Epidemiology of SARS-CoV-2 transmission and superspreading in Salt Lake County, Utah, March-May 2020.

BACKGROUND: Understanding the drivers of SARS-CoV-2 transmission can inform the development of interventions. We evaluated transmission identified by contact tracing investigations between March-May 2020 in Salt Lake County, Utah, to quantify the impact of this intervention and identify risk factors for transmission. METHODS: RT-PCR positive and untested symptomatic contacts were classified as confirmed and probable secondary case-patients, respectively. We compared the number of case-patients and close contacts generated by different groups, and used logistic regression to evaluate factors associated with transmission. RESULTS: Data were collected on 184 index case-patients and up to six generations of contacts. Of 1,499 close contacts, 374 (25%) were classified as secondary case-patients. Decreased transmission odds were observed for contacts aged <18 years (OR = 0.55 [95% CI: 0.38-0.79]), versus 18-44 years, and for workplace (OR = 0.36 [95% CI: 0.23-0.55]) and social (OR = 0.44 [95% CI: 0.28-0.66]) contacts, versus household contacts. Higher transmission odds were observed for case-patient's spouses than other household contacts (OR = 2.25 [95% CI: 1.52-3.35]). Compared to index case-patients identified in the community, secondary case-patients identified through contract-tracing generated significantly fewer close contacts and secondary case-patients of their own. Transmission was heterogeneous, with 41% of index case-patients generating 81% of directly-linked secondary case-patients. CONCLUSIONS: Given sufficient resources and complementary public health measures, contact tracing can contain known chains of SARS-CoV-2 transmission. Transmission is associated with age and exposure setting, and can be highly variable, with a few infections generating a disproportionately high share of onward transmission.

The Impact of Community-Based Testing Sites and Gift Incentives on COVID-19 Testing Uptake in Maryland, April 29 - May 9, 2021.

PURPOSE: Information on incentives for COVID-19 testing is needed to understand effective practices that encourage testing uptake. We describe characteristics of those who received an incentive after performing a rapid antigen test. DESIGN: Cross-sectional descriptive analysis of survey data. SETTING: During April 29-May 9, 2021, COVID-19 rapid antigen testing was offered in 2 Maryland cities. SAMPLE: Convenience sample of 553 adults (≥18 years) who tested and received an incentive; 93% consented to survey. MEASURES: Survey questions assessed reasons for testing, testing history, barriers, and demographics. ANALYSIS: Robust Poisson regressions were used to determine characteristic differences based on testing history and between participants who would re-test in the future without an incentive vs participants who would not. RESULTS: The most common reasons for testing were the desire to be tested (n = 280; 54%) and convenience of location (n = 146; 28%). Those motivated by an incentive to test (n = 110; 21%) were 5.83 times as likely to state they would not test again without an incentive, compared to those with other reasons for testing (95% CI: 2.67-12.72, P < .001). CRITICAL LIMITATIONS: No comparative study group. CONCLUSION: Results indicate internal motivation and convenience were prominent factors supporting testing uptake. Incentives may increase community testing participation, particularly among people who have never tested. Keywords COVID-19, pandemic, incentives, health behavior, community testing.

Tuberculosis treatment within differentiated service delivery models in global HIV/TB programming.

INTRODUCTION: Providing more convenient and patient-centred options for service delivery is a priority within global HIV programmes. These efforts improve patient satisfaction and retention and free up time for providers to focus on new HIV diagnoses or severe illness. Recently, the coronavirus disease 2019 (COVID-19) pandemic precipitated expanded eligibility criteria for these differentiated service delivery (DSD) models to decongest clinics and protect patients and healthcare workers. This has resulted in dramatic scale-up of DSD for antiretroviral therapy, cotrimoxazole and tuberculosis (TB) preventive treatment. While TB treatment among people living with HIV (PLHIV) has traditionally involved frequent, facility-based management, TB treatment can also be adapted within DSD models. Such adaptations could include electronic tools to ensure appropriate clinical management, treatment support, adherence counselling and adverse event (AE) monitoring. In this commentary, we outline considerations for DSD of TB treatment among PLHIV, building on best practices from global DSD model implementation for HIV service delivery. DISCUSSION: In operationalizing TB treatment in DSD models, we consider the following: what activity is being done, when or how often it takes place, where it takes place, by whom and for whom. We discuss considerations for various programme elements including TB screening and diagnosis; medication dispensing; patient education, counselling and support; clinical management and monitoring; and reporting and recording. General approaches include multi-month dispensing for TB medications during intensive and continuation phases of treatment and standardized virtual adherence and AE monitoring. Lastly, we provide operational examples of TB treatment delivery through DSD models, including a conceptual model and an early implementation experience from Zambia. CONCLUSIONS: COVID-19 has catalysed the rapid expansion of differentiated patient-centred service delivery for PLHIV. Expanding DSD models to include TB treatment can capitalize on existing platforms, while providing high-quality, routine treatment, follow-up and patient education and empowerment.

