Statewide Pandemic Influenza Vaccination Reminders for Children with Chronic Conditions

Objectives. We evaluated the use of a statewide immunization information system (IIS) to target influenza vaccine reminders to high-risk children during a pandemic.Methods. We used Michigan’s IIS to identify high-risk children (i.e., those with ≥ 1 chronic condition) aged 6 months to 18 years with no record of pH1N1 vaccination among children currently or previously enrolled in Medicaid (n = 202 133). Reminders were mailed on December 7, 2009. We retrospectively assessed children’s eligibility for evaluation and compared influenza vaccination rates across 3 groups on the basis of their high-risk and reminder status.Results. Of the children sent reminders, 53 516 were ineligible. Of the remaining 148 617 children, vaccination rates were higher among the 142 383 high-risk children receiving reminders than among the 6234 high-risk children with undeliverable reminders and the 142 383 control group children without chronic conditions who were not sent reminders.Conclusions. Midseason reminders to parents of unvaccinated high-risk children with current or past Medicaid enrollment were associated with increased pH1N1 and seasonal influenza vaccination rates. Future initiatives should consider strategies to expand targeting of high-risk groups and improve IIS reporting during pandemic events.Shortly after the onset of the 2009 global pandemic of influenza A (H1N1)pdm09 virus (pH1N1),1 the Advisory Committee for Immunization Practices released recommendations for vaccination that specifically identified 5 target groups, including persons at higher risk for infection or for severe influenza-related complications because of chronic medical conditions.2 Although administration of a monovalent pH1N1 vaccine began throughout the United States in October 2009, initial vaccine supplies were very limited in many jurisdictions. As a consequence, numerous state and local health departments requested that providers focus vaccine administration on a smaller subset of the initial target groups,3 based on subgroups designated by the advisory committee as a priority in the event of a vaccine shortage.2Early indications from the Centers for Disease Control and Prevention estimated that more than 1 million cases of pH1N1 influenza had occurred in the United States by August 20094 and that pediatric deaths from pH1N1 influenza were more common among children with 1 or more chronic medical conditions (hereinafter referred to as “high-risk children”).5 Reminder–recall for pH1N1 vaccine represented a potential strategy for reaching parents of high-risk children. It had previously been demonstrated as an effective mechanism for increasing pediatric seasonal influenza vaccination among children with chronic conditions.6–8 In addition, during the 2009–2010 influenza season, a midseason report from the Advisory Committee for Immunization Practices urged health departments to consider implementing practices shown to increase influenza vaccination coverage, including reminder–recall.9The Michigan Department of Community Health (MDCH) used the Michigan Care Improvement Registry (MCIR) to target pH1N1 vaccination reminders to children known to have a high-risk condition. MCIR has a high degree of provider participation with more than 95% of children age 6 years or younger having 2 or more vaccine doses entered.10 At the time of this reminder effort, all immunization providers in Michigan were required by state law to report school-exclusionary vaccinations administered to children to MCIR. In addition, pH1N1 vaccine providers were required to report to MCIR all pH1N1 doses administered during the pandemic.Although using MCIR to target reminders to high-risk children had been demonstrated on a small scale,11 the use of such notifications during an influenza pandemic was untested. With that in mind, our objective was to describe the feasibility and utility of this effort. To our knowledge, this is the first assessment of a statewide reminder–recall during an influenza pandemic.     

The Social Determinants of Health and Pandemic H1N1 2009 Influenza Severity

Objectives. We explored the effects of social determinants of health on pandemic H1N1 2009 influenza severity and the role of clinical risk factors in mediating such associations.Methods. We used multivariate logistic regression with generalized estimating equations to examine the associations between individual- and ecological-level social determinants of health and hospitalization for pandemic H1N1 2009 illness in a case-control study in Ontario, Canada.Results. During the first pandemic phase (April 23–July 20, 2009), hospitalization was associated with having a high school education or less and living in a neighborhood with high material or total deprivation. We also observed the association with education in the second phase (August 1–November 6, 2009). Clinical risk factors for severe pandemic H1N1 2009 illness mediated approximately 39% of the observed association.Conclusions. The main clinical risk factors for severe pandemic H1N1 2009 illness explain only a portion of the associations observed between social determinants of health and hospitalization, suggesting that the means by which the social determinants of health affect pandemic H1N1 2009 outcomes extend beyond clinically recognized risk factors.Similar to seasonal influenza, most cases of pandemic H1N1 2009 influenza were relatively mild; however, certain groups of individuals were at a higher risk of complication and severe disease than were others. Information from early pandemic H1N1 2009 case series indicated that risk factors typically associated with severe seasonal influenza, including underlying conditions such as pulmonary or cardiac disease, diabetes, and pregnancy, were observed among individuals very ill with pandemic H1N1 2009; however, unlike seasonal influenza, severe pandemic H1N1 2009 affected children of all ages and young adults, many of whom were previously healthy.1–6 Obesity and morbid obesity were also recognized as risk factors.2,7,8In Ontario, Canada, a case-control study was conducted as part of a pan-Canadian approach to pandemic H1N1 2009 research. The purpose of this study was to identify risk factors for pandemic H1N1 2009 infection requiring hospitalization (L. C. R. and N. C., unpublished data, 2010).9 Many of the risk factors identified in our study and others, notably the presence of chronic conditions such as diabetes10–12and obesity13,14 and health behaviors such as smoking15,16 and accessing health care,17 are known to be influenced by the social determinants of health. The social determinants of health are social and economic conditions, such as income, education, employment, and social support, that influence the health of individuals and communities. Disparities in these conditions are reflected in a gradient of socioeconomic status (SES), which, in turn, is associated with inequalities in health. It is widely recognized that individuals at the lower end of the SES gradient experience poorer health and a reduced life expectancy compared with more advantaged groups.18–20 We were therefore interested in exploring the effects of the social determinants of health on pandemic H1N1 2009 severity in Ontario and the role of clinical risk factors in mediating any such associations.In addition to individual characteristics, contextual socioeconomic factors, such as neighborhood conditions, influence health outcomes. A majority of studies investigating neighborhood effects on health have found significant associations between measures of area SES and health outcomes, such as self-reported health and mortality, that are independent of the effects of individual socioeconomic characteristics.21,22 The mechanisms by which neighborhood characteristics affect the health of individuals are not fully understood, but there are several potential pathways through which ecological exposures may affect the severity of influenza infection. For example, neighborhood problems such as vandalism, illegal drug use, noise, and litter are sources of psychological stress for residents,23–25 and psychological stress is known to influence immune function.26,27 Neighborhood-associated psychological stress could therefore place individuals at increased risk of severe influenza illness. Indeed, Cohen et al. demonstrated that among individuals experimentally infected with influenza, those reporting high psychological stress before inoculation experienced more severe illness than did individuals with low stress.28 Another possibility is that environmental exposures, such as air pollution, contribute to an individual’s risk for severe infection. Traffic-related air pollution is associated with incident asthma,29–32 and asthma was identified as an important risk factor for severe pandemic H1N1 2009 outcomes, including hospitalization.33 This evidence demonstrates that the social determinants of health exert influence on health at the ecological level as well as at the individual level.We examined the effects of individual- and ecological-level social determinants of health on pandemic H1N1 2009 severity, as indicated by hospitalization, in Ontario, Canada. Furthermore, we explored the role of known clinical risk factors for severe pandemic H1N1 2009 infection in mediating any such associations.A few studies have investigated the associations between the social determinants of health and respiratory infection outcomes, such as healthcare utilization34 and hospitalization.35–37 The outcomes measured in these studies are not specific to influenza and include outcomes from all or acute respiratory infections35 and influenza and pneumonia diagnoses combined.37 Measuring influenza-specific outcomes is challenging because of the nonspecific presentation of illness and the limited use of laboratory diagnostic testing for medical management. The prevalent use of diagnostic testing for influenza during the H1N1 2009 pandemic, therefore, provided a unique opportunity to examine the effect of the social determinants of health on influencing hospitalization specifically because of this novel strain of influenza.     

