Influenza and pneumococcal vaccination rates among smokers: data from the 2006 Behavioral Risk Factor Surveillance System

County-Level Factors Associated With Influenza and COVID-19 Vaccination in Indiana, 2020‒2022

Objectives. To assess COVID-19 and influenza vaccination rates across Indiana's 92 counties and identify county-level factors associated with vaccination. Methods. We analyzed county-level data on adult COVID-19 vaccination from the Indiana vaccine registry and 2021 adult influenza vaccination from the Centers for Disease Control and Prevention. We used multiple linear regression (MLR) to determine county-level predictors of vaccinations. Results. COVID-19 vaccination ranged from 31.2% to 87.6% (mean = 58.0%); influenza vaccination ranged from 33.7% to 53.1% (mean = 42.9%). In MLR, COVID-19 vaccination was significantly associated with primary care providers per capita (b = 0.04; 95% confidence interval [CI] = 0.02, 0.05), median household income (b = 0.23; 95% CI = 0.12, 0.34), percentage Medicare enrollees with a mammogram (b = 0.29; 95% CI = 0.08, 0.51), percentage uninsured (b = -1.22; 95% CI = -1.57, -0.87), percentage African American (b = 0.31; 95% CI = 0.19, 0.42), percentage female (b = -0.97; 95% CI = -1.79, ‒0.15), and percentage who smoke (b = -0.75; 95% CI = -1.26, -0.23). Influenza vaccination was significantly associated with percentage uninsured (b = 0.71; 95% CI = 0.22, 1.21), percentage African American (b = -0.07; 95% CI = -0.13, -0.01), percentage Hispanic (b = -0.28; 95% CI = -0.40, -0.17), percentage who smoke (b = -0.85; 95% CI = -1.06, -0.64), and percentage who completed high school (b = 0.54; 95% CI = 0.21, 0.87). The MLR models explained 86.7% (COVID-19) and 70.2% (influenza) of the variance. Conclusions. Factors associated with COVID-19 and influenza vaccinations varied. Variables reflecting access to care (e.g., insurance) and higher risk of severe disease (e.g., smoking) are notable. Programs to improve access and target high-risk populations may improve vaccination rates. (Am J Public Health. 2024;114(4):415-423. https://doi.org/10.2105/AJPH.2023.307553).

A longitudinal transition imputation model for categorical data applied to a large registry dataset

Imputation of longitudinal categorical covariates with several waves and many predictors is cumbersome in terms of implausible transitions, colinearity, and overfitting. We designed a simulation study with data obtained from a general practitioners' morbidity registry in Belgium for three waves, with smoking as the longitudinal covariate of interest. We set varying proportions of data on smoking to missing completely at random and missing not at random with proportions of missingness equal to 10%, 30%, 50%, and 70%. This study proposed a 3-stage approach that allows flexibility when imputing time-dependent categorical covariates. First, multiple imputation using fully conditional specification or multiple imputation for the predictor variables was deployed using the wide format such that previous and future information of the same patient was utilized. Second, a joint Markov transition model for initial, forward, backward, and intermittent probabilities was developed for each imputed dataset. Finally, this transition model was used for imputation. We compared the performance of this methodology with an analyses of the complete data and with listwise deletion in terms of bias and root mean square error. Next, we applied this methodology in a clinical case for years 2017 to 2021, where we estimated the effect of several covariates on the pneumococcal vaccination. This methodological framework ensures that the plausibility of transitions is preserved, overfitting and colinearity issues are resolved, and confounders can be utilized. Finally, a companion R package was developed to enable the replication and easy application of this methodology.

Pneumococcal vaccination coverage and adherence to recommended dosing schedules in adults: a repeated cross-sectional study of the INTEGO morbidity registry

BACKGROUND

Since 2014, Belgium's Superior Health Council has recommended pneumococcal vaccination for adults aged 19-85 years at increased risk for pneumococcal diseases with a specific vaccine administration sequence and timing. Currently, Belgium has no publicly funded adult pneumococcal vaccination program. This study investigated the seasonal pneumococcal vaccination trends, evolution of vaccination coverage and adherence to the 2014 recommendations.

METHODS

INTEGO is a general practice morbidity registry in Flanders (Belgium) that represents 102 general practice centres and comprised over 300.000 patients in 2021. A repeated cross-sectional study was performed for the period between 2017 and 2021. Using adjusted odds ratios computed via multiple logistic regression, the association between an individual's characteristics (gender, age, comorbidities, influenza vaccination status and socioeconomic status) and schedule-adherent pneumococcal vaccination status was assessed.

RESULTS

Pneumococcal vaccination coincided with seasonal flu vaccination. The vaccination coverage in the population at risk decreased from 21% in 2017 to 18.2% in 2018 and then started to increase to 23.6% in 2021. Coverage in 2021 was highest for high-risk adults (33.8%) followed by 50- to 85-year-olds with comorbidities (25.5%) and healthy 65- to 85-year-olds (18.7%). In 2021, 56.3% of the high-risk adults, 74.6% of the 50+ with comorbidities persons, and 74% of the 65+ healthy persons had an adherent vaccination schedule. Persons with a lower socioeconomic status had an adjusted odds ratio of 0.92 (95% Confidence Interval (CI) 0.87-0.97) for primary vaccination, 0.67 (95% CI 0.60-0.75) for adherence to the recommended second vaccination if the 13-valent pneumococcal conjugate vaccine was administered first and 0.86 (95% CI 0.76-0.97) if the 23-valent pneumococcal polysaccharide vaccine was administered first.

