The role of attitudes in understanding disparities in adult influenza vaccination

Pneumococcal polysaccharide vaccination among adults aged 65 years and older, U.S., 1989-2008

BACKGROUND

The 23-valent pneumococcal polysaccharide vaccine (PPSV23) has been recommended for all people aged ≥65 years in the U.S. since 1983; consistent surveillance for vaccine coverage has been conducted since 1989.

PURPOSE

To assess PPSV23 vaccination coverage among adults aged ≥65 years in the U.S.

METHODS

The data were analyzed from the 1989, 1991, 1993-1995, and 1997-2008 National Health Interview Surveys in 2009. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with receiving PPSV23 in 2008. Missed opportunities for vaccination were also assessed.

RESULTS

Among people aged ≥65 years, PPSV23 coverage increased from 14.1% in 1989 to 60.1% in 2008. On average, vaccination coverage increased by 3.5% annually during 1989-2000 compared with 1.0% during 2001-2008. In 2008, coverage was significantly higher for people aged 75-84 years (68.8%), and ≥85 years (69.0%) compared with those aged 65-74 years (52.5%). Coverage was significantly higher for non-Hispanic whites (64.3%) compared with non-Hispanic blacks (44.6%) and those with Hispanic ethnicity (36.4%). Among people aged ≥65 years who reported never receiving PPSV23, 90.6% reported at least one missed opportunity. Characteristics independently associated with increased likelihood of ever receiving PPSV23 were higher age, female, non-Hispanic white race/ethnicity, not employed, higher education level, more physician visits in the past year, hospitalized within past year, having Medicare and other supplemental health insurance, and having a chronic medical condition.

CONCLUSIONS

National PPSV23 coverage among people aged ≥65 years increased substantially until 2000, but the rate of increase was smaller after 2000 and coverage in 2008 remained well below the national Healthy People 2010 target of 90%. Increased efforts to avoid missed opportunities for pneumococcal vaccination are needed, especially among minority populations.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other interventions.

Effective health risk communication about pandemic influenza for vulnerable populations

The consequences of pandemic influenza for vulnerable populations will depend partly on the effectiveness of health risk communications. Strategic planning should fully consider how life circumstances, cultural values, and perspectives on risk influence behavior during a pandemic. We summarize recent scientific evidence on communication challenges and examine how sociocultural, economic, psychological, and health factors can jeopardize or facilitate public health interventions that require a cooperative public. If ignored, current communication gaps for vulnerable populations could result in unequal protection across society during an influenza pandemic. We offer insights on communication preparedness gleaned from scientific studies and the deliberations of public health experts at a meeting convened by the Centers for Disease Control and Prevention, May 1 and 2, 2008.

Does receipt of seasonal influenza vaccine predict intention to receive novel H1N1 vaccine: evidence from a nationally representative survey of U.S. adults

We analyze data on the intention of U.S. adults to receive novel H1N1 vaccine if available this fall, and studies the relationship between the intention to be vaccinated against novel H1N1 and the uptake of seasonal influenza vaccine last year. We surveyed a nationally representative sample of U.S. adults (n=2067) via the Internet between May 26th and June 8th, 2009. Our results imply a vaccination rate for novel H1N1 of 49.6%, which corresponds to roughly 115 million adult vaccinations. Moreover, novel H1N1 vaccination intentions are strongly associated with seasonal influenza vaccinations, suggesting common attitudinal barriers to both vaccines.

Pertussis immunization in a high-risk postpartum population

We provided CDC recommended postpartum tetanus, diphtheria, acellular pertussis (Tdap) immunization to medically underserved, uninsured women in Houston through a standing order protocol. From January 7-April 30, 2008, 1129 of 1570 (72%) postpartum women (93% Hispanic; 11% < or = 19 years) received Tdap before hospital discharge. Tdap uptake was 96.2% in women without self-reported contraindications. Recall of immunization history was inaccurate in 32% of unimmunized women who reported receiving antepartum immunization. Black women refused Tdap more often than other ethnicities (24% versus 8%; P=0.003). Postpartum Tdap immunization was successfully implemented in a high-risk population through a standing order protocol. Barriers to postpartum immunization include inaccurate immunization history and the need for ongoing targeted education.

Willingness to vaccinate and to be vaccinated in adults

Vaccination may be mandated by regulation, as in some national infant vaccination programs, encouraged by health authorities, as in 'Flu vaccine campaigns for adults aged 60 years and older, or linked to the informed decision of individuals. Other methods include promotion by incentives to general practitioners, and recommendations from healthcare workers. All these factors contribute to variable vaccine coverage between countries and between different age and socio-economic groups. Many other factors, including providers' patient-oriented interventions and reimbursement issues play an important role in determining the level of vaccine uptake in a given population for a particular disease. However, the first step in vaccination campaigns is to give motivating information to healthcare workers that the benefits of being vaccinated outweigh possible inconvenience or adverse reactions. The information must be complete and accurate.When it has been ascertained that this information is understood and accepted, a system providing cheap and easy vaccination must be organised. Special groups such as the house-bound will need particular attention, appropriate information, and be included in free vaccination schemes. It should be acknowledged that social pressure often influences (positively or negatively) the decision of the individual. Lastly, a massive but objective information campaign is needed for the whole population, each and every visit to a health clinic being treated as an opportunity to check vaccination status and to vaccinate immediately if necessary. Simultaneous vaccination with two or more vaccines increases the chances of reaching the required population cover.

