Assessing COVID-19 Vaccine Hesitancy and Trust in Home Health Workers in New York City: A Pilot Study.

OBJECTIVE: This study aimed to identify characteristics surrounding COVID-19 vaccine hesitancy and trust in home health workers (HHWs) in New York City. METHODS: Data were collected from HHWs through focus group sessions conducted via Zoom. We developed a facilitator guide using the 5C Scale, a validated psychometric tool for assessing vaccine hesitancy. We performed qualitative thematic analysis using a combined inductive and deductive approach. RESULTS: Major themes that emerged included the following: conflicting information decreased vaccine confidence; individualized outreach is valued when information gathering; mandates and financial incentives may increase skepticism; low health literacy and conflict in personal relationships are barriers to acceptance; and experiencing a severe infection and fear of exposure at work increase acceptance. CONCLUSIONS: Based on our study, personalized yet consistent messaging may be key to reaching hesitant HHWs.

Human papillomavirus vaccination at the first opportunity: An overview.

The Advisory Committee on Immunization Practices (ACIP) has recommended human papillomavirus (HPV) vaccination for adolescents in the United States since 2006. Though recommended at a similar time to the routine recommendations for adolescent tetanus, diphtheria, and acellular pertussis vaccination (Tdap) and quadrivalent meningococcal vaccination (MCV4), HPV vaccine uptake has consistently lagged behind these other adolescent vaccines. The ACIP recommends HPV vaccination at 11-12 y, with vaccination starting at 9 y of age included as an option that is routinely encouraged by the American Academy of Pediatrics and American Cancer Society. To support efforts to increase HPV vaccination at the first opportunity, this commentary summarizes the current HPV vaccination recommendations and available evidence regarding HPV vaccination starting at 9 y - including recent studies and trials documenting the effectiveness of HPV vaccination at 9 in supporting vaccine series completion, while providing future directions for research and implementation to improve HPV vaccination.

Factors associated with COVID-19 vaccine receipt at two integrated healthcare systems in New York City: a cross-sectional study of healthcare workers.

OBJECTIVES: To examine the factors associated with COVID-19 vaccine receipt among healthcare workers and the role of vaccine confidence in decisions to vaccinate, and to better understand concerns related to COVID-19 vaccination. DESIGN: Cross-sectional anonymous survey among front-line, support service and administrative healthcare workers. SETTING: Two large integrated healthcare systems (one private and one public) in New York City during the initial roll-out of the COVID-19 vaccine. PARTICIPANTS: 1933 healthcare workers, including nurses, physicians, allied health professionals, environmental services staff, researchers and administrative staff. PRIMARY OUTCOME MEASURES: The primary outcome was COVID-19 vaccine receipt during the initial roll-out of the vaccine among healthcare workers. RESULTS: Among 1933 healthcare workers who had been offered the vaccine, 81% had received the vaccine at the time of the survey. Receipt was lower among black (58%; OR: 0.14, 95% CI 0.1 to 0.2) compared with white (91%) healthcare workers, and higher among non-Hispanic (84%) compared with Hispanic (69%; OR: 2.37, 95% CI 1.8 to 3.1) healthcare workers. Among healthcare workers with concerns about COVID-19 vaccine safety, 65% received the vaccine. Among healthcare workers who agreed with the statement that the vaccine is important to protect family members, 86% were vaccinated. Of those who disagreed, 25% received the vaccine (p<0.001). In a multivariable analysis, concern about being experimented on (OR: 0.44, 95% CI 0.31 to 0.6), concern about COVID-19 vaccine safety (OR: 0.39, 95% CI 0.28 to 0.55), lack of influenza vaccine receipt (OR: 0.28, 95% CI 0.18 to 0.44), disagreeing that COVID-19 vaccination is important to protect others (OR: 0.37, 95% CI 0.27 to 0.52) and black race (OR: 0.38, 95% CI 0.24 to 0.59) were independently associated with COVID-19 vaccine non-receipt. Over 70% of all healthcare workers responded that they had been approached for vaccine advice multiple times by family, community members and patients. CONCLUSIONS: Our data demonstrated high overall receipt among healthcare workers. Even among healthcare workers with concerns about COVID-19 vaccine safety, side effects or being experimented on, over 50% received the vaccine. Attitudes around the importance of COVID-19 vaccination to protect others played a large role in healthcare workers' decisions to vaccinate. We observed striking inequities in COVID-19 vaccine receipt, particularly affecting black and Hispanic workers. Further research is urgently needed to address issues related to vaccine equity and uptake in the context of systemic racism and barriers to care. This is particularly important given the influence healthcare workers have in vaccine decision-making conversations in their communities.

