Beneficiary characteristics and vaccinations in the end-stage renal disease Medicare beneficiary population,an analysis of claims data 2006–2015

BackgroundThe Advisory Committee on Immunization Practices (ACIP) routinely recommends three vaccines – influenza, hepatitis B, and pneumococcal vaccines – for End-Stage Renal Disease (ESRD) dialysis patients.MethodsWe sought to assess vaccination coverage among fee-for-service (FFS) Medicare beneficiaries with ESRD who received Part B dialysis services at any point from January 1, 2006 through December 31, 2015 (through June 30, 2016 for influenza). To assess influenza vaccination rates in a given influenza season, we restricted the population to beneficiaries who were continuously enrolled in Medicare Parts A and B throughout all twelve months of that season. To assess hepatitis B and pneumococcal vaccine coverage following dialysis initiation, we developed a Kaplan-Meier curve for all patients who began dialysis between 2006 and 2015.ResultsFor influenza vaccination, we identified an average of approximately 325,000 ESRD dialysis beneficiaries enrolled through each influenza season from 2006–2015. Seasonal influenza vaccination rates steadily increased during the 10-year period, from 52% in 2006–2007 to 71% in 2015–2016. The greatest increases in influenza vaccination appear in non-white beneficiaries with overall utilization in non-whites higher than in whites (p < .001). For the hepatitis B and pneumococcal vaccinations, we identified over 350,000 ESRD dialysis beneficiaries who began dialysis over the 10-year study window. The probability of receiving a hepatitis B vaccine within the first three years of entering into the ESRD program was higher (77%) than the probability of receiving any pneumococcal vaccine (53%). 45% of ESRD patients completed at least one dose of the two hepatitis B series (three-dose or four-dose) at any time during the study period.ConclusionsOpportunities exist at regional and facility levels to improve vaccination coverage. Compliance to ACIP recommendations may directly affect risk for ESRD dialysis patients for complications from diseases that can be mitigated by vaccination.     

Seasonal influenza vaccination is associated with reduced risk of death among Medicare beneficiaries☆

BackgroundInfluenza causes substantial mortality, especially among older persons. Influenza vaccines are rarely more than 50% effective and rarely reach more than half of the US Medicare population, which is primarily an aged population. We wished to estimate the association between vaccination and mortality reduction.MethodWe used the US Center for Medicare and Medicaid Services (CMS) DataLink Project to determine vaccination status and timing during the 2017–2018 influenza season for more than 26 million Medicare enrollees. Patient-level demographic, health, co-morbidity, hospitalization, vaccination, and healthcare utilization claims data were supplied as covariates to general linear models in order to isolate and estimate the association between participation in the vaccination program and relative risk of death.FindingsThe 2017–2018 seasonal influenza vaccine reduced (Relative Risk Ratio [RRR] 0.936 [95% CI = 0.918–0.954]) the risk of all-cause death among beneficiaries following a hospitalization for sepsis and moreover the risk of death without a prior hospitalization during the 2.5-month outcome window (RRR 0.870 [95% CI = 0.853–0.887]). We estimate the number needed to vaccinate (NNV) to prevent a death in the ten-week outcome window is between 1,515 beneficiaries (95% CI = 1,351–1,754; derived from the average treatment effect of augmented inverse probability weighting) and 1,960 beneficiaries (95% CI = 1,695–2,381; derived from the average marginal effect of logistic regression). Among beneficiaries requiring hospitalization, the greatest death risk reduction accrued to those 85 + years of age who were hospitalized with sepsis, RRR 0.92 [95% CI = 0.89–0.95]. No apparent benefit was realized by beneficiaries who required custodial (nursing home) care.InterpretationSeasonal influenza immunization is associated with relative reduction of death risk among non-institutionalized Medicare beneficiaries.FundingAll authors are full-time or contractual employees of the United States Federal Government, Department of Health and Human Services, the funding agency.     

