Acute disseminated encephalomyelitis following influenza vaccination

Introduction

Approximately 5% of cases of acute disseminated encephalomyelitis are preceded by vaccination within 1 month prior to symptom onset. This occurs rarely following influenza immunization.

Methods

Case presentation and literature review.

Results

A 75-year-old woman developed acute disseminated encephalomyelitis within 3 weeks of receiving the seasonal influenza vaccine. The patient subsequently passed away, despite treatment with methylprednisolone and plasma exchange therapy.

Conclusions

The literature on post-influenza vaccination encephalomyelitis is limited. The majority of published cases had favourable outcomes following treatment with intravenous methylprednisolone. Given the limited number of cases, no incidence estimates have been published.     

Linking cohort data and Welsh routine health records to investigate children at risk of delayed primary vaccination

BackgroundDelayed primary vaccination is one of the strongest predictors of subsequent incomplete immunisation. Identifying children at risk of such delay may enable targeting of interventions, thus decreasing vaccine-preventable illness.ObjectivesTo explore socio-demographic factors associated with delayed receipt of the Diphtheria, Tetanus and Pertussis (DTP) vaccine.MethodsWe included 1,782 children, born between 2000 and 2001, participating in the Millennium Cohort Study (MCS) and resident in Wales, whose parents gave consent for linkage to National Community Child Health Database records at the age seven years contact. We examined child, maternal, family and area characteristics associated with delayed receipt of the first dose of the DTP vaccine.Results98.6% received the first dose of DTP. The majority, 79.6% (n = 1,429) received it on time (between 8 and 12 weeks of age), 14.2% (n = 251) received it early (prior to 8 weeks of age) and 4.8% (n = 79) were delayed (after 12 weeks of age); 1.4% (n = 23) never received it. Delayed primary vaccination was more likely among children with older natural siblings (risk ratio 3.82, 95% confidence interval (1.97, 7.38)), children admitted to special/intensive care (3.15, (1.65, 5.99)), those whose birth weight was > 4Kg (2.02, (1.09, 3.73)) and boys (1.53, (1.01, 2.31)). There was a reduced risk of delayed vaccination with increasing maternal age (0.73, (0.53, 1.00) per 5 year increase) and for babies born to graduate mothers (0.27, (0.08, 0.90)).ConclusionsAlthough the majority of infants were vaccinated in a timely manner, identification of infants at increased risk of early or delayed vaccination will enable targeting of interventions to facilitate timely immunisation. This is to our knowledge the first study exploring individual level socio-demographic factors associated with delayed primary vaccination in the UK and demonstrates the benefits of linking cohort data to routinely-collected child health data.     

Characteristics associated with the uptake of influenza vaccination among adults in the United States

Objective

Existing data suggest that influenza vaccination rates among adults in the United States fall far short of the Healthy People 2010 goals and the updated Healthy People 2020 targets. We identified characteristics associated with influenza vaccination that might inform strategies for increasing coverage.

Methods

We used data from the 2009 Behavioral Risk Factor Surveillance System to estimate adjusted prevalence ratios for receiving the influenza vaccine in the past 12 months.

Results

Among 134,101 adults aged ≥ 65 years, the influenza vaccination coverage level was 68.9%. Among 286,867 younger adults aged 18-64 years, coverage was markedly lower: 31.8%. Having health care coverage was the strongest predictor of vaccination in both age groups, after accounting for other sociodemographic characteristics, health behaviors, and health status. Those reporting older age, white race, higher education, non-smoking status, being physically active, or having poor physical health or a personal history of various chronic conditions were also more likely to report having received the influenza vaccine.

Conclusion

Our results show clearly that vaccine uptake in the United States is related to social position as well as other health behaviors. These findings call for renewed attention to vaccination strategies to meet the updated Healthy People 2020 goals.     

