Walter W. Williams

Influenza vaccination programs for elderly persons: cost-effectiveness in a health maintenance organization.

Annual influenza vaccination of elderly and chronically ill persons has been a long-standing recommendation of the U.S. Public Health Service [1, 2]. Recent studies have documented the health benefits of annual influenza vaccination [3-10], but despite the exhortations of the Surgeon General and the clear evidence of vaccine efficacy, many persons in high-risk groups fail to receive the recommended vaccinations [11, 12]. Because of the low level of compliance with the U.S. Public Health Service influenza vaccination guidelines [13], the Centers for Disease Control and Prevention (CDC) have proposed new strategies to increase the proportion of high-risk persons who are immunized [14]. One such strategy is to promote assessments of the net financial costs to health maintenance organizations of operational vaccine delivery programs. Successful demonstrations of net financial benefit should encourage managers of organized medical care programs and health insurance companies to advocate improved vaccine delivery. Methods General Methods Setting The study was done at Kaiser Permanente, Northwest Region, a prepaid group practice health maintenance organization (HMO) that includes 20% of the Portland, Oregon-Vancouver, Washington, Standard Metropolitan Statistic Area population. Members receive almost all of their medical care from the health plan, and each contact they make with the HMO is recorded in a single, centralized chart. Epidemic Periods Epidemic periods were defined as periods during which influenza viruses circulated persistently in Oregon according to influenza virus isolation dates reported by the Oregon State Virology Laboratory. The eight epidemic periods defined using this approach are shown in Table 1. The study period for the nonepidemic 1981-1982 reference period was defined by averaging the months and days of the epidemic periods. The number of specimens tested ranged from 118 in 1981-1982 to 652 in 1988-1989. Table 1. Influenza Epidemic Periods and Study Samples Influenza viruses were isolated from only 9 of 118 specimens (8%) tested in the 1981-1982 nonepidemic reference period; B viruses were isolated from two specimens obtained in late April. During the epidemic study periods, influenza viruses were typically isolated from 25% of specimens, isolations were sustained, and isolation frequency distributions described epidemic curves. Participants Participants included in a study period were Kaiser Permanente members 65 years of age or older, each with at least 1 month of eligibility during that period and during the September-December vaccination period. These members represent almost all elderly persons enrolled in the HMO. High-risk participants were defined as those who had had medical care contacts for chronic pulmonary (ICDA [International Classification of Diseases, Adapted] codes 9:491-493.9, 496, 500-505, 506.4, 508.1, 510-516, 714.8), cardiovascular (112.81, 130.3, 393-398, 401.0, 402-405, 410-414, 416, 420-429, 430-438, 440.1, 785.2-.3), metabolic (250-250.9, 571-571.9), renal (274.10, 580-583.9, 585, 587-588.0), or malignant (140-208.9) conditions. These risk factors for influenza-related complications are defined by the CDCs Advisory Committee for Immunization Practices. Data Sources An automated inpatient database was used to identify all hospitalizations for pneumonia and influenza during the nine study periods. This database contains discharge diagnoses and records of inpatient procedures and is the source of the discharge summaries. The outpatient database contains outpatient diagnoses and records of procedures for a continuously updated research sample composed of 5% of elderly health plan members. Each month, a random 5% sample of all new elderly Kaiser Permanente subscriber units is added to the cumulative pool of enrollees whose records are abstracted. Automated outpatient diagnoses were available through 1987. Medical record abstractions were the source of outpatient diagnoses for the first quarter of 1988. Inpatient high-risk discharge diagnoses made during the 3 years before the study period were obtained from the inpatient database. Outpatient high-risk diagnoses made during the year before the study period were obtained from the outpatient database and by chart abstraction. Influenza and pneumococcal vaccination status was abstracted from the medical records for pneumonia and influenza cases that were not in the 5% research sample. Automated vaccination data through 1987 were available for cases and controls in the research sample. Medical record abstractions were the source of 1988-1989 vaccination data for all study participants. Participants receiving influenza vaccine after the start of epidemics were classified as unvaccinated. Case-Control Assessment of Vaccine Effectiveness Population-based, casecontrol designs were used to estimate influenza vaccine effectiveness in preventing medically attended