Seasonal influenza vaccination coverage among adult populations in the United States, 2005-2011

The most effective strategy for preventing influenza is annual vaccination. We analyzed 2005-2011 data from the National Health Interview Survey (NHIS), using Kaplan-Meier survival analysis to estimate cumulative proportions of persons reporting influenza vaccination in the 2004-2005 through 2010-2011 seasons for persons aged ≥18, 18-49, 50-64, and ≥65 years, persons with high-risk conditions, and health-care personnel. We compared vaccination coverage by race/ethnicity within each age and high-risk group. Vaccination coverage among adults aged ≥18 years increased from 27.4% during the 2005-2006 influenza season to 38.1% during the 2010-2011 season, with an average increase of 2.2% annually. From the 2005-2006 season to the 2010-2011 season, coverage increased by 10-12 percentage points for all groups except adults aged ≥65 years. Coverage for the 2010-2011 season was 70.2% for adults aged ≥65 years, 43.7% for adults aged 50-64 years, 36.7% for persons aged 18-49 years with high-risk conditions, and 55.8% for health-care personnel. In most subgroups, coverage during the 2010-2011 season was significantly lower among non-Hispanic blacks and Hispanics than among non-Hispanic whites. Vaccination coverage among adults under age 65 years increased from 2005-2006 through 2010-2011, but substantial racial/ethnic disparities remained in most age groups. Targeted efforts are needed to improve influenza vaccination coverage and reduce disparities.

Influenza A (H1N1) 2009 monovalent and seasonal influenza vaccination among adults 25 to 64 years of age with high-risk conditions--United States, 2010

BACKGROUND

Seasonal influenza vaccination has been routinely recommended for adults with high-risk conditions. The Advisory Committee on Immunization Practices recommended that persons 25 to 64 years of age with high-risk conditions be one of the initial target groups to receive H1N1 vaccination during the 2009-2010 season.

METHODS

We used data from the 2009-2010 Behavioral Risk Factor Surveillance System survey. Vaccination levels of H1N1 and seasonal influenza vaccination among respondents 25 to 64 years with high-risk conditions were assessed. Multivariable logistic regression models were performed to identify factors independently associated with vaccination.

RESULTS

Overall, 24.8% of adults 25 to 64 years of age were identified to have high-risk conditions. Among adults 25 to 64 years of age with high-risk conditions, H1N1 and seasonal vaccination coverage were 26.3% and 47.6%, respectively. Characteristics independently associated with an increased likelihood of H1N1 vaccination were as follows: higher age; Hispanic race/ethnicity; medical insurance; ability to see a doctor if needed; having a primary doctor; a routine checkup in the previous year; not being a current smoker; and having high-risk conditions other than asthma, diabetes, and heart disease. Characteristics independently associated with seasonal influenza vaccination were similar compared with factors associated with H1N1 vaccination.

CONCLUSION

Immunization programs should work with provider organizations to review efforts made to reach adults with high-risk conditions during the recent pandemic and assess how and where they can increase vaccination coverage during future pandemics.

Seasonal influenza morbidity estimates obtained from telephone surveys, 2007

OBJECTIVES

We assessed telephone surveys as a novel surveillance method, comparing data obtained by telephone with existing national influenza surveillance systems, and evaluated the utility of telephone surveys.

METHODS

We used the 2007 Behavioral Risk Factor Surveillance System (BRFSS) and the 2007 National Immunization Survey-Adult (NIS-Adult) to estimate the incidence of influenza-like illness (ILI), medically attended ILI, provider-diagnosed influenza, influenza testing, and treatment of influenza with antiviral medications during the 2006-2007 influenza season.

RESULTS

With the January-May BRFSS, among persons aged 18 years and older, the cumulative incidence of seasonal ILI and provider-diagnosed influenza was 37.9 and 5.7 adults per 100 persons, respectively. Monthly medically attended ILI and provider-diagnosed influenza among adults were temporally associated with influenza activity, as documented by national surveillance. With the NIS-Adult survey data, estimated provider-diagnosed influenza, influenza testing, and antiviral treatment were 2.8%, 1.4%, and 0.6%, respectively.

CONCLUSIONS

Our telephone interview-based estimates of influenza morbidity were consistent with those from national influenza surveillance systems. Telephone surveys may provide an alternative method by which population-based influenza morbidity information can be gathered.

Perceptions matter: beliefs about influenza vaccine and vaccination behavior among elderly white, black and Hispanic Americans

BACKGROUND

Knowledge and beliefs about influenza vaccine that differ across racial or ethnic groups may promote racial or ethnic disparities in vaccination.

OBJECTIVE

To identify associations between vaccination behavior and personal beliefs about influenza vaccine by race or ethnicity and education levels among the U.S. elderly population.

METHODS

Data from a national telephone survey conducted in 2004 were used for this study. Responses for 3875 adults ≥ 65 years of age were analyzed using logistic regression methods.

RESULTS

Racial and ethnic differences in beliefs were observed. For example, whites were more likely to believe influenza vaccine is very effective in preventing influenza compared to blacks and Hispanics (whites, 60%; blacks, 47%, and Hispanics, 51%, p<0.01). Among adults who believed the vaccine is very effective, self-reported vaccination was substantially higher across all racial/ethnic groups (whites, 93%; blacks, 76%; Hispanics, 78%) compared to adults who believed the vaccine was only somewhat effective (whites 67%; blacks 61%, Hispanics 61%). Also, vaccination coverage differed by education level and personal beliefs of whites, blacks, and Hispanics.

CONCLUSIONS

Knowledge and beliefs about influenza vaccine may be important determinants of influenza vaccination among racial/ethnic groups. Strategies to increase coverage should highlight the burden of influenza disease in racial and ethnic populations, the benefits and safety of vaccinations and personal vulnerability to influenza disease if not vaccinated. For greater effectiveness, factors associated with the education levels of some communities may need to be considered when developing or implementing new strategies that target specific racial or ethnic groups.

Support for seasonal influenza vaccination requirements among US healthcare personnel

OBJECTIVE

To measure support for seasonal influenza vaccination requirements among US healthcare personnel (HCP) and its associations with attitudes regarding influenza and influenza vaccination and self-reported coverage by existing vaccination requirements.

