Andrea L. Benin

Qualitative Analysis of Mothers' Decision-Making About Vaccines for Infants: The Importance of Trust

BACKGROUND. The high visibility of controversies regarding vaccination makes it increasingly important to understand how parents decide whether to vaccinate their infants. OBJECTIVE. The purpose of this research was to investigate decision-making about vaccinations for infants. DESIGN. We conducted qualitative, open-ended interviews. PARTICIPANTS. Subjects included mothers 1 to 3 days postpartum and again at 3 to 6 months. RESULTS. We addressed 3 topics: attitudes to vaccination, knowledge about vaccination, and decision-making. Mothers who intended to have their infants vaccinated (“vaccinators,” n = 25) either agreed with or did not question vaccination or they accepted vaccination but had significant concerns. Mothers who did not intend to vaccinate (“nonvaccinators,” n = 8) either completely rejected vaccination or they purposely delayed vaccinating/chose only some vaccines. Knowledge about which vaccines are recommended for children was poor among both vaccinators and nonvaccinators. The theme of trust in the medical profession was the central concept that underpinned all of the themes about decision-making. Promoters of vaccination included trusting the pediatrician, feeling satisfied by the pediatrician’s discussion about vaccines, not wanting to diverge from the cultural norm, and wanting to adhere to the social contact. Inhibitors included feeling alienated by or unable to trust the pediatrician, having a trusting relationship with an influential homeopath/naturopath or other person who did not believe in vaccinating, worry about permanent side effects, beliefs that vaccine-preventable diseases are not serious, and feeling that since other children are vaccinated their child is not at risk. CONCLUSION. Trust or lack of trust and a relationship with a pediatrician or another influential person were pivotal for decision-making of new mothers about vaccinating their children. Attempts to work with mothers who are concerned about vaccinating their infants should focus not only on providing facts about vaccines but also on developing trusting and positive relationships.

Trends in Legionnaires Disease, 1980–1998: Declining Mortality and New Patterns of Diagnosis

New diagnostic tests and empirical therapy for pneumonia may have important ramifications for the identification, treatment, and control of legionnaires disease (LD). To determine trends in the epidemiology of LD, we analyzed data for 1980-1998 from the passive surveillance system of the Centers for Disease Control and Prevention. During this time period, there were 6757 confirmed cases of LD (median annual number, 360 cases/year). Diagnosis by culture and by direct fluorescent antibody and serologic testing decreased significantly; diagnosis by urine antigen testing increased from 0% to 69%. The frequency of isolates other than Legionella pneumophila serogroup 1 (LP1) decreased from 38% to 4% (P=.003). The case-fatality rate decreased significantly, from 34% to 12% (P<.001) for all cases, from 46% to 14% (P<.0001) for nosocomial cases, and from 26% to 10% (P=.05) for community-acquired cases. LD-related mortality has decreased dramatically. The decrease in culture-based diagnosis limits the recognition of non-LP1 disease and impairs outbreak investigation, because fewer Legionella isolates are provided for further examination.

We never thought this would happen: transitioning care of adolescents with perinatally acquired HIV infection from pediatrics to internal medicine

Abstract Purpose. Transitioning the medical care of children with perinatally acquired HIV from pediatric care to internal medicine practices has become increasingly important as newer therapies prolong survival. The study aims to describe challenges to caring for these adolescents and the potential barriers to transitioning them to internal medicine-based care. Methods. Qualitative study in which data were gathered from open-ended interviews conducted from November 2005 to April 2006 with 18 adolescents with HIV, 15 of their parents, and 9 pediatric health care providers from the Yale Pediatric AIDS Care Program, New Haven, Connecticut. Results. Issues of stigma played a prominent role in both the challenges to care and barriers to transitioning care. Challenges to care were: (1) poor adherence to medication regimens; (2) adolescent sexuality; and (3) disorganized social environments. Potential barriers to transitioning care were: (1) families’ negative perceptions of and experiences with stigma of HIV disease – which undermined the desire to meet new providers; (2) perceived and actual lack of autonomy – pediatric providers feared that staff in adult clinics would demand a level of independence that adolescents did not have; and (3) difficulty letting go of relationships – adolescents, guardians, and providers described a familial relationship and expressed anxiety about terminating their relationships. Conclusion. Understanding these challenges and barriers can inform both pediatric and adult HIV care providers and enable them to create successful transition programs, with the goal of improving retention and follow-up to care.

