Commentary-Anatomy of Racial Disparity in Influenza Vaccination

Intersectional Immunity? Examining How Race/Ethnicity and Sexual Orientation Combine to Shape Influenza Vaccination Among US Adults

Influenza vaccination is a critical preventive healthcare behavior designed to prevent spread of seasonal flu. This paper contributes to existing scholarship by applying an intersectional perspective to examine how influenza vaccination differs across specific intersections of racial/ethnic and sexual identity. Drawing on aggregated state-level data from Behavioral Risk Factor Surveillance System (BRFSS) from 2011 to 2020, I examine how flu vaccination differs across 18 racial/ethnic-by-sexual orientation groups (N = 1,986,432). Findings from descriptive analyses and logistic regression modeling demonstrate three key findings. First, it corroborates previous studies of vaccination, finding lower rates of flu vaccination among black adults relative to whites; gays/lesbians vaccinate at higher rates than heterosexuals and bisexuals, with bisexuals reporting lower vaccination relative to both heterosexuals and gays/lesbians. Second, it demonstrates how sexual orientation complicates established patterns between race/ethnicity and vaccination (e.g., influenza vaccination is more racially stratified among heterosexuals, with patterns more variable among gays/lesbians) and how race/ethnicity complicates previous patterns of vaccination by sexual orientation (e.g., Asian bisexuals vaccinate more than both heterosexuals). Third, findings pinpoint identities (e.g., black heterosexuals relative to their white peers and white bisexuals relative to their gay/lesbian peers) most in need of influenza vaccination outreach efforts. Implications for findings suggest that heterosexuals, especially black, may be less likely to vaccinate against influenza thus may need more encouragement from clinicians to vaccinate. Additionally, influenza vaccination should be free for all persons to lessen the barrier of access for this preventative healthcare.

Evaluation of a city-wide school-located influenza vaccination program in Oakland, California with respect to race and ethnicity: A matched cohort study

Background:

Increasing influenza vaccination coverage in school-aged children may substantially reduce community transmission. School-located influenza vaccinations (SLIV) aim to promote vaccinations by increasing accessibility, which may be especially beneficial to race/ethnicity groups that face high barriers to preventative care. Here, we evaluate the effectiveness of a city-wide SLIV program by race/ethnicity from 2014 to 2018.

Methods:

We used multivariate matching to pair schools in the intervention district in Oakland, CA with schools in a comparison district in West Contra Costa County, CA. We distributed cross-sectional surveys to measure caregiver-reported student vaccination status and estimated differences in vaccination coverage levels and reasons for non-vaccination between districts stratifying by race/ethnicity. We estimated difference-in-differences (DID) of laboratory confirmed influenza hospitalization incidence between districts stratified by race/ethnicity using surveillance data.

Results:

Differences in influenza vaccination coverage in the intervention vs. comparison district were larger among White (2017–18: 21.0% difference [95% CI: 9.7%, 32.3%]) and Hispanic/Latino (13.4% [8.8%, 18.0%]) students than Asian/Pacific Islander (API) (8.9% [1.3%, 16.5%]), Black (5.9% [−2.2%, 14.0%]), and multiracial (6.3% [−1.8%, 14.3%)) students. Concerns about vaccine effectiveness or safety were more common among Black and multiracial caregivers. Logistical barriers were less common in the intervention vs. comparison district, with the largest difference among White students. In both districts, hospitalizations in 2017–18 were higher in Blacks (Intervention: 111.5 hospitalizations per 100,00; Comparison: 134.1 per 100,000) vs. other races/ethnicities. All-age influenza hospitalization incidence was lower in the intervention site vs. comparison site among White/API individuals in 2016–17 (DID −25.14 per 100,000 [95% CI: −40.14, −10.14]) and 2017–18 (−36.6 per 100,000 [−52.7, −20.5]) and Black older adults in 2017–18 (−282.2 per 100,000 (−508.4, −56.1]), but not in other groups.

Conclusions:

SLIV was associated with higher vaccination coverage and lower influenza hospitalization, but associations varied by race/ethnicity. SLIV alone may be insufficient to ensure equitable influenza outcomes.

The risk of racial bias while tracking influenza-related content on social media using machine learning

OBJECTIVE

Machine learning is used to understand and track influenza-related content on social media. Because these systems are used at scale, they have the potential to adversely impact the people they are built to help. In this study, we explore the biases of different machine learning methods for the specific task of detecting influenza-related content. We compare the performance of each model on tweets written in Standard American English (SAE) vs African American English (AAE).

MATERIALS AND METHODS

Two influenza-related datasets are used to train 3 text classification models (support vector machine, convolutional neural network, bidirectional long short-term memory) with different feature sets. The datasets match real-world scenarios in which there is a large imbalance between SAE and AAE examples. The number of AAE examples for each class ranges from 2% to 5% in both datasets. We also evaluate each model's performance using a balanced dataset via undersampling.

RESULTS

We find that all of the tested machine learning methods are biased on both datasets. The difference in false positive rates between SAE and AAE examples ranges from 0.01 to 0.35. The difference in the false negative rates ranges from 0.01 to 0.23. We also find that the neural network methods generally has more unfair results than the linear support vector machine on the chosen datasets.

CONCLUSIONS

The models that result in the most unfair predictions may vary from dataset to dataset. Practitioners should be aware of the potential harms related to applying machine learning to health-related social media data. At a minimum, we recommend evaluating fairness along with traditional evaluation metrics.

Exploring Disparities in Influenza Immunization for Older Women

OBJECTIVES

While women obtain most recommended preventive health interventions more often than men, evidence is mixed regarding influenza vaccination for older adults. Therefore, we evaluated sex differences in influenza vaccination among older adults.

DESIGN

Nationally representative cross-sectional survey.

SETTING

United States.