Cumulative Risk of Guillain–Barré Syndrome Among Vaccinated and Unvaccinated Populations During the 2009 H1N1 Influenza Pandemic

Objectives. We sought to assess risk of Guillain–Barré syndrome (GBS) among influenza A (H1N1) 2009 monovalent (pH1N1) vaccinated and unvaccinated populations at the end of the 2009 pandemic.Methods. We applied GBS surveillance data from a US population catchment area of 45 million from October 15, 2009, through May 31, 2010. GBS cases meeting Brighton Collaboration criteria were included. We calculated the incidence density ratio (IDR) among pH1N1 vaccinated and unvaccinated populations. We also estimated cumulative GBS risk using life table analysis. Additionally, we used vaccine coverage data and census population estimates to calculate denominators.Results. There were 392 GBS cases; 64 (16%) occurred after pH1N1vaccination. The vaccinated population had lower average risk (IDR = 0.83, 95% confidence interval = 0.63, 1.08) and lower cumulative risk (6.6 vs 9.2 cases per million persons, P = .012) of GBS.Conclusions. Our findings suggest that at the end of the influenza season cumulative GBS risk was less among the pH1N1vaccinated than the unvaccinated population, suggesting the benefit of vaccination as it relates to GBS. The observed potential protective effect on GBS attributed to vaccination warrants further study.Guillain–Barré syndrome (GBS) is an acute, monophasic, autoimmune neurologic disorder of the peripheral nerves characterized primarily by muscle weakness and loss of reflexes. Estimates of GBS incidence range from 0.8 to 1.9 cases per 100 000 person-years, are higher in males, and increase with age.1,2 Although the exact causes of GBS are unknown, they are thought to be triggered by antigenic stimulation resulting in demyelination and damage to the peripheral nerves.3,4 GBS has been shown to be associated with antecedent gastrointestinal or upper respiratory tract illnesses, including influenza.5–9 Rarely, GBS may follow vaccination.10–12 During the 1976 swine-origin influenza A pandemic, the risk of GBS was found to be increased by nearly 8 fold in the 6 weeks following receipt of the swine-origin influenza vaccine.11 After 1976, several studies have assessed the risk of GBS following seasonal inactivated influenza vaccines demonstrating either no increased risk or a small increased risk of approximately 1 to 2 additional GBS cases per 1 million vaccine doses administered.13,14 However, the 1976 GBS incident influenced the approach to the 2009 H1N1 vaccine safety monitoring efforts, and GBS became a primary focus of surveillance activities.The pandemic (H1N1) 2009 influenza virus began widespread circulation during the first half of the influenza season with illness peaking during October and November 2009.15 At the same time, influenza A (H1N1) 2009 monovalent vaccines (pH1N1 vaccines) became available in early October 200916 and were administered rapidly and broadly throughout the United States. During this time the United States and several countries worldwide implemented enhanced pH1N1 vaccine safety monitoring.17–19 Many programs have subsequently published their surveillance and evaluation findings for the risk of GBS during the 6 weeks following the pH1N1 vaccine20–25; some but not all of the surveillance systems found a significant but small increased risk of GBS following pH1N1 vaccination. Most, however, were unable to adequately evaluate the potential confounding because of exposure to the pandemic (H1N1) 2009 influenza virus.Influenza and other respiratory illnesses have been associated with GBS,6–8,26,27 and it has been suggested that the absolute increase in risk of GBS is much higher after influenza-like illnesses (ILIs) than a potential increase in risk after vaccination.7,27 We hypothesized that the overall risk of GBS at the end of the 2009 influenza season (October 2009 through May 2010) may have been lower among the pH1N1 vaccinated population than the unvaccinated population. Surveillance for GBS using active-case finding through US Centers for Disease Control and Prevention’s (CDC’s) Emerging Infections Program (EIP) was implemented as part of enhanced pH1N1 vaccine safety monitoring activities25,28; we used these data to test our hypothesis. We evaluated the average and cumulative risk of incident GBS among those vaccinated with pH1N1 vaccine and those unvaccinated (did not receive pH1N1 vaccine) during the surveillance period of October 1, 2009, through May 31, 2010.     

Trends in Risk Perceptions and Vaccination Intentions: A Longitudinal Study of the First Year of the H1N1 Pandemic

Objectives. We sought to evaluate longitudinal trends in people’s risk perceptions and vaccination intentions during the 2009 H1N1 pandemic.Methods. We used data from 10 waves of a US national survey focusing on the H1N1 pandemic (administered between May 2009 and January 2010) to conduct a longitudinal analysis of adult respondents’ risk perceptions and vaccination intentions.Results. Self-reported perceived risk of becoming infected with H1N1 paralleled H1N1 activity throughout the pandemic’s first year. However, intention to be vaccinated declined from 50% (May 2009) to 16% (January 2010) among those who remained unvaccinated (27% had been vaccinated by January 2010). Respondents who indicated that they had previously been vaccinated against seasonal influenza reported significantly higher H1N1 vaccination intentions than those who had not been vaccinated (67% vs 26%; P < .001).Conclusions. Reported intention to be vaccinated declined well before vaccine became available and decreased throughout the pandemic year. To the extent that prior vaccination for seasonal influenza vaccination is a strong correlate of H1N1 risk perceptions, encouraging seasonal influenza vaccination may benefit pandemic preparedness efforts.Vaccination is one of the most effective means of controlling illness caused by influenza. At no time is control more critical than when a new strain of influenza emerges, causing a pandemic. Willingness to be immunized against a novel strain of influenza appears to change over time,1 yet little is known about how willingness changes with perceived risk as a pandemic evolves from an early threat of unknown severity to a more mature threat with known parameters. To be effective in limiting the spread of the disease, strategies to optimize vaccination rates during a pandemic must take into account the public’s changing perceptions of risk to target those who are hesitant to be vaccinated. Opportunities to gain an in-depth understanding of vaccination behaviors are hampered by the infrequency of pandemics and the lack of longitudinal data on risk perceptions.The recent H1N1 pandemic offered an opportunity to study evolving vaccination behaviors. On March 28, 2009, a 9-year-old California girl became the first individual with a confirmed case of H1N1 influenza in the United States.2 Within 1 month the United States declared a public health emergency,3 and within 2 months the World Health Organization declared a phase 6 pandemic (the highest level possible).4 Fortunately, by August 2009 it became clear that the death rate from H1N1 was only about 0.1% to 0.3%, comparable to that expected from seasonal influenza, according to a report by the President’s Council of Advisors on Science and Technology.5However, there was ongoing concern that up to half of the population could become infected, with the number of deaths expected to range from 30 000 to 90 000. By September 2009, a vaccine for the novel H1N1 strain had been approved by the Food and Drug Administration.6 In anticipation of this development, the Advisory Committee on Immunization Practices released criteria for vaccine prioritization in late July 2009.7 Vaccination began in October 2009. Although production delays impeded initial distribution, more than 61 million vaccine doses were ready by November 2009.8Despite the availability of a safe and effective H1N1 vaccine6 and an unprecedented public health campaign to promote its use, uptake by December 2009 was disappointingly low. Only 24% of the entire US population had been vaccinated, and the percentage was only somewhat higher (33%) for priority vaccination groups.9The failure to achieve widespread vaccination uptake has many possible causes. We speculate that some of the failure reflects the public’s evolving perceptions of H1N1 risk. Previous research has highlighted subjective risk as a key predictor of vaccine uptake.10 Yet, almost nothing is known about how the public’s perceptions of novel risks such as H1N1 track the actual evolution of a pandemic or whether variations in risk perceptions explain subsequent patterns in vaccination intentions and behaviors. Previous studies have examined the relationship between risk perceptions and intentions at a single point in time,11,12 but a longitudinal perspective is more policy relevant given that risk perception evolves over time.We sought to chronicle the US public’s evolving risk perceptions regarding the 2009 H1N1 influenza pandemic and the relationship of these perceptions to vaccination intentions. We drew on the ability of RAND’s American Life Panel (ALP) to field frequent interviews with a common sample to generate a detailed, longitudinal perspective of risk perceptions and vaccination intentions throughout the 2009 H1N1 pandemic. Our research questions were as follows: How did perceived risk of H1N1 infection and of death given H1N1 infection relate to measured disease activity in the US population? Did perceived risk of H1N1 correlate with reported intention to be vaccinated against H1N1? and What other policy-relevant factors were associated with H1N1 vaccination intentions over time?     

