Real-world effectiveness of recombinant zoster vaccine in self-identified Chinese individuals aged ≥50 years in the United States

We evaluated the vaccine effectiveness (VE) of two doses of recombinant zoster vaccine (RZV) against herpes zoster (HZ) and postherpetic neuralgia (PHN) in Chinese adults at Kaiser Permanente Southern California (KPSC). Chinese KPSC members were identified based on self-reported ethnicity or self-reported preferred spoken/written language. Those aged ≥50 years who received two doses of RZV 4 weeks to ≤ 6 months apart were matched 1:4 to RZV unvaccinated Chinese members and followed through June 2022; second doses were accrued 6/1/2018-12/31/2020. We estimated incidence and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) comparing outcomes (HZ and PHN). Adjusted VE (%) was calculated as (1-aHR)×100. 3978 RZV vaccinated Chinese members were matched to 15,912 RZV unvaccinated Chinese members. The incidence per 1000 person-years (95% CI) of HZ in the vaccinated group was 1.5 (0.9-2.5) and 10.9 (9.8-12.1) in the unvaccinated group; aHR (95% CI) was 0.12 (0.07-0.21). Adjusted VE (95% CI) was 87.6% (78.9-92.7) against HZ. We identified 0 PHN cases in the vaccinated group and 19 in the unvaccinated group. Among Chinese adults aged ≥50 years, two doses of RZV provided substantial protection against HZ and PHN supporting the real-world effectiveness of the vaccine in this population.

ChatGPT is an Unreliable Tool for Reviewing Radiation Oncology Literature

PURPOSE/OBJECTIVE(S)

To assess whether ChatGPT, a popular deep learning text generation tool, can serve as a resource for in-training and practicing clinicians by accurately identifying and summarizing studies related to radiation oncology.

MATERIALS/METHODS

Three question templates (Q1-Q3, shown in Table 1) were applied to eight cancer types to compile 24 questions posed to ChatGPT. Cancer types were designated as either common (breast, non-small cell lung, prostate, p16 positive oropharyngeal, and rectal) or uncommon (hypopharyngeal, medulloblastoma, and vulvar). ChatGPT's responses to each question were then reviewed to quantify the number of studies referenced in the response, the percentage of studies listed that were real studies, and the percentage of studies listed that were correctly summarized. Outcomes were compared between cancer types (common vs uncommon) and question types using Wilcoxon rank sum tests. As a secondary analysis, we assessed internal consistency of ChatGPT's responses by querying ChatGPT with three identical iterations of Q1-Q3 for breast cancer and comparing its responses between iterations.

RESULTS

Across all 24 of ChatGPT's responses, there were 78 studies referenced, of which 37 (47.4%) were real studies and 7 (9.0%) were correctly summarized. On average, each response included 3.25 (standard deviation (SD): 0.74) studies, of which 44.0% (SD: 44.2%) were real studies and 7.8% (SD: 14.6%) were correctly summarized. The proportion of correctly summarized studies was not significantly different between common vs uncommon cancers [p = 0.29], between questions that specified randomized-control trials (Q3) vs not (Q1 or Q2) [p = 0.94], or between questions that specified intensity modulated radiotherapy (Q2) vs not (Q1 or Q3) [p = 0.31]. Across the three iterations of ChatGPT queries for breast cancer, the number of studies listed for Q1, Q2, and Q3 ranged from 3 to 5, 2 to 3, and 3 to 5, respectively; the number of correctly summarized studies listed for each question ranged from 0 to 2, 0 to 1, and 0 to 1, respectively.

CONCLUSION

ChatGPT's responses consistently included a large proportion of non-existent and incorrectly summarized studies. Furthermore, our secondary analysis suggests variability in the content and accuracy of ChatGPT responses to identical questions, raising further concerns regarding reliability. Overall, our findings argue against the use of ChatGPT as a tool for reviewing literature related to radiation oncology.

Evaluating the Reliability of Chat-GPT Model Responses for Radiation Oncology Patient Inquiries

PURPOSE/OBJECTIVE(S)

To determine if ChatGPT, a popular deep learning text generation tool, accurately and comprehensively answers patient questions related to radiation oncology.

MATERIALS/METHODS

A total of 28 common patient-centered questions were selected across various radiation oncology content domains, including diagnosis (4), workup (3), treatment (8), toxicity (4), and survivorship (9). To assess whether ChatGPT could detect inaccurate assumptions and/or respond negatively, we included two "negative control" questions in the treatment and toxicity domains. All questions were applied to common cancer types (breast, non-small cell lung, prostate, p16+ oropharyngeal, and rectal), uncommon cancer types (hypopharyngeal, medulloblastoma, and vulvar), and colon cancer as an additional "negative control." The ChatGPT responses were graded as 0 for any incorrect information, 1 for missing essential content, and 2 for correct and appropriately comprehensive for the length of the response. Each response was graded by two blinded MD reviewers, with discordant answers resolved by a third MD reviewer. Score distribution was compared across content domains, question type ("negative control" vs other), cancer type, and cancer commonality using the Chi-squared test.

RESULTS

Overall, a total of 252 questions were submitted to ChatGPT. A total of 86 (34.1%) answers were found to contain inaccurate information, 66 (26.2%) contained correct information but were found to be missing essential context, and 100 (39.7%) responses to questions were graded as correct and comprehensive. There was no significant difference in response score by question domains (p = 0.07). However, there was significant difference in response score across cancer type (p<0.001). The top scoring cancer types were breast (grade 0 = 10%; grade 1 = 21%, grade 2 = 68%) and prostate (grade 0 = 18%, grade 1 = 25%, grade 2 = 57%), while the two lowest scoring cancer types were colon (grade 0 = 61%, grade 1 = 21%, grade 2 = 18%) and vulvar (grade 0 = 50%, grade 1 = 25%, grade 2 = 25%). ChatGPT responses were also significantly different among common, uncommon and negative control questions, with the model performing best with responses to common cancer types (p = 0.003). ChatGPT performed significantly worse when responding to "negative control" questions (p<0.001).

CONCLUSION

ChatGPT failed to consistently generate accurate and comprehensive responses to the majority of radiation oncology patient centered questions, particularly across less common cancers and with "negative control" questions that included incorrect assumptions. This raises concern for the possible ChatGPT mediated reinforcement of patient misperceptions regarding radiotherapy.

Timely Prenatal and Infant Pertussis Vaccine Uptake in an Integrated Health System

BACKGROUND

Hispanic infants bear the burden of pertussis infection. We examined pertussis protection from vaccination in infants with US-born and foreign-born Hispanic mothers.

METHODS

Retrospective cohort study of infants up to 1 year of age. Secondary data of mothers with continuous membership since the 27th week of pregnancy with infants born 1/1/2012-12/31/2017 in an integrated health care delivery organization, which broadly represent the Southern California population.

