Publications by authors named "Kristen A Feemster"

72 Publications

Human papillomavirus: optimizing opportunities for prevention.

Curr Opin Pediatr 2022 Apr;34(2):132-139

Vaccine Education Center, The Children's Hospital of Philadelphia.

Purpose Of Review: Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections worldwide and is a precursor to anogenital and oropharyngeal cancers. Effective prevention is available through HPV vaccination and emerging evidence demonstrates the potential to significantly impact HPV-associated disease through reductions in the incidence of genital warts, precancerous cervical lesions, and cervical cancer. Indications have also recently expanded to include the prevention of oropharyngeal cancer, an outcome that has been increasing in incidence for men and women. Yet despite demonstrated effectiveness, the potential for broader impact and well-established routine recommendations for administration to adolescents, barriers to vaccine uptake persist. The purpose of this review is to provide an update on HPV prevention in the US, including trends in disease burden, HPV vaccine effectiveness, evolving vaccine recommendations and opportunities and barriers to their implementation.

Recent Findings: Several studies have demonstrated that HPV vaccination has the potential to prevent most HPV-attributable cancers. Ongoing research addresses questions related to duration of protection, effectiveness in vulnerable populations, vaccine schedules and strategies to improve access and optimize uptake.

Summary: To ensure continued impact on the prevention of HPV-associated disease and subsequent cancer, it is crucial to address gaps in vaccine uptake. A strong recommendation for all persons for whom HPV vaccines are indicated, alongside initiatives to increase awareness of HPV vaccination and address specific concerns, can improve uptake among hesitant populations. Globally, efforts to bolster immunization programs are needed to broaden access to HPV vaccination.
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http://dx.doi.org/10.1097/MOP.0000000000001119DOI Listing
April 2022

Evolution of pneumococcal serotype epidemiology in Botswana following introduction of 13-valent pneumococcal conjugate vaccine.

PLoS One 2022 5;17(1):e0262225. Epub 2022 Jan 5.

Duke Global Health Institute, Duke University, Durham, NC, United States of America.

Pneumococcal conjugate vaccines reduce the burden of invasive pneumococcal disease, but the sustained effect of these vaccines can be diminished by an increase in disease caused by non-vaccine serotypes. To describe pneumococcal serotype epidemiology in Botswana following introduction of 13-valent pneumococcal conjugate vaccine (PCV-13) in July 2012, we performed molecular serotyping of 268 pneumococcal strains isolated from 221 children between 2012 and 2017. The median (interquartile range) age of the children included in this analysis was 6 (3,12) months. Fifty-nine percent of the children had received at least one dose of PCV-13 and 35% were fully vaccinated with PCV-13. While colonization by vaccine serotypes steadily declined following PCV-13 introduction, 25% of strains isolated more than 3 years after vaccine introduction were PCV-13 serotypes. We also observed an increase in colonization by non-vaccine serotypes 21 and 23B, which have been associated with invasive pneumococcal disease and antibiotic resistance in other settings.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0262225PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8730465PMC
February 2022

Coronavirus disease 2019 (COVID-19) vaccine hesitancy among physicians, physician assistants, nurse practitioners, and nurses in two academic hospitals in Philadelphia.

Infect Control Hosp Epidemiol 2021 Sep 20:1-9. Epub 2021 Sep 20.

Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Objective: To evaluate coronavirus disease 2019 (COVID-19) vaccine hesitancy among healthcare personnel (HCP) with significant clinical exposure to COVID-19 at 2 large, academic hospitals in Philadelphia, Pennsylvania.

Design, Setting, And Participants: HCP were surveyed in November-December 2020 about their intention to receive the COVID-19 vaccine.

Methods: The survey measured the intent among HCP to receive a COVID-19 vaccine, timing of vaccination, and reasons for or against vaccination. Among patient-facing HCP, multivariate regression evaluated the associations between healthcare positions (medical doctor, nurse practitioner or physician assistant, and registered nurse) and vaccine hesitancy (intending to decline, delay, or were unsure about vaccination), adjusting for demographic characteristics, reasons why or why not to receive the vaccine, and prior receipt of routine vaccines.

Results: Among 5,929 HCP (2,253 medical doctors [MDs] and doctors of osteopathy [DOs], 582 nurse practitioners [NPs], 158 physician assistants [PAs], and 2,936 nurses), a higher proportion of nurses (47.3%) were COVID-vaccine hesitant compared with 30.0% of PAs and NPs and 13.1% of MDs and DOs. The most common reasons for vaccine hesitancy included concerns about side effects, the newness of the vaccines, and lack of vaccine knowledge. Regardless of position, Black HCP were more hesitant than White HCP (odds ratio [OR], ∼5) and females were more hesitant than males (OR, ∼2).

Conclusions: Although most clinical HCP intended to receive a COVID-19 vaccine, intention varied by healthcare position. Consistent with other studies, hesitancy was also significantly associated with race or ethnicity across all positions. These results highlight the importance of understanding and effectively addressing reasons for hesitancy, especially among frontline HCP who are at increased risk of COVID exposure and play a critical role in recommending vaccines to patients.
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http://dx.doi.org/10.1017/ice.2021.410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8503076PMC
September 2021

Non-diphtheriae Corynebacterium species are associated with decreased risk of pneumococcal colonization during infancy.

ISME J 2022 03 11;16(3):655-665. Epub 2021 Sep 11.

Division of Pediatric Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.