Reduced risk of hospitalization associated with influenza vaccination in Canada

To evaluate the effectiveness of influenza vacation, we conducted analyses at both individual level and health region level. The association between influenza vaccination and hospital admission was examined among 128,677 subjects 12+ years of age who participated in a national survey in 2005. Both influenza and hospital admission proportions varied across health regions. Health regions with higher proportions of influenza vaccination had significantly lower proportions of hospitalization. A 10% increase in influenza vaccination less than 1 year ago was associated with a reduction of 11% in the risk of hospitalization over a 12-month time period at the health region level.     

Brainstem encephalitis following influenza vaccination: Favorable response to steroid treatment

We report a 44-year-old man presenting with left hemiparesis following influenza vaccination. The neuroimaging studies showed a large, contrast-enhancing brainstem lesion and multiple punctate lesions suggesting microhaemorrhages in both cerebral hemispheres. The patient showed a remarkable response to high dose steroid treatment. Detailed diagnostic studies failed to yield any results supporting inflammatory/demyelinating diseases, suggesting that influenza vaccination might have been associated with the clinical findings. Our case implies that vaccination might be related with a wide range of clinical syndromes, including brainstem encephalitis.     

Phased introduction of a universal childhood influenza vaccination programme in England: population-level factors predicting variation in national uptake during the first year, 2013/14

IntroductionThrough a phased rollout, the UK is implementing annual influenza vaccination for all healthy children aged 2–16 years old. In the first year of the programme in England in 2013/14, all 2–3 year olds were offered influenza vaccine through primary care and a primary school age programme was piloted, mainly through schools, in geographically distinct areas. Equitable delivery is a key aim of the programme; it is unclear if concerns by some religious groups over influenza vaccine content have impacted on uptake.MethodsAt the end of the 2013/14 season, variations in uptake for 2–3 year olds and 4–11 year olds were assessed and stratified by population-level predictors: deprivation, ethnicity, religious beliefs and rurality. GP practice or school level uptake was linearly regressed against these variables to determine potential predictors and changes in uptake, adjusting for significant factors.ResultsUptake varied considerably by geographic locality for both 2–3 year olds and 4–11 year olds. Lower uptake was seen in increasingly deprived areas, with an adjusted uptake in the most deprived quintile 12% and 8% lower than the least deprived areas by age-group respectively. By ethnicity, the highest non-white population quartile had an adjusted uptake 9% and 14% lower than the lowest non-white quartile by age-group respectively. Uptake also varied according to religious beliefs, with adjusted uptake in 4–11 year olds in the highest Muslim population tertile 8% lower than the lowest Muslim population tertile.ConclusionIn the first season of the childhood influenza vaccination programme, uptake was not uniform across the country, with deprivation and ethnicity both predictors of low uptake in pre-school and primary school age children, and religious beliefs also an important factor, particularly the latter group. With the continued rollout of the programme, these population-level factors should be addressed to achieve sustained successful uptake, along with assessment of contribution of individual and household-level factors.     

Epidemiology of pertussis in a country with high vaccination coverage

Introduction

Pertussis has been a preventable disease in Catalonia since 1965, but the annual number of cases remains high. The aim of this study was to analyze the epidemiology of pertussis in Catalonia and its implications for control purposes.

Methods

An epidemiological study was carried out in Catalonia between 2004 and 2008. Pertussis cases reported to the Department of Health were collected and disease reports were filled out with the case information. Incidence rates, rate ratios (RR) and their 95% confidence intervals (CI) were calculated.

Results

963 cases were reported: 555 (57.6%) were confirmed and 408 (42.4%) were suspected cases. The reported incidence rate was 2.01 × 10⁻⁵ person years in 2004 and 4.34 in 2008. The biggest increase in cases between 2004 and 2008 was observed in the ≥35 years age group (RR: 6.98; 95%CI: 2.11-36.36). 303 (31.5%) patients were hospitalized, of whom 93.7% were aged <1 year. Clinical differences were observed in paroxysmal cough (83.8% in suspected and 76.4% in confirmed cases, p = 0.005), posttussive vomiting (47.1% and 36.1%, respectively, p = 0.001), apnoea (13.7% and 21.3%, respectively, p = 0.003) and fever (20.1% and 12.4%, respectively, p = 0.001).

