US Flu Vaccine Landscape Preliminary Analysis

Quantum Flu Patch Project

8/31/2011

Contents

OVERVIEW.......................................................................................................................................................... 1

FINDINGS AND ANALYSIS.................................................................................................................................... 2

I. COVERAGE AND BARRIERS BY SEGMENT...................................................................................................................2CDC Recommendation for annual influenza vaccination.....................................................................................2Seasonal Influenza Vaccine Coverage in the US...................................................................................................3Historical coverage rates for comparison............................................................................................................4Barriers, adult general population.......................................................................................................................5Barriers, high risk populations.............................................................................................................................6Factors positively associated with seasonal influenza vaccine coverage by population group............................7

II. COVERAGE BY ACCESS POINT.................................................................................................................................8Flu vaccine access points.....................................................................................................................................82010-2011 Season Access Points, 18 and older, survey of 36,581 people............................................................9Sites for Flu Vaccination, Actual vs. Preferred 2008-2009.................................................................................11Who can deliver current flu vaccines.................................................................................................................11Incentives to receive current flu vaccines at retail access points:......................................................................12

III. SUPPLY AND MARKET SHARE...............................................................................................................................12Types of flu vaccines available in the US............................................................................................................12Influenza vaccine manufacturers in the United States 2010-2011.....................................................................12Market Share for the 2010-2011 Flu Vaccine Season by Manufacturer.............................................................13

SOURCES........................................................................................................................................................... 14

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OverviewThis preliminary US Flu Vaccine Landscape focused on understanding aspects of the current delivery system relevant to uptake in order to inform how flu patch technology benefits could affect coverage rates.

Key factors influencing our focus:• As of the 2010–2011 influenza season, the CDC recommends that all people aged > 6 months

should receive annual vaccinations for seasonal flu.1

• This reduces the relevance of quantifying disease burden associated with seasonal flu in the US, as disease burden analysis is typically used to influence policy, and a 100% coverage policy target has already been adopted.

• Accordingly, the landscape focus has shifted from analyzing historical coverage to analyzing barriers to adoption that have historically limited coverage.

Key questions:• Who receives the current vaccine, who administers the vaccine, and where?

• Who pays for influenza vaccine and how much do they pay?

• What market segments have unmet needs?

• Why are these market segments not receiving the flu vaccine?

Objectives:• Identify barriers to uptake most relevant to the value proposition of the flu patch.

• Recommend strategies for positioning the flu patch value proposition across stakeholder groups:- Healthcare professionals/policymakers- Consumers- Vaccine manufacturers

1 http://www.cdc.gov/media/pressrel/2010/r100224.htm

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Key findings:• The newly revised

CDC guidelines, which recommend that all people 6 months and older be vaccinated with the seasonal flu vaccine, represent a significant opportunity for the flu patch.

• Opportunities to increase coverage exist in every age group, with the greatest opportunities being in the 13–18 and 19–49 age groups (non-high risk).

• The primary barriers to flu vaccination are lack of perceived need and concern over side effects. These barriers must be addressed across all flu vaccination options, and are not the best focus of flu patch value statement positioning.

• Convenience and awareness are the next most important barriers. These barriers are suitable for development of flu patch value statement positioning.

• Reduced training required to supervise administration of the flu patch could increase coverage and awareness by enabling more access points.

• Cost is not a major barrier for uptake of current flu vaccines.

Findings and Analysis

I. Coverage and Barriers by Segment

CDC Recommendation for annual influenza vaccination

CDC recommendations have changed significantly over the years (revisions in 2004, 2007, and 2010). As of the 2010-2011 influenza season the CDC recommends all people 6 months of age and older be vaccinated.2 The previous recommendation for higher risk persons, children 6 months through 18 years of age, and close contacts of higher risk persons already applied to about 85 percent of the US population.3 The US is currently the only country in the world that recommends all populations be vaccinated. WHO has not adopted this coverage policy.4

Before 2008, the Advisory Committee on Immunization Practices (ACIP) had recommended annual vaccination for influenza for persons aged ≥ 50 years, 18–49 years at higher risk for influenza complications, and 6 months–4 years. In 2008, ACIP expanded the recommendations to include all children aged 5–18 years of age, beginning with the 2008–2009 season.5

This expansion of recommended coverage suggests that project resources originally allocated to disease burden analysis should be directed toward gaining a better understanding of historical actual coverage (adoption), by segment, and the barriers to adoption in each segment.