Vaccination among Medicare-fee-for service beneficiaries: Characteristics and predictors of vaccine receipt, 2014–2017

Background

Vaccination coverage rates for older adults are low. To better understand utilization of Medicare vaccination benefits we examined a retrospective cohort of more than 26 million Medicare fee-for-service beneficiaries age 65?years and older from 2014 to 2017.

Pneumococcal vaccination patterns among persons aged 65 years or older in the United States: A retrospective database analysis

ObjectiveThis study investigated the patterns of pneumococcal disease vaccination, the time between two different pneumococcal vaccine doses and factors associated with series completion.MethodsA retrospective claims database analysis was conducted using the Clinformatics DataMart™ database. Adults who turned 65 years between January 1st, 2013 to June 30th, 2017 and were continuously enrolled (≥15 months) in the Medicare Advantage plans to June 30th, 2017 were included in this study. Pneumococcal vaccination patterns included: PCV13-PPV23, PPV23-PCV13, or receiving PPV23 or PCV13 only. Pneumococcal vaccination series completion was defined as receiving PCV13-PPV23 or PPV23-PCV13 from 65 years old to June 30th, 2017 while non-completion was defined as receiving only PCV13 or only PPV23 from 65 years old to June 30th, 2017. A multivariable logistic regression model was used to identify factors associated with pneumococcal vaccination series completion.ResultsA total of 224,132 adults were included in this study. Most received no pneumococcal vaccination (49%), while 34.3% received only one vaccine. Series completion occurred in 16.8% of adults. Some adults received only one vaccination: 11.6% received PPV23 and 22.7% received PCV13. The mean time between vaccinations was 420.8 days (approximately 14 months) for the PCV-PPV23 series, and 595.5 days (approximately 20 months) for the PPV23-PCV13 series. Adults were significantly more likely to complete pneumococcal vaccination series if they had at least one doctor’s office, outpatient visit, or pharmacy visit versus no visits, or received an influenza vaccination in the first year after turning 65 years than those who did not (All: P < 0.001).ConclusionDespite the 2014 recommendation, percentages of pneumococcal vaccination series completion were found to be low, aligning with recent literature. This highlights the need to improve series completion, given the increased risk and associated economic burden of pneumococcal disease in adults aged ≥65 years.     

Seasonal influenza vaccine effectiveness against medically attended influenza illness among children aged 6–59 months,October 2011–September 2012: A matched test-negative case–control study in Suzhou,China

BackgroundSeasonal influenza infections among young children in China lead to substantial numbers of hospitalizations and financial burden. This study assessed the seasonal influenza vaccine effectiveness (VE) against laboratory confirmed medically attended influenza illness among children in Suzhou, China, from October 2011–September 2012.MethodsWe conducted a test-negative case–control study among children aged 6–59 months who sought care at Soochow University Affiliated Children's Hospital (SCH) from October 2011–September 2012. A case was defined as a child with influenza-like illness (ILI) or severe acute respiratory infection (SARI) with an influenza-positive nasopharyngeal swab by rRT-PCR. Controls were selected from children presenting with ILI or SARI without laboratory confirmed influenza. We conducted 1:1 matching by age and admission date. Vaccination status was verified from the citywide immunization system database. VE was calculated with conditional logistic regression: (1 − OR) × 100%.ResultDuring the study period, 2634 children aged 6–59 months presented to SCH with ILI (1975) or SARI (659) and were tested for influenza. The vaccination records were available for 69% (1829; ILI: 1354, SARI: 475). Among those, 23% (427) tested positive for influenza, and were included as cases. Among influenza positive cases, the vaccination rates were 3.2% for SARI and 4.5% for ILI. Among controls, the vaccination rates were 13% for SARI, and 11% for ILI. The overall VE against lab-confirmed medically attended influenza virus infection was 67% (95% CI: 41–82). The VE for SARI was 75% (95% CI: 11–93) and for ILI was 64% (95% CI: 31–82).ConclusionsThe seasonal influenza vaccine was effective against medically attended lab-confirmed influenza infection in children aged 6–59 months in Suzhou, China in the 2011–12 influenza season. Increasing seasonal influenza vaccination among young children in Suzhou may decrease medically attended influenza-associated ILI and SARI cases in this population.     

