Influenza vaccination saves lives. This is why increasing rates of vaccination was one of the core goals of Healthy People 2010. The latest report from the Centers for Disease Control & Prevention has heartening news regarding children and adolescents. The authors state that “The majority of Healthy People 2010 objectives for early childhood vaccination coverage were met by the end of 2010 … and remarkable progress has been made in improving coverage … for adolescent vaccinations.” In addition, racial and ethnic disparities among children and adolescents are closing thanks to programs like Vaccines for Children.
The news is less rosy for our older populations. Although rates of vaccine coverage for all persons age ≥65 have steadily increased, racial and ethnic disparities have persisted throughout the last decade. CDC estimates that about 74% of non-Hispanic whites in this age group received flu shots during the 2009-2010 season, while only 61% of Hispanics and 58% of non-Hispanic blacks were immunized (p<0.05). All groups continue to fall short of the 90% benchmark set for Healthy People 2010; this goal has been retained for 2020.
FIGURE: Influenza vaccination coverage for adults aged ≥65 years, by race/ethnicity – Behavioral Risk Factor Surveillance Survey (BRFSS), United States, 2000-2010
It might seem intuitive to chalk these differences up to disparities in education or health care access; we know that ethnic and racial minorities fall behind in both. The truth, however, is never quite so easy. A 2003 Morbidity and Mortality Weekly Report (MMWR) report on racial and ethinc disparities in adult vaccination had this startling result:
After accounting for variations in sex, age, education, poverty status, region, insurance status, number of doctor visits, and high-risk conditions, non-Hispanic blacks remained significantly less likely than non-Hispanic whites to report influenza vaccination (odds ratio [OR] = 0.7; 95% CI = 0.6-0.8).
Incredibly, even when all socioeconomic factors and number of health care encounters were controlled for, blacks still only received influenza vaccinations at a rate of 70% that of whites. What’s going on?
A November 2007 qualitative study published in the Journal of Family Practice interviewed focus groups of elderly African-Americans to assess roadblocks to their vaccination coverage. Participants largely thought flu shots were for children and did not know that elderly people were a target group. Many of them knew people who had gotten sick after getting a flu shot; still others worried it would interact with their medications. They also voiced safety concerns regarding tainted vaccines or allergic reactions. Although participants did voice a general mistrust of the health care system, most of them said that their doctors were the most important source of information about the flu vaccine, implying that open communication in a trusting doctor-patient relationship can overcome many of these barriers.
The same study also conducted focus groups with providers. While almost painfully aware of the popular misconception that “flu shots give you the flu,” most providers did not even consider concerns about medication interaction or allergic reactions. They were also likely to underestimate their influence with this population, instead believing that their elderly black patients would mostly trust family members.
This small, qualitative study gives us some important clues when we begin looking for evidence-based interventions to close the race gap in flu vaccination. Standing orders will ensure that doctors never forget to open the conversation with their patients about the vaccine. Registries, such as in the Patient-Centered Medical Home model, will allow practices to identify and target unvaccinated adults in their patient panels. Public financing of recommended adult vaccines would eliminate the cost barrier for all patients. Achieving the 90% target across all ethnic groups would save thousands of lives each year.