A New Shot for Success—Immunization and Vaccine Preparedness

The objective was to determine how the Internet is used to promote sexual health among adolescents. Six key words were entered into three search engines producing 87,180 results. Three percent (n = 36) were educational Web sites targeted at teenagers and covered a range of sexually transmitted diseases (STDs). These were content analyzed using sexuality education and usability guidelines. All sites addressed some STD information, but only two covered negotiation. Navigability results were mixed; only one third offered a site map. Sexual health educators may need to include more information on how to negotiate safe sex and improve Web navigability for teenagers.     

Could it happen here? Vaccine risk controversies and the specter of derailment

Controversy over vaccine safety has achieved high visibility over the past decade. At the same time, however, levels of coverage for routinely recommended childhood vaccines in the United States are at their highest ever. We examine this apparent paradox. We consider the ways in which concerns over vaccine safety have emerged and diffused through the popular media, legislative hearings, and Internet-based activism. As a case study, we review the controversy over the alleged connection between autism and the measles-mumps-rubella (MMR) vaccine and consider why it had a dramatic effect on the vaccine's acceptance in Great Britain but virtually none in the United States.     

Administration Time Between Seasonal Live-Attenuated Influenza Vaccine and Trivalent Influenza Vaccine During the “Stop Flu at School” Campaign— Hawaii, 2009

Objectives

We determined whether the administration time differed between seasonal intranasal live-attenuated influenza vaccine (LAIV) and seasonal injectable trivalent inactivated influenza vaccine (TIV) during Hawaii''s 2009 school-located influenza vaccination clinics. This information is useful for public health response and allows further investigation into possible differences between the two vaccines.

Methods

We conducted a prospective cohort study in 15 public schools to determine mean times to administer LAIV and TIV to students. We performed group analyses to control for various clinic characteristics and conducted a stratified, weighted analysis.

Results

A total of 4,701 students were enrolled in the study, and administration time was obtained for 3,869 (82%) students (1,492 [39%] LAIV and 2,377 [61%] TIV). The mean administration time for LAIV was 62 seconds and for TIV was 90 seconds, a difference of 28 seconds (p<0.01). This finding remained significant in the stratified analysis.

Conclusions

Although results indicated that both LAIV and TIV can be administered rapidly among school-aged populations, LAIV was faster to administer. This finding, in addition to the greater immunogenicity of LAIV compared with TIV among children, may be an important consideration for public health administrators in planning school-located mass vaccination clinics and encouraging patient acceptance of this vaccine.Depending on the severity of an influenza season, influenza has been reported to cause approximately 200,000 hospitalizations and up to 49,000 deaths annually.^1–3 School-aged children (those aged 5–18 years) account for approximately 40% of infections during a typical influenza season, the highest among any age group.^4–6 Additionally, children amplify transmission in a community; therefore, it is logical to focus influenza vaccination efforts on this age group.⁷ With this idea in mind, the Hawaii Department of Health (HDOH) implemented school-located influenza vaccination (SLIV) clinics throughout the state during 2007.¹ In February 2008, the Advisory Committee on Immunization Practices recommended that all children aged 6 months to 18 years receive annual influenza vaccination, thus offering support for providing alternatives to physician offices to accommodate the increased annual influenza vaccination target cohort.^8,9The HDOH “Stop Flu at School” (SFAS) campaign is a statewide program that attempts to provide students in kindergarten through eighth grade with an annual influenza vaccination. SFAS, a voluntary program, offers both seasonal intranasal live-attenuated influenza vaccine (LAIV) and injectable trivalent inactivated influenza vaccine (TIV) free to students and staff in participating schools. Vaccine doses for the period during this study were acquired by HDOH through a combination of federal programs (e.g., Vaccines for Children, Section 317) and state funds, while operational costs were secured through a combination of federal grant funds and private (e.g., vaccine manufacturers and foundations) grants and contributions.Intranasal LAIV was licensed in the United States in 2003 for use among healthy individuals aged 2–49 years.¹⁰ In comparison with TIV, LAIV is administered in two sites (i.e., the sprayer is inserted in one nostril, used, removed, and then reinserted into the second nostril), has a longer list of contraindications, and is a newer delivery system.¹¹ Recent studies suggest that LAIV can induce both mucosal and innate immunity; is more immunogenic than TIV, as it is effective after only one dose; and requires less time to elicit an antibody response.^12–15 Intramuscular TIV, in use for >30 years, has fewer contraindications, is injected in one site, and can be used in all people ≥6 months of age, including groups at high risk (e.g., those with asthma or other chronic underlying medical conditions) who cannot receive a live-virus vaccine.¹⁶During the fall of 2009, the second wave of pandemic influenza A (H1N1) was sweeping through the U.S. mainland. Hawaii state public health planners were tasked with rapidly implementing programs for H1N1 vaccine delivery, and SLIV clinics were considered an important venue to accomplish this goal.¹⁷ HDOH was in its third year of providing seasonal influenza vaccine through SFAS, and this program offered an opportunity to study logistical considerations for implementing SLIV clinics and enhance public health program planning. Additionally, given the distinctions between seasonal LAIV and seasonal TIV, we were interested in determining whether a substantial difference existed in the administration time of the two vaccines and what factors might influence a difference during the statewide 2009 SFAS campaign.     