episodes of pneumonia and influenza. To exclude pneumonias that were unlikely to be influenza related, we included only persons with pneumonia and influenza who were admitted to medical services. Because we based participant selection on discharge diagnoses, participants with both hospital- and community-acquired pneumonia and influenza were included. Pneumonia and Influenza Cases and Controls Participants who were hospitalized with pneumonia and influenza during the study period, who were eligible Kaiser Permanente members, and who had a pneumonia and influenza ICDA-9 code (480-483,485,486,487) listed as a discharge diagnosis were included as cases of hospitalized pneumonia and influenza. Controls were members of the 5% research sample who met the study eligibility criteria and who were not hospitalized with pneumonia or influenza during the given period. Pneumonia and influenza deaths during a study period were defined as hospitalized patients with pneumonia and influenza who died in the hospital. Controls were members of the 5% research sample who were not pneumonia and influenza hospital deaths during that period. Outpatient pneumonia and influenza cases included members of the 5% research sample who had an outpatient episode of pneumonia and influenza with no inpatient component during the given study period. Controls were members of the 5% research sample who did not have an outpatient episode of pneumonia and influenza during the given period. Cases and controls were group matched for high-risk status. Logistic regressions were used to adjust influenza vaccine effects on occurrence of pneumonia and influenza episodes for differences in age, sex, months of HMO eligibility, and pneumococcal vaccine status. Vaccine Effectiveness Relative risks for pneumonia and influenza episodes in unvaccinated and vaccinated populations were estimated by the adjusted exposure (unvaccinated) odds ratios. The effectiveness of influenza vaccine in preventing pneumonia and influenza episodes was computed from the estimated relative risk as effectiveness =1-(1/relative risk). Pneumonia and Influenza Episodes Prevented The population-based, casecontrol design allowed unbiased estimation of the total number of participants vaccinated and of the pneumonia and influenza episode rates among unvaccinated participants. The product of these estimates multiplied by the vaccine effectiveness is the estimated number of pneumonia and influenza episodes prevented by influenza vaccination: pneumonia and influenza episodes prevented = (number of participants vaccinated)(effectiveness of vaccination)(pneumonia and influenza episode rate among unvaccinated participants). Statistical Methods The units of analysis for period-specific vaccine effectiveness analyses were persons. A case for a given period had an episode of pneumonia or influenza during that period. A control for a given period did not have an episode of pneumonia or influenza during that period. The same person could appear as a case in more than one period. Person-periods were the units of analysis for aggregate analyses. A person contributed a person-period of observation to each period when study criteria were met. Some members of the 5% research sample were controls in some periods and cases in other periods. Study participants not in the 5% research sample could only contribute person-periods as hospitalized cases. Risks for pneumonia and influenza episodes during high-risk and nonhigh-risk person-periods are separately modeled as logistic functions of influenza vaccine status, pneumococcal vaccine status, age, sex, and length of observation time. The SAS logistic procedure was used to estimate odds ratios and confidence intervals for model variables. The Hosmer-Lemeshow statistic was used to assess the goodness of fit of logistic models. Cost Analysis Methods Medical Care Costs of Pneumonia and Influenza Episodes Costs of providing inpatient care for pneumonia and influenza episodes were obtained from Kaiser Permanente accounting systems for the various patient care cost centers. Costs of providing outpatient care were estimated from the 5% research sample, using relative value units included in the outpatient database and unit costs for accounting cost centers. Cost of Vaccine Delivery Costs of the vaccine delivery program were estimated by a micro-costing approach and included overhead costs. The purchase cost of vaccine was obtained from administrative records and included all vaccines used and wastage. Distribution costs were allocated based on the proportion of direct drug costs represented by influenza vaccine. Two methods of promoting the vaccination program were identified: an article in the member newsletter and referrals by nurses, generally by the telephone advice nurse. Time estimates were obtained from interviews with providers, and labor costs per hour were obtained from Kaiser Permanente administrative records. Cost-Effectiveness Ratios Three cost-effectiveness measures were computed: cost per prevented episode of outpa