Coronavirus Disease Contact Tracing Outcomes and Cost, Salt Lake County, Utah, USA, March-May 2020.

Outcomes and costs of coronavirus disease (COVID-19) contact tracing are limited. During March-May 2020, we constructed transmission chains from 184 index cases and 1,499 contacts in Salt Lake County, Utah, USA, to assess outcomes and estimate staff time and salaries. We estimated 1,102 staff hours and $29,234 spent investigating index cases and contacts. Among contacts, 374 (25%) had COVID-19; secondary case detection rate was ≈31% among first-generation contacts, ≈16% among second- and third-generation contacts, and ≈12% among fourth-, fifth-, and sixth-generation contacts. At initial interview, 51% (187/370) of contacts were COVID-19-positive; 35% (98/277) became positive during 14-day quarantine. Median time from symptom onset to investigation was 7 days for index cases and 4 days for first-generation contacts. Contact tracing reduced the number of cases between contact generations and time between symptom onset and investigation but required substantial resources. Our findings can help jurisdictions allocate resources for contact tracing.

Assessing clinicians' Post-Exposure Prophylaxis recommendations for rabies virus exposures in Hunan Province, China.

BACKGROUND: Timely and appropriate administration of post-exposure prophylaxis (PEP) is an essential component of human rabies prevention programs. We evaluated patient care at rabies clinics in a high-risk county in Hunan Province, China to inform strategies needed to achieve dog-mediated human rabies elimination by 2030. METHODS: We collected information on PEP, staff capacity, and service availability at the 17 rabies clinics in the high-risk county during onsite visits and key staff interviews. Additionally, we conducted observational assessments at five of these clinics, identified through purposive sampling to capture real-time information on patient care during a four-week period. Wound categories assigned by trained observers were considered accurate per national guidelines for comparison purposes. We used the kappa statistic and an alpha level of 0.05 to assess agreement between observers and clinic staff. RESULTS: In 2015, the 17 clinics provided PEP to 5,261 patients. Although rabies vaccines were available at all 17 clinics, rabies immune globulin (RIG) was only available at the single urban clinic in the county. During the assessment period in 2016, 196 patients sought care for possible rabies virus exposures. According to observers, 88 (44%) patients had category III wounds, 104 (53%) had category II wounds and 4 (2%) had category I wounds. Observers and PEP clinic staff agreed on approximately half of the assigned wound categories (kappa = 0.55, p-value< 0.001). Agreement for the urban county-level CDC clinic (kappa = 0.93, p-value<0.001) was higher than for the township clinics (kappa = 0.16, p-value = 0.007). Using observer assigned wound categories, 142 (73%) patients received rabies vaccinations and RIG as outlined in the national guidelines. CONCLUSION: Rabies PEP services were available at each town of the project county; however, gaps between clinical practice and national rabies guidelines on the use of PEP were identified. We used these findings to develop and implement a training to rabies clinic staff on wound categorization, wound care, and appropriate use of PEP. Additional risk-based approaches for evaluating human rabies virus exposures may be needed as China progresses towards elimination.

Assessment of contact tracing for COVID-19 among people experiencing homelessness, Salt Lake County Health Department, March-May 2020.

