Citation
Missed Opportunities for Influenza and Pneumococcal Vaccinations in Adults in the United States

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Title:
Missed Opportunities for Influenza and Pneumococcal Vaccinations in Adults in the United States
Creator:
Olasupo, Omotola Olamide
Place of Publication:
[Gainesville, Fla.]
Florida
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University of Florida
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english
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1 online resource (51 p.)

Thesis/Dissertation Information

Degree:
Master's ( M.S.P.)
Degree Grantor:
University of Florida
Degree Disciplines:
Pharmaceutical Sciences
Pharmaceutical Outcomes and Policy
Committee Chair:
BROWN,JOSHUA D
Committee Co-Chair:
SEGAL,RICHARD

Subjects

Subjects / Keywords:
health-policy -- influenza -- pneumonia -- preventive-medicine -- vaccines
Pharmaceutical Outcomes and Policy -- Dissertations, Academic -- UF
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bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Pharmaceutical Sciences thesis, M.S.P.

Notes

Abstract:
Despite high effectiveness achieved by vaccinations in preventing Community-Acquired Pneumonia and Influenza, vaccination coverage rates remain sub-optimal. Lack of recommendation by healthcare providers has been identified to be associated with low vaccination coverage rates. To quantify missed opportunities for vaccinations in the elderly and other high-risk adult populations, vaccination coverage and factors associated with vaccination, a retrospective cross-sectional analysis was conducted using the 2015 National Health Interview Survey. Missed opportunities for vaccinations was defined as the number of healthcare encounters in patients unvaccinated despite hospitalization, emergency room, home and doctor's office visits. In the two sub-groups, 8,046 respondents 65 years and older, and 8919 respondents 18-64 years with risk-factors, vaccination coverage was consistently higher in those with healthcare encounters compared with those without. Lowest coverage rates were recorded for those with 1-3 office visits. Respondents who had seen a Nurse Practitioner/Physician Assistant/midwife had the highest influenza vaccine coverage rate while those with home visits recorded the highest pneumococcal vaccine coverage rate. For influenza vaccinations in the elderly, 5.32 (95%CI: 5.03,5.61) missed opportunities exist for every unvaccinated person and 5.15 (95%CI: 4.90,5.39) for pneumococcal vaccination. In other adults with risk factors, 4.65 (95%CI: 4.46,4.83) missed opportunities exist for influenza vaccination and 4.83 (95%CI: 4.66,4.99) for pneumococcal vaccination. Office visits accounted for the majority of these. Factors associated with vaccination coverage include increased age, being non-Hispanic white, married, insured and having asthma, heart disease, COPD, diabetes and cancer. Hospitalization and ER visit are not associated with vaccination coverage for both vaccines. ( en )
General Note:
In the series University of Florida Digital Collections.
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Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (M.S.P.)--University of Florida, 2017.
Local:
Adviser: BROWN,JOSHUA D.
Local:
Co-adviser: SEGAL,RICHARD.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2018-06-30
Statement of Responsibility:
by Omotola Olamide Olasupo.

Record Information

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UFRGP
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Applicable rights reserved.
Embargo Date:
6/30/2018
Classification:
LD1780 2017 ( lcc )

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MISSED OPPORTUNITIES FOR INFLUENZA AND PNEUMOCOCCAL VACCINATIONS IN ADULTS IN THE UNITED STATES By OMOTOLA OLASUPO A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUI REMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN PHARMACY UNIVERSITY OF FLORIDA 2017

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2017 Omotola Olasupo

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To my family

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4 ACKNOWLEDGMENTS My first acknowledgement goes to God for making me alive and wel l to do this study. I also appreciate the effort and sacrifices of my husband and children during my graduate school education away from home. For contributions and guidance in conceptualizing th is research question as well as in analyzing the data, I app reciate Dr. Joshua Brown and Dr. Rich ard Segal. I also appreciate a colleague neighbor and sister, Omotola Olaniyi for being a ready support both in and outside the classroom. Finally I appreciate and acknowledge everyone who truly believes that an ounc e of prevention is still better than a pound of cure.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ ............... 4 LIST OF TABLES ................................ ................................ ................................ ........................... 6 LIST OF FIGURES ................................ ................................ ................................ ......................... 7 LIST OF ABBREVIATIONS ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ................................ ..... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .................. 11 Vaccination Recommendations: Community Acquired Pneumonia and Influenza ............... 11 Literature Review and Gaps in the Literature ................................ ................................ ......... 12 Risk Factors: Community Acquired Pneumonia and Influenza ................................ ............. 13 Study Objectives ................................ ................................ ................................ ..................... 13 2 METHODS ................................ ................................ ................................ ............................. 14 Study Population ................................ ................................ ................................ ..................... 14 Data Source ................................ ................................ ................................ ............................. 14 Variables: Definition and Operationalization ................................ ................................ ......... 14 Statistical Analysis ................................ ................................ ................................ .................. 16 3 RESULTS ................................ ................................ ................................ ............................... 25 Study Population Characteristics ................................ ................................ ............................ 25 Healthcare Utilization ................................ ................................ ................................ ............. 25 Vaccination Coverage Rates ................................ ................................ ................................ ... 26 Missed Opportunities for Vaccination ................................ ................................ .................... 28 Multivariable Analysis: Factors associated with Vaccination Coverage ............................... 29 4 DISCUSSION ................................ ................................ ................................ ......................... 44 Limitations ................................ ................................ ................................ .............................. 46 Conclusions ................................ ................................ ................................ ............................. 47 LIST OF REFERENCES ................................ ................................ ................................ ............... 48 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ......... 51

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6 LIST OF TABLES Table page 2 1 Characteristics of Survey Participants ................................ ................................ ............... 18 2 2 Health Conditions & Comorbidities of Survey Participants ................................ .............. 20 2 3 Influenza and Pneumococcal Vaccination Status ................................ .............................. 22 3 1 Influenza and Pneumococcal Vaccination Coverage Rates 65years and older ............... 31 3 2 Influenza & Pneumococcal Vaccination Coverage Rates 18 64 years with Risk Factors ................................ ................................ ................................ ................................ 33 3 3 Healthcare Encounters in Unvaccinated Respondents ................................ ....................... 35 3 4 Missed Opportunities for Influenza and Pneumococcal Vaccinations in Adults in the US, NHIS 2015 ................................ ................................ ................................ .................. 36 3 5 Healthcare Encounters in Vaccinated Respondents ................................ ........................... 37 3 6 Multivariable Analysis Vaccination Coverage, 65 years and older ................................ ... 38 3 7 Multivariable Analysis Vaccination Coverage, 18 64 years with Risk Factors ................ 40

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7 LIST OF FIGURES Figure page 2 1 Sample Selection Flow Chart ................................ ................................ ............................. 24 3 1 Vaccination Coverage Rates: 18 64 years with risk factors ................................ .............. 42 3 2 Vaccination Coverage Rates: 65years and older ................................ ............................... 42 3 3 Healthcare Encounters in Unvaccinated Respondents (Flu vaccinations Elderly) ........... 43

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8 LIST OF ABBREVIATIONS ACIP Advisory Committee on Immunization Practices CAP Community Acquired Pneumonia CDC Center for Dise ase Control and Prevention COPD Chronic Obstructive Pulmonary Disease ED/ER E mergency Department/Emergency Room HMO Health Maintenanc e Organization HPV Human Papilloma Virus NCHS National Cen ter for Health Statistics N HIS Nationa l Health Interview Survey OB/GYN Obstetrician / Gynecologist PCV13 Pneumococcal Conjugate Vaccine 13 PPV23 Pneumococcal Polysaccharide V accine 23 SAS S tatistical Analysis System Tdap Tetanus, diphtheria and pertussis WHO World Health Organization

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9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science in Pharmacy MISSED OPPORTUNITIES FOR INFLUENZA AND PNEUMOCOCCAL VACCINATIONS IN ADULTS IN THE UNITED STATES By Omotola Olasupo December 2017 Chair: Joshua Brown Major: Pharmaceutical Sciences Despite high effectiven ess achieved by vaccinations in preventing Community Acquired Pneumonia and Influenza, vaccination coverage rates remain sub optimal. Lack of recommendation by healthcare providers has been identified to be associated with low vaccination coverage rates. To quantify missed opportunities for vaccinations in the elderly and other high risk adult populations, vaccination coverage and factors associated with vaccination, a retrospective cross sectional analysis was conducted using the 2015 National Health Inte rview Survey. Missed opportunities for vaccinations was defined as the number of healthcare office visits. In the two sub groups, 8,046 respondents 65 years and older, and 8919 respondents 18 64 years with risk factors, vaccination coverage was consistently higher in those with healthcare encounters compared with those without. Lowest coverage rates were recorded for those with 1 3 office visits. Respondents who had seen a Nurse Practitioner/Physician Assistant/midwife had the highest influenza vaccine coverage rate while those with home visits recorded the highest pneumococcal vaccine coverage rate.

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10 For influenza vaccinations in the elderly, 5.320.15 (95%CI: 5.0 3, 5.61) missed opportunities exist for every unvaccinated person and 5.150.12 (95%CI: 4.90, 5.39) for pneumococcal vaccination. In other adults with risk factors, 4.650.09 (95%CI: 4.46, 4.83) missed opportunities exist for influenza vaccination and 4.83 0.09 (95%CI: 4.66,4.99) for pneumococcal vaccination. Office visits accounted for the majority of these. Factors associated with vaccination coverage include increased age, being non Hispanic white, married, insured and having asthma, heart disease, COP D, diabetes and cancer. Hospitalization and ER visit are not associated with vaccination coverage for both vaccines.

