martha F. Boyd, Lead Visual Information Specialist
Information Technology Specialists

MMWR Editorial Board

William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Matthew L. Boulton, MD, MPH, Ann Arbor, MI
Rima F. Khabbaz, MD, Atlanta, GA
Virginia A. Caine, MD, Indianapolis, IN
Dennis G. Maki, MD, Madison, WI
Barbara A. Ellis, PhD, MS, Atlanta, GA
Patricia Quinlisk, MD, MPH, Des Moines, IA
Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA
Patrick L. Remington, MD, MPH, Madison, WI
David W. Fleming, MD, Seattle, WA
John V. Rullan, MD, MPH, San Juan, PR
William E. Halperin, MD, DrPH, MPH, Newark, NJ
William Schaffner, MD, Nashville, TN
King K. Holmes, MD, PhD, Seattle, WA
Dixie E. Snider, MD, MPH, Atlanta, GA
Timothy F. Jones, MD, Nashville, TN

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Morbidity and Mortality Weekly Report

TABLE 1. Characteristics of persons with suspected ciguatera fish poisoning — New York City, August 2010–July 2011

Patient

Outbreak

Date fish
consumed

Age
(yrs)

Sex

1
1
1
1
1
1
2
2
None
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
5
5
6
6

Aug 6, 2010
Aug 6, 2010
Aug 6, 2010
Aug 6, 2010
Aug 6, 2010
Aug 6, 2010
Aug 16, 2010
Aug 16, 2010
Sep 14, 2010
Aug 24, 2010
Aug 24, 2010
Aug 24, 2010
Aug 24, 2010
Nov 13, 2010
Nov 9, 2010
Nov 9, 2010
Nov 9, 2010
Nov 9, 2010
Nov 9, 2010
Nov 9, 2010
Nov 9, 2010
Nov 9, 2010
Nov 9, 2010
Nov 19, 2010
Jul 13, 2011
Jul 13, 2011
Jul 13, 2011
Jul 13, 2011

47
16
50
31
12
24
43
49
50
32
31
33
41
2
28
33
56
32
58
12
53
7
7
51
54
51
48
60

F
F
M
M
F
M
F
F
M
F
M
F
M
F
F
F
F
F
M
F
F
F
F
M
F
M
F
M

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

Hours from
consumption
to symptom
onset
7
7
8
8
8
3
3.5
4.5
2
20
11
N/A
N/A
0.5
38.5
15
3.5
25.5
4.5
1
44.5
4.5
16.5
10
9
5
4
6

Symptoms
Reported fish
consumed*

Sought
medical
attention

Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Barracuda
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper
Grouper

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No

Hospitalized
Yes (ICU)
Yes (ICU)
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No

Gastrointestinal

Cardiac

N, V, D, CR
N, V, D, CR
N, V, D, CR
N, V, D, CR
CR
D, CR
N, V, D, CR
N, V, D, CR
D
N, V, D
D

S, B, LBP,
S, B, LBP, HP
S, LBP, HP
S, LBP, HP

N, V, CR
D
N, V
N, V, D, CR
N, V, D, CR
D, CR
CR
D
N, V, D, CR
N, V, CR
N, V, D, CR
N, CR
N, D, CR
N, V, D, CR
D, CR

B
B

Neurologic
NT, P
DW
NT, DW
NT, DW
NT
NT, P
DW, P
P
DW, P
DW, P
P

LBP, HP, B
HP

HP, LBP, B

NT
NT
NT
NT, PD, DW, P
NT, TP, PD, DW, P
NT, PD, DW, P
NT, DW, P
NT, DW, P
NT, P
NT, P
NT, TP, DW, P
PD, P
PD
PD

Nonspecific/
Other
ST, DZ
CS, W, DZ
CS, W, DZ
CS, W, DZ
H
R
CH, My
CH
My, W
My, DZ, Fv
My, W, DZ, Fv
My
My
Fv
W
W
W, H
W, Fv, H
W, H
W
W, H
W, H
H
W
W
W

Abbreviations: B = bradycardia; CH = chills; CR = cramps; CS = cold sweats; D = diarrhea; DW = difficulty walking; DZ = dizziness; F = female; Fv = fever; H = headache; HP = heart palpitations;
ICU = intensive-care unit; LBP = hypotension; M = male; My = myalgia; N = nausea; N/A = not available; NT = numbness or tingling; P = pruritus; PD = paradoxical dysesthesias; R = rash;
S = syncope; ST = swollen tongue; TP = tooth pain; V = vomiting; W = weakness.
* None of the fish were speciated; all species were reported from food establishment records.

TABLE 2. Frequency of reported symptoms among ciguatera patients
(N = 28) — New York City, August 2010–July 2011
Symptom
Cramps
Diarrhea
Nausea
Weakness
Pruritus
Numbness/Tingling
Vomiting
Difficulty walking
Headache
Myalgia
Dizziness
Paradoxical dysesthesias
Heart palpitations
Bradycardia
Hypotension

No.

(%)

20
20
17
16
16
16
15
12
7
6
6
6
6
6
6

(71)
(71)
(61)
(57)
(57)
(57)
(54)
(43)
(25)
(21)
(21)
(21)
(21)
(21)
(21)

Editorial Note

CTX are naturally occurring toxins that can accumulate in
commonly consumed coral reef fish (e.g., barracuda, grouper,
snapper, amberjack, and surgeonfish). Precursors of CTX are
derived from marine dinoflagellates (microalgae) that live on
the surfaces of seaweeds and denuded corals. These microalgae
are consumed by herbivorous fish and undergo bioconversion

to the more potent CTX as they move through the food chain.
CTX can accumulate in reef fish that eat other fish, reaching
levels that can cause CFP among humans when consumed. The
toxins are colorless, odorless, tasteless, and temperature-stable,
making them difficult to detect or destroy. Consequently, CFP
occurrence is not attributable to incorrect food handling, storage, preparation, or procurement methods. The attack rate
can be 80%–90% among persons who have eaten a toxic fish,
depending on the concentration of CTX in the fish, the total
amount of fish consumed, and the consumer’s body weight and
health status (2). As in the outbreaks described in this report,
symptomatology is variable.
Initial treatment options for CFP are limited and supportive
only. The majority of patients experience symptoms within
6–48 hours after eating contaminated fish. In an acutely
symptomatic patient, any vital sign instability or electrolyte
imbalance should be treated in accordance with the normal
standard of care (3). Administration of intravenous mannitol
was thought to reduce neuronal edema; however, a randomized
double-blind, clinical trial found no evidence of mannitol being
superior to normal saline, and mannitol can cause additional
side effects, including hypotension, requiring caution during
administration (4–6). Treatment of CFP symptoms (e.g.,

MMWR / February 1, 2013 / Vol. 62 / No. 4

63

Morbidity and Mortality Weekly Report

What is already known on this topic?
Ciguatera fish poisoning can occur after eating coral reef fish
(e.g., barracuda, grouper, snapper, amberjack, and surgeonfish). Cases are underreported to health authorities, and
physicians can have difficulty correctly diagnosing cases,
even in areas where poisoning commonly is reported.
What is added by this report?
During August 2010–July 2011, New York City experienced 28
ciguatera fish poisoning cases occurring in six outbreaks and
a single case, more than occurred in the previous 10 years
combined. Early detection and outreach led to additional
cases being identified and treated.
What are the implications for public health practice?
Until the time when premarket testing of fish becomes
practical, additional outreach and education to industry and
health-care providers is warranted. New York City’s experience from these outbreaks highlights the importance of
industry adherence to approved hazard analysis and critical
control points plans to reduce the risk for ciguatoxic fish
entering the market. This study also illustrates the importance of accurate diagnosis and consistent reporting to
public health agencies to ensure the prevention of additional
cases through traceback investigations, product embargoes,
and regulatory enforcement.

