Case Analysis of Factors Contributing to Patient Falls.

Falls are a constant risk for patients in acute-care hospitals, which can lead to serious consequences. The purpose of this study was to examine hospital fall case studies and to learn the contributing factors for patient falls. This was achieved by conducting a secondary analysis of 11 fall case studies obtained from two previous studies. The fall cases used the Senior Falls Investigative Methodology (SFIM) approach, which provided detailed analysis of the circumstances surrounding the falls. A total of 549 contributing factors were identified in the 11 case studies, where major categories were classified according to the four different layers of defenses using Reason's Swiss Cheese Model of Accident Causation (organizational factors, supervision, preconditions, and unsafe acts). Hospital policies, reduced supervision, disease processes, the environment, and patients transferring without assistance dominated the reasons for increased risk. Additional strategies were recommended for all layers of defense to reduce patient falls.

Risk Factors Associated With Bordetella pertussis Among Infants ≤4 Months of Age in the Pre-Tdap Era: United States, 2002-2005.

BACKGROUND: In the United States, infants have the highest reported pertussis incidence and death rates. Improved understanding of infant risk factors is needed to optimize prevention strategies. METHODS: We prospectively enrolled infants ≤4 months of age with incident-confirmed pertussis from 4 sites during 2002-2005 (preceding pertussis antigen-containing vaccination recommendations for adolescents/adults); each case-patient was age and site matched with 2 control subjects. Caregivers completed structured interviews. Infants and their contacts ≥11 years of age were offered serologic testing for IgG; being seropositive was defined as ≥94 antipertussis toxin IgG enzyme-linked immunosorbent assay units per milliliter. RESULTS: Enrolled subjects (115 case-patients; 230 control subjects) had 4396 contacts during incubation periods; 83 (72%) case-patients had ≥1 contact with prolonged (≥5 days) new cough in primary or secondary households. In multivariable analysis, the odds for pertussis were higher for infants with primary/secondary household contacts who had a prolonged new cough, compared with infants who did not. These contacts included mother [adjusted matched odds ratio (aMOR), 43.8; 95% confidence interval (CI), 6.45-298.0] and ≥1 nonmother contact (aMOR, 20.1; 95% CI, 6.48-62.7). Infants receiving breast milk with 0-1 formula feedings daily had decreased pertussis odds (aMOR, 0.27; 95% CI, 0.08-0.89), compared with those receiving more formula. Of 41 tested case-patients, 37 (90%) were seropositive. CONCLUSIONS: Pertussis in infants was associated with prolonged new cough (≥5 days) in infants' household contacts. Findings suggest that breastfeeding protects against pertussis and warrants recommendation with pertussis prevention strategies, which currently include pertussis vaccination of pregnant mothers and infants' close contacts.

Comparing active and passive varicella surveillance in Philadelphia, 2005-2010: recommendations for the transition to nationwide passive varicella disease surveillance.

OBJECTIVE: The Philadelphia Department of Public Health (PDPH) conducts active surveillance for varicella in West Philadelphia. For its approximately 300 active surveillance sites, PDPH mandates biweekly reports of varicella (including zero cases) and performs intensive case investigations. Elsewhere in Philadelphia, surveillance sites passively report varicella cases, and abbreviated investigations are conducted. We used active varicella surveillance program data to inform the transition to nationwide passive varicella surveillance. METHODS: We compared classification of reported cases, varicella disease incidence, and reporting completeness for active and passive surveillance areas for 2005-2010. We assessed reporting completeness using capture-recapture analysis of 2- to 18-year-old cases reported by schools/daycare centers and health-care providers. RESULTS: From 2005 to 2010, PDPH received 3,280 passive and 969 active surveillance varicella case reports. Most passive surveillance reports were classified as probable cases (18% confirmed, 56% probable, and 26% excluded), whereas nearly all of the active surveillance reports were either confirmed or excluded (36% confirmed, 11% probable, and 53% excluded). Overall incidence rates calculated using confirmed/probable cases were similar in the active and passive surveillance areas. Detection of laboratory-confirmed, breakthrough, and moderate-to-severe cases was equivalent for both surveillance areas. CONCLUSIONS: Although active surveillance for varicella results in better classified cases, passive surveillance provides comparable data for monitoring disease trends in breakthrough and moderate-to-severe varicella. To further improve passive surveillance in the two-dose-varicella vaccine era, jurisdictions should consider conducting periodic enhanced surveillance, encouraging laboratory testing, and collecting additional varicella-specific variables for passive surveillance.