RESULTS

Foreign-born Hispanic mothers had higher prenatal tetanus, diphtheria, acellular pertussis (Tdap) uptake compared to US-born white mothers [adjusted risk ratio (aRR): 1.04, 95% confidence interval (CI): 1.03, 1.05]. Infants with mothers on Medicaid insurance disproportionately did not enroll in the health plan by the time they were eligible for their first dose of the DTaP vaccine (68.4%). Once initiating the infant vaccine series, foreign-born Hispanic mothers more likely adhered than US-born white mothers (aRR: 1.05, CI: 1.02, 1.08).

DISCUSSION

In an integrated health system, disparities in vaccine uptake can be minimized. Infants who are born to mothers with Medicaid insurance and are not enrolled in the health plan after birth may be under-protected from pertussis.

Post-licensure safety study of new-onset immune-mediated diseases, herpes zoster, and anaphylaxis in adult recipients of HepB-CpG vaccine versus HepB-alum vaccine

BACKGROUND

HepB-CpG (Heplisav-B) is a licensed hepatitis B vaccine with a novel adjuvant that requires 2 doses (0, 1 month) compared to HepB-alum (Engerix-B) which requires 3 doses (0, 1, 6 months). Monitoring safety outcomes following receipt of vaccines with novel adjuvants outside trial settings is important. Hence, as part of a post-marketing commitment, we compared the incidence of new-onset immune-mediated diseases, herpes zoster (HZ), and anaphylaxis among recipients of HepB-CpG versus HepB-alum.

METHODS

This cohort study included adults not on dialysis who received ≥1 dose of hepatitis B vaccine from 8/7/2018 to 10/31/2019, during which HepB-CpG was routinely administered in 7 of 15 Kaiser Permanente Southern California medical centers while HepB-alum was administered in the other 8 centers. Recipients of HepB-CpG or HepB-alum were followed through electronic health records for 13 months for occurrence of pre-specified new-onset immune-mediated diseases, HZ, and anaphylaxis identified using diagnosis codes. Incidence rates were compared using Poisson regression with inverse probability of treatment weighting when there was ≥80 % power to detect a relative risk (RR) of 5 for anaphylaxis and RR of 3 for other outcomes. Chart review to confirm new-onset diagnosis was conducted for outcomes with statistically significant elevated risk.

RESULTS

There were 31,183 HepB-CpG and 38,442 HepB-alum recipients (overall 49.0 % female, 48.5 % age ≥50 years, and 49.6 % Hispanic). Among immune-mediated events that occurred frequently enough for formal comparison, rates among HepB-CpG versus Hep-B-alum recipients were similar except for rheumatoid arthritis (RA) (adjusted RR 1.53 [95 % CI: 1.07, 2.18]). After chart confirmation of new-onset RA, the adjusted RR was 0.93 (0.34, 2.49). The adjusted RR for HZ was 1.06 (0.89, 1.27). Anaphylaxis occurred in 0 HepB-CpG and 2 HepB-alum recipients.

CONCLUSIONS

This large post-licensure study did not identify evidence of safety concerns for HepB-CpG compared to HepB-alum for immune-mediated diseases, HZ, or anaphylaxis.

784. Real-world effectiveness of the mRNA-12733-dose primary series against COVID-19 in an immunocompromised population Interim results from a prospective observational cohort study

Background

While a 3-dose mRNA-1273 primary series is recommended for moderately or severely immunocompromised (IC) individuals in the U.S., some IC individuals do not complete the 3-dose series. We conducted a matched cohort study to evaluate the relative vaccine effectiveness (rVE) of the 3-dose mRNA-1273 primary series vs. 2 doses of mRNA-1273 in preventing SARS-CoV-2 infection and severe COVID-19 disease in IC individuals.

Methods

IC individuals aged ≥18 years with ≥12 months of Kaiser Permanente Southern California membership who received 3 doses of mRNA-1273 ≥24 days apart were 1:1 matched with randomly selected IC 2-dose recipients on age, sex, race/ethnicity, and 2^nd dose date. Third doses were accrued from 08/12/2021 to 12/31/2021, with follow-up through 1/31/2022, spanning the delta and omicron periods. Outcomes were SARS-CoV-2 infection (positive molecular test or diagnosis code), COVID-19 hospitalization, and COVID-19 hospital death. Adjusted hazard ratios (aHR) with confidence intervals (CI) were estimated by Cox proportional hazards models. Adjusted rVE (%) was calculated as (1-aHR) x 100.

Results

Our study included 21,942 3-dose and 21,942 2-dose mRNA-1273 IC recipients. Adjusted rVE of 3 doses compared to 2 doses of mRNA-1273 against SARS-CoV-2 infection, COVID-19 hospitalization, and COVID-19 hospital death were 55.0% (95% CI: 50.8–58.9%), 83.0% (75.4–88.3%), and 87.1% (30.6–97.6%), respectively (Table 1). Adjusted rVE against SARS-CoV-2 infection ranged from 43.0% to 59.1% across subgroups of age, sex, race/ethnicity, history of SARS-CoV-2 infection, pregnancy, and comorbidities (Table 2). Point estimates of the 3-dose rVE were higher against COVID-19 infection and hospitalization in the first 3 months, compared to 3–6 months after the 3^rd dose (Table 3).

Conclusion

Three doses of mRNA-1273 provide additional protection against SARS-CoV-2 infection and severe outcomes for IC individuals, compared to 2 doses, highlighting the importance of completing 3-doses for IC populations. However, possible waning of protection against SARS-CoV-2 infection and severe outcomes after 3 months supports the ACIP recommendation of a booster dose at least 3 months after the 3^rd primary series dose for adequate protection of IC individuals.

Disclosures

Jennifer H. Ku, PhD MPH, GSK: Grant/Research Support|Moderna: Grant/Research Support Lina S. Sy, MPH, Dynavax: Grant/Research Support|Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support|Seqirus: Grant/Research Support Lei Qian, PhD, Dynavax: Grant/Research Support|Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support Bradley Ackerson, MD, Dynavax: Grant/Research Support|Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support|Seqirus: Grant/Research Support Yi Luo, PhD, Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support|Seqirus: Grant/Research Support Julia Tubert, MPH, Moderna: Grant/Research Support|Pfizer: Grant/Research Support Gina Lee, MPH, Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support Ana Florea, PhD MPH, Gilead: Grant/Research Support|GSK: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support Carla Talarico, PhD, Moderna: Employee of and a shareholder in Moderna Inc. Sijia Qiu, MS, Dynavax: Grant/Research Support|Moderna: Grant/Research Support Yun Tian, MS, Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support Hung Fu Tseng, PhD MPH, GSK: Grant/Research Support|Janssen: Advisor/Consultant|Moderna: Grant/Research Support|Pfizer: Advisor/Consultant|Seqirus: Grant/Research Support.

115. Post-licensure Safety Study of New-onset Immune-mediated Diseases, Herpes Zoster, and Anaphylaxis in Adult Recipients of HepB-CPG Vaccine Versus HepB-alum Vaccine

Background

HepB-CpG (Heplisav-B; Dynavax) is a licensed hepatitis B vaccine with a novel adjuvant that requires only 2 doses (0, 1 month) compared to a 3-dose (0, 1, 6 months) HepB-alum vaccine (Engerix-B; GlaxoSmithKline). Monitoring of safety outcomes following receipt of vaccines with novel adjuvants is important. Hence, as part of an FDA postmarketing commitment, we compared the incidence of new-onset immune-mediated diseases, herpes zoster (HZ), and anaphylaxis among recipients of HepB-CpG versus HepB-alum at Kaiser Permanente Southern California (KPSC).

