Mehran S. Massoudi

Intussusception among Infants Given an Oral Rotavirus Vaccine

BACKGROUND Intussusception is a form of intestinal obstruction in which a segment of the bowel prolapses into a more distal segment. Our investigation began on May 27, 1999, after nine cases of infants who had intussusception after receiving the tetravalent rhesus-human reassortant rotavirus vaccine (RRV-TV) were reported to the Vaccine Adverse Event Reporting System. METHODS In 19 states, we assessed the potential association between RRV-TV and intussusception among infants at least 1 but less than 12 months old. Infants hospitalized between November 1, 1998, and June 30, 1999, were identified by systematic reviews of medical and radiologic records. Each infant with intussusception was matched according to age with four healthy control infants who had been born at the same hospital as the infant with intussusception. Information on vaccinations was verified by the provider. RESULTS Data were analyzed for 429 infants with intussusception and 1763 matched controls in a case-control analysis as well as for 432 infants with intussusception in a case-series analysis. Seventy-four of the 429 infants with intussusception (17.2 percent) and 226 of the 1763 controls (12.8 percent) had received RRV-TV (P=0.02). An increased risk of intussusception 3 to 14 days after the first dose of RRV-TV was found in the case-control analysis (adjusted odds ratio, 21.7; 95 percent confidence interval, 9.6 to 48.9). In the case-series analysis, the incidence-rate ratio was 29.4 (95 percent confidence interval, 16.1 to 53.6) for days 3 through 14 after a first dose. There was also an increase in the risk of intussusception after the second dose of the vaccine, but it was smaller than the increase in risk after the first dose. Assuming full implementation of a national program of vaccination with RRV-TV, we estimated that 1 case of intussusception attributable to the vaccine would occur for every 4670 to 9474 infants vaccinated. CONCLUSIONS The strong association between vaccination with RRV-TV and intussusception among otherwise healthy infants supports the existence of a causal relation. Rotavirus vaccines with an improved safety profile are urgently needed.

Knowledge and Awareness of Congenital Cytomegalovirus Among Women

Background. Congenital cytomegalovirus (CMV) infection is a leading cause of disabilities in children, yet the general public appears to have little awareness of CMV. Methods. Women were surveyed about newborn infections at 7 different geographic locations. Results. Of the 643 women surveyed, 142 (22%) had heard of congenital CMV. Awareness increased with increasing levels of education (P < .0001). Women who had worked as a healthcare professional had a higher prevalence of awareness of CMV than had other women (56% versus 16%, P < .0001). Women who were aware of CMV were most likely to have heard about it from a healthcare provider (54%), but most could not correctly identify modes of CMV transmission or prevention. Among common causes of birth defects and childhood illnesses, womens awareness of CMV ranked last. Conclusion. Despite its large public health burden, few women had heard of congenital CMV, and even fewer were aware of prevention strategies.

An Economic Analysis of the Current Universal 2-dose measles-mumps-rubella Vaccination Program in the United States

To evaluate the economic impact of the current 2-dose measles-mumps-rubella (MMR) vaccination program in the United States, a decision tree-based analysis was conducted with population-based vaccination coverage and disease incidence data. All costs were estimated for a hypothetical US birth cohort of 3803295 infants born in 2001. The 2-dose MMR vaccination program was cost-saving from both the direct cost and societal perspectives compared with the absence of MMR vaccination, with net savings (net present value) from the direct cost and societal perspectives of US dollars 3.5 billion and US dollars 7.6 billion, respectively. The direct and societal benefit-cost ratios for the MMR vaccination program were 14.2 and 26.0. Analysis of the incremental benefit-cost of the second dose showed that direct and societal benefit-cost ratios were 0.31 and 0.49, respectively. Varying the proportion of vaccines purchased and administered in the public versus the private sector had little effect on the results. From both perspectives under even the most conservative assumptions, the national 2-dose MMR vaccination program is highly cost-beneficial and results in substantial cost savings.

