Ryan White HIV/AIDS Program Assistance and HIV Treatment Outcomes.

BACKGROUND: The Ryan White HIV/AIDS Program (RWHAP) provides persons infected with human immunodeficiency virus (HIV) with services not covered by other healthcare payer types. Limited data exist to inform policy decisions about the most appropriate role for RWHAP under the Patient Protection and Affordable Care Act (ACA). METHODS: We assessed associations between RWHAP assistance and antiretroviral therapy (ART) prescription and viral suppression. We used data from the Medical Monitoring Project, a surveillance system assessing characteristics of HIV-infected adults receiving medical care in the United States. Interview and medical record data were collected in 2009-2013 from 18 095 patients. RESULTS: Nearly 41% of patients had RWHAP assistance; 15% relied solely on RWHAP assistance for HIV care. Overall, 91% were prescribed ART, and 75% were virally suppressed. Uninsured patients receiving RWHAP assistance were significantly more likely to be prescribed ART (52% vs 94%; P < .01) and virally suppressed (39% vs 77%; P < .01) than uninsured patients without RWHAP assistance. Patients with private insurance and Medicaid were 6% and 7% less likely, respectively, to be prescribed ART than those with RWHAP only (P < .01). Those with private insurance and Medicaid were 5% and 12% less likely, respectively, to be virally suppressed (P ≤ .02) than those with RWHAP only. Patients whose private or Medicaid coverage was supplemented by RWHAP were more likely to be prescribed ART and virally suppressed than those without RWHAP supplementation (P ≤ .01). CONCLUSIONS: Uninsured and underinsured HIV-infected persons receiving RWHAP assistance were more likely to be prescribed ART and virally suppressed than those with other types of healthcare coverage.

Differences in adult influenza vaccine-seeking behavior: the roles of race and attitudes.

BACKGROUND: Racial/ethnic disparities in influenza vaccination among adults are longstanding, and research suggests they result from multiple factors. Influenza vaccine-seeking behavior may be an important aspect to consider when evaluating disparities in vaccination coverage. OBJECTIVE: To determine whether there are differences between blacks and whites in influenza vaccine-seeking behavior among adults 65 years and older. METHODS: Data were analyzed from a national sample of 3138 adults 65 years and older collected through the adult module of the 2007 National Immunization Survey, a random digit dialing telephone survey, which included an oversample of non-Hispanic blacks. Analysis included influenza vaccination rate, location of vaccination, and whether vaccinated individuals specifically went to the location to receive the vaccine (vaccine seekers) by race. The relationship between attitudes about influenza vaccination and vaccine-seeking behavior by race was also examined. RESULTS: White adults 65 years and older were significantly more likely to receive influenza vaccine than blacks, during the 2006-2007 influenza season (68% ± 4% vs 54% ± 3%, respectively), and a significantly higher proportion of vaccinated whites reported seeking out the vaccine than vaccinated blacks (66% ± 4% vs 47% ± 4%, respectively). Blacks were less likely to be vaccine seekers, regardless of education or poverty levels. Among persons vaccinated in a doctor's office, 52% of whites specifically went there to get vaccinated, compared with 37% of blacks. Among persons who believe the vaccine is very effective, 66% ± 5% of whites versus 50% ± 6% of blacks were vaccine seekers. CONCLUSIONS: This study points to the importance of improving our understanding of what factors, in addition to beliefs about vaccination, lead to vaccine seeking and reinforces the need for systematically offering vaccine.

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.

Uptake of meningococcal conjugate vaccine among adolescents in large managed care organizations, United States, 2005: demand, supply and seasonality.

