Racial and Ethnic Disparities in Vaccination Coverage Among Adult Populations in the U.S

Racial and ethnic disparities in human papillomavirus (HPV) vaccine uptake among United States adults, aged 27-45 years

In 2018, the Food and Drug Administration expanded the age of eligibility for the human papillomavirus (HPV) vaccine to 27 to 45 years. However, it is unclear if there are racial/ethnic disparities in HPV vaccine uptake for this age-group following this expanded recommendation. We aimed to identify any disparities in HPV vaccine in 27 to 45 year-olds based on sociodemographic factors. We analyzed nationally representative, cross-sectional data from the 2019 National Health Interview Survey (n = 9440). Logistic regression models estimated the odds of vaccine uptake (receipt of ≥1 vaccine dose) based on sociodemographic factors. Participants were mostly Non-Hispanic Whites (60.7%) and females (50.9%). In adjusted models, females had over three times greater odds of vaccine uptake compared to males (aOR = 3.58; 95% CI 3.03, 4.23). Also, compared to Non-Hispanic Whites, Non-Hispanic Blacks were 36% more likely (aOR = 1.36; 95% CI 1.09, 1.70), and Hispanics were 27% less likely (aOR = 0.73; 95% CI 0.58, 0.92) to receive the vaccine. Additionally, individuals without a usual place of care had lower odds of vaccine uptake (aOR = 0.72; 95% CI 0.57, 0.93), as were those with lower educational levels (aORhigh school = 0.62; 95% CI 0.50, 0.78; aORsome college = 0.83; 95% CI 0.70, 0.98). There are disparities in HPV vaccine uptake among 27 to 45 year-olds, and adult Hispanics have lower odds of receiving the vaccine. Given the vaccine's importance in cancer prevention, it is critical that these disparities are addressed and mitigated.

Influenza Vaccination in Adults in the United States with COPD before and after the COVID-19 Pandemic (2017-2022): A Multi-Year Cross-Sectional Study

There is limited literature regarding seasonal influenza vaccination (SIV) among those with a history of chronic obstructive pulmonary disease (HCOPD) prior to the COVID-19 pandemic, and no information on the topic assessing the years following the pandemic. This cross-sectional study used the Behavioral Risk Factor Surveillance Survey (BRFSS) data from the years 2017 to 2022 (n = 822,783 adults ages 50-79 years; 50.64% males). The exposure was a HCOPD, and the outcome was SIV within the past year. Weighted and adjusted logistic regression models were conducted overall and by the significant effect modifiers: smoking status, sex, and year. Having an HCOPD significantly increases the weighted adjusted odds (WAO) of SIV when compared to not having an HCOPD overall and by smoking status, sex, and year. For 2017 through 2022, among all current, former, and never smokers with an HCOPD, the WAO of SIV were: 1.36 (1.28, 1.45), 1.35 (1.27, 1.43), and 1.18 (1.09, 1.27), respectively. Among males with an HCOPD who were current, former, and never smokers, the WAO of SIV were: 1.35 (1.23, 1.48), 1.45 (1.33, 1.58), and 1.23 (1.05, 1.44), respectively. Among females with an HCOPD who were current, former, and never smokers, the WAO of SIV were: 1.31 (1.20, 1.43), 1.24 (1.15, 1.35), and 1.13 (1.04, 1.23), respectively. Study findings suggest males had significantly greater WAO ratios of receiving SIV than females in 2020 and 2022, during and after the COVID-19 pandemic. More specifically, males with an HCOPD who were former smokers had significantly greater WAOR of receiving SIV than females in 2020 and 2022. Understanding the potential barriers to SIV receipt by smoking status and sex, especially during a pandemic, and especially for individuals impacted by an HCOPD, is essential for better health interventions in times of a national crisis such as a pandemic. Additionally, SIV receipt is low among those with an HCOPD, and efforts should be made to improve this.

Influenza-Associated Outcomes and Healthcare Utilization by Race and Ethnicity in the USA: a Retrospective Cohort Study Using the National Inpatient Sample Database

BACKGROUND

The influenza virus continues to be a public health concern every season. We aimed to evaluate influenza-associated outcomes and healthcare utilization by race and ethnicity.

METHODS

We conducted a retrospective cohort study using the National Inpatient Sample across 2019 and 2020. Influenza pneumonia was selected as the principal diagnosis. Outcomes included mortality, use of respiratory support ventilation, length of stay, and total hospitalization charge. Regression models were adjusted for age, gender, Charlson Comorbidity Index, hospitals' region, bed size, teaching status, insurance status, and median income.

RESULTS

We identified 73,098 individuals hospitalized with influenza pneumonia; 39,807 and 33,291 were admitted in 2019 and 2020, respectively. The sample included 49,829 (68%) White, 11,356 (15.5%) Black, 7526 (10%) Hispanic, 1860 (2.5%) Asian/Pacific, and 617 (0.84%) Native American patients. In-hospital mortality rates and respiratory support (non-invasive ventilation and invasive mechanical ventilation) in 2019 and 2020 were not significantly different across all the races. In 2019 and 2020, the adjusted odds ratios of in-patient mortality were not significantly different. Asians had higher odds of receiving NIV in 2019 but not in 2020 compared to White patients (adjusted odds ratio (aOR) 1.67, p value 0.04). The adjusted odds ratios for receiving IMV were not significantly different between the races in 2019 and 2020.

CONCLUSIONS

This study contributes valuable insight into influenza-associated outcomes and healthcare utilization patterns among diverse racial and ethnic groups. Disparities in healthcare utilization were observed among younger (< 65 years) individuals of Black and Hispanic ethnicity.

Hepatitis B and influenza vaccination coverage in healthcare workers, the elderly, and patients with diabetes in Malaysia

Adult immunization remains to be a neglected issue in developing countries including Malaysia. This nationwide study determined the vaccination coverage of hepatitis B and influenza among Malaysia's healthcare workers (HCWs), the elderly (aged 60 y and above) and patients with diabetes, who are the participants of The Malaysia Cohort Program. The participants were categorized based on their occupation, age and medical history. Self-reported questionnaire was used to assess the participant's hepatitis B and influenza vaccination status. A Chi-square test and logistic regression analyses were performed to determine the risk factors associated with vaccination behavior. The hepatitis B vaccination coverage for healthcare workers, elderly, and patients with diabetes were 34.6%, 10.1% and 9.8%, respectively. The influenza vaccination coverage rates for healthcare workers, the elderly and patients with diabetes were 26.3%, 5.5% and 6.4%, respectively. The Chinese were more likely to be vaccinated against hepatitis B, while Malay was more likely to be vaccinated against influenza. Individuals with higher education and living in urban areas were more likely vaccinated than those with low education levels and who lived in rural areas. The low vaccination coverage for healthcare workers was alarming because hepatitis B and influenza were subsidized for the healthcare workers. The hepatitis B and influenza vaccination coverage among healthcare workers, elderly and patients with diabetes in Malaysia were low. Specific interventions such as educational and awareness programs should be conducted to increase the vaccination rate among adults, especially those at high risk.

