Correlates of high vaccination exemption rates among kindergartens

Objectives

The present study was designed to characterize Arizona schools with high rates of permanent PBE among kindergartners, and to determine the degree to which they aggregate across the state.

Methods

Data for permanent personal belief exemptions (PBE) were accessed through the 2010–2011 kindergarten Immunization Data Report (IDR) from the Arizona Department of Health Services (AZDHS), and were linked to the 2009–2010 data from the National Center of Education Statistics (NCES). Incidence rate ratios (IRR) were calculated using negative binomial regression, and hotspots were identified using Getis-Ord Gi*.

Results

Schools with highest proportion of white students compared to the lowest had the highest exemption rates (IRR = 14.11; 95% confidence interval [CI], 9.47–21.03); furthermore charter schools and those with low prevalence of free and reduced lunches had significantly higher rates of PBE. Statewide analyses of PBE identified higher rates of permanent PBE in northern vs. southern Arizona, while a more focused examination of the central Arizona region demonstrated a pattern of increased PBE from west to east.

Conclusion

In Arizona, the profile of a high PBE school is that of a charter school attended by predominantly white, higher-income students. The local and statewide hotspots serve as a challenge that requires a multi-faceted approach that calls upon all healthcare professionals. It is important that both local and statewide pockets be targeted by local and state officials either to improve vaccination uptake or to employ careful monitoring to identify outbreaks at their onset.     

Variation in prescription contraceptive pricing across Florida ZIP code income groups

Background

The purpose of this study was to explore average monthly cost of commonly prescribed oral and transvaginal contraceptives, across ZIP code income groups, in Florida.

Study Design

In March, 2011, the MyFloridarx.com database was searched to assess monthly prices of seven commonly prescribed contraceptives charged by Florida pharmacies.

Results

With the exception of TNRG/EE 35 (χ²[4, N= 401]=18.72, p=.00), monthly costs of contraceptives did not vary significantly across Florida ZIP code median income quintile groups.

Conclusion

Overall, while there was little variability in retail pharmacy prices in Florida for seven commonly prescribed contraceptives, monthly costs of individual contraceptives varied widely.

Implications

This report found little variability, across ZIP codes, in retail pharmacy prices in Florida for seven commonly prescribed contraceptives, but the monthly costs of individual contraceptives varied widely. It is paramount that clinicians consider costs when discussing contraceptive options with their patients.     

Coverage from Ontario,Canada's school-based HPV vaccine program: The first three years

Background

In 2007, Ontario implemented a school-based human papillomavirus (HPV) vaccination program targeting grade 8 girls. Girls may complete the series in grade 9 (extended eligibility). Limitations in the existing provincial data sources for assessing HPV vaccine coverage in Ontario prompted the use of two surveys of Health Units (HUs) to calculate provincial vaccine coverage for the first three years of the vaccination program.

Methods

We surveyed Ontario's 36 HUs in March and November 2011 to obtain vaccine coverage information, including source of denominator data, and use of local information systems. The second survey was necessary in order to assess coverage including extended eligibility for the third year. HU-reported HPV vaccine coverage was compared to coverage estimates obtained from two provincial systems: the Immunization Records Information System (IRIS) and the HPV reimbursement database, a system used to remunerate HUs for HPV vaccine doses administered.

Results

100% of HUs participated in the two surveys. The provincial coverage estimates using HU-reported data were: 51% (2007–2008), 58% (2008–2009), and 59% (2009–2010) with large variation by HU. Coverage increased significantly over time. The number of HUs that were able to report on doses given as part of extended eligibility also increased over time (47% in 2007–2008 to 89% in 2009–2010; p = 0.0008). Comparisons across the three data sources (survey, IRIS and reimbursement database) revealed significantly different coverage estimates. Class or school lists were the most common source of denominator data used by HUs (27/36, 75%), however independent schools were not included by all.

Conclusions

As not all HUs were able to report on HPV vaccine coverage including extended eligibility doses these findings likely underestimate the true coverage attained by Ontario's program. Although coverage is below the Canadian Immunization Committee benchmark of 80% within two years of program implementation, the upward trend in coverage is encouraging.     

Feasibility of a randomized controlled trial to evaluate Text Reminders for Immunization Compliance in Kids (TRICKs)

Objective

To pilot test the Text Reminders for Immunization Compliance in Kids (TRICKs) program to evaluate its feasibility and potential to increase immunization coverage.

Design

Randomized controlled trial (RCT).

Setting

Pediatric clinic.

Participants

Parents of newborns being discharged from a local hospital who intended to seek child health care at the University-sponsored pediatric resident and faculty clinic.

