Social Vulnerability, Intervention Utilization, and Outcomes in US Adults Hospitalized With Influenza
Authors: Adams Katherine , Yousey-Hindes Kimberly , Bozio Catherine H. , Jain Seema , Kirley Pam Daily , Armistead Isaac , Alden Nisha B. , Openo Kyle P. , Witt Lucy S. , Monroe Maya L. , Kim Sue , Falkowski Anna , Lynfield Ruth , McMahon Melissa , Hoffman Marisa R. , Shaw Yomei P. , Spina Nancy L. , Rowe Adam , Felsen Christina B. , Licherdell Erin , Lung Krista , Shiltz Eli , Thomas Ann , Talbot H. Keipp , Schaffner William , Crossland Melanie T. , Olsen Kristen P. , Chang Larry W. , Cummings Charisse N. , Tenforde Mark W. , Garg Shikha , Hadler James L. , O’Halloran Alissa 
Published: November 2024

Importance

Seasonal influenza is associated with substantial disease burden. The relationship between census tract–based social vulnerability and clinical outcomes among patients with influenza remains unknown.

Objective

To characterize associations between social vulnerability and outcomes among patients hospitalized with influenza and to evaluate seasonal influenza vaccine and influenza antiviral utilization patterns across levels of social vulnerability.

Design, Setting, and Participants

This retrospective repeated cross-sectional study was conducted among adults with laboratory-confirmed influenza-associated hospitalizations from the 2014 to 2015 through the 2018 to 2019 influenza seasons. Data were from a population-based surveillance network of counties within 13 states. Data analysis was conducted in December 2023.

Exposure

Census tract–based social vulnerability.

Main Outcomes and Measures

Associations between census tract–based social vulnerability and influenza outcomes (intensive care unit admission, invasive mechanical ventilation and/or extracorporeal membrane oxygenation support, and 30-day mortality) were estimated using modified Poisson regression as adjusted prevalence ratios. Seasonal influenza vaccine and influenza antiviral utilization were also characterized across levels of social vulnerability.

Results

Among 57 964 sampled cases, the median (IQR) age was 71 (58-82) years; 55.5% (95% CI, 51.5%-56.0%) were female; 5.2% (5.0%-5.4%) were Asian or Pacific Islander, 18.3% (95% CI, 18.0%-18.6%) were Black or African American, and 64.6% (95% CI, 64.2%-65.0%) were White; and 6.6% (95% CI, 6.4%-68%) were Hispanic or Latino and 74.7% (95% CI, 74.3%-75.0%) were non-Hispanic or Latino. High social vulnerability was associated with higher prevalence of invasive mechanical ventilation and/or extracorporeal membrane oxygenation support (931 of 13 563 unweighted cases; adjusted prevalence ratio [aPR], 1.25 [95% CI, 1.13-1.39]), primarily due to socioeconomic status (790 of 11 255; aPR, 1.31 [95% CI, 1.17-1.47]) and household composition and disability (773 of 11 256; aPR, 1.20 [95% CI, 1.09-1.32]). Vaccination status, presence of underlying medical conditions, and respiratory symptoms partially mediated all significant associations. As social vulnerability increased, the proportion of patients receiving seasonal influenza vaccination declined (−19.4% relative change across quartiles; P &amp;lt; .001) as did the proportion vaccinated by October 31 (−6.8%; P &amp;lt; .001). No differences based on social vulnerability were found in in-hospital antiviral receipt, but early in-hospital antiviral initiation (−1.0%; P = .01) and prehospital antiviral receipt (−17.3%; P &amp;lt; .001) declined as social vulnerability increased.

Conclusions and Relevance

In this cross-sectional study, social vulnerability was associated with a modestly increased prevalence of invasive mechanical ventilation and/or extracorporeal membrane oxygenation support among patients hospitalized with influenza. Contributing factors may have included worsened baseline respiratory health and reduced receipt of influenza prevention and prehospital or early in-hospital treatment interventions among persons residing in low socioeconomic areas.