Regional factors associated with pneumococcal vaccination coverage among U.S. adults with underlying chronic or immunocompromising conditions

The Centers for Disease Control recommends pneumococcal vaccination for U.S. adults aged 19-64 years with chronic or immunocompromising conditions, however, vaccination coverage is low and regional variations in coverage are rarely studied. This study examined pneumococcal vaccination coverage at the metropolitan statistical area (MSAs) level and identified regional factors associated with pneumococcal vaccination using the combined IBM® Watson Health MarketScan® Commercial and Medicare Supplemental databases. Pneumococcal vaccination coverage, clinical and socioeconomic factors were calculated for each MSA. Ordinary least square and spatial regression models were used to examine factors associated with vaccination. Results indicated that the national pneumococcal vaccination coverage was 13.4% with a large variation across MSAs (0-34%). The spatial error model, model with the best fit, showed that proportions of the population who were ≥50 years of age, received an influenza vaccine, or had health maintenance organization health plans were positively associated with pneumococcal vaccination coverage. In summary, we found that national pneumococcal vaccination coverage was low and there was substantial variation across MSAs. Regional factors identified may help inform interventions to improve pneumococcal vaccination coverage across geographies.

Vaccination intention and uptake within the Black community in Appalachia

OBJECTIVE

Black communities have disproportionately experienced adverse health effects from the COVID-19 pandemic while simultaneously having less vaccination access and decreased vaccine utilization. As such, predictors of vaccination uptake within Black communities are a public health imperative. Black Americans from socio-geographic regions associated with health inequities (e.g., Appalachia), including vaccination disparities, represent an intersection of racial, economic, and ethnic social identities. To better understand the preventive health needs of Black communities in Appalachia and elsewhere, this study examined psychosocial predictors of vaccination intention or behavior.

METHOD

Adults (n = 336) identifying as Black or African American from West Virginia indicated demographics, reported COVID-19 vaccination intention, flu vaccination uptake, and human papillomavirus (HPV) vaccination uptake, and completed assessments of vaccine hesitancy, medical mistrust, and racial discrimination. Hierarchical logistic regression modeling examined potential associations between psychosocial predictors and each vaccine type.

RESULTS

Results showed variation in significant predictors across the vaccines of focus. Racial discrimination (OR = 0.64) and medical mistrust (OR = 0.93) were negatively associated with COVID-19 vaccination intention. Vaccine confidence was positively associated with COVID-19 vaccination intention (OR = 2.17) and HPV vaccination uptake (OR = 1.77). Total household income was the only predictor associated with flu vaccination uptake (OR = 1.12).

CONCLUSIONS

These findings suggest that social interventions targeting racial discrimination in healthcare may significantly help address vaccination disparities in rural Black communities. Moreover, results emphasize unique aspects of vaccination behavior in the Black community within Appalachia that may generalize to other Black communities living in rural regions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Racial and sociodemographic predictors of COVID-19 compared with influenza, appendicitis, and all-cause hospitalization: retrospective cohort analysis

OBJECTIVE

To determine whether inequities in COVID-19 infection and hospitalization differ from those for common medical conditions: influenza, appendicitis, and all-cause hospitalization.

DESIGN

Retrospective study based on electronic health records of three healthcare systems in San Francisco (university, public, and community) examining (1) racial/ethnic distribution in cases and hospitalization among patients with diagnosed COVID-19 (March-August 2020) and patients with diagnosed influenza, diagnosed appendicitis, or all-cause hospitalization (August 2017-March 2020), and (2) sociodemographic predictors of hospitalization among those with diagnosed COVID-19 and influenza.

RESULTS

Patients 18 years or older with diagnosed COVID-19 (N = 3934), diagnosed influenza (N = 5932), diagnosed appendicitis (N = 1235), or all-cause hospitalization (N = 62,707) were included in the study. The age-adjusted racial/ethnic distribution of patients with diagnosed COVID-19 differed from that of patients with diagnosed influenza or appendicitis for all healthcare systems, as did hospitalization from these conditions compared to any cause. For example, in the public healthcare system, 68% of patients with diagnosed COVID-19 were Latine, compared with 43% of patients with diagnosed influenza, and 48% of patients with diagnosed appendicitis (p < 0.05). In multivariable logistic regressions, COVID-19 hospitalizations were associated with male sex, Asian and Pacific Islander race/ethnicity, Spanish language, and public insurance in the university healthcare system, and Latine race/ethnicity and obesity in the community healthcare system. Influenza hospitalizations were associated with Asian and Pacific Islander and other race/ethnicity in the university healthcare system, obesity in the community healthcare system, and Chinese language and public insurance in both the university and community healthcare systems.

CONCLUSIONS

Racial/ethnic and sociodemographic inequities in diagnosed COVID-19 and hospitalization differed from those for diagnosed influenza and other medical conditions, with consistently higher odds among Latine and Spanish-speaking patients. This work highlights the need for disease-specific public health efforts in at-risk communities in addition to structural upstream interventions.

Disparities and Trends in Routine Adult Vaccination Rates Among Disaggregated Asian American Subgroups, National Health Interview Survey 2006-2018

Introduction

Vaccination rates may be improved through culturally tailored messages, but little is known about them among disaggregated Asian American subgroups. We assessed the vaccination rates for key vaccines among these subgroups.

Methods

Using the National Health Interview Survey, we analyzed recent vaccination rates (2015-2018, n=188,250) and trends (2006-2018) among Asians (Chinese [n=3,165], Asian Indian [n=3,525], Filipino [n=3,656], other Asian [n=5,819]) and non-Hispanic White adults (n=172,085) for 6 vaccines (the human papillomavirus, hepatitis B, pneumococcal, influenza, tetanus-diphtheria [tetanus], and shingles vaccines). We controlled demographic, socioeconomic, and health-related variables in multivariable logistic regression and predicted marginal modeling analyses. We also computed vaccination rates among Asian American subgroups on the 2015-2018 National Health Interview Survey data stratified by foreign-born and U.S.-born status. We used Joinpoint regression to analyze trends in vaccination rates. All analyses were conducted in 2021 and 2022.

Results

Among Asians, shingles (29.2%; 95% CI=26.6, 32.0), tetanus (53.7%; 95% CI=51.8, 55.6), and pneumococcal (53.8%; 95% CI=50.1, 57.4) vaccination rates were lower than among non-Hispanic Whites. Influenza (47.9%; 95% CI=46.2, 49.6) and hepatitis B (40.5%; 95% CI=39.0, 42.7) vaccination rates were similar or higher than among non-Hispanic Whites (48.4%; 95% CI=47.9, 48.9 and 30.7%; 95% CI=30.1, 31.3, respectively). Among Asians, we found substantial variations in vaccination rates and trends. For example, Asian Indian women had lower human papillomavirus vaccination rates (12.9%; 95% CI=9.1, 18.0) than all other Asian subgroups (Chinese: 37.9%; 95% CI=31.1, 45.2; Filipinos: 38.7%; 95% CI=29.9, 48.3; other Asians: 30.4%; 95% CI=24.8, 36.7) and non-Hispanic Whites (36.1%; 95% CI=34.8, 37.5). Being male, having lower educational attainment and income, having no health insurance or covered by public health insurance only, and lower frequency of doctor visits were generally associated with lower vaccine uptakes. Foreign-born Asian aggregate had lower vaccination rates than U.S.-born Asian aggregate for all vaccines except for influenza. We also found subgroup-level differences in vaccination rates between foreign-born and U.S.-born Asians. We found that (1) foreign-born Chinese, Asian Indians, and other Asians had lower human papillomavirus and hepatitis B vaccination rates; (2) foreign-born Chinese and Filipinos had lower pneumococcal vaccination rates; (3) foreign-born Chinese and Asian Indians had lower influenza vaccination rates; and (4) all foreign-born Asian subgroups had lower tetanus vaccination rates.

