Rosanna Setse

Depressive symptoms and health-related quality of life in early pregnancy.

OBJECTIVE: Depressive symptoms can be associated with lower health-related quality of life in late pregnancy. Few studies have quantified the effect of depressive symptoms in early pregnancy or among a racially and economically diverse group. Our goal was to estimate the independent association of depressive symptoms with health-related quality of life among a diverse group of women in early pregnancy. METHODS: We conducted a cross-sectional study of 175 pregnant women receiving prenatal care in a community and university-based setting. We related the presence of depressive symptoms, defined as a Center for Epidemiologic Studies Depression Scale score of 16 or more to health-related quality of life scores from the 8 Medical Outcomes Study Short Form domains: Physical Functioning, Role-Physical, Bodily Pain, Vitality, General Health, Social Functioning, Role-Emotional, and Mental Health. Quantile regression was used to measure the independent association of depressive symptoms with each of the 8 domains. RESULTS: The study sample was 49% African American, 38% white, and 11% Asian. Mean (± standard deviation) gestational age was 14 ± 6 weeks.The prevalence of depressive symptoms was 15%. Women with depressive symptoms had significantly lower health-related quality of life scores in all domains except Physical Functioning. After adjustment for sociodemographic, clinical, and social support factors, depressive symptoms were associated with health-related quality of life scores that were 30 points lower in Role-Physical, 19 points lower in Bodily Pain, 10 points lower in General Health, and 56 points lower in Role-Emotional. CONCLUSION: Women in early pregnancy with depressive symptoms have poor health-related quality of life. Early identification and management of depressive symptoms in pregnant women may improve their sense of well-being. LEVEL OF EVIDENCE: II-2

An algorithm for treatment of patients with hypersensitivity reactions after vaccines

Concerns about possible allergic reactions to immunizations are raised frequently by both patients/parents and primary care providers. Estimates of true allergic, or immediate hypersensitivity, reactions to routine vaccines range from 1 per 50000 doses for diphtheria-tetanus-pertussis to ∼1 per 500000 to 1000000 doses for most other vaccines. In a large study from New Zealand, data were collected during a 5-year period on 15 marketed vaccines and revealed an estimated rate of 1 immediate hypersensitivity reaction per 450000 doses of vaccine administered. Another large study, conducted within the Vaccine Safety Datalink, described a range of reaction rates to >7.5 million doses. Depending on the study design and the time after the immunization event, reaction rates varied from 0.65 cases per million doses to 1.53 cases per million doses when additional allergy codes were included. For some vaccines, particularly when allergens such as gelatin are part of the formulation (eg, Japanese encephalitis), higher rates of serious allergic reactions may occur. Although these per-dose estimates suggest that true hypersensitivity reactions are quite rare, the large number of doses that are administered, especially for the commonly used vaccines, makes this a relatively common clinical problem. In this review, we present background information on vaccine hypersensitivity, followed by a detailed algorithm that provides a rational and organized approach for the evaluation and treatment of patients with suspected hypersensitivity. We then include 3 cases of suspected allergic reactions to vaccines that have been referred to the Clinical Immunization Safety Assessment network to demonstrate the practical application of the algorithm.

Longitudinal Study of Depressive Symptoms and Health-Related Quality of Life During Pregnancy and After Delivery: The Health Status in Pregnancy (HIP) Study

Objective Depressive symptoms are known to affect functioning in early pregnancy. We estimated the effect of a change in depressive symptoms status on health-related quality of life (HRQoL) throughout pregnancy and after delivery. Methods Longitudinal study of 200 women. The independent variable was depressive symptoms, defined as a Center for Epidemiologic Studies Depression (CES-D) score of ≥16. The dependent variable was HRQoL from 8 domains of the Medical Outcomes Study (SF-36) Short Form. Women were categorized based on the change in CES-D score: (1) never depressed, (2) became well, (3) became depressed and (4) always depressed. A random effects model was used to (1) estimate the effect of a change in depressive symptomatology from the first to the second trimester on HRQOL in the second trimester and (2) estimate the change in depressive symptomatology from the second to the third trimester on HRQoL in the third trimester and after delivery, adjusting for covariates. Intra-individual correlations were accounted for using generalized estimating equations (GEE). Results The proportion of women with depressive symptoms was 15%, 14%, and 30% in the first, second and third trimesters, respectively, and 9% after delivery. Women who became depressed had scores in the social domains that were 10–23 points and 19–31 points lower in the second and third trimesters, respectively, compared to women with no depressive symptoms. Women who became well had scores that were 3–31 points lower, compared to women with no depressive symptoms. Conclusions Alterations in depressive symptomatology have a substantial effect on functioning during pregnancy and after delivery.

