Identifying Practices to Promote Inpatient Adolescent and Influenza Vaccine Delivery

OBJECTIVES Many hospitalized children are underimmunized. We assessed the association between hospital immunization practices and tetanus, diphtheria, and acellular pertussis (Tdap), meningococcal, human papillomavirus (HPV), and influenza vaccine delivery. METHODS An electronic survey regarding hospital vaccine delivery practices was distributed via the Pediatric Health Information System (PHIS) and Pediatric Research in Inpatient Settings networks to PHIS hospitals. Number of vaccines delivered and total discharges in 2018 were obtained from the PHIS database to determine hospital vaccine delivery rates; patients 11 to 18 years old (adolescent vaccines) and 6 months to 18 years old (influenza vaccine) were included. Vaccine delivery rates were risk adjusted by using generalized linear mixed-effects modeling and compared with survey responses to determine associations between the number or presence of specific practices and vaccine delivery. Adjusted HPV and meningococcal vaccine delivery rates could not be calculated because of low delivery. RESULTS Twenty-nine hospitals completed a survey (57%). 152 499 and 423 046 patient encounters were included for the adolescent and influenza vaccines, respectively. Unadjusted inpatient vaccine delivery rates varied. After adjustment, the number of practices was associated only with influenza vaccine delivery (P = .02). Visual prompts (P = .02), nurse or pharmacist ordering (P = .003), and quality improvement projects (P = .048) were associated with increased influenza vaccine delivery; nurse or pharmacist ordering had the greatest impact. No practices were associated with Tdap vaccine delivery. CONCLUSIONS The number and presence of specific hospital practices may impact influenza vaccine delivery. Further research is needed to identify strategies to augment inpatient adolescent immunization.

Immunogenicity of a new enhanced tetanus-reduced dose diphtheria-acellular pertussis (Tdap) vaccine against Bordetella pertussis in a murine model

Background The necessity of the tetanus-reduced dose diphtheria-acellular pertussis (Tdap) vaccine in adolescence and adults has been emphasized since the resurgence of small-scale pertussis in Korea and worldwide due to the waning effect of the vaccine and variant pathogenic stains in the late 1990s. GreenCross Pharma (GC Pharma), a Korean company, developed the Tdap vaccine GC3111 in 2010. Recently, they enhanced the vaccine, GC3111, produced previously in 2010 to reinforce the antibody response against filamentous hemagglutinin (FHA). In this study, immunogenicity and efficacy of the enhanced Tdap vaccine compared and evaluated with two Tdap vaccines, GC3111 vaccine produced in 2010 previously and commercially available Tdap vaccine in a murine model. Methods Two tests groups and positive control group of Balb/c mice were primed with two doses of the diphtheria-tetanus-acellular pertussis (DTaP) vaccine followed by a single booster Tdap vaccine at 9 week using the commercially available Tdap vaccine or 2 Tdap vaccines from GC Pharma (GC3111, enhanced GC3111). Humoral response was assessed 1 week before and 2 and 4 weeks after Tdap booster vaccination. The enhanced GC3111 generated similar humoral response compare to the commercial vaccine for filamentous hemagglutinin (FHA). The interferon gamma (IFN-γ) (Th1), interleukin 5 (IL-5) (Th2) and interleukin 17 (IL-17) (Th17) cytokines were assessed 4 weeks after booster vaccination by stimulation with three simulators: heat inactivated Bordetella pertussis (hBp), vaccine antigens, and hBp mixed with antigens (hBp + antigen). A bacterial challenge test was performed 4 weeks after booster vaccination. Results Regarding cell-mediated immunity, cytokine secretion differed among the three simulators. However, no difference was found between two test groups and positive control group. All the vaccinated groups indicated a Th1 or Th1/Th2 response. On Day 5 post-bacterial challenge, B. pertussis colonies were absent in the lungs in two test groups and positive control group. Conclusions Our results confirmed the immunogenicity of GC Pharma’s Tdap vaccine; enhanced GC3111 was equivalent to the presently used commercial vaccine in terms of humoral response as well as cell-mediated cytokine expression.

