Evaluating Partial Series Childhood Vaccination Services in a Mobile Clinic Setting

This study aims to evaluate the cost-benefit of vaccination services, mostly partial series administration, provided by a mobile clinic program (MCP) in Houston for children of transient and low-income families. The study included 469 patients who visited the mobile clinics on regular service days in 2 study periods in 2014 and 836 patients who attended vaccination events in the summer of 2014. The benefit of partial series vaccination was estimated based on vaccine efficacy/effectiveness data. Our conservative cost-benefit estimates show that, compared with office-based settings, every dollar spent on vaccination by the MCP would result in $0.9 societal cost averted as an incremental benefit in regular service days and $3.7 during vaccination-only events. To further improve the cost-benefit of vaccination services in the MCP, decision-makers and stakeholders may consider improving work efficiency during regular service days or hosting more vaccination events.

Evidence for Household Transmission of Rotavirus in the United States, 2011-2016

BACKGROUND

Rotavirus is a leading cause of acute gastroenteritis (AGE) in children and is highly transmissible. In this study, we assessed the presence of AGE in household contacts (HHCs) of pediatric patients with laboratory-confirmed rotavirus.

METHODS

Between December 2011 and June 2016, children aged 14 days to 11 years with AGE were enrolled at 1 of 7 hospitals or emergency departments as part of the New Vaccine Surveillance Network. Parental interviews, medical and vaccination records, and stool specimens were collected at enrollment. Stool was tested for rotavirus by an enzyme immunoassay and confirmed by real-time or conventional reverse transcription-polymerase chain reaction assay or repeated enzyme immunoassay. Follow-up telephone interviews were conducted to assess AGE in HHCs the week after the enrolled child's illness. A mixed-effects multivariate model was used to calculate odds ratios.

RESULTS

Overall, 829 rotavirus-positive subjects and 8858 rotavirus-negative subjects were enrolled. Households of rotavirus-positive subjects were more likely to report AGE illness in ≥1 HHC than were rotavirus-negative households (35% vs 20%, respectively; P < .0001). A total of 466 (16%) HHCs of rotavirus-positive subjects reported AGE illness. Of the 466 ill HHCs, 107 (23%) sought healthcare; 6 (6%) of these encounters resulted in hospitalization. HHCs who were <5 years old (odds ratio, 2.2 [P = .004]) were more likely to report AGE illness than those in other age groups. In addition, 144 households reported out-of-pocket expenses (median, $20; range, $2-$640) necessary to care for an ill HHC.

CONCLUSIONS

Rotavirus-associated AGE in children can lead to significant disease burden in HHCs, especially in children aged <5 years. Prevention of pediatric rotavirus illness, notably through vaccination, can prevent additional illnesses in HHCs.

Vaccine Hesitancy and Illness Perceptions: Comparing Parents of Children with Autism Spectrum Disorder to other Parent Groups

Fears persist despite compelling evidence refuting associations between vaccines and autism spectrum disorder (ASD). We compared vaccine hesitancy (VH) and beliefs about illness causes among parents of children in four groups: ASD, non-ASD developmental disorders, rheumatologic conditions, and the general pediatric population. VH was 19.9% overall; parents of children with ASD reported highest VH rates (29.5%) and more frequently attributed ASD to toxins in vaccines (28.9% vs. 15.7%, p=0.004). The odds of VH were increased among parents who attributed their child's condition to diet or eating habits (aOR 4.2; 95% CI: 1.6, 11.2) and toxins found in vaccines (aOR 20, 95% CI: 7.1, 55.9). Parents who attributed the condition to chance or bad luck were less likely to be vaccine hesitant (aOR 0.1; 95% CI: 0.03, 0.5).

2738. Influenza Vaccination During Pregnancy Among Mothers of Infants with Acute Respiratory Illness, United States, 2016–2018

Background

Influenza vaccination has been shown to reduce influenza risk in pregnant women and their infants who are not yet age-eligible for vaccine. Ascertainment of vaccination history is important for vaccine safety and effectiveness evaluations. Our goals were to (a) determine coverage, location, and timing of maternal influenza vaccination and (b) compare a subset of self-reported influenza vaccinations with documented vaccine records.

Methods

We enrolled children < 18 years. with acute respiratory illness in 7 pediatric hospitals and emergency departments in the New Vaccine Surveillance Network from December 1, 2016 to October 31, 2018. We interviewed all mothers of enrolled infants < 1 year, and obtained mother’s influenza vaccine information while pregnant. As an option, sites obtained maternal influenza vaccine records from reported sources (e.g., registries, provider records, pharmacies).

Results

Among 5,458 mothers, 2,944 (54%) self-reported receiving influenza vaccine during pregnancy (57% in 2016–2017; 51% in 2017–2018), varying from 49% to 74% by site. Among self-reported vaccinees, 17%, 36%, and 47% received vaccine during their first, second, and third trimester, respectively. Most women (76%) were vaccinated at their OB/GYN or midwife office, 7% at their primary care provider, 7% at their workplace, and 5% at a retail pharmacy. Among 1,338 infants < 6 months. during early influenza season (i.e., born from June to August) and thus ineligible for vaccination, only 46% of mothers reported receiving vaccine during pregnancy (42% reported not receiving it, 12% were unsure). Of 2,242 women for whom vaccine verification was attempted, 1,491 (67%) self-reported receiving influenza vaccine during pregnancy; of those, documentation of vaccine receipt was found for 901 (60%).