Benefits and Effectiveness of Administering Pneumococcal Polysaccharide Vaccine With Seasonal Influenza Vaccine: An Approach for Policymakers

For the influenza pandemic of 2009–2010, countries responded to the direct threat of influenza but may have missed opportunities and strategies to limit secondary pneumococcal infections. Delivering both vaccines together can potentially increase pneumococcal polysaccharide vaccine (PPV23) immunization rates and prevent additional hospitalizations and mortality in the elderly and other high-risk groups.We used PubMed to review the literature on the concomitant use of PPV23 with seasonal influenza vaccines. Eight of 9 clinical studies found that a concomitant program conferred clinical benefits. The 2 studies that compared the cost-effectiveness of different strategies found concomitant immunization to be more cost-effective than either vaccine given alone.Policymakers should consider a stepwise strategy to reduce the burden of secondary pneumococcal infections during seasonal and pandemic influenza outbreaks.On June 11, 2009, the World Health Organization (WHO) declared the first influenza pandemic of the 21st century and escalated the global health alert to the highest possible level, phase 6.1 The heightened alert resulted in countries implementing preventive and treatment strategies for influenza management including expanded recommendations for influenza immunization and antiviral coverage in children and adults, and for the increased use of 23-valent pneumococcal polysaccharide vaccine (PPV23).2Every year, Streptococcus pneumoniae infections account for approximately 1.6 million deaths worldwide.3 The incidence of pneumococcal infections rises and falls seasonally with the incidence of influenza. Pneumococcal infections secondary to influenza place a significant burden on health systems, which can be strained or overwhelmed during influenza epidemics, as evidenced by the 2009–2010 H1N1 influenza pandemic.4,5 The 2009–2010 H1N1 influenza pandemic also highlighted the importance of secondary pneumococcal infections6 and their association with adverse outcomes, including death.7Current pneumococcal disease–control strategies include immunization of elderly populations (≥ 65 years) and other high-risk groups (including cigarette smokers) with PPV23 and immunization of infants with conjugate pneumococcal vaccine (PCV). In the absence of pneumococcal immunization, these groups are particularly susceptible to infection.Although routine pediatric pneumococcal immunization strategies have reduced the overall burden of pneumococcal disease in children, the remaining burden has shifted to older age groups, particularly the elderly.8–12 In the United States, 85% of invasive pneumococcal disease now occurs in adults.13In general, adults and high-risk groups are known to have lower immunization coverage than the pediatric population, and can be harder to reach. Therefore, specific strategies to increase PPV23 immunization coverage are needed. One proposed strategy is to integrate a PPV23 program with seasonal influenza programs. Unlike influenza vaccine, which is administered annually, PPV23 is typically recommended to be repeated after 5 years in high-risk groups or the elderly who were immunized when younger than 65 years, but influenza immunization would nevertheless afford an ideal opportunity to access the elderly and other high-risk groups for initial and follow-up PPV23 administration.     

Timeliness of Pediatric Influenza Vaccination Compared With Seasonal Influenza Activity in an Urban Community, 2004–2008

Objectives. We assessed pediatric influenza vaccination in relation to community influenza activity.Methods. We examined seasonal influenza vaccination in 34 012 children aged 6 months through 18 years from 5 academically affiliated clinics in northern Manhattan, New York (an urban low-income community) during the 2004–2008 seasons using hospital and city immunization registries. We calculated the cumulative number of administered influenza vaccine doses and proportion of children with any (≥ 1 dose) or full (1–2 doses per age recommendations) vaccination at the onset and peak of community polymerase chain reaction–confirmed influenza activity according to state surveillance reports and by March 31 each season.Results. Influenza vaccine administration began before October 1, peaked before influenza activity onset, and declined gradually over each season. Coverage at influenza activity onset, peak, and by March 31 increased over the 5 seasons. However, most children lacked full vaccination at these time points, particularly adolescents, minorities, and those requiring 2 doses.Conclusions. Despite early initiation of influenza vaccination, few children were fully vaccinated when influenza began circulating. Interventions should address factors negatively affecting timely influenza vaccination, especially in high-risk populations.Influenza epidemics typically occur from late fall to early spring and are associated with considerable morbidity and mortality, particularly among high-risk populations such as children younger than 5 years and individuals with chronic medical conditions.1 Influenza vaccination of children is an effective strategy for preventing infection and associated complications at the individual and community levels.2–6 The timing of vaccination may be particularly important for optimizing this protection. Influenza virus strains frequently change between seasons, and influenza vaccine efficacy wanes over time; thus, annual influenza vaccination is necessary.7–9 Moreover, influenza viruses begin to circulate in communities at varying times each year, and immunity against influenza may take time to be achieved following vaccine administration.10–13 Therefore, the Advisory Committee on Immunization Practices recommends influenza vaccination of all individuals aged 6 months and older as soon as vaccine becomes available each season, ideally before the community onset of influenza activity.9Despite this recommendation, seasonal influenza vaccination coverage of children by March 31 is low, and limited data suggest that many of those who are vaccinated do not receive it early in the season.14–20 A previous study found that many adults failed to receive influenza vaccine before the peak of influenza activity despite seeing their physician during the early vaccination period.21 To our knowledge, the timing of pediatric influenza vaccination directly compared with community influenza activity in a given season has not yet been examined. Such investigation is particularly warranted among urban low-income minority children, who are at increased risk for inadequate influenza vaccination, viral transmission, and influenza-associated morbidity and mortality.15,17,22,23We assessed influenza vaccination of predominantly low-income minority children at the onset and peak of influenza activity in an urban community and by March 31 during 5 influenza seasons. We also identified determinants of timely vaccination in this population.     

Surveillance for Guillain–Barré Syndrome After Influenza Vaccination Among the Medicare Population, 2009–2010