Intervention

Text message immunization reminders prior to immunization due dates.

Main Outcome Measures

Receipt and timeliness of immunizations at 2, 4 and 6 months of age.

Results

Participants (N = 90) were English (83%) or Spanish (17%) speaking. The majority were female (83%), on public insurance (59%), and had adequate health literacy (96%). Parents were married or a member of an unmarried couple (62%). Over 66% had a high school diploma or less. Greater numbers of intervention children received immunizations and were “on time” using per protocol analysis; though not statistically significance. Limitations include sample size, problematic text messaging software, and loss of phone service at 7 months for 40% of intervention parents. However, post-intervention interviews (N = 18) indicated strong support for TRICKs; 83% found the text message reminders very helpful and 17% somewhat helpful.

Discussion

Pilot testing allowed us to assess processes, including recruitment, retention, and software, which will increase the success of an RCT. Software with built-in backup systems is needed for follow-up when mobile service is interrupted. However, in spite of limitations, immunization rates were higher in the text message reminder group, though not statistically significant. Parent support and interest was high. A fully powered RCT is needed with follow-up over the full 4-3-1-3-3-1 series. Based on our results, for 80% power where we expected 90% compliance in the intervention group and 80% in the control group we need 219 per group, plus increases to address drop out and loss of follow-up.     

How influenza vaccination policy may affect vaccine logistics

Background

When policymakers make decision about the target populations and timing of influenza vaccination, they may not consider the impact on the vaccine supply chains, which may in turn affect vaccine availability.

Purpose

Our goal is to explore the effects on the Thailand vaccine supply chain of introducing influenza vaccines and varying the target populations and immunization time-frames.

Methods

We Utilized our custom-designed software HERMES (Highly Extensible Resource for Modeling Supply Chains), we developed a detailed, computational discrete-event simulation model of the Thailand's National Immunization Program (NIP) supply chain in Trang Province, Thailand. A suite of experiments simulated introducing influenza vaccines for different target populations and over different time-frames prior to and during the annual influenza season.

Results

Introducing influenza vaccines creates bottlenecks that reduce the availability of both influenza vaccines as well as the other NIP vaccines, with provincial to district transport capacity being the primary constraint. Even covering only 25% of the Advisory Committee on Immunization Practice-recommended population while administering the vaccine over six months hinders overall vaccine availability so that only 62% of arriving patients can receive vaccines. Increasing the target population from 25% to 100% progressively worsens these bottlenecks, while increasing influenza vaccination time-frame from 1 to 6 months decreases these bottlenecks.

Conclusion

Since the choice of target populations for influenza vaccination and the time-frame to deliver this vaccine can substantially affect the flow of all vaccines, policy-makers may want to consider supply chain effects when choosing target populations for a vaccine.     

Trends in vaccination coverage disparities among children,United States, 2001–2010

Introduction

One of two overarching goals of the Healthy People 2010 initiative was to eliminate health disparities. We evaluate trends in children vaccination coverage disparities by socio-demographic characteristics in the United States from 2001 through 2010.

Methods

Disparities in vaccination coverage for the 4:3:1:3:3:1 vaccine series was assessed with National Immunization Survey (NIS) 2001–2010 data. The disparities between two categories of population were independently evaluated yearly from 2001 through 2010.

Results

In 2001, 10 out of 12 disparities were significant (P-value <0.05). Six disparities were reduced from statistically significant in 2001 to not significant in 2010. Across 2001–2010, 8 disparities narrowed significantly; the average change in disparities per year were negative and ranged from −0.30% to −0.64% (P-value <0.05).

Conclusions

Significant success has been achieved in reducing disparities in vaccination coverage for young children among most of the major socio-demographic subpopulations in the United States by 2010.     

The impact of a population-level school food and nutrition policy on dietary intake and body weights of Canadian children

Objective

The objective of this study is to assess population-level trends in children's dietary intake and weight status before and after the implementation of a provincial school nutrition policy in the province of Nova Scotia, Canada.

Method

Self-reported dietary behavior and nutrient intake and measured body mass index were collected as part of a population-level study with grade 5 students in 2003 (n = 5215) and 2011 (5508), prior to and following implementation of the policy. We applied random effects regression methods to assess the effect of the policy on dietary and health outcomes.

Results

In 2011, students reported consuming more milk products, while there was no difference in mean consumption of vegetables and fruits in adjusted models. Adjusted regression analysis revealed a statistically significant decrease in sugar-sweetened beverage consumption. Despite significant temporal decreases in dietary energy intake and increases in diet quality, prevalence rates of overweight and obesity continued to increase.

