Improving childhood vaccination coverage rates: the case of fourth dose of DTaP

Based on the most recently available national data, vaccination coverage for the combined seven-vaccine series recommended by age 24 months remains substantially below the Healthy People 2020 target of 80%. One focus for improvement is the lack of timely administration of the fourth dose of DTaP vaccine. Based on the perspective of state and local immunization program managers, key strategies include tracking immunization patterns through immunization information systems and other data sources, working with health-care providers to address challenges to timely vaccination, and developing partnerships with daycares, payers, and health systems.

Understanding Non-Completion of the Human Papillomavirus Vaccine Series: Parent-Reported Reasons for Why Adolescents Might Not Receive Additional Doses, United States, 2012

Completion rates of the human papillomavirus (HPV) vaccine series among U.S. adolescents are below public health targets. We explored parent-reported reasons for their children's non-completion of the HPV vaccine series using a nationally representative online survey of parents of children aged 9-17 years, fielded in October 2012. Among the 1,653 parents who responded, the proportion reporting that their child would definitely continue with the HPV vaccine series among those who had started the series ranged from 28% to 54%. The most common reason cited by parents for non-completion of the series was their child's fear of needles, followed by lack of awareness about additional doses and safety concerns. These findings demonstrate the need to encourage adoption of strategies addressing needle fears, utilize reminders for parents about subsequent doses, and emphasize recent HPV vaccine safety data in discussions with parents.

Change in settings for early-season influenza vaccination among US adults, 2012 to 2013

Vaccination in non-medical settings is recommended as a strategy to increase access to seasonal influenza vaccine. To evaluate change in early-season influenza vaccination setting, we analyzed data from the National Internet Flu Survey. Bivariate comparison of respondent characteristics by location of vaccination was assessed using chi-square tests. Multinomial logistic regression was performed to compare the predicted probability of being vaccinated in medical, retail, and mobile settings in 2012 vs 2013. In both 2012 and 2013, vaccination in medical settings was more likely among elderly adults, those with chronic conditions, and adults with a high school education or less. Adults 18-64 without a chronic condition had a lower probability of vaccination in the medical setting, and higher probability of vaccination in a retail or mobile setting, in 2013 compared to 2012. Adults 18-64 with a chronic condition had no change in their location of flu vaccination. Elderly adults had a lower probability of vaccination in the medical setting, and higher probability of vaccination in a retail setting, in 2013 compared to 2012. Non-medical settings continue to play an increasing role in influenza vaccination of adults, particularly for adults without a chronic condition and elderly adults. Retail and mobile settings should continue to be viewed as important mechanisms to ensure broad access to influenza vaccination.

Parent Perception of Provider Interactions Influences HPV Vaccination Status of Adolescent Females

Human papillomavirus (HPV) vaccination coverage among adolescent females is well below national public health goals. Many known barriers to HPV vaccine receipt can be addressed in parent-physician conversations. This study sought to explore parent experiences and attitudes related to HPV vaccination of adolescent girls, focused on interactions with providers. We conducted a cross-sectional survey of parents using a nationally representative online panel. Among parents with ≥1 daughter aged 11 to 17 years, provider recommendations for HPV vaccine and specified age to begin the HPV vaccine series were associated with HPV vaccine status. Parents who reported their daughters were unlikely to complete the HPV series were more likely to have had no discussion of HPV vaccine with the provider. Efforts to increase HPV vaccination rates among adolescent females should continue to focus on improving provider discussion of HPV vaccine.

Parent HPV vaccine perspectives and the likelihood of HPV vaccination of adolescent males

In 2013, approximately one-third of US adolescent males age 13-17 y had received ≥1 doses of HPV vaccines and only 14% had received ≥3 doses. This study used a nationally representative, online survey to explore experiences and attitudes related to HPV vaccination among parents with adolescent sons. Analyses compared the perspective of parents who do not intend to initiate HPV vaccine for ≥1 adolescent son to that of parents who are likely to initiate or continue HPV vaccination. Of 809 parents of sons age 11-17 years, half were classified as Unlikely to Initiate HPV vaccination and 39% as Likely to Vaccinate. A higher proportion of the Likely to Vaccinate group felt their son's doctor was knowledgeable about HPV vaccine, did a good job explaining its purpose, and spent more time discussing HPV vaccine; in contrast, over half of the Unlikely to Initiate group had never discussed HPV vaccine with their child's doctor. The majority of parents in both groups showed favorable attitudes to adolescent vaccination in general, with lower levels of support for HPV vaccine-specific statements. Physician-parent communication around HPV vaccine for adolescent males should build on positive attitude toward vaccines in general, while addressing parents' HPV vaccine-specific concerns.

Ability to deliver services in Spanish: a survey of Michigan home health agencies, 2012

The capacity of home health agencies to serve children from families with low English proficiency is not well understood. We conducted an exploratory survey of home health agencies in Michigan in 2012 to document whether they can provide services in Spanish, serve children, and accept Medicaid.

Obstetricians and the 2009-2010 H1N1 vaccination effort: implications for future pandemics

Our objective was to describe the experiences of obstetricians during the 2009–2010 H1N1 vaccination campaign in order to identify possible improvements for future pandemic situations. We conducted a cross-sectional mail survey of a national random sample of 4,000 obstetricians, fielded in Summer 2010. Survey items included availability, recommendation, and patient acceptance of H1N1 vaccine; prioritization of H1N1 vaccine when supply was limited; problems with H1N1 vaccination; and likelihood of providing vaccine during a future influenza pandemic. Response rate was 66 %. Obstetricians strongly recommended H1N1 vaccine during the second (85 %) and third (86 %) trimesters, and less often during the first trimester (71 %) or the immediate postpartum period (76 %); patient preferences followed a similar pattern. H1N1 vaccine was typically available in outpatient obstetrics clinics (80 %). Overall vaccine supply was a major problem for 30 % of obstetricians, but few rated lack of thimerosal-free vaccine as a major problem (12 %). Over half of obstetricians had no major problems with the H1N1 vaccine campaign. Based on this experience, 74 % would be “very likely” and 12 % “likely” to provide vaccine in the event of a future influenza pandemic. Most obstetricians strongly recommended H1N1 vaccine, had few logistical problems beyond limited vaccine supply, and are willing to vaccinate in a future pandemic. Addressing concerns about first-trimester vaccination, developing guidance for prioritization of vaccine in the event of severe supply constraints, and continued facilitation of the logistical aspects of vaccination should be emphasized in future influenza pandemics.

Screening practices for identifying type 2 diabetes in adolescents

OBJECTIVE

To characterize pediatrician and family physician (FP) screening practices for type 2 diabetes among adolescents and to examine the impact of the 2010 American Diabetes Association (ADA) guidelines, recommending use of Hemoglobin A1c (HbA1c).

METHODS

We conducted a cross-sectional mail survey of a random sample of 1,400 U.S. pediatricians and FPs and we received 604 eligible responses. Our main outcome measure was the types of tests ordered by physicians, particularly HbA1c, when presented with a hypothetical scenario.

