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

National trends in pneumonia-related mortality in the United States, 1999-2019

INTRODUCTION

Pneumonia is one of the most common causes of hospital admissions in the United States and remains a major cause of death. However, less is known regarding the mortality burden from pneumonia in the United States and how this burden has changed over time.

METHODS

Death rates from causes related to pneumonia were determined using the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) data from 1999-2019. Pneumonia deaths were calculated for the overall population as well as for sociodemographic subgroups. We also analysed changes in death rates over time.

RESULTS

Overall, 2.1% of total US deaths during the period between 1999 and 2019 were due to pneumonia (2.6% in 1999 and 1.5% in 2019). Mortality declined over time for both men and women, and across most age cohorts, as well as all racial, urbanisation, and regional categories. Rates of pneumonia deaths were higher among males as compared to females (age-adjusted mortality rate ratio (AAMRR) = 1.35; 95% CI: 1.34-1.35). Compared to White Americans, Black Americans had the highest pneumonia-related mortality rates of any racial group (AAMRR = 1.11; 95% CI: 1.10-1.11).

CONCLUSIONS

Rates of pneumonia-related death have decreased in the United States in recent decades. However, significant racial and gender disparities remain, indicating the need for more equitable care.

Pneumococcal vaccination coverage and vaccination-related factors among older adults in Japan: LIFE Study

PURPOSE

To investigate individual and environmental vaccination-related factors among the older adults in Japan, using administrative data.

METHODS

We conducted a cohort study and included people who reached the relevant age (≥65 years) for routine pneumococcal vaccination of older adults between April 2015 and March 2020. Monthly data of residents in the two municipalities from April 2014 to March 2020 and vaccination records from April 2015 to March 2020 were used. We defined five cohorts according to the year in which routine vaccinations were available. Each cohort was followed for a total of two years, with the first year being the "baseline period" and second year being the "vaccine follow-up period." Pneumococcal vaccination data was extracted from vaccination records at "first dose." Age, sex, socioeconomic status, comorbidities, hospital visit history, hospitalization history, Specific Health Check-ups participation, and information on contracted hospitals for pneumococcal vaccination were used as covariates. A multivariate logistic regression model was used to investigate the relationship between pneumococcal vaccination and vaccination-related factors. Odds ratios (OR) and 95 % confidence intervals (95 % CI) were calculated.

RESULTS

Analysis included 17,991 patients. Vaccination coverage was 33.6 % for all subjects. Multivariate analysis found the following as significant vaccination-related factors: female (OR: 1.18, 95 % CI: 1.11-1.26), not low income (1.76, 1.17-2.76), hospital visits: ≥once/month (1.27, 1.19-1.35), and Specific Health Check-ups participation (2.10, 1.95-2.27). No significant results were found for hospitals that contracted pneumococcal vaccination.

CONCLUSIONS

Individual factors, such as sex and Specific Health Check-ups participation, were found to be important factors affecting pneumococcal vaccination among older adults in Japan. Environmental factors, such as the characteristics of residential areas, should be evaluated in further investigations.

Catch the tweet to fight the flu: Using Twitter to promote flu shots on a college campus

Objective: Over the 2018-2019 flu season we conducted a randomized controlled trial examining the efficacy of a Twitter campaign on vaccination rates. Concurrently we investigated potential interactions between digital social network structure and vaccination status. Participants: Undergratuates at a large midwestern public university were randomly assigned to an intervention (n = 353) or control (n = 349) group. Methods: Vaccination data were collected via monthly surveys. Participant Twitter data were collected through the public-facing Twitter API. Intervention impact was assessed with logistic regression. Standard network science tools examined vaccination coverage over online social networks. Results: The campaign had no effect on vaccination outcome. Receiving a flu shot the prior year had a positive impact on participant vaccination. Evidence of an interaction between digital social network structure and vaccination status was detected. Conclusions: Social media campaigns may not be sufficient for increasing vaccination rates. There may be potential for social media campaigns that leverage network structure.

Associations Between General Vaccine Hesitancy and Healthcare Access Among Arkansans

BACKGROUND

Vaccines provide protection against numerous diseases that can cause serious illness and death. However, vaccine hesitancy threatens to undermine progress in reducing preventable diseases and illness. Vaccine hesitancy has been shown to vary by sociodemographic characteristics. However, studies examining associations between healthcare access and vaccine hesitancy are lacking.

OBJECTIVE

Using a statewide random sample of Arkansas adults, we examined the relationship between general vaccine hesitancy and healthcare access.

DESIGN

From July 12 to 30, 2021, participants were contacted by landlines and cellular phones using random digit dialing.

PARTICIPANTS

A total of 1500 Arkansas adults were surveyed. Black/African American and Hispanic/Latinx adults were oversampled to ensure adequate representation. The survey had a cooperation rate of 20%.

MAIN MEASURES

The dependent variable was an ordinal measure of general vaccine hesitancy. Age, gender, race, education, relationship status, and rural/urban residence were included in the model. Healthcare access was measured across four domains: (1) health insurance coverage; (2) having a primary care provider (PCP); (3) forgoing care due to cost; and (4) time since last routine checkup. The relationship between general vaccine hesitancy and healthcare access was modeled using ordinal logistic regression, controlling for sociodemographic characteristics.

KEY RESULTS

Mean age was 48.5 years, 51.1% were women, 28% reported a race other than White, and 36.3% held a bachelor's degree or higher. Those with a PCP and those with health insurance had approximately two-thirds the odds of being more hesitant ([OR=0.63, CI=0.47, 0.84] and [OR=0.68; CI=0.49, 0.94]) than those without a PCP and those without health insurance. Participants reporting a routine checkup in the last 2 years were almost half as likely to be more hesitant than those reporting a checkup more than 2 years prior (OR=0.58; CI=0.43, 0.79).

CONCLUSIONS

Results suggest improving access to health insurance, PCPs, and routine preventative care services may be critical to reducing vaccine hesitancy.

Survey of Physician Practices, Attitudes, and Knowledge Regarding Recombinant Zoster Vaccine

BACKGROUND

Herpes zoster vaccination rates remain low despite longstanding national recommendations to vaccinate immunocompetent adults aged ≥ 50 years. The Advisory Committee on Immunization Practice (ACIP) updated its recommendations for recombinant zoster vaccine (RZV) in October 2021 to include immunocompromised adults aged ≥19 years.

OBJECTIVE

To assess practices, attitudes, and knowledge about RZV, barriers to recommending RZV, and likelihood of recommending RZV to patients with various immunocompromising conditions.

DESIGN

Mail and internet-based survey conducted from May through July 2020.

PARTICIPANTS

General internists and family physicians throughout the USA.

MAIN MEASURES

Survey responses.

KEY RESULTS

The response rate was 66% (632/955). Many physicians were already recommending RZV to immunocompromised populations, including adults ≥50 years with HIV (67% of respondents) and on recombinant human immune modulator therapy (56%). Forty-seven percent of respondents both stocked/administered RZV and referred patients elsewhere, frequently a pharmacy, for vaccination; 42% did not stock RZV and only referred patients. The majority agreed pharmacies do not inform them when RZV has been given (64%). Physicians were generally knowledgeable about RZV; however, 25% incorrectly thought experiencing side effects from the first dose of RZV that interfere with normal activities was a reason to not receive the second dose. The top reported barrier to recommending RZV was experience with patients declining RZV due to cost concerns (67%). Most physicians reported they would be likely to recommend RZV to immunocompromised patients.

CONCLUSION

Most primary care physicians welcome updated ACIP RZV recommendations for immunocompromised adults. Knowledge gaps, communication issues, and financial barriers need to be addressed to optimize vaccination delivery.

Associations between Influenza Vaccination and Health Care Access among Adults in the United States

Few studies have investigated the relationship between influenza vaccination and health care access. Furthermore, despite the well-documented disparities in vaccine coverage for communities of color, few studies have examined how experiences of discrimination may influence vaccine uptake. To fill this gap in the literature, this study examined associations between 5-year influenza vaccination rates and sociodemographic characteristics, health care access, and racial discrimination. Age, race/ethnicity, education, health care coverage, primary care provider, no medical care due to cost, and routine doctor checkups were significant correlates of 5-year influenza vaccination. In contrast to previous studies, discrimination scores were not a significant correlate of regular influenza vaccination. Respondents who reported forgoing care due to cost were less likely to report vaccination every year out of the last 5 years compared to all of the less frequent categories combined, demonstrating a more complex association between sometimes not being able to afford medical care and influenza vaccination. Future research should examine the relationship between influenza vaccination uptake, racial discrimination, and forgone care due to cost to enhance resources and messaging for influenza vaccination uptake.