PURPOSE: Contact tracing is intended to reduce the spread of coronavirus disease 2019 (COVID-19), but it is difficult to conduct among people who live in congregate settings, including people experiencing homelessness (PEH). This analysis compares person-based contact tracing among two populations in Salt Lake County, Utah, from March-May 2020. METHODS: All laboratory-confirmed positive cases among PEH (n = 169) and documented in Utah's surveillance system were included in this analysis. The general population comparison group (n = 163) were systematically selected from all laboratory-confirmed cases identified during the same period. RESULTS: Ninety-three PEH cases (55%) were interviewed compared to 163 (100%) cases among the general population (P < .0001). PEH were more likely to be lost to follow-up at end of isolation (14.2%) versus the general population (0%; P-value < .0001) and provided fewer contacts per case (0.3) than the general population (4.7) (P-value < .0001). Contacts of PEH were more often unreachable (13.0% vs. 7.1%; P-value < .0001). CONCLUSIONS: These findings suggest that contact tracing among PEH should include a location-based approach, along with a person-based approach when resources allow, due to challenges in identifying, locating, and reaching cases among PEH and their contacts through person-based contact tracing efforts alone.

A Prospective Cohort Study in Nonhospitalized Household Contacts With Severe Acute Respiratory Syndrome Coronavirus 2 Infection: Symptom Profiles and Symptom Change Over Time.

BACKGROUND: Improved understanding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spectrum of disease is essential for clinical and public health interventions. There are limited data on mild or asymptomatic infections, but recognition of these individuals is key as they contribute to viral transmission. We describe the symptom profiles from individuals with mild or asymptomatic SARS-CoV-2 infection. METHODS: From 22 March to 22 April 2020 in Wisconsin and Utah, we enrolled and prospectively observed 198 household contacts exposed to SARS-CoV-2. We collected and tested nasopharyngeal specimens by real-time reverse-transcription polymerase chain reaction (rRT-PCR) 2 or more times during a 14-day period. Contacts completed daily symptom diaries. We characterized symptom profiles on the date of first positive rRT-PCR test and described progression of symptoms over time. RESULTS: We identified 47 contacts, median age 24 (3-75) years, with detectable SARS-CoV-2 by rRT-PCR. The most commonly reported symptoms on the day of first positive rRT-PCR test were upper respiratory (n = 32 [68%]) and neurologic (n = 30 [64%]); fever was not commonly reported (n = 9 [19%]). Eight (17%) individuals were asymptomatic at the date of first positive rRT-PCR collection; 2 (4%) had preceding symptoms that resolved and 6 (13%) subsequently developed symptoms. Children less frequently reported lower respiratory symptoms (21%, 60%, and 69% for <18, 18-49, and ≥50 years of age, respectively; P = .03). CONCLUSIONS: Household contacts with laboratory-confirmed SARS-CoV-2 infection reported mild symptoms. When assessed at a single timepoint, several contacts appeared to have asymptomatic infection; however, over time all developed symptoms. These findings are important to inform infection control, contact tracing, and community mitigation strategies.

Household Transmission of Severe Acute Respiratory Syndrome Coronavirus-2 in the United States.

BACKGROUND: The evidence base for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is nascent. We sought to characterize SARS-CoV-2 transmission within US households and estimate the household secondary infection rate (SIR) to inform strategies to reduce transmission. METHODS: We recruited patients with laboratory-confirmed SARS-CoV-2 infection and their household contacts in Utah and Wisconsin during 22 March 2020-25 April 2020. We interviewed patients and all household contacts to obtain demographics and medical histories. At the initial household visit, 14 days later, and when a household contact became newly symptomatic, we collected respiratory swabs from patients and household contacts for testing by SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) and sera for SARS-CoV-2 antibodies testing by enzyme-linked immunosorbent assay (ELISA). We estimated SIR and odds ratios (ORs) to assess risk factors for secondary infection, defined by a positive rRT-PCR or ELISA test. RESULTS: Thirty-two (55%) of 58 households secondary infection among household contacts. The SIR was 29% (n = 55/188; 95% confidence interval [CI], 23%-36%) overall, 42% among children (aged <18 years) of the COVID-19 patient and 33% among spouses/partners. Household contacts to COVID-19 patients with immunocompromised conditions and household contacts who themselves had diabetes mellitus had increased odds of infection with ORs 15.9 (95% CI, 2.4-106.9) and 7.1 (95% CI: 1.2-42.5), respectively. CONCLUSIONS: We found substantial evidence of secondary infections among household contacts. People with COVID-19, particularly those with immunocompromising conditions or those with household contacts with diabetes, should take care to promptly self-isolate to prevent household transmission.

