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Archived
June, 2007


Highlights in Minority Health
& Health Disparities
August, 2006
 

  National Immunization Awareness Month August 2006. Are you up to date? Vaccinate!  
AUGUST IS NATIONAL IMMUNIZATION AWARENESS MONTH
Each year, National Immunization Awareness Month (NIAM) increases awareness about immunization across the lifespan as parents and children prepare for the return to school, and the medical community begins preparations for the upcoming flu season. Immunization has been cited as one of the top ten public health achievements of the 20th century. Yet the burden of vaccine-preventable diseases in adults in the U.S. is staggering – more than 40,000 adults die each year from vaccine-preventable diseases.1
Each year approximately 200,000 people in the United States are hospitalized because of influenza; an average of 36,000 people die annually due to influenza and its complications– most are people 65 years of age and over. Annually there are approximately 40,000 cases of invasive pneumococcal disease in the United States and one-third of these cases occur in people 65 and older. About half of the 5,000 annual deaths from invasive pneumococcal disease occur in the elderly.1
Influenza vaccine coverage rates were up from 31% in 1989 to 65% in 2004, and pneumococcal vaccine coverage rates were up from 14% to 57%. Despite these increases, adult vaccination coverage rates for certain racial and ethnic groups remain substantially below the general population. On the national level, vaccination coverage among U.S. preschool children is at or near record high levels. This successful achievement of the past decade has largely reduced the marked racial and ethnic disparities in vaccination coverage rates among children that existed during the late 1980s and early 1990s. While data shows disparities have been greatly reduced when examining childhood coverage rates for individual vaccines, there is rising concern about data indicating that in recent years racial and ethnic disparities for series complete childhood vaccination coverage has been increasing.

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EXAMPLES OF IMPORTANT DISPARITIES
Blacks or African Americans
African Americans have significantly lower influenza and pneumococal immunization rates compared to the rest of the population.  For adults aged 65 years and over, the percent of persons receiving a flu shot during the past 12 months was 68.7% for non-Hispanic white persons and 48% for non-Hispanic black persons.
The gap for pneumococcal vaccination coverage is even wider.  Historically, blacks in the United States have had a higher incidence of invasive pneumococcal disease than whites, with the widest disparities occurring among children in the first years of life and among adults 18 to 64 years old.  Among children, before vaccine introduced in 2000, incidence among blacks was 2.9 times higher than among whites; by 2002, the black-white rate ratio was reduced to 2.2.  The percent of adults aged 65 years and over who had ever received a pneumococcal vaccination was 59.6% for non-Hispanic white persons, and 36.9% for non-Hispanic black persons.
Although disparities in childhood immunization coverage have been greatly reduced for most vaccines that children age 19-35 months routinely receive, disparities for full series immunization coverage (4:3:1:3:3 series completion)* have not been eliminated.  From 1996-2001, among the immunization coverage gap between non-Hispanic white children and non-Hispanic black children widened by an average of 1.1% each year.  The growing disparity is due to failure of series completion rates among African Americans to increase substantially during the period 1996 to 2002 (66.8% to 67.7%), while series completion rates among whites increased (68.9% to 77.7%) during this same period.2  In a follow-up study, vaccination coverage from 1998-2003, the differences between the full series vaccination coverage of white and African American children within income groups for each U.S. census region were examined.  The study found that disparities exist in at least three of the four regions specifically the Northeast, South and Midwest regions.  Widening national level disparity in full series immunization coverage appears to be primarily attributable to trends observed among African American households at or above the federal poverty level in the Northeast census region.  Although the disparity trend in the Midwest was narrowing disparities in that regions persist.  There was little change in disparities in the South.3

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Hispanics or Latinos
In 2003, Hispanic/Latino persons were less likely than non-Hispanic white persons to have received a flu shot during the past 12 months or to have ever received a pneumococcal vaccination.  For adults aged 65 years and over, the percent of persons receiving a flu shot during the past 12 months was 45.4% for Hispanic/Latino persons and 68.7% for non-Hispanic white persons. The percent of adults aged 65 years and over who had ever received a pneumococcal vaccination was 31.0% for Hispanic/Latino persons and 59.6% for non-Hispanic white persons.
Disparities in childhood immunization coverage for Hispanics, just as for African Americans, have been greatly reduced for most vaccines that children routinely receive. Disparities in the full immunization series (4:3:1:3:3 completion)* have not been eliminated.  From 1996-2001 the difference in series vaccination coverage rates between non-Hispanic whites and Hispanics widened by an average 0.5%.  During this period vaccination coverage rates for white children 19-35 months of age increased from 68.9% to 77.7% while Hispanic vaccination coverage rates only increased from 63.7% to 72.2%.
Hepatitis A is a vaccine-preventable disease that is transmitted when fecal material is ingested.  Uncooked foods or water supply contamination are the primary reasons for more widespread occurrences. Person-to person transmission is more common and occurs frequently among close contacts, or in extended family settings.  During the pre-vaccine era, the reported incidence of hepatitis A was highest among children aged 5-14 years with rates among Hispanics approximately three times higher than rates among non-Hispanics.  A childhood immunization strategy has been implemented incrementally.  Initially vaccination recommendations focused on particular high risk groups and specific U.S. areas, the west and southwest where there were high disease rates.  Although vaccination implementation strategies greatly improved disease prevention, in 2004, states without widespread hepatitis A vaccination of children had a disease rate was seven times higher among Hispanic children and four times higher among the entire Hispanic population.  In 2006 recommendations for this vaccine were expanded to include all children aged 12-23 months.  The recommendation was expanded because the highest rates of disease were occurring among children in parts of the country where vaccination had not been recommended.   This recent update is considered a final step in an incremental strategy to address routine hepatitis A vaccination of children nationwide.4

