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

Interventions in primary care to increase uptake of adult vaccines: a systematic review

BACKGROUND

There is a significant gap in understanding which strategies effectively enhance vaccination rates for recommended adult vaccines in primary care settings. This review aimed to identify interventions in outpatient clinics that increase vaccination rates for commonly recommended adult vaccines and describe the change in vaccination rate associated with each intervention aimed at increasing vaccination rates in adults.

METHODS

Systematic searches identified randomized, controlled trials aiming to increase the rate of vaccination in adults in outpatient clinics. Following PRISMA guidelines, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Two reviewers independently extracted relevant data and assessed risk of bias. Meta-analysis was not done due to heterogeneity of data.

RESULTS

Forty-four RCTs met inclusion criteria. Clinician reminders to order vaccine increased vaccination 4%-32%. Electronic health record (EHR) prompts to patients or physicians increased vaccination 1%-16%. Bundled interventions increased vaccination 4%-42%, with more intensive interventions associated with higher increases. RCT of interventions involving face-to-face contact with patients increased vaccinations 6%-17%. Group outpatient visits increased vaccination 13%-17%, home visits 6%-17%, and physician or nurse recommendation 15%.

CONCLUSIONS

Clinics may increase vaccination rates by reminding doctors to order vaccine, promoting face-to-face conversations about vaccination, and instituting bundled clinic process improvements. EHR prompts may be less effective.

Digital Gamification Tool (Let's Control Flu) to Increase Vaccination Coverage Rates: Proposal for Algorithm Development

BACKGROUND

Influenza represents a critical public health challenge, disproportionately affecting at-risk populations, including older adults and those with chronic conditions, often compounded by socioeconomic factors. Innovative strategies, such as gamification, are essential for augmenting risk communication and community engagement efforts to address this threat.

OBJECTIVE

This study aims to introduce the "Let's Control Flu" (LCF) tool, a gamified, interactive platform aimed at simulating the impact of various public health policies (PHPs) on influenza vaccination coverage rates and health outcomes. The tool aligns with the World Health Organization's goal of achieving a 75% influenza vaccination rate by 2030, facilitating strategic decision-making to enhance vaccination uptake.

METHODS

The LCF tool integrates a selection of 13 PHPs from an initial set proposed in another study, targeting specific population groups to evaluate 7 key health outcomes. A prioritization mechanism accounts for societal resistance and the synergistic effects of PHPs, projecting the potential policy impacts from 2022 to 2031. This methodology enables users to assess how PHPs could influence public health strategies within distinct target groups.

RESULTS

The LCF project began in February 2021 and is scheduled to end in December 2024. The model creation phase and its application to the pilot country, Sweden, took place between May 2021 and May 2023, with subsequent application to other European countries. The pilot phase demonstrated the tool's potential, indicating a promising increase in the national influenza vaccination coverage rate, with uniform improvements across all targeted demographic groups. These initial findings highlight the tool's capacity to model the effects of PHPs on improving vaccination rates and mitigating the health impact of influenza.

CONCLUSIONS

By incorporating gamification into the analysis of PHPs, the LCF tool offers an innovative and accessible approach to supporting health decision makers and patient advocacy groups. It enhances the comprehension of policy impacts, promoting more effective influenza prevention and control strategies. This paper underscores the critical need for adaptable and engaging tools in PHP planning and implementation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/55613.

A systematic review and meta-analysis of strategies to promote vaccination uptake

Although immunization can dramatically curb the mortality and morbidity associated with vaccine-preventable diseases, vaccination uptake remains suboptimal in many areas of the world. Here, in this meta-analysis, we analysed the results from 88 eligible randomized controlled trials testing interventions to increase vaccination uptake with 1,628,768 participants from 17 countries with variable development levels (for example, Human Development Index ranging from 0.485 to 0.955). We estimated the efficacy of seven intervention strategies including increasing access to vaccination, sending vaccination reminders, providing incentives, supplying information, correcting misinformation, promoting both active and passive motivation and teaching behavioural skills. We showed that the odds of vaccination were 1.5 (95% confidence interval, 1.27 to 1.77) times higher for intervention than control conditions. Among the intervention strategies, using incentives and increasing access were most promising in improving vaccination uptake, with the access strategy being particularly effective in countries with lower incomes and less access to healthcare.

Effectiveness of Catch-Up Vaccination Interventions Versus Standard or Usual Care Procedures in Increasing Adherence to Recommended Vaccinations Among Different Age Groups: Systematic Review and Meta-Analysis of Randomized Controlled Trials and Before-After Studies

BACKGROUND

To address the global challenge of vaccine hesitancy, the Strategic Advisory Group of Experts on Immunization strongly promotes vaccination reminder and recall interventions. Coupled with the new opportunities presented by scientific advancements, these measures are crucial for successfully immunizing target population groups.

OBJECTIVE

This systematic review and meta-analysis aims to assess the effectiveness of various interventions in increasing vaccination coverage compared with standard or usual care. The review will cover all vaccinations recommended for different age groups.

METHODS

In February 2022, 2 databases were consulted, retrieving 1850 studies. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 79 manuscripts were included after the assessment phase. These comprised 46 trials/randomized controlled trials (RCTs) and 33 before-after studies. A meta-analysis using a random-effects model was performed with STATA software (version 14.1.2). The selected outcome was the risk ratio (RR) of vaccination coverage improvement effectiveness. Additionally, meta-regression analyses were conducted for the included manuscripts.

RESULTS

The analyses showed an overall efficacy of RR 1.22 (95% CI 1.19-1.26) for RCTs and RR 1.70 (95% CI 1.54-1.87) for before-after studies when considering all interventions cumulatively. Subgroup analyses identified multicomponent interventions (RR 1.58, 95% CI 1.36-1.85) and recall clinical interventions (RR 1.24, 95% CI 1.17-1.32) as the most effective in increasing vaccination coverage for RCTs. By contrast, educational interventions (RR 2.13, 95% CI 1.60-2.83) and multicomponent interventions (RR 1.61, 95% CI 1.43-1.82) achieved the highest increases for before-after studies. Meta-regression analyses indicated that the middle-aged adult population was associated with a higher increase in vaccination coverage (RCT: coefficient 0.54, 95% CI 0.12-0.95; before-after: coefficient 1.27, 95% CI 0.70-1.84).