neuropathy, fatigue, and headache) with amitriptyline, sodium
channel blockers, and pain medications all have been tried
with variable success (4). Consultation with the local PCC is
recommended and in NYC fulfills the reporting requirement.
This report reflects the importance of surveillance and outreach networks in responding to patients’ histories, including
food consumption, that are indicative of CFP, and highlights
prevention challenges. Reports made to the NYC PCC allowed
expeditious and effective action when the first cases of CFP
were reported. Investigators notified other jurisdictions,
consulted local health departments with expertise in CFP
prevention and case management, and conducted outreach to
NYC health-care providers. In southern Florida, where CFP is
endemic, 68% of physicians who were presented with a typical
case of CFP diagnosed it correctly (7). As a result of considerable education and outreach efforts by the Florida Department
of Health during the past decade, accuracy of CFP diagnosis
in that state has improved. However, in other nonendemic
regions, diagnostic recognition remains low.
An interstate comparison of reports to PCCs revealed additional trends, beyond the increased number of NYC CFP cases.
Unpublished data from CFP-related calls to the American
Association of Poison Control Centers during 2000–2010
were analyzed for trends and changes in geographic distribution. The data revealed that the rate of CFP-related calls per

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capita during 2010, compared with the previous 10 years, was
55% higher in NYC but 44% lower in Florida. Although this
data set might not be representative of individual state CFP
records, the rate per capita of U.S. cases remained relatively
constant throughout the preceding 11 years. This increase of
reported cases in NYC might reflect changing sources and
diversity of fish species marketed in NYC and elsewhere. The
increase might also indicate improved awareness and capacity
for investigation by the medical and public health community. The decrease in CFP reports from Florida likely was the
result of improved awareness of CFP after extensive long-term
outreach and education efforts and specific guidance on the
harvest of high-risk fish in this endemic region.
CFP is considered a highly underreported illness, with
only an estimated 10% of cases reported to health authorities
(7). Increasing awareness among health-care providers might
improve reporting and investigation. However, CFP prevention is complicated by difficulty in identifying high-risk fishing
grounds and inadequate industry knowledge and compliance
with the FDA seafood Hazard Analysis and Critical Control
Point (HACCP) regulations.† Premarket testing of fish for
CTX is not feasible because of the lack of rapid field methods
and the sporadic distribution of toxic fish, even in endemic
areas. Coordinated tracebacks of implicated fish by federal and
state agencies to specific fishing grounds remains the primary
strategy for managing CFP.
The findings in this report are subject to at least three limitations. First, meal remnant samples were available only in three
of the six CFP outbreaks. Second, where physician reports to
the PCC were unavailable, the symptoms were based entirely
on self-report or secondhand reports from family members.
Finally, additional cases might have occurred but were unrecognized because of lack of physician awareness to make an
appropriate diagnosis and the need to report.
This investigation demonstrates the value of CFP-implicated
fish traceback along with updated information on emerging
CFP risks, including new harvest areas and species. Prevention
through education alone might be limited by seafood mislabeling. Reports indicate that 20%–25% of all seafood products
are mislabeled (8). A recent assessment of seafood purchased
at retail stores and restaurants in New York, New Jersey, and
Connecticut indicated that >20% of 190 specimens were mislabeled, incompletely labeled, or misidentified by employees
(8). Methods for fish species identification using DNA barcoding have been validated (9) and are being implemented in
several U.S. state and federal laboratories, as well as academic
† Additional information, including advisories and guidance related to high-risk

species and endemic regions, is available at http://www.fda.gov/food/foodsafety/
hazardanalysiscriticalcontrolpointshaccp/seafoodhaccp/default.htm.

Morbidity and Mortality Weekly Report

institutions. These methods have been applied to multiple
CFP cases. Ongoing collaborative efforts with federal, state,
and local agencies tasked with consumer protection and food
safety might be useful in controlling CFP and mislabeling of
fish (10). Until accurate and cost-effective means of premarket
testing become available, prevention of additional cases will
continue to be dependent on HACCP compliance by the
seafood industry and CFP diagnosis and reporting by healthcare providers, warranting additional outreach and education.
Acknowledgment
Munerah Ahmed, MPH, New York City Dept of Health and
Mental Hygiene, New York.
References
1. Food and Drug Administration. FDA fish and fishery products hazards
and controls guidance. 4th ed. Rockville, MD: US Department of Health
and Human Services, Food and Drug Administration; 2011. Available
at http://www.fda.gov/downloads/food/guidancecomplianceregulatory​
information/guidancedocuments/seafood/ucm251970.pdf.
2. CDC. Cluster of ciguatera fish poisoning—North Carolina, 2007.
MMWR 2009;58:283–5.

3. Thomson Reuters (Healthcare). Ciguatera fish poisoning. POISINDEX
System [database]. Greenwood Village, Colorado: Thomson Reuters
(Healthcare); 2012.
4. Friedman MA, Fleming LE, Fernandez M, et al. Ciguatera fish poisoning:
treatment, prevention and management. Mar Drugs 2008;6:456–79.
5. Achaibar KC, Moore S, Bain PG. Ciguatera poisoning. Pract Neurol
2007;7:316–22.
6. Schnorf H, Taurarii M, Cundy T. Ciguatera fish poisoning: a double-blind
randomized trial of mannitol therapy. Neurology 2002;58:873–80.
7. McKee D, Fleming LE, Tamer R, Weisman R, Blythe DG. Physician
diagnosis and reporting of ciguatera fish poisoning in an endemic area.
In: Hallegraeff GM, Blackburn SI, Bolch CJ, Lewis RJ, eds. Harmful
algal blooms 2000. Paris, France: Intergovernmental Oceanographic
Commission of United Nations Educational, Scientific, and Cultural
Organization; 2001:451–3.
8. Consumers Union. Mystery fish: the label said red snapper, the lab said
baloney. Consum Rep 2011;76:18–22.
9. Handy SM, Deeds JR, Ivanova NV, et al. A single laboratory validated
method for the generation of DNA barcodes for the identification of
fish for regulatory compliance. J AOAC Int 2011;94:201–10.
10. Government Accountability Office. Seafood fraud—FDA program
changes and better collaboration among key federal agencies could
improve detection and prevention. Washington, DC: Government
Accountability Office; 2009. Available at http://www.gao.gov/new.items/
d09258.pdf.

