Impact of a multi-component antenatal vaccine promotion package on improving knowledge, attitudes and beliefs about influenza and Tdap vaccination during pregnancy.

OBJECTIVE: Understanding whether interventions designed to improve antenatal vaccine uptake also change women's knowledge about vaccination is critical for improving vaccine coverage. This exploratory study evaluates the effectiveness of a multi-component influenza and tetanus, diphtheria, and acellular pertussis (Tdap) vaccine promotion package on improving women's knowledge, attitudes and beliefs toward antenatal vaccination. STUDY DESIGN: In 2012/2013 a cluster-randomized trial was conducted to test the effectiveness of a vaccine promotion package on improving antenatal vaccine coverage. Participants included 325 unvaccinated pregnant women from 11 obstetric practices in Georgia. Eleven health beliefs measures were assessed at baseline and 2-3 months post-partum. Outcomes were differences in proportions of women citing favorable responses to each measure between study groups at follow-up. RESULTS: Women enrolled in their third trimester had a higher probability of asking family members to vaccinate to protect the infant if they were in the intervention group versus the control group (36% vs. 22%; risk ratio [RR] = 1.65, 95% confidence interval [CI]: 1.21, 2.26). A similar association was not observed among women enrolled before their third trimester (39% vs. 44%; RR = 0.93, 95% CI: 0.50, 1.73). There were no other significant differences at follow-up between study groups. CONCLUSIONS: While exposure to the intervention package may have raised awareness that vaccinating close contacts can protect an infant, there is little evidence that the package changed women's attitudes and beliefs toward antenatal vaccination. Future research should ensure adequate exposure to the intervention and consider study design aspects including power to assess changes in secondary outcomes, discriminatory power of response options, and social desirability bias. This study is registered with clinicaltrials.gov, study ID NCT01761799.

Lack of Availability of Antenatal Vaccination Information on Obstetric Care Practice Web Sites.

OBJECTIVE: To estimate the proportion of obstetric practice web sites in the United States providing information on antenatal influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination. METHODS: Using www.healthgrades.com, a national random sample of 1,003 obstetric practice web sites was examined for provision of information on antenatal vaccination and other preventive prenatal health topics. Data were collected for this cross-sectional study between September 25, 2014, and November 12, 2014. χ tests and odds ratios were calculated to determine significance and magnitude of associations between provision of antenatal vaccination information and other practice characteristics. RESULTS: Of 1,003 web sites examined, 229 (22.8%) posted information pertaining to antenatal vaccinations. Only 105 web sites (10.5%) provided up-to-date information about both antenatal influenza and Tdap vaccination. Compared with the proportion posting on antenatal vaccination, significantly more web sites posted on safe foods (40.8%; P<.001), safe medications (36.9%; P<.001), and safe exercise (38.5%; P<.001) during pregnancy. When compared with web sites not mentioning these other prenatal health topics, web sites mentioning these topics were more likely to also mention antenatal vaccination (safe foods: 45.7% compared with 7.1%; odds ratio [OR] 11.07, 95% confidence interval [CI] 7.65-16.01; safe medications: 45.4% compared with 9.6%; OR 7.8, CI 5.58-10.89; safe exercise: 45.9% compared with 8.4%; OR 9.2, CI 6.5-13.03). CONCLUSION: A majority of obstetric care practice web sites do not provide information on antenatal vaccinations. Obstetric practices should consider using their web sites to provide reliable information on antenatal vaccinations as many already do for other prenatal health topics.

Factors Associated with Intention to Receive Influenza and Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccines during Pregnancy: A Focus on Vaccine Hesitancy and Perceptions of Disease Severity and Vaccine Safety.