Transmission Dynamics of COVID-19 Outbreaks Associated with Child Care Facilities - Salt Lake City, Utah, April-July 2020.

Reports suggest that children aged ≥10 years can efficiently transmit SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). However, limited data are available on SARS-CoV-2 transmission from young children, particularly in child care settings (3). To better understand transmission from young children, contact tracing data collected from three COVID-19 outbreaks in child care facilities in Salt Lake County, Utah, during April 1-July 10, 2020, were retrospectively reviewed to explore attack rates and transmission patterns. A total of 184 persons, including 110 (60%) children had a known epidemiologic link to one of these three facilities. Among these persons, 31 confirmed COVID-19 cases occurred; 13 (42%) in children. Among pediatric patients with facility-associated confirmed COVID-19, all had mild or no symptoms. Twelve children acquired COVID-19 in child care facilities. Transmission was documented from these children to at least 12 (26%) of 46 nonfacility contacts (confirmed or probable cases). One parent was hospitalized. Transmission was observed from two of three children with confirmed, asymptomatic COVID-19. Detailed contact tracing data show that children can play a role in transmission from child care settings to household contacts. Having SARS-CoV-2 testing available, timely results, and testing of contacts of persons with COVID-19 in child care settings regardless of symptoms can help prevent transmission. CDC guidance for child care programs recommends the use of face masks, particularly among staff members, especially when children are too young to wear masks, along with hand hygiene, frequent cleaning and disinfecting of high-touch surfaces, and staying home when ill to reduce SARS-CoV-2 transmission (4).

Evaluation of Vietnam's post-exposure prophylaxis delivery system, 2017.

BACKGROUND: Canine-mediated human rabies deaths typically occur in poor and rural populations with limited access to rabies biologics: vaccine and immunoglobulin. A critical aspect of reducing rabies deaths is understanding how these countries procure, deliver, and forecast rabies biologics. Vietnam is one of the few endemic countries where biologics is widely available. However, a formal evaluation of its current rabies biologics distribution system has not been conducted. METHODS: In 2017, we conducted a formal evaluation of Vietnam's rabies biologics distribution system. Our goals were (1) to identify centers providing rabies biologics (2) identify costs to the patient and centers and (3) assess the rabies biologic procurement and delivery system at eligible district and provincial centers (provides and orders biologics for itself and other centers directly from the manufacture). To conduct the formal evaluation, we developed a standardized survey that was distributed to centers. RESULTS: Of the 780 designated rabies biologics centers in Vietnam, 659 (84%) of them provide rabies immunoglobulin (eRIG), vaccine, or both. Of the 177 eligible centers, 90% (160) responded to the survey. The average costs to patients were $8.45 (range: 5.43-12.77) for one dose of IM injection, $13.90 (range: 11.86-16.71) for domestic eRIG, and $23 (21.11-27.11) for imported eRIG. Respondents reported experiencing delays in receiving vaccine in 50 centers and eRIG in 14 centers within the past year. Respondents stated their top three challenges in providing biologics were: delays or shortages from manufactures, lack of funds to pay for biologics, and the high cost of biologics. CONCLUSIONS AND RELEVANCE: Despite the wide availability of biologics in Vietnam, more work is needed to provide affordable and reliable supply of biologics to patients. This includes the expansion of ID injection use throughout the country to lower vaccine demand, and decrease the costs to centers and patients. Furthermore, a more coordinated effort to share biologics among centers, possibly through a more centralized system at the provincial level may alleviate delays and shortages.

Evaluating the public health response to a mass bat exposure-Wyoming, 2017.

