The Clinical and Economic Burden of Antibiotic Use in Pediatric Patients With Varicella Infection: A Retrospective Cohort Analysis of Real-World Data in England.

BACKGROUND: Varicella is a highly infectious disease, particularly affecting children, that can lead to complications requiring antibiotics or hospitalization. Antibiotic use for varicella management is poorly documented. This study assessed antibiotic use for varicella and its complications in a pediatric population in England. METHODS: Data were drawn from medical records in the Clinical Practice Research Datalink and Hospital Episode Statistics data sets. The study included patients <18 years old with varicella diagnosed during 2014-2018 and 3-month follow-up available. We determined varicella-related complications, medication use, healthcare resource utilization, and costs from diagnosis until 3 months after diagnosis. RESULTS: We identified 114 578 children with a primary varicella diagnosis. Of these, 7.7% (n = 8814) had a varicella-related complication, the most common being ear, nose, and throat related (37.1% [n = 3271]). In all, 25.9% (n = 29 706 of 114 578) were prescribed antibiotics. A higher proportion of patients with complications than without complications were prescribed antibiotics (64.3% [n = 5668 of 8814] vs 22.7% [n = 24 038 of 105 764]). Mean annualized varicella-related costs were £2 231 481 for the study cohort. Overall, antibiotic prescriptions cost approximately £262 007. CONCLUSIONS: This study highlights high antibiotic use and healthcare resource utilization associated with varicella management, particularly in patients with complications. A national varicella vaccination program in England may reduce varicella burden and related complications, medication use, and costs.

The Clinical and Economic Burden of Antibiotic Use in Pediatric Patients with Varicella Infection: a Retrospective Cohort Analysis of Real-World Data in England.

BACKGROUND: Varicella is a highly infectious disease, particularly affecting children, that can lead to complications requiring antibiotics or hospitalization. Antibiotic use for varicella management is poorly documented. This study assessed antibiotic use for varicella and its complications in a pediatric population in England. METHODS: Data were drawn from medical records in the Clinical Practice Research Datalink and Hospital Episode Statistics datasets. Patients <18 years old diagnosed with varicella during 2014-2018 with 3-month follow-up available were included. We described varicella-related complications, medication use, healthcare resource utilization, and costs from diagnosis until 3-month post-diagnosis. RESULTS: We identified 114,578 children with a primary varicella diagnosis. 7.7% (n = 8,814) had a varicella-related complication, the most common being ear, nose, and throat related (37.1%, n = 3,271). In all, 25.9% (n = 29,706/114,578) were prescribed antibiotics. A higher proportion of patients with complications than those without complications were prescribed antibiotics (64.3%, n = 5,668/8,814 vs. 22.7%, n = 24,038/105,764). Mean annualized varicella-related costs were £2,231,481 for the study cohort. Overall, antibiotic prescriptions cost ∼£262,007. CONCLUSIONS: This study highlights high antibiotic use and healthcare resource utilization associated with varicella management, particularly in patients with complications. A national varicella vaccination program in England may reduce varicella burden and related complications, medication use, and costs.

Outbreak of Acute Respiratory Illness Associated With Human Adenovirus Type 4 at the United States Coast Guard Academy, 2019.

BACKGROUND: Although a human adenovirus (HAdV) vaccine is available for military use, officers-in-training are not routinely vaccinated. We describe an HAdV-associated respiratory outbreak among unvaccinated cadets at the US Coast Guard Academy and its impact on cadet training. METHODS: We defined a case as a cadet with new onset cough or sore throat during August 1-October 4, 2019. We reviewed medical records and distributed a questionnaire to identify cases and to estimate impact on cadet training. We performed real-time polymerase chain reaction testing on patient and environmental samples and whole genome sequencing on a subset of positive patient samples. RESULTS: Among the 1072 cadets, 378 (35%) cases were identified by medical records (n = 230) or additionally by the questionnaire (n = 148). Of the 230 cases identified from medical records, 138 (60%) were male and 226 (98%) had no underlying conditions. From questionnaire responses, 113 of 228 (50%) cases reported duty restrictions. Of cases with respiratory specimens, 36 of 50 (72%) were HAdV positive; all 14 sequenced specimens were HAdV-4a1. Sixteen (89%) of 18 environmental specimens from the cadet dormitory were HAdV-positive. CONCLUSIONS: The HAdV-4-associated outbreak infected a substantial number of cadets and significantly impacted cadet training. Routine vaccination could prevent HAdV respiratory outbreaks in this population.

