Charles P. Mouton

Recommendations from the national vaccine advisory committee: Standards for adult immunization practice

National Vaccine Advisory Committee The Advisory Committee on Immunization Practices (ACIP) makes recommendations for routine vaccination of adults in the United States.1 Standards for implementing the ACIP recommendations for adults were published by the National Vaccine Advisory Committee (NVAC) in 20032 and by the Infectious Diseases Society of America in 2009.3 In addition, NVAC published a report in 2012 outlining a pathway for improving adult immunization rates.4 While most of these documents included guidelines for immunization practice, recent changes in the practice climate for adult immunization necessitated an update of existing adult immunization standards. Some of these changes include expansion of vaccination services offered by pharmacists and other community immunization providers both during and since the 2009 H1N1 influenza pandemic; vaccination at the workplace; increased vaccination by providers who care for pregnant women; and changes in the health-care system, including the Affordable Care Act (ACA), which requires first-dollar coverage of ACIP-recommended vaccines for people with certain private insurance plans, or those who are beneficiaries of expanded Medicaid plans.5 The ACA first-dollar provision is expected to increase the number of adults who will be insured for vaccines. Other changes include expanding the inclusion of adults in state immunization information systems (IISs) (i.e., registries) and the Centers for Medicare & Medicaid Services Meaningful Use Stage 2 requirements, which mandate provider reporting of immunizations to registries, including reporting of adult vaccination in states where such reporting is allowed.6 For the purposes of this report, provider refers to any individual who provides health-care services to adult patients, including physicians, physician assistants, nurse practitioners, nurses, pharmacists, and other health-care professionals. While previous versions of the adult immunization standards have been published, recommendations for adult vaccination are published annually, and many health-care organizations have endorsed routine assessment and vaccination of adults, vaccination among adults continues to be low.7–15 Several barriers to adult vaccination include:

Community Engagement Studios: A Structured Approach to Obtaining Meaningful Input From Stakeholders to Inform Research.

Problem Engaging communities in research increases its relevance and may speed the translation of discoveries into improved health outcomes. Many researchers lack training to effectively engage stakeholders, whereas academic institutions lack infrastructure to support community engagement. Approach In 2009, the Meharry-Vanderbilt Community-Engaged Research Core began testing new approaches for community engagement, which led to the development of the Community Engagement Studio (CE Studio). This structured program facilitates project-specific input from community and patient stakeholders to enhance research design, implementation, and dissemination. Developers used a team approach to recruit and train stakeholders, prepare researchers to engage with stakeholders, and facilitate an in-person meeting with both. Outcomes The research core has implemented 28 CE Studios that engaged 152 community stakeholders. Participating researchers, representing a broad range of faculty ranks and disciplines, reported that input from stakeholders was valuable and that the CE Studio helped determine project feasibility and enhanced research design and implementation. Stakeholders found the CE Studio to be an acceptable method of engagement and reported a better understanding of research in general. A tool kit was developed to replicate this model and to disseminate this approach. Next Steps The research core will collect data to better understand the impact of CE Studios on research proposal submissions, funding, research outcomes, patient and stakeholder engagement in projects, and dissemination of results. They will also collect data to determine whether CE Studios increase patient-centered approaches in research and whether stakeholders who participate have more trust and willingness to participate in research.

Toward a Positive Aging Phenotype for Older Women: Observations From the Women’s Health Initiative

BACKGROUNDnTo develop a positive aging phenotype, we undertook analyses to describe multiple dimensions of positive aging and their relationships to one another in women 65 years of age and older and evaluate the performance of individual indicators and composite factors of this phenotype as predictors of time to death, years of healthy living, and years of independent living.nnnMETHODSnData from Womens Health Initiative clinical trial and observational study participants ages 65 years and older at baseline, including follow-up observations up to 8 years later, were analyzed using descriptive statistics and principal components analysis to identify the factor structure of a positive aging phenotype. The factors were used to predict time to death, years of healthy living (without hospitalization or diagnosis of a serious health condition), and years of independent living (without nursing home admission or use of special services).nnnRESULTSnWe identified a multidimensional phenotype of positive aging that included two factors: Physical-Social Functioning and Emotional Functioning. Both factors were predictive of each of the outcomes, but Physical-Social Functioning was the strongest predictor. Each standard deviation of increase in Physical-Social Functioning was accompanied by a 23.7% reduction in mortality risk, a 19.4% reduction in risk of major health conditions or hospitalizations, and a 26.3% reduction in risk of dependent living.nnnCONCLUSIONSnPhysical-Social Functioning and Emotional Functioning constitute important components of a positive aging phenotype. Physical-Social Functioning was the strongest predictor of outcomes related to positive aging, including years of healthy living, years of independent living, and time to mortality.