Conclusion

This population-level intervention research suggests a positive influence of school nutrition policies on diet quality, energy intake and healthy beverage consumption, and that more action beyond schools is needed to curb the increases in the prevalence of childhood obesity.     

Risk of invasive pneumococcal disease in children and adults with asthma: A systematic review

Background

The Advisory Committee on Immunization Practices (ACIP) recommended the inclusion of asthma as a high-risk condition that should warrant pneumococcal vaccination, but the National Advisory Committee on Immunization (NACI) in Canada has not yet done so. We aimed to determine the risk of invasive pneumococcal disease (IPD) in patients with asthma.

Methods

We searched Ovid Medline, EMBASE, Classic EMBASE, PubMEd and Cochrane for articles published between January 1990 and February 2013, using the MeSH terms pneumococcal infections/or invasive pneumococcal disease and asthma. Google Scholar was used to retrieve articles citing the seminal article by Talbot et al. Articles were included if they were population-based studies that evaluated the relationship between IPD and asthma. Two authors independently assessed all titles and abstracts. All potentially relevant articles were retrieved as full text and assessed for inclusion.

Results

The combined searches yielded 376 articles, which were reviewed by title and abstract. At this stage, 330 articles were excluded; 40 articles were excluded at the full article review stage – leaving 6 articles. Two additional articles were found through Google Scholar. The evidence reviewed consistently showed a positive association between asthma and risk of IPD. However, the magnitude of this effect was heterogeneous with adjusted odds ratios ranging from 6.7 (95% CI 1.6–27.3) in adults >18 years to 1.7 (95% CI 0.99–3.0) in individuals aged 2–49 with low-risk asthma.

Conclusion

The positive association between asthma and risk of IPD supports the addition of asthma as a high-risk condition warranting pneumococcal vaccination. Data on vaccine effectiveness in this population is needed.     

Applicability of the Brighton Collaboration Case Definition for seizure after immunization in active and passive surveillance in Canada

Background

The Canadian Adverse Event Following Immunization Surveillance System (CAEFISS) receives reports via active syndromic surveillance for selected serious AEFI from the Canadian Immunization Monitoring Program Active (IMPACT) and via targeted passive surveillance from Federal/Provincial/Territorial health jurisdictions. Post-immunization seizure is a target of active and passive surveillance. Since 2009, the revised national AEFI reporting forms enable capture of terms specific to several Brighton Collaboration Case Definitions (BCCD) including generalized seizure and fever.

Objective

To evaluate feasibility of applying the BCCD for generalized seizure to adverse event following immunization (AEFI) reports collected by IMPACT and targeted passive surveillance (non-IMPACT).

Methods

Reports to CAEFISS coded as seizure in children <2 years of age (vaccination dates 1998–2011) were reviewed retrospectively. A BCCD level (1–5 or unclassifiable) was assigned. The effects of reporting source (IMPACT versus non-IMPACT), seriousness [serious (e.g., hospitalized) versus non-serious], vaccination year (1998–2008 versus 2009–2011), and data submission method to CAEFISS (electronic versus paper) were assessed by stratified analysis.

Results

There were 459 IMPACT and 908 non-IMPACT cases analyzed, of which 99.6% and 27%, respectively, were serious reports. The revised reporting form that captured the BCCD components (2009–2011) was associated with increased proportions of IMPACT and non-IMPACT cases meeting the BCCD for generalized seizure.

Conclusions

Incorporating the BCCD components (level of consciousness, motor manifestations and fever ≥38 °C) into the national reporting form and guidelines appeared to improve the feasibility of their use in AEFI surveillance. This effect was more pronounced among active syndromic surveillance compared to targeted passive surveillance reports.     

Prevention of HPV-related oral cancer: assessing dentists' readiness

Objectives

Epidemiological research indicates an association between the Human Papillomavirus (HPV) with a subset of oral cancers (OC). Dentists may play a role in primary prevention of HPV-related OC by discussing the HPV vaccine with patients. This study assessed dentists' readiness to discuss the HPV vaccine with female patients.

Study design

Cross-sectional web-based survey.

Methods

A web-based survey based on the Transtheoretical Model was administered among Florida dentists (n = 210).

Results

The majority of participants (97%) fell into the precontemplation and contemplation stages of readiness to discuss the HPV vaccine with patients. Perceived role and liability were determined to be predictive of dentists in contemplation stage as opposed to those in precontemplation (P < 0.05).

Conclusions

Findings suggest liability and perceived role as processes of change necessary to guide dentists to primary prevention of HPV-related OC despite high levels of knowledge. As public awareness of HPV-related OC increases, dentists may become more involved in primary prevention. Results of the current study may assist in developing intervention strategies for engaging dentists in discussing the HPV vaccine with patients.     