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11 CHAPTER 1 INTRODUCTION Vaccination Recommendations: Community Acquired Pneumonia and Influenza Community Acquired Pneumonia (CAP) and I nfluenza are two common preventable diseases with high success rates achieved by vaccinations. 1 4. Despite the high efficacy recorded for these vaccines, vaccination coverage rates remain sub optimal compared to global health goals and Healthy People 2020 targets for immunization and infectious diseases. 5 These s ub optimal coverage rates are recorded even in high risk populations such as the elderly (65 years and older) and adults 18 64 years with identified risk factors. 6 The US Center for Disease Contro l and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP), recommend influenza vaccines every season for everyone 6 months of age and older 7 In adults 19 64 years with risk factors for pneumococcal disease, p neumococcal vaccin ation recomm endation includes one dose of Pneumococcal conjugate vaccine ( PCV13 ) and at least one dose of pneumococcal polysaccharide vaccine ( PPSV23 ) depending on age and health status In the elderly 65 years or older, one dose of Pneumococcal conjugate vaccine (PCV 13) is recommended followed by a dose of pneumococcal polysaccharide vaccine (PPSV23), at least 1 year later. 8 10 According to the 2014 US vaccination surveillance data, influenza vaccination coverage 11 Pneumococcal vacci nation coverage among high risk persons aged 19 12 Factors shown to be associated with sub optimal vaccination coverage include age, race, gender, socio economic status and healthcare utilizatio n. 13 16 In addition to these inherent disparities, reason s for not vaccinating have been shown to include safety concerns and lack of recommendation by healthcare providers despite healthcare u tilization. 17, 18

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12 Literature Review and Gaps in the Literature Based on earlier definitions by the World Health Organization(WHO), m issed vaccination opportunities was 19 Emphasizing children and eligible women of child bearing ages in this definition, placed a higher focus on these groups. A vaccine specific modification to this definition helps to define missed opportunities for vaccinations as the number of visits where an eligible patient for a specific vaccine (e.g. Human Papilloma Virus (HPV) vaccine, Tetanus, diphtheria and pertussis ( Tdap ) vaccine etc. ) remained unvaccinated. 20, 21 In a study by Daley et al (2005), m issed opportunities for influenza vaccination was studied in children 6 72months, with chronic medical conditions Missed opportunities were found to o ccur in 78% of all vaccine eligible visits for children with asthma and in 74% of all visits for children with other conditions. 22 Parents of unimmunized children reported la ck of a physician recommendation and low perceived susceptibility to influenza as the primary reasons for not immunizing their child. In another study by Rao S et al (2016), missed opportunities for influenza vaccination was evaluated among hospitalized ch ildren with influenza at a tertiary care facility. In the 322 patients hospitalized with influenza included in this study, 61% were under vaccinated and 42% had at least 1 missed opportunity. High risk status was associated with increased odds of having a missed opportunity visit (OR: 6.9, 95% CI: 3.8 12.4). 23 Also, m ost were to subspecialty clinics (42%) and most (71%) occurred from September to November. While missed vaccination opportunities has been extensively studied in children (<5years) with subseq uent interventions made to address this, little is known of missed

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13 opportunities in all other high risk populations adults 18 64years old with risk factors and the elderly, 65 years and older. Risk Factors: Community Acquired Pneumonia and Influenza Ide ntified risk factors for pneumonia include gender, host immune status or presence of immunocompromising conditions, COPD, bronchiesctasis, functional or anatomic asplenia, cerebrospinal fluid leak, or cochlear implants 24,25,26 Other risk factors include u se of glucocorticoids and other immunosuppressive agents, co existing infection e.g. during influenza outbreaks and g eographical location. 27,28,29 Risk factors for influenza are similar: with age, living or working conditions, immunocompromising condition s and medications, such as c ancer treatments and corticosteroids, c hronic conditions, such as asthma, diabetes or heart problems, increasing the risk for influenza. Pregnant women are also more likely to develop influenza and influenza complications, parti cularly in the second and third trimesters. Women who are two weeks postpartum are also more likely to develop influenza related complications. 30,31 Study Objectives This study aims to quantify the number of missed opportunities for influenza and pneumococ cal vaccinations in these two groups of at risk adult patients. Secondary objectives include assessing the vaccination coverage rates as well as the factors associated with vaccination coverage in the two groups.

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14 CHAPTER 2 METHODS Study Population All su rvey respondents aged 18years and above were included in the analysis. Respondents with no sample adult records, those less than 18years old and those with zero or non asce were also excluded. A flow chart of the sample selection is provided in Figure 1. Data Source A retrospective cross sectional analysis was conducted using the 201 5 National Health Interview Survey (NHIS) data. This is an annual survey of a nationally representative sample of the US population, maintained by the National Center for Health Statistics (NCHS) of the Center for Disease Control and Prevention (CDC). To e nsure that the results of analyses represent unbiased national estimates with accurate statistical significance levels, sample weights are used for all analyses. A sample weight (assigned to each sample person), is a measure of the number of people in the population represented by that sample person, reflecting the unequal probability of selection, nonresponse adjustment and adjustment to independent population controls. For this study, the Person and Sample Adult files of the 2015 NHIS Data were extracted. Variables : Definition and Operationalization Demographic characteristics of the study population as well as other patient related variables (health conditions and co morbidities asthma COPD, heart disease, diabetes, chronic bronchitis, cancer) were ob tained and described as provided in Table 2 1 and Table 2 2. Healthcare utilization Hospitalization, emergency department/room visit, home care by healthcare professional were captured by responses to the relevant survey questions as follows.

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15 Responden ts, who in the past 12 months before the survey, had been hospitalized, visited an estions: italizations, often participate in heal responses to the relevant questions, are provided in Table 2 3. The outcome of interest is t he influenza and pneumococcal vaccination status for participants who have confirmed healthcare encounters. Influenza vaccination status was the past 12 months

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16 d for respondents who had not received one or both vaccines in the last twelve months. Missed opportunities for vaccinations was defined as the average number of healthcare encounters within 12 months, in patients who remained unvaccinated. To obtain this, the overall sum of healthcare encounters in unvaccinated respondents was obtained and divided by the total number of unvaccinated respondents. This was also calculated for the individual types of healthcare encounter(s). NHIS variables providing the numb er of healthcare encounters were used to identify the number of times these encounters occurred in unvaccinated respondents. This was presented as a presented as a range e.g. 2 3 visits, 10 12 visits etc. For these categorical variables, the lower value in the range was used to estimate the number of times an unvaccinated respondent had a healthcare exposure. Statistical Analysis Descriptive and summary statistics of demographic characteristics and co morbidities for the weighted and unweighted sample population were obtained and percentages and frequencies of healthcare utilization were also estimated (Demographic characteristics provided in T able 2 1 and Health cond itions and co morbidities provided in Table 2 2 ). Vaccination coverage as well as missed opportunities for vaccinations were calculated for influenza and pneumococcal vaccines across the different types of healthcare utilization hospitalization, out pat ient office visits, emergency room visits and home visits. Overall vaccination coverage (signifying percentage of respondents who have received either or both vaccinations) and overall missed opportunities for vaccination (signifying the percentage of

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17 resp ondents who have not received either or both vaccines) was also calculated. This was also conducted across different risk groups based on smoking status and co morbidities. To examine the factors associated with vaccination coverage in the two identified risk groups, multivariable logistic regression was conducted. For the multivariable logistic regression analyses, three (3) separate models were set up for each of the sub groups of interest. For each subgroup, a multivariable logistic regression model wa s set up for the dichotomous outcome, Yes (=1) and No (= 0) in response to the ceived a and No (= 0) to having received both vaccines compared to not receiving either vaccines. Consequently, respondents who has received either of the vaccine w here excluded in this third analysis resulting in a smaller sample size than the two previous analyses. Variables included in the multivariable analyses were those found to be statistically significant in the bivariate analysis exploring missed opportuniti es: Patient related factors ( age, gender, race, marital status, health insurance coverage, total earnings), health status and co morbidities ( reported health status, smoking status, asthma, COPD, heart disease, diabetes, chronic bronchitis, cancer) and hea lthcare utilization variables (h ospitalization, emergency room visit, home All statistical analyses were done using SAS Software 9.4 version (c) 2002 2012 by SAS Institute Inc., Cary, NC, USA.

