Immunizations in adulthood

Vaccine preventable diseases continue to be a sizable burden to adults in the United States. Despite availability of safe and effective vaccines, immunization rates remain low. While various patient, clinician, and system factors can be barriers to adult vaccination, physicians recommendations to their patients to receive the vaccinations for which they are indicated is strongly related to a patient's receipt of these immunizations.     

Strain-specific pulmonary defense achieved after repeated airway immunizations with non-typeable haemophilus influenzae in a mouse model

Strain-specific immune responses may play a critical role in the acute exacerbation of chronic obstructive pulmonary disease (COPD) caused by Haemophilus influenzae (NTHi), and the outer membrane protein P2 is one of surface antigens of NTHi, which may contribute to the strain-specific protective immunity. We examined whether repeated airway immunizations with killed-NTHi strains bearing different P2 molecules were capable of inducing protective immunity against homologous or heterologous strains in the lungs of a mouse model. Three different strains of NTHi were used in this study. Three serial intratracheal (IT) immunizations of a single strain or three different strains of NTHi led to the production of cross-reactive immunoglobulins G and A in bronchoalveolar lavage fluids. Three serial IT immunizations with a single strain enhanced the bacterial clearance of the homologous strain in the lungs, but no enhancement of bacterial clearance was found with three serial IT immunizations of heterologous strains. The enhancement in bacterial clearance, therefore, appears to be primarily strain-specific. Enhanced bacterial clearance of a heterologous strain was also found after three serial IT immunizations of a single strain among two of the three strains employed for bacterial challenge. These findings suggest that P2 molecules and surface antigens other than P2 are involved in the development of pulmonary defense against NTHi in mice. Our data may explain, in part, why patients with COPD experience recurrent NTHi infections.     

Physician and patient gender concordance and the delivery of comprehensive clinical preventive services

BACKGROUND: Understanding the role of patient- and physician-gender on delivery of preventive services has important implications for identifying strategies to increase preventive service delivery. We attempt to overcome methodological limitations of previous studies in examining the association of the patient-physician gender interaction on the delivery of preventive screening, counseling, and immunization services. METHODS: In this cross-sectional study, research nurses directly observed 3256 consecutive adult patient visits to 138 family physicians. Delivery of gender neutral US Preventive Services Task Force (USPSTF) recommended screening, health behavior counseling, and immunization services was assessed by direct observation and medical record review. Multilevel regression analyses were used to test the interaction effect of physician and patient gender with preventive service delivery, controlling for patient age, insurance type, number of office visits in the past 2 years and physician age. RESULTS: The interaction effect of physician and patient gender was not significantly associated with delivery of gender neutral screening, counseling, or immunizations. Patients of female physicians were more up-to-date on counseling services (P < 0.01) and immunizations (P < 0.05) than patients of male physicians. Male patients, independent of physician gender, were more up-to-date on counseling and immunizations (P < 0.01). CONCLUSIONS: Physician-patient gender concordance is not associated with delivery of more preventive services. Rather, female physicians provide more counseling and immunization services to all of their patients. Previous research showing higher rates of gender-specific screening achieved by women physicians may have been an indication of an overall greater prevention orientation among women physicians rather than a specific benefit of gender concordance.     

Mndical Mnemonics

In all cases of obstructive lung disease, smoking cessation, proper use of metered-dose inhalers, up-to-date immunizations, adequate nutrition, and general physical conditioning are important components of treatment. Dr Jacobs summarizes these components as well as stepwise pharmacologic approaches to controlling the inflammation of asthma, the bronchospasm of chronic bronchitis and emphysema, and the symptoms of secondary or coexisting conditions.     

Health promotion in Asian-Americans

Healthy People 2010 was developed to meet the nation's goals for better health by the end of the present decade. Its purpose focuses on eliminating health disparities in the U.S. (Ghosh, 2003). Six areas for concentration of efforts were selected specifically because of their direct impact on the health of minorities: infant mortality, immunizations, diabetes, cardiovascular diseases, HIV/AIDS, and cancer. This paper reviews the six key areas to discover the most significant points of focus for health promotion of the Asian-American population to be lack of immunizations, which results in high incidence of hepatitis B infections and liver disease.     

