Anxiety and depression among women living with HIV in Kazakhstan.

An increase in new HIV infections among women in Kazakhstan has motivated efforts to improve access to comprehensive health services. This study estimates anxiety and depression frequency among women seeking HIV services. A cross-sectional survey was administered to women seen at the Almaty AIDS Center. Bivariable analyses (e.g., Chi-square, means with 95% confidence intervals) were performed to assess the relationship between anxiety (score of 10 or more on the Generalized Anxiety Disorder-7 Scale (GAD-7)), major depression (Patient Health Questionnaire 8 (PHQ-8)), and comorbid anxiety and major depression with sociodemographic characteristics, health functioning, and medication history. Of the 410 participants, 62 (15.1%) had a GAD-7 ≥ 10; 52 (12.7%) met major depression criteria; 35 (8.5%) met both criteria, and 79 (19.3%) met GAD-7, major depression, or both criteria. Women reporting depression or anxiety were more likely to lack food security (p < 0.01), not finish secondary school (p < 0.01), speak Russian at home (p < 0.01), perceive their health to be poor (p < 0.01), and report poorer physical and mental health functioning (p < 0.05). No medications approved for the treatment of anxiety or depression were reported. The considerable number of women reporting major depression and anxiety symptoms suggests a need for improving access to mental health care.

A comparison of risk factors for osteo- and rheumatoid arthritis using NHANES data.

Osteoarthritis and rheumatoid arthritis are both diseases of joints, but they have very different etiologies. Osteoarthritis is a disease assumed to result from wear and tear over time, whereas rheumatoid arthritis is an autoimmune disease where the body's immune system attacks joint tissues. Using NHANES data (1999-2015), we have compared the influence of age, sex, ethnicity, body mass index and smoking on these two very different forms of arthritis. Incidence of both increases with age and are more frequent in females than males. There is little apparent difference between osteoarthritis and rheumatoid arthritis in women of normal as comparted to overweight, but both are more frequent in obese women, especially those over the age of 60. While osteoarthritis is more frequent in whites, blacks have more rheumatoid arthritis, and Hispanics show an intermediate prevalence. Smoking significantly increased the incidence of both osteoarthritis and rheumatoid arthritis in women, but increased prevalence of only RA in men. There was no effect of smoking on OA prevalence in males. It is remarkable that two diseases of joints, which have quite different causes, should have so many commonalities. The differences that exist appear to be due to a combination of inflammatory markers and access to health care.

Dealing with highly skewed hospital length of stay distributions: The use of Gamma mixture models to study delivery hospitalizations.

The increased focus on addressing severe maternal morbidity and maternal mortality has led to studies investigating patient and hospital characteristics associated with longer hospital stays. Length of stay (LOS) for delivery hospitalizations has a strongly skewed distribution with the vast majority of LOS lasting two to three days in the United States. Prior studies typically focused on common LOSs and dealt with the long LOS distribution tail in ways to fit conventional statistical analyses (e.g., log transformation, trimming). This study demonstrates the use of Gamma mixture models to analyze the skewed LOS distribution. Gamma mixture models are flexible and, do not require data transformation or removal of outliers to accommodate many outcome distribution shapes, these models allow for the analysis of patients staying in the hospital for a longer time, which often includes those women experiencing worse outcomes. Random effects are included in the model to account for patients being treated within the same hospitals. Further, the role and influence of differing placements of covariates on the results is discussed in the context of distinct model specifications of the Gamma mixture regression model. The application of these models shows that they are robust to the placement of covariates and random effects. Using New York State data, the models showed that longer LOS for childbirth hospitalizations were more common in hospitals designated to accept more complicated deliveries, across hospital types, and among Black women. Primary insurance also was associated with LOS. Substantial variation between hospitals suggests the need to investigate protocols to standardize evidence-based medical care.

Adherence to Timely Vaccinations in the United States.

