Assessment of Hospital-Onset SARS-CoV-2 Infection Rates and Testing Practices in the US, 2020-2022.

Importance: Characterizing the scale and factors associated with hospital-onset SARS-CoV-2 infections could help inform hospital and public health policies regarding prevention and surveillance needs for these infections. Objective: To evaluate associations of hospital-onset SARS-CoV-2 infection rates with different periods of the COVID-19 pandemic, hospital characteristics, and testing practices. Design, Setting, and Participants: This cohort study of US hospitals reporting SARS-CoV-2 testing data in the PINC AI Healthcare Database COVID-19 special release files was conducted from July 2020 through June 2022. Data were collected from hospitals that reported at least 1 SARS-CoV-2 reverse transcription-polymerase chain reaction or antigen test during hospitalizations discharged that month. For each hospital-month where the hospital reported sufficient data, all hospitalizations discharged in that month were included in the cohort. SARS-CoV-2 viral tests and results reported in the microbiology files for all hospitalizations in the study period by discharge month were identified. Data analysis was conducted from September 2022 to March 2023. Exposure: Hospitalizations discharged in an included hospital-month. Main Outcomes and Measures: Multivariable generalized estimating equation negative-binomial regression models were used to assess associations of monthly rates of hospital-onset SARS-CoV-2 infections per 1000 patient-days (defined as a first positive SARS-CoV-2 test during after hospitalization day 7) with the phase of the pandemic (defined as the predominant SARS-CoV-2 variant in circulation), admission testing rates, and hospital characteristics (hospital bed size, teaching status, urban vs rural designation, Census region, and patient distribution variables). Results: A total of 5687 hospital-months from 288 distinct hospitals were included, which contributed 4 421 268 hospitalization records. Among 171 564 hospitalizations with a positive SARS-CoV-2 test, 7591 (4.4%) were found to be hospital onset and 6455 (3.8%) were indeterminate onset. The mean monthly hospital-onset infection rate per 1000 patient-days was 0.27 (95 CI, 0.26-0.29). Hospital-onset infections occurred in 2217 of 5687 hospital-months (39.0%). The monthly percentage of discharged patients tested for SARS-CoV-2 at admission varied; 1673 hospital-months (29.4%) had less than 25% of hospitalizations tested at admission; 2199 hospital-months (38.7%) had 25% to 50% of all hospitalizations tested, and 1815 hospital months (31.9%) had more than 50% of all hospitalizations tested at admission. Postadmission testing rates and community-onset infection rates increased with admission testing rates. In multivariable models restricted to hospital-months testing at least 25% of hospitalizations at admission, a 10% increase in community-onset SARS-CoV-2 infection rate was associated with a 178% increase in the hospital-onset infection rate (rate ratio, 2.78; 95% CI, 2.52-3.07). Additionally, the phase of the COVID-19 pandemic, the admission testing rate, Census region, and bed size were all significantly associated with hospital-onset SARS-CoV-2 infection rates. Conclusions and Relevance: In this cohort study of hospitals reporting SARS-CoV-2 infections, there was an increase of hospital-onset SARS-CoV-2 infections when community-onset infections were higher, indicating a need for ongoing and enhanced surveillance and prevention efforts to reduce in-hospital transmission of SARS-CoV-2 infections, particularly when community-incidence of SARS-CoV-2 infections is high.

Estimation of Coronavirus Disease 2019 Hospitalization Costs From a Large Electronic Administrative Discharge Database, March 2020-July 2021.

