Dynamics of Anti-influenza Mucosal IgA Over a Season in a Cohort of Individuals Living or Working in a Long-term Care Facility.

BACKGROUND: Serological surveys are used to ascertain influenza infection and immunity, but evidence for the utility of mucosal immunoglobulin A (IgA) as a correlate of infection or protection is limited. METHODS: We performed influenza-like illness (ILI) surveillance on 220 individuals living or working in a retirement community in Gainesville, Florida from January to May 2018, and took pre- and postseason nasal samples of 11 individuals with polymerase chain reaction (PCR)-confirmed influenza infection and 60 randomly selected controls. Mucosal IgA against 10 strains of influenza was measured from nasal samples. RESULTS: Overall, 28.2% and 11.3% of individuals experienced a 2-fold and 4-fold rise, respectively, in mucosal IgA to at least 1 influenza strain. Individuals with PCR-confirmed influenza A had significantly lower levels of preseason IgA to influenza A. Influenza-associated respiratory illness was associated with a higher rise in mucosal IgA to influenza strains of the same subtype, and H3N2-associated respiratory illness was associated with a higher rise in mucosal IgA to other influenza A strains. CONCLUSIONS: By comparing individuals with and without influenza illness, we demonstrated that mucosal IgA is a correlate of influenza infection. There was evidence for cross-reactivity in mucosal IgA across influenza A subtypes.

Peer nomination: a tool for identifying medical student exemplars in clinical competence and caring, evaluated at three medical schools.

PURPOSE: Peer evaluation is underused in medical education. The goals of this study were to validate in a multiinstitutional study a peer nomination form that identifies outstanding students in clinical competency and interpersonal skills, to test the hypothesis that with additional survey items humanism could be identified as a separate factor, and to find the simplest method of analysis. METHOD: In 2003, a 12-item peer nomination form was administered to junior or senior medical students at three institutions. Factor analysis was used to identify major latent variables and the items related to those characteristics. On the basis of those results, in 2004 a simpler, six-item form was developed and administered. Student rankings based on factor analysis and nomination counts were compared. RESULTS: Factor analysis of peer nomination data from both surveys identified three factors: clinical competence, caring, and community service. New survey items designed to address humanism are all weighted with interpersonal skills items; thus, the second major factor is characterized as caring. Rankings based on peer nomination results analyzed by either factor analysis or simply counting nominations distinguish at least the top 15% of students for each characteristic. CONCLUSIONS: Counting peer nominations using a simple, six-item form identifies medical student exemplars for three characteristics: clinical competence, caring, and community service. Factor analysis of peer nomination data did not identify humanism as a separate factor. Peer nomination rankings provide medical schools with a reliable tool to identify exemplars for recognition in medical student performance evaluations and selection for honors (e.g., Gold Humanism Honor Society).

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.

Leukocyte esterase and protein levels in saliva, as indicators of gingival and periodontal diseases in children.

PURPOSE: This study was to determine if dip stick assays of children's saliva for leukocyte esterase or protein (Serim Research Corporation, Elkhart, Ind) reflect the presence or severity of gingival or periodontal diseases in children. METHODS: The study included 13 children with periodontitis [study group] and a control group of 17 children without periodontitis. The saliva leukocyte esterase and protein values (scales from 1 to 4) were tested with dip stick analyses. The gingival (GI) and plaque indices (PI) presence and number of sites with periodontitis, demographic data, systemic condition, caries prevalence, and the presence of dental restorations were recorded and their relationship to leukocyte esterase or protein values were analyzed. RESULTS: Most children had a protein value of 2 or 3 or a leukocyte esterase value of > or = 3. Significant differences in the distribution of protein values by the presence/absence of periodontitis (chi-square, P<0.001), or the number of sites with periodontitis by protein value (chi-square, P=.005; ANOVA, P=.03) were evident; No. 4 protein values were found only in children with periodontitis, and No. 2 and No. 3 protein values were mostly found in children without it. CONCLUSIONS: Dip stick protein analysis of saliva of children has the potential to differentiate children with periodontitis or with fewer periodontal lesions.

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.

Rapid diagnosis of bacterial sinusitis in patients using a simple test of nasal secretions.

Upper respiratory symptoms and sinusitis constitute a major reason for patient visits to their physician. The diagnosis of sinusitis is often made based on history and physical exam, but the accuracy of such diagnosis is questioned. Sinus films or CT scans are expensive. Obtaining pus from the middle meatus is impractical. We studied whether analysis of four easily measured substances (protein, pH, leukocyte esterase and nitrite) in nasal secretions could predict the presence or absence of bacterial sinusitis, as diagnosed by history combined with sinus x ray or CT. We enrolled 217 consecutive patients, aged 4-61 years, with clinically suspected bacterial sinusitis (duration of symptoms, 7-26 days), who had radiographic studies. All had their nasal secretions assayed using a simple rapid test. A clinical scoring system was developed to allow for a simple interpretation of test results of four assays in a single clinical score. All 52 patients with scores of 0 or 1 were CT or x-ray negative for bacterial sinusitis. All 144 with scores of > or =4 were imaging study positive. Of the 21 patients (10%) with scores of 2 or 3, 14 were imaging study negative and 7 were positive. We concluded that combining these four separate assays on nasal secretion into one number, it is possible to rule in or rule out bacterial sinusitis in 90% of patients. This inexpensive, simple test can decrease the cost and help increase the accuracy of the diagnosis, thus improving the care of patients with bacterial sinusitis.

Role of IgA versus IgG in the control of influenza viral infection in the murine respiratory tract.

The roles of IgG and secretory IgA in the protection of the respiratory tract (RT) against influenza infection remain unclear. Passive immunization with Ab doses resulting in serum IgG anti-influenza virus Ab titers far in excess of those observed in immune mice has compounded the problem. We compared the effects of i.v. anti-influenza virus IgG and i.v. anti-influenza virus polymeric IgA (pIgA) mAb administered in amounts designed to replicate murine convalescent serum or nasal Ab titers, respectively. A serum anti-influenza virus IgG titer 2.5 times the normal convalescent serum anti-influenza virus IgG titer was required for detectible Ab transudation into nasal secretions, and a serum IgG titer 7 times normal was needed to lower nasal viral shedding by 98%. Anti-influenza virus pIgA at a nasal Ab titer comparable to that seen in convalescent mice eliminated nasal viral shedding. The RT of influenza-infected pIgA- or IgG-protected mice were studied by scanning electron microscopy. Only pIgA was found to prevent virally induced pathology in the upper RT, suggesting that IgG did not prevent viral infection of the nose, but neutralized newly replicated virus after infection had been initiated. In contrast, IgG, but not pIgA, was found to prevent viral pathology in the murine lung. Our results help to resolve the controversy of IgA- vs IgG-mediated protection of the RT; both Abs are important, with plasma IgG Ab serving as the back-up for secretory IgA-mediated protection in the nasal compartment, and IgG being the dominant Ab in protection of the lung.