Vaccine Specialists from Health Agencies Nationwide Gather at Academy to Discuss Strategies for Reaching Vulnerable Populations

NEW YORK CITY, Sept. 11—Immunization experts from city, state and federal health agencies recently gathered at The New York Academy of Medicine to discuss strategies for vaccinating hard-to-reach populations in order to prevent the uncontainable spread of infectious diseases and deadly viruses.

The day-long, closed-door meeting on Sept. 8 was particularly timely considering the approaching influenza season, the likelihood of a pandemic flu outbreak, and the continued threat of bioterrorist attacks on our soil. Experts from the U.S. Centers for Disease Control and Prevention (CDC) National Immunization Program, the U.S. Department of Health and Human Services National Vaccine Program Office, the New York City Department of Health and Mental Hygiene (DOHMH), and the Institute of Medicine were among the approximately 30 researchers, clinicians and community members on hand, many of whom gave 15-minute presentations about their vaccine-related experiences and emergency preparedness vaccination plans.

Scientists from the Academy’s Center for Urban Epidemiologic Studies (CUES) began the meeting by explaining the small scale, successful, rapid-vaccination approach called Project VIVA they’ve developed over the past few years. VIVA, which stands for Venue-Intensive Vaccines for Adults, involves vaccinating people on busy sidewalks and door-to-door in housing projects in East Harlem and the South Bronx. Bilingual outreach workers from the Academy working with licensed nurses gave the flu vaccine to over one thousand homeless, homebound elderly, immigrants, minorities, and injection drug users—defined as hard-to-reach populations—in a 10-day period during the last flu season.

“We have data that the people who were most interested in getting the vaccine from us, otherwise wouldn’t have gotten the vaccine,” reported Sandro Galea, MD, DrPH, Associate Professor in the University of Michigan School of Public Health, and former Associate Director of CUES. Galea and CUES Director David Vlahov, PhD, launched Project VIVA several years ago after discussions with the CUES community advisory board revealed that vulnerable populations were rarely getting vaccinated, and thus faced elevated risk of disease.

Vaccinating people in disadvantaged communities is a particular challenge that remains unsatisfactorily met, speaker after speaker agreed. A significant obstacle is figuring out how many people belong to the “hard-to-reach population” category in a particular state, city, or neighborhood. That entails a tremendous amount of legwork, considering that homeless and undocumented immigrants, for example, are unlikely to be accounted for in official records such as Census tallies or Medicaid rolls. Project VIVA staff overcame this hurdle by conducting door-to-door surveys, seeking insight from local leaders, and speaking with people on the streets. The resultant numbers are “obviously not precise, but give some idea of what’s up,” said Sharon Stancliff, MD, medical director of the Harm Reduction Coalition and a member of Project VIVA’s community advisory board.

The VIVA team had expected to face difficulties gaining the public’s trust and willingness to accept a vaccination from strangers, but was pleasantly surprised. “Our outreach workers were mobbed on the street,” said Project VIVA director Micaela Coady, MS, recalling the response to the Proiect’s October 2005 vaccination drive outside of the Pathmark on 125th Street in Harlem. “We had lines around the block.” The team had done important awareness-raising work in advance to help establish trust, such as circulating bilingual flyers in the community and creating a “Team VIVA” comic book in which characters wear the same bright yellow jackets that “real” VIVA members wear when working on the streets. “People saw the yellow jackets and would actually seek them out, knowing they had vaccines available,” said Robert Brackbill, PhD, MPH, of the DOHMH, a member of the Project VIVA board

Anne Schuchat, MD, Director of the CDC National Immunization Program, said that in order to increase the numbers of vulnerable populations who get vaccinated against the flu, be it the annual vaccine or a pandemic strain, we must make them want the vaccine. That will require, among other things, an attitude change among healthcare providers who do not believe in the need for the vaccine or promote it to patients. Many healthcare workers themselves do not get the flu shot, Schuchat said. Increasing professionals’ and consumers’ demand for it is an important strategy the CDC is pursuing.