Effectiveness of Postexposure Vaccination for the Prevention of Smallpox: Results of a Delphi Analysis

We estimated the effectiveness of postexposure smallpox vaccination in preventing or modifying disease in naive and previously vaccinated adults, using the formal Delphi technique. For persons not previously vaccinated, the median effectiveness in preventing disease with vaccination at 0-6 h, 6-24 h, and 1-3 days after exposure was estimated as 93%, 90%, and 80%, respectively, and effectiveness in modifying disease among those who develop illness was estimated as 80%, 80%, and 75%, respectively. Effectiveness was greater for those vaccinated previously. High postexposure vaccination effectiveness for preventing or modifying smallpox is consistent with the limited data available, is biologically plausible, and is similar to that seen for other viral vaccine-preventable diseases. These estimates support the Advisory Committee on Immunization Practices recommendations and provide a key parameter for mathematical models on which policy decisions may be based.

Vaccine coverage levels after implementation of a middle school vaccination requirement, Florida, 1997-2000

Objective. Little information is available about the effectiveness of school entry vaccination requirements at the middle school level. This study examined coverage levels among students entering seventh grade in Florida following implementation of a school entry vaccination requirement in 1997. Methods. The authors analyzed county-specific vaccination coverage levels (three doses of hepatitis B vaccine, a second dose of measles, mumps, and rubella [MMR] vaccine, and a booster dose of tetanus and diphtheria toxoids [Td]) among students entering public and private schools in Florida from 1997 through 2000. In 1998, a survey of all county health departments was conducted, and the resulting data were linked to county-specific vaccination rates. Results. During the 1997–1998 school year, the first year the requirement went into effect, at school entry 121,219 seventh-grade students (61.8%) were fully vaccinated, 72,275 seventh grade students (36.9%) lacked one or more doses of vaccine but were considered in process, 1,817 were non-compliant (0.9%), and 763 had medical or religious exemptions (0.4%). In the 2000–2001 school year, the proportions of students reported fully vaccinated at school entry had increased to 66%. Most of this change was related to an increase in hepatitis B coverage. There was a significant inverse relationship between the proportion of students fully vaccinated and the size of the countys seventh grade population. Conclusions. The seventh grade vaccination entry requirement was associated with sustained high levels of vaccination coverage. Passing a school entry vaccination requirement appears may be sufficient to increase coverage, but other strategies may be required to achieve full immunization of middle school students.

Assessing immunization performance of private practitioners in Maine: impact of the assessment, feedback, incentives, and exchange strategy.

Introduction. A provider-based vaccination strategy that has strong supportive evidence of efficacy at raising immunization coverage level is known as Assessment, Feedback, Incentives, and Exchange. The Maine Immunization Program, and the Maine Chapter of the American Academy of Pediatrics collaborated on the implementation and evaluation of this strategy among private providers. Methods. Between November 1994 and June 1996, the Maine Immunization Program conducted baseline immunization assessments of all private practices administering childhood vaccines to children 24 to 35 months of age. Coverage level assessments were conducted using the Clinic Assessment Software Application. Follow-up assessments were among the largest practices, delivering 80% of all vaccines. Results. Of the 231 practices, 58 were pediatric and 149 were family practices. The median up-to-date vaccination coverages among all providers for 3 doses of diphtheria-tetanus-pertussis vaccine and 2 doses of oral polio vaccine, and 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at age 12 and 24 months were 90% and 78%, respectively, and did not vary by number of providers in a practice or by specialty. Urban practices had higher coverage than rural practices at 12 months (92% vs 88%). The median up-to-date coverage for 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at 24 months of age improved significantly among those practices assessed 1 year later (from 78% at baseline to 87% at the second assessment). On average, the assessments required 2½ person-days of effort. Conclusions. We document the feasibility and impact of a public/private partnership to improve immunization delivery on a statewide basis. Implications. Other states should consider using public/private partnerships to conduct private practice assessments. More cost-effective methods of assessing immunization coverage levels in private practices are needed.