BACKGROUND: Improving influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccine coverage among pregnant women is needed. PURPOSE: To assess factors associated with intention to receive influenza and/or Tdap vaccinations during pregnancy with a focus on perceptions of influenza and pertussis disease severity and influenza vaccine safety. METHODS: Participants were 325 pregnant women in Georgia recruited from December 2012 - April 2013 who had not yet received a 2012/2013 influenza vaccine or a Tdap vaccine while pregnant. Women completed a survey assessing influenza vaccination history, likelihood of receiving antenatal influenza and/or Tdap vaccines, and knowledge, attitudes and beliefs about influenza, pertussis, and their associated vaccines. RESULTS: Seventy-three percent and 81% of women believed influenza and pertussis, respectively, would be serious during pregnancy while 87% and 92% believed influenza and pertussis, respectively, would be serious to their infants. Perception of pertussis severity for their infant was strongly associated with an intention to receive a Tdap vaccine before delivery (p=0.004). Despite perceptions of disease severity for themselves and their infants, only 34% and 44% intended to receive antenatal influenza and Tdap vaccines, respectively. Forty-six percent had low perceptions of safety regarding the influenza vaccine during pregnancy, and compared to women who perceived the influenza vaccine as safe, women who perceived the vaccine as unsafe were less likely to intend to receive antenatal influenza (48% vs. 20%; p < 0.001) or Tdap (53% vs. 33%; p < 0.001) vaccinations. CONCLUSIONS: Results from this baseline survey suggest that while pregnant women who remain unvaccinated against influenza within the first three months of the putative influenza season may be aware of the risks influenza and pertussis pose to themselves and their infants, many remain reluctant to receive influenza and Tdap vaccines antenatally. To improve vaccine uptake in the obstetric setting, our findings support development of evidence-based vaccine promotion interventions which emphasize vaccine safety during pregnancy and mention disease severity in infancy.

Distribution of A(H1N1)pdm09 Influenza Vaccine: Need for Greater Consideration of Smaller Jails.

To identify factors associated with vaccine receipt among correctional facilities during the A(H1N1)pdm09 influenza pandemic, this study surveyed one third of U.S. correctional facilities. Analysis of the association of average daily population (ADP) on A(H1N1)pdm09 influenza vaccine receipt found that an ADP increase of 100 inmates resulted in a 32% increased likelihood of receiving influenza vaccine among smaller jails. Zero percent of large jails, 14% of federal prisons, 11% of nonfederal prisons, and 57% of small jails reported never receiving pandemic influenza vaccine. A qualitative assessment identified barriers to vaccine delivery, lessons learned from pandemic response, and recommendations for public health partners. Building stronger relationships between public health entities and correctional facilities to collaborate in influenza pandemic preparedness efforts may help protect correctional and community populations.

Vaccine providers' perspectives on impact, challenges, and response during the California 2010 pertussis outbreak.

INTRODUCTION: California has experienced its worst outbreak of pertussis in 50 y. In preparing for such outbreaks of pertussis, vaccine providers in the state play a key role in educating patients about the public health implications of vaccination, explaining the benefits to immunization, and facilitating patients' receipt of recommended immunizations. METHODS: We conducted a survey of 800 California vaccine providers to investigate provider level response to recent pertussis outbreaks and regulation by provider type and geography. RESULTS: Sixty-nine percent (533/777) of vaccine providers within the state of California responded to the survey. Fifty-three percent (278/527) of vaccine providers indicated that it was part of standard care at their practice or pharmacy location to ask adult patients about pertussis vaccine (Table 1) and this varied across practice types (P<0.0001). Fifty-seven percent of providers (270/476) indicated that the information they received from the state about pertussis during the 2010 California pertussis outbreak was very useful or useful, while 52% of providers indicated this information was neutral, not useful, not at all useful. Vaccine administration, patient groups seen, and challenges varied by provider type however meaningful differences among subpopulations to which the vaccine was administered were found between provider types (P<0.001, Table 2). CONCLUSION: The 2010 pertussis outbreak in California challenged vaccine providers in a way that changed the preparation, promotion, and planning for future outbreaks and emergency situations. Adaptability to the new state law and increased awareness of pertussis in the physician community were important in the number of patients receiving the vaccine. Also, forming partnerships with schools and health agencies were important in facilitating and promoting wide spread vaccination.

Lessons learned from the 2007 to 2009 Haemophilus influenzae type B vaccine shortage: implications for future vaccine shortages and public health preparedness.