Advance Directive and End-of-Life Care Preferences Among Nursing Home Residents in Wuhan,China: A Cross-Sectional Study

Objectives

To describe Chinese nursing home residents' knowledge of advance directive (AD) and end-of-life care preferences and to explore the predictors of their preference for AD.

Design

Population-based cross-sectional survey.

Settings

Nursing homes (n = 31) in Wuhan, Mainland Southern China.

Participants

Cognitively intact nursing home residents (n = 467) older than 60 years.

Measures

Face-to-face questionnaire interviews were used to collect information on demographics, chronic diseases, life-sustaining treatment, AD, and other end-of-life care preferences.

Results

Most (95.3%) had never heard of AD, and fewer than one-third (31.5%) preferred to make an AD. More than half (52.5%) would receive life-sustaining treatment if they sustained a life-threatening condition. Fewer than one-half (43.3%) chose doctors as the surrogate decision maker about life-sustaining treatment, whereas most (78.8%) nominated their eldest son or daughter as their proxy. More than half (58.2%) wanted to live and die in their present nursing homes. The significant independent predictors of AD preference included having heard of AD before (odds ratio [OR] 9.323), having definite answers of receiving (OR 3.433) or rejecting (OR 2.530) life-sustaining treatment, and higher Cumulative Illness Rating Scale score (OR 1.098).

Conclusions

Most nursing home residents did not know about AD, and nearly one-third showed positive attitudes toward it. AD should be promoted in mainland China. Education of residents, the proxy decision maker, and nursing home staff on AD is very important. Necessary policy support, legislation, or practice guidelines about AD should be made with flexibility to respect nursing home residents' rights in mainland China.     

The Benefits of Center-Based Care and Full-Day Kindergarten for School Attendance in the Early Grades

Background

School absenteeism has been recognized as a growing issue in the United States, especially during the early elementary school years when it is most pervasive. Accordingly, there has been growing interest in understanding why children are absent and whether certain early educational experiences can reduce children’s rates of school absences.

Objective

The objective of this investigation was to estimate the additive and multiplicative benefits of children’s early school experiences in preschool (center-based care) and kindergarten (center-based care and full day kindergarten enrollment) for patterns of school absenteeism in kindergarten and first grade.

Method

To address these objectives, data were drawn from the Early Childhood Longitudinal Study Kindergarten Class of 2010–2011 and included 12,835 children and families.

Results

Children who attended center-based care in preschool and kindergarten had fewer missed school days and were less likely to be chronically absent in kindergarten and first grade. Children in full-day kindergarten programs had more absences by the end of kindergarten, but fewer absences by the end of the following year. No specific combination of early school arrangements was most beneficial. Instead, children who experienced more early educational arrangements were generally absent less frequently and these benefits were larger in first grade than in kindergarten.

Conclusions

When taken together, findings underscore the importance of formal early educational programs and opportunities on longer-term school attendance.

     

Quantifying the impact of dissimilar HPV vaccination uptake among Manitoban school girls by ethnicity using a transmission dynamic model

Background

Gardasil, a human papillomavirus (HPV) vaccine, began among grade 6 girls in Manitoba, Canada in 2008. In Manitoba, there is evidence that First Nations, Métis, and Inuit women (FNMI) have higher HPV prevalence, lower invasive cervical cancer (ICC) screening, and higher ICC incidence than all other Manitoban (AOM) women. We developed a mathematical model to assess the plausible impact of unequal vaccination coverage among school girls on future cervical cancer incidence.

Methods

We fit model estimated HPV prevalence and ICC incidence to corresponding empirical estimates. We used the fitted model to evaluate the impact of varying levels of vaccination uptake by FNMI status on future ICC incidence, assuming cervical screening uptake among FNMI and AOM women remained unchanged.

Results

Depending on vaccination coverage, estimated ICC incidence by 2059 ranged from 15% to 68% lower than if there were no vaccination. The level of cross-ethnic sexual mixing influenced the impact that vaccination rates among FNMI has on ICC incidence among AOM, and vice versa. The same level of AOM vaccination could result in ICC incidence that differs by up to 10%, depending on the level of FNMI vaccination. Similarly, the same level of FNMI vaccination could result in ICC incidence that differs by almost 40%, depending on the level of AOM vaccination.

Conclusions

If we are unable to equalize vaccination uptake among all school girls, policy makers should prepare for higher levels of cervical cancer than would occur under equal vaccination uptake.     