Conclusion

Pertussis incidence rates increased during the study period, with the greatest increase occurring in the ≥35 years age group. A booster dose of vaccine in young people could reduce the circulation of B. pertussis in adolescents and adults and indirectly reduce the incidence in children.     

Cost-effectiveness of routine annual influenza vaccination by age and risk status

BackgroundThe epidemiology of circulating seasonal influenza strains changed following the 2009 pandemic influenza A(H1N1). A universal influenza vaccination recommendation has been implemented and new vaccine types have become available post-2009. The objective of this study was to evaluate the cost-effectiveness of routine annual influenza vaccination in the context of this new evidence.MethodsA state transition simulation model was constructed to estimate the health and economic outcomes of influenza vaccination compared to no vaccination for hypothetical US cohorts stratified by age and risk status. Model input parameters were derived from multiple sources, including post-2009 vaccine effectiveness data from the US Flu Vaccine Effectiveness Network. The analysis used societal and healthcare sector perspectives and a one-year time horizon, except permanent outcomes were also included. The primary outcome was the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life years (QALYs) gained.ResultsCompared to no vaccination, vaccination yielded ICERs lower than $95,000/QALY for all age and risk groups, except for non-high-risk adults 18–49 years ($194,000/QALY). Vaccination was cost-saving for adults ≥50 years at higher risk for influenza-related complications. Results were most sensitive to changes in the probability of influenza illness. Performing the analysis from the healthcare sector perspective, excluding vaccination time costs, delivering vaccinations in lower-cost settings, and including productivity losses improved the cost-effectiveness of vaccination. Sensitivity analysis revealed that vaccination remains below $100,000/QALY for older persons ≥65 years at vaccine effectiveness estimates as low as 4 %.ConclusionsCost-effectiveness of influenza vaccination varied by age and risk status and was less than $95,000/QALY for all subgroups, except for non-high-risk working-age adults. Results were sensitive to the probability of influenza illness and vaccination was more favorable under certain scenarios. Vaccination for higher risk subgroups resulted in ICERs below $100,000/QALY even at low levels of vaccine effectiveness or circulating virus.     

Smoking reduction in a population-based cohort

OBJECTIVE: To describe the factors associated with smoking reduction in a population-based cohort study in Cornella de Llobregat (Barcelona, Spain). MATERIAL AND METHODS: We used data from the Cornella Health Interview Survey Follow-up Study (n = 2,500). We included for the analysis those subjects who declared to be daily smokers at baseline (1994) and continued smoking after eight years of follow-up (n = 234). We considered as operational definition of reduction to reduce > or = 10 cigarettes/day. We calculated the relative risk (RR) of smoking reduction vs. maintain or increase tobacco consumption and 95% confidence intervals (CI) by means of a Breslow-Cox regression model. RESULTS: The average reduction on number of cigarettes among subjects who reduced their tobacco consumption was similar in men and women (13 cigarettes/day). The consumption intensity and self-perceived health are the characteristics associated with reduction: smoking reduction was associated with being a smoker > 20 cigarettes/day (RR = 3.25; 95% CI: 1.69-6.25) and individuals who declared having a suboptimal health showed a 3-fold risk of reducing smoking (RR = 3.13; 95% CI: 1.52-6.43). CONCLUSION: Heavy smokers and smokers with poor health are those smokers more likely to reduce their tobacco consumption. Specific actions targeting them could lead to increase reduction and even smoking cessation.     