Influenza immunisation coverage from 2015 to 2017: A national study of adult patients from Australian general practice

ObjectivesTo assess influenza immunisation rates and coverage in adult patients from Australian general practice and identify whether practice or patients’ characteristics are associated with vaccination uptake.DesignOpen cohort study.Setting550 Australian general practices included in the MedicineInsight database.ParticipantsPatients aged 18+ years who had at least one consultation during influenza season between 2015 and 2017. Two samples were considered: (1) ‘active’ patients (at least three consultations in any two consecutive years) and (2) ‘every year’ patients (at least one consultation per year).Main outcome measuresInfluenza vaccination rates per 1,000 consultations and coverage (% vaccinated among those who consulted) from 2015 to 2017.ResultsBetween 2015 and 2017 the influenza vaccine rate changed from 57.4 to 51.7 and 67.0 per 1,000 consultations, while correspondent values for coverage were 29.3%, 25.2% and 27.6% (in ‘active’ patients). Vaccine coverage was at least 30% higher in inner regional areas, among patients aged 65+ years or those with comorbidities. Similar associations were found among ‘every year’ patients, but average coverage across the three years was higher (41% vs 27%). Aboriginal and Torres Strait Islander people, either with or without comorbidity, showed a vaccine coverage 10–30% higher than non-Indigenous people for those aged less than 65 years (p-value for interaction < 0.001).ConclusionMedicineInsight data is a useful and low-cost method to monitor influenza immunisation coverage. Independent of the sample used, vaccination coverage among Indigenous people or patients with comorbidities could be improved. Targeted strategies for high-risk groups need to be developed.     

The causes of racial and ethnic differences in influenza vaccination rates among elderly Medicare beneficiaries

OBJECTIVE: To explore three potential causes of racial/ethnic differences in influenza vaccination rates in the elderly: (1) resistant attitudes and beliefs regarding vaccination by African-American and Hispanic Medicare beneficiaries, (2) poor access to care during influenza vaccination weeks, and (3) discriminatory behavior by providers. DATA SOURCES: Medicare beneficiaries who responded to both the 1995 and 1996 Medicare Current Beneficiary Survey (MCBS) (n=6,746). STUDY DESIGN: We combined survey information from the MCBS with Medicare claims. We measured resistance to vaccination by self-reported reasons for not receiving vaccination, access to care by claims submitted during vaccination weeks, and discrimination by racial differences in vaccinations among beneficiaries who visited the same providers during vaccination weeks. PRINCIPAL FINDINGS: White beneficiaries (66.6 percent) were more likely to self-report having received vaccination than were African Americans (43.3 percent) or Hispanics (52.5 percent). Resistance to vaccination plays a role in low vaccination rates of African-American (-11.8 percentage points), but not Hispanic beneficiaries. Unequal access accounts for <2 percent of the disparity. Minority beneficiaries remained unvaccinated despite having medical encounters with their usual providers on days when those same providers were administering vaccinations to white beneficiaries. This disparity is attributable not to provider discrimination but to a 1.6-5 x higher likelihood of white beneficiaries initiating encounters for the purpose of receiving vaccination. CONCLUSION: Disparities in access to care and provider discrimination play little role in explaining racial/ethnic disparities in influenza vaccination. Eliminating missed opportunities for vaccination in 1995 would have raised vaccination rates in three racial/ethnic groups to the Healthy People 2000 goal of 60 percent vaccination.     

Pneumococcal pneumonia and influenza vaccination: access to and use by US Hispanic Medicare beneficiaries.