Conclusions

Vaccination rates and trends differed among Asian American subgroups. Culturally tailored messaging and interventions may improve vaccine uptakes.

Attitudes toward COVID-19 Vaccine Uptake: A Qualitative Study of Mostly Immigrant Racial/Ethnic Minority Older Adults

(1) Background: Few qualitative studies address diverse older adults' perceptions of COVID-19 vaccination in the United States, including non-English speakers and immigrant populations. This study aims to understand the attitudes of diverse, primarily immigrant older adults in the U.S. toward the COVID-19 vaccine and its influences on their vaccination decision-making. (2) Methods: The research team conducted semi-structured interviews (N = 100) in 2021 focused on understanding ethnically/racially diverse older adults' perceptions of the COVID-19 vaccine. Interviews were recorded, coded, and analyzed using a thematic analysis approach. (3) Results: Thematic analyses identified three themes. (1) Older adults showed mixed attitudes toward the COVID-19 vaccine associated with information consumed and trust in healthcare systems; (2) health concerns and underlying medical conditions were the most influential factors of vaccine uptake; and (3) systemic barriers and trusted figures impacted vaccination decision-making of older adults. (4) Conclusions: Accessible information in diverse languages tailored to the community's fears is needed to combat vaccine mistrust. Vaccine rollout programs need to tackle the fear of vaccine side effects. Attitudes of religious leaders, family members, and physicians considerably influenced vaccine uptake, suggesting their role as trusted members for vaccine messaging for older, primarily immigrant adults. Systemic barriers, namely lack of transportation and inaccessible vaccination sites, contributed to vaccine deterrence.

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.

Factors Associated with Delayed or Missed Second-Dose mRNA COVID-19 Vaccination among Persons >12 Years of Age, United States

To identify demographic factors associated with delaying or not receiving a second dose of the 2-dose primary mRNA COVID-19 vaccine series, we matched 323 million single Pfizer-BioNTech (https://www.pfizer.com) and Moderna (https://www.modernatx.com) COVID-19 vaccine administration records from 2021 and determined whether second doses were delayed or missed. We used 2 sets of logistic regression models to examine associated factors. Overall, 87.3% of recipients received a timely second dose (≤42 days between first and second dose), 3.4% received a delayed second dose (>42 days between first and second dose), and 9.4% missed the second dose. Persons more likely to have delayed or missed the second dose belonged to several racial/ethnic minority groups, were 18-39 years of age, lived in more socially vulnerable areas, and lived in regions other than the northeastern United States. Logistic regression models identified specific subgroups for providing outreach and encouragement to receive subsequent doses on time.

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.

Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study

BACKGROUND

Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention.

METHODS

Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis.

DISCUSSION

This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Robust Hepatitis A Vaccination Response Within the United States Veterans Health Administration in the Wake of State Outbreaks

We assessed hepatitis A (HepA) vaccine receipt among susceptible individuals in outbreak and matched nonoutbreak states. Difference-in-differences models and multivariable logistic regression were used to compare HepA vaccination rates in these states. In the postoutbreak year, there was a 112% increase in HepA vaccinations in outbreak states versus a 6% decrease in nonoutbreak states. Differences persisted in our multivariable model (adjusted odds ratio = 2.53; 95% confidence interval = 2.45, 2.61). HepA vaccination rates increased dramatically in outbreak states, but many individuals susceptible to hepatitis A virus remain unvaccinated. (Am J Public Health. Published online ahead of print May 26, 2022: e1-e5. https://doi.org/10.2105/AJPH.2022.306845).

Factors associated with COVID-19 vaccine intent among Latino SNAP participants in Southern California

Background

COVID-19 is significantly impacting the health and well-being of the country, particularly for ethnic minority populations and low-income groups. Our goal was to determine COVID-19 vaccination intent in a low-income, Latino population receiving aid from the Supplemental Nutrition Assistance Program (SNAP) in Southern California, and identify contributing factors and concerns.

Methods

A cross-sectional, mixed-methods survey was conducted among participants in the Southern California Nutrition Incentives Program (¡Más Fresco! More Fresh). Only Latino respondents were included in this analysis. Primary outcome was vaccine intent trichotomized into: “definitely/likely yes”, “not sure/don’t know”, and “definitely/likely not.”

Results

The majority of participants (n = 486) were female (93%), Spanish speaking (74%), with a median age of 40 years (IQR = 13). Approximately half (48%) reported they would get a COVID-19 vaccine, 39% were unsure, and 13% reported “definitely/likely not”. In the multivariable multinomial logistic regression model, participants with a household member with a COVID-19 health risk factor were more likely to be unsure about getting the vaccine. Participants who were primarily English speaking, did not receive the influenza vaccine last season, and reported not reading or talking about COVID-19 were more likely to report not intending to receive the vaccine. Many respondents were concerned about “side effects and ingredients”, and did not trust the vaccine development process, particularly with how fast it happened.

Conclusion

Low-income Latinos in Southern California were generally hesitant to get a COVID-19 vaccine. Culturally sensitive vaccine promotion campaigns need to address the concerns of minority populations who experience increased morbidity and mortality from COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13027-w.

Identification of groups at high risk for under-coverage of seasonal influenza vaccination: A national study to inform vaccination priorities during the COVID-19 pandemic

PURPOSE

Seasonal influenza vaccination is an important public health strategy to reduce preventable illness, hospitalization, and death. Because of overlapping risk factors for severe illness from seasonal influenza and COVID-19, uptake of the seasonal influenza vaccination has heightened importance during the COVID-19 pandemic. We analyzed receipt of seasonal influenza vaccination among COVID-19 priority groups and further examined socio-demographic and behavioral factors associated with receiving the seasonal influenza vaccine among US adults.

METHODS

Using the 2018 National Health Interview Survey, we classified 24,772 adults into four COVID-19 priority groups: healthcare workers, medically vulnerable, non-healthcare essential workers, and the general population. We performed multiple logistic regression to compare the relative odds of receiving the influenza vaccine by COVID-19 priority group, socio-demographics, and health-related factors.

RESULTS

Healthcare workers, medically vulnerable adults, essential workers, and the general population comprised 8.9%, 58.4%, 6.6%, and 26.1 % of the US population, respectively. Compared with healthcare workers, the adjusted odds ratio (aOR) of receiving influenza vaccine were significantly lower in medically vulnerable adults (aOR=0.43, 95% CI=0.37, 0.48), essential workers (aOR=0.28, 95% CI=0.23, 0.34), and the general population (aOR=0.32, 95% CI=0.28, 0.37). Being young, male, Black, and having no health insurance were associated with lower relative odds of receiving the flu vaccine.

CONCLUSIONS

Patterns of influenza vaccine cause concern for under-coverage of populations at high risk for both seasonal influenza and COVID-19. Achieving optimal protection against vaccine-preventable respiratory illness in US adults will require emphasis on those employed outside of the healthcare sector, younger age groups, and adults with lower socioeconomic resources.

Real-world evidence on adherence and completion of the two-dose recombinant zoster vaccine and associated factors in U.S. adults, 2017-2021

INTRODUCTION

Poor compliance with adult vaccination recommendations contributes to substantial disease burden. Evidence on adherence, completion, and completion timeliness for the 2-dose recombinant herpes zoster vaccine (RZV) and factors associated with these outcomes is limited and not readily generalizable for the entire U.S.