Shedding of Culturable Virus, Seroconversion, and 6-Month Follow-up Antibody Responses in the First 14 Confirmed Cases of Coronavirus Disease 2019 in the United States.

We aimed to characterize presence of culturable virus in clinical specimens during acute illness, and antibody kinetics up to 6 months after symptom onset, among 14 early patients with coronavirus disease 2019 in the United States. We isolated viable severe acute respiratory syndrome coronavirus 2 from real-time reverse-transcription polymerase chain reaction-positive respiratory specimens collected during days 0-8 after onset, but not after. All 13 patients with 2 or more serum specimens developed anti-spike antibodies; 12 developed detectable neutralizing antibodies. We did not isolate virus after detection of neutralizing antibodies. Eight participants provided serum at 6 months after onset; all retained detectable anti-spike immunoglobulin G, and half had detectable neutralizing antibodies. Two participants reported not feeling fully recovered at 6 months.

Outbreaks of Adenovirus-associated Respiratory Illness on 5 College Campuses in the United States, 2018-2019.

BACKGROUND: Human adenoviruses (HAdVs) are commonly associated with acute respiratory illness. HAdV outbreaks are well documented in congregate military training settings, but less is known about outbreaks on college campuses. During fall 2018 and spring 2019, 5 United States (US) colleges reported increases in HAdV-associated respiratory illness. Investigations were performed to better understand HAdV epidemiology in this setting. METHODS: A case was defined as a student at one of the 5 colleges, with acute respiratory illness and laboratory-confirmed HAdV infection during October 2018-December 2018 or March-May 2019. Available respiratory specimens were typed by HAdV type-specific real-time polymerase chain reaction assays, and for a subset, whole genome sequencing was performed. We reviewed available medical records and cases were invited to complete a questionnaire, which included questions on symptom presentation, social history, and absenteeism. RESULTS: We identified 168 HAdV cases. Median age was 19 (range, 17-22) years and 102 cases (61%) were male. Eleven cases were hospitalized, 10 with pneumonia; 2 cases died. Among questionnaire respondents, 80% (75/94) missed ≥ 1 day of class because of their illness. Among those with a type identified (79%), HAdV types 4 and 7 were equally detected, with frequency of each varying by site. Genome types 4a1 and 7d were identified, respectively, by whole genome sequence analysis. CONCLUSIONS: HAdV respiratory illness was associated with substantial morbidity and missed class time among young, generally healthy adults on 5 US college campuses. HAdVs should be considered a cause of respiratory illness outbreaks in congregate settings such as college campuses.

Maternal Health Infrastructure and Interpersonal Quality of Care During Childbirth: An Examination of Facility Delivery in Malawi.

OBJECTIVES: The maternal health field has recently focused on the importance of interpersonal quality of care and continues to cite structural deficits as a contributor to poor interpersonal treatment. This hypothesis is supported by qualitative evidence. This study quantitatively tested the effect of maternal health structural inputs on interpersonal quality of care during childbirth. METHODS: Analyses were conducted using data from the 2013 to 2014 Malawi Service Provision Assessment, which documented the availability and quality of health facility services and included the observation of laboring and delivering women. Maternal health structural inputs were measured using 26 facility infrastructure variables. The outcome, interpersonal quality of care, was measured as a sum score of 12 items collected during the observations. Crude and adjusted associations between maternal health structural inputs on interpersonal quality of care were assessed using linear regression with cluster robust standard errors. RESULTS: 345 Observations of delivering women in 174 health facilities were included in the analysis. 19.1% of women delivered in a facility with high maternal health structural inputs, and the mean interpersonal quality of care score was 8.9/12. Maternal health structural inputs had a small, non-meaningful association with interpersonal quality of care during childbirth (adjusted ß - 0.19, 95% CI - 0.85, 0.47). CONCLUSIONS FOR PRACTICE: These findings do not verify the quality of care frameworks or qualitative evidence that support the relationship between structure and interpersonal quality of care. While structural inputs are important for health system performance, the results suggest that they might not be necessary for a respectful childbirth experience.

Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, March 2016-March 2019.

During March 2016-March 2019, a total of 200,936 suspected cases of Middle East respiratory syndrome coronavirus infection were identified in Saudi Arabia; infections were confirmed in 698 cases (0.3% [0.7/100,000 population per year]). Continued surveillance is necessary for early case detection and timely infection control response.

Enterovirus D68-Associated Acute Respiratory Illness - New Vaccine Surveillance Network, United States, July-October, 2017 and 2018.

In the fall of 2014, an outbreak of enterovirus D68 (EV-D68)-associated acute respiratory illness (ARI) occurred in the United States (1,2); before 2014, EV-D68 was rarely reported to CDC (2,3). In the United States, reported EV-D68 detections typically peak during late summer and early fall (3). EV-D68 epidemiology is not fully understood because testing in clinical settings seldom has been available and detections are not notifiable to CDC. To better understand EV-D68 epidemiology, CDC recently established active, prospective EV-D68 surveillance among pediatric patients at seven U.S. medical centers through the New Vaccine Surveillance Network (NVSN) (4). This report details a preliminary characterization of EV-D68 testing and detections among emergency department (ED) and hospitalized patients with ARI at all NVSN sites during July 1-October 31, 2017, and the same period in 2018. Among patients with ARI who were tested, EV-D68 was detected in two patients (0.8%) in 2017 and 358 (13.9%) in 2018. Continued active, prospective surveillance of EV-D68-associated ARI is needed to better understand EV-D68 epidemiology in the United States.

Eye of the beholder? Observation versus self-report in the measurement of disrespect and abuse during facility-based childbirth.

Human rights has been a vital tool in the global movement to reduce maternal mortality and to expose the disrespect and abuse that women experience during childbirth in facilities around the world. Yet to truly transform the relationship between women and providers, human rights-based approaches (HRBAs) will need to go beyond articulation, dissemination and even legal enforcement of formal norms of respectful maternity care. HRBAs must also develop a deeper, more nuanced understanding of how power operates in health systems under particular social, cultural and political conditions, if they are to effectively challenge settled patterns of behaviour and health systems structures that marginalise and abuse. In this paper, we report results from a mixed methods study in two hospitals in the Tanga region of Tanzania, comparing the prevalence of disrespect and abuse during childbirth as measured through observation by trained nurses stationed in maternity wards to prevalence as measured by the self-report upon discharge of the same women who had been observed. The huge disparity between these two measures (baseline: 69.83% observation vs. 9.91% self-report; endline: 32.91% observation vs. 7.59% self-report) suggests that disrespect and abuse is both internalised and normalised by users and providers alike. Building on qualitative research conducted in the study sites, we explore the mechanisms by which hidden and invisible power enforces internalisation and normalisation, and describe the implications for the development of HRBAs in maternal health.

Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study.

BACKGROUND: Abusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women's poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania. METHODS AND FINDINGS: We used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21-0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05-0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19-0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings. CONCLUSIONS: After implementation of the combined intervention, the likelihood of women's reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project's facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN 48258486.

A combination intervention strategy to improve linkage to and retention in HIV care following diagnosis in Mozambique: A cluster-randomized study.

