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Ackerson BK, Bruxvoort KJ, Qian L, Sy LS, Qiu S, Tubert JE, Lee GS, Ku JH, Florea A, Luo Y, Bathala R, Stern J, Choi SK, Takhar HS, Aragones M, Marks MA, Anderson EJ, Zhou CK, Sun T, Talarico CA, Tseng HF. Effectiveness and durability of mRNA-1273 BA.4/BA.5 bivalent vaccine (mRNA-1273.222) against SARS-CoV-2 BA.4/BA.5 and XBB sublineages. Hum Vaccin Immunother 2024; 20:2335052. [PMID: 38575149 PMCID: PMC10996830 DOI: 10.1080/21645515.2024.2335052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
Emerging SARS-CoV-2 sublineages continue to cause serious COVID-19 disease, but most individuals have not received any COVID-19 vaccine for >1 year. Assessment of long-term effectiveness of bivalent COVID-19 vaccines against circulating sublineages is important to inform the potential need for vaccination with updated vaccines. In this test-negative study at Kaiser Permanente Southern California, sequencing-confirmed BA.4/BA.5- or XBB-related SARS-CoV-2-positive cases (September 1, 2022 to June 30, 2023), were matched 1:3 to SARS-CoV-2-negative controls. We assessed mRNA-1273 bivalent relative (rVE) and absolute vaccine effectiveness (VE) compared to ≥2 or 0 doses of original monovalent vaccine, respectively. The rVE analysis included 20,966 cases and 62,898 controls. rVE (95%CI) against BA.4/BA.5 at 14-60 days and 121-180 days was 52.7% (46.9-57.8%) and 35.5% (-2.8-59.5%) for infection, and 59.3% (49.7-67.0%) and 33.2% (-28.2-68.0%) for Emergency Department/Urgent Care (ED/UC) encounters. For BA.4/BA.5-related hospitalizations, rVE was 71.3% (44.9-85.1%) and 52.0% (-1.2-77.3%) at 14-60 days and 61-120 days, respectively. rVE against XBB at 14-60 days and 121-180 days was 48.8% (33.4-60.7%) and -3.9% (-18.1-11.3%) for infection, 70.7% (52.4-82.0%) and 15.7% (-6.0-33.2%) for ED/UC encounters, and 87.9% (43.8-97.4%) and 57.1% (17.0-77.8%) for hospitalization. VE and subgroup analyses (age, immunocompromised status, previous SARS-CoV-2 infection) results were similar to rVE analyses. rVE of mRNA-1273 bivalent vaccine against BA.4/BA.5 and XBB infections, ED/UC encounters, and hospitalizations waned over time. Periodic revaccination with vaccines targeting emerging variants may be important in reducing COVID-19 morbidity and mortality.
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Affiliation(s)
- Bradley K. Ackerson
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Katia J. Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Lina S. Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Sijia Qiu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Julia E. Tubert
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Gina S. Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jennifer H. Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Radha Bathala
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Julie Stern
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Soon K. Choi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Harpreet S. Takhar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael Aragones
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Morgan A. Marks
- Infectious Disease, Epidemiology, Moderna Inc, Cambridge, MA, USA
| | - Evan J. Anderson
- Infectious Disease, Epidemiology, Moderna Inc, Cambridge, MA, USA
| | - Cindy Ke Zhou
- Infectious Disease, Epidemiology, Moderna Inc, Cambridge, MA, USA
| | - Tianyu Sun
- Infectious Disease, Epidemiology, Moderna Inc, Cambridge, MA, USA
| | - Carla A. Talarico
- Infectious Disease, Epidemiology, Moderna Inc, Cambridge, MA, USA
- Epidemiology, AstraZeneca, Gaithersburg, MD, USA
| | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Balas N, Richman JS, Landier W, Shrestha S, Bruxvoort KJ, Hageman L, Meng Q, Ross E, Bosworth A, Wong FL, Bhatia R, Forman SJ, Armenian SH, Weisdorf DJ, Bhatia S. Pre-frailty after blood or marrow transplantation and the risk of subsequent mortality. Leukemia 2024:10.1038/s41375-024-02238-2. [PMID: 38580835 DOI: 10.1038/s41375-024-02238-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/07/2024]
Abstract
We examined the prevalence, risk factors, and association between pre-frailty and subsequent mortality after blood or marrow transplantation (BMT). Study participants were drawn from the BMT Survivor Study (BMTSS) and included 3346 individuals who underwent BMT between 1974 and 2014 at one of three transplant centers and survived ≥2 years post-BMT. Participants completed the BMTSS survey at a median of 9 years from BMT and were followed for subsequent mortality for a median of 5 years after survey completion. Closest-age and same-sex biological siblings also completed the survey. Previously published self-reported indices (exhaustion, weakness, low energy expenditure, slowness, unintentional weight loss) classified participants as non-frail (0-1 indices) or pre-frail (2 indices). National Death Index was used to determine vital status and cause of death. Overall, 626 (18.7%) BMT survivors were pre-frail. BMT survivors had a 3.2-fold higher odds of being pre-frail (95% CI = 1.9-5.3) compared to siblings. Compared to non-frail survivors, pre-frail survivors had higher hazards of all-cause mortality (adjusted hazard ratio [aHR] = 1.6, 95% CI = 1.4-2.0). Female sex, pre-BMT radiation, smoking, lack of exercise, anxiety, and severe/life-threatening chronic health conditions were associated with pre-frailty. The novel association between pre-frailty and subsequent mortality provides evidence for interventions as pre-frail individuals may transition back to their robust state.
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Affiliation(s)
- Nora Balas
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Wendy Landier
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | - Qingrui Meng
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth Ross
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Ravi Bhatia
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL, USA.
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Ku JH, Fischer H, Qian LX, Li K, Skarbinski J, Shaw S, Bruxvoort KJ, Lewin BJ, Spence BC, Tartof SY. Latent tuberculosis infection testing practices in a large U.S. integrated healthcare system. Clin Infect Dis 2024:ciae015. [PMID: 38207124 DOI: 10.1093/cid/ciae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 01/13/2024] Open
Abstract
PURPOSE Tuberculosis (TB) is a public health threat with >80% of active TB in the U.S. occurring due to reactivation of latent tuberculosis infection (LTBI). We may be under-screening those with high risk for LTBI and over-testing those at lower risk. A better understanding of gaps in current LTBI testing practices in relation to LTBI test positivity is needed. METHODS This study, conducted between 01/01/2008 and 12/31/2019 at Kaiser Permanente Southern California, included individuals ≥18 years of age without a history of active TB. We examined factors associated with LTBI testing and LTBI positivity. RESULTS Among 3,816,884 adults (52% female, 37% White, 37% Hispanic, mean age 43.5 years [S.D. 16.1]), 706,367 (19%) were tested for LTBI, among whom 60,393 (9%) had ≥1 positive result. Among 1,211,971 individuals meeting ≥1 screening criteria for LTBI, 210,025 (17%) were tested for LTBI. Factors associated with higher adjusted odds (aOR) of testing positive included male sex [aOR: 1.32, 95% CI:1.30-1.35], Asian/Pacific Islander [2.78, 2.68-2.88], current smoking [1.24, 1.20-1.28], diabetes [1.13, 1.09-1.16], hepatitis B [1.45, 1.34-1.57], hepatitis C [1.54, 1.44-1.66], and birth in a country with an elevated TB rate [3.40, 3.31-3.49]). Despite being risk factors for testing positive for LTBI, none of these factors were associated with higher odds of LTBI testing. CONCLUSIONS Current LTBI testing practices may be missing individuals at high risk of LTBI. Additional work is needed to refine and implement screening guidelines that appropriately target testing for those at highest risk for LTBI.
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Affiliation(s)
- Jennifer H Ku
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Heidi Fischer
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lei X Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Kris Li
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California USA
| | - Sally Shaw
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Katia J Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Bruno J Lewin
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Brigitte C Spence
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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Bruxvoort KJ, Shi J, Song H, Narwaney K, Glanz JM, Binswanger I, Lam JA, Chang JM, Portugal C, Watanabe C, Aragones M, Palmer-Toy DE. SARS-CoV-2 Serology Did Not Predict Risk of Breakthrough Infection During the Omicron BA.1 and BA.2 Surge. Arch Pathol Lab Med 2024; 148:7-11. [PMID: 37796481 DOI: 10.5858/arpa.2023-0311-le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/29/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Katia J Bruxvoort
- Department of Epidemiology, University of Alabama at Birmingham
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jiaxiao Shi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Hubert Song
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Komal Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora; Department of Epidemiology, Colorado School of Public Health, Aurora
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora; Department of Epidemiology, Colorado School of Public Health, Aurora
| | - Ingrid Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora; Department of Epidemiology, Colorado School of Public Health, Aurora
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora
- Bernard J. Tyson School of Medicine, Pasadena, California (Binswanger)
| | - Jessica A Lam
- Department of Clinical Analysis, Southern California Permanente Medical Group, Pasadena
| | - John M Chang
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Cecilia Portugal
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Cheryl Watanabe
- Regional Reference Laboratories, Southern California Permanente Medical Group, Chino Hills
| | - Michael Aragones
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Darryl E Palmer-Toy
- Regional Reference Laboratories, Southern California Permanente Medical Group, Chino Hills
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Bruxvoort KJ, Sy LS, Hong V, Lewin B, Qian L, Huang X, Holmquist KJ, Han B, Xu S. Factors associated with uptake of bivalent mRNA COVID-19 vaccines in a large US health care system. Vaccine 2023; 41:7460-7468. [PMID: 37953096 PMCID: PMC10954380 DOI: 10.1016/j.vaccine.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/27/2023] [Accepted: 11/04/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Bivalent mRNA COVID-19 vaccines were developed to provide protection against the original SARS-CoV-2 strain and Omicron BA.4/BA.5 variants, but uptake in the United States has been low. Sociodemographic disparities in COVID-19 vaccine uptake have been documented, but it is unclear if similar disparities persist among individuals who previously completed a primary series of monovalent COVID-19 vaccine. METHODS We conducted a retrospective cohort study at Kaiser Permanente Southern California (KPSC) including youth aged 5-17 years and adults aged ≥18 years who were KPSC members and had completed a primary series of monovalent COVID-19 vaccine. Individuals were followed from index date (date of eligibility for bivalent vaccine) to 03/31/2023 to ascertain receipt of any dose of bivalent mRNA COVID-19 vaccine or until disenrollment from KPSC or death. Multivariable robust Poisson regression was conducted to assess the adjusted relative risk and 95 % confidence intervals of factors associated with receipt of bivalent vaccine. RESULTS The final cohorts included 305,339 youth and 2,534,619 adults, of whom 19.5 % and 30.7 %, respectively, had received bivalent COVID-19 vaccine. Factors associated with being more likely to receive bivalent COVID-19 vaccine included older age, Asian race, more prior year outpatient and virtual visits, Charlson score ≥1, and immunocompromised status. Factors associated with being less likely to receive a bivalent COVID-19 vaccine included age 12-17 vs 5-11 years, Hispanic and non-Hispanic Black race/ethnicity, ≥1 prior year inpatient or emergency department visits, prior history of SARS-CoV-2 infection (adults only), Medicaid insurance, and higher neighborhood deprivation index. CONCLUSION Even among youth and adults who had previously received a primary series of monovalent COVID-19 vaccine, sociodemographic and clinical disparities were observed in receipt of bivalent COVID-19 vaccine. These findings are critical to inform equitable strategies for the implementation of the updated monovalent COVID-19 vaccine targeting the Omicron XBB strain.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35233, United States; Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States.
