Randomized trial of an alternate human papillomavirus vaccine administration schedule in college-aged women.

BACKGROUND: Human papillomavirus (HPV) vaccine is effective against HPV types 16 and 18, which cause 70% of cervical cancers. The three-dose vaccination schedule at 0, 2, and 6 months may be inconvenient for college-aged women. This study assessed noninferiority of the immune response to an alternate vaccination schedule at 0, 2, and 12 months. METHODS: Two hundred nonpregnant women, aged 18-23 years, with <5 sexual partners were randomized into standard and alternate schedules. Blood samples were drawn before dose 1 and 2-6 weeks after dose 3 and analyzed with the competitive Luminex immunoassay. Seropositives at baseline were eliminated from analyses by HPV type. Log-transformed titers were used to calculate HPV type-specific geometric mean titers (GMTs) and 95% confidence intervals (CI) for each group. Noninferiority was tested against a one-sided null hypothesis that the post-dose 3 GMT ratio of the alternate to standard schedule was < or =0.5 for each HPV type. RESULTS: One hundred eighty-eight women completed the study, with all 12 dropouts in the alternate schedule group (p < 0.001). Antibody responses in the alternate schedule were noninferior to the standard schedule for all vaccine types (p < 0.0001). Among the per-protocol population, GMTs (95% CI) for the alternate schedule were 4,440 (3,080-5,696), 5,688 (3,960-7,291), 12,443 (8,611-15,977), and 2,129 (1,183-3,063) for HPV types 6, 11, 16, and 18, respectively, vs. 2,153 (1,794-2,478), 1,966 (1,401-2,491), 6,218 (4,367-7,946), and 1,370 (1,167-1,553) for the standard schedule. Time between doses 2 and 3 significantly predicted final titer for all virus types (p < 0.005). CONCLUSIONS: For all HPV vaccine types, the GMT ratios indicated noninferiority of the alternate vaccine administration schedule at 0, 2, and 12 months. The alternate schedule may be used to expand options for the timing of the third dose in the HPV vaccine schedule.

Establish the habit: influenza vaccination for health care personnel.

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

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

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

Office manager and nurse perspectives on facilitators of adult immunization.

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

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

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

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

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

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

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

Economic evaluation of standing order programs for pneumococcal vaccination of hospitalized elderly patients.

BACKGROUND: Standing order programs (SOPs), which allow for vaccination without an individual physician order, are the most effective mechanism to achieve high vaccination rates. Among the suggested settings for the utilization of SOPs are hospital inpatient units, because they provide care for those most likely to benefit from vaccination. The cost-effectiveness of this approach for elderly hospitalized persons is unknown. The purpose of this study was to estimate the cost-effectiveness of SOPs for pneumococcal polysaccharide vaccine (PPV) vaccination for patients 65 years of age or older in 2 types of hospital. METHODS: In 2004, a 1,094-bed tertiary care hospital implemented a pharmacy-based SOP for PPV, and a 225-bed community hospital implemented a nursing-based SOP for PPV. Newly admitted patients 65 years of age or older were screened for PPV eligibility and then offered PPV. Vaccination rates before and after initiation of SOPs in the United States, incidence rates of invasive pneumococcal disease in the United States, and US economic data were the bases of the cost-effectiveness analyses. One-way and multivariate sensitivity analyses were conducted. RESULTS: PPV vaccination rates increased 30.5% in the tertiary care hospital and 15.3% in the community hospital. In the base-case cost-effectiveness analysis, using a societal perspective, we found that both pharmacy-based and nursing-based SOPs cost less than $10,000 per quality-adjusted life-year gained, with program costs (pharmacy-based SOPs cost $4.16 per patient screened, and nursing-based SOPs cost $4.60 per patient screened) and vaccine costs ($18.33 per dose) partially offset by potential savings from cases of invasive pneumococcal disease avoided ($12,436 per case). Sensitivity analyses showed SOPs for PPV vaccination to be cost-effective, compared with PPV vaccination without SOPs, unless the improvement in vaccination rate was less than 8%. CONCLUSION: SOPs do increase PPV vaccination rates in hospitalized elderly patients and are economically favorable, compared with PPV vaccination rates without SOPs.

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

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

Assessing disparities in adult vaccination using multimodal approaches in primary care offices: methodology.