PARTICIPANTS

A total of 1 252 705 adults, aged 65 years and older, responding to 2013 to 2017 Medicare Consumer Assessment of Healthcare Providers and Systems surveys.

MEASUREMENTS

The dependent variable was Healthcare Effectiveness Data and Information Set self-reported influenza immunization. The primary predictor was sex. Covariates included general health status, education, race/ethnicity, and Medicare Advantage (MA; managed care) vs Fee-for-Service (FFS) coverage.

RESULTS

After adjusting for health status and other sociodemographic factors, women's immunization was 2% lower than men's immunization in MA, with no significant overall sex difference in FFS. Women were immunized less often than men in 95% of MA health plans, with the largest gaps in low-immunizing plans. Further analyses revealed variation in sex differences by health status, education, and race/ethnicity in both MA and FFS. Notably in MA, women in poor health were immunized less often than men in similar health (-4%; P < .001). Black women were immunized much less often than black men in both MA and FFS (-5%; P < .001 for each). Hispanic women were immunized less often than Hispanic men in MA (-4%; P < .001) but not within FFS.

CONCLUSION

Women in MA experience small disparities overall in influenza immunization, with larger disparities for black and Hispanic women. Providers and MA plans should increase efforts to recommend and monitor immunization for older women, especially black and Hispanic women and those in poor health. Given the potential to reduce morbidity and mortality, equitable access to a critical preventive health service, such as influenza immunization, is crucial for all older adults.

Factors contributing to racial disparities in influenza vaccinations

Background

Racial/ethnic disparities in rates of influenza vaccinations in the US remain an issue even among those with access, no out-of-pocket costs, and after adjusting for confounders. We used an approach called the Oaxaca-Blinder (OB) decomposition method to ascertain the contribution of covariates individually and in aggregate to the racial disparity in influenza vaccination.

Methods

We included members > = 18 years of age as of 05/01/2014 with continuous enrollment through 04/30/2015. Influenza vaccination was defined by diagnosis, procedure, or medication codes, or documentation in the immunization table. Characteristics were reported by race. Logistic regression models estimated the odds of vaccination associated with: (1) race; and (2) covariates stratified by race. The Oaxaca-Blinder (OB) method calculated the contribution of covariates to the difference or disparity in vaccination between Blacks and Whites.

Results

We found that among adults, 44% were vaccinated; 55% were Black; and 45% were White. Black members have 42% lower odds of vaccination than White members. The contribution of the differences in the average value of the study covariates between Black and White members (the OB covariate effect) accounted for 29% of the racial disparity. The contributions to the total White-Black disparity in vaccination included: age (16%), neighborhood median income (11%), and registration on the online patient portal (13%). The contribution of the differences in how the covariates impact vaccination (OB coefficient effect) accounted for 71% of the disparity in vaccination between Blacks and Whites.

Conclusion

In conclusion, equalizing average covariate values in Blacks and Whites could reduce the racial disparity in influenza vaccination by 29%. For health system vaccine campaigns, improving registration on the patient portal may be a target component of an effective system-level strategy to reduce racial disparities in vaccination. Additional information on patient-centered factors could further improve the value of the OB approach.

Racial/Ethnic Disparities in Influenza Vaccination Coverage Among US Adolescents, 2010-2016

OBJECTIVE

Although research suggests racial/ethnic disparities in influenza vaccination and mortality rates, few studies have examined racial/ethnic trends among US adolescents. We used national cross-sectional data to determine (1) trends in influenza vaccination rates among non-Hispanic white (hereinafter, white), non-Hispanic black (hereinafter, black), and Hispanic adolescents over time and (2) whether influenza vaccination rates among adolescents varied by race/ethnicity.

METHODS

We analyzed provider-reported vaccination histories for 2010-2016 from the National Immunization Survey-Teen. We used binary logistic regression models to determine trends in influenza vaccination rates by race/ethnicity for 117 273 adolescents, adjusted for sex, age, health insurance, physician visit in the previous 12 months, vaccination facility type, poverty status, maternal education level, children in the household, maternal marital status, maternal age, and census region of residence. We calculated adjusted probabilities for influenza vaccination for each racial/ethnic group, adjusted for the same demographic characteristics.

RESULTS

Compared with white adolescents, Hispanic adolescents had higher odds (adjusted odds ratio [aOR] = 1.11; 95% confidence interval [CI], 1.06-1.16) and black adolescents had lower odds (aOR = 0.95; 95% CI, 0.90-1.00) of vaccination. Compared with white adolescents, Hispanic adolescents had significantly higher adjusted probabilities of vaccination for 2011-2013 (2011: 0.22, P < .001; 2012: 0.23, P < .001; 2013: 0.26, P < .001). Compared with white adolescents, black adolescents had significantly lower probabilities of vaccination for 2016 (2016: 0.21, P < .001).

CONCLUSIONS

Targeted interventions are needed to improve adolescent influenza vaccination rates and reduce racial/ethnic disparities in adolescent vaccination coverage.

Racial/Ethnic Differences in Receipt of Influenza and Pneumococcal Vaccination among Long-Stay Nursing Home Residents

OBJECTIVE/STUDY QUESTION

To examine racial/ethnic differences in influenza and pneumococcal vaccination receipt and nonreceipt among nursing home (NH) residents post implementation of federal vaccination policy. DATA SOURCES/STUDY SETTING/STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: An analysis of a merged national cross-sectional dataset containing resident assessment, facility, and community data for years 2010-2013 was conducted. Logistic regressions omitting and including facility fixed effects were used to examine the influence of race and ethnicity (black, Hispanic, white) and black concentration on vaccination status across and within NHs.

