Alissa O’Halloran

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.

National and state-specific estimates of place of influenza vaccination among adult populations – United States, 2011–12 influenza season

BACKGROUND Annual influenza vaccination has been recommended for all persons ≥6 months since the 2010-11 season. New partnerships between public health agencies and medical and nonmedical vaccination providers have increased the number of vaccination providers and locations where vaccination services are delivered. METHODS Data from the 2011-12 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. Point estimates of place of vaccination and 95% confidence intervals were calculated. Multivariable logistic regression and predictive marginal modeling were conducted to identify factors associated with vaccination settings. RESULTS Among adults vaccinated during the 2011-12 influenza season, a doctors office was the most common place (38.4%) for receipt of influenza vaccination, with stores (e.g., supermarkets or drug stores) (20.1%) the next common, and workplaces (17.6%) the third common. Overall, reported vaccination in nonmedical settings by state ranged from 32.2% in California to 60.4% in Nevada, with a median of 45.8%. Characteristics significantly associated with an increased likelihood of receipt of vaccination in nonmedical settings were higher education, not having certain identified high-risk conditions, not having had a routine checkup in the previous 12 months, and not having a primary doctor for health care. Being a member of a racial/ethnic minority group, unemployed or not in the work force were significantly associated with a decreased likelihood of receipt of vaccination in nonmedical settings. CONCLUSION Doctors offices were the most common medical setting for adult influenza vaccination; workplaces and stores were important nonmedical settings. Increasing access to vaccination services in medical and nonmedical settings should be considered as important strategies for improving vaccination coverage. These results also can help guide development of strategies for achieving Healthy People 2020 objectives for influenza vaccination of adult populations.

Impact of Health Insurance Status on Vaccination Coverage Among Adult Populations

INTRODUCTION Underinsurance is a barrier to vaccination among children. Information on vaccination among adults aged ≥18 years by insurance status is limited. This study assesses vaccination coverage among adults aged ≥18 years in the U.S. in 2012 by health insurance status and access to care characteristics. METHODS The 2012 National Health Interview Survey data were analyzed in 2014 to estimate vaccination coverage among adults aged ≥18 years by health insurance status for seven routinely recommended vaccines. RESULTS Influenza vaccination coverage among adults aged ≥18 years without or with health insurance was 14.4% versus 44.3%, respectively; pneumococcal vaccination coverage among adults aged 18-64 years with high-risk conditions was 9.8% versus 23.0%; tetanus and diphtheria toxoid (Td) coverage (age ≥18 years) was 53.2% versus 64.5%; tetanus, diphtheria, and acellular pertussis (Tdap) coverage (age ≥18 years) was 8.4% versus 15.7%; hepatitis A (HepA) coverage (age 18-49 years) was 16.6% versus 19.8%; hepatitis B (HepB) coverage (age 18-49 years) was 27.5% versus 38.0%; shingles coverage (age ≥60 years) was 6.1% versus 20.8%; and human papillomavirus (HPV) coverage (women aged 18-26 years) was 20.9% versus 39.8%. In addition, vaccination coverage differed by insurance type, whether respondents had a regular physician, and number of physician contacts. CONCLUSIONS Overall, vaccination coverage among adults aged ≥18 years is lower among uninsured populations. Implementation of effective strategies is needed to help improve vaccination coverage among adults aged ≥18 years, especially those without health insurance.