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Morbidity and Mortality Weekly Report

Noninfluenza Vaccination Coverage Among Adults — United States, 2011
On January 29, 2013, this report was posted as an MMWR
Early Release on the MMWR website (http://www.cdc.gov/mmwr).
Vaccinations are recommended throughout life to prevent
vaccine-preventable diseases and their sequelae. Adult vaccination coverage, however, remains low for most routinely
recommended vaccines (1) and well below Healthy People
2020 targets.* In October 2012, the Advisory Committee on
Immunization Practices (ACIP) approved the adult immunization schedule for 2013 (2). Apart from influenza vaccination,
which is now recommended for all adults, other vaccines
recommended for adults target different populations based on
age, certain medical conditions, behavioral risk factors (e.g.,
injection drug use), occupation, travel, and other indications
(2). To assess adult (aged ≥19 years) vaccination coverage for
select vaccines, CDC analyzed data from the 2011 National
Health Interview Survey (NHIS). This report summarizes
the results of that analysis for pneumococcal vaccine, tetanus
toxoid–containing vaccines (including tetanus and diphtheria toxoid [Td] with acellular pertussis vaccine [Tdap]), and
hepatitis A, hepatitis B, herpes zoster (shingles), and human
papillomavirus (HPV) vaccines, by selected characteristics (age,
race/ethnicity,† and vaccination target criteria). Influenza vaccination coverage estimates for the 2011–12 influenza season
have been published separately (3). Compared with 2010
(1), the data indicate modest increases in Tdap vaccination
among persons aged 19–64 years and HPV vaccination among
women, but only little improvement in coverage for the other
vaccines among adults in the United States. Coverage for tetanus vaccination (with any tetanus toxoid–containing vaccine)
during the past 10 years was unchanged. Substantial increases
in vaccination coverage are needed to reduce the occurrence of
vaccine-preventable diseases among adults. The Community
Preventive Services Task Force and other authorities have recommended that health-care providers incorporate vaccination
needs assessment, recommendation, and offer of vaccination
into routine clinical practice for adult patients (4,5).
NHIS collects information about the health and health care
of the noninstitutionalized, civilian population in the United
States using nationally representative samples. Interviews are
conducted in respondents’ homes by the U.S. Census Bureau
* Healthy People 2020 objectives and targets for immunization and infectious
diseases are available at http://www.healthypeople.gov/2020/topicsobjectives​
2020/objectiveslist.aspx?topicid=23.
† Race/ethnicity was categorized as follows: Hispanic, black, white, Asian and
“other.” In this report, persons identified as Hispanic might be of any race.
Persons identified as black, white, Asian, or other race are non-Hispanic. “Other”
includes American Indian/Alaska Native and multiple race. The five racial/
ethnic categories are mutually exclusive.

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for CDC’s National Center for Health Statistics. Questions
about receipt of recommended vaccinations for adults are
asked of one randomly selected adult within each family in the
household. The presence of high-risk conditions,§ as defined
by ACIP for each vaccine, was determined by responses to
questions in the NHIS (2). The final sample adult component
response rate for the 2011 NHIS was 66.3%. Weighted data¶
were used to produce national estimates. Point estimates and
estimates of corresponding variances were calculated using
statistical software to account for the complex sample design.
Statistical significance was defined as p<0.05.

Pneumococcal Vaccination Coverage
Pneumococcal vaccination coverage among adults aged
19–64 years at high risk was 20.1% overall, a 1.6 percentage
point increase from 2010 (Table 1). Coverage among whites
aged 19–64 years at high risk was higher (20.1%) compared
with Hispanics (18.3%) and Asians (12.0%), but coverage
was not significantly different for other racial/ethnic groups.
Among adults aged ≥65 years, coverage was 62.3% overall, a
2.6 percentage point increase from 2010. Coverage among
whites aged ≥65 years increased from 2010 (by 3.0 percentage points to 66.5%) and was higher compared with Asians
(40.3%), Hispanics (43.1%), and blacks (47.6%).

Tetanus Vaccination Coverage
In 2011, the proportion of adults receiving any tetanus toxoid–containing vaccination (i.e., Td or Tdap) during the past 10
years was 64.5% for adults aged 19–49 years, 63.9% for adults
aged 50–64 years, and 54.4% for adults aged ≥65 years (Table 1).
The proportion of adults receiving tetanus vaccination during
the past 10 years across all age groups did not change compared
with 2010 (1). Whites had higher coverage across all age groups
compared with Asians, Hispanics, and blacks.
Among adults aged 19–64 years for whom Tdap vaccination
specifically could be assessed, Tdap coverage increased compared with 2010 (a 4.3 percentage point increase to 12.5%)
§ Adults

were considered at high risk for pneumococcal disease if they had ever
been told by a doctor or other health professional that they had diabetes,
emphysema, coronary heart disease, angina, heart attack, or other heart
condition; had a diagnosis of cancer during the previous 12 months (excluding
nonmelanoma skin cancer); had ever been told by a doctor or other health
professional that they had lymphoma, leukemia, or blood cancer; had been told
by a doctor or other health professional that they had chronic bronchitis or
weak or failing kidneys during the preceding 12 months; had an asthma episode
or attack during the preceding 12 months; or were current smokers. Information
on high-risk status for hepatitis B or A was not collected in 2011.
¶ Additional information on NHIS methods is available at http://www.cdc.gov/
nchs/nhis/methods.htm.

Morbidity and Mortality Weekly Report

TABLE 1. Estimated proportion of adults aged ≥19 years who received selected vaccinations, by age group, high-risk status,* race/ethnicity,†
and other selected characteristics — National Health Interview Survey, United States, 2011
Characteristic
Pneumococcal vaccination, ever§
19–64 yrs, high-risk, total
19–64 yrs, high-risk, white
19–64 yrs, high-risk, black
19–64 yrs, high-risk, Hispanic
19–64 yrs, high-risk, Asian
19–64 yrs, high-risk, other
≥65 yrs, total
≥65 yrs, white
≥65 yrs, black
≥65 yrs, Hispanic
≥65 yrs, Asian
≥65 yrs, other
Tetanus vaccination, past 10 yrs††
19–49 yrs, total
19–49 yrs, white
19–49 yrs, black
19–49 yrs, Hispanic
19–49 yrs, Asian
19–49 yrs, other
50–64 yrs, total
50–64 yrs, white
50–64 yrs, black
50–64 yrs, Hispanic
50–64 yrs, Asian
50–64 yrs, other
≥65 yrs, total
≥65 yrs, white
≥65 yrs, black
≥65 yrs, Hispanic
≥65 yrs, Asian
≥65 yrs, other
Tetanus vaccination including pertussis vaccine, past 6 yrs§§
19–64 yrs, total
19–64 yrs, white
19–64 yrs, black
19–64 yrs, Hispanic
19–64 yrs, Asian
19–64 yrs, other
19–64 yrs, living with an infant aged <1 yr
19–64 yrs, not living with an infant aged <1 yr
Hepatitis A vaccination (≥2 doses), ever¶¶
19–49 yrs, total
19–49 yrs, white
19–49 yrs, black
19–49 yrs, Hispanic
19–49 yrs, Asian
19–49 yrs, other
19–49 yrs, had traveled outside the United States to countries other than Japan,
Australia, New Zealand, Canada, or the countries of Europe since 1995
19–49 yrs, had not traveled outside the United States to countries other than
Japan, Australia, New Zealand, Canada, or the countries of Europe since 1995
19–49 yrs, with chronic liver conditions, overall

No. in sample

%

(95% CI)

Percentage point
difference from 2010

9,056
5,510
1,547
1,365
354
280
6,641
4,739
840
664
297
101

20.1
20.1
22.8
18.3
12.0
21.7
62.3
66.5
47.6
43.1
40.3
67.4

(19.1–21.1)
(18.9–21.4)
(20.3–25.5)
(15.8–21.1)**
(8.6–16.6)**
(16.7–27.7)
(60.7–63.8)
(64.8–68.2)
(43.1–52.2)**
(38.6–47.8)**
(34.5–46.4)**
(54.1–78.4)

1.6¶
1.1
4.2
3.5
0.5
-4.4
2.6¶
3.0¶
1.8
4.2
-7.9
9.0

16,843
8,889
2,509
3,793
1,223
429
7,822
4,997
1,270
1,040
359
156
6,471
4,612
809
666
286
98

64.5
69.6
54.8
56.3
52.5
69.6
63.9
67.7
54.4
52.6
45.1
67.9
54.4
57.0
44.4
45.1
37.9
63.2