CONCLUSIONS

Community, family, and health care-based multidimensional interventions, as well as education-based catch-up strategies, effectively improve vaccination coverage. Therefore, their systematic implementation is highly relevant for targeting undervaccinated population groups. This approach aligns with national vaccination schedules and aims to eliminate or eradicate vaccine-preventable diseases.

Impact of health education on promoting influenza vaccination health literacy in primary school students: a cluster randomised controlled trial protocol

INTRODUCTION

Influenza is a major public health threat, and vaccination is the most effective prevention method. However, vaccination coverage remains suboptimal. Low health literacy regarding influenza vaccination may contribute to vaccine hesitancy. This study aims to evaluate the effect of health education interventions on influenza vaccination rates and health literacy.

METHODS AND ANALYSIS

This cluster randomised controlled trial will enrol 3036 students in grades 4-5 from 20 primary schools in Dongguan City, China. Schools will be randomised to an intervention group receiving influenza vaccination health education or a control group receiving routine health education. The primary outcome is the influenza vaccination rate. Secondary outcomes include health literacy levels, influenza diagnosis rate, influenza-like illness incidence and vaccine protection rate. Data will be collected through questionnaires, influenza surveillance and self-reports at baseline and study conclusion.

ETHICS AND DISSEMINATION

Ethical approval has been sought from the Ethics Committee of the School of Public Health, Sun Yat-sen University. Findings from the study will be made accessible to both peer-reviewed journals and key stakeholders.

TRIAL REGISTRATION NUMBER

NCT06048406.

Strategies to increase the coverage of influenza and pneumonia vaccination in older adults: a systematic review and network meta-analysis

BACKGROUND

It is urgent to implement interventions to increase vaccination rates of influenza/pneumonia vaccines in older adults, yet the effectiveness of different intervention strategies has not been thoroughly evaluated.

OBJECTIVE

We aimed to assess the effectiveness of intervention strategies for increasing the coverage of influenza/pneumonia vaccination in older adults.

METHODS

PubMed, Web of Science, Cochrane Library, Embase, China Biology Medicine disc, China National Knowledge Infrastructure and Wanfang were searched from 1 January 2000 to 1 October 2022. RCTs that assessed any intervention strategies for increasing influenza/pneumonia vaccination coverage or willingness in older adults were included. A series of random-effects network meta-analysis was conducted by using frequentist frameworks.

RESULTS

Twenty-two RCTs involving 385,182 older participants were eligible for further analysis. Eight types of intervention strategies were evaluated. Compared with routine notification, health education (odds ratio [OR], 1.85 [95%CI, 1.19 to 2.88]), centralised reminder (OR, 1.63 [95%CI, 1.07 to 2.47]), health education + onsite vaccination (OR, 2.89 [95%CI, 1.30 to 6.39]), and health education + centralised reminder + onsite vaccination (OR, 20.76 [95%CI, 7.33 to 58.74]) could effectively improve the vaccination rate. The evidence grade was low or very low due to the substantial heterogeneity among studies.

CONCLUSIONS

Our findings suggest that health education + centralised reminder + onsite vaccination may potentially be an effective strategy regardless of cost, but the evidence level was low. More rigorous trials are needed to identify the association between strategies and vaccination rates among older adults and to integrate such evidence into clinical care to improve vaccination rates.

Delays in Hepatitis A vaccination in people with HIV in Houston, Texas between 2010 and 2018

Background

Studies have demonstrated low hepatitis A virus (HAV) vaccination rates among persons with HIV (PWH).

Methods

We conducted a retrospective study of persons entering HIV care at two clinics in Houston, Texas between 2010 and 2018. We defined those eligible for HAV vaccination as those who had no history of HAV vaccination and had a negative anti-HAV IgG at entry to care. Kaplan-Meier curves summarized time to receipt of HAV vaccines. The proportions of patients who received 1 and 2 HAV vaccines at 6, 12, and 24 months were estimated. Cox proportional hazards regression evaluated associations between patient characteristics and vaccination. Significant factors were included in a multivariable Cox proportional hazards model.

Results

Of 6,515 patients, 1372 were eligible for HAV vaccination. Of eligible patients, 29.2 % received 1 HAV vaccination at 6 months, 37.1 % at 12 months, and 47.8 % at 24 months. At 6 months, 10 % received 2 HAV vaccinations, 21.1 % at 12 months, and 33.4 % at 24 months. In multivariable analysis, men who have sex with men (adjusted HR 1.35, 95 % CI 1.06, 1.73) or those who had CD4 count ≥ 200 cells/µl (adjusted HR 2.52, 95 % CI 1.89, 3.37) had their second vaccination sooner than those who were not men who have sex with men or who had CD4 counts < 200 cells/µl, respectively. Patients > 50 years of age had their second vaccination sooner than those aged 30-50 years (adjusted HR 1.47, 95 % CI 1.08, 1.99). Those with active substance history had a longer time to second vaccination compared to those with no substance use history (adjusted HR 0.57, 95 % CI 0.40, 0.82).

Conclusions

HAV vaccination rates were low and highlight the need for effective solutions to address HAV immunization gaps in PWH, especially among young patients, those with active substance use disorders, and those with significant immunocompromise.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Evaluating the impact of using mobile vaccination units to increase COVID-19 vaccination uptake in Cheshire and Merseyside, UK: a synthetic control analysis

OBJECTIVE

To evaluate the impact of mobile vaccination units on COVID-19 vaccine uptake of the first dose, the percentage of vaccinated people among the total eligible population. We further investigate whether such an effect differed by deprivation, ethnicity and age.

DESIGN

Synthetic control analysis.

SETTING

The population registered with general practices (GPs) in nine local authority areas in Cheshire and Merseyside in Northwest England, UK.

INTERVENTION

Mobile vaccination units that visited 37 sites on 54 occasions between 12 April 2021 and 28 June 2021. We defined intervention neighbourhoods as having their population weighted centroid located within 1 km of mobile vaccination sites (338 006 individuals). A weighted combination of neighbourhoods that had not received the intervention (1 495 582 individuals) was used to construct a synthetic control group.

OUTCOME

The weekly number of first-dose vaccines received among people aged 18 years and over as a proportion of the population.

RESULTS

The introduction of a mobile vaccination unit into a neighbourhood increased the number of first vaccinations conducted in the neighbourhood by 25% (95% CI 21% to 28%) within 3 weeks after the first visit to a neighbourhood, compared with the synthetic control group. Interaction analyses showed smaller or no effect among older age groups, Asian and black ethnic groups, and the most socioeconomically deprived populations.