CONCLUSION

Pneumococcal vaccine coverage is slowly increasing in Flanders, displaying seasonal peaks in sync with influenza vaccination campaigns. However, with less than one-fourth of the target population vaccinated, less than 60% high-risk and approximately 74% of 50 + with comorbidities and 65+ healthy persons with an adherent schedule, there is still much room for improvement. Furthermore, adults with poor socioeconomic status had lower odds of primary vaccination and schedule adherence, demonstrating the need for a publicly funded program in Belgium to ensure equitable access.

Secular trends and determinants of influenza vaccination uptake among patients with cardiovascular disease in Korea: Analysis using a nationwide database

Background

Influenza vaccination reduces cardiovascular events in patients with cardiovascular disease (CVD). Identifying the factors that affect influenza vaccination uptake can help improve the prognosis in patients with CVD. This study aimed to evaluate the secular trends of influenza vaccination uptake and factors associated with lack of vaccination in individuals with CVD.

Materials and methods

We analyzed the annual trends and factors associated with influenza vaccination among 3,264 patients with CVD, included from the Korea National Health and Nutrition Examination Survey which reflect the health and nutritional status of the nationwide population of Korea conducted between 2007/2008 and 2018/2019. We used a stratified, multistage sampling method.

Results

The influenza vaccination rate was greater in patients with CVD (53–74%) than in those without CVD (28–40%). Multivariable logistic regression analysis showed that age <50 years [odds ratio (OR), 16.22; 95% confidence interval (CI), 7.72–34.07], 50–64 years (OR, 6.71; 95% CI, 4.37–10.28), male sex (OR, 1.45; 95% CI, 1.14–1.65), and asthma (OR, 0.45; 95% CI, 0.22–0.92) were independently associated with a lack of influenza vaccination. Among patients aged <65 years, smoking (OR, 2.30; 95% CI, 1.31–4.04), college graduation status (OR, 1.81; 95% CI, 1.16–2.82), and hypertension (OR, 0.70; 95% CI, 0.51–0.95) were independently associated with influenza vaccination. For individuals aged 65years, there was no significant determinant of lack of vaccination.

Conclusion

In patients with CVD, a continuous increase in the secular trend of influenza vaccination was demonstrated in Korea. Young age, male sex, and non-asthma status were independently associated with lack of influenza vaccination uptake.

Adherence to COVID-19 Guidelines among Current, Former, and Never Smokers

Objectives: In this paper, we explore the adherence patterns to US Centers for Disease Control and Prevention (CDC) COVID-19 mitigation guidelines among current, former, and never smokers. Methods: We used an online cross-sectional survey of adults 18 years or older in 5 northeastern states of the US (N=1084). Results: Unadjusted analyses revealed that current smokers reported lower adherence to the CDC guidelines than former smokers (27.5 vs 29.4, p<.05). After accounting for sociodemographic covariates, this finding was no longer statistically significant. However, compared to former smokers, never smokers reported wearing their mask less often (OR=0.65; 95% CI=0.45-0.94) and current smokers were less likely to report always practicing illness-related hygiene skills (OR=0.60; 95% CI=0.39-0.93).Conclusions: Never smokers had poorer adherence to CDC guidelines than former smokers, namely wearing their masks, and current smokers were less likely to always follow the hygiene recommendations. Results should inform future public health efforts in targeting current smokers with lower adherence to CDC guidelines and learning from the ability of former smokers to demonstrate high adherence.

COVID-19 Vaccination Uptake and Hesitancy Among Current Tobacco Users

Novel mRNA vaccines have been developed and were first distributed to high-risk individuals (including smokers) in the United States starting in December 2020 to combat the coronavirus (COVID-19) pandemic. Over one-half of the U.S. adult population has received at least 1 dose of a COVID-19 vaccine, but many others have reported hesitation about becoming vaccinated. We examined COVID-19 vaccine uptake and hesitancy from a convenience sample of Pennsylvanian adult smokers in April 2021, approximately 3 months after tobacco users were eligible to receive vaccination in the state. Participants (n = 231) were 23.4% male, 90.5% white, and had a mean age of 48.1 (SD = 11.9) years. All participants were current tobacco users, with the majority reporting current cigarette smoking (90.9%) with an average of 16 (SD = 8.1) cigarettes smoked per day. Nearly 60% (n = 137) reported receiving at least 1 dose of the vaccine and of those who did not (n = 94), 84% (n = 79) said they were somewhat or very unlikely to get a vaccine. Those who were unvaccinated were more likely to not consume news about COVID-19 (chi-square P-value < .01) and less likely to believe government news sources as reliable information for COVID-19 (chi-square P-value < .01). Qualitative responses among those who were vaccine hesitant expressed concerns about the lack of research on the vaccine, distrust of the safety of the vaccine, and fears about side effects. Understanding vaccine hesitancy among tobacco users can help develop targeted communication strategies and directly address concerns to promote vaccination among this population who may be at an increased risk of severe complications from COVID-19.

Cross-sectional study on the prevalence of influenza and pneumococcal vaccination and its association with health conditions and risk factors among hospitalized multimorbid older patients

BACKGROUND

Older adults with chronic conditions are at high risk of complications from influenza and pneumococcal infections. Evidence about factors associated with influenza and pneumococcal vaccination among older multimorbid persons in Europe is limited. The aim of this study was to investigate the prevalence and determinants of these vaccinations in this population.

