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. 2024 Nov 4;7(11):e2448003.
doi: 10.1001/jamanetworkopen.2024.48003.

Social Vulnerability, Intervention Utilization, and Outcomes in US Adults Hospitalized With Influenza

Katherine Adams  1 , Kimberly Yousey-Hindes  2 , Catherine H Bozio  1 , Seema Jain  3 , Pam Daily Kirley  4 , Isaac Armistead  5 , Nisha B Alden  5 , Kyle P Openo  6   7   8 , Lucy S Witt  6   7 , Maya L Monroe  9 , Sue Kim  10 , Anna Falkowski  10 , Ruth Lynfield  11 , Melissa McMahon  11 , Marisa R Hoffman  12 , Yomei P Shaw  13 , Nancy L Spina  14 , Adam Rowe  14 , Christina B Felsen  15 , Erin Licherdell  15 , Krista Lung  16 , Eli Shiltz  16 , Ann Thomas  17 , H Keipp Talbot  18 , William Schaffner  18 , Melanie T Crossland  19 , Kristen P Olsen  19 , Larry W Chang  20   21 , Charisse N Cummings  1 , Mark W Tenforde  1 , Shikha Garg  1 , James L Hadler  2 , Alissa O'Halloran  1
Affiliations

Social Vulnerability, Intervention Utilization, and Outcomes in US Adults Hospitalized With Influenza

Katherine Adams et al. JAMA Netw Open. .

Abstract

Importance: Seasonal influenza is associated with substantial disease burden. The relationship between census tract-based social vulnerability and clinical outcomes among patients with influenza remains unknown.

Objective: To characterize associations between social vulnerability and outcomes among patients hospitalized with influenza and to evaluate seasonal influenza vaccine and influenza antiviral utilization patterns across levels of social vulnerability.

Design, setting, and participants: This retrospective repeated cross-sectional study was conducted among adults with laboratory-confirmed influenza-associated hospitalizations from the 2014 to 2015 through the 2018 to 2019 influenza seasons. Data were from a population-based surveillance network of counties within 13 states. Data analysis was conducted in December 2023.

Exposure: Census tract-based social vulnerability.

Main outcomes and measures: Associations between census tract-based social vulnerability and influenza outcomes (intensive care unit admission, invasive mechanical ventilation and/or extracorporeal membrane oxygenation support, and 30-day mortality) were estimated using modified Poisson regression as adjusted prevalence ratios. Seasonal influenza vaccine and influenza antiviral utilization were also characterized across levels of social vulnerability.

Results: Among 57 964 sampled cases, the median (IQR) age was 71 (58-82) years; 55.5% (95% CI, 51.5%-56.0%) were female; 5.2% (5.0%-5.4%) were Asian or Pacific Islander, 18.3% (95% CI, 18.0%-18.6%) were Black or African American, and 64.6% (95% CI, 64.2%-65.0%) were White; and 6.6% (95% CI, 6.4%-68%) were Hispanic or Latino and 74.7% (95% CI, 74.3%-75.0%) were non-Hispanic or Latino. High social vulnerability was associated with higher prevalence of invasive mechanical ventilation and/or extracorporeal membrane oxygenation support (931 of 13 563 unweighted cases; adjusted prevalence ratio [aPR], 1.25 [95% CI, 1.13-1.39]), primarily due to socioeconomic status (790 of 11 255; aPR, 1.31 [95% CI, 1.17-1.47]) and household composition and disability (773 of 11 256; aPR, 1.20 [95% CI, 1.09-1.32]). Vaccination status, presence of underlying medical conditions, and respiratory symptoms partially mediated all significant associations. As social vulnerability increased, the proportion of patients receiving seasonal influenza vaccination declined (-19.4% relative change across quartiles; P < .001) as did the proportion vaccinated by October 31 (-6.8%; P < .001). No differences based on social vulnerability were found in in-hospital antiviral receipt, but early in-hospital antiviral initiation (-1.0%; P = .01) and prehospital antiviral receipt (-17.3%; P < .001) declined as social vulnerability increased.

