Evaluation of pandemic and seasonal influenza vaccination surveys Open Access

Singleton, James Andrew (2012)

Permanent URL: https://etd.library.emory.edu/concern/etds/p5547s30s?locale=en
Published

Abstract

To monitor 2009-10 monovalent pH1N1 and seasonal vaccination, the Centers for Disease Control and Prevention conducted the National 2009 H1N1 Flu Survey (NHFS). providing weekly estimates of pH1N1 and seasonal influenza vaccination. Evaluation of the validity of findings from the NHFS is needed to improve design, implementation, analysis and interpretation of future pandemic and inter-pandemic influenza vaccination surveys. Three questions about systematic error in measures of frequency based on influenza vaccination surveys were addressed:
1. Can a quicker and cheaper telephone survey be conducted without introducing too much additional selection bias?
2. How much selection bias is incurred by conducting a telephone survey compared to the National Health Interview Survey (NHIS), a less timely data but possibly more valid data source?
3. How accurate is parental report of young children's influenza vaccination status, compared to provider reported status in the National Immunization Survey (NIS)?
From analysis of NHFS based on interviews conducted within the first two weeks compared with the full sample recruited over five weeks, there was little difference in influenza vaccination estimates. However, estimates from the full NHFS were 6-9 percentage points higher than estimates from the NHIS. Comparison of parental to provider reported influenza vaccination status for children aged 10-37 months indicated that vaccination prevalence based on parental report was 5-12 percentage points higher. This evaluation quantified levels of potential selection and misclassification bias incurred by telephone surveys of influenza vaccination. Telephone surveys to collect influenza vaccination data by parental and self report remain a timely and efficient approach for surveillance of vaccination programs at the national and state levels. The attributes of ongoing surveillance systems must be monitored to ensure they are meeting the needs of intended use and are correctly interpreted.
Evaluation of pandemic and seasonal influenza vaccination surveys

By
James A. Singleton
B.S., University of California, Davis, 1983
M.S., University of California, Davis, 1985
Advisor: Carolyn Drews-Botsch, Ph.D., M.P.H.
A dissertation submitted to the Faculty of the
James T. Laney School of Graduate Studies of Emory University
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
in Epidemiology
2012

Table of Contents

TABLE OF CONTENTS

Table of Contents...vii

List of Tables...ix
List of Figures...xii

Chapter 1 Introduction...1

Surveillance of influenza vaccination...1
Sources of systematic error in surveys of influenza vaccination...3

Selection bias...6
Information bias...9

Dissertation aims...12

Chapter 2 Methods...13

Data sources...14

National 2009 H1N1 Flu Survey (NHFS)...14
National Health Interview Survey (NHIS)...16
National Immunization Survey (NIS)...17

Survey weighting and analysis...19
Estimating prevalence of influenza vaccination...21
Protection of human subjects...25

Chapter 3 Design of health surveys for public health emergencies: early responder bias in the National 2009 H1N1 Flu Survey (NHFS)...26

Abstract...26
Introduction...27
Methods...29

Data sources...29
Analysis...29

Nonresponse bias assessment...30
Effect of restriction to early respondents on vaccination prevalence rates...34

Results...31

Nonresponse bias assessment...33
Effect of restriction to early respondents on vaccination prevalence ratios...34

Discussion...35
Limitations...37
Conclusions...37

Chapter 4 Evaluating nonresponse and noncoverage bias in a telephone survey of Influenza vaccination by comparison to the National Health Interview Survey (NHIS)...52

Abstract...52
Introduction...53
Methods...55

Data Sources...55

National 2009 H1N1 Flu Survey (NHFS)...55
National Health Interview Survey (NHIS)...55

Analysis...56

Comparison of characteristics across sample sources and surveys...58
Prevalence of selected influenza-related outcomes to NHFS sample sources...59
Time-to-event analysis of influenza vaccination coverage...60

Results...61
Discussion...66
Limitations...70
Conclusions...72
Appendix 4-1 Undercoverage bias...82

Chapter 5 Validity of parental report of 2009-10 influenza vaccination in young children in a population-based national survey...83

