The Impact of Racial and Ethnic Disparities in Influenza

Vaccination on Minority Deaths

Kevin Fiscella, MD, MPH

Departments of Family Medicine

Community & Preventive Medicine

University of Rochester School of Medicine & Dentistry

Goals of Study

• Estimate the impact of racial and ethnic disparity in flu shots on elderly, minority deaths and lives saved by achievement of HP 2010 vaccination rates.

• Illustrate a method for quantifying the impact of health care disparities on disparities in health.

Annual All-Cause Deaths among Elderly from Influenza

• 46,000 (range 23,000-64,000) –CDC, 2003

• Racial and ethnic disparities in influenza vaccination are striking (W 67%, B 46%, H 55%)

• Impact of disparities in vaccination on elderly minority deaths is not known

Methods

• Estimate the number of influenza associated all-cause deaths attributable to influenza among elderly minority patients (both vaccinated and unvaccinated).

• Simulate the number of influenza associated all-cause deaths assuming equivalence between white, non-Hispanic and minority rates.

Influenza Vaccination Rates (MCBS, 2002)

Percent Vaccinated

Sex/race/ethnicity 65-74 ys 75-84 yrs > 85 yrs

White Male 65 78 78

White Female 67 74 75

Black Male 53 59 70

Black Female 54 51 60

Hispanic Male 60 66 56

Hispanic Female 44 55 65

Estimate of Reduction in All-Cause Mortality from Flu Shots

• Meta-analysis of cohort studies show a 68% reduction in all-cause mortality (not just flu related!) among elderly vaccinated patients.

• Estimate is improbably high – vastly exceeds the number of deaths CDC attributes to influenza.

• Selection bias confounds estimates.

Comparison of Deaths During Influenza and Non-influenza Season among

Vaccinated and Unvaccinated(Armstrong et al 2004)

• Minimizes selection bias

• Vaccination reduces influenza attributable risk percent from 13.4% to 2.2%

Estimating deaths

deaths in age, gender, race/ethnicity subgroup = annual deaths x PAR x number in subgroup x #months flu/12

Estimating deaths under varying flu shot rates

Validation in U.S.

Applying these estimates to 1998-1999 US data approximates CDC estimates of elderly flu deaths (60,230 v. 58,820)

Total and influenza associated deaths among elderly minorities, 2002

Minority Group

Total deaths Flu-Associated deaths

African Americans

162,500 5,890

Hispanics 64,600 2,220

Minority lives saved from increases in vaccination rates v. deaths from 10th leading cause

Minority

Group

Lives saved under vaccination equity

Lives saved with HP 2010 objective

Deaths from 10th leading cause of death

African

Americans

1,520 3,050 2,960

Hispanics 610 1,200 1,070

Minority Years of Life Saved

Minority

Group

YLS under vaccination equity

YLS with HP 2010 objective

African

Americans

12,600 27,100

Hispanics 5,690 11,630

Total 18,290 38,730

Limitations of findings

• Uncertainty regarding impact of influenza vaccination on mortality

• Uncertainty as comparable attributable risk of influenza among different groups or comparable benefit of vaccine.

Conclusions• Racial and ethnic disparities in flu shot contribute

appreciably to minority deaths.

• Achievement of 90% vaccination coverage for minorities would save more minority lives than elimination of the 10th leading cause of deaths.

• Deaths resulting from disparities in health care represent one means for quantifying the impact of health care disparities on minority health.

Acknowledgments

• Richard Dressler, MD, MPH

• Kathleen Holt, PhD

• RWJF for support