Adult vaccination disparities among foreign-born populations in the U.S., 2012

Disparities in HPV Vaccination Among Adolescents by Health Care Facility Type

Importance

Approximately 31 000 cases of human papillomavirus (HPV)-associated cancers are diagnosed annually in the US. The HPV vaccine can prevent more than 90% of these cancers, yet national uptake remains lower than the Healthy People 2030 target of 80% completion. To devise targeted interventions to increase the uptake of HPV vaccines, it is crucial to understand the vaccination rates across various health care settings.

Objective

To examine the association between health care facility type and adolescent HPV vaccine uptake and clinician recommendation for the vaccine in the US.

Design, Setting, and Participants

This cross-sectional study uses a complex sampling design of data from the 2020 National Immunization Survey-Teen. The study included adolescents aged 13 to 17 years. The data analysis was completed between March 1 and May 31, 2022.

Exposure

Health care facility type classified as public, hospital-based, private, mixed (more than 1 type), and other facilities (eg, military health care facility; Women, Infants, and Children clinic; school-based health center; pharmacy).

Main Outcomes and Measures

Initiation of HPV vaccination was defined as the receipt of at least 1 dose of the HPV vaccine and completion as receipt of at least 2 or 3 doses, depending on age of initiation. Parent or guardian self-reported clinician recommendation was categorized as yes or no. Weighted, multivariable logistic regression models were used to estimate the odds of initiating and completing the HPV vaccine series and receiving clinician recommendation by health care facility type adjusted for adolescent and maternal characteristics.

Results

A total of 20 162 adolescents (mean [SD] age, 14.9 [1.4] years; 51.0% male) were included. Clinician recommendation for the HPV vaccine was received by 81.4% of adolescents, and 75.1% initiated and 58.6% completed the HPV vaccine series. In the adjusted analyses, adolescents who received recommended vaccinations at public facilities had lower odds of initiating (adjusted odds ratio [AOR], 0.71; 95% CI, 0.58-0.88) and completing (AOR, 0.62; 95% CI, 0.51-0.76) HPV vaccination compared with those who received recommended vaccinations at private facilities. Similarly, adolescents who received recommended vaccinations at public facilities (AOR, 0.62; 95% CI, 0.51-0.77) had lower odds of receiving a clinician recommendation for the HPV vaccine compared with those who received recommended vaccinations at private facilities.

Conclusions and Relevance

These findings reveal health disparities in HPV vaccination among adolescent populations served by public health care facilities, suggesting that a greater focus is needed on vaccine recommendations and uptake in public facilities.

Pivoting From Influenza to COVID-19 Vaccinations: How a Minnesota Vaccination Program Reduced Barriers for Refugee, Immigrant, and Migrant Communities Accessing Vaccines During the COVID-19 Pandemic

The Minnesota Immunization Networking Initiative (MINI) led by Fairview Health Services has addressed barriers to accessing immunizations through partnerships with community organizations to provide free influenza vaccinations to historically underserved communities, especially refugee, immigrant, and migrant communities. Once the COVID-19 vaccine was available, MINI quickly pivoted operations to distribute the vaccine and provide technical assistance to community partners amidst rapidly evolving guidance. With infrastructure and a vaccination team in place, MINI responded to new and emerging needs, eg, implementing a more accessible and low-tech scheduling system, increasing staffing to meet growing needs, and expanding partnerships with community organizations and leaders. From February 2021 to September 2023, MINI organized 1120 community-based vaccine clinics and administered 43,123 COVID-19 vaccinations. Of those vaccine recipients, 88% identified as Black, Indigenous, and other people of color, and for preferred language, over half stated that they preferred a language other than English. These demographics are similar to those of the earlier influenza clinics, even as average annual clinics have tripled and average total vaccinations have quadrupled since the pivot to COVID-19 vaccination clinics. Some keys to success were: (1) consistent, bidirectional communication and shared decision-making with community partners; (2) prioritizing sustainable staffing models with the support of administrative leadership and resources; and (3) having a community-informed approach supported by the practice of hiring staff from communities served. Because of the effectiveness of this model, MINI is primed to respond to planned and unplanned emergent public health crises.

Racial and ethnic minority status in country of birth modifies racial and ethnic disparities in influenza vaccination among New York City adults

BACKGROUND

Understanding the relationship between race/ethnicity, birthplace, and health outcomes is important for reducing health disparities. This study assessed the relationship between racial/ethnic identity and minority racial/ethnic status in country of birth on influenza vaccination among New York City (NYC) adults.

METHODS

Using 2015-2019 data from NYC's Community Health Surveys, we assessed the association between racial/ethnic identity and racial/ethnic minority status in birth country with past year influenza vaccination, calculating prevalence differences per 100 and assessing interaction on the additive scale using linear binomial regression, and prevalence ratios and interaction on the multiplicative scale using log-binomial regression.

RESULTS

Effect modification between race/ethnicity and minority racial/ethnic status in birth country was significant on the additive scale for Hispanic (p = 0.018) and Black (p = 0.025) adults and the multiplicative scale for Hispanic adults (p = 0.040). After stratifying by racial/ethnic minority or majority status in birth country, vaccination was significantly lower among Black adults compared with White adults among those in the minority (adjusted prevalence difference [aPD]=-12.98, 95%CI: -22.88-(-2.92)) and significantly higher among Hispanic adults compared with White adults among those in the majority (aPD=9.28, 95%CI: 7.35-11.21).

CONCLUSIONS

Racial/ethnic minority status in birth country is an important factor when examining racial/ethnic differences in vaccination status.

Demographic Influences on Adult HPV Vaccination: Results from a Cross-Sectional Survey in Tennessee

HPV is the most prevalent sexually transmitted infection in the U.S., with more than 80% of all Americans contracting it by age 45. Effective vaccines for HPV exist and were recently approved for adults aged 27-45 years, though uptake remains low in all age groups, particularly in Tennessee where 1089 cancers were attributed to HPV in 2020. Between 29 June and 17 August 2023, we conducted a cross-sectional survey to gain insights about the barriers and facilitators of HPV in 2011 adults aged 18 to 45 years in Tennessee. We developed our survey based on previous instruments to understand predictors of HPV vaccination in adults. Using descriptive statistics and bivariate and logistic regression analyses, we found higher vaccination rates in females, participants aged 18-38 years, participants with a high school education or higher, Hispanic or Latine individuals, and participants identifying as moderate or liberal. These insights highlight the need for public health interventions that consider demographic differences to successfully increase vaccination rates and reduce HPV-associated cancer risk.

'Getting control of Corona takes many angles': COVID-19 vaccine knowledge, attitudes and beliefs among refugee/immigrant/migrant communities in four US cities

The objectives of the study were to (i) document refugee, immigrant and migrant (RIM) communities' knowledge, attitudes and beliefs (KABs) related to the Coronavirus disease (COVID-19) vaccine and (ii) identify best practices for developing and disseminating culturally and linguistically responsive health messaging addressing those KABs. Thirteen online focus groups (OFGs) in 10 languages were conducted. Each OFG was conducted in the participants' native language. OFGs were recorded, transcribed, translated and uploaded to qualitative software for coding. A thematic analysis was conducted. Results suggest that while there was some variation between different language groups (e.g. whether religious leaders were seen as trusted sources of information about COVID), there were also important commonalities. Most language groups (i) alluded to hearing about or having gaps in knowledge about COVID-19/the COVID-19 vaccine, (ii) reported hearing negative or conflicting stories about the vaccine and (iii) shared concerns about the negative side effects of the vaccine. There continues to be a need for health messaging in RIM communities that is culturally and linguistically concordant and follows health literacy guidelines. Message content about the COVID-19 vaccine should focus on vaccine importance, effectiveness and safety, should be multimodal and should be primarily delivered by healthcare professionals and community members who have already been vaccinated.

Inequities in routine preventive care utilization among persons with overweight/obesity in the United States: An analysis of nativity, racial and ethnic identity, and socioeconomic status

Extant literature documented various health disparities among immigrants and racial and ethnically marginalized individuals in the United States. However, health disparities in the intersection of nativity and race are generally less visited. This cross-sectional study assessed utilization of routine preventive care among adults with overweight/obesity at the junction of their nativity, racial/ethnic identity, and socioeconomic status (i.e., income and education). Pooling data on 120,184 adults with overweight/obesity from the 2013-2018 waves of the National Health Interview Survey (NHIS), we estimated modified Poisson regressions with robust standard errors to obtain adjusted prevalence rates of preventive care visit, receiving flu shot, and having blood pressure, cholesterol and blood glucose screened. We found that immigrant adults with overweight/obesity had lower rates of utilization of all five preventive care services. However, these patterns varied by racial and ethnic sub-populations. While White immigrants had comparable rates of cholesterol and blood glucose screening, they had 2.7%, 2.9%, and 14.5% lower rates of preventive care visit, blood pressure screening, and getting a flu shot respectively, compared to native-born Whites. These patterns were similar for Asian immigrants as well. Black immigrants, on the other hand, had comparable rates of getting a flu shot and blood glucose screening, and had 5.2%, 4.9%, and 4.9% lower rates of preventive care visit, blood pressure screening, and cholesterol screening respectively. Lastly, the rates of utilization among Hispanic immigrants were significantly lower (ranging from 9.2% to 20%) than those of their native-born counterparts for all five preventive care services. These rates further varied by education, income, and length of stay in the US, within the racial and ethnic subgroups. Our findings thus suggest a complex relationship between nativity and racial/ethnic identity in relation to preventive care utilization among adults with overweight/obesity.