OBJECTIVES: To estimate (1) the proportion of children not adhering to the Advisory Committee on Immunization Practices (ACIP) recommended early childhood immunization schedule and (2) associations between schedule adherence, sociodemographic characteristics, and up-to-date immunization status by 19 to 35 months of age. METHODS: We used 2014 National Immunization Survey provider-verified vaccination data to classify vaccination patterns as "recommended" (ie, in line with ACIP dose- and age-specific recommendations), "alternate" (ie, in line with either limiting the number of shots per visit or skipping at least 1 vaccine series), or "unknown or unclassifiable" (ie, not in line with ACIP recommendations or clearly limiting shots per visit or vaccine series). We evaluated the association between vaccination patterns and up-to-date status for all ACIP-recommended vaccinations (including rotavirus and hepatitis A vaccines) using Poisson regression. RESULTS: The majority of children's patterns were classified as "recommended" (63%), with 23% and 14% following alternate or unknown or unclassifiable patterns, respectively; 58% of children were up-to-date with all ACIP-recommended immunizations by 19 to 35 months. Not being up-to-date was associated with alternate (prevalence ratio = 4.2, 95% confidence interval: 3.9-4.5) and unknown or unclassifiable (prevalence ratio = 2.4, 95% confidence interval: 2.2-2.7) patterns. CONCLUSIONS: High vaccine coverage by 19 to 35 months of age may miss nonadherence to the recommended immunization schedule in the first 18 months of life, leaving children vulnerable to preventable diseases. With more than one-third of US children not following the ACIP schedule, targeted interventions are needed to minimize vaccine delays and disease susceptibility.

Correlation between hospital finances and quality and safety of patient care.

BACKGROUND: Hospitals under financial pressure may struggle to maintain quality and patient safety and have worse patient outcomes relative to well-resourced hospitals. Poor predictive validity may explain why previous studies on the association between finances and quality/safety have been equivocal. This manuscript employs principal component analysis to produce robust measures of both financial status and quality/safety of care, to assess our a priori hypothesis: hospital financial performance is associated with the provision of quality care, as measured by quality and safety processes, patient outcomes, and patient centered care. METHODS: This 2014 cross-sectional study investigated hospital financial condition and hospital quality and safety at acute care hospitals. The hospital financial data from the Centers for Medicare and Medicaid Services (CMS) cost report were used to develop a composite financial performance score using principal component analysis. Hospital quality and patient safety were measured with a composite quality/safety performance score derived from principal component analysis, utilizing a range of established quality and safety indicators including: risk-standardized inpatient mortality, 30-day mortality, 30-day readmissions for select conditions, patient safety indicators from inpatient admissions, process of care chart reviews, CMS value-based purchasing total performance score and patient experience of care surveys. The correlation between the composite financial performance score and the composite quality/safety performance score was calculated using linear regression adjusting for hospital characteristics. RESULTS: Among the 108 New York State acute care facilities for which data were available, there is a clear relationship between hospital financial performance and hospital quality/safety performance score (standardized correlation coefficient 0.34, p<0.001). The composite financial performance score is also positively associated with the CMS Value Based Purchasing Total Performance Score (standardized correlation coefficient 0.277, p = 0.002); while it is negatively associated with 30 day readmission for all outcomes (standardized correlation coefficient -0.236, p = 0.013), 30-day readmission for congestive heart failure (standardized correlation coefficient -0.23, p = 0.018), 30 day readmission for pneumonia (standardized correlation coefficient -0.209, p = 0.033), and a decrease in 30-day mortality for acute myocardial infarction (standardized correlation coefficient -0.211, p = 0.027). Used alone, operating margin and total margin are poor predictors of quality and safety outcomes. CONCLUSIONS: Strong financial performance is associated with improved patient reported experience of care, the strongest component distinguishing quality and safety. These findings suggest that financially stable hospitals are better able to maintain highly reliable systems and provide ongoing resources for quality improvement.