Conclusion

Influenza vaccination coverage among pregnant women was suboptimal, potentially increasing the risk of influenza in unvaccinated pregnant women. Infants born to unvaccinated women, particularly those born from June to August, may also be at higher risk since they are not age-eligible to receive vaccine before influenza season. The optimal approach to ascertainment of maternal vaccination history with accuracy and completeness merits further investigation.

Disclosures

All authors: No reported disclosures.

899. Influenza Vaccine Effectiveness Against Laboratory-Confirmed Influenza in Children Hospitalized with Respiratory Illness in the United States, 2016–2017 and 2017–2018 Seasons

Background

Annual national estimates of influenza vaccine effectiveness (VE) typically measure protection against outpatient medically attended influenza illness. We assessed influenza VE in preventing laboratory-confirmed influenza hospitalization in children across two influenza A(H3N2)-predominant seasons.

Methods

Children < 18 years hospitalized with acute respiratory illness were enrolled at 7 pediatric hospitals in the New Vaccine Surveillance Network. We included subjects ≥6 months with ≤10 days of symptoms enrolled during the 2016–2017 and 2017–2018 seasons (date of first through last influenza-positive case for each site). Combined mid-turbinate and throat swabs were tested using molecular assays. We estimated age-stratified VE from a test-negative design using logistic regression to compare the odds of vaccination among cases positive for influenza with controls testing negative, adjusting for age, enrollment month, site, underlying comorbidities, and race/ethnicity. Full/partial vaccination was defined using ACIP criteria. We verified vaccine receipt from state immunization registries and/or provider records.

Results

Among 3441 children with complete preliminary data, in 2016–2017, 156/1,710 (9%) tested positive for influenza: 91 (58%) with influenza A(H3N2), 5 (3%) with A(H1N1), and 60 (38%) with B viruses. In 2017–2018, 193/1,731 (11%) tested positive: 87 (45%) with influenza A(H3N2), 47 (24%) with A(H1N1), and 58 (30%) with B. VE for all vaccinated children (full and partial) against any influenza was 48% (95% confidence interval, 26%–63%) in 2016–2017 and 45% (24%–60%) in 2017–2018. Combining seasons, VE for fully and partially vaccinated children against any influenza type was 46% (32%–58%); by virus, VE was 30% (4%–49%) for influenza A(H3N2), 71% (46%–85%) for A(H1N1), and 57% (36%–70%) for B viruses. There was no statistically significant difference in VE by age or full/partial vaccination status for any virus (table).

Conclusion

Vaccination in the 2016–2017 and 2017–2018 seasons nearly halved the risk of children being hospitalized with influenza. These findings support the use of vaccination to prevent severe illness in children. Our study highlights the need for a better understanding of the lower VE against influenza A(H3N2) viruses.

Disclosures

All Authors: No reported Disclosures.

2639. Respiratory Virus Detections in Asthma-Related Pediatric Hospitalizations: New Vaccine Surveillance Network, United States

Background

Respiratory viruses are associated with most asthma exacerbations (AEx) in children; however, the role of different viruses in AEx is unclear. We describe respiratory virus detections among pediatric inpatients with AEx (AEx-inpatients).

Methods

Through active, prospective surveillance at 7 US medical centers, we enrolled inpatients (<18 years) with acute respiratory illness (ARI) during November 1, 2015–June 30, 2016. We defined an AEx-inpatient as an inpatient with a principal admission or discharge diagnosis of asthma (ICD-10-CM, J45.xx). Mid-turbinate nasal and/or throat swabs were tested by molecular assays for influenza A or B, respiratory syncytial virus (RSV), parainfluenza virus 1–3, rhinovirus or enterovirus (RV/EV), human metapneumovirus and adenovirus. We assessed virus detections among AEx-inpatients throughout the surveillance period or by season (winter: December–February; spring: March–May), and by patient age and history of asthma/reactive airway disease (asthma/RAD).

Results

We tested 3,897 inpatients with ARI; of whom, 954 were AEx-inpatients. Most AEx-inpatients (741/954 [78%]) reported an asthma/RAD history. Viruses were more frequently detected among AEx-inpatients <5 years (350/458 [76%]) than 5–17 years (305/496 [61%], P < 0.001). Most (615/655 [94%]) detections were of single viruses. The most frequent single virus detections were RV/EV (474/954 [50%]) and RSV (76/954 [8%]) but the frequency of each virus varied by season and age group (figure). Single RV/EVs were the most common virus detections in both seasons and all groups. Single RSV detections were prominent among <5 year olds in winter (40/185 [22%]). Among those with single RV/EV or RSV detections, 285/474 (60%) and 49/76 (64%) required supplemental oxygen, respectively (P = 0.676); median length of stay was 1 day (range: 0–45; IQR: 1–2) and 2 days (range: 0–6; IQR: 1–2.5), respectively (P < 0.001).