(63.5–65.4)
(68.4–70.8)
(52.1–57.4)**
(54.1–58.5)**
(48.9–56.0)**
(64.0–74.8)
(62.4–65.3)
(66.0–69.4)
(51.0–57.9)**
(48.8–56.4)**
(38.9–51.4)**
(58.4–76.1)
(52.9–56.0)
(55.2–58.7)
(40.0–48.8)**
(40.7–49.6)**
(31.1–45.2)**
(50.5–74.3)

0.5
0.3
-2.0
1.9
2.2
7.4
0.5
0.4
1.7
1.7
-2.7
-0.5
1.1
0.6
4.7
1.4
1.4
1.2

17,480
9,482
2,784
3,558
1,250
406
700
16,802

12.5
13.8
11.0
7.7
11.7
19.7
21.5
12.1

(11.8–13.2)
(12.9–14.7)
(9.5–12.6)**
(6.6–8.9)**
(9.4–14.5)
(15.0–25.5)
(17.9–25.6)
(11.4–12.8)

4.3¶
4.7¶
3.6¶
2.9¶
2.5
11.3¶
10.9¶
4.0¶

14,893
7,951
2,260
3,276
1,049
357
5,361

12.5
12.3
11.2
11.3
19.1
21.1
20.1

(11.8–13.3)
(11.3–13.2)
(9.4–13.2)
(9.8–12.9)
(15.7–23.0)**
(16.1–27.1)**
(18.8–21.5)

1.8¶
1.9¶
0.9
0.9
3.8
4.6
3.5¶

9,505

8.4

(7.6–9.2)

0.9

136

17.1

(10.9–25.7)

-2.7

See table footnotes on page 68.

(Table 1). Tdap coverage was estimated after excluding from the
25,783 respondents all those without a “yes” or “no” response
for tetanus vaccination status in the past 10 years (n = 1,118
[4.3%]) or tetanus vaccination status during 2005–2011
(n = 803 [3.1%]), and those who reported tetanus vaccination

during 2005–2011 but were not told (n = 5,501 [21.3%]) or
did not know the vaccine type (n = 881 [3.4%]) (Td or Tdap).
Among 9,805 respondents who received a tetanus vaccination during 2005–2011, 55.9% reported that they were not
informed of the vaccination type, and 8.9% could not recall
MMWR / February 1, 2013 / Vol. 62 / No. 4

67

Morbidity and Mortality Weekly Report

TABLE 1. (Continued) Estimated proportion of adults aged ≥19 years who received selected vaccinations, by age group, high-risk status,* race/
ethnicity,† and other selected characteristics — National Health Interview Survey, United States, 2011
Characteristic
Hepatitis B vaccination (≥3 doses), ever***
19–49 yrs, total
19–49 yrs, white
19–49 yrs, black
19–49 yrs, Hispanic
19–49 yrs, Asian
19–49 yrs, other
19–59 yrs, with diabetes, overall
≥60 yrs, with diabetes, overall
Herpes zoster (shingles) vaccination, ever†††
≥60 yrs, total
≥60 yrs, white
≥60 yrs, black
≥60 yrs, Hispanic
≥60 yrs, Asian
≥60 yrs, other
Human papillomavirus (HPV) vaccination among females (≥1 dose), ever§§§
19–21 yrs, total
22–26 yrs, total
19–26 yrs, total
19–26 yrs, white
19–26 yrs, black
19–26 yrs, Hispanic
19–26 yrs, Asian
19–26 yrs, other
HPV vaccination among males (≥1 dose), ever§§§
19–26 yrs, total
19–21 yrs, total
22–26 yrs, total

No. in sample

%

(95% CI)

Percentage point
difference from 2010

15,568
8,256
2,349
3,429
1,144
390
1,224
1,746

35.9
37.8
33.0
28.9
40.7
44.1
26.9
12.4

(34.9–36.9)
(36.5–39.2)
(30.7–35.3)**
(27.1–30.9)**
(36.8–44.6)
(38.5–49.9)
(23.8–30.3)
(10.8–14.3)

2.1¶
2.2
-1.5
3.6¶
3.5
6.6
4.2
1.5

9,278
6,531
1,204
978
409
156

15.8
17.6
7.9
8.0
14.0
12.0

(14.8–16.9)
(16.4–18.9)
(6.2–9.9)**
(6.2–10.2)**
(10.4–18.6)**
(7.2–19.3)

1.4
1.0
3.4¶
3.6¶
1.3
3.8

718
1,459
2,177
1,083
388
480
153
73

43.1
21.5
29.5
32.5
28.3
20.2
22.3
39.0

(38.4–48.0)
(18.8–24.5)
(27.0–32.1)
(29.1–36.1)
(23.3–33.9)
(16.3–24.8)**
(16.0–30.2)
(25.6–54.3)

14.9¶
5.0¶
8.8¶
10.1¶
7.9
5.1
0.3
22.5

1,833
601
1,232

2.1
2.8
1.7

(1.4–3.2)
(1.6–4.9)
(0.9–3.2)

1.5¶
2.5¶
0.9

Abbreviation: CI = confidence interval.
* Adults were considered at high risk for pneumococcal disease if they had ever been told by a doctor or other health professional that they had diabetes, emphysema,
coronary heart disease, angina, heart attack, or other heart condition; had a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin
cancer); had ever been told by a doctor or other health professional that they had lymphoma, leukemia, or blood cancer; had been told by a doctor or other health
professional that they had chronic bronchitis or weak or failing kidneys during the preceding 12 months; had an asthma episode or attack during the preceding
12 months; or were current smokers. Information on high-risk status for hepatitis B or A was not collected in 2011.
† Race/ethnicity was categorized as follows: Hispanic, black, white, Asian, and “other.” In this report, persons identified as Hispanic might be of any race. Persons
identified as black, white, Asian, or other race are non-Hispanic. “Other” includes American Indian/Alaska Native and multiple race. The five racial/ethnic categories
are mutually exclusive.
§
Respondents were asked if they had ever had a pneumonia shot.
¶ p<0.05 by t test for comparisons between 2011 and 2010 within each level of each characteristic.
** p<0.05 by t test for comparisons with whites as the reference.
†† Respondents were asked if they had received a tetanus shot in the past 10 years. Vaccinated respondents included adults who received tetanus-diphtheria toxoid
(Td) during the past 10 years or tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during 2005–2011.
§§ Respondents who had received a tetanus shot in the past 10 years were asked if their most recent shot was given in 2005 or later. Respondents who had received
a tetanus shot since 2005 were asked if they were told that their most recent tetanus shot included the pertussis or whooping cough vaccine. Among 25,783
respondents aged 19–64 years, those without a “yes” or “no” classification for tetanus vaccination in the past 10 years (n = 1,118 [4.3%]) or for tetanus vaccination
during 2005–2011 (n = 803 [3.1%]), and those who reported tetanus vaccination during 2005–2011 but were not told vaccine type by the provider (n = 5,501
[21.3%]) or did not know vaccine type (Td or Tdap) (n = 881 [3.4%]) were excluded, yielding a sample of 17,480 respondents aged 19–64 years for whom Tdap
vaccination status could be assessed. Advisory Committee on Immunization Practices recommendations on use of Tdap in certain adults aged ≥65 years were
published January 14, 2011.
¶¶
Respondents were asked if they had ever received the hepatitis A vaccine, and if yes, were asked how many shots were received.
*** Respondents were asked if they had ever received the hepatitis B vaccine, and if yes, if they had received ≥3 doses or <3 doses.
††† Respondents were asked if they had ever received a shingles vaccine.
§§§ Respondents were asked if they had ever received the HPV shot or cervical cancer vaccine.

what type of tetanus vaccination they had received (Table 2). Of
the remaining 35.2% of respondents who reported they knew
what type of tetanus vaccine they received, 61.1% reported
receiving Tdap.