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18 Table 2 1. Character istics of Survey Participants Sample Unweighted % Sample Weighted % N= 8046 N = 24306590 Elderly 65+ years. Age (Mean SD); 74.1 6.6 65 74 4540 56.4 13674558 56.3 75 84 2460 30.6 7408109 30.5 85+ 1046 13.0 3223 923 13.3 Gender Male 3350 41.6 10182224 41.9 Female 4696 58.4 14124366 58.1 Race/Ethnicity Hispanic 755 9.4 1760597 7.2 Non Hispanic White 5937 73.8 19265512 79.3 Non Hispanic Black 970 12.1 2320014 9.5 Non Hispan ic Asian 319 4.0 807398 3.3 Non Hispanic All other race groups 65 0.8 153069 0.6 Reported Health Status Excellent 1252 15.6 3837984 15.8 Very good 2374 29.5 7354382 30.3 Good 2647 32.9 8013479 33.0 Fair 1342 16.7 3868838 15.9 Poor 426 5.3 1213036 5.0 Legal Marital Status Separated 159 2.0 484082 2.0 Divorced 1407 17.5 4244681 17.5 Married 3376 42.0 10146501 41.7 Single/never married 494 6.1 1437839 5.9 Widowed 2597 32.3 7949381 32.7 Health Insur ance Private 3428 42.6 10184075 41.9 Medicaid, dual, or other public 1408 17.5 3848946 15.8 Medicare Advantage 1756 21.8 6035587 24.8 Medicare 1387 17.2 4065517 16.7 Uninsured 51 0.6 126030 0.5 Total Earnings (previous year) < $25,000 655 8.1 1799696 7.4 $ 25, 000 $74,999 470 5.8 1391434 5.7 $75,000 and above 167 2.1 521512 2.1 Refused/Don't know/Missing 6754 83.9 20593948 84.7 Smoking Status: Recode Current every day smoker 599 7.4 18167 16 7.5 Current some day smoker 149 1.9 425402 1.8 Former smoker 3095 38.5 9596611 39.5 Never smoker 4191 52.1 12436556 51.2

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19 Table 2 1. Continued Sample Unweighted % Sample Weighted % N= 8 919 N = 27512580 18 64 with R isk Factors. Age (Mean SD); 45.1 13.1 18 34 2293 25.7 7336662 26.7 35 54 3854 43.2 11675544 42.4 55 64 2772 31.1 8500374 30.9 Gender Male 3907 43.8 12428944 45.2 Female 5012 56.2 15083636 54.8 Race/Ethni city Hispanic 1221 13.7 2924280 10.6 Non Hispanic White 5867 65.8 19592415 71.2 Non Hispanic Black 1341 15.0 3808906 13.8 Non Hispanic Asian 316 3.5 794448 2.9 Non Hispanic All other race groups 174 2.0 392531 1.4 Reported Health Status Excellent 1496 16.8 4761329 17.3 Very good 2404 27.0 7613015 27.7 Good 2895 32.5 9010889 32.8 Fair 1567 17.6 4552591 16.5 Poor 554 6.2 1572194 5.7 Legal Marital Status Separated 395 4.4 1125021 4.1 Divor ced 1868 20.9 5653905 20.6 Married 3570 40.0 11220106 40.8 Single/never married 2747 30.8 8471903 30.8 Widowed 322 3.6 981388 3.6 Health Insurance Private 5087 57.0 16549566 60.2 Medicaid, dual, or other public 2529 28.4 728319 8 26.5 Uninsured 1268 14.2 3540429 12.9 Total Earnings (previous year) < $25,000 2145 24.1 6325322 23.0 $ 25, 000 $74,999 2575 28.9 8093365 29.4 $75,000 and above 722 8.1 2636732 9.6 Refused/Don't know/Missing 3477 39.0 10457 161 38.0 Smoking Status: Recode Current every day smoker 3346 37.5 10050359 36.5 Current some day smoker 319 3.6 987641 3.6 Former smoker 1521 17.1 4808975 17.5 Never smoker 3727 41.8 11652115 42.4

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20 Table 2 2. Health Condit ions & Comorbidities of Survey Participants Sample Unweighted % Sample Weighted % N= 8046 N = 24306590 Elderly 65+ years Ever Been Told You Had Asthma Yes 884 11.0 2532298 10.4 No 7150 88.9 21742472 89.5 Still Have Asthma Yes 595 7.4 1681094 6.9 No 284 3.5 836073 3.4 Told You Had Chronic Bronchitis, 12Months Yes 474 5.9 1485472 6.1 No 7558 93.9 22778431 93.7 Ever Been Told You Had A Heart Condition/Disease Yes 1398 17.4 4269024 17.6 No 6635 82.5 19998687 82.3 Ever Been Told You Had COPD Yes 667 8.3 1957215 8.1 No 7364 91.5 22307658 91.8 Ever Been Told That You Have Diabetes Yes 1711 21.3 5106739 21.0 No 6090 75.7 18463527 76.0 Borderline 234 2.9 700218 2.9 Ever Told By A Doctor You Had Cancer Yes 1926 23.9 6146542 25.3 No 6112 76.0 18138082 74.6 Body Mass Index, mg/kg 2 (29.5 12.8) Underweight: < 18.5 173 2.2 475308 2.0 Normal Weight: 18.5 24.9 2553 31.7 7878459 32.4 Overweight: 25.0 29.9 2873 35.7 8654805 35.6 2447 30.4 7298018 30.0 *COPD: Chronic Obstructive Pulmonary Disease

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21 Table 2 2. Continued Sample U nweighted % Sample Weighted % N= 8919 N = 27512580 18 64 with risk factors. Ever Been Told You Had Asthma Yes 3246 36.4 10131581 36.8 No 5670 63.6 17370285 63.1 Still Have Asthma Yes 2004 22.5 6169515 22.4 No 1224 13.7 3931741 14.3 Told You Had Chronic Bronchitis, 12Months Yes 895 10.0 2719107 9.9 No 8018 89.9 24762769 90.0 Ever Been Told You Had A Heart Condition/Disease Yes 1351 15.2 4357375 15.8 No 7565 84.8 23148869 84.1 Ever Been Told You Had COPD Yes 564 6.3 1718652 6.2 No 8350 93.6 25778180 93.7 Ever Been Told That You Have Diabetes Yes 1766 19.8 5130144 18.6 No 7009 78.6 21960042 79.8 Borderli ne 143 1.6 419982 1.5 Ever Told By A Doctor You Had Cancer Yes 1234 13.8 3824913 13.9 No 7679 86.1 23665578 86.0 Body Mass Index, m g/ k g2 (29.5 12.8) Underweight: < 18.5 153 1.7 484455 1.8 Normal Weight: 18.5 24.9 2558 28.7 8154255 29.6 Overweight: 25.0 29.9 2639 29.6 8282621 30.1 3569 40.0 10591249 38.5 Currently Pregnant Yes 61 0.7 178714 0.6 No 2686 30.1 8062780 29.3 Recently Pregnant Yes 111 1.2 303810 1.1 No 2597 29.1 7808258 28.4

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22 Table 2 3. Influenza and Pneumococcal Vaccination Status Sample Unweighted Sample Weighted % N= 8046 N = 24306590 Elderly 65+ years Influenza Vaccination(s) Flu S hot, Past 12 Months Yes 5448 16625202 68.4 No 2598 7681388 31.6 Flu Shot before/during Current Pregnancy (Interviewed Jan Mar or Aug Dec, 2015) Before This Pregnancy NA NA NA During This Pregnancy NA NA NA Flu Nasal Sp ray, Past 12 Months Yes 11 31217 0.1 No 8030 24265881 99.8 Pneumonia Vaccination(s) Pneumonia Shot (EVER) Yes 5072 15499299 63.8 No 2974 8807291 36.2 Both Vaccination(s) Both Vaccines Received 4213 1 2867268 52.9 Both Vaccines Not Received 1739 5049357 20.8 One Vaccine Not Received 2094 6389965 26.3

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23 Table 2 3. Continued Sample Unweighted Sample Weighted % N= 8919 N = 24306590 18 64 years with Risk Factors Influenza Vaccination (s) Flu Shot, Past 12 Months Yes 3567 10972828 39.9 No 5352 16539752 60.1 Flu Shot before/during Current Pregnancy (Interviewed Jan Mar or Aug Dec, 2015) Before This Pregnancy 8 29719 42.4 During This Pregnancy 11 40371 57.6 Flu Nasal Spray, Past 12 Months Yes 57 177066 0.6 No 8856 27322609 99.3 Pneumonia Vaccination(s) Pneumonia Shot (EVER) Yes 2086 6326771 23.0 No 6833 21185809 77.0 Both Vaccination(s) Both Vacci nes Received 1344 4135689 15.0 Both Vaccines Not Received 4610 14348670 52.2 One Vaccine Not Received 2965 9028221 32.8

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24 Figure 2 1. Sample Selection Flow Chart

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25 C HAPTER 3 RESULTS Study Population Characteristics 32,077 adults (weighted 98,993,629) aged 18 years and older were selected from the survey population. Of this population, 8,046 respondents were 65years and older and 8919 respondents were 18 64 years old with risk factors: representing a population of 24,306,590 and 27,512,580 respectivel y. In the subpopulation of elderly respondent, the mean ( SD) age was 74.1( 6.6) years. Majority were females (58.1%), non Hispanic whites (79.3%), with good self reported health status (33.0%), privately insured (41.9%), married (41.7%), non smokers (51 .2%), with a total annual income in the previous year either missing or between $25000 $74999. In the subpopulation of respondents 18 64 years old with risk factors, the mean ( SD) age was 45.1 ( 13.1) years. Majority were females (54.8%), non Hispanic wh ites (71.2%), with good self reported health status (32.8%), privately insured (60.2%), married (40.8%), non smokers (42.4%), with a total annual income in the previous year between $25000 $74999. Demographic characteristics of the study pop ulation are pre sented in T able 2 1 and clinical features of the population (health condition and co morbidities) are presented in Table 2 2. Healthcare Utilization Elderly 65 years and older. In the 65years and older sub group, 15.8% had been hospitalized, 22.5% had bee n in the ER, 8.3% had received a home visit from a healthcare professional and 93.5% had a physician office visit in the past 12months prior to the survey. In specifying the type of physician office visit, 87.1% of the population had visited a general doct or, 45.1% had visited a medical specialist, 26.0% had seen/talked to a Nurse Practitioner/Physician Assistant/midwife

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26 while 9.6% had seen/talked to an OB/GYN in the past 12months. 3.7% work or volunteer in a healthcare setting while 4.6% have health promot ion programs available at work. To estimate preventive health behavior, majority of this sub routine /preventive care. 18 years with Risk Factors. In the sub group 18 64 years with risk factors, 11.7% had b een hospitalized, 27.4% had been in the ER, 3.1% had received a home visit from a healthcare professional and 83.7% had a physician office visit in the past 12months prior to the survey. In specifying the type of physician office visit, 72.5% of the popula tion had visited a general doctor, 32.7% had visited a medical specialist, 28.4% had seen/talked to a Nurse Practitioner/Physician Assistant/midwife while 23.1% had seen/talked to an OB/GYN in the past 12months. 9.1% work or volunteer in a healthcare setti ng while 12.6% have health promotion programs available at work. To estimate preventive health behavior, majority of this sub group Vaccination Coverage Rates Elderly 65 year s and older. In the elderly 65years and older, who had been hospitalized, 74.6% and 74.0% had received the influenza and pneumococcal vaccines respectively compared to 67.2% and 61.8%in those not hospitalized. Coverage rates for influenza and pneumococcal vaccines for those with ER visits were 72.1% and 70.7%, home care, 75.2% and 76.2% and office visits 70.7% and 66.0% respectively. Consistently, pneumococcal vaccination coverage rates are lower compared to influenza vaccination coverage, with the exceptio n of those who had received home care from healthcare professionals. For influenza vaccines, the highest coverage rate was recorded for those who had seen/talked to a Nurse Practitioner/Physician Assistant/midwife in the past 12 months (75.8%) while the l owest coverage rate was recorded for those with 1 3 office visits (68.0%).