METHODS

This retrospective, observational study examined adherence, completion, and the impact of sociodemographic, clinical and geographical factors among U.S. adults ≥ 50 years receiving RZV (4/20/2017 to 3/31/2021), using a large, geographically representative administrative claims database. Continuous enrollment in a medical benefit plan for six months prior to and following the index date (first observed vaccine dose) was required. Adherence was defined as receipt of the 2nd dose within 2-6 months, per label recommendation. Completion (receipt of all doses) was assessed at 6, 12, 18, and 24 months.

RESULTS

Among 726,352 adults included, the adherence rate was 71.8%. Among 208,311 adults with 24-month follow-up, the completion rate was 72.3% after 6 months and 86.2% after 24 months. Logistic regression showed low adherence/completion was associated with younger age, Black or Hispanic race/ethnicity, lower income, lower educational attainment, and possessing commercial rather than Medicare healthcare insurance. Recipients identified using pharmacy claims had much higher adherence (74.0%) than those identified using medical claims (48.0%).

CONCLUSIONS

Adherence and completion rates for RZV are suboptimal, especially for adults aged 50-64, racial/ethnic minorities, individuals with lower socio-economic status and those without Medicare insurance. More research and public health efforts are needed to understand and address potential barriers to RZV uptake, adherence and completion.

Vaccine-preventable disease hospitalized patients with heart failure with reduced ejection fraction

Background

Over five million Americans suffer from heart failure (HF), and this is associated with multiple chronic comorbidities and recurrent decompensation. Currently, there is an increased incidence in vaccine‐preventable diseases (VPDs). We aim to investigate the impact of HF with reduced ejection fraction (HFrEF) in patients hospitalized with VPDs.

Hypothesis

Patient with HFrEF are at higher risk for VPDs and they carry a higher risk for in‐hospital complications.

Methods

Retrospective analysis from all hospital admissions from the 2016‐2018 National Inpatient Sample (NIS) using the ICD‐10CM codes for patients admitted with a primary diagnosis of VPDs with HFrEF and those without reduced ejection fraction. Outcomes evaluated were in‐hospital mortality, length of stay (LOS), healthcare utilization, frequency of admissions, and in‐hospital complications. Multivariate regression analysis was conducted to adjust for confounders.

Results

Out of 317 670 VPDs discharges, we identified 12 130 (3.8%) patients with HFrEF as a comorbidity. The most common admission diagnosis for VPDs was influenza virus (IV) infection (75.0% vs. 64.1%; p < .01), followed by pneumococcal pneumonia (PNA) (13% vs. 9.4%; p < .01). After adjusting for confounders, patients with HFrEF had higher odds of having diagnosis of IV (adjusted [aOR], 1.42; p < .01) and PNA (aOR, 1.27; p < .01). Patients with VPDs and HFrEF had significantly higher odds of mortality (aOR, 1.76; p < .01), LOS, respiratory failure requiring mechanical ventilation, and mechanical ventilation for less than 96 h.

Conclusion

Influenza and PNA were the most common VPDs admitted to the hospital in patients with a concomitant diagnosis of HFrEF. They were associated with increased mortality and in‐hospital complications.

Willingness to give amid pandemics: a contingent valuation of anticipated nongovernmental immunization programs

Given that altruism is crucial in assisting impoverished households to cope with health and economic crises, it is important to improve our understanding of how preferences and motives for giving differ during a pandemic. We implemented a web-based, contingent valuation survey to estimate Americans' willingness to give for nongovernmental immunization programs in the context of the COVID-19 pandemic. Our results indicate that the median person is willing to give a one-time donation of $26, or at least $13 when willingness-to-give estimates are corrected for uncertainty regarding future donations. We find that willingness to give is related to income, concern levels, vaccine usage, and sociodemographic characteristics. Our findings also shed light on purely and impurely altruistic motives underlying the willingness to fund immunization programs.

Comparison of Disease Patterns and Outcomes Between Non-Japanese and Japanese Patients at a Single Tertiary Emergency Care Center in Japan

BACKGROUND

Japan's historically low immigration rate and monolingual culture makes it a particularly interesting setting for clarifying non-national medical care. Our study objective was to examine disease patterns and outcome differences between Japanese and non-Japanese patients in a rapidly globalizing nation.

METHODS

A secondary data analysis of 325 non-Japanese and 13,370 Japanese patients requiring tertiary care or intensive-care unit or high-care unit admission to the emergency department at the Tokyo Medical and Dental University medical hospital from 2010 through 2019 was conducted. Multivariable linear and logistic regressions models were applied to examine differences in percentage of diagnosis, mortality rates, and length of stay, stratified by Glasgow Coma Scale (GCS) scores to consider the impact of language barriers. Sex and age were adjusted.

RESULTS

Non-Japanese patients had more anaphylaxis, burns, and infectious disease, but less cardiovascular diagnoses prior to adjustment. After adjustment, there were significantly more anaphylaxis (adjusted odds ratio [aOR] 2.7; 95% confidence interval [CI], 1.7-4.4) and infectious disease diagnoses (aOR 2.2; 95% CI, 1.3-3.7), and marginally more burn diagnoses (aOR 2.3; 95% CI, 0.96-5.3) than Japanese patients. Regardless of GCS scores, there were no significant differences between non-Japanese and Japanese patient length of stay for anaphylaxis, burn, and infectious disease after covariate adjustment.

CONCLUSION

There were more non-Japanese patients diagnosed with anaphylaxis, burns, and infectious disease, but no notable patient care differences for length of stay. Further prevention efforts are needed against anaphylaxis, burns, and infectious disease for non-Japanese tourists or residents.

Sociodemographic Disparities In Access To COVID-19 Vaccines Upon Initial Rollout In Florida

In this study we explored sociodemographic disparities in COVID-19 vaccine access upon initial rollout at Publix grocery store locations throughout Florida in January 2021. Florida officials reported that they chose Publix stores for the vaccine rollout because the chain has so many stores in the state and was considered at the time to be better prepared than other retailers. Data on education levels, ethnicity, race, percentage at or below the poverty level, and percentage single-parent households were collected from the 2019 census for 974 Florida ZIP codes. We used hotspot analysis to measure spatial clustering of Publix vaccination sites per 100,000 people. We identified hot spots (areas with greater vaccine availability) in moderately populated areas where the population was significantly older, richer, and Whiter than in areas of lower vaccine availability (cold spots). Cold spots were identified in areas of low and high population density, areas with a higher proportion of Hispanic residents, and areas with a higher proportion of single-parent households, including Miami-Dade County and inland regions of Florida. Multivariate analysis showed strong associations between the number of vaccination sites in a ZIP code and race and ethnicity and a weaker association with percentage of residents at or below the poverty level. Future vaccine distribution should continue to be monitored through a socioeconomic lens to help prevent unequal access.

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.

Factors influencing series completion rates of recombinant herpes zoster vaccine in the United States: A retrospective pharmacy and medical claims analysis

BACKGROUND/OBJECTIVES

Vaccination against herpes zoster (HZ) is an effective strategy in protecting the population against consequences of varicella zoster virus reactivation. Optimal immunogenicity with recombinant zoster vaccine (RZV) relies on completion of the 2-dose series within 2-6 months from the first dose. The objectives of this study were to estimate RZV completion rates and adherence with the recommended administration schedule in the general United States population aged at least 50 years and to evaluate factors influencing completion rates.

