Vaccination Motivators and Deterrents Among Undervaccinated Older Adults in North Dakota.

Despite increased risk of morbidity and mortality among older adults due to preventable infectious diseases such as influenza, shingles, pneumonia, and COVID-19, many forego receiving some, if not all, of these vaccinations. This study examines vaccination motivators and deterrents for undervaccinated older adults in North Dakota (ND). Adults aged 65+ in ND were mailed a survey (n = 901) with questions gauging vaccination behaviors and perceptions, with 132 of these indicating not receiving certain vaccinations. Further questions assessed reasons they have not been vaccinated against the following diseases: influenza, shingles, pneumonia, and COVID-19 (e.g., "Concerned about side effects", "Vaccines are dangerous", "I'm healthy and I do not need it") and what would make it more likely to get a vaccine (e.g., "More information", "Doctor recommendation", "Easy access to vaccines"). Reasons for remaining unvaccinated varied by vaccine. For influenza and pneumococcal vaccines, respondents were more likely to indicate they are healthy and do not need the vaccine. For shingles and COVID-19, respondents were more likely to indicate concerns about side effects. Factors reported to motivate increasing the likelihood of getting a vaccine were receiving a doctor recommendation, receiving more information, and having a vaccine provided at no cost. These results contribute to our understanding of vaccination behaviors among older adults and underscore specific issues around which to frame interventions tailored to increase vaccine uptake for this population.

COVID-19 Policy-Making in a Country Divided: Catholic Social Teaching as a Path to Unity.

Because no vaccines or specific treatments are available, governments around the globe have responded to the Coronavirus Virus Disease 2019 (COVID-19) pandemic with a variety of nonpharmaceutical interventions (NPIs) that include sheltering-in-place orders, social distancing, and school and business closures. While the actual and potential harm due to COVID-19 is far more severe than influenza, the harms due to the NPIs-that have clearly reduced mortality due to COVID-19-are also significant. With government-ordered "lockdowns" across the globe, many arguments for and against returning to normal social and economic activity have been reported, and in fact, Americans are divided about how and when to "open up." These arguments seem to fall into two major categories. Utilitarianism suggests that suspension of civil liberties and constitutional rights is a necessary response, while Libertarianism supports individual decision-making and greatly reduced government mandates. Protesters around the country have been vocal about one or the other points of view. First, we consider in detail the potential harms of severe acute respiratory syndrome virus-2 (SARS-CoV-2) if left unchecked by NPIs. Second, we look at harms due to restricted social and economic activity on human morbidity and mortality. Finally, we offer a framework based on the four pillars of Catholic Social Teaching and the principle of double effect that offers a more humane solution than Utilitarian or Libertarian principles alone.

Immunization attitudes, opinions, and knowledge of healthcare professional students at two Midwestern universities in the United States.

BACKGROUND: In addition to administering vaccinations, healthcare professionals (HCPs) also play a crucial role in providing education and advocacy to the public regarding immunizations. Yet, many current and future HCPs are unprepared or reluctant to address the vaccine conversation with hesitant patients. Doctors, pharmacists, and nurses are all recognized as the most trusted sources of vaccine information. By comparing future HCPs in these three distinct programs, we can better understand where potential gaps may lie in their training and education. With insight from students, potential changes to curriculum can improve future HCPs ability to address vaccine hesitancy in their respective careers. The objective of this study was to assess and compare the knowledge, attitudes, and opinions of HCP students on the topic of immunization. METHODS: A cross-sectional survey was conducted in 2017 to assess students in nursing, medical, and pharmacy programs at two universities in the state of North Dakota in the United States. The survey assessed six key themes: 1) demographic information; 2) basic vaccine knowledge; 3) vaccine hesitancy; 4) likelihood to recommend vaccines; 5) confidence in addressing vaccine-related topics with patients; 6) an appraisal of the education they have received on vaccinations. RESULTS: The survey was completed by 223 participants (overall response rate = 23.7%). Results indicated that vaccine-related knowledge varied greatly by program; high knowledge scores were achieved by 74.3% of medical students, 62.7% of pharmacy students, 57.1% of doctor of nursing practice (DNP) students, and 24.7% of bachelor of science in nursing (BSN) students. Over a third (34.2%) of BSN students believed that the current recommended immunization schedule places undue burden on a child's immune system, versus only 4.3% of medical students. Additionally, 54.2% of participants believed that spreading out recommended vaccines over several visits was an appropriate means of reducing parental stress about vaccinating. CONCLUSIONS: Participant responses suggest that negative attitudes, lack of knowledge, and general discomfort exist across all programs, but especially among nursing students, regarding vaccination. Our findings indicate potential areas where targeted interventions could be implemented to better equip future HCPs in their ability to discuss and educate the public regarding vaccination. TRIAL REGISTRATION: #PH17173.