Mass bat exposures (MBEs) occur when multiple people are exposed to a bat or a bat colony, often over an extended period. In August 2017, a public health investigation was started in response to an MBE that occurred during May-August 2017 at a national park research station in Wyoming. We identified 176 people who had slept primarily in two lodges (Lodges A and B) at the research station, and successfully contacted 165 (93.8%) of these individuals. Risk assessments (RAs) were administered to all 165 individuals to determine degree and type of exposures to bats (e.g., biting or scratching). Exposure status for research station guests was classified as "non-exposed," "low risk" or "high risk," and counselling was provided to guide post-exposure prophylaxis (PEP) recommendations. Prior to public health notification and intervention, 19 persons made the decision to pursue PEP. The healthcare-seeking behaviours of this group were taken to represent outcomes in the absence of public health intervention. (These persons received a RA, and their risk classification was retrospectively assigned.) Approximately 1-2 weeks after conducting the RAs, we conducted a follow-up survey to determine whether recommendations regarding PEP were ultimately followed. The proportion of individuals that unnecessarily pursued PEP was higher among the 19 individuals that sought health care prior to receiving the RA (p < 0.00001). Among those receiving the RA first, all persons classified as high risk followed public health guidance to seek PEP treatment. Despite this, upon re-interview, only 21/79 (26.6%) of guests could accurately recall their risk classification, with most people (55.7%) overestimating their risk. Study findings demonstrate that early public health interventions such as RAs can reduce unnecessary use of PEP and that messaging used during rabies counselling should be clear.

Rabies post-exposure prophylaxis initiation and adherence among patients in Vietnam, 2014-2016.

BACKGROUND: Adhering to post-exposure prophylaxis (PEP): wound treatment, vaccine, and rabies immunoglobulin (RIG) is a crucial step in preventing rabies mortality. When PEP is widely available, a lack of adherence to the recommended treatment guidelines can also lead to death. Our objective was to understand characteristics associated with adherence to the vaccine regimen and RIG in Vietnam. METHODS: We obtained individual-level data on PEP adherence from registries at 10 sites located in five provinces. From these registries, we extracted epidemiologic characteristics of patients including the timing of PEP initiation and completion. We used descriptive analyses and logistic regression to examine patient characteristics associated with initiation and completion of RIG and vaccine. Based on reported rabies mortality, the government defined provincial rabies burden as medium-burden (<5 and >2 deaths) and high-burden (≥5 deaths). RESULTS: During 2014-2016, 15,646 patients received PEP in our study. Among 14,296 vaccinated patients, only 41.4% (5847) completed their five-dose intramuscular (IM) injections and 81.6% (133) of patients completed their eight-dose intradermal (ID) injections. Approximately 26% of patients received RIG. Patient characteristics associated with vaccine completion were females (44%), <15 years of age (44%), category 1 exposure (68%, bite location on leg (46%), bite from bat (56%), bite from a healthy animal (45%), high-burden province (86%), and district preventive center (49%). Disparities were revealed among provinces, with high-burden provinces having highest (86%) and lowest (7%) vaccine completion rates. CONCLUSIONS AND RELEVANCE: Vietnam has made tremendous progress towards reducing the burden of rabies. However, despite the wide availability of PEP, we found relatively low rates of vaccine completion. Our findings suggest provider training and patient education is needed to ensure appropriate treatment is completed. Moreover, our data suggest changes to information reported through the national surveillance system for monitoring good clinical practice for rabies prevention and control.

Rabies vaccine initiation and adherence among animal-bite patients in Haiti, 2015.

BACKGROUND: Approximately 59,000 people die from rabies worldwide annually. Haiti is one of the last remaining countries in the Western Hemisphere with endemic canine rabies. Canine-mediated rabies deaths are preventable with post-exposure prophylaxis (PEP): wound treatment, immunoglobulin, and vaccination. In countries where PEP is available, variability in healthcare seeking behaviors and lack of adherence to recommended treatment guidelines could also contribute to these deaths. Yet, few studies have addressed these issues. METHODS: We examined animal-bite reporting and assessed adherence to treatment guidelines at nine healthcare facilities in Haiti. We analyzed individual-level, de-identified patient data (demographic characteristics, geographic location, healthcare facility type, vaccine administration, and bite injury information) using descriptive analyses and logistic regression to examine factors associated with receiving PEP. FINDINGS: During the 6 month study period, we found 2.5 times more animal-bite case-patients than reported by the national surveillance system (690 versus 274). Of the 690 animal-bite patients identified, 498 (72%) sought care at six PEP providing facilities. Of the case-patients that sought care, 110 (22%) received at least one rabies vaccine. Of the 110 patients, 60 (55%) received all five doses. Delays were observed for three events: when patients presented to a facility after an animal-bite (3.0 days, range: 0-34 days), when patients received their fourth dose (16.1 days, range: 13-52 days), and when patients received their fifth dose (29 days, range: 26-52). When comparing vaccination status and patient characteristics, we found a significant association for bite location (p < .001), severity rank score (p < .001), geographic location (p < .001), and healthcare facility type (p = .002) with vaccination. CONCLUSION: High levels of underreporting identified here are of concern since vaccine distribution may, in part, be based on the number of animal-bite cases reported. Given that the Haitian government provides PEP to the population for free and we found animal-bite victims are seeking care in a timely manner─ reducing rabies deaths is an achievable goal.