METHODS

Multimorbid patients aged ≥70 years with polypharmacy were enrolled in 4 European centers in Switzerland, Belgium, the Netherlands, and Ireland. Data on vaccinations, demographics, health care contacts, and comorbidities were obtained from self-report, general practitioners and medical records. The association of comorbidities or medical contacts with vaccination status was assessed using multivariable adjusted log-binomial regression models.

RESULTS

Among 1956 participants with available influenza vaccination data (median age 79 years, 45% women), 1314 (67%) received an influenza vaccination within the last year. Of 1400 patients with available pneumococcal vaccination data (median age 79 years, 46% women), prevalence of pneumococcal vaccination was 21% (n = 291). The prevalence of vaccination remained low in high-risk populations with chronic respiratory disease (34%) or diabetes (24%), but increased with an increasing number of outpatient medical contacts. Chronic respiratory disease was independently associated with the receipt of both influenza and pneumococcal vaccinations (prevalence ratio [PR] 1.09, 95% confidence interval [CI] 1.03-1.16; and PR 2.03, 95%CI 1.22-3.40, respectively), as was diabetes (PR 1.06, 95%CI 1.03-1.08; PR 1.24, 95%CI 1.16-1.34, respectively). An independent association was found between number of general practitioner visits and higher prevalence of pneumococcal vaccination (p for linear trend <0.001).

CONCLUSION

Uptake of influenza and particularly of pneumococcal vaccination in this population of European multimorbid older inpatients remains insufficient and is determined by comorbidities and number and type of health care contacts, especially outpatient medical visits. Hospitalization may be an opportunity to promote vaccination, particularly targeting patients with few outpatient physician contacts.

Extent of and Reasons for Vaccine Hesitancy in Adults at High-Risk for Pneumococcal Disease

Purpose:

To determine the extent of and reasons for hesitancy toward vaccination among adults at high-risk for pneumococcal disease.

Design:

Cross-sectional.

Setting:

Online survey in March-April 2019 via QuestionPro.

Subjects:

Tennessee adults (18-64 years) at high-risk of pneumococcal disease (n = 1,002).

Measures:

Modified version of the validated Vaccine Hesitancy Scale assessed vaccine-related beliefs, reasons for hesitancy, external influences on vaccination, and prior vaccination

Analysis:

Descriptive and inferential statistics provided an overview of the responses and comparisons among subgroups. Logistic regression determined the odds of being hesitant using the listed beliefs and influencers as predictors. Thematic analysis was performed on the qualitative data gathered from free response questions throughout the survey.

Results:

Analysis included 1,002 complete responses (12% response rate [total viewed = 8,331]) with 34.3% indicating hesitancy toward one or more recommended vaccinations, with 53% of which indicating hesitancy to the pneumococcal vaccine despite it being recommended by the Advisory Committee on Immunization Practices (ACIP) for all respondents. The odds of vaccine hesitancy or resistance were higher in minorities (OR: 1.6; 95% CI: 1.19-2.11), those not believing others like them get vaccinated (OR: 1.82; 95% CI: 1.262-2.613), and respondents recalling negative media about vaccines (OR: 2.56; 95% CI: 1.797-3.643).

Conclusions:

Patients at high-risk of pneumococcal disease lack awareness of the need for the recommended vaccine, and provider education may need improving to increase vaccination in this population.

Influenza vaccination rate among high risk group patients in primary health care in Greece

OBJECTIVE

Seasonal influenza vaccination is the main method for influenza prevention. The main objective of this study is to estimate the frequency of vaccinations in patients with chronic illnesses presented to a primary health care (PHC) centre.

METHODS

This cross-sectional study was performed in patients admitted to the Kapandriti Health Centre. Their vaccination status with an influenza vaccine and their underlying diseases were recorded.

RESULTS

34.8% of the subjects had been vaccinated against seasonal influenza. Vaccination coverage was found to be 53.9% in pulmonary, 55.6% in chronic kidney disease, 43.7% in cardiovascular disorders, 40.6% in diabetes, 40.6% in any kind of malignancy, and finally 33.3% in neurological patients. The most significant predictors for vaccination were the age group of 60 to 79 years (OR = 3.08, 95% CI: 1.79-5.29), age over 80 years (OR = 2.91, 95% CI: 1.58-5.36), respiratory disease (OR = 2.25, 95% CI: 1.33-3.76), cardiovascular disorder (OR = 1.46, 95% CI: 1.02-2.10), and 3 to 5 visits to the unit annually (OR = 1.57, 95% CI: 1.12-2.24). Finally, it was discovered that coexistence of one to three diseases reduced the likelihood ratio for vaccine uptake (OR = 0.15, 95% CI: 0.03-0.79, p < 0.05).

CONCLUSIONS

The influenza vaccination rate for the population of the present study has been found higher than that reported previously in literature. We believe that there is a need to implement new and more effective strategies such as educating vulnerable groups on the benefits of vaccination and so reducing the incidence of influenza and its complications especially in vulnerable groups.

Lipid-lowering therapy for primary prevention of premature atherosclerotic coronary artery disease: Eligibility, utilization, target achievement, and predictors of initiation

OBJECTIVES

Despite advances in screening and prevention, rates of premature coronary artery disease (CAD) have been stagnant. The goals of this study were to investigate the barriers to early risk detection and preventive treatment in patients with premature CAD. In particular, we: 1) assessed the performance of the latest versions of major international guidelines in detection of risk of premature CAD and eligibility for preventive treatment; and, 2) investigated real-life utilization of primary prevention with lipid-lowering therapies in these patients.

