Passive Immunization Strategies to Prevent Severe Respiratory Syncytial Virus Infection Among Newborns and Young Infants.

Newborns and young infants are at risk for severe respiratory syncytial virus (RSV) lower respiratory tract infection. Passive immunity is the mainstay of infection prevention in this cohort. Transplacental transfer of maternal antibodies provides the newborn with immediate protection from life-threatening infections, however, is dependent upon gestational age, birth weight, mother's age, recent maternal vaccination, maternal nutritional status, maternal immunocompetence and medical conditions, and placental integrity. Efficient transplacental transfer of RSV-neutralizing antibodies have led to the development and approval of maternal RSV immunization for the protection of the newborn. Additionally, administration of RSV-specific antibodies to infants leads to high serum titers of RSV-neutralizing antibodies and further protection from severe disease.

Epidemiology of RSV Bronchiolitis Among Young Children in Central New York Before and After the Onset of the COVID-19 Pandemic.

BACKGROUND: Respiratory syncytial virus (RSV) bronchiolitis is the leading cause of hospitalizations among infants in the United States. Unpredictability in RSV seasonality has occurred following the onset of the coronavirus disease 2019 (COVID-19) pandemic. Local surveillance networks can enhance the ability to appropriately time prophylaxis when exposure risk is highest. METHODS: A retrospective, cohort study was conducted to describe the epidemiologic patterns of RSV disease among outpatient, emergency department and inpatient encounters in children <5 years in Central New York before and after the onset of the COVID-19 pandemic. Local data were collected from October 2015 to January 2023 and compared to state-level data. Linear regression models were used to identify clinical and sociodemographic differences before and after the pandemic. RESULTS: Local variation in RSV seasonality was noted prior to the COVID-19 pandemic, however highly atypical circulation patterns appeared in the post-COVID-19 era. Since March 2020, patterns for local and state-defined RSV seasons have remained atypical (local season onset in 2021: week 27 and 2022: week 27; state season onset in 2021: week 31 and 2022: week 38). After adjusting for increases in testing, RSV bronchiolitis cases were not significantly different during pre- and post-pandemic eras. In comparison to the 2021 bronchiolitis season, the 2022 season had a higher proportion of RSV cases despite decreased testing. CONCLUSIONS: Temporal patterns for RSV have shifted during the COVID-19 pandemic. Local surveillance networks may be advantageous in trending community-level RSV activity to optimize prophylaxis administration. Changes in RSV testing patterns occurred throughout the study period and should be accounted for when describing infant and childhood RSV disease.

HPV vaccine knowledge, attitudes, and practices among New York State medical providers, dentists, and pharmacists.

Healthcare provider vaccine knowledge and attitudes influence delivery of a strong vaccine recommendation. We aim to describe HPV vaccine knowledge, attitudes, and recommendation or discussion practices (KAP) among New York State medical providers, dentists, and pharmacists. A survey to assess providers' KAP was distributed electronically to NYS members of medical organizations. Descriptive and inferential statistical methods were used to characterize provider KAP. Responses from 1637 surveys were included, from 864 (53%) medical providers, 737 (45%) dentists, and 36 (2%) pharmacists. 59% (509/864) of medical providers responded that they recommend HPV vaccine to patients, with 390/509 (77%) strongly recommending vaccine at 11-12 years. Medical providers were more likely to report recommending HPV vaccine for children ages 11-12 years if they strongly agreed that HPV vaccine prevents cancer 326/391 (83%) vs 64/117 (55%) and responded that HPV vaccination does not increase the risk of unprotected sex (386/494 (78%) vs 4/15 (25%)) (p < .05). Less than 1/3 of dentists reported discussing HPV vaccine with 11-26-year-old females (230/737, 31%) and males (205/737, 28%) at least "sometimes." Dentists were more likely to answer that they routinely discuss HPV vaccine with children ages 11-12 years if they responded that HPV vaccination does not increase sexual activity (70/73 (96%) vs 528/662 (80%), p < .001). Few pharmacists reported discussing HPV vaccine with 11-26-year-old females (6/36 (17%)) and males (5/36 (14%)) at least "sometimes." Gaps in HPV vaccine knowledge among providers still exist and may influence vaccine attitudes and recommendation or discussion practices.

Vaccine knowledge, attitudes, and recommendation practices among health care providers in New York State.