Disparities in Marijuana and Tobacco Smoke Incursions Among New York City Families During Early Months of the COVID-19 Pandemic.

OBJECTIVES: Once the COVID-19 pandemic arrived in New York City (NYC), stay-at-home orders led to more time spent indoors, potentially increasing exposure to secondhand marijuana and tobacco smoke via incursions from common areas or neighbors. The objective of this study was to characterize housing-based disparities in marijuana and tobacco incursions in NYC housing during the pandemic. DESIGN: We surveyed a random sample of families from May to July 2020 and collected sociodemographic data, housing characteristics, and the presence, frequency, and pandemic-related change in incursions. SETTING: Five pediatric practices affiliated with a large NYC health care system. PARTICIPANTS: In total, 230 caregivers of children attending the practices. MAIN OUTCOME MEASURES: Prevalence and change in tobacco and marijuana smoke incursions. RESULTS: Tobacco and marijuana smoke incursions were reported by 22.9% and 30.7%, respectively. Twenty-two percent of families received financial housing support (public housing, Section-8). Compared with families in private housing, families with financial housing support had 3.8 times the odds of tobacco incursions (95% CI, 1.4-10.1) and 3.7 times the odds of worsening incursions during pandemic (95% CI, 1.1-12.5). Families with financially supported housing had 6.9 times the odds of marijuana incursions (95% CI, 2.4-19.5) and 5 times the odds of worsening incursions during pandemic (95% CI, 1.9-12.8). Children in financially supported housing spent more time inside the home during pandemic (median 24 hours vs 21.6 hours, P = .02) and were more likely to have asthma (37% vs 12.9%, P = .001) than children in private housing. CONCLUSIONS: Incursions were higher among families with financially supported housing. Better enforcement of existing regulations (eg, Smoke-Free Public Housing Rule) and implementation of additional policies to limit secondhand tobacco and marijuana exposure in children are needed. Such actions should prioritize equitable access to cessation and mental health services and consider structural systems leading to poverty and health disparities.

Factors Associated with SARS-CoV-2 Infection in Physician Trainees in New York City during the First COVID-19 Wave.

Occupational and non-occupational risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported in healthcare workers (HCWs), but studies evaluating risk factors for infection among physician trainees are lacking. We aimed to identify sociodemographic, occupational, and community risk factors among physician trainees during the first wave of coronavirus disease 2019 (COVID-19) in New York City. In this retrospective study of 328 trainees at the Mount Sinai Health System in New York City, we administered a survey to assess risk factors for SARS-CoV-2 infection between 1 February and 30 June 2020. SARS-CoV-2 infection was determined by self-reported and laboratory-confirmed IgG antibody and reverse transcriptase-polymerase chain reaction test results. We used Bayesian generalized linear mixed effect regression to examine associations between hypothesized risk factors and infection odds. The cumulative incidence of infection was 20.1%. Assignment to medical-surgical units (OR, 2.51; 95% CI, 1.18-5.34), and training in emergency medicine, critical care, and anesthesiology (OR, 2.93; 95% CI, 1.24-6.92) were independently associated with infection. Caring for unfamiliar patient populations was protective (OR, 0.16; 95% CI, 0.03-0.73). Community factors were not statistically significantly associated with infection after adjustment for occupational factors. Our findings may inform tailored infection prevention strategies for physician trainees responding to the COVID-19 pandemic.

A Quality Improvement Learning Collaborative for Human Papillomavirus Vaccination.

