Influenza Vaccine Uptake and Missed Opportunities Among the Medicare-Covered Population With High-Risk Conditions During the 2018 to 2019 Influenza Season : A Retrospective Cohort Study.

BACKGROUND: Seasonal influenza causes substantial morbidity and mortality among older U.S. adults and those with comorbid health conditions. OBJECTIVE: To describe seasonal influenza vaccine uptake and identify factors associated with missed opportunities for influenza vaccination. DESIGN: Retrospective cohort study. SETTING: Medicare fee-for-service claims. PARTICIPANTS: 31.6 million U.S. adults continuously enrolled under Medicare Parts A and B during the 2018 to 2019 influenza season. MEASUREMENTS: Influenza vaccine uptake and missed opportunities by patient demographic characteristics, high-risk status (that is, ≥1 condition increasing influenza complication risk), Medicare-Medicaid dual-eligibility status, and health care provider visits (that is, vaccination opportunities). RESULTS: Overall, 50.5% of beneficiaries aged 19 years or older had Medicare claims for influenza vaccination: 31.6% among people aged 19 to 64 years and 54% among people aged 65 years or older. More White beneficiaries were vaccinated (52.9%) than Black (34.9%) or Hispanic (30.4%) beneficiaries. Uptake was higher (56.1%) for beneficiaries with high-risk conditions than for those without (27.6%). Among unvaccinated beneficiaries overall, 77.4% visited a provider during influenza season; among unvaccinated beneficiaries with and without high-risk conditions, 91% and 43%, respectively, had seen a provider at least once. The proportion of beneficiaries with missed opportunities for influenza vaccination was 44.2% and was higher for beneficiaries in the non-high-risk group (59.1%) than those in the high-risk group (42.2%). Uptake was lower and proportions of missed opportunities were higher among beneficiaries in younger age groups, of Black and Hispanic race/ethnicity, without high-risk conditions, or with Medicare-Medicaid dual eligibility. LIMITATIONS: Influenza vaccinations without claims could not be captured. Data on reasons for nonvaccination were unavailable. CONCLUSION: Influenza vaccination coverage for Medicare beneficiaries continues to be suboptimal, with missed opportunities despite availability of influenza vaccination with no copayment. Disparities persist in vaccination uptake by race/ethnicity. PRIMARY FUNDING SOURCE: None.

COVID-19 Vaccination Coverage, by Race and Ethnicity - National Immunization Survey Adult COVID Module, United States, December 2020-November 2021.

Some racial and ethnic minority groups have experienced disproportionately higher rates of COVID-19-related illness and mortality (1,2). Vaccination is highly effective in preventing severe COVID-19 illness and death (3), and equitable vaccination can reduce COVID-19-related disparities. CDC analyzed data from the National Immunization Survey Adult COVID Module (NIS-ACM), a random-digit-dialed cellular telephone survey of adults aged ≥18 years, to assess disparities in COVID-19 vaccination coverage by race and ethnicity among U.S. adults during December 2020-November 2021. Asian and non-Hispanic White (White) adults had the highest ≥1-dose COVID-19 vaccination coverage by the end of April 2021 (69.6% and 59.0%, respectively); ≥1-dose coverage was lower among Hispanic (47.3%), non-Hispanic Black or African American (Black) (46.3%), Native Hawaiian or other Pacific Islander (NH/OPI) (45.9%), multiple or other race (42.6%), and American Indian or Alaska Native (AI/AN) (38.7%) adults. By the end of November 2021, national ≥1-dose COVID-19 vaccination coverage was similar for Black (78.2%), Hispanic (81.3%), NH/OPI (75.7%), and White adults (78.7%); however, coverage remained lower for AI/AN (61.8%) and multiple or other race (68.0%) adults. Booster doses of COVID-19 vaccine are now recommended for all adults (4), but disparities in booster dose coverage among the fully vaccinated have become apparent (5). Tailored efforts including community partnerships and trusted sources of information could be used to increase vaccination coverage among the groups with identified persistent disparities and can help achieve vaccination equity and prevent new disparities by race and ethnicity in booster dose coverage.

Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury - United States, October 2019.

CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical partners are investigating a multistate outbreak of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. In late August, CDC released recommendations for health care providers regarding e-cigarette, or vaping, product use associated lung injury (EVALI) based on limited data from the first reported cases (1,2). This report summarizes national surveillance data describing clinical features of more recently reported cases and interim recommendations based on these data for U.S. health care providers caring for patients with suspected or known EVALI. It provides interim guidance for 1) initial clinical evaluation; 2) suggested criteria for hospital admission and treatment; 3) patient follow-up; 4) special considerations for groups at high risk; and 5) clinical and public health recommendations. Health care providers evaluating patients suspected to have EVALI should ask about the use of e-cigarette, or vaping, products in a nonjudgmental and thorough manner. Patients suspected to have EVALI should have a chest radiograph (CXR), and hospital admission is recommended for patients who have decreased blood oxygen (O2) saturation (<95%) on room air or who are in respiratory distress. Health care providers should consider empiric use of a combination of antibiotics, antivirals, or steroids based upon clinical context. Evidence-based tobacco product cessation strategies, including behavioral counseling, are recommended to help patients discontinue use of e-cigarette, or vaping, products. To reduce the risk of recurrence, patients who have been treated for EVALI should not use e-cigarette, or vaping, products. CDC recommends that persons should not use e-cigarette, or vaping, products that contain tetrahydrocannabinol (THC). At present, CDC recommends persons consider refraining from using e-cigarette, or vaping, products that contain nicotine. Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products.

Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use-Associated Lung Injury - United States, November 2019.

CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders are investigating a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). CDC has published recommendations for health care providers regarding EVALI (2-4). Recently, researchers from Utah and New York published proposed diagnosis and treatment algorithms for EVALI (5,6). EVALI remains a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis, and evaluation should be guided by clinical judgment. Because patients with EVALI can experience symptoms similar to those associated with influenza or other respiratory infections (e.g., fever, cough, headache, myalgias, or fatigue), it might be difficult to differentiate EVALI from influenza or community-acquired pneumonia on initial assessment; EVALI might also co-occur with respiratory infections. This report summarizes recommendations for health care providers managing patients with suspected or known EVALI when respiratory infections such as influenza are more prevalent in the community than they have been in recent months (7). Recommendations include 1) asking patients with respiratory, gastrointestinal, or constitutional symptoms about the use of e-cigarette, or vaping, products; 2) evaluating those suspected to have EVALI with pulse oximetry and obtaining chest imaging, as clinically indicated; 3) considering outpatient management for clinically stable EVALI patients who meet certain criteria; 4) testing patients for influenza, particularly during influenza season, and administering antimicrobials, including antivirals, in accordance with established guidelines; 5) using caution when considering prescribing corticosteroids for outpatients, because this treatment modality has not been well studied among outpatients, and corticosteroids could worsen respiratory infections; 6) recommending evidence-based treatment strategies, including behavioral counseling, to help patients discontinue using e-cigarette, or vaping, products; and 7) emphasizing the importance of annual influenza vaccination for all persons aged ≥6 months, including patients who use e-cigarette, or vaping products.

Preparing Master of Public Health Graduates to Work in Local Health Departments.