Adult Vaccination Disparities Among Foreign-Born Populations in the U.S., 2012

BACKGROUND Foreign-born persons are considered at higher risk of undervaccination and exposure to many vaccine-preventable diseases. Information on vaccination coverage among foreign-born populations is limited. PURPOSE To assess adult vaccination coverage disparities among foreign-born populations in the U.S. METHODS Data from the 2012 National Health Interview Survey were analyzed in 2013. For non-influenza vaccines, the weighted proportion vaccinated was calculated. For influenza vaccination, Kaplan-Meier survival analysis was used to assess coverage among individuals interviewed during September 2011-June 2012 and vaccinated in August 2011-May 2012. RESULTS Overall, unadjusted vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents: influenza, age ≥18 years (40.4% vs 33.8%); pneumococcal polysaccharide vaccine (PPV), 18-64 years with high-risk conditions (20.8% vs 13.7%); PPV, ≥65 years (62.6% vs 40.5%); tetanus vaccination, ≥18 years (65.0% vs 50.6%); tetanus, diphtheria, and acellular pertussis (Tdap), ≥18 years (15.5% vs 9.3%); hepatitis B, 18-49 years (37.2% vs 28.4%); shingles, ≥60 years (21.3% vs 12.0%); and human papilloma virus (HPV), women 18-26 years (38.7% vs 14.7%). Among the foreign born, vaccination coverage was generally lower for non-U.S. citizens, recent immigrants, and those interviewed in a language other than English. Foreign-born individuals were less likely than U.S.-born people to be vaccinated for pneumococcal (≥65 years), tetanus, Tdap, and HPV (women) after adjusting for confounders. CONCLUSIONS Vaccination coverage is lower among foreign-born adults than those born in the U.S. It is important to consider foreign birth and immigration status when assessing vaccination disparities and planning interventions.

Tetanus, diphtheria and acellular pertussis (Tdap) vaccination among healthcare personnel-United States, 2011.

BACKGROUND Health-care personnel (HCP) are at risk for exposure to and possible transmission of vaccine-preventable diseases. Receiving recommended vaccines is an essential prevention practice for HCP to protect themselves and their patients. The tetanus, diphtheria and acellular pertussis vaccine (Tdap) was recommended by the Advisory Committee on Immunization Practices (ACIP) for HCP in 2006 for protection against pertussis. We assessed the recent compliance of U.S. HCP in receiving Tdap vaccination. METHODS To estimate Tdap vaccination coverage among HCP, we analyzed data from the 2011 National Health Interview Survey (NHIS). Multivariable logistic regression and predictive marginal models were performed to identify factors independently associated with vaccination among HCP. RESULTS Overall, Tdap vaccination coverage was 26.9% among HCP aged 18-64 years (95% confidence interval (CI)=24.3%, 29.7%), which was significantly higher compared with non-HCP among the same age group (11.1%; 10.5-11.8%). Overall, vaccination coverage was significantly higher among physicians (41.5%) compared with nurses (36.5%) and other types of HCP (range 11.7-29.9%). Vaccination coverage was significantly higher among HCP aged 18-49 years compared with those 50-64 years (30.0% vs. 19.2%, respectively). Characteristics independently associated with an increased likelihood of Tdap vaccination among HCP were: younger age, higher education, living in the western United States, being hospitalized within past year, having a place for routine health care in clinic or health center, and receipt of influenza vaccination in the previous year. Marital status of widowed, divorced, or separated was independently associated with a decreased likelihood of Tdap vaccination among HCP. CONCLUSIONS By 2011, Tdap vaccination coverage was only 26.9% among HCP. Vaccination coverage varied widely by types of HCP and demographic characteristics. Emphasizing the benefits of HCP vaccination for staff and patients, providing vaccinations in the workplace and other non-traditional settings, and providing Tdap at no charge may help increase Tdap vaccination among HCP in all health-care settings.

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 Vaccination Coverage Among People With High-Risk Conditions in the U.S.

INTRODUCTION During annual influenza epidemics, rates of serious illness and death are higher among those who have medical conditions, such as pulmonary disease, diabetes, or heart disease, which place them at increased risk of influenza complications. Annual influenza vaccination was recommended for people with high-risk conditions as early as 1960. METHODS Data from the 2012-2013 Behavioral Risk Factor Surveillance System were analyzed in 2014 to estimate national and state-specific influenza vaccination coverage among people aged 18-64 years with high-risk conditions. Prevalence ratios adjusted for demographic and access-to-care characteristics were calculated using logistic regression and predictive marginal models. RESULTS Unadjusted influenza vaccination coverage was 45.4% among adults aged 18-64 years with at least one high-risk condition, compared with 32.9% among those with no high-risk conditions (p<0.05). Among adults aged 18-64 years with multiple conditions (at least two high-risk conditions), vaccination coverage was 53.2%. Coverage was 43.9% for those with pulmonary diseases, 52.7% for those with diabetes, 48.1% for those with heart disease, and 45.0% for those with cancer. Individuals with high-risk conditions were more likely to receive an influenza vaccine than those with no high-risk conditions, even after controlling for demographic and access-to-care characteristics. CONCLUSIONS Despite ongoing influenza vaccination recommendations for adults with high-risk conditions, coverage was below the Healthy People 2020 target; only about half were vaccinated. Primary care providers and subspecialists should ensure routine assessment of vaccination status every fall and winter and recommend vaccination to people with high-risk conditions.