| | - Lina S Sy
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States
| | - Vennis Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States
| | - Bruno Lewin
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States
| | - Lei Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States
| | - Xuan Huang
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States
| | - Kimberly J Holmquist
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States
| | - Bing Han
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States
| | - Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 5th Floor, Pasadena, CA 91101, United States; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA 91101, United States
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6
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Balas N, Richman J, Landier W, Shrestha S, Bruxvoort KJ, Hageman L, Meng Q, Ross E, Bosworth A, Te HS, Wong FL, Bhatia R, Forman SJ, Armenian SH, Weisdorf DJ, Bhatia S. Risky health behaviors and subsequent late mortality after blood or marrow transplantation: a BMTSS report. Blood Adv 2023; 7:7028-7044. [PMID: 37682779 PMCID: PMC10694527 DOI: 10.1182/bloodadvances.2023010633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/09/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023] Open
Abstract
We examined the association between risky health behaviors (smoking, heavy alcohol consumption, and lack of vigorous physical activity) and all-cause and cause-specific late mortality after blood or marrow transplantation (BMT) to understand the role played by potentially modifiable risk factors. Study participants were drawn from the BMT Survivor Study (BMTSS) and included patients who received transplantation between 1974 and 2014, had survived ≥2 years after BMT, and were aged ≥18 years at study entry. Survivors provided information on sociodemographic characteristics, chronic health conditions, and health behaviors. National Death Index was used to determine survival and cause of death. Multivariable regression analyses determined the association between risky health behaviors and all-cause mortality (Cox regression) and nonrecurrence-related mortality (NRM; subdistribution hazard regression), after adjusting for relevant sociodemographic, clinical variables and therapeutic exposures. Overall, 3866 participants completed the BMTSS survey and were followed for a median of 5 years to death or 31 December 2021; and 856 participants (22.1%) died after survey completion. Risky health behaviors were associated with increased hazard of all-cause mortality (adjusted hazard ratio [aHR] former smoker, 1.2; aHR current smoker, 1.7; reference, nonsmoker; aHR heavy drinker, 1.4; reference, nonheavy drinker; and aHR no vigorous activity, 1.2; reference, vigorous activity) and NRM (aHR former smoker, 1.3; aHR current smoker, 1.6; reference, nonsmoker; aHR heavy drinker, 1.4; reference: nonheavy drinker; and aHR no vigorous activity, 1.2; reference, vigorous activity). The association between potentially modifiable risky health behaviors and late mortality offers opportunities for development of interventions to improve both the quality and quantity of life after BMT.
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Affiliation(s)
- Nora Balas
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Joshua Richman
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Wendy Landier
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Hematology/ Oncology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sadeep Shrestha
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Katia J. Bruxvoort
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Qingrui Meng
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Elizabeth Ross
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Hok Sreng Te
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - F. Lennie Wong
- Department of Population Science, City of Hope, Duarte, CA
| | - Ravi Bhatia
- Division of Hematology and Oncology, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Stephen J. Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Saro H. Armenian
- Department of Population Science, City of Hope, Duarte, CA
- Department of Pediatrics, City of Hope, Duarte, CA
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Hematology/ Oncology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
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7
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Lewnard JA, Hong V, Bruxvoort KJ, Grant LR, Jódar L, Cané A, Arguedas A, Pomichowski ME, Gessner BD, Tartof SY. Burden of Lower Respiratory Tract Infections Preventable by Adult Immunization With 15- and 20-Valent Pneumococcal Conjugate Vaccines in the United States. Clin Infect Dis 2023; 77:1340-1352. [PMID: 37293708 DOI: 10.1093/cid/ciad355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/16/2023] [Accepted: 06/07/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Updated recommendations of the US Advisory Committee on Immunization Practices indicate that all adults aged ≥65 years and adults aged <65 years with comorbid conditions should receive 15- and 20-valent pneumococcal conjugate vaccines (PCV15/20). We aimed to assess the potential impact of these recommendations on the burden of lower respiratory tract infections (LRTIs) among adults. METHODS We estimated the incidence of LRTI cases and associated hospital admissions among enrollees of Kaiser Permanente Southern California from 2016 through 2019. We used a counterfactual inference framework to estimate excess LRTI-associated risk of death up to 180 days after diagnosis. We used prior estimates of PCV13 effectiveness against LRTI to model potential direct effects of PCV15/20 by age group and risk status. RESULTS Use of PCV15 and PCV20, respectively, could prevent 89.3 (95% confidence interval, 41.3-131.8) and 108.6 (50.4-159.1) medically attended LRTI cases; 21.9 (10.1-32.0) and 26.6 (12.4-38.7) hospitalized LRTI cases; and 7.1 (3.3-10.5) and 8.7 (4.0-12.7) excess LRTI-associated deaths, each per 10 000 person-years. Among at-risk adults aged <65 years, use of PCV15 and PCV20 could prevent 85.7 (39.6-131.5) and 102.7 (47.8-156.7) medically attended LRTI cases per 10 000 person-years; 5.1 (2.4-8.6) and 6.2 (2.8-10.2) LRTI hospitalizations per 10 000 person-years, and 0.9 (0.4-1.4) and 1.1 (0.5-1.7) excess LRTI-associated deaths per 10 000 person-years. CONCLUSIONS Our findings suggest recent recommendations, including PCV15/20 within adult pneumococcal vaccine series, may substantially reduce LRTI burden.
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Affiliation(s)
- Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California -Berkeley, Berkeley, California, USA
- Division of Infectious Diseases & Vaccinology, School of Public Health, University of California -Berkeley, California, USA
- Center for Computational Biology, College of Engineering, University of California -Berkeley, California, USA
| | - Vennis Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Katia J Bruxvoort
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Luis Jódar
- Pfizer Vaccines, Collegeville, Pennsylvania, USA
| | | | | | - Magdalena E Pomichowski
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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8
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Fischer H, Qian L, Li Z, Garba S, Bruxvoort KJ, Skarbinski J, Ku JH, Lewin BJ, Mahale PS, Shaw SF, Spence BC, Tartof SY. Prior Screening for Latent Tuberculosis Among Patients Diagnosed With Tuberculosis Disease: Missed Opportunities? Open Forum Infect Dis 2023; 10:ofad545. [PMID: 38023560 PMCID: PMC10651207 DOI: 10.1093/ofid/ofad545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Background California has the largest number of tuberculosis (TB) disease cases in the United States. This study in a large California health system assessed missed opportunities for latent tuberculosis (LTBI) screening among patients with TB disease. Methods Kaiser Permanente Southern California patients who were ≥18 years old with membership for ≥24 months during the study period from 1 January 2008 to 31 December 2019 were included. Prior LTBI test (tuberculin skin test or interferon-γ release assay) or diagnosis code prior to TB disease diagnosis was assessed among patients with observed TB disease (confirmed by polymerase chain reaction and/or culture). In the absence of current treatment practices, more patients screened for LTBI may have developed TB disease. We estimated hypothetical TB disease cases prevented by multiplying LTBI progression rates by the number of LTBI-positive patients prescribed treatment. Results A total of 1289 patients with observed TB disease were identified; 148 patients were LTBI positive and 84 were LTBI negative. Patients not prescreened for LTBI made up 82.0% of observed TB disease cases (1057/1289). Adding the hypothetical maximum estimate for prevented cases decreased the percentage of patients who were not prescreened for LTBI to 61.7% [1057/(1289 + 424)]. Conclusions One-fifth of patients were screened for LTBI prior to their active TB diagnosis. Assuming the upper bound of cases prevented through current screening, almost 62% of TB disease patients were never screened for LTBI. Future work to elucidate gaps in LTBI screening practices and to identify opportunities to improve screening guidelines is needed.
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Affiliation(s)
- Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Zhuoxin Li
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Saadiq Garba
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jennifer H Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Bruno J Lewin
- Department of Family Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Parag S Mahale
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Brigitte C Spence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Bruxvoort KJ, Fischer H, Lewnard JA, Hong VX, Pomichowski M, Grant LR, Jódar L, Gessner BD, Tartof SY. Risk of subsequent lower respiratory tract infection (LRTI) after hospitalization for COVID-19 LRTI and non-COVID-19 LRTI: a retrospective cohort study. Pneumonia (Nathan) 2023; 15:15. [PMID: 37794443 PMCID: PMC10552217 DOI: 10.1186/s41479-023-00117-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/17/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Respiratory pathogens, including SARS-CoV-2, can cause pulmonary structural damage and physiologic impairment, which may increase the risk of subsequent lower respiratory tract infections (LRTI). Prior hospitalization for any reason is a risk factor for LRTI, but data on the risk of subsequent new-onset LRTI following hospitalization for COVID-19 LRTI or non-COVID-19 LRTI are needed to inform strategies for immunizations targeting respiratory pathogens. METHODS We conducted a retrospective cohort study at Kaiser Permanente Southern California (KPSC) among adults hospitalized from 3/1/2020 to 5/31/2022, excluding labor and delivery. We categorized individuals into 3 mutually exclusive baseline exposure groups: those hospitalized for COVID-19 LRTI, those hospitalized for non-COVID-19 LRTI, and those hospitalized for all other causes without LRTI or COVID-19 ("non-LRTI"). Following hospital discharge, patients were followed up for new-onset LRTI, beginning 30 antibiotic-free days after hospital discharge until 8/31/2022. We used multivariable cause-specific Cox regression with time-varying covariates to estimate hazard ratios (HR) of new-onset LRTI comparing those hospitalized for COVID-19 LRTI or non-COVID-19 LRTI to those hospitalized for non-LRTI, adjusting for demographic and clinical characteristics. RESULTS The study included 22,417 individuals hospitalized for COVID-19 LRTI, 12,795 individuals hospitalized for non-COVID-19 LRTI, and 176,788 individuals hospitalized for non-LRTI. Individuals hospitalized for non-COVID-19 LRTI were older and had more comorbidities than those hospitalized for COVID-19 LRTI or non-LRTI. Incidence rates per 1,000 person-years (95% CI) of new-onset LRTI were 52.5 (51.4-53.6) among individuals hospitalized for COVID-19 LRTI, 253.5 (243.7-263.6) among those hospitalized for non-COVID-19 LRTI, and 52.5 (51.4-53.6) among those hospitalized for non-LRTI. The adjusted hazard of new-onset LRTI during follow-up was 20% higher among individuals hospitalized for COVID-19 LRTI (HR 1.20 [95% CI: 1.12-1.28]) and 301% higher among individuals hospitalized for non-COVID-19 LRTI (HR 3.01 [95% CI: 2.87-3.15]) compared to those hospitalized for non-LRTI. CONCLUSION The risk of new-onset LRTI following hospital discharge was high, particularly among those hospitalized for non-COVID-19 LRTI, but also for COVID-19 LRTI. These data suggest that immunizations targeting respiratory pathogens, including COVID-19, should be considered for adults hospitalized for LRTI prior to hospital discharge.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL, 35233, USA.