Objectives. We implemented active surveillance for Guillain–Barré syndrome (GBS) following seasonal or H1N1 influenza vaccination among the Medicare population during the 2009-2010 influenza season.Methods. We used weekly Medicare claims data to monitor vaccinations and subsequent hospitalizations with principal diagnosis code for GBS within 42 days. Group sequential testing assessed whether the observed GBS rate exceeded a critical limit based on the expected rate from 5 previous years adjusted for claims delay. We evaluated the lag between date of service and date of claims availability and used it for adjustment.Results. By July 30, 2010 (after 26 interim surveillance tests), 14.0 million seasonal and 3.3 million H1N1 vaccinations had accrued. Taking into account claims delay appropriately lowered the critical limit during early monitoring. The observed GBS rate was below the critical limit throughout the surveillance.Conclusions. Medicare data contributed rapid safety monitoring among millions of 2009–2010 influenza vaccine recipients. Adjustment for claims delay facilitates early detection of potential safety issues. Although limited by lack of medical record review to confirm cases, this claims-based surveillance did not indicate a statistically significant elevated GBS rate following seasonal or H1N1 influenza vaccination.In 2009, public health efforts in the United States to address the pandemic of a novel influenza A (H1N1) virus included a federal effort to facilitate development and distribution of vaccines.1,2 Five monovalent vaccines against the novel strain (A/California/7/09-like virus) were approved as strain change formulations to each manufacturer’s licensed seasonal influenza vaccine.3–9Safety monitoring of licensed vaccines has traditionally relied largely on passive surveillance,10 which is national and timely but subject to multiple limitations (e.g., underreporting, reporting biases, and lack of denominator data on vaccinated persons11), and epidemiological studies,12 which may require years to complete. Early detection of safety issues is especially important for influenza vaccine monitoring because most vaccinations are administered within a short period of a few months. Rapid active surveillance using data from managed care networks has emerged more recently.13–15 However, these databases may underrepresent the elderly and may not have sufficient statistical power to evaluate very infrequent adverse events.To address these issues and prepare for a potential influenza pandemic, a pilot project was initiated in 2006 by the Food and Drug Administration (FDA) and Centers for Medicare and Medicaid Services (CMS) that aimed to monitor influenza vaccine safety as rapidly as possible (i.e., near real time) among the Medicare population. Medicare insures approximately 38.8 million elderly (aged ≥ 65 years) and 7.8 million younger persons with disability or end-stage renal disease.16 The pilot phase (2006–2009) aimed to develop the technical and methodological capability to use Medicare administrative data for safety monitoring as soon as data accrued each week. It focused on surveillance for specific conditions after vaccination such as Guillain–Barré syndrome (GBS), an autoimmune disorder that produces weakness or paralysis, which was associated with the 1976–1977 swine influenza (A/New Jersey/1976/H1N1) vaccine.17–20 Some studies of the 1976–1977 vaccine indicated relative risks of 4 to 9, corresponding to 5 to 10 excess cases per million persons vaccinated, with most or all of the elevated risk within 6 weeks after vaccination. Higher relative risks (approximately 11–18 in some analyses) were found for onset in weeks 2 and 3.18–20A challenge in using claims and potentially other types of health care databases for active surveillance is the lag between date of service and date when information is available in the system. In the Medicare program, a vaccination or hospitalization is observed after a health care provider seeks payment for services by submitting a claim to Medicare administrative contractors that process it and then submit it to CMS. Not accounting for this delay can potentially lead to biased results during early monitoring. We implemented methods to account for claims delay in sequential monitoring and describe results of the first prospective application of these methods, specifically to monitor for GBS after seasonal or H1N1 influenza vaccination among the Medicare population during the 2009-2010 influenza season.     

Human Papillomavirus Vaccination Among Young Adult Gay and Bisexual Men in the United States

Objectives. We examined human papillomavirus (HPV) vaccination among gay and bisexual men, a population with high rates of HPV infection and HPV-related disease.Methods. A national sample of gay and bisexual men aged 18 to 26 years (n = 428) completed online surveys in fall 2013. We identified correlates of HPV vaccination using multivariate logistic regression.Results. Overall, 13% of participants had received any doses of the HPV vaccine. About 83% who had received a health care provider recommendation for vaccination were vaccinated, compared with only 5% without a recommendation (P < .001). Vaccination was lower among participants who perceived greater barriers to getting vaccinated (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.27, 0.78). Vaccination was higher among participants with higher levels of worry about getting HPV-related disease (OR = 1.54; 95% CI =  1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI =  1.02, 2.43).Conclusions. HPV vaccine coverage is low among gay and bisexual men in the United States. Future efforts should focus on increasing provider recommendation for vaccination and should target other modifiable factors.Oncogenic human papillomavirus (HPV) types (mainly types 16 and 18) cause an estimated 93% of anal cancers, 63% of oropharyngeal cancers, and 36% of penile cancers among men in the United States.1 Nononcogenic HPV types 6 and 11 cause almost all anogenital warts.2 Gay and bisexual men have high rates of HPV infection and HPV-related disease. A recent review suggests that more than 50% of HIV-negative gay and bisexual men have an anogenital HPV infection.3 About 7% of gay and bisexual men report a history of genital warts.4 Anal cancer is also of great concern, with incidence among HIV-negative gay and bisexual men estimated to be 35 cases per 100 000 population.5 The anal cancer incidence rate among all men in the United States is just 1.6 cases per 100 000 population.6US guidelines began including the quadrivalent HPV vaccine (against HPV types 6, 11, 16, and 18) for males in October 2009.7 The Advisory Committee on Immunization Practices (ACIP) first provided a permissive recommendation that allowed the HPV vaccine to be given to males aged 9 to 26 years but did not include the vaccine in their routine vaccination schedule.7 In October 2011, the ACIP began recommending routine vaccination for boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.8 Importantly, the ACIP recommends HPV vaccination for men who have sex with men through age 26 years.8The HPV vaccine series consists of 3 doses, with the second dose administered 1 to 2 months after the first dose, and the third dose is administered 6 months after the first dose.7 The quadrivalent HPV vaccine is currently approved to protect males against genital warts and anal cancer.9 Despite recommendations, recent data suggest that fewer than 21% of males in the United States have received any doses of the HPV vaccine.10–14Although several HPV-related disparities exist among gay and bisexual men, little research has addressed HPV vaccination among this population. Past studies have shown that knowledge about HPV and the HPV vaccine tends to be modest among gay and bisexual men.15–19 Many gay and bisexual men have indicated their willingness to get the HPV vaccine, with estimates ranging from 36% to 86%.16,18–20 Data on actual HPV vaccine coverage are sparse; a past study found only 7% of 68 young adult gay and bisexual men had received any doses of the HPV vaccine.11 This study was, however, conducted before the ACIP recommendation for routine vaccination of males.We built on this past research by examining HPV vaccination among a national sample of young adult gay and bisexual men in the recommended age range for HPV vaccination (18–26 years). We identified correlates of vaccination and why young adult gay and bisexual men are not getting the HPV vaccine. These data will help inform future programs for increasing HPV vaccination among this high-risk population.     

Prenatal,Perinatal, Early Life,and Sociodemographic Factors Underlying Racial Differences in the Likelihood of High Body Mass Index in Early Childhood

Objectives. We investigated early childhood disparities in high body mass index (BMI) between Black and White US children.Methods. We compared differences in Black and White children’s prevalence of sociodemographic, prenatal, perinatal, and early life risk and protective factors; fit logistic regression models predicting high BMI (≥ 95th percentile) at age 4 to 5 years to 2 nationally representative samples followed from birth; and performed separate and pooled-survey estimations of these models.Results. After adjustment for sample design–related variables, models predicting high BMI in the 2 samples were statistically indistinguishable. In the pooled-survey models, Black children''s odds of high BMI were 59% higher than White children''s (odds ratio [OR] = 1.59; 95% confidence interval [CI]= 1.32, 1.92). Sociodemographic predictors reduced the racial disparity to 46% (OR = 1.46; 95% CI = 1.17, 1.81). Prenatal, perinatal, and early life predictors reduced the disparity to nonsignificance (OR = 1.18; 95% CI = 0.93, 1.49). Maternal prepregnancy obesity and short-duration or no breastfeeding were among predictors for which racial differences in children’s exposures most disadvantaged Black children.Conclusions. Racial disparities in early childhood high BMI were largely explained by potentially modifiable risk and protective factors.Over recent decades, as the prevalence of high body mass index (BMI; defined as at or above the Centers for Disease Control and Prevention 95th percentile1) has increased dramatically among all children,2,3 racial disparities have been documented in nationally representative samples of children at very young ages.4–7 Reviews and prevalence studies highlight the need for a better understanding of the predictors of these disparities in BMI and other indicators of childhood obesity,8,9 especially in early childhood.7Previous research on high BMI in early childhood with racially and ethnically diverse samples has identified risk and protective factors at multiple developmental stages. In the prenatal and perinatal period, risks include higher birth weight,10–13 maternal prepregnancy BMI,14 and maternal smoking during pregnancy.14,15 In infancy and early life, risks include maternal employment,11 especially among highly educated women,12,16 nonparent child care,13,17,18 and television viewing hours.12,19–21 Protective factors include breastfeeding10,12,14 and family meals.12,21,22Studies have shown that young racial/ethnic minority children are exposed to more of these risks and fewer of these protections.23,24 Nevertheless, in analyses of nationally representative samples, high BMI remains more common among Black than White children even after adjusting for sociodemographic characteristics and risk and protective factors.6,11,12,14,16 We suspect that the persistence of racial disparities in these studies might be attributable to omitted predictors or less detailed measurement of the age and duration of children’s exposures. This type of comprehensive assessment is methodologically challenging because of the number of variables and observations required to draw statistically valid inferences.We employed a novel 2-survey methodological design to overcome these challenges. We used data from 2 nationally representative samples of US children followed from birth to age 4 to 5 years in separate and pooled-survey analyses to identify prenatal, perinatal, early life, and sociodemographic factors that may explain Black–White disparities in early childhood high BMI. The separate analyses in 2 surveys that cover a historical period of more than 10 years increased the robustness of our findings to differences in sample design, measurement protocols, and period variability in unobserved confounders. The pooled-survey analyses enhanced the statistical power of our study and thereby strengthened our conclusions about which factors explain Black–White disparities in early childhood high BMI.     