Racial Differences in Colorectal Cancer Incidence and Mortality in the Women's Health Initiative

Background: Colorectal cancer (CRC) incidence and mortality rates are higher in African–Americans as compared with other racial/ethnic groups. The womens health initiative (WHI) study sample was used to determine whether differences in CRC risk factors explain racial/ethnic differences in incidence and mortality. Methods: The WHI is a longitudinal study of postmenopausal women recruited from 40 centers. Baseline questionnaires were used to collect sociodemographic and health status information. All CRC diagnoses were centrally adjudicated. Cox regression models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for invasive CRC by race/ethnicity. Results: The study sample included 131,481 (83.7%) White, 14,323 (9.1%) African–American, 6,362 (4.1%) Hispanic, 694 (0.4%) Native American and 4,148 (2.6%) Asian/Pacific Islanders. After a mean follow-up of 10.8 years (SD 2.9), CRC incidence was the highest in African–Americans (annualized rate = 0.14%), followed by Whites and Native Americans (0.12% each), Asian/Pacific Islanders (0.10%), and Hispanics (0.08%). After adjustment for age and trial assignment, Hispanics had a lower risk compared with Whites, HR 0.73 (95% CI: 0.54–0.97) (P = 0.03), and African–Americans had a marginally greater risk, HR 1.16 (95% CI: 0.99–1.34), P = 0.06. Multivariable adjustment attenuated the difference in incidence between African–Americans and Whites (HR 0.99, 95% CI: 0.82–1.20), while strengthening the lower HR for Hispanics (HR 0.68, 95% CI: 0.48–0.97). Conclusions: African–American/White differences in CRC risk are likely due to sociodemographic/cultural factors other than race. Impact: A number of modifiable exposures could be a focus for reducing CRC risk in African–Americans. Cancer Epidemiol Biomarkers Prev; 20(7); 1368–78. ©2011 AACR.

Physical activity and inflammation in a multiethnic cohort of women.

PURPOSEnMany cross-sectional studies using data from a single time point have reported that higher levels of physical activity or fitness are associated with lower levels of inflammatory markers, but data examining change are limited, as are race/ethnicity-specific data. The purpose of this study was to examine the associations between physical activity and inflammation assessed at two time points among women of different race/ethnicities.nnnMETHODSnA total of 1355 postmenopausal women (301 whites, 300 blacks, 300 Hispanics, 300 Asians/Pacific Islanders, and 154 American Indians) age 50-79 yr were studied. Participants were from 40 US cities and were free of cardiovascular disease and cancer. At baseline and year 3, women reported their recreational physical activities and provided blood samples, which were analyzed for several inflammatory markers.nnnRESULTSnIn cross-sectional analyses, after adjusting for several potential confounders including body mass index, higher physical activity levels were generally related to lower inflammatory marker concentrations. For example, P values for a linear trend of lower C-reactive protein levels across physical activity tertiles at baseline were <0.0001 in all women and 0.94, 0.09, 0.002, 0.20, and 0.10, respectively, for the five race/ethnic groups listed above. For interleukin 6, the corresponding P values were <0.0001, 0.0007, 0.01, 0.03, 0.37, and 0.004, respectively, at baseline. Relationships at year 3 were similar to baseline. However, there was no relation between changes in physical activity and changes in inflammatory markers during the 3-yr period.nnnCONCLUSIONSnAmong middle-age and older women overall, there were strong, inverse, cross-sectional associations between physical activity level and inflammatory markers. However, changes in inflammatory markers were unrelated to changes in physical activity. These data suggest a noncausal association between physical activity and inflammatory markers.

Evaluation findings from genetics and family health history community-based workshops for African Americans

The purpose of this study was to examine the implementation and effectiveness of community education workshops to change genetics and health-related knowledge, intentions, and behavior of urban African Americans. Eight workshops were held and 183 participants consented to participate in the study. A majority of the participants were African American (97%) and female (84%) and just over half were 65xa0years and older (60%), and had some high school or were high school graduates (52%). The community-based workshops were standardized and comprised a 45-min PowerPoint presentation that included group discussions and interactive activities. The evaluation used a pre–post design with a 2-month follow-up. The group as a whole (and the subgroups by age and education level) significantly improved their knowledge of race and genetics from pretest to posttest as measured by their scores on the “Race”, Genetics, and Health knowledge questions. Findings around intentions showed that the largest number of participants pledged to collect family health history information from family members. Findings around behavior changes showed that, along the stages of change continuum, there were more participants at maintenance (stage 5) at the 2-month follow-up than at the pre-workshop for three health-related activities. Feedback was positive as participants indicated they appreciated the information they received and audience involvement. The article discusses local and global implications for practice and research among community health educators.