DESIGN

Between June 1 and June 30, 2010, we surveyed a sample of US HCP ([Formula: see text]) recruited using an existing probability-based online research panel of participants representing the US general population as a sampling frame.

SETTING

General community.

PARTICIPANTS

Eligible HCP who (1) reported having worked as medical doctors, health technologists, healthcare support staff, or other health practitioners or who (2) reported having worked in hospitals, ambulatory care facilities, long-term care facilities, or other health-related settings.

METHODS

We analyzed support for seasonal influenza vaccination requirements for HCP using proportion estimation and multivariable probit models.

RESULTS

A total of 57.4% (95% confidence interval, 53.3%-61.5%) of US HCP agreed that HCP should be required to be vaccinated for seasonal influenza. Support for mandatory vaccination was statistically significantly higher among HCP who were subject to employer-based influenza vaccination requirements, who considered influenza to be a serious disease, and who agreed that influenza vaccine was safe and effective.

CONCLUSIONS

A majority of HCP support influenza vaccination requirements. Moreover, providing HCP with information about the safety of influenza vaccination and communicating that immunization of HCP is a patient safety issue may be important for generating staff support for influenza vaccination requirements.

Influenza A (H1N1) 2009 monovalent vaccination among adults with asthma, U.S., 2010

BACKGROUND

The 2009 pandemic influenza A (H1N1) virus (2009 H1N1) was first identified in April 2009 and quickly spread around the world. The first doses of influenza A (H1N1) 2009 monovalent vaccine (2009 H1N1 vaccine) became available in the U.S. in early October 2009. Because people with asthma are at increased risk of complications from influenza, people with asthma were included among the initial prioritized groups.

PURPOSE

To evaluate 2009 H1N1 vaccination coverage and identify factors independently associated with vaccination among adults with asthma in the U.S.

METHODS

Data from the 2009-2010 BRFSS (Behavioral Risk Factor Surveillance System) influenza supplemental survey were used; responses from March through June 2010 were analyzed to estimate vaccination levels of 2009 H1N1 vaccine among respondents aged 25-64 years with asthma. Multivariable logistic regression and predictive marginal models were performed to identify factors independently associated with vaccination.

RESULTS

Among adults aged 25-64 years with asthma, 25.5% (95% CI=23.9%, 27.2%) received the 2009 H1N1 vaccination. Vaccination coverage ranged from 9.9% (95% CI=6.4%, 15.1%) in Mississippi to 46.1% (95% CI=33.3%, 61.2%) in Maine. Characteristics independently associated with an increased likelihood of vaccination among adults with asthma were as follows: had a primary doctor, had other high-risk conditions, and received seasonal influenza vaccination in the 2009-2010 season.

CONCLUSIONS

Vaccination coverage among adults aged 25-64 years with asthma was only 25.5% and varied widely by state and demographic characteristics. National and state-specific 2009 H1N1 vaccination coverage data for adults with asthma are useful for evaluating the vaccination campaign and for planning and implementing strategies for increasing vaccination coverage in possible future pandemics.

Influenza, hepatitis B, and tetanus vaccination coverage among health care personnel in the United States

BACKGROUND

Health care personnel (HCP) are at risk for exposure to and possible transmission of vaccine-preventable diseases. Maintenance of immunity is an essential prevention practice for HCP. We assessed the recent influenza, hepatitis B, and tetanus vaccination coverage among HCP in the United States.

METHODS

We analyzed data from the 2007 National Immunization Survey-Adult restricted to survey respondents aged 18 to 64 years. Influenza, hepatitis B, and tetanus vaccination coverage levels among HCP were assessed. Multivariable logistic regression was conducted to assess factors independently associated with receipt of vaccination among HCP.

RESULTS

Among HCP aged 18 to 64 years, 46.7% (95% confidence interval [CI]: 39.6%-53.8%) had received influenza vaccination for the 2006-2007 season, and 70.4% (95% CI: 63.9%-76.1%) received tetanus vaccination in the past 10 years; 61.7% (95% CI: 52.5%-70.2%) had received 3 or more doses of hepatitis B vaccination among HCP aged 18 to 49 years. Multiple logistic regression analysis showed that being married was associated with influenza vaccination coverage, higher education level was associated with hepatitis B vaccination coverage, and younger age was significantly associated with tetanus vaccination among HCP. Among those HCP who did not receive influenza vaccination, the most common reason reported was respondent concerns about vaccine safety and adverse effects.

CONCLUSION

By 2007, influenza and hepatitis B vaccination coverage among HCP remained well below the Healthy People 2010 objectives. Tetanus vaccination level was 70%, and this study provided a baseline data for tetanus vaccination among HCP. Innovative strategies are needed to further increase vaccination coverage among HCP.

Herpes zoster vaccination among adults aged 60 years and older, in the U.S., 2008

BACKGROUND

Shingles (herpes zoster [HZ]) is a localized, generally painful and debilitating disease that occurs most frequently among older adults. It is caused by reactivation of varicella-zoster virus. HZ causes substantial morbidity, especially among older adults. The vaccine to prevent HZ was approved by Food and Drug Administration and recommended by the Advisory Committee for Immunization Practices for people aged ≥60 years in 2006 (these recommendations were published in 2008).

PURPOSE

To examine HZ vaccination among people aged ≥60 years in the U.S. in 2008.

METHODS

Data from the 2008 National Health Interview Survey among people aged ≥60 years were analyzed in 2010. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with HZ vaccination. Potential missed opportunities also were assessed.

RESULTS

By 2008, only 6.7% (95% CI=5.9%, 7.6%) of adults aged ≥60 years reported having had HZ vaccination. The level of HZ vaccination coverage was lower (4.7%) among people aged 60-64 years compared to people aged 65-74 years (7.4%); 75-84 years (7.6%); and ≥85 years (8.2%). Coverage was statistically higher for non-Hispanic whites (7.6%) compared with non-Hispanic blacks (2.5%) and Hispanics (2.1%). Among people aged ≥60 years who reported never receiving HZ vaccination, 95.1% reported at least one missed opportunity to be vaccinated. People more likely to report ever having been vaccinated were older, female, non-Hispanic white, married, more educated, and reporting received influenza vaccination in the past year.

CONCLUSIONS

By 2008, HZ vaccination coverage was 6.7%. The coverage level was low among all groups, but it was lowest among minority groups. Increased efforts are needed to remove barriers and to enable HZ vaccination among all adults aged ≥60 years.

Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010

This report updates the 2009 recommendations by CDC's Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine for the prevention and control of influenza (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2009;58[No. RR-8] and CDC. Use of influenza A (H1N1) 2009 monovalent vaccine---recommendations of the Advisory Committee on Immunization Practices [ACIP], 2009. MMWR 2009;58:[No. RR-10]). The 2010 influenza recommendations include new and updated information. Highlights of the 2010 recommendations include 1) a recommendation that annual vaccination be administered to all persons aged >or=6 months for the 2010-11 influenza season; 2) a recommendation that children aged 6 months--8 years whose vaccination status is unknown or who have never received seasonal influenza vaccine before (or who received seasonal vaccine for the first time in 2009-10 but received only 1 dose in their first year of vaccination) as well as children who did not receive at least 1 dose of an influenza A (H1N1) 2009 monovalent vaccine regardless of previous influenza vaccine history should receive 2 doses of a 2010-11 seasonal influenza vaccine (minimum interval: 4 weeks) during the 2010--11 season; 3) a recommendation that vaccines containing the 2010-11 trivalent vaccine virus strains A/California/7/2009 (H1N1)-like (the same strain as was used for 2009 H1N1 monovalent vaccines), A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like antigens be used; 4) information about Fluzone High-Dose, a newly approved vaccine for persons aged >or=65 years; and 5) information about other standard-dose newly approved influenza vaccines and previously approved vaccines with expanded age indications. Vaccination efforts should begin as soon as the 2010-11 seasonal influenza vaccine is available and continue through the influenza season. These recommendations also include a summary of safety data for U.S.-licensed influenza vaccines. These recommendations and other information are available at CDC's influenza website (http://www.cdc.gov/flu); any updates or supplements that might be required during the 2010-11 influenza season also will be available at this website. Recommendations for influenza diagnosis and antiviral use will be published before the start of the 2010-11 influenza season. Vaccination and health-care providers should be alert to announcements of recommendation updates and should check the CDC influenza website periodically for additional information.

Behavior and beliefs about influenza vaccine among adults aged 50-64 years

OBJECTIVE

To examine demographics and beliefs about influenza disease and vaccine that may be associated with influenza vaccination among 50- to 64-year-olds.

METHODS

A national sample of adults aged 50-64 years surveyed by telephone.

RESULTS

Variables associated with receiving influenza vaccination included age, education level, recent doctor visit, and beliefs about vaccine effectiveness and vaccine safety. Beliefs about influenza vaccination varied by race/ethnicity, age, education, and gender.

CONCLUSION

The finding of demographic differences in beliefs suggests that segmented communication messages designed for specific demographic subgroups may help to increase influenza vaccination coverage.

Human papillomavirus (HPV) awareness and vaccination initiation among women in the United States, National Immunization Survey-Adult 2007

OBJECTIVES

To report awareness of human papillomavirus (HPV) and HPV vaccine among women aged 18-49 years and, for recommended women aged 18-26 years, estimate initiation of HPV vaccination and describe factors associated with vaccination initiation among a national sample.

METHODS

Data were analyzed from the National Immunization Survey-Adult, a nationally representative telephone survey conducted May-August 2007. Questions were asked about awareness of HPV and HPV vaccine and vaccine receipt.

RESULTS

A total of 1102 women aged 18-49 years were interviewed, 168 were aged 18-26 years. Overall, awareness of HPV (84.3%) and of HPV vaccine (78.9%) were high. Among women 18-26 years of age, vaccination initiation (> or =1 dose) was 10%. Factors associated with vaccination included not being married, living > or =200% of the federal poverty index, having health insurance, and vaccination with hepatitis B vaccine. HPV vaccination initiation among women aged 27-49 years was 1%.

CONCLUSIONS

Awareness of HPV and HPV vaccine were high. Two to 5 months after national HPV vaccination recommendations were published, one in ten women 18-26 years old had initiated the HPV vaccine series. Women at a higher socio-economic level were more likely to receive the vaccination. Vaccination initiation and completion will likely increase over the next years. Monitoring uptake is important to identify sub-groups that may not be receiving the vaccination.

Herpes zoster vaccination among adults aged 60 years or older in the United States, 2007: uptake of the first new vaccine to target seniors

BACKGROUND

Approximately one million new cases of shingles (herpes zoster [HZ]), a severely painful and debilitating disease caused by reactivation of varicella-zoster virus (VZV), occur in the United States each year. HZ incidence increases with age, especially after age 50. A vaccine to prevent HZ and its sequelae was licensed in May 2006 for those aged 60 years or older, making it the first new vaccine targeted to this age group in many years. In October 2006 the Advisory Committee on Immunization Practices (ACIP) recommended HZ vaccination of persons aged > or =60 years; these recommendations were published in 2008. We examined HZ vaccination coverage among persons aged > or =60 years in the U.S. in 2007, and evaluated factors affecting the uptake of HZ vaccine in this population.

METHODS

Data from the 2007 National Immunization Survey-Adult (NIS-Adult) restricted to individuals aged > or =60 years were analyzed using SUDAAN software to estimate national HZ vaccination coverage, and reasons for not receiving the HZ vaccine. We used multivariable logistic regression analysis to identify factors independently associated with HZ vaccination.

RESULTS

Of 3662 respondents, 1.9% (95% confidence interval=1.3%, 2.8%) reported having received the HZ vaccine. A total of 72.9% of respondents were unaware of the HZ vaccine but 77.8% stated that they would accept HZ vaccination if their doctor recommended it. Of the remaining 556 respondents, key reasons reported for not accepting HZ vaccine included 'vaccination not needed' (34.8%), 'not at risk' (12.5%), and 'don't trust in doctors or medicine' (9.5%).

CONCLUSIONS

Soon after its availability in the United States, coverage among adults recommended to receive the HZ vaccine was low. Our data provide evidence that the lack of patient awareness and of physician recommendations were barriers to vaccine uptake.

U.S. Healthcare personnel and influenza vaccination during the 2004-2005 vaccine shortage

BACKGROUND

Healthcare personnel with direct patient contact were prioritized for influenza vaccination during the 2004-2005 vaccine shortage. Data about vaccination coverage among healthcare personnel during vaccine shortages are limited.