2 http://www.cdc.gov/media/pressrel/2010/r100224.htm3 http://www.cdc.gov/media/pressrel/2010/r100224.htm4 Kathy Neuzil, personal communication, August 23, 2011.5 CDC. Influenza vaccination coverage among children and adults—United States, 2008-09 influenza season. MMWR Morb Mortal Wkly Rep. 2009; 58(39):1091–1095.

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Seasonal Influenza Vaccine Coverage in the US

Estimated influenza vaccination coverage among all children and adults, by selected age groups and race/ethnicity, United States, National Flu Survey, March 20116

Un-weighted sample size

Influenza vaccination coverage

No. % 95% CI*

All 38,113 42.3 ± 3.0By age-groups

Children 6m–17 years 6,871 46.2 ± 6.96m–4 years 1,605 60.9† ± 13.55–12 years 2,926 46.9† ± 10.513–17 years 2,340 32.1† ± 10.9

Adults ≥18 years 31,242 41.1 ± 3.118–49 years, HR§ 2,098 35.4† ± 10.618 –49 years, non-HR 9,056 26.0 ± 4.718-49 years, HR unknown 855 36.9† ± 14.850-64 years 10,445 47.7 ± 5.665+ years 8,788 74.7 ± 4.8

By race/ethnicity:Hispanic 4,695 37.7 ± 8.1Non-Hispanic, White only 25,839 45.5 ± 3.4Non-Hispanic, Black only 4,908 35.5† ± 11.8Non-Hispanic, Other or multiple race 2,671 32.9 ± 9.0

* Percentages are weighted to the US population; confidence interval half-width.† Estimate may not be reliable, confidence interval half-width >10.0.§ High risk includes asthma, other lung problems, diabetes, heart disease, kidney problems, anemia, weakened immune system caused by a chronic illness or by medicines taken for a chronic illness.

6 http://www.cdc.gov/flu/pdf/vaccination/fluvacsurvey.pdf

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All Children (6m–17 years) Adults >18 years05

101520253035404550

32.830.6

33.5

42.6 42.9 42.542.346.2

41.1

Comparison of influenza vaccination coverage estimates from the November 2010 and March 2011 National Flu

Survey, United States

Coverage, Nov 2010

Vaccinated plus definite in-tent to be vaccinated, Nov, 2010

Coverage, Mar 2011

Historical coverage rates for comparison

2009–2010 2008–2009Children7

6– 23 months 55.7% 55.2%2- 4 yrs 38.4% 33%5-12 yrs 27.1% 19%13-18 yrs 15.3% 10.9%Adults 2009–20108 2008–20099

19-49 yrs 30% 19.7%19-49 yrs (high risk) 33.4%50-64 yrs 45% 34.2%50-64 (high risk) 51.5%≥ 65 yrs 69% 65.6%

7 Seasonal influenza vaccination coverage among children aged 6 months–18 years—eight immunization information system sentinel sites, United States, 2009–10 influenza. MMWR Morb Mortal Wkly Rep. 2010;59(39):1266–1269.8 MMMR Weekly 2011 June; 60; 737-743 .9 http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm

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Follow-up ActionThese data suggest a jump in coverage rates from 2010 to 2011; this is an area for further

exploration.

Barriers, adult general populationThere have been numerous articles published examining the reasons why people do not get the flu shot. A sampling of these reasons and respective citations are included in the table below.