Community-wide vaccine uptake remains sub-optimal. Healthcare provider (HCP) vaccine recommendations influence patient vaccination; however, provider vaccine recommendation behavior is highly influenced by one's own vaccine attitudes and/or knowledge. We aim to describe vaccine knowledge, attitudes, and recommendation practices (KAP) among New York State HCPs. A survey to assess HCP KAP was developed and electronically distributed to NYS members of national medical organizations via their local chapter administrators. Descriptive statistical methods were used to define provider KAP. A total of 864 surveys were included, 500 (60%) and 336 (40%) primary and specialty care providers, respectively. Eighty-one percent (402/499) of primary care providers (PCPs) report encountering vaccine hesitant patients daily or weekly. Of the 500 PCPs who responded, only 204 (41%) stated strong agreement with confidence in their communications with vaccine hesitant patients. HCPs who correctly answered all four knowledge questions were more likely to self-report routine recommendations of standard vaccines to all patients when compared to those who correctly answered fewer questions (489/588 (83%) vs 135/241 (56%), p < .05). HCPs were more likely to routinely recommend standard vaccines to all patients if they also report initiating vaccine discussion (476/485 (98%) vs 148/344 (43%), p < .05) and reviewing and recommending vaccinations at each encounter (315/320 (98%) vs 308/508 (61%), p < .05). Vaccine hesitancy exists across healthcare specialties and provider roles. Focused interventions should include reaching all HCPs to promote vaccinations for disease prevention, tailoring messages to reduce HCP vaccine misperceptions, and increasing awareness of evidence-based office strategies known to facilitate immunizations.

Etiologies of outpatient medically attended acute respiratory infections among young Ecuadorian children prior to the start of the 2020 SARS-CoV-2 pandemic.

BACKGROUND: Implementation of respiratory virus prevention measures requires detailed understanding of regional epidemiology; however, data from many tropical countries are sparse. We describe etiologies of ambulatory pediatric acute respiratory tract infections (ARTI) in Ecuador immediately preceding the onset of the SARS-CoV-2 pandemic. METHODS: Children < 5 years presenting to a designated study site with an ARTI were eligible. Informed consent was obtained. Demographic and clinical data were recorded. A nasopharyngeal swab was collected, processed, and analyzed using multiplex polymerase chain reaction (PCR) for common respiratory pathogens. Rhinovirus/enterovirus positive samples were further characterized by genomic sequencing. RESULTS: A total of 820 subjects were enrolled in the study between July 2018 and March 2020. A total of 655 (80%) samples identified at least one pathogen. Rhinoviruses (44%) were most common, followed by enteroviruses (17%), parainfluenza viruses (17%), respiratory syncytial virus (RSV) (15%), and influenza viruses (13%). Enterovirus D68 was the most common enterovirus detected and was among the leading causes of bronchiolitis. Seasonal RSV and influenza virus activity were different along the coast compared with the highlands. CONCLUSIONS: Ongoing regional surveillance studies are necessary to optimize available and emerging pathogen-specific preventative measures.

Epidemiology and Seasonality of Childhood Respiratory Syncytial Virus Infections in the Tropics.

Infections caused by respiratory syncytial virus (RSV) are a major cause of morbidity and mortality in young children worldwide. Understanding seasonal patterns of region-specific RSV activity is important to guide resource allocation for existing and future treatment and prevention strategies. The decades of excellent RSV surveillance data that are available from the developed countries of the world are incredibly instructive in advancing public health initiatives in those regions. With few exceptions, these developed nations are positioned geographically across temperate regions of the world. RSV surveillance across tropical regions of the world has improved in recent years, but remains spotty, and where available, still lacks the necessary longitudinal data to determine the amount of seasonal variation expected over time. However, existing and emerging data collected across tropical regions of the world do indicate that patterns of infection are often quite different from those so well described in temperate areas. Here, we provide a brief summary regarding what is known about general patterns of RSV disease activity across tropical Asia, Africa and South America, then offer additional country-specific details using examples where multiple reports and/or more robust surveillance data have become available.

Multi-component cancer prevention awareness program to improve adolescent HPV vaccine uptake.

