Association of State Laws and Healthcare Workers' Influenza Vaccination Rates.

State laws are being used to increase healthcare worker (HCW) influenza vaccine uptake. Approximately 40% of states have enacted such laws but their effectiveness has been infrequently studied. Data sources for this study were the 2000-2011 U.S. National Health Interview Survey Adult Sample File and a summary of U.S. state HCW influenza vaccination laws. Hierarchical linear modeling was used for two time periods: 1) 2000-2005 (before enactment of many state laws) and 2) 2006-2011 (a time of increased enactment of state HCW influenza vaccination legislation). During 2000-2005, two states had HCW influenza vaccination laws and HCW influenza vaccination rates averaged 22.5%. In 2006-2011, 19 states had such laws and vaccination rates averaged 50.9% (p < 0.001). The likelihood of HCW vaccination increased with the scope and breadth, measured by a law score. Although laws varied widely in scope and applicability, states with HCW influenza vaccination laws reported higher HCW vaccination rates.

Are plasma mineral levels related to antibody response to influenza vaccination in older adults?

INTRODUCTION: An effective immune response to vaccination may be related to nutritional status. This study examined the association of plasma mineral levels with hemagglutination inhibition (HI) titers produced in response to influenza vaccine in older adults. METHODS: Prior to (Day 0) and 21 (range = 19-28) days after receiving the 2013-14 influenza vaccine, 109 adults ages 51-81 years, provided blood samples. Serum samples were tested for HI activity against the A/H1N1 and A/H3N2 2013-2014 vaccine virus strains. Plasma minerals were collected in zinc-free tubes and assayed by inductively coupled plasma mass spectrometry. HI titers were reported as seroprotection (≥1:40) and seroconversion (≥ 4-fold rise from Day 0 (minimum HI = 1:10) to Day 21). Both HI titers and mineral values were skewed and thus log2 transformed. Magnesium (Mg), phosphorus (P), zinc (Zn), copper (Cu), iron (Fe), potassium (K) and the Cu to Zn ratio were tested. Logistic regression analyses were used to determine the associations between mineral levels and seroconversion and seroprotection of HI titers for each influenza A strain. RESULTS: Participants were 61% white, 28% male, 39% diabetic, and 81% overweight/obese with a mean age of 62.6 y. In logistic regression, Day 21 A/H1N1 seroprotection was associated with P and Zn at Day 21(P < 0.05). Seroconversion of A/H1N1 was associated with Day 21 Cu, P, and Mg (P < 0.03). Day 21 A/H3N2 seroprotection and seroconversion were associated with Day 21 P (P < 0.05). CONCLUSIONS: Phosphorus was associated with seroprotection and seroconversion to influenza A after vaccination; these associations warrant additional studies with larger, more diverse population groups.

Hospital policies, state laws, and healthcare worker influenza vaccination rates.

This study used hierarchical linear modeling to determine the relative contribution of hospital policies and state laws to healthcare worker (HCW) influenza vaccination rates. Hospital mandates with consequences for noncompliance and race were associated with 3%-12% increases in HCW vaccination; state laws were not significantly related to vaccination rates.

Cost-effectiveness of pneumococcal conjugate vaccination in immunocompromised adults.

OBJECTIVE: Pneumococcal disease is a significant problem in immunocompromised persons, particularly in HIV-infected individuals. The CDC recently updated pneumococcal vaccination recommendations for immunocompromised adults, adding the 13-valent pneumococcal conjugate vaccine (PCV13) to the previously recommended 23-valent pneumococcal polysaccharide vaccine (PPSV23). This analysis estimates the cost-effectiveness of pneumococcal vaccination strategies in HIV-infected individuals and in the broader immunocompromised adult group. DESIGN: Markov model-based cost-effectiveness analysis. METHODS: The model considered immunocompromised persons aged 19-64 years and accounted for childhood PCV13 herd immunity; in a separate analysis, an HIV-infected subgroup was considered. PCV13 effectiveness was estimated by an expert panel; PPSV23 protection was modeled relative to PCV13 effectiveness. We assumed that both vaccines prevented invasive pneumococcal disease, but only PCV13 prevented nonbacteremic pneumonia. RESULTS: In all immunocompromised individuals, a single PCV13 cost $70,937 per quality adjusted life year (QALY) gained compared to no vaccination; current recommendations cost $136,724/QALY. In HIV patients, with a longer life expectancy (22.5 years), current recommendations cost $89,391/QALY compared to a single PCV13. Results were sensitive to variation of life expectancy and vaccine effectiveness. The prior recommendation was not favored in any scenario. CONCLUSIONS: One dose of PCV13 is more cost-effective for immunocompromised individuals than previous vaccination recommendations and may be more economically reasonable than current recommendations, depending on life expectancy and vaccine effectiveness in the immunocompromised.

