Comparison of infectious SARS-CoV-2 from the nasopharynx of vaccinated and unvaccinated individuals

The frequency of SARS-CoV-2 breakthrough infections in fully vaccinated individuals increased with the emergence of the Delta variant, particularly with longer time from vaccine completion. However, whether breakthrough infections lead to onward transmission remains unclear. Here, we conducted a study involving 125 patients comprised of 72 vaccinated and 53 unvaccinated individuals, to assess the levels of infectious virus in in vaccinated and unvaccinated individuals. Quantitative plaque assays showed no significant differences in the titers of virus between these cohorts. However, the proportion of nasopharyngeal samples with culturable virus was lower in the vaccinated patients relative to unvaccinated patients (21% vs. 40%). Finally, time-to-event analysis with Kaplan-Myer curves revealed that protection from culturable infectious virus waned significantly starting at 5 months after completing a 2-dose regimen of mRNA vaccines. These results have important implications in timing of booster dose to prevent onward transmission from breakthrough cases.

Successful HPV Vaccination in Adolescents with Sickle Cell Disease Following a Quality Improvement Bundle Intervention

Introduction Human papilloma virus (HPV) infection can cause cervical, anal, penile, vaginal, and oropharyngeal cancer. The CDC recommends HPV vaccination as a 2 or 3-dose series at <15 or ≥15 years, respectively. Completion of the vaccine series decreases rates of cervical cancer in young women by 29%(Guo, F. et al. American Journal of Preventive Medicine 2018). For this reason, focus is currently on vaccinating younger patients to optimize benefit. Historically, adolescents have had low rates of completion of the HPV vaccine series. African Americans, in particular, have significantly lower rates than whites in receiving the full series (De, P. and H. Budhwani. Public Health 2017). Vaccine hesitancy in sickle cell disease (SCD) patients exists and is exemplified by a lower uptake in teenagers with SCD compared to non-SCD counterparts (Beverung, L. et al. American Journal of Hematology 2018). However, completion of 23-pneumococcal vaccine polyvalent (PPSV-23), which is routinely administered as a series during well-child visits, has notably been high. SCD programs serve as medical homes where primary care may also be provided. With this in mind, we introduced a quality improvement (QI) intervention to improve the uptake of HPV vaccination in the adolescent SCD clinic. A bundle intervention was developed including 1) provider education about HPV vaccination importance, 2) nurse review of each adolescent's vaccine records prior to clinic visit, 3) provider notification by the nurse regarding the need for HPV during the visit, 4) discussion of the vaccine benefits with the family, 5) provision of the vaccine in the SCD clinic after parent consent, and 6) offering of MOC points as incentive to providers for project participation. We sought to evaluate the impact of the QI bundle on completion of the HPV vaccine series. We hypothesized that implementation of the QI bundle would increase the rate of completion of the HPV vaccine series among adolescents with SCD. Secondary objectives included association between completion of the HPV vaccine series and frequency of outpatient visits to the SCD clinic, quality of life (QoL), SCD-specific knowledge, completion of the PPSV-23 series, and markers of socio-economic status (SES). Methods Retrospective data was collected using the Sickle Cell Clinical Research and Intervention Program (SCCRIP) study database (Hankins JS, et al. Pediatr Blood Cancer 2018). Patients aged 12-18 years between October 1, 2018 and December 31, 2019 with any SCD genotype and who were enrolled on the SCCRIP study were included in analysis. The following variables were extracted: age, sex, race, ethnicity, age, economic hardship index (EHI), parental education level, household income, genotype, SCD-specific knowledge, and distance to healthcare facility. The prevalence of completed HPV series, defined as 2 doses ages <15 years and 3 doses ages ≥15 years, in the 12 months prior to implementation of the bundle vaccination program (before October 1, 2018) and after implementation of program (October 2, 2018 to December 31, 2019) was calculated using Fisher's exact. Demographic characteristics and QoL were compared between patients who completed the vaccine series and those who did not. Results In total, 373 patients met inclusion criteria. Their median age was 15.2 (range 12-19), 50% were female, 225 (60.3%) had HbSS/Sβ 0-thalassemia, and 114 (29.7%) had HbC/Sβ +-thalassemia. The mean SES index was 70% (±27%) and the mean QoL score 73 (±14.6). HPV vaccine completion rates increased from 31% to 56.2% after the bundle implementation (Figure 1, p<0.01). Completion of the series was associated with higher SES index, completion of the PPSV-23 series, and higher frequency of outpatient visits. There was no significant association between completion of the vaccine series and QoL, distance from healthcare facility, and disease-specific knowledge (Table 1). Discussion Prevention of communicable diseases such as HPV is imperative in the general population. However, baseline vaccination rates in adolescents with SCD is low. A QI intervention that includes provider education and incentives, active verification of HPV vaccination status, and promotes coordinated communication between the nurse, providers, and patients effectively increased completion of the HPV vaccine series among adolescents with SCD. Continued strategies are needed to further increase the rates of vaccine completion. Figure 1 Figure 1. Disclosures Hankins: Vindico Medical Education: Consultancy; Global Blood Therapeutics: Consultancy; UpToDate: Consultancy; Bluebird Bio: Consultancy.