OBJECTIVE: To identify key competencies and skills that all master of public health (MPH) graduates should have to be prepared to work in a local health department. METHODS: In 2011-2012, the New York City Department of Health and Mental Hygiene administered electronic surveys to 2 categories of staff: current staff with an MPH as their highest degree, and current hiring managers. RESULTS: In all, 312 (77%) staff members with an MPH as their highest degree and 170 (57%) hiring managers responded to the survey. Of the respondents with an MPH as their highest degree, 85% stated that their MPH program prepared them for work at the New York City Health Department. Skills for which MPH graduates most often stated they were underprepared included facility in using SAS® statistical software, quantitative data analysis/statistics, personnel management/leadership, and data collection/database management/data cleaning. Among the skills hiring managers identified as required of MPH graduates, the following were most often cited as those for which newly hired MPH graduates were inadequately prepared: quantitative data analysis, researching/conducting literature reviews, scientific writing and publication, management skills, and working with contracts/requests for proposals. CONCLUSION: These findings suggest that MPH graduates could be better prepared to work in a local health department upon graduation. To be successful, new MPH graduate hires should possess fundamental skills and knowledge related to analysis, communication, management, and leadership. Local health departments and schools of public health must each contribute to the development of the current and future public health workforce through both formal learning opportunities and supplementary employment-based training to reinforce prior coursework and facilitate practical skill development.

Design and Implementation of a Federal Program to Engage Community Partners to Reduce Disparities in Adult COVID-19 Immunization Uptake, United States, 2021-2022.

Vaccination disparities are part of a larger system of health inequities among racial and ethnic groups in the United States. To increase vaccine equity of racial and ethnic populations, the Centers for Disease Control and Prevention (CDC) designed the Partnering for Vaccine Equity program in January 2021, which funded and supported national, state, local, and community organizations in 50 states-which include Indian Health Service Tribal Areas; Washington, DC; and Puerto Rico-to implement culturally tailored activities to improve access to, availability of, and confidence in COVID-19 and influenza vaccines. To increase vaccine uptake at the local level, CDC partnered with national organizations such as the National Urban League and Asian & Pacific Islander American Health Forum to engage community-based organizations to take action. Lessons learned from the program include the importance of directly supporting and engaging with the community, providing tailored messages and access to vaccines to reach communities where they are, training messengers who are trusted by those in the community, and providing support to funded partners through trainings on program design and implementation that can be institutionalized and sustained beyond the COVID-19 pandemic. Building on these lessons will ensure CDC and other public health partners can continue to advance vaccine equity, increase vaccine uptake, improve health outcomes, and build trust with communities as part of a comprehensive adult immunization infrastructure.

Increasing equity in adult immunization through community-level action.

Inequities in availability and access to adult vaccinations represent significant gaps in the US public health infrastructure. Adults in racial and ethnic minority groups are less likely to receive routinely recommended vaccinations due to systemic barriers, distribution inequities, and lack of trust in vaccines; similar disparities were seen during early COVID-19 vaccination efforts. However, a deliberate focus on reducing disparities can yield progress. National data show narrowing of racial and ethnic adult COVID-19 vaccination coverage disparities over time, highlighting the value of the equity-focused, community-level interventions implemented during the pandemic. This paper describes the Centers for Disease Control and Prevention's efforts during the COVID-19 pandemic to address racial and ethnic disparities in adult immunization, and how lessons learned may be applied post-pandemic. Progress made is likely to be lost without sustained support for adult vaccination at national, state, and community levels.

Integrating public health--oriented e-learning into graduate medical education.

OBJECTIVES: In fall 2008, the New York City Department of Health and Mental Hygiene collaborated with Albert Einstein College of Medicine residency program directors to assess the effectiveness of an e-learning course on accurate death certificate completion among resident physicians. METHODS: We invited postgraduate year 1 and 2 (PGY1 and PGY2) residents (n = 227) to participate and administered a pretest, e-learning module, posttest, and course evaluation to PGY1 residents; PGY2 residents completed a pretest and survey only. RESULTS: In all, 142 residents (63%) participated. The average pretest scores for PGY2 residents (61%) and PGY1 residents (59%) were not significantly different. The PGY1 residents' average test score increased significantly after taking the e-learning module (59% vs 72%; P < .01). The participants rated course length, delivery method, and utility highly. CONCLUSIONS: Results suggest that e-learning can effectively integrate public health-oriented training into clinical residency programs.

