Vaccines in Long-Term Care Settings: A Narrative Review.

BACKGROUND: Older people living in long-term care facilities represent a particularly vulnerable segment of the population, who disproportionately bear the burden of infectious diseases, as recently highlighted by the COVID-19 pandemic. SUMMARY: Older long-term care residents typically cumulate several risk factors for infection and experience serious life-threatening outcomes once infected. These common infections are often compounded by the collective living environment, where it is more difficult to contain the spread of infection. Moreover, the staff may represent an additional reservoir of potential infection and mode of transmission. In this paper, we review the burden of infectious respiratory diseases in residents in long-term care and discuss the potential gains from higher vaccine coverage in this older and most vulnerable population but also from higher vaccine coverage among the facility staff. We highlight the compelling need to integrate specific vaccine recommendations for residents of long-term care into national vaccination schedules, as well as the need to include vaccination campaigns in routine protocols for infection control. Surveillance, reporting, hygiene, and individual protective measures remain key aspects in basic infection control, both in ordinary times and during epidemics. KEY MESSAGE: Vaccination of residents in long-term care facilities against respiratory diseases including influenza, pneumococcal disease, pertussis, and COVID is a simple, inexpensive, and effective means to reduce the burden of infection in this segment of the population.

Driving the life course approach to vaccination through the lens of key global agendas.

Globally, our population is ageing at an unprecedented rate and by 2030, which marks the end of the United Nations (UN) Decade of Healthy Ageing, the number of people aged 60 years and older will be 34% higher than today, reaching 1.4 billion. Vaccination is one of the most effective public health interventions of modern times and a key action in fostering healthy ageing throughout the life-course. To promote wellbeing at all ages, global agendas including the WHO Immunization Agenda 2030, the UN Decade of Healthy Ageing and the World Health Organization (WHO) Global Report on Ageism outline strategic actions and guidance to help implement policies and programs. Yet, the linkages between healthy ageing, functional ability and adult vaccination are not substantively recognized or integrated as cross-cutting themes, which impacts operationalization into national immunization plans. When aligned and connected strategically, these agendas have potential to substantially contribute to policy change to prioritize life-course immunization and support the preservation of function at all stages of life. This article describes the intersecting goals and visions of these strategic agendas and identifies specific elements of overlap, which when connected, could strengthen the development of comprehensive and effective national immunization policies.

The impact of artificial intelligence on retinal disease management: Vision Academy retinal expert consensus.

PURPOSE OF REVIEW: The aim of this review is to define the "state-of-the-art" in artificial intelligence (AI)-enabled devices that support the management of retinal conditions and to provide Vision Academy recommendations on the topic. RECENT FINDINGS: Most of the AI models described in the literature have not been approved for disease management purposes by regulatory authorities. These new technologies are promising as they may be able to provide personalized treatments as well as a personalized risk score for various retinal diseases. However, several issues still need to be addressed, such as the lack of a common regulatory pathway and a lack of clarity regarding the applicability of AI-enabled medical devices in different populations. SUMMARY: It is likely that current clinical practice will need to change following the application of AI-enabled medical devices. These devices are likely to have an impact on the management of retinal disease. However, a consensus needs to be reached to ensure they are safe and effective for the overall population.

Current status and practical considerations of artificial intelligence use in screening and diagnosing retinal diseases: Vision Academy retinal expert consensus.

PURPOSE OF REVIEW: The application of artificial intelligence (AI) technologies in screening and diagnosing retinal diseases may play an important role in telemedicine and has potential to shape modern healthcare ecosystems, including within ophthalmology. RECENT FINDINGS: In this article, we examine the latest publications relevant to AI in retinal disease and discuss the currently available algorithms. We summarize four key requirements underlining the successful application of AI algorithms in real-world practice: processing massive data; practicability of an AI model in ophthalmology; policy compliance and the regulatory environment; and balancing profit and cost when developing and maintaining AI models. SUMMARY: The Vision Academy recognizes the advantages and disadvantages of AI-based technologies and gives insightful recommendations for future directions.