《疫苗》（Vaccine）

《疫苗》（Vaccine）由爱斯维尔（Elsevier）集团出版,为爱德华·詹纳（the Edward Jenner Society）学会、国际疫苗学会（the International Society for Vaccines）和日本疫苗学会（the Japanese Society for Vaccinology）的官方期刊,创办于1983年,为周刊。     

Vaccine acceptance: Science,policy, and practice in a ‘post-fact’ world

Suboptimal vaccination uptake may be associated with outbreaks of vaccine-preventable diseases in many parts of the world. Researchers and practitioners working on improving vaccine acceptance and uptake gathered together for the fifth annual meeting on vaccine acceptance, organized by the Fondation Mérieux at its conference centre in Veyrier-du-Lac, France, to share their experiences in building, improving and sustaining vaccine confidence and uptake. The importance and value of truly listening to people and seeking to understand the perspectives of vaccine hesitant people was emphasized throughout the meeting. The benefits of social marketing, which can be used to influence behavior that benefit individuals and communities for the greater social good, and its integration into strategies aimed at improving vaccine acceptance and uptake, were discussed. Healthcare professionals (HCPs) need tools and training to help them engage effectively in vaccination acceptance conversations with parents and other patients. Two potential tools, motivational interviewing (MI) and AIMS (Announce, Inquire, Mirror, Secure), were presented. Examples of MI approaches that have successfully improved vaccination acceptance and uptake included a project in Canada aimed at parents just after the birth of their baby. The role of mandates to increase vaccination uptake in the short-term was discussed, but to achieve sustainable vaccination uptake this must be complemented with other strategies. These annual meetings have led to the creation of an informal community of practice that facilitates cross-pollination between the various disciplines and different settings of those involved in this area of research and implementation. It was agreed that we must continue our efforts to promote vaccine acceptance and thus increase vaccination uptake, by fostering more effective vaccination communication, monitoring of the media conversation on vaccination, designing and rigorously evaluating targeted interventions, and surveillance of vaccine acceptance and uptake with pertinent, reliable measures.     

Different Culture or Different Mind? Perception and Acceptance of HPV Vaccine in China and in the U.S

Unlike the United States, where human papillomavirus (HPV) vaccines have been available for decades, China recently approved its first HPV vaccines. Setting up a baseline comparison between these two countries, this study examines the influence of message framing, motivational orientation, cultural worldview, knowledge, and gender on young adults’ intentions to get vaccinated. Compared to the U.S. participants, Chinese participants perceived HPV as a more severe risk and were more willing to get the vaccine. However, they were also more skeptical about vaccine safety. Inconsistencies with previous research emerged regarding the moderating effects of motivational orientation and cultural worldview. Findings from this study offer important implications for HPV vaccine promotion in China.     

