ICU Bed Utilization During the Coronavirus Disease 2019 Pandemic in a Multistate Analysis-March to June 2020.

OBJECTIVES: Given finite ICU bed capacity, knowledge of ICU bed utilization during the coronavirus disease 2019 pandemic is critical to ensure future strategies for resource allocation and utilization. We sought to examine ICU census trends in relation to ICU bed capacity during the rapid increase in severe coronavirus disease 2019 cases early during the pandemic. DESIGN: Observational cohort study. SETTING: Thirteen geographically dispersed academic medical centers in the United States. PATIENTS/SUBJECTS: We obtained daily ICU censuses from March 26 to June 30, 2020, as well as prepandemic ICU bed capacities. The primary outcome was daily census of ICU patients stratified by coronavirus disease 2019 and mechanical ventilation status in relation to ICU capacity. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Prepandemic overall ICU capacity ranged from 62 to 225 beds (median 109). During the study period, the median daily coronavirus disease 2019 ICU census per hospital ranged from 1 to 84 patients, and the daily ICU census exceeded overall ICU capacity for at least 1 day at five institutions. The number of critically ill patients exceeded ICU capacity for a median (interquartile range) of 17 (12-50) of 97 days at these five sites. All 13 institutions experienced decreases in their noncoronavirus disease ICU population, whereas local coronavirus disease 2019 cases increased. Coronavirus disease 2019 patients reached their greatest proportion of ICU capacity on April 12, 2020, when they accounted for 44% of ICU patients across all participating hospitals. Maximum ICU census ranged from 52% to 289% of overall ICU capacity, with three sites less than 80%, four sites 80-100%, five sites 100-128%, and one site 289%. CONCLUSIONS: From March to June 2020, the coronavirus disease 2019 pandemic led to ICU censuses greater than ICU bed capacity at fives of 13 institutions evaluated. These findings demonstrate the short-term adaptability of U.S. healthcare institutions in redirecting limited resources to accommodate a public health emergency.

Impact of rotavirus vaccination on diarrhea-related hospitalizations in São Paulo State, Brazil.

INTRODUCTION: Following introduction of routine infant rotavirus vaccination, severe diarrhea hospitalization rates declined among children aged <5 years throughout Brazil. Ensuring equity of rotavirus vaccine impact is important in countries that self-finance immunization programs. The objective of this study was to examine rotavirus vaccine impact on diarrhea admission rates among children aged <5 years in Brazil's public health system, according to area-based measures of human development in the state of São Paulo, Brazil. METHODS: Ecological analysis of public health system hospitalization rates for acute gastroenteritis among children aged <5 years in the state of São Paulo, Brazil, according to five categories of municipal development based on a modified Human Development Index for municipalities. Acute gastroenteritis hospitalization rates among children aged <5 years after national rotavirus vaccine introduction (2008-2011) were compared to rates in pre-vaccine years (2000-2005) to calculate percent decline in rates (1-rate ratio) and 95% confidence intervals (CI) for each municipal development category. Direct hospitalization costs during the two periods were compared. RESULTS: Annual rates declined by 40% (95% CI, 39-42%) from 631 diarrhea hospitalizations per 100,000 person years pre-rotavirus vaccination to 377 per 100,000 post-vaccination among children aged <5 years and 50% (95% CI, 48-52%) from 1009 to 505 per 100,000 among infants. Highest rates were observed in least developed municipalities. Significant declines of 26-52% among children <5 years and 41-63% among infants were observed in all categories of municipal development. Lower diarrhea hospitalization rates resulted in annual savings of approximately 2 million USD for the state of São Paulo. Savings in direct hospitalization costs benefitted municipalities in all five categories. CONCLUSION: The introduction of rotavirus vaccination was associated with substantial reductions of diarrhea-related admissions at all levels of municipal development in São Paulo State, Brazil.

Incidence and Epidemiology of Intussusception among Infants in Ho Chi Minh City, Vietnam.