68

MMWR / February 1, 2013 / Vol. 62 / No. 4

Compared with 2010, Tdap coverage increased among all
racial/ethnic groups except Asians. For white and black respondents, coverage increased by 4.7 and 3.6 percentage points,
respectively, to 13.8% and 11.0%. For Hispanic respondents,
coverage increased by 2.9 percentage points to 7.7% (Table 1).

Morbidity and Mortality Weekly Report

The largest increase occurred among adults aged 19–64 years
who indicated a race other than Asian, black, or white, and
non-Hispanic ethnicity (a 11.3 percentage point increase to
19.7%). Increases compared with 2010 also occurred among
persons with and without household contact with an infant
aged <1 year** (a 10.9 percentage point increase to 21.5%,
and a 4.0 percentage point increase to 12.1%, respectively).
However, reported Tdap coverage among persons aged 19–64
years remained low overall. Whites had higher Tdap coverage
(13.8%) compared with blacks (11.0%) and Hispanics (7.7%).
During 2005–2011, Tdap vaccination of health-care personnel (HCP) (26.8%) was 6.5 percentage points higher
than the 2010 estimate (Table 3). White HCP had higher
Tdap coverage (27.2%) compared with black HCP (21.7%).
Compared with 2010, Tdap coverage increased for Hispanic
HCP (by 16.3 percentage points to 30.1%) and was similar
to that of white HCP.
Among persons aged 19–64 years who received a tetanus
vaccination, HCP were more likely to report receipt of Tdap
(66.8%) than non-HCP (59.7%) (Table 2).

Hepatitis A Vaccination Coverage
Compared with 2010, overall hepatitis A vaccination
coverage (≥2 doses) increased among adults aged 19–49
years (by 1.8 percentage points to 12.5%) but remained low.
Vaccination coverage was higher (20.1%) among adults aged
19–49 years who had traveled outside the United States since
1995 to a country of high or intermediate endemicity than
among respondents who had traveled only to countries of low
endemicity (8.4%) (Japan, Australia, New Zealand, Canada,
and the countries of Europe). Vaccination coverage among
adult travelers to highly endemic countries increased by 3.5
percentage points from 2010 to 2011 (Table 1). Coverage was
higher for Asians (19.1%) and adults aged 19–49 years who
indicated a race other than Asian, black, or white and nonHispanic ethnicity (21.1%) than for other groups. Coverage
among those with chronic liver conditions (17.1%) was similar
to the estimate for 2010.

Hepatitis B Vaccination Coverage
In 2011, information on high-risk status for hepatitis B virus
infection was not collected. Overall hepatitis B vaccination
coverage (≥3 doses) among all adults aged 19–49 years was
35.9% (2.1 percentage points higher than the 2010 estimate)
(Table 1). Vaccination coverage was lower for blacks (33.0%)
and Hispanics (28.9%) compared with whites (37.8%).
** In 2011, a single dose of Tdap was recommended for adults aged ≥65 years who
have or who anticipate having close contact with an infant aged <1 year (e.g.,
grandparents, child-care providers, and health-care personnel) to reduce the risk
for transmitting pertussis. Other adults aged ≥65 years may receive Tdap.

Vaccination coverage for persons with diabetes was 26.9% for
those aged 19–59 years and 12.4% for those aged ≥60 years,
similar to the estimates for 2010. Overall, hepatitis B vaccination coverage among HCP was 63.8%, similar to the estimate
for 2010. Coverage for black HCP (57.1%) and Hispanic HCP
(59.4%) was lower compared with white HCP (65.1%), but
coverage for Asian HCP (70.4%) was higher than that for
white HCP (Table 3).

Herpes Zoster Vaccination Coverage
In 2011, 15.8% of adults aged ≥60 years reported receiving herpes zoster vaccination to prevent shingles, similar to
the estimate for 2010 (Table 1). Whites aged ≥60 years had
higher herpes zoster vaccination coverage (17.6%) compared
with blacks (7.9%), Hispanics (8.0%), and Asians (14.0%).
Coverage for blacks and Hispanics aged ≥60 years increased
by more than 3 percentage points compared with herpes zoster
vaccination coverage estimates in 2010.

HPV Vaccination Coverage
In 2011, 29.5% of women aged 19–26 years reported receipt
of ≥1 dose of HPV vaccine, an increase from the 20.7% reported
for 2010 (Table 1) (1), and a further increase from the 17.1%
reported for 2009 (1). Coverage was 43.1% among women aged
19–21 years and 21.5% among those aged 22–26 years. Among
women aged 19–26 years, Hispanics had lower coverage (20.2%)
compared with whites (32.5%), but coverage across racial/ethnic
groups otherwise did not differ. Compared with 2010, receipt
of ≥1 dose of HPV vaccine increased among males aged 19–26
years (by 1.5 percentage points to 2.1%). Coverage was 2.8% for
males aged 19–21 years and 1.7% for those aged 22–26 years.
Reported by

Walter W. Williams, MD, Peng-Jun Lu, MD, PhD, Stacie Greby,
DVM, Carolyn B. Bridges, MD, Faruque Ahmed, MD, PhD,
Immunization Services Div; Jennifer L. Liang, DVM, Tamara
Pilishvili, MPH, Div of Bacterial Diseases; Craig Hales, MD,
Div of Viral Diseases, National Center for Immunization and
Respiratory Diseases, CDC. Corresponding contributor:
Walter W. Williams, [email protected], 404-718-8734.
Editorial Note

In 2011, noninfluenza adult vaccination coverage in the
United States was similar to 2010, except for modest increases in
Tdap vaccination overall and HPV vaccination among women,
with little or no improvements in coverage for the other vaccines
recommended for adults. Many adults have not received one or
more recommended vaccines. Vaccination coverage estimates
for the three vaccines in this report that are included in Healthy
People 2020 (pneumococcal, herpes zoster, and hepatitis B [for
MMWR / February 1, 2013 / Vol. 62 / No. 4

69

Morbidity and Mortality Weekly Report

TABLE 2. Type of tetanus vaccine received, and proportion that were tetanus, diphtheria, acellular pertussis (Tdap) vaccine, among adults aged
19–64 years who received a tetanus vaccination, by selected characteristics — National Health Interview Survey, United States, 2011
Type of vaccine received among those who received a tetanus vaccination during 2005–2011
Received Tdap
Characteristic
Adults aged 19–64 yrs
HCP aged 19–64 yrs†
Non-HCP aged 19–64 yrs

Received other
tetanus vaccine

Doctor did not
inform the patient

Proportion Tdap of total
tetanus vaccinations
during 2005–2011*

Could not recall
vaccine type

No. in
sample

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

No. in
sample

9,805
1,230
8,565

21.5
37.3
19.3

(20.4–22.6)
(33.9–40.8)
(18.1–20.5)

13.7
18.5
13

(12.7–14.7)
(15.9–21.5)
(12.0–14.1)

55.9
38.8
58.3

(54.5–57.3)
(35.4–42.4)
(56.8–59.8)

8.9
5.4
9.4

(8.2–9.7)
(4.1–7.0)
(8.6–10.3)

3,422
695
2,723

%

(95% CI)

61.1 (58.8–63.3)
66.8§ (62.2–71.0)
59.7 (57.0–62.3)

Abbreviations: CI = confidence interval; HCP = health-care personnel.
* Calculated by dividing number of respondents who reported receiving Tdap by the sum of those who reported receiving Tdap and those who reported receiving
other tetanus vaccination; respondents who reported that the doctor did not inform them of the vaccine type they received and those who could not recall the
vaccine type were excluded.
† Adults were classified as HCP if they reported that they currently volunteer or work (full-time or part-time) in a hospital, medical clinic, doctor’s office, dentist’s office,
or nursing home, or provided professional nursing care in the home.
§ p<0.05 by t test for comparisons between HCP and non-HCP aged 19–64 years.