Influenza Vaccination as Secondary Prevention for Cardiovascular Disease

Evidence from cohort studies and a randomized clinical trial indicates that annual vaccination against seasonal influenza prevents cardiovascular morbidity and all-cause mortality in patients with cardiovascular conditions. The American Heart Association and American College of Cardiology recommend influenza immunization with inactivated vaccine (administered intramuscularly) as part of comprehensive secondary prevention in persons with coronary and other atherosclerotic vascular disease (Class I, Level B). Immunization with live, attenuated vaccine (administered intranasally) is not currently recommended for persons with cardiovascular conditions. It is important to note that influenza vaccination coverage levels overall and in this population remain well below national goals and are marked by disparities across different age and ethnic groups. One of the barriers to vaccination for patients with cardiovascular disease is that cardiology practices frequently do not stock and administer influenza vaccine. Healthcare providers who treat individuals with cardiovascular disease can help improve influenza vaccination coverage rates by providing and strongly recommending vaccination to their patients before and throughout the influenza season.

Epidemic nephritis in Nova Serrana, Brazil

BACKGROUND Outbreaks of nephritis have been rare since the 1970s. From December, 1997, to July, 1998, 253 cases of acute nephritis were identified in Nova Serrana, Brazil. Seven patients required dialysis, and three patients died. We did a case-control study to investigate the cause of the outbreak. METHODS Using a matched cluster design, we examined seven recent patients, their family members (n=23), and members of neighbourhood-matched control households (n=22). We subsequently interviewed 50 patients and 50 matched controls about exposure to various dairy products. We also cultured dairy foods and took udder-swab and milk samples from cows. FINDINGS Throat cultures indicated that nephritis was associated with group C Streptococcus equi subspecies zooepidemicus, a cause of bovine mastitis. S. zooepidemicus was detected in four of seven case households (six of 30 people) and no control households (p=0.09). Patients were more likely than matched controls to have consumed a locally produced cheese called queijo fresco (matched odds ratio 2.1, p=0.05). The nephritis attack rate was 4.5 per 1000 in Nova Serrana but 18 per 1000 in the village Quilombo do Gaia (p=0.003). The largest supplier of unpasteurized queijo fresco was a farm in Quilombo do Gaia. S. zooepidemicus was not detected in food samples or in swabs collected from cows in August, 1998, although mastitis was evident among cows on the suspected farm. Throat cultures of the two women who prepared cheese on this farm yielded the outbreak strain of S. zooepidemicus. After the cheese was removed from the distribution system, no further cases were reported. INTERPRETATION A large outbreak of glomerulonephritis was attributed to S. zooepidemicus in unpasteurised cheese. This outbreak highlights the dangers of consuming unpasteurized dairy products and need for global efforts to promote food safety.

An Outbreak of Travel-Associated Legionnaires Disease and Pontiac Fever: The Need for Enhanced Surveillance of Travel-Associated Legionellosis in the United States

Travel-associated outbreaks of legionnaires disease (LD) and combined outbreaks of LD and Pontiac fever (PF) are rarely identified. During one travel-associated combined outbreak at a hotel, a cohort study of potentially exposed persons and an environmental investigation were performed. Two LD and 22 PF cases were identified. Legionella pneumophila serogroup 6 (Lp6) isolates from the index patient and the hotel whirlpool spa were found to be identical by amplified fragment-length polymorphism typing. Disease occurred in 10 of 26 guests who were exposed to the spa versus 2 of 29 guests who were exposed only to the pool area (38% vs. 7%; P=.005). Immunoglobulin M (IgM) antibody to the outbreak Lp6 strain was more common among persons with PF (4 of 9) than among non-ill persons (2 of 32) (44% vs. 6%; P=.02). Spa exposure correlated with disease (P=.001) and IgM seropositivity (P=.007). New laboratory techniques facilitate outbreak investigation; to expedite outbreak interruption and measure the impact of travel-associated legionellosis, surveillance must be improved.

