D.ompad

Urbancity and urbanization: Challenges

for adult access to vaccines

Danielle C. Ompad

New York University

Overview

• Trends in urbanicity and urbanization

• Distribution of vaccines to adults

– Strategies

– Challenges

Urbanicity and urbanization

• Urbanicity

• The extent to which a particular area is urban at any given

point in time, e.g., proportion of persons living in cities

• Urbanization

• The change in the extent to which a particular area is urban

over time; a dynamic process

Vlahov D, Galea S. J Urban Health 2002

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Percentage of Population Residing in Urban Areas Globally, 1950-2050

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Percentage of Population Residing in Urban Areas by Level of Development, 1950-2050

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Proportion urban and rural in less developed regions, 1950-2050

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Average Annual Rate of Change of the Urban Population by Major Area, 1950-2050



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Urban Population by Major Area, 1950-2050



Number of cities by population size and level of

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1980 2000 2010 2025

Why urban health?

• Growing importance of cities worldwide

– In 2007, reached global milestone of 50% of world’s population living

in cities

• Public health research and practice is placing more

emphasis on “context”

• Urban growth is concentrated in less developed countries

– Growth may outstrip infrastructure in some countries

Cities and TB

• Risk of transmission is higher

– Number of contacts

– Duration of infectiousness

• Lack of basic health services in many slums

• Rural patients may be attracted to cities because of better

access to health services

• TB centers may be overburdened

Trébucq, Int J Tuberc Lund Dis 2007

DISTRIBUTION OF VACCINES

TO ADULTS

Distribution of influenza vaccine to high-risk groups

• A variety of settings and approaches have been used

• Certain program features are more than others

• We reviewed interventions aims at increasing vaccination

among individuals at high risk for influenza complications in

five settings:

– Hospital/tertiary care

– Primary-care

– Venue-based targeted delivery (e.g., nursing homes)

– Large-scale regional programs

– Community-based distribution programs

Ompad D et al. Epidemiol Rev 2006

Hospital/tertiary care settings

• Nichol, 1998 – 500 elderly and high-risk Veterans’ hospital patients/Yr in

Minneapolis, MN

– Prospective evaluation of standing orders, standardized forms, and patient mailings

– Rates significantly increased for all inpatient respondents from 79% in 1990-91 to 86% in 1996-97 (p≤0.001)

• Dexter et al., 2001 – 6371 hospitalized patients in an urban hospital in Indianapolis, IN

– RCT: Computerized reminder vs. computerized standing order

– Vaccine was administered to 42% in standing order group and 30% in reminder group (p≤0.001)


Primary care settings

• Nichol et al., 1990 – 1375 high-risk outpatients in Veterans’ hospitals in Minneapolis, MN

– Cross-sectional with controls: Nurse vaccinated without physicians’ order, and completed chart-based reminders and mailings

– Vaccination coverage in intervention hospital was 58% vs. 28% - 31% in controls. For each high-risk subgroup (age ≥ 65, lung or heart disease, diabetes, other), coverage was better in intervention hospital versus controls (p≤0.001)

• Spaulding & Kugler, 1991 – 1068 high-risk outpatients (excluding patients aged ≥ 65 without other

risk factors) in military hospital family practice department in Fort Lewis, WA

– RCT: Vaccination mailings

– 25% of intervention group received influenza vaccine compared to 9% of control group. Group with higher military rank (proxy for SES) was more likely to be vaccinated


Primary care settings II

• Herman et al, 1994 – 1202 patients aged ≥ 65 in elderly ambulatory medical clinic in

Cleveland, OH

– RCT--Staff and patient education and flowsheet / standing order

– Influenza coverage was 42% in the control group, 45% in group that received education only and 55% in group that received education and flowsheet / standing order (p<0.001)

• Gaglani et al., 2001 – 925 asthma or reactive airway disease patients aged ≥ 6 months

to <19 years in health care delivery system with ~160000 enrollees in Temple, TX

– Pre/post computerized mailing and autodial telephone message

– Overall, vaccination rate went from 5% to 32% (p<0.001). Autodial resulted in vaccination of 15% of those contacted.


Venue-based targeted delivery

• Krieger et al, 2000 – 1246 individuals aged ≥ 65 residing in five contiguous zip codes served

by senior center in Seattle, WA

– RCT: Mailings, telephone calls to unvaccinated by senior volunteers and computerized vaccination tracking

– Among unvaccinated in previous year, 50% in intervention group were vaccinated vs. 23.0% in control group. Overall vaccination rate was 82%

• Stancliff et al., 2000 – 199 Injection drug users at a syringe exchange program (SEP) in New

York, NY

– Cross-sectional, no comparison group. Vaccine made available at SEPs during a one month period

– 181 people eligible for vaccine, of whom 86% accepted. Of 48 people reporting chronic medical condition, 87% accepted vaccination


Large-scale regional programs

• Bennett et al,, 1994 – 88811 Medicare enrollees aged ≥ 65 in Monroe County, NY

– 2 RCTs (3 years) of expanding program to other settings, physician tracking poster and physician financial incentives

– Influenza vaccination coverage increased from 41% in 1989 to 74% in 1991. Poster program physicians vaccinated 66% of patients compared to 50% among controls. Physicians receiving financial incentives vaccinated 73% of their patients compared to 56% of controls (p<0.001)