Healthcare Access and Experiences of Racial Discrimination as Predictors of General Vaccine Hesitancy

The literature regarding vaccine hesitancy is limited to specific vaccines rather than general vaccine hesitancy. No studies have examined the relationship of general vaccine hesitancy to healthcare access and experiences of racial discrimination. This study fills gaps by examining: (1) socio-demographic factors; (2) associations between healthcare access; and (3) experiences with racial discrimination and general vaccine hesitancy. Survey data were obtained from 2022 US adults from 7 September to 3 October 2021. Racial and ethnic minority populations were oversampled. Age, gender, race, and education were predictors of vaccine hesitancy. Asian respondents had less than two-thirds the odds of being vaccine hesitant. Healthcare access was associated with vaccine hesitancy. Not having health insurance coverage, not having a primary care provider, and not seeing a provider for a routine check-up in the past two years were associated with higher vaccine hesitancy. For every one-point increase in racial discrimination score (0-45), the odds of being more vaccine hesitant increased by a factor of 1.03. The findings demonstrate that policy, systems, and environmental factors are critical to addressing vaccine hesitancy. Given the associations between vaccine hesitancy and racial discrimination and healthcare access, more attention should be given to inequities in the healthcare systems in order to address vaccine hesitancy.

Factors associated with pneumococcal vaccine uptake among vulnerable older adults in the United States primary care setting

Pneumococcal vaccine uptake targets set by Healthy People 2020 were not met by 2019 among vulnerable United States populations, yet research suggests progress can be made in primary care settings. This study assessed factors associated with having gotten a pneumococcal vaccine among vulnerable adults aged 50 and older. This study used the 2018 Medical Expenditure Panel Survey nationally representative dataset. Eligible individuals were aged 50-64 with an 'at risk' health condition or ≥65 years and had a primary care provider as their usual source of care (N = 3,760). Binary logistic regression was used to test factors (identified from literature) for a significant association with getting the pneumococcal vaccine. Factors with significant associations were entered into an adjusted multivariable logistic regression model to generate the odds of endorsing a factor given that the respondent got the vaccine. Collinearity among variables was examined with an unacceptable threshold of 0.8 correlation. A significance threshold of 0.05 was used. Those who got the pneumococcal vaccine had 16.7 (p < 0.001), 16.0 (p < 0.001) and 11.0 times (p < 0.001) higher odds of having also gotten the influenza vaccine, the herpes zoster vaccine and a colonoscopy respectively. They had 3.86 times (p = 0.009) higher odds of having diabetes mellitus, 0.036 times (p = 0.019) higher odds of having visited their doctors three times in 2018 and 8.4 times (p = 0.009) higher odds of having seen their doctor within the last year. Concordance statistic for model fit was 0.936. There was a negative association between pneumococcal vaccination and going to three doctor office visits in 2018 vs only once. The strongest positive associations were found between pneumococcal vaccination and getting the herpes zoster vaccine, influenza vaccine and getting a colonoscopy. These results suggest that those who choose to get the pneumococcal vaccine may have higher odds of also getting other vaccines or specific preventative screenings.

Associations between 5-year influenza vaccination and sociodemographic factors and healthcare access among Arkansans

Despite wide availability, only 50.2% of the United States (US) adult population and 50.3% of adult Arkansans were vaccinated for influenza during the 2020-2021 influenza season. The proportion of the population vaccinated for influenza varies by age, sex, race/ethnicity, education, rural/urban residence, and income. However, measures of healthcare access have not been adequately investigated as predictors of influenza vaccination. Using a large, statewide random sample, this study examined 5-year influenza vaccination among Arkansans by sociodemographic characteristics (age, sex, race/ethnicity, education, rural/urban residence), general vaccine hesitancy, and healthcare access (having a primary care provider, having health insurance, forgoing health care due to cost, and frequency of doctor checkups). Older age, being female, being Hispanic, having a bachelor's degree or higher, having a primary care provider, visiting a doctor for a checkup in the past two years, and lack of hesitancy towards vaccines were significant predictors of receiving influenza vaccination.

An experimental study of the effects of messaging strategies on vaccine acceptance and hesitancy among Black Americans

•

Acknowledging past medical harm led to more positive COVID-19 vaccine attitudes.

•

Presenting general information about the vaccine did not improve vaccine attitudes.

•

Tailored messaging strategies showed no backfire effects in other racial groups.

Black Americans have been disproportionately affected by COVID-19 but have comparatively low vaccination rates, creating a need for vaccine messaging strategies that are tailored to this population. We conducted an experimental study to examine the effects of three messaging strategies on Black Americans’ reported willingness to receive the vaccine and vaccine hesitancy. We also recruited White and Hispanic Americans to assess any potential backfire effects of the tailored strategies for non-Black participants. A total of 739 participants completed the study. Results from 4x2 ANCOVAs indicate that, among Black participants, messaging that acknowledged past unethical treatment of Black Americans in medical research and emphasized current safeguards to prevent medical mistreatment was associated with significantly less vaccine hesitancy than the control condition. The same effects were not observed for messaging strategies that provided general safety information about the vaccine or that emphasized the role of the vaccine in reducing racial inequities. There were no significant differences across conditions for participants of other races. Results demonstrate that public health messages tailored to address specific vaccine concerns may aid future vaccination campaigns.

Correlates of COVID-19 vaccination intentions: Attitudes, institutional trust, fear, conspiracy beliefs, and vaccine skepticism

Successful campaigns to combat the COVID-19 pandemic depend, in part, on people's willingness to be vaccinated. It is therefore critical to understand the factors that determine people's vaccination intentions. We applied a reasoned action approach - the theory of planned behavior - to explore these factors. We used data from an online survey of adults (18-74 years; n = 5044) conducted in Germany between April 9 and April 28, 2021 and found that attitudes toward getting vaccinated predicted vaccination intentions, while normative and control beliefs did not. In turn, positive attitudes toward getting vaccinated were supported by trust in science and fear of COVID-19 whereas negative attitudes were associated with acceptance of conspiracy theories and skepticism regarding vaccines in general. We advise policymakers, physicians, and health care providers to address vaccination hesitancy by emphasizing factors that support positive attitudes toward getting vaccinated, such as prevention of serious illness, death, and long-term health detriments, as opposed to exerting social pressure or pointing to the ease of getting vaccinated.

Correlates of influenza vaccination among underserved Latinx middle-aged and older adults: a cross-sectional survey

Background

Vaccination is a powerful tool in the fight against seasonal influenza, among underserved, middle-age and older, Latinx adults. Yet, vaccine hesitancy and inconsistent uptake in this population continues to represent a substantial challenge to public health. A better understanding of factors impacting influenza vaccination behaviors in this group could result in more effective messaging and initiatives promoting universal vaccination among Latinx.

Methods

In this cross-sectional survey, we explore correlates of influenza vaccination uptake among underserved, Latinx, older adults. Our focus was on the role of socio-demographics, living arrangements, financial strain, access and satisfaction with medical care, and the presence of major chronic conditions in terms of vaccine uptake. Middle-aged and older Latinx residents diagnosed with diabetes and/or hypertension (n=165), were recruited from the South Los Angeles Service Plan Area (SPA), a historically under-resourced community. Bi-variate and multi-variate logistical regression were performed on survey data to explore independent correlates of influenza vaccination.

Results

Almost half of underserved Latinx older adults in our study (45%) reported influenza vaccination within the 12 months prior to the study. The majority (~85%) reported receiving this recommendation from their primary care provider. However, thirty percent (30%) of those receiving this advice did not get the vaccine. A decreased likelihood of vaccination was significantly associated with living alone (p-value=0.026), lacking Medicare coverage (0.028), or higher levels of financial strain (0.020). Difficulty accessing medical care (p-value=0.008) or dissatisfaction with these experiences (p-value=0.001) were also strongly associated with decreased likelihood of vaccination. Participants diagnosed with COPD had 9.5 (CI: 1.76 – 51.3) higher odds of being vaccinated compared to those without; no correlation was detected for other chronic conditions.

Conclusion

The high number of unvaccinated Latinx participants receiving a vaccine recommendation from a provider is consistent with studies among other ethnic/racial minority older adults and highlights the pivotal role of the provider in influenza vaccine adoption. Additional findings reflect negative impact of Social Determinates of Health on preventive care efforts in this group. Further efforts to quantify these associations are needed to explore structural and human factors impacting influenza vaccine uptake.