Many published accounts have shown that quality improvement (QI) initiatives within medical practice settings can increase vaccination rates. Project ECHO is a telementoring platform that uses video conferencing technology to educate and support healthcare professionals through case-based learning and brief lectures. This manuscript explores the results of a learning collaborative focused on combining QI and Project ECHO to increase human papillomavirus (HPV) vaccination rates within pediatric practices. METHODS: The American Academy of Pediatrics (AAP) recruited 3 AAP chapters that then recruited individual pediatricians and their practices for participation. Participants responded to surveys regarding chapter and pediatrician experience and satisfaction. Impact on HPV immunization rates (HPV initiation, series completion, and missed opportunities to vaccinate during visits) was measured using practice reports of chart reviews to AAP's data aggregator, which produced run charts. RESULTS: Thirty-four pediatricians within 8 practices completed the project; 1 practice withdrew. Physicians self-reported increased confidence in communicating with vaccine-hesitant families and implementing QI activities. We analyzed practice run charts utilizing QI run chart rules and found nonrandom change towards improvement for aggregate missed opportunities to vaccinate but not for HPV vaccine initiation or series completion. CONCLUSIONS: An HPV QI learning collaborative improved participant confidence in HPV vaccine communication and QI skills and decreased missed opportunities to vaccinate. Future projects should consider a more extended project period or more frequent data collection to reduce data variability to make it easier to spot nonrandom changes.

US Medical Trainees' Knowledge of Human Papilloma Virus and Head and Neck Cancer.

Given the increasing incidence of human papilloma virus (HPV)-positive head and neck cancers (HNCs), discussion of this oncologic outcome should be incorporated into HPV vaccine counseling practices. Yet, preliminary evidence shows that knowledge of the association between HPV and HNC is lacking among most medical trainees. To better characterize this deficit, we nationally assessed knowledge of HPV's association with HNC among medical students and residents across 4 specialties (pediatrics, obstetrics and gynecology, family medicine, and otolaryngology). A total of 3141 responses from 46 states were obtained (n = 402 pediatric residents, n = 346 obstetrics/gynecology residents, n = 260 family medicine residents, n = 87 otolaryngology residents, and n = 2045 medical students). Only 40.3% of surveyed medical students and 56.1% of surveyed obstetrics/gynecology, pediatrics, and family medicine residents identified associations between persistent HPV infection and HNC. When counseling on the vaccine, nonotolaryngology residents more often discussed cervical cancer (99.8%) as compared with HNC (39.7%), commonly because of less HNC knowledge (61.5%). These results suggest that it is imperative to develop educational interventions targeted at medical students and resident trainees on the front line of HPV vaccine counseling and administration.

Improving HPV vaccine delivery at school-based health centers.

OBJECTIVE: To identify characteristics associated with human papillomavirus (HPV) vaccination rates, describe barriers and facilitators to vaccine uptake and the potential role for clinician-to-clinician Assessment, Feedback, Incentives, and eXchange (AFIX) visits in school-based health centers (SBHCs). Methods: We conducted clinician-to-clinician AFIX visits at 24 New York City (NYC) high-school and middle-school SBHCs with up-to-date adolescent vaccination rates below 40%. Using NYC's immunization information system, we assessed HPV initiation and series completion rates at the time of AFIX visit and follow-up three to five months later. We analyzed responses to a questionnaire and summarized interviews to identify barriers and facilitators to HPV immunization practices and quality improvement (QI) implementation. Results: Baseline initiation and completion rates were 76% and 43% for high schools, and 81% and 45% for middle schools. SBHCs that allowed adolescent self-consent or did not require separate vaccine consent had higher baseline rates, but was not statistically significant. Barriers to series completion included challenges with scheduling and appointment compliance. At follow-up, high school SBHCs increased HPV vaccine initiation by 2.9 percentage points (p < 0.01) and series completion by 2.7 percentage points (p < 0.05). There was no statistically significant increase at middle school SBHCs. Most SBHCs (88%) chose reminder/recall systems as a QI strategy. Fewer than half (42%) implemented their QI strategy. Conclusions: We identified barriers to HPV vaccine series completion at our sample of SBHCs. Clinician-to-clinician AFIX visits may help improve vaccination rates and encourage providers to address barriers, including streamlining consent processes for HPV vaccination. Abbreviations: School-based health (SBH); quality improvement (QI).