METHODS

Behavioral Risk Factor Surveillance System 2005 data were analyzed in 2007 for a sample of healthcare facility workers (HCFW) aged 18-64 with (n=3456) and without (n=1153) direct patient contact and non-HCFWs (n=39,405). Chi-square tests and logistic regression were used to identify factors associated with influenza vaccination among HCFWs and to compare HCFWs with non-HCFWs with regard to the main reason for nonvaccination during the shortage.

RESULTS

Vaccination coverage was 37% (SE +/- 3.1) among HCFWs with direct patient contact and 25% (SE +/- 5.7) among those without. In multivariate analysis, coverage was higher among HCFWs who were older, more educated, and with higher incomes and better access to health care. The reason most commonly reported by HCFWs and non-HCFWs for nonvaccination was the belief that they did not need vaccination (35% versus 40%, respectively; p<0.05).

CONCLUSIONS

Even in a time of influenza-vaccine shortage, when most healthcare personnel were targeted for vaccination, their uptake of the vaccine remained suboptimal. Continued efforts are needed to develop effective interventions to improve the use of influenza vaccination among healthcare workers.

Status of influenza and pneumococcal vaccination among older American Indians and Alaska Natives

OBJECTIVES

We sought to estimate the influenza and pneumococcal vaccination coverage among older American Indian and Alaska Native (AIAN) adults nationally and the impact of sociodemographic factors, variations by geographic region, and access to services on vaccination coverage.

METHODS

We obtained our sample of 1981 AIAN and 179845 White respondents 65 years and older from Behavioral Risk Factor Surveillance System data from 2003 to 2005. Logistic regression provided predictive marginal vaccination coverage for each covariate and adjusted for demographic characteristics and access to care.

RESULTS

Unadjusted influenza coverage estimates were similar between AIAN and White respondents (68.1% vs 69.5%), but pneumococcal vaccination was lower among AIAN respondents (58.1% vs 67.2%; P<.01). After multivariable adjustment for sociodemographic characteristics, self-reported coverage for both vaccines was statistically similar between AIAN and White adults.

CONCLUSIONS

Although there was no disparity in influenza coverage, pneumococcal coverage was lower among AIAN than among White respondents, probably because of sociodemographic risk factors. Regional variation indicates a need to monitor coverage and target interventions to reduce disparities within geographically and culturally diverse subpopulations of AIAN persons.

Influenza vaccination of recommended adult populations, U.S., 1989-2005

OBJECTIVE

To assess influenza vaccination coverage among recommended adult populations in the United States.

METHODS

Data from the 1989 to 2005 National Health Interview Surveys (NHISs), weighted to reflect the civilian, non-institutionalized U.S. population, were analyzed to determine self-reported levels of influenza vaccination among persons aged >or=65 years, persons with high-risk conditions, health care workers (HCW), pregnant women, and persons living in households with at least one identified person at high risk of complications from influenza infection. We stratified data by race/ethnicity to identify racial/ethnic disparities.

RESULTS

Vaccination coverage levels among all recommended adult populations peaked in 2004, then declined in 2005 in association with the 2004-2005 vaccine shortage. Coverage for adults >or=65 years of age increased from 30.1% (95% confidence interval [CI]: 28.8-31.3) in 1989 to 70.0% (68.0-71.5) in 2004. In 2004, coverage was 40.7% (39.0-42.5) for all adults 50-64 years, 27.2% (24.6-29.9) for adults aged 18-49 years with high-risk conditions, 43.2% (39.9-46.6) for health care workers, 21.1% (19.1-23.4) for non-high-risk adults aged 18-64 years with a high-risk household member, and 14.4% (8.8-22.9) for pregnant women. Among each of the recommended adult sub-groups, vaccination coverage was higher for non-Hispanic whites compared to minority groups.

CONCLUSIONS

By 1997, influenza vaccination coverage had exceeded the national 2000 objective of 60% among persons aged >or=65 years, but by 2004 still remains well below the national 2010 target of 90%. Coverage levels for other groups targeted for influenza vaccination also are far short of the Healthy People 2000 and 2010 goals of 60% for persons aged 18-64 years with high-risk conditions, health care workers, and pregnant women. A concerted effort to increase provider adoption of standards for adult immunization, public awareness, and stable vaccine supplies are needed to improve influenza vaccination rates among recommended groups, and to reduce racial and ethnic disparities.

Influenza vaccination coverage of children aged 6 to 23 months: the 2002-2003 and 2003-2004 influenza seasons

BACKGROUND

Beginning in 2002 the Advisory Committee on Immunization Practices encouraged, when feasible, annual influenza vaccination of all children aged 6 to 23 months and household contacts and out-of-home caregivers of children < 2 years of age.

OBJECTIVE

We sought to report influenza vaccination coverage for the 2002-2003 and 2003-2004 influenza seasons among children aged 6 to 23 months according to demographic and immunization-provider characteristics.

METHODS

Data from the 2003 and 2004 National Immunization Survey were analyzed. Two measures of childhood influenza vaccination are reported: receipt of > or = 1 influenza vaccination and full vaccination (ie, receipt of the appropriate number of doses on the basis of previous vaccination history). chi2 tests and logistic-regression analyses to test for associations between influenza vaccination status and demographic characteristics were performed.

RESULTS

In the 2002-2003 and 2003-2004 influenza seasons only 7.4% and 17.5%, respectively, of children aged 6 to 23 months received > or = 1 influenza vaccination, whereas only 4.4% and 8.4%, respectively, were fully vaccinated. In both seasons, adjusted influenza vaccination coverage was significantly lower among children living below the poverty level; non-Hispanic black children; older children; children with less-educated mothers; children vaccinated only at public clinics; and children not residing in a metropolitan statistical area.

CONCLUSION

During the first 2 years of the Advisory Committee on Immunization Practices' encouragement for children aged 6 to 23 months to receive influenza vaccination, coverage was low, with significant demographic differences in receipt of vaccination. Beginning with the 2004-2005 influenza season, they replaced the encouragement with a recommendation that children aged 6 to 23 months receive annual influenza vaccination. Substantial work remains to fully and equitably implement this new recommendation and ensure vaccination with 2 doses for previously unvaccinated children.