TABLE 3. Estimated proportion of health-care personnel* who received selected vaccinations, by race/ethnicity† — National Health Interview
Survey, United States, 2011
Characteristic

No. in sample

Tetanus vaccination including pertussis vaccine, past 6 yrs§
19–64 yrs, total
19–64 yrs, white
19–64 yrs, black
19–64 yrs, Hispanic
19–64 yrs, Asian
19–64 yrs, other
Hepatitis B vaccination (≥3 doses), ever§§
≥19 yrs, total
≥19 yrs, white
≥19 yrs, black
≥19 yrs, Hispanic
≥19 yrs, Asian
≥19 yrs, other

%

(95% CI)

Percentage point
difference from 2010

1,759
1,046
315
217
146
35

26.8
27.2
21.7
30.1
27.8
31.2

(24.2–29.5)
(24.1–30.6)
(16.4–28.1)**
(22.7–38.7)
(19.2–38.4)
(16.9–50.4)

6.5¶
5.7
7.7
16.3¶
0.9
—††

2,564
1,581
432
314
186
51

63.8
65.1
57.1
59.4
70.4
70.0

(61.4–66.2)
(62.0–68.1)
(50.5–63.4)**
(51.7–66.7)**
(61.6–77.8)**
(50.9–84.0)

0.6
1.3
-1.7
2.4
-2.4
-0.2

Abbreviation: CI = confidence interval.
* Adults were classified as health-care personnel if they reported that they currently volunteer or work (full-time or part-time) in a hospital, medical clinic, doctor’s
office, dentist’s office, or nursing home, or provided professional nursing care in the home.
† Race/ethnicity was categorized as follows: Hispanic, black, white, Asian, and “other.” In this report, persons identified as Hispanic might be of any race. Persons
identified as black, white, Asian, or other race are non-Hispanic. “Other” includes American Indian/Alaska Native and multiple race. The five racial/ethnic categories
are mutually exclusive.
§ Respondents who had received a tetanus shot in the past 10 years were asked if their most recent shot was given in 2005 or later. Respondents who had received a tetanus
shot since 2005 were asked if they were told that their most recent tetanus shot included the pertussis or whooping cough vaccine. Among 2,439 health-care personnel
aged 19–64 years, those without a “yes” or “no” classification for tetanus vaccination status in the past 10 years (n = 60 [2.5%]) or for tetanus vaccination status during
2005–2011 (n = 85 [3.5%]), and those who reported tetanus vaccination during 2005–2011 but were not told vaccine type by the provider (n = 463 [19.0%]) or did not
know vaccine type (Td or Tdap) (n = 72 [3.0%]) were excluded, yielding a sample of 1,759 respondents aged 19–64 years for whom Tdap vaccination status could be assessed.
Advisory Committee on Immunization Practices recommendations on use of Tdap in certain adults aged ≥65 years were published January 14, 2011.
¶ p<0.05 by t test for comparisons between 2011 and 2010 within each level of each characteristic.
** p<0.05 by t test for comparisons with whites as the reference.
†† Estimate is not reliable because of small sample size (n<30) or relative standard error (standard error / estimates) >0.3.
§§ Respondents were asked if they had ever received the hepatitis B vaccine, and if yes, if they had received ≥3 doses or <3 doses.

HCP] vaccines) are well below the respective target levels of 90%
for persons aged ≥65 years and 60% for persons aged 18–64 years
at high risk (pneumococcal vaccine [objectives IID 13.1 and
IID 13.2, respectively]), 30% (herpes zoster vaccine [IID 14]),
and 90% (hepatitis vaccine for HCP [IID 15.3]). These data
indicate little progress was made in improving adult coverage
in the past year and highlight the need for continuing efforts to
increase adult vaccination coverage.

70

MMWR / February 1, 2013 / Vol. 62 / No. 4

Since 2006, ACIP has recommended that adults aged 19–64
years receive a single dose of Tdap to replace a dose of Td for
active booster vaccination against tetanus, diphtheria, and
pertussis if they received their most recent dose of Td ≥10 years
earlier (6). In October 2010, ACIP recommended expanded
use of Tdap, indicating that adults aged ≥65 years who have
or who anticipate having close contact with an infant aged
<1 year, and who previously have not received Tdap, should

Morbidity and Mortality Weekly Report

receive a single dose of Tdap to protect against pertussis and
reduce the likelihood of transmission. ACIP also recommended
that Tdap, when indicated, be administered regardless of the
interval since the most recent tetanus or diphtheria toxoid–
containing vaccine was received (6). Information on Tdap
vaccination of adults aged ≥65 years was not collected in the
2011 NHIS but is being collected starting in 2012. In February
2012, ACIP recommended that all adults aged ≥19 years who
have not yet received a dose of Tdap should receive a single
dose regardless of the interval since the most recent tetanus or
diphtheria toxoid–containing vaccine was received.†† These
recommendations supersede previous Tdap recommendations
regarding adults aged ≥65 years. Health-care providers should
not miss an opportunity to vaccinate persons aged ≥19 years
who have not received Tdap previously.
In June 2012, ACIP recommended routine use of 13-valent
pneumococcal conjugate vaccine (PCV13) in series with the
23-valent pneumococcal polysaccharide vaccine (PPSV23) for
adults aged ≥19 years with immunocompromising conditions,
functional or anatomic asplenia, cerebrospinal fluid leaks,
or cochlear implants.§§ Given the high burden of invasive
pneumococcal disease caused by serotypes in PPSV23 but
not in PCV13, ACIP noted that broader protection might be
provided through use of both pneumococcal vaccines. Current
ACIP recommendations call for use of PPSV23 in adults aged
19–64 years with chronic conditions that are not immunocompromising, such as chronic heart disease or diabetes, at
the time of diagnosis of the high-risk condition (6). All adults
are eligible for a dose of PPSV23 at age 65 years, regardless of
previous PPSV23 vaccination; however, a minimum interval
of 5 years between PPSV23 doses should be maintained. The
2012 NHIS cannot estimate the proportion of pneumococcal
vaccinations by type (PCV13 versus PPSV23).
The findings in this report provide baseline estimates of
hepatitis B vaccination coverage of adults with diabetes.
The ACIP-recommended administration of hepatitis B vaccine to unvaccinated adults with diabetes aged 19–59 years
(category A recommendation) or aged ≥60 years (category B
recommendation) in December 2011 (6). The recommendations were based on available information about risk for
contracting acute hepatitis B among persons with diabetes,
morbidity and mortality, available vaccines, age at diagnosis
of diabetes, and cost-effectiveness (6).
The percentage of age-eligible females administered HPV
vaccine has increased steadily during 2009–2011 but is still
low. The largest increase in 2011 (14.9 percentage points) was
†† Additional

information available at http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm6125a4.htm.
§§ Additional information available at http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm6140a4.htm?s_cid=mm6140a4_w.