OBJECTIVE: To evaluate rates of intussusception hospitalization among infants in Vietnam before the introduction of rotavirus vaccine. STUDY DESIGN: Between 2009 and 2011, we identified intussusception hospitalizations among infants using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification code K56.1 at 2 large pediatric hospitals in Ho Chi Minh City, Vietnam that treat most of the intussusception cases in the city. We reviewed all medical records to confirm a Brighton level 1 case definition for intussusception. RESULTS: We identified a total of 869 intussusception cases in Ho Chi Minh City during the 3-year study period, for an annual rate of 296 per 100,000 infants. The mean age of intussusception was ∼ 37 weeks (8.6 months), with <2% of the cases occurring before age 15 weeks. Cases of intussusception were observed year-round in these hospitals with no evident seasonal pattern. Ultrasonography was used to diagnose most cases (97%), and reduction was performed by air enema in >95% of the cases, with only 1% of cases at 1 hospital and 5% at the other hospital requiring surgical intervention. Ultrasound diagnosis was confirmed by an independent radiologist in 94% of a randomly selected group of intussusception cases at 1 of the 2 hospitals. No mortality was reported. CONCLUSION: Vietnam has a substantially higher rate of intussusception in children aged >15 weeks compared with most other regions of the world. Most of our cases were diagnosed by ultrasound, and only a small proportion required surgical intervention with no fatalities, suggesting that the higher rates may be related in part to better and earlier detection of intussusception.

Effectiveness of monovalent rotavirus vaccine in Bolivia: case-control study.

OBJECTIVE: To evaluate the effectiveness of two doses of a monovalent rotavirus vaccine (RV1) against hospital admission for rotavirus in Bolivia. DESIGN: Case-control study. SETTING: Six hospitals in Bolivia, between March 2010 and June 2011. PARTICIPANTS: 400 hospital admissions for rotavirus, 1200 non-diarrhea hospital controls, and 718 rotavirus negative hospital controls. MAIN OUTCOME MEASURES: Odds of antecedent vaccination between case patients and controls; effectiveness of vaccination ((1-adjusted odds ratio)×100), adjusted for age and other confounders; and stratified effectiveness by dose, disease severity, age group, and serotype. RESULTS: In comparison with non-diarrhea controls, case patients were more likely to be male and attend day care but less likely to have chronic underlying illness, higher level maternal education, and telephones and computers in their home. Rotavirus negative controls were somewhat more similar to case patients but also were more likely to be male and attend day care and less likely to have higher level maternal education and computers in their homes. The adjusted effectiveness of RV1 against hospital admission for rotavirus was 69% (95% confidence interval 54% to 79%) with rotavirus negative controls and 77% (65% to 84%) with non-diarrhea controls. The effectiveness of one dose of RV1 was 36% and 56%, respectively. With both control groups, protection was sustained through two years of life, with similar efficacy against hospital admission among children under 1 year (64% and 77%) and over 1 year of age (72% and 76%). RV1 provided significant protection against diverse serotypes, partially and fully heterotypic to the G1P[8] vaccine. Effectiveness using the two control groups was 80% and 85% against G9P[8], 74% and 93%% against G3P[8], 59% and 69% against G2P[4], and 80% and 87% against G9P[6] strains. CONCLUSION: The monovalent rotavirus vaccine conferred high protection against hospital admission for diarrhea due to rotavirus in Bolivian children. Protection was sustained through two years of life against diverse serotypes different from the vaccine strain.

The rotavirus experience in Mexico: discovery to control.

The recent introduction of a rotavirus vaccine program in Mexico to control rotavirus disease, a common killer of children worldwide, has dramatically reduced the number of Mexican children dying and being hospitalized because of diarrhea. The successful introduction of a rotavirus vaccine program was preceded by several decades of focused research efforts to document the burden of disease and to generate the knowledge base to develop and deploy a vaccine. The postlicensure experience from Mexico demonstrates that evaluating the impact and safety of the vaccination program is vitally necessary for sustaining it. All in all, the immensely successful Mexico experience with control of rotavirus disease, if copied, could yield tremendously favorable results for children and parents worldwide.