OBJECTIVES: This study examined differences between elderly Hispanic Medicare beneficiaries and other Medicare beneficiaries in the probability of being immunized for pneumococcal pneumonia and influenza. METHODS: We used the 1992 national Medicare Current Beneficiary Survey to evaluate influenza and pneumococcal pneumonia immunization rates. RESULTS: Elderly Hispanic Medicare beneficiaries were less likely than non-Hispanic White Medicare beneficiaries to have received an influenza vaccine in the past year or to have ever been immunized for pneumococcal pneumonia. Speaking Spanish was statistically significantly associated with influenza vaccination but not with pneumococcal pneumonia vaccination. Supplemental insurance status, HMO enrollment, having a usual source of care, and being satisfied with access to care were positively associated with immunization. CONCLUSIONS: Strategies that may improve immunization rates among elderly. Hispanics include reducing the inconvenience of being immunized, decreasing out-of-pocket costs, linking beneficiaries with providers, and educating Hispanic beneficiaries in Spanish about the benefits of vaccinations.     

Influenza vaccination rates in children decline when the live attenuated influenza vaccine is not recommended

BackgroundIn 2016 the Centers for Disease Control and Prevention (CDC) recommended against using the live attenuated influenza vaccine (LAIV) for the 2016–2017 influenza season. This recommendation is potentially important for vaccination rates because perceived effectiveness and ease of administration are among the primary determinants of families decisions to vaccinate their children. This investigation sought to determine whether rates of pediatric influenza vaccination changed in a season when the LAIV was not recommended.MethodsThis study used cohort and cross sectional data from an academic primary care pediatric center in central Pennsylvania that serves approximately 12,500 patients. Early season (prior to November 1) and end-of-season (prior to March 1) vaccination rates in the 2015–16 and 2016–17 influenza seasons were recorded for individuals 2–17 years old. Repeat vaccination rates (percentage of children receiving influenza vaccination in one season who were also vaccinated in the next season) were recorded for the 2015–16 into 2016–17 seasons. A logistic regression model adjusting for race, ethnicity, age, insurance type and type of vaccination received was employed to identify predictors of repeat vaccination.ResultsIn the absence of LAIV (2016–17) early vaccination rates were significantly higher (24.7% vs 22.8%, p = 0.004), but end-of-season rates were lower (50.4% vs 52.0%, p = 0.03) than when LAIV was offered (2015–16). After adjusting for covariates, those who had received IIV in the 2015–16 season had higher odds (OR 1.32, 95% CI, 1.15–1.52) of getting a repeat vaccination in the 2016–17 season, compared with those who had received LAIV in the 2015–16 season.ConclusionsEnd-of-season vaccination rates were lower in 2016–17 when LAIV was not recommended, particularly among children who received LAIV in the preceding year. Unavailability of LAIV in the 2016–17 season may have impacted influenza vaccination convenience and perceived effectiveness, two factors which could influence vaccine uptake in pediatric populations.     

The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates

ObjectiveTo evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race.Data SourcesMedicare Limited Data Set 5% sample claims 2003‐2014 and the HRSA Area Health Resources Files.Study DesignInstrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county‐level Welcome to Medicare Visit rates as an instrument.Data Collection/Extraction MethodsThree hundred twenty‐four thousand three hundred and eighty‐five fee‐for‐service Medicare beneficiaries without dementia when the AWV was introduced in 2011.Principal FindingsAnnual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6 months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (P < .001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses.ConclusionsDementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults.     

Surveillance for Guillain-Barré syndrome after influenza vaccination among U.S. Medicare beneficiaries during the 2017–2018 season