Vaccination perspectives among adolescents and their desired role in the decision-making process.

Background: To assess the knowledge and attitudes of middle school students toward vaccination, we measured their understanding of vaccine safety and effectiveness, expectations for communication with heath care providers, and their desired role in the vaccination decision-making process. Methods: A cross-sectional, self-administered survey was conducted among seventh and eighth grade students in a middle school in Upstate New York. Bivariate analyses were conducted to identify differences in perspective by gender, grade, and attitudes toward vaccination. Results: Of 346 students attending class, 336 (97.1%) participated. The majority of respondents were White (71.3%) and 11 to 13 years of age (78.2%). Boys were significantly more likely than girls to perceive vaccines to be very safe (48.4% vs 30.2%, p < 0.01) and very effective (49.7% vs 29.0%, p < 0.01). Approximately one-third of adolescents reported having a say in the decision to be vaccinated and a quarter of students expressed a desire for specific information about vaccines. Conclusions: This study found that young adolescents in a nonurban area of Upstate New York were generally marginalized in the vaccine decision-making process yet third of them indicated an interest in how vaccines work and a desire to participate in healthcare decisions. Interventions to improve vaccine uptake among adolescents should capitalize on this desire to understand vaccine safety, effectiveness and mechanism of action.

Psychological features of abstinent heroin users before and after rehabilitation in Saint Petersburg, Russia.

OBJECTIVE: The objective of the study was to describe psychological features of abstinent heroin users undergoing rehabilitation in Saint Petersburg, Russia. Study subjects (n = 197) were recruited prospectively at the time of their admission to rehabilitation between March 2010 and May 2011 at 7 inpatient opiate addiction rehabilitation centers in Saint-Petersburg and neighboring regions, Russia. The centers provided varying rehabilitation programs; 6 of them were religious centers. Socio-demographic information and self-reported HIV status were collected. Personality profiles and severity of drug-associated problems were estimated before and after rehabilitation using the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), and the Addiction Severity Index (ASI). RESULTS: Thirty-three (17%) subjects dropped out before completing rehabilitation (non-completers). All subjects (completers and non-completers) had psychopathological personality profiles according to MMPI-2. These profiles were refractory to clinically significant improvement after rehabilitation, although some statistically significant changes toward improvement were observed. ASI scores showed statistically and clinically significant improvements after rehabilitation on all scales. Participants in longer-term versus shorter-term rehabilitation programs showed similar changes in their pre- and post-rehabilitation MMPI-2 and ASI scores. Our results suggest that unmet psychiatric needs should be addressed to potentially improve treatment completion in this population.

Untreated depression among persons living with human immunodeficiency virus in Kazakhstan: A cross-sectional study.

BACKGROUND: In Kazakhstan, scarce official prevalence data exists for mood disorders. This study investigates the occurrence of depressive symptoms among people living with HIV/AIDS (PLWHA), and the relationship between depressive symptoms, HIV treatment initiation and antiretroviral treatment (ART) adherence. METHODS: A cross-sectional study was conducted among patients seen at the Almaty AIDS Center between April and December 2013. Two data sources were used: 1) self-administered survey that included the Patient Health Questionnaire (PHQ-9) to capture depression symptoms and 2) medical record review. Two primary outcomes were evaluated with log-binomial models and Fisher's exact test: the relationship between depression symptoms and 1) HIV treatment group, and 2) HIV adherence. RESULTS: Of the 564 participants, 9.9% reported symptoms consistent with a depressive disorder. None had received treatment for depression. Among those not on ART, a relationship between depressive symptoms and low CD4 counts (≤ 350 cells/mm3) was evident (7.1% for CD4 ≤ 350 cells/mm3 vs. 0.9% for CD4 > 350 cells/mm3, p = 0.029). In multivariable analysis, a higher prevalence of depressive symptoms was statistically associated with ART treatment, positive hepatitis C virus (HCV) status, and being unmarried. For those taking ART, treatment adherence was not statistically associated with a lower prevalence of depressive symptoms (12.5% vs 20.0%, p = 0.176); limited power may have impacted statistical significance. CONCLUSIONS: Untreated depression was found among PLWHA suggesting the need to evaluate access to psychiatric treatment. A collaborative strategy may be helpful to optimize HIV treatment outcomes.

