PCV13-vaccinated children still carrying PCV13 additional serotypes show similar carriage density to a control group of PCV7-vaccinated children.

BACKGROUND: In addition to reducing vaccine-type nasopharyngeal carriage rates, pneumococcal conjugate vaccines (PCVs) may decrease carriage density in vaccinated individuals still carrying vaccine serotypes. However, reduction of carriage density has not been systematically studied. This study compared the effect of PCV13 versus PCV7 on carriage density of the serotypes in PCV13 that are not included in PCV7. METHODS: This randomized, double-blind study was conducted in southern Israel and included Jewish and Bedouin subjects. Per protocol, 881 and 873 infants received PCV13 and PCV7, respectively, at ages 2, 4, 6, and 12months. Nasopharyngeal cultures at ages 7, 12, 13, 18, and 24months were plated using the 4-quadrant semiquantitative method and graded 0 (negative) to 4 (growth in all plate quadrants). In this post hoc analysis, the least squares means of cumulative colonization densities per serotype and serotype combination of the total population and each ethnic subpopulation in each vaccine group were calculated, and differences between vaccine groups derived from a linear model. RESULTS: PCV13-vaccinated children still carrying the 6 additional PCV13 serotypes unique to PCV13 showed no significant differences in carriage density compared with the PCV7-vaccinated control group. No differences in carriage density were shown between Jewish and Bedouin subpopulations despite higher carriage rates among Bedouin subjects. CONCLUSIONS: Although PCV13 vaccination reduces vaccine-type carriage compared with PCV7 vaccination by reducing nasopharyngeal acquisition of the additional PCV13 serotypes as previously reported, the current study lacks evidence of a decrease in carriage density of these serotypes when acquired in vaccinated children. Despite the lack of effect on carriage density observed, surveillance data suggest a dramatic decrease in disease rates after PCV implementation. Thus, the current analysis suggests that PCV's impact on carriage density has minimal or no impact on vaccine success. (www.ClinicalTrials.gov: NCT00508742).

Immunization disparities by Hispanic ethnicity and language preference.

BACKGROUND: Seasonal influenza and pneumococcal immunization rates are substantially lower for older Hispanics than for non-Hispanic whites. METHODS: Beneficiary-reported past-year influenza and lifetime pneumococcal immunization for English- and Spanish-preferring Hispanic beneficiaries were compared with those for non-Hispanic whites in cross-sectional bilingual survey data using data from 244 618 randomly sampled community-dwelling respondents (age ≥65 years) with the 2008 Medicare Consumer Assessment of Healthcare Providers and Systems survey (a 62% response rate). Weighted logistic regression estimated immunization disparities with and without adjustment for health status, sociodemographic variables related to access, and location. Hierarchical models examined the role of specific geographic factors in immunization disparities. RESULTS: Pneumococcal immunization rates for Spanish- and English-speaking Hispanics were substantially lower than those for non-Hispanic whites (40% and 56% vs 74%; P < .001 for both comparisons). Influenza immunization rates for Spanish- and English-speaking Hispanics were also lower than for non-Hispanic whites (64% and 68% vs 76%; P < .001 for both comparisons). Health status-adjusted differences were similar; additional adjustment for sociodemographics reduced pneumococcal disparities by approximately one-third and influenza disparities by approximately half, but all disparities remained significant. Pneumococcal disparities were consistently smaller for patients in managed care plans. Influenza disparities were greater both in linguistically isolated areas and in "new destination" areas without long-standing Hispanic populations. CONCLUSIONS: Hispanic seniors, especially when Spanish-preferring and in linguistically isolated "new destinations," such as the Southeast, continue to be immunized at markedly lower rates than non-Hispanic whites, even after adjustment for health and sociodemographics. Individual physicians and policymakers may be able to assist this vulnerable group by addressing cultural and linguistic barriers to immunization.

Antimicrobial resistance in Hispanic patients hospitalized in San Antonio, TX with community-acquired pneumonia.