1196. A Multi-faceted, Iterative Program to Increase COVID-19 Vaccine Uptake in a Midwestern HIV Clinic

Background The National Institutes of Health Office of AIDS Research recommend that patients with HIV be prioritized for COVID-19 vaccination due to high rates of co-morbidities and sociodemographic risk factors that place them at increased risk for severe disease. However, COVID-19 vaccines were not distributed specifically to those in high-risk medical categories in Nebraska, and HIV clinics were not included in the state’s COVID-19 vaccine delivery system. As a result, barriers to vaccine uptake emerged and interventions to mitigate them were needed. Methods A multi-faceted and iterative program aimed at improving COVID-19 vaccine uptake was implemented at the University of Nebraska Medical Center’s (UNMC) HIV clinic in Omaha, Nebraska in January 2021. A multidisciplinary task force was established in late January 2021 and met on a weekly basis to provide staff and patient education, linkage to vaccines, and review and analysis of vaccine completion rates as shown in the figure. Outreach interventions were continuously revised based on patient and staff feedback as well as updated data and vaccine availability. Multidisciplinary COVID-19 Task Force Overview Overview of the outreach interventions and activities conducted by the COVID-19 task force Results All 1188 patients of the UNMC HIV clinic were ultimately eligible for the COVID-19 vaccine, but availability was on a rolling basis by age group, profession, county, and, ultimately, co-morbidities. 76% were male, 45.8% non-white, median age 48, and 73% had income less than 400% of federal poverty level. Of the 1188 eligible patients, 63.1% (n=751) had received at least one dose the COVID-19 vaccine and 59.3% (n=705) had completed the COVID-19 vaccine series by June 4, 2021. In comparison, 49.32% of the population of the state of Nebraska had initiated the COVID-19 vaccine series and 43.12% had completed the vaccine series by that date. Among our clinic patients, 27.9% (n=261) of those who had received at least one vaccine were assisted by our task force. 4.5% were noted to have a potential barrier at the time of outreach and these included hesitancy (3.5%), language (1.2%) and transportation (0.9%). Conclusion A multi-faceted and iterative program to improve COVID-19 vaccine uptake in a high-risk patient population resulted in high rates of vaccine completion. Disclosures Sara H. Bares, MD, Gilead Sciences (Grant/Research Support)Janssen (Grant/Research Support)ViiV Healthcare (Grant/Research Support)

Vaccine completion and infectious diseases screening in a cohort of adult refugees following resettlement in the U.S.: 2013–2015

Background Refugees are frequently not immune to vaccine-preventable infections. Adherence to consensus guidelines on vaccination and infectious diseases screening among refugees resettling in the U.S. is unknown. We sought to determine rates of vaccine completion and infectious diseases screening in refugees following resettlement. Methods We conducted a retrospective cohort study of refugees resettling in a region in the U.S. using medical data from June 2013–April 2015. We determined the proportion of vaccine-eligible refugees vaccinated with measles-mumps-rubella (MMR), hepatitis A/B, tetanus, diphtheria, and acellular pertussis (Tdap), and human papillomavirus (HPV) following resettlement. We also determined the proportion of refugees who completed HIV and hepatitis C (HCV) screening. Results One hundred and eleven subjects were included, primarily from Iraq (53%), Afghanistan (19%), and Eritrea (11%). Of the 84 subjects who were vaccine-eligible, 78 (93%) initiated and 42 (50%) completed vaccinations within one year of resettlement. Odds of completing vaccination were higher for men (OR: 2.38; 95%CI:1.02–5.71) and for subjects with English proficiency (OR: 3.70; 95%CI:1.04–17.49). Of the 78 subjects (70%) completing HIV screening, two (3%) were diagnosed with HIV. Nearly all subjects completed screening for HCV, and one had active infection. Conclusion While most refugees initiate vaccinations, only 50% completed vaccinations and 70% completed HIV screening within 1 year of resettlement. There is a need to emphasize vaccine completion and HIV screening in refugee patients following resettlement.