Racial disparities in invasive pneumococcal disease and pneumococcal polysaccharide vaccination (PPV) persist despite significant progress. One reason may be that minority patients receive primary care at practices with fewer resources, less efficient office systems, and different priorities. The purposes of this paper are: (1) to describe the recruitment of a diverse array of primary care practices in Pittsburgh, Pennsylvania serving white and minority patient populations, and the multimodal data collection process that included surveys of key office personnel, observations of practice operations and medical record reviews for determining PPV vaccination rates; and (2) to report the results of the sampling strategy. During 2005, 18 practices participated in the study, six with a predominantly minority patient population, nine with a predominantly white patient population, and three with a racial distribution similar to that of this locality. Eight were solo practices and 10 were multiprovider practices; they included federally qualified health centers, privately owned practices and faculty and University of Pittsburgh Medical Center community practices. Providers represented several racial and ethnic groups, as did office staffs. PPV rates determined from 2,314 patients' medical records averaged 60.3 +/- 22.6% and ranged from 11% to 97%. Recruitment of practices with attention to location, patient demographics, and provider types results in a diverse sample of practices and patients. Multimodal data collection from these practices should provide a rich data source for examining the complex interplay of factors affecting immunization disparities among older adults.

Designing and implementing a hospital-based vaccine standing orders program.

PURPOSE: An inpatient pneumococcal polysaccharide vaccine (PPV) vaccination program was designed and implemented to meet federal and state regulatory requirements and national vaccination goals. SUMMARY: In 2002, the Centers for Medicare and Medicaid Services published a final rule removing the federal requirement for an individual patient physician-signed order for the pneumococcal and influenza vaccines in Medicare- and Medicaid- participating hospitals. This statute authorized implementation of standing orders programs (SOPs) in health care institutions. At the University of Pittsburgh Medical Center-Presbyterian (UPMC-P), institutional vaccination rates and the existing mechanism for providing adult vaccinations were evaluated. At the peak of the program's effectiveness in 2000, in-hospital total vaccination rates were 31%; those rates fell to 15% by the end of 2003. To rectify this poor rate of vaccination, a multidisciplinary team convened to evaluate the existing program and to design the tools and processes for a conversion to a vaccine SOP. A standing order form was designed, and it was determined that the SOP should be pharmacy driven. As a result of the SOP, the PPV vaccination rate increased dramatically; in 2005, the average rate was 69%, with the highest rate occurring in March 2005 (87%). CONCLUSION: The cooperative effort of a multidisciplinary work group including physicians, nursing staff, and pharmacy personnel led to the creation of a successful inpatient PPV SOP. Analysis of the previous vaccination program and careful planning were instrumental in designing the SOP. Defined responsibilities for daily performance and user-friendly tools with clear instructions were also crucial to the success of the program.

Improving influenza vaccination rates of high-risk inner-city children over 2 intervention years.

PURPOSE: Influenza immunization rates among children with high-risk medical conditions are disappointingly low, and relatively few data are available on raising rates, particularly over 2 years. We wanted to determine whether interventions tailored to individual practice sites improve influenza immunization rates among high-risk children in inner-city health centers over 2 years. METHOD: A before-after trial to improve influenza immunization of children was conducted at 5 inner-city health centers (residencies and faith-based). Sites selected interventions from a menu (eg, standing orders, patient and clinician reminders, education) proved to increase vaccination rates, which were directed at children aged 2 to 17 years with high-risk medical conditions. Intervention influenza vaccination rates and 1 and 2 years were compared with those of the preintervention year (2001-2002) and of a comparison site. RESULTS: Influenza vaccination rates improved modestly from baseline (10.4%) to 13.1% during intervention year 1 and to 18.7% during intervention year 2 (P <.001), with rates reaching 31% in faith-based practices. Rates increased in all racial and age-groups and in Medicaid-insured children. The increase in rates was significantly greater in intervention health centers (8.3%) than in the comparison health center (0.7%; P <.001). In regression analyses that controlled for demographic factors, vaccination status was associated with intervention year 1 (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.6-2.2) and with intervention year 2 (OR, 2.8; 95% CI, 2.3-3.4), as well as with practice type. Adolescents had lower vaccination rates than children 2 to 6 years old (OR, 0.6; 95% CI, 0.5-0.7). CONCLUSIONS: Tailored interventions selected from a menu of interventions modestly increased influenza vaccination rates over 2 years at health centers serving children from low-income families. We recommend this strategy for faith-based practices and residencies with 1 practice site, but further research is needed on multisite practices and to achieve higher influenza vaccination rates.