BackgroundThe U.S. Food and Drug Administration and the Centers for Medicare & Medicaid Services have been actively monitoring the risk of Guillain-Barré syndrome (GBS) following influenza vaccination among Fee-for-Service (FFS) Medicare beneficiaries every season since 2008. We present our evaluation of the GBS risk following influenza vaccinations during the 2017–2018 season.MethodsWe implemented a multilayered approach to active safety surveillance that included near real-time surveillance early in the season, comparing GBS rates post-vaccination during the 2017–2018 season with rates from five prior seasons using the Updating Sequential Probability Ratio Test (USPRT), and end-of-season self-controlled risk interval (SCRI) analyses.ResultsWe identified approximately 16 million influenza vaccinations. The near real-time surveillance did not signal for a potential 2.5-fold increased GBS risk either in days 8–21 or 1–42 post-influenza vaccination. In the SCRI analyses, we did not detect statistically significant increased GBS risks among influenza-vaccinated Medicare beneficiaries ≥65 years for either the 8–21 or 1–42-day risk windows for all seasonal vaccines combined, high-dose vaccine, or standard-dose vaccines; we did detect an increased GBS risk in days 8–21 post-vaccination for individuals vaccinated with the adjuvanted vaccine (OR: 3.75; 95% CI: 1.01, 13.96), although this finding was not statistically significant after multiplicity adjustment (p = 0.146).ConclusionsOur multilayered surveillance approach—which allows for early detection of elevated GBS risk and provides reliable end-of-season SCRI estimates of effect size—did not identify an increased GBS risk following 2017–2018 influenza vaccinations. The slightly increased GBS risk with the adjuvanted vaccine, which was not statistically significant following multiplicity adjustment, is consistent with the package inserts of all U.S.-licensed influenza vaccines, which warn of a potential low increased GBS risk. The benefits of influenza vaccines in preventing morbidity and mortality heavily outweigh this potential risk.     

Variation in influenza vaccine assessment,receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes

BackgroundMore older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents.MethodsWe analyzed 2014–2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination.ResultsThere were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.10 pp, 95% CL: ?3.53 pp, ?2.68 pp), or high (-4.63 pp, 95% CL: ?5.11 pp, ?4.15 pp) MA compared with NHs with the lowest prevalence of MA.ConclusionA higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings.     

Recommendations and offers for adult influenza vaccination, 2011–2012 season,United States

BackgroundProvider recommendations and offers for influenza vaccination improve adult influenza vaccination coverage. Analysis was performed to describe receipt of influenza vaccination recommendations and offers among adults who visited a healthcare provider (HCP) during the 2011–2012 influenza season and describe differences between those receiving and not receiving recommendations and offers for influenza vaccination. Associations between influenza vaccination and receipt of recommendations and offers were examined.MethodsRespondents to a random digit dial telephone survey who had visited a HCP since July 1, 2011 were asked if they had received a recommendation for influenza vaccination. Those receiving a recommendation were asked if they received an offer for vaccination. Participants were characterized by demographic and access to health care variables. Logistic regression was used to examine the relationships between participant characteristics and recommendation alone, between participant characteristics and recommendation and offer, and between influenza vaccination and recommendation and offer.ResultsOf those who reported visiting a HCP, 43.8% reported receiving a recommendation for influenza vaccination. Of those who reported receiving a recommendation, 76.6% reported receiving an offer for influenza vaccination. Persons with high-risk conditions and persons over 65 years were more likely to receive recommendations for influenza vaccination when compared to those without high-risk conditions and 18–49 year olds, respectively. Those reporting receipt of a recommendation and offer for influenza vaccination were 1.76 times more likely and those reporting receipt of a recommendation but no offer were 1.72 times more likely to report being vaccinated for influenza controlling for all patient characteristics.ConclusionsLess than half of respondents reported receipt of recommendations and offers of influenza vaccination during the 2011–2012 influenza season and disparities exist between groups. All healthcare providers seeing adults should recommend or offer influenza vaccination for all patients at every visit during the influenza season.     

Mass mailings have little effect on utilization of influenza vaccine among Medicare beneficiaries

BACKGROUND: We reviewed published and unpublished studies of mass mailings designed to increase utilization of influenza vaccine among Medicare beneficiaries. METHODS: Search of computerized indexes for published studies and the Medicare Peer Review Organization Health Care Quality Improvement Project database for unpublished studies. Study selection criteria were: use of a controlled trial design and use of mass mailings direct to Medicare beneficiaries to increase receipt of influenza vaccinations. Study selection and data extraction were performed in duplicate by physician reviewers with consensus resolution. RESULTS: Six controlled trials of mass mailings were identified. One study, published in the Morbidity and Mortality Weekly Report (MMWR), reported a modest but statistically significant improvement in influenza vaccination rates among patients who received a letter relative to those who did not. This study was cited as justification for mail interventions performed in five subsequent studies, none of which reported clinically meaningful results. None of these five studies was published. CONCLUSIONS: Mass mailings have at best had clinically trivial effects on increasing influenza vaccination among Medicare beneficiaries. Publication bias has contributed to continued use of a relatively ineffective intervention.     