| | - Heidi Fischer
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
- Division of Infectious Diseases & Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
- Center for Computational Biology, College of Engineering, University of California, Berkeley, Berkeley, CA, USA
| | - Vennis X Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Magdalena Pomichowski
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | | | | | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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10
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Xu S, Hong V, Sy LS, Bruxvoort KJ, Lewin B, Han B, Holmquist KJ, Qian L. Risk Factors for Not Completing a 2-Dose Primary Series of Messenger RNA COVID-19 Vaccination in a Large Health Care System in Southern California: Retrospective Cohort Study. JMIR Public Health Surveill 2023; 9:e46318. [PMID: 37792452 PMCID: PMC10563864 DOI: 10.2196/46318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/22/2023] [Accepted: 08/29/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND COVID-19 vaccination is crucial in combating the COVID-19 pandemic. Messenger RNA COVID-19 vaccines were initially authorized as a 2-dose primary series and have been widely used in the United States; completing the 2-dose primary series offers protection against infection, severe illness, and death. Understanding the risk factors for not completing the 2-dose primary series is critical to evaluate COVID-19 vaccination programs and promote completion of the 2-dose primary series. OBJECTIVE This study examined potential risk factors for not completing a 2-dose primary series of mRNA COVID-19 vaccination. METHODS We conducted a retrospective cohort study among members aged ≥18 years from a large integrated health care system, Kaiser Permanente Southern California, from December 14, 2020, to June 30, 2022. Noncompletion of the 2-dose primary series was defined as not completing the second dose within 6 months after receipt of the first dose. Crude noncompletion rates were estimated overall and by demographic characteristics, health care use patterns, comorbidity, and community-level socioeconomic factors. A Poisson regression model was fit to examine associations of individual-level and community-level risk factors with noncompletion of the 2-dose primary series. RESULTS Among 2.5 million recipients of ≥1 dose of mRNA COVID-19 vaccines, 3.3% (n=81,202) did not complete the second dose within 6 months. Members aged 25-44 years, 65-74 years, and ≥75 years were less likely to not complete the 2-dose primary series than those aged 18-24 years, while members aged 45-64 years were more likely to not complete the 2-dose primary series (adjusted risk ratio [aRR] 1.13, 95% CI 1.10-1.15). Male sex was associated with a higher risk of noncompletion (aRR 1.17, 95% CI 1.15-1.19). Hispanic and non-Hispanic Black race/ethnicity were associated with a lower risk of noncompletion (range aRR 0.78-0.91). Having Medicaid and prior influenza vaccination were associated with a higher risk of noncompletion. Having SARS-CoV-2 infection, experiencing an adverse event, or having an inpatient and emergency department visit during the minimum recommended dose intervals were associated with a higher risk of not completing the 2-dose primary series (aRR 1.98, 95% CI 1.85-2.12; 1.99, 95% CI 1.43-2.76; and 1.85, 95% CI 1.77-1.93, respectively). Those who received the first dose after June 30, 2021, were more likely to not complete the 2-dose primary series within 6 months of receipt of the first dose. CONCLUSIONS Despite limitations such as being a single-site study and the inability to consider social factors such as employment and vaccine attitudes, our study identified several risk factors for not completing a 2-dose primary series of mRNA vaccination, including being male; having Medicaid coverage; and experiencing SARS-CoV-2 infection, adverse events, or inpatient and emergency department visits during the minimum recommended dose intervals. These findings can inform future efforts in developing effective strategies to enhance vaccination coverage and improve the completion rate of necessary doses.
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Affiliation(s)
- Stanley Xu
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Vennis Hong
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States
| | - Lina S Sy
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States
| | - Katia J Bruxvoort
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Bruno Lewin
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States
| | - Bing Han
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States
| | - Kimberly J Holmquist
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States
| | - Lei Qian
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States
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11
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Tseng HF, Ackerson BK, Sy LS, Tubert JE, Luo Y, Qiu S, Lee GS, Bruxvoort KJ, Ku JH, Florea A, Takhar HS, Bathala R, Zhou CK, Esposito DB, Marks MA, Anderson EJ, Talarico CA, Qian L. mRNA-1273 bivalent (original and Omicron) COVID-19 vaccine effectiveness against COVID-19 outcomes in the United States. Nat Commun 2023; 14:5851. [PMID: 37730701 PMCID: PMC10511551 DOI: 10.1038/s41467-023-41537-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023] Open
Abstract
The bivalent (original and Omicron BA.4/BA.5) mRNA-1273 COVID-19 vaccine was authorized to offer broader protection against COVID-19. We conducted a matched cohort study to evaluate the effectiveness of the bivalent vaccine in preventing hospitalization for COVID-19 (primary outcome) and medically attended SARS-CoV-2 infection and hospital death (secondary outcomes). Compared to individuals who did not receive bivalent mRNA vaccination but received ≥2 doses of any monovalent mRNA vaccine, the relative vaccine effectiveness (rVE) against hospitalization for COVID-19 was 70.3% (95% confidence interval, 64.0%-75.4%). rVE was consistent across subgroups and not modified by time since last monovalent dose or number of monovalent doses received. Protection was durable ≥3 months after the bivalent booster. rVE against SARS-CoV-2 infection requiring emergency department/urgent care and against COVID-19 hospital death was 55.0% (50.8%-58.8%) and 82.7% (63.7%-91.7%), respectively. The mRNA-1273 bivalent booster provides additional protection against hospitalization for COVID-19, medically attended SARS-CoV-2 infection, and COVID-19 hospital death.
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Affiliation(s)
- Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA.
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, 91101, USA.
| | - Bradley K Ackerson
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Julia E Tubert
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Sijia Qiu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Gina S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - Jennifer H Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Harpreet S Takhar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Radha Bathala
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | | | | | | | | | - Carla A Talarico
- Moderna Inc., Cambridge, MA, 02139, USA
- AstraZeneca, Gaithersburg, MD, 20878, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
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12
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Lodise TP, Chen LH, Wei R, Im TM, Contreras R, Bruxvoort KJ, Rodriguez M, Friedrich L, Tartof SY. Clinical Risk Scores to Predict Nonsusceptibility to Trimethoprim-Sulfamethoxazole, Fluoroquinolone, Nitrofurantoin, and Third-Generation Cephalosporin Among Adult Outpatient Episodes of Complicated Urinary Tract Infection. Open Forum Infect Dis 2023; 10:ofad319. [PMID: 37534299 PMCID: PMC10390854 DOI: 10.1093/ofid/ofad319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/12/2023] [Indexed: 08/04/2023] Open
Abstract
Background Clinical risk scores were developed to estimate the risk of adult outpatients having a complicated urinary tract infection (cUTI) that was nonsusceptible to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolone, nitrofurantoin, or third-generation cephalosporin (3-GC) based on variables available on clinical presentation. Methods A retrospective cohort study (1 December 2017-31 December 2020) was performed among adult members of Kaiser Permanente Southern California with an outpatient cUTI. Separate risk scores were developed for TMP-SMX, fluoroquinolone, nitrofurantoin, and 3-GC. The models were translated into risk scores to quantify the likelihood of nonsusceptibility based on the presence of final model covariates in a given cUTI outpatient. Results A total of 30 450 cUTIs (26 326 patients) met the study criteria. Rates of nonsusceptibility to TMP-SMX, fluoroquinolone, nitrofurantoin, and 3-GC were 37%, 20%, 27%, and 24%, respectively. Receipt of prior antibiotics was the most important predictor across all models. The risk of nonsusceptibility in the TMP-SMX model exceeded 20% in the absence of any risk factors, suggesting that empiric use of TMP-SMX may not be advisable. For fluoroquinolone, nitrofurantoin, and 3-GC, clinical risk scores of 10, 7, and 11 predicted a ≥20% estimated probability of nonsusceptibility in the models that included cumulative number of prior antibiotics at model entry. This finding suggests that caution should be used when considering these agents empirically in patients who have several risk factors present in a given model at presentation. Conclusions We developed high-performing parsimonious risk scores to facilitate empiric treatment selection for adult outpatients with cUTIs in the critical period between infection presentation and availability of susceptibility results.
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Affiliation(s)
- Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Lie Hong Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Theresa M Im
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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13
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Ackerson B, Sy LS, Slezak J, Qian L, Reynolds K, Huang R, Solano Z, Towner W, Qiu S, Simmons SR, Jacobsen SJ, Bruxvoort KJ. 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. Vaccine 2023; 41:4392-4401. [PMID: 37308363 DOI: 10.1016/j.vaccine.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Bradley Ackerson
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA.
| | - Lina S Sy
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Jeff Slezak
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Lei Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Runxin Huang
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Zendi Solano
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - William Towner
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Sijia Qiu
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Sarah R Simmons
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Steven J Jacobsen
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Katia J Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL 35233, USA
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14
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Ku JH, Bruxvoort KJ, Salas SB, Varley CD, Casey JA, Raphael E, Robinson SC, Nachman KE, Lewin BJ, Contreras R, Wei RX, Pomichowski ME, Takhar HS, Tartof SY. Multidrug Resistance of Escherichia coli From Outpatient Uncomplicated Urinary Tract Infections in a Large United States Integrated Healthcare Organization. Open Forum Infect Dis 2023; 10:ofad287. [PMID: 37426945 PMCID: PMC10326677 DOI: 10.1093/ofid/ofad287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/19/2023] [Indexed: 07/11/2023] Open
Abstract
Background Urinary tract infections (UTIs) cause significant disease and economic burden. Uncomplicated UTIs (uUTIs) occur in otherwise healthy individuals without underlying structural abnormalities, with uropathogenic Escherichia coli (UPEC) accounting for 80% of cases. With recent transitions in healthcare toward virtual visits, data on multidrug resistance (MDR) (resistant to ≥3 antibiotic classes) by care setting are needed to inform empiric treatment decision making. Methods We evaluated UPEC resistance over time by care setting (in-person vs virtual), in adults who received outpatient care for uUTI at Kaiser Permanente Southern California between January 2016 and December 2021. Results We included 174 185 individuals who had ≥1 UPEC uUTI (233 974 isolates) (92% female, 46% Hispanic, mean age 52 years [standard deviation 20]). Overall, prevalence of UPEC MDR decreased during the study period (13% to 12%) both in virtual and in-person settings (P for trend <.001). Resistance to penicillins overall (29%), coresistance to penicillins and trimethoprim-sulfamethoxazole (TMP-SMX) (12%), and MDR involving the 2 plus ≥1 antibiotic class were common (10%). Resistance to 1, 2, 3, and 4 antibiotic classes was found in 19%, 18%, 8%, and 4% of isolates, respectively; 1% were resistant to ≥5 antibiotic classes, and 50% were resistant to none. Similar resistance patterns were observed over time and by care setting. Conclusions We observed a slight decrease in both class-specific antimicrobial resistance and MDR of UPEC overall, most commonly involving penicillins and TMP-SMX. Resistance patterns were consistent over time and similar in both in-person and virtual settings. Virtual healthcare may expand access to UTI care.
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Affiliation(s)
- Jennifer H Ku
- Correspondence: Jennifer H. Ku, PhD, MPH, Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101 ()
| | - Katia J Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - S Bianca Salas
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Cara D Varley
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Oregon Health & Science University-Portland State University, School of Public Health, Portland, Oregon, USA
| | - Joan A Casey
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
| | - Eva Raphael
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sarah C Robinson
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Keeve E Nachman
- Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bruno J Lewin
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Kaiser Permanente Southern California and Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rong X Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Magdalena E Pomichowski
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Harpreet S Takhar
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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15
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Ku JH, Sy LS, Qian L, Ackerson BK, Luo Y, Tubert JE, Lee GS, Florea A, Bruxvoort KJ, Xie F, Qiu S, Chavers S, Talarico CA, Tseng HF. Effectiveness of a fourth dose of mRNA-1273 against COVID-19 among older adults in the United States: Interim results from an observational cohort study. Vaccine 2023:S0264-410X(23)00668-0. [PMID: 37301708 DOI: 10.1016/j.vaccine.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/05/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023]
Abstract
We evaluated relative vaccine effectiveness (rVE) of 4- vs. 3-dose mRNA-1273 against SARS-CoV-2 infection, and COVID-19 hospitalization and death in immunocompetent adults aged ≥50 years at Kaiser Permanente Southern California. We included 178,492 individuals who received a fourth dose of mRNA-1273, and 178,492 randomly selected 3-dose recipients who were matched to 4-dose recipients by age, sex, race/ethnicity, and third dose date. Adjusted 4- vs. 3-dose rVE against SARS-CoV-2 infection, COVID-19 hospitalization, and COVID-19 hospitalization death were 25.9 % (23.5 %, 28.2 %), 67.3 % (58.7 %, 74.1 %), and 72.5 % (-35.9 %, 95.2 %), respectively. Adjusted rVE against SARS-CoV-2 infection ranged between 19.8 % and 39.1 % across subgroups. Adjusted rVE against SARS-CoV-2 infection and COVID-19 hospitalization decreased 2-4 months after the fourth dose. Four mRNA-1273 doses provided significant protection against COVID-19 outcomes compared with 3 doses, consistent in various subgroups of demographic and clinical characteristics, although rVE varied and waned over time.