Understanding Knowledge, Attitudes, and Behaviors Related to Influenza and the Influenza Vaccine in US–Mexico Border Communities

Hispanics are less likely to receive the influenza vaccine compared to other racial and ethnic groups in the US. Hispanic residents of the US–Mexico border region may have differing health beliefs and behaviors, and their cross-border mobility impacts disease control. To assess beliefs and behaviors regarding influenza prevention and control among border populations, surveys were conducted at border clinics. Of 197 respondents, 34 % reported conditions for which vaccination is indicated, and travel to Mexico was common. Few (35 %) believed influenza could make them ‘very sick’, and 76 % believed they should take antibiotics to treat influenza. Influenza vaccine awareness was high, and considered important, but only 36 % reported recent vaccination. The belief that influenza vaccination is ‘very important’ was strongly associated with recent vaccination; “Didn’t think about it” was the most common reason for being un-vaccinated. Misconceptions about influenza risk, prevention and treatment were common in this Hispanic border population; improved educational efforts and reminder systems could impact vaccination behaviors.     

Mother–Daughter Communication About HPV Vaccine

PurposeParent–child conversations about human papillomavirus (HPV) vaccine may provide parents with the opportunity to talk with their daughters about sexual health. We sought to characterize mothers' communication with their adolescent daughters about HPV vaccine.MethodsWe surveyed 609 mothers of girls aged between 11 and 20 years living in North Carolina in Fall 2008. We used logistic regression to identify the correlates of mother–daughter communication.ResultsMost mothers (81%) reported having discussed HPV vaccine with their daughters. For almost half of these families (47%), discussion of HPV vaccine led to a conversation about sex. This was more common among mothers who believed that their daughters may be sexually active (odds ratio [OR]: 1.88; 95% confidence interval [CI]: 1.25–2.83), had greater knowledge of HPV vaccine (OR: 2.46; 95% CI: 1.07–5.64), lived in urban areas (OR: 1.75; 95% CI: 1.21–2.54), or reported being born-again Christians (OR: 1.74; 95% CI: 1.17–2.58). Most mothers who talked with their daughters about HPV vaccine reported having discussed the reasons for and against getting vaccinated (86%). Mothers most commonly reported having discussed the potential HPV vaccine benefits, usually protection against cervical cancer (56%), and less frequently reported having discussed the perceived disadvantages of HPV vaccine.ConclusionsHPV vaccine conversations may provide opportunities for sexual health promotion and sexually transmitted infection (STI) prevention.     

Identifying pregnancy episodes,outcomes, and mother–infant pairs in the Vaccine Safety Datalink

Background

The need for research on the safety of vaccination during pregnancy is widely recognized. Large, population-based data systems like the Vaccine Safety Datalink (VSD) may be useful for this research, but identifying pregnancies using electronic medical record (EMR) and claims data can be challenging.

Methods

We modified an existing data processing algorithm to identify pregnancies within seven of the ten VSD sites. We validated the algorithm by calculating the agreement in pregnancy outcome type, end date, and gestational age between the algorithm and manual medical record review. At each participating site, we randomly sampled 15 episodes within four outcome type strata (live births, spontaneous abortions, elective abortions, and other pregnancy outcomes) for a total of 60 episodes per site. We also developed and validated methods to link mothers to their infants in the electronic data.

Results

We identified 595,929 pregnancy episodes ending in 2002 through 2006 among women 12 through 55 years of age. Of these pregnancies, 75% ended in live births, 12% in spontaneous abortions, and 9% in elective abortions. We were able to confirm a pregnancy within 28 days of the algorithm-estimated pregnancy start date for 99% of live births, 93% of spontaneous abortions, 92% of elective abortions, and 90% of other outcomes sampled. The agreement between the algorithm-identified and the abstractor-identified outcome date ranged from 70% (elective abortion) to 96% (live birth) depending on outcome type. When gestational age was available in the EMR, agreement ranged from 82% (other) to 98% (live birth) depending on outcome type. We confirmed 100% of the 350 sampled mother–infant linkages with manual medical record review.

Conclusions

The VSD algorithm accurately identifies pregnancy episodes and mother–infant pairs across participating sites. Additional manual record review may be needed to improve the precision of the pregnancy date estimates depending on specific study needs. These algorithms will allow us to conduct large, population-based studies of the safety of vaccination during pregnancy.     

