1. TM 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

2. TM Disclosure Information The authors have no financial or other conflicts of interest to discloseThe 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 policyThe 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

3. TM Background 2006 Advisory Committee on Immunization Practices (ACIP) recommendation: healthy adults ≥60 years receive 1 dose of herpes zoster (shingles) vaccine2006 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 vaccine2008 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

4. TM Background (2) Zoster is the most expensive vaccine routinely recommended for adultsZoster 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)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 factorsMany potential barriers to high zoster vaccination coverage: cost, low awareness, lack of perceived need, other factors

5. 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 oldTo assess attitudes and beliefs about zoster vaccine and identify factors associated with vaccine receipt in a national sample of adults ≥60 years old

6. TM Methods: Sample Selection ‘Styles’ surveys: panel of 328,000 potential respondents recruited by mail‘Styles’ surveys: panel of 328,000 potential respondents recruited by mail –ConsumerStyles 2009: stratified random sample 10,587 of 21,420 households (49%) completed10,587 of 21,420 households (49%) completed HealthStyles 2009 surveyHealthStyles 2009 survey –Random sample of 7,004 households that completed the 2009 ConsumerStyles survey –Fielded August-September 2009 –4,556/7,004 households (65.0%) responded Limited to 1,365 respondents aged ≥60 yearsLimited to 1,365 respondents aged ≥60 years

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

8. TM Results: Selected Demographics Age group 60-64 yrs. 32.3% 65-69 yrs. 23.5% 70-74 yrs. 18.8% 75-79 yrs. 13.7% 80 + yrs. 11.7% Race/ethnicity White75.7% African-American10.6% Hispanic9.5% Other4.2% Education level <HS6.5% High school graduate 23.4% Some college 34.9% College graduate or higher 34.4%

9. TM Results: Health Behaviors & Insurance Health Insurance Medicare Part B 61.3% Medicare Part D 24.2% Medicaid9.3% TRICARE/VA7.8% Private insurance 49.0% Other22.8% Uninsured3.5% Self-rated health Excellent / Very Good 42.1% Good38.6% Fair / Poor 18.2% Influenza vaccination Received last 12 months 67.% Pneumococcal vaccination Received ever 62.0%

10. TM Results: Disease & Vaccine Awareness 23.6%

11. TM Results: Vaccine Financing Heard of vaccine (n=618) Vaccinated (n=141) How much would it cost you to get shingles vaccine?* Less than $50 11.8%N/A $50 or more 18.3% Don’t know 69.9% Amount I would have to pay for shingles vaccine is too expensive Yes22.6%28.4% No21.7%44.8% Unsure53.4%21.9% My health insurance will pay for the shingles vaccine Yes, all of cost 20.3%50.4% Yes, some of cost 12.0%21.2% No / no insurance 13.2%20.2% Unsure54.6%8.3% *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.

12. TM Potential Barriers to Vaccination AgreeNeutralDisagree 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.

13. 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.

14. TM Vaccination Rates by Respondent Characteristics All respondents (n=1,365) Heard of vaccine (n=618) Race/ethnicity White12.8% 0.005 23.7% N.S. African-American3.1%11.8% Hispanic8.4%27.8% Education level ≤ High school5.9% 0.0002 14.9% 0.01 ≥ Some college13.7%26.2% Sex Male11.6% N.S. 28.7% 0.02 Female11.3%19.9% Self-rated health Excellent / V. good14.3% 0.04 25.9% N.S. Good9.9%23.3% Fair / Poor8.2%17.4%

15. TM Vaccination Rates by Respondent KABs All respondents (n=1,365) Heard of vaccine (n=618) Provider recommended shingles vaccine Yes57.8% <0.0001 59.8% <0.0001 No2.0%5.3% Amount I would have to pay for vaccine is too expensive Yes24.3% <0.0001 30.1% <0.0001 No33.4%49.2% Unsure3.7%9.4% Received influenza vaccine in last 12 mos. Yes15.3% <0.0001 27.3% 0.0001 No3.1%9.4% Ever received pneumococcal vaccine Yes14.7% <0.0001 26.4% 0.02 No6.3%16.7%

16. TM Discussion Provider recommendation is strongly associated with zoster vaccine receiptProvider 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 vaccine34% of those who had heard of zoster vaccine –Concerns about vaccine storage & reimbursement may deter providers from recommending zoster vaccine to patients

17. TM Discussion (2) Substantial lack of awareness about zoster vaccine in recommended populationSubstantial 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 importantVaccine 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

18. TM Limitations Respondents may not be representative of all U.S. adults ≥60 yearsRespondents 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 vaccineMajority 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 subgroupsOverall low coverage rate limits ability to test associations in subgroups Cross-sectional surveys cannot determine causalityCross-sectional surveys cannot determine causality

19. TM Conclusions Need targeted educational efforts regarding availability of, and need for, zoster vaccineNeed 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 coverageRemoving 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

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

21. TM Results: How Did You Hear About Shingles? I have had shingles17.3% 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

22. TM Vaccination Rates by Insurance Type Medicare Part D Yes10.6%N.S.No11.8% Medicare Part B Yes11.5%N.S. No11.4% Medicaid Yes6.8%N.S. No12.0% TRICARE / VA Yes20.2%0.009 No10.7% Private insurance Yes12.05N.S. No10.9% Other insurance Yes11.7%N.S. No11.4% Uninsured Yes1.6%N.S. No11.8%