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....
Percentage of Population Residing in Urban
Areas Globally, 1950-2050
80.0
70.0
60.0

Percent

50.0
40.0
30.0
20.0
10.0
—

...
Percentage of Population Residing in Urban
Areas by Level of Development, 1950-2050
100.0
90.0

80.0
70.0
Percent

60.0
50...
Proportion urban and rural in less developed
regions, 1950-2050
100.0
90.0
80.0

Percent

70.0
60.0

50.0
Urban

40.0

Rur...
Average Annual Rate of Change of the Urban
Population by Major Area, 1950-2050
4.50
4.00
3.50

More developed regions
3.00...
Urban Population by Major Area, 1950-2050
6,000,000

Population in Thousands

5,000,000

4,000,000

3,000,000
More develop...
Number of cities by population size and level of
country development, 1980-2025
700

Number of cities

600

≥10M
5-10M

50...
Why urban health?
• Growing importance of cities worldwide
– In 2007, reached global milestone of 50% of world’s populatio...
Cities and TB
• Risk of transmission is higher
– Number of contacts
– Duration of infectiousness

• Lack of basic health s...
DISTRIBUTION OF VACCINES
TO ADULTS
Distribution of influenza vaccine to high-risk groups
• A variety of settings and approaches have been used
• Certain prog...
Hospital/tertiary care settings
• Nichol, 1998
– 500 elderly and high-risk Veterans’ hospital patients/Yr in
Minneapolis, ...
Primary care settings
• Nichol et al., 1990
– 1375 high-risk outpatients in Veterans’ hospitals in Minneapolis, MN
– Cross...
Primary care settings II
• Herman et al, 1994
– 1202 patients aged ≥ 65 in elderly ambulatory medical clinic in
Cleveland,...
Venue-based targeted delivery
• Krieger et al, 2000
– 1246 individuals aged ≥ 65 residing in five contiguous zip codes ser...
Large-scale regional programs
• Bennett et al,, 1994
– 88811 Medicare enrollees aged ≥ 65 in Monroe County, NY
– 2 RCTs (3...
Large-scale regional programs II
• Barker et al., 1999
– 85000 Medicare enrollees in Monroe County and 58,000 in
Onondaga ...
Community-based distribution programs
• Hanna et al., 2001
– I7345 indigenous adults in Queensland, Australia who received...
Community-based distribution programs II
• Weatheril et al., 2004
– Community residents (estimated population of 16,000) i...
Findings
• Most interventions focused on the elderly, fewer on adults
with high-risk conditions and fewer still on childre...
Conclusions
• Most programs target populations that already had high
rates of vaccination
• Few studies have targeted indi...
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 influenz...
Reasons for lack of interest in receiving
flu vaccine
25

Percent

20
15
10
5
0
Vaccine unsafe

Don't like
injections

Med...
Summary
• People who are unconnected to health/ social services or
government health insurance are less likely to have bee...
The Partnership
NYAM

• Trained the
Outreach
Workers in
Research
Methods

HCAP
VIWG

PALLADIA

VNSNY

NYC
DOHMH

• Provide...
Outreach efforts

Community Organization Level
• Community Mobilization
• Outreach-based Education

Neighborhood Level
• S...
Community outreach efforts
Vaccine Distribution in Year 1, VIVA 1
Neighborhood

Addresses
approached

Opened
doors

Vaccine
distributed

BRONX 6

843...
Thank you!

Danielle C. Ompad, PhD
dco2@nyu.edu
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  1. 1. Urbancity and urbanization: Challenges for adult access to vaccines Danielle C. Ompad New York University
  2. 2. Overview • Trends in urbanicity and urbanization • Distribution of vaccines to adults – Strategies – Challenges
  3. 3. 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
  4. 4. Percentage of Population Residing in Urban Areas Globally, 1950-2050 80.0 70.0 60.0 Percent 50.0 40.0 30.0 20.0 10.0 — Year World Urbanization Prospects, the 2011 Revision
  5. 5. Percentage of Population Residing in Urban Areas by Level of Development, 1950-2050 100.0 90.0 80.0 70.0 Percent 60.0 50.0 More developed regions Less developed regions 40.0 30.0 20.0 10.0 — Year World Urbanization Prospects, the 2011 Revision
  6. 6. Proportion urban and rural in less developed regions, 1950-2050 100.0 90.0 80.0 Percent 70.0 60.0 50.0 Urban 40.0 Rural 30.0 20.0 10.0 — Year World Urbanization Prospects, the 2011 Revision
  7. 7. Average Annual Rate of Change of the Urban Population by Major Area, 1950-2050 4.50 4.00 3.50 More developed regions 3.00 Percent Less developed regions 2.50 2.00 1.50 1.00 0.50 — Years
  8. 8. Urban Population by Major Area, 1950-2050 6,000,000 Population in Thousands 5,000,000 4,000,000 3,000,000 More developed regions Less developed regions 2,000,000 1,000,000 — Year
  9. 9. Number of cities by population size and level of country development, 1980-2025 700 Number of cities 600 ≥10M 5-10M 500 1-5M 400 <1M 300 200 100 0 More developed Less developed 1980 More developed Less developed 2000 More developed Less developed 2010 More developed Less developed 2025
  10. 10. 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
  11. 11. 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
  12. 12. DISTRIBUTION OF VACCINES TO ADULTS
  13. 13. 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
  14. 14. 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) Ompad D et al. Epidemiol Rev 2006
  15. 15. 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 Ompad D et al. Epidemiol Rev 2006
  16. 16. 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. Ompad D et al. Epidemiol Rev 2006
  17. 17. 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 Ompad D et al. Epidemiol Rev 2006
  18. 18. 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%) Ompad D et al. Epidemiol Rev 2006
  19. 19. 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. Ompad D et al. Epidemiol Rev 2006
  20. 20. 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) Ompad D et al. Epidemiol Rev 2006
  21. 21. 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) Ompad D et al. Epidemiol Rev 2006
  22. 22. 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 Ompad D et al. Epidemiol Rev 2006
  23. 23. 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 Ompad D et al. Epidemiol Rev 2006
  24. 24. Challenges in adult access to vaccines
  25. 25. 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
  26. 26. Reasons for lack of interest in receiving flu vaccine 25 Percent 20 15 10 5 0 Vaccine unsafe Don't like injections Medical reason Not at high risk Already vaccinated n (%) Ever had flu vaccine If ever, flu vaccine in past year Never had flu vaccine If never, interested in getting flu shot 468 (61.6) 240 (51.4) 292 (38.4) 576 (79.6)
  27. 27. 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
  28. 28. The Partnership NYAM • Trained the Outreach Workers in Research Methods HCAP VIWG PALLADIA VNSNY NYC DOHMH • Provided Vaccines • Consulted on the planning • Outreach Staff • Vaccination Site Host • Provided nurses
  29. 29. Outreach efforts Community Organization Level • Community Mobilization • Outreach-based Education Neighborhood Level • Street Interception-Outreach Education • Surveys • Recruitment for Vaccination Sites
  30. 30. Community outreach efforts
  31. 31. Vaccine Distribution in Year 1, VIVA 1 Neighborhood Addresses approached Opened doors Vaccine distributed BRONX 6 843 384 (46%) 191 (50%) E. HARLEM 3 922 513 (56%) 191 (37%) BRONX 8 1375 512 (37%) 84 (16%) BRONX 5 Vaccine 1486 678 (46%) 100 (15%) 4626 2087 (45%) 566 (27%) Flu Pneumovax TOTAL
  32. 32. Thank you! Danielle C. Ompad, PhD dco2@nyu.edu
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