Knowledge, attitudes and practice survey on blood-borne diseases among dental health care workers in Georgia.

INTRODUCTION: In Georgia limited data exists about awareness of blood borne-diseases among dental health care workers (DHCW). METHODOLOGY: To assess DHCW knowledge, attitudes and practices related to infection control practice guidelines designed to limit transmission of blood-borne diseases, a cross-sectional study was conducted. All respondents were asked to voluntarily complete a self-administered questionnaire. Doctors of Dental Medicine, nurses, and dental residents were recruited from 13 private and governmental dental units in three large Georgian cities: Tbilisi (the capital city), Batumi (Western Georgia) and Rustavi (Eastern Georgia). RESULTS: Of 244 DHCWs recruited, 196 (80%) agreed to participate. Nearly 42% DHCWs did not know the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) in Georgia. Knowledge about risk factors for transmission of human immunodeficiency virus (HIV), HCV and HBV was low; correct response proportions among all DHCWs were 45.3%, 37.9% and 34.2% for these pathogens, respectively. The 59.7% of DHCWs were uninformed about post-exposure prophylaxis for HIV. Only 37.3% reported being well informed on infection control guidelines. Nearly all (95.6%) DHCWs expressed interest in receiving additional education on occupational transmission of blood-borne pathogens. CONCLUSIONS: Overall, the study suggests DHCWs are aware they have insufficient knowledge of universal precautions. There is a need for developing a continuous education program that is accessible to practicing DHCWs.

Relationship between day 1 and day 2 Vancomycin area under the curve values and emergence of heterogeneous Vancomycin-intermediate Staphylococcus aureus (hVISA) by Etest® macromethod among patients with MRSA bloodstream infections: a pilot study.

BACKGROUND: In vitro data suggests that suboptimal initial vancomycin exposure may select for heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) infections. However, no clinical studies have evaluated the relationship between initial vancomycin exposure and emergence of hVISA. This pilot study seeks to assess the relationship between day 1 and day 2 vancomycin area under the curve (AUC) and emergence of hVISA bloodstream infections (BSIs) by Etest® macromethod among patients with a non-hVISA BSI at baseline. METHODS: This was a retrospective cohort study of patients with methicillin-resistant Staphylococcus aureus (MRSA) BSIs at Albany Medical Center Hospital (AMCH) between January 2005 and June 2009. The vancomycin AUC exposure variables on day 1 (AUC0-24h) and day 2 (AUC24-48h) were estimated using the maximal a posteriori probability (MAP) procedure in ADAPT 5. RESULTS: There were 238 unique episodes of MRSA BSIs during the study period, 119 of which met inclusion criteria. Overall, hVISA emerged in 7/119 (5.9%) of patients. All 7 cases of hVISA involved patients who did not achieve area under the curve over broth microdilution minimum inhibitory concentration (AUC0-24h/MICBMD) ratio of 521 or an AUC24-48h/MICBMD ratio of 650. No associations between other day 1 and day 2 AUC variables and emergence of hVISA were noted. CONCLUSIONS: Although more data are needed to draw definitive conclusions, these findings suggest that hVISA emergence among patients with non-hVISA MRSA BSIs at baseline may be partially explained by suboptimal exposure to vancomycin in the first 1 to 2 days of therapy. At a minimum, these findings support further study of the relationship between initial vancomycin exposure and hVISA emergence among patients with MRSA BSIs in a well-powered, multi-center, prospective trial.

Severe maternal morbidity: A population-based study of an expanded measure and associated factors.