False positive galactomannan Platelia due to piperacillin-tazobactam

Introduction

Invasive aspergillosis is a serious disease, the lethality of which is important among hematology patients. Early diagnosis is crucial for treatment options and the prognosis. Detection of the antigen galactomannan is the most frequently used microbiological tools. But galactomannan detection may be falsely positive, and this false positivity has been associated with piperacillin-tazobactam treatment, the main antibiotic combination used in clinical hematology.

Objective

The purpose of our study, carried out from January 2009 to December 2010 at the Versailles hospital on in-patients with hematological disorders, was to evaluate the association between false galactomannan positivity and administration of piperacillin-tazobactam, and to study a possible variability of products issued by three manufacturers.

Patients and method

We noted that 207 patients were included (n = 207), accounting for 69 false positive and 138 true negative results. The intrinsic galactomannan values in the study were sensitivity 100%, specificity 68%, positive and negative predictive values respectively 16%, 100%, and a likelihood positive and negative test at respectively 3.12, and 0.

Results

The statistical analysis did not determine any association between false positivity in galactomannan and piperacillin-tazobactam issued by two manufacturers (P = 0.87 and P = 0.94). But, there was a significant association between false galactomannan positivity and piperacillin-tazobactam issued by the third manufacturer (P = 0.02). Four of the 25 batches issued by this manufacturer were tested and negative “in vitro” for galactomannan.

Discussion

This study results suggest that the association between false galactomannan positivity and piperacillin-tazobactam is not longer systematic, but can still prevail depending on the manufacturers. It also confirmed the positive contribution of testing piperacillin-tazobactam batches “in vitro” before using the antibiotic.     

Costs of,and reimbursement for,vaccines: A case study at the Board of Health Refugee Services in DeKalb county,Georgia

Background

Approximately 70,000 refugees are resettled to the United States each year. Providing vaccination to arriving refugees is important to both reduce the health-related barriers to successful resettlement, and protect the health of communities where refugees resettle. It is crucial to understand the process and resources expended at the state/local and federal government levels to provide vaccinations to refugees resettling to the United States.

Objectives

We estimated costs associated with delivering vaccines to refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic).

Methods

Vaccination costs were estimated from two perspectives: the federal government and the DeKalb clinic. Data were collected at the DeKalb clinic regarding resources used for vaccination: staff numbers and roles; type and number of vaccine doses administered; and number of patients. Clinic costs included labor and facility-related overhead. The federal government incurred costs for vaccine purchases and reimbursements for vaccine administration.

Results

The DeKalb clinic average cost to administer the first dose of vaccine was $12.70, which is lower than Georgia Medicaid reimbursement ($14.81), but higher than the State of Georgia Refugee Health Program reimbursement ($8.00). Federal government incurred per-dose costs for vaccine products and administrative reimbursement were $42.45 (adults) and $46.74 (children).

Conclusions

The total costs to the DeKalb clinic for administering vaccines to refugees are covered, but with little surplus. Because the DeKalb clinic ‘breaks even,’ it is likely they will continue to vaccinate refugees as recommended by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices.     

Student Acceptance of Plain Milk Increases Significantly 2 Years after Flavored Milk Is Removed from School Cafeterias: An Observational Study

Background

Previous studies document decreases in lunchtime milk consumption immediately after flavored milk is removed. Less is known about longer-term effects.

Relation between the level of knowledge and the rate of vaccination against the flu virus among the staff of the Clermont-Ferrand University hospital

Objective

The main aim of this study was to determine how much staff at the Clermont-Ferrand university hospital, France, knew about influenza and its relation with the vaccinal rate. The other aim was to develop better-targeted information campaigns and prevention policy in the work place.

Design

A self-administered questionnaire was sent to the 7601 salaried staff of the hospital in May 2005. The staff was asked to give details on socioprofessional characteristics, vaccinal status, and knowledge about the influenza virus (mode of transmission, contagiousness, measures of prevention, populations affected, mortality, vaccination schedule, and vaccination target populations). Multiple-choice questions on knowledge of influenza were scored according to the answer given.

Results

The response rate was 26.5%. The 2011 completed questionnaires were representative of the working staff. They showed a positive correlation between the rate of vaccination and knowledge of influenza, with a 0.98 coefficient. They also showed that the staff was very largely unaware of population groups most at risk for influenza (1% of correct answers).

Conclusions

Primary prevention campaigns will only be effective if the target population has a better awareness of the issues involved. This study highlights the areas in which knowledge was heterogeneous or inadequate, and the information that could be decisive in increasing vaccinal coverage among staff. This information should focus on modes of transmission, contagiousness, mortality, and above all on populations at risk.