Trajectories and individual determinants of repeated seasonal flu vaccination use over the long term using data from the French E3N cohort

Despite the implementation of incentive policies to promote seasonal flu vaccination for more than 20 years in France, the coverage of high-risk individuals remains largely insufficient. While there is extensive literature on the determinants of vaccination in a given year, it rarely considers the specificity of flu vaccination, which must be repeated every autumn to remain effective. We aim to fill this gap by focusing on the flu vaccination behavior of high-risk individuals (65 years and older, chronic diseases) over a 15-year period. Based on data from 87,820 women in the French E3N cohort, we used sequence analysis methods (localized Optimal Matching) to identify typical seasonal flu vaccination profiles based on individual trajectories from 2004 to 2018. Then, using a multinomial model, we studied the individual determinants associated with the different patterns of vaccination use identified. Sequence analysis resulted in a partition of 8 clusters, which can be summarized into 4 typical behaviors: almost half of the women get vaccinated against flu each year (43%); conversely, another important share never get vaccinated against flu (32%); some do not get vaccinated for several years and then get vaccinated every year (20%); and finally, a minor share discontinued vaccination (5%). Thus, once women start getting vaccinated they generally continue every year. Nonetheless, this is a double-edged sword, as an important share of women considered at risk refrain from being vaccinated for more than a decade. Determinants associated with regular vaccination are being more at risk (age, weight, and chronic diseases), being in contact with physicians, being more educated, being in couple, having children, not smoking, and undergoing breast cancer screening.     

Increases in vaccination coverage of healthcare personnel following institutional requirements for influenza vaccination: a national survey of U.S. hospitals

Background

Institutional requirements for influenza vaccination, ranging from policies that mandate declinations to those terminating unvaccinated healthcare personnel (HCP), are increasingly common in the US. Our objective was to determine HCP vaccine uptake following requirements for influenza vaccination at US hospitals.

Methods

Survey mailed in 2011 to a nationally representative sample of 998 acute care hospitals. An institutional requirement was defined as an institutional policy that requires receipt or declination of influenza vaccination, with or without consequences for vaccine refusal. Respondents reported institutional-level, seasonal influenza vaccination coverage, if known, during two consecutive influenza seasons: the season prior to (i.e., pre-requirement), and the first season of requirement (i.e., post-requirement). Weighted univariate and multivariate analyses accounted for sampling design and non-response.

Results

808 (81.0%) hospitals responded. Of hospitals with institutional requirements for influenza vaccination (n = 440), 228 hospitals met analytic inclusion criteria. Overall, mean reported institutional-level influenza vaccination coverage among HCP rose from 62.0% in the pre-requirement season to 76.6% in the post-requirement season, representing a single-season increase of 14.7 (95% CI: 12.6-16.7) percentage points. After adjusting for potential confounders, single-season increases in influenza vaccination uptake remained greater among hospitals that imposed consequences for vaccine refusal, and among hospitals with lower pre-requirement vaccination coverage. Institutional characteristics were not associated with vaccination increases of differential magnitude.

Conclusion

Hospitals that are unable to improve suboptimal influenza vaccination coverage through multi-faceted, voluntary vaccination campaigns may consider institutional requirements for influenza vaccination. Rapid and measurable increases in vaccination coverage followed institutional requirements at hospitals of varying demographic characteristics.     

北京海淀区1 390 名老年人老年期痴呆流行病学调查

对北京地区６０岁以上老年人进行老年期痴呆的流行病学调查，调查社区内的所有老年人，用简单精神量表（ＭＭＳＥ）进行初筛，再根据ＤＳＭ－Ⅲ－Ｒ和修改的Ｈａｃｈｉｎｓｋｉ缺血量表进一步区分为Ａｌｚｈｅｉｍｅｒ型痴呆（ＡＤ）和多发性脑梗塞性痴呆（ＭＩＤ）。结果：ＡＤ和ＭＩＤ的患病率分别为１．３７％和０．９７％，总患病率为２．３３５，ＡＤ的患病率与国内报道相近，而ＭＩＤ的患病率偏低，高龄和文化程度低是ＡＤ和Ｍ     

COVID-19 and seasonal flu vaccination hesitancy: Links to personality and general intelligence in a large,UK cohort

