Awareness and Uptake of Zoster Vaccine among U

Awareness and Uptake of Zoster Vaccine among U. S. Adults ≥ 60 Years Megan C. Lindley, Rafael Harpaz, Stephanie R. Bialek National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA TM

Disclosure Information • The authors have no financial or other conflicts of interest to disclose • The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy TM

Background • 2006 Advisory Committee on Immunization Practices (ACIP) recommendation: healthy adults ≥ 60 years receive 1 dose of herpes zoster (shingles) vaccine • 2008 national data shows only 7% of adults aged 60+ have ever received a dose of zoster vaccine – ACIP statement published 2008 – Production issues limited availability until 2009 TM

Background (2) • Zoster is the most expensive vaccine routinely recommended for adults • Zoster is the first older adult vaccine that is covered by Medicare Part D (vs. Part B) – Plans vary by state & may include cost-sharing – Physicians report difficulty billing Part D • Many potential barriers to high zoster vaccination coverage: cost, low awareness, lack of perceived need, other factors TM

Objective • To assess attitudes and beliefs about zoster vaccine and identify factors associated with vaccine receipt in a national sample of adults ≥ 60 years old TM

Methods: Sample Selection • ‘Styles’ surveys: panel of 328, 000 potential respondents recruited by mail – Consumer. Styles 2009: stratified random sample • 10, 587 of 21, 420 households (49%) completed • Health. Styles 2009 survey – Random sample of 7, 004 households that completed the 2009 Consumer. Styles survey – Fielded August-September 2009 – 4, 556/7, 004 households (65. 0%) responded • Limited to 1, 365 respondents aged ≥ 60 years TM

Methods: Data Collection & Analysis • Questions: respondent characteristics, awareness of disease/vaccine, financial perceptions, reasons for non-vaccination • Outcome: Ever received a dose of zoster vaccine (yes/no) • Descriptive statistics & bivariate associations • Data weighted to 2008 census population – Age, race, sex, household size & income TM

Results: Selected Demographics Age group Race/ethnicity Education level 60 -64 yrs. 32. 3% 65 -69 yrs. 23. 5% 70 -74 yrs. 18. 8% 75 -79 yrs. 13. 7% 80 + yrs. 11. 7% White 75. 7% African-American 10. 6% Hispanic 9. 5% Other 4. 2% <HS 6. 5% High school graduate 23. 4% Some college 34. 9% College graduate or higher 34. 4% TM

Results: Health Behaviors & Insurance Medicare Part B 61. 3% Medicare Part D 24. 2% Medicaid 9. 3% TRICARE/VA 7. 8% Private insurance 49. 0% Other 22. 8% Uninsured 3. 5% Excellent / Very Good 42. 1% Good 38. 6% Fair / Poor 18. 2% Influenza vaccination Received last 12 months 67. % Pneumococcal vaccination Received ever 62. 0% Health Insurance Self-rated health TM

Results: Disease & Vaccine Awareness 23. 6% TM

Results: Vaccine Financing Heard of vaccine (n=618) Vaccinated (n=141) Less than $50 11. 8% $50 or more 18. 3% Don’t know 69. 9% Amount I would have to pay for shingles vaccine is too expensive Yes 22. 6% 28. 4% No 21. 7% 44. 8% Unsure 53. 4% 21. 9% My health insurance will pay for the shingles vaccine Yes, all of cost Yes, some of cost 20. 3% 12. 0% 50. 4% 21. 2% No / no insurance 13. 2% 20. 2% Unsure 54. 6% 8. 3% How much would it cost you to get shingles vaccine? * N/A *Asked only of the unvaccinated (n=475 who had heard of shingles vaccine). When vaccinees were asked how much shingles vaccine cost them, 48% reported no cost and 50% could not remember the cost or did not respond. TM

Potential Barriers to Vaccination Agree Neutral Disagree Cannot find shingles vaccine in my town or city 59. 8% 30. 2% 9. 9% Do not need the shingles vaccine 38. 1% 33. 9% 28. 0% Do not have enough information about the shingles vaccine 25. 2% 30. 0% 44. 7% Shingles vaccine is too expensive 26. 6% 46. 0% 27. 5% Worried about side effects from the shingles vaccine 32. 6% 41. 4% 26. 0% *Restricted to unvaccinated persons who had heard of the shingles vaccine, n=475. Proportions reported above are among those who responded; 11%-16% did not answer these questions. TM