Streptococcus pneumoniae (pneumococcus) is a leading cause of severe infections among children and adults. Interactions between commensal microbes in the upper respiratory tract and S. pneumoniae are poorly described. In this study, we sought to identify interspecies interactions that modify the risk of S. pneumoniae colonization during infancy and to describe development of the upper respiratory microbiome during infancy in a sub-Saharan African setting. We collected nasopharyngeal swabs monthly (0-6 months of age) or bimonthly (6-12 months of age) from 179 mother-infant dyads in Botswana. We used 16S ribosomal RNA gene sequencing to characterize the nasopharyngeal microbiome and identified S. pneumoniae colonization using a species-specific PCR assay. We detect S. pneumoniae colonization in 144 (80%) infants at a median age of 71 days and identify a strong negative association between the relative abundance of the bacterial genera Corynebacterium within the infant nasopharyngeal microbiome and the risk of S. pneumoniae colonization. Using in vitro cultivation experiments, we demonstrate growth inhibition of S. pneumoniae by secreted factors from strains of several Corynebacterium species isolated from these infants. Finally, we demonstrate that antibiotic exposures and the winter season are associated with a decline in the relative abundance of Corynebacterium within the nasopharyngeal microbiome, while breastfeeding is associated with an increase in the Corynebacterium relative abundance. Our findings provide novel insights into the interspecies interactions that contribute to colonization resistance to S. pneumoniae and suggest that the nasopharyngeal microbiome may be a previously unrecognized mechanism by which environmental factors influence the risk of pneumococcal infections during childhood. Moreover, this work lays the foundation for future studies seeking to use targeted manipulation of the nasopharyngeal microbiome to prevent infections caused by S. pneumoniae.
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http://dx.doi.org/10.1038/s41396-021-01108-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8857224PMC
March 2022

Impact of 13-Valent Pneumococcal Conjugate Vaccine on Nasopharyngeal Carriage Rates of Streptococcus pneumoniae in a Rural Community in the Dominican Republic.

J Infect Dis 2021 09;224(12 Suppl 2):S237-S247

Department of Pediatrics, Global Health Center and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Background: Invasive pneumococcal disease (IPD) leads to thousands of pediatric deaths annually. Pneumococcal colonization precedes IPD. In 2013, the Dominican Republic introduced the 13-valent pneumococcal conjugate vaccine (PCV13) into its routine infant immunization program, with doses at ages 2, 4, and 12 months. Prevalence of pneumococcal nasopharyngeal colonization was evaluated post-PCV13 introduction.

Methods: A prospective cohort study of 125 children aged 2-35 months was conducted in a rural Dominican Republic community November 2016 through July 2017. Nasopharyngeal swabs and clinical and vaccination data were collected at enrollment and 4-6 months later. Serotypes included in PCV13 were defined as vaccine-type. Colonization rates and serotype distribution were compared at baseline and follow-up, and the association between colonization and vaccination status among the entire cohort was evaluated at each time point.

Results: Of 125 children enrolled, 118 (94%) completed follow-up. Overall and vaccine-type pneumococcal colonization rates were 62% and 25%, respectively, at baseline and 60% and 28% at follow-up. Among children age-eligible for 3 doses, 50% and 51% were fully vaccinated at baseline and follow-up, respectively. At baseline assessment, children up-to-date for age for PCV13 were less likely to be colonized with vaccine-type pneumococci than children not up-to-date, and the same was found for fully vaccinated children (3 doses) compared to those not fully vaccinated (odds ratios [ORs], 0.38 [95% confidence interval {CI}, .18-.79], and 0.14 [95% CI, .04-.45], respectively). The same associations were not found at follow-up assessment.

Conclusions: Three years post -PCV13 introduction, vaccine-type colonization rates remained high. Low vaccination coverage for 3 PCV13 doses may have contributed. The protective effect of PCV13 on vaccine-type carriage suggests an increase in PCV13 coverage could lead to substantial declines in pneumococcal vaccine-type carriage.
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http://dx.doi.org/10.1093/infdis/jiab172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8409531PMC
September 2021

Racial/Ethnic Differences in COVID-19 Vaccine Hesitancy Among Health Care Workers in 2 Large Academic Hospitals.

JAMA Netw Open 2021 Aug 2;4(8):e2121931. Epub 2021 Aug 2.

Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.

Importance: Significant differences in hesitancy to receive COVID-19 vaccination by race/ethnicity have been observed in several settings. Racial/ethnic differences in COVID-19 vaccine hesitancy among health care workers (HCWs), who face occupational and community exposure to COVID-19, have not been well described.

Objective: To assess hesitancy to COVID-19 vaccination among HCWs across different racial/ethnic groups and assess factors associated with vaccine hesitancy.

Design, Setting, And Participants: This survey study was conducted among HCWs from 2 large academic hospitals (ie, a children's hospital and an adult hospital) over a 3-week period in November and December 2020. Eligible participants were HCWs with and without direct patient contact. A 3-step hierarchical multivariable logistic regression was used to evaluate associations between race/ethnicity and vaccine hesitancy controlling for demographic characteristics, employment characteristics, COVID-19 exposure risk, and being up to date with routine vaccinations. Data were analyzed from February through March 2021.

Main Outcomes And Measures: Vaccine hesitancy, defined as not planning on, being unsure about, or planning to delay vaccination, served as the outcome.

Results: Among 34 865 HCWs eligible for this study, 12 034 individuals (34.5%) completed the survey and 10 871 individuals (32.2%) completed the survey and reported their race/ethnicity. Among 10 866 of these HCWs with data on sex, 8362 individuals (76.9%) were women, and among 10 833 HCWs with age data, 5923 individuals (54.5%) were younger than age 40 years. (Percentages for demographic and clinical characteristics are among the number of respondents for each type of question.) There were 8388 White individuals (77.2%), 882 Black individuals (8.1%), 845 Asian individuals (7.8%), and 449 individuals with other or mixed race/ethnicity (4.1%), and there were 307 Hispanic or Latino individuals (2.8%). Vaccine hesitancy was highest among Black HCWs (732 individuals [83.0%]) and Hispanic or Latino HCWs (195 individuals [63.5%]) (P < .001). Among 5440 HCWs with vaccine hesitancy, reasons given for hesitancy included concerns about side effects (4737 individuals [87.1%]), newness of the vaccine (4306 individuals [79.2%]), and lack of vaccine knowledge (4091 individuals [75.2%]). The adjusted odds ratio (aOR) for vaccine hesitancy was 4.98 (95% CI, 4.11-6.03) among Black HCWs, 2.10 (95% CI, 1.63-2.70) among Hispanic or Latino HCWs, 1.48 (95% CI, 1.21-1.82) among HCWs with other or mixed race/ethnicity, and 1.47 (95% CI, 1.26-1.71) among Asian HCWs compared with White HCWs (P < .001). The aOR was decreased among Black HCWs when adjusting for employment characteristics and COVID-19 exposure risk (aOR, 4.87; 95% CI, 3.96-6.00; P < .001) and being up to date with prior vaccines (aOR, 4.48; 95% CI, 3.62-5.53; P < .001) but not among HCWs with other racial/ethnic backgrounds.