Immunization Policies and Vaccine Coverage Among Adults The Risk for Missed Opportunities

A substantial proportion of vaccine-preventable diseases occur among adults. Each year, there are more than 20,000 influenza-associated deaths during epidemics, approximately 40,000 deaths related to pneumococcal disease, and one to five cases of diphtheria. More than 300,000 hepatitis B infections occur annually, mostly in patients 15 to 29 years old. From 1982 to 1986, 96% of patients with tetanus were age 20 and older. Among young adults, 5% to 20% are susceptible to rubella and measles, and outbreaks occur where these persons congregate. Most adults are not immunized, despite recommendations for vaccines against these diseases. Vigorous efforts are needed to implement strategies to reduce disease incidence, morbidity, and death among adults.

Guideline for infection control in health care personnel, 1998

I. Infection control issues for health care personnel: An overview A. EXECUTIVE SUMMARY 291 B. INTRODUCTION 292 C. INFECTION CONTROL OBJECTIVES FOR A PERSONNEL HEALTH SERVICE 292 D. ELEMENTS OF A PERSONNEL HEALTH SERVICE FOR INFECTION CONTROL 293 1. Coordination with other departments 293 2. Medical evaluations 293 3. Personnel health and safety education 293 4. Immunization programs 296 5. Management of job-related illnesses and exposures 298 6. Health counseling 301 7. Maintenance of records, data management, and confidentiality 301 E. EPIDEMIOLOGY AND CONTROL OF SELECTED INFECTIONS TRANSMITTED AMONG HEALTH CARE PERSONNEL AND PATIENTS 302 1. Bloodborne pathogens 302 Affiliations: National Center for Infectious Diseases, National Immunization Program, National Institute of Occupational Safety and Health.

Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older - United States, 2014.

In October 2015, the Advisory Committee on Immunization Practices (ACIP)* approved the Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2016. This schedule provides a summary of ACIP recommendations for the use of vaccines routinely recommended for adults aged 19 years or older in two figures, footnotes for each vaccine, and a table that describes primary contraindications and precautions for commonly used vaccines for adults. Although the figures in the adult immunization schedule illustrate recommended vaccinations that begin at age 19 years, the footnotes contain information on vaccines that are recommended for adults that may begin at age younger than age 19 years. The footnotes also contain vaccine dosing, intervals between doses, and other important information and should be read with the figures.

Guideline for Infection Control in Healthcare Personnel, 1998

This guideline updates and replaces the previous edition of the Centers for Disease Control and Prevention (CDC) “Guideline for Infection Control in Hospital Personnel,” published in 1983. The revised guideline, designed to provide methods for reducing the transmission of infections from patients to healthcare personnel and from personnel to patients, also provides an overview of the evidence for recommendations considered prudent by consensus of the Hospital Infection Control Practices Advisory Committee members. A working draft of this guideline was also reviewed by experts in infection control, occupational health, and infectious diseases; however, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Infection Control in Pulmonary Function Laboratories

The role of the pulmonary function (PF) laboratory and PF testing equipment in the transmission of infections has not been established. Although microorganisms have been cultured from parts of in-use pulmonary function testing equipment, a relationship between equipment contamination and transmission of infection or colonization has not been documented. Nosocomial outbreaks of respiratory infections, eg, influenza, tuberculosis, and legionellosis have been described, but transmission of the microorganisms has not been shown to be more likely in the PF laboratory or with PF testing equipment than in other areas in the hospital or with other hospital equipment. Unlike nebulizers, which have been implicated in epidemic and endemic nosocomial gram-negative bacterial infections, PF machines do not generate aerosols. PF testing equipment is thus built without provision for easy machine disassembly and disinfection, except for parts that routinely come in contact with mucous membranes or secretions (eg, mouthpieces, valves, and some tubings).

Human papillomavirus (HPV) vaccine initiation and HPV and vaccine awareness among men 18–26 years in the United States, 2010

BACKGROUND In 2009, the quadrivalent human papillomavirus (HPV) vaccine was licensed by the U.S. Food and Drug Administration for use in men/boys aged 9-26 years. In 2009, the Advisory Committee on Immunization Practices (ACIP) provided a permissive recommendation allowing HPV vaccine administration to this group. PURPOSE To assess HPV vaccination initiation and coverage, evaluate awareness of HPV and HPV vaccine, and identify factors independently associated with such awareness among men aged 18-26 years. METHODS Data from the 2010 National Health Interview Survey were analyzed in 2011. RESULTS In 2010, HPV vaccination initiation among men aged 18-26 years was 1.1%. Among the 1741 men interviewed in this age group, nearly half had heard of HPV (51.8%). Overall, about one third of these men had heard of the HPV vaccine (34.8%). Factors independently associated with a higher likelihood of awareness of both HPV and HPV vaccine among men aged 18-26 years included having non-Hispanic white race/ethnicity; a higher education level; a U.S. birthplace; more physician contacts; private health insurance; received other vaccines; and reported risk behaviors related to sexually transmitted diseases, including HIV. CONCLUSIONS HPV vaccination initiation among men aged 18-26 years in 2010 was low. HPV and HPV vaccine awareness were also low, and messages in this area directed to men are needed. Since ACIP published a recommendation for routine use of HPV4 among men/boys in December 2011, continued monitoring of HPV vaccination uptake among men aged 18-26 years is useful for evaluating the vaccination campaigns, and planning and implementing strategies to increase coverage.