Conclusion

AEx-inpatients <5 years were more likely to have respiratory virus detections than those 5–17 years. Single RV/EVs formed the majority of virus detections throughout the surveillance period, regardless of age. RSV played a notable role in winter among patients <5 years. These findings could inform prevention or treatment strategies for virus-associated AEx.

Disclosures

All authors: No reported disclosures.

2614. Demographic and Clinical Characteristics by Antiviral Prescription in Influenza-Positive Children who Presented to Seven US Emergency Departments

Background

Antiviral (AV) therapy is recommended for children < 2 years, hospitalized, or with underlying conditions (UC) and suspected influenza (flu). We sought to compare demographic and clinical characteristics by AV prescription in flu-positive children who presented to the emergency department (ED) and determine the percentage of AV prescription in these high-risk children.

Methods

Children < 18 years who presented with respiratory symptoms and/or fever at seven New Vaccine Surveillance Network sites were enrolled. We conducted interviews, obtained mid-turbinate nasal and/or throat swabs for molecular flu testing (results unknown to providers), and reviewed medical charts for AV prescription after presenting to the ED. These are preliminary data.

Results

From December 2016 to June 2018, 9,524 subjects were enrolled and tested for flu; 1,260 (13%) were flu-positive by research testing; 54% were male, median age was 41 months, and 23% were prescribed an AV. The frequency of AV prescription differed by study site (Figure 1). Among research-tested flu-positive patients, AV were prescribed to 25% of children < 2 years, 31% of children with UC, and 51% admitted to the hospital from the ED (Table 1). Of the 388 (31%) clinically-tested flu-positive patients, 52%, 66%, and 77% of the same high-risk groups were prescribed an AV, respectively.

Conclusion

AV prescriptions varied by study site and differences by race, ethnicity, and clinical presentation were noted. Clinical testing was associated with higher use of AV treatment in appropriate target patients. Efforts are needed to understand AV use patterns and improve prescription rates in recommended patients.

Disclosures

All authors: No reported disclosures.

Association of Rotavirus Vaccination With Inpatient and Emergency Department Visits Among Children Seeking Care for Acute Gastroenteritis, 2010-2016

IMPORTANCE

Rotavirus vaccines have been recommended for universal US infant immunization for more than 10 years, and understanding their effectiveness is key to the continued success of the US rotavirus vaccine immunization program.

OBJECTIVE

To assess the association of RotaTeq (RV5) and Rotarix (RV1) with inpatient and emergency department (ED) visits for rotavirus infection.

DESIGN, SETTING, AND PARTICIPANTS

This case-control vaccine effectiveness study was performed at inpatient and ED clinical settings in 7 US pediatric medical institutions from November 1, 2009, through June 30, 2016. Children younger than 5 years seeking medical care for acute gastroenteritis were enrolled. Clinical and epidemiologic data, vaccination verification, and results of stool sample tests for laboratory-confirmed rotavirus were collected. Data were analyzed from November 1, 2009, through June 30, 2016.

MAIN OUTCOMES AND MEASURES

Rotavirus vaccine effectiveness for preventing rotavirus-associated inpatient and ED visits over time for each licensed vaccine, stratified by clinical severity and age.

RESULTS

Among the 10 813 children included (5927 boys [54.8%] and 4886 girls [45.2%]; median [range] age, 21 [8-59] months), RV5 and RV1 analyses found that compared with controls, rotavirus-positive cases were more often white (RV5, 535 [62.2%] vs 3310 [57.7%]; RV1, 163 [43.1%] vs 864 [35.1%]), privately insured (RV5, 620 [72.1%] vs 4388 [76.5%]; RV1, 305 [80.7%] vs 2140 [87.0%]), and older (median [range] age for RV5, 26 [8-59] months vs 21 [8-59] months; median [range] age for RV1, 22 [8-59] months vs 19 [8-59] months) but did not differ by sex. Among 1193 rotavirus-positive cases and 9620 rotavirus-negative controls, at least 1 dose of any rotavirus vaccine was 82% (95% CI, 77%-86%) protective against rotavirus-associated inpatient visits and 75% (95% CI, 71%-79%) protective against rotavirus-associated ED visits. No statistically significant difference during this 7-year period was observed for either rotavirus vaccine. Vaccine effectiveness against inpatient and ED visits was 81% (95% CI, 78%-84%) for RV5 (3 doses) and 78% (95% CI, 72%-82%) for RV1 (2 doses) among the study population. A mixed course of both vaccines provided 86% (95% CI, 74%-93%) protection. Rotavirus patients who were not vaccinated had severe infections 4 times more often than those who were vaccinated (74 of 426 [17.4%] vs 28 of 605 [4.6%]; P < .001), and any dose of rotavirus vaccine was 65% (95% CI, 56%-73%) effective against mild infections, 81% (95% CI, 76%-84%) against moderate infections, and 91% (95% CI, 85%-95%) against severe infections.