OBJECTIVE: We introduced a multi-component cancer prevention awareness program to primary care practices across New York State to evaluate its impact on adolescent human papillomavirus (HPV) vaccination rates. METHODS: Eight pediatric and three family medicine practices were recruited to participate in this program. On-site training sessions were provided for all practice providers and staff to discuss the importance of HPV vaccine and cancer prevention and teach strategies for delivering a strong vaccine recommendation. Each practice received a study-specific booklet that included HPV vaccine information and other commonly provided cancer prevention guidance. These booklets were distributed to all adolescents and their parents during well visits over a one-year period. Practice specific and county-wide HPV vaccination rates were assessed before and 12 months after the program training session. RESULTS: One year after program initiation, aggregate data show statistically higher vaccine series initiation rates among 11-12 and 13-18-year-olds and higher vaccine series completion rates among 13-18-year-olds. The greatest and most consistent improvements were seen in vaccine initiation rates for the 11-12-year-old cohort. Disparities in vaccine uptake were observed by gender and medical specialty. CONCLUSION: Cancer prevention education targeting providers, office staff, patients, and parents, improved adolescent HPV vaccine series initiation rates.

Medically Attended Outpatient Coronavirus Infections in Ecuadorean Children During the 20 Months Preceding Countrywide Lockdown Related to the SARS-CoV-2 Pandemic of 2020.

BACKGROUND: Human coronaviruses (HCoVs) cause respiratory tract infections during childhood manifesting as common colds, bronchiolitis, croup and pneumonia. In temperate geographies, HCoV activity peaks between December and March. The epidemiology and manifestations of HCoV infections have not been previously reported from Ecuador. METHODS: Children <5 years who presented with ≥2 symptoms consistent with an acute respiratory tract infection were eligible for enrollment. After obtaining informed consent, demographic data and details regarding the acute illness were recorded. Secretions collected with a nasopharyngeal swab underwent diagnostic testing using multiplex polymerase chain reaction. RESULTS: A total of 850 subjects were enrolled. A total of 677 (80%) tested positive for at least 1 pathogen, including 49 (7.2%) who tested positive for ≥1 HCoV type. HCoV-NL63 was the most frequent type detected (39%), followed by HCoV-OC43 (27%), 229E (22%) and HKU1 (12%). Nearly all subjects who tested positive for HCoV had nasal congestion or secretions (47/49; 96%). The most frequent syndromic diagnosis was common cold (41%), followed by bronchiolitis (27%). We found no association between the infecting HCoV type and subject's syndromic diagnosis (P > 0.05) or anatomic location of infection (upper vs. lower respiratory tract; P > 0.05). The 2018-2019 peak HCoV activity occurred from October to November; the 2019-2020 peak occurred from January to February. CONCLUSIONS: HCoVs were detected in ~7% of outpatient Ecuadorean children <5 years of age with symptoms of acute respiratory tract infection. The most frequently detected HCoV types, and the period of peak HCoV activity differed for the 2018-2019 and 2019-2020 seasons.

A quality improvement education initiative to increase adolescent human papillomavirus (HPV) vaccine completion rates.

HPV vaccine uptake is low, nationwide. Quality improvement (QI) principles have the potential to change practice; however, not all providers are confident with QI skills. We developed an educational program designed to enhance QI skills and improve HPV vaccination rates. Five pediatric practices participated in the pilot initiative. Training consisted of presentations regarding QI methods, data tracking and analysis, and system changes to reduce missed opportunities. Monthly for 6 months, participants performed chart audits, captured data, printed run charts, and developed, implemented, and tracked interventions. Outcome measures included rates of HPV vaccine completion and missed opportunities. A second phase included eight different pediatric practices who received similar training. Outcome measures included rates of HPV vaccine initiation and completion. Over the 6 months, mean HPV vaccine completion rates increased (45% to 65%) and missed opportunities for HPV vaccination decreased (45% to 19%) in the pilot program. When the program was replicated in phase 2, an increase was seen in both HPV vaccine initiation (46% to 61%) and completion (62% to 94%) rates. Combining QI education with workflow-focused strategies was associated with a reduction in missed opportunities and a substantial increase in HPV vaccine completion rates.

Associations between population based voting trends during the 2016 US presidential election and adolescent vaccination rates.

BACKGROUND: Politics play a role in the dissemination of public health information, including immunization-related issues. We aim to describe relationships between HPV vaccination rates and state voting patterns during the 2016 US presidential election. METHODS: We classified each of the 50 states as either "Red" or "Blue," based on whether a higher proportion of the state's casted votes were for the Republican or Democratic nominee during the 2016 US presidential election. State-specific HPV, Tdap, and meningococcal vaccination rates were obtained from the 2016-National Immunization Survey-Teen. State socio-demographic factors and HPV vaccine legislation were obtained from the US Census Bureau and National Conference of State Legislatures. Vaccination rates and socio-demographic variables were compared using independent t-tests. Multiple linear regression compared vaccination rates between "Red" and "Blue" states, adjusting for percentage of both uninsured children and educational attainment. RESULTS: Compared to "Blue" states, "Red" states had significantly lower unadjusted HPV vaccine series initiation (56% vs 66%, p < 0.05) and completion (39% vs 50%, p < 0.05) rates; yet had similar rates of Tdap (88% vs 89%, p > 0.05) and meningococcal (79% vs 83%, p > 0.05) vaccinations. After adjusting for potential confounders, the regression-adjusted mean rate for HPV vaccine initiation and completion remained significantly lower for "Red" states compared to "Blue" states (57% vs 65%, p < 0.05, and 41% vs 48%, p < 0.05, respectively). CONCLUSION: HPV vaccination rates are associated with statewide-level voting patterns. Future interventions aimed at improving HPV vaccination rates should consider engaging local and national elected leaders to be proactive in disseminating accurate and authoritative immunization information.