Racial and ethnic disparities in influenza vaccination coverage among adults during the 2004-2005 season

During the 2004-2005 influenza season, the supply of vaccine to the United States was significantly reduced. In response, the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices issued interim recommendations for prioritizing vaccination. Given trends in racial/ethnic disparities in vaccination for influenza, the authors assessed the impact of the shortage on those historically less likely to be vaccinated. Using data from the Behavioral Risk Factor Surveillance System, they considered vaccination coverage among those non-Hispanic Whites, non-Hispanic Blacks, and Hispanics who had priority for being vaccinated during the 2004-2005 influenza season. The vaccine shortage had a significant negative effect on coverage among adults aged 65 years or older across the three racial/ethnic groups. Yet, the magnitude of the disparities in coverage did not change significantly from previous seasons. This finding may imply similar patterns of vaccine-seeking behavior during shortage and nonshortage years. No racial/ethnic differences were seen among adults aged 18-64 years, which likely reflects the higher percentage of health-care workers in this age group. Yearly monitoring of influenza vaccine coverage is important to assess the long-term impact of shortages on overall coverage and gaps in coverage between racial/ethnic groups.

A community-based study of hepatitis B infection and immunization among young adults in a high-drug-use neighborhood in New York City

We conducted a community-based study of the prevalence and correlates of hepatitis B virus (HBV) infection and immunization among young adults in a "drug supermarket" neighborhood in New York City. Four hundred eighty-nine young adults ages 18-24 years were recruited from Bushwick, Brooklyn through multistage household probability sampling (n = 332) and targeted sampling (n = 157), interviewed, and tested for three hepatitis B markers (HBsAg, anti-HBc, and anti-HBs). Serological evidence of HBV infection was found in 8.0% (6.0% in the household sample and 12.1% in the targeted sample) and of hepatitis B immunization in 19.6% (22.6% in the household sample and 13.4% in the targeted sample). HBV infection was higher among young adults who either used crack or injected drugs and among those who traded sex for money or drugs. Having Medicaid was significantly associated with lower odds of infection in the household sample and higher odds of immunization in the targeted sample. Although adolescent hepatitis B immunization has been a public health priority in the United States since 1995, nearly three-quarters of young adults in this community did not have serological evidence of being either exposed or immunized. Whereas subsequent younger generations benefited from universal childhood hepatitis B immunization, this particular cohort of young adults who live in communities like Bushwick presents a unique group for prevention intervention.

Factors associated with receiving hepatitis B vaccination among high-risk adults in the United States: an analysis of the National Health Interview Survey, 2000

BACKGROUND AND OBJECTIVES

Although an effective vaccine against hepatitis B has been licensed in the United States since 1981, and successful childhood vaccination programs have been implemented, hepatitis B virus transmission continues to occur among high-risk adults. In this study, we identified factors associated with receipt of one or more doses of hepatitis B vaccine among adults at high risk for hepatitis B infection.

METHODS

We analyzed data from the 2000 National Health Interview Survey of selected adults ages 18-49 years who were at high risk for hepatitis B infection (n=1,036). Multivariable regression analysis was conducted to determine factors independently associated with vaccination.

RESULTS

Although more than 80% (n=841) of high-risk adults reported previous visits to a clinician during the past year, only 30% (n=498) of men and 31% (n=538) of women reported having received a single dose of hepatitis B vaccine. Young age (18-29 years), never being married, past blood donation, and past human immunodeficiency virus (HIV) testing were independently associated with receiving vaccination for men. For women, young age (18-29 years) and previous vaccinations were significant factors associated with vaccination receipt. Additionally, having a primary care source (men) and seeing an obstetrician-gynecologist provider in the past year (women) were significantly associated with vaccination.

CONCLUSIONS

Hepatitis B vaccination rates for high-risk adults are low, and missed opportunities are frequent. Additional strategies are needed to increase immunization rates of adults at high risk for hepatitis B.

Economic analysis of promotion of hepatitis B vaccinations among Vietnamese-American children and adolescents in Houston and Dallas

OBJECTIVE

To ascertain the cost-effectiveness and benefit-cost ratios of 2 public health campaigns conducted in Dallas and Houston in 1998-2000 for "catch-up" hepatitis B vaccination of Vietnamese-Americans born 1984-1993.

DESIGN

Program evaluation.

SETTING

Houston and Dallas, Texas.

PARTICIPANTS

A total of 14,349 Vietnamese-American children and adolescents.

INTERVENTIONS

Media-led information and education campaign in Houston, and community mobilization strategy in Dallas. Outcomes were compared with a control site: Washington, DC.

MAIN OUTCOME MEASURES

Receipt of 1, 2, or 3 doses of hepatitis B vaccine before and after the interventions, costs of interventions, cost-effectiveness ratios for intermediate outcomes, intervention cost per discounted year of life saved, and benefit-cost ratio of the interventions.

RESULTS

The number of children who completed the series of 3 hepatitis B vaccine doses increased by 1176 at a total cost of 313,904 dollars for media intervention, and by 390 and at 169,561 dollars for community mobilization. Costs per child receiving any dose, per dose, and per completed series were 363 dollars, 101 dollars, and 267 dollars for media intervention and 387 dollars, 136 dollars, and 434 dollars for community mobilization, respectively. For media intervention, the intervention cost per discounted year of life saved was 9954 dollars and 131 years of life were saved; for community mobilization, estimates were 11,759 dollars and 60 years of life. The benefit-cost ratio was 5.26:1 for media intervention and 4.47:1 for community mobilization.

CONCLUSION

Although the increases in the number of children who completed series of 3 doses were modest for both the Houston and Dallas areas, both media education and, to a lesser degree, community mobilization interventions proved cost-effective and cost-beneficial.

Successful promotion of hepatitis B vaccinations among Vietnamese-American children ages 3 to 18: results of a controlled trial

OBJECTIVE

Chronic infection with the hepatitis B virus is endemic in Southeast Asian populations, including Vietnamese. Previous research has documented low rates of hepatitis B vaccine coverage among Vietnamese-American children and adolescents ages 3 to 18. To address this problem, we designed and tested in a controlled trial 2 public health outreach "catch-up" campaigns for this population.