Category Factor References (see endnotes)

Perception of needPersonal need 1, 2, 3, 4, 5Don’t believe in flu vaccine 3, 4, 5Negative perceptions (illness or side effects) 1, 3, 4, 5Lack of Physician’s recommendation 3, 5, 2, 6*

ConvenienceIt takes too much time 4, 5Didn’t get around to it 2, 3Convenience (access point) 7

Awareness/educationKnowledge- Didn’t know about it 5Don’t know where to get it 5Don’t know enough to make a decision 4Failed to think about it 1

FinancialCost 4, 5, 6*Lack of insurance coverage 5, 6*

SupplyConcerns about availability of the vaccine 1, 3Others might need it more than I do 3, 4, 5

OtherFear of needles 3, 4, 5, 6*

*Verification necessary with full text of the article.

Barriers to flu vaccine uptake were identified in two robust studies in the general adult population. Those listed in green are ones that the flu patch could potentially address (related to awareness, convenience, and cost).

2009–201010 N=4,04018–49 yrs

2003–2004 11 N=4,02818–65 yrs

Don’t need it 28% Not necessary 33%Didn’t get around to it 16% Never thought about it 21%Don’t believe in it 14% Not effective 9%Might get sick/suffer side 14% Could cause illness 21%10Seasonal Influenza Vaccine Use by Adults in the U.S. Detailed Survey Data Tables for the 2009–2010 Vaccination Season. http://www.rand.org/content/dam/rand/pubs/occasional_papers/2010/RAND_OP311.1.pdf.11 Jones TF, Ingram LA, Craig AS, Schaffner W. Determinants of influenza vaccination, 2003-2004: shortages, fallacies and disparities. Clin Infect Dis. 2004;39(12):1824–1828.

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2009–2010 N=4,04018–49 yrs

2003–2004 N=4,02818–65 yrs

effectsSide effects not worth it 10%

Others need it more 6%Dislike needles 5%Vaccine not available 5% Vaccine not available 5%Costs too much 4% Cost 3%

Never saw provider to ask 2%No doctor recommendation

3%

Other 8% No time 5%

Barriers, high risk populations

Category(where applicable)

Factor References (see end notes)

ChildrenConvenience Convenience (medical setting) 12

Competing time demands (medical setting) 12Cost Cost (medical setting) 12

Other Parent’s desire to be with their children (school setting) 12Competence of person delivering vaccine (school setting)

12

ElderlyAwareness/Education Lack of Education 8

Other Lack of enforcement by health care providers 8Health Personnel

Perception of Value Value 18Concerns about vaccine effectiveness 9, 11Misconceptions regarding the effectiveness and health risks of the vaccine

11

Adverse events 13, 14Need 11

Supply Concerns about availability 14Other Belief in personal health as a protector against influenza 9

Lack of employer mandate 9Pregnant women

Perception of Value Value 17Awareness/Education Awareness 10

Not knowledgeable about where to obtain vaccination 17Other Healthcare providers did not say anything about 15

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Category(where applicable)

Factor References (see end notes)

vaccinationConcerns for effects on fetal and maternal health 17

Health indicationsPerception of value Fear of side effects 16

Other Lack of being at risk 16

Factors positively associated with seasonal influenza vaccine coverage by population group

Adults: Pharmacists increased immunization uptake 5% to 7% across all age groups for states

allowing pharmacists to provide immunizations.12

Children:13

Child had received all recommended immunizations. Child had a regular health-care provider. Child saw a pediatrician most of the time for well-child care visits (compared with

children who saw a family doctor or nurse practitioner). Child had uninterrupted health insurance coverage. Child had received an influenza vaccination during the previous influenza season.

12 http://www.omnisys-llc.com/pdf_files/ImmunizationWhitePaper01132011.pdf 13 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6029a2.htm?s_cid=mm6029a2_w

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Follow-up Action:Continue to flesh out and

analyze barriers for priority high-risk population groups

(children and health care workers).

Follow-up Action:Flesh out factors

positively associated with seasonal influenza vaccine

coverage. Could any of these factors be leveraged by

the flu patch?