Willingness to Receive the COVID-19 Vaccine in California: Disparities by Race and Citizenship Status

Although it is widely acknowledged that racialized minorities may report lower COVID-19 vaccine willingness compared to non-Hispanic white individuals, what is less known, however, is whether the willingness to receive the COVID-19 vaccine also differs by citizenship. Understanding disparities in vaccine willingness by citizenship is particularly important given the misleading rhetoric of some political leaders regarding vaccine eligibility by citizenship status. This study used the 2020 California Health Interview Survey (n = 21,949) to examine disparities in vaccine willingness by race/ethnicity and citizenship among Asian, Latinx, and non-Hispanic white individuals. Overall, 77.7% of Californians indicated that they were willing to receive the COVID-19 vaccine if it was made available. However, there were distinct differences by race/ethnicity and citizenship. Asian people, regardless of citizenship, had the highest predicted probability of vaccine willingness, accounting for demographic, socioeconomic, and health factors. Non-citizen Latinx and non-citizen non-Hispanic white people had higher predicted probabilities of vaccine willingness compared to their US-born counterparts, accounting for demographic, socioeconomic, and health factors. Our results reveal that although vaccine willingness may be high among non-citizen individuals, it may not necessarily translate into actual vaccine uptake. Furthermore, while individual-level factors may account for some of the differences in vaccine willingness by race/ethnicity and citizenship, other institutional and structural barriers prevent vaccine uptake.

Does the Integration of Migrants in the Host Society Raise COVID-19 Vaccine Acceptance? Evidence From a Nationwide Survey in Japan

Research indicates that integration contributes to maintaining health among migrants, yet little is known about the association between integration and vaccination acceptance. This study aimed to explore COVID-19 vaccine intention and acceptance, and the association between integration and vaccine hesitancy among migrants in Japan. We conducted an internet survey among migrants in Japan from October 5 to October 14, 2021. Among 1,455 participants, 11.6% reported hesitancy toward COVID-19 vaccination. We found that the overall integration and social integration were associated with the vaccination intention. Some commonly identified barriers (e.g., financial difficulties, language) were not related to COVID-19 vaccination acceptance among migrants in Japan. Highly integrated migrants were less likely to report vaccine hesitancy against COVID-19. To promote COVID-19 acceptance among migrants, customized intervention policies should focus on the migrants with a lower level of integration, especially those with little social connection with the locals.

Predictor of HPV Vaccination Uptake among Foreign-Born College Students in the U.S.: An Exploration of the Role of Acculturation and the Health Belief Model

OBJECTIVE

to measure the HPV vaccination rate and knowledge about HPV and its vaccine among foreign-born college students; additionally, to measure the effect of acculturation and HBM constructs on the HPV vaccination behavior among foreign-born college students.

METHODS

a cross-sectional design with a non-probability sample of foreign-born college students was collected via a web-based self-administered survey that measured the HPV vaccination rate, assessed knowledge about HPV and its vaccine, and evaluated the effect of acculturation and HBM constructs on HPV vaccination behavior among foreign-born college students.

RESULTS

Foreign-born college students had moderate knowledge about HPV and the HPV vaccine, and about 63% were HPV-vaccinated. Perceived susceptibility, perceived barriers, and cues to action were significantly associated with the HPV vaccination behavior, while knowledge levels about HPV and the HPV vaccine and acculturation levels were not significantly associated with the HPV vaccination behavior of foreign-born college students.

CONCLUSIONS

The current study shows a moderate vaccination rate and moderate knowledge about HPV and its vaccine among foreign-born college students. Additionally, vaccination campaigns need to increase awareness about the susceptibility to acquiring HPV and minimize the barriers to receiving the vaccine to increase the HPV vaccination rate among foreign-born college students.

Impact of the COVID-19 pandemic on human papillomavirus (HPV) vaccination among a national sample of United States adults ages 18-45: A cross-sectional study

To assess how the COVID-19 pandemic affected catch-up HPV vaccination among age-eligible adults (ages 18-45). The current study leverages a national, cross-sectional sample of US adults ages 18-45 years to assess the prevalence and determinants of COVID-19 pandemic-related disruptions to catch-up HPV vaccination in 2021. The sample was restricted to adults intending to receive the HPV vaccine. Multinomial logistic regression analysis was conducted to assess the probability of 1) pandemic-related HPV vaccination disruption and 2) uncertainty about pandemic-related HPV vaccination disruption. Report of 'no pandemic-related HPV vaccination disruption' served as the reference category. Among adults intending to get the HPV vaccine (n = 1,683), 8.6 % reported pandemic-related HPV vaccination disruption, 14.7 % reported uncertainty about vaccination disruption, and 76.7 % reported no disruption. Factors associated with higher odds of pandemic-related vaccination disruption included non-English language preference (OR: 3.20; 95 % CI: 1.99-5.13), being a parent/guardian (OR: 1.77; 95 % CI: 1.18-2.66), having at least one healthcare visit in the past year (OR: 1.97; 95 % CI: 1.10-3.53), being up-to-date on the tetanus vaccine (OR: 1.81; 95 % CI: 1.19-2.75), and being a cancer survivor (OR: 2.57; 95 % CI: 1.52-4.34). Catch-up HPV vaccination for age-eligible adults is a critical public health strategy for reducing HPV-related cancers. While a small percentage of adults reported pandemic-related disruptions to HPV vaccination, certain adults (e.g., individuals with a non-English language preference and cancer survivors) were more likely to report a disruption. Interventions may be needed that increase accessibility of catch-up HPV vaccination among populations with reduced healthcare access during the pandemic.

Vaccine hesitancy in the refugee, immigrant, and migrant population in the United States: A systematic review and meta-analysis

Refugees, immigrants, and migrants (RIM) in the United States (US) have been identified as an underimmunized population prior to the COVID-19 pandemic. Vaccine acceptance is critical to combat the public health threat incited by COVID-19 and other vaccine-preventable disease. To better understand escalating vaccine hesitancy among US RIM, a comprehensive evaluation of the problem and solutions is necessary. In this systematic review, we included 57 studies to describe vaccination rates, barriers, and interventions addressing vaccine hesitancy over the past decade. Meta-analysis was performed among 22 studies, concluding that RIM represent an underimmunized population compared to the general US population. Narrative synthesis and qualitative methods were used to identify critical barriers, including gaps in knowledge, poor access to medical care, and heightened distrust of the medical system. Our results demonstrate the need for effective, evidence-based interventions to increase vaccination rates among diverse RIM populations.

COVID-19 vaccine coverage among immigrants and refugees in Alberta: A population-based cross-sectional study

Background

Studies have shown that immigrants have lower vaccination rates than the Canadian-born population. We sought to assess COVID-19 vaccine coverage and factors associated with uptake among foreign-born immigrants relative to the non-immigrant population in Alberta, Canada.

Methods

In this cross-sectional study, we analysed population-based linked administrative health data from Alberta to examine vaccine coverage for 3 931 698 Albertans, of which 731 217 were immigrants. We calculated COVID-19 vaccination coverage as the proportion of eligible Albertans with a record of receiving at least one dose of a COVID-19 vaccine as of November 29, 2021. We used multivariable logistic regression to examine the association of vaccine coverage with migration status (immigrants: four categories based on time since migration and non-immigrants) adjusting for socio-demographic variables.

Results

Overall, COVID-19 vaccination coverage was 78.2% (95% confidence interval (CI) = 78.1%-78.3%) among immigrants and 76.0% (95% CI = 75.9%-76.0%) among non-immigrants. Coverage among immigrants differed by continent of origin, with North America, Oceania, and Europe having the lowest coverage. Although vaccine coverage was relatively uniform across neighbourhood income quintiles for immigrants, immigrants living in rural areas had lower vaccine coverage compared to non-immigrants living in rural areas. Multivariable logistic regression analysis showed a significant interaction between age category and migration status. While immigrants below 50 years of age generally had significantly higher vaccine coverage compared to non-immigrants, there was some variation based on time since migration. Immigrants above 50 years of age showed significantly lower coverage compared to non-immigrants of the same age.