Interventions over 2 years to increase influenza vaccination of children aged 6-23 months in inner-city family health centers.

The purposes of this study were to test the ability of tailored interventions to raise influenza immunization rates and assess the effect on timely receipt of other vaccines. We conducted a before/after trial over 2 years to increase influenza vaccination rates of patients 6-23 months old in five inner-city family health centers serving low-income children with a sixth site as a concurrent control. Influenza vaccination rates improved significantly from a baseline of 4.7-24.7% in the first year and 36.6% in the second year, P < 0.001. The increase in rates was greater in intervention sites than the control site (31.9% versus 25.7%, P = 0.02). In regression analyses of influenza vaccination, intervention year was associated with an odds ratio (OR) of 9.4 (95% confidence interval (CI) = 4.4-20.0) for the first intervention year and OR = 13.4 (95% CI = 6.5-28.0) for the second intervention year. Children vaccinated against influenza were more likely to have received DTaP 3 and MMR within 2 months of the recommended age than children not vaccinated against influenza (P < 0.001).

Overcoming barriers to establishing an inpatient vaccination program for pneumococcus using standing orders.

OBJECTIVES: To identify and classify barriers to establishing a standing orders program (SOP) for adult pneumococcal vaccination in acute care inpatient facilities and to provide recommendations for overcoming these roadblocks. Vaccination rates in hospitals with SOPs are generally higher than those in hospitals that require individual physician orders. The array of solutions drawn from our experience in different hospital settings should permit many types of facilities to anticipate and overcome barriers, allowing a smoother transition from initiation to successful implementation of an inpatient pneumococcal vaccination SOP. DESIGN: Descriptive study of barriers and solutions encountered during implementation of a pneumococcal vaccination SOP in three hospitals of the University of Pittsburgh Medical Center Health System (UPMC) and in the scientific literature. SETTING: As of 2004, two UPMC tertiary-care hospitals and one UPMC community hospital had incorporated SOPs into existing physician order-driven programs for inpatient vaccination with pneumococcal polysaccharide vaccine. RESULTS: Barriers were identified at each step of implementation and categorized as patient related, provider related, or institutional. Based on a process of continual review and revision of our programs in response to encountered barriers, steps were taken to overcome these impediments. CONCLUSIONS: A strong commitment by key individuals in the facility's administration including a physician champion; ongoing, persistent efforts to educate and train staff; and close monitoring of the vaccination rate were essential for successful implementation of a SOP for pneumococcal vaccination of eligible inpatients. Legal statutes and evaluations of external hospital-rating associations regarding the effectiveness of the vaccination program were major motivating factors in its success.

Vaccine criticism on the World Wide Web.

BACKGROUND: The incidence of vaccine-preventable diseases is directly related to the number of unvaccinated children. Parents who refuse vaccination of their children frequently express concerns about vaccine safety. The Internet can influence perceptions about vaccines because it is the fastest growing source of consumer health information. However, few studies have analyzed vaccine criticism on the Web. OBJECTIVE: The purposes of this paper are to examine vaccine criticism on the Internet and to analyze the websites in order to identify common characteristics and ethical allegations. METHODS: A structured Web search was conducted for the terms "vaccine," "vaccination," "vaccinate," and "anti-vaccination" using a metasearch program that incorporated 8 search engines. This yielded 1138 Web pages representing 750 sites. Two researchers reviewed the sites for inclusion/exclusion criteria, resulting in 78 vaccine-critical sites, which were then abstracted for design, content, and allegations. RESULTS: The most common characteristic of vaccine-critical websites was the inclusion of statements linking vaccinations with specific adverse reactions, especially idiopathic chronic diseases such as multiple sclerosis, autism, and diabetes. Other common attributes (> or = 70% of websites) were links to other vaccine-critical websites; charges that vaccines contain contaminants, mercury, or "hot lots" that cause adverse events; claims that vaccines provide only temporary protection and that the diseases prevented are mild; appeals for responsible parenting through education and resisting the establishment; allegations of conspiracies and cover-ups to hide the truth about vaccine safety; and charges that civil liberties are violated through mandatory vaccination. CONCLUSIONS: Vaccine-critical websites frequently make serious allegations. With the burgeoning of the Internet as a health information source, an undiscerning or incompletely educated public may accept these claims and refuse vaccination of their children. As this occurs, the incidence of vaccine-preventable diseases can be expected to rise.