II. Coverage by Access Point

Flu vaccine access points

Both medical and nonmedical settings are common places for adults to receive influenza vaccinations. Doctors’ offices are the primary medical settings, while workplaces and stores are the primary nonmedical settings.14

Primary locations for adult vaccination:

Work place (company flu shot clinics through companies such as Maxim Wellness15 Retail stores (either flu clinics or pharmacies):

o As of 2009 all states allow pharmacies to provide the flu shot.16

o The proportion of adults vaccinated in retail stores reached 18.4% during the 2010–2011 season, a jump from 7% in 2006–2007 (attributed to changing laws that allow pharmacists to administer the flu vaccine).17

Doctors offices. Hospitals & health department clinics.

Primary locations for child vaccination:

Doctors offices. Hospitals and health department clinics. Limited access:

o Retail stores (either flu clinics or pharmacies): Depends on license of administrator. Some vaccinate 18 months+, while

others are limited to 3 yrs+ or 9 yrs+). Schools.

14 MMWR / June 17, 2011 / Vol. 60 / No. 23 http://www.cdc.gov/mmwr/pdf/wk/mm6023.pdf 15 http://www.whyus.us/MaximWellness/Corporate_Flu_Services_video_draft_c.htm16 http://www.nnbw.com/ArticleRead.aspx?storyID=16132 17 http://www.fiercepharmamanufacturing.com/story/pharmacies-bolster-supply-chain-role-giving-flu-shots/2011-06-21

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2010-2011 Season Access Points, 18 and older, survey of 36,581 people18

Location 2010–2011Total 18-49 50-64 65+

Medical settingDoctor’s office/HMO 39.8% 32.2% 38.8% 51.5%Hospital/emergency dept. 7.2% 9.0% 7.0% 4.9%Another type of clinic 7.1% 7.8% 6.5% 6.7%Health Dept. 4.4% 5.3% 4.0% 3.8%Non-Medical settingStore 18.4% 14.5% 18% 24.3%Workplace 17.4% 25.7% 21.1% 1.9%Senior/community center 1.4% 0.4% 0.8% 3.4%School 1.2% 2.0% 1.1% 0.3%Other 2.9% 2.9% 2.5% 3.1%

Analysis from this survey: Overall, respondents with high-risk conditions were more likely to receive their

vaccinations in a medical setting (69.4%) than those without these conditions (54.1%)

By type of setting, a greater percentage of respondents overall were vaccinated in medical settings (58.6%) than nonmedical settings (41.4%)

o The percentage of non-Hispanic whites receiving their influenza vaccination in a nonmedical setting (43.6%) was greater than the percentage of non-Hispanic blacks (28.7%) overall

Overall, the percentage of persons vaccinated in nonmedical settings increased with education level: 27.5% for those with less than a high school education, 35.9% for high school graduates, and 46.7% for those who had attended college

Additional analysis on access points:19

Working individuals or those without any other reason to see a physician may be less willing to endure the inconvenience of making an appointment in advance and the associated work absence, travel and wait time with an appointment

Alternative locations address some population segments not captured by the traditional health care system.

Retail stores capture patients who are older, white, and low-risk for influenza.

Work- places appeal to those who value convenience in the vaccination decision.

Alternative locations are not serving many other population segments (e.g., rural or lower income patients) that do not regularly interact with the traditional health care system. In

18 MMWR / June 17, 2011 / Vol. 60 / No. 23 http://www.cdc.gov/mmwr/pdf/wk/mm6023.pdf 19 Lee BY, Mehrotra A, Burns RM, Harris KM. Alternative vaccination locations: who uses them and can they increase flu vaccination rates? Vaccine. 2009;27(32):4252–4256.

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fact, retail stores are serving many individuals who have had multiple physician visits over the prior year.