Rabies Vaccine Hesitancy and Deaths Among Pregnant and Breastfeeding Women - Vietnam, 2015-2016.

Human rabies deaths are preventable through prompt administration of postexposure prophylaxis (PEP) with rabies immune globulin and rabies vaccine after exposure to a rabid animal (1); there are no known contraindications to receiving PEP (1,2). Despite widespread availability of PEP in Vietnam, in 2015 the Ministry of Health (MoH) received reports of pregnant and breastfeeding women with clinically diagnosed rabies. MoH investigated factors associated with these rabies cases. MoH found that, during 2015-2016, among 169 cases reported in Vietnam, two probable cases of rabies were reported in breastfeeding mothers and four in pregnant women, all of whom had been bitten by dogs. All six patients died. Three of the four pregnant women had cesarean deliveries. One of the three newborns died from complications believed to be unrelated to rabies; the fourth pregnant woman contracted rabies too early in pregnancy for the fetus to be viable. Two of the patients sought care from a medical provider or traditional healer; however, none sought PEP after being bitten. In each case, families reported the patient's fear of risk to the fetus or breastfed child as the primary barrier to receiving PEP. These findings highlight the need for public health messaging about the safety and effectiveness of PEP in preventing rabies among all persons with exposures, including pregnant and breastfeeding women.

Investigation of Canine-Mediated Human Rabies Death, Haiti, 2015.

In Haiti, an investigation occurred after the death of a 4-year-old girl with suspected rabies. With tips provided by community members, the investigation led to the identification of 2 probable rabies-related deaths and 16 persons bitten by rabid dogs, 75% of which chose postexposure prophylaxis. Community engagement can bolster rabies control.

Cost-Effectiveness Evaluation of a Novel Integrated Bite Case Management Program for the Control of Human Rabies, Haiti 2014-2015.

AbstractHaiti has the highest burden of rabies in the Western hemisphere, with 130 estimated annual deaths. We present the cost-effectiveness evaluation of an integrated bite case management program combining community bite investigations and passive animal rabies surveillance, using a governmental perspective. The Haiti Animal Rabies Surveillance Program (HARSP) was first implemented in three communes of the West Department, Haiti. Our evaluation encompassed all individuals exposed to rabies in the study area (N = 2,289) in 2014-2015. Costs (2014 U.S. dollars) included diagnostic laboratory development, training of surveillance officers, operational costs, and postexposure prophylaxis (PEP). We used estimated deaths averted and years of life gained (YLG) from prevented rabies as health outcomes. HARSP had higher overall costs (range: $39,568-$80,290) than the no-bite-case-management (NBCM) scenario ($15,988-$26,976), partly from an increased number of bite victims receiving PEP. But HARSP had better health outcomes than NBCM, with estimated 11 additional annual averted deaths in 2014 and nine in 2015, and 654 additional YLG in 2014 and 535 in 2015. Overall, HARSP was more cost-effective (US$ per death averted) than NBCM (2014, HARSP: $2,891-$4,735, NBCM: $5,980-$8,453; 2015, HARSP: $3,534-$7,171, NBCM: $7,298-$12,284). HARSP offers an effective human rabies prevention solution for countries transitioning from reactive to preventive strategies, such as comprehensive dog vaccination.

Sustainability of school-located influenza vaccination programs in Florida.