What is already known on this topic?
During 2008–2010, coverage with routinely recommended
vaccinations among U.S. adults aged ≥19 years remained low.
What is added by this report?
Compared with 2010 estimates, modest gains occurred in
human papillomavirus vaccination coverage among women
aged 19–26 years and in tetanus and diphtheria toxoid with
acellular pertussis vaccine (Tdap) vaccination overall and
among household contacts of children. Coverage for other
vaccines and risk groups increased little, and racial/ethnic
disparities persisted for routinely recommended adult vaccines.
Coverage for all vaccines for adults remained low.
What are the implications for public health practice?
Despite improvements in vaccination, coverage remains low for
most vaccines routinely recommended for adults. Wider use of
practices shown to improve adult vaccination is needed,
including assessment of patients’ vaccination needs by
health-care providers and routine recommendation and
offering of needed vaccines to adults, implementing reminderrecall systems, use of standing order programs for vaccination,
and assessment of practice-level vaccination rates with
feedback to staff members.

reported among women aged 19–21 years. This finding might
reflect the knowledge, attitude, and practices of the health-care
providers of young women (7); the social norms of young
women and the perceptions and vaccination intentions of
peers (8); or receipt of vaccine when eligible for the Vaccines
for Children Program (age <18 years) but aged ≥19 years when
interviewed (7). The percentage of age-eligible adult males
administered HPV vaccine increased by 1.5 percentage points
but remained very low. The ACIP recommendation for routine
use of HPV vaccine in females age 11–26 years was made in
2006, whereas use in males aged 11–21 years and males aged
22–26 years at high risk was recommended in October 2011
(6). Thus, coverage levels for males in 2011 would not reflect
this new recommendation. The primary target group for HPV
vaccine is girls and boys aged 11–12 years.
The findings in this report are subject to at least five limitations. First, the NHIS sample excludes persons in the military
and those residing in institutions, which might result in underestimation or overestimation of vaccination coverage levels.
Second, the response rate was 66.3%. A low response rate can
result in sampling bias if the nonresponse is unequal among the
participants regarding vaccination. Third, the determination
of vaccination status and identification of high-risk conditions
in NHIS were not validated by medical records. Self-report
of vaccination is subject to recall bias and overestimation of
rates. However, adult self-reported pneumococcal vaccination
status has been shown to be sensitive and specific (9). Fourth,
the Tdap estimate is subject to considerable uncertainty.

MMWR / February 1, 2013 / Vol. 62 / No. 4

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Morbidity and Mortality Weekly Report

Many respondents were excluded from estimations of Tdap
coverage, creating a potential for bias. All respondents who
reported a tetanus vaccination during 2005–2011 but were
unable to say whether Td or Tdap was used, were excluded.
Sensitivity calculations were conducted to assess the magnitude
of potential bias. Depending on what proportion of excluded
respondents actually received Tdap, actual Tdap coverage could
fall within the range of 8.0%–36.4%. Comparisons of Tdap
coverage across years within subgroups might be affected by
bias resulting from excluding persons who did not report the
type of tetanus vaccine they received. Finally, age at vaccination is not known for vaccines adults reported having “ever”
received (e.g., HPV and hepatitis B vaccines), so it is not clear
for younger adults whether vaccination occurred as an adult or
was given as part of a child or adolescent vaccination program.
Vaccination coverage levels among adults are unacceptably
low. Substantial improvement in adult vaccination is needed
to reduce the health consequences of vaccine-preventable diseases among adults. Successful vaccination programs combine
1) education of potential vaccine recipients and publicity to
promote vaccination; 2) increased access to vaccination services
in medical and complementary settings, such as workplaces
and commercial establishments (e.g., pharmacies); and 3) use
of practices shown to improve vaccination coverage, including
reminder-recall systems, efforts to remove administrative and
financial barriers to vaccination, use of standing order programs
for vaccination, and assessment of practice-level vaccination
rates with feedback to staff members (5). Health-care provider
recommendations for vaccination are associated with patient
vaccination (10). Routine assessment of adult patient vaccination needs, recommendation, and offer of needed vaccinations
for adults should be incorporated into routine clinical care of
adults (4,5). The adult immunization schedule (2), updated
annually, provides current recommendations for vaccinating
adults and a ready resource for persons who provide health-care
services for adults in various settings.

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MMWR / February 1, 2013 / Vol. 62 / No. 4

References
1. CDC. Adult vaccination coverage—United States, 2010. MMWR 2012;​
61:66–72.
2. CDC. Advisory Committee on Immunization Practices (ACIP)
recommended immunization schedules for persons aged 0 through 18
years and adults aged 19 years and older—United States, 2013. MMWR
2013;62(Suppl 1).
3. CDC. Flu vaccination coverage, United States, 2011–12 influenza
season. National Immunization Survey and Behavioral Risk Factor
Surveillance System, August 2011 through May 2012. Atlanta, GA: US
Department of Health and Human Services, CDC; 2011. Available at http://
www.cdc.gov/flu/professionals/vaccination/coverage_1112estimates.htm.
4. Poland GA, Shefer AM, McCauley M, et al. Standards for adult
immunization practices. Am J Prev Med 2003;25:144–50.
5. Community Preventive Services Task Force. The guide to community
preventive services. Increasing appropriate vaccination: universally
recommended vaccinations. Atlanta, GA: US Department of Health
and Human Services, CDC; 2011. Available at http://www.
thecommunityguide.org/vaccines/universally/index.html.
6. CDC. Advisory Committee on Immunization Practices (ACIP)
recommendations. Atlanta, GA: US Department of Health and Human
Services, CDC; 2012. Available at http://www.cdc.gov/vaccines/pubs/
acip-list.htm.
7. Taylor LD, Hariri S, Sternberg M, Dunne EF, Markowitz LE. Human
papillomavirus vaccine coverage in the United States, National Health
and Nutrition Examination Survey, 2007–2008. Prev Med 2011;​
52:398–400.
8. Allen JD, Mohllajee AP, Shelton RC, et al. Stage of adoption of the
human papillomavirus vaccine among college women. Prev Med
2009;48:420–5.
9. Shenson D, DiMartino D, Bolen J, Campbell M, Lu PJ, Singleton JA.
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;23:1015–20.
10. Winston CA, Wortley PM, Lees KA. Factors associated with vaccination
of Medicare beneficiaries in five U.S. communities: results from the
racial and ethnic adult disparities in immunization initiative survey,
2003. J Am Geriatr Soc 2006;54:303–10.

Morbidity and Mortality Weekly Report

Notes from the Field
Multistate Outbreak of Human Salmonella
Typhimurium Infections Linked to Contact with
Pet Hedgehogs — United States, 2011–2013
CDC is collaborating with the U.S. Department of
Agriculture’s Animal and Plant Health Inspection Service
(USDA-APHIS) and state health departments to investigate
an outbreak of human Salmonella Typhimurium infections
with an indistinguishable pulsed-field gel electrophoresis
pattern linked to contact with pet hedgehogs. This outbreak
strain is historically rare, with only one to two cases reported
via PulseNet (the national molecular subtyping network for
foodborne disease surveillance) annually since 2002. Since
2011, an increasing number of cases have been detected.
PulseNet identified 14 human isolates in 2011, 18 in 2012,
and two in 2013.
Since January 2012, a total of 20 persons infected with the
outbreak strain of Salmonella Typhimurium have been reported
from eight states: Alabama (one), Illinois (one), Indiana (one),
Michigan (three), Minnesota (three), Ohio (three), Oregon
(one), and Washington (seven). Illness onset dates ranged from
December 26, 2011, to December 31, 2012. The median
patient age was 13 years (range: <1–91 years); 55% of patients
were female. Four patients were hospitalized. One death associated with Salmonella infection has been reported. Fourteen
out of 15 patients (or their proxies) reported direct or indirect
contact between the patient and a hedgehog during the week
before illness onset. The hedgehogs were purchased from various hedgehog breeders, many of whom were USDA-APHIS
licensed, in several states. CDC, USDA-APHIS, and state health
departments currently are collaborating to conduct a traceback
investigation of hedgehogs purchased from USDA-APHIS
licensed breeders by members of the households of ill persons.
Salmonellosis is most commonly foodborne; however, contact
with infected animals and their environments also can cause
illness (1). Salmonellosis has been linked with pet hedgehogs
previously (2,3). Children aged <5 years, elderly persons, and
immunocompromised persons are at increased risk for severe
illness. Infections can result from direct contact with hedgehogs