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Affiliation(s)
- Jennifer H Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA.
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Bradley K Ackerson
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Julia E Tubert
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Gina S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA; Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Fagen Xie
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Sijia Qiu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | | | | | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA 91101, USA
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Florea A, Casey JA, Nachman K, Price LB, Pomichowski ME, Takhar HS, Quinlivan V, Childs LD, Davis MF, Wei R, Hong V, Ku JH, Liu CM, Pressman A, Robinson S, Bruxvoort KJ, Salas SB, Tartof SY. Impact of California's Senate Bill 27 on Antimicrobial-Resistant Escherichia coli Urinary Tract Infection in Humans: Protocol for a Study of Methods and Baseline Data. JMIR Res Protoc 2023; 12:e45109. [PMID: 37145842 PMCID: PMC10199382 DOI: 10.2196/45109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/17/2023] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Overuse of antibiotics contributes to antimicrobial resistance (AMR) and is a growing threat to human health worldwide. Previous work suggests a link between antimicrobial use in poultry and human AMR extraintestinal pathogenic Escherichia coli (E coli) urinary tract infections (UTIs). However, few US-based studies exist, and none have comprehensively assessed both foodborne and environmental pathways using advanced molecular and spatial epidemiologic methods in a quasi-experimental design. Recently, California enacted Senate Bill 27 (SB27), which changed previous policy to require a veterinarian's prescription for the use of antibiotic drugs, and which banned antibiotic use for disease prevention in livestock. This provided an opportunity to evaluate whether SB27 will result in a reduction in antimicrobial-resistant infections in humans. OBJECTIVE We describe in detail the methods implemented to achieve the overarching objective of this study to evaluate the impact of SB27 on downstream antibiotic resistance rates in human UTIs. METHODS A summary of the overall approach and the partnerships between Columbia University, George Washington University (GWU), Johns Hopkins Bloomberg School of Public Health, Kaiser Permanente Southern California (KPSC) Research and Evaluation, the Natural Resources Defense Council, Sanger Institute at Stanford University, Sutter Health Center for Health Systems Research, the University of Cambridge, and the University of Oxford is presented. The collection, quality control testing, and shipment of retail meat and clinical samples are described. Retail meat (chicken, beef, turkey, and pork) was purchased from stores throughout Southern California from 2017 to 2021. After processing at KPSC, it was shipped to GWU for testing. From 2016 to 2021, after clinical specimens were processed for routine clinical purposes and immediately before discarding, those with isolated colonies of E coli, Campylobacter, and Salmonella from KPSC members were collected and processed to be shipped for testing at GWU. Detailed methods of the isolation and testing as well as the whole-genome sequencing of the meat and clinical samples at GWU are described. KPSC electronic health record data were used to track UTI cases and AMR patterns among the cultured specimens. Similarly, Sutter Health electronic health record data were used to track UTI cases in its Northern California patient population. RESULTS From 2017 to 2021, overall, 12,616 retail meat samples were purchased from 472 unique stores across Southern California. In addition, 31,643 positive clinical cultures were collected from KPSC members during the same study period. CONCLUSIONS Here, we presented data collection methods for the study, which was conducted to evaluate the impact of SB27 on downstream antibiotic resistance rates in human UTI. To date, it is one of the largest studies of its kind to be conducted. The data collected during this study will be used as the foundation for future analyses specific to the various objectives of this large body of work. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/45109.
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Affiliation(s)
- Ana Florea
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Joan A Casey
- Columbia University Mailman School of Public Health, New York City, NY, United States
| | - Keeve Nachman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Lance B Price
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Magdalena E Pomichowski
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Harpreet S Takhar
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Vanessa Quinlivan
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Lee D Childs
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Meghan F Davis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Rong Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Vennis Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Jennifer H Ku
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Cindy M Liu
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Alice Pressman
- Center for Health Systems Research, Sutter Health, Walnut Creek, CA, United States
| | - Sarah Robinson
- Center for Health Systems Research, Sutter Health, Walnut Creek, CA, United States
| | - Katia J Bruxvoort
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - S Bianca Salas
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, United States
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17
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Ku JH, Sy LS, Qian L, Ackerson BK, Luo Y, Tubert JE, Lee GS, Florea A, Bruxvoort KJ, Talarico CA, Qiu S, Tian Y, Tseng HF. Vaccine effectiveness of the mRNA-1273 3-dose primary series against COVID-19 in an immunocompromised population: A prospective observational cohort study. Vaccine 2023:S0264-410X(23)00498-X. [PMID: 37173268 PMCID: PMC10154542 DOI: 10.1016/j.vaccine.2023.04.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Data on the effectiveness of the 3-dose mRNA-1273 primary series are limited, particularly in comparison to 2 doses. Given suboptimal COVID-19 vaccine uptake among immunocompromised populations, it is important to monitor the effectiveness of fewer than the recommended doses in this population. METHODS We conducted a matched cohort study at Kaiser Permanente Southern California to evaluate the relative vaccine effectiveness (rVE) of the 3-dose series vs 2 doses of mRNA-1273 in preventing SARS-CoV-2 infection and severe COVID-19 outcomes among immunocompromised individuals. RESULTS We included 21,942 3-dose recipients who were 1:1 matched with randomly selected 2-dose recipients (third doses accrued 08/12/2021-12/31/2021, with follow-up through 01/31/2022). Adjusted rVE of 3 vs 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. CONCLUSION Three doses of mRNA-1273 were associated with a significantly higher rVE against SARS-CoV-2 infection and severe outcomes, compared to 2 doses. These findings were consistent across subgroups of demographic and clinical characteristics, and mostly consistent across subgroups of immunocompromising conditions. Our study highlights the importance of completing the 3-dose series for immunocompromised populations.
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Affiliation(s)
- Jennifer H Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA.
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Bradley K Ackerson
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Julia E Tubert
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Gina S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA; Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL 35233, USA
| | | | - Sijia Qiu
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Yun Tian
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA
| | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S. Los Robles Ave., Pasadena, CA 91101, USA
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18
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Bruxvoort KJ, Skarbinski J, Fischer H, Li Z, Eaton A, Qian L, Spence B, Wei R, Rieg G, Shaw S, Tartof SY. Latent Tuberculosis Infection Treatment Practices in Two Large Integrated Health Systems in California, 2009-2018. Open Forum Infect Dis 2023; 10:ofad219. [PMID: 37265669 PMCID: PMC10230566 DOI: 10.1093/ofid/ofad219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/19/2023] [Indexed: 06/03/2023] Open
Abstract
Background Treatment of latent tuberculosis infection (LTBI) is highly effective at preventing active tuberculosis (TB) disease. Understanding LTBI treatment practices in US health system settings is critical to identify opportunities to improve treatment prescription, initiation, and completion, and thus to prevent TB disease. Methods We assessed LTBI treatment practices among a cohort of adults after their first positive LTBI test (tuberculin skin test [TST] or interferon gamma release assay [IGRA]) between 2009 and 2018 at 2 large integrated health systems in California. We described the prescription, initiation, and completion of LTBI treatment (isoniazid [INH], rifampin, and rifamycin-INH short-course combinations) by demographic and clinical characteristics. We used multivariable robust Poisson regression to examine factors that were independently associated with treatment prescription and completion. Results Among 79 302 individuals with a positive LTBI test, 33.0% were prescribed LTBI treatment, 28.3% initiated treatment, and 18.5% completed treatment. Most individuals were prescribed INH (82.0%), but treatment completion was higher among those prescribed rifamycin-INH short-course combinations (69.6% for INH + rifapentine and 70.3% for INH + rifampin) compared with those prescribed INH (56.3%) or rifampin (56.6%). In adjusted analyses, treatment prescription and completion were associated with older age, female sex, more comorbidities, immunosuppression, not being born in a high-TB incidence country, and testing positive with IGRA vs TST. Conclusions LTBI treatment is underutilized, requiring tailored interventions to support treatment prescription and completion for patients with LTBI.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Epidemiology, School of Public Health,University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
| | - Heidi Fischer
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Zhuoxin Li
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Abigail Eaton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lei Qian
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Brigitte Spence
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Rong Wei
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Gunter Rieg
- Department of Infectious Diseases, South Bay Medical Center, Kaiser Permanente Southern California, Harbor City, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Sally Shaw
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Sara Y Tartof
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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19
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Bruxvoort KJ, Lewnard JA, Chen LH, Tseng HF, Chang J, Veltman J, Marrazzo J, Qian L. Prevention of Neisseria gonorrhoeae With Meningococcal B Vaccine: A Matched Cohort Study in Southern California. Clin Infect Dis 2023; 76:e1341-e1349. [PMID: 35642527 DOI: 10.1093/cid/ciac436] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/18/2022] [Accepted: 05/26/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Neisseria gonorrhoeae is acquiring increasing resistance to available oral antibiotics, and current screening and treatment approaches have not decreased gonorrhea incidence. Although a gonorrhea-specific vaccine does not exist, N. gonorrhoeae shares much of its genome with Neisseria meningitidis, notably critical antigenic determinants including outer membrane vesicles (OMV). Prior observational studies have suggested that OMV-based meningococcal serogroup B vaccines confer protection against gonorrhea. METHODS We conducted a matched cohort study from 2016 to 2020 to examine the association of OMV-containing recombinant meningococcal serogroup B vaccine (4CMenB) with gonorrhea infection among teens and young adults at Kaiser Permanente Southern California. Recipients of 4CMenB were matched in a ratio of 1:4 to recipients of non-OMV-containing polysaccharide-conjugate vaccine targeting serotypes A, C, W, and Y (MenACWY) who had not received 4CMenB and were followed for incident gonorrhea. We used Cox proportional hazards regression to compare gonorrhea rates among recipients of 4CMenB vs MenACWY, adjusting for potential confounders. We conducted the same analysis with chlamydia as a negative control outcome. RESULTS The study included 6641 recipients of 4CMenB matched to 26 471 recipients of MenACWY. During follow-up, gonorrhea incidence rates per 1000 person-years (95% confidence intervals [CIs]) were 2.0 (1.3-2.8) for recipients of 4CMenB and 5.2 (4.6-5.8) for recipients of MenACWY. In adjusted analyses, gonorrhea rates were 46% lower among recipients of 4CMenB vs MenACWY (hazard ratio [HR], 0.54; 95% CI, .34-.86), but chlamydia rates were similar between vaccine groups (HR, 0.98; 95% CI, .82-1.17). CONCLUSIONS These results suggest cross-protection of 4CMenB against gonorrhea, supporting the potential for vaccination strategies to prevent gonorrhea.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California-Berkeley, Berkeley, California, USA.,Division of Infectious Diseases & Vaccinology, School of Public Health, University of California-Berkeley, Berkeley, California, USA.,Center for Computational Biology, College of Engineering, University of California-Berkeley, Berkeley, California, USA
| | - Lie H Chen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Hung Fu Tseng
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Jennifer Chang
- Department of Infectious Diseases, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Jennifer Veltman
- Division of Infectious Diseases, Loma Linda University Health School of Medicine, Loma Linda, CA, USA
| | - Jeanne Marrazzo
- Division of Infectious Diseases, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Lei Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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20
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Tseng HF, Ackerson BK, Bruxvoort KJ, Sy LS, Tubert JE, Lee GS, Ku JH, Florea A, Luo Y, Qiu S, Choi SK, Takhar HS, Aragones M, Paila YD, Chavers S, Talarico CA, Qian L. Effectiveness of mRNA-1273 vaccination against SARS-CoV-2 omicron subvariants BA.1, BA.2, BA.2.12.1, BA.4, and BA.5. Nat Commun 2023; 14:189. [PMID: 36635284 PMCID: PMC9836332 DOI: 10.1038/s41467-023-35815-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/03/2023] [Indexed: 01/14/2023] Open
Abstract
Studies have reported reduced natural SARS-CoV-2 infection- and vaccine-induced neutralization against omicron BA.4/BA.5 compared with earlier omicron subvariants. This test-negative case-control study evaluates mRNA-1273 vaccine effectiveness (VE) against infection and hospitalization with omicron subvariants. The study includes 30,809 SARS-CoV-2 positive and 92,427 SARS-CoV-2 negative individuals aged ≥18 years tested during 1/1/2022-6/30/2022. While 3-dose VE against BA.1 infection is high and wanes slowly, VE against BA.2, BA.2.12.1, BA.4, and BA.5 infection is initially moderate to high (61.0%-90.6% 14-30 days post third dose) and wanes rapidly. The 4-dose VE against infection with BA.2, BA.2.12.1, and BA.4 ranges between 64.3%-75.7%, and is low (30.8%) against BA.5 14-30 days post fourth dose, disappearing beyond 90 days for all subvariants. The 3-dose VE against hospitalization for BA.1, BA.2, and BA.4/BA.5 is 97.5%, 82.0%, and 72.4%, respectively; 4-dose VE against hospitalization for BA.4/BA.5 is 88.5%. Evaluation of the updated bivalent booster is warranted.
