The development of a staphylococcus aureus four antigen vaccine for use prior to elective orthopedic surgery

Staphylococcus aureus (S. aureus) is a challenging bacterial pathogen which can cause a range of diseases, from mild skin infections, to more serious and invasive disease including deep or organ space surgical site infections, life-threatening bacteremia, and sepsis. S. aureus rapidly develops resistance to antibiotic treatments. Despite current infection control measures, the burden of disease remains high. The most advanced vaccine in clinical development is a 4 antigen S. aureus vaccine (SA4Ag) candidate that is being evaluated in a phase 2b/3 efficacy study in patients undergoing elective spinal fusion surgery (STaphylococcus aureus suRgical Inpatient Vaccine Efficacy [STRIVE]). SA4Ag has been shown in early phase clinical trials to be generally safe and well tolerated, and to induce high levels of bactericidal antibodies in healthy adults. In this review we discuss the design of SA4Ag, as well as the proposed clinical development plan supporting licensure of SA4Ag for the prevention of invasive disease caused by S. aureus in elective orthopedic surgical populations. We also explore the rationale for the generalizability of the results of the STRIVE efficacy study (patients undergoing elective open posterior multilevel instrumented spinal fusion surgery) to a broad elective orthopedic surgery population due to the common pathophysiology of invasive S. aureus disease and commonalties of patient and procedural risk factors for developing postoperative S. aureus surgical site infections.

Vaccine development to prevent Staphylococcus aureus surgical-site infections

BACKGROUND

Staphylococcus aureus surgical-site infections (SSIs) are a major cause of poor health outcomes, including mortality, across surgical specialties. Despite current advances as a result of preventive interventions, the disease burden of S. aureus SSI remains high, and increasing antibiotic resistance continues to be a concern. Prophylactic S. aureus vaccines may represent an opportunity to prevent SSI.

METHODS

A review of SSI pathophysiology was undertaken in the context of evaluating new approaches to developing a prophylactic vaccine to prevent S. aureus SSI.

RESULTS

A prophylactic vaccine ideally would provide protective immunity at the time of the surgical incision to prevent initiation and progression of infection. Although the pathogenicity of S. aureus is attributed to many virulence factors, previous attempts to develop S. aureus vaccines targeted only a single virulence mechanism. The field has now moved towards multiple-antigen vaccine strategies, and promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI.

CONCLUSION

There is an unmet medical need for novel S. aureus SSI prevention measures. Advances in understanding of S. aureus SSI pathophysiology could lead to the development of effective and safe prophylactic multiple-antigen vaccines to prevent S. aureus SSI.

SA4Ag, a 4-antigen Staphylococcus aureus vaccine, rapidly induces high levels of bacteria-killing antibodies

BACKGROUND

Staphylococcus aureus is a leading cause of healthcare-associated infections. No preventive vaccine is currently licensed. SA4Ag is an investigational 4-antigen S. aureus vaccine, composed of capsular polysaccharide conjugates of serotypes 5 and 8 (CP5 and CP8), recombinant surface protein clumping factor A (rmClfA), and recombinant manganese transporter protein C (rMntC). This Phase 1 study aimed to confirm the safety and immunogenicity of SA4Ag produced by the final manufacturing process before efficacy study initiation in a surgical population.

METHODS

Healthy adults (18-<65years) received one intramuscular SA4Ag injection. Serum functional antibodies were measured at baseline and Day 29 post-vaccination. An opsonophagocytic activity (OPA) assay measured the ability of vaccine-induced antibodies to CP5 and CP8 to kill S. aureus clinical isolates. For MntC and ClfA, antigen-specific immunogenicity was assessed via competitive Luminex® immunoassay (cLIA) and via fibrinogen-binding inhibition (FBI) assay for ClfA only. Reactogenicity and adverse event data were collected.

RESULTS

One hundred participants were vaccinated. SA4Ag was well tolerated, with a satisfactory safety profile. On Day 29, OPA geometric mean titers (GMTs) were 45,738 (CP5, 95% CI: 38,078-54,940) and 42,652 (CP8, 95% CI: 32,792-55,477), consistent with 69.2- and 28.9-fold rises in bacteria-killing antibodies, respectively; cLIA GMTs were 2064.4 (MntC, 95% CI: 1518.2-2807.0) and 3081.4 (ClfA, 95% CI: 2422.2-3920.0), consistent with 19.6- and 12.3-fold rises, respectively. Similar to cLIA results, ClfA FBI titers rose 11.0-fold (GMT: 672.2, 95% CI: 499.8-904.2). The vast majority of participants achieved the pre-defined biologically relevant thresholds: CP5: 100%; CP8: 97.9%, ClfA: 87.8%; and MntC 96.9%.