Methods

This cohort study included adults not on dialysis who received ≥1 dose of a hepatitis B vaccine from 8/7/2018 to 10/31/2019, during which HepB-CpG was routinely administered in 7 of 15 KPSC medical centers while HepB-alum was administered at the other 8 medical centers. Recipients of HepB-CpG or HepB-alum were followed through electronic health records for 13 months after receipt of the first dose during the vaccine accrual period for occurrence of pre-specified new-onset immune-mediated diseases, HZ, and anaphylaxis identified using diagnosis codes. Incidence rates were compared using Poisson regression with inverse probability of treatment weighting when there was 80% power to detect a relative risk (RR) of 5 for anaphylaxis and a RR of 3 for all other outcomes

Results

There were 31,183 HepB-CpG and 38,442 HepB-alum recipients (overall 49.0% female, 48.5% ≥50 years of age, and 49.6% Hispanic). Among immune-mediated events that occurred frequently enough for formal comparison, rates among HepB-CpG versus Hep-B-alum recipients were similar except for rheumatoid arthritis (RA) (adjusted RR 1.53 [95% CI: 1.07, 2.18]). (Table 1) After adjudication of new-onset RA, the adjusted RR was 0.93 (0.34, 2.49). (Table 2) The adjusted RR for HZ was 1.06 (0.89, 1.27). Anaphylaxis occurred in 0 HepB-CpG and 2 HepB-alum recipients.

Conclusion

These data suggest no safety concerns for HepB-CpG compared to HepB-alum for select immune-mediated diseases, HZ, or anaphylaxis in this observational study of over 69,000 recipients of hepatitis B vaccines.

Disclosures

Bradley Ackerson, MD, Dynavax: Grant/Research Support|Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support|Seqirus: Grant/Research Support Lina S. Sy, MPH, Dynavax: Grant/Research Support|Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support|Seqirus: Grant/Research Support Jeff Slezak, MS, ALK, Inc.: Grant/Research Support|Dynavax: Grant/Research Support|Novavax, Inc.: Grant/Research Support|Pfizer, Inc.: Grant/Research Support Lei Qian, PhD, Dynavax: Grant/Research Support|Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support Kristi Reynolds, PhD, Amgen: Grant/Research Support|Dynavax: Grant/Research Support|Merck: Grant/Research Support|Novartis: Grant/Research Support Runxin Huang, MS, Dynavax: Grant/Research Support Zendi Solano, BS, Dynavax: Grant/Research Support|Gilead: Grant/Research Support|GlaxoSmithKline: Grant/Research Support William Towner, MD, Dynavax: Grant/Research Support|Gilead: Grant/Research Support|Merck: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support|ViiV: Grant/Research Support Sijia Qiu, MS, Dynavax: Grant/Research Support|Moderna: Grant/Research Support Sarah Simmons, MPH, Dynavax: Grant/Research Support|Glaxo-Smith Kline: Grant/Research Support|Pfizer: Grant/Research Support Steven Jacobsen, MD, Dynavax: Grant/Research Support Katia J. Bruxvoort, PhD, MPH, Dynavax: Grant/Research Support|Gilead: Grant/Research Support|Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support|Seqirus: Grant/Research Support.

Association Between 2-Dose vs 3-Dose Hepatitis B Vaccine and Acute Myocardial Infarction

IMPORTANCE

The 2-dose hepatitis B vaccine with a cytosine phosphoguanine adjuvant (HepB-CpG vaccine; Heplisav-B) generated higher seroprotection in prelicensure trials than did a 3-dose hepatitis B vaccine with an aluminum hydroxide adjuvant (HepB-alum vaccine; Engerix-B). However, in 1 trial, a higher number of acute myocardial infarction (MI) events were observed among those who received the HepB-CpG vaccine than among those who received the HepB-alum vaccine, an outcome requiring further study.

OBJECTIVE

To compare the rate of acute MI between recipients of HepB-CpG vaccine and HepB-alum vaccine.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort noninferiority study was conducted at Kaiser Permanente Southern California (KPSC), an integrated health care system with 15 medical centers and approximately 4.7 million members. The study included 69 625 adults not undergoing dialysis who received at least 1 dose of a hepatitis B vaccine in either family medicine or internal medicine departments at KPSC from August 7, 2018, to October 31, 2019 (November 30, 2020, final follow-up).

EXPOSURES

Receipt of HepB-CpG vaccine vs HepB-alum vaccine. The first dose during the study period was the index dose.

MAIN OUTCOMES AND MEASURES

Individuals were followed up for 13 months after the index dose for occurrence of type 1 acute MI. Potential events were identified using diagnosis codes and adjudicated by cardiologists. The adjusted hazard ratio (HR) of acute MI was estimated comparing recipients of HepB-CpG vaccine with recipients of HepB-alum vaccine, with inverse probability of treatment weighting (IPTW) to adjust for demographic and clinical characteristics. The upper limit of the 1-sided 97.5% CI was compared with a noninferiority margin of 2.

RESULTS

Of the 31 183 recipients of HepB-CpG vaccine (median age, 49 years; IQR, 38-56 years), 51.2% (n = 15 965) were men, and 52.7% (n = 16 423) were Hispanic. Of the 38 442 recipients of HepB-alum (median age, 49 years; IQR, 39-56 years), 50.8% (19 533) were men, and 47.1% (n = 18 125) were Hispanic. Characteristics were well-balanced between vaccine groups after IPTW. Fifty-two type 1 acute MI events were confirmed among recipients of HepB-CpG vaccine for a rate of 1.67 per 1000-person-years, and 71 type 1 acute MI events were confirmed among recipients of HepB-alum vaccine for a rate of 1.86 per 1000 person-years (absolute rate difference, -0.19 [95% CI, -0.82 to 0.44]; adjusted HR, 0.92 [1-sided 97.5% CI, ∞ to 1.32], which was below the noninferiority margin; P < .001 for noninferiority).

CONCLUSIONS AND RELEVANCE

In this cohort study, receipt of HepB-CpG vaccine compared with HepB-alum vaccine did not meet the statistical criterion for increased risk of acute myocardial infarction.

Herpes Zoster Following Recombinant Zoster Vaccine With or Without Concomitant Vaccination

Background

The 2-dose recombinant zoster vaccine (RZV) series is recommended for prevention of herpes zoster (HZ) in adults aged ≥50 years, but data are limited on the impact of concomitant administration with other vaccines on subsequent HZ risk.

Methods

This cohort study included Kaiser Permanente Southern California members aged ≥50 years who received 2 doses of RZV 4 weeks to ≤6 months apart during 1 April 2018–30 September 2019. RZV recipients with and without same-day concomitant vaccination for either RZV dose were followed up for incident HZ beginning 31 days after the second RZV dose until 30 September 2020. The hazard ratio (HR) for HZ comparing RZV recipients with and without concomitant vaccination was estimated using Cox proportional hazards regression, adjusting for confounders.