Catholic Social Teaching and the Duty to Vaccinate.

Since the last century, vaccination has been one of the most important tools we possess for the prevention and elimination of disease. Yet the tremendous gains from vaccination are now threatened by a growing hesitance to vaccinate based on a variety of concerns or objections. Geographic clustering of some families who choose not to vaccinate has led to a number of well-publicized outbreaks of vaccine-preventable diseases. Of note is that some of these outbreaks are centered within some Christian religious groups that increasingly avoid vaccination due to moral concerns, fears about safety, or doubts about the necessity of vaccines. We argue from the perspective of Catholic social teaching on why there is a moral duty to vaccinate.

Characteristics of antibody responses in West Nile virus-seropositive blood donors.

West Nile virus (WNV) is now endemic in the United States. Protection against infection is thought to be conferred in part by humoral immunity. An understanding of the durability and specificity of the humoral response is not well established. We studied the magnitude and specificity of antibody responses in 370 WNV-seropositive blood donors. We also recalled 18 donors who were infected in 2005 to compare their antibody responses at 6 months following infection versus at 5 years postinfection. There were no significant differences in IgG antibody levels based on age, sex, or recent infection (as evidenced by IgM positivity). Specific antibody responses by viral plaque reduction neutralization testing (PRNT) were seen in 51/54 subjects evaluated. All donors who were seropositive in 2005 remained seropositive at 5 years and maintained neutralizing antibodies. IgG levels at 5 years postinfection showed fairly minimal decreases compared with the paired levels at 6 months postinfection (mean of paired differences,-0.54 signal-to-cutoff ratio (S/CO) units [95% confidence interval {CI}, -0.86 to -0.21 S/CO units]) and only minimal decreases in PRNT titers. WNV induces a significant antibody response that remains present even 5 years after infection.

Reliance on sources of immunization information and vaccine uptake among older adults in a rural state: The mediating role of trust.

Older adults are more vulnerable to the negative impacts of infectious diseases than younger individuals. However, regardless of the importance and effectiveness of vaccines to reduce morbidity and mortality, issues remain with vaccine hesitancy among this population. Older adults' sources of immunization information and their level of trust in those sources may play a role in their vaccination behaviors. This research aimed to better understand the role of information sources and related issues of trust as related to vaccine uptake among older adults. A community-based, cross-sectional survey was conducted with 901 older adults in North Dakota in May-July 2022. Measures included extent of reliance on specific sources of immunization information, levels of trust, and uptake for influenza, pneumonia, shingles, and COVID-19 vaccinations. Immunization information sources were grouped into medical experts, informal, and public outlets. Results indicated older adults were more likely to rely on medical experts than informal sources or public outlets for immunization information. Greater reliance on medical experts was associated with a greater likelihood of vaccine uptake for all vaccines, while reliance on public outlets was associated with a greater likelihood of vaccine uptake only for COVID primary series and boosters. Reliance on informal sources for immunization information was associated with a reduced likelihood of vaccine uptake for all vaccines except shingles. Nearly half of respondents were uncertain who to trust for vaccine information. Uncertainty who to trust for immunization information significantly mediated the associations between reliance on medical experts and uptake for most vaccines indicating that trust in medical experts fosters vaccine uptake. Increasing reliance on medical experts as sources of immunization information is vital to increasing vaccine uptake among older adults. Additionally, this population must be assisted in increasing their ability to successfully assess the trustworthiness of immunization information sources.

Vaccine attitudes and acceptance among older adults in North Dakota: Understanding demographic characteristic variability.

OBJECTIVES: Older adults face increased risks from infectious diseases which are often preventable with vaccines. The current study examines demographic variation in vaccine hesitancy among older adults in North Dakota. METHODS: A mailed survey assessing age, gender, years of education, self-rated health, rurality, and political leaning as well as vaccine attitudes and vaccine acceptance was conducted with 739 older adults (65+), oversampled from rural counties. RESULTS: Vaccine hesitant attitudes were significantly higher among rural and politically-conservative older adults; whereas, vaccine acceptance was significantly higher among older, healthier, and politically-liberal older adults. Vaccine attitudes were significantly associated with vaccine acceptance and mediated the association between political leaning and vaccine acceptance. DISCUSSION: These findings highlight the demographic characteristics predictive of older adults' vaccine attitudes and acceptance. By better understanding the nuanced factors leading to hesitation to be vaccinated, practitioners can develop strategies to increase vaccination rates among this at-risk population.

