Timeliness of Early Childhood Vaccinations and Undervaccination Patterns in Montana.

INTRODUCTION: Early childhood vaccination rates are lower in rural areas than those in urban areas of the U.S. This study's objective is to quantify vaccine timeliness and the prevalence of undervaccination patterns in Montana and to measure the associations between timeliness and series completion by age 24 months. METHODS: Using records from January 2015 to November 2019 in Montana's centralized immunization information system, days undervaccinated were calculated for the combined 7-vaccine series. Undervaccination patterns indicative of certain barriers to vaccination, including parental vaccine hesitancy, were identified. Using multivariable log-linked binomial regression, the association between timing of vaccine delay and not completing the combined 7-vaccine series by age 24 months was assessed. Analyses were conducted in March 2020-August 2020. RESULTS: Among 31,422 children, 38.0% received all vaccine doses on time; 24.3% received all doses, but some were received late; and 37.7% had not completed the combined 7-vaccine series. Approximately 18.7% had an undervaccination pattern suggestive of parental vaccine hesitancy, and 19.7% started all series but were missing doses needed for multidose series completion. Although falling behind on vaccinations at any age was associated with failing to complete the combined 7-vaccine series, being late at age 12-15 months had the strongest association (adjusted prevalence ratio=3.73, 95% CI=3.56, 3.91) compared with being on time at age 12-15 months. CONCLUSIONS: Fewer than 2 in 5 Montana children were fully vaccinated on time for the combined 7-vaccine series. To increase vaccination rates, initiatives to increase vaccine confidence and remind parents to complete vaccine series are needed.

COVID-19 Incidence and Mortality Among American Indian/Alaska Native and White Persons - Montana, March 13-November 30, 2020.

Geographic differences in infectious disease mortality rates have been observed among American Indian or Alaska Native (AI/AN) persons in the United States (1), and aggregate analyses of data from selected U.S. states indicate that COVID-19 incidence and mortality are higher among AI/AN persons than they are among White persons (2,3). State-level data could be used to identify disparities and guide local efforts to reduce COVID-19-associated incidence and mortality; however, such data are limited. Reports of laboratory-confirmed COVID-19 cases and COVID-19-associated deaths reported to the Montana Department of Public Health and Human Services (MDPHHS) were analyzed to describe COVID-19 incidence, mortality, and case-fatality rates among AI/AN persons compared with those among White persons. During March-November 2020 in Montana, the estimated cumulative COVID-19 incidence among AI/AN persons (9,064 cases per 100,000) was 2.2 times that among White persons (4,033 cases per 100,000).* During the same period, the cumulative COVID-19 mortality rate among AI/AN persons (267 deaths per 100,000) was 3.8 times that among White persons (71 deaths per 100,000). The AI/AN COVID-19 case-fatality rate (29.4 deaths per 1,000 COVID-19 cases) was 1.7 times the rate in White persons (17.0 deaths per 1,000). State-level surveillance findings can help in developing state and tribal COVID-19 vaccine allocation strategies and assist in local implementation of culturally appropriate public health measures that might help reduce COVID-19 incidence and mortality in AI/AN communities.

Continuous subcutaneous infusion of opiates at end-of-life.

OBJECTIVE: To review pertinent controlled trials using the continuous subcutaneous infusion of opioids (CSIO) at end-of-life and offer insight to pharmacists and clinicians into the appropriate use of this route of administration. DATA SOURCES: A MEDLINE search for information regarding the subcutaneous administration of opioids in terminally ill patients (1975-December 2002) was conducted using the key words subcutaneous, narcotics, morphine, hydromorphone, fentanyl, pain, hospices, and palliative care. Additional references were located through review of bibliographies of the articles cited. Case reports and postsurgical studies were excluded. Searches were limited to English-language studies using humans. STUDY SELECTION AND DATA EXTRACTION: Experimental and observational studies were evaluated, using prospective trials as the evidence base for conclusions and including pertinent retrospective trials as they relate to the subcutaneous infusion of opioids at end-of-life. DATA SYNTHESIS: CSIO is effective and safe for use in terminal illness. Appropriate situations for consideration of CSIO are when difficulties arise in using the oral route, standard oral opiate therapy has failed adequate trials, the patient has limited intravenous access, adequate supervision of the CSIO is present, and CSIO will not unduly limit the functional activity of the patient. CONCLUSIONS: CSIO has a proven role in the management of pain at end-of-life. CSIO should not be considered the first route for administration of opiates, but does offer distinct advantages in the appropriate setting. CSIO continues to be a choice for end-of-life patients and is gradually becoming a standard practice in palliative medicine.

Sequential hydride generation/pneumatic nebulisation inductively coupled plasma mass spectrometry for the fractionation of arsenic and selenium species.

The toxicity of certain elements is known to be related to their organic substituents and/or oxidation states. As such, total elemental determinations do not always yield sufficient information for accurate risk assessments and therefore speciation or fractionation data are required. In order to obtain fractionation data for trace levels of arsenic and selenium, a novel sequential pneumatic nebulisation (PN)/hydride generation (HG) inductively coupled plasma mass spectrometry (ICP-MS) method was developed. The method offers the advantage of sample introduction via either PN or HG by simply rotating a 4-way switching valve while the system is in operation. In PN mode, the liquid sample is aspirated into ICP, allowing for the determination of the total amount of each element, whilst in HG mode only the arsenic and selenium species that form volatile hydrides are determined. Conveniently, in the case of arsenic, this allows for differentiation between the four most toxic arsenic species (arsenate, arsenite, monomethylarsonic acid and dimethylarsinic acid), which form volatile hydrides, and the virtually non-toxic forms (arsenobetaine, arsenosugars, etc.), which do not. This allows for the rapid estimation of the amounts of toxic and non-toxic arsenic species present in a sample. For arsenic, the technique gave detection limits of 36 ng l(-1) in PN mode and 1 ng l(-1) in HG mode. For selenium, detection limits of 150 ng l(-1) were achieved in PN mode and 220 ng l(-1) in HG mode. The technique also gave good long- and short-term stabilities of under 6% RSD for both elements. A variety of samples, including water and urine standard reference materials, were analysed in both modes, and the precision and accuracy of the results for total arsenic and selenium levels were assessed. Using the technique in both modes also allowed for the fractionation of As and Se species into their volatile hydride-forming and non-hydride-forming species. This was particularly informative, with respect to As species present, in the case of a kelp powder extract. Digested tobacco samples were only analysed for their total As levels, in which case results obtained via both sample introduction modes showed good agreement.