Reducing Racial Disparities in Influenza Vaccination Among Children With Asthma

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.

Improving Vaccination for Young Children (IVY): A Stepped-Wedge Cluster Randomized Trial

BACKGROUND

High childhood vaccination rates are critical for public health. We hypothesized that implementation of a vaccine education and quality improvement (QI) program, Improving Vaccinations for Young Children (IVY), would improve childhood vaccine rates.

METHODS

Eight pediatric practices (3 academic-based, 5 community-based) were randomized to implement IVY within a stepped-wedge cluster randomized trial (SWCRT) in middle Tennessee. Two educational modules on vaccines were developed using best practices in instructional design. Modules were provided electronically and were tailored to providers or office staff. Practices completed in-person QI coaching sessions and selected at least 2 vaccination-related QI changes. Data were collected monthly. The primary analysis examined intervention effect on the primary outcome of Combination 10 vaccination status for children who turned 2 in the previous month. Combination 10 status without influenza vaccine was a secondary outcome, and exploratory analyses assessed intervention effects after adjusting for time and practice type.

RESULTS

Data from 4041 patients (1788 control; 2253 intervention) were collected. The intervention effect was not significant on the primary outcome (OR = 1.01; 95% CI [0.76, 1.34]; P > .9), however there were positive intervention effects in secondary and exploratory models analyzing Combination10 rates without flu, including models adjusting for variation over time (0.20; 95% CI [0.04,0.35]; P = .01) and practice type (higher vaccination rate in academic practices, 0.23; 95% CI [0.03,0.42]; P = .03).

CONCLUSIONS

Combination 10 rates were not significantly improved with IVY, yet evidence of beneficial effect on rates without flu vaccine was found. Future studies could evaluate effects over a longer time period and within a larger practice sample.

Improving Influenza Vaccination in Children With Comorbidities: A Systematic Review

CONTEXT

Children with medical comorbidities are at greater risk for severe influenza and poorer clinical outcomes. Despite recommendations and funding, influenza vaccine coverage remains inadequate in these children.

OBJECTIVE

We aimed to systematically review literature assessing interventions targeting influenza vaccine coverage in children with comorbidities and assess the impact on influenza vaccine coverage.

DATA SOURCES

PubMed, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, and Web of Science databases were searched.

STUDY SELECTION

Interventions targeting influenza vaccine coverage in children with medical comorbidities.

DATA EXTRACTION

Two reviewers independently screened articles, extracting studies' methods, interventions, settings, populations, and results. Four reviewers independently assessed risk of bias.

RESULTS

From 961 screened articles, 35 met inclusion criteria. Published studies revealed that influenza vaccine coverage was significantly improved through vaccination reminders and education directed at either patients' parents or providers, as well as by vaccination-related clinic process changes. Interventions improved influenza vaccine coverage by an average 60%, but no significant differences between intervention types were detected. Significant bias and study heterogeneity were also identified, limiting confidence in this effect estimate.

LIMITATIONS

A high risk of bias and overall low quality of evidence limited our capacity to assess intervention types and methods.

CONCLUSIONS

Interventions were shown to consistently improve influenza vaccine coverage; however, no significant differences in coverage between different intervention types were observed. Future well-designed studies evaluating the effectiveness of different intervention are required to inform future optimal interventions.

Influenza epidemics: The role of allergists-immunologists

OBJECTIVE

To review influenza epidemics and pandemics for practicing allergists-immunologists.

DATA SOURCES

English-language articles published in PubMed from 1990 to present with relevance to allergic disorders and articles cited by or similar to these articles.

STUDY SELECTIONS

A total of 472 articles were identified from PubMed. Two independent reviewers appraised the titles for relevance.

RESULTS

A total of 212 relevant articles were selected. Additional articles and government websites increased the number to 295 relevant citations.

CONCLUSION

Influenza epidemics and pandemics have recurred throughout history. Patients with asthma and immunodeficiency are at an increased risk. Nonpharmaceutical interventions, vaccination, and neuraminidase inhibitors are key strategies for the prevention and treatment of influenza epidemics/pandemics. Allergists play a vital role in protecting high-risk groups and increasing influenza vaccination coverage.

Vaccinating in the Emergency Department, a Novel Approach to Improve Influenza Vaccination Rates via a Quality Improvement Initiative

Supplemental Digital Content is available in the text.