RESULTS

The overall response rate was 52% (57% for pediatricians and 48% for FPs). Fasting glucose and HbA1c were the most commonly ordered tests. Overall, at least 58% of physicians ordered HbA1c; 35% ordered HbA1c in conjunction with fasting tests; and 22% ordered HbA1c alone or with nonfasting tests. Only 38% of providers were aware of the new ADA recommended HbA1c screening guidelines. However, a majority (67%) said they would change their screening practices. In the context of the guidelines, 84% of physicians would now order HbA1c. Furthermore, there was a large increase in the proportion of physicians who would shift to using HbA1c only or with other nonfasting tests.

CONCLUSIONS

When screening adolescents for type 2 diabetes, providers are more likely to order HbA1c and order fewer fasting tests in response to the new ADA guidelines. HbA1c has lower sensitivity and higher costs than other testing modalities in children, therefore increasing uptake of this test (HbA1c) in children may have implications for both detection rates and healthcare costs.

Statewide pandemic influenza vaccination reminders for children with chronic conditions

OBJECTIVES

We evaluated the use of a statewide immunization information system (IIS) to target influenza vaccine reminders to high-risk children during a pandemic.

METHODS

We used Michigan's IIS to identify high-risk children (i.e., those with ≥ 1 chronic condition) aged 6 months to 18 years with no record of pH1N1 vaccination among children currently or previously enrolled in Medicaid (n = 202,133). Reminders were mailed on December 7, 2009. We retrospectively assessed children's eligibility for evaluation and compared influenza vaccination rates across 3 groups on the basis of their high-risk and reminder status.

RESULTS

Of the children sent reminders, 53,516 were ineligible. Of the remaining 148,617 children, vaccination rates were higher among the 142,383 high-risk children receiving reminders than among the 6234 high-risk children with undeliverable reminders and the 142,383 control group children without chronic conditions who were not sent reminders.

CONCLUSIONS

Midseason reminders to parents of unvaccinated high-risk children with current or past Medicaid enrollment were associated with increased pH1N1 and seasonal influenza vaccination rates. Future initiatives should consider strategies to expand targeting of high-risk groups and improve IIS reporting during pandemic events.

Involvement of endocrinologists in the 2009 to 2010 H1N1 vaccination effort

OBJECTIVE

To assess the level of participation of endocrinologists in the United States in the 2009 to 2010 H1N1 vaccination campaign and explore their perspectives on H1N1 vaccination.

METHODS

We conducted a cross-sectional, mailed survey of a national sample of 1,991 endocrinologists in June through September 2010. The extent of the response and the survey responses are reported and analyzed.

RESULTS

The overall response rate was 59%. The majority of endocrinologists strongly recommended H1N1 vaccine for children, whereas about a third did so for both nonelderly adults and seniors. Just over half (52%) of the responding endocrinologists had agreed to participate in the 2009 to 2010 H1N1 vaccine campaign and received vaccine, in comparison with 73% who offered seasonal influenza vaccine. The supply of H1N1 vaccine was a significant challenge, but otherwise endocrinologists reported few major problems with administration of H1N1 vaccine. Overall, less than half of the respondents thought that they would be "very likely" to provide vaccine in the event of a future influenza pandemic, with a much higher proportion among those endocrinologists who offered seasonal influenza vaccine and H1N1 vaccine.

CONCLUSION

Although the experiences of endocrinologists who provided H1N1 vaccine were generally positive, many did not offer the vaccine and indicated that they are hesitant about providing vaccine during a future influenza pandemic. Approaches to increase their participation in future pandemics in an effort to reach persons at high risk for influenza and its complications, such as those with diabetes, should be further explored.

Feasibility of initiating and sustaining registry-based immunization recall in private practices

OBJECTIVE

To assess the feasibility of initiating and sustaining immunization recall by private practices, including the barriers and costs, using a statewide immunization information system (IIS).

METHODS

Private practices in southeast Michigan were recruited in 2007 to perform IIS-based immunization recalls. Enrolled practices were provided with training and asked to conduct 4 recalls during the course of 12 months of children 19 to 35 months of age. Each practice recorded the time they spent performing recall-related activities; labor costs were estimated. Formative and summative evaluations with semistructured interviews were conducted to identify barriers.

RESULTS

Of 97 eligible pediatric and family medicine practices, 44 declined to participate, 32 did not respond to repeated contacts, and 20 agreed to enroll in the study (21%). A total of 56 recalls were conducted during the study period, with 9 practices completing at least 4 recalls and 7 practices completing 1 to 3 recalls; 4 practices conducted no recalls. Common barriers reported included time constraints and executing all steps of the recalls. Practice costs per patient recalled ranged from $0.05 to more than $6 and were primarily driven by the type of personnel who performed recalls. The costs of creating a roster of current patients comprised nearly one-half of total labor costs.

CONCLUSIONS

Few private provider practices that we contacted were willing to participate in this study of IIS-based recall, and less than one-half of enrolled practices completed the desired 4 recall cycles in 12 months. Time constraints and other real-world problems should not be underestimated in determining the feasibility of practice-based immunization recall. Efforts to increase the use of a statewide IIS for recall in private practice settings should emphasize ongoing training and technical support to practice staff. Improved interoperability with electronic health record systems may foster practice-based recall by reducing the labor intensity of roster building and other recall activities.

Perspectives of allergists/immunologists on the 2009-2010 H1N1 vaccination effort

BACKGROUND

Persons with high-risk conditions such as asthma were a target group for national H1N1 vaccine recommendations. Allergists/immunologists (allergists) are a provider group that could vaccinate persons with asthma and other high-risk conditions. Their level of participation in and experiences with the 2009-2010 H1N1 vaccination campaign are unknown.

OBJECTIVE

To describe the experiences of allergists related to the 2009-2010 H1N1 vaccination campaign.

METHODS

A cross-sectional, mailed survey of a national sample of 1955 allergists providing outpatient care was conducted in June-September 2010.

RESULTS

The overall response rate was 72%. Most allergists "strongly recommended" H1N1 vaccine for children, and most "recommended" or "strongly recommended" vaccine for adults. The majority (71%) agreed to participate in the H1N1 vaccine campaign and received vaccine. Vaccine supply was a significant challenge, but otherwise few major problems were experienced with administering H1N1 vaccine. The majority of respondents, particularly among those who participated in the 2009-2010 H1N1 vaccination campaign, felt they would be very likely to vaccinate in the event of future influenza pandemic.

CONCLUSIONS

The experiences of allergists in the H1N1 vaccine campaign were generally positive. Most allergists are willing to serve as vaccinators in future influenza pandemics, which will help facilitate broad access to vaccine for patients with asthma and other high-risk conditions.

Influenza vaccine-related information needs of US primary care physicians

OBJECTIVE

To explore influenza-related information needs of primary care providers, given expanded influenza vaccine recommendations and new influenza vaccine products.

METHODS

A cross-sectional, mailed survey of a national sample of primary care physicians (family physicians, general internists, pediatricians), conducted in July-October 2010. The overall response rate was 70%.