DESIGN

In the Houston, Texas metropolitan area, we mounted a media-led information and education campaign, and in the Dallas metropolitan area, we organized a community mobilization strategy. We evaluated the success of these interventions in a controlled trial, using the Washington, DC metropolitan area as a control site. To do so, we conducted computer-assisted telephone interviews with random samples of approximately 500 Vietnamese-American households in each of the 3 study sites both before and after the interventions. We assessed respondents' awareness and knowledge of hepatitis B and asked for hepatitis B vaccination dates for a randomly selected child in each household. When possible, we validated vaccination dates through direct contact with each child's providers.

RESULTS

Awareness of hepatitis B increased significantly between the pre- and postintervention surveys in all 3 areas, and the increase in the media education area (+21.5 percentage points) was significantly larger than in the control area (+9.0 percentage points). At postintervention, significantly more parents knew that free vaccines were available for children in the media education (+31.9 percentage points) and community mobilization (+16.7 percentage points) areas than in the control area (+4.7 percentage points). An increase in knowledge of sexual transmission of hepatitis B virus was significant in the media education area (+14.0 percentage points) and community mobilization (+13.6 percentage points) areas compared with the control area (+5.2 percentage points). Parent- or provider-reported data (n = 783 for pre- and n = 784 for postintervention surveys) suggest that receipt of 3 hepatitis B vaccinations increased significantly in the community mobilization area (from 26.6% at pre- to 38.8% at postintervention) and in the media intervention area (28.5% at pre- and 39.4% at postintervention), but declined slightly in the control community (37.8% at pre- and 33.5% at postintervention). Multiple logistic regression analyses estimated that the odds of receiving 3 hepatitis B vaccine doses were significantly greater for both community mobilization (odds ratio 2.15, 95% confidence interval 1.16-3.97) and media campaign (odds ratio 3.02, 95% confidence interval 1.62-5.64) interventions compared with the control area. The odds of being vaccinated were significantly greater for children who had had at least 1 diphtheria-tetanus-pertussis shot, and whose parents were married, knew someone with liver disease, had heard of hepatitis B, and had greater knowledge about hepatitis B. The odds of being vaccinated were significantly lower for older children.

CONCLUSIONS

Both community mobilization and media campaigns significantly increased the knowledge of Vietnamese-American parents about hepatitis B vaccination, and the receipt of "catch-up" vaccinations among their children.

Hepatitis B surface antigen prevalence among pregnant women in urban areas: implications for testing, reporting, and preventing perinatal transmission

OBJECTIVES

To estimate race/ethnicity-specific prevalence of hepatitis B surface antigen (HBsAg) in pregnant urban women and to evaluate factors associated with maternal HBsAg testing.

METHODS

A multicenter, retrospective chart review was conducted of a racially/ethnically stratified random sample of maternal/infant charts of 10 523 women who gave birth to live infants during 1990-1993 in 4 urban areas in the United States. Data were collected on multiple variables, including demographic variables, HBsAg test dates and results, prenatal care type, and amount and source of payment.

RESULTS

HBsAg prevalence among white non-Hispanics was 0.60% (95% confidence interval [CI]: 0.22-0.98), black non-Hispanics 0.97% (95% CI: 0.48-1.47), Hispanics 0.14% (95% CI: 0.01-0.26), and Asians 5.79% (95% CI: 4.42-7.16). HBsAg testing rates increased from 56.6% in 1990 to 78.2% in 1993. Factors associated with not being tested varied by urban area, but in the combined area model, they were having no or private prenatal care (odds ratios: 18.75 and 5.07, respectively) and being black (odds ratios: 2.08). Only 20.9% (95% CI: 19.1%-22.8%) of those not tested prenatally were tested at delivery. The expected number of infants born to HBsAg-positive study-area women was 3327 using study prevalence rates, compared with 1761 using national rates.

CONCLUSIONS

To help ensure that all urban infants who are born to HBsAg-positive women receive appropriate prophylaxis, health officials in urban areas should use urban-area prevalence rates to ascertain completeness of reporting maternal HBsAg positivity. Needed steps to increase maternal HBsAg testing rates include ensuring that more pregnant women receive prenatal care, promoting testing by private providers, educating providers about testing in all racial and ethnic groups, and reminding providers to test at delivery those women not tested prenatally.

Impact of four urban perinatal hepatitis B prevention programs on screening and vaccination of infants and household members

During 1992-2000, the authors studied compliance with perinatal hepatitis B prevention recommendations, including vaccination of household contacts, at four metropolitan sites in Connecticut, Georgia, Texas, and Michigan. Demographic and hepatitis B-related knowledge, attitudes, practices, and barrier data were collected on pregnant women testing positive for hepatitis B surface antigen and on their infants, children, and household and sexual contacts. Generalized estimating equations with repeated measures in a multivariable model were used to obtain adjusted relative risks of household noncompliance. In 1,458 households studied, 1,490 infants and 3,502 other contacts were identified. Among infants, vaccination start/finish rates were 92%/72%, and 73% were serotested postvaccination. Prevaccination serotesting rates among contacts were 22% preenrollment and 47% postenrollment. Among 2,519 contacts whose immunity status was susceptible or unknown, the vaccination start/finish rate was 45%/41%. Site-specific adjusted relative risks of household noncompliance compared with Texas were 2.14 (Michigan), 1.96 (Georgia), and 1.30 (Connecticut). Mother's birth in the United States increased the relative risk of household noncompliance (1.32). Home visits, implemented only in Texas, most likely account for higher compliance rates in that state. Findings may indicate that many perinatal programs could achieve higher overall rates of infant and contact identification; pre- and postvaccination serologic testing in contacts and infants, respectively; and contact hepatitis B vaccination.

Antibody response to postexposure prophylaxis in infants born to hepatitis B surface antigen-positive women

BACKGROUND

Annually 20,000 infants are born to hepatitis B surface antigen (HBsAg)-positive US women. Without prophylaxis 30% risk chronic hepatitis B virus infection, and 25% of those risk dying from resulting liver cirrhosis or liver cancer as adults.

METHODS

We attempted to interview each HBsAg-positive pregnant woman reported to the health department between 1992 and 1997, to provide their infants with immunoprophylaxis at birth and in the clinic or home and to serotest at 9 to 15 months of age.