Neuroinvasive disease and West Nile virus infection, North Dakota, USA, 1999-2008.

To determine risk for West Nile virus (WNV) neuroinvasive disease in North Dakota, we tested plasma samples from blood donors for WNV IgG and compared infection rates with reported WNV neuroinvasive disease incidence. We estimate that 1 in 244 WNV infections leads to neuroinvasive disease; risk is substantially increased among men and older persons.

Plasma cell cerebrospinal fluid pleocytosis does not predict West Nile virus infection.

PURPOSE: Diagnosis of WNV (WNV) relies upon serologic testing which may take several days after the onset of clinical symptoms to turn positive. Anecdotal reports suggest the presence of plasma cells or plasmacytoid lymphocytes in the cerebrospinal fluid (CSF) may be an early indicator of WNV infection. METHODS: The CSFs of 89 patients (12 with WNV, 12 with other viral illness {OVI}, and 65 with nonviral illness{NVI}) were compared for the presence of either plasma cells or plasmacytoid lymphocytes. RESULTS: Plasma cells were rarely seen in any of the patients. Plasmacytoid lymphocytes were more commonly seen in WNV (58%) and OVI (50%) than NVI (11%). The differences were significant for WNV versus NVI, but not WNV versus OVI (P < 0.001 and P = 0.58, resp.). CONCLUSIONS: A CSF pleocytosis with plasma cells or plasmacytoid lymphocytes was neither sensitive nor specific for the diagnosis of WNV infection.

Failure of a Best Practice Alert to Reduce Antibiotic Prescribing Rates for Acute Sinusitis Across an Integrated Health System in the Midwest.

BACKGROUND: Antimicrobial resistance is a growing concern, and in recent years, there has been increased interest in ambulatory antimicrobial stewardship. Acute rhinosinusitis (ARS) is one of the most common outpatient diagnoses that results in an antibiotic prescription. OBJECTIVE: To determine if a best practice alert (BPA) will affect the percentage of oral antibiotic prescriptions for adults with ARS. METHODS: A prospective, pre/post study was initiated to evaluate the percentage of oral antibiotic prescriptions for ARS in 117 primary care clinics in the Midwest. Included in the study results were 16,570 adults who had an office visit for ARS: 8,106 patients from December 1, 2015, to February 28, 2016, were in the pre-intervention group without an active BPA, and 8,464 patients from December 1, 2016, to February 28, 2017, were in the post-intervention group when the BPA was active. The primary outcome was the number of oral antibiotic prescriptions for ARS compared with the number of office visits for ARS in the pre- and postintervention groups. RESULTS: The percentage of oral antibiotics prescribed for the pre- and postintervention groups were 94.8% and 94.3%, respectively (P = 0.152). The BPA displayed for 7,780 visits, prompting discontinuation of an antibiotic for 10 (0.1%) visits in the postintervention group. CONCLUSIONS: This study suggests that, although an electronic alert may be attractive to facilitate antimicrobial stewardship, it may be ineffective. These results warrant alternative measures to facilitate ambulatory antimicrobial stewardship. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Hansen, D. Leedahl, and N. Leedahl. Hansen and N. Leedahl took the lead in data collection, with assistance from Carson and D. Leedahl. Data interpretation was performed by all the authors. The manuscript was written by Hansen, along with the other authors, and revised by all the authors.

A Pilot Study for Antimicrobial Stewardship Post-Discharge: Avoiding Pitfalls at the Transitions of Care.

