State-level variations and factors associated with adult vaccination coverage: a multilevel modeling approach
Journal: PharmacoEconomics - Open
Authors: Diana Garbinsky, Shannon Hunter, Elizabeth M. La, Sara Poston, Cosmina Hogea
Correspondence: Sara Poston; GSK, sara.a.poston@gsk.com
Conflicts of interest: EL, SP and CH are employed by the GSK
group of companies and hold shares in the GSK group of companies.
DG and SH are employees of RTI Health Solutions, which was contracted by the GSK group of companies to design and implement the present study. The authors declare no other financial and non- financial relationships and activities.
Online Resource 2
Data Sources
Behavioral Risk Factor Surveillance System
Under the coordination of the Centers for Disease Control and Prevention (CDC), all US states conduct the Behavioral Risk Factor Surveillance System (BRFSS) surveys, each state separately from the other [1]. The BRFSS questionnaire consists of a core group of questions with questions to be asked to all states, an optional module from which the states may select questions to include in the year’s survey, and a state-specific part. One part of the core group questions has standard questions to be asked unchanged every year, a second part has questions to be asked in alternating years, and the third part has questions relevant to ‘late breaking’-issues.
States’ adults are randomly chosen and asked every year to take part in the survey[2]
and are told that there is not monetary compensation for their participation however their contribution will enforce a cross-country endeavor to improve the health of all people in the US [3]. The random selection of numbers called is made from lists of landline and cell phone numbers, which include unlisted telephone numbers, The number of interviews conducted depends on funding and the size of the state regions where the interviews are being conducted [3]. Mail, landline phones, and cell phones are used to contact potential respondents [4].
Kaiser Family Foundation State Health Facts
This was the primary source for the state-level data and provides health data for all of the US. These data are gathered from a variety of public and private sources, including Kaiser Family Foundation (KFF) reports, public websites, government surveys and reports, and private organizations [5].
Immunization Information Systems
Immunization information systems (IIS) are databases, regulated by the CDC, in which participating health care providers confidentially record the immunization doses administered within a specific area [6]. Immunization histories for patients at points of clinical care are stored in the IIS and aggregate data are used in vaccination surveillance and monitoring programs. The CDC’s IIS website provides percentages of individuals participating in an IIS with one or more immunizations for young children (aged <6 years), adolescents (aged 11–17 years), and adults (aged ≥19 years) by state. Participation rates by state were available for years 2010–2017 [7].
Immunization and Vaccine-Preventable Disease-Related State Mandates and Exemptions
The CDC works with and provides funding for the Immunization Action Coalition (IAC) to educate health care professionals about US vaccine recommendations. The IAC website (www.immunize.org) distributes educational materials for health care professionals and the public that enhance the delivery of safe and effective immunization services [8]. The website includes information about state-level mandates related to immunization. It also includes information on exemptions permitted for state immunization requirements. Although these mandates and exemptions pertain to individuals enrolled in daycare, kindergarten through 12th grades, and colleges/universities, the mandates and exemptions may help to inform adult behaviors and/or capture general attitudes and beliefs toward vaccinations within each state. Previous research has indicated that nonmedical and personal belief exemptions are associated with decreased childhood vaccination coverage and increased rates of childhood vaccine-preventable diseases [9-12]. However, the relationship between exemptions and adult vaccination coverage is less clear. The
data on state mandates and exemptions were up to date as of October 2018.
Variations in Statutes and Regulations Related to Pharmacist Vaccination Authority
Currently, pharmacists in all 50 states and the District of Columbia have the authority to vaccinate, and the scope of pharmacists’ authority to vaccinate has been expanding [13].The American Pharmacists Association (APhA) provides information on pharmacists’ authority to administer vaccines in all 50 states and the District of Columbia based on a survey conducted by APhA/National Alliance of State Pharmacy Associations on state immunization laws and rules [14]. The data provided were reported in July 2016.
CDC Grant Funding Allocated to Immunization Programs
The CDC provides funding to “state and local health departments, universities, and other public and private agencies for a variety of public health programs” [15].
The CDC launched the Grant Funding Profiles tool in 2011 to make grant funding data publicly available. The CDC Grant Funding Profiles website includes fiscal year end summaries of funding data categorized by the CDC appropriation account used to make the investment [15]. In particular, the site includes information about the amount of funding allocated to immunization funding by state. CDC funding data were available for fiscal year 2016 through 2017.
References to the Online Resource
1. Washington State Department of Health. Behavioral Risk Factor
Surveillance System (BRFSS) Sampling Method.
https://www.doh.wa.gov/DataandStatisticalReports/DataSystems/BehavioralRiskFact orSurveillanceSystemBRFSS/BRFSSCollectingData. Accessed 14 February 2020.
2. Alaska Department of Health and Social Services. Alaska Behavioral
Risk Factor Surveillance System (BRFSS).
http://dhss.alaska.gov/dph/Chronic/Pages/brfss/default.aspx. Accessed 14 February 2020.
3. Centers for Disease Control and Prevention (CDC). Behavioral Risk
Factor Surveillance System - About BRFSS.
https://www.cdc.gov/brfss/about/brfss_faq.htm. Accessed 14 February 2020.
4. Centers for Disease Control and Prevention (CDC). Behavioral Risk
Factor Surveillance System History Fact Sheet.
https://www.cdc.gov/brfss/factsheets/pdf/brfss-history.pdf. Accessed 14 February 2020.
5. Kaiser Family Foundation (KFF) State Health Facts. Data source: the Centers for Disease Control and Prevention (CDC). About state health facts.
https://www.kff.org/about-state-health-facts/. Accessed January 3, 2019.
6. Centers for Disease Control and Prevention (CDC). About
Immunization Information Systems (IIS).
https://www.cdc.gov/vaccines/programs/iis/about.html. Published 2012. Updated June 7, 2019. Accessed February 23, 2020.
7. Centers for Disease Control and Prevention (CDC). IISAR Data Participation Rates and Maps. National Child, Adolescent, and Adult Tables and Maps. https://www.cdc.gov/vaccines/programs/iis/annual-report-iisar/rates-maps- table.html. Updated October 9, 2018. Accessed August 14, 2019.
8. Immunization Action Coalition (IAC). About Us.
https://www.immunize.org/aboutus/. Updated January 1, 2020. Accessed February 25,
2020.
9. Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA. 2000;284(24):3145-3150.
10. Immunization Action Coalition (IAC). Personal Belief Exemptions for Vaccination Put People at Risk. Examine the Evidence for Yourself. 2019.
https://www.immunize.org/catg.d/p2069.pdf Accessed February 25, 2020.
11. Olive JK, Hotez PJ, Damania A, Nolan MS. The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties. PLoS Med. 2018;15(6):e1002578.
12. Omer SB, Enger KS, Moulton LH, Halsey NA, Stokley S, Salmon DA.
Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol. 2008;168(12):1389-1396.
13. Schmit CD, Penn MS. Expanding state laws and a growing role for pharmacists in vaccination services. J Am Pharm Assoc (2003). 2017;57(6):661-669.
14. American Pharmacists Association (APhA). Pharmacist Administered Vaccines. https://www.pharmacist.com/sites/default/files/files/Slides%20on
%20Pharmacist%20IZ%20Authority_July_2016%20v2mcr.pdf?dfptag=imz. Updated July 2016. Accessed July 26, 2019.
15. Centers for Disease Control and Prevention (CDC). Office of Financial Resources. Grant Funding Profiles. https://www.cdc.gov/fundingprofiles/. Updated February 28, 2019. Accessed Aug 14, 2019.