Severe maternal morbidity conditions such as sepsis, embolism and cardiac arrest during the delivery hospitalization period can lead to extended length of hospital stays, life-long maternal health problems, and high medical costs. Most importantly, these conditions also contribute to the risk of maternal death. This population-based observational study proposed and evaluated the impact of expanding the Centers for Disease Control and Prevention (CDC) measure of severe maternal morbidity by including additional comorbidities and intensive care admissions during delivery hospitalizations and examined associated factors. A New York State linked hospitalization and birth record database was used. Study participants included all New York State female residents, ages 10 to 55 years, who delivered a live infant in a New York acute care hospital between 2008 and 2013, inclusive. Incidence trends for both severe maternal morbidity measures were evaluated longitudinally. Associations between covariates and the two severe maternal morbidity measures were examined with logistic regression models, solved using generalized estimating equations and stratified by method of delivery. The New York expanded severe maternal morbidity measure identified 34,478 cases among 1,352,600 hospital deliveries (estimated incidence 2.55%) representing a 3% increase in the number of cases compared to the CDC measure. Both estimates increased over the study period (p<0.001). Covariates with an odds ratio > 1.5 included most measured comorbidities (e.g., pregnancy-induced hypertension, placentation disorder), multiple births, preterm birth, no prenatal care, hospitalization prior to delivery, higher levels of perinatal care birthing facilities and race/ethnicity. Expanding the measure for severe maternal morbidity during delivery to capture intensive care admissions provides a more sensitive estimate of disease burden. Perinatal regionalization in New York appears effective in routing high risk pregnancies to higher levels of perinatal care birthing facilities.

Developing effective HIV education in Central Asia: a cross-sectional study among Kazakh medical students.

INTRODUCTION: The HIV epidemic continues to expand in Central Asia, bridging from injecting drug users to the general population, largely through heterosexual transmission. This study describes medical students' attitudes and behaviours regarding HIV and sexual practices in response to recently introduced HIV curriculum. METHODOLOGY: Medical students in Almaty, Kazakhstan, were invited to participate in a cross-sectional survey between April and November, 2013. The survey assessed participant's risk behaviours (e.g., injecting drug use, condom use), concerns related to HIV infection risk (e.g., medical care exposures, personal behaviours), and ability to identify HIV-positive individuals without asking their status. Bivariate analyses (Chi-square test or Fisher's exact test) and multivariate analysis (log-binomial regression) were conducted. RESULTS: Of 647 medical students, the majority were female (82.2%) and single (92.8%) with a median age of 21-22 years. Sexual activity was reported by 176 (27.2%); males were substantially more likely to report sexual activity (74.8% males vs. 16.9% females, p <.0001). The majority of sexually active medical students (65.6% and 68.3% males and females, respectively) believe they can determine if their partner is HIV-positive without asking or seeking a laboratory test. This proportion is much higher (92.6%) among married or cohabitating women. No association between perceived ability to ascertain HIV status and condom use was identified. CONCLUSIONS: The medical students in our study had a relatively naïve perception of HIV risk, and their knowledge of risk did not translate to appropriate precautionary behaviours. Much work remains if the epidemic in Central Asia is to be contained.

Postpartum Loss to HIV Care and HIV Viral Suppression among Previously Diagnosed HIV-Infected Women with a Live Birth in New York State.