Using Veterans Affairs Medical Center (VAMC) data to identify missed opportunities for HPV vaccination.

Despite high HPV prevalence and low vaccination rates in the military, HPV vaccination is not required upon military service initiation. Given that national HPV vaccination rates remain low among people age 19-26 years, military service may represent an opportune time for intervention. The purpose of this study was to quantify the rate of HPV vaccination among young patients entering primary care at a single Veterans Affairs Medical Center (VAMC). Vaccination rates among veterans age ≤ 26 years old at first primary care visit were identified from the institutional data warehouse. Among 1,258 eligible patients, most were male (n = 782). The HPV vaccine initiation rate was 21.2%. Overall, 10.4% of patients received at least 1 HPV vaccine prior to initiating care at the VA (25.2% females and 1.4% males). An additional 10.8% of patients received their first HPV vaccine upon initiating care at the VA. Median age of first HPV vaccination was 21.4 years among patients that initiated the vaccine in the military versus 24.8 years among those that initiated vaccination at the VA. In conclusion, this study demonstrated low HPV vaccination rates both prior to transitioning to VA primary care and once receiving care at the VA. Additionally, among veterans that had not received vaccination upon initiating care at the VA, older age at vaccination was observed. Older age at vaccination may reduce HPV vaccine effectiveness given higher risk of exposure. Addition of HPV to the list of mandated vaccines upon military service initiation should be considered.

Single- Versus Multiple-Site Harvesting Techniques for Bone Marrow Concentrate: Evaluation of Aspirate Quality and Pain.

BACKGROUND: Bone marrow concentrate (BMC) is growing in popularity as an alternative treatment option in orthopaedics. The regenerative capacity of BMC has been linked to the number of mesenchymal stem cells (MSCs) present in the graft at the time of its clinical application. MSC counts in bone marrow aspirate (BMA) are affected by harvest technique, but controversy exists over which aspiration method optimizes cellular yield while taking patient comfort and risk into consideration. PURPOSE: To compare a single- versus multiple-site bone marrow aspiration technique to determine which would generate a sufficient volume of high-quality BMA for concentration into a BMC graft. The level of pain experienced by the patient was monitored, since patient comfort should be included in the determination of a safe and effective aspiration technique. STUDY DESIGN: Controlled laboratory study and cohort study; Level of evidence, 2. METHODS: BMC samples from 6 patients were sent to an outside source for laboratory analysis. All 6 participants underwent bilateral bone marrow aspiration. Each patient received both techniques at the posterior iliac crest: one side underwent a multiple-site aspiration technique, and the contralateral side underwent a single-site technique with needle redirection. BMA and BMC samples were analyzed for concentrations white blood cells, total nucleated cells, red blood cells, neutrophils, and hematopoietic stem cells. One BMC sample was cultured, and MSC analysis was performed via flow cytometry. All patients underwent monitoring of pain scores during and after the procedure through a visual analog pain scale at 24 hours, 72 hours, and 7 days after BMA. RESULTS: No significant difference was found between the cell ratios of the single- and multiple-site groups. Both aspiration techniques were found to provide ample colony-forming units without a marked difference in appearance. Additionally, no significant difference was found between groups with regard to MSC numbers. Pain during and 24 hours after the procedure was significantly greater with the multiple-site method than the single-insertion method. CONCLUSION: The single-insertion method produced final cellular concentrations and culture results that were not significantly different from those of a multiple-insertion method. Additionally, the single-insertion site technique was significantly less painful to the patient at the time of the procedure as well as 24 hours after aspiration. CLINICAL RELEVANCE: The results of this study indicated that a high-quality bone marrow aspirate is possible with a single-stick aspiration method.

Commercial Separation Systems Designed for Preparation of Platelet-Rich Plasma Yield Differences in Cellular Composition.

