Influenza vaccination among cancer survivors: disparities in prevalence between blacks and whites

Social determinants of health in post-treatment cancer survivors: Scoping review

PURPOSE

To identify, analyze and describe the available scientific evidence about the influence of social determinants of health on cancer survivors.

METHODS

A scoping review was outlined according to the steps described by the Joanna Brigs Institute Reviewer's Manual: selection of studies, data mapping, and results grouping, synthesis and report, was conducted. PubMed, CINAHL, Scopus and LILACS databases were searched from 2011 to 2023.

RESULTS

Out of a total of 1783 papers initially screened, only 19 studies met the inclusion criteria for the scoping review, focusing on the primary social determinants impacting the health of cancer survivors. These studies were categorized into six main themes: a) employment (challenges in work reintegration and work-place difficulties); b) variations among different ethnic groups; c) disparities based on sex; d) barriers and facilitators in accessing health and social security services; e) the role of support networks and social environments; and f) socioeconomic lever (influence of income and socioeconomic status).

CONCLUSIONS

Understanding the impact of social determinants on the post-treatment quality of life for cancer survivors is crucial. Comprehensive survivorship care should address not just medical needs but also holistic aspects like social support, education, overall well-being, and improvements in physical and social environments. This multifaceted approach ensures the well-rounded support needed for optimal survivorship outcomes.

Vaccination uptake among post-treatment cancer survivors: A multi-vaccine scoping review

BACKGROUND

Our goal was to provide an overview of uptake rates across vaccine types and factors associated with vaccine uptake among cancer survivor populations.

METHODS

A literature search was conducted using Ovid MEDLINE® ALL (Wolters Kluwer), Embase (Elsevier) and CINAHL Complete (EBSCO) databases and according to PRISMA guidelines. Eligible articles were limited to those examining vaccination uptake among cancer survivors who had completed treatment, reported factors associated with uptake (e.g., barriers and facilitators), and published in English between 2011 and 2021. Two independent reviewers screened citations for inclusion and two performed data abstraction, verified by an arbiter.

RESULTS

The search returned 4,215 total articles, and 271 duplicates were removed. During abstract/title screening, 212 articles were identified. Following full-text screening, 47 articles/abstracts were found to meet inclusion criteria, 16 articles/abstracts were removed, and 31 studies were included in the review. Among the 31 studies, participant age ranged from 9 years to adults of all ages. Vaccine types included: influenza (n = 18), human papillomavirus (n = 10), pneumococcal (n = 8), hepatitis A/B (n = 1), shingles (n = 1), measles (n = 1), tetanus/diphtheria (n = 1), and haemophilus influenza B (n = 1). Vaccine uptake varied greatly across studies, vaccine types, and participant populations. Factors affecting vaccination uptake included sociodemographic variables and social determinants of health, health beliefs/attitudes/knowledge, provider recommendation, and cancer treatment/clinical variables.

CONCLUSIONS

Our findings highlight the need for further examining factors associated with vaccine uptake, the need for clinical guidelines that specifically address vaccination among cancer survivors, and potential targets for multi-level interventions to improve vaccination rates among cancer survivor populations.

The coverage of influenza vaccination and predictors of influenza non-vaccination in Danish cancer patients: A nationwide register-based cohort study

BACKGROUND

Influenza vaccination is recommended and provided free-of-charge to Danish citizens aged ≥65 years and to individuals with acquired immunodeficiency. We aimed to estimate influenza vaccination coverage and investigate predictors of influenza non-vaccination in Danish cancer patients.

METHODS

A nationwide cohort study of all Danish citizens aged ≥18 years with an incident cancer diagnosis between 2002 and 2017. Using national registries, we assessed information on influenza vaccination and potential predictors of influenza non-vaccination. We estimated adjusted prevalence ratios (aPR) of influenza non-vaccination for patients aged <65 years and ≥65 years.

RESULTS

We observed 269,863 patients during 840,876 influenza vaccination seasons. The influenza vaccination coverage was 14 % for cancer patients <65 years and 51 % for those ≥65 years. No influenza vaccination in the previous season was associated with non-vaccination in the current season (<65 years: aPR = 2.75, 95 %CI = 2.71-2.80; ≥65 years: aPR = 5.15, 95 %CI = 5.10-5.21). Haematological cancer patients receiving chemotherapy had lower vaccination prevalence compared with those not receiving chemotherapy.