Mother-to-child-transmission of HIV in the United States has been greatly reduced, with clear benefits for the child. However, little is known about factors that predict maternal loss to HIV care in the postpartum year. This retrospective cohort study included 980 HIV-positive women, diagnosed with HIV at least one year before pregnancy, who had a live birth during 2008-2010 in New York State. Women who did not meet the following criterion in the 12 months after the delivery-related hospital discharge were considered to be lost to HIV care: two or more laboratory tests (CD4 or HIV viral load), separated by at least 90 days. Adjusted relative risks (aRR) and 95% confidence intervals (CI) for predictors of postpartum loss to HIV care were identified with Poisson regression, solved using generalized estimating equations. Having an unsuppressed (>200 copies/mL) HIV viral load in the postpartum year was also evaluated. Overall, 24% of women were loss to HIV care during the postpartum year. Women with low participation in HIV care during preconception were more likely to be lost to HIV care during the postpartum year (aRR: 2.70; 95% CI: 2.09-3.49). In contrast, having a low birth weight infant was significantly associated with a decreased likelihood of loss to HIV care (aRR: 0.72; 95% CI: 0.53-0.98). While 75% of women were virally suppressed at the last viral load before delivery only 44% were continuously suppressed in the postpartum year; 12% had no viral load test reported in the postpartum year and 44% had at least one unsuppressed viral load test. Lack of engagement in preconception HIV-related health care predicts postpartum loss to HIV care for HIV-positive parturient women. Many women had poor viral control during the postpartum period, increasing the risk of disease progression and infectivity.

Postpartum Human Immunodeficiency Virus Care Among Women Diagnosed During Pregnancy.

OBJECTIVE: To identify factors associated with continuity of care and human immunodeficiency virus (HIV) virologic suppression among postpartum women diagnosed with HIV during pregnancy in New York State. METHODS: This retrospective cohort study was conducted among 228 HIV-infected women diagnosed during pregnancy between 2008 and 2010. Initial receipt of HIV-related medical care (first CD4 or viral load test after diagnosis) was evaluated at 30 days after diagnosis and before delivery. Retention in care (2 or more CD4 or viral load tests, 90 days or greater apart) and virologic suppression (viral load 200 copies/mL or less) were evaluated in the 12 months after hospital discharge. RESULTS: Most women had their initial HIV-related care encounter within 30 days of diagnosis (74%) and before delivery (87%). Of these women, 70% were retained in the first year postpartum. Women waiting more than 30 days for their initial HIV-related care encounter were more likely diagnosed in the first (29%) compared with the third (11%) trimester and were of younger (younger than 25 years, 32%) compared with older (35 years or older, 13%) age. Loss to follow-up within the first year was significantly greater among women diagnosed in the third compared with the first trimester (adjusted relative risk 2.21, 95% confidence interval [CI] 1.41-3.45) and among women who had a cesarean compared with vaginal delivery (adjusted relative risk 1.76, 95% CI 1.07-2.91). Of the 178 women with one or more HIV viral load test in the first year postpartum, 58% had an unsuppressed viral load. CONCLUSION: Despite the high proportion retained in care, many women had poor postpartum virologic control. Robust strategies are needed to increase virologic suppression among newly diagnosed postpartum HIV-infected women.

Affluence as a predictor of vaccine refusal and underimmunization in California private kindergartens.

BACKGROUND: Non-medical vaccine exemption rates in California private schools far exceed those of public schools, but little is known about specific factors which may be associated with high exemption rates in private schools. METHODS: The percent of personal-belief exemptions (PBEs) among California public and private kindergartens were computed for 2000-2001 to 2014-2015 academic years. For the 2014-2015 academic year, a random sample of private schools was selected to investigate associations between kindergarten characteristics (tuition amount, religious affiliation) and vaccine profile (non-medical vaccine exemptions, vaccine coverage). RESULTS: The proportion of private kindergartens reporting 5% or more children with PBEs increased from 9% (2000-2001) to 34% (2013-2014), followed by a small decrease in 2014-2015 (31%). Overall, 93.7% (565/605) of kindergartens sampled in 2014-2015 had data available. Very high PBE levels (>20%) were seen among secular and non-Catholic, Christian kindergartens but not Roman Catholic, Jewish or Islamic kindergartens. However, the majority of schools at all tuition levels had fewer than 5% of children with a PBE. Kindergartens with an annual tuition of $10,000 or more were over twice as likely to have 20% or more children with PBEs than kindergartens with a lower tuition (p<.01). Additionally, the conditional admission proportions for kindergartens with tuitions of $10,000 or more were 39% compared to 22% for less expensive kindergartens (p<.01). Only about half of all private kindergartens had 95% coverage of the MMR (49%) and pertussis-containing vaccines (51%). CONCLUSIONS: School-entry vaccination requirements are critical to preventing outbreaks of vaccine preventable diseases in the US. Nonmedical exemptions increased between the 2000-2001 and 2014-2015 academic years and appear to be associated with affluence, raising social justice concerns.