RESULTS

Among respondents who offer immunizations, almost all expected to provide injectable influenza vaccine for the 2010-11 influenza season, while only pediatricians planned wide use of intranasal vaccine. The information needs most frequently rated as high priority were subpopulations to prioritize if vaccine supply is limited and use of a higher dose formulation for the elderly. Most physicians who do not currently use intranasal vaccine rated that topic as a low priority.

CONCLUSION

Primary care providers have a number of high-priority information needs related to influenza vaccination. However, the limited interest of family physicians and internists in receiving more information about intranasal vaccine may impede efforts to expand its use among healthy adults.

Primary care physician perspectives on providing adult vaccines

Recently, several new vaccines have been recommended for adults. Little is known regarding the immunization purchase and stocking practices of adult primary care physicians. To determine the proportion of family practice and internal medicine physicians who routinely stock specific adult vaccines and their rationale for those decisions, we conducted a cross-sectional survey in 2009 of a national random sample of 993 family physicians (FPs) and 997 general internists (IMs) in the US. Of the 1109 respondents, 886 reported that they provide primary care to adults aged 19-64 years and 96% of these physicians stock at least one vaccine recommended for adults. Of those, 2% plan to stop and 12% plan to increase vaccine purchases; the rest plan to maintain status quo. Of the respondents, 27% (31% FPs vs 20% IMs) stocked all adult vaccines. We conclude that many primary care physicians who provide care to adults do not stock all recommended immunizations. Efforts to improve adult immunization rates must address this fundamental issue.

Influenza vaccine for high-risk non-elderly adults: a national survey of subspecialists

Despite long-standing recommendations for non-elderly adults with certain chronic pulmonary, cardiovascular and metabolic conditions to receive influenza vaccine, vaccination rates remain low. Visits to subspecialists represent an important vaccination opportunity, but little is known regarding subspecialists' perceptions related to influenza vaccination. In February 2003, we conducted a cross-sectional mail survey of a random sample (N = 2,007) of board-certified cardiologists, endocrinologists and pulmonologists from the entire United States who provided outpatient care to adults aged 18-64 years, to assess their patterns of and attitudes toward administering influenza vaccine to high-risk, non-elderly patients. The overall response rate was 33%. Among 621 eligible respondents, 483 stocked influenza vaccine in their practice (Stockers) and 138 did not stock the vaccine (Non-Stockers). Pulmonologists were most likely to stock vaccine and strongly recommend vaccination; cardiologists were least likely. Among Stockers, barriers to vaccination varied by subspecialty. Among Non-Stockers, the most common factor in the decision to not stock vaccine was the perception that patients will receive the vaccine elsewhere. Most subspecialists who provide care to a large proportion of high-risk, non-elderly persons recommend influenza vaccination to some degree, particularly pulmonologists. To reduce missed opportunities overall, subspecialists should be encouraged to vaccinate patients who say that they plan to get the vaccine elsewhere. For cardiologists in particular, barriers to stocking influenza vaccine and recommending vaccination more strongly must be addressed.

Variation in provider vaccine purchase prices and payer reimbursement

OBJECTIVE

The purpose of this work was to collect data regarding vaccine prices and reimbursements in private practices. Amid reports of physicians losing money on vaccines, there are limited supporting data to show how much private practices are paying for vaccines and how much they are being reimbursed by third-party payers.

METHODS

We conducted a cross-sectional survey of a convenience sample of private practices in 5 states (California, Georgia, Michigan, New York, and Texas) that purchase vaccines for administration to privately insured children/adolescents. Main outcome measures included prices paid to purchase vaccines recommended for children and adolescents and reimbursement from the 3 most common, non-Medicaid payers for vaccine purchase and administration.

RESULTS

Detailed price and reimbursement data were provided by 76 practices. There was a considerable difference between the maximum and minimum prices paid by practices, ranging from $4 to more than $30 for specific vaccines. There was also significant variation in insurance reimbursement for vaccine purchase, with maximum and minimum reimbursements for a single vaccine differing from $8 to more than $80. Mean net yield per dose (reimbursement for vaccine purchase minus price paid per dose) varied across vaccines from a low of approximately $3 to more than $24. Reimbursement for the first dose of vaccine administered ranged from $0 to more than $26, with a mean of $16.62.

CONCLUSIONS

There is a wide range of prices paid by practices for the same vaccine product and in the reimbursement for vaccines and administration fees by payers. This variation highlights the need for individual practices to understand their own costs and reimbursements and to seek opportunities to reduce costs and increase reimbursements.

Primary care physician perspectives on reimbursement for childhood immunizations

OBJECTIVES

The purpose of this research was to explore physicians' attitudes and behaviors related to vaccine financing issues within their practice. Amid the increasing number of vaccine doses recommended for children and adolescents, anecdotal reports suggest that physicians are facing increasing financial pressures from vaccine purchase and administration and may stop providing vaccines altogether to privately insured children. Whether these sentiments are widely held among immunization providers is unknown.

METHODS

We conducted a cross-sectional mail survey from July to September 2007 of a random sample of 1280 US pediatricians and family physicians engaged in direct patient care. Main outcome measures included delay in the purchase of specific vaccines for financial reasons; reported decrease in profit margin from immunizations; and practice consideration of whether to stop providing all vaccines to privately insured children.

RESULTS

The response rate was 70% for pediatricians and 60% for family physicians. Approximately half of the respondents reported that their practice had delayed the purchase of specific vaccines for financial reasons (49%) and experienced decreased profit margin from immunizations (53%) in the previous 3 years. Twenty-one percent of respondents strongly disagreed that "reimbursement for vaccine purchase is adequate," and 17% strongly disagreed that "reimbursement for vaccine administration is adequate." Eleven percent of respondents said their practice had seriously considered whether to stop providing all vaccines to privately insured children in the previous year.

CONCLUSIONS

Physicians who provide vaccines to children and adolescents report dissatisfaction with reimbursement levels and increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address root causes of financial pressures should be undertaken.

Influenza vaccination attitudes and practices among US registered nurses

BACKGROUND

The influenza vaccination rate among US health care personnel (HCP) remains low and may vary by occupational categories. The objective of this study was to explore knowledge, attitudes, and beliefs associated with influenza vaccination in a broad population of registered nurses.

METHODS

The study used a cross-sectional mail survey, administered January-March 2006, of 2000 registered nurses in 4 US states.

RESULTS

Of the 2000 surveys sent, 1310 (72%) were returned, and 1017 (67%) were eligible for analysis. The majority of respondents (59%) reported receiving influenza vaccine during the 2005-2006 influenza season. The most common reason for being vaccinated was protecting oneself from illness (95%), and the most common reason for not being vaccinated was concern about adverse reactions (39%). Respondents who reported their patient population as high risk related to influenza were more likely to be vaccinated and to agree with statements regarding influenza disease and influenza vaccination of HCP.

CONCLUSION

Concerns about adverse reactions and vaccine effectiveness continue to be barriers to influenza vaccination among registered nurses. Those most knowledgeable about influenza vaccination of HCP have higher vaccination rates. Future efforts to improve vaccination rates should include data on vaccine effectiveness and adverse effects, as well as descriptions of high-risk populations.