PURPOSE: Lack of patient follow-up is a major concern during care transitions, and the role of an antimicrobial stewardship program (ASP) in assessing antimicrobial regimens after hospital discharge is not well described. We implemented an expanded ASP to include patients recently discharged from the hospital and measured its impact on inappropriate antimicrobial therapy 72 hours after inpatient culture data were finalized. METHODS: A prospective cohort study was conducted at a 583-bed tertiary care center in the Upper Midwest of America. All patients discharged from our facility on antimicrobial therapy with pending culture results between February 3, 2016, and March 2, 2016, were included for review. If a pathogen nonsusceptible to all prescribed antimicrobials was identified post-discharge, a recommendation for therapy modification was communicated to the prescriber. RESULTS: Thirty-eight patients discharged from our hospital on antimicrobial therapy with pending culture results were evaluated for intervention. When final culture susceptibilities were considered, 5 of 38 patients had been prescribed an inappropriate antimicrobial agent. An ASP pharmacist intervened on 4 of 5 patients, resulting in 3 of 5 patients transitioning to appropriate antimicrobial therapy. When compared to a historical cohort, our transitions-of-care ASP yielded a 3.6-fold increase in antimicrobial-related interventions among discharged patients while reducing inappropriate outpatient antimicrobial therapy by 39%. CONCLUSION: We believe this is the first pharmacist-driven ASP represented in the medical literature which evaluated all available inpatient culture data to serve patients discharged from the hospital. Antimicrobial stewardship for patients in care transitions may provide an opportunity to increase ASP interventions and reduce inappropriate antimicrobial therapy.

Enforcement Associated With Higher School-Reported Immunization Rates.

INTRODUCTION: North Dakota's school-reported kindergarten immunization rates were among the lowest in the U.S. during the 2015-2016 school year. Ninety percent of kindergartners were fully immunized in accordance with state requirements, 3% had an exemption, and as many as 7% were noncompliant. School enforcement of immunization requirements has been noted as variable. This study sought to better understand the relationship between school-reported immunization rates and the enforcement of immunization requirements. METHODS: Kindergarten immunization rates were compared between schools annually enforcing immunization requirements to the point of excluding noncompliant children and schools not enforcing. In addition, immunization rates were assessed after an educational intervention that led some school districts to change their enforcement policies during the 2015-2016 school year. Analyses were completed in 2016 and 2017. RESULTS: Kindergarten immunization rates were significantly higher in schools that annually enforced compared with schools that did not enforce (p≤0.001, all vaccines; difference between means: diphtheria-tetanus-attenuated pertussis=7.5% [95% CI=3.9%, 11.1%]; polio=6.2% [95% CI=3.3%, 9.1%]; measles, mumps, and rubella=7% [95% CI=3.5%, 10.5%]; hepatitis B=3.7% [95% CI=1.5%, 5.9%]; and varicella=6.9% [95% CI=3.4%, 10.4%]). School districts that began enforcing saw a significant increase in vaccination rates (diphtheria-tetanus-attenuated pertussis=6% [95% CI=2%, 11%] and measles, mumps, and rubella=7% [95% CI=3%, 11%]). Enforcement in newly enforcing districts led to a large decrease in the number of noncompliant students and did not lead to significant increases in exemption rates. CONCLUSIONS: In North Dakota, lack of school enforcement is strongly associated with lower immunization rates and a large noncompliant population. Addressing noncompliance through school enforcement could significantly increase school-reported immunization rates.

Long-term clinical and neuropsychological outcomes of West Nile virus infection.

BACKGROUND: Since its introduction in 1999, West Nile virus has rapidly become the most common arboviral infection in North America. Little is known about the long-term clinical sequelae of West Nile virus infection. METHODS: A total of 49 patients with laboratory-confirmed West Nile virus infection were identified through state-based surveillance. Stratification for disease severity was based on hospitalization during the infection episode. Assessment occurred a mean of 13 months after diagnosis. Medical records were reviewed, and a complete neurologic examination was performed. Standardized surveys for quality of life, functional ability, fatigue, and depression were performed for all subjects. An extensive battery of neuropsychological tests was performed to assess cognitive function. RESULTS: Self-reported fatigue, memory problems, extremity weakness, word-finding difficulty, and headache were common complaints. Standardized survey data confirmed an overall sense of poor physical health, fatigue, depression, and moderate-to-severe disability in 24 (49%), 24 (49%), 12 (24%), and 4 (8%) patients, respectively. New tremor was seen or reported for 10 (20%) of the patients. Neuropsychological testing showed abnormalities of motor skills, attention, and executive functions. Univariate analysis of multiple risk factors did not identify any predictors of adverse outcomes. CONCLUSIONS: Multiple somatic complaints, tremor, and abnormalities in motor skills and executive functions are common long-term problems among patients who have had West Nile virus infection. Patients with milder illness are just as likely as patients with more-severe illness to experience adverse outcomes.

Utility of a single nasal polymerase chain reaction assay in predicting absence of skin and environmental contamination in hospitalized patients with past methicillin-resistant Staphylococcus aureus.