CONCLUSIONS AND RELEVANCE

Evidence from this large postlicensure study of rotavirus vaccine performance in the United States from 2010 to 2016 suggests that RV5 and RV1 rotavirus vaccines continue to perform well, particularly in preventing inpatient visits and severe infections and among younger children.

Enterovirus D68-Associated Acute Respiratory Illness - New Vaccine Surveillance Network, United States, July-October, 2017 and 2018

In the fall of 2014, an outbreak of enterovirus D68 (EV-D68)-associated acute respiratory illness (ARI) occurred in the United States (1,2); before 2014, EV-D68 was rarely reported to CDC (2,3). In the United States, reported EV-D68 detections typically peak during late summer and early fall (3). EV-D68 epidemiology is not fully understood because testing in clinical settings seldom has been available and detections are not notifiable to CDC. To better understand EV-D68 epidemiology, CDC recently established active, prospective EV-D68 surveillance among pediatric patients at seven U.S. medical centers through the New Vaccine Surveillance Network (NVSN) (4). This report details a preliminary characterization of EV-D68 testing and detections among emergency department (ED) and hospitalized patients with ARI at all NVSN sites during July 1-October 31, 2017, and the same period in 2018. Among patients with ARI who were tested, EV-D68 was detected in two patients (0.8%) in 2017 and 358 (13.9%) in 2018. Continued active, prospective surveillance of EV-D68-associated ARI is needed to better understand EV-D68 epidemiology in the United States.

Factors Associated With Rotavirus Vaccine Coverage

BACKGROUND

Rotavirus vaccines (RVVs) were included in the US immunization program in 2006 and are coadministered with the diphtheria-tetanus-acellular pertussis (DTaP) vaccine, yet their coverage lags behind DTaP. We assessed timing, initiation, and completion of the RVV series among children enrolled in active gastroenteritis surveillance at 7 US medical institutions during 2014-2016.

METHODS

We compared coverage and timing of each vaccine series and analyzed characteristics associated with RVV initiation and completion. We report odds ratios (ORs) and 95% confidence intervals (CIs) from multivariable logistic regression models.

RESULTS

We enrolled 10 603 children. In 2015, ≥1 dose coverage was 91% for RVV and 97% for DTaP. Seven percent of children received their first DTaP vaccine at age ≥15 weeks versus 4% for RVV (P ≤ .001). Recent birth years (2013-2016) were associated with higher odds of RVV initiation (OR = 5.72; 95% CI 4.43-7.39), whereas preterm birth (OR = 0.32; 95% CI 0.24-0.41), older age at DTaP initiation (OR 0.85; 95% CI 0.80-0.91), income between $50 000 and $100 000 (OR = 0.56; 95% CI 0.40-0.78), and higher maternal education (OR = 0.52; 95% CI 0.36-0.74) were associated with lower odds. Once RVV was initiated, recent birth years (2013-2016; OR = 1.57 [95% CI 1.32-1.88]) and higher maternal education (OR = 1.31; 95% CI 1.07-1.60) were associated with higher odds of RVV completion, whereas preterm birth (OR = 0.76; 95% CI 0.62-0.94), African American race (OR = 0.82; 95% CI 0.70-0.97) and public or no insurance (OR = 0.75; 95% CI 0.60-0.93) were associated with lower odds. Regional differences existed.

CONCLUSIONS

RVV coverage remains lower than that for the DTaP vaccine. Timely DTaP administration may help improve RVV coverage.

751. Acute Respiratory Illness Hospitalizations Among Young Children: Multi-Center Viral Surveillance Network, United States, 2015–2016

Background

Viral infections are a significant cause of severe acute respiratory illnesses (ARI) in young children. Understanding the current epidemiology of these viruses is important for informing treatment and prevention measures. We describe the New Vaccine Surveillance Network (NVSN) and report preliminary results from 2015 to 2016.

Methods

Prospective active surveillance for hospitalized ARI was conducted from November 1, 2015 to June 30, 2016 among children <5 years of age at seven pediatric hospital sites (figure) using a broad case definition based on admission diagnoses. Parent interviews and medical chart reviews were performed, and mid-turbinate nasal and throat flocked swabs and/or tracheal aspirates were tested for adenovirus, human metapneumovirus (HMPV), influenza, parainfluenza viruses (PIV) 1–3, respiratory syncytial virus (RSV), and rhinovirus/enterovirus using molecular diagnostic assays at each site. Asymptomatic controls <5 years of age were also enrolled.