A review of factors influencing vaccination policies and programs for older adults globally.

Policies and programs to increase vaccine coverage rates among adults 50 years of age or older are limited and vaccine uptake is often suboptimal. Our review evaluated evidence on the effectiveness and success of adult-targeted vaccination interventions and identified literature gaps. Literature was retrieved (2021) from PubMed, Embase, and Google Scholar databases. Outcomes assessed included data on an intervention's effectiveness and impact on vaccine uptake. Interventions were characterized thematically: affordability (n = 9), awareness (n = 25), and vaccination access (n = 6); and included influenza, pneumococcal, tetanus-containing, and herpes zoster vaccines. Interactive interventions directed toward patients, including provider-led educational initiatives and provider recommendations showed more positive associations than less interactive interventions, such as posters and reminder-recall letters. Provider interventions, including awareness campaigns, incentives, affordability efforts, or vaccination site expansion generally showed positive associations. Combining interventions was found to be successful across several studies. Barriers and interventions varied for population subgroups, therefore, tailoring programs is critical.

The management of neovascular age-related macular degeneration: A systematic literature review of patient-reported outcomes, patient mental health and caregiver burden.

PURPOSE: The aim of this systematic literature review was to describe patient-reported outcomes, mental health and caregiver burden in patients with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor (VEGF) agents in routine clinical practice. METHODS: Electronic searches were conducted in Embase and MEDLINE according to pre-defined criteria. RESULTS: Of 856 records identified, 63 met inclusion criteria. Depression or depressive symptoms were reported in up to 42% of patients with nAMD. Of 25/63 (40%) studies evaluating quality of life (QoL) and using various tools, eight studies reported composite National Eye Institute Visual Functioning Questionnaire scores following anti-VEGF treatment. Of these, seven reported a statistically significant improvement at the earliest time point measured (Month 3-12) and approximately 50% reported sustained QoL benefits at 12 months. In studies comparing the attributed or different regimens, the most important factor from the patient's perspective was the likelihood that a particular regimen would maintain vision. There was a preference towards treat and extend, which was associated with a perceived reduction in patient and caregiver burden, compared to fixed dosing. CONCLUSIONS: A coordinated holistic approach to patient care is key to optimizing patient well-being as well as visual outcomes. Further research regarding the patient-reported impact of nAMD management outside the trial setting (particularly international longitudinal studies) is warranted. Standardization of QoL studies would assist in establishing whether sustained QoL improvement, rather than prevention of QoL decline, should be a realistic expectation of treatment of nAMD in the longer term.

The Patient Voice in Neovascular Age-Related Macular Degeneration: Findings from a Qualitative Study.

INTRODUCTION: Visual impairment resulting from diseases such as neovascular age-related macular degeneration (nAMD) may cause behavioural, environmental, psychological, and logistical challenges that could act as barriers to effective uptake and sustainability of treatment with anti-vascular endothelial growth factor agents (anti-VEGFs). Understanding emotions and experiences of patients with nAMD may help inform the determinants of adherence, and could contribute to improvements in ophthalmic outcomes and quality of life. METHODS: Seventeen patients with nAMD receiving anti-VEGF injections were enrolled from three clinics: one each in France (n = 5), Germany (n = 6), and the UK (n = 6). Patients' health information and treatment characteristics were collected. Individual phone interviews were conducted by experienced health care interviewers. Transcripts were analysed thematically. RESULTS: Patients (53% female) had a mean age of 77 years. Bilateral anti-VEGF injections were received by 24% (n = 4); and most (76%, n = 13) were adherent to their treatment. Patient emotions at diagnosis ranged from happiness at learning about the treatment for nAMD to being terrified of receiving an injection in the eye. Most patients mentioned feeling anxious and fearful before their first injection despite receiving reassurance. After the first injection, these feelings and apprehension abated for many, but not all. With the goal of maintaining the best possible vision, few (24%, n = 4) patients reported more than one missed appointment, and most had never considered stopping treatment. No patient reported additional assistance beyond family support; however, many had difficulties with recreational and domestic activities and had developed coping strategies. CONCLUSION: This study provides insights on patients' emotions related to their experience of nAMD and its management, highlighting the varying experiences between individuals. It shows the importance of the patient's voice when considering patient care and management, and how the nature and timing of interventions can improve the experience of living with and managing nAMD.