Association of Tdap vaccine guidelines with vaccine uptake during pregnancy

Objective In 2012, recommendations for universal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination during pregnancy were released. Our objective was to determine if Tdap, influenza, and pneumococcal vaccine uptake during pregnancy changed after the release of the guidelines, and identify factors associated with receiving the Tdap and influenza vaccine after 2012. Methods We conducted a retrospective cohort study on pregnant individuals who initiated prenatal care before 20 weeks’ gestation between 11/2011-11/2012 (“pre-guideline”) and 12/2012-12/2015 (“post-guideline”). Vaccine uptake dates were abstracted from medical records. The pre and post-guideline cohorts were compared to determine if Tdap vaccine uptake and timing improved after the new Tdap guidelines. We additionally examined influenza and pneumococcal vaccine uptake before and after guidelines. Factors associated with receipt of the Tdap and influenza vaccine during pregnancy in the post-guideline cohort were evaluated using multivariable logistic regression models. Results Of 2,294 eligible individuals, 1,610 (70.2%) received care in the post-guideline cohort. Among the pre-guideline cohort, 47.4% received Tdap, whereas Tdap uptake increased to 86.1% after the guidelines (p<0.001). Similarly, receiving the Tdap vaccine between the recommended time of 27–36 weeks gestational age improved from 52.5% to 91.8% after the guidelines (p<0.001). Vaccine frequency for influenza improved significantly from 61.2% to 72.0% (p<0.001), while frequency for pneumococcus were low and unchanged. An increased number of prenatal visits was associated with receiving the Tdap and influenza vaccines during pregnancy (respective, aOR 1.09 95% CI 1.05–1.13; aOR 1.50 95% CI 1.17–1.94). Non-Hispanic Black individuals were less likely to receive both the Tdap and influenza vaccines during pregnancy compared to non-Hispanic White individuals (respective, aOR 0.51 95% CI 0.33–0.80; aOR 0.68 95% CI 0.48–0.97). Conclusions Receipt and timing of Tdap vaccine improved after implementation of the 2012 ACIP guidelines. Receipt of influenza vaccine uptake also improved during the study period, while uptake of the pneumococcal vaccine remained low. Significant racial disparities exist in receipt of Tdap and influenza vaccine during pregnancy.

The Effect of Tetanus-Diphtheria-Acellular-Pertussis Immunization During Pregnancy on Infant Antibody Responses: Individual-Participant Data Meta-Analysis

BackgroundImmunization with tetanus-diphtheria-acellular pertussis (Tdap) vaccine in pregnancy is increasingly recommended. We determined the effect of Tdap immunization in pregnancy on infants’ vaccine responses.MethodsIndividual-participant data meta-analysis of ten studies (n=1884) investigating infants’ antibody response to routine immunizations following Tdap immunization in pregnancy was performed. Geometric mean ratios (GMRs) of antigen-specific immunoglobulin G (IgG) levels were calculated using mixed-effects models. Seroprotection rates were compared using chi-squared tests.ResultsInfants of Tdap-immunized women had significantly lower IgG against pertussis toxin (GMR 0.65; 95%CI 0.57-0.74), filamentous haemagglutinin (FHA) (0.68; 0.53-0.87), pertactin (0.65; 0.58-0.72) and fimbria 2/3 (FIM2/3) (0.41; 0.32-0.52) after primary immunization, compared with infants of unimmunized women. These lower levels persisted after booster immunization for FHA (0.72; 0.61-0.84) and FIM2/3 (0.53; 0.29-0.96). After primary immunization, infants of Tdap-immunized women had lower seroprotection rates against diphtheria (90% [843/973] vs 98% [566/579]; p&lt;0.001) and invasive pneumococcal disease (IPD) caused by 5 Streptococcus pneumoniae (SPN) serotypes (SPN5, SPN6B, SPN9V, SPN19A, SPN23F), and higher seroprotection rates against Haemophilus influenzae type b (short-term and long-term seroprotection rates, 86%[471/547] vs 76%[188/247] and 62%[337/547] vs 49%(121/247), respectively, all p=0.001). After booster immunization, seroprotection rates against diphtheria and tetanus were 99% (286/288) and (618/619) in infants of Tdap-immunized women, respectively.ConclusionsInfants of Tdap-immunized women in pregnancy had lower IgG levels against pertussis, diphtheria and some SPN serotypes after their immunization compared with infants of unimmunized women. Enhanced surveillance of pertussis, diphtheria and IPD in infants is needed to determine the clinical significance of these findings.Systematic Review RegistrationCRD42017079171.

