Could Emergency Rooms Close Vaccination Gaps? A 2024 Survey in Eight U.S. Cities

Checking whether patients are up to date on vaccines, and counseling them about what they need, is a basic part of primary care. But about one-third of U.S. adults get no primary health care at all, so they rarely, if ever, have their vaccinations reviewed. For millions of people, the emergency department (ED) is their only point of contact with the health system. Meanwhile, the list of CDC-recommended vaccines has grown over the past two decades — shingles, RSV and COVID-19 among them — with recommendations that vary by age and risk, making the schedule harder to follow.

In two earlier ED trials, COVID-19 and flu vaccine messaging raised vaccine acceptance and receipt among underserved patients twofold to threefold. A study published in CDC's MMWR asked a broader question: what do ED patients know about all the recommended adult vaccines, which have they had, and would they accept the missing ones during their ED visit?

The survey

From April 18 to December 31, 2024, researchers surveyed non–critically ill adults at 10 EDs in eight cities in five states: Chicago; Detroit; Durham, North Carolina; Fresno, Los Angeles, San Francisco and Sylmar, California; and Philadelphia. Patients answered age-specific questions, in English, Spanish or (at two sites) Mandarin, about each vaccine CDC recommended for their age group as of April 2024: had they heard of it, had they received it, why not, and would they accept missing vaccines that day. Plain language was used — "shingles," not "varicella zoster."

Of 4,326 patients approached, 3,285 (75.9%) took part. About 30% each were Black, non-Hispanic White and Hispanic; 17.9% spoke Spanish as their main language; 7.8% had unstable or marginal housing; and 21.0% had no source of primary care.

What they found

Knowledge gaps were common. About half (49.4%) had never heard of at least one vaccine recommended for their age. Not having heard of one was linked to being male, Black or Hispanic, speaking a language other than English, lacking primary care, and being uninsured.

Most were missing something. 85.9% had not received at least one recommended vaccine; on average, participants had received about half (51.3%) of the vaccines recommended for them. Being behind was linked to being Black, lacking primary care (adjusted odds ratio 2.91), being uninsured (3.01), being 27 or older, and visiting an ED in Chicago, Detroit or Fresno.

Among vaccines recommended for all ages, 82.6% reported having had a COVID-19 vaccine, 42.9% a tetanus-containing vaccine in the past 10 years, and 41.6% a flu vaccine.

Why they'd missed vaccines: most often, they hadn't heard of the vaccine (40.7%) or hadn't known it was recommended for them (9.6%) — in short, no one had told them or offered it.

Many would say yes in the ED. Of the 2,821 participants not up to date, 1,309 (46.4%) said they would accept at least one missing vaccine during the visit, and 1,135 of them (86.7%) would accept all of them. Only one factor predicted greater willingness: being seen at the Sylmar site. Those who would decline most often said they felt too sick at the time (27.4%) or wanted more information about the vaccines and the diseases they prevent (19.3%).

What it means

Standard surveillance, such as the National Health Interview Survey, misses people whose only health care happens in EDs. Here, up-to-date coverage was lower in every age group than the 22.8% the 2022 National Health Interview Survey reported — though that survey used household interviews, had a lower response rate and left out some vaccines included here. Based on the 1,135 people willing to take every missing vaccine, the authors estimate that up-to-date coverage in this population could, in theory, more than triple, from 14% to as high as 48%.

With 155 million U.S. ED visits in 2022, asking stable adult patients about their vaccines and offering missed doses could raise coverage. Giving every recommended vaccine in the ED is probably impractical, but ED programs that recommend vaccines, counsel patients and refer them to vaccine providers are logical next steps — ideally automated and built into the ED's routine so they don't add to staff workload.

Limitations

Vaccination status was self-reported, not checked against medical records (though other studies find self-reports match records closely), and memories fade — older adults may better remember vaccines they sought out, like shingles shots. Acceptance may differ in other EDs and may have been inflated by people giving the answer they thought was expected.

Sources

• Rodriguez RM, Torres JR, Chinnock B, et al. "Emergency Department Survey of Vaccination Knowledge, Vaccination Coverage, and Willingness to Receive Vaccines in an Emergency Department Among Underserved Populations — Eight U.S. Cities, April–December, 2024," MMWR Vol. 74, No. 29, CDC; a work of the United States government in the public domain.