National and State-Specific Shingles Vaccination Among Adults Aged ≥60 Years

INTRODUCTION Shingles (herpes zoster) causes substantial morbidity, especially among older adults. The shingles vaccine has been recommended for people aged ≥60 years since 2006. This study assessed recent shingles vaccination at national and state levels among adults aged ≥60 years. METHODS The 2014 Behavioral Risk Factor Surveillance System data were analyzed in 2015 to assess shingles vaccination coverage among adults aged ≥60 years at national and state levels. Multivariable logistic regression and predictive marginal models identified factors independently associated with vaccination. RESULTS Shingles vaccination coverage among adults aged ≥60 years was 31.8% (95% CI=31.4%, 32.2%). Among states, shingles vaccination coverage ranged from 17.8% (95% CI=15.8%, 20.0%) in Mississippi to 46.6% (95% CI=44.3%, 48.8%) in Vermont, with a median of 33.3%. Coverage was <25% in four states and >40% in nine states. For all states, coverage was significantly higher among non-Hispanic whites compared with non-white races except for Oregon, with coverage differences ranging from -33.2% in the District of Columbia to 0.9% in Oregon and a median of -16.0%. Characteristics independently associated with vaccination were age, race/ethnicity, sex, education, employment status, household income, region, perceived health status, health insurance status, personal healthcare provider, routine checkup status, and whether reporting that cost was a barrier to seeing a doctor. CONCLUSIONS Coverage varied dramatically by state. State-level comparisons may aid in designing tailored intervention programs through sharing of best practices. Strategies are needed to mitigate financial barriers for both provider and patients, improve awareness, and increase provider recommendation of the vaccine.

Pneumococcal vaccination coverage among persons ≥65 years--United States, 2013.

BACKGROUND Invasive pneumococcal disease is a major cause of illness in the United States, and rates are higher among persons ≥65 years. Pneumococcal vaccination has been recommended to adults ≥65 years since 1997. METHODS Data from the 2005-2013 Behavioral Risk Factor Surveillance System were analyzed. Weighted estimates of pneumococcal vaccination coverage were calculated by state and race/ethnicity and tests for linear trend were performed. RESULTS In 2013, the median state vaccination coverage among adults ≥65 years was 69.5%, and coverage ranged from 61.9% in New Jersey to 75.6% in Oregon. Coverage overall among non-Hispanic whites (71.1%) was higher than coverage for non-Hispanic blacks (57.7%), Hispanics (51.9%), and non-Hispanic persons of other race (65.4%). Coverage increased from 2005 to 2013 overall and by racial/ethnic subgroups. CONCLUSION Although pneumococcal vaccination coverage has improved in the past several years, coverage remains below the Healthy People 2020 target of 90% and racial/ethnic disparities exist.

National and State-Specific Td and Tdap Vaccination of Adult Populations.

INTRODUCTION The Advisory Committee on Immunization Practices recommends a single dose of tetanus, diphtheria, and acellular pertussis vaccine (Tdap) for adults followed by tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter. This study assessed recent Td and Tdap vaccination among adult populations. METHODS The 2013 Behavioral Risk Factor Surveillance System data were analyzed in 2015 to assess Td and Tdap vaccination coverage among adults at national and state levels. Multivariable logistic regression and predictive marginal models were performed to identify factors independently associated with vaccination. RESULTS Overall, national vaccination coverage among adults aged ≥18 years for Td was 57.5% and for Tdap was 28.9%. Among states, Td vaccination coverage ranged from 47.8% in Nevada to 73.1% in Minnesota, and Tdap coverage ranged from 17.7% in Mississippi to 47.6% in Minnesota. Characteristics independently associated with an increased likelihood of Tdap vaccination among adults aged ≥18 years were younger age; being female; American Indian/Alaska Native race; being never married; higher education; not being in the workforce; reporting a household income ≥