METHODS

Longitudinal, open-source pharmacy and medical claims databases were analyzed for adults aged at least 50 years with a first RZV prescription filled between October 2017 and September 2019. The data were linked to Experian Marketing Services Consumer View data to obtain information regarding race. Completion rates and adherence were calculated overall and stratified according to claim source, age class, sex, and payer type. Logistic regression models were built for each subpopulation of interest to identify factors correlating with completion rates.

RESULTS

Overall, cumulative completion rates were 70.41% and 81.80% at 6 and 12 months, respectively. Median time to second dose was approximately 4 months (4.08-5.13 months) and adherence 67.62%. Completion rates were lower in the medical claims database compared with the pharmacy claims database (48.98% vs. 73.23% at 6 months). Regression models confirmed that pharmacy claim was an independent factor for higher completion rates, while African American race and Medicaid status were associated with lower completion rates. Most comorbidities, including chronic obstructive pulmonary disease and type 2 diabetes mellitus, were associated with lower completion rates.

CONCLUSION

Pharmacists contribute substantially to the overall high RZV completion rates in the United States. However, completion rates can be improved, especially in people receiving their first RZV dose at a physician's office. Future strategies should aim at lowering barriers to completing vaccination series in African Americans, Medicaid beneficiaries, and people with comorbidities.

Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations

Adult immunization rates are low and continue to fail to meet national targets. The coronavirus disease 2019 pandemic halted routine health care services for many, including vaccinations. This study explored whether the National Committee for Quality Assurance's Adult Immunization Status (AIS) measure, which had previously only been evaluated for reporting by health plans, could be leveraged by health care organizations (HCOs) as a tactic to improve immunization rates. Methods included a quantitative analysis of deidentified patient electronic health record data from 3 HCOs, supplemented by qualitative interviews to further understand opportunities and barriers. The analysis indicated that the data necessary for calculation of the AIS measure are available within HCOs and that measure performance could be enhanced with supplemental data from external sources, such as state immunization registries. Although HCOs rates were consistent with national estimates, this research further validated that adult immunization rates in the United States are low and highlighted the profound disparities that exist. For instance, the likelihood of completing all age-appropriate vaccinations was lower if patients were Black or African American, enrolled in Medicaid, or without health insurance. As a result of this study, the authors concluded that the AIS measure is feasible for use in medical groups and could potentially help drive quality improvements in immunization rates; however, there are considerations for implementation particularly if providers are being held accountable for measure performance.

Impact of Socioeconomic Status and Race on Sepsis Epidemiology and Outcomes

BACKGROUND

Socioeconomic status (SES) is a complex variable that is derived primarily from an individual's education, income, and occupation and has been found to be inversely related to outcomes of health conditions. Sepsis is the sixth most common admitting diagnosis and one of the most costly conditions for in-hospital spending in the United States. The objective of this review is to report on the relationship between SES and sepsis incidence and associated outcomes.

CONTENT

Sepsis epidemiology varies when explored by race, education, geographic location, income, and insurance status. Sepsis incidence was significantly increased in individuals of Black race compared with non-Hispanic white race; in persons who have less formal education, who lack insurance, and who have low income; and in certain US regions. People with low SES are likely to have onset of sepsis significantly earlier in life and to have poorly controlled comorbidities compared with those with higher SES. Sepsis mortality and hospital readmission is increased in individuals who lack insurance, who reside in low-income or medically underserved areas, who live far from healthcare, and who lack higher level education; however, a person's race was not consistently found to increase mortality.

SUMMARY

Interventions to minimize healthcare disparity for individuals with low SES should target sepsis prevention with increasing measures for preventive care for chronic conditions. Significant barriers described for access to care by people with low SES include cost, transportation, poor health literacy, and lack of a social network. Future studies should include polysocial risk scores that are consistently defined to allow for meaningful comparison across studies.

County-level Predictors of Coronavirus Disease 2019 (COVID-19) Cases and Deaths in the United States: What Happened, and Where Do We Go from Here?

BACKGROUND

The United States has been heavily impacted by the coronavirus disease 2019 (COVID-19) pandemic. Understanding microlevel patterns in US rates of COVID-19 can inform specific prevention strategies.

METHODS

Using a negative binomial mixed-effects regression model, we evaluated the associations between a broad set of US county-level sociodemographic, economic, and health status-related characteristics and cumulative rates of laboratory-confirmed COVID-19 cases and deaths between 22 January 2020 and 31 August 2020.

RESULTS

Rates of COVID-19 cases and deaths were higher in US counties that were more urban or densely populated or that had more crowded housing, air pollution, women, persons aged 20-49 years, racial/ethnic minorities, residential housing segregation, income inequality, uninsured persons, diabetics, or mobility outside the home during the pandemic.

CONCLUSIONS

To our knowledge, this study provides results from the most comprehensive multivariable analysis of county-level predictors of rates of COVID-19 cases and deaths conducted to date. Our findings make clear that ensuring that COVID-19 preventive measures, including vaccines when available, reach vulnerable and minority communities and are distributed in a manner that meaningfully disrupts transmission (in addition to protecting those at highest risk of severe disease) will likely be critical to stem the pandemic.

Portrayals of Vaccination in Entertainment Television: A Content Analysis

Entertainment media have been found to influence viewers' health perceptions and behaviors, yet little is currently known about how vaccination, an issue that has become controversial, is being portrayed in fictional television. The present study combined constructs from the health belief model and entertainment theory to conduct a quantitative content analysis of 51 television episodes released in 2000 or after. Results indicate that vaccination is portrayed in a variety of different program types including, but not limited to, medical dramas. The tone of vaccination portrayals was mostly positive across the episodes examined. Episodes with a positive vaccination tone tended to have more information than those presenting vaccination negatively, but overall there was little information provided. Pro-vaccination characters tended to be cast as the protagonists in a main starring role, whereas anti-vaccination characters played supporting characters, typically as parents making vaccination decisions for their children. The majority of episodes featured anti-vaccination arguments, such as those perpetuating the link between vaccines and autism.

Assessing Human Papillomavirus Awareness and the Role of Oropharyngeal Squamous Cell Carcinoma Education on Improving Intention to Vaccinate

OBJECTIVES/HYPOTHESIS

The current state of the U.S. public's knowledge of the relationship between human papillomavirus (HPV) and HPV vaccinations to oropharyngeal squamous cell carcinoma (OPSCC) is unknown. Our objective was to 1) assess the general population's knowledge of human papillomavirus (HPV) and willingness to vaccinate, and 2) assess whether targeted education on HPV-related OPSCC can change intentions to vaccinate.

STUDY DESIGN

Online cross-sectional survey.

METHODS

An online, cross-sectional survey utilizing U.S. census-derived quotas to represent the U.S. population was distributed and analyzed to 517 adults in 2020.

RESULTS

Exactly 72.7% of participants stated that they had or would vaccinate their child against HPV and were designated as "vaccinators." In multivariate regression, Black individuals were less likely to be vaccinators (OR 0.51 [95% CI 0.27-0.94]), but those who were aware of HPV's role in OPSCC were more likely to vaccinate (OR 2.56 [95% CI 1.47-4.46]). Knowledge about vaccination side-effects, eligibility, and mechanisms of HPV spread was low. Only 30.6% of the sample reported understanding the role of HPV in OPSCC. Of these, 43.0% gained this knowledge exclusively from nonhealthcare professional sources, like television. When presented with four short HPV-OPSCC-centered facts (HPV's role in OPSCC etiology, prevalence of infection, clinically silent course, and vaccine preventative effects), 54.0% of "nonvaccinators" indicated a willingness to change their minds.