Neovascular age-related macular degeneration (nAMD), also known as wet age-related macular degeneration (wAMD), is an eye condition that is a common cause of vision loss and worsens over time without treatment. This condition mainly occurs in people aged 70 years or older. The standard of care is an injection of anti-vascular endothelial growth factor (anti-VEGF) into the eye to minimise vision loss that continues over time without treatment. To maximise the benefits of treatment, injections are required at regular intervals over time. The purpose of this study was to understand the emotions and experiences of patients with nAMD about their disease, its consequences, and its management. Seventeen patients from three countries (France, Germany, and the UK) were interviewed over the telephone. Patients reported diverse feelings and responses to their disease and treatment. Many felt nervous and anxious at diagnosis and before their first injection (despite reassurances from their doctors); however, after the first injection, these feelings and apprehension abated for many, but not all. Most patients (76%) missed fewer than two appointments in the past year, and almost all (82%) did not consider stopping treatment. Patients learned to deal with their nAMD, but many had difficulties with daily activities. Patients developed ways to manage tasks such as cooking, cleaning, knitting, and driving. The insights from this study help understand how care for patients with nAMD can be improved by addressing patients' concerns and feelings about their disease and treatment.

Drivers of and barriers to routine adult vaccination: A systematic literature review.

We performed a systematic literature review in PubMed and Embase (2016-2021) to investigate the drivers of and barriers to routine vaccination in adults aged 50 and older globally. A thematic assessment identified three categories across 61 publications: sociodemographic, health-related, and attitudinal. The most common sociodemographic determinants (factors identified in studies; n = 47) associated with vaccination uptake were economic status, age, education, and household composition, which had mixed effects on vaccine uptake. For health-related determinants (n = 27), individuals with comorbidities and health care consumption were the most common factors, both increased vaccine uptake. The most common attitudinal factors (n = 42) were self-efficacy, provider or other's recommendations, and vaccine-preventable disease awareness; across studies, all attitude factors had a positive effect, unlike the sociodemographic and health status categories. Findings suggest that patient and provider awareness and education campaigns are effective ways to increase uptake of routine vaccinations in older adults.

Towards Ending Immunization Inequity.

Vaccine-preventable diseases (VPD) are responsible for a significant portion of mortality across the life course in both low-income countries and in medium- and high-income countries. Yet, countries are consistently below the adult influenza vaccination targets, with rates in recent times even falling in some areas. (1) The study Towards Ending Immunization Inequity seeks to understand the various factors that contribute to the accessibility and effectiveness of vaccine-related messages and campaigns including the effects of social determinants, with the knowledge that these opportunities for communication represent a unique policy lever to improving uptake rates of vaccination in the most at-risk communities. (2) To address this knowledge gap, a 3-phase mixed-methods study was conducted including a preliminary scan of existing vaccine schedules and NITAG recommendations, focus groups and a cross-sectional survey. (3) Study results indicated that social determinants play a key role in an individual's knowledge of vaccine-related information including types of vaccines available, vaccination gateways, vaccine recommendations and vaccine safety. (4) However, knowing that social determinants can influence uptake rates does not readily create opportunities and entry points for governments to implement tangible actions. An accessible entry point to reducing and ending immunization inequity is through changes in public health messaging to reach those who are currently unreachable.

The epidemiologic and biologic basis for classifying older age as a high-risk, immunocompromising condition for pneumococcal vaccine policy.