Using theoretical constructs to identify key issues for targeted message design: African American seniors' perceptions about influenza and influenza vaccination

African American seniors (65 and older) are less likely to be vaccinated against influenza than are non-Hispanic White seniors. There is a clear need for targeted messages and interventions to address this disparity. As a first step, 6 focus groups of African American seniors (N = 48) were conducted to identify current perceptions about influenza and influenza vaccination. Emergent thematic categories were organized using the 4 main constructs of the extended parallel process model. Susceptibility varied based on perceptions of individual health status, background knowledge, and age-related risk. Some participants saw influenza as a minor nuisance; others viewed it as threatening and potentially deadly. Participants discussed issues related or antecedent to self-efficacy, including vaccine accessibility and affordability. Regarding response efficacy, some participants had confidence in the vaccine, some questioned its preventive ability or believed that the vaccine caused influenza, and others noted expected side effects. Implications and recommendations for message development are discussed.

Influenza vaccination of recommended adult populations, U.S., 1989-2005

OBJECTIVE

To assess influenza vaccination coverage among recommended adult populations in the United States.

METHODS

Data from the 1989 to 2005 National Health Interview Surveys (NHISs), weighted to reflect the civilian, non-institutionalized U.S. population, were analyzed to determine self-reported levels of influenza vaccination among persons aged >or=65 years, persons with high-risk conditions, health care workers (HCW), pregnant women, and persons living in households with at least one identified person at high risk of complications from influenza infection. We stratified data by race/ethnicity to identify racial/ethnic disparities.

RESULTS

Vaccination coverage levels among all recommended adult populations peaked in 2004, then declined in 2005 in association with the 2004-2005 vaccine shortage. Coverage for adults >or=65 years of age increased from 30.1% (95% confidence interval [CI]: 28.8-31.3) in 1989 to 70.0% (68.0-71.5) in 2004. In 2004, coverage was 40.7% (39.0-42.5) for all adults 50-64 years, 27.2% (24.6-29.9) for adults aged 18-49 years with high-risk conditions, 43.2% (39.9-46.6) for health care workers, 21.1% (19.1-23.4) for non-high-risk adults aged 18-64 years with a high-risk household member, and 14.4% (8.8-22.9) for pregnant women. Among each of the recommended adult sub-groups, vaccination coverage was higher for non-Hispanic whites compared to minority groups.

CONCLUSIONS

By 1997, influenza vaccination coverage had exceeded the national 2000 objective of 60% among persons aged >or=65 years, but by 2004 still remains well below the national 2010 target of 90%. Coverage levels for other groups targeted for influenza vaccination also are far short of the Healthy People 2000 and 2010 goals of 60% for persons aged 18-64 years with high-risk conditions, health care workers, and pregnant women. A concerted effort to increase provider adoption of standards for adult immunization, public awareness, and stable vaccine supplies are needed to improve influenza vaccination rates among recommended groups, and to reduce racial and ethnic disparities.

Impact of influenza vaccination disparities on elderly mortality in the United States

PURPOSE

Racial and ethnic disparities in influenza vaccination among the elderly are well documented, but their impact on minority mortality is unknown.

METHODS

We model racial and ethnic parity in influenza vaccination on reduction in annual minority deaths among the elderly using age-, sex-, race-, and ethnicity-specific influenza vaccination data from the 2002 Medicare Current Beneficiary Survey, national mortality data and a relative risk (0.89; 95% confidence interval 0.80-0.98) for all-cause mortality during influenza season associated with vaccination. We also estimate the impact of 90% influenza coverage (Healthy People 2010 objective) on annual minority and white deaths. Lastly, we estimate years of minority lives saved from parity in annual vaccination beginning at age 65.

RESULTS

Parity in influenza vaccination would reduce elderly minority deaths by 1880 annually. Achievement of 90% vaccination coverage would reduce minority and White deaths by 3750 and 11,840 annually. Parity in vaccination beginning at age 65 and continuing through out life would save more than 33,000 minority years of life.

CONCLUSIONS

Based on conservative estimates, elimination of racial and ethnic disparities in influenza vaccination would significantly reduce elderly minority mortality and save substantial years of minority life.

Strategies for improving influenza immunization rates among hard-to-reach populations

Whereas considerable attention has been devoted to achieving high levels of influenza immunization, the importance of this issue is magnified by concern over pandemic influenza. Most recommendations for vaccine administration address high risk groups such as the elderly and those with chronic diseases, but coverage for hard-to-reach (HTR) populations has had less attention. HTR populations include minorities but also include other primarily urban groups such as undocumented immigrants, substance users, the homeless, and homebound elderly. Obstacles to the provision of immunization to HTR populations are present at the patient, provider, and structural levels. Strategies at the individual level for increasing immunization coverage include community-based educational campaigns to improve attitudes and increase motivation for receiving vaccine; at the provider level, education of providers to encourage immunizations, improving patient-provider interactions, broadening the provider base to include additional nurses and pharmacists, and adoption of standing orders for immunization administration; and at the structural level, promoting wider availability of and access to vaccine. The planning process for an influenza pandemic should include community engagement and extension of strategies beyond traditional providers to involve community-based organizations addressing HTR populations.