Cancer Prevention Education for Providers, Staff, Parents, and Teens Improves Adolescent Human Papillomavirus Immunization Rates.

OBJECTIVE: To develop a program to educate providers, office staff, patients, and parents on life-long cancer prevention strategies, including the use of human papillomavirus (HPV) vaccine to improve adolescent HPV vaccination rates. STUDY DESIGN: A 2-phase program was implemented at 6 pediatric practices across upstate New York. Phase 1 included provider and staff education regarding practice-specific vaccination challenges and discussion of the contents of a study-specific cancer-prevention booklet, which included HPV vaccine information. Throughout phase 2, the booklets were distributed to all adolescents and their parents during office visits over a 12-month period. Practice-specific, countywide, and statewide HPV vaccination rates were assessed before phase 1, and 6 and 12 months after the launch of phase 2. RESULTS: One year after implementing phase 2 in 6 practices, adolescent HPV vaccine series initiation increased by at least 10% in 3 practices, and at least 5% in 5 practices. Similarly, adolescent vaccine series completion rates increased by more than 10% in 3 practices. The percent change in vaccine series completion rates across all study sites postintervention ranged from 12% to 20% for 11- to 12-year-olds, and from 7% to 23% for 13- to 18-year-olds. CONCLUSIONS: Cancer prevention education targeting providers, office staff, patients, and parents was modestly effective for improving adolescent HPV vaccination rates.

Immunization attitudes and practices among family medicine providers.

OBJECTIVE: To describe immunization attitudes and practices among family medicine providers across New York State. METHODS: In this cross-sectional survey study, family medicine providers across New York State completed a questionnaire to assess vaccine beliefs and barriers and immunization practices. STATISTICAL ANALYSIS: Descriptive statistical methods were used to define provider characteristics, knowledge and vaccine practices. RESULTS: Completed questionnaires from 226 family medicine providers were included for analysis. As a group, 207/218 (95%) of providers who answered the question state they always recommend standard pediatric vaccines. Of the 209 providers who answered both questions, 47 (22%) state they always recommend standard pediatric vaccines but do not always recommend HPV vaccine to eligible 11-12 year-old patients. Only 75% of providers strongly disagreed with the statement 'vaccinating adolescents against HPV increases the likelihood of unprotected sex'. Even though 178/190 (94%) and 164/188 (87%) of surveyed family medicine providers reported recommending that their pregnant patients receive influenza vaccine and Tdap vaccine, respectively, only 134/185 (72%) routinely do so in their office. CONCLUSION: Most family medicine providers self-report always recommending standard pediatric vaccines, however only a minority are following ACIP recommendations. Educational sessions to update family medicine providers on ACIP recommendations and address individual provider concerns may improve provider vaccine confidence and uptake of vaccines by their patients.

"Being Persistent without Being Pushy": Student Reflections on Vaccine Hesitancy.

Our goal as pediatric educators is to graduate physicians who have witnessed effective approaches and have grasped the nuances of communication strategies between vaccine-hesitant families and health care providers. We identified vaccine hesitancy as a recurring topic in 19 of 304 medical student reflective narratives addressing an issue in professionalism or systems-based practice. We conducted content analysis on the narratives in order to gain a better understanding of student perceptions of visits in which they observed a provider discussing vaccine hesitancy with a parent. We identified four major themes: perceived effectiveness of provider-family communication, student reaction to the encounter, physician approach to vaccine hesitancy, and gaps in students' own knowledge. Most students described communication positively, despite only 4 of 19 observing eventual vaccine acceptance. Information regarding vaccines, vaccine delivery, and approaches to vaccine hesitancy needs to be introduced and enhanced in the educational curriculum of providers at all levels, including medical students, resident physicians, and attending physicians, in order to ensure that providers possess the comprehension and communication skills to ethically optimize vaccine uptake among patients.

