Adult Immunization Rates

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1 Adult Immunization Rates California Immunization Coalition Summit May 5, 2014 Eileen Yamada, MD, MPH California Department of Public Health Immunization Branch

2 Adult Immunization Rates California Data - Behavioral Risk Factor Surveillance System Influenza vaccine Pneumococcal vaccine for those 65 years and older Tetanus/Tdap U.S. Data - National Health Interview Survey Pneumococcal Vaccine Zoster vaccine Td/Tdap Hep A (limited risk data: travel status & chronic liver disease) Hep B (limited risk data: diabetes) HPV U.S. Data multiple sources BRFSS, internet panel Influenza Vaccine

3 Recommendations for Pneumococcal Vaccine All persons should be vaccinated with pneumococcal polysaccharide vaccine (PPSV23) at age 65 years. Adults aged years should be vaccinated with PPSV23 if they: Have certain chronic or immunosuppressing medical conditions. Smoke cigarettes. In 2012, ACIP also recommended routine use of pneumococcal conjugate vaccine (PCV13) in adults with immunocompromising conditions, asplenia, CSF leaks or cochlear implants.

4 ACIP Recommendations for Zoster Vaccine Zoster vaccine is recommended for all persons aged >60 years.

5 Adult Vaccination Coverage, Selected Vaccines by Age and High-risk Status, United States 2012 HP2020 Targets: 90% PPV 65 yrs, 60% PPV HR yrs, 30% Shingles Data Source: 2012 NHIS From Presentation by Walter Williams, MD, MPH. NVAC, March 19, 2014

6 Self-reported Pneumococcal Immunization Coverage for 65 Years and Older-California, % 80% Healthy People 2020 Goal 90% Percent 60% 40% 20% 0% Year Behavioral Risk Factor Surveillance System,

7 ACIP Recommendations for Influenza Immunization Recommended annually for all persons 6 months of age and older

8 Self-reported Flu Immunization Coverage by Age Group-California, % 65+ Percent 80% 60% 40% * * * % 0% Year Behavioral Risk Factor Surveillance System, *Wording change of influenza vaccine question

9 U.S. Flu Vaccination Rates Health Care Personnel and before and during Pregnancy -women-nov2013.htm Healthy People 2020 Objective: 90% annual influenza immunization coverage for health care personnel

10 U.S. Influenza Vaccination Coverage Rates for Children and Adults, and Healthy People 2020 Objective: 70% annual influenza immunization coverage for adults 18 years and older

11 ACIP Tdap Recommendations All persons aged 11 years or older who haven t received Tdap vaccine or if vaccination status unknown should receive a dose of Tdap, regardless of interval since last tetanus- or diphtheriacontaining vaccine Tdap vaccine should be administered to pregnant women during EACH pregnancy regardless of interval since prior Tdap

12 Self-Reported Tdap coverage-california, 2012 N= years N= years N= years N=2981 Received tetanus shot in 2005 or later Dr. said vaccine contained pertussis vaccine? (subset of above) Overall estimated Tdap rate* 46% 45% 42% 39% 35% 28% 18% 16% 12% *Limitations: self-report (recall), refused or don t know answers, Dr. communication Source: Behavioral Risk Factor Surveillance System, 2012

13 Adult Vaccination Coverage, Tetanus-containing Vaccines by Age and High-risk Status, United States From Presentation by Walter Williams, MD, MPH. NVAC, March 19, Data Source: 2012 NHIS

14 ACIP Adult Hepatitis A Vaccine Recommendations Hepatitis A vaccine recommended for any person seeking protection from hepatitis A virus infection and persons with any of the following indications: Men who have sex with men Injection or non-injection illicit drug use Persons working with HAV-infected primates or HAV in a research lab setting Chronic liver disease or receiving clotting factor concentrates Travel to or work in countries with high or intermediate endemicity of hepatitis A Anticipating close contact with an international (country with high or intermediate hepatitis A endemicity) adoptee during the first 60 days after U.S. arrival