PRINCIPLE FINDINGS

Vaccination receipt of 107,874 residents in 742 NHs was examined. Blacks were less likely than whites to receive influenza and pneumococcal vaccinations (OR = 0.75; OR = 0.81, respectively, p-values <.001). The likelihood of not being offered the influenza vaccination was greater for blacks (OR=1.25, p = .004) and the likelihood of not being offered the pneumococcal vaccination was greater for Hispanics (OR = 1.65, p = .04) compared to whites. Fixed effects showed that within the same NH, Hispanics were more likely to receive both vaccinations compared to whites (OR=1.22, p = .004 (influenza); OR=1.34, p < .001 (pneumococcal)). Facilities highly concentrated with blacks accounted for large proportions of differences seen in vaccination receipt.

CONCLUSIONS

Racial/ethnic differences remain despite policy changes. Focused strategies aimed at NH personnel and racially segregated NHs are critical to improving vaccination delivery and eliminating disparities in care.

Extreme precipitation and emergency room visits for influenza in Massachusetts: a case-crossover analysis

BACKGROUND

Influenza peaks during the wintertime in temperate regions and during the annual rainy season in tropical regions - however reasons for the observed differences in disease ecology are poorly understood. We hypothesize that episodes of extreme precipitation also result in increased influenza in the Northeastern United States, but this association is not readily apparent, as no defined 'rainy season' occurs. Our objective was to evaluate the association between extreme precipitation (≥ 99th percentile) events and risk of emergency room (ER) visit for influenza in Massachusetts during 2002-2008.

METHODS

A case-crossover analysis of extreme precipitation events and influenza ER visits was conducted using hospital administrative data including patient town of residence, date of visit, age, sex, and associated diagnostic codes. Daily precipitation estimates were generated for each town based upon data from the National Oceanic and Atmospheric Administration. Odds ratio (OR) and 95% confidence intervals (CI) for associations between extreme precipitation and ER visits for influenza were estimated using conditional logistic regression.

RESULTS

Extreme precipitation events were associated with an OR = 1.23 (95%CI: 1.16, 1.30) for ER visits for influenza at lag days 0-6. There was significant effect modification by race, with the strongest association observed among Blacks (OR = 1.48 (1.30, 1.68)).

CONCLUSIONS

We observed a positive association between extreme precipitation events and ER visits for influenza, particularly among Blacks. Our results suggest that influenza is associated with extreme precipitation in a temperate area; this association could be a result of disease ecology, behavioral changes such as indoor crowding, or both. Extreme precipitation events are expected to increase in the Northeastern United States as climate change progresses. Additional research exploring the basis of this association can inform potential interventions for extreme weather events and influenza transmission.

Trends in Influenza and Pneumococcal Vaccination Among US Nursing Home Residents, 2006-2014

BACKGROUND

Institutionalized adults are at increased risk of morbidity and mortality from influenza and pneumococcal infection. Influenza and pneumococcal vaccination have been shown to be effective in reducing hospitalization and deaths due to pneumonia and influenza in this population.

OBJECTIVE

To assess trends in influenza vaccination coverage among US nursing home residents from the 2005-2006 through 2014-2015 influenza seasons and trends in pneumococcal vaccination coverage from 2006 to 2014 among US nursing home residents, by state and demographic characteristics.

METHODS

Data were analyzed from the Centers for Medicare and Medicaid Services' (CMS's) Minimum Data Set (MDS). Influenza and pneumococcal vaccination status were assessed for all residents of CMS-certified nursing homes using data reported to the MDS by all certified facilities.

RESULTS

Influenza vaccination coverage increased from 71.4% in the 2005-2006 influenza season to 75.7% in the 2014-2015 influenza season and pneumococcal vaccination coverage increased from 67.4% in 2006 to 78.4% in 2014. Vaccination coverage varied by state, with influenza vaccination coverage ranging from 50.0% to 89.7% in the 2014-2015 influenza season and pneumococcal vaccination coverage ranging from 55.0% to 89.7% in 2014. Non-Hispanic black and Hispanic residents had lower coverage compared with non-Hispanic white residents for both vaccines, and these differences persisted over time.

CONCLUSION

Influenza and pneumococcal vaccination among US nursing home residents remains suboptimal. Nursing home staff can employ strategies such as provider reminders and standing orders to facilitate offering vaccination to all residents along with culturally appropriate vaccine promotion to increase vaccination coverage among this vulnerable population.

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.

The Impact of Vaccine Concerns on Racial/Ethnic Disparities in Influenza Vaccine Uptake Among Health Care Workers

OBJECTIVES

We explored whether collective concerns about the safety, effectiveness, and necessity of influenza vaccines mediate racial/ethnic disparities in vaccine uptake among health care workers (HCWs).

METHODS

We used a self-administered Web-based survey to assess race/ethnicity (exposure), concerns about influenza vaccination (mediator; categorized through latent class analysis), and influenza vaccine uptake (outcome) for the 2012 to 2013 influenza season among HCWs at St. Jude Children's Research Hospital in Memphis, Tennessee. We used mediation analysis to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the total, direct, and indirect effects of race/ethnicity on influenza vaccine uptake.

RESULTS

Non-Hispanic Blacks had lower influenza vaccine uptake than non-Hispanic Whites (total effect: PR = 0.87; 95% CI = 0.75, 0.99), largely mediated by high concern about influenza vaccines (natural indirect effect: PR = 0.89; 95% CI = 0.84, 0.94; controlled direct effect: PR = 0.98; 95% CI = 0.85, 1.1). Hispanic and Asian HCWs had modestly lower uptake than non-Hispanic Whites, also mediated by high concern about influenza vaccines.

CONCLUSIONS

Racial/ethnic disparities among HCWs could be attenuated if concerns about the safety, effectiveness, and necessity of influenza vaccines were reduced.