ICD-10 anaphylaxis algorithm and the estimate of vaccine-attributable anaphylaxis incidence in Medicare

BackgroundAnaphylaxis is a rare, serious allergic reaction. Its identification in large healthcare databases can help better characterize this risk.ObjectiveTo create an ICD-10 anaphylaxis algorithm, estimate its positive predictive values (PPVs) in a post-vaccination risk window, and estimate vaccination-attributable anaphylaxis rates in the Medicare Fee For Service (FFS) population.MethodsAn anaphylaxis algorithm with core and extended portions was constructed analyzing ICD-10 anaphylaxis claims data in Medicare FFS from 2015 to 2017. Cases of post-vaccination anaphylaxis among Medicare FFS beneficiaries were then identified from October 1, 2015 to February 28, 2019 utilizing vaccine relevant anaphylaxis ICD-10 codes. Information from medical records was used to determine true anaphylaxis cases based on the Brighton Collaboration’s anaphylaxis case definition. PPVs were estimated for incident anaphylaxis and the subset of vaccine-attributable anaphylaxis within a 2-day post-vaccination risk window. Vaccine-attributable anaphylaxis rates in Medicare FFS were also estimated.ResultsThe study recorded 66,572,128 vaccinations among 21,685,119 unique Medicare FFS beneficiaries. The algorithm identified a total of 190 suspected anaphylaxis cases within the 2-day post-vaccination window; of these 117 (62%) satisfied the core algorithm, and 73 (38%) additional cases satisfied the extended algorithm. The core algorithm’s PPV was 66% (95% CI [56%, 76%]) for identifying incident anaphylaxis and 44% (95% CI [34%, 56%]) for vaccine-attributable anaphylaxis. The vaccine-attributable anaphylaxis incidence rate after any vaccination was 0.88 per million doses (95% CI [0.67, 1.16]).ConclusionThe ICD-10 claims algorithm for anaphylaxis allows the assessment of anaphylaxis risk in real-world data. The algorithm revealed vaccine-attributable anaphylaxis is rare among vaccinated Medicare FFS beneficiaries.     

A cross sectional survey to evaluate knowledge,attitudes and practices regarding seasonal influenza and influenza vaccination among diabetics in Pretoria,South Africa

BackgroundIn South Africa, influenza vaccination is recommended to all diabetics. However, vaccination coverage among diabetics remains low. Therefore, this study aimed to explore the knowledge, attitudes, and practices among people with diabetes in Pretoria regarding seasonal influenza and influenza vaccination.MethodA cross-sectional survey was conducted among type 1 and 2 diabetes mellitus patients who attended diabetic clinics in two major tertiary hospitals in Pretoria, South Africa from October to December 2015. The pilot-tested questionnaire consists of 32 quantitative questions that covered seasonal influenza and influenza vaccination in terms of the patient’s demographics, medical history and knowledge, attitudes and practices.ResultsA total of 292 completed questionnaires were received with a response rate of 70.0%. Of these, 162 participants (55.5%) believed that influenza is the same as common cold. While 96 (32.9%) participants were aware that they were at higher risk of complications of influenza, only 86 (29.5%) participants considered vaccination as an effective means in preventing serious influenza-related complication. Even though 167 (57.2%) participants had heard of the vaccine to prevent influenza, only 84 (28.8%) participants were previously vaccinated. Multivariate analysis shows that participants with good attitude score for influenza vaccination were 18.4 times more likely to be vaccinated compared with those with poor attitude score (OR =18.4, 95%CI. 5.28–64.10, p = .001). Among those previously vaccinated, advice from their doctors (82/84, 97.6%) was the main factor encouraging vaccination. Top reasons given by participants who had never been vaccinated before (208/292, 71.2%) include use of alternative protection (107/208, 51.4%) and that vaccination is not necessary because flu is just a minor illness (93/208, 44.7%).ConclusionUptake of seasonal vaccination among diabetics in Pretoria is low. Level of knowledge and perception are the main barriers to vaccination. Health care provider’s advice may be an important key predictor of previous influenza vaccination and they should continue to educate and encourage all diabetics to get vaccinated for influenza at least once yearly.     