Limited information is available on the antimicrobial resistance of patients with community-acquired pneumonia (CAP) depending on their ethnicity. Our aim was to compare the clinical characteristics, etiology, and microbiological resistance of Hispanic versus non-Hispanic white patients. A retrospective cohort of 601 patients with a diagnosis of CAP included 288 non-Hispanic whites and 313 Hispanics. Penicillin-resistant Streptococcus pneumoniae was more common among Hispanic patients (21.7% vs 0%; P=0.03) but there were no significant differences in macrolide-resistant S pneumoniae, drug-resistant S pneumoniae, or potential or actual multidrug-resistant pathogens (eg, drug-resistant S pneumoniae, methicillin-resistant Staphylococcus aureus, Pseudomonas spp., and Acinetobacter spp.). There were no differences among groups in length of hospital stay, intensive care unit (ICU) admission, or 30-day mortality. This study suggests that Hispanic patients with CAP have a higher rate of penicillin-resistant S pneumoniae, but no differences in antimicrobial resistance, 30-day mortality, ICU admission, or length of stay when compared with non-Hispanic white patients.

Receipt of influenza and pneumonia vaccinations: the dual disparity of rural minorities.

OBJECTIVES: To examine the receipt of age-appropriate influenza and pneumococcal polysaccharide vaccinations (PPV), with particular attention to rural minority persons. DESIGN: Data were drawn from the 2005 Behavioral Risk Factor Surveillance System. The dependent variables were self-reported receipt of annual influenza immunizations in adults aged 50 and older (n=177,417) or lifetime pneumococcal immunizations in adults aged 65 and older (n=81,762). The main independent variables were residence and race. MEASUREMENTS: All data are self-reported. Multivariate analysis controlled for selected personal and county-level characteristics. Analyses were conducted in 2009/10. RESULTS: Forty-two percent of adults aged 50 and older reported an influenza vaccination; 31.1% of rural African Americans reported an influenza vaccination, and 64.6% reported a PPV. White and African-American rural residents reported lower vaccination rates. Adjusted analysis indicated an interaction between race and rurality. White rural residents were more likely to be vaccinated than other whites, whereas rural African Americans were less likely to be vaccinated than urban African Americans. CONCLUSION: This study confirms previous findings while finding an interactive effect between rurality and race. The results indicated the importance of provider availability to delivery. Alternative delivery methods may be an effective solution to improve delivery rates.

Socioeconomic and racial/ethnic disparities in the incidence of bacteremic pneumonia among US adults.

OBJECTIVES: We examined associations between the socioeconomic characteristics of census tracts and racial/ethnic disparities in the incidence of bacteremic community-acquired pneumonia among US adults. METHODS: We analyzed data on 4870 adults aged 18 years or older with community-acquired bacteremic pneumonia identified through active, population-based surveillance in 9 states and geocoded to census tract of residence. We used data from the 2000 US Census to calculate incidence by age, race/ethnicity, and census tract characteristics and Poisson regression to estimate rate ratios (RRs) and 95% confidence intervals (CIs). RESULTS: During 2003 to 2004, the average annual incidence of bacteremic pneumonia was 24.2 episodes per 100 000 Black adults versus 10.1 per 100 000 White adults (RR = 2.40; 95% CI = 2.24, 2.57). Incidence among Black residents of census tracts with 20% or more of persons in poverty (most impoverished) was 4.4 times the incidence among White residents of census tracts with less than 5% of persons in poverty (least impoverished). Racial disparities in incidence were reduced but remained significant in models that controlled for age, census tract poverty level, and state. CONCLUSIONS: Adults living in impoverished census tracts are at increased risk of bacteremic pneumonia and should be targeted for prevention efforts.

Effectiveness of 7-valent pneumococcal conjugate vaccine against radiologically diagnosed pneumonia in indigenous infants in Australia.