RESULTS

Of 879 women reported, 92% enrolled; 787 delivered 796 live infants; 91% of infants received hepatitis B immunoglobulin; 98, 95 and 89% received hepatitis B vaccine (HepB) Doses 1, 2 and 3, respectively; and 80% were serotested. Of these 2.2% were HBsAg-positive and 97% had antibody to HBsAg (anti-HBs) of > or =10 mIU/ml. Anti-HBs concentrations measured in 504 infants were 10 to 99 mIU/ml (25%), 100 to 999 mIU/ml (43%) and > or =1000 mIU/ml (29%). Serotesting was less likely among infants of mothers <20 years of age [odds ratio (OR) 2.5]; white, non-Hispanic (OR 2.8); or with a household income of <$15,000/year (OR 2.0). Lower antibody titers were found when serotesting at 4 to 12 months than at <4 months after HepB-3 (OR 1.8 to 4.4), with HepB-3 receipt <6 months after HepB-2 (OR 2.5) and when household income was <$15,000/year (OR 2.1).

CONCLUSIONS

Centralized case management with home visits resulted in high rates of complete immunoprophylaxis and postvaccination testing among infants born to HBsAg-positive women. Perinatal immunoprophylaxis was immunogenic under routine public health use, with higher anti-HBs titers occurring in infants tested <4 months postvaccination. Because infants in households with low income had higher rates of nonprotective antibody responses, they may benefit from extra efforts to ensure that serotesting is conducted postvaccination.

The epidemiology of hepatitis B vaccination catch-up among AAPI children in the United States

PURPOSE

The purpose of this paper is to report on progress in addressing a major health disparity. During the 1970s hepatitis B virus (HBV) infection rates in U.S. Asian American and Pacific Islander (AAPI) children were 20-30 times higher than among white children. These rates remained 17 times greater among AAPI children into the 1990s. Now, although almost 90% of AAPI children born after 1993 receive hepatitis B vaccine (HepB) in time to prevent HBV infection, many born before 1993 do not. Among this group, household HBV transmission remains relatively high--0.5%-1% annually.

METHODS

In the mid-1980s household HBV transmission was studied among AAPI communities and by 1999 HepB coverage surveys, demonstration projects, and interventions in schools, communities, and provider offices were conducted followed by ethnic-specific controlled trials and cost-benefit research. The goal was established to reach 90% coverage by 2004.

PRINCIPAL FINDINGS

Since 1995, catch-up efforts raised HepB coverage among AAPI children born 1983-1993 from 10% to 60%. Now, AAPI children targeted for catch-up are 9-19 years of age. Currently, most students entering middle school have not received their HepB series, but recently enacted middle school entry requirements in 26 states and Washington D.C. ensure at least 60% of AAPI students receive HepB by 12 years of age. High school students are less likely to have received HepB--no high school entry regulations are present to ensure vaccination.

CONCLUSIONS

Much progress has been made toward eliminating this health disparity. More progress can be made if more health departments in the largest cities conduct high school HepB interventions, starting in schools with the highest numbers of AAPI. In addition, physicians and nurses can remove existing barriers to vaccination services and implement effective tracking/reminder/recall procedures to ensure the AAPI teenagers in their practice receive HepB.

Economic analysis of a child vaccination project among Asian Americans in Philadelphia, Pa

OBJECTIVE

To ascertain the cost-effectiveness and the benefit-cost ratios of a community-based hepatitis B vaccination catch-up project for Asian American children conducted in Philadelphia, Pa, from October 1, 1994, to February 11, 1996.

DESIGN

Program evaluation.

SETTING

South and southwest districts of Philadelphia.

PARTICIPANTS

A total of 4384 Asian American children.

INTERVENTIONS

Staff in the community-based organizations (1) educated parents about the hepatitis B vaccination, (2) enrolled physicians in the Vaccines for Children program, and (3) visited homes of children due for a vaccine dose. Staff in the Philadelphia Department of Public Health developed a computerized database; sent reminder letters for children due for a vaccine dose; and offered vaccinations in public clinics, health fairs, and homes.

MAIN OUTCOME MEASURES

The numbers of children having received 1, 2, or 3 doses of vaccine before and after the interventions; costs incurred by the Philadelphia Department of Public Health and the community-based organizations for design, education, and outreach activities; the cost of the vaccination; cost-effectiveness ratios for intermediate outcomes (ie, per child, per dose, per immunoequivalent patient, and per completed series); discounted cost per discounted year of life saved; and the benefit-cost ratio of the project.

RESULTS

For the completed series of 3 doses, coverage increased by 12 percentage points at a total cost of $268 660 for design, education, outreach, and vaccination. Costs per child, per dose, and per completed series were $64, $119, and $537, respectively. The discounted cost per discounted year of life saved was $11 525, and 106 years of life were saved through this intervention. The benefit-cost ratio was 4.44:1.

CONCLUSION

Although the increase in coverage was modest, the intervention proved cost-effective and cost-beneficial.

Hepatitis B immunization coverage among Vietnamese-American children 3 to 18 years old

OBJECTIVE

Persons with chronic hepatitis B virus (HBV) infection are at increased risk of chronic hepatitis, cirrhosis, and liver cancer. Although HBV infection is relatively uncommon in the United States, the disease is endemic in persons born in Southeast Asia, including Vietnamese-Americans. Current US infant immunization recommendations and state-mandated school-entry programs have left many nontargeted age-cohorts unvaccinated and at risk of infection. To assess the need for catch-up hepatitis B immunizations, this study reports the hepatitis B immunization rates of Vietnamese-American children 3 to 18 years old living in the metropolitan areas of Houston and Dallas, Texas, and the Washington, DC, area.

DESIGN

We conducted 1508 telephone interviews with random samples of Vietnamese households in each of the 3 study sites. We asked for hepatitis B immunization dates for a randomly selected child in each household. Attempts were made to verify immunization dates through direct contact with each child's providers. Low and high estimates of coverage were calculated using reports from providers when reached (n = 720) and for the entire sample (n = 1508).

RESULTS

Rates of having 3 hepatitis B vaccinations ranged from 13.6% (entire sample) to 24.1% (provider reports, Dallas), 10. 3% to 26.4% (Houston), and 18.1% to 37.8% (Washington, DC). Children living in the Texas sites, older children, children whose families had lived in the United States for a longer time, and children whose provider was Vietnamese or who had an institutional provider were less likely to have been immunized. The odds of being immunized were greater, however, for children who had had at least 1 diphtheria, tetanus toxoid, and pertussis shot, and whose parents had heard about HBV infection, and were married.