Impact of a routine two-dose varicella vaccination program on varicella epidemiology.

OBJECTIVE: One-dose varicella vaccination for children was introduced in the United States in 1995. In 2006, a second dose was recommended to further decrease varicella disease and outbreaks. We describe the impact of the 2-dose vaccination program on varicella incidence, severity, and outbreaks in 2 varicella active surveillance areas. METHODS: We examined varicella incidence rates and disease characteristics in Antelope Valley (AV), CA, and West Philadelphia, PA, and varicella outbreak characteristics in AV during 1995-2010. RESULTS: In 2010, varicella incidence was 0.3 cases per 1000 population in AV and 0.1 cases per 1000 population in West Philadelphia: 76% and 67% declines, respectively, since 2006 and 98% declines in both sites since 1995; incidence declined in all age groups during 2006-2010. From 2006-2010, 61.7% of case patients in both surveillance areas had been vaccinated with 1 dose of varicella vaccine and 7.5% with 2 doses. Most vaccinated case patients had <50 lesions with no statistically significant differences among 1- and 2-dose cases (62.8% and 70.3%, respectively). Varicella-related hospitalizations during 2006-2010 declined >40% compared with 2002-2005 and >85% compared with 1995-1998. Twelve varicella outbreaks occurred in AV during 2007-2010, compared with 47 during 2003-2006 and 236 during 1995-1998 (P < .01). CONCLUSIONS: Varicella incidence, hospitalizations, and outbreaks in 2 active surveillance areas declined substantially during the first 5 years of the 2-dose varicella vaccination program. Declines in incidence across all ages, including infants who are not eligible for varicella vaccination, and adults, in whom vaccination levels are low, provide evidence of the benefit of high levels of immunity in the population.

Validity of medical record documented varicella-zoster virus among unvaccinated cohorts.

BACKGROUND: A varicella diagnosis or verification of disease history by any healthcare provider is currently accepted for determining evidence of immunity by the Advisory Committee on Immunization Practices (ACIP). OBJECTIVE: To examine the accuracy of medical record (MR) documented varicella history as a measure of varicella-zoster virus (VZV) immunity among unvaccinated individuals born after 1980. We also assessed methods to practically implement ACIP guidelines to verify varicella history using medical records. STUDY DESIGN: As part of a larger cross-sectional study conducted at three Philadelphia clinics from 2004-2006, we recruited 536 unvaccinated patients aged 5-19 y (birth years: 1985-2001). Varicella history was obtained from three sources: parent/patient interview, any MR documentation (sick and well visits) and MR documentation of a sick visit for varicella. All participants were tested for VZV IgG. For each source and three age groups (5-9, 10-14, 15-19 y old), positive predictive value (PPV) was calculated. Specificity of varicella history was compared between different sources using McNemar's Chi-square. RESULTS: Among participants aged 5-9, 10-14 and 15-19 y the PPV for any MR documentation and sick visit diagnosis were 96% and 100%, 92% and 97%, and 99% and 100%, respectively. The specificity for sick visit documentation was higher than any MR documentation and patient/parent recall among all age groups; however, these differences were only statistically significant when comparing sick visit documentation to parent/patient recall for 10-14 y olds. CONCLUSION: Sick visit documentation of varicella in the MR is an accurate predictor of varicella seropositivity and useful for confirming disease history among unvaccinated persons (birth years: 1985-2001). This method is a practical way to verify varicella history using the ACIP guidelines.

Association of postpartum maternal tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine administration and timeliness of infant immunization.

A retrospective cohort study was conducted on infants of mothers delivering at an inner-city hospital in October 2009 where postpartum maternal tetanus toxoid, reduced diptheria toxoid and acellular pertussis (Tdap) vaccination had been initiated in May 2008. We compared mothers and infants in a Tdap intervention group discharged July 2008 (n=250) with a pre-Tdap control group discharged July 2007 (n=238). Postpartum maternal Tdap impacted positively timeliness of early infant immunization.

