Understanding Over-immunization in North Dakota's Adult Population.

CONTEXT: Over-immunization, or administration of excess doses of vaccine, is an understudied topic in immunization. Adult over-immunization is particularly understudied, so building a basic understanding of the sources and scope of over-immunization is necessary to direct action. OBJECTIVE: The aim of this evaluation was to quantify the extent of over-immunization in North Dakota's adult population from 2016 to 2021. DESIGN: Records for all pneumococcal, zoster, and influenza vaccines administered to adults in North Dakota were extracted from the North Dakota Immunization Information System (NDIIS) from January 1, 2016, through December 31, 2021. The NDIIS is a state-wide immunization registry that captures all childhood and most adult immunizations. SETTING: North Dakota. PARTICIPANTS: North Dakotan adults 19 years or older. MAIN OUTCOME MEASURE: The number and percentage of adults identified as over-immunized as well as the number and percentage of doses identified as an extra dose. RESULTS: Frequency of over-immunization was less than 3% for all vaccines over the 6-year period assessed. Pharmacies and private practices were the most common sources of over-immunization of adults. CONCLUSIONS: These data show that over-immunization is still an issue in North Dakota, although the percentage of the adult population impacted is low. Reducing over-immunization is worth pursuing but should be balanced with the importance of improving low immunization coverage rates in the state. Improving utilization of the NDIIS by adult providers can help prevent over-immunization and under-immunization alike.

Pharmacoeconomic, Medication Access, and Patient-Satisfaction Analysis of a Pharmacist-Managed VTE Clinic Compared to Primary Care Physician Outpatient Therapy.

Venous thromboembolism (VTE) is a common medical condition often treated with direct oral anticoagulants (DOACs). Current literature supports outpatient treatment of select, low-risk VTE patients by a pharmacist with DOACs; however, no studies exist to demonstrate if a pharmacist-managed VTE clinic provides financial benefit compared to physician-managed outpatient care. To compare the financial implications and patient satisfaction of pharmacist-managed VTE care versus outpatient VTE care by a primary care physician. A single-center retrospective chart review was conducted on all patients seen at a pharmacist-managed VTE clinic for safety and reimbursement outcomes between August 1, 2018 and July 31, 2019. These data points were used to assess the primary endpoint of net gain per patient visit and secondary outcomes, including patient satisfaction score. The primary outcome median (IQR) for net gain per visit was $16.57 (16.57, 16.57) for the pharmacist-managed group and $64.37 (47.04, 64.37) in the physician-managed group with a 95% CI of 39.13-47.80. The median cost to the organization per visit was $4.96 (4.96, 4.96) for the pharmacist-managed group and $39.41 (23.65, 39.41) for the physician managed group with a 95% CI of 26.57-34.45. Statistical difference was also found for a secondary outcome of percentage of days covered for the pharmacist-managed group compared to the physician managed group, median (IQR) 100% (76,100) vs 92.2% (67.2, 98.9) respectfully, with a p-value of 0.043. The pharmacist-managed VTE clinic, although financially sustainable, provides significantly less net revenue per patient than physician managed clinics, demonstrating the need for increased payer recognition for pharmacists.

Evaluation of Dosing Strategies of N-acetylcysteine for Acetaminophen Toxicity in Patients Greater than 100 Kilograms: Should the Dosage Cap Be Used?

INTRODUCTION: Acetaminophen is a commonly used analgesic and antipyretic, with the potential to cause significant injury when ingested in toxic amounts. Although the antidote n-acetylcysteine (NAC) is available, evidence supporting dose recommendations for patients weighing over 100 kg are lacking. We performed a retrospective, multi-center analysis to determine if a capped NAC dosing scheme is similar to a non-capped dosing scheme in patients weighing over 100 kg. METHODS: Between January 2009 and January 2016, we identified patients presenting to 12 different centers who were evaluated for acetaminophen poisoning treatment. Patients must have weighed greater than 100 kg and were evaluated and identified as needing treatment for acetaminophen-related poisoning with NAC. The primary outcome was occurrence of hepatic injury, defined as an AST or ALT ≥ 100 IU/L. Secondary endpoints included number of drug-related adverse events, occurrence of hepatotoxicity, cumulative NAC dose, regimen cost, length of hospital and intensive care unit stays, and in-hospital mortality. RESULTS: There were 83 patients identified as meeting the pre-specified inclusion and exclusion criteria. A capped NAC dosing scheme resulted in no difference in hepatic injury when compared to a non-capped regimen (49.4% vs 50%, p = 1.000). The capped dosage regimen was associated with a lower cumulative dose (285.2 mg/kg vs 304.6 mg/kg, p < 0.001) and cost. No other statistically significant differences were identified among the secondary endpoints. CONCLUSION: A capped NAC dosing scheme was not associated with higher rates of hepatic injury or hepatotoxicity in obese patients in the setting of acetaminophen poisoning when compared to a non-capped regimen. Further research is needed to verify these results.