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Affiliation(s)
- Hung Fu Tseng
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA. .,Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S. Los Robles Ave., Pasadena, CA, 91101, USA.
| | - Bradley K Ackerson
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Katia J Bruxvoort
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA.,University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL, 35233, USA
| | - Lina S Sy
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Julia E Tubert
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Gina S Lee
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Jennifer H Ku
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Ana Florea
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Yi Luo
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Sijia Qiu
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Soon Kyu Choi
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Harpreet S Takhar
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Michael Aragones
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
| | - Yamuna D Paila
- Moderna, Inc., 200 Technology Square, Cambridge, MA, 02139, USA
| | - Scott Chavers
- Moderna, Inc., 200 Technology Square, Cambridge, MA, 02139, USA
| | - Carla A Talarico
- Moderna, Inc., 200 Technology Square, Cambridge, MA, 02139, USA.,AstraZeneca, 1 Medimmune Way, Gaithersburg, MD, 20878, USA
| | - Lei Qian
- Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA, 91101, USA
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21
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Ku JH, Sy LS, Qian L, Ackerson B, Luo Y, Tubert J, Lee G, Florea A, Bruxvoort KJ, Talarico C, Qiu S, Tian Y, Tseng HF. 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. Open Forum Infect Dis 2022. [PMCID: PMC9752185 DOI: 10.1093/ofid/ofac492.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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 2nd 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 3rd 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 3rd 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.
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Affiliation(s)
- Jennifer H Ku
- Kaiser Permanente Southern California, Pasadena, California
| | - Lina S Sy
- Kaiser Permanente Southern California, Pasadena, California
| | - Lei Qian
- Kaiser Permanente Southern California, Pasadena, California
| | | | - Yi Luo
- Kaiser Permanente Southern California, Pasadena, California
| | - Julia Tubert
- Kaiser Permanente Southern California, Pasadena, California
| | - Gina Lee
- Kaiser Permanente Southern California, Pasadena, California
| | - Ana Florea
- Kaiser Permanente Southern California, Pasadena, California
| | | | | | - Sijia Qiu
- Kaiser Permanente Southern California, Pasadena, California
| | - Yun Tian
- Kaiser Permanente Southern California, Pasadena, California
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Dionne J, Pol BVD, Long D, Tih P, Mbah R, Ngah E, Pekwarake S, Kifem M, Fondzeyuf A, Bruxvoort KJ, Tita A, Marrazzo J. 219. A Randomized, Double-Masked, Placebo-Controlled Phase IIB Trial of Azithromycin and Trimethoprim-Sulfamethoxazole as Bacterial STI Prophylaxis in Pregnant Women with HIV. Open Forum Infect Dis 2022. [PMCID: PMC9752407 DOI: 10.1093/ofid/ofac492.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background This phase IIB randomized clinical trial was designed to test the efficacy of a novel regimen to prevent bacterial sexually transmitted infections and malaria in pregnant women with HIV in Cameroon, where HIV prevalence in pregnancy is 5.7%. Here we present the analysis of STI rates. Methods Pregnant women in prenatal care with confirmed HIV, gestational age < 28 weeks and singleton pregnancies were randomized to monthly azithromycin (AZ) 1 gram daily for 3 days and daily trimethoprim-sulfamethoxazole (TMPS) or the standard regimen of daily TMPS with monthly placebo AZ. The main outcome of interest was the proportion of women with a composite STI measure: chlamydia, gonorrhea and/or incident syphilis at delivery. Nucleic acid amplification testing (NAAT) for CT/NG was performed on provider-collected vaginal swabs. Incident syphilis was defined serologically as a newly positive treponemal test or 4 fold increase in RPR/VDRL titer since baseline. The proportion was compared by relative risk with 95% confidence intervals and a significant p value set at < 0.05. Results A total of 308 women were enrolled at three hospital facilities between March 2018 and August 2020. In all, 155 women were randomized to the AZ/TMPS arm and 153 women to the TMPS arm. A total of 260 women (84%) had delivery samples collected. Both groups were similar with median age 32 years, maternal education (71% secondary school or university), HIV diagnosis 3 years prior, and 94% reported excellent adherence to antiretroviral therapy (ART). Median CD4 count was 473 cells/mm3 (IQR 326-663). At baseline, prevalence of chlamydia was 1.4%, gonorrhea 1.0% and syphilis 1.9%. There was no difference in the proportion of women with the composite STI measure (3.2% in the AZ/TMPS arm and 3.3% in the TMPS arm; RR 0.78 (95% CI 0.21 – 2.84); p=0.70). Adverse birth outcomes were lower in the AZ/TMPS arm, but not significantly (preterm delivery 5% vs 10.3% [p=0.1], low birthweight 2.8% vs 5.1% [p=0.34], composite adverse birth outcome 8.4% vs 13.1% [p=0.19].
Baseline Characteristics of Study Participants (n=308) ![]() Efficacy Outcomes at Delivery by Arm - Intention to Treat Analysis (n= 278) ![]() Conclusion The addition of monthly azithromycin to standard daily TMPS prophylaxis in pregnant women living with HIV in Cameroon did not reduce the rate of bacterial STI at delivery. Women reported excellent ART adherence and rates of STI, malaria, and adverse birth outcome were low. Disclosures 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.
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Affiliation(s)
- Jodie Dionne
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Pius Tih
- CBCHS, Bamenda, Nord-Ouest, Cameroon
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Ackerson B, Sy LS, Slezak J, Qian L, Reynolds K, Huang R, Solano Z, Towner W, Qiu S, Simmons S, Jacobsen S, Bruxvoort KJ. 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. Open Forum Infect Dis 2022. [PMCID: PMC9752391 DOI: 10.1093/ofid/ofac492.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Lina S Sy
- Kaiser Permanente Southern California, Pasadena, California
| | - Jeff Slezak
- Kaiser Permanente Southern California, Pasadena, California
| | - Lei Qian
- Kaiser Permanente Southern California, Pasadena, California
| | | | - Runxin Huang
- Kaiser Permanente Southern California, Pasadena, California
| | - Zendi Solano
- Kaiser Permanente Southern California, Pasadena, California
| | - William Towner
- Kaiser Permanente Southern California, Pasadena, California
| | - Sijia Qiu
- Kaiser Permanente Southern California, Pasadena, California
| | - Sarah Simmons
- Kaiser Permanente Southern California, Pasadena, California
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Lodise TP, Chen LHH, Bruxvoort KJ, Wei R, Im TM, Contreras R, Rodriguez M, Friedrich L, Reese J, Tartof SY. 2232. Association between Inappropriate Empiric Therapy (IET) and 30-Day Emergency Department/Inpatient (ED/IP) Visits Among Adult Outpatients (OPs) with Complicated Urinary Tract Infections (cUTIs). Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Deleterious outcomes associated with IET are well documented among hospitalized patients with infections. However, scant data exist on the consequences of IET among adult OPs with cUTIs. This study evaluated the association between receipt of IET and 30-day ED/IP visits among adult OPs with cUTIs.
Methods
Retrospective cohort study among Kaiser Permanente Southern California members from 2017-20. Inclusion criteria were age ≥18 years; cUTI diagnosis during an OP visit; positive urine culture with antibiotic (AB) susceptibility results; receipt of AB ±3 days of index urine culture; and not hospitalized on day of OP visit. For OPs with multiple cUTIs, only the index cUTI was considered. IET was defined as failure to receive an AB with in vitro microbiologic activity against all recovered cUTI pathogens ±3 days of culture collection date. Outcomes included all-cause and cUTI-related ED/IP visits ≥3 days to ≤30 days from index culture date. Logistic regression was used to adjust for baseline differences between appropriateness groups.
Results
During study period, 25,980 OPs with cUTIs met study criteria. Mean age was 60 years, majority female (57%), and E. coli (66%) was the most common pathogen. IET was noted in 2656 (10%) of patients. Comparison of baseline characteristics between appropriateness groups is shown in Table. Comparison of 30-day all-cause and cUTI-related ED/IP visits between IET and appropriate empiric therapy (AET) is shown in Figure. In the logistic regression, receipt of IET was associated with an increase odds of 30-day all-cause ED/IP visits (adjusted odds ratio (aOR)= 1.3; 95% CI: 1.2-1.4) and 30-day cUTI-related ED/IP visits (aOR=1.5; 95% CI: 1.4-1.7), respectively. Figure
Conclusion
Thirty-day all-cause and cUTI-related ED/IP visits were significantly higher among adult OPs with cUTI who received IET. As culture and susceptibility results are frequently unknown at the time of empiric therapy selection, the findings highlight the critical need to use institution-specific antibiotic resistance risk stratification tools, in tandem with rapid diagnostic tests, to guide empiric antibiotic decisions among OPs with cUTIs as measures to ensure patients receive AET and maximize chances of a successful clinical outcome.