Access points from previous years for comparison

2008–200920 2009–201021 2010–201122

Location Age group 18-49 50-64 65+ 18 yrs + 18 yrs +Doctor’s office 46% 39% 45% 47.5% 39.8%

Workplace 26% 18% 1% 19.5% 18.4%

Clinic/Community Health Center

4% 16% 18% 17% 11.5%

Retail Store 10% 6% 11% 16% 18.7%

Place of vaccination, children and adults, National Flu Survey interviews conducted March 3 through March 30, 2011, United States23

20 2008–2009 Influenza Vaccine Production & Distribution Market Brief. 21 Seasonal Influenza Vaccine Use by Adults in the US: Detailed Survey Data Tables for the 2009-2010 Vaccination Season, Rand Health.22 MMWR / June 17, 2011 / Vol. 60 / No. 2323 http://www.cdc.gov/flu/pdf/vaccination/fluvacsurvey.pdf

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Sites for Flu Vaccination, Actual vs. Preferred 2008-200924

Location 18–49 50–64 65+

Doctor’s office Actual 46% 39% 45%Preferred 59% 46% 52%

Workplace Actual 26% 18% 1%Preferred 25% 17% 0%

Clinic/Community Health Center

Actual 4% 16% 18%Preferred 2% 13% 14%

Retail Store Actual 10% 6% 11%Preferred 0% 2% 5%

Who can deliver current flu vaccines Physician. Nurse.

o Nurse practitioners primarily staff retail clinics and work place immunization clinics.25

o Retail clinics staffed by nurse practitioners can immunize 18 months and up.26

Pharmacist:27

o Pharmacists are now allowed to immunize in all 50 states. There are age restrictions on who a pharmacist can immunize. Pharmacists have a key role to play in combating disease through vaccine

delivery as they have proven a critical link to increasing awareness and access in a cost effective manner. A study published in 2004 in the journal Vaccine found that pharmacists increased immunization uptake 5 to 7% across all age groups for states allowing pharmacists to provide immunizations.

Pharmacy intern under supervision.28

24 http://www.flusupplynews.com/documents/09_FluBrief_000.pdf 25 Lee BY, Mehrotra A, Burns RM, Harris KM. Alternative vaccination locations: who uses them and can they increase flu vaccination rates? Vaccine. 2009;27(32):4252–4256.26 PATH primary research27 http://www.omnisys-llc.com/pdf_files/ImmunizationWhitePaper01132011.pdf 28 http://www.gpha.org/displaycommon.cfm?an=1&subarticlenbr=270

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Follow-up Action:Determine the age groups that pharmacists can vaccinate and whether this varies by state.

Could the flu patch expand access?

Incentives to receive current flu vaccines at retail access points:Retailers’ promotions provide incentives to encourage customers to obtain a flu shot in their clinic/pharmacy, examples include:29

At Rite Aid recipients receive a free booklet containing $128 in store coupons, while supplies last. Members of the Wellness+ rewards program also earn 25 points (125 earns a 10% off savings pass).

At SuperValu customers who obtained a flu shot received a free booklet with $75 worth of store coupons and a sample bag of cold, cough and flu items.

At Winn Dixie members of the supermarket chain s free loyalty program get a $5 discount, bringing the price to $23.

CVS offers shoppers a 10 percent discount on the purchases they make after they get a flu shot at one of the approximately 20 CVS stores in the region.30

III.Supply and Market Share

Types of flu vaccines available in the US

There are currently four types of flu vaccines being produced for the United States market:31

The regular seasonal flu shot utilizes an inactivated vaccine delivered via needle & syringe (“NS”) syringe at intramuscular (“IM”) depth. It has been used for decades and is approved for use in people 6 months of age and older, including healthy people, people with chronic medical conditions and pregnant women. Regular flu shots make up the bulk of the flu vaccines administered in the United States.

A high-dose inactivated vaccine is available for people 65 and older, and is also delivered via NS at IM depth. This vaccine was first made available during the 2010–2011 flu season.

An intradermal (“ID”) inactivated vaccine for people 18 to 64 years of age which is injected via NS into the “dermis” or skin. This vaccine is being made available for the first time for the 2011–2012 season.

