Dwight E. Fox

Randomized Trial of an Alternate Human Papillomavirus Vaccine Administration Schedule in College-Aged Women

BACKGROUND Human papillomavirus (HPV) vaccine is effective against HPV types 16 and 18, which cause 70% of cervical cancers. The three-dose vaccination schedule at 0, 2, and 6 months may be inconvenient for college-aged women. This study assessed noninferiority of the immune response to an alternate vaccination schedule at 0, 2, and 12 months. METHODS Two hundred nonpregnant women, aged 18-23 years, with <5 sexual partners were randomized into standard and alternate schedules. Blood samples were drawn before dose 1 and 2-6 weeks after dose 3 and analyzed with the competitive Luminex immunoassay. Seropositives at baseline were eliminated from analyses by HPV type. Log-transformed titers were used to calculate HPV type-specific geometric mean titers (GMTs) and 95% confidence intervals (CI) for each group. Noninferiority was tested against a one-sided null hypothesis that the post-dose 3 GMT ratio of the alternate to standard schedule was < or =0.5 for each HPV type. RESULTS One hundred eighty-eight women completed the study, with all 12 dropouts in the alternate schedule group (p < 0.001). Antibody responses in the alternate schedule were noninferior to the standard schedule for all vaccine types (p < 0.0001). Among the per-protocol population, GMTs (95% CI) for the alternate schedule were 4,440 (3,080-5,696), 5,688 (3,960-7,291), 12,443 (8,611-15,977), and 2,129 (1,183-3,063) for HPV types 6, 11, 16, and 18, respectively, vs. 2,153 (1,794-2,478), 1,966 (1,401-2,491), 6,218 (4,367-7,946), and 1,370 (1,167-1,553) for the standard schedule. Time between doses 2 and 3 significantly predicted final titer for all virus types (p < 0.005). CONCLUSIONS For all HPV vaccine types, the GMT ratios indicated noninferiority of the alternate vaccine administration schedule at 0, 2, and 12 months. The alternate schedule may be used to expand options for the timing of the third dose in the HPV vaccine schedule.

Factorial Design for Improving Influenza Vaccination Among Employees of a Large Health System

OBJECTIVE As healthcare personnel (HCP) influenza vaccination becomes a quality indicator for healthcare facilities, effective interventions are needed. This study was designed to test a factorial design to improve HCP vaccination rates. DESIGN A before-after trial with education, publicity, and free and easily accessible influenza vaccines used a factorial design to determine the effect of mobile vaccination carts and incentives on vaccination rates of HCP, who were divided into groups on the basis of their level of patient contact (ie, business and/or administrative role, indirect patient contact, and direct patient contact). SETTING Eleven acute care facilities in a large health system. PARTICIPANTS More than 26,000 nonphysician employees. RESULTS Influenza vaccination rates increased significantly in most facilities and increased system-wide from 32.4% to 39.6% (P<.001). In the baseline year, business unit employee vaccination rates were significantly higher than among HCP with patient contact; rates did not differ significantly across groups in the intervention year. In logistic regression that accounted for demographic characteristics, intervention year, and other factors, the use of incentives and/or mobile carts that provided access to vaccine at the work unit significantly increased the likelihood of vaccination among HCP with direct and indirect patient contact, compared with control sites. CONCLUSIONS Interventions to improve vaccination rates are differentially effective among HCP with varying levels of patient contact. Mobile carts appear to remove access barriers, whereas incentives may motivate HCP to be vaccinated. Education and publicity may be sufficient for workers in business or administrative positions. Interventions tailored by worker type are likely to be most successful for improving HCP vaccination rates.

Economic evaluation of standing order programs for pneumococcal vaccination of hospitalized elderly patients.

BACKGROUND Standing order programs (SOPs), which allow for vaccination without an individual physician order, are the most effective mechanism to achieve high vaccination rates. Among the suggested settings for the utilization of SOPs are hospital inpatient units, because they provide care for those most likely to benefit from vaccination. The cost-effectiveness of this approach for elderly hospitalized persons is unknown. The purpose of this study was to estimate the cost-effectiveness of SOPs for pneumococcal polysaccharide vaccine (PPV) vaccination for patients 65 years of age or older in 2 types of hospital. METHODS In 2004, a 1,094-bed tertiary care hospital implemented a pharmacy-based SOP for PPV, and a 225-bed community hospital implemented a nursing-based SOP for PPV. Newly admitted patients 65 years of age or older were screened for PPV eligibility and then offered PPV. Vaccination rates before and after initiation of SOPs in the United States, incidence rates of invasive pneumococcal disease in the United States, and US economic data were the bases of the cost-effectiveness analyses. One-way and multivariate sensitivity analyses were conducted. RESULTS PPV vaccination rates increased 30.5% in the tertiary care hospital and 15.3% in the community hospital. In the base-case cost-effectiveness analysis, using a societal perspective, we found that both pharmacy-based and nursing-based SOPs cost less than

