Urbanization is increasing globally, with more people living in urban areas. This presents challenges for distributing adult vaccines. The document reviews different strategies used in various settings to increase adult vaccination rates. Hospital/clinic-based interventions like standing orders and reminders showed success. Community-based programs distributing vaccines in non-traditional settings also increased rates. While many focused on the elderly, few targeted high-risk adults or children. A limitation is reaching those not engaged in healthcare.

1. Urbancity and urbanization: Challenges
for adult access to vaccines
Danielle C. Ompad
New York University

2. Overview
• Trends in urbanicity and urbanization
• Distribution of vaccines to adults
– Strategies
– Challenges

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. 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. 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. 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. 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. 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. 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. 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. 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. DISTRIBUTION OF VACCINES
TO ADULTS

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Challenges in adult access to vaccines

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. 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. 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

31. 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

32. Outreach efforts
Community Organization Level
• Community Mobilization
• Outreach-based Education
Neighborhood Level
• Street Interception-Outreach Education
• Surveys
• Recruitment for Vaccination Sites

33. Community outreach efforts

34. 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

35. Thank you!
Danielle C. Ompad, PhD
dco2@nyu.edu