OBJECTIVE: To evaluate the effectiveness of the 7-valent pneumococcal conjugate vaccine (PCV7) in preventing pneumonia, diagnosed radiologically according to World Health Organization (WHO) criteria, among indigenous infants in the Northern Territory of Australia. METHODS: We conducted a historical cohort study of consecutive indigenous birth cohorts between 1 April 1998 and 28 February 2005. Children were followed up to 18 months of age. The PCV7 programme commenced on 1 June 2001. All chest X-rays taken within 3 days of any hospitalization were assessed. The primary endpoint was a first episode of WHO-defined pneumonia requiring hospitalization. Cox proportional hazards models were used to compare disease incidence. FINDINGS: There were 526 pneumonia events among 10,600 children - an incidence of 3.3 per 1000 child-months; 183 episodes (34.8%) occurred before 5 months of age and 247 (47.0%) by 7 months. Of the children studied, 27% had received 3 doses of vaccine by 7 months of age. Hazard ratios for endpoint pneumonia were 1.01 for 1 versus 0 doses; 1.03 for 2 versus 0 doses; and 0.84 for 3 versus 0 doses. CONCLUSION: There was limited evidence that PCV7 reduced the incidence of radiologically confirmed pneumonia among Northern Territory indigenous infants, although there was a non-significant trend towards an effect after receipt of the third dose. These findings might be explained by lack of timely vaccination and/or occurrence of disease at an early age. Additionally, the relative contribution of vaccine-type pneumococcus to severe pneumonia in a setting where multiple other pathogens are prevalent may differ with respect to other settings where vaccine efficacy has been clearly established.

Maori have a much higher incidence of community-acquired pneumonia and pneumococcal pneumonia than non-Maori: findings from two New Zealand hospitals.

To determine the incidence rates of community-acquired pneumonia and pneumococcal pneumonia requiring hospitalisation among Maori and non-Maori, an observational study was conducted in Christchurch and Hamilton. Self-reported data were collected using an interviewer-administered questionnaire. Routine clinical, radiological, and microbiological techniques were used apart from the BinaxNow pneumococcal antigen test for diagnosis of this infection. Census data was used to determine the denominator for statistical analyses. The pneumonia rate overall was 3.03 times higher among Maori than non-Maori (p<0.001). Differences were significant for each 10-year age group from age 45-74 years (p<0.05). The rate of pneumococcal pneumonia was 3.23 fold higher for Maori than non-Maori (p<0.001), but it did not reach statistical significance in the age-related comparisons. These ethnic disparities are of major concern, and policy planners should consider further interventions to improve the efficacy of current anti-smoking campaigns and to undertake studies of conjugate pneumococcal vaccines for Maori.

Adult immunization disparities: a challenge for the public health/primary care partnership.

Vaccine preventable pneumonias account for 5% of all the years of potential life lost (YPLL) attributable to racial and ethnic health disparities. Eliminating disparities in influenza and pneumococcal vaccination rates could eliminate many of these pneumonia deaths and hospitalizations among at-risk individuals. This represents one of the most focused and achievable targets within the broader agenda of eliminating racial and ethnic health disparities, which is one of two major health goals for the nation outlined in Healthy People 2010. A broad, three-dimensional conceptual framework guiding a strong public health/primary care partnership will be required to achieve this goal.

Who's getting shots and who's not: racial/ethnic disparities in immunization coverage.

This brief report provides data from the National Health Interview Survey (1989-2002) and offers commentary on reasons for the racial/ethnic disparities in immunization coverage for both influenza and pneumococcal vaccines for persons aged > or = 65 years. The findings in this report indicate that, although influenza and pneumococcal vaccination rates have increased for non-Hispanic Blacks and Hispanics, substantial gaps by race/ethnicity persist. Differences are observed even among individuals with similar characteristics (eg, education levels, similar numbers of healthcare visits, and similar insurance status) but from different ethnic groups. In addition, rates of vaccination for ethnic/racial groups have not increased at a sufficient rate to reach the national health objective for 2010 (90% of persons aged > 64 years receiving annual influenza vaccination and having ever received pneumococcal vaccination). By examining the successes of new initiatives such as the READII (Racial Ethnic Adult Disparities in Immunization) demonstration projects, researchers hope that progress can be made to close these racial/ethnic disparities.