Abstract...83
Introduction...84
Methods...86

Data Source - the National Immunization Survey (NIS)...86
Determination of household reported influenza vaccination status...87
Determination of provider reported influenza vaccination status...89
Definition of validity parameters...89
Primary validity analysis...90
Accuracy of joint distribution of household reported pH1N1 and seasonal influenza vaccination status...92
Accuracy of household reported month of vaccination...92
Accuracy of household reported type of pH1N1 and seasonal influenza vaccination...93
Completeness of provider reported influenza vaccinations...93
Scenarios to illustrate potential implications of imperfect recall...94

Results...95

Characteristics of study population...95
Primary validity results...95
Characteristics associated with sensitivity and specificity...97
Joint distribution of household reported pH1N1 and seasonal influenza vaccination status...99
Accuracy of household reported month of vaccination...99
Accuracy of household reported type of pH1N1 and seasonal influenza vaccination...101
Effects of under-ascertainment of provider reported vaccinations on validity Parameter estimates...102
Scenarios to illustrate potential implications of imperfect recall...104

Discussion...106
Limitations...112
Conclusions...113
Appendix 5-1 Definitions of validity parameters...147
Appendix 5-2 Model for misclassification of provider reported vaccination status...149
Appendix 5-3 Estimating actual vaccination prevalence using validity studies...152

Chapter 6 Conclusions...154

Contributions to public health and survey methodology...155
Limitations...157
Conclusions...159