Results

RZV with and without concomitant vaccination was received by 12 898 and 28 353 individuals, respectively. HZ occurred among 41 individuals with concomitant vaccination (incidence rate, 2.2 [95% confidence interval {CI}, 1.6–3.0] per 1000 person-years) and 136 without concomitant vaccination (3.4 [95% CI, 2.9–4.0] per 1000 person-years). The adjusted HR for HZ comparing RZV recipients with and without concomitant vaccination was 0.75 (95% CI, .53–1.08).

Conclusions

HZ risk was not significantly different between RZV recipients with and without concomitant vaccination, supporting recommendations allowing for concomitant administration of RZV with other vaccines.

Recombinant Adjuvanted Zoster Vaccine and Reduced Risk of Coronavirus Disease 2019 Diagnosis and Hospitalization in Older Adults

BACKGROUND

Some vaccines elicit nonspecific immune responses that may protect against heterologous infections. We evaluated the association between recombinant adjuvanted zoster vaccine (RZV) and coronavirus disease 2019 (COVID-19) outcomes at Kaiser Permanente Southern California.

METHODS

In a cohort design, adults aged ≥50 years who received ≥1 RZV dose before 1 March 2020 were matched 1:2 to unvaccinated individuals and followed until 31 December 2020. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for COVID-19 outcomes were estimated using Cox proportional hazards regression. In a test-negative design, cases had a positive severe acute respiratory syndrome coronavirus 2 test and controls had only negative tests, during 1 March-31 December 2020. Adjusted odds ratios (aORs) and 95% CIs for RZV receipt were estimated using logistic regression.

RESULTS

In the cohort design, 149 244 RZV recipients were matched to 298 488 unvaccinated individuals. The aHRs for COVID-19 diagnosis and hospitalization were 0.84 (95% CI, .81-.87) and 0.68 (95% CI, .64-.74), respectively. In the test-negative design, 8.4% of 75 726 test-positive cases and 13.1% of 340 898 test-negative controls had received ≥1 RZV dose (aOR, 0.84 [95% CI, .81-.86]).

CONCLUSIONS

RZV vaccination was associated with a 16% lower risk of COVID-19 diagnosis and 32% lower risk of hospitalization. Further study of vaccine-induced nonspecific immunity for potential attenuation of future pandemics is warranted.

Rate and severity of suspected SARS-Cov2 reinfection in a cohort of PCR-positive COVID-19 patients

Objectives

To estimate the burden and severity of suspected reinfection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Methods

A retrospective cohort of members of Kaiser Permanente Southern California with PCR-positive SARS-CoV-2 infection between 1st March 2020 and 31st October 2020 was followed through electronic health records for subsequent positive SARS-CoV-2 tests (suspected reinfection) ≥90 days after initial infection, through 31st January 2021. Incidence of suspected reinfection was estimated using the Kaplan–Meier method. Cox proportional hazards models estimated the association of suspected reinfection with demographic and clinical characteristics, hospitalization, and date of initial infection.

Results

The cohort of 75 149 was predominantly Hispanic (49 648/75 149, 66.1%) and included slightly more females than males (39 736, 52.9%), with few immunocompromised patients (953, 1.3%); 315 suspected reinfections were identified, with a cumulative incidence at 270 days of 0.8% (95% confidence interval (CI) 0.7–1.0%). Hospitalization was more common at suspected reinfection (36/315, 11.4%) than initial infection (4094/75 149, 5.4%). Suspected reinfection rates were higher in females (1.0%, CI 0.8–1.2% versus 0.7%, CI 0.5–0.9%, p 0.002) and immunocompromised patients (2.1%, CI 1.0–4.2% versus 0.8%, CI 0.7–1.0%, p 0.004), and lower in children than adults (0.2%, CI 0.1–0.4% versus 0.9%, CI 0.7–1.0%, p 0.023). Patients hospitalized at initial infection were more likely to have suspected reinfection (1.2%, CI 0.6–1.7% versus 0.8%, CI 0.7–1.0%, p 0.030), as were those with initial infections later in 2020 (150-day incidence 0.4%, CI 0.2–0.5% September–October versus 0.2%, CI 0.1–0.3% March–May and 0.3%, CI 0.2–0.3% June–August, p 0.008). In an adjusted Cox proportional hazards model, being female (hazard ratio (HR) 1.44, CI 1.14–1.81), adult (age 18–39, HR 2.71, CI 1.38–5.31, age 40–59 HR 2.22, CI 1.12–4.41, age ≥60 HR 2.52, CI 1.23–5.17 versus <18 years), immunocompromised (HR 2.48, CI 1.31–4.68), hospitalized (HR 1.60, CI 1.07–2.38), and initially infected later in 2020 (HR 2.26, CI 1.38–3.71 September–October versus March–May) were significant independent predictors of suspected reinfection.

Conclusions

Reinfection with SARS-CoV-2 is uncommon, with suspected reinfections more likely in women, adults, immunocompromised subjects, and those previously hospitalized for coronavirus 2019 (COVID-19). This suggests a need for continued precautions and vaccination in patients with COVID-19 to prevent reinfection.

Cost of Hospitalization Associated With Respiratory Syncytial Virus Infection Versus Influenza Infection in Hospitalized Older Adults

Despite the severity of respiratory syncytial virus (RSV) disease in older adults, data on its costs are limited. We compared hospitalization costs for 2090 adults aged ≥ 60 years hospitalized with RSV or influenza by assigning direct health care costs. Hospitalization with RSV was associated with longer hospitalization and increased frequency of diagnosis-related groups for pulmonary complications, resulting in costs at least as great as those for influenza ($16 034 vs $15 163; 95% confidence interval for the difference, -$811 to $2547). Awareness of RSV disease burden in adults is needed to facilitate vaccination and treatment when they become available.

Severe Morbidity and Short- and Mid- to Long-term Mortality in Older Adults Hospitalized with Respiratory Syncytial Virus Infection

BACKGROUND

We describe the clinical epidemiology and outcomes among a large cohort of older adults hospitalized with respiratory syncytial virus (RSV) infection in the United States.

METHODS

Hospitalized adults aged ≥60 years who tested positive for RSV between 1 January 2011 and 30 June 2015 were identified from Kaiser Permanente Southern California. Patient-level demographics, comorbidities, clinical presentation, utilization, complications, and mortality were evaluated.

RESULTS

There were 664 patients hospitalized with RSV (61% female, 64% aged ≥75 years). Baseline chronic diseases were prevalent (all >30%); 66% developed pneumonia, 80% of which were radiographically confirmed. Very severe tachypnea (≥26 breaths/minute) was common (56%); 21% required ventilator support and 18% were admitted to intensive care unit. Mortality during hospitalization was 5.6% overall (4.6% in 60-74 year olds and 6.1% in ≥75 year olds). Cumulative mortality within 1, 3, 6, and 12 months of admission was 8.6%, 12.3%, 17.2%, and 25.8%, respectively.