CONCLUSIONS

General knowledge about HPV, HPV's role in OPSCC, and the vaccine remains low in the general population. There are racial disparities in willingness to vaccinate within this sample, but these may be overcome by effective education on HPV-related OPSCC.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Vaccination Rates Among Patients Age 65 Years and Older Who Require Interpreter Services in the State of Minnesota

In the United States, the growing population of older adults with limited English language proficiency (LEP) faces profound health care disparities. Previous research on vaccination of older adults has been based on self-reported data, without clinical verification. We compared pneumococcal vaccination rates between a patient group with LEP and a group of English speakers in an older community-dwelling population. A population-nested matched cohort of participants age 65 years and older was identified in Minnesota. Patients with LEP were identified through an electronic alert within the electronic health record, designed to determine the need for an interpreter. Patients were matched 1 to 1 for age, sex, and Charlson comorbidity index. We used conditional logistic regression for the final analysis. In total, 24,052 patients were identified as older patients (mean [SD] age, 74 [7] years). Of them, 617 patients (2.6%) had LEP. The most common primary languages were Somali (24%), Vietnamese (15%), and Spanish (13%). We found lower rates of vaccination with 13-valent pneumococcal conjugate vaccine (PCV13) in the LEP group compared with English speakers [62% vs 77%; odds ratio (OR) (95% CI) 2.07 (1.61-2.66); P < 0.001]. Results were similar for 23-valent pneumococcal polysaccharide vaccine (PPSV23) [60% vs 75%; OR (95% CI) 1.97 91.54-2.51); P < 0.001]. These data are suggestive that older adults who required a language interpreter during health care encounters were less likely to be vaccinated with PCV13 and PPSV23 than older adults who did not require an interpreter. Effectiveness studies are needed to determine which interventions can help improve vaccination rates in the LEP population of elderly patients.

Factors associated with COVID-19 vaccine trust and hesitancy among adults with chronic conditions

In a survey of older adults at higher risk for COVID-19 complications, we sought to describe expectations of trust in the safety and efficacy of a future COVID-19 vaccine, and level of hesitancy about receiving it. We also assessed whether these expectations were associated with known or suspected contributors to vaccine hesitancy, disparities in vaccine receipt, and potential targets for public health outreach.

From May 1–22, 2020, we performed telephone surveys of 601 older adults with chronic conditions in metro Chicago about their COVID-19 experiences and levels of vaccine trust and hesitancy. All participants previously completed assessments of demographics, health status, health literacy and activation. Bivariate associations were performed using t-tests or one-way ANOVA, and multivariate analyses using least square means.

Younger age (<60), Black race, greater complacency about contracting COVID-19, and lower confidence in state or local government were associated with significantly lower trust in a vaccine’s safety and efficacy. Black race and greater complacency about contracting COVID-19 were associated with a significantly greater vaccine hesitancy. Amongst Black participants, vaccine hesitancy varied significantly by confidence in the federal government.

Trust and hesitancy regarding a future COVID-19 vaccine were associated with age, race, complacency regarding contracting COVID-19, and confidence in government response to the pandemic, but not education, health literacy or activation. Therefore, efforts to vaccinate higher risk older adults must aim not only to educate and provide vaccine access, but engender trust in the vaccine development process and vaccination strategies at both the federal and the local level.

COVID-19 Vaccine Discourse on Twitter: A Content Analysis of Persuasion Techniques, Sentiment and Mis/Disinformation

This research aims to understand the persuasion techniques used in Twitter posts about COVID-19 vaccines by the different vaccine sentiments (i.e., Pro-Vaccine, Anti-Vaccine, and Neutral) using the Elaboration Likelihood Model, Social judgment Theory, and the Extended Parallel Process Model as theoretical frameworks. A content analysis was conducted on a data set of 1,000 Twitter posts. The corpus of Tweets was examined using the persuasion frameworks; tweets that were identified as emanating from bots were further examined. Results found Anti-Vaccine messages predominantly used Anecdotal stories, Humor/Sarcasm, and Celebrity figures as persuasion techniques, while Pro-Vaccine messages primarily used Information, Celebrity figures, and Participation. Results also showed the Anti-Vaccine messages primarily focused on values related to the categories of Safety, Political/Conspiracy Theories, and Choice. Finally, results revealed Anti-Vaccine messages primarily used Perceived Severity and Perceived Susceptibility, which are fear appeal elements. The findings for messages by bots were comparable to the messages in the larger corpus of tweets. Based on the findings, a response framework-Health Information Persuasion Exploration (HIPE)-is proposed to address mis/disinformation and Anti-Vaccine messaging. The results of this study and the HIPE framework can inform a national COVID-19 vaccine health campaign to increase vaccine adoption.

Patterns of recommended vaccine receipt among women ages 24-45 years: a cross-sectional analysis

Background

Vaccine receipt among mid-adults remains low, with only one quarter of adults being up to date for all recommended vaccines. It is important to understand the myriad factors that influence vaccine receipt among mid-adult women to address these low rates.

Methods

We conducted a cross-sectional analysis of data from women ages 24–45 years collected as part of an ongoing case-control study of the effectiveness of HPV vaccine. We examined associations between demographic characteristics and healthcare utilization and receipt of individual vaccines and combinations of multiple vaccines using logistic regression analyses for three routinely recommended vaccines: tetanus, influenza and HPV.

Results

Among the 309 women enrolled in the study, only 19 (6.2%) were up to date for all three recommended vaccines and 41 (13.3%) had not received any of the recommended vaccines. A greater number of health care visits in the past year was associated with receipt of influenza (aOR = 6.37, 95% CI = 2.53, 16.1) and tetanus (aOR = 2.17, 95% CI = 1.14, 4.12) vaccines. White women were more likely to have received HPV vaccine (aOR = 2.39, 95% CI = 1.07, 5.36).

Conclusions

Uptake of recommended vaccines is low among young and mid-adult women. There is a need for greater understanding of the underlying factors influencing vaccine receipt in this population.

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.

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.

Food Insecurity and Influenza and Pneumonia Vaccines Uptake Among Community-Dwelling Older Adults in the United States

Influenza and pneumonia vaccines can reduce morbidities and mortality associated with infectious diseases among older adults. Food security, good nutrition, and high-quality diets are critical for the wellbeing of older adults. However, little is known about the relationship between food insecurity and use of preventive health services, such as influenza and pneumonia vaccinations, among older adults. In this study, we analyzed data on 40,555 adults aged ≥ 65 years from the 2014-2018 National Health Interview Survey in the United States. Through multiple hierarchical logistic regression models, we investigated the associations between food insecurity and influenza and pneumonia vaccines uptake in this population. We found that, during 2014-2018, about 12.6 million (5.3%) adults aged ≥ 65 years lived in food-insecure households in the United States. Of those, 60.6% reported getting an influenza vaccine in the past 12 months, and 54.2% reported ever getting a pneumonia vaccine. Compared to food-secure older adults, food-insecure individuals were not significantly different in terms of influenza vaccine uptake. However, they were 25% less likely to have ever gotten a pneumonia vaccine (adjusted odds ratio = 0.75, 95% CI 0.65-0.86, P < .001). Efforts should be made to develop strategies to improve immunization rates among food-insecure older adults. Healthcare providers could routinely assess their vaccination status and screen them for food insecurity. Also, community level screening and intervention programs should target food-insecure older adults, who often face structural disadvantages. Future studies could explore and identify the underlying predictive factors contributing to low pneumonia vaccination rates among food-insecure older adults.