METHODS

We included patients in the Study to Avoid cardioVascular Events in British Columbia (SAVE BC), an observational study of patients with premature (males ​≤ ​50 years, females ​≤ ​55 years) angiographically confirmed CAD. Eligibility for primary prevention and treatment received were assessed retrospectively based on information recorded prior to or at the index presentation with CAD.

RESULTS

Of 417 patients (28.1% females) who met the criteria, 94.3% had at least one major cardiovascular risk factor. In the retrospective risk assessment, 41.7%, 61.4%, and 34.3% (p ​< ​0.001) of patients met criteria for initiation of statin therapy, and an additional 13.9%, 8.4%, and 46.8% may be considered for treatment using the American College of Cardiology/American Heart Association, Canadian Cardiovascular Society, and European Society of Cardiology guidelines, respectively. Only 17.1% of patients received statins and 11.0% achieved guideline-recommended lipid goals before presentation. Diabetes and elevated plasma lipid levels were positively associated with treatment initiation, while smoking was associated with non-treatment.

CONCLUSIONS

The current versions of major guidelines fail to recognize many patients who develop premature CAD as being at risk. The vast majority of these patients, including patients who have guideline-directed indications, do not receive lipid-lowering therapy before presenting with CAD. Our findings highlight the need for more effective screening and prevention strategies for premature CAD.

Determinants of vaccine hesitancy in Quebec: a large population-based survey

Objectives: Vaccine hesitancy is a global phenomenon that needs to be measured and addressed. This study aimed to identify the determinants of vaccine hesitancy among a large regional population.Methods: A structured telephone survey was administered to a random digit sample in Quebec's Eastern Townships region. In addition to socioeconomic information, respondents were asked questions on several health topics such as knowledge and beliefs about immunization, medical consultations, health status, and life habits. Data were weighted according to age, sex, and territories. Statistically significant variables in the univariate analysis were introduced into a multivariate logistic regression model to determine independent factors for vaccine hesitancy (adjusted odds ratios [aOR] and 95% confidence intervals).Results: A total of 8,737 interviews were conducted (participation rate 48.3%). Among all respondents, 32.2% were vaccine-hesitant. Several beliefs were significantly associated with vaccine hesitancy: belief that children receive too many vaccines (aOR = 2.72; 2.32-3.18), belief that a healthy lifestyle can eliminate the need for vaccination (aOR = 2.48; 2.09-2.93), and belief that the use of alternative medicine practices can eliminate the need for vaccination (aOR = 1.39; 1.16-1.68). Other determinants associated with vaccine hesitancy were having consulted a massage therapist (aOR = 2.34; 1.46-3.75), not being vaccinated against influenza (aOR = 1.80; 1.49-2.16), having a low (<$30,000) (aOR = 1.58; 1.24-2.02) or moderate ($30,000-$79,000) (aOR = 1.37; 1.12-1.67) household income, distrust in public health authorities (aOR = 1.40; 1.21-1.63), perceived insufficient knowledge about immunization (aOR = 1.26; 1.04-1.51), and smoking (aOR = 1.22; 1.01-1.47).Conclusions: Many determinants are related to vaccine hesitancy. These determinants should be taken into account when health professionals engage with vaccine-hesitant individuals.

The impact of smoking on patient outcomes in severe sepsis and septic shock

BACKGROUND

To assess, in the setting of severe sepsis and septic shock, whether current smokers have worse outcomes compared to non-smokers.

METHODS

This is a retrospective analysis of immunocompetent adult patients with severe sepsis and septic shock at a tertiary medical center. The primary outcome was the effect of active smoking on hospital mortality. Chi-square test and logistic regression were used to assess categorical outcomes. Wilcoxon rank-sum was utilized to test the differences in continuous outcomes among the varied smoking histories. Multivariable logistic regression was used to evaluate the association of smoking and mortality, need for vasopressors, mechanical ventilation, and ICU admission.

RESULTS

Of the 1437 charts reviewed, 562 patients were included. Current smokers accounted for 19% (107/562) of patients, while 81% (455/562) were non-smokers. The median hospital length of stay in survivors was significantly longer in current smokers versus non-smokers (8 vs 7 days, p = 0.03). There was a trend towards a higher mortality among current smokers, but this failed to meet statistical significance (OR 1.81, 95% CI 0.92-3.54, p = 0.08). On multivariable analysis, current smoking was associated with the need for mechanical ventilation (OR 2.38, 95% CI 1.06-5.34, p = 0.04), but that association was not observed with the need for vasopressors (OR 2.10, 95% CI 1.01-4.36, p = 0.58) nor ICU admission (OR 0.93, 95% CI 0.41-2.13, p = 0.86).

CONCLUSIONS

In patients with severe sepsis or septic shock, current smoking was associated with a longer hospital stay, the need for mechanical ventilation, and trended towards a higher mortality. Larger multicenter prospective case-control studies are needed to confirm these findings.

Determinants of influenza vaccination among a large adult population in Quebec

OBJECTIVES

Very low uptake has been noted for influenza vaccination in the province of Quebec. This study aimed to identify the determinants of influenza vaccination among a large regional population.