Putting public health into practice: a model for assessing the relationship between local health departments and practicing physicians.

The New York City (NYC) Department of Health and Mental Hygiene (Health Department) surveyed practicing NYC physicians to quantify Health Department resource use. Although the Health Department successfully reaches most physicians, and information is valued in practice, knowledge of several key resources was low. Findings suggested 3 recommendations for all local health departments seeking to enhance engagement with practicing physicians: (1) capitalize on physician interest, (2) engage physicians early and often, and (3) make interaction with the health department easy. Also, older physicians may require targeted outreach.

An intervention to improve cause-of-death reporting in New York City hospitals, 2009-2010.

INTRODUCTION: Poor-quality cause-of-death reporting reduces reliability of mortality statistics used to direct public health efforts. Overreporting of heart disease has been documented in New York City (NYC) and nationwide. Our objective was to evaluate the immediate and longer-term effects of a cause-of-death (COD) educational program that NYC's health department conducted at 8 hospitals on heart disease reporting and on average conditions per certificate, which are indicators of the quality of COD reporting. METHODS: From June 2009 through January 2010, we intervened at 8 hospitals that overreported heart disease deaths in 2008. We shared hospital-specific data on COD reporting, held conference calls with key hospital staff, and conducted in-service training. For deaths reported from January 2009 through June 2011, we compared the proportion of heart disease deaths and average number of conditions per death certificate before and after the intervention at both intervention and nonintervention hospitals. RESULTS: At intervention hospitals, the proportion of death certificates that reported heart disease as the cause of death decreased from 68.8% preintervention to 32.4% postintervention (P < .001). Individual hospital proportions ranged from 58.9% to 79.5% preintervention and 25.9% to 45.0% postintervention. At intervention hospitals the average number of conditions per death certificate increased from 2.4 conditions preintervention to 3.4 conditions postintervention (P < .001) and remained at 3.4 conditions a year later. At nonintervention hospitals, these measures remained relatively consistent across the intervention and postintervention period. CONCLUSION: This NYC health department's hospital-level intervention led to durable changes in COD reporting.

NYC Epi Scholars program: promoting applied health disparities research in an urban public health department-a program model.

OBJECTIVE: Although health disparities research has already contributed to decreased mortality and morbidity in underserved communities, more work is needed. The NYC Epi Scholars program of the New York City Department of Health and Mental Hygiene (NYC DOHMH) aims to address gaps in critical public health needs and to train future public health leaders in epidemiology. The program is designed to increase racial/ethnic and socioeconomic diversity in the public health workforce, to provide fieldwork and practica opportunities, and to cultivate future leaders in epidemiology and public health. METHODS: Since its inception in 2007, the NYC Epi Scholars program of the NYC DOHMH has sought talented epidemiology students interested in gaining practical experience in applied health disparities research. NYC Epi Scholars is open to graduate epidemiology students who have demonstrated achievement and leadership potential and gives them an opportunity to provide high-quality research assistance to projects that identify and address health disparities of public health significance. RESULTS: Many of the program's 32 alumni have made notable contributions to public health: publishing articles in peer-reviewed journals; making presentations at national and international conferences; and after graduating, pursuing careers at the DOHMH, Centers for Disease Control and Prevention, the Environmental Protection Agency, and the National Institutes of Health. CONCLUSIONS: Because of its noted success, the NYC Epi Scholars program may serve as a "best-practice" model for expansion in other urban health departments.

The importance of seasonal influenza vaccination for people with disabilities during the COVID-19 pandemic.

A large proportion of Americans have at least one disability and yet people with disabilities face inequities in health and health care access. Factors associated with underlying disability and health, how they perceive and interact with the world, and where they live, or work may increase the risk people with disabilities face for illness or severe outcomes from seasonal influenza. Given the need to reduce the burden of respiratory illness on a healthcare system already overwhelmed by the COVID-19 pandemic, maximizing seasonal influenza vaccination coverage is particularly important in 2020-2021. It is critical this season to ensure equitable access to influenza vaccination for people with disabilities. Providing influenza vaccination services in the unique places where people with disabilities are living, working, or receiving care during the COVID-19 pandemic is crucial, as well as communicating effectively to people with different types of disabilities.