BACKGROUND: Information on the costs of inpatient care for patients with coronavirus disease 2019 (COVID-19) is very limited. This study estimates the per-patient cost of inpatient care for adult COVID-19 patients seen at >800 US hospitals. METHODS: Patients aged ≥18 years with ≥1 hospitalization during March 2020-July 2021 with a COVID-19 diagnosis code in a large electronic administrative discharge database were included. We used validated costs when reported; otherwise, costs were calculated using charges multiplied by cost-to-charge ratios. We estimated costs of inpatient care per patient overall and by severity indicator, age, sex, underlying medical conditions, and acute complications of COVID-19 using a generalized linear model with log link function and gamma distribution. RESULTS: The overall cost among 654673 patients hospitalized with COVID-19 was $16.2 billion. Estimated per-patient hospitalization cost was $24 826. Among surviving patients, estimated per-patient cost was $13 090 without intensive care unit (ICU) admission or invasive mechanical ventilation (IMV), $21 222 with ICU admission alone, and $59 742 with IMV. Estimated per-patient cost among patients who died was $27 017. Adjusted cost differential was higher among patients with certain underlying conditions (eg, chronic kidney disease [$12 391], liver disease [$8878], cerebrovascular disease [$7267], and obesity [$5933]) and acute complications (eg, acute respiratory distress syndrome [$43 912], pneumothorax [$25 240], and intracranial hemorrhage [$22 280]). CONCLUSIONS: The cost of inpatient care for COVID-19 patients was substantial through the first 17 months of the pandemic. These estimates can be used to inform policy makers and planners and cost-effectiveness analysis of public health interventions to alleviate the burden of COVID-19.

Risk of Clinical Severity by Age and Race/Ethnicity Among Adults Hospitalized for COVID-19-United States, March-September 2020.

BACKGROUND: Older adults and people from certain racial and ethnic groups are disproportionately represented in coronavirus disease 2019 (COVID-19) hospitalizations and deaths. METHODS: Using data from the Premier Healthcare Database on 181 813 hospitalized adults diagnosed with COVID-19 during March-September 2020, we applied multivariable log-binomial regression to assess the associations between age and race/ethnicity and COVID-19 clinical severity (intensive care unit [ICU] admission, invasive mechanical ventilation [IMV], and death) and to determine whether the impact of age on clinical severity differs by race/ethnicity. RESULTS: Overall, 84 497 (47%) patients were admitted to the ICU, 29 078 (16%) received IMV, and 27 864 (15%) died in the hospital. Increased age was strongly associated with clinical severity when controlling for underlying medical conditions and other covariates; the strength of this association differed by race/ethnicity. Compared with non-Hispanic White patients, risk of death was lower among non-Hispanic Black patients (adjusted risk ratio, 0.96; 95% CI, 0.92-0.99) and higher among Hispanic/Latino patients (risk ratio [RR], 1.15; 95% CI, 1.09-1.20), non-Hispanic Asian patients (RR, 1.16; 95% CI, 1.09-1.23), and patients of other racial and ethnic groups (RR, 1.13; 95% CI, 1.06-1.21). Risk of ICU admission and risk of IMV were elevated among some racial and ethnic groups. CONCLUSIONS: These results indicate that age is a driver of poor outcomes among hospitalized persons with COVID-19. Additionally, clinical severity may be elevated among patients of some racial and ethnic minority groups. Public health strategies to reduce severe acute respiratory syndrome coronavirus 2 infection rates among older adults and racial and ethnic minorities are essential to reduce poor outcomes.

National Estimates of Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Hospitalized Patients in the United States.

BACKGROUND: Treating patients with infections due to multidrug-resistant pathogens often requires substantial healthcare resources. The purpose of this study was to report estimates of the healthcare costs associated with infections due to multidrug-resistant bacteria in the United States (US). METHODS: We performed retrospective cohort studies of patients admitted for inpatient stays in the Department of Veterans Affairs healthcare system between January 2007 and October 2015. We performed multivariable generalized linear models to estimate the attributable cost by comparing outcomes in patients with and without positive cultures for multidrug-resistant bacteria. Finally, we multiplied these pathogen-specific, per-infection attributable cost estimates by national counts of infections due to each pathogen from patients hospitalized in a cohort of 722 US hospitals from 2017 to generate estimates of the population-level healthcare costs in the US attributable to these infections. RESULTS: Our analysis cohort consisted of 16 676 patients with community-onset infections and 172 712 matched controls and 8246 patients with hospital-onset infections and 66 939 matched controls. The highest cost was seen in hospital-onset invasive infections, with attributable costs (95% confidence intervals) ranging from $30 998 ($25 272-$36 724) for methicillin-resistant Staphylococcus aureus to $74 306 ($20 377-$128 235) for carbapenem-resistant (CR) Acinetobacter. The highest attributable costs for community-onset invasive infections were seen in CR Acinetobacter ($62 396; $20 370-$104 422). Treatment of these infections cost an estimated $4.6 billion ($4.1 billion-$5.1 billion) in 2017 in the US for community- and hospital-onset infections combined. CONCLUSIONS: We found that antimicrobial-resistant infections led to substantial healthcare costs.