CONCLUSIONS

SA4Ag was safe, well tolerated, and rapidly induced high levels of bacteria-killing antibodies in healthy adults. A Phase 2B efficacy trial in adults (18-85years) undergoing elective spinal fusion is ongoing to assess SA4Ag's ability to prevent postoperative invasive surgical site and bloodstream infections caused by S. aureus. Clinicaltrials.gov Identifier: NCT02364596.

Staphylococcus aureus: the current state of disease, pathophysiology and strategies for prevention

Staphylococcus aureus is both a commensal organism and also an important opportunistic human pathogen, causing a variety of community and hospital-associated pathologies, such as bacteremia-sepsis, endocarditis, pneumonia, osteomyelitis, arthritis and skin diseases. The resurgence of S. aureus during the last decade in many settings has been facilitated not only by bacterial antibiotic resistance mechanisms but also by the emergence of new S. aureus clonal types with increased expression of virulence factors and the capacity to neutralize the host immune response. Prevention of the spread of S. aureus infection relies on the use of contact precautions and adequate procedures for infection control that so far have not been fully effective. Prevention using a prophylactic vaccine would complement these processes, having the potential to bring additional, significant progress toward decreasing invasive disease due to S. aureus.

Repeat abortions in New York City, 2010

This study aims to describe factors associated with the number of past abortions obtained by New York City (NYC) abortion patients in 2010. We calculated rates of first and repeat abortion by age, race/ethnicity, and neighborhood-level poverty and the mean number of self-reported past abortions by age, race/ethnicity, neighborhood-level poverty, number of living children, education, payment method, marital status, and nativity. We used negative binomial regression to predict number of past abortions by patient characteristics. Of the 76,614 abortions reported for NYC residents in 2010, 57% were repeat abortions. Repeat abortions comprised >50% of total abortions among the majority of sociodemographic groups we examined. Overall, mean number of past abortions was 1.3. Mean number of past abortions was higher for women aged 30-34 years (1.77), women with ≥5 children (2.50), and black non-Hispanic women (1.52). After multivariable regression, age, race/ethnicity, and number of children were the strongest predictors of number of past abortions. This analysis demonstrates that, although socioeconomic disparities exist, all abortion patients are at high risk for repeat unintended pregnancy and abortion.

Effect of cause-of-death training on agreement between hospital discharge diagnoses and cause of death reported, inpatient hospital deaths, New York City, 2008-2010

INTRODUCTION

Accurate cause-of-death reporting is required for mortality data to validly inform public health programming and evaluation. Research demonstrates overreporting of heart disease on New York City death certificates. We describe changes in reported causes of death following a New York City health department training conducted in 2009 to improve accuracy of cause-of-death reporting at 8 hospitals. The objective of our study was to assess the degree to which death certificates citing heart disease as cause of death agreed with hospital discharge data and the degree to which training improved accuracy of reporting.

METHODS

We analyzed 74,373 death certificates for 2008 through 2010 that were linked with hospital discharge records for New York City inpatient deaths and calculated the proportion of discordant deaths, that is, death certificates reporting an underlying cause of heart disease with no corresponding discharge record diagnosis. We also summarized top principal diagnoses among discordant reports and calculated the proportion of inpatient deaths reporting sepsis, a condition underreported in New York City, to assess whether documentation practices changed in response to clarifications made during the intervention.

RESULTS

Citywide discordance between death certificates and discharge data decreased from 14.9% in 2008 to 9.6% in 2010 (P < .001), driven by a decrease in discordance at intervention hospitals (20.2% in 2008 to 8.9% in 2010; P < .001). At intervention hospitals, reporting of sepsis increased from 3.7% of inpatient deaths in 2008 to 20.6% in 2010 (P < .001).

CONCLUSION

Overreporting of heart disease as cause of death declined at intervention hospitals, driving a citywide decline, and sepsis reporting practices changed in accordance with health department training. Researchers should consider the effect of overreporting and data-quality changes when analyzing New York City heart disease mortality trends. Other vital records jurisdictions should employ similar interventions to improve cause-of-death reporting and use linked discharge data to monitor data quality.

Test of an electronic program to query clinicians about nonspecific causes reported for pneumonia deaths, New York City, 2012

We tested an electronic cause-of-death query system at a hospital in New York City to evaluate clinicians’ reporting of cause of death. We used the system to query clinicians about all deaths assigned International Classification of Disease code J189 (pneumonia, unspecified) as the underlying cause of death. Of 29 death certificates that generated queries, 28 were updated with additional information, which led to revisions in the underlying cause of 27 deaths. The electronic system for querying reported cause of death was feasible and enabled quicker than usual responses; however, follow-up with clinicians to ensure timely, accurate, and complete responses was labor-intensive. Educating clinicians and enforcing reporting standards would reduce the time and effort required to ensure accurate and timely cause-of-death reporting.