Results

Among 2,974 hospitalized children with ARI whose specimens were tested for viruses, 2,228 (75%) were <2 years old, with 745 (25%) 0–2 months, and 309 (10%) 3–5 months old. The majority were male (58%; n = 1,732) and 63% (n = 1,093) had no documented comorbid conditions. The median length of stay was 2 days; 1,683 (57%) received supplemental oxygen, 435 (15%) were admitted to intensive care, 95 (3%) required mechanical ventilation, and 1 (<1%) died. Viruses were detected in 2,242 (75%) children with ARI, with >1 virus detected in 234 (8%). RSV was detected in 1,039 (35%) children with ARI, HMPV in 245 (8%), influenza in 104 (4%), and PIV-1, PIV-2, and PIV-3 in 49 (2%), 2 (<1%), and 78 (3%), respectively. Rhinovirus/enterovirus was detected in 849 (29%) and adenovirus in 118 (4%) children with ARI, but were also detected in 18% (n = 227) and 5% (n = 60), respectively, of the 1,243 controls tested; the other viruses were more rarely detected in controls.

Conclusion

During the 2015–2016 season, viral detections were common in young children hospitalized for ARI at seven US sites. NVSN combines clinical data with current molecular laboratory techniques to describe respiratory virus epidemiology in cases of hospitalized pediatric ARI in order to inform current and future prevention, treatment, and healthcare utilization measures.

Disclosures

N. Halasa, Sanofi Pasteur: Investigator, Research support. GSK: Consultant, Consulting fee. Moderna: Consultant, Consulting fee. J. Englund, Gilead: Consultant and Investigator, Consulting fee and Research support. Novavax: Investigator, Research support. GlaxoSmithKline: Investigator, Research support. Alios: Investigator, Research support. MedImmune: Investigator, Research support. J. V. Williams, Quidel: Board Member, Consulting fee. GlaxoSmithKline: Consultant, Consulting fee.

721. Clinical Respiratory Syndromes and Association with Influenza Clinical Diagnostic Testing and Antiviral Treatment among Children Hospitalized with Acute Respiratory Illness, 2015–2016

Background

We investigated clinical influenza testing and treatment in children hospitalized with acute respiratory illness (ARI) who had distinct respiratory syndromes.

Methods

Children <18 years old with ARI were enrolled at seven hospitals in the New Vaccine Surveillance Network (NVSN) between November 1, 2015–June 30, 2016. ICD10 admission diagnosis codes were grouped to define syndromes of bronchiolitis, asthma, pneumonia, and croup. At clinician discretion, influenza testing with a rapid influenza diagnostic test or molecular assay was performed on respiratory samples. As part of the study, each site performed influenza testing using molecular assays on mid-turbinate nasal and throat swabs from all enrolled children. Analysis was restricted to influenza season; children who received antivirals before hospitalization were excluded.

Results

Among 2,134 children with available ICD10 codes, on preliminary analysis 1,119 (52%) had influenza testing ordered by a clinician: 111 (10%) were positive, and 57 (51%) of 111 received antiviral treatment. Of the 2,134, 858 (40%) had one of the four mutually exclusive syndromes (table). Hospital clinical testing per clinician discretion was influenza positive in 16 of the 858 children (percent positivity per syndrome ranged from <1% to 38%; table). Research study testing of children not undergoing clinical influenza testing identified 11 additional positives. Antiviral treatment was highest for pneumonia patients.

Conclusion

Understanding testing and treatment practices by clinical syndrome may help to identify missed opportunities for influenza diagnosis and treatment.

Table:

Disclosures

J. Englund, Gilead: Consultant and Investigator, Consulting fee and Research support. Novavax: Investigator, Research support. GlaxoSmithKline: Investigator, Research support. Alios: Investigator, Research support. MedImmune: Investigator, Research support. N. B. Halasa, sanofi pasteur: Investigator, Research support. GSK: Consultant, Consulting fee. Moderna: Consultant, Consulting fee.

Arboviral Surveillance among Pediatric Patients with Acute Febrile Illness in Houston, Texas

We instituted active surveillance among febrile patients presenting to the largest Houston-area pediatric emergency department to identify acute infections of dengue virus (DENV), West Nile virus (WNV), and chikungunya virus (CHIKV). In 2014, 1,063 children were enrolled, and 1,015 (95%) had blood and/or cerebrospinal fluid specimens available for DENV, WNV, and CHIKV testing. Almost half (49%) reported recent mosquito bites, and 6% (N = 60) reported either recent international travel or contact with an international traveler. None were positive for acute WNV; three had false-positive CHIKV results; and two had evidence of DENV. One DENV-positive case was an acute infection associated with international travel, whereas the other was identified as a potential secondary acute infection, also likely travel-associated. Neither of the DENV-positive cases were clinically recognized, highlighting the need for education and awareness. Health-care professionals should consider the possibility of arboviral disease among children who have traveled to or from endemic areas.

Influenza Clinical Diagnostic Testing and Antiviral Treatment among Children Hospitalized with Acute Respiratory Illness During the 2015–16 Influenza Season

Background

Although antiviral therapy is recommended for hospitalized patients with suspected or confirmed influenza, clinicians often rely on test results to determine management. Rapid influenza diagnostic tests (RIDTs) have suboptimal sensitivity; use of molecular assays may improve care. We evaluated clinical influenza testing and antiviral treatment practices in hospitalized children.