CONCLUSIONS

Mobile vaccination units are effective interventions for increasing vaccination uptake, at least in the short term. While mobile units can be geographically targeted to reduce inequalities, we found evidence that they may increase inequalities in vaccine uptake within targeted areas, as the intervention was less effective among groups that tended to have lower vaccination uptake. Mobile vaccination units should be used in combination with activities to maximise outreach with black and Asian communities and socioeconomically disadvantaged groups.

Use of Information and Communication Technology Strategies to Increase Vaccination Coverage in Older Adults: A Systematic Review

BACKGROUND

Coverage rates of routinely recommended vaccines in older adults still fall below the targets established by international and national advisory committees. As a result, related diseases still have a high incidence, morbidity, and mortality. Information and Communication Technologies (ICT) could provide useful tools to improve immunization rates by bringing information directly to the target user at a relatively low cost. The present research aims to systematically review recent literature on interventions applying ICT to improve the uptake of influenza, pneumococcal, COVID-19 and herpes zoster immunization rates among older adults.

METHODS

Studies published in English between 1 January 2000 and 10 November 2022 were identified by searching electronic medical databases (PubMed, Scopus) and were independently reviewed by two different authors. A total of 22 studies were included in this review.

FINDINGS

Interventions applied the following ICT tools: phone calls, text messages, messages sent via personal electronic medical records, automated phone calls, remote patient monitoring in a home telehealth program and emails. In terms of the vaccines promoted, 11 studies prompted the influenza vaccine, four prompted the influenza and pneumococcal vaccines, three the pneumococcal vaccine, two the herpes zoster vaccine, one the COVID-19 vaccine and one both the pneumococcal and herpes zoster vaccines. Overall, more than half of the studies (n = 12) found some level of effectiveness of these ICT strategies in increasing vaccination rates among older adults, while five studies were partially effective (for specific vaccines or population subgroups), and five reported no significant effect.

CONCLUSIONS

Prevention programs using ICT tools could be effective in promoting immunizations among older adults.

The association between internet use to obtain health information and receiving three doses of the Hepatitis B vaccine in a multi-ethnic population in Ohio

While most cancer incidence and mortality rates are decreasing, liver cancer rates are increasing. The Hepatitis B Virus (HBV) vaccine prevents liver cancer, although not everyone receives all three doses of the vaccine. This study examined the association between using the internet as the primary source of health information and receiving three HBV vaccine doses among a multi-ethnic population in Ohio. From May 2017 through February 2018, participants in the Community Initiative Towards Improving Equity and Health Status (CITIES) study reported their primary health information source and if they received three HBV vaccine doses. A multivariable logistic regression model was fit using backwards selection. Overall, 26.6% received three HBV vaccine doses. After adjusting for race/ethnicity and education, the association between internet use and receiving three HBV vaccine doses was not significant (p-value = 0.73). In the process of model-building, race/ethnicity and educational attainment were identified as factors associated with completing the HBV vaccine; Hispanics (OR = 0.35; 95% CI = 0.17, 0.69) and African Americans (OR = 0.53; 95% CI = 0.35, 0.81) had lower odds of receiving three doses compared to whites; compared to college graduates, those with a high school diploma or less also had lower odds (OR = 0.33; 95% CI = 0.21, 0.52). This study suggests no association between internet use and complete HBV vaccination; however, associations between both race/ethnicity and educational attainment and HBV vaccine completion were identified. Future research should consider factors that stem from racial/ethnic and educational disparities that may influence adherence to HBV vaccination (i.e., healthcare system mistrust, access to accurate health information).

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.

Interventions on Socioeconomic and Racial Inequities in Respiratory Pandemics: a Rapid Systematic Review

Purpose of Review

Racial and socioeconomic inequities in respiratory pandemics have been consistently documented, but little official guidance exists on effective action to prevent these. We systematically reviewed quantitative evaluations of (real or simulated) interventions targeting racial and socioeconomic inequities in respiratory pandemic outcomes.

Recent Findings

Our systematic search returned 10,208 records, of which 5 met inclusion criteria, including observational (n = 1), randomized trial (n = 1), and simulation (n = 3) studies. Interventions studied included vaccination parity, antiviral distribution, school closure, disinfection, personal protective equipment, and paid sick leave, with a focus on Black (n = 3) and/or Latinx (n = 4) or low-SES (n = 2) communities. Results are suggestive that these interventions might be effective at reducing racial and/or SES disparities in pandemics.

Summary

There is a dearth of research on strategies to reduce pandemic disparities. We provide theory-driven, concrete suggestions for incorporating equity into intervention research for pandemic preparedness, including a focus on social and economic policies.

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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 Healthcare Inequity: Lessons Learned from Annual Influenza Vaccination Rates to Mitigate COVID-19 Vaccine Disparities

The COVID-19 pandemic has infected 33 million Americans and resulted in more than 600,000 deaths as of late Spring 2021. Black, Indigenous, and Latinx (BIL) people are disproportionately infected, hospitalized, and dying. Effective vaccines were rapidly developed and have been widely available in the United States since their initial rollout in late 2020-early 2021 but vaccination rates in BIL communities have remained low compared with non-BIL communities. Limited access to the vaccine, lack of customized information, and mistrust of the medical system, all contribute to vaccine hesitancy and low vaccination rates. Regrettably, COVID-19 is not the only vaccine-preventable illness with racial/ethnic inequities. Similar inequities are seen with the seasonal influenza vaccine. We review the racial/ethnic health disparities in COVID-19 illness and vaccination rates and what inequities contribute to these disparities. We use evidence from the seasonal influenza vaccination efforts to inform potential strategies to attenuate these inequities. The development of effective and sustainable strategies to improve vaccination rates and reduce factors that result in health inequities is essential in managing current and future pandemics and promoting improved health for all communities.

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.

