Increasing equity in adult immunization through community-level action.

Inequities in availability and access to adult vaccinations represent significant gaps in the US public health infrastructure. Adults in racial and ethnic minority groups are less likely to receive routinely recommended vaccinations due to systemic barriers, distribution inequities, and lack of trust in vaccines; similar disparities were seen during early COVID-19 vaccination efforts. However, a deliberate focus on reducing disparities can yield progress. National data show narrowing of racial and ethnic adult COVID-19 vaccination coverage disparities over time, highlighting the value of the equity-focused, community-level interventions implemented during the pandemic. This paper describes the Centers for Disease Control and Prevention's efforts during the COVID-19 pandemic to address racial and ethnic disparities in adult immunization, and how lessons learned may be applied post-pandemic. Progress made is likely to be lost without sustained support for adult vaccination at national, state, and community levels.

Successful Use of Interventions in Combination to Improve Human Papillomavirus Vaccination Coverage Rates Among Adolescents-Chicago, 2013 to 2015.

In 2013, National Immunization Survey-Teen data indicated that >40% of female adolescents had not initiated the human papillomavirus (HPV) vaccine series and >60% had not completed the series, documenting vaccination rates much lower than those for other vaccines recommended for adolescents. The Chicago Department of Public Health (CDPH) was 1 of 22 jurisdictions nationwide to receive a Prevention and Public Health Fund award through the Centers for Disease Control and Prevention to improve HPV vaccination rates among adolescents. The CDPH implemented 5 interventions targeting the public, clinicians and their staff, and diverse immunization and cancer prevention stakeholders. Compared with 2013 jurisdiction-specific HPV vaccination rates among all adolescents, Chicago's HPV vaccination rates were increased significantly in 2014 and 2015. This article details the methods and results of Chicago's successful interventions, the particular strengths as well as barriers encountered, and future steps necessary for sustaining improvement.

Chicago Ebola Response Network (CERN): A Citywide Cross-hospital Collaborative for Infectious Disease Preparedness.

The 2014-2015 Ebola virus disease (EVD) epidemic and international public health emergency has been referred to as a "black swan" event, or an event that is unlikely, hard to predict, and highly impactful once it occurs. The Chicago Ebola Response Network (CERN) was formed in response to EVD and is capable of receiving and managing new cases of EVD, while also laying the foundation for a public health network that can anticipate, manage, and prevent the next black swan public health event. By sharing expertise, risk, and resources among 4 major academic centers, Chicago created a sustainable network to respond to the latest in a series of public health emergencies. In this respect, CERN is a roadmap for how a region can prepare to respond to public health emergencies, thereby preventing negative impacts through planning and implementation.

Leveraging community concerns regarding meningococcal disease to address racial and socioeconomic disparities in immunization coverage.

Following the death of 2 adolescents due to serogroup C invasive meningococcal disease (SCIMD) in April 2008, the Chicago Department of Public Health (CDPH) observed a high level of concern in 2 Chicago communities inferred to have low meningococcal vaccine (MCV) coverage rates. In response, CDPH promptly mobilized additional resources, administering 5,343 doses of MCV in 40 schools over 2 weeks and immunizing 44% of enrolled students aged 11 to 18 years. The number of eligible students vaccinated per school ranged from 9 to 466 (median, 112) and the proportion of age-eligible students receiving the vaccine ranged from 5% to 87% (median, 52%). The attributes of the SCIMD activity did not meet the definition of a community-based outbreak, but presented an opportunity to promptly intensify existing mechanisms for meningococcal vaccination of adolescents in the affected neighborhoods and overcome traditional barriers to vaccination.

Influenza-like illness in a community surrounding a school-based outbreak of 2009 pandemic influenza A (H1N1) virus-Chicago, Illinois, 2009.