15 ACIP Adult Hepatitis B Vaccine Recommendations Recommended for any person seeking protection from hepatitis B virus and persons who: Sexually active and not in a long-term, mutually monogamous relationship (more than 1 sex partner in prior 6 months); persons seeking evaluation or treatment for STDs; current or recent injection drug users; MSM. Health care personnel or public safety workers potentially exposed to blood or other infectious bodily fluids Persons with diabetes Persons with end-stage renal disease Household contact or sex partners of hepatitis B surface Ag positive persons, clients and staff members of institutions for persons with developmental disabilities, and international travelers in countries with high or intermediate prevalence of chronic HBV infection All persons in settings working with the above risk groups

16 Adult Vaccination Coverage, Hepatitis A and B Vaccines by Age and High-risk Status, United States Data Source: 2012 NHIS HP2020 Target 90% HepB Healthcare Personnel (HCP) From Presentation by Walter Williams, MD, MPH. NVAC, March 19, 2014.

17 ACIP Adult HPV Vaccine Recommendations 3 dose series Recommended for females through age 26 years if not previously vaccinated or haven t completed the 3 dose series. Recommended for males through age 21 years if not previously vaccinated. Males 22 through 26 years may also be vaccinated. Recommended through age 26 years for men who have sex with men, immunocompromised men (including those with HIV), and for all those who did not complete the 3 dose series.

18 HPV Vaccination Coverage ( 1 dose ever), Adults years by Sex, United States Data Source: 2012 NHIS From Presentation by Walter Williams, MD, MPH. NVAC, March 19, 2014.

19 Racial/Ethnic Vaccination Disparities -- NHIS 2012 Vaccination Group % Vaccinated Whites Disparity, Blacks Disparity, Hispanics Disparity, Asians Pneumo., HR yrs Pneumo., 65 yrs Tetanus, yrs Tetanus, yrs Tetanus, 65 yrs Tdap, 19 yrs Tdap, yrs Tdap, 65 yrs HepA, yrs HepB, yrs Herpes Zoster, 60 yrs HPV, Females yrs Tdap, HCP 19 yrs HepB, HCP 19 yrs

20 Racial/Ethnic Vaccination Disparities Non-Hispanic blacks, Hispanics, and Non-Hispanic Asians had lower vaccination coverage than that of non-hispanic whites for all of the non-influenza vaccines routinely recommended for adults, except for: PPSV/PCV HR -- Blacks had coverage similar to whites Tdap 19+ Asians had coverage similar to whites Tdap Blacks had coverage similar to whites Hep A Blacks had coverage similar to and Asians had coverage higher than whites Hep B Asians had coverage similar to whites Health Care Personnel (HCP) Non-Hispanic black and Hispanic HCP had lower coverage for Tdap, but coverage similar to whites for HepB For influenza, non-hispanic blacks had lower coverage than non-hispanic whites. Early season flu vaccination coverage among adults was similar across all other racial/ethnic groups.

21 Conclusions Overall adult immunization coverage remains low and far below the Healthy People 2020 targets Some improvement: Modest increases for HPV (women, 19-26), Tdap (19-64 year olds), herpes zoster ( 60 year olds) vaccines in 2012 from 2011 (U.S.) Some increase in overall early season U.S. adult influenza coverage in (compared to early ) No improvements for other vaccines or early season influenza vaccine for HCP or pregnant women (U.S.) Much remains to be done to increase vaccine coverage among adults and to eliminate disparities

22 Acknowledgements Walter W. Williams, MD Centers for Disease Control and Prevention Nisha Gandhi, MPH California Department of Public Health, Immunization Branch

23 Questions?

24 Extra Slides

25 California General Acute Care Hospitals CDPH Report Healthy People 2020 Target of 90% for influenza vaccination of health care personnel Mean hospital-specific employee vaccination percentage was 67.8% for % higher than prior year 203 (55%) of Ca hospitals reached over 60% vaccination among employees Only 28 (7.6%) hospitals reached 90% for employee influenza vaccination

26 Place of Influenza Immunization, California Adults (BRFSS) years years

27 Place of Influenza Immunization, California Adults (BRFSS) 65 years and older

28 Definition of High-Risk for Pneumococcal Disease (NHIS) Adults were considered at high risk for pneumococcal disease if they had been told by a doctor or other health professional that they: Ever had: Diabetes Emphysema Coronary Heart Disease, Angina, Heart Attack, or other Heart Condition Lymphoma, Leukemia, or Blood Cancer Had during the preceding 12 months: Cancer Diagnosis (excluding nonmelanoma skin cancer) Asthma Episode or Attack, Chronic Bronchitis Weak or Failing Kidneys Or were Current Smokers