When insurance is not enough: racial and ethnic disparities in immunizations for the Medicare population.

This review article discusses disparities in immunization rates for beneficiaries of the US Medicare program. The review considers: 1) historical and statistical information on rates of immunization; 2) goals set forward by the Centers for Medicaid and Medicare Services (CMS) to eliminate racial and ethnic health disparities related to adult immunization; 3) barriers experienced by Medicare beneficiaries in receiving immunizations; 4) barriers experienced by health professionals in providing adult immunizations; and 5) CMS efforts to increase influenza and pneumococcal immunization rates and to eliminate immunization rate disparities among Medicare beneficiaries.

Race, culture, and trust: why should I take a shot if I'm not sick?

This three-part panel discussion provides information on: 1) the role religious leaders can take in influencing health care, health access, and compliance; 2) barriers to equal health care and major gaps in immunizations among Hispanics; and 3) population management strategies for public health officials and private practice physicians. Citing barriers such as mistrust of government programs, socioeconomic conditions, lack of access to preventive healthcare services, cultural attitudes, and lack of education about immunizations, the speakers also offered solutions to overcome resistance to immunization. Panel members supported these strategies and provided techniques to implement the strategy: engaging faith-based organizations, improving patient-provider communication; and creating public health initiatives to be culturally competent.

Best-practice models that work: the CDC's Racial and Ethnic Adult Disparities Immunization Initiative (READII) Programs.

In this panel discussion, three health leaders provide information on techniques and approaches used to effectively implement the CDC's Racial and Ethnic Adult Disparities Immunization Initiative (READII) Programs. Part 1 offers an overview of READII and information on early results and program accomplishments. In Part 2, the Mississippi READII initiative is explored, with insights on how this program has served 10,000 African Americans in inner-city Jackson, Mississippi as well 23,000 elderly African Americans in 18 rural Delta counties, said to be the poorest counties in the nation. The third segment of this presentation explains challenges and successes found in San Antonio, Texas where READII efforts focused on immunizing the city's elderly Hispanics. Readers will find lessons learned and plans for future expansion to use as models when considering implementation of immunization programs in local communities.

Critical elements in the design of culturally appropriate interventions intended to reduce health disparities: immunization rates among Hispanic seniors in New Mexico.

The importance of immunization in protecting seniors against influenza and pneumonia has long been recognized. Nevertheless, immunization rates among Medicare beneficiaries continue to fall short of what is both desirable and achievable. The problem is even more acute among certain racial and ethnic groups in the United States within which rates are below the rate for the country as a whole. This is true in New Mexico where 40 percent of the population is estimated to be Hispanic. As part of its work on behalf of the Centers for Medicare & Medicaid Services (CMS), the New Mexico Medical Review Association (NMMRA) undertook a project aimed both at reducing the disparities that exist in immunization status between the Hispanic and non-Hispanic population in the state and attempting to increase overall rates in the state for all groups. Developing interventions to reduce disparaties in immunization rates between Hispanic seniors and the rest of the senior population requires more than a straightforward review of the literature and must take into account not only the cultural differences that exist between Hispanics and non-Hispanics but, certainly, in the case of New Mexico, it must attempt to understand the richness and diversity that exists within the Hispanic communities across the state. To do otherwise runs the risk of designing interventions that are at best ineffective and at worst culturally insensitive and potentially damaging to future efforts to improve health status. This article describes the process undertaken by NMMRA, a Medicare Quality Improvement Organization (QIO), to collect qualitative data from three culturally different groups of Hispanics in New Mexico. The data are used to design interventions that will increase immunization rates for all Hispanics in New Mexico.

Pneumococcal vaccination: an important strategy to prevent pneumonia in Aboriginal and Torres Strait Island adults.