OBJECTIVE: To understand immunization programs' experience managing the 2007 to 2009 Haemophilus influenzae type B (Hib) vaccine shortage and identify ways in which the US immunization system can be improved to assist in responses to future shortages of routine vaccines and large-scale public health emergencies. METHODS: An Internet-based survey was conducted from July 2009 to October 2009 among the 64 city, state, and territorial immunization program managers (IPMs). RESULTS: Fifty-eight percent (37 of the 64) of IPMs responded. Forty percent of responding IPMs indicated not having enough Hib vaccine within their Vaccines for Children program to fulfill the temporary 3-dose recommendation issued in December 2007 in response to the Hib vaccine shortage. While 73% of IPMs indicated success in monitoring provider inventory and 68% indicated success in monitoring doses administered during the shortage, fewer than half indicated success in monitoring providers' compliance with shortage-specific recommendations regarding Hib vaccine. Forty-six percent of IPMs used their immunization information system (IIS) to monitor provider compliance with recommendations regarding Hib vaccine use, and of these, nearly 60% reported success in monitoring provider compliance with recommendations compared with 35% of IPMs who did not use their IIS in this way. Forty-two percent of IPMs felt that the Centers for Disease Control and Prevention (CDC) was successful in determining stockpiled vaccine allocations to their program, and 56% felt that the CDC was successful in communicating its rationale for their immunization program's Hib allocation during the shortage. CONCLUSIONS: Experiences from the 2007 to 2009 Hib vaccine shortage offer insights on how the US immunization system and system-wide response to vaccine shortages can be improved. Results from this survey suggest that improving vaccine transfer between jurisdictions and using IIS to track provider compliance with shortage recommendations are 2 ways that can help the US immunization system respond to future vaccine shortages and large-scale public health emergencies like influenza pandemics.

Perspectives of immunization program managers on 2009-10 H1N1 vaccination in the United States: a national survey.

In June and July 2010, we conducted a national internet-based survey of 64 city, state, and territorial immunization program managers (IPMs) to assess their experiences in managing the 2009-10 H1N1 influenza vaccination campaign. Fifty-four (84%) of the managers or individuals responsible for an immunization program responded to the survey. To manage the campaign, 76% indicated their health department activated an incident command system (ICS) and 49% used an emergency operations center (EOC). Forty percent indicated they shared the leadership of the campaign with their state-level emergency preparedness program. The managers' perceptions of the helpfulness of the emergency preparedness staff was higher when they had collaborated with the emergency preparedness program on actual or simulated mass vaccination events within the previous 2 years. Fifty-seven percent found their pandemic influenza plan helpful, and those programs that mandated that vaccine providers enter data into their jurisdiction's immunization information system (IIS) were more likely than those who did not mandate data entry to rate their IIS as valuable for facilitating registration of nontraditional providers (42% vs. 25%, p<0.05) and tracking recalled influenza vaccine (50% vs. 38%, p<0.05). Results suggest that ICS and EOC structures, pandemic influenza plans, collaborations with emergency preparedness partners during nonemergencies, and expanded use of IIS can enhance immunization programs' ability to successfully manage a large-scale vaccination campaign. Maintaining the close working relationships developed between state-level immunization and emergency preparedness programs during the H1N1 influenza vaccination campaign will be especially important as states prepare for budget cuts in the coming years.

Seroepidemiologic and occupational risk survey for Coxiella burnetii antibodies among US veterinarians.

BACKGROUND: Little is known about the occurrence of Q fever among veterinarians in the United States. In this study, we sought to estimate the prevalence of Coxiella burnetii antibodies among veterinarians and to identify risk factors for exposure. METHODS: We tested serum samples from 508 veterinarians who attended the 143rd American Veterinary Medical Association Annual Convention in 2006. Samples were screened using a Q fever IgG enzyme-linked immunosorbent assay (ELISA). Samples with positive or equivocal results of ELISA were confirmed using phase I and phase II IgG immunofluorescence antibody assays, and end point IgG titers were determined for samples with positive results. RESULTS: Antibodies against C. burnetii were detected in 113 (22.2%) of 508 veterinarians. Risk factors associated with seropositivity included age 46 years, routine contact with ponds, and treatment of cattle, swine, or wildlife. CONCLUSIONS: Veterinarians have a high level of exposure to C. burnetii, the causative organism of Q fever, especially those veterinarians who treat livestock. In this study, risk of C. burnetii seropositivity was also independently associated with contact with ponds. The role of exposure to standing bodies of water in infection is not usually considered and should be investigated in future studies. Additionally, the evidence of past infection with C. burnetii in >20% of veterinarians also highlights the need for use of appropriate personal protective equipment when treating animals that are potentially infected with C. burnetii. Physicians should consider the risk of infection with C. burnetii when treating ill veterinarians and others with potential occupational exposures.