Methods

Children aged <18 years with acute respiratory illness (ARI) were enrolled through active surveillance at 7 hospitals in the New Vaccine Surveillance Network between November 2015 and June 30, 2016; analysis was restricted to the influenza season. Preliminary data were analyzed for children who had clinical influenza diagnostic testing with a rapid influenza diagnostic test or molecular assay on nasopharyngeal or nasal swabs or nasal washes. Children who had received antivirals prior to hospitalization were excluded.

Results

Of 2267 children, 1165 (51%) had clinical diagnostic testing on upper respiratory samples: 276 (24%) by RIDT alone, 780 (67%) by molecular testing alone, and 109 (9%) by both. The use of molecular testing alone varied by site, from 10% to 100% of samples tested. Of 116 (10%) children testing positive for influenza, 60 (52%) were treated; by site, treatment of children positive for influenza ranged from 25% to 83%. Antiviral treatment was given to 16/20 (80%) of those admitted ≤2 days from symptom onset vs. 44/96 (46%) children admitted >2 days after onset. Among 94 children tested by one method who were positive, >80% had samples collected in the emergency department or on day of admission, and 47 started treatment (Figure, A): 16/37 (43%) and 31/57 (54%) were treated when tested by RIDT alone and molecular testing alone, respectively. Of those positive children treated, 7/16 (44%) tested by RIDT vs. 22/31 (71%) by molecular testing started treatment on the day of testing (Figure, B).

Conclusion

Half of hospitalized children with ARI who tested positive for influenza received antiviral treatment. Although there was high variability in testing and treatment by site, in positive patients who were treated the use of molecular testing appeared to be associated with prompt antiviral therapy. Understanding clinician reasons for relatively low treatment overall will require further investigation.

Disclosures

J. Englund, Gilead: Consultant and Investigator, Research support Chimerix: Investigator, Research support Alios: Investigator, Research support Novavax: Investigator, Research support MedImmune: Investigator, Research support GlaxoSmithKline: Investigator, Research support N. B. Halasa, sanofi pasteur: Research Contractor, Research support Astra Zeneca: Research Contractor, Grant recipient

Understanding the Financial Implications of Immunization Reminder/Recall in a Multipractice Pediatric Group

OBJECTIVE

Immunization reminder/recall is widely recommended as an effective strategy for increasing vaccination rates. We examined the revenue generated from well-child visits scheduled as a result of reminder/recall activities implemented in a multipractice pediatric organization.

METHODS

Patients aged 19 to 35 months who were due or overdue for vaccines were identified from participating practices and assigned to either standard or enhanced reminder/recall activities. Participants who received standard reminder/recall were observed for the 6-week study period, and the number of appointments in which vaccines were administered was tracked. Participants who received enhanced reminder/recall were contacted up to 3 times and received a letter followed by up to 2 phone calls. Financial information associated with appointments scheduled during the study period was obtained, and revenue was calculated for each dose of vaccine administered. Reminder/recall costs were calculated and overall revenue generated was calculated.

RESULTS

We identified 3916 children who were potentially due or overdue for immunizations. After review and manual uploading of missing historical vaccines, a total of 1892 participants received the reminder/recall initiative; 942 received standard reminder/recall, and 950 received enhanced reminder/recall. One hundred eighty-two (19%) standard and 277 (29%) enhanced reminder/recall participants scheduled an appointment by the end of the study period (P < .001). After subtracting the cost of reminder/recall activities, an additional $20,066 and $20,235 were generated by standard and enhanced reminder/recall, respectively.

CONCLUSIONS

We show that conducting reminder/recall is at a minimum financially neutral, and might increase revenue generated by vaccine administration.

Rotavirus Strain Trends During the Postlicensure Vaccine Era: United States, 2008-2013

BACKGROUND

Group A rotaviruses (RVA) are a significant cause of pediatric gastroenteritis worldwide. The New Vaccine Surveillance Network (NVSN) has conducted active surveillance for RVA at pediatric hospitals and emergency departments at 3-7 geographically diverse sites in the United States since 2006.

METHODS

Over 6 consecutive years, from 2008 to 2013, 1523 samples from NVSN sites that were tested positive by a Rotaclone enzyme immunoassay were submitted to the Centers for Disease Control and Prevention for genotyping.

RESULTS

In the 2009, 2010, and 2011 seasons, genotype G3P[8] was the predominant genotype throughout the network, with a 46%-84% prevalence. In the 2012 season, G12P[8] replaced G3P[8] as the most common genotype, with a 70% prevalence, and this trend persisted in 2013 (68.0% prevalence). Vaccine (RotaTeq; Rotarix) strains were detected in 0.6%-3.4% of genotyped samples each season. Uncommon and unusual strains (eg, G8P[4], G3P[24], G2P[8], G3P[4], G3P[6], G24P[14], G4P[6], and G9P[4]) were detected sporadically over the study period. Year, study site, and race were found to be significant predictors of genotype.

CONCLUSIONS

Continued active surveillance is needed to monitor RVA genotypes in the United States and to detect potential changes since vaccine licensure.