Diagnosis and testing practices for adolescent pertussis among a national sample of primary care physicians

OBJECTIVE

Adolescents are a primary reservoir for propagating pertussis infection. This study aimed to describe diagnosis and testing practices for adolescent pertussis among a national sample of primary care physicians.

METHODS

From January to March, 2007 we administered a written survey to a United States sample of American Medical Association physicians that included 725 family practitioners (FPs) and 725 general pediatricians (PDs).

RESULTS

Response rate was 60% (n=702). Overall, 16% of respondents indicated that they did not test adolescents for pertussis as part of their clinical practice. A similar proportion did not recognize the clinical manifestations of pertussis in a standardized adolescent case patient. FPs were less likely than PDs to test for pertussis in general and to diagnose the case patient with pertussis. Barriers to testing adolescents for pertussis included delay in obtaining test results (52%), inconvenience of sample collection (29%), lack of testing supplies (29%), lack of familiarity with testing protocols (28%) and cost (22%).

CONCLUSION

Our results suggest that a substantial number of primary care physicians do not utilize pertussis testing and may not be able to recognize the clinical symptoms of this infection in adolescents. Interventions to improve physician knowledge about this important public health issue may be warranted.

Adolescent Tdap vaccine use among primary care physicians

PURPOSE

In 2006 the Advisory Committee on Immunization Practices (ACIP) recommended replacement of the adolescent tetanus and diphtheria toxoids (Td) booster with combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap). We examined the degree to which pediatricians and family practitioners have adopted this recommendation.

METHODS

National mail-based survey of a random sample of 725 pediatricians and 725 family practitioners from January through March, 2007.

RESULTS

Overall response rate was 60%. The majority of respondents indicated they routinely recommended Tdap to adolescents at the preferred age for vaccination, 11-12 years old (87%), and also for "catch up" vaccination among adolescents 13-18 years old (89%). In bivariate analyses, pediatrician specialty, specialty society membership, stocking Tdap in the office, and prior experience diagnosing adolescent pertussis were associated with routinely recommending Tdap to adolescents. In multivariable models adjusting for these factors simultaneously, only pediatrician specialty (OR = 4.8, 95% CI = 2.5-9.3) and stocking Tdap in the office (OR = 14.5, 95% CI = 7.5-28.5) remained significantly associated with routine recommendation. Pediatricians were significantly more likely than family practitioners to accept shorter time intervals for administering Tdap following Td vaccination, and to co-administer Tdap with MCV4. Lack of adolescent visits was the most commonly cited major barrier to adolescent Tdap administration.

CONCLUSIONS

Based on self report, our results indicate the majority of physicians have adopted recent recommendations from the ACIP to administer Tdap to adolescents. However, specialty-based disparities in attitudes and practices persist, suggesting that ongoing efforts are needed to motivate physicians to recommend this vaccine to adolescents and to clarify how to integrate Tdap with other adolescent vaccinations.

Analysis of dye binding by and membrane potential in spores of Bacillus species

AIMS

To determine roles of coats in staining Bacillus subtilis spores, and whether spores have membrane potential.

METHODS AND RESULTS

Staining by four dyes and autofluorescence of B. subtilis spores that lack some (cotE, gerE) or most (cotE gerE) coat protein was measured. Wild-type, cotE and gerE spores autofluorescenced and bound dyes, but cotE gerE spores did not autofluorescence and were stained only by two dyes. A membrane potential-sensitive dye DiOC6(3) bound to dormant Bacillus megaterium and B. subtilis spores. While this binding was abolished by the protonophore FCCP, DiOC6(3) bound to heat-killed spores, but not to dormant B. subtilis cotE gerE spores. However, DiOC6(3) bound well to all germinated spores.

CONCLUSIONS

The autofluorescence of dormant B. subtilis spores and the binding of some dyes are due to the coat. There is no membrane potential in dormant Bacillus spores, although membrane potential is generated when spores germinate.

SIGNIFICANCE AND IMPACT OF THE STUDY

The elimination of the autofluorescence of B. subtilis spores may allow assessment of the location of low abundance spore proteins using fluorescent reporter technology. The dormant spore's lack of membrane potential may allow tests of spore viability by assessing membrane potential in germinating spores.

Variation in provider vaccine purchase prices and payer reimbursement

OBJECTIVE

The purpose of this work was to collect data regarding vaccine prices and reimbursements in private practices. Amid reports of physicians losing money on vaccines, there are limited supporting data to show how much private practices are paying for vaccines and how much they are being reimbursed by third-party payers.

METHODS

We conducted a cross-sectional survey of a convenience sample of private practices in 5 states (California, Georgia, Michigan, New York, and Texas) that purchase vaccines for administration to privately insured children/adolescents. Main outcome measures included prices paid to purchase vaccines recommended for children and adolescents and reimbursement from the 3 most common, non-Medicaid payers for vaccine purchase and administration.

RESULTS

Detailed price and reimbursement data were provided by 76 practices. There was a considerable difference between the maximum and minimum prices paid by practices, ranging from $4 to more than $30 for specific vaccines. There was also significant variation in insurance reimbursement for vaccine purchase, with maximum and minimum reimbursements for a single vaccine differing from $8 to more than $80. Mean net yield per dose (reimbursement for vaccine purchase minus price paid per dose) varied across vaccines from a low of approximately $3 to more than $24. Reimbursement for the first dose of vaccine administered ranged from $0 to more than $26, with a mean of $16.62.

CONCLUSIONS

There is a wide range of prices paid by practices for the same vaccine product and in the reimbursement for vaccines and administration fees by payers. This variation highlights the need for individual practices to understand their own costs and reimbursements and to seek opportunities to reduce costs and increase reimbursements.

Primary care physician perspectives on reimbursement for childhood immunizations

OBJECTIVES

The purpose of this research was to explore physicians' attitudes and behaviors related to vaccine financing issues within their practice. Amid the increasing number of vaccine doses recommended for children and adolescents, anecdotal reports suggest that physicians are facing increasing financial pressures from vaccine purchase and administration and may stop providing vaccines altogether to privately insured children. Whether these sentiments are widely held among immunization providers is unknown.

METHODS

We conducted a cross-sectional mail survey from July to September 2007 of a random sample of 1280 US pediatricians and family physicians engaged in direct patient care. Main outcome measures included delay in the purchase of specific vaccines for financial reasons; reported decrease in profit margin from immunizations; and practice consideration of whether to stop providing all vaccines to privately insured children.

RESULTS

The response rate was 70% for pediatricians and 60% for family physicians. Approximately half of the respondents reported that their practice had delayed the purchase of specific vaccines for financial reasons (49%) and experienced decreased profit margin from immunizations (53%) in the previous 3 years. Twenty-one percent of respondents strongly disagreed that "reimbursement for vaccine purchase is adequate," and 17% strongly disagreed that "reimbursement for vaccine administration is adequate." Eleven percent of respondents said their practice had seriously considered whether to stop providing all vaccines to privately insured children in the previous year.

CONCLUSIONS

Physicians who provide vaccines to children and adolescents report dissatisfaction with reimbursement levels and increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address root causes of financial pressures should be undertaken.