Cost-Effectiveness of Pneumococcal Vaccination and Uptake Improvement Programs in Underserved and General Population Adults Aged < 65 Years

In US adults aged < 65 years, pneumococcal vaccination is recommended when high-risk conditions are present, but vaccine uptake is low. Additionally, there are race-based differences in illness risk and vaccination rates. The cost-effectiveness of programs to improve vaccine uptake or of alternative vaccination policies to increase protection is unclear. A decision analysis compared, in US black and general population cohorts aged 50 years, the public health impact and cost-effectiveness of pneumococcal vaccination recommendations, without and with a vaccine uptake improvement program, and alternative population vaccine policies. Program-based uptake improvement (base case: 12.3% absolute increase, costing $1.78/eligible patient) was based on clinical trial data. US data informed population-specific pneumococcal risk. Vaccine effectiveness was estimated using Delphi panel and trial data. In both black and general population cohorts, an uptake improvement program for current vaccination recommendations was favored, costing $48,621 per QALY gained in black populations ($54,929/QALY in the general population) compared to current recommendations without a program. Alternative vaccination policies largely prevented less illness and were economically unfavorable. In sensitivity analyses, uptake programs were favored, at a $100,000/QALY threshold, unless they improved absolute vaccine uptake < 2.1% in blacks or < 2.6% in the general population. Results were robust in sensitivity analyses. Programs to increase adult pneumococcal vaccination uptake are economically reasonable compared to changes in vaccination recommendations, and more favorable in underserved minorities than in the general population. If addressing race-based health disparities is a priority, evidence-based programs to increase vaccination should be considered.

U.S. clinicians' and pharmacists' reported barriers to implementation of the Standards for Adult Immunization Practice

BACKGROUND

The Standards for Adult Immunization Practice (Standards), revised in 2014, emphasize that adult-care providers assess vaccination status of adult patients at every visit, recommend vaccination, administer needed vaccines or refer to a vaccinating provider, and document vaccinations administered in state/local immunization information systems (IIS). Providers report numerous systems- and provider-level barriers to vaccinating adults, such as billing, payment issues, lower prioritization of vaccines due to competing demands, and lack of information about the use and utility of IIS. Barriers to vaccination result in missed opportunities to vaccinate adults and contribute to low vaccination coverage. Clinicians' (physicians, physician assistants, nurse practitioners) and pharmacists' reported barriers to assessment, recommendation, administration, referral, and documentation, provider vaccination practices, and perceptions regarding their adult patients' attitudes toward vaccines were evaluated.

METHODS

Data from non-probability-based Internet panel surveys of U.S. clinicians (n = 1714) and pharmacists (n = 261) conducted in February-March 2017 were analyzed using SUDAAN. Weighted proportion of reported barriers to assessment, recommendation, administration, referral, and documentation in IIS were calculated.

RESULTS

High percentages (70.0%-97.4%) of clinicians and pharmacists reported they routinely assessed, recommended, administered, and/or referred adults for vaccination. Among those who administered vaccines, 31.6% clinicians' and 38.4% pharmacists' submitted records to IIS. Reported barriers included: (a) assessment barriers: vaccination of adults is not within their scope of practice, inadequate reimbursement for vaccinations; (b) administration barriers: lack of staff to manage/administer vaccines, absence of necessary vaccine storage and handling equipment and provisions; and (c) documentation barriers: unaware if state/city has IIS that includes adults or not sure how their electronic system would link to IIS.

CONCLUSION

Although many clinicians and pharmacists reported implementing most of the individual components of the Standards, with the exception of IIS use, there are discrepancies in providers' reported actual practices and their beliefs/perceptions, and barriers to vaccinating adults remain.

RCT of Centralized Vaccine Reminder/Recall for Adults

INTRODUCTION

A proven, but underutilized, method to increase current low vaccination rates is reminder/recall. Centralized reminder/recall using an Immunization Information System reduces the burden of an individual practice conducting reminder/recall. The objectives were to assess the effectiveness of centralized vaccine reminder/recall on improving adult vaccination rates using Colorado's Immunization Information System.

STUDY DESIGN

This study is a pragmatic RCT.

SETTING/PARTICIPANTS

Denver Health patients were divided into three strata: 25,039 individuals aged 19-64 years without a high-risk condition for pneumococcal disease, 16,897 individuals aged 19-64 years with a high-risk condition, and 5,332 individuals aged ≥65 years. Data were collected from October 2015 to April 2016 and analyzed between September 2016 and June 2017.

INTERVENTION

Adults aged 19-64 years without a high-risk condition who needed influenza or tetanus, diphtheria, acellular pertussis vaccine or both, and adults with a high-risk condition and adults aged ≥65 years who needed influenza, or tetanus, diphtheria, acellular pertussis, or pneumococcal vaccine, or all three vaccines were randomized to receive up to three reminder/recalls or usual care.

MAIN OUTCOME MEASURES

Documentation of receipt of any needed vaccine in Immunization Information System ≤6 months after the reminder/recall was the primary outcome. A secondary outcome included implementation costs of the reminder/recall effort. A mixed effects model assessed the association between the intervention and receipt of any needed vaccine while controlling for gender, age, race, ethnicity, insurance type, and history of vaccine refusal.

RESULTS

The intervention was associated with receipt of any needed vaccine in the adults aged ≥65 years population (AOR=1.15, 95% CI=1.02, 1.30), but not the other two populations. Influenza vaccine was the source of this difference, with 32.0% receiving a vaccine in intervention versus 28.6% in usual-care groups (p≤0.01). Start-up and implementation costs per person were $0.86. In the population aged ≥65 years, 29.4 patients would need to be contacted to gain one additional vaccination.

CONCLUSIONS

Centralized reminder/recall was effective at increasing influenza vaccination rates in adults aged ≥65 years over a short time period, without burdening the practices, and at a reasonable cost.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02133391.

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.

Patient reminder and recall interventions to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.

OBJECTIVES

To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.

SELECTION CRITERIA

We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.

MAIN RESULTS

The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).

AUTHORS' CONCLUSIONS

Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

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.

A cross sectional survey to evaluate knowledge, attitudes and practices regarding seasonal influenza and influenza vaccination among diabetics in Pretoria, South Africa

BACKGROUND

In South Africa, influenza vaccination is recommended to all diabetics. However, vaccination coverage among diabetics remains low. Therefore, this study aimed to explore the knowledge, attitudes, and practices among people with diabetes in Pretoria regarding seasonal influenza and influenza vaccination.

METHOD

A cross-sectional survey was conducted among type 1 and 2 diabetes mellitus patients who attended diabetic clinics in two major tertiary hospitals in Pretoria, South Africa from October to December 2015. The pilot-tested questionnaire consists of 32 quantitative questions that covered seasonal influenza and influenza vaccination in terms of the patient's demographics, medical history and knowledge, attitudes and practices.