Disclosures
Thomas P. Lodise, PharmD, PhD, Spero Therapeutics: Advisor/Consultant Lie Hong H. Chen, DrPH, MSPH, Spero Therapeutics: 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 Rong Wei, MA, Spero Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support Theresa M. Im, MPH, Spero Therapeutics: Grant/Research Support Richard Contreras, MS, Spero Therapeutics: Grant/Research Support Mauricio Rodriguez, PharmD, MS-HEOR, BCPS, BCCCP, BCIDP, Spero Therapeutics: Employee Larry Friedrich, PharmD, Spero Therapeutics: Employee Jennifer Reese, PharmD, Spero Therapeutics: Employee Sara Y. Tartof, PhD MPH, Pfizer: Grant/Research Support|Spero: Grant/Research Support.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences , Albany, New York
| | - Lie Hong H Chen
- Kaiser Permanente Southern California Department of Research & Evaluation , Pasadena, California
| | | | - Rong Wei
- Kaiser Permanente Southern California Department of Research & Evaluation , Pasadena, California
| | - Theresa M Im
- Kaiser Permanente Southern California Department of Research & Evaluation , Pasadena, California
| | - Richard Contreras
- Kaiser Permanente Southern California Department of Research & Evaluation , Pasadena, California
| | | | | | | | - Sara Y Tartof
- Kaiser Permanente Southern California , Pasadena, California
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Lodise TP, Chen LHH, Bruxvoort KJ, Wei R, Im TM, Contreras R, Rodriguez M, Friedrich L, Reese J, Tartof SY. 2233. Clinical Risk Scores (CRSs) to Predict Resistance to Trimethoprim-Sulfamethoxazole (TMP-SMX), Fluoroquinolone (FQ), Nitrofurantoin (NIT), or Third Generation Cephalosporins (3GC) among Adult Outpatients (OPs) with Complicated Urinary Tract Infections (cUTIs). Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Increased resistance rates to available oral antibiotics (ABs) contribute to delays in receipt of appropriate treatment and adverse outcomes among patients with cUTI in the OP setting. To optimize empiric AB selection in adult OPs with cUTIs, we developed CRSs using information available at presentation to estimate the risk of having a cUTI that was resistant to TMP-SMX, FQ, NIT, or 3GC.
Methods
Retrospective cohort study among Kaiser Permanente Southern California members from 2017-2020. Inclusion criteria: age ≥18 yrs; cUTI diagnosis during an OP visit; positive urine culture with antibiotic susceptibility results; receipt of antibiotic ±3 days of index urine culture, and not hospitalized on day of OP visit. Resistance to TMP-SMX, FQ, NIT, and 3GC on index urine culture was quantified. OPs were randomly split (60:40) into training and validation datasets. Covariates present on clinical presentation were collected. Least absolute shrinkage and selection operator logistic regression (LR) were used to develop separate models to estimate the likelihood of resistance to TMP-SMX, FQ, NIT, and 3GC. The prediction models were developed using training and validation datasets. For all 4 LR models, CRSs were calculated as the weighted sums of regression coefficients. Variables in each of the final LR models were assigned point(s), and an OP’s CRS for cUTI resistant to TMP-SMX, FQ, NIT, or 3GC was based on total points in each of the respective models.
Results
A total of 30,450 cUTIs among 26,326 OPs met study criteria. Mean age was 61, 54% were female, and E. coli (66%) was the most common pathogen. Resistance to TMP-SMX, FQ, NIT, and 3GC was 37%, 27%, 24%, and 19%, respectively. Baseline covariates and associated points for the 4 LR models are shown in Table 1. A CRS of 0, 5, 8, 12 corresponded to a >20% risk of resistance to TMP-SMX, FQ, NIT, or 3GC, respectively (Figure 1). Table 1.Baseline Clinical Covariates and Associated Point Values in Each of the 4 Clinical Risk Scores Covariates in each of the Final ResistanceFigure 1.Clinical Risk Scores for Resistance to TMP-SMX, FQ, NIT, and 3GC
Conclusion
We developed a high-performing parsimonious CRS to aid clinicians in appropriate treatment selection of adult OPs with cUTI. This tool can be used to facilitate empiric antibiotic selection and ensure adult OPs with cUTI have a greater probability of receiving early appropriate therapy. Given its high baseline resistance, TMP/SMX should not be considered for empiric therapy.
Disclosures
Thomas P. Lodise, PharmD, PhD, Spero Therapeutics: Advisor/Consultant Lie Hong H. Chen, DrPH, MSPH, Spero Therapeutics: 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 Rong Wei, MA, Spero Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support Theresa M. Im, MPH, Spero Therapeutics: Grant/Research Support Richard Contreras, MS, Spero Therapeutics: Grant/Research Support Mauricio Rodriguez, PharmD, MS-HEOR, BCPS, BCCCP, BCIDP, Spero Therapeutics: Employee Larry Friedrich, PharmD, Spero Therapeutics: Employee Jennifer Reese, PharmD, Spero Therapeutics: Employee Sara Y. Tartof, PhD MPH, Pfizer: Grant/Research Support|Spero: Grant/Research Support.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences , Albany, New York
| | - Lie Hong H Chen
- Kaiser Permanente Southern California Department of Research & Evaluation , Pasadena, California
| | | | - Rong Wei
- Kaiser Permanente Southern California Department of Research & Evaluation , Pasadena, California
| | - Theresa M Im
- Kaiser Permanente Southern California Department of Research & Evaluation , Pasadena, California
| | - Richard Contreras
- Kaiser Permanente Southern California Department of Research & Evaluation , Pasadena, California
| | | | | | | | - Sara Y Tartof
- Kaiser Permanente Southern California , Pasadena, California
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26
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Chang JJ, Chen Q, Dionne-Odom J, Hechter RC, Bruxvoort KJ. Changes in Testing and Diagnoses of Sexually Transmitted Infections and HIV During the COVID-19 Pandemic. Sex Transm Dis 2022; 49:851-854. [PMID: 35470350 PMCID: PMC9668362 DOI: 10.1097/olq.0000000000001639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/16/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT We evaluated changes in rates of testing and diagnoses of sexually transmitted infections during the 2017-2020 period at Kaiser Permanente Southern California. During the COVID-19 pandemic period, we observed profound reductions in testing and fewer diagnoses of chlamydia, gonorrhea, and HIV compared with prepandemic periods, but syphilis diagnoses rates increased by 32%.
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Affiliation(s)
- Jennifer J. Chang
- From the Department of Infectious Diseases, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles
| | - Qiaoling Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Jodie Dionne-Odom
- Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Rulin C. Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Katia J. Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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Choi KR, Cohen CC, Bruxvoort KJ. Getting the Message Right: Nurses and Vaccine Hesitancy. Am J Public Health 2022; 112:1576-1578. [DOI: 10.2105/ajph.2022.307092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Kristen R. Choi
- Kristen R. Choi and Katia J. Bruxvoort are with the Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena. Kristen R. Choi is also with the University of California, Los Angeles (UCLA) School of Nursing and the Department of Health Policy and Management, UCLA Fielding School of Public Health. Catherine C. Cohen is with the RAND Corporation, Santa Monica, CA. Katia J. Bruxvoort is also with the Department of Epidemiology, School of Public Health, University of Alabama at
| | - Catherine C. Cohen
- Kristen R. Choi and Katia J. Bruxvoort are with the Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena. Kristen R. Choi is also with the University of California, Los Angeles (UCLA) School of Nursing and the Department of Health Policy and Management, UCLA Fielding School of Public Health. Catherine C. Cohen is with the RAND Corporation, Santa Monica, CA. Katia J. Bruxvoort is also with the Department of Epidemiology, School of Public Health, University of Alabama at
| | - Katia J. Bruxvoort
- Kristen R. Choi and Katia J. Bruxvoort are with the Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena. Kristen R. Choi is also with the University of California, Los Angeles (UCLA) School of Nursing and the Department of Health Policy and Management, UCLA Fielding School of Public Health. Catherine C. Cohen is with the RAND Corporation, Santa Monica, CA. Katia J. Bruxvoort is also with the Department of Epidemiology, School of Public Health, University of Alabama at
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Florea A, Sy LS, Qian L, Ackerson BK, Luo Y, Tubert JE, Lee GS, Ku JH, Bruxvoort KJ, Talarico CA, Qiu S, Tian Y, Tseng HF. Effectiveness of Messenger RNA-1273 Vaccine Booster Against Coronavirus Disease 2019 in Immunocompetent Adults. Clin Infect Dis 2022; 76:252-262. [PMID: 36134518 PMCID: PMC9619452 DOI: 10.1093/cid/ciac785] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/12/2022] [Accepted: 09/19/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND We conducted a prospective cohort study at Kaiser Permanente Southern California to evaluate the relative vaccine effectiveness (rVE) of a booster dose vs 2-dose primary series of messenger RNA (mRNA)-1273 in immunocompetent individuals. METHODS Immunocompetent adults who received a booster dose of mRNA-1273 from October 2021 through December 2021 were matched 1:1 to randomly selected 2-dose mRNA-1273 recipients by age, sex, race/ethnicity, and second-dose date and followed up through January 2022. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs), comparing outcomes (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection and coronavirus disease 2019 [COVID-19] hospitalization and hospital death) in the booster-dose and 2-dose groups. Adjusted rVE (%) was calculated as (1 - aHR) × 100. aHRs and rVE were also estimated by subgroup and month of follow-up. RESULTS The study included 431 328 booster-dose vaccinated adults matched to 431 328 2-dose vaccinated adults. rVE was 61.3% (95% CI: 60.5%-62.2%) against SARS-CoV-2 infection, 89.0% (86.2%-91.2%) against COVID-19 hospitalization, and 96.0% (68.0%-99.5%) against COVID-19 hospital death. rVE against SARS-CoV-2 infection ranged from 55.6% to 66.7% across all subgroups. rVE against SARS-CoV-2 infection decreased from 67.1% (0 to <1 month of follow-up) to 30.5% (2 to <3 months). For COVID-19 hospitalization, rVE decreased from 91.2% (0 to <1 month) to 78.7% (2 to <3 months). CONCLUSIONS Among immunocompetent adults, the mRNA-1273 booster conferred additional protection against SARS-CoV-2 infection and severe COVID-19 disease compared with the 2-dose mRNA-1273 primary series during periods of Delta and Omicron predominance.
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Affiliation(s)
- Ana Florea
- Correspondence: A. Florea, Kaiser Permanente Southern California, 100 S Los Robles, Pasadena, CA 91101, USA ()
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Bradley K Ackerson
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Julia E Tubert
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Gina S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jennifer H Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA,Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Carla A Talarico
- Infectious Disease, Clinical Development, Moderna, Inc, Cambridge, Massachusetts, USA
| | - Sijia Qiu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Yun Tian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Hechter RC, Bruxvoort KJ, Zhou H, Towner WJ, Contreras R, Schumacher CM, Grant DL, Jones J. Sexually Transmitted Infections Among Men and Transgender Women Using HIV Pre-exposure Prophylaxis in a Large Integrated Health System-A Cohort Study. J Acquir Immune Defic Syndr 2022; 91:1-8. [PMID: 35499561 DOI: 10.1097/qai.0000000000003015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sexually transmitted infections (STIs) are common in people using pre-exposure prophylaxis (PrEP). We examined risk and factors associated with STIs in a cohort of PrEP users in an integrated health system in the United States. SETTING The Kaiser Permanente Southern California is a large integrated health system that provides comprehensive medical services to approximately 4.7 million demographically diverse members. METHODS We identified men and transgender women initiating PrEP between January 1, 2014, and June 1, 2018, and followed through December 31, 2018. Demographic and clinical factors potentially associated with the risk of bacterial STIs during PrEP use were evaluated using Poisson regression models. RESULTS Among 5042 individuals tested for STIs with 7198 person-years of follow-up, 1709 (33.9%) had at least one new STI. The estimated incidence of STIs was 48.3 per 100 person-years, and the most common STI was rectal chlamydia. Most repeat STIs (61.4%) occurred <180 days apart. In a multivariable analysis, an history of STIs in the prior 6 months through 7 days after the PrEP initiation was the most prominent risk factor of STIs during PrEP use (adjusted risk ratio: 1.78, 95% confidence intervals: 1.65 to 1.93). Other risk factors included younger age (<35 years), being Hispanic, and having a history of alcohol use disorder or drug use disorder. CONCLUSIONS Quarterly STI testing and targeted intervention to mitigate STI risk are warranted for young and racial minority PrEP users, particularly for those with prior history of STIs and substance use disorders.