INTRODUCTION: Immunosenescence is a normal biologic process involving deterioration of protective immune responses. Consequently, older adults experience increased risk of infectious diseases, particularly pneumonia, and its leading bacterial cause, Streptococcus pneumoniae. Pneumococcal vaccine recommendations are often limited to adults with specific medical conditions despite similar disease risks among older adults due to immunosenescence. AREAS COVERED: This article reviews epidemiologic, biologic, and clinical evidence supporting the consideration of older age due to immunosenescence as an immunocompromising condition for the purpose of pneumococcal vaccine policy and the role vaccination can play in healthy aging. EXPERT OPINION: Epidemiologic and biologic evidence suggest that pneumococcal disease risk increases with age and is comparable for healthy older adults and younger adults with immunocompromising conditions. Because immunocompromising conditions are already indicated for pneumococcal conjugate vaccines (PCVs), a comprehensive public health strategy would also recognize immunosenescence. Moreover, older persons should be vaccinated before reaching the highest risk ages, consistent with the approach for other immunocompromising conditions. To facilitate PCV use among older adults, vaccine technical committees (VTCs) could classify older age as an immunocompromising condition based on the process of immunosenescence. With global aging, VTCs will need to consider immunosenescence and vaccine use during healthy aging.

Defining Nonadherence and Nonpersistence to Anti-Vascular Endothelial Growth Factor Therapies in Neovascular Age-Related Macular Degeneration.

Importance: Poor adherence or persistence to treatment can be a barrier to optimizing clinical practice (real-world) outcomes to intravitreal injection therapy in patients with neovascular age-related macular degeneration (nAMD). Currently, there is a lack of consensus on the definition and classification of adherence specific to this context. Objective: To describe the development and validation of terminology on patient nonadherence and nonpersistence to anti-vascular endothelial growth factor therapy. Design, Setting, and Participants: Following a systematic review of currently used terminology in the literature, a subcommittee panel of retinal experts developed a set of definitions and classification for validation. Definitions were restricted to use in patients with nAMD requiring intravitreal anti-vascular endothelial growth factor therapy. Validation by the full nAMD Barometer Leadership Coalition was established using a modified Delphi approach, with predetermined mean scores of 7.5 or more signifying consensus. Subsequent endorsement of the definitions was provided from a second set of retinal experts, with more than 50% members agreeing or strongly agreeing with all definitions. Main Outcomes and Measures: Development of consensus definitions for the terms adherence and persistence and a classification system for the factors associated with treatment nonadherence or nonpersistence in patients with nAMD. Results: Nonadherence was defined as missing 2 or more treatment or monitoring visits over a period of 12 months, with a visit considered missed if it exceeded more than 2 weeks from the recommended date. Nonpersistence was defined by nonattendance or an appointment not scheduled within the last 6 months. The additional terms planned discontinuation and transfer of care were also established. Reasons for treatment nonadherence and nonpersistence were classified into 6 dimensions: (1) patient associated, (2) condition associated, (3) therapy associated, (4) health system and health care team associated, (5) social/economic, and (6) other, with subcategories specific to treatment for nAMD. Conclusions and Relevance: This classification system provides a framework for assessing treatment nonadherence and nonpersistence over time and across different health settings in the treatment of nAMD with current intravitreal anti-vascular endothelial growth factor treatments. This may have additional importance, given the potential association of the coronavirus pandemic on adherence to treatment in patients with nAMD.

Nonadherence or Nonpersistence to Intravitreal Injection Therapy for Neovascular Age-Related Macular Degeneration: A Mixed-Methods Systematic Review.