during routine care and indirect transmission through contact
with objects (e.g., cages, toys, or bedding) or household surfaces
that come in contact with infected hedgehogs.
Hand washing with soap and water after handling hedgehogs, especially before handling food or drinks, can reduce
the risk for infection. Any equipment or materials associated
with hedgehog care (e.g., feed, water, and bathing containers) should be cleaned outside the home. Detailed safe
handling instructions for hedgehogs should be provided at
the point of sale, and owners should ensure that anyone in
direct or indirect contact with hedgehogs is aware of proper
precautions to prevent Salmonella transmission. Additional
information is available at http://www.cdc.gov/salmonella/
typhimurium-hedgehogs-09-12.
Reported by

Nicola Marsden-Haug, MPH, Communicable Disease
Epidemiology, Washington State Dept of Health. Stephanie Meyer,
MPH, Acute Disease Investigation and Control Section, Infectious
Disease Epidemiology, Prevention, and Control Div, Minnesota
Dept of Health. Sally A. Bidol, MPH, Michigan Dept of
Community Health. Jennifer Schmitz, Animal Care, Animal and
Plant Health Inspection Svc, US Dept of Agriculture. Wright
Culpepper, MSPH, Casey Barton Behravesh, DVM, DrPH, Div
of Foodborne, Waterborne, and Environmental Diseases, National
Center for Emerging and Zoonotic Infectious Diseases; Jamae
Morris, PhD, Tara Creel Anderson, DVM, PhD, EIS officers,
CDC. Corresponding contributor: Tara Creel Anderson,
[email protected], 404-718-4876.
References
1. Hale CR, Scallan E, Cronquist AB, et al. Estimates of enteric illness
attributable to contact with animals and their environments in the United
States. Clin Infect Dis 2012;54(Suppl 5):S472–9.
2. CDC. African pygmy hedgehog-associated salmonellosis—Washington,
1994. MMWR 1995;44:462–3.
3. Craig C, Styliadis S, Woodward D, Werker D. African pygmy hedgehog–
associated Salmonella tilene in Canada. Can Commun Dis Rep
1997;23:129–32.

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Announcement
National Black HIV/AIDS Awareness Day —
February 7, 2013
February 7 is National Black HIV/AIDS Awareness Day, an
observance intended to raise awareness of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome
(AIDS) and encourage action to reduce the disproportionate
impact of HIV/AIDS on blacks or African Americans in the
United States. Compared with other races and ethnicities,
blacks or African Americans had the highest HIV prevalence
in 2009 (1) and the highest incidence in 2010 (2), with an
estimated HIV incidence of 68.9 per 100,000 population,
which was 7.9 times the rate in whites (8.7). Two of the three
goals of the National HIV/AIDS Strategy are to reduce HIV
incidence and HIV-related disparities (3).
In 2010, among black or African American females, heterosexual contact with a person known to have, or to be at high
risk for, HIV infection was associated with an estimated 87%
of new infections (2). From 2008 to 2010, the number of new
infections among black or African American females decreased
21%, from 7,700 to 6,100. By comparison, the rate of new
HIV infections for black or African American females (38.1
per 100,000 population) in 2010 was 20.1 times the rate for
white females (1.9).
In 2010, among black or African American males in the
United States, male-to-male sexual contact was associated
with an estimated 72% of new HIV infections. Among black
or African American men who have sex with men, males aged
13–24 years accounted for 45% of new HIV infections. This

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MMWR / February 1, 2013 / Vol. 62 / No. 4

group had the highest HIV incidence of any age and racial/
ethnic subgroup. The number of new HIV infections among
black or African American males was stable at 14,400 in 2008
and 14,700 in 2010. By comparison, the rate of new HIV
infections for black or African American males (103.6 per
100,000 population) in 2010 was 6.6 times the rate for white
males (15.8).
National Black HIV/AIDS Awareness Day is an opportunity
to increase HIV prevention activities, such as HIV testing,
and to link persons with HIV to effective HIV medical care
that reduces morbidity, mortality, and HIV transmission (4).
Additional information about National Black HIV/AIDS
Awareness Day is available at http://www.cdc.gov/features/
blackhivaidsawareness. Additional information regarding
blacks or African Americans and HIV/AIDS is available at
http://www.cdc.gov/hiv.
References
1. CDC. Diagnoses of HIV infection and AIDS in the United States and
dependent areas, 2010. HIV surveillance report, 2010. Vol. 22. Atlanta,
GA: US Department of Health and Human Services, CDC; 2012.
Available at http://www.cdc.gov/hiv/surveillance/resources/reports/​
2010report/index.htm.
2. CDC. Estimated HIV incidence in the United States, 2007–2010. HIV
surveillance supplemental report, 2012. Vol. 17. Atlanta, GA: US Department
of Health and Human Services, CDC; 2012. Available at http://www.cdc.
gov/hiv/surveillance/resources/reports/2010supp_vol17no4.
3. Office of National AIDS Policy. National HIV/AIDS strategy for the
United States. Washington, DC: Office of National AIDS Policy; 2010.
Available at http://www.whitehouse.gov/administration/eop/onap/nhas.
4. CDC. Vital signs: HIV prevention through care and treatment—United
States. MMWR 2011;60:1618–23.

Morbidity and Mortality Weekly Report

QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Percentage of Adults Aged ≥65 Years Who Had Ever Received a
Pneumococcal Vaccination,* by Selected Race/Ethnicity† —
National Health Interview Survey, United States, 2000–2011§
100
White, non-Hispanic

90

Black, non-Hispanic
Hispanic

80
70

Percentage

60
50
40
30
20
10
0
2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Year
* Based on a survey question that asked respondents, “Have you ever had a pneumonia shot? This shot is usually
given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal
vaccine.” Unknowns were not included in the denominators when calculating percentages.
† Persons of Hispanic ethnicity might be of any race or combination of races.
§ Estimates were based on household interviews of a sample of the U.S. civilian, noninstitutionalized population
included in the National Health Interview Survey.

The percentage of adults aged ≥65 years who had ever received a pneumococcal vaccination increased from 56.8% in 2000 to
66.5% in 2011 among non-Hispanic whites, from 30.5% in 2000 to 47.6% in 2011 among non-Hispanic blacks, and from 30.4%
in 2000 to 43.1% in 2011 among Hispanics. Throughout 2000–2011, the percentage who had ever received a pneumococcal
vaccination was higher among non-Hispanic white adults aged ≥65 years than among Hispanics and non-Hispanic blacks.
Source: National Health Interview Survey, 2001–2011 sample adult core component. Available at http://www.cdc.gov/nchs/nhis.htm.
Reported by: Lindsey I. Jones, MPH, [email protected], 301-458-4548; Jeannine S. Schiller, MPH.

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