BACKGROUND: Concerning gaps in the HIV care continuum compromise individual and population health. We evaluated a combination intervention strategy (CIS) targeting prevalent barriers to timely linkage and sustained retention in HIV care in Mozambique. METHODS AND FINDINGS: In this cluster-randomized trial, 10 primary health facilities in the city of Maputo and Inhambane Province were randomly assigned to provide the CIS or the standard of care (SOC). The CIS included point-of-care CD4 testing at the time of diagnosis, accelerated ART initiation, and short message service (SMS) health messages and appointment reminders. A pre-post intervention 2-sample design was nested within the CIS arm to assess the effectiveness of CIS+, an enhanced version of the CIS that additionally included conditional non-cash financial incentives for linkage and retention. The primary outcome was a combined outcome of linkage to care within 1 month and retention at 12 months after diagnosis. From April 22, 2013, to June 30, 2015, we enrolled 2,004 out of 5,327 adults ≥18 years of age diagnosed with HIV in the voluntary counseling and testing clinics of participating health facilities: 744 (37%) in the CIS group, 493 (25%) in the CIS+ group, and 767 (38%) in the SOC group. Fifty-seven percent of the CIS group achieved the primary outcome versus 35% in the SOC group (relative risk [RR]CIS vs SOC = 1.58, 95% CI 1.05-2.39). Eighty-nine percent of the CIS group linked to care on the day of diagnosis versus 16% of the SOC group (RRCIS vs SOC = 9.13, 95% CI 1.65-50.40). There was no significant benefit of adding financial incentives to the CIS in terms of the combined outcome (55% of the CIS+ group achieved the primary outcome, RRCIS+ vs CIS = 0.96, 95% CI 0.81-1.16). Key limitations include the use of existing medical records to assess outcomes, the inability to isolate the effect of each component of the CIS, non-concurrent enrollment of the CIS+ group, and exclusion of many patients newly diagnosed with HIV. CONCLUSIONS: The CIS showed promise for making much needed gains in the HIV care continuum in our study, particularly in the critical first step of timely linkage to care following diagnosis. TRIAL REGISTRATION: ClinicalTrials.gov NCT01930084.

Next generation maternal health: external shocks and health-system innovations.

In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape.

Informing efforts to reach UNAIDS' 90-90-90 targets: a comparison of characteristics of people diagnosed with HIV in health facilities to the general population of people living with HIV in Mozambique.

Global targets aim to increase the number of people living with HIV (PLWH) who know their status. Using data from Mozambican facility-based HIV testing and counseling (HTC) and a population-based survey, we compared characteristics of PLWH diagnosed in HTC to the general population of PLWH to identify subgroups that are missing from the health system and may be undiagnosed. Male and female PLWH aged 50+ (PPR = 0.47, p = .0001) and with higher HIV knowledge (PPR = 0.52, p = .004) were underrepresented in HTC. A higher proportion of patients diagnosed in health facilities were aged 25-39 (PPR = 1.23, p = .02). Female PLWH with lower economic (PPR = 0.70, p = .04) and educational status (PPR = 0.86, p = .02) and male PLWH aged 18-24 (PPR = 0.47, p = .03) were underrepresented in HTC. Comparing HTC data to population-based data can inform efforts to increase HIV diagnoses and to ensure that all PLWH know their status.

Methods used in prevalence studies of disrespect and abuse during facility based childbirth: lessons learned.

BACKGROUND: Several recent studies have attempted to measure the prevalence of disrespect and abuse (D&A) of women during childbirth in health facilities. Variations in reported prevalence may be associated with differences in study instruments and data collection methods. This systematic review and comparative analysis of methods aims to aggregate and present lessons learned from published studies that quantified the prevalence of Disrespect and Abuse (D&A) during childbirth. METHODS: We conducted a systematic review of the literature in accordance with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Five papers met criteria and were included for analysis. We developed an analytical framework depicting the basic elements of epidemiological methodology in prevalence studies and a table of common types of systematic error associated with each of them. We performed a head-to-head comparison of study methods for all five papers. Using these tools, an independent reviewer provided an analysis of the potential for systematic error in the reported prevalence estimates. RESULTS: Sampling techniques, eligibility criteria, categories of D&A selected for study, operational definitions of D&A, summary measures of D&A, and the mode, timing, and setting of data collection all varied in the five studies included in the review. These variations present opportunities for the introduction of biases - in particular selection, courtesy, and recall bias - and challenge the ability to draw comparisons across the studies' results. CONCLUSION: Our review underscores the need for caution in interpreting or comparing previously reported prevalence estimates of D&A during facility-based childbirth. The lack of standardized definitions, instruments, and study methods used to date in studies designed to quantify D&A in childbirth facilities introduced the potential for systematic error in reported prevalence estimates, and affected their generalizability and comparability. Chief among the lessons to emerge from comparing methods for measuring the prevalence of D&A is recognition of the tension between seeking prevalence measures that are reliable and generalizable, and attempting to avoid loss of validity in the context where the issue is being studied.