National Public Health Burden Estimates of Endocarditis and Skin and Soft-Tissue Infections Related to Injection Drug Use: A Review.

BACKGROUND: Despite concerns about the burden of the bacterial and fungal infection syndromes related to injection drug use (IDU), robust estimates of the public health burden of these conditions are lacking. The current article reviews and compares data sources and national burden estimates for infective endocarditis (IE) and skin and soft-tissue infections related to IDU in the United States. METHODS: A literature review was conducted for estimates of skin and soft-tissue infection and endocarditis disease burden with related IDU or substance use disorder terms since 2011. A range of the burden is presented, based on different methods of obtaining national projections from available data sources or published data. RESULTS: Estimates using available data suggest the number of hospital admissions for IE related to IDU ranged from 2900 admissions in 2013 to more than 20 000 in 2017. The only source of data available to estimate the annual number of hospitalizations and emergency department visits for skin and soft-tissue infections related to IDU yielded a crude estimate of 98 000 such visits. Including people who are not hospitalized, a crude calculation suggests that 155 000-540 000 skin infections related to IDU occur annually. DISCUSSION: These estimates carry significant limitations. However, regardless of the source or method, the burden of disease appears substantial, with estimates of thousands of episodes of IE among persons with IDU and at least 100 000 persons who inject drugs (PWID) with skin and soft-tissue infections annually in the United States. Given the importance of these types of infections, more robust and reliable estimates are needed to better quantitate the occurrence and understand the impact of interventions.

Surgical site infection risk following cesarean deliveries covered by Medicaid or private insurance.

OBJECTIVE: To compare risk of surgical site infection (SSI) following cesarean delivery between women covered by Medicaid and private health insurance. STUDY DESIGN: Retrospective cohort. STUDY POPULATION: Cesarean deliveries covered by Medicaid or private insurance and reported to the National Healthcare Safety Network (NHSN) and state inpatient discharge databases by hospitals in California (2011-2013). METHODS: Deliveries reported to NHSN and state inpatient discharge databases were linked to identify SSIs in the 30 days following cesarean delivery, primary payer, and patient and procedure characteristics. Additional hospital-level characteristics were obtained from public databases. Relative risk of SSI by primary payer primary payer was assessed using multivariable logistic regression adjusting for patient, procedure, and hospital characteristics, accounting for facility-level clustering. RESULTS: Of 291,757 cesarean deliveries included, 48% were covered by Medicaid. SSIs were detected following 1,055 deliveries covered by Medicaid (0.75%) and 955 deliveries covered by private insurance (0.63%) (unadjusted odds ratio, 1.2; 95% confidence interval [CI], 1.1-1.3; P < .0001). The adjusted odds of SSI following cesarean deliveries covered by Medicaid was 1.4 (95% CI, 1.2-1.6; P < .0001) times the odds of those covered by private insurance. CONCLUSIONS: In this, the largest and only multicenter study to investigate SSI risk following cesarean delivery by primary payer, Medicaid-insured women had a higher risk of infection than privately insured women. These findings suggest the need to evaluate and better characterize the quality of maternal healthcare for and needs of women covered by Medicaid to inform targeted infection prevention and policy.

Assessing the social cost and benefits of a national requirement establishing antibiotic stewardship programs to prevent Clostridioides difficile infection in US hospitals.