Assessing influenza vaccination coverage and predictors in persons living with HIV/AIDS in Louisiana, June 2002-June 2013

Background

Despite the burden of disease and increased risk of influenza-associated morbidity and mortality among PLWHA, influenza vaccination has been understudied in this population.

Methods

We built an 11-year cohort of HIV-infected adults from medical records of PLWHA seeking care within the Louisiana State University medical system from June 2002-June 2013. Influenza vaccination uptake among PLWHA was calculated overall and for each medical facility for each influenza season. Linear regression was used to assess influenza vaccination uptake over time, both overall and by facility. Data were restricted to the final influenza season (2012-13) to assess predictors of PLWHA vaccination. Individuals were nested within medical facilities in order to assess the amount of variability in influenza vaccination rates across medical facilities.

Results

Influenza vaccination uptake among PLWHA increased over the study period (p < 0.01). The overall proportion of PLWHA vaccinated during the 2012-13 influenza season was 33.7%. 37.9% of the variability in the model occurred at the facility-level.

Conclusions

Although there was an increase in influenza vaccination within the PLWHA cohort over the course of the study, vaccination rates remained low overall. Special efforts must be made to increase vaccination uptake among PLWHA, with particular focus on those within the population who are likely to be at highest risk. The substantial variability at the facility-level indicates that there are unmeasured facility-level factors that contribute significantly to PLWHA vaccination.

Racial and Ethnic Disparities in Adult Vaccination: A Review of the State of Evidence

Background

Adult vaccination coverage remains low in the United States, particularly among racial and ethnic minority populations.

Objective

To conduct a comprehensive literature review of research studies assessing racial and ethnic disparities in adult vaccination.

Search Methods

We conducted a search of PubMed, Cochrane Library, ClinicalTrials.gov, and reference lists of relevant articles.

Selection Criteria

Research studies were eligible for inclusion if they met the following criteria: (1) study based in the United States, (2) evaluated receipt of routine immunizations in adult populations, (3) used within-study comparison of race/ethnic groups, and (4) eligible for at least one author-defined PICO (patient, intervention, comparison, and outcome) question.

Data Collection and Analysis

Preliminary abstract review was conducted by two authors. Following complete abstraction of articles using a standardized template, abstraction notes and determinations were reviewed by all authors; disagreements regarding article inclusion/exclusion were resolved by majority rule. The Social Ecological Model framework was used to complete a narrative review of observational studies to summarize factors associated with disparities; a systematic review was used to evaluate eligible intervention studies.

Results

Ninety-five studies were included in the final analysis and summarized qualitatively within two main topic areas: (1) factors associated with documented racial-ethnic disparities in adult vaccination and (2) interventions aimed to reduce disparities or to improve vaccination coverage among racial-ethnic minority groups. Of the 12 included intervention studies, only 3 studies provided direct evidence and were of Level II, fair quality; the remaining 9 studies met the criteria for indirect evidence (Level I or II, fair or poor quality).

Conclusions

A considerable amount of observational research evaluating factors associated with racial and ethnic disparities in adult vaccination is available. However, intervention studies aimed at reducing these disparities are limited, are of poor quality, and insufficiently address known reasons for low vaccination uptake among racial and ethnic minority adults.

County Social Vulnerability and Influenza Vaccine Rates: National and Local Estimates for Medicare Recipients

INTRODUCTION

Seasonal influenza vaccination among older adults is well below the recommendation of Healthy People 2020. Although geographic disparities in influenza vaccination are well documented, it remains unclear how community attributes correlate with influenza vaccination rates. Social vulnerability measures play an important role in interventions addressing vaccine equity; however, social vulnerability dimensions as corollaries of vaccination are poorly understood. To inform vaccine equity interventions, this analysis investigates spatially varying associations between county social vulnerability and influenza vaccination rate among Medicare recipients.

METHODS

County-level 2018 data (N=3,105) from the Centers for Disease Control and Prevention's Social Vulnerability Index were merged with the percentage of Medicare recipients vaccinated against influenza. Multilevel linear regression and geographically weighted regression generated global and local estimates, adjusted for potential confounders. Analyses were conducted in November 2020-April 2021.

RESULTS

A 10-percentile point increase in the overall Social Vulnerability Index was associated with an 0.87-point decrease in percentage vaccinated (p<0.001) with substantial variation by Social Vulnerability Index theme and geography. A 10-percentile point increase in socioeconomic vulnerability was associated with a 1.6-point decrease in vaccination (p<0.001) with stronger associations in higher Social Vulnerability Index quartiles and in parts of the Midwest, South, and coastal Northeast. Other Social Vulnerability Index themes had smaller associations with mixed directions: household composition and disability estimates were negative, whereas estimates for minority status and language and housing and transportation were positive.

CONCLUSIONS

Medicare recipients in socioeconomically vulnerable counties have low influenza vaccination rates, particularly in select regions of the country. Best practices to improve vaccine access and uptake should be targeted and should explicitly consider local socioeconomic vulnerability.

Influenza Vaccine Uptake and Missed Opportunities Among the Medicare-Covered Population With High-Risk Conditions During the 2018 to 2019 Influenza Season : A Retrospective Cohort Study

BACKGROUND

Seasonal influenza causes substantial morbidity and mortality among older U.S. adults and those with comorbid health conditions.

OBJECTIVE

To describe seasonal influenza vaccine uptake and identify factors associated with missed opportunities for influenza vaccination.

DESIGN

Retrospective cohort study.

SETTING

Medicare fee-for-service claims.

PARTICIPANTS

31.6 million U.S. adults continuously enrolled under Medicare Parts A and B during the 2018 to 2019 influenza season.

MEASUREMENTS

Influenza vaccine uptake and missed opportunities by patient demographic characteristics, high-risk status (that is, ≥1 condition increasing influenza complication risk), Medicare-Medicaid dual-eligibility status, and health care provider visits (that is, vaccination opportunities).

RESULTS

Overall, 50.5% of beneficiaries aged 19 years or older had Medicare claims for influenza vaccination: 31.6% among people aged 19 to 64 years and 54% among people aged 65 years or older. More White beneficiaries were vaccinated (52.9%) than Black (34.9%) or Hispanic (30.4%) beneficiaries. Uptake was higher (56.1%) for beneficiaries with high-risk conditions than for those without (27.6%). Among unvaccinated beneficiaries overall, 77.4% visited a provider during influenza season; among unvaccinated beneficiaries with and without high-risk conditions, 91% and 43%, respectively, had seen a provider at least once. The proportion of beneficiaries with missed opportunities for influenza vaccination was 44.2% and was higher for beneficiaries in the non-high-risk group (59.1%) than those in the high-risk group (42.2%). Uptake was lower and proportions of missed opportunities were higher among beneficiaries in younger age groups, of Black and Hispanic race/ethnicity, without high-risk conditions, or with Medicare-Medicaid dual eligibility.

LIMITATIONS

Influenza vaccinations without claims could not be captured. Data on reasons for nonvaccination were unavailable.

CONCLUSION

Influenza vaccination coverage for Medicare beneficiaries continues to be suboptimal, with missed opportunities despite availability of influenza vaccination with no copayment. Disparities persist in vaccination uptake by race/ethnicity.

PRIMARY FUNDING SOURCE

None.

Vaccination uptake amongst older adults from minority ethnic backgrounds: A systematic review

BACKGROUND

Older adults from minority ethnic backgrounds are at increased risk of contracting COVID-19 and developing severe infection and have increased risk of mortality. Whilst an age-based vaccination approach prioritising older groups is being implemented worldwide, vaccine hesitancy is high amongst minority ethnic groups.

