Research Letter | Public Health

Association of COVID-19 Vaccination With Influenza Vaccine History

and Changes in Influenza Vaccination
Andrew M. Parker, PhD; Samer Atshan, MPA; Matthew M. Walsh, PhD; Courtney A. Gidengil, MD, MPH; Raffaele Vardavas, PhD

Introduction + Supplemental content

Understanding willingness to receive new vaccines is critical for vaccine rollout and addressing Author affiliations and article information are
1 listed at the end of this article.
vaccine hesitancy. Future COVID-19 and influenza vaccination may coincide, creating a need to
understand the dynamics between ongoing vaccine adherence for familiar diseases and novel
vaccine acceptance. We combine longitudinal data with a classification of individual influenza
vaccination histories2 to answer 2 questions: (1) how COVID-19 vaccination differs across historical
influenza vaccination patterns, and (2) how influenza vaccination changed during the COVID-19
pandemic.

Methods
This survey study’s longitudinal survey data came from RAND’s American Life Panel (ALP), a
probability-sampled panel of US adults. Walsh and colleagues2 analyzed ALP self-reported
vaccination across 6 influenza seasons spanning 2009 to 2017. Modeling individuals’ year-to-year
tendency to repeat prior vaccination behaviors, panelists were classified as never, sometimes, or
always influenza vaccinators.2 Subsequent influenza vaccination behavior (2019 to 2020) was
assessed in May to June 2020 (N = 1643; 85% completion), which was largely prepandemic.
COVID-19 vaccination, along with 2020 to 2021 and 2021 to 2022 influenza vaccination, was
assessed in February to March 2022 (N = 2145; 68.8% completion). COVID-19 vaccination is
operationalized as fully vaccinated (primary series, meaning single dose Janssen/Johnson & Johnson
or 2 doses Pfizer/BioNTech or Moderna) vs not; boosters are not considered. Race and ethnicity were
self-reported. An analytic sample of 1366 respondents have complete data. Sampling weights were
applied for all analyses. Recruitment and retention are detailed in the eMethods of the Supplement.
Online consent was obtained in accordance with study approval by RAND’s Human Subjects
Protection Committee. Our approach followed the (AAPOR) reporting guideline. Two-sided P < .05
was considered statistically significant. Analyses were performed from June to September 2022.

Results
Among the 1366 survey respondents, 771 (56%) were female, 33 (2%) were Asian, 101 (7%) were
Black, 156 (11%) were Hispanic, and 1161 (85%) were White; mean (SD) age was 56 (13) years. Table 1

Table 1. Proportion Receiving Influenza and COVID-19 Vaccines by Individual Influenza Vaccination History

Individual influenza vaccination history (2009-2017), No. (%)

Never vaccinate Sometimes vaccinate Always vaccinate
Vaccine received, No. 642 367 358
2019-20 influenza 130 (20.3) 253 (68.9) 330 (92.2)
2020-21 influenza 151 (23.5) 233 (63.7) 312 (87.2)
2021-22 influenzaa 147 (22.9) 205 (56.0) 291 (81.4)
Primary COVID-19 vaccine seriesa 413 (64.3) 294 (80.2) 319 (89.0) a
As of February-March 2022.

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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 JAMA Network Open | Public Health Association of COVID-19 Vaccination With Influenza Vaccine History and Changes in Influenza Vaccination

describes how historical influenza vaccination classification was associated with later influenza and
COVID-19 vaccination. For example, 81.4% (291 of 358) to 92.2% (330 of 358) of individuals classified
as always influenza vaccinators through 2017 continued to vaccinate against influenza 2 to 4
influenza seasons later. Conversely, 20.3% (130 of 642) of individuals classified as never influenza
vaccinators through 2017 got influenza vaccination in 2019-2020, which was largely prepandemic;
this increased to 23.5% (151 of 642) during the pandemic. Individuals classified as always influenza
vaccinators were 24.7% more likely to get COVID-19 vaccination vs never influenza vaccinators.
Overall, the probability of full COVID-19 vaccination was 50% higher if the respondent reported
getting the influenza vaccine in the 2021-2022 season (90.9% [858 of 944] vs 60.9% [440 of 723];
risk ratio [RR], 1.50; 95% CI, 1.40-1.59). Conversely, 2021-2022 influenza vaccination was 230%
higher if the respondent reported getting a full initial COVID-19 vaccine (57.1% [585 of 1025] vs 17.3%
[59 of 341]; RR, 3.30 [95% CI, 2.65-4.27]).
Table 2 focuses only on panelists classified as never influenza vaccinators through 2017. Those
receiving the COVID-19 vaccine were significantly more likely to have switched from not receiving (in
2020) to receiving (in 2022) the influenza vaccine (OR, 12.82; 95% CI, 1.46-112.67). Both outcomes
were more likely among more educated. Identifying as Democrat (vs Republican) was associated
with COVID-19 vaccination (OR, 4.43; 95% CI, 1.51-12.97), but not associated with switching from no
influenza vaccination to influenza vaccination.