Trends in intussusception-associated deaths among US infants from 1979-2007.

OBJECTIVE: We examined data from 1979-2007 to generate up-to-date baseline estimates of rotavirus intussusception mortality in US infants, to inform policy deliberations of the risks and benefits of vaccination. STUDY DESIGN: Secular trends in the infant intussusception mortality rate were evaluated using national multiple cause-of-death and natality data from 1979- 2007. Linked birth/infant death data from 1998-2006 were examined to identify risk factors for intussusception deaths. RESULTS: After declining from 1979-1996, the average annual intussusception mortality rate stabilized from 1997-2007 at 2.1 per 1 million live births (range, 1.0-3.0). In multivariate analysis, significant variables associated with intussusception deaths included no prenatal care (OR, 5.4; 95% CI, 1.9-15.4) and birth order (≥3rd) (OR, 2.4; 95% CI, 1.4-4.4 [reference: birth order (1st)]). CONCLUSIONS: Given the annual variation in intussusceptions mortality and low baseline rates, if a low vaccine-associated risk of death from intussusception exists in the United States, it would be difficult to assess using intussusception mortality trend data alone. Factors associated with intussusception mortality risk may be related to delayed or reduced health care access.

Reduction in morbidity and mortality from childhood diarrhoeal disease after species A rotavirus vaccine introduction in Latin America : a review

Countries in Latin America were among the first to implement routine vaccination against species A rotavirus (RVA). We evaluate data from Latin America on reductions in gastroenteritis and RVA disease burden following the introduction of RVA vaccine. Published literature was reviewed to identify case-control studies of vaccine effectiveness and population-based studies examining longitudinal trends of diarrhoeal disease reduction after RVA vaccine introduction in Latin American countries. RVA vaccine effectiveness and impact on gastroenteritis mortality and hospitalization rates and RVA hospitalization rates are described. Among middle-income Latin American countries with published data (Mexico, Brazil, El Salvador and Panama), RVA vaccine contributed to a gastroenteritis-associated mortality reduction of 22-41 percent, a gastroenteritis-associated hospitalization reduction of 17-51 percent and a RVA hospitalization reduction of 59-81 percent among children younger than five years of age. In Brazil and El Salvador, case-control studies demonstrated that a full RVA vaccination schedule was 76-85 percent effective against RVA hospitalization; a lower effectiveness of 46 percent was seen in Nicaragua, the only low-income country with available data. A growing body of literature offers convincing evidence of "real world" vaccine program successes in Latin American settings, which may be expanded as more countries in the region include RVA vaccine in their immunization programs.

Monovalent rotavirus vaccine provides protection against an emerging fully heterotypic G9P[4] rotavirus strain in Mexico.

After the introduction of monovalent rotavirus vaccine (RV1) in Mexico in 2006-2007, diarrhea mortality and morbidity declined substantially among Mexican children under 5 years of age. In January 2010, surveillance identified the emergence of a novel G9P[4] rotavirus strain nationwide. We conducted a case-control study to assess the field effectiveness of RV1 against severe rotavirus gastroenteritis caused by this unusual strain and to determine whether the G9P[4] emergence was related to vaccine failure or failure to vaccinate. RV1 was 94% effective (95% confidence interval, 16%-100%) against G9P[4] rotavirus-related hospitalization, indicating that its emergence was likely unrelated to vaccine pressure.

Intussusception risk and health benefits of rotavirus vaccination in Mexico and Brazil.