CONCLUSIONS

The influenza vaccination coverage was low among cancer patients. Influenza non-vaccination in the previous season was the strongest predictor of not receiving influenza vaccination in the current season. Haematological cancer patients on current chemotherapy had lower vaccination prevalence than those not currently receiving chemotherapy.

Social determinants of flu vaccine uptake among racial/ethnic minorities in the United States

Research on the social determinants of vaccine uptake often occur between racial/ethnic groups and not within groups. Though minoritized individuals face inequalities across the board, these are also not evenly distributed amongst minoritized individuals within groups. Using the National Health Interview Survey data, we examined disparities in flu vaccine uptake across racial/ethnic groups in the United States (US). We examined (a) NH (non-Hispanic) White (n = 32,655), (b) NH Asian (n = 2335), (c) NH African American (n = 5137), and (d) Hispanic (n = 5718) respondents who lived in the United States using the combined 2017 and 2018. We used multivariable logistic regression to predict flu vaccination (yes/no) both in models comparing racial/ethnic groups and within groups. Less than 50% of any of the four major racial/ethnic groups in the US received a flu vaccination in 2017–18. Flu vaccine uptake varied within racial and ethnic groups. These results suggest that increasing vaccination may require a complex, multi-faceted perspective that considers subgroups more directly.

Structural inequities in seasonal influenza vaccination rates

BACKGROUND

Influenza immunization is a highly effective method of reducing illness, hospitalization and mortality from this disease. However, influenza vaccination rates in the U.S. remain below public health targets and persistent structural inequities reduce the likelihood that Black, American Indian and Alaska Native, Latina/o, Asian groups, and populations of low socioeconomic status will receive the influenza vaccine.

METHODS

We analyzed correlates of influenza vaccination rates using the 2019 Behavioral Risk Factor Surveillance System (BRFSS) in the year 2020. Our analysis compared influenza vaccination as the outcome of interest with the variables age, sex, race, education, income, geographic location, health insurance status, access to primary care, history of delaying care due to cost, and comorbidities such as: asthma, cardiovascular disease, hypertension, body mass index, cancer and diabetes.

RESULTS

Non-Hispanic White (46.5%) and Asian (44.1%) participants are more likely to receive the influenza vaccine compared to Non-Hispanic Black (36.7%), Hispanic (33.9%), American Indian/Alaskan Native (36.6%), and Native Hawaiian/Other Pacific Islander (37.9%) participants. We found persistent structural inequities that predict influenza vaccination, within and across racial and ethnic groups, including not having health insurance [OR: 0.51 (0.47-0.55)], not having regular access to primary care [OR: 0.50 (0.48-0.52)], and the need to delay medical care due to cost [OR: 0.75 (0.71-0.79)].

CONCLUSION

As COVID-19 vaccination efforts evolve, it is important for physicians and policymakers to identify the structural impediments to equitable U.S. influenza vaccination so that future vaccination campaigns are not impeded by these barriers to immunization.

A cross-sectional study of factors associated with influenza vaccination in Korean cancer survivors

OBJECTIVE

To investigate factors associated with influenza vaccination in cancer survivors.

METHODS

Study subjects were 1,945 Korean adult cancer survivors. Through medical record review and self-administered questionnaires, social and medical information was collected. Influenza vaccination was defined as ever having received a flu vaccine between one year before cancer diagnosis and the survey date. Multiple logistic regression analysis was used to evaluate factors associated with influenza vaccination.

RESULTS

Overall, 60.8% of study subjects had received an influenza vaccination. Younger survivors had a significantly lower vaccination rate than did the elderly survivors (80.22% vs. 54.73%). In younger survivors, longer time elapsed since cancer diagnosis, lifestyle modification counselling during cancer treatment, adequate physical exercise (≥150 min/week) and complementary medication use were positively associated with vaccination, whereas extra-pulmonary cancers, multimodality (≥3) cancer treatment and higher educational achievement were inversely associated. In elderly survivors, fewer factors had a positive (adequate physical exercise) or inverse (multimodality cancer treatment and current smoking) association with influenza vaccination.