Attitudes of US obstetricians toward a combined tetanus-diphtheria-acellular pertussis vaccine for adults

OBJECTIVE

To describe obstetricians' perspectives related to tetanus-diphtheria-acellular pertussis (Tdap) vaccination of mothers and other adults in close contact with infants.

METHODS

Mail survey of national random sample of 400 obstetricians.

RESULTS

Response rate was 54%. Most respondents would likely recommend Tdap for women during the postpartum hospital stay (78%) or during pregnancy (69%) if a national recommendation was issued. Expected barriers were knowing the date of patients' most recent Td booster (74%) and patient resistance (46%). Most felt that obstetricians have a role in promoting and administering Tdap vaccine to adults other than mothers likely to come in close contact with infants.

CONCLUSION

Obstetricians are likely to agree with the recent provisional US recommendation to administer Tdap to postpartum mothers and other adults expected to come in close contact with infants. Obstetricians would also be likely to support a potential recommendation to administer Tdap during pregnancy. Barriers to adoption of new Tdap vaccine recommendations should be monitored.

New combined tetanus-diptheria-acellular pertussis vaccines for adults: primary care physician attitudes and preferences

Availability of combined tetanus-diphtheria-acellular pertussis (Tdap) vaccines for adults offers a new pertussis prevention strategy for the US. Successful uptake of Tdap vaccine will depend partly on the attitudes and practices of primary care physicians, including their experience with Td boosters. We conducted a mail survey in August 2005 of a national random sample of 399 family physicians (FPs) and 399 general internists (IMs) to assess practices related to Td boosters, clinical experience with pertussis, and attitudes toward a potential Tdap vaccine recommendation for adults. The response rate was 49% (52% FPs, 46% IMs). Among 336 eligible respondents, half reported having clinical experience with pertussis. Most (81%) would recommend Tdap vaccine for their adult patients, and 73% support targeting adults likely to come in close contact with infants. Attitudes toward a potential Tdap vaccine recommendation differed by whether providers stock and administer Td boosters. We conclude that adult primary care providers in the US are likely to recommend Tdap vaccine to their adult patients, in concordance with recent national recommendations. Future research should assess the extent to which barriers impede adoption of Tdap vaccine recommendations.

Physician attitudes regarding breakthrough varicella disease and a potential second dose of varicella vaccine

OBJECTIVE

We assessed physicians' attitudes about the 1-dose varicella vaccination program and whether physicians think a 2-dose recommendation is needed to reduce the risk of breakthrough disease.

METHODS

We conducted a national mail survey of a random sample of 550 pediatricians and 550 family physicians from April to June 2005. Physicians who provide outpatient primary care to children < or = 6 years of age were eligible for analysis.

RESULTS

Surveys were returned by 727 respondents, for a response rate of 69%; 610 physicians were eligible. Most respondents (94%) recommend routine 1-dose varicella vaccination, and 79% have seen breakthrough disease in the past 5 years (95% of pediatricians and 58% of family physicians). The majority (68%) agreed or strongly agreed that the current burden of breakthrough disease is acceptable. Only 38% (46% of pediatricians and 28% of family physicians) agreed or strongly agreed that a second dose of varicella vaccine is needed to address the burden of breakthrough disease, whereas 40% were neutral. However, if the Advisory Committee on Immunization Practices were to recommend a second dose of varicella vaccine, then 65% of pediatricians and 39% of family physicians would likely follow the recommendation. Most respondents (78%) would be more willing to recommend a second dose if a combination measles-mumps-rubella-varicella vaccine was available.

CONCLUSIONS

Pediatricians and family physicians support the 1-dose varicella vaccination program. A new Advisory Committee on Immunization Practices recommendation for a second dose of varicella vaccine for children was issued after the survey (in June 2006). Two of 3 pediatricians and 2 of 5 family physicians stated that they would adopt a 2-dose recommendation in practice; rates of adoption may be bolstered with current availability of measles-mumps-rubella-varicella vaccine and harmonization of the varicella vaccination schedule with that of measles-mumps-rubella vaccine.

Physician perspectives to inform a new recommendation for meningococcal conjugate vaccine (MCV4)

PURPOSE

In January 2005, the U.S. Food and Drug Administration licensed a new tetravalent meningococcal conjugate vaccine (MCV4). Before any policy decisions by the U.S. Advisory Committee on Immunization Practices (ACIP) related to MCV4, the Centers for Disease Control and Prevention requested a study to explore the perspective of primary care physicians regarding different recommendation scenarios for use of MCV4.

METHODS

Cross-sectional mail survey of a national random sample of pediatricians (PDs) and family physicians (FPs), conducted January 2005. Respondents chose from four MCV4 recommendation scenarios in terms of ability to implement, perceived patient/parent preferences, scientific evidence, and overall best fit.

RESULTS

Response rate to the single-mailing survey was 57%. In terms of ability to implement, respondents generally preferred an MCV4 recommendation targeted to middle-school entry (11-12 years old) or with the Td booster at any age, but on the basis of scientific evidence they favored MCV4 at high school completion. For "overall best fit," relatively equal proportions of respondents favored a recommendation at middle school entry and one linked to Td booster administration (whenever it occurred); there were no significant differences between PDs and FPs. Major influences on willingness to recommend MCV4 were vaccine safety/side effects and insurance coverage/reimbursement.

CONCLUSIONS

Support for an MCV4 recommendation at middle school entry is common but not universal among primary care providers. Data suggest that respondents appreciate the potential discrepancy between practical aspects of vaccine delivery and the need to protect those adolescents at greatest risk of disease. Respondents' preferences for the overall best fit appear to prioritize ease of implementation over epidemiologic patterns.

Physician attitudes and preferences about combined Tdap vaccines for adolescents

BACKGROUND

Combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) boosters for adolescents are a new strategy to prevent pertussis. We examined the current practices of pediatricians and family physicians regarding adolescent tetanus and diphtheria toxoids (Td) vaccine immunizations and providers' potential adherence to new Tdap recommendations for adolescents.

METHODS

Using a brief survey instrument sent to a random sample of pediatricians and family physicians in January 2005, we assessed providers' patterns of administration of Td boosters, barriers to Td boosters, and agreement that pertussis vaccination of adolescents is warranted. Results of analyses in February 2005 were presented to the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) to inform its deliberations regarding adolescent Tdap vaccination.

RESULTS

The overall response rate was 56% (57% pediatricians, 55% family physicians). Among 297 respondents (154 pediatricians, 143 family physicians) eligible for analysis because they provide care to adolescents, pediatricians (77%) were significantly more likely than family physicians (51%, p < 0.0001) to report that they routinely administer Td at preventive care visits for adolescents aged 11 to 12 years, but otherwise the specialties were similar in their Td practices. Forty-four percent of respondents cited infrequency of adolescent visits as a barrier to Td immunization. Slightly more than half the sample (57%) agreed or strongly agreed that pertussis is serious enough to warrant replacing Td with Tdap for adolescents; pediatricians (70%) were significantly more likely than family physicians (42%, p < 0.0001) to endorse this statement.