Conclusions

Public health interventions should focus on older immigrants, immigrants living in rural areas, and immigrants from specific continental backgrounds in order to improve COVID-19 vaccination coverage.

Association of culturally competent care with influenza vaccination coverage in the United States

BACKGROUND

Cultural minority groups in the United States have lower vaccination rates or worse influenza-related outcomes. Culturally competent care, which aims to engage the social, cultural, and linguistic needs of all patients, may address some of these disparities.

OBJECTIVE

We investigate how self-reported measures of culturally competent care is associated with influenza vaccination rates in the United States.

METHODS

The National Health Interview Survey (NHIS) 2017 was queried for respondents asked a set of questions which assessed respondents' access to culturally competent care in the past year. The outcome of interest was self-reported receipt of the annual influenza vaccine. Sample-weighted multivariable logistic regressions estimated the adjusted odds ratios and 95 % confidence intervals (95 %CI) of influenza vaccination with response to the cultural competency survey questions as the dependent variable of interest. Subsequent marginal modeling predicted the adjusted vaccination rates among cultural minorities (racial/ethnic minorities, LGBTQ + adults, foreign-born individuals, and non-English speakers) and respondents with high-risk comorbidities for worse influenza outcomes. Models were adjusted for other known determinants of vaccination coverage.

RESULTS

20,303 sample adults were included in the analyses. There were significantly higher odds of influenza vaccination among respondents who were "always" or "most of the time" treated with respect by their providers (aOR 1.53, 95 %CI [1.23-1.90], P < 0.001), given easy-to-understand information (aOR 1.37, 95 %CI [1.19-1.58], P < 0.001), asked about their opinions or beliefs about their care (aOR 1.29, 95 %CI [1.19-1.39], P < 0.001), and seen by providers who shared or understood their culture (aOR 1.15 95 %CI [1.01-1.30], P = 0.03), compared to their counterparts who responded with "some" or "none of the time" to the same survey questions. Higher adjusted influenza vaccination rates were seen among multiple racial/ethnic groups, LGBTQ + adults, foreign-born individuals, non-English speakers, and individuals with high-risk comorbidities who reported positive responses to the cultural competency survey questions.

CONCLUSIONS

We demonstrate a positive association between self-reported frequency of access to culturally competent care and receipt of the annual influenza vaccine. These findings support future efforts to evaluate vaccination outcomes among patients who receive components of culturally competent care, such as linguistically appropriate services, race-concordant healthcare workforce, and community engagement.

Records request response rate and vaccination status of first-time college students at a mid-sized Midwestern university

Objective: The purpose of this study was to establish the response rate of first-time college students to a vaccination records request, and to obtain student vaccination rates for selected vaccines. Participants: Student health records for the fall 2018 cohort of first-time college students were reviewed. Methods: Vaccination and response rates were compared based on sex, race/ethnicity, and home state. Results: There was a 66% response rate to the vaccination records request with no difference in response rate based on student demographics. Students exceeded most of the Healthy Campus 2020 vaccination targets. The human papillomavirus (HPV) and meningitis ACWY vaccines had the greatest room for improvement. Female students were significantly more likely to have a completed HPV vaccine series. Conclusions: Records response rates may be improved by students accessing and reporting state vaccination information during a required orientation. Following (CDC) guidelines for vaccination success may improve vaccination rates for HPV and menACWY.

Embracing the Diversity of Latinx Communities to Promote Vaccinations

While vaccine hesitancy is well documented in the literature among the Latinx community, little attention or effort is given to the nuances among the members of individual communities, such as country of origin, immigration status, generational status, primary language, race, age, sex, gender, or rural residence and how these complexities affect vaccine messaging and uptake. We have evidence that this heterogeneity causes differences in access to healthcare, attitudes towards vaccines, and degree of health disparities. In this review we will describe their impact on vaccination rates in the Latinx community, highlighting missed opportunities for public health outreach, and how targeted messaging could improve vaccine uptake.

Coronavirus Disease 2019 (COVID-19) Vaccination Coverage, Intentions, Attitudes, and Barriers by Race/Ethnicity, Language of Interview, and Nativity-National Immunization Survey Adult COVID Module, 22 April 2021-29 January 2022

The National Immunization Survey Adult COVID Module used a random-digit-dialed phone survey during 22 April 2021-29 January 2022 to quantify coronavirus disease 2019 (COVID-19) vaccination, intent, attitudes, and barriers by detailed race/ethnicity, interview language, and nativity. Foreign-born respondents overall and within racial/ethnic categories had higher vaccination coverage (80.9%), higher intent to be vaccinated (4.2%), and lower hesitancy toward COVID-19 vaccination (6.0%) than US-born respondents (72.6%, 2.9%, and 15.8%, respectively). Vaccination coverage was significantly lower for certain subcategories of national origin or heritage (eg, Jamaican [68.6%], Haitian [60.7%], Somali [49.0%] in weighted estimates). Respondents interviewed in Spanish had lower vaccination coverage than interviewees in English but higher intent to be vaccinated and lower reluctance. Collection and analysis of nativity, detailed race/ethnicity and language information allow identification of disparities among racial/ethnic subgroups. Vaccination programs could use such information to implement culturally and linguistically appropriate focused interventions among communities with lower vaccination coverage.

Influenza vaccination coverage among adults by nativity, race/ethnicity, citizenship, and language of the interview - United States, 2012-2013 through 2017-2018 influenza seasons

BACKGROUND

Approximately 20,000 people died from influenza in the US in the 2019-2020 season. The best way to prevent influenza is to receive the influenza vaccine. Persons who are foreign-born experience disparities in access to, and utilization of, preventative healthcare, including vaccination.

METHODS

National Health Interview Survey data were analyzed to assess differences in influenza vaccination coverage during the 2012-2013 through 2017-2018 influenza seasons among adults by nativity, citizenship status of foreign-born persons, race/ethnicity, and language of the interview.

RESULTS

Influenza vaccination coverage increased significantly during the study period for US-born adults but did not change significantly among foreign-born racial/ethnic groups except for increases among foreign-born Hispanic adults. Coverage for foreign-born adults, those who completed an interview in a non-English language, and non-US citizens, had lower vaccination coverage during most influenza seasons studied, compared with US-born, English-interviewed, and US-citizen adults, respectively.

CONCLUSIONS

Strategies to improve influenza vaccination uptake must consider foreign-born adults as an underserved population in need of focused, culturally-tailored outreach. Achieving high influenza vaccination coverage among the foreign-born population will help reduce illness among the essential workforce, achieve national vaccination goals, and reduce racial and ethnic disparities in vaccination coverage in the US.

COVID-19 vaccination intention and behavior in a large, diverse, U.S. refugee population

Introduction

Refugees often face increased risk of exposure to COVID-19 due to their disproportionate representation in the essential workforce and crowded household conditions. There is a paucity of data about risk factors for under-immunization for COVID-19 among refugees.

Methods

Refugees were surveyed in two phases that corresponded to before and after wide availability of COVID-19 vaccines. Participants were asked about their attitudes, and perceptions about COVID-19, previous acceptance of vaccines, sources utilized to obtain trusted health information, and intent to get vaccinated. The overall participant vulnerability was assessed using the social vulnerability index. In-depth semi-structured interviews were completed with key stakeholders through snowball sampling.

Results

Of 247 refugees, 244 agreed to participate in the initial survey. Among those, 140 (57.4%) intended to get vaccinated, 43 (17.6%) were unsure, and 61 (25%) did not intend to get vaccinated. In the follow up survey, all 215 who were reached, agreed to provide information about their vaccination status. Among those respondents, 141 (65.6%) were either vaccinated or expressed intent to do so, and 74 (34.4%) remained hesitant. We did not observe any significant correlation between socio-demographic variables, country of origin, and vaccination status/intent. Among those who initially intended to get vaccinated, nearly 1 in 5 changed their mind and decided to forego vaccination, and among those who initially did not plan getting vaccinated, 1 in 3 changed their mind and got vaccinated. Fears related to the vaccine, concerns that the vaccine is religiously prohibited, “wait and see” how others did with the vaccine, communication and transportation barriers were commonly cited as reason not to get vaccinated.

Conclusions

Over a third of refugees in our study were hesitant to get vaccinated. Refugees desired additional education about the benefits and safety of vaccines along with easier access to vaccination clinics in their communities.

HPV vaccination uptake among foreign-born Blacks in the US: insights from the National Health Interview Survey 2013-2017

INTRODUCTION

Human papillomavirus (HPV) vaccination uptake is lower among foreign-born than US-born individuals, but HPV-related (e.g., cervical) cancer risks are disproportionately higher among immigrant populations. Although timely vaccination can help reduce these risks, less is known about differences in the low HPV vaccination uptake among foreign-born groups, especially Black immigrants. The purpose of this study was to examine the differences in HPV vaccination initiation among US- and foreign-born Black men and women.