Table 2. Weighted Logistic Regressions Estimating COVID-19 Vaccination and Change in Influenza Vaccination
During the Pandemic Among Those Who Historically Were Never Vaccinated

OR (95% CI)
Model 1: Received full primary series Model 2: Received flu shot in 2022
Variables of COVID-19 vaccine but not in 2020
Received 2021-2022 flu vaccine 4.26 (0.72-25.16) NA
Received 2020-2021 flu vaccine 1.76 (0.36-8.56) NA
Received 2019-2020 flu vaccine 1.04 (0.21-5.25) NA
Received full primary series of NA 12.82 (1.46-112.67)
COVID-19 vaccine
Female 0.44 (0.21-0.92) 1.89 (0.71-5.02)
Age 1.02 (1.00-1.05) 1.03 (1.00-1.06)
Married 2.19 (0.85-5.62) 3.95 (1.04-14.95)
Urban 1.77 (0.77-4.09) 0.54 (0.20-1.49)
Hispanic 0.93 (0.34-2.57) 4.84 (1.05-22.26)
Race
White [Reference] [Reference]
Asiana NA 0.08 (0.01-0.64)
Black 0.72 (0.22-2.32) 0.44 (0.11-1.78)
Otherb 1.54 (0.14-16.85) 0.04 (0.00-0.36)
Education
High school or less [Reference] [Reference]
Some college 1.04 (0.40-2.69) 0.64 (0.13-3.24)
BS or more 6.46 (2.79-14.94) 3.72 (1.07-12.91)
Unemployed 1.00 (0.24-4.18) 11.42 (1.81-72.09)
Political affiliation
Republican [Reference] [Reference] Abbreviations: OR, odds ratio.
a
Democrat 4.43 (1.51-12.97) 1.65 (0.59-4.58) Coefficient on Asian race category was not defined
because all Asian individuals in the sample received
Independent 2.19 (0.89-5.38) 2.33 (0.64-8.52)
full primary series of the COVID-19 vaccine.
Other 4.55 (0.85-24.38) 24.70 (4.43-137.84)
b
Includes American Indian or Alaska Native and self-
Not sure 1.40 (0.42-4.69) 1.49 (0.15-14.84)
reported other.

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 JAMA Network Open | Public Health Association of COVID-19 Vaccination With Influenza Vaccine History and Changes in Influenza Vaccination

Discussion
This survey study uses a historical data set that classifies influenza vaccination behavior across 8
years,2 following these same individuals up to 5 years later. The results of this study are limited by
self-reported vaccination, the validity of which is supported by past research.3
COVID-19 vaccination was highest among those who historically always received the influenza
vaccine, reinforcing studies showing shorter-term correlation between influenza and COVID-19
vaccination.4,5 Most strikingly, among individuals who historically never got the influenza vaccine,
those receiving COVID-19 vaccine were substantially more likely to switch toward getting the
influenza vaccine. This suggests that investing in vaccine acceptance has payoffs beyond the
vaccine itself.

ARTICLE INFORMATION
Accepted for Publication: September 30, 2022.
Published: November 14, 2022. doi:10.1001/jamanetworkopen.2022.41888
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Parker AM
et al. JAMA Network Open.
Corresponding Author: Andrew M. Parker, PhD, RAND Corporation, 4570 Fifth Ave, Ste 600, Pittsburgh, PA
15213-2665 (parker@rand.org).
Author Affiliations: RAND Corporation, Pittsburgh, Pennsylvania (Parker, Walsh); Pardee RAND Graduate School,
Santa Monica, California (Atshan); RAND Corporation, Boston, Massachusetts (Gidengil); RAND Corporation, Santa
Monica, California (Vardavas).
Author Contributions: Dr Parker had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Parker, Gidengil, Vardavas.
Acquisition, analysis, or interpretation of data: Parker, Atshan, Gidengil, Walsh.
Drafting of the manuscript: Parker, Atshan.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Parker, Atshan, Gidengil, Walsh.
Obtained funding: Parker, Vardavas.
Administrative, technical, or material support: Parker, Gidengil.
Supervision: Parker.
Conflict of Interest Disclosures: Dr Parker reported receiving a cooperative agreement with the Centers for
Disease Control and Prevention (CDC) and grants from the National Science Foundation outside the submitted
work. Mr Atshan reported receiving a cooperative agreement from the CDC and grants from the National Science
Foundation outside the submitted work. Dr Gidengil reported receiving grants from the CDC outside the submitted
work. No other disclosures were reported.
Funding/Sponsor: This study was funded by the National Institutes of Health (NIH) National Institute of Allergy
and Infectious Diseases (NIAID) (grant Nos. R01AI118705 and R01AI160240).
Role of the Funder/Sponsor: The funders had no role in design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or
decision to submit the manuscript for publication.

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behavior over time: a longitudinal analysis of individuals across eight years. Ann Behav Med. 2020;54(10):
783-793. doi:10.1093/abm/kaaa017
3. Mangtani P, Shah A, Roberts JA. Validation of influenza and pneumococcal vaccine status in adults based on
self-report. Epidemiol Infect. 2007;135(1):139-143. doi:10.1017/S0950268806006479

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SUPPLEMENT.
eMethods. Supplementary Materials

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