METHODS

A telephone survey was administered to a random digit sample in the Eastern Townships region (Quebec, Canada). Respondents were asked questions on several health topics such as perceived knowledge and beliefs about influenza immunization, medical consultations, perceived health status and life habits. Significant variables in the univariate analysis were introduced into a multivariate logistic regression model to determine independent factors for having received the influenza vaccine (aOR and 95% CI) among adults aged ≥60 years and younger adults with ≥1 chronic condition.

RESULTS

A total of 4,620 interviews were analyzed. Among the target groups, 55.4% of adults aged ≥60 and 32.2% of adults aged 18-59 with at least one chronic disease had received the influenza vaccine during the 2013-2014 season. Several determinants were significantly associated with influenza vaccination in both groups such as having received a recommendation from a healthcare professional. Among adults aged ≥60, not having consulted a chiropractor over the last 12 months (aOR = 2.37; 1.09-5.19), non-smokers (aOR = 1.78; 1.22-2.59) and self-perceived poor health status (aOR = 1.45; 1.01-2.06) were significantly linked to flu vaccination. In the younger group, influenza vaccination was independently associated to low alcohol consumption (aOR = 2.14; 1.13-4.05) and being overweight (aOR = 1.63; 1.12-2.38).

CONCLUSIONS

Many determinants influence the decision to get vaccinated against influenza. Specific messages should be tailored for high-risk groups to effectively increase influenza vaccine coverage.

Influenza vaccination for patients with chronic obstructive pulmonary disease: Implications for pharmacists

BACKGROUND

Influenza virus is responsible for substantial morbidity and mortality. Specific populations are at higher risk for exacerbations from influenza virus, such as patients with chronic obstructive pulmonary disease (COPD). Influenza vaccination coverage among COPD patients is low. Pharmacists can improve influenza vaccination among COPD patients by recognizing factors that influence vaccination and addressing these factors.

OBJECTIVES

To (1) determine the recent influenza vaccination coverage among patients with COPD, (2) identify factors that were associated with immunization, and (3) interpret the results based upon Andersen's healthcare utilization model.

METHODS

The 2012 Behavioral Risk Factor Surveillance System (BRFSS) was accessed for the study. Among respondents age ≥ 25 years with COPD, presence of influenza vaccination was captured along with demographic, provider, insurance, and clinical variables. Weighted multiple logistic regression was used to identify significant factors associated with receiving influenza vaccination. The findings were interpreted according to predisposing, enabling, and need factors relevant to Anderson's model.

RESULTS

Influenza vaccination rate was 53% among COPD patients. Older age was a significant predisposing factor that increased vaccination (adjusted odds ratio [AOR] = 2.4; 95% CI:2.02-2.88). Predisposing factors that decreased vaccination were being Black or Hispanic (AOR = 0.72, 95% CI:0.59-0.86, and AOR = 0.78, 95% CI:0.61-0.98 respectively), and being a non smoker (former and never smokers had higher vaccination rates [AOR = 1.53, 95% CI = 1.3-1.72, and AOR = 1.36, 95% CI = 1.19-1.55 respectively]). Significant enabling factors included having health insurance (AOR = 1.68, 95% CI = 1.37-2.06), a primary physician (AOR = 1.63, 95% CI = 1.30-2.02), and the ability to see a physician regardless of cost (AOR = 1.33, 95% CI = 1.17-1.52). Significant need factors included the presence of comorbidities such as asthma (AOR = 1.18, 95% CI = 1.1-1.3), or diabetes (AOR = 1.36, 95% CI = 1.20-1.53), activity limitation (AOR = 1.16, 95% CI = 1.04-1.29), and having the last medical checkup within less than one year (AOR = 1.49, 95% CI = 1.31-1.70).

CONCLUSION

Influenza vaccination coverage among COPD patients is far below the Healthy People 2020 national goal. Several predisposing, enabling, and need factors influenced vaccination rate among COPD patients. Pharmacists can improve vaccination rate among COPD patients by recognizing these influencing factors and by acting as advocates, counselors, and administrators of influenza vaccine. Ultimately, with the collaborative efforts of other healthcare providers and public health initiatives, pharmacists can help achieve Healthy People 2020 objectives related to influenza vaccination.

Racial/Ethnic Disparities in Influenza Vaccination of Chronically Ill US Adults: The Mediating Role of Perceived Discrimination in Health Care

BACKGROUND

Despite well-established programs, influenza vaccination rates in US adults are well below federal benchmarks and exhibit well-documented, persistent racial and ethnic disparities. The causes of these disparities are multifactorial and complex, though perceived racial/ethnic discrimination in health care is 1 hypothesized mechanism.

OBJECTIVES

To assess the role of perceived discrimination in health care in mediating influenza vaccination RACIAL/ETHNIC disparities in chronically ill US adults (at high risk for influenza-related complications).

RESEARCH DESIGN

We utilized 2011-2012 data from the Aligning Forces for Quality Consumer Survey on health and health care (n=8127), nationally representative of chronically ill US adults. Logistic regression marginal effects examined the relationship between race/ethnicity and influenza vaccination, both unadjusted and in multivariate models adjusted for determinants of health service use. We then used binary mediation analysis to calculate and test the significance of the percentage of this relationship mediated by perceived discrimination in health care.

RESULTS

Respondents reporting perceived discrimination in health care had half the uptake as those without discrimination (32% vs. 60%, P=0.009). The change in predicted probability of vaccination given perceived discrimination experiences (vs. none) was large but not significant in the fully adjusted model (-0.185; 95% CI, -0.385, 0.014). Perceived discrimination significantly mediated 16% of the unadjusted association between race/ethnicity and influenza vaccination, though this dropped to 6% and lost statistical significance in multivariate models.