METHOD

Data from the 2013-2017 National Health Interview Survey on Black adults, aged 18-37 years, were analyzed in 2019. HPV vaccination initiation prevalence among US- and foreign-born blacks by region of birth were examined. Multivariate binary logistic regression analysis was used to examine the relationship between foreign-birth status and HPV vaccination initiation separately among men and women, after adjusting for sociodemographic and health-related factors.

RESULTS

There were significant differences (p < 0.001) in HPV vaccination initiation among Blacks from the US (22.5%), Africa (14.2%), and Americas/Caribbean Islands (11.4%). Adjusted odds of HPV vaccination initiation were lower among foreign- than US-born Blacks (AOR 0.71, CI 0.52, 0.98) but insignificant after controlling for health-related factors. Being ≤ 17 years versus 18-26 years at age of vaccine eligibility (AOR 3.44, CI 2.90, 4.07) was associated with HPV vaccination, and this relationship remained significant among men and women. Being single was associated with vaccination initiation among men, and some college experience, fair/poor health, obstetric/gynecological visit, and pap test were associated with HPV vaccination. Conclusion Cancer prevention strategies to promote HPV vaccination should consider making age-appropriate, gender-specific, and culturally relevant programs among foreign-born blacks in the US. Health insurance is also a key factor that might help with the lower rates of vaccinated black immigrants.

Advancing COVID-19 Vaccination Equity Among the Refugee Community: An Innovative Multi-Sector Collaborative Outreach Program

INTRODUCTION

Multi-sector outreach collaborations have the potential to improve COVID-19 vaccine access among underserved populations, including refugees.

METHODS

Using a four-pronged strategy, we offered the local refugee community COVID-19 vaccine appointments within the next week.

RESULTS

Over a thousand (1,327) individuals from more than 20 countries were identified; mean age 36.5 (SD=16.4); 55% female. Initially, 613 (46%) reported being scheduled/vaccinated prior to outreach efforts; 312 (24%) appointments were scheduled that resulted from outreach efforts. By February 2022, 895 (67.4%) of the 1,327 patients had at least one dose; the majority of these were Pfizer (n=750, 84%). Of 895 with first dose, 843 completed two-dose series (94.2%). Overall completion rate of initial series was 63.5%. Reasons for declining (171, 13%) included wanting to speak with a physician or family member first; pregnancy hesitation; postponing until after Ramadan.

DISCUSSION

Although lower than local and state rates, this refugee community's COVID-19 vaccine uptake is on par with the overall population in the United States (65.8%). Because of COVID-19's disproportionately negative impact on refugee and other underserved populations, we offer recommendations for future equity-informed efforts.

[Hepatitis B virus infection and vaccine-induced immunity: the role of sociodemographic determinants : Results of the study "German Health Interview and Examination Survey for Adults" (DEGS1, 2008-2011)]

Hintergrund und Ziel

Trotz niedriger Prävalenz der Hepatitis-B-Virus-(HBV-)Infektion in Deutschland ist es wichtig, vulnerable Gruppen und Ansatzpunkte für die Prävention zu identifizieren. In ersten Analysen der „Studie zur Gesundheit Erwachsener in Deutschland“ (DEGS1, 2008–2011) waren HBV-Infektion und -Impfung mit sozidemografischen Determinanten assoziiert. In dieser Arbeit werden die Ergebnisse im Detail untersucht.

Material und Methoden

In DEGS1 lag für 7046 Teilnehmende (Alter: 18–79 Jahre) eine HBV-Serologie vor. Die stattgehabte HBV-Infektion war durch Antikörper gegen das Hepatitis-B-Core-Antigen (Anti-HBc) definiert, die impfinduzierte Immunität durch alleinigen Nachweis von Antikörpern gegen das Hepatitis-B-Surface-Antigen (Anti-HBs). Seroprävalenzen von HBV-Infektions- und -Impfstatus wurden geschlechtsstratifiziert geschätzt und Assoziationen mit Alter, Gemeindegröße, Einkommen, formaler Bildung, Krankenversicherung und Migrationsgeneration in logistischen Regressionen analysiert.

Ergebnisse

Die HBV-Infektion war bei Männern und Frauen unabhängig mit den Altersgruppen 34–64 und ≥ 65 Jahre, erster Migrationsgeneration und Leben in größeren Gemeinden assoziiert, zudem bei Männern mit niedrigem Einkommen und bei Frauen mit niedriger Bildung. Die impfinduzierte Immunität war bei Männern und Frauen unabhängig mit den Altersgruppen 18–33 und 34–64 Jahre, mittlerer und hoher Bildung und hohem Einkommen assoziiert, darüber hinaus bei Männern mit mittlerem Einkommen und privater Krankenversicherung und bei Frauen mit fehlendem Migrationshintergrund.

Diskussion

Die Berücksichtigung von Migrationsstatus, Einkommen und Bildung könnte zur zielgenauen Ausrichtung der HBV-Prävention beitragen.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03473-z) enthalten.

Tetanus: A Rare Complication of Black Tar Heroin Use

Tetanus is associated with high morbidity and mortality, although this is rarely encountered in high-income countries. We present a case of tetanus in an unvaccinated patient secondary to black tar heroin use that highlights the importance of considering tetanus in appropriate clinical contexts, harm reduction interventions, and universal tetanus vaccination campaigns.

Race, Nativity, and Sex Disparities in Human Papillomavirus Vaccination Among Young Adults in the USA

Research has demonstrated that the human papillomavirus (HPV) vaccine is a safe and effective way to decrease HPV-related cervical cancers; however, the vaccination rate in the USA is suboptimal. The current study examined racial and ethnic disparities in HPV vaccination among a nationally representative sample, including Native Hawaiian and Pacific Islanders (NHPI). This study also investigated the associations between nativity and vaccination, and sex differences between race/ethnicity and vaccination and nativity and vaccination. A cross-sectional study was conducted with a sample of adults aged 18-26 years drawn from the 2014 NHPI National Health Interview Survey (n = 2590) and the general 2014 National Health Interview Survey (n = 36,697). Log-binomial models were fitted to examine differences in vaccination. There was a statistically significant racial/ethnic difference in HPV vaccination (p = 0.003). More women than men were vaccinated (41.8% vs. 10.1%) (p < 0.001). There was a significant difference in HPV vaccination based on nativity: 27.4% of adults aged 18 to 26 years who were born in the USA and 27.7% born in a US territory received the HPV vaccine compared with 14.3% among those not born in the USA or a US territory (p < 0.001). The association of HPV vaccination with nativity and race/ethnicity differed by sex and showed several nuanced differences. Overall, the prevalence of HPV vaccination was low. The study's findings demonstrate the need for public health strategies to increase vaccination rates among all populations, with the critical need to identify strategies that are effective for men, racial/ethnic minorities, and immigrant women born outside the USA.

Acceptance of COVID-19 Vaccine Among Refugees in the United States

OBJECTIVE

Little is known about COVID-19 vaccination intentions among refugee communities in the United States. The objective of this study was to measure COVID-19 vaccination intentions among a sample of refugees in the United States and the reasons for their vaccine acceptance or hesitancy.

METHODS

From December 2020 through January 2021, we emailed or text messaged anonymous online surveys to 12 bilingual leaders in the Afghan, Bhutanese, Somali, South Sudanese, and Burmese refugee communities in the United States. We asked community leaders to complete the survey and share the link with community members who met the inclusion criteria (arrived in the United States as refugees, were aged ≥18, and currently lived in the United States). We compared the characteristics of respondents who intended to receive the COVID-19 vaccine with those of respondents who did not intend to receive the vaccine or were unsure. We then conducted crude and adjusted logistic regression analysis to measure the association between employment as an essential worker and COVID-19 vaccine acceptance.

RESULTS

Of 435 respondents, 306 (70.3%) indicated that they planned to receive a COVID-19 vaccine. Being an essential worker (adjusted odds ratio [aOR] = 2.37; 95% CI, 1.44-3.90) and male sex (aOR = 1.87; 95% CI, 1.12-3.12) were significantly associated with higher odds of intending to receive a COVID-19 vaccine. Among respondents who intended to receive a COVID-19 vaccine, wanting to protect themselves (68.6%), family members (65.0%), and other people (54.3%) were the main reasons.

CONCLUSION

Many refugees who responded to the survey, especially those who worked in essential industries, intended to receive a COVID-19 vaccine. Community organizations, health care providers, and public health agencies should work together to ensure that vaccine registration and vaccination sites are accessible to refugees.