Correlates of Sexual Activity and Sexually Transmitted Infections Among Human Immunodeficiency Virus-infected Youth in the LEGACY Cohort, United States, 2006

Background: To determine the prevalence and correlates of sexual activity and sexually transmitted infections (STIs) among human immunodeficiency virus (HIV)-infected youth. Methods: The Longitudinal Epidemiologic Study to Gain Insight into HIV/AIDS in Children and Youth (LEGACY) is an observational medical record study of perinatally and behaviorally HIV-infected (PHIV and BHIV) youth followed at 22 US HIV clinics. PHIV youth were HIV infected at birth or by breast-feeding. BHIV youth were HIV infected sexually or by injection drug use. We determined the prevalence of sexual activity during 2006 and examined correlates of sexual activity among 13- to 24-year-old PHIV youth using multivariable generalized linear models. Among sexually active persons, we determined the association between mode of HIV acquisition and non-HIV STI diagnosis using multivariable generalized linear models. Results: In all, 34% (195/571) of PHIV and 89% (162/181) of BHIV youth were sexually active. Eighty percent (155/195) of sexually active PHIV youth reported ever using condoms. Ninety-three percent discussed sex with a health care provider. Increasing age (adjusted prevalence ratio [APR]: 1.17 per year of age, 95% confidence interval [CI] = 1.12–1.23), having a boyfriend/girlfriend (APR: 2.74, 95% CI = 1.75–4.29), and injection drug use (APR: 1.38, 95% CI = 1.06–1.79) correlated with sexual activity after adjusting for socio-demographic and HIV-related clinical variables. Among sexually active youth, after adjusting for relevant confounders, PHIV youth were less likely than BHIV youth to have been diagnosed with an STI in 2006 (APR: 0.25, 95% CI = 0.13–0.46). Conclusions: Sexual activity among HIV-infected adolescents is common. Factors associated with sexual activity in this study should be taken into account in developing behavioral risk reduction interventions targeting PHIV youth.

Immediate hypersensitivity reactions following monovalent 2009 pandemic influenza A (H1N1) vaccines: reports to VAERS.

BACKGROUND Hypersensitivity disorders following vaccinations are a cause for concern. OBJECTIVE To determine the type and rate by age, gender, and vaccine received for reported hypersensitivity reactions following monovalent 2009 pandemic influenza A (H1N1) vaccines. DESIGN A systematic review of reports to the Vaccine Adverse Event Reporting System (VAERS) following monovalent 2009 pandemic influenza A (H1N1) vaccines. SETTING/PATIENTS US Civilian reports following vaccine received from October 1, 2009 through May 31, 2010. MEASUREMENTS Age, gender, vaccines received, diagnoses, clinical signs, and treatment were reviewed by nurses and physicians with expertise in vaccine adverse events. A panel of experts, including seven allergists reviewed complex illnesses and those with conflicting evidence for classification of the event. RESULTS Of 1984 reports, 1286 were consistent with immediate hypersensitivity disorders and 698 were attributed to anxiety reactions, syncope, or other illnesses. The female-to-male ratio was ≥4:1 for persons 20-to-59 years of age, but approximately equal for children under 10. One hundred eleven reports met Brighton Collaboration criteria for anaphylaxis; only one-half received epinephrine for initial therapy. The overall rate of reported hypersensitivity reactions was 10.7 per million vaccine doses distributed, with a 2-fold higher rate for live vaccine. LIMITATIONS Underreporting, especially of mild events, would result in an underestimate of the true rate of immediate hypersensitivity reactions. Selective reporting of events in adult females could have resulted in higher rates than reported for males. CONCLUSIONS Adult females may be at higher risk of hypersensitivity reactions after influenza vaccination than men. Although the risk of hypersensitivity reactions following 2009 pandemic influenza A (H1N1) vaccines was low, all clinics administering vaccines should be familiar with treatment guidelines for these adverse events, including the use of intramuscular epinephrine early in the course of serious hypersensitivity reactions.

