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6 Vaccination Rates in Certain Populations Although increasing vaccination rates across the board is important, workshop participants said several population groups were of particular concern. They suggested that special attention be given to increasing vaccination rates in these groups in future emergency vaccination cam- paigns. These groups included pregnant women, healthcare workers, and members of racial and ethnic minorities. Pregnant women emerged as one of the groups at highest risk of developing serious complications (Jamieson et al., 2009). Despite this risk, workshop participants reported low percentages of vaccination among pregnant women. Participants noted that it is important to consider how to address barriers to vaccina- tion and to increase rates of acceptance of vaccine in this population be- fore another public health emergency occurs that similarly affects pregnant women. Participants also suggested that efforts focus on in- creasing vaccination among healthcare workers, not only because they are at higher risk of contracting disease from contact with patients, but also because their attitude toward vaccination may heavily impact whether or not their patients decide to be vaccinated. Finally, participants noted that vaccination rates were lowest in some racial and ethnic mi- norities, including African Americans. They noted that this is not particu- lar to 2009 H1N1—this effect is also found for seasonal influenza vaccine—but emphasized that this broader issue should be addressed before the next public health emergency. Issues pertaining to these popu- lation groups are discussed in more detail in this section. 55

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56 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN Pregnant Women Pregnant women were at high risk for developing complications from 2009 H1N1 and were disproportionately represented among hospi- tal and intensive care unit cases and mortality related to 2009 H1N1. They were also one of the ACIP target groups, yet vaccine uptake in this group varied across the nation. Pregnant women and their physicians had many questions and concerns about vaccine safety during pregnancy. “Even with all the information out there about how it was so important and it was safe during pregnancy, and how it was made in the same fash- ion as a seasonal vaccine, some of the private practitioners had a lot of issues getting their pregnant women to take it,” said Sheffield of the Maternal–Fetal Medicine Fellowship at the University of Texas. Compli- cating matters, many OB/GYNs referred patients to their primary-care physicians because they do not routinely give seasonal flu vaccinations, but primary-care physicians referred women back to the OB/GYNs be- cause they were unsure about vaccinating pregnant women. Public health authorities, medical associations, and the OB/GYN provider community should work together, participants said, to improve vaccination rates for pregnant women by ensuring that influenza vaccine is routinely recommended for pregnant women and “institutionalizing” access to vaccine where obstetrical care is provided. Three concrete sug- gestions were made: (1) Use electronic standing orders (“opt out”) and automatic “best practice” alerts in electronic medical records for preg- nant women; (2) educate healthcare providers about the safety and im- portance of vaccinating pregnant women so that they are more likely to encourage their patients to be vaccinated; and (3) increase the number of OB/GYNs who provide seasonal influenza vaccine to their patients and make vaccination a regular part of their practice. To increase vaccine uptake in its pregnant population, the University of Texas Southwestern Medical Center developed a best practice alert within its electronic medical record system. Each time a healthcare pro- vider opened the patient’s chart, he or she received an alert asking, “Have you offered H1N1 vaccine?” The provider was required to answer yes or no. If no was checked, the provider had to enter an explanation. This questioning enabled the organization to track the percentage of pa- tients vaccinated and the reasons why vaccinations did not occur. The same system was used for the seasonal influenza vaccine. A benefit of the best practice alert was increased awareness among healthcare provid- ers. Kim Boggess, assistant professor of obstetrics and gynecology at the

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57 VACCINATION RATES IN CERTAIN POPULATIONS University of North Carolina at Chapel Hill, also reported success using electronic standing orders for vaccination. Setting up rules and alerts in electronic medical records based on age and pregnancy status allows physicians to be proactive in reaching pa- tients. Some systems are set up to allow physicians to e-mail their pa- tients directly to notify them to come in for vaccinations or reach them with educational materials. In California, Sutter of the California Department of Health reported working with ACOG to bring OB/GYNs on board. The department used CDC focus group data to address challenges associated with vaccine safety perceptions. In West Virginia, concerns about poor vaccine uptake in pregnant women led the state to change its media campaign to focus in part on that population. Additionally, a special clinic for pregnant women and children with chronic medical conditions ran weekly. Panel participants found that individuals weighed the perceived risk of the pathogen against the perceived risk of the vaccine. “One of the lessons that we took from that was that there is not really an absolute rejection of vaccine for most patients. It is simply a balance between what they perceive as the threat of the pathogen itself, and potential dan- gers of the vaccine. When that tips in favor of the threat being more harmful, then people will be accepting of the vaccine,” said Leonardo Pereira, division director of maternal–fetal medicine and director of ob- stetrics at Oregon Health and Science University. Healthcare Workers Only 37 percent of healthcare workers were vaccinated as of January 2010 (CDC, 2010g). This undervaccination is problematic, said many workshop participants, because healthcare provider support is critical in increasing vaccine uptake. If providers do not accept vaccination for themselves, convincing the general public to be vaccinated is more diffi- cult. Although there is general agreement about the importance of mak- ing vaccine available to healthcare workers and encouraging them to be vaccinated, there is less agreement about whether vaccination should be required for healthcare workers by state or local laws or by hospitals and other employers. When this issue arose during the 2009 H1N1 campaign, some healthcare workers and unions argued that vaccination should not be mandatory because individuals should be free to choose whether to be vaccinated without fear of termination. Those favoring mandatory vacci-