Potential Effects of California’s New Vaccine Exemption Law on the Prevalence and Clustering of Exemptions

Exemptions from childhood immunizations required for school entry have continued to increase among California kindergartners, and exemptions show spatial clustering within the state. A 2014 change in California’s school-entry vaccine exemption law requires parents filing for an exemption to submit signed documents from a health care provider. However, the evidence presented here suggests that the policy change will probably not be sufficient to reverse the growing trend in vaccine refusals.State-mandated immunization requirements for school entry have been instrumental in achieving high immunization coverage rates and ensuring herd immunity against infectious disease outbreaks.1 However, in most states parents can obtain a personal beliefs exemption (PBE) from school-entry requirements.2 A growing trend of parental vaccine hesitancy has led to an increase in PBE rates, and such increases are associated with higher risks of disease outbreaks.3 In California, for example, rates of PBEs among children entering kindergarten increased by 380% from 1996 to 2010 (from 0.5% to 2.3%).4,5In response to rising PBE rates, California passed Assembly Bill 2109 (AB2109) in September 2012.6 California’s previous law allowed a parent to obtain a PBE by signing an affidavit stating that immunization is contrary to the parent’s beliefs.7 This affidavit was preprinted on the California School Immunization Record, making exemptions readily accessible. Previous research demonstrates an association between easier state exemption procedures and higher exemption rates.8,9 Authored by state assembly member and pediatrician Richard Pan, AB2109 requires parents filing an exemption to submit an attestation signed by a health care provider stating that they have been provided information about the risks and responsibilities of refusing vaccination and an attestation signed by parents indicating receipt of this information.6 AB2109 went into effect in January 2014.It is not yet known whether this policy change will reverse or slow the trend of increasing PBE rates in California, although a similar regulatory change in Washington appears to have reduced PBEs.10 Here we present the most recent data on PBEs in California and demonstrate continued spatial variation in PBE rates statewide. These data represent the last kindergarten cohort before AB2109 was passed, so they will provide a useful baseline as the new law takes effect. We also discuss the implications of spatial clustering for the potential effectiveness of AB2109.     

Vaccine properties of Brucella melitensis 16MΔwzm and reactivation of placental infection in pregnant sheep

Brucellosis, a worldwide zoonotic disease, is endemic in many developing countries. Besides causing significant economic losses for the livestock industry, it has severe consequences for human health. In endemic regions, small ruminants infected by Brucella melitensis are the main source of human brucellosis. Rev1, the only vaccine currently recommended to control the disease in sheep and goats, has several drawbacks. Rough lipopolysaccharide (R-LPS) mutants have been tested as alternatives, but most lack efficacy. Those in the Wzm/Wzt system responsible for O-polysaccharide export to the periplasm have been proposed as promising vaccine candidates, although to date they have been scarcely investigated in the natural host. In the present work, we studied the biological properties of a 16MΔwzm in-frame deletion mutant, including its safety in pregnant mice and sheep. In mice, 16MΔwzm prevented placental and fetal infections before parturition and protected against B. melitensis and Brucella ovis infections. In sheep, 16MΔwzm was equally safe in lambs, rams, and non-pregnant ewes, inducing some transient Rose Bengal reactions (<7 weeks). The serological reactions occurred earlier and more strongly in pregnant than in non-pregnant ewes and were significantly reduced when conjunctival rather than subcutaneous vaccination was used. In ewes vaccinated at mid-pregnancy, 16MΔwzm was not shed in vaginal discharges during the pregnancy and did not induce abortions/stillbirths. However, some ewes showed a transitory reactivation of infection in placentas and/or milk at parturition, accompanied by a seroconversion in smooth LPS (S-LPS) and/or R-LPS tests. Overall, 16MΔwzm can be considered as a safe vaccine for lambs, rams, and non-pregnant ewes, but its use at mid-pregnancy should be avoided to prevent vaccine dissemination at parturition. If the efficacy results against B. melitensis and B. ovis observed in mice are confirmed by further studies in the natural host, 16MΔwzm could constitute a useful vaccine.     