Varicella immunity in vaccinated healthcare workers.

BACKGROUND: Nosocomial spread of varicella-zoster virus (VZV) infection can cause severe disease among vulnerable patient-populations and healthcare personnel (HCP). Limited data are available on duration of varicella vaccine-induced protection among adults and to what extent cell-mediated immunity (CMI) and antibody avidity contribute to protection. OBJECTIVE: Evaluate humoral and cell-mediated immune responses of HCP who received a 2-dose regimen of varicella vaccine, and observe the responses to a 3rd vaccine dose among HCP who were seronegative after vaccination. STUDY DESIGN: A convenience sample of HCP with documented 2 doses of varicella vaccine was used to assess acquired VZV immune parameters (cytokine production, IgG avidity). HCP seronegative after 2 doses of vaccine were offered a third dose and evaluated further. Vaccine recipients' immune responses were compared with responses from persons with history of wild-type VZV infection. RESULTS: The convenience sample consisted of 101 HCP with documented 2 doses of varicella vaccine; 12 (11.9%) were seronegative post-vaccination. 11.5% of 61 seropositive 2-dose recipients produced low avidity antibody, suggesting suboptimal response to vaccine. Seven 2-dose vaccinees who were VZV seronegative seroconverted after a third dose; however, 3/7 (42.9%) produced low avidity IgG. 142 persons with a history of varicella were all VZV IgG seropositive, and all had moderate to high avidity IgG. CONCLUSIONS: Measurements of serum IgG titers alone may not accurately reflect vaccine protection. Varicella vaccination of HCP remains important but further studies are needed to evaluate CMI and antibody avidity responses in HCP vaccinated with two doses of varicella vaccine.

Knowledge, attitudes, and practices for diagnosing breakthrough varicella in the outpatient setting.

OBJECTIVES: We assessed provider knowledge, attitudes, and practices for the management of breakthrough varicella and identified barriers to implementation of laboratory testing and reporting. METHODS: We surveyed 145 health-care providers (HCPs) from 30 pediatric practices in Philadelphia who did not have a history of laboratory testing for breakthrough varicella. The self-administered survey instrument collected information on clinicians' practices for management of children presenting with rash, infection-control strategies, reporting to public health agencies, and laboratory testing. RESULTS: Among the 144 HCPs who completed the survey, 73 (51%) had practiced for more than 10 years. While 115 HCPs (80%) would elect to evaluate a child with rash in the office, only 19 (13%) would submit diagnostics. When patients had a known recent exposure to varicella, 84 HCPs (58%) would use laboratory tests: 40% would use direct fluorescent antibody staining on a specimen from a cutaneous lesion, 24% would use polymerase chain reaction on a lesion specimen, 21% would use acute and convalescent serology, and 10% would use other tests. While waiting for test results, 82 HCPs (57%) would advise that the child be kept at home, 39 (27%) would notify the local health department, and 33 (23%) would inform the school nurse. CONCLUSION: As varicella becomes increasingly uncommon, laboratory confirmation becomes more critical for appropriate diagnosis, similar to poliomyelitis and measles. Our findings suggest that HCPs need further education regarding laboratory confirmation, containment, and reporting of breakthrough varicella.

Transmission of varicella zoster virus from individuals with herpes zoster or varicella in school and day care settings.

BACKGROUND: Because the varicella incidence has declined following varicella vaccine licensure, herpes zoster (HZ) cases may play a larger role in varicella zoster virus (VZV) transmission. We investigated how HZ and varicella cases contribute to the varicella incidence in schools and day care centers. METHODS: Surveillance data collected in Philadelphia during September 2003-June 2010 were analyzed. A varicella case was considered to be sporadic if it was reported from a school or day care facility >6 weeks after or ≥10 days before other reports of VZV transmission. A varicella case was considered to be secondary if it occurred 10-21 days after report of a case of HZ or sporadic varicella. Analysis compared VZV transmission from individuals with HZ or sporadic varicella, stratified by varicella vaccination status and disease severity. RESULTS: Of 290 HZ cases reported, 27 (9%) resulted in 84 secondary varicella cases. Of 1358 sporadic varicella cases reported, 205 (15%) resulted in 564 secondary varicella cases. Approximately half of the HZ and sporadic varicella cases resulted in single secondary cases. The proportion of individuals who had secondary cases with mild disease was similar for those exposed to HZ and those exposed to varicella (70% and 72%, respectively). VZV transmission was highest from unvaccinated individuals with sporadic varicella (P < .01). CONCLUSIONS: VZV transmission from individuals with HZ contributes to varicella morbidity. More research is needed to understand risk factors and guide recommendations for preventing VZV transmission from individuals with HZ.