Overcoming Barriers to Low HPV Vaccine Uptake in the United States: Recommendations from the National Vaccine Advisory Committee: Approved by the National Vaccine Advisory Committee on June 9, 2015

An average of 25,900 cases of human papillomavirus (HPV)-associated cancers are newly diagnosed in the United States each year.1,2 An estimated 14 million people are newly infected with HPV each year, and nearly half of these infections occur in people aged 14–25 years.3 Although most infections resolve over time, persistent infection with oncogenic HPV types is associated with a variety of cancers. Virtually all cervical cancers are caused by HPV, along with 90% of anal, 69% of vaginal, 60% of oropharyngeal, 51% of vulvar, and 40% of penile cancers.1 Furthermore, 87% of anal, 76% of cervical, 60% of oropharyngeal, 55% of vaginal, 44% of vulva, and 29% of penile cancers are caused by oncogenic HPV type 16 or 18.4 Of the 35,000 HPV cancers reported in 2009 in the United States, 39% occurred in males.1 Three HPV vaccines are currently available in the United States. One is a bivalent vaccine (designated as HPV2) designed to protect against HPV types 16 and 18, which are responsible for the most HPV-associated cancers. One is a quadrivalent vaccine (HPV4), which protects against HPV types 16 and 18 and two additional types, 6 and 11, that are the most common causes of genital warts. One is a nonavalent vaccine (HPV9) that protects against HPV types 6, 11, 16, and 18, and offers additional protection against five oncogenic HPV types, 31, 33, 45, 52, and 58. To prevent cancers associated with HPV infections, the Advisory Committee on Immunization Practices (ACIP) recommends HPV immunization for all children aged 11 or 12 years with the licensed three-doses series. The ACIP has recommended routine HPV immunization for girls since 2006 and for boys since 2011.2 Despite ACIP’s recommendations, rates of vaccination have remained low. In 2013, initiation rates for the HPV vaccine series were just 57.3% for girls and 34.6% for boys, and completion rates were ,40% for girls and 15% for boys.2 These completion rates are well below the national Healthy People 2020 target of 80%.

Barriers to follow-up of hypertensive patients.

Lack of follow-up care for hypertension adversely affects health in urban communities. The authors designed this study to (1) evaluate the effectiveness of a specialized intervention program for hypertension follow-up and (2) evaluate the associations with loss to follow-up. They evaluated factors related to loss to follow-up to either a routine care medical clinic or a special primary care intervention program (the Competitive Initiative Program [CIP]). They also conducted interviews to provide in-depth information on the barriers to this program. They found that patients referred through the CIP were significantly more likely to receive follow-up care through a primary care provider. Cost of care, long waiting times, lack of physician continuity, and more pressing priorities explained the lack of follow-up care. Despite a program to provide health care at no cost to patients, lack of insurance and worries about cost are described as barriers to adequate follow-up for hypertension treatment.

Cardiovascular Health Disparities in Underserved Populations

African Americans are at increased risk for hypertension, hyperlipidemia, obesity, and diabetes, which contribute to the burden of cardiovascular disease (CVD). The disparities of CVD in underserved populations require targeted attention from primary care clinicians to eliminate. Primary care can provide this targeted care for their patients by assessing cardiovascular risk, addressing blood pressure control, and selecting appropriate intervention strategies. Using community resources is also effective for addressing CVD disparities in the underserved population.

A Call for Greater Consideration for the Role of Vaccines in National Strategies to Combat Antibiotic-Resistant Bacteria: Recommendations from the National Vaccine Advisory Committee Approved by the National Vaccine Advisory Committee on June 10, 2015

The emergence of a novel virus receives widespread attention in the news media and among the public. However, the greatest threat to public health in the United States is unlikely to be an exotic disease but, rather, the mounting threat of antibiotic resistance in commonly acquired bacterial infections. The human and economic costs of this growing crisis are notable.1,2 In the 2013 report by the Centers for Disease Control and Prevention (CDC), Antibiotic Resistance Threats in the United States, it is estimated that more than two million people contract an antibiotic-resistant infection each year in the United States, and approximately 23,000 die as a result of their infection.2 The escalating rate of resistance among bacterial pathogens is being facilitated by the abundant (and often inappropriate) use of antibiotics, and concern is rising that the arsenal of effective products to treat bacterial infections will soon run out.3 For example, it is now estimated that 6,700 (13%) of the 51,000 health-care–associated Pseudomonas aeruginosa infections that occur in the United States each year are resistant to at least three classes of antibiotics, and some strains show resistance to nearly all classes of antibiotics.2 The lack of effective antibiotic therapy will have a significant impact in nearly all areas of medicine, but especially in surgery, oncology, intensive care, and transplant medicine. In September 2014, the White House released the President’s National Strategy to Combat AntibioticResistant Bacteria4 concurrently with the President’s Council of Advisors on Science and Technology (PCAST) report and recommendations to the president on combating antibiotic resistance.5 Together, these reports identify priorities and guide coordination across U.S. government agencies to (1) better prevent and respond to the spread of antibiotic resistance through improved prevention and stewardship of antibiotic use; (2) increase surveillance of emerging antibiotic resistance in humans, animals, and the environment; (3) improve capabilities for detection and diagnostics; (4) accelerate development of new products, including new classes of antibiotics, therapeutics, and vaccines; and (5) enhance international collaboration.4 The federal commitment to addressing this issue was further emphasized by Presidential Executive Order 13676,6 which calls for the development of a five-year National Action Plan7 that proposes concrete activities and milestones for achieving the goals outlined in the National Strategy and a presidential budget request to Congress for