Cost-effectiveness of procalcitonin-guided antibiotic use in community acquired pneumonia.

BACKGROUND: Although prior randomized trials have demonstrated that procalcitonin-guided antibiotic therapy effectively reduces antibiotic use in patients with community-acquired pneumonia (CAP), uncertainties remain regarding use of procalcitonin protocols in practice. OBJECTIVE: To estimate the cost-effectiveness of procalcitonin protocols in CAP. DESIGN: Decision analysis using published observational and clinical trial data, with variation of all parameter values in sensitivity analyses. PATIENTS: Hypothetical patient cohorts who were hospitalized for CAP. INTERVENTIONS: Procalcitonin protocols vs. usual care. MAIN MEASURES: Costs and cost per quality adjusted life year gained. KEY RESULTS: When no differences in clinical outcomes were assumed, consistent with clinical trials and observational data, procalcitonin protocols cost $10-$54 more per patient than usual care in CAP patients. Under these assumptions, results were most sensitive to variations in: antibiotic cost, the likelihood that antibiotic therapy was initiated less frequently or over shorter durations, and the likelihood that physicians were nonadherent to procalcitonin protocols. Probabilistic sensitivity analyses, incorporating procalcitonin protocol-related changes in quality of life, found that protocol use was unlikely to be economically reasonable if physician protocol nonadherence was high, as observational study data suggest. However, procalcitonin protocols were favored if they decreased hospital length of stay. CONCLUSIONS: Procalcitonin protocol use in hospitalized CAP patients, although promising, lacks physician nonadherence and resource use data in routine care settings, which are needed to evaluate its potential role in patient care.

Modeling of cost effectiveness of pneumococcal conjugate vaccination strategies in U.S. older adults.

BACKGROUND: The 13-valent pneumococcal conjugate vaccine (PCV13) is approved by the U.S. Food and Drug Administration for adults, but its role in older adults is unclear. PURPOSE: To compare PCV13 strategies to currently recommended vaccination strategies in adults aged ≥65 years. METHODS: Using a Markov model, the cost effectiveness of PCV13 and the 23-valent pneumococcal polysaccharide vaccine (PPSV23), alone or in combination, was estimated, in adults aged either 65 years or 75 years. No prior vaccination, prior vaccination, and vaccine hyporesponsiveness scenarios were examined. Pneumococcal disease rates, indirect childhood PCV13 effects, and costs were estimated using CDC Active Bacterial Core surveillance data and U.S. national databases. An expert panel estimated vaccine-related protection. A societal perspective was taken and outcomes were discounted 3% per year. RESULTS: In those aged 65 years, single-dose PCV13 cost $11,300 per quality-adjusted life-year (QALY) gained compared to no vaccination; at ages 65 and 80 years, PCV13 cost $83,000/QALY. In those aged 75 years, single-dose PCV13 cost $62,800/QALY gained. PPSV23 cost more and was less effective than PCV13. Results were sensitive to varying vaccine effectiveness and indirect effect estimates. In hyporesponsiveness scenarios, cost-effectiveness ratios increased by 37%-78% for single-dose strategies and 29%-35% for multiple-dose strategies. CONCLUSIONS: Single-dose PCV13 strategies are likely to be economically reasonable in older adults.

Impact of hospital policies on health care workers' influenza vaccination rates.

BACKGROUND: Overall annual influenza vaccination rate has slowly increased among health care workers but still remains below the national goal of 90%. METHODS: To compare hospitals that mandate annual health care worker (HCW) influenza vaccination with and without consequences for noncompliance, a 34-item survey was mailed to an infection control professional in 964 hospitals across the United States in 4 waves. Respondents were grouped by presence of a hospital policy that required annual influenza vaccination of HCWs with and without consequences for noncompliance. Combined with hospital characteristics from the American Hospital Association, data were analyzed using χ(2) or Fisher exact tests for categorical variables and t tests for continuous variables. RESULTS: One hundred fifty hospitals required influenza vaccination, 84 with consequences (wear a mask, termination, education, restriction from patient care duties, unpaid leave) and 66 without consequences for noncompliance. Hospitals whose mandates have consequences for noncompliance included a broader range of personnel, were less likely to allow personal belief exemptions, or to require formal declination. The change in vaccination rates in hospitals with mandates with consequences (19.5%) was nearly double that of the hospitals with mandates without consequences (11%; P=.002). Presence of a state law regulating HCW influenza vaccination was associated with an increase in rates for mandates with consequences nearly 3 times the increase for mandates without consequences. CONCLUSION: Hospital mandates for HCW influenza vaccination with consequences for noncompliance are associated with larger increases in HCW influenza vaccination rates than mandates without such consequences.

