| 摘要: | 研究背景
患有心血管疾病的族群是感染帶狀皰疹的高危險群，且併發感染後的二次心血管事件風險較高。美國疾病管制與預防中心(CDC) 建議心血管疾病族群透過接種Zostavax? 或 Shingrix?任一種帶狀皰疹疫苗，來預防帶狀皰疹及其後續併發症的發生。然而過往並無研究針對此族群在帶狀皰疹疫苗接種的趨勢及差異狀況分析。
研究目的
第一研究目的: 描述2011-2022年美國50歲以上成人中，按照心血管狀態區分的帶狀皰疹疫苗接種趨勢。
第一子研究目的: 描述2011-2022年美國50歲以上成人中，依不同心血管疾病種類區分的帶狀皰疹疫苗接種趨勢。
第二研究目的: 描述2011-2022年美國50歲以上成人中，兩種帶狀皰疹疫苗各自的接種趨勢，趨勢按照心血管狀態區分。
第三研究目的: 描述美國50歲以上患有心血管疾病的成人，在不同的健康社會決定因素(social determinants of health, (SDOH))下，帶狀皰疹疫苗接種的差異狀況。
第四研究目的: 分析美國50歲以上患有心血管疾病的成人中，有哪些決定性因素會影響帶狀皰疹疫苗接種的狀況。
研究方法
本研究使用了2011-2022年美國全國健康訪問調查（NHIS）的數據來分析。NHIS是一項每年進行的全國代表性調查，旨在監測美國人口的健康狀況。本研究中的所有分析均考慮到此調查複雜的抽樣設計。所有研究目的的結果均定義為受訪者自我回報曾接種過帶狀皰疹疫苗。疫苗接種率(%)以NHIS調查權重計算得出，能反映出真實美國人口接種率。
第一研究目的，目標族群為美國50歲以上成人，分成有無心血管疾病兩組，分別描繪出帶狀皰疹疫苗從2011到2022的接種趨勢。第一子研究目的，目標族群相同，以四種不同的心血管疾病劃分(冠狀動脈疾病、心絞痛、心肌梗塞及中風)，分別描繪出帶狀皰疹疫苗的接種趨勢。第二研究目的，目標族群為美國50歲以上成人，分成有無心血管疾病兩組，分別描繪出Zostavax?及Shingrix?兩種疫苗各自的接種趨勢。接著會利用連結點迴歸模型 (Joinpoint regression model) 來分析帶狀皰疹疫苗接種趨勢的方向及幅度。第三研究目的，目標族群為美國50歲以上患有心血管疾病成人，描繪出帶狀皰疹疫苗在不同的社會健康決定因素下的接種差異。第四研究目的，目標族群為美國50歲以上患有心血管疾病成人，分析有哪些相關因子會影響帶狀皰疹疫苗的接種，相關因子的選擇是基於Anderson的行為模式(Behavioral Model)，接著使用多元邏輯斯迴歸分析計算因子與帶狀皰疹疫苗接種的相關性，並以勝算比及95%信賴區間表示。
研究結果
第一研究結果顯示，有心血管疾病族群的疫苗接種率從2011的12.2% 顯著增加至2022的40.5% (趨勢p值<0.01)，且接種率趨勢比沒有心血管疾病族群來的更高。在有心血管疾病族群中，疫苗接種率在2011年至2014年間成長最快速，隨後成長趨勢放緩 (2011至2014間 年平均百分比變化: 21.4%, p值< 0.01; 2014年至2022年間 年平均百分比變化: 7.1%, p值< 0.01)。
第一子研究結果顯示，冠狀動脈疾病患者的疫苗接種率從13.0%增至41.9% (趨勢p值<0.01)，心絞痛患者接種率從13.2%增至43.6% (趨勢p值<0.01)，心肌梗塞患者接種率從12.0%增至38.1% (趨勢p值<0.01)，中風患者接種率從10.7%增至38.8% (趨勢p值<0.01)。在不同類型的心血管疾病中，心肌梗塞患者的接種率增長速度最慢(2011年至2022年間 年平均百分比變化: 10.4%, p值< 0.01)。
第二研究結果顯示，在有心血管疾病的成人中，Zostavax?的接種率在2011年至2016年間有顯著上升(年平均百分比變化: 15.6%, p值< 0.01), 但在2016年至2021年間則呈現下降趨勢(年平均百分比變化: -5.9%, p值< 0.01)。相反地，在有心血管疾病的成人中，Shingrix?疫苗接種率在2018年至2022年間則呈現顯著上升趨勢(年平均百分比變化: 51.7%, p值< 0.01)，但在2022年，有心血管疾病者接種完整兩劑Shingrix?的比例還是偏低。
第三研究結果顯示，心血管疾病族群在不同的社會健康決定因素下，其帶狀皰疹疫苗的接種率存在差異。本研究觀察到在某些因素下的人，會有較高的疫苗接種率，因素包含有年紀?70歲，白人、美國本土出生、自覺健康狀況良好者、有固定就醫地點、在一年內就醫過、有大學以上學歷、有醫療保險、家庭收入?200%聯邦貧困線、無工作者、有結婚者、居住於美國西部、還有精通英文者。
第四研究結果顯示，心血管疾病族群在校正的模型中，與較高帶狀皰疹疫苗接種率相關的特徵包括年紀?70歲、女性、無工作者、擁有大學學歷或更高學歷、家庭收入?200%聯邦貧困線、有醫療保險、有固定就醫地點、在一年內就醫過、居住於美國西部、自覺健康狀況良好者、接種過流感疫苗、以及患有氣喘或癌症合併症。相比之下，與較低帶狀皰疹疫苗接種率相關的特徵包括西裔、非西裔黑人、外國出生、未婚和患有糖尿病。
研究結論
這項研究顯示出美國心血管疾病成人中，帶狀皰疹疫苗的接種率呈現上升趨勢，並指出在不同因素中存在疫苗接種的差異。這些發現可以幫助醫療端和施政者制定有效的免疫接種策略，促進疫苗接種的公平性，並提高該族群的整體疫苗接種率。
Background
Recently studies have found the elevated risk of cardiovascular disease (CVD) following herpes zoster (HZ) infection. Patients with CVD are at a higher risk of HZ and subsequent cardiovascular events. The Centers for Disease Control and
Prevention (CDC) recommends two zoster vaccines, Zostavax? and Shingrix?, for this population to prevent zoster and its complications. However, studies investigating zoster vaccination coverage and disparities among U.S. adults with CVD are scarce.