CONCLUSION

Influenza vaccination rate was suboptimal, especially among younger cancer survivors. Targeted strategies are necessary to improve influenza vaccination in cancer survivors with consideration of individual characteristics such as age, lifestyle, cancer treatment modality, cancer type and education level.

Factors associated with seasonal influenza immunization in people with chronic diseases

Annually, at a global level, 3 to 5 million people present severe clinical forms of seasonal influenza and up to 650 000 people die of influenza-related complications. People with chronic diseases, such as cardiovascular, pulmonary, renal, hepatic, neurologic, hematologic and metabolic diseases or those reciveing immunosuppressive therapy, constitute a high-risk population group for the development of influenza-related complications, more severe clinical course and poorer health-related outcomes. Due to all of the above, people with chronic diseases are of high priority to receive the influenza vaccine. Immunization represents the key strategy to prevent influenza both in terms of effectiveness and health care costs. Based on the World Health Organization (WHO) recommendations, adequate seasonal influenza immunization coverage among people with chronic diseases is set at 75%. However, few countries achieve this threshold. Understanding predictive factors of vaccination, at different levels of health care delivery (such as individuals, service providers, health policy), is essential to secure acceptance of influenza immunization and achieve the recommended level of vaccination coverage. In this mini review, all the available evidence regarding seasonal influenza vaccination coverage is summarized, alongside factors associated with vaccine uptake in people with chronic diseases as a whole, as well as according to specific diseases such as: cardiovascular and pulmonary disorders, diabetes and cancer. Based on the reviewed empirical evidence, a wide spectrum of factors associated with immunization against influneza was found in people who have chronic diseases. Although diverse, these factors can be systematized into 4 distinctive groups: socio-demographic characteristics, individual attitudes and beliefs, health promoting behaviors and factors related to the health care system. Further efforts are needed to improve the seasonal influenza vaccination coverage. The immunization strategy needs to include the health care system and the community to support people with chronic diseases to continously accept the influenza vaccine.

Clinical Preventive Services and Self-Management Practices Among Adult Cancer Survivors in the United States Over Time

The objective of this research was to determine if the engagement/participation in health promotion activities of cancer survivors in the United States (US) changed between 2006 and 2015. We pooled two independent cross-sectional data of cancer survivors using Medical Expenditure Panel Surveys from 2006 (N = 791; weighted N = 9,532,674) and 2015 (N = 1067; weighted N = 15,744,959). Health promoting activities consisted of past year influenza immunization, routine physical examination, and dental visit. Self-care included maintaining normal weight, not smoking, and engagement in recommended vigorous physical activity. We conducted unadjusted and adjusted logistic regression analyses to examine the change in engagement in health promoting activities over time. We found rates of annual influenza immunization (66.8% vs 70.3%), dental visit (71.8% vs 70.3%), and normal weight (33.9% vs 33.5%) did not change from 2006 to 2015. The percent with physical examination (90.8% vs 93.8%; P = .03) and non-smokers increased (87.9% vs 91.2; P = .04). Between 2006 and 2015, despite guidelines and recommendations for personalized cancer survivorship health plans, health promoting activities among cancer survivors did not change significantly.

Prevalence of COVID-19-related risk factors and risk of severe influenza outcomes in cancer survivors: A matched cohort study using linked English electronic health records data

BACKGROUND

People with active cancer are recognised as at risk of COVID-19 complications, but it is unclear whether the much larger population of cancer survivors is at elevated risk. We aimed to address this by comparing cancer survivors and cancer-free controls for (i) prevalence of comorbidities considered risk factors for COVID-19; and (ii) risk of severe influenza, as a marker of susceptibility to severe outcomes from epidemic respiratory viruses.

METHODS

We included survivors (≥1 year) of the 20 most common cancers, and age, sex and general practice-matched cancer-free controls, derived from English primary care data linked to cancer registrations, hospital admissions and death registrations. Comorbidity prevalences were calculated 1 and 5 years from cancer diagnosis. Risk of hospitalisation or death due to influenza was compared using Cox models adjusted for baseline demographics and comorbidities.