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Asian Americans or Pacific Islanders
Although relatively rare in the United States, hepatitis B is endemic in parts of Asia where hundreds of millions of individuals may be infected. HBV is transmitted horizontally by blood and blood products and sexual transmission. It is also transmitted vertically from mother to infant in the Perinatal period which is a major mode of transmission in regions where hepatitis B is endemic.
Immunization with hepatitis B vaccine is the most effective means of preventing hepatitis B virus infection and its consequences. However, while the rate of acute Hepatitis B (HBV) among Asian Americans and Pacific Islanders (AAPIs) has been decreasing, the reported rate in 2001 was more than twice as high among AAPIs (2.95 per 100,000 population) as among white Americans (1.31 per 100,000 population).

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American Indians or Alaska Natives

In FY2005, the vaccination coverage rate for AI/ANs age 65 or older was 59% for influenza vaccination and 69% for pneumococcal vaccination in Indian Health Service (IHS) healthcare facilities.5   This compares to 65.5% of all Americans aged 65 or older who received an influenza vaccination in 2003, and 55.6% of all Americans aged 65 or older who had ever received a pneumococcal vaccination.6

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ADDRESSING DISPARITIES - WHAT WORKS - EVIDENCE-BASED STRATEGIES
The Guide to Community Preventive Services (Community Guide) serves as a premier source of high quality information on those public health interventions and policies proven to work in promoting health and preventing disease, injury, and impairment.   The Community Guide review of  vaccine-preventable disease studies consistently show that focusing efforts to improve coverage on health care providers, as well as health care systems, is the most effective means of raising vaccine coverage in adults. For example, all health care providers should assess routinely the vaccination status of their patients. Likewise, health plans should develop mechanisms for assessing the vaccination status of their participants.  Also, nursing home facilities and hospitals should ensure that policies exist to promote vaccination.4
For children living in poverty, childhood vaccination efforts need to be strengthened. Substantial numbers of under-vaccinated children remain in some areas, particularly the large urban areas with traditionally underserved populations, creating great concern because of the potential for outbreaks of disease. Reasons for racial disparities in coverage rates for the full vaccination series among pre-school aged children are incompletely understood. Further studies are planned to develop an understanding of the underlying causes of these disparities so that effective strategies to reduce the disparities can be developed.

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FEDERAL PROGRAMS THAT ADDRESS RACIAL/ETHNIC DISPARITIES IN IMMUNIZATION
CDC’s National Immunization Program (NIP) strives to prevent disease, disability, and death in children and adults through vaccination.  NIP is committed to promoting immunization at every stage of life, providing leadership on vaccines and immunization, strengthening and communicating immunization science, establishing partnerships and fostering collaboration, providing immunization education and information, and improving health in the United States and globally. NIP supports the following programs:
  Racial and Ethnic Adult Disparities Immunization Initiative (READII)
  The Department of Health and Human Services (HHS) has made the elimination of racial and ethnic disparities in influenza and pneumococcal vaccination coverage for people 65 years of age and older a priority. To address these disparities and to assist in reaching the 2010 national health goal of 90% influenza and pneumococcal vaccination rates among persons 65 and over, HHS, in collaboration with the Centers for Disease Control and Prevention (CDC) and other federal partners, launched the Racial and Ethnic Adult Disparities in Immunization Initiative (READII) in July 2002. READII was a two-year demonstration project conducted in five sites (Chicago, IL; Rochester, NY; San Antonio, TX; Milwaukee, WI; and 19 counties in the Mississippi Delta region) to improve influenza and pneumococcal vaccination rates for African-Americans and Hispanics 65 years of age and older. CDC implemented the READII project with the support of the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, the Administration on Aging, the Agency for Healthcare Research and Quality, and other federal agencies.
  Vaccines for Children (VFC)
  Since 1994, the Vaccines for Children (VFC) program has allowed eligible children to receive vaccinations as part of routine care, supporting the reintegration of vaccination and primary care.  Based on the total doses of routinely recommended pediatric vaccines distributed in the U.S., the VFC program served about 40% of the childhood population in 2004.  The VFC program provides publicly purchased vaccines for use by all participating providers.  These vaccines are given to eligible children without cost to the provider or the parent.  The VFC program provides immunizations for children who are uninsured, Medicaid recipients, Native Americans, or Alaska Natives at their doctors' offices. VFC also provides immunizations for children whose insurance does not cover immunizations at participating federally qualified health centers (FQHCs) and rural health clinics (RHCs).  The program has contributed to high immunization rates and reduced delays in immunizations and, subsequently, the risk of serious illness or death from vaccine-preventable diseases.
 