CONCLUSIONS

The causes of persistent racial/ethnic disparities are complex and a single explanation is unlikely to be sufficient. We suggest reevaluation in a larger cohort as well as potential directions for future research.

Self-reported influenza vaccination and protective serum antibody titers in a cohort of COPD patients

BACKGROUND

COPD patients are advised vaccination against seasonal influenza, yet few studies have evaluated the protective antibody titers obtained in this patient group.

AIMS

1) To describe protective titers in COPD patients who self-reported influenza vaccination compared with vaccinated subjects without COPD and unvaccinated COPD patients, 2) analyze whether clinical parameters predicted influenza-specific antibody titers, and 3) whether antibody titers to influenza A at baseline could predict exacerbation risk or 5 years all-cause mortality.

METHODS

Influenza A (H1N1 and H3N2) titers were measured by haemagglutination inhibition assay in serum from 432 COPD patients and 77 controls in the Bergen COPD Cohort Study, at yearly visits between 2006/09. Titers of 40 or above were considered protective. We examined the variables sex, age, body composition, smoking, GOLD stage, yearly exacerbations, inhaled steroids, and Charlson score as predictive of titers, both univariately and in a multivariable model estimated by generalized estimating equations. The exacerbation incidence rate ratios and mortality hazard ratios were assessed by negative binominal and cox regression models respectively.

RESULTS

At baseline, 59% of COPD patients reported influenza vaccination during the last season. Levels of predictive titers varied considerably each season, but trended lower in COPD patients compared with controls. Neither sex, age, body composition, smoking, comorbidities, GOLD stage nor use of inhaled steroids consistently predicted titers. Having high titers at baseline did not impact later risk for exacerbations, but seemed to be associated with higher all-cause mortality, even after adjustment for COPD disease characteristics.

CONCLUSION

Vaccination coverage for influenza is imperfect for COPD patients in Norway, and there is a concern that immunization is suboptimal.

Identification of Barriers to Influenza Vaccination in Patients with Chronic Obstructive Pulmonary Disease: Analysis of the 2012 Behavioral Risk Factors Surveillance System

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for influenza-related morbidity and mortality. Influenza vaccination is known to decrease influenza incidence, severity, hospitalizations, and mortality. Identification of barriers to influenza vaccination among patients with COPD may aid in efforts to increase vaccination rates. This study aims to identify predictors of influenza vaccination in COPD patients.

METHODS

This study used data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS). Participants with self-reported COPD and receiving an influenza vaccination in the prior 12 months were identified. Independent predictors of the exposure were identified by estimating a parsimonious logistic regression model of influenza vaccination. All analyses were performed using weighted data.

RESULTS

The final study sample consisted of 36,811 COPD participants, with 48.5% of COPD patients reporting having been vaccinated and 51.5% reporting being unvaccinated. A total of 15 independent predictors of influenza vaccination in COPD patients were identified. Negative predictors included predisposing factors (younger age, male gender, household children, black or non-white/non-Hispanic/non-black race/ethnicity, lower education level, heavy alcohol use, current tobacco use) and enabling factors that reflect access to medical care (insurance status, ability to afford care, having a recent check-up). Positive predictors of influenza vaccination included need factors (chronic comorbidities), being a military veteran, or being a former smoker.

CONCLUSIONS

This analysis identifies multiple predictors of influenza vaccination in persons with COPD. Identification of at risk-groups provides the foundation for development of focused efforts to improve influenza vaccination rates in patients with COPD.

Tobacco smoking increases the risk for death from pneumococcal pneumonia

BACKGROUND

Active smoking increases the risk of developing community-acquired pneumonia (CAP) and invasive pneumococcal disease, although its impact on mortality in pneumococcal CAP outcomes remains unclear. The aim of this study was to investigate the influence of current smoking status on pneumococcal CAP mortality.

METHODS

We performed a multicenter, prospective, observational cohort study in 4,288 hospitalized patients with CAP. The study group consisted of 892 patients with pneumococcal CAP: 204 current smokers (22.8%), 387 nonsmokers (43.4%), and 301 exsmokers (33.7%).

RESULTS

Mortality at 30 days was 3.9%: 4.9% in current smokers vs 4.3% in nonsmokers and 2.6% in exsmokers. Current smokers with CAP were younger (51 years vs 74 years), with more alcohol abuse and fewer cardiac, renal, and asthma diseases. Current smokers had lower CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years) scores, although 40% had severe sepsis at diagnosis. Current smoking was an independent risk factor (OR, 5.0; 95% CI, 1.8-13.5; P = .001) for 30-day mortality of pneumococcal CAP after adjusting for age (OR, 1.06; P = .001), liver disease (OR, 4.5), sepsis (OR, 2.3), antibiotic adherence to guidelines, and first antibiotic dose given < 6 h. The independent risk effect of current smokers remained when compared only with nonsmokers (OR, 4.0; 95% CI, 1.3-12.6; P = .015) or to exsmokers (OR, 3.9; 95% CI, 1.09-4.95; P = .02).

CONCLUSIONS

Current smokers with pneumococcal CAP often develop severe sepsis and require hospitalization at a younger age, despite fewer comorbid conditions. Smoking increases the risk of 30-day mortality independently of tobacco-related comorbidity, age, and comorbid conditions. Current smokers should be actively targeted for preventive strategies.