Cost-effectiveness of seasonal inactivated influenza vaccination among pregnant women

ObjectiveTo evaluate the cost-effectiveness of seasonal inactivated influenza vaccination among pregnant women using data from three recent influenza seasons in the United States.Design, setting, and participantsWe developed a decision-analytic model following a cohort of 5.2 million pregnant women and their infants aged <6 months to evaluate the cost-effectiveness of vaccinating women against seasonal influenza during pregnancy from a societal perspective. The main outcome measures were quality-adjusted life-year (QALY) gained and cost-effectiveness ratios. Data sources included surveillance data, epidemiological studies, and published vaccine cost data. Sensitivity analyses were also performed. All costs and outcomes were discounted at 3% annually.Main outcome measuresTotal costs (direct and indirect), effects (QALY gains, averted case numbers), and incremental cost-effectiveness of seasonal inactivated influenza vaccination among pregnant women (cost per QALY gained).ResultsUsing a recent benchmark of 52.2% vaccination coverage among pregnant women, we studied a hypothetical cohort of 2,753,015 vaccinated pregnant women. With an estimated vaccine effectiveness of 73% among pregnant women and 63% among infants <6 months, QALY gains for each season were 305 (2010–2011), 123 (2011–2012), and 610 (2012–2013). Compared with no vaccination, seasonal influenza vaccination during pregnancy was cost-saving when using data from the 2010–2011 and 2012–2013 influenza seasons. The cost-effectiveness ratio was greater than $100,000/QALY with the 2011–2012 influenza season data, when CDC reported a low attack rate compared to other recent seasons.ConclusionsInfluenza vaccination for pregnant women can reduce morbidity from influenza in both pregnant women and their infants aged <6 months. Seasonal influenza vaccination during pregnancy is cost-saving during moderate to severe influenza seasons.     

Pneumococcal vaccine uptake among Medicare Beneficiaries aged ≥65 years following the shared clinical decision-making recommendation for 13-valent pneumococcal conjugate vaccine in 2019

BackgroundIn November 2019, the US Advisory Committee on Immunization Practices recommended shared clinical decision-making (SCDM) for use of 13-valent pneumococcal conjugate vaccine (PCV13) among immunocompetent elderly adults. The impact of SCDM on PCV13 use in this population, immunocompromised persons, and vulnerable subgroups has not been well documented.MethodsUsing Medicare Research Identifiable Files (01/2018 – 09/2020), monthly uptake of pneumococcal vaccine (PCV13, 23-valent pneumococcal polysaccharide vaccine [PPSV23]) was identified among fee-for-service beneficiaries aged ≥ 65 years with Part B coverage and no evidence of prior PCV13. Uptake was stratified by vaccine, risk profile, and demographics.ResultsAmong the > 12 M beneficiaries included each month, PCV13 uptake declined from > 70% of pneumococcal vaccinations before SCDM to < 60% after SCDM (02/2020). Reductions in PCV13 uptake were consistent across vulnerable subgroups as well as immunocompromised persons.ConclusionsPCV13 use decreased among immunocompetent and immunocompromised persons alike, despite continued routine PCV13 recommendation for the latter group.     