Programmatic impact of 5 years of mortality surveillance of New York City homeless populations

A homeless mortality surveillance system identifies emerging trends in the health of the homeless population and provides this information to key stakeholders in a timely and ongoing manner to effect evidence-based, programmatic change. We describe the first 5 years of the New York City homeless mortality surveillance system and, for the first time in peer-reviewed literature, illustrate the impact of key elements of sustained surveillance (i.e., timely dissemination of aggregate mortality data and real-time sharing of information on individual homeless decedents) on the programs of New York City's Department of Homeless Services. These key elements had a positive impact on the department's programs that target sleep-related infant deaths and hypothermia, drug overdose, and alcohol-related deaths among homeless persons.

Impact of a hospital-level intervention to reduce heart disease overreporting on leading causes of death

INTRODUCTION

The quality of cause-of-death reporting on death certificates affects the usefulness of vital statistics for public health action. Heart disease deaths are overreported in the United States. We evaluated the impact of an intervention to reduce heart disease overreporting on other leading causes of death.

METHODS

A multicomponent intervention comprising training and communication with hospital staff was implemented during July through December 2009 at 8 New York City hospitals reporting excessive heart disease deaths. We compared crude, age-adjusted, and race/ethnicity-adjusted proportions of leading, underlying causes of death reported during death certification by intervention and nonintervention hospitals during preintervention (January-June 2009) and postintervention (January-June 2010) periods. We also examined trends in leading causes of death for 2000 through 2010.

RESULTS

At intervention hospitals, heart disease deaths declined by 54% postintervention; other leading causes of death (ie, malignant neoplasms, influenza and pneumonia, cerebrovascular disease, and chronic lower respiratory diseases) increased by 48% to 232%. Leading causes of death at nonintervention hospitals changed by 6% or less. In the preintervention period, differences in leading causes of death between intervention and nonintervention hospitals persisted after controlling for race/ethnicity and age; in the postintervention period, age accounted for most differences observed between intervention and nonintervention hospitals. Postintervention, malignant neoplasms became the leading cause of premature death (ie, deaths among patients aged 35-74 y) at intervention hospitals.

CONCLUSION

A hospital-level intervention to reduce heart disease overreporting led to substantial changes to other leading causes of death, changing the leading cause of premature death. Heart disease overreporting is likely obscuring the true levels of cause-specific mortality.

A case study of the impact of inaccurate cause-of-death reporting on health disparity tracking: New York City premature cardiovascular mortality

OBJECTIVES

Heart disease death overreporting is problematic in New York City (NYC) and other US jurisdictions. We examined whether overreporting affects the premature (< 65 years) heart disease death rate disparity between non-Hispanic Blacks and non-Hispanic Whites in NYC.

METHODS

We identified overreporting hospitals and used counts of premature heart disease deaths at reference hospitals to estimate corrected counts. We then corrected citywide, age-adjusted premature heart disease death rates among Blacks and Whites and a White-Black premature heart disease death disparity.

RESULTS

At overreporting hospitals, 51% of the decedents were White compared with 25% at reference hospitals. Correcting the heart disease death counts at overreporting hospitals decreased the age-adjusted premature heart disease death rate 10.1% (from 41.5 to 37.3 per 100,000) among Whites compared with 4.2% (from 66.2 to 63.4 per 100,000) among Blacks. Correction increased the White-Black disparity 6.1% (from 24.6 to 26.1 per 100,000).

CONCLUSIONS

In 2008, NYC's White-Black premature heart disease death disparity was underestimated because of overreporting by hospitals serving larger proportions of Whites. Efforts to reduce overreporting may increase the observed disparity, potentially obscuring any programmatic or policy-driven advances.

An intervention to improve cause-of-death reporting in New York City hospitals, 2009-2010

Introduction

Poor-quality cause-of-death reporting reduces reliability of mortality statistics used to direct public health efforts. Overreporting of heart disease has been documented in New York City (NYC) and nationwide. Our objective was to evaluate the immediate and longer-term effects of a cause-of-death (COD) educational program that NYC’s health department conducted at 8 hospitals on heart disease reporting and on average conditions per certificate, which are indicators of the quality of COD reporting.

Methods

From June 2009 through January 2010, we intervened at 8 hospitals that overreported heart disease deaths in 2008. We shared hospital-specific data on COD reporting, held conference calls with key hospital staff, and conducted in-service training. For deaths reported from January 2009 through June 2011, we compared the proportion of heart disease deaths and average number of conditions per death certificate before and after the intervention at both intervention and nonintervention hospitals.

Results

At intervention hospitals, the proportion of death certificates that reported heart disease as the cause of death decreased from 68.8% preintervention to 32.4% postintervention (P < .001). Individual hospital proportions ranged from 58.9% to 79.5% preintervention and 25.9% to 45.0% postintervention. At intervention hospitals the average number of conditions per death certificate increased from 2.4 conditions preintervention to 3.4 conditions postintervention (P < .001) and remained at 3.4 conditions a year later. At nonintervention hospitals, these measures remained relatively consistent across the intervention and postintervention period.