Primary care house staff attitudes toward osteoporosis management

OBJECTIVE: This study assessed possible institutional and patient-related factors influencing the delivery of postmenopausal osteoporosis (PMO) care and the diagnostic priority placed on addressing PMO, relative to other common medical conditions, by primary care house staff at our institution. METHODS: A questionnaire was designed and distributed to eligible house staff at our institution. RESULTS: Approximately 50% (n = 52) of the house staff participated. The supervising clinic attending, patients' lack of insurance, accessibility to medical care, comorbid conditions, and university formulary were reported to influence decisions regarding osteoporosis care. Osteoporosis was ranked 6th of 7 medical issues (hypertension, coronary artery disease, diabetes, hypercholesterolemia, adult immunizations, osteoporosis, thyroid disease) to address during a comprehensive medical visit. CONCLUSIONS: Our institution's primary care house staff reported multiple influences on decision making regarding osteoporosis care, and an overall low priority to address this issue. Based on PMO's associated morbidity and mortality, primary care training programs are challenged to put resources toward optimizing house staff delivery of osteoporosis care.     

Making a difference: immunizing infants and children

Childhood immunizations, particularly for those under the age of two, is a major health issue. Since the measles epidemic in 1989-1991, the American Nurses Association/Foundation has collaborated with Every Child By Two (ECBT) to protect the nation's youngest from the ravages of vaccine preventable disease. Immunizations are the first line of prevention for infants and children. Healthy People 2000, together with the Presidential Administration's Childhood Immunization Initiative has mandated a goal of 90% immunizations for children under the age of two by the year 2000. As a nation, we are very close to meeting that goal.     

Vaccine verification guide: demystifying childhood immunizations for inpatient and other nurses

Provision of childhood immunizations continues to be an essential component in reducing morbidity and mortality worldwide. Inpatient nurses can play an essential role in assuring that children who are eligible for vaccinations are identified and provided with the appropriate immunizations. However, maintaining current knowledge of the rapidly changing immunization schedule can be a barrier, especially in a setting where immunizations and preventive care are not the main focus. This article emphasizes the importance of hospital nurses advocating for immunization of children and presents a Vaccine Verification Guide that serves as a tool for quickly and accurately identifying the vaccination needs of children, whether on-track or delayed in their immunizations.     

Preparing adult patients for international travel

More than 50 million Americans engage in international travel annually. Travel to developing countries can expose patients to a myriad of infectious diseases. Primary care clinicians can provide counseling, immunizations, and drugs to keep patients healthy while traveling. This article reviews risk assessment and required and recommended immunizations. Patients can greatly reduce their risk for travel-acquired illness by updating immunizations, taking prophylactic drugs, and observing recommended health behaviors.     

Immunizations for international travelers.

Immunizations for international travel are an important component of pretravel medical care. Travelers should receive protection against vaccine-preventable exotic diseases, and their immunity against common infectious diseases should be reviewed and updated. There are no immunizations for some important infectious hazards of travel. In the course of considering a traveler's risk for exposure to infectious disease on the basis of geographic destination, style of travel, and anticipated activities, the health care provider should discuss preventive measures and personal behavior with regard to food and water, avoidance of insect bites, personal safety, and sexual activity.     

Communicable diseases: infection prevention for nurses at work and at home.

Nurses are at risk for acquiring communicable disease both at work and home. This article discusses methods to protect nurses, their patients, and their families from acquiring or spreading some of the more common communicable diseases. Pertinent immunizations, recommended postexposure prophylaxis, and current work-restriction guidelines are presented. The special concerns of the pregnant nurse are also addressed.     

Office immunization

Nothing has improved disease control as thoroughly as immunizations. In well-immunized populations, there is no flaccid paralysis (polio), almost no epiglottitis or postmeningitis deafness (Haemophilus influenzae), and little postviral male sterility (mumps). Immunizations are not perfect; they may cause side effects, some of which have led to the discontinuation of the vaccine when side effects have outweighed the vaccine's protective effects. However, immunization works best not by the protection it provides the individual but by the protection provided to the population at risk. This article discusses the currently available vaccines along with recommendations for their use.     