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27 For pneumococcal vaccines, the highest coverage rate was recorded for those who had received a home visit from healthcare professional (76.2%) while the lowest coverage was recorde d for those with 1 3 office visits (62.4%). Compared with those without healthcare exposure, coverage rates were consistently higher in participants with healthcare exp osure. (Table 3 2 ). Respondents with a single hospitalization, ER, home and out patien t visit had lower vaccination coverage rates compared to those with multiple healthcare utilization. 18 64 years with risk factors. In the sub group of survey participants 18 64 years with co existing asthma, COPD, heart disease, chronic bronchitis, diabet es or cancer, who had been hospitalized, 53.2% and 40.9% had received the influenza and pneumococcal vaccines respectively compared to 38.1% and 20.6% for those not hospitalized. Coverage rates for influenza and pneumococcal vaccines for those with ER visi ts were 41.3% and 31.0%, home care 57.6% and 56.0%% and office visits 44.7% and 25.6% respectively. Similar to the elderly group, pneumococcal vaccination coverage rates are lower compared to influenza vaccination coverage, with no exception in those who h ad received home care from healthcare professionals. For both influenza and pneumococcal vaccines, the highest coverage rates were recorded for those who had received home care from healthcare professionals (57.6% and 56.0% respectively) while the lowest coverage rates were recorded for those with 1 3 office visits (39.4% and 20.2% respectively). Similar to the elderly group, coverage rates were higher in participants with healthcare utilization compared to those without healthcare utilization (Table 3 2 ) The only exception was in participants who has seen an OB/GYN having lower pneumococcal vaccination rates compared to those who had not seen an OB/GYN.

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28 Respondents with a single hospitalization, ER, home and out patient visit had lower vaccination cover age rates compared to those with multiple healthcare utilization. Missed Opportunities for Vaccination In adults 18 64 years at risk for influenza or pneumonia, a total of 4.65 0.09 (95% CI: 4.46, 4.83 ) healt hcare encounters/visits exist for every person who has not received the influenza vaccine and a total of 4.83 0.09 (95% CI: 4.66, 4.99 ) encounters which did not result in pneumococcal vaccination. For influenza vaccinations, office visits account for 84.8% of missed opportunities while for pneumococca l vaccinations, office visits account for 79.8% of missed opportunities. In the elderly 65years and older, a total of 5.320.15 (95% CI: 5.03, 5.61 ) healthcare encounters/visits exist for every person who has not received the influenza vaccine and a total of 5.15 0.12 (95% CI: 4.90, 5.39 ) encounters which did not result in pneumococcal vaccination. Similar to the younger age group, office visits account for the majority of these missed opportunities for both influenza and pneumococcal vaccinations ( F i g u r e 3 3 ). Missed opportunities for vaccinations are higher for the elderly compared to younger adults (5.32 vs 4.65 and 5.15 vs 4.83). This could be explained by the higher healthcare utilization in the elderly and not necessarily that more elderly w e re unvaccinated. Healthcare encounters in vaccinated respondents In adults 18 64 years at risk for influenza or pneumonia, 7.18 0. 14 (95%CI: 6.90, 7.45) healthcare encounters/visits exist(s) for every person who has received the influenza vaccine and a total of 8.43 0.23 (95% CI: 7.99, 8.88) encounters which resulted in pneumococcal vaccination. In the elderly 65years and older, a total of 7.04 0.15 (95% CI: 6.81, 7.27) healthcare encounters/visits exist for every person who has received the influen za vaccine and a total of 7.26 0.12 (95% CI: 7.02, 7.50 ) encounters which resulted in pneumococcal vaccination (Table

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29 3 5 ). Consistently, healthcare utilization is higher in the vaccinated group compared to the unvaccinated. Multivariable Analysis: Fact ors associated with Vaccination Coverage In the elderly population, respondents who have had an office visit, seen/talked with a nurse practitioner, physician assistant, midwife, medical specialist or general doctor have higher odds of receiving both influ enza and pneumococcal vaccine. Receiving home care increased the odds of receiving pneumococcal vaccine but not influenza vaccine. Having been in the ER/ED or in the hospital overnight is not significantly associated with being vaccinated with either of th e vaccines. Hispanics and non Hispanic blacks have lower odds of being vaccinated for both vaccines. Having health insurance coverage is associated with increased odds of pneumococcal vaccination but not with influenza vaccination. Men have lower odds of receiving pneumococcal vaccines compared to women. The effect of earnings in the previous year was associated with higher odds of pneumococcal vaccination in those with low earnings (< $25000) compared to those in the middle income range ($25000 $74999). T hose with poor health status have reduced odds of receiving both vaccines compared with those in excellent health. Otherwise, reported health status was not associated with vaccination status. (Table 3 6 ) Survey participants with asthma, COPD, diabetes and cancer have higher odds of receiving both influenza and pneumococcal vaccines. However, those with chronic bronchitis and heart disease only have increased the odds of receiving pneumococcal vaccine but not influenza vaccine. (Table 3 6 ) In respondents 18 64 years with risk factors, those who have had seen/talked with medical specialist or general doctor or had been in the hospital overnight have higher odds of receiving both influenza and pneumococcal vaccine. Receiving home care, ER/ED visit, being

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30 Hispa nic and marital status is not significantly associated with being vaccinated with either of the vaccines. Having health insurance coverage is associated with increased odds of receiving both vaccines. Similar to the elderly population, non Hispanic blacks have lower odds of being vaccinated for both vaccines. Men have lower odds of receiving pneumococcal vaccines compared to women. The effect of earnings in the previous year was associated with higher odds of influenza vaccination in those with high earning s (> $75000) compared to those in the middle income range ($25000 $74999). Reported health status was associated with pneumococcal vaccination status but not consistently with influenza vaccination. Survey participants with asthma, chronic bronchitis and h eart disease have increased the odds of receiving pneumococcal vaccine but not influenza vaccine. Those with COPD and diabetes have higher odds of receiving both vaccines while who have had cancer only have increased the odds of receiving influenza vaccine but not pneumococcal vaccine Factors associated with vaccination coverage in 18 64 years old respondents with risk factors are presented in T able 3 7

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31 Table 3 1 Influenza and Pneumococcal Vaccination Coverage Rates 65years and older Sample Weighted % Influenza Pneumococcal Both vaccines One vaccine N= 24306590 Covered Missed Covered Missed Covered Missed Missed Hospitalization ( In patient Hospital Events) Has Been In A Hospital Overnight, 12Months Yes 3836739 15.8% 74.6% 25.4% 74.0% 26.0% 63.2% 14.6% 22.2% No 20445846 84.1% 67.2% 32.8% 61.8% 38.2% 51.0% 21.9% 27.1% Emergency Department /Room Visit Have You Been In The ER/ED, Past 12Months Yes 5458951 22.5% 72.1% 27.9% 70.7% 29.3% 58.9% 16.2% 24.2% No 18847639 77.5% 67.3% 3 2.7% 61.8% 38.2% 51.1% 22.0% 26.9% 1Time 3376553 61.9% 71.6% 28.4% 69.6% 30.4% 58.5% 17.3% 24.2% 2 4Times 1976976 36.2% 73.0% 27.0% 73.5% 26.5% 61.3% 14.8% 23.9% 5 7Times 47750 0.9% 83.0% 17.0% 52.3% 47.7% 41.7% 6.4% 51.9% 8Times And Above 5 7672 1.1% 60.2% 39.8% 59.2% 40.8% 48.8% 8.7% 42.5% Home Care By Healthcare Professional Received Home Care From Health Professional, Past 12 M onths Yes 2025360 8.3% 75.2% 24.8% 76.2% 23.8% 66.1% 14.7% 19.2% No 22277200 91.7% 67.8% 32.2% 62.6% 37.4% 51.7% 21.3% 26.9% Outpatient And Doctor's Office Visit (Out Patient Hospital Events) Have You Had An Office Visit, Past 12 M onths Yes 22736198 93.5% 70.7% 29.3% 66.0% 34.0% 55.3% 18.5% 26.2% No 1570392 6.5% 34.4% 65 .6% 31.2% 68.8% 19.3% 53.7% 26.0% 1 3Visits 13619527 59.9% 68.0% 32.0% 62.4% 37.6% 51.3% 21.0% 27.7% 4 6Visits 6393833 28.1% 74.3% 25.7% 70.7% 29.3% 60.2% 15.2% 24.6% 7Visits 742337 3.3% 71.1% 28.9% 67.5% 32.5% 55.0% 16.3% 28. 7% 8 And Above 1980501 8.7% 78.5% 21.5% 75.4% 24.6% 66.5% 12.7% 21.8% Seen/Talked To A General Doctor, Past 12 Months Yes 21181098 87.1% 71.7% 28.3% 67.2% 32.8% 56.4% 17.6% 26.0% No 3112775 12.8% 46.3% 53.7% 40.3% 59.7% 29.1% 42.5% 28.3% Seen/Talked To A Medical Specialist, Past 12 Months Yes 10963897 45.1% 75.1% 24.9% 72.3% 27.7% 62.1% 14.7% 23.2% No 13338762 54.9% 62.9% 37.1% 56.7% 43.3% 45.4% 25.7% 28.9% *ED/ER: Emergency Department/Emergency Ro om, NP: Nurse Practitioner, PA: Physician Assistant, OB/GYN: Obstetrician/ Gynecologist HMO: Health Maintenance Organization