A Review of Racial and Ethnic Disparities in Immunizations for Elderly Adults

Vaccine preventable diseases are responsible for a substantial degree of morbidity in the United States as over 18 million annual cases of vaccine preventable disease occur in the U.S. annually. The morbidity due to vaccine preventable disease is disproportionately borne by adults as over 99% of the deaths due to vaccine preventable diseases occur within adults, and national data indicates that there racial disparities in the receipt of vaccines intended for elderly adults. A literature review was conducted by using the PubMed database to identify research articles that contained information on the vaccination rates among minority populations for selected vaccines intended for use in elderly populations including those for herpes zoster, tetanus, diphtheria, pertussis, hepatitis A, and hepatitis B. A total of 22 articles were identified, 8 of which focused on tetanus related vaccines, 2 of which focused on hepatitis related vaccines, and 12 of which focused on herpes zoster. The findings indicate that magnitude of the disparity for the receipt of tetanus and herpes related vaccines is not decreasing over time. Elderly patients having a low awareness of vaccines and suboptimal knowledge for when or if they should receive specific vaccines remains a key contributor to suboptimal vaccination rates. There is an urgent need for more intervention-based studies to enhance the uptake of vaccines within elderly populations, particularly among ethnic minorities where culturally sensitive and tailored messages may be of use.

Factors Associated with Influenza Vaccination Uptake among U.S. Adults: Focus on Nativity and Race/Ethnicity

To support implementation strategies for upcoming influenza (flu) vaccinations for foreign-born and racial/ethnic minority groups, we analyzed the 2018 National Health Interview Survey (NHIS) database and performed logistic regression to examine the factors associated with, and the interaction between nativity and race/ethnicity in directing flu vaccination rates during the past 12 months (n = 25,045). As a result, we found nativity and race/ethnicity were associated with flu vaccination rates; foreign-born and non-Hispanic black respondents were less likely to take the vaccine than U.S.-born and non-Hispanic white respondents. The odds ratios were largest for the elderly, those working in the healthcare industry, those with health insurance, and those with a usual source of care (ORs = 3.058, 2.871, 2.317, and 2.342, respectively), suggesting that access to healthcare resources is critical for the uptake of the flu vaccine. There was a significant interaction effect between nativity and race/ethnicity. For improving flu vaccination rates, more support is necessary for foreign-born people and racial/ethnic minorities who have lower health insurance rates and usual sources of care than U.S.-born people and non-Hispanic whites, and thus are less able to adequately access healthcare resources in a timely manner.

Surveillance of Vaccination Coverage Among Adult Populations -United States, 2018

PROBLEM/CONDITION

Adults are at risk for illness, hospitalization, disability and, in some cases, death from vaccine-preventable diseases, particularly influenza and pneumococcal disease. CDC recommends vaccinations for adults on the basis of age, health conditions, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults remains low.

REPORTING PERIOD

August 2017-June 2018 (for influenza vaccination) and January-December 2018 (for pneumococcal, herpes zoster, tetanus and diphtheria [Td]/tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], hepatitis A, hepatitis B, and human papillomavirus [HPV] vaccination).

DESCRIPTION OF SYSTEM

The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. NHIS's objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. Adult receipt of influenza, pneumococcal, herpes zoster, Td/Tdap, hepatitis A, hepatitis B, and at least 1 dose of HPV vaccines was assessed. Estimates were derived for a new composite adult vaccination quality measure and by selected demographic and access-to-care characteristics (e.g., age, race/ethnicity, indication for vaccination, travel history [travel to countries where hepatitis infections are endemic], health insurance status, contacts with physicians, nativity, and citizenship). Trends in adult vaccination were assessed during 2010-2018.

RESULTS

Coverage for the adult age-appropriate composite measure was low in all age groups. Racial and ethnic differences in coverage persisted for all vaccinations, with lower coverage for most vaccinations among non-White compared with non-Hispanic White adults. Linear trend tests indicated coverage increased from 2010 to 2018 for most vaccines in this report. Few adults aged ≥19 years had received all age-appropriate vaccines, including influenza vaccination, regardless of whether inclusion of Tdap (13.5%) or inclusion of any tetanus toxoid-containing vaccine (20.2%) receipt was measured. Coverage among adults for influenza vaccination during the 2017-18 season (46.1%) was similar to the estimate for the 2016-17 season (45.4%), and coverage for pneumococcal (adults aged ≥65 years [69.0%]), herpes zoster (adults aged ≥50 years and aged ≥60 years [24.1% and 34.5%, respectively]), tetanus (adults aged ≥19 years [62.9%]), Tdap (adults aged ≥19 years [31.2%]), hepatitis A (adults aged ≥19 years [11.9%]), and HPV (females aged 19-26 years [52.8%]) vaccination in 2018 were similar to the estimates for 2017. Hepatitis B vaccination coverage among adults aged ≥19 years and health care personnel (HCP) aged ≥19 years increased 4.2 and 6.7 percentage points to 30.0% and 67.2%, respectively, from 2017. HPV vaccination coverage among males aged 19-26 years increased 5.2 percentage points to 26.3% from the 2017 estimate. Overall, HPV vaccination coverage among females aged 19-26 years did not increase, but coverage among Hispanic females aged 19-26 years increased 10.8 percentage points to 49.6% from the 2017 estimate. Coverage for the following vaccines was lower among adults without health insurance compared with those with health insurance: influenza vaccine (among adults aged ≥19 years, 19-49 years, and 50-64 years), pneumococcal vaccine (among adults aged 19-64 years at increased risk), Td vaccine (among all age groups), Tdap vaccine (among adults aged ≥19 years and 19-64 years), hepatitis A vaccine (among adults aged ≥19 years overall and among travelers aged ≥19 years), hepatitis B vaccine (among adults aged ≥19 years and 19-49 years and among travelers aged ≥19 years), herpes zoster vaccine (among adults aged ≥60 years), and HPV vaccine (among males and females aged 19-26 years). Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting ≥1 physician contact during the preceding year compared with those who had not visited a physician during the preceding year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts during the preceding year, depending on the vaccine, 20.1%-87.5% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was significantly higher than that of foreign-born adults, including influenza vaccination (aged ≥19 years), pneumococcal vaccination (all ages), tetanus vaccination (all ages), Tdap vaccination (all ages), hepatitis B vaccination (aged ≥19 years and 19-49 years and travelers aged ≥19 years), herpes zoster vaccination (all ages), and HPV vaccination among females aged 19-26 years. Vaccination coverage also varied by citizenship status and years living in the United States.

INTERPRETATION

NHIS data indicate that many adults remain unprotected against vaccine-preventable diseases. Coverage for the adult age-appropriate composite measures was low in all age groups. Individual adult vaccination coverage remained low as well, but modest gains occurred in vaccination coverage for hepatitis B (among adults aged ≥19 years and HCP aged ≥19 years), and HPV (among males aged 19-26 years and Hispanic females aged 19-26 years). Coverage for other vaccines and groups with Advisory Committee on Immunization Practices vaccination indications did not improve from 2017. Although HPV vaccination coverage among males aged 19-26 years and Hispanic females aged 19-26 years increased, approximately 50% of females aged 19-26 years and 70% of males aged 19-26 years remained unvaccinated. Racial/ethnic vaccination differences persisted for routinely recommended adult vaccines. Having health insurance coverage, having a usual place for health care, and having ≥1 physician contacts during the preceding 12 months were associated with higher vaccination coverage; however, these factors alone were not associated with optimal adult vaccination coverage, and findings indicate missed opportunities to vaccinate remained.

PUBLIC HEALTH ACTIONS

Substantial improvement in adult vaccination uptake is needed to reduce the burden of vaccine-preventable diseases. Following the Standards for Adult Immunization Practice (https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html), all providers should routinely assess adults' vaccination status at every clinical encounter, strongly recommend appropriate vaccines, either offer needed vaccines or refer their patients to another provider who can administer the needed vaccines, and document vaccinations received by their patients in an immunization information system.

An Innovative United States-Mexico Community Outreach Initiative for Hispanic and Latino People in the United States: A Collaborative Public Health Network

Collaborative partnerships are a useful approach to improve health conditions of disadvantaged populations. The Ventanillas de Salud (VDS) ("Health Windows") and Mobile Health Units (MHUs) are a collaborative initiative of the Mexican government and US public health organizations that use mechanisms such as health fairs and mobile clinics to provide health information, screenings, preventive measures (eg, vaccines), and health services to Mexican people, other Hispanic people, and underserved populations (eg, American Indian/Alaska Native people, geographically isolated people, uninsured people) across the United States. From 2013 through 2019, the VDS served 10.5 million people (an average of 1.5 million people per year) at Mexican consulates in the United States, and MHUs served 115 461 people from 2016 through 2019. We describe 3 community outreach projects and their impact on improving the health of Hispanic people in the United States. The first project is an ongoing collaboration between VDS and the Centers for Disease Control and Prevention (CDC) to address occupational health inequities among Hispanic people. The second project was a collaboration between VDS and CDC to provide Hispanic people with information about Zika virus infection and health education. The third project is a collaboration between MHUs and the University of Arizona to provide basic health services to Hispanic communities in Pima and Maricopa counties, Arizona. The VDS/MHU model uses a collaborative approach that should be further assessed to better understand its impact on both the US-born and non-US-born Hispanic population and the public at large in locations where it is implemented.