Early Life Exposure to the 1918 Influenza Pandemic and Old-Age Mortality by Cause of Death

Objectives. We sought to analyze how early exposure to the 1918 influenza pandemic is associated with old-age mortality by cause of death.Methods. We analyzed the National Health Interview Survey (n = 81 571; follow-up 1989–2006; 43 808 deaths) and used year and quarter of birth to assess timing of pandemic exposure. We used Cox proportional and Fine-Gray competing hazard models for all-cause and cause-specific mortality, respectively.Results. Cohorts born during pandemic peaks had excess all-cause mortality attributed to increased noncancer mortality. We found evidence for a trade-off between noncancer and cancer causes: cohorts with high noncancer mortality had low cancer mortality, and vice versa.Conclusions. Early disease exposure increases old-age mortality through noncancer causes, which include respiratory and cardiovascular diseases, and may trigger a trade-off in the risk of cancer and noncancer causes. Potential mechanisms include inflammation or apoptosis. The findings contribute to our understanding of the causes of death behind the early disease exposure–later mortality association. The cancer–noncancer trade-off is potentially important for understanding the mechanisms behind these associations.Adverse early life conditions may have lasting effects on old-age health and mortality.1–8 Some even consider reductions in early life disease exposure to be a primary driver of historical mortality declines.9 Although the precise mechanisms linking early disease exposure to poor adult health remain unclear, numerous pathways have been postulated including those relating to fetal undernutrition and dysregulation of immune function.3,10,11In animal models, experimental evidence suggests a negative causal effect of early disease exposure on later health.12–14 For humans, historical epidemics have been used to study the effects of early disease exposure on later health.1,2,4,15 These studies often find that those born around the time of an epidemic exhibit worse adult health and mortality than do neighboring cohorts.1,2,4 However, the causes of death contributing to the excess mortality are not known. Moreover, research on early exposure to the deadliest epidemic of the 20th century—the 1918 influenza pandemic—is mixed, showing increased cardiovascular disease prevalence and lower socioeconomic attainment,1,4 but no long-term mortality effects.15We investigated whether US cohorts with early exposure to the 1918 pandemic experience differential mortality at old ages compared with neighboring cohorts. The 1918 pandemic, caused by the influenza A virus (subtype H1N1), arrived in the United States in 3 waves.16 During the first wave, which began in March 1918 and was completed by July 1918, incidence rates were high, but mortality was only slightly elevated. The second and the deadliest wave began in September 1918 and lasted until the end of the year. The third wave, with a mortality impact between those of the first 2 waves, occurred from January 1919 to March 1919. Approximately 30% of the US population was infected and about 0.5% of the population died because of the pandemic, mostly from pneumonia.16 Excess mortality had an unusual pattern as those aged 20 to 40 years were affected particularly strongly.16The advantages of focusing on the 1918 pandemic are threefold. First, the pandemic arrived unexpectedly and lasted for only a short period, allowing treatment of the pandemic as a “natural experiment” wherein cohorts born months apart experienced different exposures but were otherwise compositionally similar in terms of other childhood characteristics and environmental conditions. Moreover, the exposed and nonexposed cohorts were born in a narrow enough time interval that timing of birth is not systematically linked to subsequent differences in the adult environment. Second, in contrast to older epidemics, existing data permit cause-of-death analyses. Third, although food shortages and disease tended to co-occur in historical populations, the 1918 pandemic allows focusing on disease because there were no generalized food shortages in the United States during the pandemic. Nutritional deprivation caused by disease, however, may function as a mediator.We extended previous research in 3 important dimensions. First, although earlier studies have analyzed the relationship between early disease exposure and later-life mortality,2,15,17 it is not known what causes of death drive the association. We analyzed mortality by cause, which can enhance our understanding of potential mechanisms. Second, previous research on early disease exposure and later mortality has analyzed annual birth cohorts.2,5,15 We distinguished cohorts by year and quarter of birth, which provides a far more nuanced analysis of exposure timing. Third, previous work on the long-lasting effects of the pandemic has not accounted for the fact that the pandemic arrived in waves.1,4,15 Because of variation in the immediate mortality effects of each wave, there may be differences with respect to long-lasting effects. Our analysis accounted for exposure to each wave.     

Reaching Children Never Previously Vaccinated for Influenza Through a School-Located Vaccination Program

Objectives. We determined the success of the school-located vaccination (SLV) program, implemented in 2009 in New York City to deliver pandemic influenza A (H1N1) monovalent vaccine (pH1N1), versus provider offices in reaching children who had never previously received influenza vaccine.Methods. We compared the immunization history of children vaccinated in school versus provider offices. We included records in the Citywide Immunization Registry with pH1N1 administered between October 2009 and March 2010 to elementary school-aged children.Results. In total, 96 524 children received pH1N1 vaccine in schools, and 102 933 children received pH1N1 vaccine in provider offices. Of children vaccinated in schools, 34% had never received seasonal influenza vaccination in the past, compared with only 10% of children vaccinated at provider offices (P < .001). Children vaccinated in schools were more likely to have received a second dose of pH1N1 in 2009–2010 than those vaccinated in provider offices (80% vs 45%).Conclusions. The SLV program was more successful at reaching children who had never received influenza immunization in the past and should be considered as a strategy for delivering influenza vaccine in routine and emergency situations.Improving vaccination coverage in children may lead to decreased morbidity and mortality in the general population, including decreasing influenza deaths and illness in adults.1–4 In 2006, the Advisory Committee on Immunization Practices recommended influenza vaccine for healthy children aged 6 months to 4 years5 and expanded their recommendation in subsequent years to include children aged 5 to 18 years.6 The goal of vaccinating all children annually raises a significant operational question of how to target children most effectively.Pediatricians provide the majority of immunizations given to children. However, after the 4- to 6-year-old well child visits, children may not visit medical providers regularly. School-located vaccination (SLV) offers a convenient alternative because it reaches the majority of children regardless of their access to medical care,7 and schools have been successfully used for hepatitis B vaccination administration in the past.8,9 SLV also offers parents the convenience of not having to make a trip to the provider’s office or even be present. Jurisdictions such as Hawaii have routinely offered influenza vaccine through schools and have achieved vaccination rates as high as 46% in children aged 5 to 13 years.10Despite the potential advantages of SLV, to our knowledge, whether it successfully reaches children who otherwise would have gone unvaccinated is unknown. We examined this issue in New York City (NYC) in 2009 when the NYC Department of Health and Mental Hygiene offered pandemic influenza A (H1N1) monovalent vaccine (pH1N1) through an elementary school–located campaign. During this influenza season, because of a late-emerging strain of novel H1N1, pH1N1 vaccine was developed and offered separately from routine seasonal influenza vaccination. Using data on pH1N1 vaccination from the Citywide Immunization Registry (CIR), the NYC Department of Health and Mental Hygiene’s Immunization Information System, we compared the demographic characteristics and immunization history of children vaccinated through the SLV campaign with those of children vaccinated in medical provider offices. We examined the proportion of children in each setting for whom the pH1N1 vaccine was the first influenza vaccine ever received to determine the potential for SLV programs to effectively reach children who have not previously received an influenza vaccination and who therefore might be unlikely to get vaccinated in the current season as well. We also predicted the probability of being vaccinated at schools controlling for demographic characteristics and immunization history.     