Predictors of willingness to get a COVID-19 vaccine in the U.S

BACKGROUND

As COVID-19 vaccine distribution efforts continue, public health workers can strategize about vaccine promotion in an effort to increase willingness among those who may be hesitant.

METHODS

In April 2020, we surveyed a national probability sample of 2279 U.S. adults using an online panel recruited through address-based sampling. Households received a computer and internet access if needed to participate in the panel. Participants were invited via e-mail and answered online survey questions about their willingness to get a novel coronavirus vaccine when one became available. The survey was completed in English and Spanish. We report weighted percentages.

RESULTS

Most respondents were willing to get the vaccine for themselves (75%) or their children (73%). Notably, Black respondents were less willing than White respondents (47% vs. 79%, p < 0.001), while Hispanic respondents were more willing than White respondents (80% vs. 75%, p < 0.003). Females were less likely than makes (72% vs. 79%, p < 0.001). Those without insurance were less willing than the insured (47% vs. 78%, p < 0.001). Willingness to vaccinate was higher for those age 65 and older than for some younger age groups (85% for those 65 and older vs. 75% for those 50-64, p < 0.017; 72% for those 35-49, p < 0.002; 70% for those 25-34, p = NS and 75% for ages 18-24, p = NS), but other groups at increased risk because of underlying medical conditions or morbid obesity were not more willing to get vaccinated than their lower risk counterparts.

CONCLUSIONS

Most Americans were willing to get a COVID-19 vaccine, but several vulnerable populations reported low willingness. Public health efforts should address these gaps as national implementation efforts continue.

The racial/ethnic and sociocultural aspects of the pandemic in rheumatology

The disproportionate impact of coronavirus-2019 (COVID-19) on communities of color is gaining global attention. Current research demonstrates that historically marginalized populations are experiencing disproportionate levels of SARS-Cov-2 infection and adverse clinical outcomes. However, research examining whether COVID-19 outcomes vary by race and ethnicity within the rheumatic disease population is limited. This paper will review data showing how SARS-CoV-2 infection has differentially affected racial and ethnic minorities in the general population and those with rheumatic disease. We will also highlight disparities in rheumatic disease risk and severity that existed prior to the pandemic, and discuss recent work examining severe outcomes of COVID-19 in rheumatic disease patients by race and ethnicity. Finally, we propose several actionable steps for the rheumatology community to address COVID-19 health disparities, which may have long-term effects on patients with rheumatic disease.

Completion of the two-dose recombinant zoster vaccine series in adults 50 years and older

BACKGROUND

In 2017, a new adjuvanted recombinant zoster vaccine (RZV) was recommended for adults ≥50 years as two-dose series 2-6 months apart. We evaluated two-dose RZV completion and factors associated with completion.

METHODS

The study included Kaiser Permanente Southern California members ≥50 years who received an RZV dose during April-November 2018 and had continuous membership 12 months before to 9 months after the first RZV dose. Completion was defined as receipt of the second dose ≥4 weeks to 9 months after the first dose (allowing 3-month grace period). Characteristics including age, sex, race/ethnicity, Medicaid status, neighborhood level income and education, comorbidities, history of zoster, health care utilization before and after the first dose, receipt of influenza vaccine, vaccination month (supply shortage proxy), concomitant vaccine, medical center, and medically attended reactions, pain, or gout after the first dose were compared between completers and non-completers. Adjusted odds ratios and 95% confidence intervals for factors associated with completion were estimated by multivariable logistic regression.

RESULTS

Among 31,120 first dose recipients, 67.2% completed the series within 9 months. In adjusted analyses, higher completion was associated with White compared with Black or Hispanic race/ethnicity, higher neighborhood income and education, no chronic pulmonary disease, diabetes, or dementia, more outpatient visits and fewer emergency department visits before or after the first dose, no hospitalizations after the first dose, receipt of influenza vaccine, receipt of the first dose in June-November rather than April-May 2018, and no concomitant vaccine with the first dose. Systemic reactions or pain after the first dose was not associated with completion.

CONCLUSION

Completion of RZV series appears suboptimal in the early phase of implementation. Despite similar accessibility in a health care system, completion varied by race/ethnicity, socioeconomic status, health status, and care seeking behavior, suggesting areas to target for improvement.

Evaluation of a midwife-led, hospital based vaccination service for pregnant women

Background: Vaccines against whooping cough (pertussis) and seasonal-influenza are recommended for pregnant women in England. Uptake however varies regionally and by ethnicity. Pregnant women are traditionally vaccinated in primary care, though some hospitals now offer vaccines through antenatal clinics. This mixed-methods evaluation describes the demographic characteristics of women seen in a hospital midwife-led antenatal vaccine clinic and explores vaccine decision making. Methods: Descriptive statistics of women seen in a London hospital's midwife-led vaccine clinic were generated from electronic routine maternity records, including data on ethnicity, parity, age and deprivation indices. Reasons for vaccine decline given by women to midwives were categorized by themes. Qualitative interviews of women seen in the clinic were also undertaken. Results: Between 1st April 2017 and 31st March 2018 the vaccine clinic saw 1501 pregnant women. Of these, 83% received pertussis vaccine and (during flu season) 51% received influenza vaccine, from the clinic. Fewer Black Afro-Caribbean women seen by the clinic were vaccinated, compared to other ethnicities with only 68% receiving pertussis and 34% flu vaccines respectively (p < .05). Among all women delivering at the hospital over the year, 42%, (1334/3147) were vaccinated by the clinic. Qualitative interviews found that reassurance from healthcare professionals, particularly midwives, was the most important factor influencing maternal vaccine decisions. Conclusions: Midwife-led hospital clinics can offer an effective alternative to primary care provision for vaccines in pregnancy. Consistent with previous work, vaccine uptake varied by ethnicity. Midwives play a key role in the provision of vaccine services and influence women's vaccine decisions.

Shared Decision-Making and Prevention Recommendations: Evolution, Implications, and Challenges for Public Health

Recent guidelines and recommen dations from government prevention advisory groups endorsing shared clinical decision-making reflect an emerging trend among public health bodies.

Clinical Outcomes Of A COVID-19 Vaccine: Implementation Over Efficacy

The global effort to develop a coronavirus disease 2019 (COVID-19) vaccine is on track to produce one or more authorized vaccines. We examine how different definitions and thresholds of vaccine efficacy, coupled with different levels of implementation effectiveness and background epidemic severity, translate into outcomes including cumulative infections, hospitalizations, and deaths. Using a mathematical simulation of vaccination, we find that factors related to implementation will contribute more to the success of vaccination programs than a vaccine's efficacy as determined in clinical trials. The benefits of a vaccine will decline substantially in the event of manufacturing or deployment delays, significant vaccine hesitancy, or greater epidemic severity. Our findings demonstrate the urgent need for health officials to invest greater financial resources and attention to vaccine production and distribution programs, to redouble efforts to promote public confidence in COVID-19 vaccines, and to encourage continued adherence to other mitigation approaches, even after a vaccine becomes available.

Age and Location in Severity of COVID-19 Pathology: Do Lactoferrin and Pneumococcal Vaccination Explain Low Infant Mortality and Regional Differences?