Conclusions And Relevance: This study found that vaccine hesitancy before the authorization of the COVID-19 vaccine was increased among Black, Hispanic or Latino, and Asian HCWs compared with White HCWs. These findings suggest that interventions focused on addressing vaccine hesitancy among HCWs are needed.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.21931DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8406078PMC
August 2021

Vaccipack, A Mobile App to Promote Human Papillomavirus Vaccine Uptake Among Adolescents Aged 11 to 14 Years: Development and Usability Study.

JMIR Nurs 2020 Jan-Dec;3(1):e19503. Epub 2020 Oct 29.

Children's Hospital of Philadelphia Philadelphia, PA United States.

Background: More than 90% of human papillomavirus (HPV)-related cancers could be prevented by widespread uptake of the HPV vaccine, yet vaccine use in the United States falls short of public health goals.

Objective: The purpose of this study was to describe the development, acceptability, and intention to use the mobile app Vaccipack, which was designed to promote uptake and completion of the adolescent HPV vaccine series.

Methods: Development of the mobile health (mHealth) content was based on the integrated behavioral model (IBM). The technology acceptance model (TAM) was used to guide the app usability evaluation. App design utilized an iterative process involving providers and potential users who were parents and adolescents. App features include a vaccine-tracking function, a discussion forum, and stories with embedded messages to promote intention to vaccinate. Parents and adolescents completed surveys before and after introducing the app in a pediatric primary care setting with low HPV vaccination rates.

Results: Surveys were completed by 54 participants (20 adolescents aged 11 to 14 years and 34 parents). Notably, 75% (15/20) of adolescents and 88% (30/34) of parents intended to use the app in the next 2 weeks. Acceptability of the app was high among both groups: 88% (30/34) of parents and 75% (15/20) of adolescents indicated that Vaccipack was easy to use, and 82% (28/34) of parents and 85% (17/20) of adolescents perceived the app to be beneficial. Higher levels of app acceptability were found among parents with strong intentions to use the app (=.09; 95% CI -2.15 to 0.15).

Conclusions: mHealth technology, such as Vaccipack, may be an acceptable and nimble platform for providing information to parents and adolescents and advancing the uptake of important vaccines.
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http://dx.doi.org/10.2196/19503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8279454PMC
October 2020

Efficacy of tailored messages to improve behavioral intent to accept HPV vaccination among mothers may be moderated by sociodemographics.

Prev Med Rep 2021 Sep 29;23:101413. Epub 2021 May 29.

Department of Family & Community Health, University of Pennsylvania School of Nursing, Division of Adolescent Medicine, Perelman School of Medicine, 418 Curie Boulevard, Office 401, Philadelphia, PA 19104, USA.

We assessed differences in response to a tailored recommendation intervention for HPV vaccine by participants' sociodemographic characteristics in this exploratory sub-analysis of a larger web-based, randomized-controlled trial on tailored messaging among mothers with low intent to vaccinate their 11-14-year-old child against HPV. The intervention consisted of pre-recorded video messages tailored to 1-5 common concerns about HPV vaccine. In these exploratory analyses, we used generalized linear models to assess differences in post-intervention intent across intervention arms, stratified by sociodemographic characteristics among 496 trial participants. We found significantly higher post-intervention intent in the intervention participants versus the control group among mothers: 1) with younger children; 2) with white vs. black children; 3) with Non-Hispanic children; 4) who were younger; 5) with some college or vocational training; with household incomes of ≥$100,000; and 7) with 1-2 children. Our findings of effect modification by certain sociodemographic factors such as age, race/ethnicity, and household income should be considered when designing similar tailored messaging interventions.
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http://dx.doi.org/10.1016/j.pmedr.2021.101413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192722PMC
September 2021

"This choice does not just affect me." Attitudes of pregnant women toward COVID-19 vaccines: a mixed-methods study.

Hum Vaccin Immunother 2021 10 19;17(10):3371-3376. Epub 2021 May 19.

School of Medicine, University College Dublin, Dublin, Ireland.

Public health experts agree that pregnant women who fall into priority groups may be offered a Coronavirus Disease 2019 (COVID-19) vaccine. However, little is known about attitudes of pregnant women toward COVID-19 vaccination. We surveyed 300 pregnant women during the roll out of the Pfizer-BioNTech vaccine in Ireland. Women rated likelihood of receipt of a vaccine during pregnancy, on a 1-10 scale (1 = very unlikely, 10 = very likely). One hundred and thirteen (38%) women responded with a score of ≥8, while a similar proportion (36%) selected a score of ≤2. Safety of their unborn infant was the primary driver of decision making among survey participants, but specific safety concerns differed according to likely acceptance of a vaccine. Communication about COVID-19 vaccines to pregnant women must explicitly address safety. Pregnant women and their health-care providers should be supported with accessible interpretations of data so that they can make the best choice for their individual risk profile.
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http://dx.doi.org/10.1080/21645515.2021.1924018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8437526PMC
October 2021

Detection of respiratory syncytial virus defective genomes in nasal secretions is associated with distinct clinical outcomes.

Nat Microbiol 2021 05 1;6(5):672-681. Epub 2021 Apr 1.

Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Respiratory syncytial virus (RSV) causes respiratory illness in children, immunosuppressed individuals and the elderly. However, the viral factors influencing the clinical outcome of RSV infections remain poorly defined. Defective viral genomes (DVGs) can suppress virus replication by competing for viral proteins and by stimulating antiviral immunity. We studied the association between detection of DVGs of the copy-back type and disease severity in three RSV A-confirmed cohorts. In hospitalized children, detection of DVGs in respiratory samples at or around the time of admission associated strongly with more severe disease, higher viral load and a stronger pro-inflammatory response. Interestingly, in experimentally infected adults, the presence of DVGs in respiratory secretions differentially associated with RSV disease severity depending on when DVGs were detected. Detection of DVGs early after infection associated with low viral loads and mild disease, whereas detection of DVGs late after infection, especially if DVGs were present for prolonged periods, associated with high viral loads and severe disease. Taken together, we demonstrate that the kinetics of DVG accumulation and duration could predict clinical outcome of RSV A infection in humans, and thus could be used as a prognostic tool to identify patients at risk of worse clinical disease.
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http://dx.doi.org/10.1038/s41564-021-00882-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9098209PMC
May 2021

Perspectives on the receipt of a COVID-19 vaccine: A survey of employees in two large hospitals in Philadelphia.

Vaccine 2021 03 16;39(12):1693-1700. Epub 2021 Feb 16.

Vaccine Education Center, Children's Hospital of Philadelphia, United States.

Background: Health care personnel have been identified by the ACIP as a priority group for COVID-19 vaccination. We conducted a survey in November-December 2020 at two large, academic hospitals in Philadelphia to evaluate the intention of hospital employees to be vaccinated.

Methods: The survey was sent electronically to all employees (clinical and nonclinical staff) at a children's hospital and an adult hospital. The survey was voluntary and confidential. Questions focused on plans to receive a COVID-19 vaccine when available, reasons why employees would/would not get vaccinated, when employees planned to be vaccinated, vaccine safety and efficacy features that would be acceptable, and past history of receipt of other vaccines by the employee and family. Responses were analyzed using univariate and multiple logistic regression methods.

Results: A total of 12,034 hospital employees completed the survey (a 34.5% response rate). Overall, 63.7% of employees reported that they planned to receive a COVID-19 vaccine, 26.3% were unsure, and 10.0% did not plan to be vaccinated. Over 80% of those unsure or unwilling to be vaccinated expressed concerns about vaccine side effects and the vaccines' newness. In multivariable logistic regression, persons planning to take a COVID-19 vaccine were more likely to be older, male, more educated, Asian or White, up-to-date on vaccinations, without direct patient contact, and tested for COVID-19 in the past. No significant difference in intention to be vaccinated was found between those with higher versus lower levels of exposure to COVID-19 patients or the number of previous exposures to patients with COVID-19.

Conclusions: While the majority of hospital employees are planning to receive a COVID-19 vaccine, many are unsure or not planning to do so. Further education of hospital employees about the safety, efficacy, and value of the currently available COVID-19 vaccines is critical to vaccine acceptance in this population.
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http://dx.doi.org/10.1016/j.vaccine.2021.02.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885691PMC
March 2021

Comparison of immunization systems in Japan and the United States - What can be learned?

Vaccine 2020 10 29;38(46):7401-7408. Epub 2020 Sep 29.

Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.

Recently, efforts have been made to fill a so-called "vaccine gap" between Japan and other countries; however, more work remains. Concerns about adverse events following immunization (AEFI) resulted in an historically passive approach to policy making in the National Immunization Program (NIP). For example, reports of AEFI following human papillomavirus vaccine (HPVV) in 2013 led the Japanese government to withdraw its proactive recommendations, resulting in a sharp drop in HPVV coverage rate to less than 1.0%. In this report, we review key historical incidents that led to the current immunization system in Japan, compare it to that in the United States, and discuss strategies for improving the Japanese immunization system. By strengthening existing policies and programs, such as National Immunization Technical Advisory Groups and AEFI reporting, compensation laws, and immunization education, the remaining vaccine gap in Japan could be filled.
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http://dx.doi.org/10.1016/j.vaccine.2020.09.028DOI Listing
October 2020

The burden of gastroenteritis outbreaks in long-term care settings in Philadelphia, 2009-2018.

Infect Control Hosp Epidemiol 2020 11 17;41(11):1310-1314. Epub 2020 Aug 17.

Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, Pennsylvania.

Objective: Gastroenteritis causes significant morbidity and mortality in long-term care facility (LTCF) residents, a growing population within the United States. We set out to better understand gastroenteritis outbreaks in LTCF by identifying outbreak and facility characteristics associated with outbreak incidence as well as outbreak duration and size.

Design: We conducted a retrospective cross-sectional study on LTCFs in Philadelphia County from 2009 to 2018. Outbreak characteristics and interventions were extracted from Philadelphia Department of Public Health (PDPH) database and quality data on all LTCFs was extracted from Centers for Medicare and Medicaid Services Nursing Home Compare database.

Results: We identified 121 gastroenteritis outbreaks in 49 facilities. Numbers of affected patients ranged from 2 to 211 patients (median patient illness rate, 17%). Staff were reported ill in 94 outbreaks (median staff illness rate, 5%). Outbreak facilities were associated with higher occupancy rates (91% vs 88%; P = .033) and total bed numbers (176 vs 122; P = .071) compared to nonoutbreak facilities. Higher rates of staff illness were associated with prolonged outbreaks (13% vs 4%; P < .001) and higher patient illness rates (9% vs 4%; P = .012). Prolonged outbreaks were associated with lower frequency of cohorting for outbreak management (13% vs 41%; P = .046).

Conclusion: This study is the largest published analysis of gastroenteritis outbreaks in LTCFs. Facility characteristics and staff disease activity were associated with more severe outbreaks. Heightened surveillance for gastrointestinal symptoms among staff and increased use of cohorting might reduce the risk of prolonged gastroenteritis outbreaks in LTCF.
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http://dx.doi.org/10.1017/ice.2020.263DOI Listing
November 2020

Interpretation of pediatric chest radiographs by non-radiologist clinicians in Botswana using World Health Organization criteria for endpoint pneumonia.

Pediatr Radiol 2020 06 10;50(7):913-922. Epub 2020 Jun 10.

Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: In low- and middle-income countries, chest radiographs are most frequently interpreted by non-radiologist clinicians.