Cost-Effectiveness Analysis of a Television Campaign to Promote Seasonal Influenza Vaccination Among the Elderly

BACKGROUND

The U.S. policy goals regarding influenza vaccination coverage rate among the elderly include the increase in the coverage rate and the elimination of disparities across racial/ethnic groups.

OBJECTIVE

To examine the potential effectiveness of a television (TV) campaign to increase seasonal influenza vaccination among the elderly.

METHODS

We estimated the incremental cost-effectiveness ratio (ICER, defined as incremental cost per additionally vaccinated Medicare individual) of a hypothetical nationwide TV campaign for influenza vaccination compared with no campaign. We measured the effectiveness of the nationwide TV campaign (advertised once a week at prime time for 30 seconds) during a 17-week influenza vaccination season among four racial/ethnic elderly groups (N=39 million): non-Hispanic white (W), non-Hispanic African American (AA), English-speaking Hispanic (EH), and Spanish-speaking Hispanic (SH).

RESULTS

The hypothetical campaign cost was $5,960,000 (in 2012 US dollars). The estimated campaign effectiveness ranged from -1.1% (the SH group) to 1.42% (the W group), leading to an increased disparity in influenza vaccination among non-Hispanic white and non-Hispanic African American (W-AA) groups (0.6 percentage points), W-EH groups (0.1 percentage points), and W-SH groups (1.5 percentage points). The estimated ICER was $23.54 (95% confidence interval $14.21-$39.37) per additionally vaccinated Medicare elderly in a probabilistic analysis. Race/ethnicity-specific ICERs were lowest among the EH group ($22.27), followed by the W group ($22.47) and the AA group ($30.55). The nationwide TV campaign was concluded to be reasonably cost-effective compared with a benchmark intervention (with ICER $44.39 per vaccinated individual) of a school-located vaccination program. Break-even analyses estimated the maximum acceptable campaign cost to be $14,870,000, which was comparable to the benchmark ICER.

CONCLUSIONS

The results could justify public expenditures on the implementation of a future nationwide TV campaign, which should include multilingual campaigns, for promoting seasonal influenza vaccination.

Determinants of healthcare provider recommendations for influenza vaccinations

OBJECTIVE

Investigate determinants of receiving healthcare provider (HCP) recommendations for seasonal and H1N1 influenza vaccinations.

METHODS

Using a United States national sample of adults 18 + from the National 2009 H1N1 Flu Survey, multivariate regression models estimated the likelihood of receiving a HCP recommendation. Covariates included demographics, socioeconomic status, and Advisory Committee on Immunization Practices (ACIP) priority groups.

RESULTS

Adults age 55-64 and 65 + were more likely to report a HCP recommendation when compared to adults age 18-34 (OR: 1.483, 95%CI: 1.237-1.778 and OR: 1.738, 95%CI: 1.427-2.116, respectively). Chronically ill adults had 58.0% (95%CI: 1.414-1.765) higher odds of receiving a HCP recommendation than non-chronically ill adults. Patients visiting a doctor once and twice had 28.7% (95%CI: 0.618-0.821) and 17.1% (95%CI: 0.721-0.952) lower odds of receiving a HCP recommendation when compared to adults visiting their doctor at least four times. And, compared to Non-Hispanic Whites, Non-Hispanic Blacks had 28.4% (95%CI: 1.064-1.549) higher odds of receiving a recommendation.

CONCLUSIONS

ACIP priority groups experienced higher rates of recommendations compared to non-ACIP groups. Racial differences in HCP recommendations cannot explain racial disparities in flu vaccination rates.

Differences in adult influenza vaccine-seeking behavior: the roles of race and attitudes

BACKGROUND

Racial/ethnic disparities in influenza vaccination among adults are longstanding, and research suggests they result from multiple factors. Influenza vaccine-seeking behavior may be an important aspect to consider when evaluating disparities in vaccination coverage.

OBJECTIVE

To determine whether there are differences between blacks and whites in influenza vaccine-seeking behavior among adults 65 years and older.

METHODS

Data were analyzed from a national sample of 3138 adults 65 years and older collected through the adult module of the 2007 National Immunization Survey, a random digit dialing telephone survey, which included an oversample of non-Hispanic blacks. Analysis included influenza vaccination rate, location of vaccination, and whether vaccinated individuals specifically went to the location to receive the vaccine (vaccine seekers) by race. The relationship between attitudes about influenza vaccination and vaccine-seeking behavior by race was also examined.

RESULTS

White adults 65 years and older were significantly more likely to receive influenza vaccine than blacks, during the 2006-2007 influenza season (68% ± 4% vs 54% ± 3%, respectively), and a significantly higher proportion of vaccinated whites reported seeking out the vaccine than vaccinated blacks (66% ± 4% vs 47% ± 4%, respectively). Blacks were less likely to be vaccine seekers, regardless of education or poverty levels. Among persons vaccinated in a doctor's office, 52% of whites specifically went there to get vaccinated, compared with 37% of blacks. Among persons who believe the vaccine is very effective, 66% ± 5% of whites versus 50% ± 6% of blacks were vaccine seekers.

CONCLUSIONS

This study points to the importance of improving our understanding of what factors, in addition to beliefs about vaccination, lead to vaccine seeking and reinforces the need for systematically offering vaccine.

Trends in racial/ethnic disparities in influenza vaccination coverage among adults during the 2007-08 through 2011-12 seasons

BACKGROUND

Annual influenza vaccination is recommended for all persons aged ≥6 months. The objective of this study was to assess trends in racial/ethnic disparities in influenza vaccination coverage among adults in the United States.

METHODS

We analyzed data from the 2007-2012 National Health Interview Survey (NHIS) and Behavioral Risk Factor Surveillance System (BRFSS) using Kaplan-Meier survival analysis to assess influenza vaccination coverage by age, presence of medical conditions, and racial/ethnic groups during the 2007-08 through 2011-12 seasons.