METHODS AND FINDINGS

We conducted a systematic review and convergent synthesis to systematically examine perceptions of vaccinations amongst older adults from minority ethnic backgrounds. We included studies that reported on perceptions, beliefs, and attitudes towards vaccinations in older adults aged ≥65 years from a minority ethnic background. We excluded studies of vaccinations in investigation or development, studies focused on specific medical conditions, studies where ethnic background or age group was unidentifiable, systematic reviews, editorials, and conference abstracts. We searched MEDLINE, Embase, Virtual Health Library, Web of Science, Cochrane Library, medRxiv, and PROSPERO databases from inception to 15 July 2021. Risk of bias for studies was assessed using the Mixed Methods Appraisal Tool. The quality of evidence of collective outcomes was estimated using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework. A total of 28 eligible studies conducted between 1997 and 2020 were included in the final analysis (17 quantitative surveys, 8 focus group or interview studies, 2 mixed methods studies, and 1 case-control study). The majority were US studies in English or Spanish, except for 6 studies set in Hong Kong, 2 studies in Japan, 1 study in Brazil, and 1 multi-centre study (including China, Indonesia, Turkey, South Korea, Greece, UK, Brazil, and Nigeria). In total, 28,262 individuals with an estimated mean age of 69.8 years were included, 63.2% of whom were female. We summarised the common concepts and themes across studies and populations using a convergent synthesis analysis. Thirteen themes categorised as barriers or facilitators were identified and grouped into structural factors-healthcare provider and system related, patient related, and policy and operational-and were analysed by minority ethnic group. The main limitation of the study was the predominance of studies from the US and East Asia.

CONCLUSIONS

In this systematic review, we found that factors influencing vaccination uptake involve healthcare provider and system, patient-related, and governance-level factors that are specific to the older ethnic minority community being served. The evidence included in this review is supported by high or moderate certainty and can be translated to practice and policy. A tailored, multi-level approach combining increased education, access, and culturally competent discussions with trusted healthcare professionals to address health beliefs can maximise the potential impact of widespread vaccination policies.

Hepatitis B Vaccination Among Adults With Diabetes Mellitus, U.S., 2018

INTRODUCTION

Hepatitis B vaccination is routinely recommended for adults with diabetes mellitus aged <60 years and for those aged ≥60 years at the discretion of their healthcare provider. The purpose of this study is to assess hepatitis B vaccination coverage among adults with and without diabetes mellitus.

METHODS

Data from the 2014-2018 National Health Interview Survey were analyzed in 2020 to determine hepatitis B vaccination series completion (≥3 doses) among adults aged 18-59 and ≥60 years with diabetes mellitus. Multivariable logistic regression analysis was conducted to identify the factors independently associated with hepatitis B vaccination among adults aged 18-59 and ≥60 years with diabetes mellitus.

RESULTS

In 2018, among adults aged 18-59 years with diabetes mellitus, 33.2% had received hepatitis B vaccination (≥3 doses), an increase of 9.7 percentage points from 2014 (p<0.05). Among adults aged ≥60 years with diabetes mellitus, coverage was 15.3% in 2018 and did not increase during 2014-2018. Coverage was not significantly different among adults with diabetes mellitus compared with those without diabetes mellitus, even after controlling for the assessed factors. Among adults with diabetes mellitus aged 18-59 and ≥60 years, younger age, having some college or college education, having been tested for HIV, being healthcare personnel, or having traveled to hepatitis B virus-endemic areas were independently associated with an increased likelihood of vaccination.

CONCLUSIONS

Self-reported hepatitis B vaccination coverage among adults with diabetes mellitus remains suboptimal. Healthcare providers should assess patients' diabetes status, recommend and offer needed vaccinations to patients, or refer them to alternate sites for vaccination.

Racial/Ethnic and Socioeconomic Disparities in Adult Vaccination Coverage

INTRODUCTION

Adults from racial and ethnic minorities and low-income groups are disproportionately affected by vaccine-preventable diseases. The objective of this study is to examine the trends in adult vaccination coverage in the U.S. by race/ethnicity and SES from 2010 to 2019.

METHODS

Temporal trends in influenza; pneumococcal; herpes zoster; and tetanus, diphtheria, and acellular pertussis vaccination coverage were examined by race/ethnicity and SES in 2020 using the National Health Interview Surveys from 2010 to 2019.

RESULTS

Influenza vaccination coverage differed by race/ethnicity among adults aged ≥65 years (61.4% for Black, 63.9% for Hispanic, 71.9% for Asian, and 72.4% for White adults). Race/ethnicity, household income, education level, and health insurance type were significantly associated with receipt of influenza; pneumococcal; tetanus, diphtheria, and acellular pertussis; and zoster vaccinations among adults aged ≥65 years in a multivariable-adjusted regression model. Socioeconomic differences in influenza vaccine uptake narrowed among adults aged 18-64 years from 2010 to 2019. By contrast, racial/ethnic and socioeconomic differences in vaccine uptake persisted from 2010 to 2019 among adults aged ≥65 years.

CONCLUSIONS

Racial and ethnic disparities in vaccine uptake persisted over the last decade. Socioeconomic disparities in influenza vaccine coverage narrowed among adults aged 18-64 years; however, disparities persisted among adults aged ≥65 years. Efforts are urgently needed to achieve equity in immunization rates.

COVID-19 Vaccine Hesitancy Among Community-Dwelling Older Adults: The Role of Information Sources

Despite high enthusiasm surrounding the rollout of the COVID-19 vaccine, some older adults continue to remain hesitant about its receipt. There is limited evidence on vaccine hesitancy among community-dwelling older adults. In this study, we examine the prevalence and predictors (particularly the role played by information sources) of vaccine hesitancy in this group. We use the Medicare Current Beneficiary Survey and employ multivariable logistic regression models to explore this. Relative to those relying on regular news, those depending on health care providers (HCPs), social media, other internet/webpages, and family/friends as the main information source on COVID-19 expressed higher negative vaccine intent. The high negative intent with HCPs as the main information source should be interpreted with caution. This could be reflective of the timing of the survey and changing attitude toward the vaccine among HCPs themselves.

Determinants of Influenza Vaccine Uptake in Patients With Cardiovascular Disease and Strategies for Improvement

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Influenza infection is associated with an increased risk of cardiovascular events (myocardial infarction, stroke, and heart failure exacerbation) and mortality, and all‐cause mortality in patients with CVD. Infection with influenza leads to a systemic inflammatory and thrombogenic response in the host body, which further causes destabilization of atherosclerotic plaques. Influenza vaccination has been shown to be protective against cardiovascular and cerebrovascular events in several observational and prospective studies of at‐risk populations. Hence, many international guidelines recommend influenza vaccination for adults of all ages, especially for individuals with high‐risk conditions such as CVD. Despite these long‐standing recommendations, influenza vaccine uptake among US adults with CVD remains suboptimal. Specifically, vaccination uptake is strikingly low among patients aged <65 years, non‐Hispanic Black individuals, those without health insurance, and those with diminished access to healthcare services. Behavioral factors such as perceived vaccine efficacy, vaccine safety, and attitudes towards vaccination play an important role in vaccine acceptance at the individual and community levels. With the ongoing COVID‐19 pandemic, there is a potential threat of a concurrent epidemic with influenza. This would be devastating for vulnerable populations such as adults with CVD, further stressing the need for ensuring adequate influenza vaccination coverage. In this review, we describe a variety of strategies to improve the uptake of influenza vaccination in patients with CVD through improved understanding of key sociodemographic determinants and behaviors that are associated with vaccination, or the lack thereof. We further discuss the potential use of relevant strategies for COVID‐19 vaccine uptake among those with CVD.

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

PROBLEM/CONDITION

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

REPORTING PERIOD

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

DESCRIPTION OF SYSTEM

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

RESULTS

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

INTERPRETATION

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

PUBLIC HEALTH ACTIONS

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

Geographic Heterogeneity in Influenza and Pneumonia Mortality in Hispanic Americans

(1) Background: Influenza and pneumonia (IP) is a leading cause of death in the US. The hypothesis was tested that the mortality rate differential between Hispanic whites (HW) and non-Hispanic whites (NHW) from IP varied by geographic region in the US. (2) Methods: The CDC database for multiple causes of death between 1999-2018 was used for this study. For ages 25-84, age-adjusted mortality rates per 100,000 (AAMR) for IP were computed by Hispanic ethnicity in whites for 10 Health & Human Services (HHS) regions and for urbanization levels in HHS Region 2. (3) Results: AAMR for IP was 13.76 (13.62-13.9) in HW and 14.91 (14.86-14.95) in NHW (rate ratio 1.08). Among HHS regions, rates were generally lower in HW than in NHW with the major exception of HHS Region 2. The rate there was 21.78 (21.24-22.33) in HW, 36.5% greater (p < 0.05) than that in NHW of 15.71 (15.56-15.86). In large central metro areas of Region 2, the rate was 27.10 (26.36-27.83) in HW compared to 19.78 (19.47-20.09) in NHW. (4) Conclusion: The difference in AAMR from IP between HW and NHW varied by region and urbanization with much higher rates for HW than NHW only in metropolitan areas of New York and New Jersey.