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Affiliation(s)
- Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - William J Towner
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Christina M Schumacher
- Department of Pediatrics, Center for Child and Community Health Research, John Hopkins University School of Medicine, Baltimore, MD; and
| | - Deborah L Grant
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Joyce Jones
- Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, MD
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Fischer H, Qian L, Skarbinski J, Bruxvoort KJ, Wei R, Li K, Amsden LB, Wood MS, Eaton A, Spence BC, Shaw SF, Tartof SY. Development and validation of a prediction algorithm to identify birth in countries with high tuberculosis incidence in two large California health systems. PLoS One 2022; 17:e0273363. [PMID: 36006985 PMCID: PMC9409495 DOI: 10.1371/journal.pone.0273363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/07/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Though targeted testing for latent tuberculosis infection ("LTBI") for persons born in countries with high tuberculosis incidence ("HTBIC") is recommended in health care settings, this information is not routinely recorded in the electronic health record ("EHR"). We develop and validate a prediction model for birth in a HTBIC using EHR data. MATERIALS AND METHODS In a cohort of patients within Kaiser Permanente Southern California ("KPSC") and Kaiser Permanent Northern California ("KPNC") between January 1, 2008 and December 31, 2019, KPSC was used as the development dataset and KPNC was used for external validation using logistic regression. Model performance was evaluated using area under the receiver operator curve ("AUCROC") and area under the precision and recall curve ("AUPRC"). We explored various cut-points to improve screening for LTBI. RESULTS KPSC had 73% and KPNC had 54% of patients missing country-of-birth information in the EHR, leaving 2,036,400 and 2,880,570 patients with EHR-documented country-of-birth at KPSC and KPNC, respectively. The final model had an AUCROC of 0.85 and 0.87 on internal and external validation datasets, respectively. It had an AUPRC of 0.69 and 0.64 (compared to a baseline HTBIC-birth prevalence of 0.24 at KPSC and 0.19 at KPNC) on internal and external validation datasets, respectively. The cut-points explored resulted in a number needed to screen from 7.1-8.5 persons/positive LTBI diagnosis, compared to 4.2 and 16.8 persons/positive LTBI diagnosis from EHR-documented birth in a HTBIC and current screening criteria, respectively. DISCUSSION Using logistic regression with EHR data, we developed a simple yet useful model to predict birth in a HTBIC which decreased the number needed to screen compared to current LTBI screening criteria. CONCLUSION Our model improves the ability to screen for LTBI in health care settings based on birth in a HTBIC.
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Affiliation(s)
- Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Katia J. Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Kris Li
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Laura B. Amsden
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Mariah S. Wood
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Abigail Eaton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Brigitte C. Spence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Sally F. Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Sara Y. Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States of America
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Lewnard JA, Bruxvoort KJ, Fischer H, Hong VX, Grant LR, Jódar L, Gessner BD, Tartof SY. Prevention of Coronavirus Disease 2019 Among Older Adults Receiving Pneumococcal Conjugate Vaccine Suggests Interactions Between Streptococcus pneumoniae and Severe Acute Respiratory Syndrome Coronavirus 2 in the Respiratory Tract. J Infect Dis 2022; 225:1710-1720. [PMID: 33693636 PMCID: PMC7989304 DOI: 10.1093/infdis/jiab128] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND While secondary pneumococcal pneumonia occurs less commonly after coronavirus disease 2019 (COVID-19) than after other viral infections, it remains unclear whether other interactions occur between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Streptococcus pneumoniae. METHODS We probed potential interactions between these pathogens among adults aged ≥65 years by measuring associations of COVID-19 outcomes with pneumococcal vaccination (13-valent conjugate vaccine [PCV13] and 23-valent pneumococcal polysaccharide vaccine [PPSV23]). We estimated adjusted hazard ratios (aHRs) using Cox proportional hazards models with doubly robust inverse-propensity weighting. We assessed effect modification by antibiotic exposure to further test the biologic plausibility of a causal role for pneumococci. RESULTS Among 531 033 adults, there were 3677 COVID-19 diagnoses, leading to 1075 hospitalizations and 334 fatalities, between 1 March and 22 July 2020. Estimated aHRs for COVID-19 diagnosis, hospitalization, and mortality associated with prior PCV13 receipt were 0.65 (95% confidence interval [CI], .59-.72), 0.68 (95% CI, .57-.83), and 0.68 (95% CI, .49-.95), respectively. Prior PPSV23 receipt was not associated with protection against the 3 outcomes. COVID-19 diagnosis was not associated with prior PCV13 within 90 days following antibiotic receipt, whereas aHR estimates were 0.65 (95% CI, .50-.84) and 0.62 (95% CI, .56-.70) during the risk periods 91-365 days and >365 days, respectively, following antibiotic receipt. CONCLUSIONS Reduced risk of COVID-19 among PCV13 recipients, transiently attenuated by antibiotic exposure, suggests that pneumococci may interact with SARS-CoV-2.
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Affiliation(s)
- Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
- Center for Computational Biology, College of Engineering, University of California, Berkeley, Berkeley, California, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Vennis X Hong
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Luis Jódar
- Pfizer Vaccines, Collegeville, Pennsylvania, USA
| | | | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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Florea A, Sy LS, Luo Y, Qian L, Bruxvoort KJ, Ackerson BK, Lee GS, Ku JH, Tubert JE, Tian Y, Talarico CA, Tseng HF. Durability of mRNA-1273 against COVID-19 in the time of Delta: Interim results from an observational cohort study. PLoS One 2022; 17:e0267824. [PMID: 35482785 PMCID: PMC9049574 DOI: 10.1371/journal.pone.0267824] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/15/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND We conducted a prospective cohort study at Kaiser Permanente Southern California to study the vaccine effectiveness (VE) of mRNA-1273 over time and during the emergence of the Delta variant. METHODS The cohort for this planned interim analysis consisted of individuals aged ≥18 years receiving 2 doses of mRNA-1273 through June 2021, matched 1:1 to randomly selected unvaccinated individuals by age, sex, and race/ethnicity, with follow-up through September 2021. Outcomes were SARS-CoV-2 infection, and COVID-19 hospitalization and hospital death. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHR) with 95% confidence intervals (CIs) comparing outcomes in the vaccinated and unvaccinated groups. Adjusted VE (%) was calculated as (1-aHR)x100. HRs and VEs were also estimated for SARS-CoV-2 infection by age, sex, race/ethnicity, and during the Delta period (June-September 2021). VE against SARS-CoV-2 infection and COVID-19 hospitalization was estimated at 0-<2, 2-<4, 4-<6, and 6-<8 months post-vaccination. RESULTS 927,004 recipients of 2 doses of mRNA-1273 were matched to 927,004 unvaccinated individuals. VE (95% CI) was 82.8% (82.2-83.3%) against SARS-CoV-2 infection, 96.1% (95.5-96.6%) against COVID-19 hospitalization, and 97.2% (94.8-98.4%) against COVID-19 hospital death. VE against SARS-CoV-2 infection was similar by age, sex, and race/ethnicity, and was 86.5% (84.8-88.0%) during the Delta period. VE against SARS-CoV-2 infection decreased from 88.0% at 0-<2 months to 75.5% at 6-<8 months. CONCLUSIONS These interim results provide continued evidence for protection of 2 doses of mRNA-1273 against SARS-CoV-2 infection over 8 months post-vaccination and during the Delta period, and against COVID-19 hospitalization and hospital death.
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Affiliation(s)
- Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Lina S. Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Katia J. Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Bradley K. Ackerson
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Gina S. Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Jennifer H. Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Julia E. Tubert
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Yun Tian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | | | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America
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Tseng HF, Ackerson BK, Luo Y, Sy LS, Talarico CA, Tian Y, Bruxvoort KJ, Tubert JE, Florea A, Ku JH, Lee GS, Choi SK, Takhar HS, Aragones M, Qian L. Author Correction: Effectiveness of mRNA-1273 against SARS-CoV-2 Omicron and Delta variants. Nat Med 2022; 28:1095. [PMID: 35449419 PMCID: PMC9022057 DOI: 10.1038/s41591-022-01818-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA. .,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Bradley K Ackerson
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Yun Tian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Katia J Bruxvoort
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Julia E Tubert
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jennifer H Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Gina S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Soon Kyu Choi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Harpreet S Takhar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael Aragones
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Lewnard JA, Bruxvoort KJ, Hong VX, Grant LR, Jódar L, Cané A, Gessner BD, Tartof SY. Effectiveness of Pneumococcal Conjugate Vaccination Against Virus-Associated Lower Respiratory Tract Infection Among Adults: A Case-Control Study. J Infect Dis 2022; 227:498-511. [PMID: 35323906 PMCID: PMC9383607 DOI: 10.1093/infdis/jiac098] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/21/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Interactions of Streptococcus pneumoniae with viruses feature in the pathogenesis of numerous respiratory illnesses. METHODS We undertook a case-control study among adults at Kaiser Permanente Southern California between 2015 and 2019. Case patients had diagnoses of lower respiratory tract infection (LRTI; including pneumonia or nonpneumonia LRTI diagnoses), with viral infections detected by multiplex polymerase chain reaction testing. Controls without LRTI diagnoses were matched to case patients by demographic and clinical attributes. We measured vaccine effectiveness (VE) for 13-valent (PCV13) against virus-associated LRTI by determining the adjusted odds ratio for PCV13 receipt, comparing case patients and controls. RESULTS Primary analyses included 13 856 case patients with virus-associated LRTI and 227 887 matched controls. Receipt of PCV13 was associated with a VE of 24.9% (95% confidence interval, 18.4%-30.9%) against virus-associated pneumonia and 21.5% (10.9%-30.9%) against other (nonpneumonia) virus-associated LRTIs. We estimated VEs of 26.8% (95% confidence interval, 19.9%-33.1%) and 18.6% (9.3%-27.0%) against all virus-associated LRTI episodes diagnosed in inpatient and outpatient settings, respectively. We identified statistically significant protection against LRTI episodes associated with influenza A and B viruses, endemic human coronaviruses, parainfluenza viruses, human metapneumovirus, and enteroviruses but not respiratory syncytial virus or adenoviruses. CONCLUSIONS Among adults, PCV13 conferred moderate protection against virus-associated LRTI. The impacts of pneumococcal conjugate vaccines may be mediated, in part, by effects on polymicrobial interactions between pneumococci and respiratory viruses.