Introduction:

Annual influenza vaccination is recommended for all US children 6 months and older to prevent morbidity and mortality. Despite these recommendations, only ~50% of US children are vaccinated annually. Influenza vaccine administration in the pediatric emergency department (ED) is an innovative solution to improve vaccination rates. However, during the 2017–2018 influenza season, only 75 influenza vaccinations were given in this tertiary care ED. We aimed to increase the number of influenza vaccines administered to ED patients from 75 to 1,000 between August 2018 and March 2019.s

Methods:

Process mapping identified potential barriers and solutions. Key interventions included mandatory vaccine screening, creation of a vaccine administration protocol, education for family, provider, and nursing, a revised pharmacy workflow, and weekly staff feedback. Interventions were tested using plan-do-study-act cycles. The process measure was the percent of patients screened for vaccine status. The primary outcome was the number of influenza vaccines administered. The balancing measures were ED length of stay (LOS), wasted vaccines, and financial impact on the institution.

Results:

We included 33,311 children in this study. Screening for vaccine status improved from 0% to 90%. Of those screened, 58% were eligible for vaccination, and 8.5% of eligible patients were vaccinated in the ED. In total, 1,323 vaccines were administered with no significant change in ED LOS (139 min) and no lost revenue to the hospital.

Conclusions:

We implemented an efficient, cost-effective, influenza vaccination program in the pediatric ED and successfully increased vaccinations in a population that might not otherwise receive the vaccine.

Spread tools: a systematic review of components, uptake, and effectiveness of quality improvement toolkits

BACKGROUND

The objective was to conduct a systematic review of toolkit evaluations intended to spread interventions to improve healthcare quality. We aimed to determine the components, uptake, and effectiveness of publicly available toolkits.

METHODS

We searched PubMed, CINAHL, and the Web of Science from 2005 to May 2018 for evaluations of publicly available toolkits, used a forward search of known toolkits, screened references, and contacted topic experts. Two independent reviewers screened publications for inclusion. One reviewer abstracted data and appraised the studies, checked by a second reviewer; reviewers resolved disagreements through discussion. Findings, summarized in comprehensive evidence tables and narrative synthesis addressed the uptake and utility, procedural and organizational outcomes, provider outcomes, and patient outcomes.

RESULTS

In total, 77 studies evaluating 72 toolkits met inclusion criteria. Toolkits addressed a variety of quality improvement approaches and focused on clinical topics such as weight management, fall prevention, vaccination, hospital-acquired infections, pain management, and patient safety. Most toolkits included introductory and implementation material (e.g., research summaries) and healthcare provider tools (e.g., care plans), and two-thirds included material for patients (e.g., information leaflets). Pre-post studies were most common (55%); 10% were single hospital evaluations and the number of participating staff ranged from 17 to 704. Uptake data were limited and toolkit uptake was highly variable. Studies generally indicated high satisfaction with toolkits, but the perceived usefulness of individual tools varied. Across studies, 57% reported on adherence to clinical procedures and toolkit effects were positive. Provider data were reported in 40% of studies but were primarily self-reported changes. Only 29% reported patient data and, overall, results from robust study designs are missing from the evidence base.

CONCLUSIONS

The review documents publicly available toolkits and their components. Available uptake data are limited but indicate variability. High satisfaction with toolkits can be achieved but the usefulness of individual tools may vary. The existing evidence base on the effectiveness of toolkits remains limited. While emerging evidence indicates positive effects on clinical processes, more research on toolkit value and what affects it is needed, including linking toolkits to objective provider behavior measures and patient outcomes.

TRIAL REGISTRATION

PROSPERO registration number: PROSPERO 2014: CRD42014013930 .

Influenza burden, prevention, and treatment in asthma-A scoping review by the EAACI Influenza in asthma task force

To address uncertainties in the prevention and management of influenza in people with asthma, we performed a scoping review of the published literature on influenza burden; current vaccine recommendations; vaccination coverage; immunogenicity, efficacy, effectiveness, and safety of influenza vaccines; and the benefits of antiviral drugs in people with asthma. We found significant variation in the reported rates of influenza detection in individuals with acute asthma exacerbations making it unclear to what degree influenza causes exacerbations of underlying asthma. The strongest evidence of an association was seen in studies of children. Countries in the European Union currently recommend influenza vaccination of adults with asthma; however, coverage varied between regions. Coverage was lower among children with asthma. Limited data suggest that good seroprotection and seroconversion can be achieved in both children and adults with asthma and that vaccination confers a degree of protection against influenza illness and asthma-related morbidity to children with asthma. There were insufficient data to determine efficacy in adults. Overall, influenza vaccines appeared to be safe for people with asthma. We identify knowledge gaps and make recommendations on future research needs in relation to influenza in patients with asthma.