Adult Immunization Rates

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

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 - 2012 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

Recommendations for Pneumococcal Vaccine All persons should be vaccinated with pneumococcal polysaccharide vaccine (PPSV23) at age 65 years. Adults aged 19 64 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. http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html

ACIP Recommendations for Zoster Vaccine Zoster vaccine is recommended for all persons aged >60 years. http://www.cdc.gov/mmwr/pdf/rr/rr5705.pdf

Adult Vaccination Coverage, Selected Vaccines by Age and High-risk Status, United States 2012 HP2020 Targets: 90% PPV 65 yrs, 60% PPV HR 19-64 yrs, 30% Shingles Data Source: 2012 NHIS From Presentation by Walter Williams, MD, MPH. NVAC, March 19, 2014

Self-reported Pneumococcal Immunization Coverage for 65 Years and Older-California, 2007-2012 100% 80% Healthy People 2020 Goal 90% Percent 60% 40% 20% 0% 2007 2008 2009 2010 2011 2012 Year Behavioral Risk Factor Surveillance System, 2007-2012

ACIP Recommendations for Influenza Immunization Recommended annually for all persons 6 months of age and older http://www.cdc.gov/mmwr/pdf/rr/rr6207.pdf

Self-reported Flu Immunization Coverage by Age Group-California, 2004-2012 100% 65+ Percent 80% 60% 40% * * * 50-64 19-49 20% 0% 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year Behavioral Risk Factor Surveillance System, 2004-2012 *Wording change of influenza vaccine question

U.S. Flu Vaccination Rates Health Care Personnel and before and during Pregnancy http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2013.htm http://www.cdc.gov/flu/fluvaxview/pregnant -women-nov2013.htm Healthy People 2020 Objective: 90% annual influenza immunization coverage for health care personnel

U.S. Influenza Vaccination Coverage Rates for Children and Adults, 2012-13 and 2013-14 Healthy People 2020 Objective: 70% annual influenza immunization coverage for adults 18 years and older http://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2013.htm

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 http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html

Self-Reported Tdap coverage-california, 2012 N=9635 18-29 years N=1047 30-64 years N=5607 65 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

Adult Vaccination Coverage, Tetanus-containing Vaccines by Age and High-risk Status, United States From Presentation by Walter Williams, MD, MPH. NVAC, March 19, 2014. Data Source: 2012 NHIS

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 http://www.cdc.gov/mmwr/pdf/rr/rr5507.pdf

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

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.

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.

HPV Vaccination Coverage ( 1 dose ever), Adults 19-26 years by Sex, United States Data Source: 2012 NHIS From Presentation by Walter Williams, MD, MPH. NVAC, March 19, 2014.

Racial/Ethnic Vaccination Disparities -- NHIS 2012 Vaccination Group % Vaccinated Whites Disparity, Blacks Disparity, Hispanics Disparity, Asians Pneumo., HR 19-64 yrs 21-2 -8-8 Pneumo., 65 yrs 64-18 -21-23 Tetanus, 19-49 yrs 70-14 -16-15 Tetanus, 50-64 yrs 68-15 -15-19 Tetanus, 65 yrs 58-13 -13-12 Tdap, 19 yrs 16-6 -7-1 Tdap, 19-64 yrs 18-8 -9-2 Tdap, 65 yrs 9-3 -6-5 HepA, 19-49 yrs 12-1 -2 +7 HepB, 19-49 yrs 38-3 -10 +2 Herpes Zoster, 60 yrs 23-14 -14-6 HPV, Females 19-26 yrs 42-13 -24-27 Tdap, HCP 19 yrs 33-11 -8 +6 HepB, HCP 19 yrs 66-4 -5 +7

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/PCV13 19-64-HR -- Blacks had coverage similar to whites Tdap 19+ Asians had coverage similar to whites Tdap 65+ -- 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.

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 2013-14 (compared to early 2012-13) 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

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

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California General Acute Care Hospitals CDPH 2011-12 Report Healthy People 2020 Target of 90% for influenza vaccination of health care personnel Mean hospital-specific employee vaccination percentage was 67.8% for 2011-12 3.5% 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

Place of Influenza Immunization, California Adults -2012 (BRFSS) 19-49 years 50-64 years

Place of Influenza Immunization, California Adults -2012 (BRFSS) 65 years and older

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

Underlying Medical Conditions or other Indications for PPSV23 among Adults aged 19 64 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.

California Health Interview Survey Interested in flu coverage for your county? Go to http://www.chis.ucla.edu/main/default.asp.

Percentage of health-care personnel (HCP) who received influenza vaccination, by occupation Internet panel surveys, United States, 2009 10, 2010 11, and 2011 12 influenza seasons Percentage of health-care personnel (HCP) who received influenza vaccination, by work setting Internet panel surveys, United States, 2009 10, 2010 11, and 2011 12 influenza seasons