Relationship between vitamin D and human immunodeficiency virus (HIV) viral load among HIV-infected patients in Kazakhstan.

INTRODUCTION: Human immunodeficiency virus (HIV) is associated with inflammation. An association between vitamin D deficiency and inflammation also exists. Our study attempts to examine whether there may be a relationship between vitamin D and HIV viral load (HIV RNA) by: 1) characterizing the distribution of 25-hydroxyvitamin D (25-OHD), and 2) determining if 25-OHD is independently associated with HIV RNA. METHODOLOGY: A cross-sectional study among HIV-infected adults was conducted. Demographics, clinical / social / HIV characteristics and data on antiretroviral therapy were collected by questionnaire, medical records and laboratory testing. All patients provided blood samples. Bivariate and multivariate analyses were conducted to quantify the relationship between vitamin D and HIV RNA. RESULTS: Among the 564 patients, the median (interquartile range, IQR) 25-OHD value was 24.42 (16.22 - 34.10) ng/mL. The mean (standard deviation, SD) log-HIV RNA was 3.51 (1.11) copies/mL. There were 304 patients (53.9%) with an undetectable HIV RNA (< 500 copies/mL). In the bivariate analyses, no differences were observed between patients with and without an undetectable HIV RNA in mean (SD) 25-OHD, 25-OHD insufficiency (< 30 ng/mL), or 25-OHD deciles. In the log-binomial regression analyses, there was no association between 25-OHD and an undetectable HIV RNA (prevalence ratio: 1.00, 95% confidence interval: 0.99 - 1.01, p = 0.67). CONCLUSIONS: No relationship was observed between 25-OHD and HIV RNA among HIV-infected patients in Kazakhstan.

Incidence and Clinical Predictors of Nonresponse to Hepatitis B Vaccination among Patients Receiving Hemodialysis: Importance of Obesity.

OBJECTIVES: The objectives of this study were to quantify the incidence of hepatitis B virus (HBV) vaccine nonresponse and identify clinical characteristics associated with vaccine nonresponse. METHODS: A retrospective cohort study was conducted among patients undergoing hemodialysis (HD) receiving the HBV vaccine. Study inclusion criteria were age 18 years and older, receipt of HD treatment for ≥ 1 month, receipt of ≥ 1 dose of HBV vaccine, availability of anti-HB surface antibody (anti-HBs) laboratory values ≥ 2 weeks after last HBV vaccine, and prevaccine anti-HBs value <10 mIU/mL. Clinical data were abstracted from patients' medical records. The outcome of interest was vaccine nonresponse, defined as anti-HBs values <10 IU/mL. Multivariate regression was used to determine variables independently associated with vaccine nonresponse. Kaplan-Meier estimates were constructed for determining HBV vaccine response retention. RESULTS: Of the 119 patients evaluated, nonresponse was observed in 58%. Mean age at first vaccination for vaccine responders and nonresponders was 58.8 ± 16.5 and 65.9 ± 14.1 (P = 0.01), respectively. Variables independently associated with nonresponse were age 58 years and older (adjusted relative risk, 95% confidence interval 1.62, 1.06-2.46; P = 0.02) and body mass index ≥ 36.4 kg/m(2) (adjusted relative risk, 95% confidence interval 1.66, 1.34-2.07; P < 0.01). Among the 50 patients who achieved an initial vaccine response, 26% were not able to maintain vaccine response upon subsequent anti-HBs measurement. The probability of retaining vaccine response over time was significantly modified by body mass index ≥ 25 kg/m(2). CONCLUSIONS: The frequency of nonresponse to the HBV vaccine was high among patients undergoing HD. The clinical covariates most predictive of vaccine nonresponse were advanced age at the time of vaccination and excess body weight.