Associations between insurance-related affordable care act policy changes with HPV vaccine completion

Background Although all 11- or 12-year-olds in the US were recommended to receive a 3-dose series of the human papillomavirus (HPV) vaccine within a 12-month period prior to 2016, rates of completion of the HPV vaccine series remained suboptimal. The effects of the Affordable Care Act (ACA), including private insurance coverage with no cost-sharing and health insurance expansions, on HPV vaccine completion are largely unknown. The aim of this study was to examine the associations between the ACA’s 2010 provisions and 2014 insurance expansions with HPV vaccine completion by sex and health insurance type. Methods Using 2009–2015 public and private health insurance claims from Maine, New Hampshire, and Massachusetts, we identified 9-to-26-year-olds who had at least one HPV vaccine dose. We conducted a logistic regression model to examine the associations between the ACA policy changes with HPV vaccine completion (defined as receiving a 3-dose series within 12 months from the date of initiation) as well as interactions by sex and health insurance type. Results Over the study period, among females and males who initiated the HPV vaccine, 27.6 and 28.0%, respectively, completed the series within 12 months. Among females, the 2010 ACA provision was associated with a 4.3 percentage point increases in HPV vaccine completion for the privately-insured (0.043; 95% CI: 0.036–0.061) and a 5.7 percentage point increase for Medicaid enrollees (0.057; 95% CI: 0.032–0.081). The 2014 health insurance expansions were associated with a 9.4 percentage point increase in vaccine completion for females with private insurance (0.094; 95% CI: 0.082–0.107) and a 8.5 percentage point increase for Medicaid enrollees (0.085; 95% CI: 0.068–0.102). Among males, the 2014 ACA reforms were associated with a 5.1 percentage point increase in HPV vaccine completion for the privately-insured (0.051; 95% CI: 0.039–0.063) and a 3.4 percentage point increase for Medicaid enrollees (0.034; 95% CI: 0.017–0.050). In a sensitivity analysis, findings were similar with HPV vaccine completion within 18 months. Conclusions Despite low HPV vaccine completion overall, both sets of ACA provisions were associated with increases in completion among females and males. Our results suggest that expanding Medicaid across the remaining states could increase HPV vaccine completion among publicly-insured youth and prevent HPV-related cancers.

Barriers to Human Papillomavirus Vaccine Series Completion among Insured Individuals in an Integrated Healthcare Setting

Introduction: Infection with certain types of human papillomavirus (HPV) can lead to cervical cancer as well as other cancers in both men and women. However, the requirement for multiple doses may limit the vaccine’s effectiveness for cancer prevention. We conducted a pilot study to investigate barriers to HPV vaccine series completion among members of an integrated healthcare system with clinical documentation of only 1 dose. Methods: We surveyed parents or legal guardians of 11-17-year-old girls (n = 10) and boys (n = 18), as well as 18-31-year-old women (n = 20) and men (n = 9), about their reasons for not completing the HPV vaccine series. Results: Most participants (70.2%) were non-Hispanic white. Among parents of children, commonly reported barriers to HPV vaccine series completion included not being aware or informed of the need for additional doses (28.6%), as well as the inconvenience of returning for additional doses (17.9%). Concerns about the HPV vaccine or vaccines in general were more common among parents of girls (30.0%) compared with parents of boys (16.7%). Among adults, barriers to HPV vaccine series completion included the inconvenience of returning for additional doses (31.0%), not being aware or informed of the need for additional doses (10.3%), and forgetting (10.3%). Conclusion: Our findings suggest that clinicians and healthcare systems can play a greater role in promoting awareness of the multiple-dose requirement, addressing vaccine concerns, and increasing opportunistic vaccination in a variety of settings. Increasing these efforts may facilitate HPV vaccine completion and increase its effectiveness in cancer prevention.