Factors Not Associated with Vaccination Rates* • • Age Region Employment status Marital status Personal history of zoster disease Family history of zoster disease Health insurance: Medicare Part B, Medicare Part D, Medicaid, private insurance, “other” insurance *Among both all respondents and among only respondents who had heard of the zoster vaccine. TM

Vaccination Rates by Respondent Characteristics Race/ethnicity Education level Sex Self-rated health All respondents (n=1, 365) Heard of vaccine (n=618) White 12. 8% 23. 7% African-American 3. 1% Hispanic 8. 4% 27. 8% ≤ High school 5. 9% 14. 9% ≥ Some college 13. 7% Male 11. 6% Female 11. 3% Excellent / V. good 14. 3% Good 9. 9% Fair / Poor 8. 2% 0. 005 0. 0002 11. 8% 26. 2% N. S. 0. 01 28. 7% N. S. 19. 9% 0. 02 25. 9% 0. 04 23. 3% N. S. 17. 4% TM

Vaccination Rates by Respondent KABs All respondents (n=1, 365) Heard of vaccine (n=618) Provider recommended shingles vaccine Yes 57. 8% No 2. 0% Amount I would have to pay for vaccine is too expensive Yes 24. 3% No 33. 4% Unsure 3. 7% 9. 4% Received influenza vaccine in last 12 mos. Yes No 15. 3% 3. 1% <0. 0001 27. 3% 9. 4% 0. 0001 Ever received pneumococcal vaccine Yes No 14. 7% 6. 3% <0. 0001 26. 4% 16. 7% 0. 02 <0. 0001 59. 8% 5. 3% <0. 0001 30. 1% 49. 2% <0. 0001 TM

Discussion • Provider recommendation is strongly associated with zoster vaccine receipt – 58% of those reporting a recommendation were vaccinated (vs. 2% who did not) – However, providers do not appear to be recommending vaccine • 34% of those who had heard of zoster vaccine – Concerns about vaccine storage & reimbursement may deter providers from recommending zoster vaccine to patients TM

Discussion (2) • Substantial lack of awareness about zoster vaccine in recommended population – Over half of adults ≥ 60 in this survey were not aware of zoster vaccine – Majority who know about vaccine do not know if insurance will pay for it or what it will cost • Vaccine cost may be less important – Only 27% of unvaccinated agreed zoster vaccine is “too expensive” – However, coverage is significantly lower among those with financial concerns TM

Limitations • Respondents may not be representative of all U. S. adults ≥ 60 years – Weighting reduces but does not eliminate bias • Majority of respondents were unaware of shingles vaccine – Analyses limited to those who heard of vaccine • Overall low coverage rate limits ability to test associations in subgroups • Cross-sectional surveys cannot determine causality TM

Conclusions • Need targeted educational efforts regarding availability of, and need for, zoster vaccine – Limited awareness of vaccine’s existence – 38% of unvaccinated agreed with statement “I do not need the shingles vaccine” – Differences in awareness may be contributing to race disparities in coverage • Removing barriers to vaccination among providers and patients may increase coverage – Production issues may continue to limit availability – Confusion re: insurance coverage may deter patients – Addressing provider concerns will support provider recommendations for vaccination TM

Questions? Megan C. Lindley National Center for Immunization and Respiratory Diseases MLindley@cdc. gov TM

Results: How Did You Hear About Shingles? I have had shingles 17. 3% An immediate family member* had it 25. 9% Someone else I know** had it 52. 3% Healthcare provider told me about it 13. 7% Someone else told me about it 14. 9% Other source (e. g. radio, TV, book) 18. 7% Not sure / Don’t remember 8. 6% I had never heard of shingles before 5. 2% * E. g. parent, sibling, child (excluding spouse) ** E. g. spouse, other family member, friend, acquaintance TM

Vaccination Rates by Insurance Type Medicare Part D Medicare Part B Medicaid TRICARE / VA Private insurance Other insurance Uninsured Yes 10. 6% No 11. 8% Yes 11. 5% No 11. 4% Yes 6. 8% No 12. 0% Yes 20. 2% No 10. 7% Yes 12. 05 No 10. 9% Yes 11. 7% No 11. 4% Yes 1. 6% No 11. 8% N. S. 0. 009 N. S. TM