Backgound: Economic evaluations of interventions to prevent healthcare-associated infections in the United States rarely take the societal perspective and thus ignore the potential benefits of morbidity and mortality risk reductions. Using new Department of Health and Human Services guidelines for regulatory impact analysis, we developed a cost-benefit analyses of a national multifaceted, in-hospital Clostridioides difficile infection prevention program (including staffing an antibiotic stewardship program) that incorporated value of statistical life estimates to obtain economic values associated with morbidity and mortality risk reductions. Methods: We used a net present value model to assess costs and benefits associated with antibiotic stewardship programs. Model inputs included treatment costs, intervention costs, healthcare-associated Clostridioides difficile infection cases, attributable deaths, and the value of statistical life which was used to estimate the economic value of morbidity and mortality risk reductions. Results: From 2015 to 2020, total net benefits of the intervention to the healthcare system range from $300 million to $7.6 billion when values for morbidity and mortality risk reductions are ignored. Including these values, the net social benefits of the intervention range from $21 billion to $624 billion with the annualized net benefit of $25.5 billion under our most likely outcome scenario. Conclusions: Incorporating the economic value of morbidity and mortality risk reductions in economic evaluations of healthcare-associated infections will significantly increase the benefits resulting from prevention.

Assessing Variability in Hospital-Level Mortality Among U.S. Medicare Beneficiaries With Hospitalizations for Severe Sepsis and Septic Shock.

OBJECTIVES: To assess the variability in short-term sepsis mortality by hospital among Centers for Medicare and Medicaid Services beneficiaries in the United States during 2013-2014. DESIGN: A retrospective cohort design. SETTING: Hospitalizations from 3,068 acute care hospitals that participated in the Centers for Medicare and Medicaid Services inpatient prospective payment system in 2013 and 2014. PATIENTS: Medicare fee-for-service beneficiaries greater than or equal to 65 years old who had an inpatient hospitalization coded with present at admission severe sepsis or septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Individual level mortality was assessed as death at or within 7 days of hospital discharge and aggregated to calculate hospital-level mortality rates. We used a logistic hierarchal linear model to calculate mortality risk-adjusted for patient characteristics. We quantified variability among hospitals using the median odds ratio and calculated risk-standardized mortality rates for each hospital. The overall crude mortality rate was 34.7%. We found significant variability in mortality by hospital (p < 0.001). The middle 50% of hospitals had similar risk-standardized mortality rates (32.7-36.9%), whereas the decile of hospitals with the highest risk-standardized mortality rates had a median mortality rate of 40.7%, compared with a median of 29.2% for hospitals in the decile with the lowest risk-standardized mortality rates. The median odds ratio (1.29) was lower than the adjusted odds ratios for several measures of patient comorbidities and severity of illness, including present at admission organ dysfunction, no identified source of infection, and age. CONCLUSIONS: In a large study of present at admission sepsis among Medicare beneficiaries, we showed that mortality was most strongly associated with underlying comorbidities and measures of illness on arrival. However, after adjusting for patient characteristics, mortality also modestly depended on where a patient with sepsis received care, suggesting that efforts to improve sepsis outcomes in lower performing hospitals could impact sepsis survival.

Estimating National Trends in Inpatient Antibiotic Use Among US Hospitals From 2006 to 2012.