Literature Cited...162


LIST OF TABLES
Table 3-1 Comparison of respondent characteristics between early and later responders, by sample source, National 2009 H1N1 Flu Survey (standalone component)...38
Table 3-2a Comparisons of adjusted prevalence (%) of influenza-related outcomes between early and later responders, National 2009 H1N1 Flu Survey (standalone component)...40
Table 3-2b Comparisons of adjusted prevalence (%) of influenza-related outcomes between 1st week and later responders, National 2009 H1N1 Flu Survey (standalone component)...41
Table 3-3a Influenza vaccination coverage - pH1N1 - through May 2010 for early vs. later and early weighted vs. all responders, by vaccine and selected respondent characteristics, National 2009 H1N1 Flu Survey (standalone component)...42
Table 3-3b Influenza vaccination coverage - trivalent seasonal - through May 2010for early vs. later and early weighted vs. all responders, by vaccine and selected respondent characteristics, National 2009 H1N1 Flu Survey (standalone component)...43
Table 3-3c Influenza vaccination coverage - pH1N1 - through May 2010 for 1st week vs. later and 1st week weighted vs. all responders, by vaccine and selected respondent characteristics, National 2009 H1N1 Flu Survey (standalone component)...44
Table 3-3d Influenza vaccination coverage - trivalent seasonal - through May 2010for 1st week vs. later and 1st week weighted vs. all responders, by vaccine and selected respondent characteristics, National 2009 H1N1 Flu Survey (standalone component)...45
Table 3-4a Comparison of influenza vaccination prevalence ratios from main effects logistic regression models, child overall sample, early weighted respondents, and 1st week weighted respondents, National 2009 H1N1 Flu Survey (standalone component)...46
Table 3-4b Comparison of influenza vaccination prevalence ratios from main effects logistic regression models, adult overall sample, early weighted respondents, and 1st week weighted respondents, National 2009 H1N1 Flu Survey (standalone component)...47
Table 3-4c Comparison of influenza vaccination prevalence ratios from logistic regression models with opinion covariates, adult overall sample, early weighted respondents, and 1st week weighted respondents, National 2009 H1N1 Flu Survey (standalone component)...49
Table 4-1 Comparison of adult respondent characteristics by sample source, National 2009 H1N1 Flu Survey (NHFS) (standalone component) and National Health Interview Survey (NHIS), January-June 2010 interview data...74
Table 4-2 Comparison of child characteristics by sample source, National 2009 H1N1 Flu Survey (NHFS) (standalone component) and National Health Interview Survey (NHIS), January-June 2010 interview data...76
Table 4-3 Comparisons of unadjusted and adjusted prevalence (%) of influenza-related outcomes between landline and cell only/mainly adult respondents, National 2009 H1N1 Flu Survey (standalone component)...77
Table 4-4 Comparisons of unadjusted and adjusted prevalence (%) of influenza-related outcomes for children between landline and cell only/mainly respondents, National 2009 H1N1 Flu Survey (standalone component)...77
Table 4-5 Influenza vaccination coverage - pH1N1 - among adults through May 2010, by selected respondent characteristics, January-June 2010 interviews from the National 2009 H1N1 Flu Survey (standalone component) and National Health Interview Survey...78
Table 4-6 Influenza vaccination coverage - Seasonal - among adults through May 2010, by selected respondent characteristics, January-June 2010 interviews from the National 2009 H1N1 Flu Survey (standalone component) and National Health Interview Survey...79
Table 4-7 Influenza vaccination coverage - pH1N1 - among children through May 2010, by selected respondent characteristics, January-June 2010 interviews from the National 2009 H1N1 Flu Survey (standalone component) and National Health Interview Survey...80
Table 4-8 Influenza vaccination coverage - Seasonal - among children through May 2010, by selected respondent characteristics, January-June 2010 interviews from the National 2009 H1N1 Flu Survey (standalone component) and National Health Interview Survey...81
Table 5-1 Weighted distribution of study sample by shot card status† and selected characteristics, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...115
Table 5-2 Estimated validity of household as compared to provider reported seasonal influenza vaccination status (one or more doses in past 12 months) by shot card status and month of interview, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...117
Table 5-3 Estimated validity of household as compared to provider reported pH1N1influenza vaccination status (one or more doses since October 2009) by shot card status and month of interview, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...118
Table 5-4 Estimated validity of household as compared to provider reported seasonal influenza vaccination status (two or more doses in past 12 months) by shot card status and month of interview, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...119
Table 5-5 Estimated validity of household as compared to provider reported pH1N1influenza vaccination status (two or more doses in since October 2009) by shot card status and month of interview, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...120
Table 5-6 Adjusted estimates (%) of sensitivity and specificity of parental report of child's seasonal influenza vaccination status (one or more doses in past 12 months) as of date of interview using shot card and recall (shot card group), by selected characteristics, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...121
Table 5-7 Adjusted estimates (%) of sensitivity and specificity of parental report of child's seasonal influenza vaccination status (one or more doses in past 12 months) as of date of interview using recall only (recall only group), by selected characteristics, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...123
Table 5-8 Adjusted estimates (%) of sensitivity and specificity of parental report of child's pH1N1 influenza vaccination status (since October 2009) as of date of interview using shot card and recall (shot card group), by selected characteristics, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...125
Table 5-9 Adjusted estimates (%) of sensitivity and specificity of parental report of child's pH1N1 influenza vaccination status (since October 2009) as of date of interview using recall only (recall only group), by selected characteristics, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...127
Table 5-10 Joint distribution of seasonal and pH1N1 influenza vaccination status by provider and household report, by shot card status, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...129
Table 5-11 Percent of children with provider reported seasonal influenza vaccination in a given month with household reported seasonal influenza vaccination in each month, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...130
Table 5-12 Percent of children with provider reported pH1N1 influenza vaccination in a given month with household reported pH1N1 influenza vaccination in each month, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...130
Table 5-13 Sensitivity and specificity of parental report of child's seasonal influenza vaccination status by date of interview using shot card and recall (shot card group), by monthly vaccination periods October-December 2009 and month of survey interview, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...131
Table 5-14 Sensitivity and specificity of parental report of child's seasonal influenza vaccination status by date of interview using recall only (recall only group) , by monthly vaccination periods October-December 2009 and month of survey interview, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...132
Table 5-15 Sensitivity and specificity of parental report of child's pH1N1 influenza vaccination status by date of interview using shot card and recall (shot card group), by monthly vaccination periods October-December 2009 and month of survey interview, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...133
Table 5-16 Sensitivity and specificity of parental report of child's pH1N1 influenza vaccination status by date of interview using recall only (recall only group) , by monthly vaccination periods October-December 2009 and month of survey interview, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...134
Table 5-17 Distributions of types of seasonal and pH1N1 influenza vaccinations received by provider and household report among children with influenza vaccination reported by both sources, by shot card status and age as of November 2009, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...135
Table 5-18 Provider ascertainment of influenza vaccinations reported by survey respondents from vaccination records, by provider response category, National Immunization Survey (NIS), Quarter 4 2009 - Quarter 2 2010...136
Table 5-19 Effect of incomplete of provider ascertainment of influenza vaccinations status on validity parameters, assuming non-differential under-ascertainment by household reported influenza vaccination status...137
Table 5-20 Effect of incomplete of provider ascertainment of influenza vaccinations status on validity parameters, assuming higher under-ascertainment when the household reports that the child has not received influenza vaccination...138

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