The nasal-spray flu vaccine—a vaccine made with live, weakened flu viruses that is given as a nasal spray (sometimes called LAIV for “Live Attenuated Influenza Vaccine”). LAIV is approved for use in healthy people 2 to 49 years of age who are not pregnant.

Influenza vaccine manufacturers in the United States 2010-201132

29 http://www.smartmoney.com/spend/family-money/get-a-flu-shot-for-less/ 30 http://www.nnbw.com/ArticleRead.aspx?storyID=16132 31 http://www.cdc.gov/flu/keyfacts.htm#whento 32 http://www.nyc.gov/html/doh/flu/downloads/pdf/providers/flu-vac-ordering-form.pdf

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sanofi pasteur Inc. produces Fluzone® an inactivated influenza virus vaccine in infant formulation (0.25 single-dose syringe for six to 35 months), child and adult formulation (0.5 single-dose syringe, multi-dose vial for 3 years and older) and a high-dose formulation (65 years and older). An intradermal version has been released for the 2010-2011 flu season, Fluzone Intradermal® for ages 18-64.

Novartis produces Fluvirin® inactivated influenza virus vaccine. Fluvirin® is indicated foruse in persons 4 years of age and older (0.5 single-dose syringe or multi-dose vial) and Agriflu® for 18 years and older. www.chiron.com.

GlaxoSmithKline produces Fluarix® inactivated influenza virus vaccine, which is licensed for use in persons 3 years of age and older (0.5 single-dose syringe), and FluLaval® for use in persons 18 years of age and older (multi-dose vial). www.gsk.com.

MedImmune, Inc produces FluMist®, a live attenuated intranasal influenza virus vaccine. This intranasal vaccine is only for use in healthy people 2 - 49 years of age. www.medimmune.com.

CSL Biotherapies produces Afluria® (distributed by Merck) an inactivated influenza virus vaccine, for use in children 9 years of age and older (0.5 single-dose).

Market Share for the 2010-2011 Flu Vaccine Season by Manufacturer

171 million doses of vaccine are anticipated (this compares to 150 million doses in the 2009-2010 flu season).33

Manufacturer No. of doses (millions)2010–2011

Percentage of total2010–2011

Sanofi Pasteur 70 41%GlaxoSmithKline 36 21%Novartis 35 20%MedImmune 16 9%CSL 14 8%

33 http://www.flusupplynews.com/supply_info.cfm

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Follow-up Action:Determine how market share has evolved since FluMist was launched in 2003.

Sources 1.Influenza vaccination coverage among children aged 6–23 months—United States, 2007-08

influenza season. MMWR Morb Mortal Wkly Rep. 2009;58(38):1063–1066.

2.Influenza vaccination coverage among children and adults—United States, 2008-09 influenza season. MMWR Morb Mortal Wkly Rep. 2009; 58(39):1091–1095

3.Seasonal influenza vaccination coverage among children aged 6 months–18 years—eight immunization information system sentinel sites, United States, 2009–10 influenza. MMWR Morb Mortal Wkly Rep. 2010;59(39):1266–1269.

4.Ahluwalia IB, Jamieson DJ, Rasmussen SA, D'Angelo D, Goodman D, Kim H. Correlates of seasonal influenza vaccine coverage among pregnant women in Georgia and Rhode Island. Obstet Gynecol. 2010;116(4):949–955.

5.Allison MA, Reyes M, Young P, et al. Parental attitudes about influenza immunization and school-based immunization for school-aged children. Pediatr Infect Dis J. 2010;29(8):751–755.

6.Chi RC, Rock MT, Neuzil KM. Immunogenicity and safety of intradermal influenza vaccination in healthy older adults. Clin Infect Dis. 2010;50(10):1331–1338.

7.Christini AB, Shutt KA, Byers KE. Influenza vaccination rates and motivators among healthcare worker groups. Infect Control Hosp Epidemiol. 2007;28(2):171–177.