Importance: The rising threat of antibiotic resistance and other adverse consequences resulting from the misuse of antibiotics requires a better understanding of antibiotic use in hospitals in the United States. Objective: To use proprietary administrative data to estimate patterns of US inpatient antibiotic use in recent years. Design, Setting, and Participants: For this retrospective analysis, adult and pediatric in-patient antibiotic use data was obtained from the Truven Health MarketScan Hospital Drug Database (HDD) from January 1, 2006, to December 31, 2012. Data from adult and pediatric patients admitted to 1 of approximately 300 participating acute care hospitals provided antibiotic use data for over 34 million discharges representing 166 million patient-days. Main Outcomes and Measures: We retrospectively estimated the days of therapy (DOT) per 1000 patient-days and the proportion of hospital discharges in which a patient received at least 1 dose of an antibiotic during the hospital stay. We calculated measures of antibiotic usage stratified by antibiotic class, year, and other patient and facility characteristics. We used data submitted to the Centers for Medicare and Medicaid Services Healthcare Cost Report Information System to generate estimated weights to apply to the HDD data to create national estimates of antibiotic usage. A multivariate general estimating equation model to account for interhospital covariance was used to assess potential trends in antibiotic DOT over time. Results: During the years 2006 to 2012, 300 to 383 hospitals per year contributed antibiotic data to the HDD. Across all years, 55.1% of patients received at least 1 dose of antibiotics during their hospital visit. The overall national DOT was 755 per 1000 patient-days. Overall antibiotic use did not change significantly over time. The multivariable trend analysis of data from participating hospitals did not show a statistically significant change in overall use (total DOT increase, 5.6; 95% CI, -18.9 to 30.1; P = .65). However, the mean change (95% CI) for the following antibiotic classes increased significantly: third- and fourth-generation cephalosporins, 10.3 (3.1-17.5); macrolides, 4.8 (2.0-7.6); glycopeptides, 22.4 (17.5-27.3); ß-lactam/ß-lactamase inhibitor combinations, 18.0 (13.3-22.6); carbapenems, 7.4 (4.6-10.2); and tetracyclines, 3.3 (2.0-4.7). Conclusions and Relevance: Overall DOT of all antibiotics among hospitalized patients in US hospitals has not changed significantly in recent years. Use of some antibiotics, especially broad spectrum agents, however, has increased significantly. This trend is worrisome in light of the rising challenge of antibiotic resistance. Our findings can help inform national efforts to improve antibiotic use by suggesting key targets for improvement interventions.

The Likelihood of Hospital Readmission Among Patients With Hospital-Onset Central Line-Associated Bloodstream Infections.

OBJECTIVE: To determine whether central line-associated bloodstream infections (CLABSIs) increase the likelihood of readmission. DESIGN: Retrospective matched cohort study for the years 2008-2009. SETTING: Acute care hospitals. PARTICIPANTS: Medicare recipients. CLABSI and readmission status were determined by linking National Healthcare Safety Network surveillance data to the Centers for Medicare and Medicaid Services' Medical Provider and Analysis Review in 8 states. Frequency matching was used on International Classification of Diseases, Ninth Revision, Clinical Modification procedure code category and intensive care unit status. METHODS: We compared the rate of readmission among patients with and without CLABSI during an index hospitalization. Cox proportional hazard analysis was used to assess rate of readmission (the first hospitalization within 30 days after index discharge). Multivariate models included the following covariates: race, sex, length of index hospitalization stay, central line procedure code, Gagne comorbidity score, and individual chronic conditions. RESULTS: Of the 8,097 patients, 2,260 were readmitted within 30 days (27.9%). The rate of first readmission was 7.1 events/person-year for CLABSI patients and 4.3 events/person-year for non-CLABSI patients (P<.001). The final model revealed a small but significant increase in the rate of 30-day readmissions for patients with a CLABSI compared with similar non-CLABSI patients. In the first readmission for CLABSI patients, we also observed an increase in diagnostic categories consistent with CLABSI, including septicemia and complications of a device. CONCLUSIONS: Our analysis found a statistically significant association between CLABSI status and readmission, suggesting that CLABSI may have adverse health impact that extends beyond hospital discharge.

Medicare Reimbursement Attributable to Periprosthetic Joint Infection Following Primary Hip and Knee Arthroplasty.