Critical Considerations for COVID-19 Vaccination of Refugees, Immigrants, and Migrants

As COVID-19 vaccines are distributed across the United States, it is essential to address the pandemic’s disproportionate impact on refugee, immigrant, and migrant (RIM) communities. Although the National Academies Press Framework for Equitable Allocation of COVID-19 Vaccine provides recommendations for an equitable vaccine campaign, implementation remains. Practical considerations for vaccine rollout include identifying and overcoming barriers to vaccination among RIM communities. To identify barriers, information regarding vaccine beliefs and practices must be incorporated into the pandemic response. To overcome barriers, effective communication, convenience of care, and community engagement are essential. Taking these actions now can improve health among RIM communities.

Preventive Care and Management of Chronic Diseases in Immigrant Adults

Immigrants may have variable access to chronic disease screening and treatment in their countries of origin and host country, often limited by their immigration status. Immigrants face barriers to chronic disease management and preventive care, including health insurance access, linguistic challenges, lack of culturally sensitive care, limited records, and acculturation. Health care providers should prioritize chronic disease screening and follow up regularly to encourage preventive care and self-management of chronic disease.

Awareness of HPV and drivers of HPV vaccine uptake among university students: A quantitative, cross-sectional study

HPV vaccination is a milestone in primary prevention. However in Italy, vaccine coverage is still nowhere near the target of 95%. We investigated factors associated with inclination to get vaccinated in university students, as they are likely to have just assumed a central role in their healthcare decision-making. University students aged 18-25 were asked to fill in a questionnaire. The effect of socio-demographic and behavioural characteristics on HPV awareness was assessed with a logistic regression adjusting for age, gender, nationality, degree course, relationship, age at first intercourse, number of sexual partners, smoking, sexual orientation, past diagnosis of STDs and knowledge of people who had received HPV vaccine. A second regression adjusting also for information sources, awareness and knowledge investigated factors associated with inclination to receive vaccine. Nine thousand nine hundred and eighty-eight questionnaires were included (response rate 91.3%); awareness of HPV and vaccine was 83.3% and 69.9% respectively. Awareness (AOR: 3.3; 95% CI: 2.3-4.6) and a good knowledge positively affected acceptability, as well as a previous diagnosis of STDs and knowledge of vaccinated people. Healthcare workers (AOR: 1.6; 95% CI: 1.4-1.9) and family members (AOR: 1.7; 95% CI: 1.4-2.1) were the most influencing information sources, even if knowledge of vaccinated people was by far more persuasive (AOR: 2.7; 95% CI: 2.2-3.3). Only 12% of participants were acquainted with skin to skin HPV transmission, while 75% believed in a full effectiveness of condom; less than 22% associated HPV with cancer (other than cervical cancer). Efforts to increase awareness are likely to be worth considering that: awareness is the main determinant of vaccine acceptance; only 50% of individuals not interested in receiving vaccine were aware of it; males are much less aware (AOR: 0.09; 95% CI: 0.07-0.11). Moreover, this study spotlights some misconceptions around HPV and acknowledges a pivotal role of healthcare workers, family and peer influence.

Epidemiology of varicella among immigrants and non-immigrants in Quebec, Canada, before and after the introduction of childhood varicella vaccination: a retrospective cohort study

BACKGROUND

Many immigrants are susceptible to varicella on arrival to Canada because of different transmission dynamics in their countries of origin and scarcity of vaccination. Universal childhood vaccination programmes decrease varicella incidence rates through herd immunity, but the accumulating number of susceptible adult immigrants could remain at risk for severe varicella. Our aim was to describe the epidemiology of varicella among immigrants and non-immigrants before and after childhood varicella vaccination.

METHODS

We did a population-based, retrospective cohort study of all varicella cases in Quebec, Canada, diagnosed between 1996 and 2014 in administrative health databases linked to immigration data. Cases of varicella met diagnostic codes in the International Classification of Diseases, Ninth and Tenth Revision Canadian modifications. Cases with a co-occurring zoster diagnostic code and immigrants from Australia, New Zealand, the USA, and western European countries were excluded. Vaccination periods included pre-vaccination (1996-98), private vaccination (1999-2005), and public vaccination (2006-14). Incidence rate and comparative rate ratios were estimated using census data.

FINDINGS

A total of 231 339 varicella cases diagnosed between Jan 1, 1996, and Dec 31, 2014, were linked to 1 115 696 immigrants who arrived between Jan 1, 1980, and Dec 31, 2014. 1444 herpes zoster cases and 1276 immigrants from Australia, western Europe, New Zealand, and the USA were excluded. Among 228 619 varicella cases, 13 315 (5·8%) occurred in immigrants. In pre-vaccination versus public vaccination periods, varicella incidence declined in immigrants by 87% (95% CI 86·6-87·9; 324·3 cases per 100 000 person-years to 40·9 cases per 100 000 person-years) and in non-immigrants by 93% (92·4-92·7; 484 cases per 100 000 person-years to 36 cases per 100 000 person-years). Mean age at diagnosis increased in both groups (15·1 vs 19·4 years in immigrants and 8·4 vs 12·0 years in non-immigrants). In the public vaccination period, immigrants younger than 50 years had higher varicella rates than non-immigrants, with relative risk ranging from 1·53 (95% CI 1·37-1·72) to 4·64 (3·90-5·53) with the highest risk in adolescents and young adults, and people from Latin America and the Caribbean (age-specific incidence rate ratio [aIRR]_I-NI pre-vaccination 2·19 and post-vaccination aIRR_I-NI6·07) and south Asia (aIRR_I-NI pre-vaccination 3·41 and aIRR_I-NI post-vaccination 4·46) and in childbearing women (15-40 years; IRR_I-NI 2·48).

INTERPRETATION

Immigrant adolescents, young adults, and women of childbearing age had higher age-standardised rates of varicella than non-immigrants, with increasing disparities following vaccine introduction. Immigrants younger than 50 years of age would benefit from targeted vaccination upon arrival to host countries.

FUNDING

The Canadian Institutes of Health Research and The Department of Medicine, Jewish General Hospital, Montreal, QC, Canada.

Barriers to Hepatitis B Screening and Prevention for African Immigrant Populations in the United States: A Qualitative Study

Chronic hepatitis B infection (HBV) disproportionately affects African Immigrant (AI) communities in the U.S., with a reported infection rate of 15%. HBV screening rates within these communities are low. This study sought to better understand the socio-cultural determinants associated with low HBV screening among AI communities and identify potential strategies to help inform the development of effective HBV education and screening interventions. Seventeen in-depth interviews were conducted with community health experts working in AI communities throughout the U.S. Interviews explored the potential impact of culture, perception of health, awareness of HBV, religious practices, current screening practice, provider relationship, and behaviors towards general prevention. Interview data were analyzed using thematic analysis. Religious preferences and cultural norms affect health care access, perceptions towards prevention, awareness of HBV, and contribute to myths and stigma within this population. Participants reported a lack of HBV knowledge and awareness and barriers to health care access including, cost, language, racism, understanding of Western Medicine, and usage of traditional medicine. This study elucidates the role of religious and cultural beliefs as barriers to HBV screening and care. Results can contribute to public health efforts to increase awareness, screening and vaccination efforts within AI communities.

Differences in human papillomavirus (HPV) vaccine uptake by nativity status among men aged 18-34 years

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Only 1 in 11 men had initiated and 1 in 30 men had completed the HPV vaccine series.

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Immigrants from Indian subcontinent had the lowest HPV vaccination rates.

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Foreign-born men who reported US citizenship had higher rates of HPV vaccination rates.

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Foreign-born men had lower odds of having initiated the HPV vaccination compared with US-born men.

Annually, about 16,500 HPV-associated cancers occur in the US among men. Data regarding HPV vaccine uptake among men based on nativity status (i.e., US-versus foreign-born) is limited, yet potentially important for informing interventions. We assessed differences in HPV vaccine uptake by nativity status among men aged 18–34 years in the US. The 2014–2017 National Health Interview Survey was examined for men, aged 18–34 years (n = 14,056). HPV vaccine initiation was defined as receipt of at least one dose of the vaccine and completion as receipt of three doses. Weighted, multivariable binary logistic regression models were used to assess the association between nativity status and HPV vaccine uptake, adjusting for demographic, socioeconomic, and healthcare factors. Analyses were performed in July 2018. Overall, 17% of men self-identified as foreign-born, 9.9% of men had initiated the HPV vaccine, and 3.3% had completed the HPV vaccine. Among foreign-born men, Asians had the highest HPV vaccination rates whereas those from Indian subcontinental region had the lowest rates. After accounting for demographic, socioeconomic, and healthcare factors, compared to US-born men, foreign-born men were 46% (adjusted odds ratio = 0.54; 95% CI = 0.39–0.72) less likely to initiate the HPV vaccine but there was no difference between the two groups in terms of vaccine completion. We found that HPV vaccine uptake among men was very low overall, and foreign-born men had lower initiation compared to US-born men. Public health interventions which improve HPV vaccination need to be developed for all men, irrespective of nativity status.