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 19 64 yrs, high risk Total 9,333 20.0 (18.9 21.1) -0.1 White 5,736 21.4 (20.1 22.9) 1.3 Black 1,605 19.7 (17.4 22.2) -3.1 Hispanic 1,326 13.8 (11.5 16.4) -4.6** Asian 350 13.2 (9.5 18.1) 1.2 Others 316 20.2 (15.2 26.2) -1.5 65 yrs Total 7,076 59.9 (58.4 61.4) -2.4 White 4,993 64.0 (62.3 65.7) -2.5 Black 919 46.1 (41.7 50.6) -1.5 Hispanic or Latino 698 43.4 (39.0 48.0) 0.3 Asian 373 41.3 (35.4 47.5) 1.0 Others 93 44.7 (32.6 57.5) -22.7** Tetanus vaccination, past 10 yrs 19 49 yrs Total 16,927 64.2 (63.2 65.1) -0.3 White 8,969 69.7 (68.5 70.9) 0.1 Black 2,491 56.1 (53.5 58.6) 1.3 Hispanic 3,772 53.9 (51.9 56.0) -2.4 Asian 1,195 54.3 (50.6 58.0) 1.9 Others 500 71.9 (66.5 76.8) 2.3 50 64 yrs Total 8,525 63.5 (62.1 64.8) -0.4 White 5,577 67.5 (65.9 69.0) -0.2 Black 1,373 52.3 (49.0 55.7) -2.1 Hispanic 1,031 52.3 (47.8 56.8) -0.3 Asian 371 48.2 (41.8 54.7) 3.1 Others 173 69.9 (60.3 78.0) 2.0 65 yrs Total 6,905 55.1 (53.6 56.7) 0.7 White 4,864 57.7 (55.9 59.5) 0.8 Black 904 44.6 (40.8 48.4) 0.2 Hispanic 678 44.8 (40.1 49.6) -0.3 Asian 366 45.8 (39.5 52.2) 7.9 Others 93 50.2 (36.8 63.6) -13.0

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*** 19 49 yrs Total 14,834 12.2 (11.5 13.0) -0.3 White 7,887 12.2 (11.2 13.2) -0.1 Black 2,207 11.3 (9.6 13.2) 0.1 Hispanic 3,341 10.5 (9.2 11.9) -0.8 Asian 992 18.7 (15.7 22.1) -0.4 Others 407 16.1 (11.4 22.2) -5.0 Had traveled outside the United States since 1995, other than to Europe, Japan, Australia, New Zealand, or Canada 5,259 18.9 (17.6 20.3) -1.2 Had not traveled outside the United States since 1995, other than to Europe, Japan, Australia, New Zealand, or Canada 9,548 8.6 (7.8 9.5) 0.2 With chronic liver conditions, overall 121 Hepatitis B vaccination ( 3 doses), ever 19 49 yrs total 15,649 35.3 (34.3 36.2) -0.7 white 8,296 37.5 (36.3 38.8) -0.3 black 2,338 34.2 (31.5 36.9) 1.2 Hispanic 3,465 27.1 (25.1 29.2) -1.8 Asian 1,105 39.7 (35.5 44.0) -0.9 others 445 37.4 (31.9 43.3) -6.7 With diabetes Overall 1,286 28.6 (25.4 32.1) 1.7 60 yrs, overall 1,907 15.1 (12.9 17.4) 2.6

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 9,924 20.1 (19.1 21.2) 4.4** White 6,957 22.8 (21.5 24.0) 5.2** Black 1,354 8.8 (6.9 11.2) 0.9 Hispanic 990 8.7 (6.6 11.4) 0.7 Asian 487 16.9 (13.2 21.5) 3.0 Others 136 19.7 (11.5 31.6) 7.7 Human papillomavirus (HPV) vaccination among females ( 1 dose), ever 19 26 yrs Total 2,300 34.5 (31.7 37.3) 5.0** White 1,165 42.2 (38.5 46.0) 9.7** Black 385 29.1 (23.4 35.7) 0.9 Hispanic 507 18.7 (14.9 23.1) -1.5 Asian 148 15.6 (9.5 24.5) -6.7 Others 95 41.2 (28.7 55.0) 2.2 19 21 yrs, total 760 44.3 (39.5 49.2) 1.2 22 26 yrs, total 1,540 28.2 (25.2 31.5) 6.7** Human papillomavirus (HPV) vaccination among males ( 1 dose), ever 19 26 yrs, total 1,783 2.3 (1.6 3.4) 0.2 19 21 yrs, total 634 2.4 (1.4 4.4) -0.3 22 26 yrs, total 1,149 2.2 (1.3 3.8) 0.5

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%)

Framework Adult Immunization Standards

Framework Adult Immunization Standards (continue)

Influenza Vaccination Coverage by Age Group, Adults 18 Years and Older, 2012-13 Season, California and U.S. California % (95% CI) U.S. % (95% CI) 18 years and older 40.2 ± 2.0 41.5 ± 0.4 18-64 years 34.7 ± 2.4 35.7 ± 0.6 18-64 years at high risk 47.0 ± 5.5 47.0 ± 1.4 18-49 years 29.8 ± 2.9 31.1± 0.8 18-49 years at high risk 38.8 ± 8.8 39.8 ± 2.2 50-64 years 45.0 ± 3.5 45.1 ± 0.8 65 years and older 66.5 ± 3.3 66.2 ± 0.8 http://www.cdc.gov/flu/fluvaxview/reports/reporti1213/reportii/index.htm

Influenza Vaccination Coverage by Race/Ethnicity, People 6 Months and Older, 2012-13 Season, California and U.S. California % (95% CI) U.S. % (95% CI) White only, non-hispanic 46.6 ± 2.2 46.4 ± 0.4 Black only, non-hispanic 42.4 ± 8.0 41.3 ± 1.4 Hispanic 39.7 ± 3.1 42.7 ± 1.4 Other, Non-Hispanic 48.3 ± 5.4 46.7 ± 1.7

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

Tetanus Vaccination: Proportion Tdap, >19 years, NHIS 2012 United States Group Not Told (%) Not Recall Tdap/Td+Tdap* (%) Adults, >19 years, Overall 52.6 11.1 65.4 HCP, >19 years 33.1 9.3 76.3 Non-HCP, >19 years 55.1 11.3 63.1 *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.

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 2005-2012 (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 19-64 years); 6.0%-31.0% (adults >65 years)

Non-Influenza Adult Vaccination Coverage Vaccines with Increases from 2011 to 2012 32.6% 20.1% 15.6% Data Source: NHIS 2011-2012

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