BACKGROUND: In February 2005, the US Advisory Committee on Immunization Practices recommended the new meningococcal conjugate vaccine (MCV4) for routine use among 11- to 12-year-olds (at the preadolescent health-care visit), 14- to 15-year-olds (before high-school entry), and groups at increased risk. Vaccine distribution started in March; however, in July, the manufacturer reported inability to meet demand and widespread MCV4 shortages were reported. Our objectives were to determine early uptake patterns among target (11-12 and 14-15 year olds) and non-target (13- plus 16-year-olds) age groups. A post hoc analysis was conducted to compare seasonal uptake patterns of MCV4 with polysaccharide meningococcal (MPSV4) and tetanus diphtheria (Td) vaccines. METHODS: We analyzed data for adolescents 11-16 years from five managed care organizations participating in the Vaccine Safety Datalink (VSD). For MCV4, we estimated monthly and cumulative coverage during 2005 and calculated risk ratios. For MPSV4 and Td, we combined 2003 and 2004 data and compared their seasonal uptake patterns with MCV4. RESULTS: Coverage for MCV4 during 2005 among the 623,889 11-16 years olds was 10%. Coverage for 11-12 and 14-15 year olds was 12% and 11%, respectively, compared with 8% for 13- plus 16-year-olds (p < 0.001). Of the 64,272 MCV4 doses administered from March-December 2005, 73% were administered June-August. Fifty-nine percent of all MPSV4 doses and 38% of all Td doses were administered during June-August. CONCLUSION: A surge in vaccine uptake between June and August was observed among adolescents for MCV4, MPSV4 and Td vaccines. The increase in summer-time vaccinations and vaccination of non-targeted adolescents coupled with supply limitations likely contributed to the reported shortages of MCV4 in 2005.

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.

The annual impact of seasonal influenza in the US: measuring disease burden and costs.

BACKGROUND: Despite preventive efforts, influenza epidemics are responsible for substantial morbidity and mortality every year in the United States (US). Vaccination strategies to reduce disease burden have been implemented. However, no previous studies have systematically estimated the annual economic burden of influenza epidemics, an estimate necessary to guide policy makers effectively. OBJECTIVE: We estimate age- and risk-specific disease burden, and medical and indirect costs attributable to annual influenza epidemics in the United States. METHODS: Using a probabilistic model and publicly available epidemiological data we estimated the number of influenza-attributable cases leading to outpatient visits, hospitalization, and mortality, as well as time lost from work absenteeism or premature death. With data from health insurance claims and projections of either earnings or statistical life values, we then estimated healthcare resource utilization associated with influenza cases as were their medical and productivity (indirect) costs in $2003. RESULTS: Based on 2003 US population, we estimated that annual influenza epidemics resulted in an average of 610,660 life-years lost (undiscounted), 3.1 million hospitalized days, and 31.4 million outpatient visits. Direct medical costs averaged $10.4 billion (95% confidence interval [C.I.], $4.1, $22.2) annually. Projected lost earnings due to illness and loss of life amounted to $16.3 billion (C.I., $8.7, $31.0) annually. The total economic burden of annual influenza epidemics using projected statistical life values amounted to $87.1 billion (C.I., $47.2, $149.5). CONCLUSIONS: These results highlight the enormous annual burden of influenza in the US. While hospitalization costs are important contributors, lost productivity from missed work days and lost lives comprise the bulk of the economic burden of influenza.

Survey of state practices during the 2004-2005 influenza vaccine shortage.

To describe state-level actions and policies during the 2004-2005 influenza vaccine shortage and determine whether these or other factors were related to vaccination coverage, we surveyed all state health departments (including the District of Columbia). We included 2004-2005 Behavioral Risk Factor Surveillance System data to examine whether state-level actions, policies, or other factors like vaccine supply were related to changes in vaccination coverage in adults aged > or = 65 years from the previous non-shortage year. We found that 96% (n = 49) of states reported adopting or recommending adherence to the initial national interim influenza vaccination recommendations. Of these, at some point during the season, 22% (n = 11) reported local public health agencies issued prioritization recommendations that differed from the state health department's guidance. Eighty percent (n = 41) initiated at least one emergency response activity and 43% (n = 22) referred to or implemented components of their pandemic influenza plans. In 35% (n = 18), emergency or executive orders were issued or legislative action occurred. In a multivariable linear regression model, the availability and use of practitioner contact lists and having a relatively high vaccine supply in early October 2004 were associated with smaller decreases in coverage for adults aged > or = 65 years from the previous non-shortage season (p = 0.003, r2 = 0.26). States over-whelmingly followed national vaccination prioritization guidelines and used a range of activities to manage the 2004-2005 vaccine shortage. The availability and use of practitioner contact lists and having a relatively high vaccine supply early in the season were associated with smaller decreases in coverage from the previous non-shortage season.