How the immune response to vaccines is created, maintained and measured: addressing patient questions about vaccination.

This article gives an overview of the immune response to vaccines, including ways in which it is measured and/or augmented to enhance its effectiveness. A brief description is given of the immune response, adaptive immunity, immunologic memory, antibodies, and adjuvants. Given that many young parents and physicians have never witnessed the ravages of vaccine-preventable diseases, it is hoped this article will aid the many people involved in the prevention of infectious disease to understand better the concepts and practicalities of immunization and vaccine development.

Varicella in infants after implementation of the US varicella vaccination program.

OBJECTIVE: To describe varicella disease in infants since implementation of the varicella vaccination program in the United States. PATIENTS AND METHODS: From 1995 to 2008, demographic, clinical, and epidemiologic data on cases of varicella in infants were collected prospectively through a community-based active surveillance project. We examined disease patterns for infants in 2 age groups: 0 to 5 and 6 to 11 months. RESULTS: Infant varicella disease incidence declined 89.7% from 1995 to 2008. Infants aged 0 to 5 months had milder clinical disease than those aged 6 to 11 months: ≥50 lesions, 49% vs 58% (P = .038); fever (body temperature > 38°C), 12% vs 21% (P = .014); and varicella-related complications, 6% vs 14% (P = .009), respectively. Age was an independent predictor of the occurrence of complications. CONCLUSIONS: The varicella vaccination program has resulted in substantial indirect benefits for infants, who are not eligible for vaccination. Presence of maternal varicella-zoster virus antibodies might explain attenuated disease in very young infants likely born to mothers with history of varicella. Although varicella disease incidence has declined, exposure to varicella-zoster virus continues to occur. Improving varicella vaccination coverage in all age groups will further reduce the risk of varicella exposure and protect those not eligible for varicella vaccination.

Evaluation of laboratory methods for diagnosis of varicella.

BACKGROUND: The incidence of varicella disease is declining as a result of vaccination, making clinical diagnosis more challenging, particularly for vaccine-modified cases. We conducted a comprehensive evaluation of laboratory tests and specimen types to assess diagnostic performance and determine what role testing can play after skin lesions have resolved. METHODS: We enrolled patients with suspected varicella disease in 2 communities. Enrollees were visited at the time of rash onset and 2 weeks later. Multiple skin lesion, oral, urine, and blood or serum specimens were requested at each visit and tested for varicella zoster virus (VZV) immunoglobulin (Ig) G, IgM, and IgA antibody by enzyme-linked immunoassay; for VZV antigen by direct fluorescent antibody; and/or for VZV DNA by polymerase chain reaction (PCR). Clinical certainty of the diagnosis of varicella disease was scored. PCR results from first-visit vesicles or scab specimens served as the gold standard in assessing test performance. RESULTS: Of 93 enrollees, 53 were confirmed to have varicella disease. Among 20 unmodified cases, PCR testing was 95%-100% sensitive for macular and/or papular lesions and for oral specimens collected at the first visit; most specimens from the second visit yielded negative results. Among 27 vaccine-modified cases, macular and/or papular lesions collected at the first visit were also 100% sensitive; yields from other specimens were poorer, and few specimens from the second visit tested positive. Clinical diagnosis was 100% and 85% sensitive for diagnosing unmodified and vaccine-modified varicella cases, respectively. CONCLUSIONS: PCR testing of skin lesion specimens remains convenient and accurate for diagnosing varicella disease in vaccinated and unvaccinated persons. PCR of oral specimens can sometimes aid in diagnosis of varicella disease, even after rash resolves.

Incremental effectiveness of second dose varicella vaccination for outbreak control at an elementary school in Philadelphia, pennsylvania, 2006.

