American Journal of Preventive Medicine
Volume 47, Issue 6, p689-852, e11-e14 December 2014
http://www.ajpmonline.org/current

Adult Vaccination Disparities Among Foreign-Born Populations in the U.S., 2012
Peng-jun Lu, MD, PhD, Alfonso Rodriguez-Lainz, PhD, DVM, MPVM, Alissa O’Halloran, MSPH, Stacie Greby, DVM, Walter W. Williams, MD, MPH
Published Online: October 06, 2014
DOI: http://dx.doi.org/10.1016/j.amepre.2014.08.009
Abstract
Background
Foreign-born persons are considered at higher risk of undervaccination and exposure to many vaccine-preventable diseases. Information on vaccination coverage among foreign-born populations is limited.
Purpose
To assess adult vaccination coverage disparities among foreign-born populations in the U.S.
Methods
Data from the 2012 National Health Interview Survey were analyzed in 2013. For non-influenza vaccines, the weighted proportion vaccinated was calculated. For influenza vaccination, Kaplan–Meier survival analysis was used to assess coverage among individuals interviewed during September 2011–June 2012 and vaccinated in August 2011–May 2012.
Results
Overall, unadjusted vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents: influenza, age ≥18 years (40.4% vs 33.8%); pneumococcal polysaccharide vaccine (PPV), 18–64 years with high-risk conditions (20.8% vs 13.7%); PPV, ≥65 years (62.6% vs 40.5%); tetanus vaccination, ≥18 years (65.0% vs 50.6%); tetanus, diphtheria, and acellular pertussis (Tdap), ≥18 years (15.5% vs 9.3%); hepatitis B, 18–49 years (37.2% vs 28.4%); shingles, ≥60 years (21.3% vs 12.0%); and human papilloma virus (HPV), women 18–26 years (38.7% vs 14.7%). Among the foreign born, vaccination coverage was generally lower for non-U.S. citizens, recent immigrants, and those interviewed in a language other than English. Foreign-born individuals were less likely than U.S.-born people to be vaccinated for pneumococcal (≥65 years), tetanus, Tdap, and HPV (women) after adjusting for confounders.
Conclusions
Vaccination coverage is lower among foreign-born adults than those born in the U.S. It is important to consider foreign birth and immigration status when assessing vaccination disparities and planning interventions.

Effect of Decision Support on Missed Opportunities for Human Papillomavirus Vaccination
Stephanie L. Mayne, MHS, Nathalie E. duRivage, MPH, Kristen A. Feemster, MD, MPH, MSHP, A. Russell Localio, PhD, Robert W. Grundmeier, MD, Alexander G. Fiks, MD, MSCE
DOI: http://dx.doi.org/10.1016/j.amepre.2014.08.010
Abstract
Background
Missed opportunities for human papilloma virus (HPV) vaccination are common, presenting a barrier to achieving widespread vaccine coverage and preventing infection.
Purpose
To compare the impact of clinician- versus family-focused decision support, none, or both on captured opportunities for HPV vaccination.
Design
Twelve-month cluster randomized controlled trial conducted in 2010–2011.
Setting/participants
Adolescent girls aged 11–17 years due for HPV Dose 1, 2, or 3 receiving care at primary care practices.
Intervention
Twenty-two primary care practices were cluster randomized to receive a three-part clinician-focused intervention (educational sessions, electronic health record–based alerts, and performance feedback) or none. Within each practice, girls were randomized at the patient level to receive family-focused, automated, educational phone calls or none. Randomization resulted in four groups: clinician-focused, family-focused, combined, or no intervention.
Main outcome measures
Standardized proportions of captured opportunities (due vaccine received at clinician visit) were calculated among girls in each study arm. Analyses were conducted in 2013.
Results
Among 17,016 adolescent girls and their 32,472 visits (14,247 preventive, 18,225 acute), more HPV opportunities were captured at preventive than acute visits (36% vs 4%, p<0.001). At preventive visits, the clinician intervention increased captured opportunities by 9 percentage points for HPV-1 and 6 percentage points for HPV-3 (p≤0.01), but not HPV-2. At acute visits, the clinician and combined interventions significantly improved captured opportunities for all three doses (p≤0.01). The family intervention was similar to none. Results differed by practice setting; at preventive visits, the clinician intervention was more effective for HPV-1 in suburban than urban settings, whereas at acute visits, the clinician intervention was more effective for all doses at urban practices.
Conclusions
Clinician-focused decision support is a more effective strategy than family-focused to prevent missed HPV vaccination opportunities. Given the persistence of missed opportunities even in intervention groups, complementary strategies are needed. This study is registered at clinicaltrials.gov NCT01159093.