Facility-Wide Testing for SARS-CoV-2 in Nursing Homes - Seven U.S. Jurisdictions, March-June 2020.

Undetected infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) contributes to transmission in nursing homes, settings where large outbreaks with high resident mortality have occurred (1,2). Facility-wide testing of residents and health care personnel (HCP) can identify asymptomatic and presymptomatic infections and facilitate infection prevention and control interventions (3-5). Seven state or local health departments conducted initial facility-wide testing of residents and staff members in 288 nursing homes during March 24-June 14, 2020. Two of the seven health departments conducted testing in 195 nursing homes as part of facility-wide testing all nursing homes in their state, which were in low-incidence areas (i.e., the median preceding 14-day cumulative incidence in the surrounding county for each jurisdiction was 19 and 38 cases per 100,000 persons); 125 of the 195 nursing homes had not reported any COVID-19 cases before the testing. Ninety-five of 22,977 (0.4%) persons tested in 29 (23%) of these 125 facilities had positive SARS-CoV-2 test results. The other five health departments targeted facility-wide testing to 93 nursing homes, where 13,443 persons were tested, and 1,619 (12%) had positive SARS-CoV-2 test results. In regression analyses among 88 of these nursing homes with a documented case before facility-wide testing occurred, each additional day between identification of the first case and completion of facility-wide testing was associated with identification of 1.3 additional cases. Among 62 facilities that could differentiate results by resident and HCP status, an estimated 1.3 HCP cases were identified for every three resident cases. Performing facility-wide testing immediately after identification of a case commonly identifies additional unrecognized cases and, therefore, might maximize the benefits of infection prevention and control interventions. In contrast, facility-wide testing in low-incidence areas without a case has a lower proportion of test positivity; strategies are needed to further optimize testing in these settings.

Comparing vaccination coverage of American Indian children with White children in North Dakota.

OBJECTIVES: The objective of this study was to compare immunization rates of American Indian (AI) and White children in North Dakota and identify disparities in immunization rates by race. STUDY DESIGN: The study design was to assess immunization coverage rates by race using immunization information system (IIS) data. METHODS: Data from the North Dakota Immunization Information System (NDIIS) for children aged 19-35 months during quarter four of 2014, 2015, 2016, 2017 and 2018 were used to assess and compare immunization coverage rates for AI and White children. NDIIS data were also analyzed for timeliness of vaccine administration, Vaccines for Children (VFC) status, and the number of doses still needed to be considered up to date (UTD) with routinely recommended immunizations. RESULTS: In quarter four of 2018 (Q4 2018), only 60% of AI children were UTD with the complete 4:3:1:3:3:1:4 vaccine series compared with 74.5% of White children of the same age. Fewer VFC-eligible AI children (59.1%) are UTD than VFC-eligible White children (68.7%). AI children were also more likely to be delayed at each immunization milestone, leading to fewer AI children to be UTD by 19 to 35 months of age. CONCLUSIONS: This study shows that there is a racial disparity in immunization coverage rates between AI and White children in North Dakota. Public health and private healthcare providers should work to identify and address barriers to vaccination and should implement strategies to increase immunization rates for AI children.

COVID-19 in Correctional and Detention Facilities - United States, February-April 2020.