Disparities in hepatitis A virus (HAV) vaccination coverage among adult travelers to intermediate or high-risk countries: The role of birthplace and race/ethnicity

BACKGROUND

While the hepatitis A virus (HAV) vaccine is recommended for United States (US) travelers to endemic regions, vaccination rates are lower among non-US-born adults and some racial minority groups.

PURPOSE

We aimed to examine the relationship between birthplace, race and their interaction as predictors of self-reported HAV vaccination among adult travelers to high-risk countries (HRCs) through analysis of the National Health Interview Survey (NHIS), 2012-2015.

METHODS

The study included 36,872 US adult participants in the 2012-2015 NHIS who traveled to countries where HAV is endemic. The main outcome was self-reported HAV vaccination (≥2 doses). Complex survey methods were applied to all models to provide statistical estimates that were representative of US adults. Multivariable logistic regression models adjusting for demographic, socioeconomic, medical, and access-to-care characteristics were fitted to examine the association between birthplace, race, race-by-birthplace (for interaction) and vaccination status.

RESULTS

For adult travelers to HRCs, the adjusted odds ratio (AOR) of HAV vaccination was lower for non-US-born compared to US-born adults, AOR 0.86 (95% CI; 0.76, 0.98). For Hispanics, the AOR of HAV vaccination was 0.80 (95% CI; 0.70, 0.91) as compared to non-Hispanic-Whites. Furthermore, a significant qualitative interaction between birthplace and race was found (P-value 0.0005). Among non-Hispanic Blacks, the adjusted odds of HAV vaccination for non-US-born adults were 1.35 (95% CI; 1.06, 1.72) times the odds for US-born adults. In contrast, the AORs of HAV vaccination of non-US-born versus US-born adults were 36% (95% CI; 17%, 51%) and 30% (95% CI; 12%, 44%), lower for Asians and Hispanics, respectively.

CONCLUSIONS

The association between birthplace and HAV vaccination status differs by race among travelers to HRCs, with US-born non-Hispanic Black and non-US-born Asian and Hispanic adults having lower odds of vaccination. Health care resources should be focused on these target populations to improve travel vaccination compliance.

Determinants of Tetanus Vaccination among Adult Immigrants: Findings from the Portuguese National Health Survey 2014

Vaccination is an effective strategy to prevent tetanus, and in Portugal this service is provided free of charge. Despite this, immigrants reported lower tetanus vaccination coverage than did Portuguese natives. The objective of this study was to identify sociodemographic, migration-related, and access-to-care factors associated with tetanus vaccination coverage among adult immigrants, using data from the Portuguese National Health Survey 2014. For the sample of 1277 immigrants aged ≥18 years, we estimated self-reported tetanus vaccination within the preceding 10 years and its determinants using complex samples logistic regression. The overall self-reported tetanus vaccination coverage was 79.5% (95% CI: 75.8-82.8). Age (adjusted odd ratio (aOR) per 1 year age increase = 0.97, 95% CI: 0.95-0.99), higher household income per adult (aOR = 0.42, 95% CI: 0.19-0.96), having Portuguese citizenship (aOR = 2.30, 95% CI: 1.25-4.24), having private health insurance (aOR = 1.99, 95% CI: 1.06-3.71), and contact with family/general physician in the last 12 months (aOR = 1.59, 95% CI: 1.01-2.51) were associated with self-reported tetanus vaccination coverage among adult immigrants. We also found significant disparities in coverage between regions of residence. This study identified several determinants associated with self-reported tetanus vaccination coverage among adult immigrants in Portugal. These findings may help policymakers to design specific interventions to increase tetanus vaccination coverage among this population.

The Influence of Hispanic Ethnicity and Nativity Status on 2009 H1N1 Pandemic Vaccination Uptake in the United States

Previous research suggests Hispanic vaccination rates for H1N1 were similar to non-Hispanic whites. These previous estimates do not take into account nativity status. Using the 2010 National Health Interview Survey, we estimate adult H1N1 vaccination rates for non-Hispanic whites (n = 8780), U.S.-born Hispanics (n = 1142), and foreign-born Hispanics (n = 1912). To test Fundamental Cause Theory, we estimate odds of H1N1 vaccination while controlling for flexible resources (e.g., educational and economic capital), ethnicity, and nativity status. Foreign-born Hispanics experienced the lowest rates of H1N1 vaccination (15%), followed by U.S.-born Hispanics (18%) and non-Hispanic whites (21%). Regression models show odds of H1N1 vaccination did not differ among these three groups after controlling for sociodemographic characteristics. Insufficient access to flexible resources and healthcare coverage among foreign-born Hispanics was responsible for relatively low rates of H1N1 vaccination. Addressing resource disparities among Hispanics could increase vaccination uptake in the future, reducing inequities in disease burden.

Trends in anogenital wart incidence among Tennessee Medicaid enrollees, 2006-2014: The impact of human papillomavirus vaccination

Introduction

Evidence of human papillomavirus (HPV) vaccine impact on anogenital warts (AGWs) by race or urbanicity in the US is lacking. We evaluated HPV vaccine impact in Tennessee by assessing AGW trends among Tennessee Medicaid (TennCare) enrollees aged 15–39 years from 2006-2014.

Methods

Persons with incident AGWs were identified using diagnosis/pharmacy codes from TennCare billing claims. We calculated sex-specific annual AGW incidence by age group, race, and urbanicity; estimated annual percent changes (APCs) using log-linear models; and performed pairwise comparisons by race and urbanicity.

Results

AGW incidence decreased among females aged 15–19 (APC = −10.6; P < 0.01) and 20–24 years (APC = −3.9; P = 0.02). Overall trends were similar between Whites and Blacks, and between those living in metropolitan statistical areas (MSAs) and non-MSAs. Rates among males aged 15–19 years began decreasing after 2010. Among enrollees aged 25–39 years, rates increased or were stable.

Conclusions

Following introduction of the HPV vaccine in 2006, AGWs decreased among age groups most likely to be vaccinated. The change in trend among young males after 2010 suggests early herd effects. Our findings indicate vaccine effects and support the importance of improving adherence to current vaccination recommendations for preventing AGWs and other HPV-related diseases.

Engaging Communities to Reach Immigrant and Minority Populations: The Minnesota Immunization Networking Initiative (MINI), 2006-2017

In Minneapolis-St Paul, Minnesota, factors such as cultural and linguistic diversity make it difficult for public health agencies to reach immigrant and racial/ethnic minority populations with health initiatives. Founded in 2006, the Minnesota Immunization Networking Initiative (MINI) is a community project that has provided more than 80 000 free influenza vaccinations to vulnerable populations, including immigrants and racial/ethnic minority groups. MINI administered 5910 vaccinations through 99 community-based vaccination clinics during the 2017-2018 influenza season and surveyed the clients in their own language about influenza vaccination knowledge and practices. Among those surveyed, 2545 (43.1%) were uninsured and 408 (6.9%) received a first-time influenza vaccination at the MINI clinic. A total of 2893 (49.0%) respondents heard about the clinic through their faith community. Lessons learned included the importance of building relationships with community leaders and involving them as full partners, holding clinics in community-based settings to bring vaccinations to clients, and reporting outcomes to partners.

The Quick and Dirty: A Tetanus Case Report

Tetanus is an increasingly rare diagnosis in the post-vaccination era, although it continues to have significant morbidity and mortality worldwide. In the United States (U.S.), the incidence of tetanus has declined dramatically due to the widespread use of the vaccine. High-risk populations for tetanus in the U.S. include the elderly, diabetics, injection drug users, and unvaccinated individuals. This is a report of a 78-year-old male with an incomplete immunization history who presented to an emergency department with jaw pain and who was ultimately diagnosed with tetanus. This report highlights the importance of prompt diagnosis, treatment, and prevention of tetanus.

Human papillomavirus immunization uptake among girls with a refugee background compared with Danish-born girls: a national register-based cohort study

Refugee children and their families may experience impaired access to healthcare; therefore, we aimed to uncover human papillomavirus (HPV) immunization patterns among a large group of refugee girls compared with Danish-born girls. We also examined possible predictors of uptake among refugee girls. We used a register-based cohort design where refugee girls (n=3264) who, between 1 January 1994 and 31 December 2010, obtained residency permits in Denmark, were included and matched on age and sex with Danish-born girls (n=19 584). Personal identification numbers were cross-linked to the National Danish Health Service Register, identifying all contacts for HPV-immunization in both the ordinary HPV-immunization program and in a catch-up program. We applied logistic regression to estimate the odds ratios (OR) of uptake. We found that refugee girls had significantly lower HPV immunization uptake compared with Danish-born girls in the ordinary immunization program (OR=0.44; 95% confidence interval: 0.37-0.51) and the catch-up program (OR=0.61; 95% confidence interval: 0.54-0.69). The difference in odds decreased after adjusting by family income, but remained significant for the ordinary immunization program. We also identified that region of origin, duration of residence, and income were predictors of uptake among refugee girls. The lower uptake of HPV immunization among refugee girls raises questions about the coverage of this immunization program across increasingly ethnic diverse societies. More efforts to secure equal uptake are needed.