RESULTS

During the 2011-12 season, influenza vaccination coverage was significantly lower among non-Hispanic blacks and Hispanics compared with non-Hispanic whites among most of the adult subgroups, with smaller disparities observed for adults age 18-49 years compared with other age groups. Vaccination coverage for non-Hispanic white, non-Hispanic black, and Hispanic adults increased significantly from the 2007-08 through the 2011-12 season for most of the adult subgroups based on the NHIS (test for trend, P < .05). Coverage gaps between racial/ethnic minorities and non-Hispanic whites persisted at similar levels from the 2007-08 through the 2011-12 seasons, with similar results from the NHIS and BRFSS.

CONCLUSIONS

Influenza vaccination coverage among most racial/ethnic groups increased from the 2007-08 through the 2011-12 seasons, but substantial racial and ethnic disparities remained in most age groups. Targeted efforts are needed to improve coverage and reduce these disparities.

Effectiveness of hospital-based postpartum procedures on pertussis vaccination among postpartum women

OBJECTIVE

Pertussis causes significant morbidity among adults, children, and especially infants. Since 2006, pertussis vaccination has been recommended for women after delivery. We conducted a prospective, controlled evaluation of in-hospital postpartum pertussis vaccination of birth mothers from October 2009 through July 2010 to evaluate the effectiveness of hospital-based procedures in increasing postpartum vaccination.

STUDY DESIGN

The intervention and comparison hospitals are private community facilities, each with 2000-6000 births/year. At the intervention hospital, physician opt-in orders for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) before discharge were implemented in November 2009, followed by standing orders in February 2010. The comparison hospital maintained standard practice. Randomly selected hospital charts of women after delivery were reviewed for receipt of Tdap and demographic data. We evaluated postpartum Tdap vaccination rates and conducted multivariate analyses to evaluate characteristics that are associated with vaccination. We reviewed 1264 charts (658 intervention hospital; 606 comparison hospital) from women with completed deliveries.

RESULTS

Tdap postpartum vaccination was 0% at both hospitals at baseline. In the intervention hospital, the introduction of the opt-in order was followed by an increase in postpartum vaccination to 18%. The introduction of the standing order approach was followed by a further increase to 69% (P < .0001). No postpartum Tdap vaccinations were documented in the comparison hospital. Postpartum Tdap vaccination in the intervention hospital did not differ by demographic characteristics.

CONCLUSION

In-hospital ordering procedures substantially increased Tdap vaccination coverage in women after delivery. Opt-in orders increased coverage that increased substantially with standing orders.

Coverage and predictors of vaccination against 2012/13 seasonal influenza in Madrid, Spain: analysis of population-based computerized immunization registries and clinical records

We aim to determine 2012–13 seasonal influenza vaccination coverage. Data were analyzed by age group and by coexistence of concomitant chronic conditions. Factors associated with vaccine uptake were identified. We also analyze a possible trend in vaccine uptake in post pandemic seasons.

We used computerized immunization registries and clinical records of the entire population of the Autonomous Community of Madrid, Spain (6 284 128 persons) as data source.

A total of 871 631 individuals were vaccinated (13.87%). Coverage for people aged ≥ 65 years was 56.57%. Global coverage in people with a chronic condition was 15.7% in children and 18.69% in adults aged 15–59 years.

The variables significantly associated with a higher likelihood of being vaccinated in the 2012–13 campaign for the age groups studied were higher age, being Spanish-born, higher number of doses of seasonal vaccine received in previous campaigns, uptake of pandemic vaccination, and having a chronic condition.

We conclude that vaccination coverage in persons aged &lt;60 years with chronic conditions is less than acceptable. The very low coverage among children with chronic conditions calls for urgent interventions. Among those aged ≥60 years, uptake is higher but still far from optimal and seems to be descending in post-pandemic campaigns. For those aged ≥65 years the mean percentage of decrease from the 2009/10 to the actual campaign has been 12%.

Computerized clinical and immunization registers are useful tools for providing rapid and detailed information about influenza vaccination coverage in the population.

Seasonal influenza vaccination coverage among adult populations in the United States, 2005-2011

The most effective strategy for preventing influenza is annual vaccination. We analyzed 2005-2011 data from the National Health Interview Survey (NHIS), using Kaplan-Meier survival analysis to estimate cumulative proportions of persons reporting influenza vaccination in the 2004-2005 through 2010-2011 seasons for persons aged ≥18, 18-49, 50-64, and ≥65 years, persons with high-risk conditions, and health-care personnel. We compared vaccination coverage by race/ethnicity within each age and high-risk group. Vaccination coverage among adults aged ≥18 years increased from 27.4% during the 2005-2006 influenza season to 38.1% during the 2010-2011 season, with an average increase of 2.2% annually. From the 2005-2006 season to the 2010-2011 season, coverage increased by 10-12 percentage points for all groups except adults aged ≥65 years. Coverage for the 2010-2011 season was 70.2% for adults aged ≥65 years, 43.7% for adults aged 50-64 years, 36.7% for persons aged 18-49 years with high-risk conditions, and 55.8% for health-care personnel. In most subgroups, coverage during the 2010-2011 season was significantly lower among non-Hispanic blacks and Hispanics than among non-Hispanic whites. Vaccination coverage among adults under age 65 years increased from 2005-2006 through 2010-2011, but substantial racial/ethnic disparities remained in most age groups. Targeted efforts are needed to improve influenza vaccination coverage and reduce disparities.

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

INTRODUCTION

Cancer survivors are at increased risk for influenza-related complications. Racial disparities in preventive health services have not been extensively studied among cancer survivors. Our objective is to compare influenza vaccination prevalence among black and white cancer survivors

METHODS

We performed a secondary data analysis of 41,346 white and black cancer survivors (excluding non-melanoma skin cancer) from the 2009 Behavioral Risk Factor Surveillance System survey. Respondents were asked whether they had received an influenza vaccination in the previous year. Multivariable logistic regression was used to estimate the odds of having influenza vaccine by race.