Conclusion

This NYC health department’s hospital-level intervention led to durable changes in COD reporting.

Etiology of nonspecific cause of death coding in New York City motor vehicle crash-related fatalities

OBJECTIVES

Nearly 20 percent of New York City's (NYC) accidental deaths are related to motor vehicles crashes (MVCs). Detailed International Classification of Disease (ICD-10; World Health Organization [WHO] 2007) cause-of-death coding of MVC-related fatalities improves surveillance and resulting identification of prevention strategies. We investigated ICD-10 codes in these fatalities and the potential to make them more specific.

METHODS

We defined "nonspecific" MVC ICD-10 codes as all globally unspecific codes (V870-V878, V892) and any codes with nonspecific components regarding vehicle involved, decedent position in vehicle, or MVC setting. We calculated nonspecific-code frequency for 1999-2008 MVC deaths. We reviewed a random 10 percent sample of 2007-2008 MVC deaths (N=61) and medical examiner (ME) records of all nonspecific death certificates (N=52), including police accident reports ("full PAR") and summaries prepared by onsite police officers ("brief PAR") to determine whether MEs had sufficient information available but did not include that information at death certification.

RESULTS

Among 1999-2008 NYC MVC deaths, 82.9 percent had nonspecific ICD-10 cause-of-death codes. Similarly, of the 61 recent randomly sampled MVC deaths, 52 (85.2%) had nonspecific codes. Of 52 nonspecific death certificates from the random sample, 38 (73.1%) death certificates had adequate information available on full or brief PAR to be more specific at the time of death certification. Consistent with MEs' reports of high reliance on the brief PAR, most nonspecific death certificates (76.9%) lacked adequate information in the brief PAR to be more specific.

CONCLUSION

Specific ICD-10 codes for MVC deaths depends on the level of detail provided by the ME in the "How Injury Occurred" and "If Transportation Injury Specify" death certificates sections. We have worked to ensure that key information is available to MEs in the brief PAR and educated MEs on the importance of this information to reduce the frequency of nonspecific codes and enhance injury prevention research.

Jail-based providers' perceptions of challenges to routine HIV testing in New York City jails

About 25% of New York City jail inmates are tested for HIV despite a universal offer of rapid testing at medical intake. Health care workers were surveyed to examine provider-related challenges to testing at medical intake. Of the 291 eligible staff, 215 (73.9%) responded. Most (87.0%) felt confident recommending rapid HIV testing; however, only 85.5% of medical professionals and 70.8% of nurses felt confident providing negative rapid HIV test results. Identified barriers are those common to other medical settings (insufficient staffing, inadequate privacy or space, and ''too much'' paperwork) and those specific to correctional settings (limited time for medical intake and competing Department of Correction priorities). Staff have been given extended training to address their lack of confidence with key aspects of the HIV testing process, including providing negative results.

HIV screening among U.S. physicians, 1999-2000

In 2006, the Centers for Disease Control and Prevention (CDC) put forth recommendations for routine HIV screening for all individuals aged 13-64. The frequency and correlates of HIV screening among U.S. physicians in 2000 were examined to provide baseline data for evaluating the implementation of the 2006 CDC HIV testing guidelines through a survey mailed to a random sample of U.S. physicians in the American Medical Association's Masterfile. The primary outcome was self-reported HIV screening of asymptomatic male and nonpregnant female patients. A total of 4133 (adjusted completion rate of 70.2%) returned a completed survey. Overall, 1133 (28.4%) of physicians reported HIV screening. U.S. physicians, who were female, black, Hispanic, practiced in a city of more than 250,000 people, diagnosed HIV in the past 2 years, or followed up with patients to see if they notified their sexual partners, were more likely to screen their patients for HIV. Emergency medicine, internal medicine, and pediatrics specialists were less likely to screen than family/general practitioners. In 2000, only a quarter of U.S. physicians reported screening their patients for HIV and these rates varied by physician characteristics and practice settings.

Training and experience of psychiatric residents in identifying domestic violence

Of 221 psychiatric residents at four U.S. medical schools, 145 responded to a survey about their training and clinical experience in recognizing domestic violence and providing referrals and treatment. Only 28 percent reported receiving training in this area. Almost half reported that they asked about domestic violence in less than a quarter of their cases involving female patients. Fifty-nine percent of respondents did so "only when a problem was suspected." Eighty-seven percent had seen at least one case of domestic violence in the previous year. Those with training in recognizing domestic violence identified significantly more cases. Sixty-five percent of all residents surveyed were unable to list a local agency for referral.