FINDINGS

108,215 cancer survivors and 523,541 cancer-free controls were included. Cancer survivors had more diabetes, asthma, other respiratory, cardiac, neurological, renal, and liver diseases, and less obesity, compared with controls, but there was variation by cancer site. There were 205 influenza hospitalisations/deaths, with cancer survivors at higher risk than controls (adjusted HR 2.78, 95% CI 2.04-3.80). Haematological cancer survivors had large elevated risks persisting for >10 years (HR overall 15.17, 7.84-29.35; HR >10 years from cancer diagnosis 10.06, 2.47-40.93). Survivors of other cancers had evidence of raised risk up to 5 years from cancer diagnosis only (HR >5 years 2.22, 1.31-3.74).

INTERPRETATION

Risks of severe COVID-19 outcomes are likely to be elevated in cancer survivors. This should be taken into account in policies targeted at clinical risk groups, and vaccination for both influenza, and, when available, COVID-19, should be encouraged in cancer survivors.

Seasonal influenza vaccination among cancer patients: A systematic review and meta-analysis of the determinants

Cancer patients are among high-risk individuals for whom seasonal influenza vaccine (SIV) is recommended, but rates of vaccination in this subpopulation remain suboptimal; even in jurisdictions with universal influenza vaccination programs. We sought to summarize the evidence to better understand the determinants of SIV uptake (vaccine receipt) among cancer patients. We searched MEDLINE, Embase, and CINAHL from 2000 to February 12, 2020, focusing on articles on the determinants of seasonal influenza vaccination among cancer patients, published in English. Study selection was conducted independently by 2 reviewers. One reviewer extracted data from the included studies and another reviewer checked the extracted data for errors. Outcomes were sociodemographic and health-related factors. We pooled adjusted results from studies using the inverse variance, random-effects method, and reported the odds ratios (OR) and their 95% confidence intervals (CI). Out of 2664 citations, 10 studies (mostly from USA and South Korea) met our eligibility criteria. Overall, being older (OR 2.23, 95% CI 1.46-3.38; I² 92.3%, [6 studies]), a nonsmoker (1.43, 1.32-1.51; I² 0%, [4 studies]), having a chronic illness (1.18, 1.07-1.29; I² 15.7%, [5 studies]), having had a medical check-up in the past year (1.75, 1.65-1.86; I² 0%, [2 studies]), and having health insurance (1.39, 1.13-1.72; I² 21.8%, [3 studies]) were associated with increased SIV uptake. Compared with being African-American, being Caucasian was also associated with increased SIV uptake (1.79, 1.47-2.13; I² 10.7%, [3 studies]). Limited evidence suggests seasonal influenza vaccination among cancer patients may be determined by some sociodemographic and health-related factors.

Trends in Influenza Vaccination Coverage Rates among Korean Cancer Survivors: Analysis of the Korea National Health and Nutrition Examination Survey III-VI

Background

Few studies have reported on the trends in influenza vaccination rates among cancer survivors in Korea. We investigated these trends over a recent 11-year period (2005–2015).

Methods

Data were obtained from the Korea National Health and Nutrition Examination Survey (KNHANES) III– VI (2005–2015). After excluding individuals younger than 40 years of age, the participants included 2,210 cancer survivors (861 men and 1,349 women). We categorized these study participants into four groups according to age and sex.

Results

The influenza vaccination rate decreased significantly among male cancer survivors, with rates of 74.8, 64.7, 56.2, and 55.2% (β coefficient=-0.257, P for trend <0.001) in KNHANES III, VI, V, and VI, respectively. While influenza vaccination rates decreased significantly among older male cancer survivors (≥65 years) (β coefficient=-0.359, P for trend=0.017), they increased among older female cancer survivors (β coefficient=0.375, P for trend=0.011) from 2005 to 2015.

Conclusion

Influenza vaccination rates in older cancer survivors significantly decreased in men but increased in women in successive KNHANES phases. Efforts are needed to improve immunization education and awareness, especially in older male cancer survivors.

Racial disparities in U.S. maternal influenza vaccine uptake: Results from analysis of Pregnancy Risk Assessment Monitoring System (PRAMS) data, 2012-2015

BACKGROUND

Pregnant women are at increased risk of hospitalization, serious complications, poor pregnancy outcomes, and mortality from influenza. Prior research suggests that there are racial/ethnic disparities in vaccination coverage and that a healthcare provider vaccination recommendation is associated with significantly higher vaccine uptake than without such a recommendation. The purpose of this study is to examine racial/ethnic disparities in healthcare providers' recommendations for pregnant women to receive the influenza vaccine and in vaccine uptake.