Factors Associated with Influenza & Tdap Vaccine Uptake in Pregnant Patients at the UT Family Medicine Clinic in Memphis

INTRODUCTION: Given the increased risk for infections among pregnant patients and newborns, vaccination against influenza (>50,000,000 annual US cases affecting all ages) and pertussis (>15,000 annual US cases disproportionately affecting newborns) are recommended among pregnant patients in order to protect them and their babies via passive immunity to cover a newborn’s window of vaccine ineligibility. Though flu and Tdap vaccination rates among pregnant patients have been trending upwards nationally, there is still room for improvement to achieve optimal rates. OBJECTIVES: The primary objectives were to study factors that affect the vaccination rates at the University of Tennessee Family Medicine Clinic at Memphis (UTFMC-M), compare those rates with national pregnancy flu/Tdap vaccination rates, and to generate recommendations based off observed factors associated with vaccine uptake to improve flu/Tdap vaccination rates in UTFMC-M pregnant patients. METHODS: This was a retrospective chart review of UTFMC-M patients who were pregnant from September 1, 2019-April 24, 2020 (included 2019-2020 flu season) (n=465). Variables studied included demographic data (race, age, insurance), immunization history (vaccine status, history of physician encouragement), and prenatal history (parity, number of prenatal visits, trimester at first visit, high risk clinic (HRC) admittance status). Vaccination status was based on ACIP recommendations (Flu shot eligible = any gestational age; Tdap eligible = ≥27 weeks). Positive HRC admittance was noted for patients with ≥2 visits to the UTFMC-M HRC, a clinic that specializes in high risk pregnant patient care. RESULTS: The patient sample was predominantly black (84.3%) and insured by Medicaid programs (88%). Among eligible UTFMC-M pregnant patients, 50.1% were flu-vaccinated (n=465); 73.8% were Tdap-vaccinated (n=317); and 52.1% were Flu+Tdap-vaccinated (n=317). No significant associations were found between vaccine uptake and HRC status, parity, and age. However, statistically significant relationships were found between vaccine uptake and physician encouragement (positive relationship with flu shot: X2(1, N = 465) =131, p < 0.001, Tdap: X2 (6, N = 465) =476, p < 0.001), number of prenatal visits (flu shot group median 8 visits, Tdap group median 9 visits vs. unvaccinated group median 4 visits; p < 0.001), and early trimester age at first prenatal visit (X2(6, N = 465) =47.635 , p CONCLUSION: 2019-2020 UTFMC-M vaccination rates were on par with 2018-2019 US flu vaccine rates and higher than 2018-2019 US Tdap and Flu+Tdap rates. There were statistically significant relationships between vaccine uptake at UTFMC-M and physician encouragement, number of prenatal visits, and early trimester age at first prenatal visit but no significant relationships with UTFMC-M HRC admittance, parity, or age. Recommendations following from our observations to address further vaccine rate improvement include: continue vaccine encouragement, continue booking multiple visits (8 for flu, 9 for Tdap), prioritize Tdap vaccine higher for late trimester intake patients, and focus on flu vaccine encouragement and education.