Immunization disparities in older Americans: determinants and future research needs

BACKGROUND: Marked racial disparities persist in influenza and pneumococcal vaccinations among Medicare beneficiaries. This study sought to assess the contribution that patient, physician, health system, and area-level characteristics make to these racial disparities in immunization. METHODS: Cross-sectional and decomposition analyses were performed on a nationally representative sample of 18,013 non-institutionalized Medicare beneficiaries who responded to the Medicare Current Beneficiary Survey (MCBS) in 2000 to 2002. The physician characteristics of interest included specialty type, accessibility, information-giving skills, perceived quality, and continuity of care. Health system characteristics included HMO enrollment and numbers of primary care physicians per elderly. The outcomes were receipt of influenza vaccine in the past year and ever having received a pneumococcal vaccine. RESULTS: Immunization rates were below recommended levels for all Medicare beneficiaries. Disparities between white and black beneficiaries in the receipt of vaccinations were large-an absolute 17% difference for each vaccine. After adjusting for patient, physician, health system, and area-level characteristics, white beneficiaries had significantly higher odds of vaccination than did black beneficiaries: adjusted odds ratio (aOR) = 1.52 (95% confidence interval [CI] = 1.35-1.71) for influenza vaccination, and aOR = 1.82 (95% CI = 1.61-2.07) for pneumococcal vaccination. Beneficiaries with a usual physician that they rated as having good information-giving skills and whose practice was more accessible, had higher immunization rates. Beneficiaries with a primary care generalist as their usual physician had higher odds of immunization than those with a specialist as their usual physician. At the county level, a higher number of primary care physicians per elderly resident was associated with higher odds of immunization. Only 7% of the racial disparity in influenza immunization was explained by the measured characteristics of beneficiaries and their health systems. CONCLUSIONS: Despite similar insurance coverage and presence of a usual physician, black beneficiaries were significantly less likely than their white counterparts to receive influenza and pneumococcal vaccinations. The implications for future research are discussed, including the need for system-based interventions that make the offering and discussion of vaccination routine.     

Retrospective cost-effectiveness of the 23-valent pneumococcal polysaccharide vaccination program in Australia

BackgroundThe Australian infant pneumococcal vaccination program was funded in 2005 using the 7-valent pneumococcal conjugate vaccine (PCV7) and the 13-valent conjugate vaccine (PCV13) in 2011. The PCV7 and PCV13 programs resulted in herd immunity effects across all age-groups, including older adults. Coincident with the introduction of the PCV7 program in 2005, 23-valent pneumococcal polysaccharide vaccine (PPV23) was funded for all Australian adults aged over 65 years.MethodsA multi-cohort Markov model with a cycle length of one year was developed to retrospectively evaluate the cost-effectiveness of the PPV23 immunisation program from 2005 to 2015. The analysis was performed from the healthcare system perspective with costs and quality-adjusted life years discounted at 5% annually. The incremental cost-effectiveness ratio (ICER) for PPV23 doses provided from 2005 to 2015 was calculated separately for each year when compared to no vaccination. Parameter uncertainty was explored using deterministic and probabilistic sensitivity analysis.ResultsIt was estimated that PPV23 doses given out over the 11-year period from 2005 to 2015 prevented 771 hospitalisations and 99 deaths from invasive pneumococcal disease (IPD). However, the estimated IPD cases and deaths prevented by PPV23 declined by more than 50% over this period (e.g. from 12.9 deaths for doses given out in 2005 to 6.1 in 2015), likely driven by herd effects from infant PCV programs. The estimated ICER over the period 2005 to 2015 was approximately A$224,000/QALY gained compared to no vaccination. When examined per year, the ICER for each individual year worsened from $140,000/QALY in 2005 to $238,000/QALY in 2011 to $286,000/QALY in 2015.ConclusionThe cost-effectiveness of the PPV23 program in older Australians was estimated to have worsened over time. It is unlikely to have been cost-effective, unless PPV23 provided protection against non-invasive pneumococcal pneumonia and/or a low vaccine price was negotiated. A key policy priority should be to review of the future use of PPV23 in Australia, which is likely to be more cost-effective in certain high-risk groups.