Text4baby: Development and Implementation of a National Text Messaging Health Information Service

Text4baby is the first free national health text messaging service in the United States that aims to provide timely information to pregnant women and new mothers to help them improve their health and the health of their babies.Here we describe the development of the text messages and the large public–private partnership that led to the national launch of the service in 2010. Promotion at the local, state, and national levels produced rapid uptake across the United States. More than 320 000 people enrolled with text4baby between February 2010 and March 2012.Further evaluations of the effectiveness of the service are ongoing; however, important lessons can be learned from its development and uptake.The US infant mortality rate (6.59/1000 live births) is higher than in most developed countries.1 In the United States, the infant mortality rate for non-Hispanic African American women is 2.4 times the rate for non-Hispanic White women.1 Rates are also elevated for Native American Indian and Alaska Native women. In 2008, 12.3% of the 4 251 095 babies born in the United States were born prematurely and 8.2% had a low birth weight.2 Health-related behaviors in the prenatal and postnatal periods, such as nutrition, tobacco smoking, breastfeeding, safe sleep practices, and vaccination are known to affect maternal and infant outcomes.3 Women without access to affordable and appropriate care may not be receiving information needed to support prenatal and postnatal pediatric care. Recent studies have also shown limited health literacy in the United States to be related to a lack of prenatal planning, such as taking folic acid, and difficulties with informed parental decision-making.4,5Mobile phones may be an appropriate means for addressing the challenges of health literacy6 and for reaching women from underserved communities. Mobile phone ownership in the United States is similar across racial/ethnic groups (80% of Whites and 87% of African Americans and Hispanics). African Americans (79%) and Hispanic Americans (83%) are more likely than are White Americans (68%) to send text messages.7 Americans living in or near poverty are more likely to live in cell phone–only households (no fixed phone line), and those living in cell phone–only households are more likely to have experienced numerous barriers to health care.8Mobile phone text messaging has been used to support healthy behavior change and health care delivery processes.9–12 Successful behavior change interventions have used text messaging to support smoking cessation,13–15 weight management through diet or physical activity,16–19 and management of anxiety symptoms.20 Health care process interventions have included appointment reminders21–24 and reminders to take medications.25–30Here we describe the development of text4baby, a free national text messaging service that provides timely information to pregnant women and new mothers to help them improve their health and the health of their babies. More than 320 000 people enrolled with text4baby between its launch in February 2010 and March 2012. Little has been published in peer-reviewed journals on mobile health initiatives of this scale in the United States. Published international examples of national-scale services include a text messaging smoking cessation service in New Zealand, which was established after a randomized trial and registered 3905 clients in the first year,13,31 and a public health campaign in South Africa, which sent 968 million HIV/AIDS awareness messages embedded in free “Please call me” text messages over two years.32,33 Lessons from the development of text4baby could guide similar mobile health developments.     

Improving Adult Immunization Practices Using a Team Approach in the Primary Care Setting

Objectives. The objective of this study was to improve the immunization rates of primary care practices using a team approach.Methods. Practices performed 35 random chart abstractions at 2 time points and completed a survey about immunizations at baseline and 12 months after intervention. Data were collected for the following immunizations: influenza, pneumococcal, tetanus diphtheria (Td)/tetanus diphtheria pertussis (Tdap), hepatitis A, hepatitis B, meningococcal, varicella, herpes zoster, and human papilloma virus. Between baseline and after intervention, practice teams were given feedback reports and access to an online educational tool, and attended quality improvement coaching conference calls.Results. Statistically significant improvements were seen for Td/Tdap (45.6% pre-intervention, 55.0% post-intervention; P ≤ .01), herpes zoster (12.3% pre-intervention, 19.3% post-intervention; P ≤ .01), and pneumococcal (52.2% pre-intervention, 74.5% post-intervention; P ≤ .01) immunizations. Data also revealed an increase in the number of physicians who discussed herpes zoster and pneumococcal vaccinations with their patients (23.2% pre-intervention, 43.3% post-intervention; P ≤ .01 and 19.9% pre-intervention, 43.0% post-intervention; P ≤ .01, respectively) as well as an increase in physicians using the Centers for Disease Control and Prevention immunization schedule (52.9% pre-intervention, 88.2% post-intervention; P ≤ .02).Conclusions. The immunization rates of the primary care practices involved in this study improved.The need for improving quality is pervasive in the primary care setting, involving physicians, their practice teams, and administrative staff. The issue of low quality is well documented1–3 and is not partial to any 1 disease condition.4–15 Poor quality is a result of our medical system’s orientation to the urgent, its focus on acute and not chronic care, lack of adherence to evidence-based guidelines, and an increasing number of patients with complex medical conditions.2 Quality is characterized as a systems issue rather than an individual one,16 which has led efforts to focus on the practice team. Practice teams have been shown to improve quality in primary care.17,18 The issues with poor quality in primary care extend to the practice of adult immunizations.19 It is estimated that between 50 000 and 70 000 US adults die each year because of diseases that could be prevented by vaccination.20 For example, influenza is the sixth leading cause of death for adults and contributes to at least 200 000 hospitalizations and 36 000 deaths annually.21,22 Economic costs associated with influenza are projected to be $87.1 billion.23Adult vaccination guidelines, such as those published by the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices,24 are increasingly evidence-based and are a good reference for practices to measure themselves against when doing immunization practice redesign work. Although childhood vaccinations have become a public health success, adult vaccination rates are low, prompting the movement toward “lifespan immunizations.”20,25 However, quality gaps and missed opportunities for vaccination exist between the number of patients who are recommended to receive vaccinations and those who actually receive them.26–30 A variety of barriers at the practice, patient, economic, and social level help explain these missed opportunities. For instance, only 60% of physicians reported using CDC and Advisory Committee on Immunization Practice guidelines as their reference for adult immunizations, and most often reported recommending vaccinations at well visits compared with sick visits.31 Physicians also reported multiple barriers to vaccinating patients, including lack of health insurance, fear of needles, and misconception of the safety and efficacy of vaccinations.31 In turn, patients consistently reported that their physicians do not recommend vaccinations.31,32A comprehensive quality approach was considered to be more effective than mere guideline dissemination because the latter has not been shown to be successful alone in changing practice patterns.33,34 The American College of Physicians (ACP) developed this quality improvement program to help physicians and practice teams learn about the current recommendations and best practices for adult immunization. The goal of this prospective study was to improve the immunization practices of primary care practices by using a team approach.     