CONCLUSIONS

This national survey indicates moderate willingness, stronger among pediatricians than among family physicians, to support recommendations for Tdap among adolescents. In February 2006, CDC released recommendations that adolescents aged 11 to 18 (preferred age 11 to 12) receive a single dose of Tdap in place of Td if they have not already received the latter. Near-term efforts regarding Tdap recommendations must address providers' concerns about infrequent routine visits for adolescents and convince more physicians of the importance of pertussis booster immunization during adolescence.

Use of a new combined vaccine in pediatric practices

OBJECTIVE

On December 13, 2002, Pediarix, a combination vaccine that contains diphtheria, tetanus, acellular pertussis; hepatitis B; and inactivated polio vaccines, was licensed by the Food and Drug Administration for use in the primary immunization series. Use of this vaccine decreases the number of injections that children receive when completing their primary immunization series at the 2-, 4-, and 6-month well-child visits. The objective of this study was to determine the factors that influence the use of this combined vaccine in private pediatric practices, with particular attention to the perceived economic impact of Pediarix and actions taken to address this impact within the private pediatric setting.

METHODS

A mail survey study was conducted of a random sample of 565 practicing pediatricians that was obtained from the American Medical Association Masterfile. Frequency distributions were developed for all responses, and the vaccine financing policies of the state of practice for each respondent were determined. Chi2 analysis was performed to assess any associations of the predictor variables with the outcome variables of interest, use or consideration of use of the Pediarix vaccine. Logistic regression was used to determine the independent association of the predictor variables with use or consideration of use of Pediarix. Regression models that did and did not include practice ownership as a predictor variable were developed.

RESULTS

Response rate was 63% (N = 355). A total of 39% (n = 123) of the respondents' practices were purchasing Pediarix for use with their private patients. An additional 18% (n = 55) were considering purchasing the vaccine. Those who were in practices that were owned by hospitals or health systems were more likely than those who were in solo or group practices to purchase Pediarix for their private patients. Approximately half of the remaining respondents order Pediarix through their state immunization program. Among the 52% of respondents who did not, 23% reported that the vaccine was not yet available through their state program, and 47% stated that they did not want to use different vaccines for their public and private patients. Only 11% believed that Pediarix was not compatible with their other vaccine products. Physicians that currently were purchasing or considering purchasing Pediarix were more likely to be influenced by both parental and provider desire to decrease the number of injections at a single visit and the reduced time for immunization delivery. Fewer than 1% of respondents reported either having experienced or expecting to experience a significant decrease in practice revenue as a result of the use of Pediarix.

CONCLUSIONS

Although use of the vaccine results in fewer administration fees for most physicians, the magnitude of the change seemed not to be significant for the majority of respondents or was outweighed by other factors. It also is possible that larger practices or buying cooperatives were able to negotiate discounted rates for Pediarix relative to the constituent products. This may have been a strategy of manufacturers and/or distributors to provide incentive for practices to switch to the combination product. Of note was the appreciation of respondents for the preferences of patients for fewer vaccines and, to a lesser degree, for the decrease in office staff time required to provide vaccination with multiple antigens when using Pediarix. Also, the role of the availability of a given vaccine through the Vaccines for Children program is important in its adoption into practice.

Influenza vaccination status and influenza-related perspectives and practices among US physicians

BACKGROUND AND OBJECTIVE

The influenza vaccination rate among US healthcare workers (HCWs) remains low. This survey was designed to assess influenza vaccination status and related knowledge, attitudes, and beliefs among a national sample of primary care physicians and subspecialists likely to see patients at high risk for complications from influenza.

METHODS

We used a mail survey of a national random sample of 495 family physicians (FPs), 491 internists (IMs), 498 geriatricians (GERs), and 497 pulmonologists (PUDs).

RESULTS

The overall response rate was 38%. Almost all respondents (87%) reported receiving an influenza vaccine during the 2003-2004 influenza season, with no significant difference across specialty groups (84% FPs, 87% IMs, 87% GERs, 91% PUDs). In a multivariate model, adjusted for physician specialty and age group, significant predictors of vaccination were: strong agreement that HCWs have professional responsibility to be vaccinated, access to vaccination on site and free of charge, strong worksite recommendation for HCWs to be vaccinated, and strong agreement that benefits of vaccination outweigh risk of side effects.

CONCLUSIONS

Physicians reported a high influenza vaccination rate. To improve these rates further, with likely benefits for other HCWs, worksite policies that facilitate access to vaccination and documentation of reductions in nosocomial influenza associated with HCW vaccination should continue to be pursued.

Private provider participation in statewide immunization registries

Background

Population-based registries have been promoted as an effective method to improve childhood immunization rates, yet rates of registry participation in the private sector are low. We sought to describe, through a national overview, the perspectives of childhood immunization providers in private practice regarding factors associated with participation or non-participation in immunization registries.

Methods

Two mailed surveys, one for 264 private practices identified as registry non-participants and the other for 971 identified as registry participants, from 15 of the 31 states with population-based statewide immunization registries. Frequency distributions were calculated separately for non-participants and participants regarding the physician-reported factors that influenced decisions related to registry participation. Pearson chi-square tests of independence were used to assess associations among categorical variables.

Results

Overall response rate was 62% (N = 756). Among non-participants, easy access to records of vaccines provided at other sites (N = 101, 68%) and printable immunization records (N = 82, 55%) were most often cited as "very important" potential benefits of a registry, while the most commonly cited barriers to participation were too much cost/staff time (N = 36, 38%) and that the practice has its own system for recording and monitoring immunizations (N = 35, 37%). Among registry participants, most reported using the registry to input data on vaccines administered (N = 326, 87%) and to review immunization records of individual patients (N = 302, 81%). A minority reported using it to assess their practice's immunization coverage (N = 110, 29%) or generate reminder/recall notices (N = 54, 14%). Few participants reported experiencing "significant" problems with the registry; the most often cited was cost/staff time to use the registry (N = 71, 20%).

Conclusion

Most registry participants report active participation with few problems. The problems they report are generally consistent with the barriers anticipated by non-participants, but did not impede participation. Recruitment efforts should focus on demonstrating the benefits of the registry to providers. In addition, many participants are not utilizing the full range of registry features; further study is needed to determine how best to increase use of these features.

Willingness of Private Physicians to Be Involved in Smallpox Preparedness and Response Activities

BACKGROUND

The public health system continues its efforts to prepare for bioterrorist events, such as a smallpox outbreak, but may need to call on other health professionals to ensure sufficient capacity to implement preparedness plans.

OBJECTIVE

The goal was to understand the willingness of primary care physicians to participate in possible smallpox pre- or post-event activities.

METHODS

A 23-question mail survey was sent to a national random sample of 727 internists and 720 family physicians. After three mailings, a one-page version of the survey was sent to nonrespondents.

RESULTS

Response rates were 26% for questions common to both surveys and 22% for questions on the longer survey only. Respondents to the survey expressed moderate support for participating in certain smallpox pre- and post-event activities. Under a pre-event scenario, many providers would be willing to vaccinate first responders in their practice, and roughly one-third would be willing to vaccinate patients in their practice or to work in a public health clinic as a vaccinator. Most physicians, however, would be unwilling to be vaccinated themselves. Under post-event conditions, most providers would be willing to vaccinate their own patients, and many would vaccinate other community members in their practice.