Perspectives on the receipt of a COVID-19 vaccine: A survey of employees in two large hospitals in Philadelphia

BACKGROUND

Health care personnel have been identified by the ACIP as a priority group for COVID-19 vaccination. We conducted a survey in November-December 2020 at two large, academic hospitals in Philadelphia to evaluate the intention of hospital employees to be vaccinated.

METHODS

The survey was sent electronically to all employees (clinical and nonclinical staff) at a children's hospital and an adult hospital. The survey was voluntary and confidential. Questions focused on plans to receive a COVID-19 vaccine when available, reasons why employees would/would not get vaccinated, when employees planned to be vaccinated, vaccine safety and efficacy features that would be acceptable, and past history of receipt of other vaccines by the employee and family. Responses were analyzed using univariate and multiple logistic regression methods.

RESULTS

A total of 12,034 hospital employees completed the survey (a 34.5% response rate). Overall, 63.7% of employees reported that they planned to receive a COVID-19 vaccine, 26.3% were unsure, and 10.0% did not plan to be vaccinated. Over 80% of those unsure or unwilling to be vaccinated expressed concerns about vaccine side effects and the vaccines' newness. In multivariable logistic regression, persons planning to take a COVID-19 vaccine were more likely to be older, male, more educated, Asian or White, up-to-date on vaccinations, without direct patient contact, and tested for COVID-19 in the past. No significant difference in intention to be vaccinated was found between those with higher versus lower levels of exposure to COVID-19 patients or the number of previous exposures to patients with COVID-19.

CONCLUSIONS

While the majority of hospital employees are planning to receive a COVID-19 vaccine, many are unsure or not planning to do so. Further education of hospital employees about the safety, efficacy, and value of the currently available COVID-19 vaccines is critical to vaccine acceptance in this population.

Public Insurance Status Negatively Affects Access to Care in Pediatric Patients With Meniscal Injury

Background:

Non- and underinsured individuals experience poor access to care and treatment delays. Meniscal injury is a common reason for surgical intervention in the pediatric population, and delays in care can lead to progression of the tear and other associated problems.

Purpose:

To investigate the impact of insurance status on access to care and severity of meniscal injury in the pediatric population.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Enrolled in this study were 49 patients receiving care for a meniscal injury between 2016 and 2018 from a safety-net medical system that does not prioritize patients based on insurance status. The patients were stratified into those publicly insured and those privately insured. Access to care was measured as wait time to various points of care: initial injury to clinic, injury to magnetic resonance imaging (MRI), injury to surgery, clinic to MRI, clinic to surgery, and MRI to surgery. The severity of the meniscal tear was measured by findings at the time of arthroscopy, including the type of tear identified, surgery performed, and cartilage injury.

Results:

Publicly insured patients waited a mean 230 days longer (347 vs 117 days; P < .01) to undergo surgery after injury compared with privately insured patients. The mean wait times in all categories except time from MRI to surgery were significantly longer for publicly insured patients, including injury to clinic (212 vs 73 days; P < .01), injury to MRI (260 vs 28 days; P < .001), injury to surgery (347 vs 117 days; P < .01), clinic to MRI (36 vs 3.9 days; P < .001), and clinic to surgery (136 vs 44 days; P < .01). Neither increased wait times nor insurance status were associated with greater surgical repair rate, severe tear type, or cartilage injury.

Conclusion:

Publicly insured pediatric patients waited significantly longer for a diagnosis of meniscal tear compared with privately insured patients, even in a safety-net setting. These delays were not associated with greater tear severity or cartilage changes. Providers in all models of care should recognize that insurance status and the socioeconomic factors it represents prevent publicly insured patients from timely diagnostic points of care and strive to minimize the resulting delayed return to normal activity as well as the potential long-term clinical effects thereof.

Geographic Variation in Racial Disparities in Mortality From Influenza and Pneumonia in the United States in the Pre-Coronavirus Disease 2019 Era

BACKGROUND

In 2018, influenza and pneumonia was the eighth leading cause of death in the United States. Since 1950, non-Hispanic blacks (NHBs) have experienced higher rates of mortality than non-Hispanic whites (NHWs). Previous studies have revealed geographic variation in mortality rates by race. The identification of areas with the greatest disparity in influenza and pneumonia mortality may assist policymakers in the allocation of resources, including for the coronavirus disease 2019 pandemic.

RESEARCH QUESTION

Does geographic variation in racial disparity in influenza and pneumonia mortality exist?

STUDY DESIGN AND METHODS

The Centers for Disease Control and Prevention database for Multiple Cause of Death between 1999 and 2018 for NHB and NHW decedents ≥ 25 years of age with a Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems code for influenza (J09-J11) and pneumonia (J12-J18) was used. Age-adjusted mortality rates (AAMRs) with 95% CIs were computed by race for Health & Human Services (HHS) regions and urbanization in NHBs and NHWs.

RESULTS

In 1999 through 2018, there were 540,476 deaths among NHBs and NHWs 25 to 84 years of age. AAMRs were higher in NHBs than NHWs in each age group and in seven of 10 HHS regions. The greatest disparity was in HHS regions 2 (New York and New Jersey) and 9 (Arizona, California, Hawaii, and Nevada). In HHS region 2, NHBs (24.6; 95% CI, 24.1-25.1) were more likely to die than NHWs (15.7; 95% CI, 15.6-15.9). Similarly, in region 9, NHBs (23.2; 95% CI, 22.7-23.8) had higher mortality than NHWs (16.1; 95% CI, 15.9-16.2). Within these regions, disparities were greatest in the core of major metropolitan areas. A very high AAMR in NHBs was noted in large, central metropolitan areas of region 2: 28.2 (95% CI, 27.6-28.9).

INTERPRETATION

In 1999 through 2018, the NHB-NHW disparity in AAMRs from influenza and pneumonia was greatest in central metropolitan areas of HHS regions 2 and 9.

Influenza Vaccination among Underserved African-American Older Adults

BACKGROUND

Racial disparities in influenza vaccination among underserved minority older adults are a public health problem. Understanding the factors that impact influenza vaccination behaviors among underserved older African-Americans could lead to more effective communication and delivery strategies.

AIMS

We aimed to investigate rate and factors associated with seasonal influenza vaccination among underserved African-American older adults. We were particularly interested in the roles of demographic factors, socioeconomic status, and continuity and patient satisfaction with medical care, as well as physical and mental health status.

METHODS

This community-based cross-sectional study recruited 620 African-American older adults residing in South Los Angeles, one of the most under-resources areas within Los Angeles County, with a population of over one million. Bivariate and multiple regression analyses were performed to document independent correlates of influenza vaccination.

RESULTS

One out of three underserved African-American older adults aged 65 years and older residing in South Los Angeles had never been vaccinated against the influenza. Only 49% of participants reported being vaccinated within the 12 months prior to the interview. One out of five participants admitted that their health care provider recommended influenza vaccination. However, only 45% followed their provider's recommendations. Multivariate logistic regression shows that old-old (≥75 years), participants who lived alone, those with a lower level of continuity of care and satisfaction with the accessibility, availability, and quality of care, and participants with a higher number of depression symptoms were less likely to be vaccinated. As expected, participants who indicated that their physician had advised them to obtain a flu vaccination were more likely to be vaccinated. Our data shows that only gender was associated with self-report of being advised to have a flu shot. Discussion. One of the most striking aspects of this study is that no association between influenza vaccination and being diagnosed with chronic obstructive pulmonary disease or other major chronic condition was detected. Our study confirmed that both continuity of care and satisfaction with access, availability, and quality of medical care are strongly associated with current influenza vaccinations. We documented that participants with a higher number of depression symptoms were less likely to be vaccinated.

CONCLUSION

These findings highlight the role that culturally acceptable and accessible usual source of care van play as a gatekeeper to facilitate and implement flu vaccination among underserved minority older adults. Consistent disparities in influenza vaccine uptake among underserved African-American older adults, coupled with a disproportionate burden of chronic diseases, places them at high risk for undesired outcomes associated with influenza. As depression is more chronic/disabling and is less likely to be treated in African-Americans, there is a need to screen and treat depression as a strategy to enhance preventive care management such as vaccination of underserved African-American older adults. Quantification of associations between lower vaccine uptake and both depression symptoms as well as living alone should enable health professionals target underserved African-American older adults who are isolated and suffer from depression to reduce vaccine-related inequalities.