In April 2009, following the first school closure due to 2009 pandemic influenza A (H1N1) (pH1N1) in Chicago, Illinois, area hospitals were inundated with patients presenting with influenza-like illness (ILI). The extent of disease spread into the surrounding community was unclear. We performed a household survey to estimate the ILI attack rate among community residents and compared reported ILI with confirmed pH1N1 cases and ILI surveillance data (ie, hospital ILI visits, influenza testing, and school absenteeism). The estimated ILI attack rate was 4.6% (95% confidence interval, 2.8%-7.4%), with cases distributed throughout the 5-week study period. In contrast, 36 (84%) of 43 confirmed pH1N1 cases were identified the week of the school closure. Trends in surveillance data peaked during the same week and rapidly decreased to near baseline. Public awareness and health care practices impact standard ILI surveillance data. Community-based surveys are a valuable tool to help assess the burden of ILI in a community.

Outbreak of antiviral drug-resistant influenza a in long-term care facility, Illinois, USA, 2008.

An outbreak of oseltamivir-resistant influenza A (H1N1) occurred in a long-term care facility. Eight (47%) of 17 and 1 (6%) of 16 residents in 2 wards had oseltamivir-resistant influenza A virus (H1N1) infections. Initial outbreak response included treatment and prophylaxis with oseltamivir. The outbreak abated, likely because of infection control measures.

Effect of a school-entry vaccination requirement on racial and ethnic disparities in hepatitis B immunization coverage levels among public school students.

OBJECTIVE: We evaluated the overall effect of Illinois' school-entry mandate on hepatitis B vaccination coverage levels and racial/ethnic differences in vaccination coverage before and after the mandate. METHODS: In 1997, the Illinois Department of Public Health mandated hepatitis B vaccination before entry into 5th grade. We conducted a retrospective cohort study of 6 consecutive Chicago public schools' 12th-grade classes; 4 entered 5th grade before the mandate (premandate cohorts) and 2 afterward (postmandate cohorts). We used Chicago public schools' vaccination database and calculated annual coverage levels for 2nd through 12th grades; the cohorts entered 12th grade during 2000-2005. We compared hepatitis B vaccination coverage levels according to race/ethnicity and coverage levels for the premandate and postmandate cohorts. RESULTS: We evaluated 106 541 students. The postmandate cohort had significantly higher hepatitis B vaccination coverage levels than the premandate cohort at 5th-grade (38.2% vs 4.3%) and 9th-grade (85.0% vs 37.4%) entry. For 9th-grade students, compared with white students, black students were less likely to have received hepatitis B vaccination before the mandate; this disparity decreased for the first postmandate cohort. For Hispanic students, the disparity was less pronounced and also decreased after the mandate. By 9th grade in the postmandate cohorts, coverage levels for all racial/ethnic groups exceeded 80%. CONCLUSIONS: There was a dramatic decrease in the disparity of hepatitis B vaccination coverage between white and black or Hispanic students. School-entry requirements effectively increased hepatitis B vaccination coverage levels regardless of race or ethnicity and should be considered for other recently recommended adolescent vaccines.

Addressing racial and ethnic disparities in adult immunization, Chicago.

In 2002, Chicago was selected as one of five demonstration sites for the Racial and Ethnic Adult Disparities in Immunization Initiative (READII). READII was a multiyear demonstration project focused on identifying effective methods to increase influenza and pneumococcal vaccination rates among African American and Hispanic senior citizens (> or =65 years of age).

Measles immunization coverage determined by serology and immunization record from children in two Chicago communities.

OBJECTIVES: We compared the prevalence of measles immunization determined by serology with the prevalence of measles immunization determined by immunization records, and identified factors predictive of measles immunization among a sample of children from two Chicago communities. METHODS: We collected demographic information and blood specimens from a sample of children aged 12-71 months in two Chicago communities at risk for low measles immunization coverage levels. We collected immunization information from provider records, parent-held records, and the statewide immunization registry. We compared evidence of immunization determined by serology with evidence of immunization from these three sources of immunization records. RESULTS: The sample of children from the two communities had serologic measles immunity levels of 85% and 90%. Significantly fewer children had evidence of immunization by record in both communities (45% and 63%, respectively). CONCLUSIONS: Immunization coverage levels determined using immunization records were significantly lower than immunization coverage determined using serology. A fully populated immunization registry used by all immunization providers could prevent the problems of record loss and scatter.