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32 Table 3 1. Continued Sample Weighted % Influenza Pneumococcal Both vaccines One vaccine N= 24306590 Covered Missed Covered Missed Covered Missed Missed Seen/Talked To A NP/PA/Midwife, Past 12 Months Yes 6317805 26.0% 75.8% 24.2% 74.9% 25.1% 64.4% 13.6% 22.0% No 17918209 73.7% 65.7% 34.3% 59.9% 40.1% 48.9% 23.3% 27.8% Seen / Talked To OB/GYN, Past 12 Months Yes 23 37731 9.6% 75.7% 24.3% 66.8% 33.2% 58.1% 15.6% 26.3% No 11774304 48.4% 66.5% 33.5% 64.8% 35.2% 52.1% 20.8% 27.1% Place Usually Go For Routine/Preventive Care Doesn't Get Preventive Care Anywhere 564879 34.1% 22.2% 77.8% 22.6% 77.4% 9.9% 65.1% 25.1% Clinic Or Health Center 164996 10.0% 47.6% 52.4% 38.9% 61.1% 29.4% 42.9% 27.7% Doctor's Office Or HMO 688403 41.5% 70.6% 29.4% 55.7% 44.3% 46.8% 20.5% 32.8% Hospital Emergency Room 28407 1.7% 7.4% 92.6% 23.8% 76.2% 7.4% 76.2% 16.3% Hos pital Outpatient Department 29491 1.8% 36.3% 63.7% 76.7% 23.3% 34.3% 21.3% 44.4% Some Other Place 66767 4.0% 55.5% 44.5% 39.7% 60.3% 35.7% 40.5% 23.8% Doesn't Go To One Place Most Often 114085 6.9% 31.5% 68.5% 30.4% 69.6% 18.8% 56.9% 24.3% Health Promotion Programs Available At Work, Past Year Yes 1115612 4.6% 71.3% 28.7% 59.8% 40.2% 51.0% 19.9% 29.1% No 1783400 7.3% 58.9% 41.1% 55.9% 44.1% 41.6% 26.8% 31.6% How Often Participate In Health Promotion Programs, Past Year Never 458172 1.9% 67.1% 32.9% 60.3% 39.7% 49.7% 22.2% 28.1% Once 115601 0.5% 72.5% 27.5% 53.7% 46.3% 48.1% 21.8% 30.1% A Few Times 379638 1.6% 75.4% 24.6% 60.4% 39.6% 54.1% 18.4% 27.5% Monthly 83968 0.3% 83.3% 16.7% 56.6% 43.4% 52.7% 12.8% 34.6% Weekl y 20332 0.1% 47.0% 53.0% 64.4% 35.6% 31.6% 20.2% 48.3% Daily 57901 0.2% 65.7% 34.3% 67.4% 32.6% 51.6% 18.4% 30.0% Work Or Volunteer In A Health Care Setting Yes 910432 3.7% 82.5% 17.5% 66.7% 33.3% 61.4% 12.2% 26.4% No 23349922 96.1 % 67.9% 32.1% 63.7% 36.3% 52.7% 21.1% 26.2% *ED/ER: Emergency Department/Emergency Room, NP: Nurse Practitioner, PA: Physician Assistant, OB/GYN: Obstetrician/ Gynecologist HMO: Health Maintenance Organization

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33 Table 3 2 Influenza & Pneumococcal Vacci nation Coverage Rates 18 64 years with Risk Factors Sample Weighted % Influenza Pneumococcal Both vaccines One vaccine N= 27512580 Covered Missed Covered Missed Covered Missed Missed Hospitalization ( In patient Hospital Events) Has Be en In A Hospital Overnight, 12Months Yes 3228059 11.7% 53.2% 46.8% 40.9% 59.1% 31.0% 37.0% 32.0% No 24271439 88.2% 38.1% 61.9% 20.6% 79.4% 12.9% 54.2% 32.9% Emergency Department /Room Visit Have You Been In The ER/ED, Past 12Months Yes 7552069 27.4% 41.3% 58.7% 31.0% 69.0% 20.5% 48.2% 31.3% No 19933265 72.5% 39.4% 60.6% 20.0% 80.0% 13.0% 53.6% 33.4% 1Time 4192531 55.5% 40.4% 59.6% 26.4% 73.6% 17.9% 51.1% 31.0% 2 4Times 3070993 40.7% 41.5% 58.5% 35.9% 64.1% 22.9% 45.6% 31.5% 5 7Times 225793 3.0% 47.8% 52.2% 47.0% 53.0% 32.6% 37.7% 29.7% 8Times And Above 62752 0.8% 68.0% 32.0% 40.4% 59.6% 34.0% 25.5% 40.5% Home Care By Healthcare Professional Received Home Care From Health Professional, Past 12 M Yes 843486 3.1% 57.6% 42.4% 56.0% 44.0% 40.7% 27.1% 32.2% No 26668608 96.9% 39.3% 60.7% 22.0% 78.0% 14.2% 52.9% 32.8% Outpatient And Doctor's Office Visit (Out Patient Hospital Events) Have You Had An Office Visit, Past 12 Months Yes 23024866 83.7% 44.7% 55.3% 25.6% 74.4% 17.4% 47.0% 35.6% No 4487714 16.3% 15.0% 85.0% 9.6% 90.4% 2.9% 78.4% 18.7% 1 3Visits 142901 38 51.9% 39.4% 60.6% 20.2% 79.8% 12.7% 53.0% 34.3% 4 6Visits 5399032 19.6% 51.9% 48.1% 32.7% 67.3% 23.6% 39.0% 37.4% 7Visits 875518 3.2% 53.7% 46.3% 34.6% 65.4% 25.8% 37.5% 36.8% 8 And Above 2460178 8.9% 56.7% 43.3% 38.3% 61.7% 28.4% 33.4% 38.3% Seen/Talked To A General Doctor, Past 12 Months Yes 19946158 72.5% 46.4% 53.6% 26.9% 73.1% 18.6% 45.3% 36.1% No 7550195 27.4% 22.8% 77.2% 12.8% 87.2% 5.8% 70.2% 24.1% Seen/Talked To A Medical Spec ialist, Past 12 Months Yes 9061816 32.9% 52.9% 47.1% 34.8% 65.2% 25.0% 37.4% 37.6% No 18430433 67.0% 33.5% 66.5% 17.2% 82.8% 10.1% 59.4% 30.5% *ED/ER: Emergency Department/Emergency Room, NP: Nurse Practitioner, PA: Physician Assistant, OB/GYN: Obstetrician/ Gynecologist HMO: Health Maintenance Organization

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34 Table 3 2 Continued Sample Weighted % Influenza Pneumococcal Both vaccines One vaccine N= 27512580 Covered Missed Covered Missed Covered Missed Missed Seen/Talk ed To A NP/PA/Midwife, Past 12 Months Yes 7804371 28.4% 49.3% 50.7% 30.4% 69.6% 20.9% 41.1% 38.0% No 19679901 71.5% 36.1% 63.9% 20.0% 80.0% 12.7% 56.6% 30.8% Seen Talked To OB/GYN, Past 12 Months Yes 6346434 23.1% 48.4% 51.6% 22.8% 77.2% 16.3% 45.0% 38.7% No 8721091 31.7% 40.8% 59.2% 24.7% 75.3% 16.2% 50.6% 33.1% Place Usually Go For Routine/Preventive Care Doesn't Get Preventive Care Anywhere 2710198 9.9% 14.9% 85.1% 8.9% 91.1% 2.8% 78.9% 18.3% Clinic Or Health Center 712831 2.6% 20.6% 79.4% 13.3% 86.7% 5.8% 71.9% 22.3% Doctor's Office Or H MO 1188469 4.3% 33.8% 66.2% 16.2% 83.8% 9.0% 59.0% 32.0% Hospital Emergency Room 186141 0.7% 11.5% 88.5% 7.4% 92.6% 2.7% 83.8% 13.5% Hospital Outpatient Departmen t 72067 0.3% 35.7% 64.3% 15.9% 84.1% 15.9% 64.3% 19.8% Some Other Place 171427 0.6% 19.5% 80.5% 16.4% 83.6% 9.2% 73.3% 17.5% Doesn't Go To One Place Most Often 383416 1.4% 15.5% 84.5% 8.2% 91.8% 1.2% 77.6% 21.2% Heal th Promotion Programs Available At Wo rk, Past Year Yes 7660529 27.8% 49.8% 50.2% 18.7% 81.3% 13.5% 44.9% 41.6% No 8473278 30.8% 29.5% 70.5% 16.6% 83.4% 9.5% 63.3% 27.3% How Often Participate In Health Promotion Programs, Past Year Never 3469860 12.6% 43.5 % 56.5% 18.6% 81.4% 12.2% 50.0% 37.8% Once 1113946 4.0% 52.0% 48.0% 18.1% 81.9% 14.3% 44.1% 41.5% A Few Times 1875210 6.8% 56.9% 43.1% 17.6% 82.4% 14.7% 40.1% 45.2% Monthly 510573 1.9% 56.9% 43.1% 26.1% 73.9% 18.2% 35.2% 46.7% Weekly 370210 1.3 % 52.6% 47.4% 20.1% 79.9% 11.4% 38.7% 50.0% Daily 305953 1.1% 55.5% 44.5% 13.8% 86.2% 12.0% 42.8% 45.2% Work Or Volunteer In A Health Care Setting Yes 2489907 9.1% 64.1% 35.9% 24.5% 75.5% 18.5% 29.9% 51.5% No 24951682 90.7% 37.5% 62 .5% 22.8% 77.2% 14.7% 54.3% 31.0% *ED/ER: Emergency Department/Emergency Room, NP: Nu rse Practitioner, PA: Physician Assistant, OB/GYN: Obstetrician/ Gynecologist HMO: Health Maintenance Organization