Objective: We examined the reliability of chest radiograph interpretations performed by non-radiologist clinicians in Botswana and conducted an educational intervention aimed at improving chest radiograph interpretation accuracy among non-radiologist clinicians.

Materials And Methods: We recruited non-radiologist clinicians at a referral hospital in Gaborone, Botswana, to interpret de-identified chest radiographs for children with clinical pneumonia. We compared their interpretations with those of two board-certified pediatric radiologists in the United States. We evaluated associations between level of medical training and the accuracy of chest radiograph findings between groups, using logistic regression and kappa statistics. We then developed an in-person training intervention led by a pediatric radiologist. We asked participants to interpret 20 radiographs before and immediately after the intervention, and we compared their responses to those of the facilitating radiologist. For both objectives, our primary outcome was the identification of primary endpoint pneumonia, defined by the World Health Organization as presence of endpoint consolidation or endpoint effusion.

Results: Twenty-two clinicians interpreted chest radiographs in the primary objective; there were no significant associations between level of training and correct identification of endpoint pneumonia; concordance between respondents and radiologists was moderate (κ=0.43). After the training intervention, participants improved agreement with the facilitating radiologist for endpoint pneumonia from fair to moderate (κ=0.34 to κ=0.49).

Conclusion: Non-radiologist clinicians in Botswana do not consistently identify key chest radiographic findings of pneumonia. A targeted training intervention might improve non-radiologist clinicians' ability to interpret chest radiographs.
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http://dx.doi.org/10.1007/s00247-020-04625-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539136PMC
June 2020

Building vaccine acceptance through communication and advocacy.

Hum Vaccin Immunother 2020 05;16(5):1004-1006

Department of Pediatrics, University of Pennsylvania Perelman School of Medicine; Division of Infectious Diseases, The Children's Hospital of Philadelphia; Philadelphia Department of Public Health Division of Disease Control, Philadelphia, PA.

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http://dx.doi.org/10.1080/21645515.2020.1746603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227644PMC
May 2020

Tailored Messages Addressing Human Papillomavirus Vaccination Concerns Improves Behavioral Intent Among Mothers: A Randomized Controlled Trial.

J Adolesc Health 2020 08 18;67(2):253-261. Epub 2020 Mar 18.

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana.

Purpose: The aim of the study was to determine whether supplementing a bundled recommendation (recommendation for all 11- to 12-year-old platform vaccines) with tailored messaging that addressed one versus all parental concerns improved human papillomavirus (HPV) vaccination intent among mothers.

Methods: We conducted a Web-based randomized controlled trial, randomizing mothers who did not intend to vaccinate their 11- to 14-year-old child against HPV to (1) bundled recommendation video ("control"); (2) control + video addressing the top HPV vaccine concern; or (3) control + ≥1 videos addressing all concerns. Outcomes were HPV vaccination intent (1 = extremely unlikely and 10 = extremely likely) and strength of main concern (1 = a little concerned and 10 = very concerned). We assessed differences in intervention effects using generalized linear models for vaccine intent and mixed models for the strength of main concern.

Results: Of the 762 mothers, 51% had a female child, 82% of children were white, and 90% were non-Hispanic. The mean intent to vaccinate postintervention ranged from 3.5 (95% confidence interval [CI] = 3.1-3.8) in the control group to 4.2 (95% CI = 3.9-4.6) in the all-concerns group (p = .01). The mean strength of the concerns declined pre- to postintervention by .1 (95% CI = -.1 to .3) in the control group (p = .42), .6 (95% CI = .4-.9) in the top concern group (p < .001), and .7 (95% CI = .5-1.0) in the all-concerns group (p < .001). However, the mean strength of the main concerns postintervention remained high (≥7.0 for each group).

Conclusions: Tailored messages addressing all concerns improved HPV vaccination intent and reduced the strength of the main concern more than bundled messages alone, but intent remained low and strength of the main concerns remained high in this vaccine-hesitant population.
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http://dx.doi.org/10.1016/j.jadohealth.2020.01.024DOI Listing
August 2020

Impact of school-entry vaccination requirement changes on clinical practice implementation and adolescent vaccination rates in metropolitan Philadelphia.

Hum Vaccin Immunother 2020 05 24;16(5):1155-1165. Epub 2020 Jan 24.

Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

In 2017, Pennsylvania amended school-entry vaccination requirements including reduction of the provisional period from eight months to the first five days of school and requirement of meningococcal-conjugate vaccine (MCV4) for students entering 12th grade. This cross-sectional study evaluates the impact of these new requirements on clinical practice and vaccination rates among requirement-eligible adolescents within a large pediatric network in metropolitan Philadelphia. We surveyed providers from 24 pediatric primary care facilities across five Southeastern Pennsylvania counties to assess strategies for timely vaccination of children, facilitators and barriers to implementation of these strategies, and attitudes toward the new school vaccine requirements. Vaccination rates post-five-day grace period among eligible 12-18-year-old adolescents were calculated using aggregate electronic health record data and compared pre- and post-policy implementation (2016 vs. 2017) using two-sample tests of proportion. Overall, providers were supportive of the new vaccination requirements and reported that their facilities were equipped to accommodate the increased demand for vaccination visits prior to the beginning of the school year. There were modest increases in Tdap and MCV4 vaccination rates among 12-13-year-old adolescents by mid-September and a significant increase for MCV4 among 17-18-year-old adolescents ( > .001) in all regions. There were also statistically significant increases ( > .001) in MenB and HPV vaccination rates in this older age group. Our results suggest that these amended school-entry vaccination requirements may help improve timely vaccination rates for both required and non-required vaccines, increasing protection among students at the beginning of the school year.
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http://dx.doi.org/10.1080/21645515.2020.1712934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227691PMC
May 2020

Resurgence of measles in the United States: how did we get here?

Curr Opin Pediatr 2020 02;32(1):139-144

Vaccine Education Center, The Children's Hospital of Philadelphia.