This study estimated Medicare reimbursement attributable to periprosthetic joint infection (PJI) across the continuum of covered services four years following hip or knee arthroplasty. Using 2001-2008 Medicare claims data, total and annual attributable reimbursements were assessed using generalized linear regression, adjusting for potential confounders. Within one year following arthroplasty, 109 (1.04%) of 10,418 beneficiaries were diagnosed with PJI. Cumulative Medicare reimbursement in the PJI arm was 2.2-fold (1.9-2.6, P<.0001) or $53,470 ($39,575-$68,221) higher than that of the non-PJI arm. The largest difference in reimbursement occurred the first year (3.2-fold); differences persisted the second (2.3-fold) and third (1.9-fold) follow up years. PJI following hip or knee arthroplasty appears costly to Medicare, with cost traversing several years and health care service areas.

The cost-benefit of federal investment in preventing Clostridium difficile infections through the use of a multifaceted infection control and antimicrobial stewardship program.

OBJECTIVE: To determine the potential epidemiologic and economic value of the implementation of a multifaceted Clostridium difficile infection (CDI) control program at US acute care hospitals DESIGN: Markov model with a 5-year time horizon PARTICIPANTS: Patients whose data were used in our simulations were limited to hospitalized Medicare beneficiaries ≥65 years old. BACKGROUND: CDI is an important public health problem with substantial associated morbidity, mortality, and cost. Multifaceted national prevention efforts in the United Kingdom, including antimicrobial stewardship, patient isolation, hand hygiene, environmental cleaning and disinfection, and audit, resulted in a 59% reduction in CDI cases reported from 2008 to 2012. METHODS: Our analysis was conducted from the federal perspective. The intervention we modeled included the following components: antimicrobial stewardship utilizing the Antimicrobial Use and Resistance module of the National Healthcare Safety Network (NHSN), use of contact precautions, and enhanced environmental cleaning. We parameterized our model using data from CDC surveillance systems, the AHRQ Healthcare Cost and Utilization Project, and literature reviews. To address uncertainty in our parameter estimates, we conducted sensitivity analyses for intervention effectiveness and cost, expenditures by other federal partners, and discount rate. Each simulation represented a cohort of 1,000 hospitalized patients over 1,000 trials. RESULTS In our base case scenario with 50% intervention effectiveness, we estimated that 509,000 CDI cases and 82,000 CDI-attributable deaths would be prevented over a 5-year time horizon. Nationally, the cost savings across all hospitalizations would be $2.5 billion (95% credible interval: $1.2 billion to $4.0 billion). CONCLUSIONS: The potential benefits of a multifaceted national CDI prevention program are sizeable from the federal perspective.

CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 Million during 1990-2008.

The prevention of central line-associated bloodstream infections in patients in hospital critical care units has been a target of efforts by the Centers for Disease Control and Prevention (CDC) since the 1960s. We developed a historical economic model to measure the net economic benefits of preventing these infections in Medicare and Medicaid patients in critical care units for the period 1990-2008-a time when reductions attributable to federal investment resulted primarily from CDC efforts-using the cost perspective of the federal government as a third-party payer. The estimated net economic benefits ranged from $640 million to $1.8 billion, with the corresponding net benefits per case averted ranging from $15,780 to $24,391. The per dollar rate of return on the CDC's investments ranged from $3.88 to $23.85. These findings suggest that investments in CDC programs targeting other health care-associated infections also have the potential to produce savings by lowering Medicare and Medicaid reimbursements.

Medicare reimbursement attributable to catheter-associated urinary tract infection in the inpatient setting: a retrospective cohort analysis.

BACKGROUND: Most catheter-associated urinary tract infections (CAUTIs) are considered preventable and thus a potential target for health care quality improvement and cost savings. OBJECTIVES: We sought to estimate excess Medicare reimbursement, length of stay, and inpatient death associated with CAUTI among hospitalized beneficiaries. RESEARCH DESIGN: Using a retrospective cohort design with linked Medicare inpatient claims and National Healthcare Safety Network data from 2009, we compared Medicare reimbursement between Medicare beneficiaries with and without CAUTIs. SUBJECTS: Fee-for-service Medicare beneficiaries aged 65 years or older with continuous coverage of parts A (hospital insurance) and B (supplementary medical insurance). RESULTS: We found that beneficiaries with CAUTI had higher median Medicare reimbursement [intensive care unit (ICU): $8548, non-ICU: $1479) and length of stay (ICU: 8.1 d, non-ICU: 3.6 d) compared with those without CAUTI controlling for potential confounding factors. Odds of inpatient death were higher among beneficiaries with versus without CAUTI only among those with an ICU stay (ICU: odds ratio 1.37). CONCLUSIONS: Beneficiaries with CAUTI had increased Medicare reimbursement and length of stay compared with those without CAUTI after adjusting for potential confounders.