Evaluation of a toolkit to introduce standing orders for influenza and pneumococcal vaccination in adults: a multimodal pilot project.

BACKGROUND: Immunization of adults with influenza vaccine and pneumococcal polysaccharide vaccine remains lower than recommended levels. Standing order programs (SOPs) in which non-physician medical personnel are permitted to assess an adult patient's immunization status and administer vaccines without an individual physician order are a proven method of increasing adult vaccinations, yet they are used by less than one half of primary care physicians caring for adults. METHODS: Following a national survey of primary care physicians about barriers to SOPs for adult immunizations, a SOP toolkit was developed. After review by a panel of experts, the toolkit was pilot tested in three primary care practices in a health care network with the same electronic medical record (EMR) system and low adult vaccination rates. Practice staffs were trained in the use of SOPs and the toolkit at a group meeting. This study was designed to pilot-test and evaluate the toolkit with the express intention of improving it. Three methods were used to evaluate the toolkit: (1) direct observation and interviews of each practice's staff; (2) surveys of each practice's staff; and (3) influenza and pneumococcal polysaccharide vaccine (PPV) vaccination rates. RESULTS: The staffs at all sites were equally likely to find the presentations and toolkit useful and did not differ in their knowledge of using SOPs for vaccination. They expressed a common set of barriers to implementing SOPs despite using the toolkit, and provided ideas for improving implementation. One site viewed SOPs in general in a more negative light and expressed that SOPs unfairly increased their workload. Vaccination rates in this site did not differ from those of the control site. CONCLUSION: The evaluation suggested that the SOP toolkit should be expanded to include additional strategies to improve its applicability and effectiveness.

Cost-effectiveness of adult vaccination strategies using pneumococcal conjugate vaccine compared with pneumococcal polysaccharide vaccine.

CONTEXT: The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear. OBJECTIVE: To estimate the cost-effectiveness of PCV13 vaccination strategies in adults. DESIGN, SETTING, AND PARTICIPANTS: A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included Centers for Disease Control and Prevention Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey. MAIN OUTCOME MEASURES: Pneumococcal disease cases prevented and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS: In the base case scenario, administration of PCV13 as a substitute for PPSV23 in current recommendations (ie, vaccination at age 65 years and at younger ages if comorbidities are present) cost $28,900 per QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost $45,100 per QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 years to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing $496,000 per QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored. CONCLUSION: Overall, PCV13 vaccination was favored compared with PPSV23, but the analysis was sensitive to assumptions about PCV13 effectiveness against nonbacteremic pneumococcal pneumonia and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution.

Cost-effectiveness of dual influenza and pneumococcal vaccination in 50-year-olds.

Influenza vaccination is now recommended for all ages; CDC pneumococcal polysaccharide vaccination (PPV) recommendations are comorbidity-based in nonelderly patients. We constructed a Markov model to estimate the cost-effectiveness of dual influenza and pneumococcal vaccination in 50-year-olds. Patients were followed for 10 years, with differing time horizons examined in sensitivity analyses. With 100% vaccine uptake, dual vaccination cost $37,700/QALY gained compared to a CDC recommendation strategy; with observed vaccine uptake, dual vaccination cost $5,300/QALY. Results were sensitive to shorter time horizons, favoring CDC recommendations. We found dual vaccination of all 50-year-olds economically reasonable. Shorter duration models may not fully account for PPV effectiveness.

Importance of vaccination habit and vaccine choice on influenza vaccination among healthy working adults.