Use of public school immunization data to determine community-level immunization coverage.

OBJECTIVES: To evaluate whether immunization data collected on a child's entry into kindergarten, i.e., Chicago Public School Immunization Data (PSID), was comparable to coverage levels determined by the National Immunization Survey (NIS) and to use these data to identify community areas with consistently low immunization coverage. METHODS: The Chicago Department of Public Health obtained four years of PSID (2000-2003); these data included demographic information, home address, and immunization records. Coverage levels were determined in two ways: (1) one dose of measles-containing vaccine (MCV) and (2) four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, and one dose of measles-containing vaccine (the 4:3:1 series), stratified by racial/ethnic group; these levels were compared to NIS estimates for the respective time periods. We used geographic information system software to illustrate variations in coverage levels between distinct community areas within Chicago. RESULTS: Year 2000 MCV coverage levels determined from PSID closely approximated NIS estimates (84.6% vs. 87.2% +/- 4.6%, respectively). MCV coverage levels determined by race/ethnicity from PSID were within the 95% confidence intervals (CI) for all racial categories (white, 89.5% vs. 92.2% +/- 6.4%; black, 79.0% vs. 83.5% +/- 9.4%; Hispanic, 89.5% vs. 87.5% +/- 5.8%). Comparison of PSID and NIS 4:3:1 coverage levels revealed similar findings. For each study year, PSID identified 12 community areas with consistently low MCV coverage levels, i.e., < 80%. CONCLUSIONS: PSID closely approximated NIS coverage estimates for MCV and 4:3:1 immunization. These methods can be used by state and city health departments to identify and direct resources to communities at greatest need.

African-American children are at risk of a measles outbreak in an inner-city community of Chicago, 2000.

BACKGROUND: Since the measles resurgence of 1989-1991, which affected predominantly inner-city preschoolers, national vaccination rates have risen to record-high levels, but rates among inner-city, preschool-aged, African-American children lag behind national rates. The threat of measles importations from abroad exists and may be particularly important in large U.S. cities. To stop epidemic transmission, measles vaccination coverage should be at least 80%. OBJECTIVE: To determine measles vaccination rates and predictors for having received a dose of measles-containing vaccine by age 19 to 35 months among children in an inner-city community of Chicago. METHODS: We used a cross-sectional survey with probability proportional to size cluster sampling. Immunization histories from parent-held records and providers were combined to establish a complete vaccination history. RESULTS: A total of 2545 households were contacted, and 170 included a resident child aged 12 to 35 months. Of these, 97% (N=165 children) agreed to participate. Immunization history from a parent or provider was not available for 20 children. Among children aged 19 to 35 months with available immunization histories, 74% received measles vaccine (n=100); of these, 84% received the vaccine as recommended at ages 12 to 15 months. However, when including children without immunization histories, measles coverage levels among children aged 19 to 35 months were 64% (n=114). Among children with records, predictors for receipt of measles vaccine by age 19 to 35 months were possessing a hand-held immunization card (odds ratio [OR]=16.8; 95% confidence interval [CI]=4.2-67.1); utilizing a public health department provider for a usual source of care (OR=8.9; 95% CI=1.6-47.2); and being up-to-date for vaccines at 3 months of age (OR=5.0; 95% CI=1.8-14.1). CONCLUSIONS: Optimistically assuming that children without immunization histories are as well immunized as children with immunization histories, the measles vaccination rate among Englewood's children aged 19 to 35 months is too low to maintain immunity (74%). Measles coverage levels lagged behind coverage reported in a national survey in Chicago (86%) and the nation as a whole (92%). Efforts to raise and sustain coverage should be undertaken.