TOPIC: Systematic review of risk factors for nonadherence and nonpersistence to intravitreal anti-vascular endothelial growth factor (VEGF) injection therapy for neovascular age-related macular degeneration (nAMD). CLINICAL RELEVANCE: Lack of adherence (nonadherence) or undertreatment (nonpersistence) with respect to evidence from clinical trials remains a significant barrier to optimizing real-world outcomes for patients with nAMD. Contributing factors and strategies to address this are poorly understood. METHODS: Studies that reported factors for nonadherence and nonpersistence to anti-VEGF therapy as well as studies examining strategies to improve this were included. Trial eligibility and data extraction were conducted according to Cochrane review methods. Risk of bias was assessed using the Mixed Method Assessment Tool and certainty of evidence evaluated according to the GRADE Confidence in the Evidence from Reviews of Qualitative Research tool. Data were collated descriptively. RESULTS: Of the 1284 abstract results screened, 124 articles were assessed in full and 37 studies met the inclusion criteria. Definitions of nonadherence and nonpersistence varied or were not reported. Nonpersistence occurred early, with up to 50% of patients stopping treatment by 24 months. High rates of nonadherence were similarly reported, occurring in 32% to 95% of patients. Certainty of this finding was downgraded to a moderate level because of the heterogeneity in definitions used across studies. Multiple factors determine nonadherence and nonpersistence, including at the condition, therapy, patient, social/economic, and health systems/healthcare team levels. Moderate quality evidence points to lower baseline vision and poorer response to treatment as condition-related variables. The effects of other factors were of lower certainty, predominantly due to small numbers and potential biases in retrospective assessment. Although many factors are not modifiable (e.g., patient comorbidity), other factors are potentially correctable (e.g., lack of transport or mismatched patient expectations). Evidence on strategies to improve adherence and persistence is limited, but where available, these have proven effective. CONCLUSIONS: Awareness of factors related to poor patient adherence and persistence in nAMD could help identify at-risk populations and improve real-world outcomes. Further work is required to develop uniform definitions and establish high-quality evidence on interventions that can be easily implemented.

A global agenda for older adult immunization in the COVID-19 era: A roadmap for action.

Given our global interconnectedness, the COVID-19 pandemic highlights the urgency of building a global system that can support both routine and pandemic/epidemic adult immunization. As such, a framework to recommend vaccines and build robust platforms to deliver them to protect the rapidly expanding demographic of older adults is needed. Adult immunization as a strategy has the broad potential to preserve and improve medical, social, and economic outcomes, including maintaining functional ability that benefits older adults, their families, communities, and countries. While we will soon have multiple vaccines against COVID-19, we must recognize that we already have a variety of vaccines against other pathogens that can keep adults healthier. They can prevent simultaneous co-infection with COVID-19, and may favorably impact- the outcome of a COVID-19 illness. Further, administering a vaccine against COVID-19 requires planning now to determine delivery strategies impacting how older adults will be immunized in a timely manner. A group of international experts with various backgrounds from health and aging disciplines met to discuss the evidence case for adult immunization and crucial knowledge gaps that must be filled in order to implement effective policies and programs for older adult immunization. This group, coming together as the International Council on Adult Immunization (ICAI), outlined a high-level roadmap to catalyze action, provide policy guidance, and envision a global adult immunization platform that can be adapted by countries to fit their local contexts. Further meetings centered around the value of adult immunization, particularly in the context of COVID-19. There was agreement that programs to deliver existing influenza, pneumococcal, herpes zoster vaccines, and future COVID-19 vaccines to over a billion older adults who are at substantially higher risk of death and disability due to vaccine-preventable diseases are more urgent than ever before. Here we present a proposed framework for delivering routine and pandemic vaccines. We call upon the global community and governments to prioritize action for integrating robust adult immunization programs into the public health agenda.

Correction to: Fundamental principles of an effective diabetic retinopathy screening program.

Authors would like to correct few errors in their publication which are listed below.

Fundamental principles of an effective diabetic retinopathy screening program.

BACKGROUND: Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults worldwide. Early detection and treatment are necessary to forestall vision loss from DR. METHODS: A working group of ophthalmic and diabetes experts was established to develop a consensus on the key principles of an effective DR screening program. Recommendations are based on analysis of a structured literature review. RESULTS: The recommendations for implementing an effective DR screening program are: (1) Examination methods must be suitable for the screening region, and DR classification/grading systems must be systematic and uniformly applied. Two-field retinal imaging is sufficient for DR screening and is preferable to seven-field imaging, and referable DR should be well defined and reliably identifiable by qualified screening staff; (2) in many countries/regions, screening can and should take place outside the ophthalmology clinic; (3) screening staff should be accredited and show evidence of ongoing training; (4) screening programs should adhere to relevant national quality assurance standards; (5) studies that use uniform definitions of risk to determine optimum risk-based screening intervals are required; (6) technology infrastructure should be in place to ensure that high-quality images can be stored securely to protect patient information; (7) although screening for diabetic macular edema (DME) in conjunction with DR evaluations may have merit, there is currently insufficient evidence to support implementation of programs solely for DME screening. CONCLUSION: Use of these recommendations may yield more effective DR screening programs that reduce the risk of vision loss worldwide.