RESULTS

A total of 292 completed questionnaires were received with a response rate of 70.0%. Of these, 162 participants (55.5%) believed that influenza is the same as common cold. While 96 (32.9%) participants were aware that they were at higher risk of complications of influenza, only 86 (29.5%) participants considered vaccination as an effective means in preventing serious influenza-related complication. Even though 167 (57.2%) participants had heard of the vaccine to prevent influenza, only 84 (28.8%) participants were previously vaccinated. Multivariate analysis shows that participants with good attitude score for influenza vaccination were 18.4 times more likely to be vaccinated compared with those with poor attitude score (OR =18.4, 95%CI. 5.28-64.10, p = .001). Among those previously vaccinated, advice from their doctors (82/84, 97.6%) was the main factor encouraging vaccination. Top reasons given by participants who had never been vaccinated before (208/292, 71.2%) include use of alternative protection (107/208, 51.4%) and that vaccination is not necessary because flu is just a minor illness (93/208, 44.7%).

CONCLUSION

Uptake of seasonal vaccination among diabetics in Pretoria is low. Level of knowledge and perception are the main barriers to vaccination. Health care provider's advice may be an important key predictor of previous influenza vaccination and they should continue to educate and encourage all diabetics to get vaccinated for influenza at least once yearly.

Surveillance of Vaccination Coverage among Adult Populations - United States, 2015

PROBLEM/CONDITION

Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, 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 is low.

PERIOD COVERED

August 2014-June 2015 (for influenza vaccination) and January-December 2015 (for pneumococcal, tetanus and diphtheria [Td] and tetanus and diphtheria with acellular pertussis [Tdap], hepatitis A, hepatitis B, herpes zoster, 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. The survey 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.

RESULTS

Compared with data from the 2014 NHIS, increases in vaccination coverage occurred for influenza vaccine among adults aged ≥19 years (a 1.6 percentage point increase compared with the 2013-14 season to 44.8%), pneumococcal vaccine among adults aged 19-64 years at increased risk for pneumococcal disease (a 2.8 percentage point increase to 23.0%), Tdap vaccine among adults aged ≥19 years and adults aged 19-64 years (a 3.1 percentage point and 3.3 percentage point increase to 23.1% and to 24.7%, respectively), herpes zoster vaccine among adults aged ≥60 years and adults aged ≥65 years (a 2.7 percentage point and 3.2 percentage point increase to 30.6% and to 34.2%, respectively), and hepatitis B vaccine among health care personnel (HCP) aged ≥19 years (a 4.1 percentage point increase to 64.7%). Herpes zoster vaccination coverage in 2015 met the Healthy People 2020 target of 30%. Aside from these modest improvements, vaccination coverage among adults in 2015 was similar to estimates from 2014. Racial/ethnic differences in coverage persisted for all seven vaccines, with higher coverage generally for whites compared with most other groups. Adults without health insurance reported receipt of influenza vaccine (all age groups), pneumococcal vaccine (adults aged 19-64 years at increased risk), Td vaccine (adults aged ≥19 years, 19-64 years, and 50-64 years), Tdap vaccine (adults aged ≥19 years and 19-64 years), hepatitis A vaccine (adults aged ≥19 years overall and among travelers), hepatitis B vaccine (adults aged ≥19 years, 19-49 years, and among travelers), herpes zoster vaccine (adults aged ≥60 years), and HPV vaccine (males and females aged 19-26 years) less often than those with health insurance. 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 one or more physician contacts in the past year compared with those who had not visited a physician in the past year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts within the past year, depending on the vaccine, 18.2%-85.6% 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 higher than that among foreign-born adults, with few exceptions (influenza vaccination [adults aged 19-49 years and 50-64 years], hepatitis A vaccination [adults aged ≥19 years], and hepatitis B vaccination [adults aged ≥19 years with diabetes or chronic liver conditions]).

INTERPRETATION

Coverage for all vaccines for adults remained low but modest gains occurred in vaccination coverage for influenza (adults aged ≥19 years), pneumococcal (adults aged 19-64 years with increased risk), Tdap (adults aged ≥19 years and adults aged 19-64 years), herpes zoster (adults aged ≥60 years and ≥65 years), and hepatitis B (HCP aged ≥19 years); coverage for other vaccines and groups with vaccination indications did not improve. The 30% Healthy People 2020 target for herpes zoster vaccination was met. Racial/ethnic disparities persisted for routinely recommended adult vaccines. Missed opportunities to vaccinate remained. Although having health insurance coverage and a usual place for health care were associated with higher vaccination coverage, these factors alone were not associated with optimal adult vaccination coverage. HPV vaccination coverage for males and females has increased since CDC recommended vaccination to prevent cancers caused by HPV, but many adolescents and young adults remained unvaccinated.

PUBLIC HEALTH ACTIONS

Assessing factors associated with low coverage rates and disparities in vaccination is important for implementing strategies to improve vaccination coverage. Evidence-based practices that have been demonstrated to improve vaccination coverage should be used. These practices include assessment of patients' vaccination indications by health care providers and routine recommendation and offer of needed vaccines to adults, implementation of reminder-recall systems, use of standing-order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. For vaccination coverage to be improved among those who reported lower coverage rates of recommended adult vaccines, efforts also are needed to identify adults who do not have a regular provider or insurance and who report fewer health care visits.

Racial and ethnic disparities in vaccination coverage among adult populations in the U.S

INTRODUCTION

Reducing racial/ethnic disparities in immunization rates is a compelling public health goal. Disparities in childhood vaccination rates have not been observed in recent years for most vaccines. The objective of this study is to assess adult vaccination by race/ethnicity in the U.S.

METHODS

The 2012 National Health Interview Survey was analyzed in 2014 to assess adult vaccination by race/ethnicity for five vaccines routinely recommended for adults: influenza, tetanus, pneumococcal (two vaccines), human papilloma virus, and zoster vaccines. Multivariable logistic regression analysis was performed to identify factors independently associated with all adult vaccinations.

RESULTS

Vaccination coverage was significantly lower among non-Hispanic blacks, Hispanics, and non-Hispanic Asians compared with non-Hispanic whites, with only a few exceptions. Age, sex, education, health insurance, usual place of care, number of physician visits in the past 12 months, and health insurance were independently associated with receipt of most of the examined vaccines. Racial/ethnic differences narrowed, but gaps remained after taking these factors into account.