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

Objectives. We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.Methods. The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10–20 years) at a multisite community health center in 2011.Results. Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%–5%) than among other adolescents (23%–45%).Conclusions. Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.Human papillomavirus (HPV) infection is a known risk factor for the development of several cancers. Between 2004 and 2008, there was a national average of 33 369 HPV-associated cancers annually, including cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancers.1 The Centers for Disease Control and Prevention estimates 26 000 new HPV-associated cancers each year, 18 000 for women and 8000 for men,1 which could be prevented through the HPV vaccine.According to the US Cancer Statistics Working Group,2 there are pervasive disparities in national morbidity and mortality rates of HPV-related cancers for Black and Hispanic individuals. Cervical cancer is more common among Black and Hispanic women and results in disproportionately higher mortality for Black women. In 2009, the national age-adjusted cervical cancer incidence rates (per 100 000) for Hispanic and Black women (10.9 and 10.0, respectively) were higher than the rate for White women (7.6).2 The national age-adjusted cervical cancer mortality rate (per 100 000) for Black women (4.2) is considerably higher than the rates for White and Hispanic women (2.1 and 2.9, respectively).2 Also, Black women have higher morbidity and mortality rates of vaginal cancer. Morbidity and mortality rates of penile cancers are significantly higher among Black and Hispanic men. Black men have higher morbidity and mortality rates of anal cancer.2 In addition to race/ethnicity, incidence rates of penile, cervical, and vaginal cancers increase with higher poverty rates.3 Factors that contribute to cancer disparities among Black, Hispanic, and low-income populations include higher exposure to risk factors such as smoking, physical inactivity, and HPV infection as well as lack of access to early detection and treatment services.4New Jersey had the 10th highest morbidity rate for cervical cancer nationally for 2006 through 2010.5 According to the New Jersey State Cancer Registry, cervical cancer morbidity from 2005 to 2009 was significantly higher in the Greater Newark area (relative risk = 1.86; the study target area) than other areas in the state, as well as among women who are Black, Hispanic, foreign-born, non–English-speaking, uninsured, with lower income and education, unmarried, unemployed, and living in a rented residence.6 According to a community health needs assessment for the City of Newark in 2013,7 52.4% of the residents are Black, 33.8% are Hispanic, and 30% are foreign-born, compared with 13%, 18%, and 20%, respectively, in the state. Also, 28.4% of the residents are below the federal poverty level compared with 9.4% statewide, and 28% are uninsured compared with 8.4% statewide. A significant proportion of the residents has less than a high-school education (30%) and a low level of English proficiency (25%).7Transmission of HPV can be reduced through limiting the number of sexual partners, delaying the initiation of sexual activity, practicing safe sex, and getting vaccinated.8 Two vaccines have been approved by the Food and Drug Administration for protection against HPV: the quadrivalent vaccine (Gardasil, Merck, Kenilworth, NJ) for female and male individuals aged 9 to 26 years,9 and the bivalent vaccine (Cervarix, GlaxoSmithKline, Middlesex, England) for female individuals aged 10 to 25 years.10 The HPV vaccine requires a series of 3 injections within 6 months. Markowitz et al.11 examined the rates of HPV infection among female individuals before and after the vaccine was introduced in 2006, by using data from the National Health and Nutrition Examination Surveys for 2003 through 2010. They found that for female adolescents aged 14 to 19 years, there was a 55.7% reduction in vaccine-type HPV infection rate (HPV types 6, 11, 16, and 18) and a 50% reduction in high-risk vaccine-type HPV infection rate (HPV types 16 and 18). There was also an 88% decrease among the sexually active women in their rate of vaccine-type HPV infection when they compared those who were vaccinated to those who were not vaccinated.11 Niccolai et al.12 also found significant decline in the rates of high-grade cervical lesions from 2008 to 2011 among women aged 21 to 24 years in Connecticut. Unfortunately, this trend was attenuated in urban areas as well as areas with higher concentrations of Black, Hispanic, and low-income populations.12According to the National Immunization Survey—Teen (NIS-Teen),13 HPV vaccine initiation rates for female adolescents were 44.3% in 2009, 48.7% in 2010, 53.0% in 2011, and 53.8% in 2012. This reflects minimal improvement in 2011, no improvement in 2012, and reaching a plateau for female vaccination at a level dramatically lower than the goal of 80% completion rate for girls aged 13 to 15 years set by Healthy People 2020. In site-based studies, HPV vaccine initiation among female adolescents ranged between 9.4% and 62.9%.14–21 Also, initiation for female adolescents was lower for Spanish speakers,22 those who were uninsured,23–25 those with shorter duration of enrollment in health insurance,26 in nonpediatric settings,21,24 among those who have not had a preventive visit in the past 12 months,21,24,27–30 and with mothers’ lack of knowledge about HPV infection or vaccine.18,27,28,31,32 Some studies reported lower initiation among younger female adolescents,15,18,21,24,29,30 whereas others reported the opposite.21,26 Several studies have shown the importance of health care providers’ (HCPs’) recommendations for HPV vaccine initiation among female adolescents.16,28,30,31,33According to NIS-Teen,13 HPV vaccine initiation rates for male adolescents were 1.4% in 2010, 8.3% in 2011, and 20.8% in 2012. This reflects low but steady improvement in HPV vaccination rates among male adolescents. In site-based studies, HPV vaccine initiation among male adolescents ranged between 1.1% and 30%.14,34–37 Literature is lacking on factors associated with HPV vaccine initiation among male adolescents. One study reported lower levels of knowledge among Black and Hispanic parents about the use of HPV vaccine for male adolescents.35 A few studies indicated the importance of HCPs’ recommendation for HPV vaccine initiation among male adolescents.14,35,36,38Pervasive disparities exist in HPV vaccination among Black, Hispanic, and low-income groups, and more specifically in the study target area. Even though the NIS-Teen data for 2011 and 2012 show slightly higher HPV vaccination among Black and low-income groups,39,40 several studies have demonstrated a significant and continuing trend of lower HPV vaccination among Black and Hispanic adolescents,14,15,17,24,26,41,42 as well as in low-income and urban areas.22,33,41,43 Vaccination disparities in urban areas (compared with suburban or rural areas) may be attributed to residential segregation, differential distribution of health clinics and health professionals, and unequal access to a broad range of services.44–46 As urban areas, particularly the Greater Newark area, have high proportions of immigrants who may be hesitant to seek health care services because of cultural or language barriers or concerns about immigration status,7 a study of adolescents’ adherence to public health recommendations in underserved, inner-city areas is warranted and important.Literature is lacking information on correlates of HPV vaccination among Black and Hispanic adolescents in low-income urban areas, who represent populations with the greatest disparities in cervical cancer and other HPV-related cancers compared with White and higher-income groups. Therefore, the purpose of this study was to examine the correlates of HPV vaccine initiation in a sample of predominantly Black and Hispanic adolescents at inner-city community health centers. The study addresses gaps in knowledge about the correlates of HPV vaccination among both male and female adolescents as well as a low-income predominantly minority population with pervasive disparities in cervical cancer morbidity and mortality.1–3,5,6     

Trust,Medication Adherence,and Hypertension Control in Southern African American Men

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively).Trust remains an important issue with African Americans (AAs), particularly in the South where its history of mistreatment and racial discrimination at times were highly prevalent.1 Racial and ethnic minorities are more prone than are Whites to distrust the health care establishment, and historically, minority men have had less access to culturally competent providers.2–4 Southern AAs are more likely than are Whites to report perceived racial barriers to care,5 and AA men are more likely than are AA women to report perceived discrimination.6–10 Perceived discrimination and mistreatment are associated with poorer medical adherence and delays in seeking health care.11–14 In addition, higher levels of trust in the health care system are associated with better adherence to recommended care, greater patient satisfaction, and better outcomes.15–18 This has significant implications considering that AA men develop hypertension (HTN) at an earlier age, have higher rates of advanced (stage 3) HTN, are more likely to experience HTN complications, and are less likely to achieve HTN-control compared with White men.19–21 The rates of HTN are even higher in the South for AA men, accounting, in part, for higher stroke (80% higher) and cardiovascular mortality (50% higher) in this subpopulation compared with other groups in other regions.21–23The goal of this brief study was to assess the relationship between trust in the medical, medication adherence,24 and HTN control25 among Southern AA men. Other covariates were perceived discrimination, perceived racism, self-efficacy, and participation in medical decision-making. This study is based on the Race and Health Outcomes Model developed by Williams et al.26     

Policies to Reduce Influenza in the Workplace: Impact Assessments Using an Agent-Based Model