BACKGROUND: Because postlicensure surveillance determined that a previous rotavirus vaccine, RotaShield, caused intussusception in 1 of every 10,000 recipients, we assessed the association of the new monovalent rotavirus vaccine (RV1) with intussusception after routine immunization of infants in Mexico and Brazil. METHODS: We used case-series and case-control methods to assess the association between RV1 and intussusception. Infants with intussusception were identified through active surveillance at 69 hospitals (16 in Mexico and 53 in Brazil), and age-matched infants from the same neighborhood were enrolled as controls. Vaccination dates were verified by a review of vaccination cards or clinic records. RESULTS: We enrolled 615 case patients (285 in Mexico and 330 in Brazil) and 2050 controls. An increased risk of intussusception 1 to 7 days after the first dose of RV1 was identified among infants in Mexico with the use of both the case-series method (incidence ratio, 5.3; 95% confidence interval [CI], 3.0 to 9.3) and the case-control method (odds ratio, 5.8; 95% CI, 2.6 to 13.0). No significant risk was found after the first dose among infants in Brazil, but an increased risk, albeit smaller than that seen after the first dose in Mexico--an increase by a factor of 1.9 to 2.6 - was seen 1 to 7 days after the second dose. A combined annual excess of 96 cases of intussusception in Mexico (approximately 1 per 51,000 infants) and in Brazil (approximately 1 per 68,000 infants) and of 5 deaths due to intussusception was attributable to RV1. However, RV1 prevented approximately 80,000 hospitalizations and 1300 deaths from diarrhea each year in these two countries. CONCLUSIONS: RV1 was associated with a short-term risk of intussusception in approximately 1 of every 51,000 to 68,000 vaccinated infants. The absolute number of deaths and hospitalizations averted because of vaccination far exceeded the number of intussusception cases that may have been associated with vaccination. (Funded in part by the GAVI Alliance and the U.S. Department of Health and Human Services.).

Decline in rotavirus hospitalizations and health care visits for childhood diarrhea following rotavirus vaccination in El Salvador.

BACKGROUND: A recent postlicensure study from El Salvador showed that the monovalent rotavirus vaccine conferred 76% protection against rotavirus hospitalizations. We further examined the impact of rotavirus vaccination on the national burden of childhood diarrhea to help assess the total public health benefits of vaccination. METHODS: We compared all-cause diarrhea and rotavirus-specific hospitalization rates during prevaccine year 2006, with postvaccine years 2008 and 2009 in children < 5 years of age from 7 sentinel surveillance hospitals. We also compared annual rates of diarrhea-related healthcare events during prevaccine years 2005 and 2006 with postvaccine years 2008 and 2009 to examine the national burden of healthcare utilization for all-cause diarrhea. RESULTS: Among sentinel surveillance hospitals, rotavirus hospitalization rates among children < 5 years of age declined by 81% (95% confidence interval [CI]: 78%-84%) in 2008 when 2-dose rotavirus vaccine coverage was 50% among infants < 1 year; the decline was 69% (95% CI: 65%-73%) in 2009 when 2-dose vaccine coverage was 61% among infants < 1 year, compared with 2006. The greatest declines were observed in children ≤ 1 year of age, although sizeable reductions were also observed among children ≥ 2 years in 2008. National diarrhea-related healthcare visits during rotavirus season decreased by 48% (95% CI: 47%-48%) in 2008 and by 35% (95% CI: 34%-35%) in 2009 compared with the mean rate from the 2005 and 2006 rotavirus seasons. CONCLUSIONS: Rotavirus vaccination had a substantial public health impact on rotavirus disease and overall diarrhea events in El Salvador. Important age-related changes in diarrheal incidence emphasize the need for ongoing rotavirus surveillance after vaccine introduction.

Reduction in morbidity and mortality from childhood diarrhoeal disease after species A rotavirus vaccine introduction in Latin America - a review.