METHODS

This cross-sectional population-based study analyzed data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System (PRAMS) during 2012-2015 (n = 130161). Both healthcare provider recommendation and vaccine uptake were assessed dichotomously. Logistic regression was conducted to ascertain adjusted odds ratios and 95% confidence intervals, controlling for maternal age, marital status, education, prenatal care utilization, and smoking status.

RESULTS

Influenza vaccine uptake during pregnancy ranged from 39.1% among non-Hispanic (NH) Black women to 55.4% among NH Asian women. In the adjusted analysis, NH Black and NH Asian women had 19% (95% CI 0.75-0.86) and 34% (95% CI 0.61-0.72) decreased odds of receiving a provider recommendation for influenza vaccine during pregnancy, respectively, compared to NH White women. For influenza vaccine uptake, NH Black women were 30% less likely (95% CI 0.65-0.74) to receive influenza vaccine during pregnancy compared to NH White women.

CONCLUSIONS

Our findings indicate that there are racial/ethnic disparities in healthcare provider recommendation and influenza vaccine uptake among pregnant women in the United States. Targeted efforts toward providers and interventions focusing on pregnant women may be warranted to reduce the disparity.

Influenza Among Breast Cancer Survivors in South Korea: A Nationwide Population-Based Study

BACKGROUND/AIM

In this study, we analyzed the prevalence of influenza disease in breast cancer survivors using claims data from the Health Insurance Review and Assessment Service (HIRA) in South Korea.

PATIENTS AND METHODS

We defined influenza among a nationwide cohort of 87,843 patients who were diagnosed with breast cancer and underwent surgery from January 1, 2010 to December 31, 2014, based on HIRA claim data. Descriptive statistics were calculated to estimate the frequency of influenza disease using diagnostic code and utilization pattern at medical institutions.

RESULTS

Two thousand four hundred breast cancer survivors (2.7%) were diagnosed with influenza. The overall frequency of influenza increased from November (n=98) and peaked in February (n=1,745). Over 60% (2,693) of claims for influenza disease treatment were in the clinic, whereas general hospitals accounted for 22.0% (873). Among 3,967 claims, admission rate was 7.6% (n=301) and the average length of hospitalization was 4.7 days. Elderly breast cancer survivors over 70 years old had the longest length of hospitalization at 5.9 days.

CONCLUSION

Breast cancer survivors are more susceptible to influenza than non-cancer survivors. It is important not only to raise the vaccination rate among young cancer survivors, but also to quickly identify symptoms and begin treatment for flu in elderly cancer survivors.

Barriers of Influenza Vaccination Intention and Behavior - A Systematic Review of Influenza Vaccine Hesitancy, 2005 - 2016

BACKGROUND

Influenza vaccine hesitancy is a significant threat to global efforts to reduce the burden of seasonal and pandemic influenza. Potential barriers of influenza vaccination need to be identified to inform interventions to raise awareness, influenza vaccine acceptance and uptake.

OBJECTIVE

This review aims to (1) identify relevant studies and extract individual barriers of seasonal and pandemic influenza vaccination for risk groups and the general public; and (2) map knowledge gaps in understanding influenza vaccine hesitancy to derive directions for further research and inform interventions in this area.

METHODS

Thirteen databases covering the areas of Medicine, Bioscience, Psychology, Sociology and Public Health were searched for peer-reviewed articles published between the years 2005 and 2016. Following the PRISMA approach, 470 articles were selected and analyzed for significant barriers to influenza vaccine uptake or intention. The barriers for different risk groups and flu types were clustered according to a conceptual framework based on the Theory of Planned Behavior and discussed using the 4C model of reasons for non-vaccination.

RESULTS

Most studies were conducted in the American and European region. Health care personnel (HCP) and the general public were the most studied populations, while parental decisions for children at high risk were under-represented. This study also identifies understudied concepts. A lack of confidence, inconvenience, calculation and complacency were identified to different extents as barriers to influenza vaccine uptake in risk groups.

CONCLUSION

Many different psychological, contextual, sociodemographic and physical barriers that are specific to certain risk groups were identified. While most sociodemographic and physical variables may be significantly related to influenza vaccine hesitancy, they cannot be used to explain its emergence or intensity. Psychological determinants were meaningfully related to uptake and should therefore be measured in a valid and comparable way. A compendium of measurements for future use is suggested as supporting information.