An estimated 2.1 million U.S. adults are housed within approximately 5,000 correctional and detention facilities† on any given day (1). Many facilities face significant challenges in controlling the spread of highly infectious pathogens such as SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Such challenges include crowded dormitories, shared lavatories, limited medical and isolation resources, daily entry and exit of staff members and visitors, continual introduction of newly incarcerated or detained persons, and transport of incarcerated or detained persons in multiperson vehicles for court-related, medical, or security reasons (2,3). During April 22-28, 2020, aggregate data on COVID-19 cases were reported to CDC by 37 of 54 state and territorial health department jurisdictions. Thirty-two (86%) jurisdictions reported at least one laboratory-confirmed case from a total of 420 correctional and detention facilities. Among these facilities, COVID-19 was diagnosed in 4,893 incarcerated or detained persons and 2,778 facility staff members, resulting in 88 deaths in incarcerated or detained persons and 15 deaths among staff members. Prompt identification of COVID-19 cases and consistent application of prevention measures, such as symptom screening and quarantine, are critical to protecting incarcerated and detained persons and staff members.

Using the North Dakota IIS to Assess the Response of Health Care Providers to the ACIP Recommendation for Tdap Vaccination During Pregnancy.

OBJECTIVES: To evaluate the response of North Dakota health care providers to follow the recommendation set forth by the Advisory Committee on Immunization Practices (ACIP) to administer a dose of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine to women during each pregnancy using the North Dakota Immunization Information System (NDIIS). METHODS: Data from the NDIIS for North Dakota infants born during calendar years 2013-2018 were extracted. Mother's name was taken from the newborn records and matched to NDIIS female client records to identify the population of mothers of newborns who would have been recommended to receive Tdap during their pregnancy. Doses of Tdap vaccine administered after October 1, 2012, were extracted from the NDIIS, and the dose records were matched back to the mother's record. The time from baby's birthdate back to the doses of Tdap vaccine administered to the mother was measured to find any doses that would have been administered during pregnancy. RESULTS: The percentage of women receiving Tdap vaccine during pregnancy increased from 31.5% in 2013 to 60.6% in 2018. Of those women who received Tdap during pregnancy, 94% received the vaccine during the ACIP-recommended interval of 27 to 36 weeks' gestation, using the assumption that all babies were born at 40 weeks' gestation. CONCLUSIONS: North Dakota health care providers have responded positively to the recommendation of the ACIP to administer a dose of Tdap vaccine to women during each pregnancy and have increased their administration of the vaccine to their patients.

Enforcement Associated With Higher School-Reported Immunization Rates.

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

The impact of electronic health record (EHR) interoperability on immunization information system (IIS) data quality.

Objectives: To evaluate the impact of electronic health record (EHR) interoperability on the quality of immunization data in the North Dakota Immunization Information System (NDIIS). Methods: NDIIS doses administered data was evaluated for completeness of the patient and dose-level core data elements for records that belong to interoperable and non-interoperable providers. Data was compared at three months prior to electronic health record (EHR) interoperability enhancement to data at three, six, nine and twelve months post-enhancement following the interoperability go live date. Doses administered per month and by age group, timeliness of vaccine entry and the number of duplicate clients added to the NDIIS was also compared, in addition to, immunization rates for children 19 - 35 months of age and adolescents 11 - 18 years of age. Results: Doses administered by both interoperable and non-interoperable providers remained fairly consistent from pre-enhancement through twelve months post-enhancement. Comparing immunization rates for infants and adolescents, interoperable providers had higher rates both pre- and post-enhancement than non-interoperable providers for all vaccines and vaccine series assessed. The overall percentage of doses entered into the NDIIS within one month of administration varied slightly between interoperable and non-interoperable providers; however, there were significant changes between the percentage of doses entered within one day and within one week with the percentage entered within one day increasing and within one week decreasing with interoperability. The number of duplicate client records created by interoperable providers increased from 94 duplicates pre-enhancement to 10,552 at twelve months post-enhancement, while the duplicates from non-interoperable providers only increased from 300 to 637 over the same period. Of the 40 core data elements in the NDIIS, there was some difference in completeness between the interoperable versus non-interoperable providers. Only middle name, sex, county, phone number, mother's maiden name, vaccine manufacturer, lot number and expiration date were significantly (>=5%) different between the two provider groups. Conclusions: Interoperability with provider EHRs has had an impact on NDIIS data quality. Timeliness of data entry has improved and overall doses administered have remained fairly consistent, as have the immunization rates for the providers assessed. There are more technical and non-technical interventions that will need to be accomplished by NDIIS staff and vendor to help reduce the negative impact of duplicate record creation, as well as, data completeness.