We evaluated hospitalized patients with a history of methicillin-resistant Staphylococcus aureus (MRSA) for persistent colonization and need for contact precautions. Up to 3 daily cultures of nares, skin, and any present wounds were compared with a single nasal polymerase chain reaction (PCR) assay. Most patients (76.2%) were no longer colonized with MRSA. A single PCR assay was sufficient to exclude persistent colonization and environmental contamination and remove the contact precautions.

"Bringing down the flag": removing the contact precautions label for non-hospitalized patients with prior methicillin-resistant Staphylococcus aureus infection or colonization.

A policy consensus has not been reached regarding discontinuing contact precautions in patients with a history of methicillin-resistant Staphylococcus aureus (MRSA). We found that as many as 72% of outpatients flagged for past MRSA were no longer carriers, and a single nasal PCR test provided a reasonable negative predictive value for removing contact precautions.

Plasma cell pleocytosis in cerebrospinal fluid in patients with West Nile virus encephalitis.

We describe 4 patients with West Nile virus encephalitis who all displayed previously unreported plasma cell pleocytosis of the cerebrospinal fluid (CSF). Three patients recovered but had varying degrees of mild neurologic disability on discharge from the hospital, and 1 patient died. The finding of significant numbers of plasma cells in CSF may serve as a useful early diagnostic clue for West Nile virus encephalitis.

Histoplasma capsulatum endocarditis: multicenter case series with review of current diagnostic techniques and treatment.

Infective endocarditis is an uncommon manifestation of infection with Histoplasma capsulatum. The diagnosis is frequently missed, and outcomes historically have been poor. We present 14 cases of Histoplasma endocarditis seen in the last decade at medical centers throughout the United States. All patients were men, and 10 of the 14 had an infected prosthetic aortic valve. One patient had an infected left atrial myxoma. Symptoms were present a median of 7 weeks before the diagnosis was established. Blood cultures yielded H. capsulatum in only 6 (43%) patients. Histoplasma antigen was present in urine and/or serum in all but 3 of the patients and provided the first clue to the diagnosis of histoplasmosis for several patients. Antibody testing was positive for H. capsulatum in 6 of 8 patients in whom the test was performed. Eleven patients underwent surgery for valve replacement or myxoma removal. Large, friable vegetations were noted at surgery in most patients, confirming the preoperative transesophageal echocardiography findings. Histopathologic examination of valve tissue and the myxoma revealed granulomatous inflammation and large numbers of organisms in most specimens. Four of the excised valves and the atrial myxoma showed a mixture of both yeast and hyphal forms on histopathology. A lipid formulation of amphotericin B, administered for a median of 29 days, was the initial therapy in 11 of the 14 patients. This was followed by oral itraconazole therapy, in all but 2 patients. The length of itraconazole suppressive therapy ranged from 11 months to lifelong administration. Three patients (21%) died within 3 months of the date of diagnosis. All 3 deaths were in patients who had received either no or minimal (1 day and 1 week) amphotericin B.

Clinical and economic outcomes of a prospective antimicrobial stewardship program.

PURPOSE: A pre-post analysis of an antimicrobial stewardship program (ASP) involving the use of data-mining software to prospectively identify cases for ASP intervention was conducted. METHODS: The investigators evaluated clinical outcomes and cost metrics before and after implementation of the ASP, which entailed daily physician review of summary reports on all adult inpatients receiving antimicrobial therapy. The primary outcome measures were annual antimicrobial expenditures and rates of infections due to common nosocomial pathogens; secondary outcome measures included patient survival and length of stay (LOS) in cases involving the indicator diagnoses of pneumonia and abdominal sepsis. RESULTS: Antimicrobial expenditures, which had increased by an average of 14.4% annually in the years preceding ASP implementation, decreased by 9.75% in the first year of the program and remained relatively stable in subsequent years, with overall cumulative cost savings estimated at $1.7 million. Rates of nosocomial infections involving Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci all decreased after ASP implementation. A pre-post comparison of survival and LOS in patients with pneumonia (n = 2186) or abdominal sepsis (n = 225) showed no significant differences in those outcomes in either patient group, possibly due to the hospital's initiation of other, concurrent infection-control programs during the study period. CONCLUSION: A prospective collaborative ASP employed automated reports to efficiently identify key data for ASP review. After ASP implementation, antimicrobial expenditures and rates of nosocomial infections caused by resistant pathogens dropped without significant changes in patient survival, LOS, and readmissions for the two studied illness categories.