Molecular characterization of the first G24P[14] rotavirus strain detected in humans

Here we report the genome of a novel rotavirus A (RVA) strain detected in a stool sample collected during routine surveillance by the Centers for Disease Control and Prevention's New Vaccine Surveillance Network. The strain, RVA/human-wt/USA/2012741499/2012/G24P[14], has a genomic constellation of G24-P[14]-I2-R2-C2-M2-A3-N2-T9-E2-H3. The VP2, VP3, VP7 and NSP3 genes cluster phylogenetically with bovine strains. The other genes occupy mixed clades containing animal and human strains. Strain RVA/human-wt/USA/2012741499/2012/G24P[14] most likely is the product of interspecies transmission and reassortment events. This is the second report of the G24 genotype and the first report of the G24P[14] genotype combination in humans.

Epidemiologic Association Between FUT2 Secretor Status and Severe Rotavirus Gastroenteritis in Children in the United States

IMPORTANCE

A genetic polymorphism affecting FUT2 secretor status in approximately one-quarter of humans of European descent affects the expression of histo-blood group antigens on the mucosal epithelia of human respiratory, genitourinary, and digestive tracts. These histo-blood group antigens serve as host receptor sites necessary for attachment and infection of some pathogens, including norovirus.

OBJECTIVE

We investigated whether an association exists between FUT2 secretor status and laboratory-confirmed rotavirus infections in US children.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter case-control observational study involving active surveillance at 6 US pediatric medical institutions in the inpatient and emergency department clinical settings. We enrolled 1564 children younger than 5 years with acute gastroenteritis (diarrhea and/or vomiting) and 818 healthy controls frequency matched by age and month, from December 1, 2011, through March 31, 2013.

MAIN OUTCOMES AND MEASURES

Paired fecal-saliva specimens were tested for rotavirus and for secretor status. Comparisons were made between rotavirus test-positive cases and healthy controls stratified by ethnicity and vaccination status. Adjusted multivariable analyses assessed the preventive association of secretor status against severe rotavirus gastroenteritis.

RESULTS

One (0.5%) of 189 rotavirus test-positive cases was a nonsecretor, compared with 188 (23%) of 818 healthy control participants (P < .001). Healthy control participants of Hispanic ethnicity were significantly less likely to be nonsecretors (13%) compared with healthy children who were not of Hispanic ethnicity (25%) (P < .001). After controlling for vaccination and other factors, children with the nonsecretor FUT2 polymorphism appeared statistically protected (98% [95% CI, 84%-100%]) against severe rotavirus gastroenteritis.

CONCLUSIONS AND RELEVANCE

Severe rotavirus gastroenteritis was virtually absent among US children who had a genetic polymorphism that inactivates FUT2 expression on the intestinal epithelium. We observed a strong epidemiologic association among children with rotavirus gastroenteritis compared with healthy control participants. The exact cellular mechanism behind this epidemiologic association remains unclear, but evidence suggests that it may be rotavirus genotype specific. The lower prevalence of nonsecretors among Hispanic children may translate to an enhanced burden of rotavirus gastroenteritis among this group. Our findings may have bearing on our full understanding of rotavirus infections and the effects of vaccination in diverse populations.

Long-term Consistency in Rotavirus Vaccine Protection: RV5 and RV1 Vaccine Effectiveness in US Children, 2012-2013

BACKGROUND

Using a multicenter, active surveillance network from 2 rotavirus seasons (2012 and 2013), we assessed the vaccine effectiveness of RV5 (RotaTeq) and RV1 (Rotarix) rotavirus vaccines in preventing rotavirus gastroenteritis hospitalizations and emergency department (ED) visits for numerous demographic and secular strata.

METHODS

We enrolled children hospitalized or visiting the ED with acute gastroenteritis (AGE) for the 2012 and 2013 seasons at 7 medical institutions. Stool specimens were tested for rotavirus by enzyme immunoassay and genotyped, and rotavirus vaccination histories were compared for rotavirus-positive cases and rotavirus-negative AGE controls. We calculated the vaccine effectiveness (VE) for preventing rotavirus associated hospitalizations and ED visits for each vaccine, stratified by vaccine dose, season, clinical setting, age, predominant genotype, and ethnicity.

RESULTS

RV5-specific VE analyses included 2961 subjects, 402 rotavirus cases (14%) and 2559 rotavirus-negative AGE controls. RV1-specific VE analyses included 904 subjects, 100 rotavirus cases (11%), and 804 rotavirus-negative AGE controls. Over the 2 rotavirus seasons, the VE for a complete 3-dose vaccination with RV5 was 80% (confidence interval [CI], 74%-84%), and VE for a complete 2-dose vaccination with RV1 was 80% (CI, 68%-88%).Statistically significant VE was observed for each year of life for which sufficient data allowed analysis (7 years for RV5 and 3 years for RV1). Both vaccines provided statistically significant genotype-specific protection against predominant circulating rotavirus strains.

CONCLUSIONS

In this large, geographically and demographically diverse sample of US children, we observed that RV5 and RV1 rotavirus vaccines each provided a lasting and broadly heterologous protection against rotavirus gastroenteritis.