Influenza Vaccination Coverage Among English-Speaking Asian Americans

INTRODUCTION

English-speaking non-Hispanic Asians (Asians) in the U.S. include populations with multiple geographic origins and ethnicities (e.g., Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese). Health behaviors and outcomes can differ widely among Asian ethnicities, and highlight the importance of subgroup analysis. Aggregating Asians may mask differences in influenza vaccination across various ethnicities.

METHODS

Combined data from 2013 to 2015 Behavioral Risk Factor Surveillance System, a population-based, telephone survey of the non-institutionalized, U.S. population aged ≥18years, were analyzed in 2017 to assess influenza vaccination among Asians. Weighted proportions were calculated. Multivariable logistic regression was used to determine independent associations between sociodemographic factors and receipt of influenza vaccination.

RESULTS

Influenza vaccination varied widely among Asian ethnicities, both nationally and by state. Overall, 42.1% of Asians reported having received an influenza vaccine, similar to vaccination among whites (42.4%). Coverage ranged from 36.1% among Koreans to 50.9% among Japanese. Factors independently associated with influenza vaccination among some or all Asian ethnicities included age (≥50 years), female, never married, high school or higher education, annual household income ≥$75,000, possession of medical insurance and personal healthcare provider, routine checkup in the previous year, and presence of certain chronic conditions.

CONCLUSIONS

Though Asians and whites had similar overall influenza vaccination coverage, differences existed between Asian ethnicities, both nationally and by state. This information may help community-based, state-level, and national-level public health agencies to support targeted approaches for outreach to these populations, such as improving cultural and linguistic access to care, to improve influenza vaccination.

Knowledge and attitudes toward HPV infection and vaccination among immigrants and refugees in Italy

BACKGROUND

The objectives of the present cross-sectional study were to investigate the level of knowledge and attitudes regarding Human papillomavirus (HPV) infection and its vaccination and to understand the impact of different determinants among immigrants and refugees in Italy.

METHODS

Between September 2016 and March 2018, a total of 519 potential participants were randomly recruited. The information was collected through a questionnaire administered by two researchers.

RESULTS

Only 15.9% reported that they had heard of HPV infection before completing the survey and 83.8% of them were aware that the infection could be transmitted through sexual intercourses, 32.3% that it can lead to cervical cancer, 22% to warts, 16.2% to penile cancer, 13.2% to oral cancer, 39.7% that cervical cancer is a very severe disease, 47.1% that receiving the vaccine could protect against the infection, and 44.1% that a vaccine against HPV is available in Italy. Females, those who originated from Eastern Europe, Asia and South America, those who lived in a house compared to those who lived in a street, and those who had 1-10 years and 11 or more years of education compared to those illiterate were more likely to have heard about the HPV infection before completing the survey. Only 3 participants (0.7%) received the HPV vaccination. Out of the unvaccinated who had heard of HPV, 50.7% and 59% of those between the ages of 12 and 26 and of those who had at least one child aged 12-26 years, were willing to receive vaccination for themselves as well as their children.

CONCLUSION

The results underscored the necessity to develop health education and promotion aimed at improving the knowledge and vaccination practice in immigrants and refugees.

Intersectional nativity and racial/ethnic disparities in human papillomavirus vaccination initiation among U.S. women: a national population-based study

BACKGROUND

Overall, foreign-born women are less likely than U.S.-born women to have initiated human papillomavirus (HPV) vaccination. However, foreign-born women are a racially/ethnically diverse population, and race/ethnicity is an independent predictor of HPV vaccination.

METHODS

Using 2011-2015 National Health Interview Survey data, we used multivariable logistic regression to estimate odds ratios for foreign-born black, Latina, and Asian women compared to foreign-born white women and U.S.-born white women, adjusting for sociodemographic factors. We added socioeconomic factors followed by health care access indicators, which we conceptualized as potential mediators, to each model to assess whether they helped explain observed disparities.

RESULTS

Foreign-born Asian ([odds ratio=] 0.43; [95% confidence interval:] 0.29-0.65) and Latina (0.46; 0.32-0.68) women had significantly lower adjusted odds of initiating HPV vaccination compared to foreign-born white women. Foreign-born white (0.64; 0.45-0.90), black (0.44; 0.29, 0.67), Latina (0.29; 0.24-0.35), and Asian (0.28; 0.21-0.38) women had significantly lower adjusted odds of HPV vaccination initiation compared to U.S.-born white women. Socioeconomic factors only explained HPV vaccination initiation disparities between foreign-born Latina women and foreign-born and U.S.-born white women. Health care access indicators modestly explained disparities between foreign-born white, black, and Latina women and U.S.-born white women only.

CONCLUSIONS

We observed pronounced HPV vaccination initiation disparities among foreign-born women in relation to race/ethnicity and between foreign-born women from minoritized racial/ethnic backgrounds and U.S.-born white women. Research on nativity disparities in HPV vaccination should take into account race/ethnicity, and vice versa. Interventions that seek to facilitate HPV vaccination among foreign-born women are needed and should address the unique needs of those from minoritized racial/ethnic backgrounds to promote cancer equity.

Heterogeneity of Hepatitis B Infection Among Pregnant Asian American and Pacific Islander Women

INTRODUCTION

Perinatal transmission of hepatitis B virus among Asian Americans and Pacific Islanders is a key driver of racial health disparities in liver cancer and mortality in the U.S. This study documents the prevalence of hepatitis B virus infection among pregnant women across racial/ethnic groups and among Asian Americans and Pacific Islanders to assess the need for intervention, and then identifies the individual correlates of hepatitis B virus infection among Asian American and Pacific Islander pregnant women.

METHODS

Using the 2014-2015U.S. birth rate population data, this study estimates a series of logistic regression models to examine the associations between individual-level correlates and hepatitis B virus infection among Asian American and Pacific Islanders pregnant women. Data were analyzed in July 2017.

RESULTS

Among Asian American and Pacific Islander pregnant women, Chinese American mothers are ten times more likely to experience hepatitis B virus infection than are Asian Indian and Japanese American mothers. Foreign-born mothers are significantly more likely to experience hepatitis B virus infection during pregnancy than those of their U.S.-born counterparts. Maternal SES characteristics are important correlates of hepatitis B virus infection among pregnant women.

CONCLUSIONS

Studies must disaggregate the pan-ethnic Asian American and Pacific Islander category to examine the health and health disparities of Asian Americans and Pacific Islanders. Given the heterogeneity of hepatitis B virus infection prevalence among Asian American and Pacific Islander pregnant women, the effectiveness of prevention and intervention programs depends on careful consideration of ethnicity in conjunction with group-specific factors.

Vaccination Coverage Disparities Between Foreign-Born and U.S.-Born Children Aged 19-35 Months, United States, 2010-2012

Healthy People 2020 targets high vaccination coverage among children. Although reductions in coverage disparities by race/ethnicity have been described, data by nativity are limited. The National Immunization Survey is a random-digit-dialed telephone survey that estimates vaccination coverage among U.S. children aged 19-35 months. We assessed coverage among 52,441 children from pooled 2010-2012 data for individual vaccines and the combined 4:3:1:3*:3:1:4 series (which includes ≥4 doses of diphtheria, tetanus, and acellular pertussis vaccine/diphtheria and tetanus toxoids vaccine/diphtheria, tetanus toxoids, and pertussis vaccine, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, ≥3 or ≥4 doses of Haemophilus influenzae type b vaccine (depending on product type of vaccine; denoted as 3* in the series name), ≥3 doses of hepatitis B vaccine, ≥1 dose of varicella vaccine, and ≥4 doses of pneumococcal conjugate vaccine). Coverage estimates controlling for sociodemographic factors and multivariable logistic regression modeling for 4:3:1:3*:3:1:4 series completion are presented. Significantly lower coverage among foreign-born children was detected for DTaP, hepatitis A, hepatitis B, Hib, pneumococcal conjugate, and rotavirus vaccines, and for the combined series. Series completion disparities persisted after control for demographic, access-to-care, poverty, and language effects. Substantial and potentially widening disparities in vaccination coverage exist among foreign-born children. Improved immunization strategies targeting this population and continued vaccination coverage monitoring by nativity are needed.