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35 Table 3 3. Healthcare Encounters in Unvaccinat ed Respondents Healthcare Utilization Total Number of Visits Number Unvaccinated Missed Opportunities for Vaccination Std. Error of Mean 95% CI for Mean Flu Vaccinations 65+ (N=8046) ER/ED Visit 886 2598 0.33 0.02 0.28 0.37 Hom e Visit 1601 2598 0.57 0.06 0.46 0.69 Office Visit 10880 2598 4.24 0.11 4.02 4.46 Hospitalization 532 2598 0.18 0.01 0.16 0.21 Total Number of Exposures 13899 2598 5.32 0.15 5.03 5.61 Pneumococcal Vaccinations 65+ (N=8046) ER/ ED Visit 921 2974 0.30 0.02 0.25 0.34 Home Visit 1568 2974 0.46 0.05 0.36 0.56 Office Visit 12324 2974 4.22 0.1 4.03 4.42 Hospitalization 522 2974 0.17 0.01 0.14 0.19 Total Number of Exposures 15335 2974 5.15 0.12 4.9 5.39 Flu Vaccinati ons 18 64 years with risk factors (N=8919) ER/ED Visit 2918 5352 0.52 0.02 0.48 0.57 Home Visit 1133 5352 0.21 0.03 0.15 0.28 Office Visit 20458 5352 3.77 0.07 3.63 3.92 Hospitalization 765 5352 0.14 0.01 0.12 0.16 Total Number of Exposures 25 274 5352 4.65 0.09 4.46 4.83 Pneumococcal Vaccinations 18 64 years with risk factors (N=8919) ER/ED visit 3363 6833 0.47 0.02 0.44 0.51 Home Visit 1113 6833 0.16 0.02 0.11 0.2 Office Visit 27579 6833 4.07 0.07 3.93 4.21 Hospitaliz ation 903 6833 0.13 0.01 0.11 0.14 Total Number of Exposures 32958 6833 4.83 0.09 4.66 4.99 *ED/ER: Emergency Department/Emergency Room Missed Opportunities for Vaccination: Average number of healthcare encounters in unvaccinated respondents

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36 Table 3 4 Missed Opportunities for Influenza and Pneumococcal Vaccinations in Adults in the US, NHIS 2015 Vaccine Type 18 64 years with risk factors N=8919 N = 8606 Influenza Pneumococcal Influenza Pneumococcal Total Number Unvacc inated 5352 6833 2598 2974 Number of Visits Per Unvaccinated person (Mean SE) ER/ED Visit 0.52 0.02 0.47 0.02 0.33 0.02 0.30 0.02 Home Visit 0.21 0.03 0.16 0.02 0.57 0.06 0.46 0.05 Office Visit 3.77 0.07 4.07 0.07 4.24 0.11 4.22 0.10 Hospitalization 0.14 0.01 0.13 0.01 0.18 0.01 0.17 0.01 Total 4.65 0.09 4.83 0.09 5.32 0.15 5.15 0.12

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37 Table 3 5. Healthcare Encounters in Vaccinated Respondents Healthcare Utilization Total Number of Visi ts Number Vaccinated Mean number of visits in the Vaccinated Std. Error of Mean 95% CI for Mean Flu Vaccinations 65+ (N=8046) ER/ED Visit 2255 5448 0.40 0.02 0.37 0.43 Home Visit 4888 5448 0.83 0.05 0.72 0.94 Office Visit 2962 6 5448 5.53 0.08 5.37 5.68 Hospitalization 1490 5448 0.28 0.01 0.25 0.31 Total Number of Exposures 38259 5448 7.04 0.12 6.81 7.27 Pneumococcal Vaccinations 65+ (N=8046) ER/ED Visit 921 5072 0.42 0.02 0.39 0.46 Home Visit 1568 5072 0.91 0.06 0.80 1.03 Office Visit 12324 5072 5.63 0.08 5.46 5.79 Hospitalization 522 5072 0.30 0.01 0.27 0.32 Total Number of Exposures 15335 5072 7.26 0.12 7.02 7.50 Flu Vaccinations 18 64 years with risk factors (N=8919) E R/ED Visit 2287 3567 0.63 0.03 0.56 0.69 Home Visit 1548 3567 0.42 0.05 0.32 0.51 Office Visit 20560 3567 5.87 0.10 5.68 6.06 Hospitalization 926 3567 0.26 0.02 0.23 0.29 Total Number of Exposures 25321 3567 7.18 0.14 6.90 7.45 Pneumoco ccal Vaccinations 18 64 years with risk factors (N=8919) ER/ED visit 1842 2086 0.87 0.05 0.77 0.97 Home Visit 1568 2086 0.76 0.09 0.58 0.93 Office Visit 13439 2086 6.42 0.14 6.14 6.70 Hospitalization 788 2086 0.39 0.03 0.32 0.46 Total Number of Exposures 17637 2086 8.43 0.23 7.99 8.88 *ED/ER: Emergency Department/Emergency Room Missed Opportunities for Vaccination: Average number of healthcare encounters in unvaccinated respondents

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38 Table 3 6 Multivariable Analysis Vaccination Cove rage, 65 years and older Influenza Pneumococcal Both OR Lower Upper OR Lower Upper OR Lower Upper Hospitalized 1.065 0.864 1.313 1.183 0.966 1.45 1.127 0.857 1.483 E R /E D Visit 0.947 0.798 1.123 1.009 0.862 1.181 1.026 0.832 1.266 Home Care From Healt h Professional 1.154 0.906 1.47 1.443 1.135 1.835 1.249 0.907 1.72 Office Visit 1.881 1.4 2.528 1.508 1.082 2.102 2.044 1.36 3.073 Seen/Talked to A NP/PA/Midwife 1.25 1.072 1.459 1.398 1.193 1.637 1.524 1.238 1.875 Seen/Talked To A Medical Sp ecialist 1.24 1.082 1.423 1.328 1.154 1.529 1.37 1.152 1.631 Seen/Talked To A General Doctor 1.644 1.334 2.026 1.805 1.441 2.261 2.333 1.743 3.122 Health Promotion Programs Available At Work 1.674 1.147 2.443 1.22 0.87 1.71 1.776 1.132 2.788 75 84 1.156 0.999 1.338 1.348 1.155 1.574 1.323 1.086 1.611 85 And Older 1.33 1.068 1.655 1.245 1.001 1.549 1.42 1.062 1.898 Male 1.076 0.937 1.235 0.849 0.739 0.975 0.93 0.776 1.114 Hispanic 0.669 0.545 0.822 0.424 0.342 0.525 0.3 77 0.29 0.489 Non Hispanic Black 0.695 0.577 0.838 0.561 0.474 0.663 0.489 0.388 0.617 Non Hispanic Asian 0.991 0.722 1.361 0.568 0.425 0.761 0.639 0.425 0.96 All Other Race Groups 0.857 0.383 1.915 0.712 0.368 1.38 0.707 0.255 1.957 Very Go od Health Status 1.066 0.88 1.291 0.975 0.807 1.179 1.021 0.802 1.3 Good Health Status 0.966 0.791 1.18 0.974 0.802 1.182 0.992 0.766 1.285 Fair Health Status 0.96 0.765 1.205 0.696 0.562 0.862 0.83 0.621 1.108 Poor Health Status 0.652 0.476 0.893 0.53 0.387 0.726 0.481 0.325 0.711 Response variable: (1) Flu shot past 12 m (2) Have you ever received a Pneumonia shot? (3) Binary logistic regression: Both vaccines received versus both not received. Reference categories: Age Group (65 74), Female, Non His panic White, Excellent Health status, Married, Uninsured, Earnings $25000 $74999, Never Smoker. OR=Odds Ratio