A Population-Based, Nationwide Cross-Sectional Study on Influenza Vaccination Status among Cancer Survivors in Korea

Cancer survivors are at increased risk of developing influenza-related complications. The purpose of this study was to investigate the vaccination coverage among cancer survivors in Korea using the Korea National Health and Nutrition Examination Survey (KNHANES). Adult cancer survivors were selected from fourth (2007–2009) and fifth (2010–2012) KNHANES (n = 1156) datasets. General characteristics, cancer-related data, and influenza vaccination status were collected using self-report questionnaires. Chi-square tests and multiple logistic regression analyses were performed to investigate the association between influenza vaccination coverage and associated factors. Overall, 51% of survivors were vaccinated. Vaccine prevalence exceeded 75% in those more than 65 years but was only 26% in survivors aged 19–44. Increasing age, low frequency of alcohol consumption, having poor self-rated health, and having a shorter duration since cancer diagnosis were significant predictors of vaccination status among cancer survivors under 65 years of age. Influenza vaccine coverage remains much lower than recommended among cancer survivors, particularly in the younger age groups. Further study is needed to determine the factors that contribute to the lack of vaccination in cancer survivors, despite their increased risk for influenza.

Influenza vaccination coverage among adult survivors of pediatric cancer

BACKGROUND

A large proportion of long-term survivors of childhood cancer have treatment-related adverse cardiac and pulmonary late-effects, with related mortality. Consequently, this population of approximately 379,000 individuals in the U.S. is at high risk of complications from influenza infections.

PURPOSE

To estimate influenza vaccination coverage overall and among subgroups of adult survivors of pediatric cancer aged 18-64 years and to compare coverage with the general adult U.S. population.

METHODS

Data from the 2009 Behavioral Risk Factor Surveillance System were analyzed in 2013 using binomial regression to estimate influenza vaccination coverage differences (CDs) and corresponding 95% confidence limits (CLs) between adult survivors of pediatric cancer and the general U.S. population. Analyses were stratified by demographic characteristics and adjusted for design effects, non-coverage, and non-response.

RESULTS

Influenza vaccination coverage was 37% for adult pediatric cancer survivors overall and 31% for the general adult U.S. population (CD=6.3%, 95% CL=0.04%, 13%). Dramatically lower coverage was observed for non-Hispanic black survivors (6%) than for non-Hispanic blacks in the general U.S. population (26%; CD=-18%, 95% CL=-25%, -11%).

CONCLUSIONS

Although influenza vaccination coverage was modestly higher among adult survivors of pediatric cancer than the general U.S. population, coverage was less than desirable for a population with a high prevalence of cardiopulmonary conditions and early mortality, and far lower than the Healthy People 2010 goal of 60% or Healthy People 2020 goal of 80% for the general population.

Influenza vaccination in patients with diabetes: disparities in prevalence between African Americans and Whites

Background

Patients with diabetes who contract influenza are at higher risk of complications, such as hospitalization and death. Patients with diabetes are three times more likely to die from influenza complications than those without diabetes. Racial disparities among patients with diabetes in preventive health services have not been extensively studied.

Objective

To compare influenza vaccination rates among African Americans and Whites patients with diabetes and investigate factors that might have an impact on racial disparities in the receipt of influenza vaccinations.

Methods

A secondary data analysis of 47,283 (unweighted) patients with diabetes from the 2011 Behavioral Risk Factor Surveillance System survey (BRFSS) (15,902,478 weighted) was performed. The survey respondents were asked whether they received an influenza vaccination in the last twelve months. We used logistic regression to estimate the odds of receiving the influenza vaccine based on race.

Results

The results indicated a significantly lower proportion of African Americans respondents (50%) reported receiving the influenza vaccination in the last year when compared with Whites respondents (61%). Age, gender, education, health care coverage, health care cost, and employment status were found to significantly modify the effect of race on receiving the influenza vaccination.

Conclusions

This study found a significant racial disparity in influenza vaccination rates in adults with diabetes with higher rates in Whites compared to African Americans individuals. The public health policies that target diabetes patients in general and specifically African Americans in the 65+ age group, women, and homemakers, may be necessary to diminish the racial disparity in influenza vaccination rates between African Americans and Whites diabetics.