CONCLUSIONS

Racial and ethnic differences in vaccination levels narrow when adjusting for socioeconomic factors analyzed in this survey, but are not eliminated, suggesting that other factors that are associated with vaccination disparities are not measured by the National Health Interview Survey and could also contribute to the differences in coverage. Additional efforts, including systems changes to ensure routine assessment and recommendations for needed vaccinations among adults for all racial/ethnic groups, are essential for improving vaccine coverage.

Influenza and pneumococcal vaccination in Australian adults: a systematic review of coverage and factors associated with uptake

BACKGROUND

In the absence of an adult vaccination register, coverage estimates for influenza and pneumococcal vaccination come from surveys and other data sources.

METHODS

Systematic review and meta-analysis of studies examining vaccination coverage in Australian adults from 1990 to 2015, focusing on groups funded under the National Immunisation Program, and intervals prior to and following the introduction of universal funding.

RESULTS

Twenty-two studies met the inclusion criteria; 18 used self-report to determine vaccination status. There were 130 unique estimates of coverage extracted. Among adults aged ≥65y, during the period of universal funding (1999-onwards), the summary estimate of annual influenza vaccination coverage from 27 point estimates was 74.8 % (95 % CI 73.4-76.2 %; range 63.9-82.4 %); prior to this period (1992-1998) from 10 point estimates it was 61.3 % (95 % CI 58.0-64.6 %; range 44.3-71.3 %). For the period of universal funding for pneumococcal vaccination (2005-onwards) the summary estimate for coverage was 56.0 % (95 % CI 53.2-58.8 %; range 51.2-72.8 %, 10 point estimates); prior to 2005 it was 35.4 % (95 % CI 18.8-52.0 %; range 15.4-45.2 %). Coverage for both vaccines was significantly higher following the introduction of universal funding. Influenza vaccination coverage in those aged 18-65 years with a medical indication was lower but data were not combined. Seven studies reported on Aboriginal Australians with three studies reporting five coverage estimates for influenza vaccination in adults ≥65 years (range 71 % - 89 %).

CONCLUSIONS

Adult influenza and pneumococcal vaccination coverage has increased since the introduction of universal funding, but remains sub-optimal, with pneumococcal coverage lower than influenza.

IMPLICATIONS

This review highlights the need for more coverage data overall and in high risk groups, to support public health programs to improve coverage.

Surveillance of Vaccination Coverage Among Adult Populations - United States, 2014

PROBLEM/CONDITION

Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, 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 is low.

REPORTING PERIOD

August 2013-June 2014 (for influenza vaccination) and January-December 2014 (for pneumococcal, tetanus and diphtheria [Td] and tetanus and diphtheria with acellular pertussis [Tdap], hepatitis A, hepatitis B, herpes zoster, 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. The survey 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.

RESULTS

Compared with data from the 2013 NHIS, increases in vaccination coverage occurred for Tdap vaccine among adults aged ≥19 years (a 2.9 percentage point increase to 20.1%) and herpes zoster vaccine among adults aged ≥60 years (a 3.6 percentage point increase to 27.9%). Aside from these modest improvements, vaccination coverage among adults in 2014 was similar to estimates from 2013 (for influenza coverage, similar to the 2012-13 season). Influenza vaccination coverage among adults aged ≥19 years was 43.2%. Pneumococcal vaccination coverage among high-risk persons aged 19-64 years was 20.3% and among adults aged ≥65 years was 61.3%. Td vaccination coverage among adults aged ≥19 years was 62.2%. Hepatitis A vaccination coverage among adults aged ≥19 years was 9.0%. Hepatitis B vaccination coverage among adults aged ≥19 years was 24.5%. HPV vaccination coverage among adults aged 19-26 years was 40.2% for females and 8.2% for males. Racial/ethnic differences in coverage persisted for all seven vaccines, with higher coverage generally for whites compared with most other groups. Adults without health insurance were significantly less likely than those with health insurance to report receipt of influenza vaccine (aged ≥19 years), pneumococcal vaccine (aged 19-64 years with high-risk conditions and aged ≥65 years), Td vaccine (aged ≥19 years), Tdap vaccine (aged ≥19 years and 19-64 years), hepatitis A vaccine (aged ≥19 years overall and among travelers), hepatitis B vaccine (aged ≥19 years, 19-49 years, and 19-59 years with diabetes), herpes zoster vaccine (aged ≥60 years and 60-64 years), and HPV vaccine (females aged 19-26 years and males aged 19-26 years). Adults who reported having a usual place for health care generally were more likely to receive recommended vaccinations than those who did not have a usual place for health care, regardless of whether they had health insurance. Vaccination coverage was significantly higher among those reporting one or more physician contacts in the past year compared with those who had not visited a physician in the past year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended either for all persons or for those with some specific indication. Overall, vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents with few exceptions (influenza vaccination [adults aged 19-49 years], hepatitis A vaccination [adults aged ≥19 years], hepatitis B vaccination [adults with diabetes aged ≥60 years], and HPV vaccination [males aged 19-26 years]).

INTERPRETATION

Overall, increases in adult vaccination coverage are needed. Although modest gains occurred in Tdap vaccination coverage among adults aged ≥19 years and herpes zoster vaccination coverage among adults aged ≥60 years, coverage for other vaccines and risk groups did not improve, and racial/ethnic disparities persisted for routinely recommended adult vaccines. Coverage for all vaccines for adults remained low, and missed opportunities to vaccinate adults continued. Although having health insurance coverage and a usual place for health care are associated with higher vaccination coverage, these factors alone do not assure optimal adult vaccination coverage.

PUBLIC HEALTH ACTIONS

Assessing associations with vaccination is important for understanding factors that contribute to low coverage rates and to disparities in vaccination, and for implementing strategies to improve vaccination coverage. Practices that have been demonstrated to improve vaccination coverage should be used. These practices include assessment of patients' vaccination indications by health care providers and routine recommendation and offer of needed vaccines to adults, implementation of reminder-recall systems, use of standing-order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. For vaccination to be improved among those least likely to be up-to-date on recommended adult vaccines, efforts also are needed to identify adults who do not have a regular provider or insurance and who report fewer health care visits.

Sustained Reduction in Health Disparities Achieved through Targeted Quality Improvement: One-Year Follow-up on a Three-Year Intervention

OBJECTIVE

To assess a quality improvement disparity reduction intervention and its sustainability.

DATA SOURCES/STUDY SETTING

Electronic health records and Quality Index database of Clalit Health Services in Israel (2008-2012).