This randomized cluster trial was designed to improve workplace influenza vaccination rates using enhanced advertising, choice of vaccine type (intranasal or injectable) and an incentive. Workers aged 18-49 years were surveyed immediately following vaccination to determine factors associated with vaccination behavior and choice. The questionnaire assessed attitudes, beliefs and social support for influenza vaccine, demographics, and historical, current, and intentional vaccination behavior. Of the 2389 vaccinees, 83.3% received injectable vaccine and 16.7% received intranasal vaccine. Factors associated with previous influenza vaccination were older age, female sex, higher education and greater support for injectable vaccine (all P<.02). Current influenza vaccination with intranasal vaccine vs. injectable vaccine was associated with higher education, the study interventions, greater support for the intranasal vaccine and nasal sprays, less support of injectable vaccine, more negative attitudes about influenza vaccine, and a greater likelihood of reporting that the individual would not have been vaccinated had only injectable vaccine been offered (all P<.01). Intentional vaccine choice was most highly associated with previous vaccination behavior (P<.001). A key to long term improvements in workplace vaccination is to encourage first time influenza vaccination through interventions that include incentives, publicity and vaccine choice.

Establish the habit: influenza vaccination for health care personnel.

Influenza vaccination of health care personnel (HCP) is a patient safety issue, but the national rate is only 42%. Following an intervention in 2006-2007, HCP in a large health system were surveyed. Self-reported influenza vaccination rate was 61.6% overall, did not differ by race, education level, or employment status but was higher for older HCP (> or =50 years; p=.002). In logistic regression, the strongest predictor of vaccination was receiving influenza vaccine the previous year, although other factors were significantly associated for younger and older HCP groups. Establishing the influenza vaccination habit using age-based targeted messages may be the most effective way to increase rates for HCP without mandates.

Cost-effectiveness of pneumococcal polysaccharide vaccine among healthcare workers during an influenza pandemic.

OBJECTIVE: To assess the usefulness and cost-effectiveness of pneumococcal polysaccharide vaccine (PPV) among healthcare workers compared with nonuse of PPV during an influenza pandemic. STUDY DESIGN: Markov modeling was used to estimate the cost-effectiveness of PPV in previously unvaccinated healthcare workers during an influenza pandemic. METHODS: Invasive pneumococcal disease (IPD) incidence rates were incorporated into the model, which assumed that IPD events occurred at twice the usual rate during a year of pandemic influenza. Societal and hospital perspectives were examined. Assumptions were that pneumococcal disease transmission from healthcare worker to patient did not occur, heightened IPD risk occurred for only 1 year, and PPV did not prevent noninvasive pneumonia, all of which potentially bias against vaccination. RESULTS: From a societal standpoint, PPV of healthcare workers during an influenza pandemic is economically reasonable, costing $2935 per quality-adjusted life-year gained; results were robust to variation in multiple sensitivity analyses. However, from the hospital perspective, vaccinating healthcare workers was expensive, costing $1676 per employee absence day avoided, given an IPD risk that (although increased) would remain less than 1%. CONCLUSIONS: Vaccinating all healthcare workers to protect against pneumococcal disease during a pandemic influenza outbreak is likely to be economically reasonable from the societal standpoint. However, PPV is expensive from the hospital perspective, which might prevent implementation of a PPV program unless it is externally subsidized.

Improving influenza vaccination rates in the workplace: a randomized trial.

BACKGROUND: To minimize absenteeism resulting from influenza, employers frequently offer on-site influenza vaccination to employees. Yet the level of uptake of vaccine is low among working adults. This study was designed to increase workplace influenza vaccination rates by offering both a choice of intranasal (LAIV) and injectable (TIV) influenza vaccines to eligible employees, and an incentive for being vaccinated, and by increasing awareness of the vaccine clinic. DESIGN: This study used a stratified randomized cluster trial. SETTING/PARTICIPANTS: A total of 12,222 employees in 53 U.S. companies with previous influenza vaccine clinics were examined. INTERVENTIONS: Control sites advertised and offered vaccine clinics as previously done. Choice sites offered LAIV or TIV and maintained their previous advertising level but promoted the choice of vaccines. Choice Plus sites increased advertising and promoted and offered a choice of vaccines and a nominal incentive. MAIN OUTCOME MEASURES: These included vaccination rates among eligible employees. Hierarchic linear modeling (HLM) was used to determine factors associated with vaccination. RESULTS: The overall vaccination rate increased from 39% in 2007-2008 to 46% in 2008-2009 (p<0.001). The difference in vaccination rates for LAIV was 6.5% for Choice versus Control and 9.9% for Choice Plus versus Control (both p<0.001). Rates of TIV increased by 15.9 percentage points in the Choice Plus arm versus Control for workers aged > or =50 years (p=0.024). Rates of TIV did not change in workers aged 18-49 years in either intervention arm or in workers aged > or =50 years in the Choice arm. In HLM analyses, factors significantly associated with increased vaccination were older age, female gender, previous company vaccination rate, and the Choice Plus intervention. CONCLUSIONS: An incentive for vaccination, an intensified advertising campaign, and offering a choice of influenza vaccines improved vaccination rates in the workplace.