The objective of the study was to examine the appropriateness of the National Health and Medical Research Council (NHMRC) recommendations concerning pneumococcal vaccination for Aboriginal and Torres Strait Island adults. Laboratory surveillance of invasive pneumococcal disease identified 95 cases acquired by adults 15 years of age and over in Far North Queensland from 1992 to 1995. The most common diagnosis was pneumonia (77 per cent). Sixty-one cases (64 per cent) occurred in Aboriginal and Torres Strait Island adults, who acquired the disease at a younger age (mean 40 years) than did other adults (mean 50 years). Most (93 per cent) of the Aboriginal and Torres Strait Island adults had at least one of the pre-existing medical conditions in the NHMRC criteria for pneumococcal vaccination. The most common was 'alcohol abuse' (62 per cent). Fifty-three (93 per cent) of the pneumococcal isolates from the Aboriginal and Torres Strait Island adults who had pre-existing conditions were serotyped. Fifty (94 per cent) belonged to types included in the currently available pneumococcal vaccine. We conclude that the NHMRC recommendations for pneumococcal vaccination are appropriate, considering the pattern of invasive pneumococcal disease that occurs in Aboriginal and Torres Strait Island adults in Far North Queensland. Because pneumococcal vaccination can reduce the pneumonia-associated morbidity and premature mortality experienced by Aboriginal and Torres Strait Island adults, the vaccine should be offered routinely to those considered to be at risk, particularly young men who have recently begun to consume hazardous amounts of alcohol, and recently diagnosed diabetics.

The epidemiology of invasive pneumococcal disease in Alaska, 1986-1990--ethnic differences and opportunities for prevention.

To assess prevention strategies for pneumococcal disease in Alaska, prospective surveillance during 1986-1990 identified 672 invasive pneumococcal infections, including 315 among Alaska Natives. Age-adjusted annual incidence was 74 per 100,000 for Alaska Natives and 16 per 100,000 for nonnatives. The annual incidence in Alaska Native children < 2 years old was 624 per 100,000; rates of 84 per 100,000 for meningitis and 290 per 100,000 for bacteremic pneumonia were 8-10 times higher than for other US groups. By age 75, cumulative incidence (7%) and mortality (1%) in Alaska Natives were almost 4 times higher than for nonnatives. Only 17% of Alaska Native adults with predisposing conditions and invasive infections previously received pneumococcal vaccine. For Alaska Natives, a proposed heptavalent conjugate pneumococcal vaccine will include serotypes responsible for 85% of invasive isolates from children < 2 years but only 32% of those from adults. The 23-valent polysaccharide pneumococcal vaccine, which contains > 94% of serotypes identified in Alaska Native toddlers and adults, should be used more widely.

High incidence rates of invasive pneumococcal disease in the White Mountain Apache population.

OBJECTIVE: In this article we determine the incidence and clinical spectrum of invasive pneumococcal disease in the White Mountain Apache population, a group known to have a high incidence of invasive disease due to Haemophilus influenzae type b. DESIGN: Patients from whom cultures of normally sterile body sites yielded Streptococcus pneumoniae were identified retrospectively through review of hospital laboratory records from a 6.8-year period. Clinical data were reviewed and incidence rates were computed. SETTING: The Whiteriver Indian Health Service Hospital is located on the 1.7-million-acre White Mountain Apache Reservation in eastern Arizona. PATIENTS: Approximately 10,000 members of the White Mountain Apache Tribe reside on or near the reservation and receive health care through the Whiteriver Indian Health Service Hospital. OUTCOME MEASURES: The average annual incidence rates of invasive pneumococcal disease were calculated and clinical characteristics were reviewed. RESULTS: One hundred thirty-eight cases of invasive pneumococcal disease were identified. The average annual incidence rate was 207 per 100,000 population, and 156 per 100,000 population when adjusted for age by direct standardization to the 1988 US population. The incidence rate was highest in children between 1 and 2 years--2396 per 100,000. The overall case-fatality rate was 5%. Pneumococcal pneumonia was the diagnosis in 79% of the patients 5 years of age or older. Alcohol abuse, identified in 66% of the cases in adults, was the most common underlying medical condition. CONCLUSION: The incidence rates in White Mountain Apaches are the highest reported for any population. A vaccine effective in children would greatly benefit this population.