CONCLUSION

RSV infection in hospitalized older adults often manifested as severe, life-threatening lower respiratory tract illness with high rates of pneumonia, requirement for ventilatory support, and short- and long-term mortality. Increased recognition of the substantial RSV disease burden in adults will be important in evaluation and use of urgently needed interventions.

The Epidemiology of Herpes Zoster in Immunocompetent, Unvaccinated Adults ≥50 Years Old: Incidence, Complications, Hospitalization, Mortality, and Recurrence

Background

Data on the epidemiology of herpes zoster (HZ), particularly in the unvaccinated immunocompetent population, are needed to assess disease burden and the potential impact of vaccination.

Methods

The study at a large health care organization comprised: (1) incidence estimated from immunocompetent adults aged ≥50 years unvaccinated with zoster vaccine live who had incident HZ in 2011–2015; (2) proportion of HZ-related nonpain complications assessed by double abstraction of electronic health records (EHRs) of 600 incident patients 2011–2015; (3) HZ-related hospitalizations among HZ patients diagnosed in 2015; (4) HZ-related death determined from automated data and EHRs; and (5) recurrent HZ identified from a cohort initially diagnosed with HZ in 2007–2008 and followed through 2016.

Results

HZ incidence rate was 9.92/1000 person-years (95% confidence interval [CI], 9.82–10.01). Proportions of cutaneous, neurologic, and other complications were 6.40% (95% CI,1.73%–11.07%), 0.77% (95% CI, .00%–2.36%), and 1.01% (95% CI, .00%–2.93%), respectively. Only 0.86% of patients had an HZ-related hospitalization. The case-fatality rate was 0.04%. Recurrence rate was 10.96/1000 person-years (95% CI, 10.18–11.79) with 10-year recurrence risk of 10.26% (95% CI, 9.36%–11.23%).

Conclusions

These recent HZ epidemiology data among an immunocompetent, unvaccinated population measure real-world disease burden.

Completion of the two-dose recombinant zoster vaccine series in adults 50 years and older

BACKGROUND

In 2017, a new adjuvanted recombinant zoster vaccine (RZV) was recommended for adults ≥50 years as two-dose series 2-6 months apart. We evaluated two-dose RZV completion and factors associated with completion.

METHODS

The study included Kaiser Permanente Southern California members ≥50 years who received an RZV dose during April-November 2018 and had continuous membership 12 months before to 9 months after the first RZV dose. Completion was defined as receipt of the second dose ≥4 weeks to 9 months after the first dose (allowing 3-month grace period). Characteristics including age, sex, race/ethnicity, Medicaid status, neighborhood level income and education, comorbidities, history of zoster, health care utilization before and after the first dose, receipt of influenza vaccine, vaccination month (supply shortage proxy), concomitant vaccine, medical center, and medically attended reactions, pain, or gout after the first dose were compared between completers and non-completers. Adjusted odds ratios and 95% confidence intervals for factors associated with completion were estimated by multivariable logistic regression.

RESULTS

Among 31,120 first dose recipients, 67.2% completed the series within 9 months. In adjusted analyses, higher completion was associated with White compared with Black or Hispanic race/ethnicity, higher neighborhood income and education, no chronic pulmonary disease, diabetes, or dementia, more outpatient visits and fewer emergency department visits before or after the first dose, no hospitalizations after the first dose, receipt of influenza vaccine, receipt of the first dose in June-November rather than April-May 2018, and no concomitant vaccine with the first dose. Systemic reactions or pain after the first dose was not associated with completion.

CONCLUSION

Completion of RZV series appears suboptimal in the early phase of implementation. Despite similar accessibility in a health care system, completion varied by race/ethnicity, socioeconomic status, health status, and care seeking behavior, suggesting areas to target for improvement.

Text-Based Identification of Herpes Zoster Ophthalmicus With Ocular Involvement in the Electronic Health Record: A Population-Based Study

Background

Diagnosis codes are inadequate for accurately identifying herpes zoster ophthalmicus (HZO). Manual review of medical records is expensive and time-consuming, resulting in a lack of population-based data on HZO.

Methods

We conducted a retrospective cohort study, including 87 673 patients aged ≥50 years who had a new HZ diagnosis and associated antiviral prescription between 2010 and 2018. We developed and validated an automated natural language processing (NLP) algorithm to identify HZO with ocular involvement (ocular HZO). We compared the characteristics of NLP-identified ocular HZO, nonocular HZO, and non-HZO cases among HZ patients and identified the factors associated with ocular HZO among HZ patients.

Results

The NLP algorithm achieved 94.9% sensitivity and 94.2% specificity in identifying ocular HZO cases. Among 87 673 incident HZ cases, the proportion identified as ocular HZO was 9.0% (n = 7853) by NLP and 2.3% (n = 1988) by International Classification of Diseases codes. In adjusted analyses, older age and male sex were associated with an increased risk of ocular HZO; Hispanic and black race/ethnicity each were associated with a lower risk of ocular HZO compared with non-Hispanic white.

Conclusions

The NLP algorithm achieved high accuracy and can be used in large population-based studies to identify ocular HZO, avoiding labor-intensive chart review. Age, sex, and race were strongly associated with ocular HZO among HZ patients. We should consider these risk factors when planning for zoster vaccination.

19. Completion of Two-Dose Recombinant Zoster Vaccine Series in Adults 50 Years and Older

Background

In 2017, the Advisory Committee on Immunization Practices preferentially recommended adjuvanted recombinant zoster vaccine (RZV) for adults ≥ 50 years as a two-dose series 2–6 months apart.¹ We evaluated two-dose RZV completion and factors associated with completion.

Methods

The study included Kaiser Permanente Southern California members ≥ 50 years who received an RZV dose during April-November 2018 and had continuous membership 12 months before to 9 months after the 1^st RZV dose (RZV1). Completion was defined as receipt of the 2^nd dose ≥4 weeks to 9 months after RZV1 (allowing a 3-month grace period). Characteristics including age at RZV1, sex, race/ethnicity, Medicaid status, neighborhood level income and education, distance from home to medical office, comorbidities, history of herpes zoster, health care utilization before and after RZV1, receipt of influenza vaccine, vaccination month (supply shortage proxy), concomitant vaccine, department administering RZV1, medical center, and medically attended local or systemic reaction, pain, or gout after RZV1 were compared between completers and non-completers. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) for factors associated with completion were estimated by multivariable logistic regression.

Results

Among 31,120 RZV1 recipients, 67.2% completed the series within 9 months. In adjusted analyses, higher completion was associated with White compared with Black or Hispanic race/ethnicity, higher neighborhood income and education, no chronic pulmonary disease, diabetes, or dementia, more outpatient visits and fewer emergency department visits before or after RZV1, no hospitalizations after RZV1, receipt of influenza vaccine, receipt of RZV1 in June-November rather than April-May 2018, no concomitant vaccine with RZV1, and receipt of RZV1 in Family Practice rather than Internal Medicine. Systemic reactions or pain after RZV1 was not associated with completion.