Conclusions and relevance: In this cross-sectional study, social vulnerability was associated with a modestly increased prevalence of invasive mechanical ventilation and/or extracorporeal membrane oxygenation support among patients hospitalized with influenza. Contributing factors may have included worsened baseline respiratory health and reduced receipt of influenza prevention and prehospital or early in-hospital treatment interventions among persons residing in low socioeconomic areas.

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Conflict of interest statement

Conflict of Interest Disclosures: Ms Yousey-Hindes reported receiving grants to the institution from the Centers for Disease Control and Prevention (CDC) during the conduct of the study. Dr Armistead reported receiving grants to the institution from CDC during the conduct of the study. Ms Alden reported receiving grants to the institution from CDC during the conduct of the study. Ms Monroe reported receiving grants from CDC during the conduct of the study. Ms Kim reported receiving grants from the Michigan Department of Health and Hunan Services Council of State and Territorial Epidemiologists (CSTE) during the conduct of the study. Ms Falkowski reported receiving grants from the Michigan Department of Health and Human Services CSTE during the conduct of the study. Dr Lynfield reported receiving grants to the institution from CDC during the conduct of the study, being an associate editor for the AAP Red Book, and receiving a fee for work which she donated to Minnesota Department of Health outside the submitted work. Dr Shaw reported salary support from CDC during the conduct of the study. Ms Felsen reported receiving grants from CDC during the conduct of the study. Mr Shiltz reported grants from CSTE for during the conduct of the study as well as receiving grants from CDC outside the submitted work. Dr Talbot reported receiving grants from CDC during the conduct of the study. Dr Schaffner reported receiving grants from CDC during the conduct of the study. Dr Hadler reported receiving grants from CDC during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Adjusted Prevalence Ratio (PR) of Influenza Outcomes by Social Vulnerability Index (SVI) 2018 Quartile (Q) in the 2014 to 2015 Through 2018 to 2019 Influenza Seasons, FluSurv-NET
Quartile 1 had the lowest vulnerability; and 4, the highest. a Models for ICU admission and IMV/ECMO adjusted for age, No. of categories of medical conditions, flu season, sex, and race/ethnicity; cases with unknown outcome were excluded. Models for death additionally adjusted for type of residence.
Figure 2.
Figure 2.. Influenza Intervention Coverage Across Overall Social Vulnerability Index Quartile (Q), 2014 to 2015 Through 2018 to 2019 Influenza Seasons, FluSurv-NET
See this image and copyright information in PMC

References

    1. Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases (NCIRD). About estimated flu burden. Accessed June 6, 2024. https://www.cdc.gov/flu-burden/php/about/index.html
    1. Stephenson I, Zambon M. The epidemiology of influenza. Occup Med (Lond). 2 002;52(5):241–247. doi:10.1093/occmed/52.5.241 - DOI - PMC - PubMed
    1. Putri WCWS, Muscatello DJ, Stockwell MS, Newall AT. Economic burden of seasonal influenza in the United States. Vaccine. 2018;36(27):3960–3966. doi:10.1016/j.vaccine.2018.05.057 - DOI - PubMed
    1. Centers for Disease Control and Prevention Agency for Toxic Substances and Disease Registry (ATSDR). CDC/ATSDR SVI fact sheet. Accessed October 21, 2022. https://www.atsdr.cdc.gov/placeandhealth/svi/fact_sheet/fact_sheet.html
    1. Centers for Disease Control and Prevention National Center for HIV Viral Hepatitis STD and TB Prevention. Health disparities in HIV, viral hepatitis, STDs, and tuberculosis. Updated September 14, 2020. Accessed January 9, 2023. https://www.cdc.gov/health-disparities-hiv-std-tb-hepatitis/index.html

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