29 Underlying Medical Conditions or other Indications for PPSV23 among Adults aged years, ACIP 2010 Immunocompetent persons Chronic heart disease (excluding hypertension)* Chronic lung disease Diabetes mellitus Cerebrospinal fluid leaks Cochlear implant Alcoholism Chronic liver disease, including cirrhosis Cigarette smoking Persons with functional or anatomic asplenia Immunocompromised persons * Including congestive heart failure and cardiomyopathies. Including chronic obstructive pulmonary disease, emphysema, and asthma. A second dose of PPSV23 is recommended 5 years after the first dose for persons with functional or anatomic asplenia and for immunocompromised persons.

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32 California Health Interview Survey Interested in flu coverage for your county? Go to

33 Percentage of health-care personnel (HCP) who received influenza vaccination, by occupation Internet panel surveys, United States, , , and influenza seasons Percentage of health-care personnel (HCP) who received influenza vaccination, by work setting Internet panel surveys, United States, , , and influenza seasons

34 Estimated proportion of adults aged 19 years who received selected vaccinations, by age group, high-risk status,* race/ethnicity, and other selected characteristics National Health Interview Survey, United States, 2012 Vaccination, age group, high-risk status, and race/ethnicity Sample size % (95% CI) Difference from 2011 Pneumococcal vaccination, ever yrs, high risk Total 9, ( ) -0.1 White 5, ( ) 1.3 Black 1, ( ) -3.1 Hispanic 1, ( ) -4.6** Asian ( ) 1.2 Others ( ) yrs Total 7, ( ) -2.4 White 4, ( ) -2.5 Black ( ) -1.5 Hispanic or Latino ( ) 0.3 Asian ( ) 1.0 Others ( ) -22.7** Tetanus vaccination, past 10 yrs yrs Total 16, ( ) -0.3 White 8, ( ) 0.1 Black 2, ( ) 1.3 Hispanic 3, ( ) -2.4 Asian 1, ( ) 1.9 Others ( ) yrs Total 8, ( ) -0.4 White 5, ( ) -0.2 Black 1, ( ) -2.1 Hispanic 1, ( ) -0.3 Asian ( ) 3.1 Others ( ) yrs Total 6, ( ) 0.7 White 4, ( ) 0.8 Black ( ) 0.2 Hispanic ( ) -0.3 Asian ( ) 7.9 Others ( ) -13.0

35 Estimated proportion of adults aged 19 years who received selected vaccinations, by age group, high-risk status,* race/ethnicity, and other selected characteristics National Health Interview Survey, United States, 2012 Vaccination, age group, high-risk status, and race/ethnicity Sample size % (95% CI) Difference from 2011 Hepatitis A vaccination ( 2 doses), ever*** yrs Total 14, ( ) -0.3 White 7, ( ) -0.1 Black 2, ( ) 0.1 Hispanic 3, ( ) -0.8 Asian ( ) -0.4 Others ( ) -5.0 Had traveled outside the United States since 1995, other than to Europe, Japan, Australia, New Zealand, or Canada 5, ( ) -1.2 Had not traveled outside the United States since 1995, other than to Europe, Japan, Australia, New Zealand, or Canada 9, ( ) 0.2 With chronic liver conditions, overall 121 Hepatitis B vaccination ( 3 doses), ever yrs total 15, ( ) -0.7 white 8, ( ) -0.3 black 2, ( ) 1.2 Hispanic 3, ( ) -1.8 Asian 1, ( ) -0.9 others ( ) -6.7 With diabetes Overall 1, ( ) yrs, overall 1, ( ) 2.6