BACKGROUND: The role of platelet-rich plasma (PRP) in the treatment of sport-related injuries is unclear, largely due to the heterogeneity of clinical results. This may relate to compositional differences in PRP from different separation systems. QUESTIONS/PURPOSES: This study aims to compare the composition of PRP produced with five different commercially available systems, focusing on cellular concentrations and pH. METHODS: Seven donors (41 ± 12 years) provided blood for PRP preparation using five systems (Arthrex Angel, Emcyte Genesis CS, Arteriocyte Magellan, Harvest SmartPrep, and Biomet GPS III). Post processing, cellular composition was measured including platelets (PLT), white blood cells (WBC), neutrophils (NE), and red blood cells (RBC), as well as pH. RESULTS: Platelet concentration and capture efficiency were similar between systems, except the Angel 7% preparation had a greater concentration than Genesis CS (2310 ± 524 vs. 1129 ± 264 k/µL). WBC concentration was variable between systems; however, significant differences were only found between the Angel 2% and GPS III preparations (11.0 ± 4.5, 27.3 ± 7.1 k/µL). NE concentration was significantly lower in the Angel 2% and 7% preparations compared with GPS III (0.6 ± 0.6 and 1.8 ± 1.3 k/µL vs. 9.4 ± 7.0 k/µL). RBC concentration was highest in SmartPrep (3.2 ± 0.6 M/µL) and Genesis CS systems (3.1 ± 0.6 M/µL) compared with all other systems (≤1.1 ± 1.2 M/µL). Finally, pH was significantly lower with the SmartPrep system (6.95 ± 0.06) compared with all others (≥7.26 ± 0.06). CONCLUSION: Aside from platelet concentration and capture efficiency, significant compositional differences were identified between preparation systems. Caution should be employed when interpreting clinical results of studies utilizing PRP, as the role of compositional differences and their effect on outcome are unknown. Further study is necessary to determine the clinical significance of these differences.

Orthobiologics and Knee Osteoarthritis: A Recent Literature Review, Treatment Algorithm, and Pathophysiology Discussion.

This article reviews the current options in orthobiologics for the clinical treatment of knee osteoarthritis (OA). We describe a new model of knee OA that fills the gap in our understanding of it as a purely traumatic and/or inflammation-induced cartilage degenerative condition, to a current model of multinodal pathophysiology. We discuss graft choice and patient selection in the current state of understanding of the treatment of knee OA in a tissue engineering model with orthobiologics. We present a sample treatment algorithm and decision nest for deciding how to proceed with patient care.

HPV vaccination: Population approaches for improving rates.

OBJECTIVE: To review the literature on interventions to increase HPV vaccinations and assess whether The Community Preventive Services Task Force recommendations are supported by current evidence. METHODS: We used a PubMed search to identify studies that assessed interventions that looked at provider assessment and feedback, provider reminders, client reminder and recall, and clinic based education programs. RESULTS: Of the 13 studies identified, 8 included client reminder and recall interventions, 4 included provider assessment and feedback and/or provider reminders and 2 included clinic based education. 11 of the 13 studies demonstrated a positive effect on HPV vaccine initiation or completion. Provider assessment and feedback studies were more likely to report a positive effect on HPV vaccine initiation than on series completion, while client reminder recall interventions more frequently produced an effect on series completion than on initiation. CONCLUSIONS: There is evidence to support the application of the Community Preventive Services Task Force recommendations specifically to HPV vaccination both for client reminder and recall programs and for provider assessment and feedback interventions. Multiple targeted approaches will be needed to substantially impact HPV vaccine rates.

Information literacy of U.S. and Indian engineering undergraduates.

To be competitive, contemporary engineers must be capable of both processing and communicating information effectively. Available research suggests that Indian students would be disadvantaged in information literacy in their language of instruction (English) compared to U.S. students because English is not Indian students' native language. Compared to U.S. students, Indian students (a) were predicted to apply practical text processing strategies to a greater extent than analytic strategies and (b) endorse the direct transmission of information over critical, interpretive analysis of information. Two validated scales measuring self-reported use of reading strategies and beliefs about interpreting and critiquing written information were administered to engineering students at an Indian Institute of Technology in their freshman to senior years. Neither prediction was supported: Indian students reported applying analytic strategies over pragmatic strategies and were more disposed to critically analyze information rather than accept it passively. Further, Indian students reported being more analytic and more reflective in their reading behaviors than U.S. engineering students. Additional data indicated that U.S. and Indian students' text-processing strategies and beliefs are associated with the texts that they read and their academic behaviors.