Rationale, design and respondent characteristics of the 2013-2014 New York City Health and Nutrition Examination Survey (NYC HANES 2013-2014).

PURPOSE: Capacity to monitor non-communicable diseases (NCDs) at state or local levels is limited. Emerging approaches include using biomeasures and electronic health record (EHR) data. In 2004, New York City (NYC) performed a population-based health study on adult residents using biomeasures (NYC Health and Nutrition Examination Study, or NYC HANES), modeled after NHANES. A second NYC HANES was launched in 2013 to examine change over time, evaluate municipal policies, and validate a proposed EHR-based surveillance system. We describe the rationale and methods of NYC HANES 2013-2014. METHODS: NYC HANES was a population-based, cross-sectional survey of NYC adults using three-stage cluster sampling. Between August 2013 and June 2014, selected participants completed a health interview and physical exam (blood pressure, body mass index, and waist circumference). Fasting biomeasures included diabetes, lipid profiles, kidney function, environmental biomarkers, and select infectious diseases. RESULTS: Of the 3065 households approached, 2742 were eligible and 1827 were successfully screened (67%). A total of 1524 of eligible participants completed the survey (54%), for an overall response rate of 36%. CONCLUSION: Completing a second NYC HANES a decade after the first study affords an opportunity to understand changes in prevalence, awareness and control of NCDs and evaluate municipal efforts to manage them.

Lung disease in a global context. A call for public health action.

As described in a recently released report of the Forum of International Respiratory Societies, four of the leading causes of death in the world are chronic obstructive pulmonary disease, acute respiratory tract infections, lung cancer, and tuberculosis. A fifth, asthma, causes enormous global morbidity. Not enough progress has been made in introducing new therapies and reducing disease burden for these illnesses in the last few decades, despite generous investments and some notable progress in biomedical research. Four external and modifiable drivers are responsible for a substantial percentage of the disease burden represented by the major lung diseases: tobacco, outdoor air pollution, household air pollution, and occupational exposures to lung toxins. Especially in low- and middle-income countries, but in highly developed economies as well, pressures for economic development and lax regulation are contributing to the continued proliferation of these drivers. Public health approaches to the most common lung diseases could have enormous effects on reducing morbidity and mortality. There must be increased advocacy from and mobilization of civil society to bring attention to the drivers of lung diseases in the world. The World Health Organization should negotiate accords similar to the Framework Convention on Tobacco Control to address air pollution and occupational exposures. Large increases in funding by government agencies and nongovernmental organizations around the world are needed to identify technologies that will reduce health risks while allowing populations to enjoy the benefits of economic development. This paradigm, focused more on public health than on individual medical treatment, has the best chance of substantial reduction in the burden of lung disease around the world in the next several years.

Integrating public health-oriented e-learning into graduate medical education.

PURPOSE: In fall 2008, the New York City Department of Health and Mental Hygiene collaborated with Albert Einstein College of Medicine residency program directors to assess the effectiveness of an e-learning course on accurate death certificate completion among resident physicians. METHODS: We invited postgraduate year 1 and 2 (PGY1 and PGY2) residents (n = 227) to participate and administered a pretest, e-learning module, posttest, and course evaluation to PGY1 residents; PGY2 residents completed a pretest and survey only. RESULTS: In all, 142 residents (63%) participated. The average pretest scores for PGY2 residents (61%) and PGY1 residents (59%) were not significantly different. The PGY1 residents' average test score increased after taking the e-learning module (59% vs 72%, p<0.01). The participants rated course length, delivery method, and utility highly. CONCLUSIONS: Results suggest that e-learning can effectively integrate public health-oriented training into clinical residency programs.