Non-Pharmaceutical Interventions during an Outbreak of 2009 Pandemic Influenza A (H1N1) Virus Infection at a Large Public University, April–May 2009

Nonpharmaceutical interventions (NPIs), such as home isolation, social distancing, and infection control measures, are recommended by public health agencies as strategies to mitigate transmission during influenza pandemics. However, NPI implementation has rarely been studied in large populations. During an outbreak of 2009 Pandemic Influenza A (H1N1) virus infection at a large public university in April 2009, an online survey was conducted among students, faculty, and staff to assess knowledge of and adherence to university-recommended NPI. Although 3924 (65%) of 6049 student respondents and 1057 (74%) of 1401 faculty respondents reported increased use of self-protective NPI, such as hand washing, only 27 (6.4%) of 423 students and 5 (8.6%) of 58 faculty with acute respiratory infection (ARI) reported staying home while ill. Nearly one-half (46%) of student respondents, including 44.7% of those with ARI, attended social events. Results indicate a need for efforts to increase compliance with home isolation and social distancing measures.

Childhood Vaccination Providers in the United States

OBJECTIVES This study sought to provide a characterization of US childhood vaccination providers. METHODS The state was used as the analytic unit in examining 1997 data from the National Immunization Survey and the Vaccines for Children program, state immunization reports, and natality records. RESULTS Overall, 57% of children were vaccinated in the private sector, 18% were vaccinated in the public sector, and 25% were vaccinated by a mixture of providers. Of the 50 883 immunization sites, 81% were private and 19% public. Average patient load was 77 infants per site. Private-sector patient loads were lower than public-sector loads. CONCLUSIONS US childhood vaccination provider capacity is adequate. Efforts to raise coverage rates should focus on increasing preventive care use among children, improving the vaccination performance of providers, and ensuring continuity of care.

Exposure to Protein Aeroallergens in Egg Processing Facilities

Proteinaceous materials in the air can be highly allergenic and result in a range of immunologically mediated respiratory effects, including asthma. We report on the largest evaluation of exposure to date of airborne egg protein concentrations in an egg breaking and processing plant that had cases of occupational asthma. Personal air samples for egg protein were analyzed in duplicate on each PTFE filter using two analytical methods: (1) a commercial assay for non-specific total protein, and (2) indirect competitive inhibition assay using an ELISA method to quantify specific egg protein components. The highest concentrations were found in the egg washing room (mean exposure 644 microg/m3) and breaking room (255 microg/m3), which were also the areas where the risk of being sensitized was the greatest. There was excellent quantitative agreement between the airborne concentrations of total protein and sum of the specific protein antigens (ovalbumin, ovomucoid, and lysozyme). The correlation coefficient of the log-transformed data from the two methods was 0.88 (p < 0.0001). Size-selective sampling also indicated that most of the aerosol was capable of reaching the small airways. The methods described can be utilized to evaluate employee exposure to egg proteins. Exposure documentation, coupled with recommended exposure reduction strategies, could facilitate prevention of future employee sensitization and allergic respiratory responses by identifying high-exposure jobs and evaluating control measures.

Developing the Evidence Base to Inform Best Practice: A Scoping Study of Breast and Cervical Cancer Reviews in Low- and Middle-Income Countries

Background Breast and cervical cancers have emerged as major global health challenges and disproportionately lead to excess morbidity and mortality in low- and middle-income countries (LMICs) when compared to high-income countries. The objective of this paper was to highlight key findings, recommendations, and gaps in research and practice identified through a scoping study of recent reviews in breast and cervical cancer in LMICs. Methods We conducted a scoping study based on the six-stage framework of Arskey and O’Malley. We searched PubMed, Cochrane Reviews, and CINAHL with the following inclusion criteria: 1) published between 2005-February 2015, 2) focused on breast or cervical cancer 3) focused on LMIC, 4) review article, and 5) published in English. Results Through our systematic search, 63 out of the 94 identified cervical cancer reviews met our selection criteria and 36 of the 54 in breast cancer. Cervical cancer reviews were more likely to focus upon prevention and screening, while breast cancer reviews were more likely to focus upon treatment and survivorship. Few of the breast cancer reviews referenced research and data from LMICs themselves; cervical cancer reviews were more likely to do so. Most reviews did not include elements of the PRISMA checklist. Conclusion Overall, a limited evidence base supports breast and cervical cancer control in LMICs. Further breast and cervical cancer prevention and control studies are necessary in LMICs.