The role of attitudes in understanding disparities in adult influenza vaccination.

BACKGROUND: Racial/ethnic disparities in influenza vaccine coverage of adults aged 65 years and older persist even after controlling for access, healthcare utilization, and socioeconomic status. Differences in attitudes toward vaccination may help explain these disparities. The purpose of this study was to describe patient characteristics and attitudes toward influenza vaccination among whites and African Americans aged 65 years and older, and to examine their effect on racial disparities in vaccination coverage. METHODS: A cross-sectional telephone survey of Medicare beneficiaries in five U.S. sites, sampled on race/ethnicity and ZIP code. Multivariate analysis controlling for demographics, healthcare utilization, and attitudes toward influenza vaccination was conducted in 2005 to assess racial disparities in vaccine coverage during the 2003-2004 season. RESULTS: The analysis included 1859 white and 1685 African-American respondents; 79% of whites versus 50% of African Americans reported influenza vaccination in the past year (p < 0.00001). Both vaccinated and unvaccinated African Americans were significantly less likely than whites to report positive attitudes toward influenza vaccination. Even among respondents with provider recommendations, respondents with positive attitudes were more likely to be vaccinated than those with negative attitudes. After multivariate adjustment, African Americans had significantly lower odds of influenza vaccination than whites (odds ratio = 0.55, 95% confidence interval = 0.42-0.72). CONCLUSIONS: A significant gap in vaccination coverage between African Americans and whites persisted even after controlling for specific respondent attitudes. Future research should focus on other factors such as vaccine-seeking behavior.

Factors associated with vaccination of medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003.

OBJECTIVES: To examine vaccination in seniors in the five U.S. communities of the Racial and Ethnic Adult Disparities in Immunization Initiative. DESIGN: Cross-sectional telephone survey in spring 2003 using stratified sampling by ZIP code and race/ethnicity. SETTING: New York, Texas, Wisconsin, Illinois, and Mississippi. PARTICIPANTS: Four thousand five hundred seventy-seven Medicare beneficiaries. MEASUREMENTS: Outcomes were pneumococcal vaccination ever and influenza vaccination in 2002/03 and were determined according to race/ethnicity, awareness of vaccination, and provider recommendation. Survey questions also asked about future plans for vaccination, whether respondents believed they had become sick from prior influenza vaccination, and whether unvaccinated respondents would be vaccinated if a health professional recommended it. RESULTS: Pneumococcal vaccination coverage was 70.3% for whites, 40.8% for blacks, and 53.2% for Hispanics, and the proportion reporting provider recommendation for vaccination differed significantly according to race/ethnicity. In multivariate regression, provider recommendation (risk ratio (RR) = 2.32, 95% confidence intervals (CI) = 2.10-2.57) and awareness of vaccination (RR = 1.60, 95% CI = 1.40-1.82) were associated with greater pneumococcal vaccination. Influenza vaccination coverage was 76.2% for whites, 50.7% for blacks, and 65.7% for Hispanics. A little more than half of respondents reported provider recommendation for influenza vaccination, with no differences according to race/ethnicity. Provider recommendation was associated with influenza vaccination (RR = 1.31, 95% CI = 1.25-1.38). More blacks and Hispanics believed they had become sick from prior influenza vaccination than whites, and this belief was associated with lower vaccination rates. CONCLUSION: This survey details vaccination patterns in an ethnically and geographically diverse sample of seniors and identifies some differences between blacks, Hispanics, and whites that may contribute to disparities in vaccination coverage. Survey findings highlight the importance of provider vaccination recommendations.

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.