Understanding adult vaccination in urban, lower-socioeconomic settings: influence of physician and prevention systems.

PURPOSE: Vaccination rates for pneumococcal polysaccharide vaccine (PPV) and influenza vaccine are relatively low in disadvantaged urban populations. This study was designed to assess which physician and practice characteristics might explain differences in rates across physicians. METHODS: PPV and influenza vaccination rates were determined for 2,021 patients aged 65 years and older receiving care from 30 physicians in 17 practices surveyed about their office systems for providing adult immunizations. Hierarchical linear modeling (HLM) analyses were used to examine the relationships among vaccination rates, patient-level characteristics, and physician variables. RESULTS: Overall, the weighted PPV vaccination rate was 60.0% and varied widely across physicians (range, 11%-98%). At the patient level in HLM, patient race (P=.01) and age (P = .02), but not neighborhood income, were associated with PPV status. By linking physician survey data with PPV rates, we found the best pair of physician variables to be "reported time spent with patients for a well visit" (P = .01) and "use of enhanced immunization documentation" (P=.10). The overall influenza vaccination rate was 51.9% (range, 22%-96%). Patient race (P=.003) and age (P = .002) were associated with influenza vaccination. The pair of physician variables with the strongest association with influenza vaccination was "use of standing orders" (P <.001) and "average observed physician examination room time," regardless of visit type (P=.02). CONCLUSIONS: Vaccination rates vary widely in urban settings and are associated with practice characteristics such as time spent with patients and, for influenza vaccine, use of standing orders.

Office manager and nurse perspectives on facilitators of adult immunization.

OBJECTIVE: To assess which characteristics of primary care practices serving low- to middle-income white and minority patients relate to pneumococcal polysaccharide vaccine (PPV) and influenza vaccination rates. METHODS: In an intentional sample of 18 primary care practices, PPV and influenza vaccination rates were determined for a sample of 2289 patients >or=65 years old using medical record review. Office managers and lead nurses were surveyed about their office systems for providing adult immunizations, beliefs about PPV and influenza vaccines, and their own vaccination status. Hierarchical linear modeling (HLM) analyses were used to account for the clustered nature of the data. RESULTS: Sampled patients were most frequently female (61%) and white (83%), and averaged 76 years of age. Weighted vaccination rates were 61.1% for PPV and 52.5% for influenza; rates varied by practice. Using HLM, with patient age and race entered as level 1 variables and office factors entered as level 2 variables, time allotted for an annual well visit was associated with a higher likelihood of influenza vaccination (odds ratio [OR] = 1.04; 95% confidence interval [CI] = 1.02, 1.07; P = .003). Nurse influenza vaccination status was associated with a higher likelihood of PPV vaccination (OR = 3.81; 95% CI = 1.49, 9.78; P = .009). CONCLUSIONS: In addition to race and age, visit length and the nurses' vaccination status were associated with adult vaccination rates. Quality improvement initiatives for adult vaccination might include strengthening social influence of providers and/or ensuring that adequate time is scheduled for preventive care.

Using quantitative and qualitative approaches to understand racial disparities in adult vaccination.

BACKGROUND: One proposed explanation for the persistence of racial disparities in adult immunizations is that minority patients receive primary care at practices that differ substantively from practices where white patients receive care. This study used both quantitative and qualitative methods to assess physician and practice factors contributing to disparities in a sample of inner-city, urban, and suburban practices in low to moderate income neighborhoods. METHODS: Pneumococcal polysaccharide vaccine (PPV) and influenza vaccination rates were determined from medical record review in a sample of 2021 elderly (aged > or = 65 years) patients. Their physicians were surveyed about office systems for adult immunizations and structured observations of practice physical features, and operations were conducted. Case studies of practices with lowest and highest rates and the largest racial disparities are presented. RESULTS: Overall, weighted PPV vaccination rate was 60%, but rates differed significantly by race (65.8% for whites vs 36.5% for minorities, P < .001 by stratified Cochran-Mantel-Haenszel test). Two of 6 minority panels had PPV rates less than 20%. Overall, weighted influenza vaccination rate, as measured by receipt of the vaccine in 3 of the 5 most recent seasons, was 51.9%, but rates also differed significantly by race (55.6% for whites vs 36.2% for minorities, P < .03, by stratified Cochran-Mantel-Haenszel test). CONCLUSIONS: Low rates in 2 minority panels, racial disparity between minorities and whites in mixed panels, and between-panel variation in rates contributed to the overall differences in vaccination rates by race.