Diarrhea: Case definition and guidelines for collection, analysis, and presentation of immunization safety data ,

. Gidudua,∗, D.A. Sackb, M. Pinac, M.J. Hudsond, K.S. Kohla, P. Bishope, A. Chatterjee f, E. Chiappinig, . Compingbutraa, C. da Costah, R. Fernandopulle i, T.K. Fischer j, P. Habera, W. Masanak, artins R. de Menezes l, G. Kangm, N. Khuri-Bulosn, L.A. Killiono, C. Nairp, G. Poerschkeq, B. Rathr, . Salazar-Lindos, R. Setseb, P. Wenger t, V.C.N. Wongu, K. Zamanv, he Brighton Collaboration Diarrhea Working Group

Monitoring adverse events following yellow fever vaccination using an integrated telephone and Internet-based system.

TeleWatch is an automated telephone/Internet-based system that collects medical product adverse event reports in real-time through an algorithm driven by the patient. 1341 patients, who received yellow fever vaccine and were recruited through 15 travel clinics, contacted the system within 48h of vaccination and 765 (57%) made follow-up contacts. Participation rates were higher among females and persons older than 60 years of age. TeleWatch can be expanded for use in large campaigns involving influenza or other vaccines.

Cervical Pap Screening Cytological Abnormalities among HIV-Infected Adolescents in the LEGACY Cohort

OBJECTIVES To determine the prevalence of cervical Pap screening (CPAP-S), identify factors associated with CPAP-S, and explore risk factors for abnormal cervical cytology in female adolescents with perinatally and behaviorally acquired HIV infection. DESIGN Cross-sectional. SETTING LEGACY is a national observational cohort chart review study of 1478 HIV-infected persons (<age 24 years) managed in 22 HIV specialty clinics in the United States. PARTICIPANTS Sexually active females aged 13-24 years in the LEGACY cohort. MAIN OUTCOME MEASURES CPAP-S and abnormal cervical cytology. RESULTS Of 231 sexually active female LEGACY participants 13-24 years of age 49% had documentation of CPAP-S between 2001 and 2006. Fifty-eight percent of 113 cervical tests were abnormal (2% high-grade). In multivariable analysis, perinatal HIV infection and black race were associated with decreased likelihood of CPAP-S (adjusted prevalence ratio [APR] 0.66, 95% CI 0.45-0.96 and APR 0.74, 95% CI 0.56-0.96, respectively). Presence of any sexually transmitted infection (STI) was independently associated with increased likelihood of CPAP-S (APR 1.56, 95% CI 1.21, 2.02). CD4+ T-lymphocyte count <200 cells/mL and previous STI diagnosis were independently associated with increased likelihood of abnormal cervical cytology (APR 2.19, 95% CI 1.26-3.78 and APR 1.94, 95% CI 1.29-2.92, respectively). CONCLUSIONS Among sexually active HIV-infected adolescent females, prevalence of CPAP-S was low and cytology was abnormal in more than half of Pap smears. Perinatally HIV-infected, sexually active females were less likely to undergo CPAP-S than their behaviorally HIV-infected counterparts. Interventions targeted at HIV-infected adolescents and care providers are needed to improve CPAP-S in HIV-infected young women, especially those with perinatally acquired HIV infection.