RESULTS

Sixty-five percent of whites reported receiving the vaccine in the last year compared to 50 % of blacks. Blacks had significantly lower odds of vaccination after controlling for covariates significantly associated with the odds of influenza vaccination. Higher education, having health insurance, having a primary care provider, and having a routine check-up in the last year increased the odds of receiving an influenza vaccine.

CONCLUSIONS

Our analysis supports that racial disparities in vaccine coverage persist among cancer survivors, a group strongly recommended to receive annual influenza vaccine, even when predictors significantly associated with increased vaccination are controlled for.

IMPLICATIONS FOR CANCER SURVIVORS

As a nationally representative survey with a large sample size, our study provides a picture of self-reported vaccine coverage among cancer survivors in the USA and the disparity that exists between blacks and whites in this population. Care teams can use these findings to better target follow-up care for cancer survivors.

Despite small improvement, black nursing home residents remain less likely than whites to receive flu vaccine

Vaccination is a key deterrent to influenza and its related complications and outcomes, including hospitalization and death. Using 2006-09 data, we found a small improvement in vaccination rates among nursing home residents, particularly for blacks. Nonetheless, overall vaccination rates remained well below the 90 percent target for high-quality care, and black nursing home residents remained less likely to be vaccinated than whites. Blacks were less likely to be vaccinated than were whites in the same facility and were more likely to live in facilities with lower vaccination rates. Blacks were also more likely to be noted as refusing vaccination. Strategies are needed to ensure that facilities offer vaccination to all residents and to make vaccination more acceptable to black residents and their families.

Association between quality of care and the sociodemographic composition of physicians' patient panels: a repeat cross-sectional analysis

BACKGROUND

Pay-for-performance programs could worsen health disparities if providers who care for disadvantaged patients face systematic barriers to providing high-quality care. Risk adjustment that includes sociodemographic factors could mitigate the financial incentive to avoid disadvantaged patients.

OBJECTIVE

To test for associations between quality of care and the composition of a physician's patient panel.

DESIGN

Repeat cross-sectional analysis

PARTICIPANTS

Nationally representative sample of US primary care physicians responding to a panel telephone survey in 2000-2001 and 2004-2005

MAIN MEASURES

Quality of primary care as measured by provision of eight recommended preventive services (diabetic monitoring [hemoglobin A1c testing, eye examinations, cholesterol testing and urine protein analysis], cancer screening [screening colonoscopy/sigmoidoscopy and mammography], and vaccinations against influenza and pneumococcus) documented in Medicare claims data and the association between quality and the sociodemographic composition of physicians' patient panels.

KEY RESULTS

Across eight quality measures, physicians' quality of care was not consistently associated with the composition of their patient panel either in a single year or between time periods. For example, a substantial number (seven) of the eighteen significant associations seen between sociodemographic characteristics and the delivery of preventive services in the first time period were no longer seen in the second time period. Among sociodemographic characteristics, panel Medicaid eligibility was most consistently associated with differences in the delivery of preventive services between time points; among preventive services, the delivery of influenza vaccine was most likely to demonstrate disparities in both time points.

CONCLUSIONS

In a Medicare pay-for-performance program, a better understanding of the effect of effect of patient panel composition on physicians' quality of care may be necessary before implementing routine statistical adjustment, since the association of quality and sociodemographic composition is small and inconsistent. In addition, we observed improvements between time periods among physicians with varying panel composition.

Increasing inner-city adult influenza vaccination rates: a randomized controlled trial

OBJECTIVES

In a population of seniors served by urban primary care centers, we evaluated the effect of the practice-based intervention on influenza immunization rates and disparities in vaccination rates by race/ethnicity and insurance status.

METHODS

A randomized controlled trial during 2003-2004 tested patient tracking/recall/outreach and provider prompts on improving influenza immunization rates. Patients aged > or = 65 years in six large inner-city primary care practices were randomly allocated to study or control group. Influenza immunization coverage was measured prior to enrollment and on the end date.

RESULTS

At study end, immunization rates were greater for the intervention group than for the control group (64% vs. 22%, p < 0.0001). When controlling for other factors, the intervention group was more than six times as likely to receive influenza vaccine. The intervention was effective across gender, race/ ethnicity, age, and insurance subgroups. Among the intervention group, 3.5% of African Americans and 3.2% of white people refused influenza immunization.

CONCLUSIONS

Patient tracking/recall/outreach and provider prompts were intensive but successful approaches to increasing seasonal influenza immunization rates among this group of inner-city seniors.

Influenza vaccine supply and racial/ethnic disparities in vaccination among the elderly

BACKGROUND

The impact of vaccine shortages on disparities in influenza vaccination is uncertain.

PURPOSE

The objective of this research was to examine the association between influenza vaccine supply and racial/ethnic disparities in vaccination rates among elderly Medicare beneficiaries.

METHODS

Cross-sectional multivariable logistic regression analyses were performed in 2010 to examine whether racial/ethnic disparities in vaccination rates changed across two consecutive seasons: from (Period 1) 2000-2001 and 2001-2002 seasons through (Period 4) 2003-2004 and 2004-2005 seasons. Self-reported receipt of influenza vaccine across consecutive years was examined among community-dwelling non-Hispanic African-American (AA); non-Hispanic white (W); English-speaking Hispanic (EH); and Spanish-speaking Hispanic (SH) elderly enrolled in the Medicare Current Beneficiary Survey (unweighted n=2306-2504, weighted n=8.23-8.99 million for Periods 1 through 4).