Table 2. RZV Series Completion by Selected Characteristics During Follow-up of Members Aged ≥50 Years Who Received at Least One Dose of RZV at Kaiser Permanente Southern California in April-November 2018

Table 2. RZV Series Completion by Selected Characteristics During Follow-up of Members Aged ≥ 50 Years Who Received at Least One Dose of RZV at KPSC in April-November 2018

Figure 1. Factors Associated with RZV Series Completion of Members Aged ≥ 50 Years Who Received at Least One Dose of RZV at KPSC in April-November 2018

Conclusion

Completion of RZV series appears moderate in the early phase of implementation. Despite similar accessibility in a health care system, completion varied by race/ethnicity, socioeconomic status, health status, and care seeking behavior, suggesting areas to target for improvement.

Disclosures

Hung-Fu Tseng, MPH, PhD, GlaxoSmithKlein (Research Grant or Support) Lei Qian, PhD, GlaxoSmithKlein (Research Grant or Support) Jun Wu, MD, MS, GlaxoSmithKlein (Research Grant or Support) Yi Luo, PhD, GlaxoSmithKlein (Research Grant or Support) Lina S. Sy, MPH, GlaxoSmithKlein (Research Grant or Support) Katia Bruxvoort, PhD, MPH, GlaxoSmithKlein (Research Grant or Support) Bradley Ackerson, MD, GlasoSmithKlein (Research Grant or Support)

Association of Number of Doses With Hepatitis B Vaccine Series Completion in US Adults

IMPORTANCE

Receipt of hepatitis B virus vaccine is important to prevent infection. However, adherence to the hepatitis B vaccine series among adults at risk of infection has been low.

OBJECTIVE

To assess whether recipients of a 2-dose hepatitis B vaccine with cytosine phosphoguanine adjuvant (HepB-CpG vaccine; Heplisav-B) are more likely to complete their series compared with recipients of a 3-dose vaccine with alum adjuvant (comparator vaccine; Engerix-B [HepB-alum]).

DESIGN, SETTING, AND PARTICIPANTS

This nested cohort study was conducted from August 7 to December 31, 2018, at Kaiser Permanente Southern California, an integrated health care system with a diverse population of approximately 4.6 million members. Adults not receiving dialysis who received a first dose of a hepatitis B vaccine series in family practice or internal medicine departments of 15 Kaiser Permanente Southern California medical centers were followed up through electronic health records for up to 1 year after receipt of the first dose. Data were analyzed from March 16 to September 23, 2020.

EXPOSURES

Receipt of a first dose of the HepB-CpG vaccine (2-dose vaccine) vs receipt of a first dose of the HepB-alum vaccine (3-dose vaccine).

MAIN OUTCOMES AND MEASURES

Series completion within the recommended vaccine schedule plus 3 months (primary outcome) and series completion within 1 year after receipt of the first dose (secondary outcome).

RESULTS

Of 4727 individuals who initiated the HepB-CpG vaccine series and 6161 individuals who initiated the HepB-alum vaccine series included in the study, 2876 (60.8%) and 3789 (61.5%), respectively, were ages 40 to 59 years, 2415 (51.1%) and 3113 (50.5%) were male, and 2364 (50.0%) and 2881 (46.8%) were Hispanic. The vaccine series was completed within the recommended schedule plus 3 months for 2111 (44.7%) individuals who initiated the HepB-CpG vaccine series and 1607 (26.1%) individuals who initiated the HepB-alum vaccine series, and within 1 year for 2858 (60.5%) and 1989 (32.3%) individuals, respectively. The individuals who initiated the HepB-CpG vaccine series were significantly more likely to complete the series (adjusted relative risk, 1.77; 95% CI, 1.68-1.87). Results were consistent across clinical and demographic strata.

CONCLUSIONS AND RELEVANCE

In this study, use of the HepB-CpG vaccine was associated with hepatitis B vaccine series completion, but tailored strategies to increase completion of hepatitis B vaccine series are warranted.

Severe Morbidity and Mortality Associated With Respiratory Syncytial Virus Versus Influenza Infection in Hospitalized Older Adults

Background

Respiratory syncytial virus (RSV) is an important cause of serious respiratory illness in older adults. Comparison of RSV and influenza infection in hospitalized older adults may increase awareness of adult RSV disease burden.

Methods

Hospitalized adults aged ≥60 years who tested positive for RSV or influenza between 1 January 2011 and 30 June 2015 were identified from Kaiser Permanente Southern California electronic medical records. Baseline characteristics, comorbidities, utilization, and outcomes were compared.

Results

The study included 645 RSV- and 1878 influenza-infected hospitalized adults. Patients with RSV were older than those with influenza (mean, 78.5 vs 77.4 years; P = .035) and more likely to have congestive heart failure (35.3% vs 24.5%; P < .001) and chronic obstructive pulmonary disease (COPD) (29.8% vs 24.3%; P = .006) at baseline. In adjusted analyses, RSV infection was associated with greater odds of length of stay ≥7 days (odds ratio [OR] = 1.5; 95% confidence interval [CI], 1.2–1.8; P < .001); pneumonia (OR = 2.7; 95% CI, 2.2–3.2; P < .001); intensive care unit admission (OR = 1.3; 95% CI, 1.0–1.7; P = .023); exacerbation of COPD (OR = 1.7; 95% CI, 1.3–2.4; P = .001); and greater mortality within 1 year of admission (OR = 1.3; 95% CI, 1.0–1.6; P = .019).

Conclusions

RSV infection may result in greater morbidity and mortality among older hospitalized adults than influenza. Increased recognition of adult RSV disease burden will be important in the evaluation and use of new RSV vaccines and antivirals.

Differences in Estimates of Post-Herpetic Neuralgia Between Medical Chart Review and Self-Report

PURPOSE

Post-herpetic neuralgia (PHN) is a common herpes zoster (HZ) complication, where pain persists 90 days after the initial HZ diagnosis. Evaluating PHN risk is essential for determining the burden on patients and health-care systems, but research shows variable estimates. The extent to which these differences are related to the assessment method has not been examined. The purpose of this study is to compare the proportion of PHN among HZ patients measured by medical chart review and self-report surveys.

METHODS

PHN risk was assessed among a sample of Kaiser Permanente Southern California members with HZ. Chart reviews identified lingering pain 90-180 days post-HZ diagnosis and the Zoster Brief Pain Inventory was administered 90 days post-HZ diagnosis by telephone. Frequencies of PHN identified with each approach were cross-tabulated and stratified by sex, age group, and zoster vaccine live vaccination status.

RESULTS

Chart review and self-report were largely concordant (n=875, 89.20%); however, chart review yielded lower PHN risk overall and for the stratified subgroups. PHN from self-report was substantially higher (6.30-8.33%) among patients who were male, ≥70 years, or unvaccinated. Among those who typically seek care more often (female, younger, vaccinated), the discrepancy between each method was notably lower (1.60-2.92%).

CONCLUSION

Our findings suggest that chart review underestimates cases among those less likely to seek health care, including males, the elderly, and unvaccinated individuals. The agreement between the methods indicates that each can provide a reasonable approximation of PHN, but analyses should carefully control for health-care utilization.