“We estimate 43 percent of healthcare workers get flu vaccinations, and that’s really low,” Schuchat said. “There’s a lot of mistrust among them about flu vaccines.” Jane Zucker, MD, Assistant Commissioner of the DOHMH Bureau of Immunization, said that in New York City, only one-third of healthcare workers report receiving a flu shot. While the vaccine does not offer fail-safe protection, it is proven effective at preventing serious complications of the flu among people with health risks.

Nancy M. Bennett, MD, Director of the Center for Community Health at the University of Rochester Medical Center, explained that her center’s local initiative dramatically increased the number of minorities getting the flu vaccine. She led the Rochester portion of the CDC’s Racial and Ethnic Adult Disparities in Immunization Initiative, a two-year effort to reduce flu shot disparities among minority seniors in five U.S. cities. From 2001 to 2005, Rochester increased the percentage of African American seniors getting flu shots from 39 to 74 percent. This was accomplished by intervening with primary care providers, increasing awareness and education about the vaccine’s protective qualities, and making more doses available, Bennett said. Project staff did extensive tracking of who had and had not received the vaccine, sent reminders by mail, and made follow-up phone calls.

Making more doses available is probably not an approach that will work when pandemic flu strikes, said Bruce Gellin, MD, MPH, Director of the National Vaccine Program Office of the U.S. Department of Health and Human Services. Twelve times as much antigen is needed to make a vaccine for pandemic flu, as for a seasonal flu strain, he said. The nation has 300 million Americans, but only three flu vaccine manufacturers with the combined capacity to make 15 million pandemic flu vaccine doses in a year’s time.

“The bottom line is, there’s not going to be a lot of vaccine around,” Gellin said. “Then how do you decide who to give it to?” This decision will be heavily politicized, Gellin said, and the hard-to-reach are most likely to be left out. Cautioning that the nation will probably never be adequately prepared for a pandemic flu outbreak, he said somberly, “In some ways it’s like, where do you stand when the comet is coming?” Some of the big-picture changes that are needed to overcome our limitations of vaccine preparedness, he said, are to switch from egg-based to cell-culture-based vaccine development, and to increase vaccine production capacity, an initiative that the government has been funding. Flu vaccines are now made with hens' eggs, but cell-culture technologies would allow a flu vaccine manufacturer to produce more vaccine rapidly should the need suddenly arise.

Zucker said the city Health Department does extensive community outreach to increase flu vaccinations, including media and advertising campaigns in multiple languages. As of October, people will be able to dial 3-1-1 to locate flu shot clinics nearby. Flu shots are also offered at 400 senior services agencies, as well as at homeless shelters and methadone clinics to reach those most vulnerable. Zucker added that state leaders are being pressured to permit pharmacists and nurses to administer flu vaccinations without the need for a physician’s exam or direct order. The CDC allows each state to implement this “standing orders” program, but New York State is among only a handful of states in the nation that has not done so.

Although Health Department officials have historically targeted vaccination-awareness efforts in communities known to be lagging behind, they noticed in recent years that flu shot levels weren’t budging in some locations, including Central Brooklyn. “We could not get people into our flu clinics there,” Zucker said. The Health Department launched the Central Brooklyn Flu Study to find out why, forming focus groups of African Americans ages 50 and over, most of them women. Participants gave invaluable feedback, reporting that they don’t get the flu shot because they fear it will make them ill, they believe most strongly in using herbs or foods to stay well, and/or are not encouraged by their healthcare providers to get the vaccine. The Health Department revised its printed outreach materials based on these insights, demonstrating that working with community residents truly pays off.

“We need to think about building trust in the community, rather than just trying to implement a plan quickly before it’s needed,” said the Academy’s Vlahov, in concluding the meeting. The Academy expects to produce a report in the coming months summarizing the productive discussion and proposing next steps. Founded in 1847, the Academy is an independent, non-partisan, non-profit institution whose mission is to enhance the health of people living in cities worldwide through research, education, advocacy, and prevention. Visit us online at www.nyam.org.

Posted on September 29, 2006

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Contact:
Andrew J. Martin
Director of Communications
The New York Academy of Medicine
1216 Fifth Avenue
New York, New York 10029
212-822-7285
amartin@nyam.org

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