Variation in rotavirus vaccine coverage by provider location and subsequent disease burden

BACKGROUND

Rotavirus vaccines were introduced in the United States in 2006. Full-series coverage is lower than for other vaccines, and disease continues to occur. We examined variation in vaccine coverage among provider locations and correlated coverage with the detection of rotavirus in children who sought treatment of severe acute gastroenteritis (AGE).

METHODS

Vaccine records of children enrolled in an AGE surveillance program were obtained and children were grouped by the location that administered each child's 2-month vaccines. Cases were children with laboratory-confirmed rotavirus AGE; controls were children with rotavirus-negative AGE or acute respiratory infection. Location-level coverage was calculated using ≥ 1 dose rotavirus vaccine coverage among controls and classified as low (<40%), medium (≥ 40% to <80%), or high (≥ 80%). Rotavirus detection rates among patients with AGE were calculated by vaccine coverage category.

RESULTS

Of controls, 80.4% (n = 1123 of 1396) received ≥ 1 dose of rotavirus vaccine from 68 locations. Four (5.9%) locations, including a NICU, were low coverage, 22 (32.3%) were medium coverage, and 42 (61.8%) were high coverage. In low-coverage locations, 31.4% of patients with AGE were rotavirus-positive compared with 13.1% and 9.6% in medium- and high-coverage locations, respectively. Patients with AGE from low-coverage locations had 3.3 (95% confidence interval 2.4-4.4) times the detection rate of rotavirus than patients with AGE from high vaccine coverage locations.

CONCLUSIONS

We observed the highest detection of rotavirus disease among locations with low rotavirus vaccine coverage, suggesting that ongoing disease transmission is related to failure to vaccinate. Educational efforts focusing on timely rotavirus vaccine administration to age-eligible infants are needed.

The Texas Children's Hospital immunization forecaster: conceptualization to implementation

OBJECTIVES

Immunization forecasting systems evaluate patient vaccination histories and recommend the dates and vaccines that should be administered. We described the conceptualization, development, implementation, and distribution of a novel immunization forecaster, the Texas Children's Hospital (TCH) Forecaster.

METHODS

In 2007, TCH convened an internal expert team that included a pediatrician, immunization nurse, software engineer, and immunization subject matter experts to develop the TCH Forecaster. Our team developed the design of the model, wrote the software, populated the Excel tables, integrated the software, and tested the Forecaster. We created a table of rules that contained each vaccine's recommendations, minimum ages and intervals, and contraindications, which served as the basis for the TCH Forecaster.

RESULTS

We created 15 vaccine tables that incorporated 79 unique dose states and 84 vaccine types to operationalize the entire United States recommended immunization schedule. The TCH Forecaster was implemented throughout the TCH system, the Indian Health Service, and the Virginia Department of Health. The TCH Forecast Tester is currently being used nationally.

CONCLUSIONS

Immunization forecasting systems might positively affect adherence to vaccine recommendations. Efforts to support health care provider utilization of immunization forecasting systems and to evaluate their impact on patient care are needed.

Effectiveness of pentavalent and monovalent rotavirus vaccines in concurrent use among US children <5 years of age, 2009-2011

BACKGROUND

We assessed vaccine effectiveness (VE) for RotaTeq (RV5; 3 doses) and Rotarix (RV1; 2 doses) at reducing rotavirus acute gastroenteritis (AGE) inpatient and emergency department (ED) visits in US children.

METHODS

We enrolled children <5 years of age hospitalized or visiting the ED with AGE symptoms from November 2009-June 2010 and from November 2010-June 2011 at 7 medical institutions. Fecal specimens were tested for rotavirus by enzyme immunoassay and genotyped. Vaccination among laboratory-confirmed rotavirus cases was compared with rotavirus-negative AGE controls. Regression models calculated VE estimates for each vaccine, age, ethnicity, genotype, and clinical setting.

RESULTS

RV5-specific analyses included 359 rotavirus cases and 1811 rotavirus-negative AGE controls. RV1-specific analyses included 60 rotavirus cases and 155 rotavirus-negative AGE controls. RV5 and RV1 were 84% (95% confidence interval [CI], 78%-88%) and 70% (95% CI, 39%-86%) effective, respectively, against rotavirus-associated ED visits and hospitalizations combined. By clinical setting, RV5 VE against ED and inpatient rotavirus-associated visits was 81% (95% CI, 70%-84%) and 86% (95% CI, 74%-91%), respectively. RV1 was 78% (95% CI, 46%-91%) effective against ED rotavirus disease; study power was insufficient to evaluate inpatient RV1 VE. No waning of immunity was evident during the first 4 years of life for RV5, nor during the first 2 years of life for RV1. RV5 provided genotype-specific protection against each of the predominant strains (G1P[8], G2P[4], G3P[8], G12P[8]), while RV1 VE was statistically significant for the most common genotype, G3P[8].

CONCLUSIONS

Both RV5 and RV1 significantly protected against medically attended rotavirus gastroenteritis in this real-world assessment.