Safety of trivalent inactivated influenza vaccine in children aged 24 to 59 months in the vaccine safety datalink.

OBJECTIVES: To evaluate the safety of trivalent inactivated influenza vaccine (TIV) in children aged 24 to 59 months and to evaluate the risk of medically attended events (MAEs) in a subcohort of children who had multiple annual doses of TIV over their lifetimes. DESIGN: Self-controlled screening study. SETTING: Seven US managed care organizations from October 1, 2002, to March 31, 2006. PARTICIPANTS: Children aged 24 to 59 months who received at least 1 TIV dose (66 283 children and 91 692 TIV doses). EXPOSURE: Vaccination with TIV. MAIN OUTCOME MEASURES: Medically attended events in inpatient and emergency department settings in one of the following risk windows: 0 to 2, 1 to 14, or 1 to 42 days after vaccination. All MAEs that met the screening criteria of incidence rate ratios (IRRs) exceeding 1.0 and P ≤ .05 or IRRs exceeding 2.0 and P < .20 underwent medical record review. A secondary analysis examined the risk of MAEs in children who had multiple annual lifetime TIV doses. RESULTS: Nine diagnoses met the screening criteria. After medical record review, gastrointestinal tract symptoms (IRR, 1.18; 95% confidence interval [CI], 1.10-1.25), gastrointestinal tract disorders (7.70; 1.11-53.52), and fever (1.71; 1.64-1.80) remained significantly associated with vaccination. None of the events seemed to be serious, and none had complications. In the secondary analysis, there was an apparent dose response for vaccine and allergic reactions in the 1- to 3-day risk window. CONCLUSIONS: There was no evidence of serious MAEs following vaccination with TIV among children aged 24 to 59 months. Further studies are warranted to evaluate the risk of MAEs in children with multiple lifetime TIV doses.

Compliance with multiple-dose vaccine schedules among older children, adolescents, and adults: results from a vaccine safety datalink study.

OBJECTIVES: We studied compliance with multiple-dose vaccine schedules, assessed factors associated with noncompliance, and examined timeliness of series completion among older children, adolescents, and adults. METHODS: We conducted a large, multisite, retrospective cohort study of older children, adolescents, and adults in the Vaccine Safety Datalink population from 1996 through 2004. We quantified the rates of completion of all required doses for varicella, hepatitis A, and hepatitis B vaccines according to their recommended schedules. RESULTS: Among those who received a first dose of varicella (n = 16 075), hepatitis A (n = 594 917), and hepatitis B (n = 590 445) vaccine, relatively few completed the series (55%-65% for hepatitis B vaccine and 40%-50% for hepatitis A and varicella vaccines in most age groups). Compliance was lowest among adolescents (35.9%) and Medicaid recipients (29.7%) who received varicella vaccine and among younger adult age groups who received hepatitis A vaccine (25%-35% across those age groups). Even among series completers, there was a relatively long interval of undervaccination between the first and last doses. CONCLUSIONS: Compliance with multiple-dose vaccine series among older children, adolescents, and adults is suboptimal. Further evaluations of strategies to improve compliance in these populations are needed.

Influenza vaccination coverage among adult solid organ transplant recipients at three health maintenance organizations, 1995-2005.