BACKGROUND: School-located influenza vaccination (SLIV) programs are a promising strategy for increasing vaccination coverage among schoolchildren. However, questions of economic sustainability have dampened enthusiasm for this approach in the United States. We evaluated SLIV sustainability of a health department led, county-wide SLIV program in Alachua County, Florida. Based on Alachua's outcome data, we modeled the sustainability of SLIV programs statewide using two different implementation costs and at different vaccination rates, reimbursement amount, and Vaccines for Children (VFC) coverage. METHODS: Mass vaccination clinics were conducted at 69 Alachua County schools in 2013 using VFC (for Medicaid and uninsured children) and non-VFC vaccines. Claims were processed after each clinic and submitted to insurance providers for reimbursement ($5 Medicaid and $47.04 from private insurers). We collected programmatic expenditures and volunteer hours to calculate fixed and variable costs for two different implementation costs (with or without in-kind costs included). We project program sustainability for Florida using publicly available county-specific student populations and health insurance enrollment data. RESULTS: Approximately 42% (n=12,853) of pre-kindergarten - 12th grade students participated in the SLIV program in Alachua. Of the 13,815 doses provided, 58% (8042) were non-VFC vaccine. Total implementation cost was $14.95/dose or $7.93/dose if "in-kind" costs were not included. The program generated a net surplus of $24,221, despite losing $4.68 on every VFC dose provided to Medicaid and uninsured children. With volunteers, 99% of Florida counties would be sustainable at a 50% vaccination rate and average reimbursement amount of $3.25 VFC and $37 non-VFC. Without volunteers, 69% of counties would be sustainable at 50% vaccination rate if all VFC recipients were on Medicaid and its reimbursement increased from $5 to $10 (amount private practices receive). CONCLUSIONS AND RELEVANCE: Key factors that contributed to the sustainability and success of an SLIV program are: targeting privately insured children and reducing administration cost through volunteers. Counties with a high proportion of VFC eligible children may not be sustainable without subsidies at $5 Medicaid reimbursement.

School-located influenza vaccination reduces community risk for influenza and influenza-like illness emergency care visits.

BACKGROUND: School-located influenza vaccination (SLIV) programs can substantially enhance the sub-optimal coverage achieved under existing delivery strategies. Randomized SLIV trials have shown these programs reduce laboratory-confirmed influenza among both vaccinated and unvaccinated children. This work explores the effectiveness of a SLIV program in reducing the community risk of influenza and influenza-like illness (ILI) associated emergency care visits. METHODS: For the 2011/12 and 2012/13 influenza seasons, we estimated age-group specific attack rates (AR) for ILI from routine surveillance and census data. Age-group specific SLIV program effectiveness was estimated as one minus the AR ratio for Alachua County versus two comparison regions: the 12 county region surrounding Alachua County, and all non-Alachua counties in Florida. RESULTS: Vaccination of ∼50% of 5-17 year-olds in Alachua reduced their risk of ILI-associated visits, compared to the rest of Florida, by 79% (95% confidence interval: 70, 85) in 2011/12 and 71% (63, 77) in 2012/13. The greatest indirect effectiveness was observed among 0-4 year-olds, reducing AR by 89% (84, 93) in 2011/12 and 84% (79, 88) in 2012/13. Among all non-school age residents, the estimated indirect effectiveness was 60% (54, 65) and 36% (31, 41) for 2011/12 and 2012/13. The overall effectiveness among all age-groups was 65% (61, 70) and 46% (42, 50) for 2011/12 and 2012/13. CONCLUSION: Wider implementation of SLIV programs can significantly reduce the influenza-associated public health burden in communities.

Implementing a community-supported school-based influenza immunization program.

School-based influenza immunization programs are increasingly recognized as a key component of community-based efforts to control annual influenza epidemics. Computer modeling suggests that immunizing 70% of schoolchildren could protect an entire community from the flu. Most of the school-based influenza immunization programs described in the literature have had support from industry or federal grants. This article describes a program that used only community resources to administer live, attenuated influenza vaccine supplied by the state health department. Beginning in 2006, the Alachua County Health Department and school system, working in collaboration with the University of Florida, began exploration of a non-mandatory community-wide school-based influenza immunization program, with the goal of achieving high levels of immunization of the ~22,000 public and private pre-K through grade 8 students in the county. In 2009-10 the program was repeated. This report describes the procedures developed to achieve the goal, the barriers that were encountered, and solutions to problems that occurred during the implementation of the program. Preliminary data suggest that the crude immunization rate in the schools was approximately 55% and that at least 10% more students were immunized by their health providers. At an operational level, it is possible to achieve high immunization rates if the stakeholders share a common vision and there is extensive community involvement.