36 Estimated proportion of adults aged 19 years who received selected vaccinations, by age group, high-risk status,* race/ethnicity, and other selected characteristics National Health Interview Survey, United States, 2012 Vaccination, age group, highrisk status, and race/ethnicity Sample size % (95% CI) Difference from 2011 Herpes Zoster (shingles) vaccination, ever 60 yrs Total 9, ( ) 4.4** White 6, ( ) 5.2** Black 1, ( ) 0.9 Hispanic ( ) 0.7 Asian ( ) 3.0 Others ( ) 7.7 Human papillomavirus (HPV) vaccination among females ( 1 dose), ever yrs Total 2, ( ) 5.0** White 1, ( ) 9.7** Black ( ) 0.9 Hispanic ( ) -1.5 Asian ( ) -6.7 Others ( ) yrs, total ( ) yrs, total 1, ( ) 6.7** Human papillomavirus (HPV) vaccination among males ( 1 dose), ever yrs, total 1, ( ) yrs, total ( ) yrs, total 1, ( ) 0.5

37 Tetanus and Pertussis Vaccination in Adults, CA (18-64 yrs) Question Did you receive a tetanus shot in past 10 years? n=12303 Was your most recent tetanus shot given in 2005 or later? n=2363 Did your doctor tell you that your tetanus shot included pertussis vaccine? n=1314 Response Yes: 57% (55%-59%) No: 31% (29%-33%) Don t Know: 3% (2%-4%) Yes: 56% (53%-59%) No: 40% (37%-43%) Don t Know: 4% (3%-5%) Yes: 15% (12%-17%) No: 55% (51%-59%) Don t Know: 30% (26%-34%)

38 Framework Adult Immunization Standards

39 Framework Adult Immunization Standards (continue)

40 Influenza Vaccination Coverage by Age Group, Adults 18 Years and Older, Season, California and U.S. California % (95% CI) U.S. % (95% CI) 18 years and older 40.2 ± ± years 34.7 ± ± years at high risk 47.0 ± ± years 29.8 ± ± years at high risk 38.8 ± ± years 45.0 ± ± years and older 66.5 ± ± 0.8

41 Influenza Vaccination Coverage by Race/Ethnicity, People 6 Months and Older, Season, California and U.S. California % (95% CI) U.S. % (95% CI) White only, non-hispanic 46.6 ± ± 0.4 Black only, non-hispanic 42.4 ± ± 1.4 Hispanic 39.7 ± ± 1.4 Other, Non-Hispanic 48.3 ± ± 1.7

42 National Health Interview Survey, 2012 Annual in-home survey of U.S. non-institutionalized civilian population Detailed health survey of one sample adult in the household Provides national coverage estimates Final sample adult component Response Rate: 61.2% N = 34,218

43 Tetanus Vaccination: Proportion Tdap, >19 years, NHIS 2012 United States Group Not Told (%) Not Recall Tdap/Td+Tdap* (%) Adults, >19 years, Overall HCP, >19 years Non-HCP, >19 years *Respondents who reported that the doctor did not inform them of the vaccine type they received and those who could not recall the vaccine type were excluded. Adults were classified as HCP if they reported they currently work in a hospital, medical clinic, doctor s office, dentist s office, nursing home or some other healthcare facility, including part-time and unpaid work as well as professional nursing care provided in the home. p<0.05 by T test for comparisons between HCP and non-hcp >19 years.

44 Tdap Estimates NHIS, 2012: Potential for Bias Many were excluded (33.8% of respondents): All those without a yes or no response for tetanus vaccination, past 10 years (5.4%) All those without response to tetanus vaccination during (3.7%) Those who reported tetanus vaccination but not told what type (20.4%) Those who reported tetanus vaccination but did not know the vaccine type (4.3%) Sensitivity analysis to assess magnitude of bias: Tdap coverage could range from: 11.2% -39.4% (adults years); 6.0%-31.0% (adults >65 years)

45 Non-Influenza Adult Vaccination Coverage Vaccines with Increases from 2011 to % 20.1% 15.6% Data Source: NHIS

46 Limitations of Findings NHIS excludes persons in the military and those residing in institutions results apply to the civilian, non-institutionalized population Response rate 61.2% -- low response rate can result in sampling bias if the nonresponse is unequal among participants regarding vaccination Self-report of vaccination subject to recall bias Tdap estimates: potential bias due to exclusions Age of vaccination not known for vaccines reported as ever received unclear if vaccination occurred as an adult or as part of child or adolescent programs

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