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58 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN nation emphasized the traditionally low vaccination rate among health- care workers and associated concerns that healthcare workers could in- fect their patients before symptoms are detectable and that many healthcare workers could become infected, resulting in a shortage of healthcare workers at the peak of a pandemic. To increase healthcare worker uptake, a number of strategies were tried in different areas. In Massachusetts, emergency regulations were passed requiring hospitals to offer immunization to employees. “We did not go so far as to require that employees be immunized,” said Smith of Massachusetts, “but hospitals had to offer it, and then there needed to be an active declination and documentation of that by the healthcare provider.” Falk, UTMB’s director of health epidemiology, described the ap- proach UTMB used. An interdisciplinary committee composed of physi- cians (including pediatricians and a vaccine specialist), administration, employee health, and public affairs created a strong vaccine campaign, part of which required any employee who had not been vaccinated to wear a mask for every patient interaction. Not only did this decrease transmission rates, but it also increased awareness. Ninety-six percent of hospital staff members were immunized. But even with this requirement and increased vaccination awareness, gaps remained: Only 70 percent of resident physicians were immunized, and only 48 percent of attending OB/GYNs were immunized, which was problematic because they were dealing with a high-risk patient population. Some areas of vaccine uptake among healthcare providers were high. Turner of the American College Health Association noted that 75 percent of college healthcare professionals were vaccinated, double the rate for healthcare workers across the nation. This happened without any specific campaign aimed at increasing participation, although college healthcare workers typically see a large volume of contagious-disease cases and thus may embrace vaccination. Racial Disparities in Vaccine Uptake Vaccine uptake was not constant across racial and ethnic lines. In Washington, DC, where African Americans are the majority, public health officials noticed the large racial disparities early. A similar situa- tion was found in jurisdictions surrounding Atlanta, Georgia. Pamela Blackwell, director of the Center for Emergency Preparedness and Re- sponse for Cobb & Douglas Public Health in Georgia, said, “It was very,

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59 VACCINATION RATES IN CERTAIN POPULATIONS very obvious in our mass clinics that we had not somehow targeted the African American population well at all.” In Chicago, the turnout at neighborhood clinics demonstrated signifi- cant differences in demand for vaccine based on race and ethnicity. Clin- ics located in primarily African American communities received much lower turnout than those in primarily Latino or white communities. This was not a new phenomenon. “We knew from seasonal flu and from pneumococcal vaccine as well,” said Morita of Chicago Public Health. “It played out as it had in previous seasons.” LA County also had disproportionate utilization among racial groups. Nine percent of the county population is African American, yet this group received less than 3 percent of the vaccine from points of dis- pensing (PODs). By contrast, the Latino population was represented about equal to their share of the population, and Asian/Pacific Islanders were represented in PODs at about double the percentage of their popula- tion in the county. Participants emphasized the need to understand the ethnic variations inherent in their communities and develop strong partnerships before events in order to appropriately engage the community. Opportunities for Improving Vaccination Rates in Certain Populations Numerous individual suggestions were made about opportunities to improve vaccination rates in certain populations, including pregnant women and healthcare workers. Suggestions were also made about ad- dressing health disparities among racial and ethnic groups. These sug- gestions are compiled here as part of the factual summary of the workshops and should not be construed as reflecting consensus or en- dorsement by the workshops, the Preparedness Forum, or The National Academies. Pregnant Women There were several individual suggestions about improving vaccina- tion rates among pregnant women for consideration by public health au- thorities and health systems, among others. These included

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60 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN • Public health authorities, medical associations, and the OB/GYN provider community should routinely recommend influenza vaccination for pregnant women and “institutional- ize” access to vaccine where obstetrical care is provided. • Use electronic standing orders (“opt out”) or automatic “best practices” alerts in electronic medical records to increase vaccination among pregnant women and other patients for whom vaccination is recommended. • Increase education for healthcare workers regarding the safety and importance of vaccinating pregnant women so that workers will be more likely to encourage their patients to be vaccinated. “The tangible low-hanging fruit seems to be things like how we better reach our pregnant women,” said Slemp of West Virginia. “There is lots of room there to work with provider communities and networks that work with our pregnant women, to increase the understanding that not only is this safe and effective vaccine, but they are really at increased risk.” Healthcare Workers There were several individual suggestions about improving vaccina- tion rates among healthcare workers for consideration by public health authorities and health systems, among others. These included • Examine ways to increase healthcare provider participation in vaccine campaigns. Should vaccinations be required for healthcare workers? Or would a model similar to that in Massa- chusetts, which required that healthcare workers be offered vac- cination, be enough to increase participation? • Consider incentives for healthcare provider immunizations. • Educate healthcare providers about the safety of vaccines and their importance so they will be more likely to be vacci- nated themselves and advise patients to be vaccinated.

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61 VACCINATION RATES IN CERTAIN POPULATIONS Racial Disparities There were several individual suggestions for addressing health dis- parities among racial and ethnic groups for consideration by public health authorities and health systems, among others. These included • Evaluate, plan around, and identify best practices for inter- ventions to address racial/ethnic health disparities now in order to improve vaccination rates. Participants stressed that “this can’t be done on game day.”

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