BACKGROUND: In 2006, the Philadelphia Department of Public Health conducted an investigation of a varicella outbreak at an elementary school in which second-dose vaccination for outbreak control (VOC) was implemented. We evaluated the effectiveness of this intervention. METHODS: Self-administered questionnaires collected varicella disease and vaccination information. Students eligible for second-dose VOC were 1-dose vaccine recipients without prior varicella disease. A breakthrough varicella case was defined as a maculopapulovesicular rash in a student with onset >42 days after 1-dose vaccination without other apparent cause. Vaccine effectiveness was evaluated using survival analysis techniques and analyzed by vaccine status (first dose versus second dose). Multivariable Cox proportional hazard models were used to identify statistical interactions and adjust for confounders. RESULTS: The questionnaire response rate was 92% (342/370). Of the 286 eligible students, 187 (65%) received a second-dose VOC. The crude attack rate was 9/187 (5%) among second-dose VOC recipients; 43/99 (43%) among 1-dose recipients, and 5/6 (83%) among unvaccinated students. Second-dose VOC recipients had milder rashes, compared with 1-dose or unvaccinated students. The adjusted incremental second-dose vaccine effectiveness was 76% (95% confidence interval: 44%-90%) for students with classroom exposure. Incremental effectiveness was similar (79%) when we extended the immune response time from 4 days to 7 days after second-dose VOC. CONCLUSIONS: Second-dose VOC resulted in a substantial reduction in varicella incidence for students with classroom exposure. Until high rates of routine second-dose vaccine coverage are achieved, clinicians should consider second-dose VOC an appropriate intervention to reduce disease transmission in institution-based outbreaks.

Experiences and needs of bereaved carers during palliative and end-of-life care for people with chronic obstructive pulmonary disease.

AIM: This study explored the experiences of palliative care that bereaved carers had while providing care to a dying loved one with chronic obstructive pulmonary disease (COPD). METHOD: Semi-structured interviews were undertaken with nine carers who had lost a loved one in the preceding 6 to 24 months. These interviews explored levels of satisfaction with disease management, symptom management, and end-of-life care. With permission, interviews were tape recorded, transcribed, and subjected to content analysis. FINDINGS: Three themes emerged from the data: the impact of the caring experience, the lack of support services, and end-of-life and bereavement support. Carers experienced carer burden, lack of access to support services, a need for palliative care, and bereavement support. CONCLUSION: The findings provide a first insight into the experiences of carers of patients with advanced COPD. Bereaved carers of patients who had suffered advanced COPD reported that they had received inadequate support and had a range of unmet palliative care needs. Special attention should be paid to educating and supporting carers during their caring and bereavement periods to ensure that their quality of life is maintained or enhanced.

Validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated children, adolescents, and young adults in the post-vaccine licensure era.

OBJECTIVES: We assessed the validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated persons 1 to 29 years of age, and we examined varicella disease characteristics associated with varicella zoster virus immunity among those reporting positive histories. METHODS: We conducted a cross-sectional study at 7 community-based sites in Philadelphia, Pennsylvania, between June 2004 and May 2006 and recruited 1476 participants 1 to 29 years of age who had not been vaccinated against varicella. Sensitivity, specificity, and positive predictive value were determined by comparing self-reported or parent-reported varicella histories from a standardized study interview with varicella zoster virus immunoglobulin G serological results for each participant. We performed multivariate logistic regression analyses to determine which disease characteristics best predicted seropositivity. RESULTS: The sensitivity of reported varicella history was highest (81%-89%) among participants > or =10 years of age, whereas specificity was highest among participants 1 to 4 years of age (99%) and > or =20 years (88%). Reported varicella history was highly predictive of seropositivity (>95%) only among participants > or =15 years of age. For participants 10 to 14 years of age, parental reports of a generalized itchy rash with 1 of the following were highly predictive of seropositivity: varicella transmission to another household member or being raised in a household with no other children. Among participants < or =9 years of age, no combination of disease characteristics was both highly predictive of seropositivity and common. CONCLUSIONS: The validity of reported varicella history varies according to age, and a reported history is no longer highly predictive of seropositivity among cohorts born since 1994 (participants < or =9 years of age). Universal varicella vaccination, regardless of history, for these children should be considered, as should simplified criteria for varicella zoster virus immunity among unvaccinated persons born before 1994.