Purpose Of Review: In September 2019, the United States was at risk of losing measles elimination status due to several large-scale outbreaks resulting in more than 1200 confirmed cases across 31 states. This resurgence caps approximately 10 years of increasing incidence, marked by a highly publicized outbreak in 2015 associated with Disneyland when an infected traveler from the Philippines unknowingly spread the virus to susceptible park visitors and the recently ended large outbreak in undervaccinated Orthodox Jewish communities in New York City and Rockland counties. This review highlights current literature elucidating factors associated with current trends in measles epidemiology in the United States, the public health implications of current measles outbreaks and a path forward for addressing challenges contributing to the resurgence of measles in the United States and globally.

Recent Findings And Summary: As the most highly transmissible vaccine preventable disease, measles is especially sensitive to changes in herd immunity, the impact of vaccine refusal and globalization. Results highlight the confluence of these factors in current outbreaks, provide tools to predict outbreak risk, demonstrate the growing impact of misinformation and evaluate the impact of policy approaches for outbreak control and prevention.
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http://dx.doi.org/10.1097/MOP.0000000000000845DOI Listing
February 2020

Psychological reactance impacts ratings of pediatrician vaccine-related communication quality, perceived vaccine safety, and vaccination priority among U.S. parents.

Hum Vaccin Immunother 2020 05 12;16(5):1024-1029. Epub 2019 Dec 12.

Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Physician communication surrounding vaccination is important in driving patient compliance with schedules and recommendations, but patient psychological factors suggest that communication strategies may have differential effects on patients. This paper investigates how psychological reactance, defined as an individuals' propensity to restore their autonomy when they perceive that others are trying to impose their will on them, impacts perceptions about physician communication and perceptions and prioritizations of vaccination. We propose and describe the results of a study that was conducted to assess the relationship between individual differences in reactance, perceived quality of pediatrician communication, perceptions of vaccination safety, and vaccination prioritization using a sample of parents. We recruited 300 parent participants via the online platform Prolific Academic in which they completed a computer-mediated survey. Results show that compared to those who are low in psychological reactance, those high in psychological reactance place less of a priority on vaccination, and that this relationship is driven by evaluations of physician communication quality and perceived vaccine safety. Our findings suggest that physicians should not adopt a one-size-fits-all approach when interacting with patients and should tailor messaging to patients based on psychological factors including reactance.
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http://dx.doi.org/10.1080/21645515.2019.1694815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227688PMC
May 2020

The prevalence and clinical characteristics of pertussis-associated pneumonia among infants in Botswana.

BMC Pediatr 2019 11 16;19(1):444. Epub 2019 Nov 16.

Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.

Background: There are scant data on the prevalence and clinical course of pertussis disease among infants with pneumonia in low- and middle-income countries. While pertussis vaccination coverage is high (≥90%) among infants in Botswana, human immunodeficiency virus (HIV) infection affects nearly one-third of pregnancies. We aimed to evaluate the prevalence and clinical course of pertussis disease in a cohort of HIV-unexposed uninfected (HUU), HIV-exposed uninfected (HEU), and HIV-infected infants with pneumonia in Botswana.

Methods: We recruited children 1-23 months of age with clinical pneumonia at a tertiary care hospital in Gaborone, Botswana between April 2012 and June 2016. We obtained nasopharyngeal swab specimens at enrollment and tested these samples using a previously validated in-house real-time PCR assay that detects a unique sequence of the porin gene of Bordetella pertussis.

Results: B. pertussis was identified in 1/248 (0.4%) HUU, 3/110 (2.7%) HEU, and 0/33 (0.0%) HIV-infected children. All pertussis-associated pneumonia cases occurred in infants 1-5 months of age (prevalence, 1.0% [1/103] in HUU and 4.8% [3/62] in HEU infants). No HEU infants with pertussis-associated pneumonia were taking cotrimoxazole prophylaxis at the time of hospital presentation. One HUU infant with pertussis-associated pneumonia required intensive care unit admission for mechanical ventilation, but there were no deaths.

Conclusions: The prevalence of pertussis was low among infants and young children with pneumonia in Botswana. Although vaccination against pertussis in pregnancy is designed to prevent classical pertussis disease, reduction of pertussis-associated pneumonia might be an important additional benefit.
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http://dx.doi.org/10.1186/s12887-019-1820-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858628PMC
November 2019

Rotavirus-associated seizures and reversible corpus callosum lesion.

Acta Med Litu 2019 ;26(2):113-117

Children's Hospital of Philadelphia, Philadelphia Department of Public Health Philadelphia, USA.

Rotavirus is a non-enveloped double-stranded RNA virus that causes severe gastroenteritis in children, but complications are rarely reported. Some reports have shown that rotavirus can induce diverse complications of the central nervous system, such as seizures, encephalopathy with a reversible splenial lesion, encephalitis, cerebral white matter abnormalities, and cerebellitis. Here, we present a 2-year-old patient with seizures, who had an isolated splenial lesion in the corpus callosum on neuroimaging, and the rotavirus antigen detected in faeces.
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http://dx.doi.org/10.6001/actamedica.v26i2.4031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6779472PMC
January 2019

Placental Transfer of Respiratory Syncytial Virus Antibody Among HIV-Exposed, Uninfected Infants.

J Pediatric Infect Dis Soc 2020 Jul;9(3):349-356

Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina.

Background: Maternal human immunodeficiency virus (HIV) infection is associated with lower placental transfer of antibodies specific to several childhood pathogens. Our objective for this study was to evaluate the effect of maternal HIV infection on the placental transfer of respiratory syncytial virus (RSV)-neutralizing antibodies.

Methods: We conducted a cross-sectional study of mothers and their newborn infants at a tertiary hospital in Gaborone, Botswana, between March 2015 and December 2015. We measured serum RSV antibody levels by using a microneutralization assay. We used multivariable linear regression to evaluate the effect of maternal HIV infection on maternal RSV antibody levels, placental transfer of RSV antibodies, and newborn RSV antibody levels.