Nasopharyngeal pneumococcal carriage rates among HIV-infected adults following widespread pediatric use of conjugate pneumococcal vaccine-13.

BACKGROUND: Nasopharyngeal pneumococcal carriage rates among HIV-infected adults has not been described since conjugate pneumococcal vaccine-13 (PCV13) was added to the universal infant and childhood vaccination schedule in 2010. METHODS: HIV-infected adults presenting for routine health care visits to the Designated AIDS Center in Syracuse, NY between December 2013 and June 2015 were eligible for enrollment. Demographic, medical, and social history were recorded after obtaining informed consent. Nasopharyngeal samples were collected and cultured for the presence of Streptococcus pneumoniae using standard microbiologic techniques. Antibiotic susceptibility testing was performed using E-test→. RESULTS: 707 nasopharyngeal samples were collected from 414 HIV-infected adults. 18 samples were culture positive for S. pneumoniae; 1 (6%) isolate was of vaccine-type, 9 (50%) were non-vaccine types, and 8 (44%) were non-typeable. The 18 isolates were recovered from 15 different patients (4% of those enrolled). Three patients were culture positive for pneumococcus isolated from 2 consecutive samples, with non-typeable pneumococci identified consecutively from 2 patients and serotype 35B identified consecutively from 1 patient. The most commonly identified non-vaccine serotypes were 35B and 15B/C. Identified pneumococci were penicillin and cefotaxime susceptible. CONCLUSION: Four percent of HIV-infected adults in our study population were colonized with S. pneumoniae. The non-vaccine serotypes 35B and 15B/C predominated.

Student HPV vaccine attitudes and vaccine completion by education level.

PURPOSE: We describe HPV vaccine attitudes among students of different education levels. METHODS: High school, college, and graduate-level health care professional students were surveyed regarding HPV vaccine knowledge, attitudes, and receipt. Relationships between categorical variables were analyzed using chi-square tests of independence and z-tests for proportions. Means for quantitative variables were compared using t-tests and one-way analysis of variance. RESULTS: 57% and 42% of the 889 students reported starting and completing HPV vaccine series, respectively, with no statistical difference by education level. 61% of students who reported receiving a provider recommendation had completed the series, compared to 6% of those who did not receive recommendation (p<0.001). The belief that HPV vaccine prevents cancer was strongly associated with vaccine completion (p=0.003). CONCLUSION: HPV vaccine coverage rates remain suboptimal. Future interventions should focus on improving provider recommendation and patient belief that HPV vaccine prevents cancer.

Pediatric provider vaccine hesitancy: An under-recognized obstacle to immunizing children.

OBJECTIVE: To describe vaccine attitudes among pediatric healthcare providers attending immunization conferences. STUDY DESIGN: Attendees of 5 American Academy of Pediatrics (AAP)-sponsored vaccine conferences held between June and November 2013 anonymously completed a questionnaire assessing vaccine attitudes and practices prior to the opening of educational sessions. Pearson's chi-square tests and Fisher's exact tests were used to analyze associations between vaccine attitudes, vaccine practices and provider characteristics. RESULTS: 680 providers attending AAP-sponsored vaccine conferences were included. 661/666 (99%) enrolled providers state they routinely recommend standard pediatric vaccines, yet, 30 (5%) state that they do not routinely recommend influenza and/or human papillomavirus (HPV) vaccines. These providers expressed vaccine safety (87/680 (13%)) and efficacy (21/680 (31%)) concerns and stated belief in vaccine misperceptions: vaccine causes autism (34/668, 5%), multiple vaccines at a single visit reduces vaccine efficacy (43/680, 6%) or overwhelms the immune system (63/680, 9%), and administering HPV vaccine will increase the likelihood of unprotected adolescent sexual activity (29/680, 4%). Six percent of providers who do not routinely recommend all pediatric vaccines correctly identified themselves as vaccine hesitant. CONCLUSION: Vaccine hesitancy is under-recognized among pediatric providers attending AAP-sponsored immunization conferences. Educational interventions tailored to address provider vaccine concerns are needed to improve provider vaccine confidence.

Chronic meningococcemia presenting as a recurrent painful rash without fever in a teenage girl.

Chronic meningococcemia is a rare diagnosis seen in patients with recurrent fever and rash. We describe a case of chronic meningococcemia in a teenage girl who presented with a recurrent painful rash, without fever, over a period of 8 weeks.