Risk factors for Buruli ulcer disease (Mycobacterium ulcerans Infection): results from a case-control study in Ghana.

BACKGROUND: Morbidity due to Buruli ulcer disease (BUD), a cutaneous infection caused by Mycobacterium ulcerans, has been increasingly recognized in rural West Africa. The source and mode of transmission remain unknown. METHODS: To identify BUD risk factors, we conducted a case-control study in 3 BUD-endemic districts in Ghana. We enrolled case patients with clinically diagnosed BUD and obtained skin biopsy specimens. M. ulcerans infection was confirmed by at least 1 of the following diagnostic methods: histopathologic analysis, culture, polymerase chain reaction, and Ziehl-Neelsen staining of a lesion smear. We compared characteristics of case patients with confirmed BUD with those of age- and community-matched control subjects using conditional logistic regression analysis. RESULTS: Among 121 case patients with confirmed BUD, leg lesions (49%) or arm lesions (36%) were common. Male case patients were significantly more likely than female case patients to have lesions on the trunk (25% vs. 6%; P = .009). Multivariable modeling among 116 matched case-control pairs identified wading in a river as a risk factor for BUD (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.27-5.68; P = .0096). Wearing a shirt while farming (OR, 0.27; 95% CI, 0.11-0.70; P = .0071), sharing indoor living space with livestock (OR, 0.36; 95% CI, 0.15-0.86; P = .022), and bathing with toilet soap (OR, 0.41; 95% CI, 0.19-0.90; P = .026) appeared to be protective. BUD was not significantly associated with penetrating injuries (P = .14), insect bites near water bodies (P = .84), bacille Calmette-Guerin vaccination (P = .33), or human immunodeficiency virus infection (P = .99). CONCLUSIONS: BUD is an environmentally acquired infection strongly associated with exposure to river areas. Exposed skin may facilitate transmission. Until transmission is better defined, control strategies in BUD-endemic areas could include covering exposed skin.

One-year health assessment of adult survivors of Bacillus anthracis infection.

CONTEXT: Little is known about potential long-term health effects of bioterrorism-related Bacillus anthracis infection. OBJECTIVE: To describe the relationship between anthrax infection and persistent somatic symptoms among adults surviving bioterrorism-related anthrax disease approximately 1 year after illness onset in 2001. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 15 of 16 adult survivors from September through December 2002 using a clinical interview, a medical review-of-system questionnaire, 2 standardized self-administered questionnaires, and a review of available medical records. MAIN OUTCOME MEASURES: Health complaints summarized by the body system affected and by symptom categories; psychological distress measured by the Revised 90-Item Symptom Checklist; and health-related quality-of-life indices by the Medical Outcomes Study 36-Item Short-Form Health Survey (version 2). RESULTS: The anthrax survivors reported symptoms affecting multiple body systems, significantly greater overall psychological distress (P<.001), and significantly reduced health-related quality-of-life indices compared with US referent populations. Eight survivors (53%) had not returned to work since their infection. Comparing disease manifestations, inhalational survivors reported significantly lower overall physical health than cutaneous survivors (mean scores, 30 vs 41; P =.02). Available medical records could not explain the persisting health complaints. CONCLUSION: The anthrax survivors continued to report significant health problems and poor life adjustment 1 year after onset of bioterrorism-related anthrax disease.

Bacillus anthracis aerosolization associated with a contaminated mail sorting machine.

On October 12, 2001, two envelopes containing Bacillus anthracis spores passed through a sorting machine in a postal facility in Washington, D.C. When anthrax infection was identified in postal workers 9 days later, the facility was closed. To determine if exposure to airborne B. anthracis spores continued to occur, we performed air sampling around the contaminated sorter. One CFU of B. anthracis was isolated from 990 L of air sampled before the machine was activated. Six CFUs were isolated during machine activation and processing of clean dummy mail. These data indicate that an employee working near this machine might inhale approximately 30 B. anthracis-containing particles during an 8-h work shift. What risk this may have represented to postal workers is not known, but this estimate is approximately 20-fold less than a previous estimate of sub-5 micro m B. anthracis-containing particles routinely inhaled by asymptomatic, unvaccinated workers in a goat-hair mill.