Identifying infants at increased risk for late initiation of immunizations: maternal and provider characteristics.

OBJECTIVE: We identified maternal, provider, and community predictors among infants for late initiation of immunizations. METHODS: We performed a retrospective cohort study of infants born between January 1, 2002, and December 31, 2004, in Philadelphia, Pennsylvania. Primary outcomes were age in days at first office-based immunization and status as a late starter (i.e., initiating office-based immunizations after 90 days of age). Candidate predictors included sociodemographic and prenatal characteristics, immunization provider practice type and size, and neighborhood factors. We performed hierarchical logistic regression and Cox regression models to identify independent predictors for being a late starter and prolonged time to first immunization. RESULTS: Of the 65,519 infants from this birth cohort in Philadelphia's immunization registry, 54,429 (88.1%) were included in analysis and 12.6% of these were late starters. Infants whose mothers were younger, received less than five prenatal visits, had less than a high school education, had more than two children, and who smoked cigarettes prenatally were significantly more likely to be late starters. Receiving care at hospital/university-based or public health clinics was also significantly associated with likelihood of being a late starter. Neither distance between infant's residence and practice nor neighborhood socioeconomic indicators was independently associated with the outcomes. Common risk factor profiles based on practice type and four maternal characteristics were found to reliably identify infant risk. CONCLUSIONS: Maternal receipt of fewer prenatal care visits, younger maternal age, higher birth order, and receiving care at public health clinics were the strongest predictors of being a late starter and time to first immunization. Risk factor profiles based on information already collected at birth can be used to identify higher-risk infants. Early intervention and potentially partnering with prenatal care providers may be key strategies for preventing underimmunization.

Active carers: living with chronic obstructive pulmonary disease.

It has long been recognised that the majority of care provided in chronic illness comes not from health and social care professionals, but from family and friends. One such illness is chronic obstructive pulmonary disease (COPD), a leading cause of morbidity and mortality in the developed world.To explore the specific care needs of informal caregivers of patients with advanced COPD, interviews were conducted with seven active family caregivers. Interviews were taped, transcribed and content analysed to obtain the caregivers' needs. Results confirm that family caregivers provide direct care with little support and assistance. Participants reported restricted activities of daily living and some emotional distress. There were knowledge deficiencies among caregivers relating to the COPD illness trajectory and little awareness of the potential of palliative care. Family caregivers need social and professional support while caring for a patient at home. This would help to ensure that their physical and emotional health does not suffer. There is a need to devise interventions to ensure family caregivers are supported.

Implementation of rotavirus immunization in Philadelphia, Pennsylvania: high levels of vaccine ineligibility and off-label use.

OBJECTIVE: Our goal was to predict, using delayed diphtheria-tetanus-acellular pertussis vaccination as an indicator, whether the current narrowly defined age limits for pentavalent rotavirus vaccine exclude a substantial proportion of children from complete immunization against rotavirus and to assess adherence of providers to recommended age limits by examining the first 6 months of use of pentavalent rotavirus vaccine in Philadelphia, Pennsylvania. PATIENTS AND METHODS: Data from a computerized children's immunization registry in Philadelphia were analyzed. Demographics and age at immunization with first 3 diphtheria-tetanus-acellular pertussis doses were examined from 2001 to 2005. Similar characteristics were evaluated for children who received pentavalent rotavirus vaccine doses during the first 6 months of its availability (August 2006 through January 2007). RESULTS: During the 5-year period, 24 403 of 103 967 recipients of first diphtheria-tetanus-acellular pertussis vaccine were >12 weeks of age; only 56 411 of 79 564 first diphtheria-tetanus-acellular pertussis recipients 12 weeks of age. Hospital-based providers were less likely to administer pentavalent rotavirus vaccine off-label. CONCLUSIONS: With the current level of vaccine implementation and current pentavalent rotavirus vaccine recommendations for series initiation, a substantial proportion of children are expected to be excluded from receiving any pentavalent rotavirus vaccine or completing the series. In the first 6 months of availability, pentavalent rotavirus vaccine frequently was used off-label for age, underscoring the importance of education of immunization providers. Current outreach programs for finding 10-month-old toddlers delinquent for immunizations will not improve the possibility of protection against rotavirus.