A Comparison of Chronic Pain Between an Urban and Rural Population

A community-wide survey of 302 parents of 2-year-old children and 90 private medical practitioners in a large midwestern city revealed low immunization rates (31%) and differences in parent and provider perceptions of barriers to preschool immunizations. Parents most frequently identified barriers of system factors such as cost, lack of insurance coverage, and long office waits. System barriers were reported across differing sources of immunizations (private physician as well as public clinics) and were pervasive across income groups. Providers were more likely to report barriers of parental difficulties with forgetting immunizations or not knowing when the immunizations were due. Even though providers identified parental shortcomings with scheduling as problematic, only one fifth employed tracking and reminder systems. Implications of findings for modifications of the delivery of immunization services and for parent education are discussed.     

Suppression by autogenous complementary idiotypes: the priority of the first response.

Complementary idiotypes or antibodies are considered to have combining site structures which are at least partly directed against each other. Complementary antibodies were induced in A/He mice by immunization with phosphorylcholine (PC)-containing antigens and by immunization with the PC-binding IgA myeloma protein TEPC-15 (T15). Both responses were monitored by enumerating plaque-forming cells (PFC) and assaying serum antibody levels against the corresponding antigens. Mice immunized at least three times with T15 in adjuvants had markedly suppressed responses to subsequent immunization with PC; similarly, mice preimmunized multiple times with PC had suppressed responses to immunizations with T15. In contrast, mice immunized with T15 in the interval between "primary" and "secondary" immunizations with PC had undiminished PFC responses to both antigens but significantly decreased antibody titers to PC. Simultaneous responses were also induced by immunizations with T15 superimposed on weekly immunizations with PC; with this regime, immunization with T15 actually enhanced the PFC response to PC, but serum antibody to PC was significantly lower than for mice immunized with PC only. Levels of serum antibody to PC were probably lower, either because anti-PC antibody was complexed with the complementary antibody directed against T15, or because the antibody directed against T15 prevented synthesis and/or release of anti-PC antibody by cells in vivo. Thus, an established prior autogenous immune response can dramatically suppress a subsequent primary complementary response, but the effects of complementary responses on each other are more complex with different sequences of immunization. Also, the effects of variables such as the amounts and ratios of the classes of antibodies on regulation of complementary responses remain to be defined.     

An Emergency Department–based Vaccination Program: Overcoming the Barriers for Adults at High Risk for Vaccine-preventable Diseases

Background: More than 10% of the population visit emergency departments (ED) every year. Many of these patients are not up‐to‐date on routine vaccinations that could prevent future illnesses. The ED could significantly impact these vaccination trends. Objectives: This study was a feasibility study to determine whether patients would be amenable to an ED‐based program that provided appropriate immunizations when they were at high risk for these diseases. In addition, the authors sought to identify barriers that predict high‐risk patients who did not receive immunizations before ED presentation and to identify barriers that predict those high‐risk unvaccinated patients who are unwilling to receive vaccinations when offered in the ED. Methods: This study was a prospective cross‐sectional study of all patients arriving in the ED at one inner‐city trauma center between 10 am and 10 pm over the course of a three‐week intervention period. The subjects completed a survey that included information about their risk of influenza (flu) and pneumococcal disease, their immunization history, and their perceptions of their need for immunization. Demographic information collected included insurance status, age, gender, and primary language. All high‐risk patients who were not current with their immunizations were offered vaccination. The primary outcome was improvement in vaccination coverage based on an ED surveillance and treatment system for vaccinations. The secondary outcomes were barriers to successful vaccination before ED presentation and barriers to acceptance of vaccination in the ED. Results were compared using chi‐square test and confidence interval analysis. Characteristics of barriers to immunization were determined using a logistic regression model. A p‐value < 0.05 was considered significant. Results: A total of 674 subjects were entered into the study. Vaccination of subjects at high risk for flu increased significantly from 16% before to 83% after ED evaluation and treatment, and vaccination of subjects at high risk for pneumococcal disease increased significantly from 18% before to 84% after ED evaluation and treatment. Significant barriers to vaccination before ED presentation were lack of insurance (odds ratio [OR] = 0.31 for flu, 0.22 for pneumococcal disease), age younger than 50 years (OR = 0.18 for flu, 0.24 for pneumococcal disease), and no perceived need for vaccination (OR = 0.07 for flu). The sole significant barrier to vaccine administration in the ED was perceived need for vaccination (OR = 0.32 for flu). Conclusions: An ED‐based vaccination program is both feasible and successful. Other than a shortage of vaccine, the only ED barrier to vaccination (perceived need) might be overcome with patient education.