HPV Vaccine–Related Knowledge,Beliefs, Acceptability,and Uptake Among Latinas Who Prefer English and Those Who Prefer Spanish

Latinas compose almost 10% of the U.S. population and suffer the highest incidence of and one of the highest mortality rates from cervical cancer. Human papillomavirus (HPV) vaccination can prevent most HPV infections that cause more than 90% of cervical cancer. Unfortunately, limited knowledge and low rates of HPV vaccination persist among Latinas. The current study compared awareness, knowledge, beliefs, acceptability, uptake, and 3-dose series completion of HPV vaccination between Latinas who prefer English (EPL) and those who prefer Spanish (SPL), ages 18–62, living in Southern California. (The 3-dose series completion was based on HPV vaccine completion guidelines at the time of the study. HPV vaccination guidelines do change over time to improve coverage.) More EPL (n = 57) than SPL (n = 150) reported significantly (a) more HPV vaccine awareness and more knowledge of where to access the vaccine and additional vaccine information and (b) greater endorsement of vaccine effectiveness and safety (p < .05). Regardless of language preference, Latinas reporting knowledge of where to access the vaccine and additional information endorsed greater acceptability of the vaccine and more favorable beliefs regarding vaccine safety and effectiveness (p < .05). In multivariate analyses, language and income predicted the outcomes of knowledge regarding accessing the vaccine and additional information. Only 15.6% of all eligible Latinas (n = 45) initiated the HPV vaccine, with 8.9% completion. Interventions seeking to improve HPV vaccination should address linguistic and socioecological differences within Latinas to enhance effectiveness.     

Meningococcus Vaccine—Yes; Gonococcus—No

Abstract

Introduction: Delay in surgery for hip fractures in older patients may affect mortality and the risk of delirium. Delay in surgery may occur as a result of several factors. It has not been established whether certain patient-related factors, such as a high international normalized ratio (INR) caused by warfarin treatment is associated with delay in surgery. The aim of this study was to explore the associations between warfarin treatment, INR, and time from admission to surgery. Methods: This is an observational study based on data from a database of all hip fracture patients aged ≥ 65 years who were admitted to an orthogeriatric unit. The database included data from 1192 consecutive patients admitted from January 2007 to April 2010. Data were collected during routine work. Use of warfarin, patient characteristics, medical complications, length of stay, and time from admission to surgery were registered from the patients' records, and INR at admission in warfarin users. Results: Warfarin was used by 117 (9.8%) patients at admission, which included more men (n = 42; 14.4%) than women (n = 75; 8.3%) (P = 0.003). The mean age was 85 years, with no difference between users and nonusers. Warfarin users had more comorbid diseases (mean, 2.1 vs 1.8; P = 0.003), poorer health status (American Society of Anesthesiologists score of 3–5 in 77.8% vs 51.0%), and longer waiting time for surgery compared with nonusers (mean, 23 vs 12 hours; P < 0.001). There was no difference in need for blood transfusions (28.2% of users compared with 25.3% of nonusers; P = 0.49). Length of stay was longer among warfarin users compared with nonusers (mean, 14.6 vs 11.7 days; P = 0.002). Warfarin users with an INR of ≥ 2 had a longer waiting time than those with an INR of < 2, but they had a longer waiting time than nonusers. Conclusion: Hip fracture patients who are using warfarin experience a longer waiting time for surgery, most likely due to more comorbidities. A more active approach to better management of comorbidities may reduce waiting time for surgery in warfarin users.     

Vaccine quality--can a single standard be defined?

To analyze the current global situation with respect to vaccine quality and to monitor progress in attaining it, it is first necessary to define what this means. While acknowledging that manufacturers are responsible for the quality of the vaccines they produce, World Health Organization (WHO) proposes a definition for "vaccines of assured quality" which depends on the existence of a competent and fully functional regulatory authority as assessed by an external expert team using widely agreed indicators to regulate the product. A vaccine of assured quality is defined as one that consistently meets appropriate levels of purity, potency, safety and efficacy as judged through an independent review system competent to take an evidence-based decision on the product for a specified population in a specific context. Such a review system would make use of all available information, such as licensing dossiers, surveillance of field performance, lot-by-lot scrutiny, appropriate laboratory testing, cGMP inspection of manufacturers, and evaluation of clinical trials, generally assumed by a fully functional regulatory authority. This definition implies that, faced with the same risk/benefit, any competent group would come to the same decision. The definition also indicates clear pathways to improve vaccine quality by strengthening national regulatory authorities and WHO is actively engaged in this task. By insisting on competent regulatory oversight, while recognizing the role of risk analysis in the selection of vaccines for use, WHO strongly reiterates the need for a single standard of quality. Only vaccine of assured quality should be considered for use in national immunization programs on the basis of the risk/benefit ratio for the particular population.