Results: Of 316 mothers, 154 (49%) were infected with HIV. The placental transfer ratios for RSV antibodies to HIV-exposed, uninfected (HEU) and HIV-unexposed, uninfected infants were 1.02 and 1.15, respectively. The geometric mean titer (95% confidence interval) of RSV-neutralizing antibodies was 2657 (2251-3136) among HEU newborns and 2911 (2543-3331) among HIV-unexposed, uninfected newborns. In multivariable analyses, maternal HIV infection was associated with lower placental transfer of RSV antibodies (P = .02) and a lower level of RSV antibodies among newborns (P = .002). Among HEU newborns, higher birth weight (P = .004) and an undetectable maternal antenatal viral load (P = .01) were associated with more effective placental transfer of RSV antibodies.

Conclusions: Maternal human immunodeficiency virus (HIV) infection is associated with lower mother-to-fetus transfer of serum RSV-neutralizing antibodies. HEU infants should be prioritized for preventive interventions for RSV. Maternal viral suppression through combination antiretroviral therapy has the potential to improve immunity to RSV among HIV-exposed infants.
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http://dx.doi.org/10.1093/jpids/piz056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358043PMC
July 2020

Perspectives on state vaccine education mandate policy and implementation among public health department officials: a qualitative study.

Hum Vaccin Immunother 2020 05 30;16(5):1145-1154. Epub 2019 Sep 30.

Immunization Program and Acute Communicable Diseases, Philadelphia Department of Public Health, Philadelphia, PA, USA.

In response to the increase in non-medical vaccine exemptions (NME), many states have adopted education mandates (EM), required vaccine education for parents requesting NMEs for their school-age children, but these EMs vary greatly in implementation. In order to learn about the administrative aspects of each state's EM, we interviewed fourteen health department officials from nine states with EMs. Interviews were conducted over the phone, transcribed by a professional transcription service, and double-coded using NVivo 12 by two members of the study staff. The coding resulted in 3698 comments overall, 98.5% inter-coder reliability, and a κ statistic of 0.691. We found no consistent format for content delivery, and methods used included in-person dialogs, web-based education, and video modules. Content of the education is not standardized, and education length ranges from 15 to 60 minutes. Four major themes about the EM policies emerged: (1) the use of EMs to eliminate "convenience exemptions;" (2) the importance of health department communication with health-care providers; (3) facilitators and barriers to implementation; and (4) the positive recommendation for other states to adopt EM policies. We concluded that current EM implementation varies greatly, but officials in states which have adopted EMs for parents requesting NMEs for school-entry vaccinations overwhelmingly recommend other states to adopt them as well. Key features of successful programs may include conversations with parents requesting NMEs and strong communication channels with health-care providers. Systematic tracking of vaccine status after exemption requests and education is necessary to quantitatively determine the effectiveness of EM programs.
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http://dx.doi.org/10.1080/21645515.2019.1654352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227698PMC
May 2020

Student health administrator perspectives on college vaccine policy development and implementation.

Vaccine 2019 07 1;37(30):4118-4123. Epub 2019 Jun 1.

Children's Hospital of Philadelphia, Vaccine Education Center, 3615 Civic Center Boulevard, Suite 1202 ARC, Philadelphia, PA 19104, United States; University of Pennsylvania, Philadelphia, PA 19104, United States; Philadelphia Department of Public Health, 1101 Market St, Philadelphia, PA 19107, United States. Electronic address:

Background: Immunization policies at colleges and universities differ greatly for many reasons, including prior experience with disease outbreaks and state immunization requirements. Few studies comprehensively explore the range of factors that influence the development of college vaccine policies or facilitators and barriers to their implementation.

Objective: To explore the perceptions and decision-making process that influence college vaccine policy development and implementation from the perspective of student health administrators.

Methods: This qualitative study used semi-structured interviews with student health administrators (N = 10) from ten U.S. colleges and universities purposefully sampled by school type (public vs. private) and geographic region. A descriptive codebook was developed from the interview guide, and each interview was double-coded using NVivo 11 software (κ = 0.87; inter-observer reliability = 99.4%).

Results: We coded 5785 phrases. Administrators positively viewed their institutions' vaccine requirements, but some expressed concerns about the acceptance of philosophical and religious exemptions. They noted that students were generally ambivalent towards vaccine requirements, and while students recognized the benefits of vaccination, they did not prioritize immunizations. All administrators cited reliance on governmental and professional organizations as well as state regulations for decisions regarding vaccine requirements and recommendations at their institutions. Partnerships with other school departments, pharmaceutical companies, immunization coalitions, and healthcare providers were frequently cited as facilitators of college vaccine programs. Costs of purchasing, storing, and tracking vaccines were identified as major barriers.

Conclusions: We identified key themes that can be evaluated in subsequent studies to identify factors associated with successful implementation of university immunization programs and inform initiatives to increase vaccine acceptance and optimize immunization rates on college and university campuses.
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http://dx.doi.org/10.1016/j.vaccine.2019.05.073DOI Listing
July 2019

Disparities in Human Papillomavirus Vaccine Series Completion by Adolescent Males: A Retrospective Cohort Study.

Acad Pediatr 2020 04 18;20(3):364-373. Epub 2019 May 18.

Division of Infectious Diseases (KA Feemster).

Objective: Human papillomavirus (HPV) vaccine has been recommended for male patients for the prevention of genital warts and precancerous anal lesions since 2009. Our objective was to characterize race and insurance-based disparities in HPV vaccine completion among male patients who initiated the HPV vaccine series.

Methods: This was a retrospective cohort study of adolescent male patients in a primary care network who initiated the HPV vaccine series from October 2009 to December 2013. We measured vaccine series completion as the primary outcome. We evaluated associations between outcomes and race and insurance status, controlling for potential confounders and effect modification with multivariable logistic regression. Analyses were stratified by vaccine recommendation era (permissive vs routine).