Vaccines are a powerful and relatively safe tool to protect against a range of serious diseases. Nonetheless, a sizeable minority of people express ‘vaccination hesitancy’. Accordingly, understanding the bases of this hesitancy represents a significant public health opportunity. In the present study we sought to examine the role of Big Five personality traits and general intelligence as predictors of vaccination hesitancy across two vaccination types in a large (N = 9667) sample of UK adults drawn from the Understanding Society longitudinal household study. We found that lower levels of general intelligence were associated with COVID-19 and seasonal flu vaccination hesitancy, and lower levels of neuroticism was associated with COVID-19 vaccination hesitancy. Although the self-reported reasons for being vaccine hesitant indicated a range of factors were important to people, lower general intelligence was associated with virtually all of these reasons. In contrast, Big Five personality traits showed more nuanced patterns of association.     

Revaccination management of a large cohort of pediatric patients following a potential lapse in cold storage

IntroductionIn a pediatric clinic in California (US), 3823 patients were vaccinated with potentially-compromised vaccines following lapses in cold storage chain management between February 2014 and April 2015. A revaccination program was initiated in May 2015. Families were contacted by mail and encouraged to discuss follow-up options with their care team, namely: revaccination, serological testing and/or revaccination, or no further action. This study aimed: to understand which families were more likely to respond to the outreach, and to engage in any testing and/or revaccination; to determine whether or not vaccination with these potentially-compromised vaccines elicited sufficient immune response in pediatric patients; and to estimate the program cost.MethodsPatients who had received potentially-compromised vaccines were identified, and relevant data were extracted from their electronic health records. Logistic regression analyses were performed to identify factors associated with response to outreach, serological testing and/or revaccination.Results3823 patients between 0 and 21 years received an average of 3.1 potentially-compromised vaccines. 2547 revaccinations were performed (1515 patients) and 544 patients had serological testing results. Non-immune titer levels were only reported for 3–4% and 8% of the tested patients who had received potentially-compromised tetanus and hepatitis B vaccines, respectively, and only for children two years old and younger. Three years after the revaccination program started, 77% of all cases were considered resolved and 62.5% of patients (1970/3152) who were administered potentially-compromised vaccines were either revaccinated or had seroprotective titers. Response to outreach and decision to choose serological testing and/or revaccinate were affected by patient age, race/ethnicity and zip code median income (p < 0.05).ConclusionWe observed race/ethnicity, patient age and income differences in response to the outreach and decision-making. For patients vaccinated with potentially-compromised vaccines, serological testing should be considered prior to revaccination. Revaccination may not be the most appropriate course of action for all patients.     

Cost-effectiveness of childhood influenza vaccination in England and Wales: Results from a dynamic transmission model

This study uses a dynamic influenza transmission model to directly compare the cost-effectiveness of various policies of annual paediatric influenza vaccination in England and Wales, varying the target age range and level of coverage. The model accounts for both the protection of those immunised and the indirect protection of the rest of the population via herd immunity. The impact of augmenting current practice with a policy to vaccinate pre-school age children, on their own or with school age children, was assessed in terms of quality adjusted life years and health service costs. Vaccinating 2–18 year olds was estimated to be the most cost-effective policy in an incremental cost-effectiveness analysis, at an assumed annual vaccine uptake rate of 50%. The mean incremental cost-effectiveness ratios for this policy was estimated at £251/QALY relative to current practice. Paediatric vaccination would appear to be a highly cost-effective intervention that directly protects those targeted for vaccination, with indirect protection extending to both the very young and the elderly.     