Aims
Aim 1: To describe the trends in zoster vaccination coverage among adults aged ?50 years by cardiovascular status through 2011-2022.
Aim 1 subgroup: To describe the trends in zoster vaccination coverage among adults aged ?50 years by different types of cardiovascular disease through 2011-2022.
Aim 2: To describe the trends in each zoster vaccination coverage among adults aged ?50 years by cardiovascular status.
Aim 3: To examine the disparities in zoster vaccination among adults aged ?50 years with cardiovascular disease across various social determinants of health (SDOH).
Aim 4: To evaluate factors associated with zoster vaccine uptake among adults aged ?50 years with cardiovascular disease.
Methods
Data from the 2011 to 2022 National Health Interview Survey (NHIS) were used. NHIS is a nationally representative survey conducted annually to monitor the health of the U.S. population. All analyses in this study accounted for the complex sampling design. The outcomes for all the Aims were defined as respondents who self-reported having ever received the zoster vaccine. Vaccination rates were estimated using NHIS survey weights and presented as weighted percentages.
In Aim 1, Aim 1 subgroup and Aim 2, the study population was adults aged ?50 years. Temporal trends in vaccination rates were plotted by CVD status over the study period. Joinpoint regression analysis was then employed to assess changes in the direction and magnitude of these trends.
In Aim 3, the study population was adults aged ?50 years with cardiovascular disease. Trends in vaccination rates were plotted by various social determinants of health (SDOH) throughout the study period.
In Aim 4, the study population was adults aged ?50 years with cardiovascular disease. The independent variables were the factors associated with zoster vaccine uptake. Anderson Behavioral Model were used to select the associated factors. Multivariable logistic regression models were conducted to calculate odds ratios and 95% CI for the association between factors and zoster vaccine uptake.
Results
In Aim 1, zoster vaccination coverage significantly increased from 12.2% to 40.5% among the CVD population (p trend <0.01). This coverage was consistently higher than that of the non-CVD population. Among the CVD population, the vaccination rates showed the largest growth from 2011 to 2014, followed by a slower growth path (2011-2014 annual percentage change (APC): 21.4% (95% CI=14.1-37.5); 2014-2022 APC: 7.1% 95% CI=5.7-8.3)).
In Aim 1 subgroup, the vaccination rates grew from 13.0% to 41.9% (p trend <0.01) among adults with coronary artery disease (CAD), from 13.2% to 43.6% (p trend <0.01) among adults with angina, from 12.0% to 38.1% (p trend <0.01) among adults with myocardial infarction (MI), and from 10.7% to 38.8% (p trend <0.01) among adults with stroke. Among different types of CVD, adults with MI experienced the slowest pace of increase (average annual percentage change (AAPC): 10.4% (95%CI=8.6-13.4)).
In Aim 2, there was an upward trend in Zostavax? coverage from 2011 to 2016 (APC: 15.6%, 95%CI=9.5-33.5), followed by a downward trend from 2016 to 2021 (APC: -5.9%, 95% CI=-14.2- -1.0) among the CVD population. Conversely, a significant increase in Shingrix? coverage from 2018 to 2022 was noted (AAPC: 51.7%, 95% CI=38.8-71.7). However, Shingrix? series completion rate remained low among the CVD population.
In Aim 3, disparities in zoster vaccination among adults with CVD were found across several SDOH. A higher prevalence of vaccination was observed among individuals who were aged?70 years, non-Hispanic White, U.S. born, perceived their health status as excellent to good, had a usual place of care, had seen a doctor within the last year, had a college degree or higher, had insurance coverage, had a family income ?200% of the federal poverty level (FPL), were unemployed, were married, lived in the western region of the U.S., and were proficient in English.
In Aim 4, in the adjusted model, several characteristics independently associated with a higher likelihood of zoster vaccination included older age?70 years, being female, being unemployed, with education level of college degree or higher, having a family income ?200% FPL, having insurance coverage, having a usual place of care, having seen a doctor within one year, living in the western region, reporting excellent to good health status, having a flu vaccination, and having asthma and cancer comorbidities. In contrast, characteristics associated with a lower likelihood of zoster vaccination included being Hispanic, non-Hispanic Black, being foreign born, being unmarried and having a comorbidity of diabetes.
Conclusion
This study indicated an increasing trend in zoster vaccination and identified disparities in zoster vaccine uptake among adults with cardiovascular disease in the U.S. These findings can assist healthcare providers and policymakers in implementing effective immunization strategies to eliminate disparities in vaccination and increase overall vaccine uptake among this population. |