The effect of depression symptoms and social support on black-white differences in health-related quality of life in early pregnancy: the health status in pregnancy (HIP) study

BackgroundLower physical and social functioning in pregnancy has been linked to an increased risk of preterm delivery and low birth weight infants, butt few studies have examined racial differences in pregnant women’s perception of their functioning. Even fewer studies have elucidated the demographic and clinical factors contributing to racial differences in functioning. Our objective was to determine whether there are racial differences in health-related quality of life (HRQoL) in early pregnancy; and if so, to identify the contributions of socio-demographic characteristics, depression symptoms, social support and clinical factors to these differences.MethodsCross-sectional study of 175 women in early pregnancy attending prenatal clinics in urban setting. In multivariate analysis, we assessed the independent relation of black race (compared to white) to HRQoL scores from the eight domains of the Medical Outcomes (SF-36) Survey: Physical Functioning, Role-Physical, Bodily Pain, Vitality, General Health, Social Functioning, Role-Emotional, and Mental Health. We compared socio-demographic and clinical factors and depression symptoms between black and white women and assessed the relative importance of these factors in explaining racial differences in physical and social functioning.ResultsBlack women comprised 59% of the sample; white women comprised 41%. Before adjustment, black women had scores that were 14 points lower in Physical Function and Bodily Pain, 8 points lower in General Health, 4 points lower in Vitality and 7 points lower in Social Functioning. After adjustment for depression symptoms, social support and clinical factors, black women still had HRQoL scores that were 4 to 10 points lower than white women, but the differences were no longer statistically significant. Level of social support and payment source accounted for most of the variation in Physical Functioning, Bodily Pain and General Health. Social support accounted for most of the differences in Vitality and Social Functioning.ConclusionsPayment source and social support accounted for much of the racial differences in physical and social function scores. Efforts to reduce racial differences might focus on improving social support networks and Socio-economic barriers.

Meningococcal Conjugate and Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccination Among HIV-infected Youth.

Background: The meningococcal conjugate vaccine (MCV4) and the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) were first recommended for adolescents in the US in 2005. The goal of our study was to determine MCV4 and Tdap vaccines coverage among perinatally and behaviorally HIV-infected adolescents in 2006 and to compare coverage estimates in our study population to similarly aged healthy youth in 2006. Methods: Longitudinal Epidemiologic Study to Gain Insight into HIV/AIDS in Children and Youth (LEGACY) is a retrospective cohort study of HIV-infected youth in 22 HIV specialty clinics across the US. Among LEGACY participants ≥11 years of age in 2006, we conducted a cross-sectional analysis to determine MCV4, Tdap and MCV4/Tdap vaccine coverage. We compared vaccine coverage among our study population to coverage among similarly aged youth in the 2006 National Immunization Survey for Teens (NIS-Teen Survey). Multivariable mixed effects logistic regression modeling was used to examine associations between MCV4/Tdap vaccination and mode of HIV transmission. Results: MCV4 and Tdap coverage rates among 326 eligible participants were 31.6% and 28.8%, respectively. Among adolescents 13–17 years of age, MCV4 and Tdap coverage was significantly higher among HIV-infected youth than among youth in the 2006 NIS-Teen Survey (P <0.01). In multivariable analysis, perinatally HIV-infected youth were significantly more likely to have received MCV4/Tdap vaccination compared with their behaviorally infected counterparts (adjusted odds ratio: 5.1; 95% confidence interval: 2.0, 12.7). HIV-infected youth with CD4 cell counts of 200–499 cells/&mgr;L were more likely to have had MCV4/Tdap vaccination compared with those with CD4 counts ≥500 cells/&mgr;L (adjusted odds ratio: 2.2; 95% confidence interval: 1.2, 4.3). Participants with plasma HIV RNA viral loads of >400 copies/mL were significantly less likely to have received MCV4/Tdap vaccination (P < 0.05). Conclusions: MCV4 and Tdap coverage among HIV-infected youth was suboptimal but higher than for healthy adolescents in the 2006 NIS-Teen Survey. Perinatal HIV infection was associated with increased likelihood of vaccination. Specific measures are needed to improve vaccine coverage among adolescents in the US.