Association Between Disrespect and Abuse During Childbirth and Women's Confidence in Health Facilities in Tanzania.

OBJECTIVES: In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite efforts to reduce barriers to utilization. Disrespect and abuse during childbirth has not been explored as a contributor to delivery satisfaction or as a deterrent to institutional delivery. We assessed the association between reported disrespectful treatment during childbirth and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future. METHODS: Interviews using a structured questionnaire were conducted in Tanga Region, Tanzania with women on discharge from delivery at two hospitals. Disrespect and abuse was measured by asking women about specific disrespectful events during childbirth. Multivariable logistic regression models were used to assess the association between disrespect/abuse and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders. RESULTS: 1388 women participated in the survey (67 % response rate). Disrespect/abuse during childbirth was associated with lower satisfaction with delivery (OR 0.26, 95 % CI 0.19-0.36) and reduced likelihood of rating perceived quality of care as excellent/very good (OR 0.55, 95 % CI 0.35-0.85). Of women who planned to have more children (N = 766), those who experienced disrespect/abuse were half as likely to plan to deliver again at the same facility (OR 0.51, 95 % CI 0.32-0.82). CONCLUSIONS: Our study highlights disrespectful and abusive treatment during childbirth as an important factor in reducing women's confidence in health facilities. Improving interpersonal care must be an integral part of quality improvement in maternal health.

Healthcare resource utilization and costs associated with hepatitis A in the United States: a retrospective database analysis.

AIM: To investigate hepatitis A-related healthcare resource use and costs in the US. METHODS: The Merative Marketscan Commercial Claims and Encounters database was retrospectively analyzed for hepatitis A-related inpatient, outpatient, and emergency department (ED) claims from January 1, 2012 to December 31, 2018. We calculated the hepatitis A incidence proportion per 100,000 enrollees, healthcare resource utilization, and costs (in 2020 USD). Results were stratified by age, gender, and select comorbidities. RESULTS: The overall hepatitis A incidence proportion was 6.1 per 100,000 enrollees. Among individuals with ≥1 hepatitis A-related claim, the majority (92.6%) had ≥1 outpatient visit related to hepatitis A; 9.1% were hospitalized and 4.2% had ≥1 ED visit. The mean (standard deviation [SD]) length of hospital stay was 5.2 (8.1) days; the mean (SD) number of outpatient and ED visits were 1.3 (1.3) and 1.1 (0.6), respectively. The incidence proportion per 100,000 was higher among adults than children (7.5 vs. 1.5), individuals with HIV than those without (126.7 vs. 5.9), and individuals with chronic liver disease than those without (143.6 vs. 3.8). The total mean (SD)/median (interquartile range, IQR) per-patient cost for hepatitis A-related care was $2,520 ($10,899)/$156 ($74-$529) and the mean cost of hospitalization was 18.7 times higher than that of outpatient care ($17,373 vs. $928). LIMITATIONS: The study data included only a commercially insured population and may not be representative of all individuals. CONCLUSIONS: In conclusion, hepatitis A is associated with a substantial economic burden among privately insured individuals in the US.