• Honkanen et al., 1997 – 41500 persons aged ≥ 65 in Northern Finland Elderly Regional public

health program

– Controlled trial: Free vaccine with and without mailing targeting by age or disease

– Age-based program with personal reminders had the highest vaccination rate (82%) compared to age-based program without reminders (50-56%) and disease-based program (19-22%)


Large-scale regional programs II • Barker et al., 1999

– 85000 Medicare enrollees in Monroe County and 58,000 in Onondaga County, NY

– Program evaluation of multi-media public service announcements, targeting to minority communities, mailings, and physician monitoring of vaccination coverage

– Vaccination rates increased from 41% in year 1 to 60% and 74% in years 2 and 3, respectively. Modest increase in vaccination rates observed in Onondaga County (46% to 57%)

• Steyer et al., 2004 – Adults aged ≥ 65 participating in BRFSS in 16 U.S. states

– Cross-sectional with comparison group: Pharmacist vaccinating

– 1995 – 1999: Vaccine coverage increased from 58% to 68% in states where pharmacists could administer vaccine and from 61% to 65% in states where they could not. Difference between years and states in 1999 was significant.


Community-based distribution programs

• Hanna et al., 2001

– I7345 indigenous adults in Queensland, Australia who received first dose of influenza

– Retrospective: Indigenous public health officers recruited for program promotion and development of materials. Key stakeholders involved in early planning and promotion

– Greater uptake of pneumococcal vaccine during first two years may reflect effectiveness of client pamphlet. When more balanced materials and emphasis was used, influenza uptake increased

• Zimmerman et al., 2003

– Elderly Inner-city adults aged ≥ 50 at Faith-based neighborhood health centers in Pittsburgh, PA

– Comparison of community selected interventions. Both centers: Free/ low-cost vaccines for indigent, exam room posters, staff education, chart reminders, standing orders. Center A: Mailings. Center B: Off-site vaccination clinics and community advertisement

– Vaccination coverage in Center A increased from 24 to 30% among adults aged 50 - 64 and 45 to 53% among adults aged ≥ 65 (p<0.001)


Community-based distribution programs II • Weatheril et al., 2004

– Community residents (estimated population of 16,000) in 10 square block area of Vancouver, Canada

– Program evaluation: Vaccination offered in non-traditional settings (e.g., streets, alleys, single room occupancy hotels, etc.)

– Influenza vaccines distributed to 8043 people in 1999, 3718 in 2000, 5175 in 2001 and 4131 in 2002

• Zimmerman et al., 2004 – 1534 children aged <2 in urban health in Pittsburgh, PA

– Pre/post tests: Site-selected interventions from strategies proven to increase vaccination rates

– Vaccination coverage increased from 7% to 39% for the first dose and 2% to 13% for the second dose compared to pre-intervention (p<0.001)


Findings

• Most interventions focused on the elderly, fewer on adults with high-risk conditions and fewer still on children

• Vaccination was largely examined within the context of primary care settings or large-scale regional programs

• One major limitation: unable to reach those not engaged in the health care system, specifically hard-to-reach populations (homeless, substance users, elderly shut-ins and undocumented immigrants)

• Very few interventions included active community engagement or were targeted to specific communities


Conclusions

• Most programs target populations that already had high rates of vaccination

• Few studies have targeted individuals outside of the health care and social service sectors

• Most interventions were not community based but relied instead on programs that were professionally directed and administered


Challenges in adult access to vaccines

The Main Problem, and a potential solution

• Generally have to go through the health care system to

get an annual influenza vaccination

– For some people, this can be challenging

• If we expand vaccine availability to non-traditional venues,

we can vaccinate more people

Reasons for lack of interest in receiving

flu vaccine

0

5

10

15

20

25

Vaccine unsafe Don't like

injections

Medical reason Not at high risk Already

vaccinated

Perc

en

t

n (%)

Ever had flu vaccine 468 (61.6)

If ever, flu vaccine in past year 240 (51.4)

Never had flu vaccine 292 (38.4)

If never, interested in getting flu shot 576 (79.6)

Summary

• People who are unconnected to health/ social services or

government health insurance are less likely to have been

vaccinated in the past

• BUT, if flu vaccine were available, they would be willing to

receive it

NYAM

• Trained the Outreach Workers in Research Methods

HCAP

VIWG

• Consulted on the planning

PALLADIA

• Outreach Staff

• Vaccination Site Host

VNSNY • Provided

nurses

NYC DOHMH

• Provided Vaccines

The Partnership

Outreach efforts

Community Organization Level

• Community Mobilization

• Outreach-based Education

Neighborhood Level

• Street Interception-Outreach Education

• Surveys

• Recruitment for Vaccination Sites

Community outreach efforts

Vaccine Distribution in Year 1, VIVA 1

Vaccine Neighborhood Addresses

approached

Opened

doors

Vaccine

distributed

Flu

BRONX 6 843 384 (46%) 191 (50%)

E. HARLEM 3 922

513 (56%)

191 (37%)

Pneumovax

BRONX 8 1375

512 (37%)

84 (16%)

BRONX 5 1486

678 (46%)

100 (15%)

TOTAL 4626 2087 (45%) 566 (27%)

Danielle C. Ompad, PhD

[email protected]

Thank you!

Health & Medicine

D.ompad