Countries in Latin America were among the first to implement routine vaccination against species A rotavirus (RVA). We evaluate data from Latin America on reductions in gastroenteritis and RVA disease burden following the introduction of RVA vaccine. Published literature was reviewed to identify case-control studies of vaccine effectiveness and population-based studies examining longitudinal trends of diarrhoeal disease reduction after RVA vaccine introduction in Latin American countries. RVA vaccine effectiveness and impact on gastroenteritis mortality and hospitalization rates and RVA hospitalization rates are described. Among middle-income Latin American countries with published data (Mexico, Brazil, El Salvador and Panama), RVA vaccine contributed to a gastroenteritis-associated mortality reduction of 22-41%, a gastroenteritis-associated hospitalization reduction of 17-51% and a RVA hospitalization reduction of 59-81% among children younger than five years of age. In Brazil and El Salvador, case-control studies demonstrated that a full RVA vaccination schedule was 76-85% effective against RVA hospitalization; a lower effectiveness of 46% was seen in Nicaragua, the only low-income country with available data. A growing body of literature offers convincing evidence of "real world" vaccine program successes in Latin American settings, which may be expanded as more countries in the region include RVA vaccine in their immunization programs.

Impact of rotavirus vaccination on diarrhea-related hospitalizations among children < 5 years of age in Mexico.

BACKGROUND: Single-strain rotavirus vaccine was added to the national immunization program in Mexico in May 2007. We assessed the impact of vaccination on the number of diarrhea-related hospitalizations in Mexican children in 2008 and 2009. METHODS: We obtained data on all-cause diarrhea-related hospitalizations from January 2003 to June 2009 in Mexican children <5 years of age. We compared diarrhea-related hospitalizations during the 2008 and 2009 rotavirus seasons with the median number of diarrhea-related hospitalizations at baseline (2003-2006), before rotavirus vaccine introduction, at 306 Ministry of Health hospitals. We estimated vaccine coverage using administrative data. RESULTS: A median number of 10,993 diarrhea-related hospitalizations (range: 9877-11958) occurred each prevaccine rotavirus season from 2003 to 2006 among children < 5 years of age. Diarrhea-related hospitalizations decreased by 11% (N = 9836) in 2008 and by 40% (N = 6597) in 2009. The greatest declines occurred in infants < 12 months of age during 2008 (25%) and 2009 (52%), with 1-dose rotavirus vaccination coverage of 74% and 89% during these years, respectively. A 43% decline was also noted among children 12 to 23 months of age during the 2009 season. No declines were noted during either 2008 or 2009 among unvaccinated children >24 months of age during the study period. CONCLUSIONS: Marked declines in diarrhea-related hospitalizations among vaccine-eligible Mexican children < 24 months of age have occurred during the first 2 complete rotavirus seasons following rotavirus vaccination. Rotavirus-specific surveillance and epidemiologic studies are necessary for a better understanding of the changes in disease epidemiology and public health impact from rotavirus vaccination.

Reduction of diarrhea-associated hospitalizations among children aged < 5 Years in Panama following the introduction of rotavirus vaccine.

BACKGROUND: In March 2006, rotavirus vaccine (Rotarix, RV1) was introduced into the Panamanian national immunization program. We assessed the effect of vaccine on diarrhea-associated hospitalizations among young Panamanian children. METHODS: We obtained monthly numbers of diarrhea-associated hospitalizations among children aged ≤ 5 years during 2003 and 2008 from 5 health regions in Panama, representing 53% of the birth cohort. We compared the number of diarrhea-associated hospitalizations during the postvaccine years of 2007 and 2008 with the prevaccine mean numbers 2003-2005 among children < 1 year and those 1 to 4 years of age. Administrative data were used to estimate national rotavirus vaccine coverage. RESULTS: During prevaccine years, diarrhea-associated hospitalizations among children < 5 years in the 5 regions averaged 4057 annually. After the vaccine introduction, a decrease in diarrhea-associated hospitalizations of 22% (898 fewer) occurred in 2007 and 37% (1502 fewer) in 2008. Greater reductions were observed during January through June, the months presumed to have high rotavirus activity in prevaccine years (33% reduction in 2007 and 58% in 2008, compared with prevaccine mean). Reduction estimates were similar among infants and those aged 1-4 years of age, even though only 25% of the latter group was likely to have received vaccine by early 2008. Estimated coverage with ≥ 1 dose of rotavirus vaccine among infants increased from 63% at the end of 2006 to 94% at the end of 2008. CONCLUSIONS: RV1 appears to have had a substantial impact on diarrhea-associated hospitalizations among young children in Panama.