Physicians' Use of Evidence-Based Strategies to Increase Adult Vaccination Uptake

INTRODUCTION

This study assesses the following among primary care physicians: (1) the use of evidence-based strategies to improve adult vaccination rates, (2) the number of strategies employed simultaneously, and (3) characteristics associated with assessing adult vaccinations at each visit.

METHODS

An internet and mail survey was administered between December 2015 and January 2016 on primary care physicians designed to be representative of the American College of Physicians and American Academy of Family Physicians memberships. Data analysis was conducted in 2019.

RESULTS

The response rate was 66% (617 of 935); 94% reported using electronic health records. Standing orders (84%) and electronic provider reminders at a visit (61%) were the most common strategies reported for influenza vaccine. Electronic provider reminders at a visit (53%) and recording a vaccination in an immunization registry (32%) were the most common strategies reported for all noninfluenza vaccines. Most physicians reported using 2 or more strategies, although this was more common for influenza (74%) than for noninfluenza (62%) vaccines. In multivariable analysis, physicians who reported assessing adult vaccinations at every patient visit were more likely to work in practices where decisions about purchasing and handling vaccines were made at a larger system level (RR=1.20, 95% CI=1.04,1.40), and they reported using electronic provider reminders (RR=1.38, 95% CI=1.15, 1.69) and standing orders (RR=1.45, 95% CI=1.21, 1.75) for all noninfluenza adult vaccines.

CONCLUSIONS

Several strategies are being used to increase adult vaccination, particularly for the influenza vaccine. Investment in implementing standing orders and electronic clinical decision support for all routine adult vaccinations could help facilitate assessment of adult vaccinations at each visit and potentially improve adult vaccination rates.

Prevalence and predictors of influenza vaccination among residents of long-term care facilities

Influenza is a respiratory illness which results in significant morbidity and mortality, especially in the older population. Older people living in Long-Term Care Facilities (LTCFs) have a significantly higher risk of infection and complications from influenza. Influenza vaccine is considered the best strategy to prevent infection in high-risk populations. In Australia, the Communicable Diseases Network Australia (CNDA) suggests a vaccination coverage rate of 95% in both staff and residents¹. This study aims to measure the vaccination coverage rates for residents in LTCFs and identify predictors of vaccination uptake for these individuals. This study was conducted in nine LTCFs in four sites from March to September 2018. This was done via medical record reviews for residents over 65 years old in these LTCFs, collecting information such as vaccination status, age, gender, ethnicity and occupation. Simple and multivariable logistic regression was used to calculate the Odds Ratio (OR) to determine significant predictors of influenza vaccination uptake. The overall vaccination rate among LTCF residents was 83.6%. Significant predictors of vaccination were LTCF location, ethnicity and previous year vaccination status. Residents in LTCF Site D were less likely to be vaccinated compared to Site A (OR 0.11, 95% CI 0.02-0.61), non-Caucasians were less likely to get vaccinated (OR 0.09, 95% CI 0.01-0.67), and residents who refused the 2017 vaccine were less likely to be vaccinated (OR 0.04, 95% CI 0.01-0.15). Compared with previous Australian studies on LTCF vaccination rates, the overall vaccination rate was high in these LTCFs (83.6% versus 66-84%), but it varied across different sites. Reasons for varying vaccination rates should be explored further - for example, lower rates in non-Caucasians with diverse cultural backgrounds. Better understanding the causes of under-vaccination can help improve vaccination programs in LTCFs.

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.

The role of provider characteristics on the hepatitis A and B vaccination status of adults in the United States during 2007-2015

Hepatitis A and B vaccine coverage is suboptimal in US adults, even among those at increased risk for infection, morbidity, or mortality. To understand where medical education and resources might enhance vaccine coverage, it is important to first identify providers and places most commonly associated with the administration of hepatitis vaccinations.

We conducted a retrospective analysis of commercial and Medicare insurance claims data from 2007 to 2015 to describe provider types and places of vaccination against hepatitis A and B among adults in the US, and estimated the time to initial vaccination from first diagnosis of a condition for which the Advisory Committee on Immunization Practices (ACIP) recommends hepatitis A and/or B vaccination among at-risk adults. We identified 183,326 adults who received hepatitis A vaccine, 148,119 hepatitis B vaccine, and 64,953 a bivalent vaccine. Mean age was 42.1–45.8 years. Family practice and internal medicine physicians were the main vaccine providers: 38.9% and 20.2% for hepatitis A, 43.7% and 21.4% for hepatitis B, 35.3% and 15.9% for bivalent vaccinations, respectively. ≥90% of initial vaccinations occurred in an office practice. In at-risk patients, median time to first-dose received was 11.8, 20.9, and 20.9 months for hepatitis A, hepatitis B, and hepatitis A/B vaccines, respectively.

Primary care and office practices were the most common providers and places of vaccination, respectively, for hepatitis A and B vaccine. For at-risk patients, further research is needed to design vaccination strategies to improve the median time from first ACIP-recommended condition diagnosis to initial vaccination against hepatitis A and B.

•

Most frequent provider type for hepatitis vaccination is primary care providers.

•

Physician offices are the most frequent site for hepatitis vaccinations.

•

Time to initial hepatitis vaccination from first at-risk diagnosis needs improvement.

Disparities in uptake of 13-valent pneumococcal conjugate vaccine among older adults in the United States

BACKGROUND

In September 2014, 13-valent pneumococcal conjugate vaccine (PCV13) was universally recommended for all US adults aged ≥65 years. Adult PCV13 coverage, including whether disparities in uptake exist, however, is not well-described.

METHODS

We used a monthly series of cross-sectional analyses of administrative medical and prescription claims data collected by IQVIA and linked to sociodemographic data collected by Experian to estimate overall and subpopulation-level uptake of PCV13 among US adults aged ≥65 years.

RESULTS

Among adults aged ≥65 years, 43.3% received PCV13 by the end of November 2017. Race/ethnicity, annual household income, education status, and neighborhood urbanicity were strongly related to PCV13 uptake among adults aged ≥65 years. Lower uptake of PCV13 was observed for non-Hispanic black (36.3%) and Hispanic (30.0%) adults (vs 45.6% for non-Hispanic whites, P < .01), the poor (30.7% vs 54.2% among lowest vs highest income deciles, P < .01), adults with low educational status (33.0% vs 49.0% among those without high school education vs college educated, P < .01), and those living in rural communities (22.9%) or urban/inner-city (33.8%) areas (vs 45.8% in suburban areas, P < .01).

CONCLUSIONS

PCV13 uptake among adults aged ≥65 occurred rapidly in the three years after universal recommendation in September 2014. Yet, poor and minority communities, rural and urban/inner-city areas, and communities with low educational attainment had substantially lower PCV13 coverage. These same populations are at increased risk of pneumococcal disease. In order to maximize the benefits of pneumococcal vaccination, further targeted and tailored interventions to increase PCV13 uptake in these underserved populations are still necessary.

Primary care physicians' perspectives on respiratory syncytial virus (RSV) disease in adults and a potential RSV vaccine for adults

BACKGROUND

Deaths attributable to respiratory syncytial virus (RSV) among adults are estimated to exceed 11,000 annually, and annual adult hospitalizations for influenza and RSV may be comparable. RSV vaccines for older adults are in development. We assessed the following among primary care physicians (PCPs) who treat adults: (1) perception of RSV disease burden; (2) current RSV testing practices; and (3) anticipated barriers to adoption of an RSV vaccine.

METHODS

We administered an Internet and mail survey from February to March 2017 to national networks of 930 PCPs.

RESULTS

The response rate was 67% (620/930). Forty-nine percent of respondents (n = 303) were excluded from analysis as they reported never or rarely caring for an adult patient with possible RSV in the past year. Among respondents who reported taking care of RSV patients (n = 317), 73% and 57% responded that in patients ≥ 50 years, influenza is generally more severe than RSV and that they rarely consider RSV as a potential pathogen, respectively. Most (61%) agreed that they do not test for RSV because there is no treatment. The most commonly reported anticipated barriers to a RSV vaccine were potential out-of-pocket expenses for patients if the vaccine is not covered by insurance (93%) and lack of reimbursement for vaccination (74%).

CONCLUSIONS

Physicians reported little experience with RSV disease in adults. They are generally not testing for it and the majority believe that influenza disease is more severe. Physicians will require more information about RSV disease burden in adults and the potential need for a vaccine in their adult patients.