Passive smoking at home is a risk factor for community-acquired pneumonia in older adults: a population-based case-control study

OBJECTIVE

To assess whether passive smoking exposure at home is a risk factor for community-acquired pneumonia (CAP) in adults.

SETTING

A population-based case-control study was designed in a Mediterranean area with 860 000 inhabitants >14 years of age.

PARTICIPANTS

1003 participants who had never smoked were recruited.

PRIMARY AND SECONDARY OUTCOME MEASURES

Risk factors for CAP, including home exposure to passive smoking, were registered. All new cases of CAP in a well-defined population were consecutively recruited during a 12-month period.

METHODS

A population-based case-control study was designed to assess risk factors for CAP, including home exposure to passive smoking. All new cases of CAP in a well-defined population were consecutively recruited during a 12-month period. The subgroup of never smokers was selected for the present analysis.

RESULTS

The study sample included 471 patients with CAP and 532 controls who had never smoked. The annual incidence of CAP was estimated to be 1.14 cases×10(-3) inhabitants in passive smokers and 0.90×10(-3) in non-passive smokers (risk ratio (RR) 1.26; 95% CI 1.02 to 1.55) in the whole sample. In participants ≥65 years of age, this incidence was 2.50×10(-3) in passive smokers and 1.69×10(-3) in non-passive smokers (RR 1.48, 95% CI 1.08 to 2.03). In this last age group, the percentage of passive smokers in cases and controls was 26% and 18.1%, respectively (p=0.039), with a crude OR of 1.59 (95% CI 1.02 to 2.38) and an adjusted (by age and sex) OR of 1.56 (95% CI 1.00 to 2.45).

CONCLUSIONS

Passive smoking at home is a risk factor for CAP in older adults (65 years or more).

The association of smoking with medical treatment adherence in the workforce of a large employer

PURPOSE

Prior descriptive epidemiology studies have shown that smokers have lower compliance rates with preventive care services and lower chronic medication adherence rates for preventive care services in separate studies. The goal of this study was to perform a more detailed analysis to validate both of these findings for current smokers versus nonsmokers within the benefit-covered population of a large US employer.

PATIENTS AND METHODS

This study involved the analysis of incurred medical and pharmacy claims for employee and spouse health plan enrollees of a single US-based employer during 2010. Multivariate regression models were used to compare data by active or never-smoker status for preventive care services and medication adherence for chronic conditions. Analysis controlled for demographic variables, chronic condition prevalence, and depression.

RESULTS

Controlling for demographic variables and comorbid conditions, smokers had significantly lower cancer screening rates, with absolute reductions of 6%-13%. Adherence to chronic medication use for hypertension was also significantly lower among smokers, with nearly 7% fewer smokers having a medication possession ratio of ≥80%. Smokers were less adherent to depression medications (relative risk =0.79) than nonsmokers (P=0.10). While not statistically significant, smokers were consistently less adherent to all other medications than nonsmokers.

CONCLUSION

Current smokers are less compliant with recommended preventive care and medication use than nonsmokers, likely contributing to smoking-related employer costs. Awareness of these care gaps among smokers and direct management should be considered as part of a comprehensive population health-management strategy.

Community-acquired pneumonia among smokers

Recent studies have left absolutely no doubt that tobacco increases susceptibility to bacterial lung infection, even in passive smokers. This relationship also shows a dose-response effect, since the risk reduces spectacularly 10 years after giving up smoking, returning to the level of non-smokers. Streptococcus pneumoniae is the causative microorganism responsible for community-acquired pneumonia (CAP) most frequently associated with smoking, particularly in invasive pneumococcal disease and septic shock. It is not clear how it acts on the progress of pneumonia, but there is evidence to suggest that the prognosis for pneumococcal pneumonia is worse. In CAP caused by Legionella pneumophila, it has also been observed that smoking is the most important risk factor, with the risk rising 121% for each pack of cigarettes smoked a day. Tobacco use may also favor diseases that are also known risk factors for CAP, such as periodontal disease and upper respiratory viral infections. By way of prevention, while giving up smoking should always be proposed, the use of the pneumococcal vaccine is also recommended, regardless of the presence of other comorbidities.

Examination of pneumococcal vaccination rates among U.S. adult smokers

PURPOSE

Pneumococcal vaccination rates among U.S. adult smokers in rural and nonrural areas were compared to determine the effect of federal vaccination recommendations.

METHODS

Using bivariate and multivariate techniques, 2005 and 2010 Behavioral Risk Factor Surveillance Survey data were analyzed for comparative purposes. The dependent variable for this analysis was receipt of pneumococcal vaccine. The population of interest was U.S. adults age 19-64 years who reported that they currently smoked. Covariates included sex, race and ethnicity, household income, educational attainment, geographic area (rural or nonrural location of last routine medical checkup), having a personal health care provider, having health insurance, deferring medical care because of cost, self-defined health status, and receipt of seasonal influenza vaccination in the past 12 months. Results In 2005, 15.5% of smokers reported that they had ever received a pneumonia vaccine; by 2010, this percentage increased to 20.8%. In 2005, rural adult smokers were more likely to receive a pneumococcal vaccine (odds ratio [OR], 1.357; 95% confidence interval [CI], 1.338-1.377) than their nonrural counterparts. In 2010, rural adult smokers were less likely to receive the vaccine (OR, 0.952; 95% CI, 0.938-0.966). In both years, men were more likely to receive pneumococcal vaccine, as were those with health insurance and a health care provider. Overall, receipt of a seasonal influenza vaccine was the strongest predictor of smokers receiving pneumococcal vaccine.

