Elsevier

Vaccine

Volume 31, Issue 41, 23 September 2013, Pages 4564-4568
Vaccine

Trends and disparity in zoster vaccine uptake in a managed care population

https://doi.org/10.1016/j.vaccine.2013.07.053Get rights and content

Highlights

  • We assessed trends in zoster vaccine coverage in adults ≥60 years from 2007 to 2011.

  • Zoster vaccine coverage remained low in older adults.

  • Racial/ethnic disparity was observed and worsened over time.

Abstract

Objectives

Zoster vaccine is recommended for prevention of herpes zoster among adults aged 60 years and older. We examined the zoster vaccination rates during 2007–2011 and assessed association with age, sex, race/ethnicity, neighborhood income and education attainment in eligible adults at Kaiser Permanente Southern California, a managed care organization in the US.

Methods

We calculated annual zoster vaccination rate among members ≥60 years without documented contraindications. Multivariable logistic regression was performed to examine factors associated with zoster vaccine uptake in an open cohort of 819,466 adults.

Results

The zoster vaccination rates increased annually in all groups and the overall rate reached 21.7% in 2011 (P-trend < 0.001). Coverage was highest among individuals aged 65–74 years, who were female and non-Hispanic White. In the adjusted analysis, odds of vaccination decreased by age. Females (odds ratio [OR] = 1.19, 95% confidence interval [CI] = 1.17–1.20) and those who lived in neighborhoods with higher education attainment were more likely to be vaccinated (>75% vs. <50% adults with some college education: OR = 1.76, 95% CI = 1.73–1.80). Compared to Whites, non-Hispanic Blacks and Hispanics were less likely to receive the vaccine (non-Hispanic Blacks: OR = 0.56, 95% CI = 0.55–0.58; Hispanics: OR = 0.59, 95% CI = 0.58–0.60).

Conclusion

The zoster vaccine coverage is higher in this insured population than previously reported in the US general population, but it remains low. Significant racial/ethnic disparity was observed and worsened even among individuals with relatively equal access to zoster vaccination.

Introduction

Herpes zoster (HZ), also known as shingles, is a highly prevalent disease in the United States with approximately one million cases diagnosed annually before the zoster vaccine was introduced [1], [2]. HZ is caused by the reactivation of a latent varicella zoster virus (VZV), the same virus that causes chickenpox. HZ is generally painful and debilitating and its manifestations and complications can lead to significant short- and long-term morbidity. The majority of those affected are older individuals, and persons age 60 are 8–10 times more likely to develop HZ and significantly more prone to develop complications than their younger counterparts [3]. Although progress has been made in the treatment of HZ and its associated complications, available therapeutic options are only partially effective. Evidence from a clinical trial demonstrated that a live-attenuated VZV vaccine (zoster vaccine) is effective at reducing the incidence of HZ and the burden of illness [2]. In 2006, the United States Food and Drug Administration (FDA) approved a live attenuated zoster vaccine (Zostavax®), referred to as zoster vaccine, for the prevention of HZ in immunocompetent adults age 60 and over. After FDA approval, the Centers for Disease Control and Prevention (CDC) issued its recommendation of zoster vaccine for all individuals 60 and older who have no contraindications. Persons who report a previous episode of zoster and persons with chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease) can be vaccinated unless those conditions are contraindications or precautions [4].

Recent data from a large observational study have shown that among immunocompetent community-dwelling adults aged 60 years and older, receipt of the herpes zoster vaccine is associated with a decreased incidence of HZ across all age strata and among individuals with chronic diseases [5]. However, according to the National Health Interview Survey [6], [7], the estimated zoster vaccination coverage among adults aged 60 and older (6.7% in 2008 and 15.8% in 2011) was well below the target coverage level of 30% in Healthy People 2020 (see IID-14) [8]. Furthermore, vaccination coverage was lower in racial/ethnic minority groups. These data highlight the need for continuing efforts to increase zoster vaccination coverage. The major barriers to the use of zoster vaccine identified in previous studies include low public awareness of the vaccine [9], the high vaccine cost, and the providers being discouraged by the complexity of the reimbursement process through Medicare Part D and the need for a freezer for vaccine storage [10].

In this study we sought to assess the coverage of zoster vaccination among a large cohort of insured persons aged 60 years and older during 2007–2011, 5 years following the recommendation for routine zoster vaccination. We were also interested in identifying missed opportunities for vaccination and any differences in the zoster vaccination uptake related to age, sex, race/ethnicity, and socioeconomic status (SES) in this insured population.

Section snippets

Study setting

This study is carried out among health plan members aged 60 years and older in Kaiser Permanente Southern California (KPSC) during 2007–2011. KPSC is the largest managed care organization (MCO) in Southern California, United States, that provides integrated care to members enrolled in pre-paid insurance health plans. As of 2012, KPSC serves more than 3.5 million racially/ethnically diverse members (37% White, 40% Hispanic, 10% African American, 10% Asian/Pacific Islanders and 3% other races)

Study design

This study included a cross-sectional assessment of the trend in zoster vaccination coverage and a cohort study to examine factors associated with zoster vaccine uptake.

In order to examine the trend in zoster vaccination coverage, we calculated zoster vaccination rate among eligible members in each year over the study period. For each year, enrolled members aged 60 years or older who did not have documented contraindications such as HIV/AIDS, leukemia, lymphomas, or other malignant neoplasms

Statistical analyses

The annual zoster vaccination coverage rate was calculated as the number of eligible members who had received zoster vaccine divided by the total number of eligible members at the end of each calendar year. The annual coverage rate was plotted as an overall rate over time, as well as by age, sex and race/ethnicity. The Cochran–Armitage test was performed to detect a linear trend of zoster vaccination coverage over the study period.

Bivariate and multivariable logistic regression models were used

Results

During 2007–2011, the overall vaccination coverage significantly increased among all age, sex and race/ethnicity groups, from 7.1% in 2007 to 20.7% in 2011 (P-trend < 0.001) (Table 1). In general, the coverage rate was highest among members aged 65–74 years and who were female and non-Hispanic White. The coverage among non-Hispanic Whites was similar to that among Asian/Pacific Islanders, but was significantly higher than that among non-Hispanic Blacks and Hispanics. Notably, the differences

Discussion

In this study, we observed a general increasing trend in zoster vaccination coverage in adults aged 60 years and older in all age, sex and race/ethnicity groups from 2007 to 2011 in this insured population with relatively equal access to zoster vaccination. The increase was relatively slower in 2010 and 2011, which might be associated with the zoster vaccine shortage in the US during that period of time [12]. The observed rates were higher in this insured population compared to that among the

Conflict of interest disclosures

Dr. Jacobsen has received research funding from Merck Research Laboratories and has served as an unpaid consultant to Merck Research Laboratories. All the other authors claim no potential conflict of interest.

References (16)

There are more references available in the full text version of this article.

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