RESULTS

During Periods 1 and 2, when vaccine supply increased nationally, adjusted racial/ethnic disparities in the influenza vaccination rate decreased by 1.8%-7.4% (W-AA disparity); 4.5%-6.6% (W-EH disparity); and 6.6%-11% (W-SH disparity) (all p<0.001). During Period 4, when vaccine supply declined, adjusted disparities in vaccination rates increased by 2.3% (W-AA disparity) and 6.1% (W-EH disparity) but decreased by 6.6% (W-SH disparity) probably due to a "floor effect" (constant low rates among SH; all p<0.001).

CONCLUSIONS

Improved vaccine supply was generally associated with reduced racial/ethnic disparities in influenza vaccination rates, whereas worse supply was associated with increased disparities. To avoid future widening of racial health disparities, policy options include stabilizing the vaccine supply and preferential delivery of vaccines to safety-net providers serving AA and Hispanic populations during a shortage.

Protection of racial/ethnic minority populations during an influenza pandemic

Racial/ethnic minority populations experience worse health outcomes than do other groups during and after disasters. Evidence for a differential impact from pandemic influenza includes both higher rates of underlying health conditions in minority populations, increasing their risk of influenza-related complications, and larger socioeconomic (e.g., access to health care), cultural, educational, and linguistic barriers to adoption of pandemic interventions. Implementation of pandemic interventions could be optimized by (1) culturally competent preparedness and response that address specific needs of racial/ethnic minority populations, (2) improvements in public health and community health safety net systems, (3) social policies that minimize economic burdens and improve compliance with isolation and quarantine, and (4) relevant, practical, and culturally and linguistically tailored communications.

Significant differences in the use of healthcare resources of native-born and foreign born in Spain

Background

In the last decade, the number of foreign residents in Spain has doubled and it has become one of the countries in the European Union with the highest number of immigrants There is no doubt that the health of the immigrant population has become a relevant subject from the point of view of public healthcare. Our study aimed at describing the potential inequalities in the use of healthcare resources and in the lifestyles of the resident immigrant population of Spain.

Methods

Cross-sectional, epidemiological study from the Spanish National Health Survey (NHS) in 2006, from the Ministry of Health and Consumer Affairs. We have worked with individualized secondary data, collected in the Spanish National Health Survey carried out in 2006 and 2007 (SNHS-06), from the Ministry of Health and Consumer Affairs. The format of the SNHS-06 has been adapted to the requirements of the European project for the carrying out of health surveys.

Results

The economic immigrant population resident in Spain, present diseases that are similar to those of the indigenous population. The immigrant population shows significantly lower values in the consumption of alcohol, tobacco and physical activity (OR = 0.76; CI 95%: 0.65–0.89, they nonetheless perceive their health condition as worse than that reported by the autochthonous population (OR = 1.63, CI 95%: 1.34–1.97). The probability of the immigrant population using emergency services in the last 12 months was significantly greater than that of the autochthonous population (OR = 1.31, CI 95%: 1.12–1.54). This situation repeats itself when analyzing hospitalization data, with values of probability of being hospitalized greater among immigrants (OR = 1.39, CI 95%: 1.07–1.81).

Conclusion

The economic immigrants have better parameters in relation to lifestyles, but they have a poor perception of their health. Despite the fact that immigrant population shows higher percentages of emergency attendance and hospitalization than the indigenous population, with respect to the use of healthcare resources, their usage of healthcare resources such as drugs, influenza vaccinations or visits to the dentist is lower.

Disparities in influenza immunization among US adults

In the United States, health disparities exist among ethnic minority groups, the uninsured, and those with other barriers to health care access. Health disparities exist for many diseases, but are especially pronounced for preventive health services and preventable diseases. Persons affected by disparities experience higher incidences of vaccine-preventable diseases, such as influenza, and are more likely to die from those diseases as well. Although influenza vaccines are relatively safe, inexpensive, and effective in reducing infection and disease complications, many groups in the United States do not yet benefit from this potentially lifesaving intervention. Possible explanations for disparities in influenza vaccination include: (1) barriers to access such as cost, insurance status, and language differences; (2) underestimation of personal risk and misunderstanding of vaccination risks; (3) mistrust toward the health care system. Proposed strategies to minimize these disparities include: (1) changes to health care system structural factors that serve as access barriers, (2) education to increase awareness and improve demand for vaccines, (3) involvement of community-based organizations to assess local needs and design responsive solutions.

Trust in the health care system and the use of preventive health services by older black and white adults

OBJECTIVES

We sought to find racial differences in the effects of trust in the health care system on preventive health service use among older adults.

METHODS

We conducted a telephone survey with 1681 Black and White older adults. Survey questions explored respondents' trust in physicians, medical research, and health information sources. We used logistic regression and controlled for covariates to assess effects of race and trust on the use of preventive health services.

RESULTS

We identified 4 types of trust through factor analysis: trust in one's own personal physician, trust in the competence of physicians' care, and trust in formal and informal health information sources. Blacks had significantly less trust in their own physicians and greater trust in informal health information sources than did Whites. Greater trust in one's own physician was associated with utilization of routine checkups, prostate-specific antigen tests, and mammograms, but not with flu shots. Greater trust in informal information sources was associated with utilization of mammograms.

CONCLUSIONS

Trust in one's own personal physician is associated with utilization of preventive health services. Blacks' relatively high distrust of their physicians likely contributes to health disparities by causing reduced utilization of preventive services. Health information disseminated to Blacks through informal means is likely to increase Blacks' utilization of preventive health services.