Measles among adults, United States, 1985–1995

OBJECTIVE To report the incidence and characteristics of adult measles cases in the United States and address the adequacy of current vaccination policies to eliminate measles transmission. METHODS Confirmed measles cases reported to the Centers for Disease Control and Prevention (CDC) from 1985 through 1995 were reviewed. Demographic data, exposure setting, and vaccination status of cases were analyzed and incidence rates calculated based on U.S. census data. MAIN OUTCOME MEASURES Age-specific incidence rates of measles and exposure setting. RESULTS Of the 75,204 reported measles cases of known age, 16,006 (21.3%) occurred in adults (persons > 19 years of age). The incidence in persons < 19 years of age (7.8/100,000) was 9.6 times that of all adults. Of 11,520 adult measles cases for whom vaccination status was reported, 8,055 (69.9%) indicated no prior receipt of measles vaccine. Exposure setting was unknown for the majority of adult measles cases (8,475, 52.9%); most frequently reported were college or school (2840, 17.7%), home (1443, 9.0%), or a medical setting (1286, 8.0%). International travel was associated with 289 (1.8%) adult cases. From 1993 to 1995, incidence rates in all age groups were at record low levels, with adults contributing 29.5% (467/1584) of reported cases. CONCLUSION Although adults accounted for a steadily increasing proportion of measles cases during the study period, incidence rates in all age groups have decreased. Most adults who had measles were susceptible because of lack of vaccination rather than vaccine failure. This analysis supports current strategies to ensure the immunity of school/college-aged populations, and health care workers.

Factors Related to Pertussis and Tetanus Vaccination Status Among Foreign-Born Adults Living in the United States

Pertussis is a common vaccine-preventable disease (VPD) worldwide. Its reported incidence has increased steadily in the United States, where it is endemic. Tetanus is a rare but potentially fatal VPD. Foreign-born adults have lower tetanus–diphtheria–pertussis (Tdap) and tetanus–diphtheria (Td) vaccination coverage than do U.S.-born adults. We studied the association of migration-related, socio-demographic, and access-to-care factors with Tdap and Td vaccination among foreign-born adults living in the United States. The 2012 and 2013 National Health Interview Survey data for foreign-born respondents were analyzed. Multivariable logistic regression was conducted to calculate prevalence ratios and 95% confidence intervals, and to identify variables independently associated with Tdap and Td vaccination among foreign-born adults. Tdap and Td vaccination status was available for 9316 and 12,363 individuals, respectively. Overall vaccination coverage was 9.1% for Tdap and 49.8% for Td. Younger age, higher education, having private health insurance (vs. public insurance or uninsured), having visited a doctor in the previous year, and region of residence were independently associated with Tdap and Td vaccination. Among those reporting a doctor visit, two-thirds had not received Tdap. This study provides further evidence of the need to enhance access to health care and immunization services and reduce missed opportunities for Tdap and Td vaccination for foreign-born adults in the United States. These findings apply to all foreign-born, irrespective of their birthplace, citizenship, language and years of residence in the United States. Addressing vaccination disparities among the foreign-born will help achieve national vaccination goals and protect all communities in the United States.

Influenza vaccination coverage among US-Mexico land border crossers: 2009 H1N1 pandemic and 2011–2012 influenza season

BACKGROUND The high volume of US-Mexico land border crossings can facilitate international dissemination of influenza viruses. METHODS We surveyed adult pedestrians crossing into the United States at two international land ports of entry to assess vaccination coverage during the 2009H1N1 influenza pandemic and 2011-2012 influenza season. RESULTS Of 559 participants in 2010, 23.4% reported receipt of the 2009H1N1 vaccine. Of 1423 participants in 2012, 33.7% received the 2011-2012 influenza vaccine. Both years, those crossing the border ≥8 times per month had lower vaccination coverage than those crossing less frequently. US-border residents had lower H1N1 coverage than those in other locations. Vaccination coverage was higher for persons age ≥65 years and, in 2010 only, those with less than high school education. Although most participants believed it is important to get vaccinated, only half believed the influenza vaccine was safe and effective. The main reasons for not receiving the influenza vaccine were beliefs of low risk of disease, time constraints, and concerns about vaccine safety (in 2010) or efficacy (in 2012). CONCLUSIONS International land border crossers are a large and unique category of travelers that require targeted binational strategies for influenza vaccination and education.