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39 Table 3 6 Continued Influenza Pneumococcal Both OR Lower Upper OR Lower Upper OR Lower Upper Separated 0.876 0.567 1.353 0.535 0.3 74 0.767 0.595 0.357 0.991 Divorced 0.632 0.532 0.751 0.796 0.665 0.954 0.575 0.461 0.718 Single/Never Married 0.695 0.534 0.904 0.831 0.655 1.054 0.673 0.492 0.92 Widowed 0.807 0.68 0.957 0.953 0.812 1.118 0.869 0.7 1.078 Privat e Insurance 2.027 0.828 4.965 4.157 1.633 10.584 6.092 1.652 22.471 Medicaid, Dual, Or Other Public 1.759 0.707 4.374 3.478 1.36 8.892 4.721 1.266 17.61 Medicare Advantage 2.243 0.9 5.59 5.124 2.023 12.98 8.059 2.18 29.795 Medicare 1.553 0.632 3.815 3.2 42 1.267 8.296 4.217 1.131 15.726 Earnings < $25000 1.173 0.827 1.665 1.597 1.157 2.204 1.547 0.996 2.404 Earnings $75000+ 0.888 0.51 1.549 0.967 0.627 1.491 0.897 0.489 1.647 Current Every Day Smoker 0.783 0. 62 0.987 0.92 0.728 1.162 0.783 0.582 1.055 Current Some Day Smoker 0.862 0.533 1.393 0.894 0.567 1.41 0.831 0.453 1.525 Former Smoker 1.104 0.966 1.261 1.249 1.101 1.417 1.264 1.069 1.494 Asthma 1.481 1.186 1.849 1.788 1.439 2.221 1.973 1.479 2.632 Chronic Bronchitis 1.196 0.875 1.636 1.469 1.058 2.041 1.364 0.866 2.15 Heart Condition/Disease 1.177 0.994 1.393 1.385 1.156 1.66 1.427 1.12 1.818 COPD 1.612 1.212 2.144 2.141 1.608 2.851 2.75 1.841 4.108 Diabetes 1.176 1.025 1.35 1 .497 1.263 1.776 1.581 1.282 1.95 Cancer 1.185 1.027 1.367 1.234 1.066 1.428 1.301 1.075 1.573 Response variable: (1) Flu shot past 12 m (2) Have you ever received a Pneumonia shot? (3) Binary logistic regression: Both vaccines recei ved versus both not received. Reference categories: Age Group (65 74), Female, Non Hispanic White, Excellent Health status, Married, Uninsured, Earnings $25000 $749 99, Never Smoker. OR=Odds Ratio

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40 Table 3 7 Multivariable Analysis Vaccination Coverag e, 18 64 years with Risk Factors Influenza Pneumococcal Both OR Lower Upper OR Lower Upper OR Lower Upper Hospitalized 1.504 1.251 1.808 1.353 1.107 1.654 1.792 1.372 2.342 E R /E D Visit 0.871 0.752 1.008 1.139 0.978 1.328 1.058 0.855 1.31 Home Care F rom Health Professional 1.041 0.744 1.456 1.631 0.948 2.806 1.704 1.065 2.728 Office Visit 1.604 1.263 2.036 1.159 0.862 1.56 1.866 1.151 3.026 Seen/Talked to A NP/PA/Midwife 1.125 0.98 1.291 1.115 0.961 1.294 1.106 0.894 1.367 Seen /Talked To A Medical Specialist 1.268 1.101 1.461 0.664 0.524 0.842 1.578 1.304 1.91 Seen/Talked To A General Doctor 1.449 1.223 1.718 1.237 1.015 1.508 1.739 1.306 2.316 Health Promotion Programs Available At Work 1.656 1.398 1.962 0.966 0.779 1.198 1.4 28 1.078 1.893 35 54 1.043 0.893 1.219 1.24 1.019 1.51 1.362 0.999 1.858 55 64 1.671 1.367 2.043 2.382 1.897 2.991 3.551 2.506 5.031 Male 0.803 0.705 0.915 1.092 0.942 1.267 0.841 0.687 1.029 Hispanic 1.021 0.864 1.207 0.873 0.712 1.071 0.884 0.68 1.15 Non Hispanic Black 0.745 0.625 0.888 0.801 0.668 0.96 0.663 0.512 0.858 Non Hispanic Asian 1.394 1.018 1.909 0.985 0.673 1.442 1.198 0.731 1.964 All Other Race Groups 0.985 0.6 1.618 0 .977 0.573 1.665 0.841 0.435 1.626 Very Good Health Status 1.12 0.927 1.354 1.542 1.205 1.972 1.795 1.293 2.494 Good Health Status 1.105 0.922 1.324 1.653 1.31 2.086 1.81 1.305 2.509 Fair Health Status 1.306 1.05 1.623 1.767 1.344 2.322 2.128 1.447 3.128 Poor Health Status 0.953 0.691 1.314 1.639 1.162 2.311 1.509 0.942 2.417 Response variable: (1) Flu shot past 12 months (2) Have you ever received a Pneumonia shot? (3) Binary logistic regression: Both vaccines received versus bot h not received. Reference categories: Age Group (18 34), Female, Non Hispanic White, Excellent Health status, Married, Uninsured, Earnings $25000 $74999, Never Smoker. OR= Odds Ratio

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41 Table 3 7 Continued Influenza Pneumococcal Both OR Lower U pper OR Lower Upper OR Lower Upper Separated 1.012 0.742 1.379 0.91 0.63 1.314 0.753 0.471 1.206 Divorced 0.935 0.8 1.092 0.89 0.751 1.054 0.898 0.717 1.125 Single/Never Married 1.002 0.845 1.188 1.034 0.86 1.243 0.966 0.747 1.248 Widowed 1.004 0.75 3 1.339 1.17 0.838 1.634 1.077 0.719 1.613 Private Insurance 2.47 1.962 3.109 1.479 1.107 1.976 3.833 2.33 6.305 Medicaid, dual, or other public 2.41 1.889 3.075 1.53 1.142 2.049 4.113 2.531 6.686 Earnings < $25 000 0.94 0.781 1.132 1.11 0.921 1.338 0.961 0.72 1.283 Earnings $75000+ 1.553 1.211 1.992 1.071 0.813 1.411 1.582 1.092 2.292 Current Every Day Smoker 0.63 0.538 0.739 0.943 0.787 1.13 0.681 0.526 0.881 Current Some Day Smoker 0.7 98 0.582 1.095 0.947 0.661 1.356 0.869 0.53 1.425 Former Smoker 0.979 0.838 1.145 1.112 0.931 1.327 1.186 0.95 1.481 Asthma 1.077 0.927 1.251 1.652 1.419 1.923 1.66 1.332 2.07 Chronic Bronchitis 1.168 0.96 1.422 1.328 1.066 1.655 1 .386 1.022 1.881 Heart Condition/Disease 0.923 0.787 1.084 1.274 1.041 1.56 1.105 0.843 1.449 COPD 1.373 1.084 1.737 2.603 1.99 3.406 2.54 1.829 3.529 Diabetes 1.438 1.216 1.699 2.131 1.752 2.591 2.469 1.949 3.128 Cancer 1.217 1.007 1.471 1.133 0.932 1 .377 1.313 1.015 1.7 Response variable: (1) Flu shot past 12 months (2) Have you ever received a Pneumonia shot? (3) Binary logistic regression: Both vaccines received versus both not received. Reference categories: Age Group (18 34), Female, Non Hispanic White, Excellent Health status, Married, Uninsured, Earnings $25000 $74999, Never Smoker. OR= Odds Ratio

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42 Figure 3 1 Vaccination Coverage Rates: 18 64 years with risk factors F igure 3 2 Vaccination Coverage Rates: 65year s and older

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43 Figure 3 3 Healthcare Encounters in Unvaccinated Respondents (Flu vaccinations Elderly)

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44 CHAPTER 4 DISCUSSION Consistently, pneumococcal vaccination coverage rates are lower compared to influenza vaccination coverage While respondents w ith a visit to a Nurse Practitioner/Physician Assistant/midwife recorded the highest vaccination coverage for influenza vaccines, those with a home visit from healthcare professional recorded the highest vaccination coverage for pneumococcal vaccines The lowest coverage rate for both vaccines was recorded for thos e with 1 3 office visits Compared with those without healthcare exposure, coverage rates were consistently higher in participants with h ealthcare exposure while r espondents with a single hospita lization, ER, home and out patient visit had lower vaccination coverage rates compared to those with multiple healthcare utilization. An average of 4.65 (95% CI: 4.46, 4.83 ) and 4.83 (95% CI: 4.66, 4.99 ) missed opportunities for influenza and pneumococcal vaccination s respectively, occur in adults 18 64 years with risk factors. While in the elderly 65years and older, a n average of 5.32 (95% CI: 5.03, 5.61 ) and 5.15 (95% CI: 4.90, 5.39 ) missed opportunities for influenza and pneumococcal vaccinations occur r espectively. In this analysis also, consistent with the earlier results for vaccination coverage, office visits accounted for the majority of these missed opportunities Missed opportunities for vaccinations are higher for the elderly compared to younger a dults (5.32 vs 4.65 and 5.15 vs 4.83). This could be explained by the higher healthcare utilization in the elderly and not necessarily that more of the elderly population were unvaccinated. In comparison with respondents who were vaccinated, healthcare ut ilization was consistently higher in vaccinated respondents compared to those unvaccinated. For instance, in the younger sub group for influenza vaccination an average of 7.18 healthcare encounters

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45 occurred for every person who has received the influenza vaccine compared to an average of 4.65 in those unvaccinated. This is consistently true for each type of healthcare encounter examined. Gender earnings and health insurance status were shown not to be statistically significant factors associated with inf luenza vaccination coverage, especially in the elderly. However, increased age, race, marital status and presence of asthma, chronic bronchitis, heart condition, COPD, diabetes and cancer were associated with increased odds of being vaccinated. In the youn ger sub group, marital status is not significantly associated with influenza vaccination coverage. As a function of healthcare utilization metrics, h aving been in the ER/ED or in the hospital overnight is not significantly associated with being vaccinated with either or both of the vaccines in both sub groups This is consistent with the acute nature of most ED visits. A policy recommendation is to include a follow up plan for preventive care for ED patients after the resolution of the primary reason for the visit. Hospitalization, although associated with higher odds of being vaccinated in both subgroups, it was consistently not statistically significant in the elderly. Home care, although also associated with higher odds of being vaccinated, it was only statistically significant for pneumococcal vaccination in the elderly and for receiving both vaccines in the 18 64 subgroup with risk factors. Office visit is consistently associated with increased odds of being vaccinated with the exception of pneumococ cal vaccination in the younger population. This could be explained by the relatively high cost of this vaccination for those with out of pocket payments or with high