STUDY DESIGN

Interrupted time-series with pre-, during, and postintervention disparities measurement between 55 target clinics (serving approximately 400,000 mostly low socioeconomic, minority populations) and all other (126) clinics.

DATA COLLECTION/EXTRACTION METHODS

Data on a Quality Indicator Disparity Scale (QUIDS-7) of 7 indicators, and on a 61-indicator scale (QUIDS-61).

PRINCIPAL FINDINGS

The gap between intervention and nonintervention clinics for QUIDS-7 decreased by 66.7 percent and by 70.4 percent for QUIDS-61. Disparity reduction continued (18.2 percent) during the follow-up period.

CONCLUSIONS

Quality improvement can achieve significant reduction in disparities in a wide range of clinical domains, which can be sustained over time.

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

INTRODUCTION

Reducing racial/ethnic disparities in immunization rates is a compelling public health goal. Disparities in childhood vaccination rates have not been observed in recent years for most vaccines. The objective of this study is to assess adult vaccination by race/ethnicity in the U.S.

METHODS

The 2012 National Health Interview Survey was analyzed in 2014 to assess adult vaccination by race/ethnicity for five vaccines routinely recommended for adults: influenza, tetanus, pneumococcal (two vaccines), human papilloma virus, and zoster vaccines. Multivariable logistic regression analysis was performed to identify factors independently associated with all adult vaccinations.

RESULTS

Vaccination coverage was significantly lower among non-Hispanic blacks, Hispanics, and non-Hispanic Asians compared with non-Hispanic whites, with only a few exceptions. Age, sex, education, health insurance, usual place of care, number of physician visits in the past 12 months, and health insurance were independently associated with receipt of most of the examined vaccines. Racial/ethnic differences narrowed, but gaps remained after taking these factors into account.

CONCLUSIONS

Racial and ethnic differences in vaccination levels narrow when adjusting for socioeconomic factors analyzed in this survey, but are not eliminated, suggesting that other factors that are associated with vaccination disparities are not measured by the National Health Interview Survey and could also contribute to the differences in coverage. Additional efforts, including systems changes to ensure routine assessment and recommendations for needed vaccinations among adults for all racial/ethnic groups, are essential for improving vaccine coverage.

Strategies for addressing vaccine hesitancy - A systematic review

The purpose of this systematic review is to identify, describe and assess the potential effectiveness of strategies to respond to issues of vaccine hesitancy that have been implemented and evaluated across diverse global contexts.

METHODS

A systematic review of peer reviewed (January 2007-October 2013) and grey literature (up to October 2013) was conducted using a broad search strategy, built to capture multiple dimensions of public trust, confidence and hesitancy concerning vaccines. This search strategy was applied and adapted across several databases and organizational websites. Descriptive analyses were undertaken for 166 (peer reviewed) and 15 (grey literature) evaluation studies. In addition, the quality of evidence relating to a series of PICO (population, intervention, comparison/control, outcomes) questions defined by the SAGE Working Group on Vaccine Hesitancy (WG) was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria; data were analyzed using Review Manager.

RESULTS

Across the literature, few strategies to address vaccine hesitancy were found to have been evaluated for impact on either vaccination uptake and/or changes in knowledge, awareness or attitude (only 14% of peer reviewed and 25% of grey literature). The majority of evaluation studies were based in the Americas and primarily focused on influenza, human papillomavirus (HPV) and childhood vaccines. In low- and middle-income regions, the focus was on diphtheria, tetanus and pertussis, and polio. Across all regions, most interventions were multi-component and the majority of strategies focused on raising knowledge and awareness. Thirteen relevant studies were used for the GRADE assessment that indicated evidence of moderate quality for the use of social mobilization, mass media, communication tool-based training for health-care workers, non-financial incentives and reminder/recall-based interventions. Overall, our results showed that multicomponent and dialogue-based interventions were most effective. However, given the complexity of vaccine hesitancy and the limited evidence available on how it can be addressed, identified strategies should be carefully tailored according to the target population, their reasons for hesitancy, and the specific context.

[Strategies to improve influenza vaccination coverage in Primary Health Care]

INTRODUCTION

Vaccination coverage reached in adults is insufficient, and there is a real need for new strategies.

OBJECTIVE

To compare strategies for improving influenza vaccination coverage in persons older than 64 years.

PATIENTS AND METHODS

New strategies were introduced in our health care centre during 2013-2014 influenza vaccination campaign, which included vaccinating patients in homes for the aged as well as in the health care centre. A comparison was made on vaccination coverage over the last 4 years in 3 practices of our health care centre: P1, the general physician vaccinated patients older than 64 that came to the practice; P2, the general physician systematically insisted in vaccination in elderly patients, strongly advising to book appointments, and P3, the general physician did not insist.

RESULTS

These practices looked after P1: 278; P2: 320; P3: 294 patients older than 64 years. Overall/P1/P2/P3 coverages in 2010: 51.2/51.4/55/46.9% (P=NS), in 2011: 52.4/52.9/53.8/50.3% (P=NS), in 2012: 51.9/52.5/55.3/47.6% (P=NS), and in 2013: 63.5/79.1/59.7/52.7 (P=.000, P1 versus P2 and P3; P=NS between P2 and P3). Comparing the coverages in 2012-2013 within each practice P1 (P=.000); P2 (P=.045); P3 (P=.018). In P2 and P3 all vaccinations were given by the nurses as previously scheduled. In P3, 55% of the vaccinations were given by the nurses, 24.1% by the GP, 9.7% rejected vaccination, and the remainder did not come to the practice during the vaccination period (October 2013-February 2014).

CONCLUSIONS

The strategy of vaccinating in the homes for the aged improved the vaccination coverage by 5% in each practice. The strategy of "I've got you here, I jab you here" in P1 improved the vaccination coverage by 22%.