Annual immunization against influenza is recommended for solid organ transplant (SOT) recipients. We used Vaccine Safety Datalink data from 1995 to 2005 to assess influenza vaccination during the first full vaccination season (September-February) following transplant among 1800 kidney, liver, and heart transplant recipients at three health maintenance organizations. Overall, 52% of recipients were vaccinated. Older age at transplant (age 50-64 years, OR 1.81, 95% CI 1.43-2.30; age > or =65 years, OR 1.94, 95% CI 1.39-2.69), receiving vaccination in the full season pre-transplant (OR 4.54, 95% CI 3.67-5.60), and year of transplantation were significant predictors of post-transplant vaccination. Although vaccine coverage increased during study years, SOT recipients are under-immunized against influenza. Efforts to understand barriers to vaccination and increase education of physicians managing patients while awaiting and after receipt of transplant are needed.

Assessment of the safety of a third dose of pneumococcal polysaccharide vaccine in the Vaccine Safety Datalink population.

There is little information on the safety of administration of a third dose of pneumococcal polysaccharide vaccine (PPV). The authors conducted a retrospective assessment of 316,995 adult members of three health maintenance organizations who had received one, two, or three PPV doses. Medical encounters associated with diagnosis codes potentially indicative of an injection site reaction in the week following a first, second, or third PPV dose were identified. These presumptive events occurred in 0.3% (911/279504) of the first PPV group, 0.7% (257/36888) of the second PPV group, and 0.5% (3/603) of the third PPV group (p>0.5 for both comparisons with the third PPV group). These findings do not suggest that a third PPV dose is associated with an increased risk of medically attended injection site reactions compared with a first or second PPV dose.

Workplace health and safety regulations: Impact of enforcement and consultation on workers' compensation claims rates in Washington State.

BACKGROUND: There has been considerable debate in the public policy arena about the appropriate mix of regulatory enforcement and consultation in achieving desired health and safety behavior across industries. Recently there has been a shift in federal policy toward voluntary approaches and constraining the scope of enforcement programs, although there is little evidence that this might improve health and safety outcomes. To address this, we examined changes in lost time workers compensation claims rates for Washington State employers who had (1) no OSHA State Plan (WISHA) activity, (2) enforcement, (3) consultation, and (4) both types of visits. METHODS: Compensable claims rates, hours, and WISHA activity were determined for each employer account with a single business location that had payroll hours reported for every quarter from 1997-2000 and more than 10 employees. We used a generalized estimating equations (GEE) approach to Poisson regression to model the association between WISHA activity and claims rate controlling for other external factors. RESULTS: Controlling for previous claims rate and average size, claims rates for employers with WISHA enforcement activity declined 22.5% in fixed site industry SIC codes compared to 7% among employers with no WISHA activity (P < 0.05), and in non-fixed site SICs (e.g., construction) claims rates declined 12.8% for employers with enforcement activity compared to a 7.4% decline for those with no WISHA activity (P > 0.10). WISHA consultation activity was not associated with a greater decline in compensable claims rates (-2.3% for fixed sites and +3.5% for non-fixed sites). WISHA activity did not adversely affect worksite survivability through the study period. CONCLUSIONS: Enforcement inspections are significantly associated with decreasing compensable workers compensation claims rates especially for fixed site employers. We were unable to identify an association between consultation activities and decreasing claims rates.

Work-related burns in Washington State, 1994 to 1998.

This article describes an investigation of work-related burns in Washington State during 1994-1998. Workers' compensation data were used to describe the general characteristics of burn injuries, estimate industrial claims rates, and compare nonhospitalized and hospitalized burn cases. The completeness of workers' compensation data as a source for surveillance was evaluated. During 1994-1998, a total of 20,213 burn claims were accepted by the workers' compensation system. Hospitalized burn cases represented only 1.5% of burn claims but incurred 55% of the costs. In addition, workers' compensation data underestimated the frequency and rate of burns. Although workers' compensation claims rates decreased during 1994-1998, work-related burns remain a problem in Washington State. Several industries (e.g., roofing, foundries, and aluminum smelting) were identified as priorities for prevention of burn hospitalizations, which incur the greater cost and time loss.