Improving Influenza Vaccination Rates of High-Risk Inner-City Children Over 2 Intervention Years

10,000 per quality-adjusted life-year gained, with program costs (pharmacy-based SOPs cost

Understanding Adult Vaccination in Urban, Lower-Socioeconomic Settings: Influence of Physician and Prevention Systems

4.16 per patient screened, and nursing-based SOPs cost

Overcoming barriers to establishing an inpatient vaccination program for pneumococcus using standing orders.

4.60 per patient screened) and vaccine costs (

Raising Adult Vaccination Rates over 4 Years Among Racially Diverse Patients at Inner-City Health Centers

18.33 per dose) partially offset by potential savings from cases of invasive pneumococcal disease avoided (

Establish the Habit: Influenza Vaccination for Health Care Personnel

12,436 per case). Sensitivity analyses showed SOPs for PPV vaccination to be cost-effective, compared with PPV vaccination without SOPs, unless the improvement in vaccination rate was less than 8%. CONCLUSION SOPs do increase PPV vaccination rates in hospitalized elderly patients and are economically favorable, compared with PPV vaccination rates without SOPs.

Assessing disparities in adult vaccination using multimodal approaches in primary care offices: methodology.

PURPOSE Influenza immunization rates among children with high-risk medical conditions are disappointingly low, and relatively few data are available on raising rates, particularly over 2 years. We wanted to determine whether interventions tailored to individual practice sites improve influenza immunization rates among high-risk children in inner-city health centers over 2 years. METHOD A before-after trial to improve influenza immunization of children was conducted at 5 inner-city health centers (residencies and faith-based). Sites selected interventions from a menu (eg, standing orders, patient and clinician reminders, education) proved to increase vaccination rates, which were directed at children aged 2 to 17 years with high-risk medical conditions. Intervention influenza vaccination rates and 1 and 2 years were compared with those of the preintervention year (2001–2002) and of a comparison site. RESULTS Influenza vaccination rates improved modestly from baseline (10.4%) to 13.1% during intervention year 1 and to 18.7% during intervention year 2 (P <.001), with rates reaching 31% in faith-based practices. Rates increased in all racial and age-groups and in Medicaid-insured children. The increase in rates was significantly greater in intervention health centers (8.3%) than in the comparison health center (0.7%; P <.001). In regression analyses that controlled for demographic factors, vaccination status was associated with intervention year 1 (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.6–2.2) and with intervention year 2 (OR, 2.8; 95% CI, 2.3–3.4), as well as with practice type. Adolescents had lower vaccination rates than children 2 to 6 years old (OR, 0.6; 95% CI, 0.5–0.7). CONCLUSIONS Tailored interventions selected from a menu of interventions modestly increased influenza vaccination rates over 2 years at health centers serving children from low-income families. We recommend this strategy for faith-based practices and residencies with 1 practice site, but further research is needed on multisite practices and to achieve higher influenza vaccination rates.

Using Quantitative and Qualitative Approaches to Understand Racial Disparities in Adult Vaccination

PURPOSE Vaccination rates for pneumococcal polysaccharide vaccine (PPV) and influenza vaccine are relatively low in disadvantaged urban populations. This study was designed to assess which physician and practice characteristics might explain differences in rates across physicians. METHODS PPV and influenza vaccination rates were determined for 2,021 patients aged 65 years and older receiving care from 30 physicians in 17 practices surveyed about their office systems for providing adult immunizations. Hierarchical linear modeling (HLM) analyses were used to examine the relationships among vaccination rates, patient-level characteristics, and physician variables. RESULTS Overall, the weighted PPV vaccination rate was 60.0% and varied widely across physicians (range, 11%–98%). At the patient level in HLM, patient race (P=.01) and age (P = .02), but not neighborhood income, were associated with PPV status. By linking physician survey data with PPV rates, we found the best pair of physician variables to be “reported time spent with patients for a well visit” (P = .01) and “use of enhanced immunization documentation” (P=.10). The overall influenza vaccination rate was 51.9% (range, 22%–96%). Patient race (P=.003) and age (P = .002) were associated with influenza vaccination. The pair of physician variables with the strongest association with influenza vaccination was “use of standing orders” (P <.001) and “average observed physician examination room time,” regardless of visit type (P=.02). CONCLUSIONS Vaccination rates vary widely in urban settings and are associated with practice characteristics such as time spent with patients and, for influenza vaccine, use of standing orders.