ABSTRACT
Background: Cancer patients have increased risk of serious illness or death from COVID-19. Vaccination protects against severe disease, but cancer patients were excluded from COVID-19 vaccine registration trials. Different cancer therapies may have varying impact on immune response. We assessed seroconversion post COVID-19 vaccination among cancer patients in a setting of high vaccine uptake with minimal community transmission. Methods: Solid tumour patients and healthy controls from Canberra who received COVID-19 vaccination between 3/2021 - 1/2022 were included. Patients received active cancer therapy within two weeks of COVID-19 vaccination. Blood was collected at baseline, pre 2nd vaccine dose, then one, three and six months post 2nd dose. SARS-CoV-2 anti-spike receptor binding domain and anti-nucleocapsid immunoglobulin G(IgG) levels were measured by enzyme-linked immunosorbent assay and calibrated with the National Institutes of Health serology standard. Primary endpoint was seroconversion three months post 2nd vaccine dose, or within two weeks prior to 3rd vaccine dose in patients. Results: There were 96 solid tumour patients (76 evaluable for the primary endpoint) and 19 healthy controls. Median age 62 years with 70 (61%) being female. COVID-19 vaccines included AZD1222 (65%) and BNT162b2 (35%). Majority (69%) of patients had metastatic cancer. Baseline lymphopenia (<1.2x10-9/L) was seen in 41% of patients. Median Charlson comorbidity index score was 7 (2 - 12). Among primary endpoint evaluable patients, 47 (62%) patients received chemotherapy, alone or in combination with other cancer therapy;8 (11%) received immunotherapy alone;21 (28%) had targeted therapy. Seroconversion at three months post vaccination occurred in 86% of cancer patients and 100% of controls (p=0.11). Mean anti-spike antibody titre was 88 binding antibody units (BAU)/ml in cancer patients and 179 BAU/ml in controls, p=0.10. No subjects had positive antinucleocapsid IgG confirming absence of past COVID-19 infection. Seroconversion occurred in patients who received chemotherapy alone or in combination (83%), immunotherapy (75%) and targeted therapy (95%;p=0.2). Mean anti-spike IgG levels were 77, 63 and 137 BAU/mL with chemotherapy, immunotherapy and targeted therapy respectively. Age, metastatic disease and lymphocyte count were not associated with antispike antibody level. Among cancer patients, 40% and 95% were seropositive after 1 and 2 vaccine doses respectively. A decline in anti-spike antibody titre was seen from three months post the 2nd vaccine dose. Cancer patients had an increase in anti-spike post 3rd vaccine dose, while levels declined in controls (pre booster), at 6 months post the 2nd vaccine dose. Conclusions: Cancer patients achieved comparable seroconversion rates three months post vaccination compared with healthy controls. Although the anti-spike antibody titre was numerically lower among cancer patients than controls, the difference was not statistically significant. Recent cancer therapy did not appear to significantly affect vaccine response, however, the anti-spike antibody level was numerically lower among recipients of chemotherapy compared with targeted therapy. Patients on immunotherapy had the lowest antibody level, although the small sample size limits definitive conclusion in this subgroup. Reassuringly, a rise in anti-spike antibody occurred after the 3rd primary dose in cancer patients, surpassing the level among controls prior to receipt of booster vaccination.
ABSTRACT
Background: In skilled nursing facilities (SNF), 50-70% of residents fall per year. SNF residents with dementia are more prone to fall, with an annual incidence of 60%. The Community Living Center (CLC) at the San Francisco Veterans Affairs Medical Center (SFVAMC), reported annual fall rate of 50%, compared to the national VA fall rate of 42%. Our goal was to reduce the rate of fall by 20% compared to fiscal year 2019. Methods: We conducted process mapping with CLC interdisciplinary team members to identify barriers to fall prevention. The barriers included staff, patient population-specific challenges, environmental obstacles, and documentation, communication, and care protocol. Studies have shown that multi-pronged approaches yield the best results. We implemented 3 interventions: fall education, purposeful huddles, and toilet seat risers. Physical therapists and occupational therapists stated that low toilet seats were fall risk for Veterans. Results: We partnered with the CLC's nurse educator to adapt the “5 P's Proactive Patient Rounding” education tool as a pocket card for the CLC nursing staff. By end of May 2020, all CLC nurses were educated in these 5 P's and fall prevention. Watch List Huddle was started in January 2020, to discussed care plans for residents who nurses were concerned about. Every resident who fell were discussed during these rounds which met three times a week. Lastly, toilet seat risers were placed in each bathroom in July 2020. Implementation of our interventions lead to 40% decrease in the average number of falls. Conclusion: Re-training in fall prevention, improving communication and care plan after fall and raising the toilet seats significantly reduce the rate of falls by 40%. This result was much larger than our goal 20% reduction. An increase in nursing staff hiring and a decreased census within the CLC due to COVID-19 quarantine may have contributed to better than expected outcome.