Effectiveness of the 23-valent polysaccharide vaccine against invasive pneumococcal disease in Navajo adults.

Invasive pneumococcal disease occurs 2-3-fold more often among Navajo adults than among adults in the general United States population. The objective of this observational study was to determine the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) among Navajo adults. Active surveillance identified cases of invasive pneumococcal disease during 1996-1997. Three control patients per case patient were matched according to underlying medical conditions, sex, age, and location of medical care. Effectiveness was calculated by regression analysis of case-control sets and by indirect cohort methodology. Diabetes and alcoholism occurred in 41% and 43% of 108 case patients, respectively; 62% of case patients and 64% of control patients were immunized. Overall vaccine effectiveness was 26% (95% confidence interval [CI], -29% to 58%); 15% (95% CI, -116% to 67%) for patients with diabetes and -5% (95% CI, -141% to 54%) for patients with alcoholism. Overall vaccine effectiveness, as determined by use of the indirect cohort methodology, was 35% (95% CI, -33% to 69%). PPV23 was not significantly effective among Navajo adults and may be inadequate to prevent serious pneumococcal disease in this population.

Validity of using an electronic medical record for assessing quality of care in an outpatient setting.

Objective:We sought to evaluate the validity of retrieving data from a commercial, outpatient electronic medical record (EMR) to assess the management of pharyngitis, an important measure of quality of healthcare in pediatrics and a new measure for the Health Plan Employer Data and Information Set (HEDIS). Methods:For children ages 3–18 years, we electronically identified clinical encounters with diagnoses of pharyngitis using 3 different strategies (an EMR-based strategy, an administrative data-based strategy, and a reference strategy which used medical record review). By each strategy, we calculated the proportion of episodes of pharyngitis during 1 year for which management of pharyngitis adhered to published guidelines. Results:Among 479 total episodes of pharyngitis, 434 (91%) were from the EMR-based strategy and 281 (59%) from the administrative data-based strategy. Review of the records (the reference strategy) found that 391 of 479 (82%) were confirmed episodes of pharyngitis. A diagnostic test for group A streptococcus (GAS) was performed at 310 of 434 (71%) of episodes identified by the EMR-based strategy and at 214 of 281 (76%) of episodes by the administrative data-based strategy (P = 0.045). By the reference strategy, a diagnostic test was done in 301 of 391 (77%); more than at episodes found by the EMR-based strategy (71%, P < 0.001). Conclusions:The EMR-based strategy resulted in a statistically different proportion of episodes having diagnostic testing for GAS compared with a reference strategy. Complete evaluations to validate strategies for extracting data from electronic databases are necessary before assuming that measures of quality of care will be the same regardless of the source of data.

Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators

Objective The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital. Methods We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians. Results Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees. Conclusions The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.

Invasive Pneumococcal Disease among Navajo Adults, 1989–1998

Compared with white and black persons in the United States, some Native American groups are at increased risk for invasive pneumococcal disease (IPD). To characterize the epidemiology of IPD among Navajo adults, we conducted active surveillance for IPD on the Navajo Nation and reviewed medical records of patients with IPD. For 1997-1998, the annual incidence (cases per 100,000 persons) was 56 for Navajos aged 18-64 years and 190 for Navajos aged > or =65 years. The corresponding rates were 10 and 57 for white and 44 and 82 for black persons in the United States. The case-fatality rate was 14%. Eighty percent of cases were caused by serotypes included in the 23-valent pneumococcal polysaccharide vaccine. Navajo adults have rates of IPD that are 3-5-fold higher than those of the general US population. Additional research is needed to understand the reasons for this elevated risk and to develop prevention strategies.