Results: In total, 42% of males in the cohort (16,691) completed the vaccine series. In the permissive vaccine era (2009-2011), non-black patients (53%) were more likely to complete than black patients (32%) and non-Medicaid patients (49%) were more likely to complete than Medicaid patients (33%). These differences persisted in the routine recommendation era (2012-2013). In both the permissive and routine eras, Medicaid insurance was associated with a larger reduction in the predicted probability of vaccine series completion for non-black patients. Adherence to the recommended vaccination schedule was low, with a median time to completion of 8.9 months. Using the updated completion schedule (2016), we found that completion rates were greater (54.1%) with continued differences based on race (60% vs 45.7% for non-black vs black patients) and insurance (57.4% vs 46.4% completion for non-Medicaid vs Medicaid patients).

Conclusions: We found significant disparities in HPV vaccine series completion rates among male patients based on race and insurance, unchanged based on era of initiation or visit frequency.
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http://dx.doi.org/10.1016/j.acap.2019.05.002DOI Listing
April 2020

Japanese physicians' attitudes and intentions regarding human papillomavirus vaccine compared with other adolescent vaccines.

Papillomavirus Res 2019 06 30;7:193-200. Epub 2019 Apr 30.

Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States.

Introduction: Japan has experienced extremely low human papillomavirus vaccine (HPVV) coverage following the suspension of proactive governmental recommendations in 2013. Several studies have reported that recommendations from physicians increase adolescents' vaccine acceptance. In this survey, we evaluated the attitudes and intentions of Japanese physicians related to adolescent immunizations, particularly HPVV.

Methods: We conducted a cross-sectional study using a mailed questionnaire targeting 330 Japanese physicians including 78 pediatricians, 225 internists and 27 obstetricians and gynecologists (OB/GYNs) in Kawasaki City, Japan in 2016. The survey measured physicians' reported frequency of educating adolescents about vaccines as well as their own perceptions and intentions related to adolescent immunizations.

Results: Valid responses were obtained from 148 (45%) physicians. Though 53% agreed that the HPVV should be recommended, only 21% reported educating about HPVV. The majority of respondents (90%) agreed that they would restart HPVV for adolescents if the government reinstated its recommendation.

Conclusions: Although Japanese physicians reported support for adolescent immunizations, they were less likely to recommend or discuss HPVV compared with other adolescent vaccines. Responses indicated this was, at least in part, due to the lack of governmental support for HPVV, indicating that their recommendations would improve with government endorsement of the vaccine.
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http://dx.doi.org/10.1016/j.pvr.2019.04.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520551PMC
June 2019

Clinical Impact of Malaria Rapid Diagnostic Testing at a US Children's Hospital.

J Pediatric Infect Dis Soc 2020 Jul;9(3):298-304

Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania.

Background: Children who develop malaria after returning to a setting in which the disease is not endemic are at high risk for critical delays in diagnosis and initiation of antimalarial therapy. We assessed the clinical impact of the implementation of malaria rapid diagnostic testing (RDT) on the management of children with malaria at an urban US children's hospital that serves a large immigrant population.

Methods: This was a retrospective cohort study of all children diagnosed with laboratory-confirmed malaria at the Children's Hospital of Philadelphia (CHOP) between 2000 and 2014. RDT using a US Food and Drug Administration-approved immunochromatographic assay was introduced at CHOP on August 1, 2007. We compared clinical management and outcomes of patients with malaria diagnosed before and after RDT introduction.

Results: We analyzed 82 pediatric malaria cases (32 before and 50 after RDT implementation). The majority of these patients had traveled to West Africa (91.5%) and were infected with Plasmodium falciparum (80.5%). The mean time to a positive result decreased from 10.4 to 0.9 hours (P < .001) after the introduction of RDT for patients with P falciparum. The mean time to antimalarial therapy decreased from 13.1 to 6.9 hours (P =; .023) in hospitalized patients. We found no significant reduction in the mean number of clinical signs of severe malaria between 0 and 48 hours of hospitalization and no difference in the need for exchange transfusion, time to resolution of parasitemia, or length of hospital stay.

Conclusions: Implementation of RDT for malaria was associated with shorter times to malaria diagnosis and initiation of antimalarial therapy. The results of this study support RDT in the optimal management of patients with malaria who present in settings in which the disease is not endemic.
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http://dx.doi.org/10.1093/jpids/piz022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358041PMC
July 2020

Understanding vaccine knowledge, attitudes, and decision-making through college student interviews.

J Am Coll Health 2020 Aug-Sep;68(6):593-602. Epub 2019 Mar 25.

Children's Hospital of Philadelphia, Vaccine Education Center, Philadelphia, Pennsylvania, USA.

We aimed to explore knowledge, attitudes, and beliefs about vaccines required for college-entry and vaccine-related behaviors among college students. Thirty-three full-time undergraduate students, ≥ 18 years old, enrolled at public (2) and private (3) colleges and universities in metropolitan Philadelphia in fall 2016. We conducted semistructured interviews, which were double-coded with 5,015 comments overall and 99.3% intercoder reliability ( = 0.779) using NVivo 11 software. Six key themes emerged: (1) low knowledge about vaccines and requirements; (2) mixed attitudes about required vs. recommended vaccines; (3) high trust in medical professionals; (4) low perceived risk for vaccine-preventable disease outbreaks; (5) substantial parental influence on students' decision-making; and (6) low utilization of Student Health Services. This study revealed lack of knowledge about and low prioritization of vaccination despite overall positive attitudes towards vaccines. Prematriculation education of college students is critical to increasing vaccine knowledge and use.
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http://dx.doi.org/10.1080/07448481.2019.1583660DOI Listing
May 2021

Predictors of Poor Outcomes Among Infants With Respiratory Syncytial Virus-associated Acute Lower Respiratory Infection in Botswana.

Pediatr Infect Dis J 2019 05;38(5):525-527

Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina.

Among children 1-23 months of age with respiratory syncytial virus-associated acute lower respiratory infection in Botswana, young age (<6 months), household use of wood as a cooking fuel, moderate or severe malnutrition and oxygen saturation <90% on room air were independent predictors of clinical nonresponse at 48 hours. Among HIV-uninfected infants less than six months of age, HIV exposure was associated with a higher risk of in-hospital mortality.
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http://dx.doi.org/10.1097/INF.0000000000002168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465100PMC
May 2019
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