Meta-analysis of number needed to treat for diagnosis of melanoma by clinical setting

OBJECTIVE

To provide a formal statistical comparison of the efficacy of melanoma detection among different clinical settings.

METHODS

A systematic review and meta-analysis of all relevant observational studies on number needed to treat (NNT) in relation to melanoma was performed in MEDLINE. We performed a random-effects model meta-analysis and reported NNTs with 95% confidence intervals (CIs). The subgroup analysis was related to clinical setting.

RESULTS

In all, 29 articles including a total of 398,549 biopsies/excisions were analyzed. The overall NNT was 9.71 (95% CI, 7.72-12.29): 22.62 (95% CI, 12.95-40.10) for primary care, 9.60 (95% CI, 6.97-13.41) for dermatology, and 5.85 (95% CI, 4.24-8.27) for pigmented lesion specialists.

LIMITATIONS

There is heterogeneity in data reporting and the possibility of missing studies. In addition, the incidence of melanoma varies among clinical settings, which could affect NNT calculations.

CONCLUSION

Pigmented lesion specialists have the lowest NNT, followed by dermatologists, suggesting that involving specialists in the diagnosis and treatment of pigmented skin lesions can likely improve patient outcomes.

2300. Incidence, Complications, and Recurrence of Herpes Zoster in Unvaccinated Adults ≥50 Years of Age

Background

More recent baseline epidemiological data for Herpes Zoster (HZ) in adults ≥ 50 years of age, obtained before the introduction of the adjuvanted Recombinant Zoster Vaccine (RZV), are needed for future evaluations of the impact of RZV on HZ epidemiology.

Methods

The study comprised five elements: (1) The incidence of HZ was estimated from immunocompetent adults ≥ 50 years of age not vaccinated with Zoster Vaccine Live who had incident HZ between 2011–2015. HZ was identified by International Classification of Diseases (ICD) codes from electronic health records (EHR) of 4.6 million Kaiser Permanente Southern California members; (2) Postherpetic neuralgia (PHN) was identified by validated survey and medical record review of laboratory-confirmed incident HZ cases recruited during 2012–2015 for HZ-related pain ≥ 90 days after initial HZ diagnosis; (3) HZ Ophthalmicus (HZO) with ocular complications was identified by ICD codes and keyword search in EHR among patients identified with HZO using a validated natural language processing algorithm; (4) The proportion of HZ-related non-PHN and non-HZO cutaneous, neurological or other complications was assessed by double abstraction of EHRs from a sample of 600 incident HZ cases; (5) Recurrent HZ was identified by having an HZ diagnosis with HZ antiviral medication ≥ 6 months after the most recent HZ diagnosis with HZ antiviral medication in a cohort initially diagnosed with HZ between 2007 and 2008 and followed through 2016.

Results

We identified 40,893 incident HZ cases with an overall incidence of 9.92 (95% confidence interval [CI]: 9.82–10.01) per 1000 person-years. The proportion of incident HZ cases with PHN and HZO with ocular involvement was 18.37% (95% CI: 14.90–21.84%) and 8.06% (95% CI: 7.80–8.32%), respectively. The proportion of cutaneous, neurological, and other complications was 7.20% (95% CI: 5.44–8.96%), 0.87% (95% CI: 0.79–0.95%), and 1.24% (95% CI: 1.15–1.33%), respectively. The incidence of recurrent HZ was 10.96/1000 person-years (95% CI: 10.18–11.79).

Conclusion

HZ is common among unvaccinated US adults ≥ 50 years of age, with PHN and HZO occurring most frequently among incident HZ cases.

Funding

GlaxoSmithKline Biologicals SA, GSK study identifier: HO-17-18378.

Disclosures

All authors: No reported disclosures.

286. Hepatitis B Vaccine Compliance: Comparing 2-Dose and 3-Dose Vaccines

Background

Less than 1 in 3 US adults who initiated the 3-dose (0, 1, 6 months) hepatitis B vaccine series have completed it. HepB-CpG (Heplisav-B; Dynavax) is a new licensed adjuvanted vaccine that requires only 2 doses (0, 1 month). As part of a cluster study performed at Kaiser Permanente Southern California, we compared compliance with second dose and series completion for HepB-CpG vs. comparator vaccine (Engerix-B; GlaxoSmithKline) recipients.

Methods

The cohort included adults not on dialysis who received their first dose of hepatitis B vaccine in family or internal medicine departments from 8/7/2018 to 2/1/2019. Second dose compliance was assessed for the full cohort, but series completion was assessed for a subset vaccinated from August 7, 2018 to September 30, 2018 to allow at least 6 months’ follow-up. Compliance rates were estimated using the Kaplan Meier method. Adjusted hazard ratios (aHR) were estimated using Cox proportional hazard regression with robust variance to account for within medical center correlation, adjusting for age, race/ethnicity, census block income and education, prior healthcare utilization, and factors that trigger alerts for hepatitis B vaccination (diabetes and testing for sexually transmitted infections).

Results

There were 6500 HepB-CpG and 7733 comparator vaccine recipients (1,442 and 2,604 prior to September 30, 2018). Rates of second dose compliance at 60 days were 32.9% for HepB-CpG and 29.1% for comparator vaccine, and rates of series completion at 210 days were 56.9% and 20.6%. There was no significant difference in second dose compliance (aHR 1.14, 95% CI: 0.91, 1.47), but HepB-CpG recipients were 5 times more likely to complete the series (aHR 5.17; 95% CI: 3.84, 6.98). Second dose compliance and series completion were significantly less likely among Blacks compared with Whites and significantly more likely among Asians, adults ≥60 years compared with those < 30 years, and adults living in census blocks with a median annual income of $40,000–69,000 compared with < $40,000.

Conclusion

Overall, second dose compliance was similar, but series completion was better for HepB-CpG recipients than comparator vaccine recipients, suggesting that the 2-dose vaccine could lead to improvements in coverage and protection against hepatitis B virus.

Disclosures

All authors: No reported disclosures.

Morbidity, and Short- and Intermediate-term Mortality, in Adults ≥60 Years Hospitalized with Respiratory Syncytial Virus Infection vs. Seasonal Influenza Virus Infection

Background

There is increasing evidence that respiratory syncytial virus (RSV) infection can cause serious health problems among older adults, whether healthy and community-dwelling, or high-risk. In older adults, RSV infection can lead to complications that are similar to those resulting from seasonal influenza infection. The aim of this study was to compare the morbidity and mortality in older adults ≥60 years hospitalized with RSV disease vs. those hospitalized with seasonal influenza.

Methods

This cohort study included members of Kaiser Permanente Southern California aged ≥ 60 years who tested positive for RSV or influenza A/B by multiplex RT-PCR in clinical diagnostic testing during January 1, 2011 to June 30, 2015 and were hospitalized. For multiple eligible hospitalizations, only the first RSV hospitalization for the RSV cohort or first influenza A/B hospitalization for the influenza cohort was included. Electronic medical records for each hospitalized individual were used to extract necessary information, including baseline characteristics, symptoms, comorbidities, and outcomes.