Two conundrums puzzle COVID-19 investigators: 1) morbidity and mortality is rare among infants and young children and 2) rates of morbidity and mortality exhibit large variances across nations, locales, and even within cities. It is found that the higher the rate of pneumococcal vaccination in a nation (or city) the lower the COVID-19 morbidity and mortality. Vaccination rates with Bacillus Calmette-Guerin, poliovirus, and other vaccines do not correlate with COVID-19 risks, nor do COVID-19 case or death rates correlate with number of people in the population with diabetes, obesity, or adults over 65. Infant protection may be due to maternal antibodies and antiviral proteins in milk such as lactoferrin that are known to protect against coronavirus infections. Subsequent protection might then be conferred (and correlate with) rates of Haemophilus influenzae type B (Hib) (universal in infants) and pneumococcal vaccination, the latter varying widely by geography among infants, at-risk adults, and the elderly. Also see the video abstract here https://youtu.be/GODBYRbPL00.

A global agenda for older adult immunization in the COVID-19 era: A roadmap for action

Given our global interconnectedness, the COVID-19 pandemic highlights the urgency of building a global system that can support both routine and pandemic/epidemic adult immunization. As such, a framework to recommend vaccines and build robust platforms to deliver them to protect the rapidly expanding demographic of older adults is needed. Adult immunization as a strategy has the broad potential to preserve and improve medical, social, and economic outcomes, including maintaining functional ability that benefits older adults, their families, communities, and countries. While we will soon have multiple vaccines against COVID-19, we must recognize that we already have a variety of vaccines against other pathogens that can keep adults healthier. They can prevent simultaneous co-infection with COVID-19, and may favorably impact- the outcome of a COVID-19 illness. Further, administering a vaccine against COVID-19 requires planning now to determine delivery strategies impacting how older adults will be immunized in a timely manner. A group of international experts with various backgrounds from health and aging disciplines met to discuss the evidence case for adult immunization and crucial knowledge gaps that must be filled in order to implement effective policies and programs for older adult immunization. This group, coming together as the International Council on Adult Immunization (ICAI), outlined a high-level roadmap to catalyze action, provide policy guidance, and envision a global adult immunization platform that can be adapted by countries to fit their local contexts. Further meetings centered around the value of adult immunization, particularly in the context of COVID-19. There was agreement that programs to deliver existing influenza, pneumococcal, herpes zoster vaccines, and future COVID-19 vaccines to over a billion older adults who are at substantially higher risk of death and disability due to vaccine-preventable diseases are more urgent than ever before. Here we present a proposed framework for delivering routine and pandemic vaccines. We call upon the global community and governments to prioritize action for integrating robust adult immunization programs into the public health agenda.

Shingles Vaccination of U.S. Adults Aged 50-59 Years and ≥60 Years Before Recommendations for Use of Recombinant Zoster Vaccine

INTRODUCTION

In 2006, zoster vaccine live was recommended for adults aged ≥60 years. In 2011, zoster vaccine live was approved for use but not recommended for adults aged 50-59 years. This study assessed zoster vaccine live coverage among adults aged 50-59 years and ≥60 years.

METHODS

Data from the 2013-2017 National Health Interview Surveys were analyzed in 2019 to estimate national zoster vaccine live coverage among adults aged ≥50 years. State-specific zoster vaccine live coverage among adults aged ≥50 years was assessed using 2017 Behavioral Risk Factor Surveillance System data.

RESULTS

Among adults aged 50-59 years, zoster vaccine live coverage was 5.7% in 2017, ranging from 4% to 6% during 2013-2017 (test for trend, p>0.05). Zoster vaccine live coverage among adults aged 50-59 years ranged from 5.8% in Pennsylvania to 14.7% in South Dakota. By 2017, zoster vaccine live was received by 34.9% of adults aged ≥60 years, a significant increase from 24.2% in 2013. Zoster vaccine live coverage among adults aged ≥60 years in 2017 ranged from 26.0% in Mississippi to 51.8% in Vermont. In 2017, major characteristics significantly associated with increased likelihood of zoster vaccine live vaccination among adults aged 50-59 years and ≥60 years were older age, having 4 to 9 physician contacts in the past 12 months, and having a usual place for health care.

CONCLUSIONS

This study provides an assessment of zoster vaccine live coverage among adults aged ≥50 years before the newly recommended recombinant zoster vaccine came into widespread use. Providers should routinely assess adults' vaccination status and strongly recommend or offer needed vaccines to their patients.

Does self-rated health status influence receipt of an annual flu vaccination?

Despite 79,400 deaths due to the influenza (flu) virus during the 2017-18 season, <50% of US adults receive an annual flu vaccination (AFV). Self-rated health status (SRH) is associated with health behavior utilization. The current study aims to determine if an association exists between an individual's SRH and their receipt of an AFV. In the 2017 US Behavioral Risk Factor Surveillance System survey, 39.1% of respondents had received a flu vaccination within the last 12 months. There was a statistically significant difference (p < 0.0001) between the vaccination rates of men (35.7%) and women (42.4%). There was a significant positive association between SRH and AFV for individuals who self-reported an SRH of either "Fair" (AOR 1.19; 95% CI 1.12-1.27) or "Poor" (AOR 1.24; 95% CI 1.14-1.35), compared to those reporting a status of "Excellent". For those reporting an SRH status of "Fair", there was a significant positive association for both men (AOR 1.20; 95% CI 1.10-1.32) and women (AOR 1.17; 95% CI 1.08-1.28). An association was also found for men (AOR 1.203; 95% CI 1.09-1.39) and women (AOR 1.23; 95% CI 1.09-1.399) who reported their SRH as "Poor". Only women showed a significant association (AOR 1.12; 95% CI 1.04-1.20) among those whose SRH was "Good". No association was found for individuals who reported SRH as "Very Good". These findings are of interest to health policy makers as they show there is still work required to convince individuals with a high SRH that they too need to receive an AFV.

Factors associated with perceptions of influenza vaccine safety and effectiveness among adults, United States, 2017-2018

BACKGROUND

Annual vaccination against seasonal influenza is widely recognized as the primary intervention method in preventing morbidity and mortality from influenza, but coverage among adults is suboptimal in the United States. Safety and effectiveness perceptions regarding vaccines are consistently cited as factors that influence adults' decisions to accept or reject vaccination. Therefore, we conducted this analysis in order to understand sociodemographic, attitude, and knowledge factors associated with these perceptions for influenza vaccine among adults in three different age groups.

METHODS

Probability-based Internet panel surveys using nationally representative samples of adults aged ≥19 years in the United States were conducted during February-March of 2017 and 2018. We asked respondents if they believed the influenza vaccine was safe and effective. We calculated prevalence ratios using chi-square and pairwise t-tests to determine associations between safety and effectiveness beliefs and sociodemographic variables for adults aged 19-49, 50-64, and ≥65 years.

RESULTS

Survey completion rates were 58.2% (2017) and 57.2% (2018); we analyzed 4597 combined responses. Overall, most adults reported the influenza vaccine was safe (86.3%) and effective (73.0%). However, fewer younger adults reported positive perceptions compared with older age groups. Respondents who believed the vaccine was safe also reported it was effective.

CONCLUSIONS

Generally, adults perceived the influenza vaccine as safe and effective. Considering this, any improvements to these perceptions would likely be minor and have a limited effect on coverage. Future research to understand why, despite positive perceptions, adults are still choosing to forego the vaccine may be informative.