Hepatitis A is an acute liver infection caused by the hepatitis A virus. In the US, safe and effective vaccines for hepatitis A have been available since 1996. Vaccination recommendations include children (all children aged 12­23 months and previously unvaccinated children aged 2­18 years old) and adults at risk of infection or severe disease (e.g. international travelers, men who have sex with men, persons experiencing homelessness, persons with chronic liver disease or persons with HIV infection). Since 2016, the US has experienced person-to-person outbreaks of hepatitis A, primarily affecting unvaccinated individuals who use drugs or are experiencing homelessness. To better understand the impact of hepatitis A in the US, we assessed healthcare resource use and costs in 15,435 patients with hepatitis A from 2012 to 2018 in the Merative Marketscan Commercial Claims and Encounters database. We found that slightly more than 6 per 100,000 enrollees had hepatitis A from 2012 to 2018 and the number of people treated for hepatitis A per 100,000 was highest for people living with HIV or with chronic liver disease. The majority (92.6%) of people reported at least an outpatient visit, 9.1% were hospitalized, and 4.2% had an emergency department visit. The average cost for hepatitis A-related care was $2,520 per patient and was 18.7 times higher for hospitalized patients ($17,373) than for patients treated in outpatient care ($928). Our results are limited by the generalizability of the dataset, which is a convenience sample of private insurance claims, and are therefore unlikely to capture groups at high-risk for hepatitis A, such as individuals experiencing homelessness. In conclusion, hepatitis A leads to considerable healthcare costs for privately insured individuals in the US.

Clinical and Economic Burden of Antibiotic Use Among Pediatric Patients With Varicella Infection in the Outpatient Setting: A Retrospective Cohort Analysis of Real-world Data in France.

BACKGROUND: Varicella infects 90% of children before age 9. Though varicella is self-limiting, its complications may require antibiotics, though how antibiotics are utilized for varicella in France is not well known. This study assessed antibiotic use and costs associated with varicella and its complications in pediatric patients managed in the outpatient setting in France. METHODS: A retrospective cohort study using the Cegedim Strategic Data-Longitudinal Patient Database, an electronic medical record database from general practitioners and office-based specialists in France, was conducted. Children <18 years old diagnosed with varicella between January 2014 and December 2018 with 3-month follow-up available were included. We used descriptive analysis to assess varicella-related complications, medication use, healthcare resource utilization and costs. RESULTS: Overall, 48,027 patients were diagnosed with varicella; 15.3% (n = 7369) had ≥1 varicella-related complication. Antibiotics were prescribed in up to 25.1% (n = 12,045/48,027) of cases with greater use in patients with complications (68.1%, n = 5018/7369) compared with those without (17.3%, n = 7027/40,658). Mean medication and outpatient varicella-related costs were €32.82 per patient with medications costing a mean of €5.84 per patient; antibiotics contributed ~23% to total costs annually. CONCLUSION: This study showed high antibiotic use for the management of varicella and its complications. A universal varicella vaccination program could be considered to alleviate complications and associated costs in France.

Acute pulmonary emboli in a patient on long-term dabigatran therapy.

OBJECTIVE: To describe the case of a patient who developed acute pulmonary emboli (PE) despite long-term anticoagulation with dabigatran. CASE SUMMARY: A 69-year-old obese woman was hospitalized for worsening shortness of breath, dyspnea on exertion, and left pleuritic chest pain. On admission, a computed tomography angiogram revealed acute bilateral PE, despite use of dabigatran for atrial fibrillation for approximately 5 years prior to admission. Dabigatran was stopped and therapeutic enoxaparin was initiated concomitantly with warfarin. An investigation into possible causes for the development of the PE, including hypercoagulability, was unrevealing. Since dabigatran should have protected against PE, the patient was questioned regarding adherence to her regimen. She stated that she was adherent but reported using a pillbox. The patient was discharged home on warfarin with an enoxaparin bridge until her international normalized ratio was at least 2.0. DISCUSSION: The underlying cause for the patient's acute PE is unknown but could possibly be attributed to obesity and reduced mobility. Although dabigatran should have prevented PE, the presence of interacting drugs, patient-specific pharmacokinetics, suboptimal medication storage, and laboratory abnormalities may have resulted in reduced dabigatran exposure and protection. This is a reasonable hypothesis; however, the patient did not develop a stroke while receiving dabigatran. CONCLUSIONS: Our patient developed acute bilateral PE despite receiving long-term anticoagulation with dabigatran. While it is possible that patient-specific factors resulted in reduced dabigatran exposure and efficacy, conclusions cannot be made.