Coverage and predictors of influenza vaccination among adults living in a large metropolitan area in Spain: a comparison between the immigrant and indigenous populations

This study sought to evaluate influenza vaccination coverage in Madrid (Spain). Coverages were estimated for vaccine target groups and special attention was placed on the immigrant population. Individual data from 7341 adults included in the Madrid City Health Survey conducted in 2005 was used. Overall influenza vaccination coverage was 24%. Compliance with age-based influenza vaccine guidelines (>or=65 years) was 63.9%, among those<65 years who had an associated chronic condition, it was 37.9% and 24.1% among HCWs. Immigrants accounted for 12.4% of the sample. Overall crude coverage was significantly lower among immigrants than among the indigenous population (11.2% vs. 25.9%), but once the multivariate analysis had been performed, the association became non-significant. In conclusion, it must be said that all the available evidence indicates an inadequate level of influenza vaccination coverage among HCWs and high-risk subjects <65 years. On the other hand, coverages among subjects aged >or=65 years are acceptable and there is no observable difference in vaccine use between immigrants and indigenous subjects. Strategies that have demonstrated their effectiveness in enhancing vaccination coverages should be applied in Madrid.

Racial/ethnic differences in influenza vaccination in the Veterans Affairs Healthcare System

BACKGROUND

Racial/ethnic differences in influenza vaccination exist among elderly adults despite nearly universal Medicare health insurance coverage. Overall influenza vaccination prevalence in the Veterans Affairs (VA) Healthcare System is higher than in the general population; however, it is not known whether racial/ethnic differences exist among older adults receiving VA healthcare. Racial/ethnic differences in influenza vaccination in VA were assessed, and barriers to and facilitators of influenza vaccination were examined among veteran outpatients aged 50 years and older.

METHODS

A random sample of 121,738 veterans receiving care at VA outpatient clinics during the 2003-2004 influenza season completed the mailed Survey of Health Experiences of Patients (77% response rate). Multivariate logistic regression was used to examine associations among race/ethnicity and influenza vaccination prevalence, barriers, and facilitators. Analyses were conducted during 2005 and 2006.

RESULTS

Based on unadjusted prevalences, non-Hispanic blacks, Hispanics, and American Indian/Alaskan Natives were significantly less likely to be vaccinated for influenza compared to non-Hispanic whites (71%, 79%, and 74%, respectively, vs 82%). After adjustment for age, gender, marital status, education level, employment, having a primary care provider, confidence and/trust in provider, and health status, only non-Hispanic blacks remained significantly less likely to be vaccinated compared to non-Hispanic whites (75% vs 81%). Influenza vaccination barriers and facilitators varied by race/ethnic group.

CONCLUSIONS

Compared to non-Hispanic whites, non-Hispanic blacks were less likely to receive influenza vaccination in the VA healthcare system during the 2003-2004 influenza season. Although these differences were small, results suggest the need for further study and culturally informed interventions.

Factors associated with vaccination of medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003

OBJECTIVES

To examine vaccination in seniors in the five U.S. communities of the Racial and Ethnic Adult Disparities in Immunization Initiative.

DESIGN

Cross-sectional telephone survey in spring 2003 using stratified sampling by ZIP code and race/ethnicity.

SETTING

New York, Texas, Wisconsin, Illinois, and Mississippi.

PARTICIPANTS

Four thousand five hundred seventy-seven Medicare beneficiaries.

MEASUREMENTS

Outcomes were pneumococcal vaccination ever and influenza vaccination in 2002/03 and were determined according to race/ethnicity, awareness of vaccination, and provider recommendation. Survey questions also asked about future plans for vaccination, whether respondents believed they had become sick from prior influenza vaccination, and whether unvaccinated respondents would be vaccinated if a health professional recommended it.

RESULTS

Pneumococcal vaccination coverage was 70.3% for whites, 40.8% for blacks, and 53.2% for Hispanics, and the proportion reporting provider recommendation for vaccination differed significantly according to race/ethnicity. In multivariate regression, provider recommendation (risk ratio (RR) = 2.32, 95% confidence intervals (CI) = 2.10-2.57) and awareness of vaccination (RR = 1.60, 95% CI = 1.40-1.82) were associated with greater pneumococcal vaccination. Influenza vaccination coverage was 76.2% for whites, 50.7% for blacks, and 65.7% for Hispanics. A little more than half of respondents reported provider recommendation for influenza vaccination, with no differences according to race/ethnicity. Provider recommendation was associated with influenza vaccination (RR = 1.31, 95% CI = 1.25-1.38). More blacks and Hispanics believed they had become sick from prior influenza vaccination than whites, and this belief was associated with lower vaccination rates.

CONCLUSION

This survey details vaccination patterns in an ethnically and geographically diverse sample of seniors and identifies some differences between blacks, Hispanics, and whites that may contribute to disparities in vaccination coverage. Survey findings highlight the importance of provider vaccination recommendations.

Racial and ethnic disparities in influenza vaccination coverage among adults during the 2004-2005 season

During the 2004-2005 influenza season, the supply of vaccine to the United States was significantly reduced. In response, the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices issued interim recommendations for prioritizing vaccination. Given trends in racial/ethnic disparities in vaccination for influenza, the authors assessed the impact of the shortage on those historically less likely to be vaccinated. Using data from the Behavioral Risk Factor Surveillance System, they considered vaccination coverage among those non-Hispanic Whites, non-Hispanic Blacks, and Hispanics who had priority for being vaccinated during the 2004-2005 influenza season. The vaccine shortage had a significant negative effect on coverage among adults aged 65 years or older across the three racial/ethnic groups. Yet, the magnitude of the disparities in coverage did not change significantly from previous seasons. This finding may imply similar patterns of vaccine-seeking behavior during shortage and nonshortage years. No racial/ethnic differences were seen among adults aged 18-64 years, which likely reflects the higher percentage of health-care workers in this age group. Yearly monitoring of influenza vaccine coverage is important to assess the long-term impact of shortages on overall coverage and gaps in coverage between racial/ethnic groups.