Pharmacy-based interventions to increase vaccine uptake: report of a multidisciplinary stakeholders meeting.

BACKGROUND: Despite the existence of efficacious vaccines, the burden of vaccine-preventable diseases remains high and the potential health benefits of paediatric, adolescent and adult vaccination are not being achieved due to suboptimal vaccine coverage rates. Based on emerging evidence that pharmacy-based vaccine interventions are feasible and effective, the European Interdisciplinary Council for Ageing (EICA) brought together stakeholders from the medical and pharmacy professions, the pharmaceutical industry, patient/ageing organisations and health authorities to consider the potential for pharmacy-based interventions to increase vaccine uptake. We report here the proceedings of this 3-day meeting held in March 2018 in San Servolo island, Venice, Italy, focussing firstly on examples from countries that have introduced pharmacy-based vaccination programmes, and secondly, listing the barriers and solutions proposed by the discussion groups. CONCLUSIONS: A range of barriers to vaccine uptake have been identified, affecting all target groups, and in various countries and healthcare settings. Ease of accessibility is a potentially modifiable determinant in vaccine uptake, and thus, improving the diversity of settings where vaccines can be provided to adults, for example by enabling community pharmacists to vaccinate, may increase the number of available opportunities for vaccination.

Latin American Adult Immunisation Advocacy Summit: Overcoming regional barriers to adult vaccination.

Older adults in Latin America are at an increased risk of hospitalisation, ill health, catastrophic disability and death due to vaccine-preventable diseases such as influenza, herpes zoster, and pneumonia. The Latin American Adult Immunisation Advocacy Summit, held in Mexico City, gathered 40 experts in health, ageing and immunisation from 12 Latin American countries to explore good practices of adult vaccination, key country and regional barriers, and strategies to overcome these barriers. The Summit comprised of introductory lectures, plenary panels and breakout sessions with the overarching goal of improving adult vaccination uptake rates throughout the region. Several key messages and recommendations arose from the Summit. Delegates agreed upon the need for a paradigm shift in thinking towards a life course perspective on vaccination to sustain good health throughout life and promote well-being, dignity and functional capacity in older age. Delegates revealed the need for national financial commitment to fixed and irrevocable funding for universal vaccination and the urgent requirement for robust scientific, epidemiologic research in Latin American communities on the cost benefits of such coverage. The recommendations were strengthened through a common understanding of the unique multisectoral and multidisciplinary collaborations essential to influence and help shape public policy.

Adult immunisation: A key element of public health programs: Synopsis of Asia Pacific Adult Immunisation Meeting, Tokyo, 1-2 December 2016.

OBJECTIVES: To (i) improve scientific knowledge and understanding of the importance of adult vaccination within a public health framework; (ii) share an understanding of the principles of good practice that have improved adult vaccination uptake rates; (iii) appreciate the diverse nature of country-specific barriers; and (iv) reach consensus on principles of a call to action to increase adult vaccination uptake rates. METHODS: Non-governmental organisations, the International Federation on Ageing and Friends of International Federation on Ageing Japan, convened the Asia Pacific Adult Immunisation Meeting, herein referred to as the 'Asia Pacific Meeting'. RESULTS: Delegates identified fundamental barriers to adult vaccination similar to those reported at previous meetings in Latin America and Europe and formed a road map to respond to key barriers in countries represented at the Asia Pacific Meeting. CONCLUSION: Older people are uniquely vulnerable to vaccine-preventable diseases and therefore need to be the target of a series of actions intended to improve uptake rates in this subpopulation.