8.Clark SJ, Cowan AE, Wortley PM. Influenza vaccination attitudes and practices among US registered nurses. Am J Infect Control. 2009;37(7):551–556.

9.Dutheil F, Kelly C, Biat I, et al. [Relation between the level of knowledge and the rate of vaccination against the flu virus among the staff of the Clermont-Ferrand University hospital]. Med Mal Infect. 2008;38(11):586–594.

10.Fisher BM, Scott J, Hart J, Winn VD, Gibbs RS, Lynch AM. Behaviors and perceptions regarding seasonal and H1N1 influenza vaccination during pregnancy. Am J Obstet Gynecol. 2011;204(6 Suppl 1):S107–S111.

11.Harris KM, Maurer J, Lurie N. Do people who intend to get a flu shot actually get one? J Gen Intern Med. 2009;24(12):1311–1313.

12.Hofmann F, Ferracin C, Marsh G, Dumas R. Influenza vaccination of healthcare workers: a literature review of attitudes and beliefs. Infection. 2006;34(3):142–147.

13.Hubble MW, Zontek TL, Richards ME. Predictors of influenza vaccination among emergency medical services personnel. Prehosp Emerg Care. 2011;15(2):175–183.

14.Johnson DR, Nichol KL, Lipczynski K. Barriers to adult immunization. Am J Med. 2008;121(7 Suppl 2):S28–S35.

15.Jones TF, Ingram LA, Craig AS, Schaffner W. Determinants of influenza vaccination, 2003-2004: shortages, fallacies and disparities. Clin Infect Dis. 2004;39(12):1824–1828.

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17.Kelly C, Dutheil F, Haniez P, et al. [Analysis of motivations for antiflu vaccination of the Clermont-Ferrand University Hospital staff]. Med Mal Infect. 2008;38(11):574–585.

18.Lee BY, Mehrotra A, Burns RM, Harris KM. Alternative vaccination locations: who uses them and can they increase flu vaccination rates? Vaccine. 2009;27(32):4252–4256.

19.Li Y, Mukamel DB. Racial disparities in receipt of influenza and pneumococcus vaccinations among US nursing-home residents. Am J Public Health. 2010;100 Suppl 1:S256–S262.

20.Madjid M, Alfred A, Sahai A, Conyers JL, Casscells SW. Factors contributing to suboptimal vaccination against influenza: results of a nationwide telephone survey of persons with cardiovascular disease. Tex Heart Inst J. 2009;36(6):546–552.

21.Millner VS, Eichold BH, Franks RD, Johnson GD. Influenza vaccination acceptance and refusal rates among health care personnel. South Med J. 2010;103(10):993–998.

22.O'Malley AS, Forrest CB. Immunization disparities in older Americans: determinants and future research needs. Am J Prev Med. 2006;31(2):150–158.

23.Panda B, Stiller R, Panda A. Influenza vaccination during pregnancy and factors for lacking compliance with current CDC guidelines. J Matern Fetal Neonatal Med. 2011;24(3):402–406.

24.Piccirillo B, Gaeta T. Survey on use of and attitudes toward influenza vaccination among emergency department staff in a New York metropolitan hospital. Infect Control Hosp Epidemiol. 2006;27(6):618–622.

25.Poland GA, Johnson DR. Increasing influenza vaccination rates: the need to vaccinate throughout the entire influenza season. Am J Med. 2008;121(7 Suppl 2):S3–10.

26.Shah S, Caprio M. Trivalent inactivated influenza vaccine compliance rate in neonatal intensive care unit parents. Adv Neonatal Care. 2007;7(6):295–298.

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28.Uscher-Pines L, Maurer J, Kellerman A, Harris KM. Healthy young and middle age adults: what will it take to vaccinate them for influenza? Vaccine. 2010;28(46):7420–7422.

29.Winston CA, Wortley PM, Lees KA. Factors associated with vaccination of medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003. J Am Geriatr Soc. 2006;54(2):303–310.

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