CONCLUSIONS

The low rates of hepatitis B vaccine coverage among children and adolescents portend a generation which, too old to benefit from infant programs and school entry laws, will grow into adulthood without the protection of immunization. Increased efforts are needed to design successful catch-up campaigns for this population.

Vaccine recommendations for patients on chronic dialysis. The Advisory Committee on Immunization Practices and the American Academy of Pediatrics

Pediatric patients on dialysis should receive all the vaccines currently recommended by the ACIP and the AAP for healthy children, except the oral polio vaccine (34, 35). Adult patients should receive the hepatitis B vaccine series, pneumococcal vaccine, yearly influenza vaccinations, tetanus-diphtheria toxoids, and varicella vaccine, if they are susceptible (33, 48, 69). Vaccines are well tolerated by these patients (33), but higher doses and/or additional boosters may be required periodically to adequately protect dialysis patients from vaccine-preventable diseases (33, 36, 37, 82, 83). Following vaccination, antibody concentrations for hepatitis B vaccine should be measured annually and booster doses administered when antibody concentrations fall below protective levels (33, 38). Although both children and adults on dialysis may show an impaired and/or delayed immunologic response to certain antigens, particularly hepatitis B virus and S. pneumoniae, appropriate immunizations can significantly reduce the risk of serious complications from vaccine-preventable diseases (11, 84). Because the protection these vaccines provide may be incomplete or transient, infection control strategies at hospitals and other health care facilities should be implemented simultaneously. Health care providers are encouraged to assess each patients need for vaccinations individually and formulate immunization strategies early in the course of progressive renal disease, ideally before the patient requires dialysis.

Applications of a method for setting air quality standards based on epidemiological data

A method for setting air quality standards for long-term cumulative exposures of a population based on epidemiological studies has been developed. It uses exposure estimates interpolated from monitoring stations to zip code centroids, each month applied to zip code by month residence histories of the population. Two alternative cumulative exposure indices are used--hours in excess of a threshold, and the sum of concentrations above a threshold. The indices are then used with multiple logistic regression models for the health outcome data to form dose response curves for relative risk, adjusting for covariates. These curves are useful for determination of at what exposure amounts and threshold levels, effects which have both statistical and public health significance begin to occur. The method is applied to a ten year follow-up of a sub cohort of 7,343 members of the National Cancer Institute-funded Adventist Health Study. Up to 20 years of residence history was available. Analysis for prevalence of symptoms was conducted for four air pollutants--total oxidants, sulfur dioxide, nitrogen dioxide, and total suspended particulates. For each pollutant, cumulated exposures were calculated above each of five different thresholds. Statistically significant effects were noted for total suspended particulates, total oxidants, sulfur dioxide, past and passive smoking.

Chronic obstructive pulmonary disease symptom effects of long-term cumulative exposure to ambient levels of total oxidants and nitrogen dioxide in California Seventh-Day Adventist residents

To assess the risk of chronic obstructive pulmonary disease symptoms due to long-term exposure to ambient levels of total oxidants and nitrogen dioxide (NO2), symptoms were ascertained using the National Heart, Lung, and Blood Institute (NHLBI) respiratory symptoms questionnaire. A total of 7,445 Seventh-day Adventist (SDA) nonsmokers who were 25 yr of age or older and had resided at least 11 yr in areas of California with high to low photochemical air pollution were included in this study. Cumulative exposures to each pollutant in excess of four thresholds were estimated for each participant, using zip codes for months of residence and interpolated dosages from state air-monitoring stations. Multiple logistic regression analyses were conducted individually and together for pollutants and included eight covariables, including passive smoking. A statistically significant association with chronic symptoms was seen for total oxidants above 10 pphm (196 mcg/m3) (p less than .004, relative risk of 1.20 for 750 hr/yr). Chronic respiratory disease symptoms were not associated with relatively low NO2 exposure levels in this population. When these pollutant exposures were studied with exposures to total suspended particulates (TSP) and sulfur dioxide (SO2), only TSP exposure above 200 mcg/m3 showed statistical significance (p less than .01). Exposure to TSP is either more strongly associated with symptoms of chronic obstructive pulmonary disease than the other measured exposures or is the best single surrogate representing the mix of pollutants present.

Chronic obstructive pulmonary disease symptom effects of long-term cumulative exposure to ambient levels of total suspended particulates and sulfur dioxide in California Seventh-Day Adventist residents

Risk of chronic obstructive pulmonary disease symptoms due to long-term exposure to ambient levels of total suspended particulates (TSP) and sulfur dioxide (SO2) symptoms was ascertained using the National Heart, Lung, and Blood Institute (NHLBI) respiratory symptoms questionnaire on 7,445 Seventh-Day Adventists. They were non-smokers, at least 25 yr of age, and had lived 11 yr or more in areas ranging from high to low photochemical air pollution in California. Participant cumulative exposures to each pollutant in excess of four thresholds were estimated using monthly residence zip code histories and interpolated dosages from state air monitoring stations. These pollutant thresholds were entered individually and in combination in multiple logistic regression analyses with eight covariables including passive smoking. Statistically significant associations with chronic symptoms were seen for: SO2 exposure above 4 pphm (104 mcg/m3), (p = .03), relative risk 1.18 for 500 hr/yr of exposure; and for total suspended particulates (TSP) above 200 mcg/m3, (p less than .00001), relative risk of 1.22 for 750 hr/yr.

COPD prevalence in nonsmokers in high and low photochemical air pollution areas

The prevalence of respiratory symptoms, as ascertained by questionnaire, was evaluated in 6,666 nonsmokers who had lived for at least 11 years in either a high photochemical pollution area (4,379 individuals) or a low photochemical pollution area (2,287 individuals). Of these, 5,178 had never smoked, and none was currently smoking. The risk estimate for "definite" COPD, as defined in this study, was 15 percent higher in the high pollution area (p = 0.03), after adjusting for sex, age, race, education, occupational exposure, and past smoking history. Past smokers had a risk estimate 22 percent higher than never smokers (p = 0.01). Multivariate analysis showed a significant effect of air pollution on the prevalence of "definite" COPD which univariate analysis failed to demonstrate.