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46 co payments for those with health insurance coverage. Based on these findings, policy rec ommendation s can be made to further reinforce vaccinations during office visits. A nother policy recommendation would be to further implement vaccination initiatives in locations that are not necessarily healthcare facilities e.g. in work places, especiall y for the younger working population. The presence of asthma, COPD, diabetes and cancer are associated with higher odds of receiving both influenza and pneumococcal vaccines in the elderly While presence of asthma, chronic bronchitis and heart disease in creased the odds of receiving pneumococcal vaccine but not influenza vaccine in the younger population Limitations The NHIS provides data on selected participants who are representative of the civilian, non institutionalized U.S. population. It therefore excludes certain groups of people such as patients in long term care facilities; persons on active duty with the Armed Forces (though their dependents are included); persons incarcerated in the prison system; and U.S. nationals living in foreign countries However, with the exclusion of this groups, the data is nationally representative. Being a database based on survey, the NHIS is expected to have issues common to survey data such as inaccurate recall, non validated responses, ambiguous questions, under or overzealous interviewers and missing values know, missing or not ascertained for the key variables signifying vaccination status were not included in the analyses. Also, there is no variable indicating whether patient declined vaccination in those not vaccinated. Therefore, the estimates for missed opportunities for vaccination is solely based on

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47 the fact that the respondent used a healthcare facility or was in contact with a healthcare provider. In esti mating missed opportunities, NHIS variables for the number of ER, home and 3 visits, 10 12 visits etc. the lower value in the range was used to estimate the number of times an unvaccinated respondent had a healthcare exposure. Therefore, estimates for missed opportunities for vaccinations are expected to be conservative. Conclusions Significant missed opportunities exist for both influenza and pneumococcal vaccinations in the elderly and other high risk adu lt groups. An increased focus on vaccinations during office visits will increase vaccine coverage especially when availability and use of health services is high.

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48 LIST OF REFERENCES 1. Osterholm MT, Kelley NS, Sommer A, Belongia EA. Efficacy and effectiven ess of influenza vaccines: A systematic review and meta analysis. The Lancet Infectious Diseases 2012;12(1):36 44. https://doi.org/10.1016/S1473 3099(11)70295 X 2. Black S, Shinefield H, Fireman B, et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Pediatric Infectious Disease Journa l. 2000;19(3):187 195. 3. Whitney CG, Pilishvili T, Farley MM, et al. Effectiveness of seven valent pneumococcal conj ugate vaccine against invasive pneumococcal disease: A matched case control study. The Lancet 2006;368(9546):1495 1502. https://doi.org/10.1016/S0140 6736(06)69637 2 4. Fine MJ, Smith MA, Carson CA, et al. Efficacy of pneumococcal vaccination in adults. A meta analysis of randomized controlled trials. Arch Intern Me d. 1994.;154(23):2666 2677. https://jama network.com/journals/jamainternalmedicine/article abstract/619742 doi: 10.1001/archinte.1994.00420230051007. 5. US Department of Health and Human Services (DHHS). 2020 Topics and Objectives: Immunization and Infectious Diseases. https://www.healthypeople.gov/2020/topics objectives/topic/immunization and infectious diseases Updated October 25, 2017. Accessed Feb 15, 2017. 6. Shippee ND, Mullan RJ, Nabhan M, et al. Adherence to preventive recommendations: Experience of a cohort presenting for executive health care. Population Health Managemen t. 2012, 15(2): 65 70.;15(2):65 70. 7. National Center for Immunization and Respiratory Diseases, Centers for Di sease Control and Prevention. 2017 Recommended Immunizations for Adults: By Health Condition. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult s chedule easy read.pdf Updated 2017. Accessed March 8, 2017. 8. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13 valent pneumococcal conjugate vaccine and 23 years: Recommendations of the advisory committee on immunization practices (ACIP). Morbidity a nd Mortality Weekly Report (MMWR ). 2014;63(37):822 825. 9. National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Pneumococcal Vaccination: Information for Healthcare Professionals. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/index.html Updated 2016. Accessed February 18, 2017. 10. Kim DK, Riley LE, Harriman KH, Hunter P, Bridges CB. Recommended immunization schedule for adults aged 19 years or older, United States, 2017. Ann Intern Me d. 2017;166(3):209 219.

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49 11. populations United States, 2014. MMWR Surveill Summ 2016;65(1):1 36. 12. Williams WW, Lu P, O'Halloran A, et al. Vaccination coverage among adults, excluding influenza vaccination United States, 2013. Morbidity and Mortality Weekly Report (MMWR ) [ Williams WW et al]. 2015;64(4):95 102. 13. and ethnic disparities in vaccination coverage among adult populations in the U.S. American Journal of Preventive Medicine 2015;49(6, Supplement 4): S412 S425. https://doi.org/10.1016/j.amepre.20 15.03.005 14. Lu P, Rodriguez disparities among foreign born populations in the U.S., 2012. American Journal of Preventive Medicine 2014;47(6):722 733. https://doi.org/10.1016/j.amepre.2014.08.009 15. Van Essen GA, Kuyvenhoven MM, De Melker RA. Why do healthy elderly people fail to comply with influenza vaccination? Age and Agein g. 1997; 26:275 279. 16. Charland KM, Brownstein JS, Verma A, Brien S, Buckeridge DL. Socio economic disparities in the burden of seasonal influenza: The effect of social and material deprivation on rates of influenza infection. PLoS ON E. 2011;6(2): e17207. 17. Nichol KL, Zimmerman R. Generalist and subspecialist physi cians' knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high risk Patients. A nationwide survey. Arch Intern Me d. 2001;161(22):2702 2708. 18. Mukherjee K, Segal R. Discussions with healthcare provide rs about prostate specific antigen testing: Evidence from the behavioral risk factor surveillance system in the USA. Journal of Pharmaceutical Health Services Researc h. 2015;6(1):47 52. 19. World Health Organization. Immunization, Vaccines and Biologicals Sy stematic review of missed opportunities for vaccination. http://www.who.int/immunization/rfp_review_missed_opportunities_vaccination/en/ Updated 2017. Accessed March 18, 2017. 20. Wong CA, Taylor JA, Wright JA, Opel DJ, Katzenellenbogen RA. Missed opportunities for adolescent vaccination, 2006 2011. Journal of Adolescent Healt h. 2013;53(4):492 497. 21. Williams WW, Hickson MA, Kane MA, et. al. Immunization policies an d vaccine coverage among adults: The risk for missed opportunities. 1988; 108:616 625. Ann Intern Me d. 1988; 108:616 625.

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50 22. Daley MF, Beaty BL, Barrow J. Missed opportunities for influenza vaccination in children with chronic medical conditions. Archives of Pediatrics & Adolescent Medicin e. 2005;159(10):986 991. 23. Rao S, Williams JTB, Torok MR, Cunningham MA, Glod MP, Wilson KM. Missed opportunities for influenza vaccination among hospitalized children with influenza at a tertiary care facility. H ospital Ped iatrics 2016;6(9):513 519. 24. National Foundation of Infectious Diseases. Pneumococcal disease. http://www.nfid.org/idinfo/pneumococcal Updated 2017. Accessed March 18, 2017. 25. National Center for Im munization and Respiratory Diseases, Center for Disease Control and Prevention. About pneumococcal disease. https://www.cdc.gov/pneumococcal/about/index.html Updated 2017. Accessed Feb 15, 2 017. 26. National Center for Health Statistics, Center for Disease Control and Prevention. Pneumonia. https://www.cdc.gov/nchs/fastats/pneumonia.htm Updated 2017. Accessed February 15, 2017. 27. Cass iere HA. Severe pneumonia in the elderly: Risks, treatment, and prevention. Medscape General Medicin e. 1998;1(3). 28. Hanibuchi T, Nakaya T, Chiyoe M. Soci o economic status and self rated health in east asia: A comparison of China, Japan, South Korea and Taiwan. European Journal of Public Healt h 2012;22(1):47 52. 29. Rudan I, Boschi Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of ch ildhood pneumonia. Bulletin of the World Health Organizatio n. 2008;86(5):408 416. 30. Viboud C, Bolle P, Cauchemez S, et al. Risk factors of influenza transmission in household. Br J Gen Pract 2004; 54 (506): 684 689. 31. National Center for Immunization and Respiratory Diseases (NCIRD) CDC. People at High Risk of Developing Flu Related Complications. https://www.cdc.gov/flu/about/disease/high_ risk.htm Updated 2017. Accessed September, 2017

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51 B IOGRAPHICAL SKETCH Omotola obtained a Bachelor of Pharmacy (BPharm) degree from the University of Ibadan, Nigeria in the spring of 2006 After which she has been in the Pharmaceutical Industry as the Fie ld Force Manager, Oncology at Roche Genentech. She majored in pharmaceutical sciences w hile simultaneously working for the Department of Pharmaceutical Outcomes and Policy, graduating with a Master of Science in Pharmacy degree in the fall of 2017. Her interests are in Pharmacoeconomics and Pharmacoepidemiology involving Biotechnologies, Preventive Health and Health Policy.