Seroprevalence and awareness of human papillomavirus infection and cervical cancer screening results among reproductive-aged Georgian women.

INTRODUCTION: As is the case in many developing countries, more than half of the new cervical cancer cases in Georgia are late-stage diagnoses, thus reducing the opportunity for effective treatment. A state cancer screening programme was launched in Tbilisi in 2006; 5 years later the programme had expanded to other regions in Georgia. METHODS: This study was designed to estimate awareness about human papillomavirus (HPV), cervical cancer screening, the HPV vaccine, and the seroprevalence of HPV infection among reproductive-aged Georgian women. Study participants were recruited from four women's consultation centres in different regions of Georgia. Data were collected through interviewer-administered questionnaires and HPV seroprevalence was assessed for HPV types 6/11/16/18. RESULTS: Of the 500 study participants, 52.0% were aware of HPV and 36.4% stated that the main cause of cervical cancer is HPV. Of those aware of HPV, 78% reported attending for cervical cancer screening at least once during their lifetime. Half (50.8%) of all respondents were unaware of the HPV vaccine. Of the women who agreed to be tested for anti-HPV antibodies (n=317), 21.1% were positive. Women reporting no condom use were more likely to have HPV antibodies (prevalence ratio 2.77; 95% confidence interval 1.79-4.27). Awareness of cervical cancer screening was significantly associated with HPV seropositivity. With multivariate analysis, both absence of condom use and lack of knowledge about cervical cancer screening were independently associated with HPV seropositivity. CONCLUSION: More comprehensive public awareness campaigns should be developed to raise awareness about HPV screening and prevention.

Low uptake of influenza vaccine among university students: evaluating predictors beyond cost and safety concerns.

INTRODUCTION: Annual influenza vaccine coverage for young adults (including college students) remains low, despite a 2011 US recommendation for annual immunization of all people 6 months and older. College students are at high risk for influenza morbidity given close living and social spaces and extended travel during semester breaks when influenza circulation typically increases. We evaluated influenza vaccine uptake following an on-campus vaccine campaign at a large, public New York State university. METHODS: Consecutive students visiting the University Health Center were recruited for a self-administered, anonymous, written survey. Students were asked about recent influenza vaccination, barriers to influenza vaccination, and willingness to get vaccinated to protect other vulnerable individuals they may encounter. Frequencies and proportions were evaluated. RESULTS: Of 653 students approached, 600 completed surveys (92% response proportion); respondents were primarily female (61%) and non-Hispanic white (59%). Influenza vaccine coverage was low (28%). Compared to coverage among non-Hispanic white students (30%), coverage was similar among Hispanic (30%) and other race/ethnicity students (28%) and lowest among non-Hispanic black students (17%). Among the unvaccinated, the most commonly selected vaccination barriers were "Too lazy to get the vaccine" (32%) and "Don't need the vaccine because I'm healthy" (29%); 6% of unvaccinated students cited cost as a barrier. After being informed that influenza vaccination of young, healthy people can protect other vulnerable individuals (e.g., infants, elderly), 71% of unvaccinated students indicated this would increase their willingness to get vaccinated. CONCLUSIONS: Influenza vaccine uptake among college students is very low. While making vaccine easily obtained may increase vaccine uptake, college students need to be motivated to get vaccinated. Typically healthy students may not perceive a need for influenza vaccine. Education about vaccinating healthy individuals to prevent the spread of influenza to close contacts, such as vulnerable family members, may provide this motivation to get vaccinated.