CONCLUSIONS

Despite the low response rate, information from this study on the smallpox preparedness activities in which physicians are most willing to participate can help to inform efforts by public health officials and private physicians to collaborate on bioterrorism preparedness efforts.

Hospital Decision-Making Regarding the Smallpox Pre-Event Vaccination Program

OBJECTIVES

To understand the factors underlying the decision by U.S. hospitals to participate or not in the U.S. Smallpox Pre-Event Vaccination Program (SPVP).

METHODS

We conducted semistructured telephone interviews with a convenience sample of 123 hospital decision-makers in nine states between June and November 2003.

RESULTS

Within our sample, 88 hospitals (72%) decided to participate in the SPVP and 35 (28%) decided against doing so. Nearly all hospital decision-makers considered the risk of a smallpox outbreak, risks associated with vaccination, hospital costs, and the reaction of hospital stakeholders. However, these factors often were weighed differently by hospitals that decided to participate compared to those that did not. Fewer than half of all hospitals reported that public health officials played an important role in their decision-making process, but those that did felt the influence of public health officials was positive.

CONCLUSIONS

Strengthening the linkage between the public and private health sectors may help to address some of the barriers to broader participation by hospitals in the SPVP and foster the success of smallpox outbreak response preparedness efforts in the future.

Emergency department use among Michigan children with special health care needs: an introductory study

OBJECTIVE

To describe patterns of emergency department (ED) use among children dual-enrolled in Medicaid and Michigan's Children's Special Health Care Services (CSHCS).

DATA SOURCES

Individual claims and enrollment data from Michigan's Medicaid and CSHCS programs for the period January 1, 1998, to June 30, 1999. Claims data were linked with eligibility data and then used to develop a 100 percent sample of claims for individuals enrolled in both Medicaid and CSHCS.

STUDY DESIGN

Poisson regression analysis was used to examine the rate of ED use for dual-enrolled children. A time-varying hazard analysis was also used to examine the impact of changes over time. The key variables were gender, age, race, county of residence, Medicaid eligibility category, and qualifying diagnosis.

PRINCIPAL FINDINGS

Dual-enrolled children under one year of age, and those with qualifying diagnoses of anemia, hemophilia, asthma, epilepsy, and juvenile diabetes displayed especially high rates of ED use. Significant geographic variation in ED use remained after controlling for qualifying diagnoses, race/ethnicity, and other factors. African Americans displayed higher rates of ED utilization than non-Hispanic whites. Supplemental Security Income (SSI) recipients demonstrated higher utilization than other groups.

CONCLUSIONS

Children dually enrolled in CSHCS and Medicaid face diverse challenges of both poverty and chronic illness. Differences in patterns of use highlight the importance, but also the difficulty, of developing systems of care to manage complex chronic conditions in low-income populations.

Germination of spores of Bacillus subtilis with dodecylamine

AIMS

To determine the properties of Bacillus subtilis spores germinated with the alkylamine dodecylamine, and the mechanism of dodecylamine-induced spore germination.

METHODS AND RESULTS

Spores of B. subtilis prepared in liquid medium were germinated efficiently by dodecylamine, while spores prepared on solid medium germinated more poorly with this agent. Dodecylamine germination of spores was accompanied by release of almost all spore dipicolinic acid (DPA), degradation of the spore's peptidoglycan cortex, release of the spore's pool of free adenine nucleotides and the killing of the spores. The dodecylamine-germinated spores did not initiate metabolism, did not degrade their pool of small, acid-soluble spore proteins efficiently and had a significantly lower level of core water than did spores germinated by nutrients. As measured by DPA release, dodecylamine readily induced germination of B. subtilis spores that: (a) were decoated, (b) lacked all the receptors for nutrient germinants, (c) lacked both the lytic enzymes either of which is essential for cortex degradation, or (d) had a cortex that could not be attacked by the spore's cortex-lytic enzymes. The DNA in dodecylamine-germinated wild-type spores was readily stained, while the DNA in dodecylamine-germinated spores of strains that were incapable of spore cortex degradation was not. These latter germinated spores also did not release their pool of free adenine nucleotides.

CONCLUSIONS

These results indicate that: (a) the spore preparation method is very important in determining the rate of spore germination with dodecylamine, (b) wild-type spores germinated by dodecylamine progress only part way through the germination process, (c) dodecylamine may trigger spore germination by a novel mechanism involving the activation of neither the spore's nutrient germinant receptors nor the cortex-lytic enzymes, and (d) dodecylamine may trigger spore germination by directly or indirectly activating release of DPA from the spore core, through the opening of channels for DPA in the spore's inner membrane.

SIGNIFICANCE AND IMPACT OF THE STUDY

These results provide new insight into the mechanism of spore germination with the cationic surfactant dodecylamine, and also into the mechanism of spore germination in general. New knowledge of mechanisms to stimulate spore germination may have applied utility, as germinated spores are much more sensitive to processing treatments than are dormant spores.

Primary care pediatrician knowledge of nutritional rickets

OBJECTIVE

The purpose of this study is to determine primary care pediatricians' level of awareness in the diagnosis and management of rickets. The information will be useful in assessing the need for provider education related to appropriate advice regarding vitamin D supplementation for infants.

STUDY DESIGN

A one-page questionnaire was sent to a sample of 510 pediatricians in states surrounding the Great Lakes. These physicians were chosen depending based on practice listings from local telephone directories. Results were analyzed using the Chi-squared (chi2) test.

RESULTS

Of the 248 respondents, 43% (n = 105) had encountered at least one actual or suspected case of rickets in the past five years. Sixty-nine percent of respondents chose vitamin D deficiency rickets-specific diagnostic tests, 24% chose rickets-specific tests, and 7% chose tests that are not specific to diagnosing rickets. Ninety-four percent of respondents chose treatments specific to vitamin D deficiency rickets, while 6% chose treatments not specific to rickets.

CONCLUSION

Most primary care pediatricians from major metropolitan areas in the Great Lakes region are aware of the appropriate methods to diagnose and treat vitamin D-deficiency rickets. However, educational interventions are still necessary for both physicians and parents to promote widespread use of vitamin D supplementation in all breastfed infants.

Studies on the mechanism of killing of Bacillus subtilis spores by hydrogen peroxide

AIMS

To determine the mechanism of killing of Bacillus subtilis spores by hydrogen peroxide.

METHODS AND RESULTS

Killing of spores of B. subtilis with hydrogen peroxide caused no release of dipicolinic acid (DPA) and hydrogen peroxide-killed spores were not appreciably sensitized for DPA release upon a subsequent heat treatment. Hydrogen peroxide-killed spores appeared to initiate germination normally, released DPA and hydrolysed significant amounts of their cortex. However, the germinated killed spores did not swell, did not accumulate ATP or reduced flavin mononucleotide and the cores of these germinated spores were not accessible to nucleic acid stains.

CONCLUSIONS

These data indicate that treatment with hydrogen peroxide results in spores in which the core cannot swell properly during spore germination.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results provide further information on the mechanism of killing of spores of Bacillus species by hydrogen peroxide.