瑞典斯德哥尔摩市社区人群老年痴呆和阿尔茨海默病的危险因素队列研究

目的探讨老年痴呆和阿尔茨海默病（AD）的危险因素。方法在6年问（1991-1996年）对斯德哥尔摩市一个社区非痴呆老年人群（n=1301,年龄≥75岁）进行两次随访检查,并按照美国老年精神病协会制订的DSM—Ⅲ—R标准诊断随访期间痴呆和AD新发病例。研究对象在基线调查时对有关因素暴露情况系经问卷调查、临床检查和查阅住院病例登记资料库等方法确定。采用Cox比例风险模型对资料进行统计分析。结果随访期间共有350例被诊断为痴呆,包括260例AD患者。多因素分析结果显示,痴呆和AD发病的危险因素有年龄大、文化程度低、认知功能损害、体力活动障碍、低舒张压、糖尿病、缺血性心脏病和携带APOEa4基因。脑卒中和心房纤维颤动亦能增加痴呆的危险性,而服用抗高血压药物则可降低痴呆和AD发病的危险性。结论某些人口统计学因素、认知和体力功能障碍、血管性疾病及遗传易感性是老年痴呆和AD的重要危险因素;使用抗高血压药物及控制高血压相关的血管性疾病可能会降低痴呆发病的危险性。     

Factors associated with vaccination status among Korean submariners who are eligible for free non-mandatory influenza vaccination

IntroductionSubmarine crews live in a confined setting and are vulnerable to influenza. Thus, it would be useful to identify factors that are associated with influenza vaccination. In this study, we investigated the influenza vaccination rate and the influence of health beliefs on the vaccination rate among submariners who were eligible for a free but non-mandatory vaccination program.MethodsA total of 487 Korean submariners participated in this study after the closing of a free influenza vaccination program in 2015. Data regarding the participants’ general characteristics and health beliefs (based on the health belief model [HBM]) were collected using a self-administered questionnaire, and their vaccination status was determined using their medical records. Multiple logistic regression analysis were performed to evaluate the associations of the HBM components with influenza vaccination.ResultsThe overall vaccination rate was 78% (921/1183). The unvaccinated and vaccinated respondents exhibited similar characteristics, although the vaccinated group was significantly more likely to have high-risk family members (chronic disease, age of <2 years, or age of ⩾65 years; p = 0.025). Among the HBM components, perceived severity (odds ratio: 1.38, p = 0.019) and cue to action (odds ratio: 1.74, p = 0.002) were significantly associated with a higher likelihood of influenza vaccination.ConclusionVaccination policies that emphasize the severity of influenza and prompt individuals to undergo vaccination are needed to increase the vaccination rate among people who live in confined environments or institutions with non-mandatory vaccination programs.     

Risk of intussusception following rotavirus vaccination: An evidence based meta-analysis of cohort and case-control studies

BackgroundInternational post-licensure studies on rotavirus vaccines have identified an increased risk of intussusception in infants after administration. The first developed rotavirus vaccine (Rotashield (RRV-TV)) was suspended post-licensure in 1999 after an association with intussusception was found. The currently available second-generation rotavirus vaccines (Rotateq (RV5) and Rotarix (RV1)), are recommended as a routine vaccine by the World Health Organisation (WHO). Post-licensure studies of these vaccines have shown a smaller but temporal increased risk for developing intussusception.MethodsA meta-analysis was performed to summarise available evidence and to give an overall risk of developing intussusception from case-control and cohort studies for all rotavirus vaccines that have been manufactured up to date. A search was conducted on MEDLINE, PubMed, EMBASE and Google Scholar up to May 2017. Eligible studies assessed the relationship between the rotavirus vaccine administration and subsequent development of intussusception both after receiving the first dose and after receiving all doses combined. Data was extracted on study characteristics, methods and outcomes. Results were pooled using the random-effect model.ResultsSix cohort studies involving 4506265 total first doses and five case-control studies involving a total sample of 9643 children were included in this analysis. The cohort data revealed that there was an associated increased risk of intussusception after the first 7 days post first dose of the vaccine (RR:3.71, 95% CI:1.08–12.69) and after receiving all doses of the rotavirus vaccine (RR:3.47, 95% CI:1.23–9.78). Similarly, the case-control data found an increased risk of intussusception following the first dose (OR: 8.45, 95% CI: 4.08–17.50) and following all doses (OR: 1.59, 95% CI: 1.11–2.27).ConclusionsFindings of this meta-analysis suggest that the rotavirus vaccine is associated with an increased risk on the development of intussusception, principally seen after administration of the first dose of vaccine.