Effectiveness of monovalent rotavirus vaccine (Rotarix) against severe diarrhea caused by serotypically unrelated G2P[4] strains in Brazil.

BACKGROUND. In a Latin American trial, a monovalent G1P[8] rotavirus vaccine showed high efficacy against severe rotavirus diarrhea. Protection was lower against serotypically unrelated G2P[4] strains, which circulated infrequently. This case-control study was undertaken to assess the effectiveness of this monovalent G1P[8] rotavirus vaccine against G2P[4] strains in Brazil. METHODS. Case patients were children with severe G2P[4] rotavirus diarrhea who presented at a hospital in Recife, Brazil, from March 2006 through September 2008. Vaccination rates among case patients were compared with rates among 2 groups of control participants-children with rotavirus-negative diarrhea and children admitted for acute respiratory tract infection (ARI)-to calculate vaccine effectiveness, after controlling for the birth month and year. RESULTS. We enrolled 70 G2P[4] rotavirus-positive case patients with severe diarrhea, 484 rotavirus-negative control participants with diarrhea, and 416 control participants with ARI, aged 6 months. Among children aged 6-11 months, the effectiveness of the vaccine against G2P[4] diarrhea was 77% (95% confidence interval [CI], 42%-91%) and 77% (95% CI, 43%-90%) among the rotavirus-negative control participants with diarrhea and control participants with ARI, respectively. Vaccine effectiveness in children aged 12 months decreased to -24% (95% CI, -190% to 47%) and 15% (95% CI, -101 to 64) among the rotavirus-negative control groups with diarrhea and ARI, respectively. CONCLUSIONS. This monovalent G1P[8] rotavirus vaccine was effective against severe G2P[4] rotavirus diarrhea among children aged 6-11 months. Effectiveness declined among children aged 12 months, which suggests waning immunity.

Use of lead isotope ratios to identify sources of lead exposure in Alaska Natives.

OBJECTIVES: Although banned nationwide for waterfowl hunting, lead shot is still used for hunting in regions of Alaska. Consumption of birds hunted with lead shot may be a route of human lead exposure in susceptible populations. The Centers for Disease Control and Prevention (CDC) and Alaskan health officials conducted a cross-sectional exposure assessment and used isotope ratios (IR) to test that assumption. STUDY DESIGN: Cross-sectional exposure assessment study. METHODS: We compared isotopic profiles of blood lead in Alaska Native women from Bethel (n = 10) and Barrow (n = 10) to lead shot samples purchased from the respective regions. To evaluate the source of lead for the buckshot, we evaluated IR profiles for lead mineral and ore from a smelter in Torreon, Mexico, a suspected source of origin for the lead. RESULTS: The lead IRs for the blood lead differed significantly from the lead shot IRs (p < 0.001); thus, lead shot is unlikely to be the sole source of lead exposure of public health significance in participants of this study. Overlap in IRs for the lead shot and blood lead existed for 6 (30%) of the women from Bethel and Barrow; however, no correlation was noted between lead levels and the IRs for the blood lead. IR profiles for lead mineral and ore from Mexico were substantially different from the IRs of lead shot from Alaska, confirming that buckshot in this study is unlikely to originate from the Mexican smelter. CONCLUSIONS: Lead shot from the manufacturer in this study does not appear to be the sole source of lead exposure in most participants; nonetheless, lead shot could yet be a potential source of exposure in some populations, possibly those whose diet consists of game hunted with lead shot.