Factorial design for improving influenza vaccination among employees of a large health system.

OBJECTIVE: As healthcare personnel (HCP) influenza vaccination becomes a quality indicator for healthcare facilities, effective interventions are needed. This study was designed to test a factorial design to improve HCP vaccination rates. DESIGN: A before-after trial with education, publicity, and free and easily accessible influenza vaccines used a factorial design to determine the effect of mobile vaccination carts and incentives on vaccination rates of HCP, who were divided into groups on the basis of their level of patient contact (ie, business and/or administrative role, indirect patient contact, and direct patient contact). SETTING: Eleven acute care facilities in a large health system. PARTICIPANTS: More than 26,000 nonphysician employees. RESULTS: Influenza vaccination rates increased significantly in most facilities and increased system-wide from 32.4% to 39.6% (P<.001). In the baseline year, business unit employee vaccination rates were significantly higher than among HCP with patient contact; rates did not differ significantly across groups in the intervention year. In logistic regression that accounted for demographic characteristics, intervention year, and other factors, the use of incentives and/or mobile carts that provided access to vaccine at the work unit significantly increased the likelihood of vaccination among HCP with direct and indirect patient contact, compared with control sites. CONCLUSIONS: Interventions to improve vaccination rates are differentially effective among HCP with varying levels of patient contact. Mobile carts appear to remove access barriers, whereas incentives may motivate HCP to be vaccinated. Education and publicity may be sufficient for workers in business or administrative positions. Interventions tailored by worker type are likely to be most successful for improving HCP vaccination rates.

Self-reported influenza vaccination rates among health care workers in a large health system.

BACKGROUND: The national health care worker (HCW) influenza vaccination rate is only 42% despite recommendations that HCWs receive influenza vaccine to prevent influenza among patients. METHODS: Following an educational intervention to improve influenza vaccination in 6 facilities in a large health system (University of Pittsburgh Medical Center), surveys were mailed to 1200 nonphysician HCWs to determine factors related to influenza vaccination and inform the following year's intervention. HCWs were proportionally sampled with oversampling for minority HCWs, and analyses were weighted to adjust for the clustered nature of the data. RESULTS: Response rate was 61%. Influenza vaccination rates were 77% overall, 65% for minority HCWs and 80% for white HCWs (P = .02) for ever receiving vaccine; and 57% overall, 45% for minority HCWs and 60% for white HCWs (P = .009) for receiving vaccine in 2005-2006. In logistic regression, belief that getting vaccinated against influenza is wise, physician recommendation, and older age were associated with higher likelihood of vaccination, whereas minority race and good health were associated with lower likelihood of ever receiving influenza vaccine. CONCLUSION: To increase influenza vaccination, interventions should address HCWs' most important reasons for getting vaccinated: convenience and protecting themselves from influenza.

Raising adult vaccination rates over 4 years among racially diverse patients at inner-city health centers.

OBJECTIVES: To increase adult immunizations at inner-city health centers serving primarily minority patients. DESIGN: A before-after trial with a concurrent control. SETTING: Five inner-city health centers. PARTICIPANTS: All adult patients at the health centers eligible for influenza and pneumococcal vaccines. INTERVENTION: Four intervention sites chose from a menu of culturally appropriate interventions based on the unique features of their respective health centers. MEASUREMENTS: Immunization and demographic data from medical records of a random sample of 568 patients aged 50 and older who had been patients at their health centers since 2000. RESULTS: The preintervention influenza vaccination rate of 27.1% increased to 48.9% (P<.001) in intervention sites in Year 4, whereas the concurrent control rate remained low (19.7%). The pneumococcal polysaccharide vaccine (PPV) rate in subjects aged 65 and older increased from 48.3% to 81.3% (P<.001) in intervention sites in Year 4. Increase in PPV in the concurrent control was not significant. In logistic regression analysis, the likelihood of influenza vaccination was significantly associated with the intervention (odds ratio (OR)=2.07, 95% confidence interval (CI)=1.77-2.41) and with age of 65 and older (OR=2.0, 95% CI=1.62-2.48) but not with race. Likelihood of receiving the pneumococcal vaccination was also associated with older age and, to a lesser degree, with intervention. CONCLUSION: Culturally appropriate, evidence-based interventions selected by intervention sites resulted in increased adult vaccinations in disadvantaged, racially diverse, inner-city populations over 2 to 4 years.