Mechanisms of killing spores of Bacillus subtilis by acid, alkali and ethanol

AIMS

To determine the mechanisms of killing of Bacillus subtilis spores by ethanol or strong acid or alkali.

METHODS AND RESULTS

Killing of B. subtilis spores by ethanol or strong acid or alkali was not through DNA damage and the spore coats did not protect spores against these agents. Spores treated with ethanol or acid released their dipicolinic acid (DPA) in parallel with spore killing and the core wet density of ethanol- or acid-killed spores fell to a value close to that for untreated spores lacking DPA. The core regions of spores killed by these two agents were stained by nucleic acid stains that do not penetrate into the core of untreated spores and acid-killed spores appeared to have ruptured. Spores killed by these two agents also did not germinate in nutrient and non-nutrient germinants and were not recovered by lysozyme treatment. Spores killed by alkali did not lose their DPA, did not exhibit a decrease in their core wet density and their cores were not stained by nucleic acid stains. Alkali-killed spores released their DPA upon initiation of spore germination, but did not initiate metabolism and degraded their cortex very poorly. However, spores apparently killed by alkali were recovered by lysozyme treatment.

CONCLUSIONS

The data suggest that spore killing by ethanol and strong acid involves the disruption of a spore permeability barrier, while spore killing by strong alkali is due to the inactivation of spore cortex lytic enzymes.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results provide further information on the mechanisms of spore killing by various chemicals.

Guinea pig fertilin exhibits restricted lateral mobility in epididymal sperm and becomes freely diffusing during capacitation

The guinea pig sperm protein fertilin functions in sperm-egg plasma membrane binding. Fertilin is initially present in the plasma membrane of the whole head in testicular sperm, then becomes concentrated into the posterior head domain during epididymal passage. Fertilin remains localized to the posterior head plasma membrane following the acrosome reaction, when it functions in sperm-egg interaction. Fluorescence redistribution after photobleaching was used to examine the lateral mobility of fertilin in both acrosome-intact and acrosome-reacted sperm. Fertilin exhibited highly restricted lateral mobility in both testicular and epididymal sperm (D < 10(-10) cm(2)/s). However, fertilin in acrosome-reacted sperm was highly mobile within the membrane bilayer (D = 1.8 x 10(-9) cm(2)/s and %R = 84). Measurement of the lateral mobility of fertilin in capacitated, acrosome-intact sperm revealed two populations of cells. In approximately one-half of the cells, lateral mobility of fertilin was similar to sperm freshly isolated from the cauda epididymis; while in the other half fertilin was highly mobile. The release of fertilin from interactions that restrict its lateral mobility may regulate its function in sperm-egg interaction.

State-level perspectives on immunization policies, practices, and program financing in the 1990s

This article reports on a series of structured interviews with immunization program officials in all 50 states regarding the effects of changes in federal policies and funding in the 1990s on the goals, priorities, and activities of state immunization programs. The purchase of vaccines is a major component of all state immunization programs. The Vaccines for Children (VFC) program, implemented in 1994, has become the primary source of vaccine purchase support in almost all states. A concern of many state immunization programs is their ability to ensure that vaccines are available to children who are not VFC eligible.State immunization programs also are involved in a myriad of activities necessary to ensure that children are adequately and appropriately immunized (e.g. , vaccine administration, outreach to parents). Federal funding to support these activities increased significantly during the mid-1990s, but was substantially reduced beginning in 1997. Because of these funding decreases, most states had to reduce the scale and scope of their immunization activities.State-level funding support for immunization programs varies, with state governments more likely to support vaccine purchase than immunization activities. Immunization will never be completed. Along with each new birth cohort, changes to the primary immunization schedule (i.e., addition of new vaccines and expansion of existing recommendations to encompass broader target groups) create ongoing needs for vaccine purchase and other immunization activities. Long-term immunization planning must reflect these continually expanding needs.

Analysis of nucleoid morphology during germination and outgrowth of spores of Bacillus species

After a few minutes of germination, nucleoids in the great majority of spores of Bacillus subtilis and Bacillus megaterium were ring shaped. The major spore DNA binding proteins, the alpha/beta-type small, acid-soluble proteins (SASP), colocalized to these nucleoid rings early in spore germination, as did the B. megaterium homolog of the major B. subtilis chromosomal protein HBsu. The percentage of ring-shaped nucleoids was decreased in germinated spores with lower levels of alpha/beta-type SASP. As spore outgrowth proceeded, the ring-shaped nucleoids disappeared and the nucleoid became more compact. This change took place after degradation of most of the spores' pool of major alpha/beta-type SASP and was delayed when alpha/beta-type SASP degradation was delayed. Later in spore outgrowth, the shape of the nucleoid reverted to the diffuse lobular shape seen in growing cells.

Barriers to diffusion of plasma membrane proteins form early during guinea pig spermiogenesis

The plasma membrane of the mature guinea pig sperm is segregated into at least four domains of different composition. Previous studies have shown that some proteins localized within these domains are free to diffuse laterally, suggesting that barriers to protein diffusion are responsible for maintaining the nonuniform distribution of at least some surface proteins in mature sperm. The different membrane domains appear sequentially during sperm morphogenesis in the testis and during later passage through the epididymis. To determine when diffusion barriers become functional during sperm development, we examined the diffusion of two proteins that are expressed on the cell surface of developing spermatids and become segregated to different plasma membrane domains during the course of spermiogenesis. Both proteins exhibited rapid lateral diffusion throughout spermiogenesis, even after they become localized to specific regions of the surface membrane. These results suggest that barriers to membrane diffusion form concomitantly with membrane domains during spermiogenesis.

Analysis of the relationship between the decrease in pH and accumulation of 3-phosphoglyceric acid in developing forespores of Bacillus species

Analysis of the pH decrease and 3-phosphoglyceric acid (3PGA) accumulation in the forespore compartment of sporulating cells of Bacillus subtilis showed that the pH decrease of 1 to 1.2 units at approximately 4 h of sporulation preceded 3PGA accumulation, as observed previously in B. megaterium. These data, as well as analysis of the forespore pH decrease in asporogenous mutants of B. subtilis, indicated that sigma G-dependent forespore transcription, but not sigma K-dependent mother cell transcription, is required for the forespore pH decrease. Further analysis of these asporogenous mutants showed an excellent correlation between the forespore pH decrease and the forespore's accumulation of 3PGA. These latter results are consistent with our previous suggestion that the decrease in forespore pH results in greatly decreased activity of phosphoglycerate mutase in the forespore, which in turn leads to 3PGA accumulation. In further support of this suggestion, we found that (i) elevating the pH of developing forespores of B. megaterium resulted in rapid utilization of the forespore's 3PGA depot and (ii) increasing forespore levels of PGM approximately 10-fold in B. subtilis resulted in a large decrease in the spore's depot of 3PGA. The B. subtilis strain with a high phosphoglycerate mutase level sporulated, and the spores germinated and went through outgrowth normally, indicating that forespore accumulation of a large 3PGA depot is not essential for these processes.