Factors Associated With Missed Opportunities for Influenza Vaccination

Objective: Annual influenza vaccination rates remain well below health objectives. Most primary care clinic visits present opportunities for vaccination. The purpose of this study was to quantify missed opportunities (MOs) during the entire influenza season. Patients and clinic characteristics associated with vaccination and MOs are identified. Methods: Influenza vaccinations recorded in random chart reviews of children 6 months to 5 years and of adults 50 years and older at 6 pediatric and 7 adult primary care clinics were assessed during the 2010-2011 influenza season. Patient-specific MOs accounted for variable timing and number of visits throughout the vaccination season. Data were assessed using descriptive, graphical, proportional hazards regression methods. Results: Data for 1136 children and 1329 adults were analyzed. By the end of the season, influenza vaccination coverage recorded in medical records reached 56% and 26% for children and adults, respectively. MOs are common throughout the season and rise sharply after December. By the end of the season, 30.2% of children and 44.9% of adults had 2 or more MOs. Characteristics associated with MOs included age, insurance type, number of visits, and type of medical practice. Conclusions: Missed opportunities abound, especially after December. Strategies targeting patients most likely to have MOs and encouraging the use standing orders, reminders, and monitoring in order to reduce them need to be sustained.

Factors associated with seasonal influenza immunization among church-going older African Americans

OBJECTIVES

Churches and faith institutions can frequently influence health behaviors among older African Americans. The church is a centerpiece of spiritual and social life among African American congregants. We explored its influence on influenza immunization coverage during the 2012-2013 influenza season.

METHODS

A cross-sectional study was conducted among congregation members ages 50-89 years from six churches in the Atlanta region in 2013-2014. We computed descriptive statistics, bivariate associations, and multivariable models to examine factors associated with immunization uptake among this population.

RESULTS

Of 208 study participants, 95 (45.7%) reported receiving the influenza vaccine. Logistic regression showed that increased trust in their healthcare providers' vaccine recommendations was a positive predictor of vaccination among participants who had not experienced discrimination in a faith-based setting (OR: 14.8 [3.7, 59.8]), but was not associated with vaccination for participants who had experienced such discrimination (OR: 1.5 [0.2, 7.0]). Belief in vaccine-induced influenza illness (OR: 0.1 [0.05, 0.23]) was a negative predictor of influenza vaccination.

CONCLUSION

Members of this older cohort of African Americans who expressed trust in their healthcare providers' vaccine recommendations and disbelief in vaccine-induced influenza were more likely to obtain seasonal influenza immunization. They were also more likely to act on their trust of healthcare provider's vaccine recommendations if they did not encounter negative influenza immunization attitudes within the church. Having healthcare providers address negative influenza immunization attitudes and disseminate vaccine information in a culturally appropriate manner within the church has the potential to enhance future uptake of influenza vaccination.

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

BACKGROUND

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

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 (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

MAIN RESULTS

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level.

AUTHORS' CONCLUSIONS

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

Evaluating community engagement in an academic medical center

From the perspective of academic medical centers (AMCs), community engagement is a collaborative process of working toward mutually defined goals to improve the community's health, and involves partnerships between AMCs, individuals, and entities representing the surrounding community. AMCs increasingly recognize the importance of community engagement, and recent programs such as Prevention Research Centers and Clinical and Translational Science Awards have highlighted community engagement activities. However, there is no standard or accepted metric for evaluating AMCs' performance and impact of community engagement activities.In this article, the authors present a framework for evaluating AMCs' community engagement activities. The framework includes broad goals and specific activities within each goal, wherein goals and activities are evaluated using a health services research framework consisting of structure, process, and outcome criteria. To illustrate how to use this community engagement evaluation framework, the authors present specific community engagement goals and activities of the University of Rochester Medical Center to (1) improve the health of the community served by the AMC; (2) increase the AMC's capacity for community engagement; and (3) increase generalizable knowledge and practices in community engagement and public health.Using a structure-process-outcomes framework, a multidisciplinary team should regularly evaluate an AMC's community engagement program with the purpose of measurably improving the performance of the AMC and the health of its surrounding community.

A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents

OBJECTIVE

To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents.

METHODS

We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices. The main outcome measures were immunization rates for routine vaccines (meningococcus, pertussis, HPV) and preventive visit rates at study end.

RESULTS

Intervention and control groups were similar at baseline for demographics, immunization rates, and preventive visits. Among adolescents who were behind at the start, immunization rates at study end increased by 21% for mailed (P < .01 vs control), 17% for telephone (P < .05), and 13% for control groups. The proportion of adolescents with a preventive visit (within 12 months) was: mailed (65%; P < .01), telephone (63%; P < .05), and controls (59%). The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders; for an additional preventive visit, it was 17 and 29. The intervention cost $18.78 (mailed) or $16.68 (phone) per adolescent per year to deliver. The cost per additional adolescent fully vaccinated was $463.99 for mailed and $714.98 for telephone; the cost per additional adolescent receiving a preventive visit was $324.75 and $487.03.

CONCLUSIONS

Managed care-based mail or telephone reminder/recall improved adolescent immunizations and preventive visits, with modest costs and modest impact.

Strategies to increase influenza vaccination rates: outcomes of a nationwide cross-sectional survey of UK general practice

OBJECTIVE

To identify practice strategies associated with higher flu vaccination rates in primary care.

DESIGN

Logistic regression analysis of data from a cross-sectional online questionnaire.

SETTING

795 general practices across England.

PARTICIPANTS

569 practice managers, 335 nursing staff and 107 general practitioners.

PRIMARY OUTCOME MEASURES

Flu vaccination rates achieved by each practice in different groups of at-risk patients.

RESULTS

7 independent factors associated with higher vaccine uptake were identified. Having a lead staff member for planning the flu campaign and producing a written report of practice performance predicted an 8% higher vaccination rate for at-risk patients aged <65 years (OR 1.37, 95% CI 1.10 to 1.71). These strategies, plus sending a personal invitation to all eligible patients and only stopping vaccination when Quality and Outcomes Framework targets are reached, predicted a 7% higher vaccination rate (OR 1.45, 95% CI 1.10 to 1.92) in patients aged ≥65 years. Using a lead member of staff for identifying eligible patients, with either a modified manufacturer's or in-house search programme for interrogating the practice IT system, independently predicted a 4% higher vaccination rate in patients aged ≥65 years (OR 1.22, 95% CI 1.06 to 1.41/OR 1.20, 95% CI 1.03 to 1.40). The provision of flu vaccine by midwives was associated with a 4% higher vaccination rate in pregnant women (OR 1.19, 95% CI 1.02 to 1.40).

CONCLUSIONS

Clear leadership, effective communication about performance and methods used to identify and contact eligible patients were independently associated with significantly higher rates of flu vaccination. Financial targets appear to incentivise practices to work harder to maximise seasonal influenza vaccine uptake. The strategies identified here could help primary care providers to substantially increase their seasonal flu vaccination rates towards or even above the Chief Medical Officer's targets.