CONCLUSION

U.S. adult smokers were most likely to receive pneumococcal vaccine if they were men, had health insurance, had a health care provider, and received a seasonal influenza vaccination within the past year.

Cigarette smoking and mechanisms of susceptibility to infections of the respiratory tract and other organ systems

The predisposition of cigarette smokers for development of oral and respiratory infections caused by microbial pathogens is well recognised, with those infected with the human immunodeficiency virus (HIV) at particularly high risk. Smoking cigarettes has a suppressive effect on the protective functions of airway epithelium, alveolar macrophages, dendritic cells, natural killer (NK) cells and adaptive immune mechanisms, in the setting of chronic systemic activation of neutrophils. Cigarette smoke also has a direct effect on microbial pathogens to promote the likelihood of infective disease, specifically promotion of microbial virulence and antibiotic resistance. In addition to interactions between smoking and HIV infection, a number of specific infections/clinical syndromes have been associated epidemiologically with cigarette smoking, including those of the upper and lower respiratory tract, gastrointestinal tract, central nervous and other organ systems. Smoking cessation benefits patients in many ways, including reduction of the risk of infectious disease.

Do people taking flu vaccines need them the most?

Background

A well targeted flu vaccine strategy can ensure that vaccines go to those who are at the highest risk of getting infected if unvaccinated. However, prior research has not explicitly examined the association between the risk of flu infection and vaccination rates.

Purpose

This study examines the relationship between the risk of flu infection and the probability of getting vaccinated.

Methods

Nationally representative data from the US and multivariate regression models were used to estimate what individual characteristics are associated with (1) the risk of flu infection when unvaccinated and (2) flu vaccination rates. These results were used to estimate the correlation between the probability of infection and the probability of getting vaccinated. Separate analyses were performed for the general population and the high priority population that is at increased risk of flu related complications.

Results

We find that the high priority population was more likely to get vaccinated compared to the general population. However, within both the high priority and general populations the risk of flu infection when unvaccinated was negatively correlated with vaccination rates (r = −0.067, p<0.01). This negative association between the risk of infection when unvaccinated and the probability of vaccination was stronger for the high priority population (r = −0.361, p<0.01).

Conclusions

There is a poor match between those who get flu vaccines and those who have a high risk of flu infection within both the high priority and general populations. Targeting vaccination to people with low socioeconomic status, people who are engaged in unhealthy behaviors, working people, and families with kids will likely improve effectiveness of flu vaccine policy.

Smoking and the outcome of infection

Smoking has substantial local and systemic adverse effects on the immune system, respiratory tract and skin and soft tissues. Smokers are at increased risk of invasive pneumococcal disease, pneumonia, periodontitis, surgical infections, tuberculosis, influenza and meningococcal disease. The results of several studies indicate that smokers with periodontitis or tuberculosis suffer more severe disease. Data on the impact of smoking on sepsis and pneumonia are controversial and limited, and systematic data regarding the outcome of the majority of infections in smokers are scarce. Abundant data indicate that children exposed to environmental tobacco smoke (ETS) suffer from more severe infections. However, information regarding the effects of ETS on the outcome of infections in adults is limited. Various aspects of the relation between smoking and the outcome of bacterial infection (e.g. potential dose-dependent effects and the interactions between smoking and other environmental factors that may affect the course of infectious diseases) remain to be established.

The convergence of the global smoking, COPD, tuberculosis, HIV, and respiratory infection epidemics

At the beginning of the 21st century, we are facing the convergence of several epidemics. These include tobacco smoking, tuberculosis, HIV infection, influenza, and chronic obstructive pulmonary disease. These epidemics interact by way of increasing disease susceptibility and worsening outcomes. To control these interacting epidemics, we need to better understand each infection and how it influences the others. Multifaceted approaches will be necessary to reduce the impact on those in developing nations most likely to be affected by the convergence of all epidemics.

Determinants of influenza immunization uptake in Canadian youths

OBJECTIVE

To describe rate and determinants of influenza vaccination among Canadian youths.

METHODS

We conducted an analysis of cross-sectional data from the Canadian Community Health Survey (CCHS) cycle 3.1 collected by Statistics Canada in 2005. This is a population-based survey collecting information pertaining to the Canadian population health status, health care utilization and health determinants. The CCHS 3.1 included 12,170 respondents age 12-17 years old who answered questions pertaining to influenza vaccination. We used multivariate logistic regression to estimate the odds of having received the influenza vaccination in the last 12 months, adjusting for potential confounders.

RESULTS

Less than a quarter of Canadian youth reported receiving the influenza vaccination in the previous year. The most common reason for not getting the vaccination was "did not think it was necessary" (40.82%). Having chronic illness, and being an immigrant was significantly associated with a higher odds of receiving the influenza vaccination, while having an allergy and increasing frequency of alcohol drinking was associated with lower odds of receiving influenza vaccination. Smoking status acted as an effect modifier for many variables except for immigration status.

CONCLUSIONS

Influenza vaccination rate in Canadian youths is low. Judgement values on its necessity are a major factor in the decision to receive influenza vaccination. Strategies to involve youths in influenza vaccination programs and campaigns will be essential to achieve better national coverage.