Objectives. We examined the impact of access to paid sick days (PSDs) and stay-at-home behavior on the influenza attack rate in workplaces.Methods. We used an agent-based model of Allegheny County, Pennsylvania, with PSD data from the US Bureau of Labor Statistics, standard influenza epidemic parameters, and the probability of staying home when ill. We compared the influenza attack rate among employees resulting from workplace transmission, focusing on the effects of presenteeism (going to work when ill).Results. In a simulated influenza epidemic (R₀ = 1.4), the attack rate among employees owing to workplace transmission was 11.54%. A large proportion (72.00%) of this attack rate resulted from exposure to employees engaging in presenteeism. Universal PSDs reduced workplace infections by 5.86%. Providing 1 or 2 “flu days”—allowing employees with influenza to stay home—reduced workplace infections by 25.33% and 39.22%, respectively.Conclusions. PSDs reduce influenza transmission owing to presenteeism and, hence, the burden of influenza illness in workplaces.Voluntary social distancing measures, such as encouraging sick people to stay home from work, are powerful tools for controlling spread during a contagious disease outbreak.1 For example, the Centers for Disease Control and Prevention recommends that people with influenza stay home for 24 hours after their fever has resolved.2 However, not everyone is able to adhere to these recommendations: 42% of workers would not get paid if they stayed home when ill.3 Willingness to stay home when ill may thus be correlated with access to paid sick days (PSDs).4–6 In the United States, the Bureau of Labor Statistics reports that 33% of the civilian workforce lacked PSDs in 2010 and that access to PSDs varies depending on workplace size and wage level. Access to PSDs ranged from 53% in workplaces with fewer than 50 employees to 85% in workplaces with 500 or more employees and from 35% in the lowest wage quartile to 87% in the highest quartile.7Unequal access to PSDs has been hypothesized to be a source of health disparities in the workplace. Blumenshine et al.8 proposed a model in 2008 that predicted that social determinants, including inability to take time off from work, could result in unequal levels of illness and death during an influenza pandemic. They hypothesized that staying away from work, if employed as a social distancing policy during a pandemic, was likely to be more difficult for lower-wage workers, as they would be less able to afford losing income. Those who lack PSDs at work may be at higher risk for exposure owing to colleagues not staying home when ill.9 Presenteeism (going to work or school when ill) leads to further spread of illness by infectious people. Employees who lack PSDs may go to work ill, leading to the spread of infection at work. However, the number of cases expected owing to presenteeism among employees has not previously been examined to our knowledge.In the 2009 H1N1 pandemic, risk of exposure owing to work-related inability to engage in social distancing was significantly related to race and ethnicity.5 Furthermore, those who reported work-related barriers to social distancing, including lack of access to sick leave, had 1.08 times higher odds (P < .01) of self-reported influenza-like illness incidence compared with those who were able to engage in social distancing.4 Recent research has shown that independent of infectious disease spread in the workplace, nonfatal occupational injuries occurred at a higher rate among those without access to PSDs than among those with access to PSDs.10Bills under consideration at multiple levels—city and state legislatures—propose providing access to PSDs for employees.11 Health impact assessments of such PSD policies have hypothesized that they would reduce workplace contagion because ill workers would stay home from work, thus reducing workplace transmission.9,12,13 These assessments did not account for the nonlinearity in infectious disease spread (each infected person can infect multiple contacts, resulting in an exponential increase in attack rate over time) or the multiple locations in which contacts can occur (households, schools, workplaces, neighborhoods).We examined the impact of access to PSDs on influenza incidence using an agent-based model. In an agent-based model, each individual in a population is represented along with the individual’s social contact networks in households, schools, workplaces, and neighborhoods. Such a model thus permits an examination of transmission patterns in these locations. Infectious disease researchers have used agent-based models extensively to quantify policy impacts, including studies that examine the effects of vaccination and school closure policies during an influenza pandemic on disease outcomes at the overall population level.14–18 However, previous models have not examined the determinants of behavior but, instead, have usually assumed certain levels of compliance in the population.14–18 Agent-based modeling remains fairly novel among health behavior researchers studying the impact of access to resources on behavior, disease, and disparities in outcomes.19–22We examined the impact of a universal PSD policy and alternative interventions aimed at increasing voluntary social distancing behavior by asking the following questions: How much does presenteeism contribute to disease transmission in the workplace? What proportion of transmission owing to presenteeism is from those without access to PSD? How many cases of influenza would a universal PSD policy prevent? Would alternative interventions to increase the number of days spent at home when ill have an impact on reducing workplace contagion? In keeping with calls for equity-focused health impact assessments,23,24 we have reported the effect of policies and interventions on health equity in the workplace.     

Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

Objectives. We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors.Methods. In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up.Results. Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctor’s recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003).Conclusions. Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.Quadrivalent human papillomavirus (HPV) vaccine against types 6, 11, 16, and 18 is approved to protect against genital warts (caused mostly by HPV types 6 and 111) and anal cancer (caused mostly by HPV types 16 and 182) in males.3 About 4% of men in the United States report a previous diagnosis of genital warts,4 and about 2250 new cases of anal cancer occur annually among males in the United States.5 Given the high levels of HPV concordance among sexual partners,6 vaccinating males may also have indirect health benefits for their partners.7 United States guidelines began including HPV vaccine for males in October 2009.8 The Advisory Committee on Immunization Practices first provided a permissive recommendation, recommending the 3-dose quadrivalent vaccine series for males aged 9 to 26 years but not making it part of their routine vaccination schedule.8 In October 2011, the Advisory Committee on Immunization Practices updated its stance on HPV vaccine for males and recommended routine vaccination of boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.9 The updated recommendation continues to allow HPV vaccine to be given to males aged as young as 9 years and up to 26 years.9Although numerous studies have examined HPV vaccine uptake among females,10 data on HPV vaccine uptake among males are sparse. Despite mostly encouraging early levels of parental acceptability of the vaccine for males,11–13 initial estimates found that only about 2% of male adolescents in the United States had received any doses of HPV vaccine by the end of 2010.14,15 Recent data suggest that this increased to about 8% by the end of 2011.16 We are not aware of any studies that have examined predictors of vaccine uptake among males.Our study addresses several important gaps in the existing literature. We provide the first longitudinal examination of HPV vaccination among males and identify predictors of vaccine uptake. In doing so, we used data from both parents and their adolescent sons because many adolescents are involved in vaccination decisions.17 We also examined longitudinal changes in vaccine acceptability among parents and sons and parents’ reasons for not getting their sons HPV vaccine, because these data may provide valuable insight about future HPV vaccine uptake among males.     

Influenza and Seasonal Patterns of Hospital Use by Older Adults in Long-Term Care and Community Settings in Ontario,Canada

Objectives. We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings.Methods. We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates.Results. Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%–20%) in LTC and 28% (27%–29%) in the community. Results for hospital admissions were comparable.Conclusions. We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.Influenza has been identified as among the top 10 infectious agents that are causes of health burden,1 and it continues to create significant morbidity and mortality among older adults. Individuals older than 65 years, in particular those with preexisting chronic conditions, are at increased risk for hospitalization2,3 and death4,5 associated with influenza. The Canadian province of Ontario first introduced universal influenza immunization in 2000, granting all provincial residents aged 6 months or older the option for annual immunization without out-of-pocket cost. Although immunization coverage in the general population remains relatively low, levels are highest among community-dwelling adults older than 65 years, with coverage exceeding 70%.6For residents of long-term care (LTC) facilities, also known as nursing homes, immunization coverage generally exceeds 90% in Ontario7 and 80% in other jurisdictions, mainly because of concerted efforts to reach this group.8,9 LTC residents are a particularly vulnerable segment of the older population, with an average age of 80 years, significant cognitive and physical impairments, and a high burden of complex chronic conditions, including cardiovascular and respiratory illnesses. Despite high immunization coverage in residents, influenza continues to cause significant burden. Influenza has been associated with increased rates of functional decline and pressure ulcers in this group.10 It is also among the most common reasons for transfer to the hospital and accounts for a significant proportion of mortality in this population.11–13A single study reported that rates of hospitalization for influenza were 3 times as high among LTC as among community residents, both during and before the identified influenza season.14 In addition to their heightened vulnerability, LTC residents face other risk factors for infection, including congregate living and shared bedrooms, that community residents do not experience. Because of this, LTC is targeted for strong infection prevention and control (IPC) measures, including staff immunization. Although evidence from Ontario suggests that LTC staff immunization rates are generally higher than 70%,7 well above that reported in hospitals, other evidence points to generally poor compliance with other IPC practices.15To date, little is known about the burden of influenza in LTC and how it compares to that in the community. Our objectives were to compare the burden of influenza, as measured by hospital use, both emergency department (ED) visits and inpatient admissions, among older adults in LTC and community settings.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.