Results

The study included 664 RSV (mean age 78.5 years, 39.5% male) and 1922 influenza A/B (mean age 77.5 years, 49.7% male) hospitalizations. There were 310 (46.7%) RSV patients and 501 (26.1%) influenza patients with a diagnosis of pneumonia. There were 119 RSV patients (17.9%) vs. 272 (14.2%) influenza patients that were admitted to the intensive care unit during hospitalization (mean stay 6.8 vs. 7.8 days). The short-term mortality rate during hospitalization and within 90 days of discharge was 5.6% (n = 37) and 7.4% (n = 49) in the RSV cohort vs. 4.4% (n = 85) and 6.7%&#x2028;(n = 129) in the influenza cohort. The intermediate-term mortality rate within 91–180 days of discharge was significantly different between the RSV and the influenza cohorts (4.4% vs. 2.5%).

Conclusion

RSV infection can lead to complications and severe outcomes that are similar to those of seasonal influenza in older adults. Effective prevention and treatment strategies such as vaccination and antivirals against RSV could potentially reduce the burden of RSV infection as well as complications from disease.

Disclosures

H. F. Tseng, Novavax: Grant Investigator, Research grant. L. S. Sy, Novavax: Collaborator, Research grant. C. Fischetti, Novavax: Collaborator, Research grant. J. Slezak, Novavax: Collaborator, Grant recipient. Y. Luo, Novavax: Collaborator, Grant recipient. Z. Solano, Novavax Inc.: Collaborator, My employer received research funds to conduct the study. S. Chen, Novavax: Collaborator, Research grant. V. Shinde, Novavax Inc.: Collaborator, My employer received research funds to conduct the study.

Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine

OBJECTIVE

An observational safety study of the quadrivalent human papillomavirus vaccine (HPV4) in women was conducted. This report presents findings from autoimmune surveillance. Design.  Subjects were followed for 180days after each HPV4 dose for new diagnoses of 16 prespecified autoimmune conditions.

SETTING

Two managed care organizations in California. Subjects.  Number of 189,629 women who received ≥1 dose of HPV4 between 08/2006 and 03/2008.

OUTCOME

Potential new-onset autoimmune condition cases amongst HPV4 recipients were identified by electronic medical records. Medical records of those with ≥12-month health plan membership prior to vaccination were reviewed by clinicians to confirm the diagnosis and determine the date of disease onset. The incidence of each autoimmune condition was estimated for unvaccinated women at one study site using multiple imputations and compared with that observed in vaccinated women. Incidence rate ratios (IRR) were calculated. Findings were reviewed by an independent Safety Review Committee (SRC).

RESULTS

Overall, 1014 potential new-onset cases were electronically identified; 719 were eligible for case review; 31-40% were confirmed as new onset. Of these, no cluster of disease onset in relation to vaccination timing, dose sequence or age was found for any autoimmune condition. None of the estimated IRR was significantly elevated except Hashimoto's disease [IRR=1.29, 95% confidence interval: 1.08-1.56]. Further investigation of temporal relationship and biological plausibility revealed no consistent evidence for a safety signal for autoimmune thyroid conditions. The SRC and the investigators identified no autoimmune safety concerns in this study.

CONCLUSIONS

No autoimmune safety signal was found in women vaccinated with HPV4.

Human immunodeficiency virus nucleocapsid protein polymorphisms modulate the infectivity of RNA packaging mutants

The nucleocapsid protein (NC) of retroviruses is involved in viral RNA packaging and initiation of reverse transcription. NC also mediates interactions between Gag and actin filaments. We found that residues at the amino terminus of NC are involved in efficient actin binding. When alanine residues were substituted for the arginine and lysine at positions 10 and 11 of NC in HIV(NL4-3), these mutations decreased actin binding but had only a modest effect on virus infectivity. A similarly mutated virus based on the HXB2 clone of HIV was not infectious. Mutational analysis of NL4-3 NC residues demonstrated that NC polymorphisms modulated the phenotype of NC mutations. Conservative amino acid differences between HXB2 and NL4-3 NCs were sufficient to explain the difference in infectivity of viruses carrying the R10A and K11A mutations.

The E7 oncoprotein of human papillomavirus type 16 interacts with F-actin in vitro and in vivo

We report here that E7 oncoprotein of human papillomavirus type 16 (HPV-16) forms a complex in vivo and in vitro with actin, one of the components of the cellular cytoskeleton. The in vivo interaction was detected by immunofluorescent staining and confocal microscopic examination of normal human oral keratinocytes (NHOK) and CV-1 cells after transient expression of E7 employing the vaccinia virus-T7 RNA polymerase system and by coimmunoprecipitation from an immortalized, nontumorigenic cell line obtained after transfecting NHOK with the cloned HPV-16 DNA genome. The in vitro interaction was detected by cosedimentation of bacterially expressed E7 phosphorylated with rabbit reticulocyte lysate or purified casein kinase II (CKII) prior to incubation with F-actin. This interaction was inhibited if E7 phosphorylation by the rabbit reticulocyte lysate was prevented with heparin, a CKII inhibitor, or if the amino acids Ser-31 and Ser-32 in E7, which are phosphorylated by CKII, were replaced with amino acids that cannot be phosphorylated. Interestingly, a decrease in the amount of polymerized actin occurred in cells expressing E7.

Cryoelectron microscopic examination of human immunodeficiency virus type 1 virions with mutations in the cyclophilin A binding loop

The human immunodeficiency virus type 1 capsid protein contains a conserved P217X4PX2PX5P231 motif. Mutation at Pro-222 decreases virion incorporation of cyclophilin A, while mutation at Pro-231 abolishes infectivity. Although viral RNA incorporation and protease cleavage of the Gag precursor were not affected by these mutations, cryoelectron microscopy revealed a loss of virion maturation in P231A particles.

Cells with high cyclophilin A content support replication of human immunodeficiency virus type 1 Gag mutants with decreased ability to incorporate cyclophilin A

Gag polyprotein-mediated incorporation of cellular cyclophilin A (CyPA) into virions is essential for the formation of infectious human immunodeficiency virus type 1 (HIV-1) virions. Either a point mutation in Gag (P222A) or drugs which bind CyPA decrease virion incorporation of CyPA and interfere with HIV-1 replication. We have found that lymphoid cells varied greatly in their CyPA content and that cells with high CyPA content supported the replication of P222A HIV-1 Gag mutants. These experiments demonstrated that a higher cellular CyPA content of some cells was able to compensate for the decreased binding affinity of P222A mutant Gag for CyPA, allowing virus replication to occur.

The case for integration of social work psychosocial services into rural primary care practice

This article argues for health and mental health collaboration between social workers and rural primary care physicians and describes a study of physicians' attitudes toward integrated services. The physicians who expressed interest in a collaborative arrangement differed in practice characteristics, attitudes toward social workers, and endorsement of social work roles. Also, interested physicians treated significantly more patients, had the lowest proportion of patients over age 65, and endorsed as useful a significantly larger number of social work activities. If social workers aspire to collaborative arrangements in rural primary care, they must provide excellent services now, continue to work toward a better understanding of their broad mental health competencies, and be willing to provide services that conform to the expectations and limitations of primary care.