The effects of vaccination forecasts and value-based payment on adult immunizations by community pharmacists

BACKGROUND

The prevalence of vaccine-preventable diseases in adults remains a significant public health issue in the United States. The objectives of this demonstration project were to increase the number of influenza, pneumococcal, pertussis, and herpes zoster immunizations administered to adults by community pharmacists, evaluate the percentage of immunizations documented in the state immunization information system (IIS), and design and pilot a value-based payment model.

METHODS

A one-year prospective, observational demonstration project was conducted in 70 community pharmacies in western Washington State from September 1, 2016 to August 31, 2017. An immunization interface was integrated into workflow at each pharmacy to enable "forecasting" of and proactive recommendation to patients about their vaccine needs and documentation of vaccines administered in the state IIS. Categorical value-based payment models were developed and implemented in a subgroup of 12 community pharmacies from March 1 to November 30, 2017. The change in the number of immunizations administered in comparison to the baseline period and the percentage of immunizations documented in the state IIS during the demonstration period were analyzed using descriptive statistics.

RESULTS

There was a 15% total increase in the collective number of influenza, pneumococcal, pertussis, and herpes zoster vaccines administered in the demonstration year in the 70 pharmacies, due to increases in influenza and pertussis vaccinations. Eighty-three percent of the vaccines administered were documented in the state IIS. Pneumococcal, pertussis, and herpes zoster performance appeared to be unaffected by the value-based payment models while influenza performance improved across the 12 pilot pharmacies.

CONCLUSIONS

This work demonstrated that community pharmacists contribute to improving adult immunizations through vaccine "forecasting" and proactive recommendation. Meaningful quality measures with both positive and negative incentives could further drive adoption of best immunization practices. Further implementation and outcomes research is needed to fully examine the impact and scalability of these strategies.

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.

Relationship between patient copayments in Medicare Part D and vaccination claim status for herpes zoster and tetanus-diphtheria-acellular pertussis

OBJECTIVE

To assess the relationship between copay amount and vaccination claim submission status for tetanus-diphtheria-acellular pertussis (Tdap) and herpes zoster (GSK study identifier: HO-14-14319).

METHODS

Retrospective analyses were performed using vaccination administrative claims data in patients aged ≥65 years with ≥1 claim for Tdap or zoster vaccines between 2012 and 2014. To avoid confounding by other financial responsibility, analyses were conducted among patients in the copayment phase of insurance. The impact of patient copay amount on vaccination claim status ("canceled" vs. "paid") was evaluated by logistic regression separately for Tdap and zoster, adjusting for patient and provider characteristics.

RESULTS

A total of 81,027 (39.2% with canceled claims) and 346,417 patients (56.8% with canceled claims) were included in the Tdap and zoster analyses, respectively. Mean (standard deviation) copay for canceled vs. paid claims was $37.2 (18.4) vs. $31.1 (20.1) for Tdap and $64.9 (36.9) vs. $53.5 (38.8) for zoster. The adjusted odds ratios (ORs) for a canceled Tdap vaccine claim, compared with $0 copay, were 1.19 ($1-25 copay), 1.76 ($26-50 copay), 2.42 ($51-75 copay) and 2.40 ($76-100 copay), all p < .001. The adjusted ORs for a canceled zoster vaccine claim, compared with $0 copay, were 1.02 ($1-25), 1.39 ($26-50), 1.66 ($51-75), 2.07 ($76-100) and 2.71 (>$100), all p < .001 except for $1-25 (p = .172).

CONCLUSIONS

High patient copay is a barrier to Tdap and zoster vaccinations in Medicare Part D patients. Providing vaccines at low or no copay may improve vaccination rates in these adults. GSK study identifier: HO-14-14319.

Association between provider recommendation and influenza vaccination status among children

BACKGROUND

Provider recommendation is associated with influenza vaccination receipt. The objectives of this study were to estimate the percentage of children 6 months-17 years for whom a provider recommendation for influenza vaccination was received, identify factors associated with receipt of provider recommendation, and evaluate the association between provider recommendation and influenza vaccination status among children.

METHODS

National Immunization Survey-Flu (NIS-Flu) parentally reported data for the 2013-14, 2014-15, and 2015-16 seasons were analyzed. Tests of association between provider recommendation and demographic characteristics were conducted using Wald chi-square tests and pairwise comparison t-tests. Multivariable logistic regression was used to determine variables independently associated with receiving provider recommendation and the association between provider recommendation and influenza vaccination status.

RESULTS

Approximately 70% of children had a parent report receiving a provider recommendation for influenza vaccination for their child. The strongest association between receipt of provider recommendation and demographic characteristics was with child's age, with younger children (6-23 months, 2-4 years, and 5-12 years) being more likely to have a provider recommendation than older children (13-17 years). In addition, children living in a household above poverty with household income >$75,000 were more likely to have a parent report receipt of a provider recommendation than children living below poverty. Children with a provider recommendation were twice as likely to be vaccinated than those without.

CONCLUSIONS

This study affirms the importance of provider recommendation for influenza vaccination among children. Ensuring that parents of all children receive a provider recommendation may improve vaccination coverage.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

Hepatitis B vaccination coverage among adults aged ≥18 years traveling to a country of high or intermediate endemicity, United States, 2015

BACKGROUND

Persons from the United States who travel to developing countries are at substantial risk for hepatitis B virus (HBV) infection. Hepatitis B vaccine has been recommended for adults at increased risk for infection, including travelers to high or intermediate hepatitis B endemic countries.

PURPOSE

To assess hepatitis B vaccination coverage among adults ≥18 years traveling to a country of high or intermediate endemicity from the United States.

METHODS

Data from the 2015 National Health Interview Survey (NHIS) were analyzed to determine hepatitis B vaccination coverage (≥1 dose) and series completion (≥3 doses) among persons aged ≥18 years who reported traveling to a country of high or intermediate hepatitis B endemicity. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with hepatitis B vaccination.

RESULTS

In 2015, hepatitis B vaccination coverage (≥1 dose) among adults aged ≥18 years who reported traveling to high or intermediate hepatitis B endemic countries was 38.6%, significantly higher compared with 25.9% among non-travelers. Series completion (≥3 doses) was 31.7% and 21.2%, respectively (P < 0.05). On multivariable analysis among all respondents, travel status was significantly associated with hepatitis B vaccination coverage and series completion. Other characteristics independently associated with vaccination (≥1 dose, and ≥3 doses) among travelers included age, race/ethnicity, educational level, duration of US residence, number of physician contacts in the past year, status of ever being tested for HIV, and healthcare personnel status.

CONCLUSIONS

Although travel to a country of high or intermediate hepatitis B endemicity was associated with higher likelihood of hepatitis B vaccination, hepatitis B vaccination coverage was low among adult travelers to these areas. Healthcare providers should ask their patients about travel plans and recommend and offer travel related vaccinations to their patients or refer them to alternate sites for vaccination.

Hepatitis B vaccination coverage among adults aged ≥ 18 years traveling to a country of high or intermediate endemicity, United States, 2015

BACKGROUND

Persons from the United States who travel to developing countries are at substantial risk for hepatitis B virus (HBV) infection. Hepatitis B vaccine has been recommended for adults at increased risk for infection, including travelers to high or intermediate hepatitis B endemic countries.

PURPOSE

To assess hepatitis B vaccination coverage among adults ≥ 18 years traveling to a country of high or intermediate endemicity from the United States.

METHODS

Data from the 2015 National Health Interview Survey (NHIS) were analyzed to determine hepatitis B vaccination coverage (≥1 dose) and series completion (≥3 doses) among persons aged ≥ 18 years who reported traveling to a country of high or intermediate hepatitis B endemicity. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with hepatitis B vaccination.

RESULTS

In 2015, hepatitis B vaccination coverage (≥1 dose) among adults aged ≥ 18 years who reported traveling to high or intermediate hepatitis B endemic countries was 38.6%, significantly higher compared with 25.9% among non-travelers. Series completion (≥3 doses) was 31.7% and 21.2%, respectively (P < 0.05). On multivariable analysis among all respondents, travel status was significantly associated with hepatitis B vaccination coverage and series completion. Other characteristics independently associated with vaccination (≥1 dose, and ≥ 3 doses) among travelers included age, race/ethnicity, educational level, duration of U.S. residence, number of physician contacts in the past year, status of ever being tested for HIV, and healthcare personnel status.

CONCLUSIONS

Although travel to a country of high or intermediate hepatitis B endemicity was associated with higher likelihood of hepatitis B vaccination, hepatitis B vaccination coverage was low among adult travelers to these areas. Healthcare providers should ask their patients about travel plans and recommend and offer travel related vaccinations to their patients or refer them to alternate sites for vaccination.