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  National Asian Women's Health Organization (NAWHO)
  The National Asian Woman’s Health Organization (NAWHO) is one of the largest organizations in the country working toward improved health of Asian Americans.  This cooperative agreement helps support Promoting Prevention for Healthy Communities: The National Asian American Immunization Project. Activities by grantees and sub-grantees will target  cultural subgroups in Asian-American communities in Atlanta, GA, Denver, CO, Long Beach, CA, Los Angeles, CA, San Francisco, CA, Palo Alto, CA, New York, NY, Stoneham, MA, Portland, OR and Chicago, IL.  Activities include partnership-building, community capacity-building, and educating healthcare providers and the public.
 

Specifically, NAWHO will:

1) provide cultural competence workshops to providers of Asian Americans,
2) create and distribute linguistically appropriate and culturally sensitive educational materials, and
3) work with mass media sources to develop and promote immunization campaign messages.
  Black Women's Health Imperative
  Established in 1983, the Black Women’s Health Imperative works to move health issues for Black women to the top of the agenda for legislative, policy, and the research agenda of the nation. With a membership of more than 150,000 and because Black women are the primary decision makers regarding health matters for the entire family, they are uniquely positioned to implement positive change in immunization programs targeting African American families.
 

Specifically, the Imperative will:

1) collaborate with faith based organizations such as the African American Episcopal Church, community based organizations such as Mocha Moms Inc., the National Black Nurses Association, and local and state health departments to improve immunization coverage among African Americans,
2) They will develop resources that will address the knowledge, attitudes, and beliefs of African American families toward immunization, and
3) increase capacity of providers to implement culturally sensitive strategies into their practice.

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  Migrant Clinicians Network (MCN)
  The Migrant Clinicians Network was founded in 1984 and is the oldest and second largest clinical network devoted to the care of the underserved. Together in partnership with Texas Tech University Health Science Center, they will be focusing on projects that address immunization issues specific to minority populations (primarily Hispanic) and migrant populations.
 

Specifically, MCN will:

1) Provide training and technical assistance to migrant health centers, head start schools and state and local health departments to improve immunization coverage,
2) Develop educational materials and programs utilizing the animation series called Pepin to address immunization issues such as vaccine safety, administration, and the recommended schedule, and
3) Educate providers on cultural sensitivity and the elimination of barriers to providing medical care to mobile underserved populations.
  Indian Health Service (IHS)
  IHS clinics are encouraged to provide influenza and pneumococcal vaccine during clinic visits and during mass immunization clinics in accordance with ACIP guidelines.  Educating patients is a part of the strategy to ensure influenza vaccine is provided.  The proposed FY 2005 IHS budget will support the capacity for sites to continue existing strategies and maintain current immunization coverage levels in the face of population growth.

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FOR MORE INFORMATION
immunizations CDC’s Office of Minority health (OMH)
    Eliminate Disparities in Adult and Child Immunization Rates
immunizations National Immunization Program (NIP)
  Parents Guide to Childhood Immunization
  Protect the Circle of Life: Immunize Our Nations
  Racial and Ethnic Adult Disparities Immunization Initiative (READII)
  Vaccines for Children (VFC)
immunizations National Center for Infectious Diseases (NCID)
  HBV: A Silent Killer
  Preventing Emerging Infectious Diseases: A Strategy for the 21st Century
immunizations Department of Health and Human Services (HHS)
  National Vaccine Program Office
immunizations Indian Health Service
immunizations Healthy People 2010
  Chapter 14: Immunization and Infectious Diseases
immunizations The Community Guide
  Vaccine Preventable Diseases Improving Coverage in Children, Adolescents and Adults
*Series completion is defined as up to date for the 4:3:1:3:3 series (4 or more doses of diphtheria and tetanus toxoids and [acellular] pertussis vaccine; 3 or more doses of poliovirus vaccine; 1 or more doses of measles-containing vaccine; 3 or more doses of Haemophilus influenzae type b vaccine; and 3 or more doses of hepatitis B vaccine.

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SOURCES
1. Racial and Ethnic Adult Disparities in Immunization Initiative (READII)
2. Chu et. al. Racial/Ethnic Disparities in Preschool Immunizations: United States, 1996-2001.  American Journal of Public Health June 2004, Vol 94, No. 6
3. Barker et. al.  Disparities between white and African-American children in immunization coverage.  Journal National Medical Association. 2006 Feb;98(2):130-5.
4. The Community Guide to Preventive Services
Vaccine Preventable Diseases: Improving Coverage in Children, Adolescents,and Adults
5. “Indian Health Service Twelve-Area Summary Report, GPRA 2005”, IHS Division of Epidemiology and Disease Prevention.
6. NCHS, Health US, 2005, table 76

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