Predicting Measles Outbreaks in the United States: Evaluation of Machine Learning Approaches.

BACKGROUND: Measles, a highly contagious viral infection, is resurging in the United States, driven by international importation and declining domestic vaccination coverage. Despite this resurgence, measles outbreaks are still rare events that are difficult to predict. Improved methods to predict outbreaks at the county level would facilitate the optimal allocation of public health resources. OBJECTIVE: We aimed to validate and compare extreme gradient boosting (XGBoost) and logistic regression, 2 supervised learning approaches, to predict the US counties most likely to experience measles cases. We also aimed to assess the performance of hybrid versions of these models that incorporated additional predictors generated by 2 clustering algorithms, hierarchical density-based spatial clustering of applications with noise (HDBSCAN) and unsupervised random forest (uRF). METHODS: We constructed a supervised machine learning model based on XGBoost and unsupervised models based on HDBSCAN and uRF. The unsupervised models were used to investigate clustering patterns among counties with measles outbreaks; these clustering data were also incorporated into hybrid XGBoost models as additional input variables. The machine learning models were then compared to logistic regression models with and without input from the unsupervised models. RESULTS: Both HDBSCAN and uRF identified clusters that included a high percentage of counties with measles outbreaks. XGBoost and XGBoost hybrid models outperformed logistic regression and logistic regression hybrid models, with the area under the receiver operating curve values of 0.920-0.926 versus 0.900-0.908, the area under the precision-recall curve values of 0.522-0.532 versus 0.485-0.513, and F2 scores of 0.595-0.601 versus 0.385-0.426. Logistic regression or logistic regression hybrid models had higher sensitivity than XGBoost or XGBoost hybrid models (0.837-0.857 vs 0.704-0.735) but a lower positive predictive value (0.122-0.141 vs 0.340-0.367) and specificity (0.793-0.821 vs 0.952-0.958). The hybrid versions of the logistic regression and XGBoost models had slightly higher areas under the precision-recall curve, specificity, and positive predictive values than the respective models that did not include any unsupervised features. CONCLUSIONS: XGBoost provided more accurate predictions of measles cases at the county level compared with logistic regression. The threshold of prediction in this model can be adjusted to align with each county's resources, priorities, and risk for measles. While clustering pattern data from unsupervised machine learning approaches improved some aspects of model performance in this imbalanced data set, the optimal approach for the integration of such approaches with supervised machine learning models requires further investigation.

Changes in vaccine administration trends across the life-course during the COVID-19 pandemic in the United States: a claims database study.

BACKGROUND: This study provides an updated and expanded analysis of the impact of the COVID-19 pandemic on routine vaccinations across the life-course in the United States. RESEARCH DESIGN AND METHODS: Routine wellness visits and vaccination rates were calculated using structured claims data for each month during the impact period (January 2020 to August 2022) and compared to the respective baseline period (January 2018 to December 2019). Monthly rates were aggregated as annual accumulated and cumulative percent changes. RESULTS: The complete monthly rate interactive dataset can be viewed at https://vaccinationtrends.com. The greatest decrease in annual accumulated administration rates in the 0-2 and 4-6 years age groups was for the measles, mumps, and rubella vaccine; for adolescents and older adults, it was for human papillomavirus and pneumococcal vaccines, respectively. Routine in-person wellness visit rates recovered faster and more completely than vaccination rates in all age groups, indicating potential missed opportunities to administer vaccines during visits. CONCLUSIONS: This updated analysis reveals that the negative impact of the COVID-19 pandemic on routine vaccination continued through 2021 and into 2022. Proactive efforts to reverse this decline are needed to increase individual- and population-level vaccination coverage and avoid the associated preventable morbidity, mortality, and health care costs.