The relative burden of community-acquired pneumonia hospitalizations in older adults: a retrospective observational study in the United States

Background

The risk of community-acquired pneumonia (CAP) increases with age and significantly impacts morbidity and mortality in the elderly population. The burden of illness and cost of preventing CAP has not been compared to other serious diseases.

Methods

This retrospective analysis used claims data from 2014 to 2015 and compared hospitalizations for CAP, myocardial infarction (MI), stroke, and osteoporotic fractures (OF) in adults aged ≥65 years enrolled in a Medicare Advantage insurance plan. Individuals who had not already been hospitalized for one of these conditions and did not have evidence of long-term care were included in the study. Hospitalizations for each condition were described by length of stay, readmissions, mortality, and total costs. Preventive measures included vaccinations for CAP and medications for MI, stroke, and OF.

Results

A total of 1,949,352 individuals were included in the cohort. In 2015, the rate of CAP-related hospitalizations was the highest at 846.7 per 100,000 person-years compared to 405 for MI, 278.9 for stroke, and 343.9 for OF. Vaccination costs for CAP were $40.2 million including $14.1 million for pneumococcal and $26.1 million for influenza vaccines. The cost of preventive medications for MI and stroke reached over $661 million and OF totaled $169 million.

Conclusions

Although CAP has a higher burden of hospitalization and total costs than MI, stroke, and OF in the elderly population, prevention efforts were disproportionately smaller for CAP. Prioritization of CAP prevention is needed to substantially reduce the burden of CAP.

Factors influencing seasonal influenza vaccination behaviour among elderly people: a systematic review

OBJECTIVES

To explore the behaviour-related factors influencing influenza vaccination among elderly people using a framework derived from the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA).

STUDY DESIGN

Systematic review.

METHODS

Five databases were searched using predetermined strategies in March 2016, and 1927 citations were identified. Articles were selected according to inclusion and exclusion criteria. Key information was extracted from selected studies using a predesigned sheet. Both authors assessed study quality using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) or Critical Appraisal Skills Programme (CASP) checklist.

RESULTS

Thirty-six articles were selected. A new framework was proposed that contributes to shared understanding of factors influencing health behaviour. Possible determinants of influenza vaccination among elderly people were knowledge, health promotion factors, all constructs of the HBM, and some concepts of the TRA. Key factors were threat perception, behavioural beliefs, subjective norms, recommendations, past behaviour and perceived barriers.

CONCLUSIONS

This is the first systematic review to analyse the factors influencing influenza vaccination behaviour of elderly people using a framework integrating the HBM and the TRA. The framework identified key factors of influenza vaccination and presented the inter-relation of behaviour-related variables. However, further well-designed studies are required to explore the inter-relationships accurately and comprehensively.

Evaluation of the Impact of an Innovative Immunization Practice Model Designed to Improve Population Health: Results of the Project IMPACT Immunizations Pilot

The goal of the initiative was to evaluate the impact of an innovative practice model on identification of unmet vaccination needs and vaccination rates. This was accomplished through a prospective, multisite, observational study in 8 community pharmacy practices with adults receiving an influenza vaccine with a documented vaccination forecast review from October 22, 2015 through March 22, 2016. When patients presented for influenza vaccinations, pharmacists utilized immunization information systems (IIS) data at the point of care to identify unmet vaccination needs, educate patients, and improve vaccination rates. The main outcome measures were the number of vaccination forecast reviews, patients educated, unmet vaccination needs identified and resolved, and vaccines administered. Pharmacists reviewed vaccination forecasts generated by clinical decision-support technology based on patient information documented in the IIS for 1080 patients receiving influenza vaccinations. The vaccination forecasts predicted there were 1566 additional vaccinations due at the time patients were receiving the influenza vaccine. Pharmacist assessments identified 36 contraindications and 196 potential duplications, leaving a net of 1334 unmet vaccination needs eligible for vaccination. In all, 447 of the 1334 unmet vaccinations needs were resolved during the 6-month study period, and the remainder of patients received information about their vaccination needs and recommendations to follow up for their vaccinations. Integration of streamlined principle-centered processes of care in immunization practices that allow pharmacists to utilize actionable point-of-care data resulted in identification of unmet vaccination needs, education of patients about their vaccination needs, a 41.4% increase in the number of vaccines administered, and significant improvements in routinely recommended adult vaccination rates.

Association of provider recommendation and offer and influenza vaccination among adults aged ≥18 years - United States

BACKGROUND

Influenza vaccination has been recommended for all persons aged ≥6 months since 2010.

METHODS

Data from the 2016 National Internet Flu Survey were analyzed to assess provider vaccination recommendations and early influenza vaccination during the 2016-17 season among adults aged ≥18 years. Predictive marginals from a multivariable logistic regression model were used to identify factors independently associated with early vaccine uptake by provider vaccination recommendation status.

RESULTS

Overall, 24.0% visited a provider who both recommended and offered influenza vaccination, 9.0% visited a provider who only recommended but did not offer, 25.1% visited a provider who neither recommended nor offered, and 41.9% did not visit a doctor from July 1 through date of interview. Adults who reported that a provider both recommended and offered vaccine had significantly higher vaccination coverage (66.6%) compared with those who reported that a provider only recommended but did not offer (48.4%), those who neither received recommendation nor offer (32.0%), and those who did not visit a doctor during the vaccination period (28.8%). Results of multivariable logistic regression indicated that having received a provider recommendation, with or without an offer for vaccination, was significantly associated with higher vaccination coverage after controlling for demographic and access-to-care factors.

CONCLUSIONS

Provider recommendation was significantly associated with influenza vaccination. However, overall, 67.0% of adults did not visit a doctor during the vaccination period or did visit a doctor but did not receive a provider recommendation. Evidence-based strategies such as client reminder/recall, standing orders, provider reminders, or health systems interventions in combination should be undertaken to improve provider recommendation and influenza vaccination coverage. Other factors significantly associated with a higher level of influenza vaccination included age ≥50 years, being Hispanic, having a college or higher education, having a usual place for medical care, and having public health insurance.

Primary Care Physicians' Struggle with Current Adult Pneumococcal Vaccine Recommendations

INTRODUCTION

In 2012, the Advisory Committee on Immunization Practices recommended 13-valent pneumococcal conjugate vaccine (PCV13) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) for at-risk adults ≥19; in 2014, it expanded this recommendation to adults ≥65. Primary care physicians' practice, knowledge, attitudes, and beliefs regarding these recommendations are unknown.

METHODS

Primary care physicians throughout the U.S. were surveyed by E-mail and post from December 2015 to January 2016.

RESULTS

Response rate was 66% (617 of 935). Over 95% of respondents reported routinely assessing adults' vaccination status and recommending both vaccines. A majority found the current recommendations to be clear (50% "very clear," 38% "somewhat clear"). Twenty percent found the upfront cost of purchasing PCV13, lack of insurance coverage, inadequate reimbursement, and difficulty determining vaccination history to be "major barriers" to giving these vaccines. Knowledge of recommendations varied, with 83% identifying the PCV13 recommendation for adults ≥65 and only 21% identifying the recommended interval between PCV13 and PPSV23 in an individual <65 at increased risk.

CONCLUSIONS

Almost all surveyed physicians reported recommending both pneumococcal vaccines, but a disconnect seems to exist between perceived clarity and knowledge of the recommendations. Optimal implementation of these recommendations will require addressing knowledge gaps and reported barriers.

Attitudes about adult vaccines and reminder/recall in a safety net population

Little is known about adult patients' attitudes toward vaccination and preferences for reminder/recall. The objective of this study was to determine patient perspectives on adult vaccines generally; attitudes about Tdap, pneumococcal polysaccharide (PPSV-23), and seasonal influenza vaccines specifically; and preferences for adult reminder/recall delivery. Twelve focus groups were conducted with 68 patients in a safety net health system. The sample was stratified by preferred language (English or Spanish), age (18-64 or 65+), and health status (with or without chronic conditions). Participants expressed positive attitudes toward vaccines generally, but had little knowledge of specific vaccines other than influenza, about which they expressed concerns. Although none reported previous experience receiving reminder/recall notices for adult vaccines, all were in favor of receiving them. These results suggest potential patient interest in greater adoption of evidence-based methods to improve immunization rates, and highlight the need for improved communication between providers and patients about adult vaccines.