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Affiliation(s)
- Joseph A Lewnard
- Correspondence: Joseph A. Lewnard, 2121 Berkeley Way, Room 5410, Berkeley, CA 94720 ()
| | - Katia J Bruxvoort
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA,Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Vennis X Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Luis Jódar
- Pfizer Vaccines, Collegeville, Pennsylvania, USA
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Bruxvoort KJ, Qian L, Wu J, Florea A, Ackerson B, Sy LS, Vega Daily L, Takhar H, Tseng HF. Herpes Zoster Following Recombinant Zoster Vaccine With or Without Concomitant Vaccination. Open Forum Infect Dis 2022; 9:ofac011. [PMID: 35146050 PMCID: PMC8825562 DOI: 10.1093/ofid/ofac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA.,Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jun Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Bradley Ackerson
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Leticia Vega Daily
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Harpreet Takhar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA.,Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Bruxvoort KJ, Sy LS, Qian L, Ackerson BK, Luo Y, Lee GS, Tian Y, Florea A, Takhar HS, Tubert JE, Talarico CA, Tseng HF. Real-world effectiveness of the mRNA-1273 vaccine against COVID-19: Interim results from a prospective observational cohort study. Lancet Reg Health Am 2022; 6:100134. [PMID: 34849505 PMCID: PMC8614600 DOI: 10.1016/j.lana.2021.100134] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Phase 3 trials found mRNA-1273 was highly effective in preventing COVID-19. We conducted a prospective cohort study at Kaiser Permanente Southern California (KPSC) to determine the real-world vaccine effectiveness (VE) of mRNA-1273 in preventing COVID-19 infection and severe disease. Methods For this planned interim analysis, individuals aged ≥18 years receiving 2 doses of mRNA-1273 ≥24 days apart (18/12/2020-31/03/2021) were 1:1 matched to randomly selected unvaccinated individuals by age, sex, and race/ethnicity, with follow-up through 30/06/2021. Outcomes were COVID-19 infection (SARS-CoV-2 positive molecular test or COVID-19 diagnosis code) or severe disease (COVID-19 hospitalization and COVID-19 hospital death). Adjusted hazard ratios (aHR) and confidence intervals (CI) for COVID-19 outcomes comparing vaccinated and unvaccinated individuals were estimated by Cox proportional hazards models accounting for multiple comparisons. Adjusted VE was calculated as (1-aHR)x100. Whole genome sequencing was performed on SARS-CoV-2 positive specimens from the KPSC population. Findings This analysis included 352,878 recipients of 2 doses of mRNA-1273 matched to 352,878 unvaccinated individuals. VE (99·3% CI) against COVID-19 infection was 87·4% (84·8–89·6%). VE against COVID-19 hospitalization and hospital death was 95·8% (90·7–98·1%) and 97·9% (66·9-99·9%), respectively. VE was higher against symptomatic (88·3% [98·3% CI: 86·1–90·2%]) than asymptomatic COVID-19 (72·7% [53·4–84·0%]), but was generally similar across age, sex, and racial/ethnic subgroups. VE among individuals with history of COVID-19 ranged from 8·2–33·6%. The most prevalent variants were Alpha (41·6%), Epsilon (17·5%), Delta (11·5%), and Gamma (9·1%), with Delta increasing to 54·0% of variants by June 2021. Interpretation These interim results provide reassuring evidence of the VE of 2 doses of mRNA-1273 across age, sex, and racial/ethnic subgroups, and against asymptomatic and symptomatic COVID-19, and severe COVID-19 outcomes. Among individuals with history of COVID-19, mRNA-1273 vaccination may offer added protection beyond immunity acquired from prior infection. Longer follow-up is needed to fully evaluate VE of mRNA-1273 against emerging SARS-CoV-2 variants. Funding Moderna Inc.
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Affiliation(s)
- Katia J Bruxvoort
- Kaiser Permanente Southern California, Pasadena, CA, USA.,University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lina S Sy
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Lei Qian
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Yi Luo
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Gina S Lee
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Yun Tian
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Ana Florea
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Julia E Tubert
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Hung Fu Tseng
- Kaiser Permanente Southern California, Pasadena, CA, USA.,Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Lewnard JA, Bruxvoort KJ, Fischer H, Hong VX, Grant LR, Jódar L, Cané A, Gessner BD, Tartof SY. Effectiveness of 13-valent pneumococcal conjugate vaccine against medically-attended lower respiratory tract infection and pneumonia among older adults. Clin Infect Dis 2021; 75:832-841. [PMID: 34967907 DOI: 10.1093/cid/ciab1051] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Among older adults, 13-valent pneumococcal conjugate vaccine (PCV13) has been found efficacious against non-bacteremic pneumonia associated with vaccine-serotype pneumococci. However, the burden of lower-respiratory tract infection (LRTI) and pneumonia preventable by direct immunization of older adults continues to be debated. METHODS We analyzed data from an open cohort of adults aged ≥65 years enrolled in Kaiser Permanente Southern California health plans from 2016 to 2019, who received PCV13 concordant with US Advisory Committee on Immunization Practices guidelines. We estimated PCV13 vaccine effectiveness (VE) via the adjusted hazards ratio (aHR) for first LRTI and pneumonia episodes during each respiratory season, comparing PCV13-exposed and PCV13-unexposed time at risk for each participant using a self-matched inference framework. Analyses used Cox proportional hazards models, stratified by individual. RESULTS Among 42,700 adults who met inclusion criteria, VE was 9.5% (95% confidence interval: 2.2% to 16.3%) against all-cause medically-attended LRTI and 8.8% (-0.2% to 17.0%) against all-cause medically-attended pneumonia. In contrast, we did not identify evidence of protection against LRTI and pneumonia following receipt of 23-valent pneumococcal polysaccharide vaccine. PCV13 prevented 0.7 (0.2 to 1.4) and 0.5 (0.0 to 1.0) cases of LRTI and pneumonia, respectively, per 100 vaccinated persons annually; over 5 years, one case of LRTI and one case of pneumonia were prevented for every 27 and 42 individuals vaccinated, respectively. CONCLUSIONS PCV13 vaccination among older adults substantially reduced incidence of medically-attended respiratory illness. Direct immunization of older adults is an effective strategy to combat residual disease burden associated with PCV13-type pneumococci.
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Affiliation(s)
- Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California.,Division of Infectious Diseases & Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, California, United States.,Center for Computational Biology, College of Engineering, University of California, Berkeley, Berkeley, California, United States
| | - Katia J Bruxvoort
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States.,Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Heidi Fischer
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Vennis X Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | | | - Luis Jódar
- Pfizer Vaccines, Collegeville, Pennsylvania, United States
| | - Alejandro Cané
- Pfizer Vaccines, Collegeville, Pennsylvania, United States
| | | | - Sara Y Tartof
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States
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Bruxvoort KJ, Ackerson B, Sy LS, Bhavsar A, Tseng HF, Florea A, Luo Y, Tian Y, Solano Z, Widenmaier R, Shi M, Van Der Most R, Schmidt JE, Danier J, Breuer T, Qian L. Recombinant Adjuvanted Zoster Vaccine and Reduced Risk of Coronavirus Disease 2019 Diagnosis and Hospitalization in Older Adults. J Infect Dis 2021; 225:1915-1922. [PMID: 34962997 PMCID: PMC8755259 DOI: 10.1093/infdis/jiab633] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/23/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Katia J Bruxvoort
- Correspondence: Katia Bruxvoort, PhD MPH, Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL 35233, USA ()
| | | | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA,Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Yun Tian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Zendi Solano
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Meng Shi
- GlaxoSmithKline, Rockville, Maryland, USA
| | | | | | | | | | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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Bruxvoort KJ, Sy LS, Qian L, Ackerson BK, Luo Y, Lee GS, Tian Y, Florea A, Aragones M, Tubert JE, Takhar HS, Ku JH, Paila YD, Talarico CA, Tseng HF. Effectiveness of mRNA-1273 against delta, mu, and other emerging variants of SARS-CoV-2: test negative case-control study. BMJ 2021; 375:e068848. [PMID: 34911691 PMCID: PMC8671836 DOI: 10.1136/bmj-2021-068848] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of the mRNA-1273 vaccine against SARS-CoV-2 variants and assess its effectiveness against the delta variant by time since vaccination. DESIGN Test negative case-control study. SETTING Kaiser Permanente Southern California (KPSC), an integrated healthcare system. PARTICIPANTS Adult KPSC members with a SARS-CoV-2 positive test sent for whole genome sequencing or a negative test from 1 March 2021 to 27 July 2021. INTERVENTIONS Two dose or one dose vaccination with mRNA-1273 (Moderna covid-19 vaccine) ≥14 days before specimen collection versus no covid-19 vaccination. MAIN OUTCOME MEASURES Outcomes included infection with SARS-CoV-2 and hospital admission with covid-19. In pre-specified analyses for each variant type, test positive cases were matched 1:5 to test negative controls on age, sex, race/ethnicity, and specimen collection date. Conditional logistic regression was used to compare odds of vaccination among cases versus controls, with adjustment for confounders. Vaccine effectiveness was calculated as (1-odds ratio)×100%. RESULTS The study included 8153 cases and their matched controls. Two dose vaccine effectiveness was 86.7% (95% confidence interval 84.3% to 88.7%) against infection with the delta variant, 98.4% (96.9% to 99.1%) against alpha, 90.4% (73.9% to 96.5%) against mu, 96-98% against other identified variants, and 79.9% (76.9% to 82.5%) against unidentified variants (that is, specimens that failed sequencing). Vaccine effectiveness against hospital admission with the delta variant was 97.5% (92.7% to 99.2%). Vaccine effectiveness against infection with the delta variant declined from 94.1% (90.5% to 96.3%) 14-60 days after vaccination to 80.0% (70.2% to 86.6%) 151-180 days after vaccination. Waning was less pronounced for non-delta variants. Vaccine effectiveness against delta infection was lower among people aged ≥65 years (75.2%, 59.6% to 84.8%) than those aged 18-64 years (87.9%, 85.5% to 89.9%). One dose vaccine effectiveness was 77.0% (60.7% to 86.5%) against infection with delta. CONCLUSIONS Two doses of mRNA-1273 were highly effective against all SARS-CoV-2 variants, especially against hospital admission with covid-19. However, vaccine effectiveness against infection with the delta variant moderately declined with increasing time since vaccination.
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Affiliation(s)
- Katia J Bruxvoort
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
- University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Lina S Sy
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Lei Qian
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | | | - Yi Luo
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Gina S Lee
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Yun Tian
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | - Ana Florea
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | | | - Julia E Tubert
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | | | - Jennifer H Ku
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
| | | | | | - Hung Fu Tseng
- Kaiser Permanente Southern California, Pasadena, CA 91101, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA 91101, USA
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Malden DE, Bruxvoort KJ, Tseng HF, Ackerson B, Choi SK, Florea A, Tubert J, Takhar H, Aragones M, Hong V, Talarico CA, McLaughlin JM, Qian L, Tartof SY. Distribution of SARS-CoV-2 Variants in a Large Integrated Health Care System - California, March-July 2021. MMWR Morb Mortal Wkly Rep 2021; 70:1415-1419. [PMID: 34618801 PMCID: PMC8519275 DOI: 10.15585/mmwr.mm7040a4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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41
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Bruxvoort KJ, Schumacher CM, Towner W, Jones J, Contreras R, Ling Grant D, Hechter RC. Referral Linkage to Preexposure Prophylaxis Care and Persistence on Preexposure Prophylaxis in an Integrated Health Care System. J Acquir Immune Defic Syndr 2021; 87:918-927. [PMID: 33633035 DOI: 10.1097/qai.0000000000002668] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Successful linkage to preexposure prophylaxis (PrEP) and retention in care are important for HIV prevention. We examined gaps in PrEP care following referral and factors associated with PrEP linkage and persistence in an integrated health care system in the United States. METHODS We identified individuals referred for PrEP from 2014 to 2017 at the Kaiser Permanente Southern California using electronic health records and assessed linkage to care, PrEP prescription orders and fills, and PrEP persistence (medication possession ratio ≥80%) in the year after the first fill. We evaluated demographic and clinical factors potentially associated with PrEP linkage and persistence using a series of multivariable modified Poisson regression models. RESULTS Of 2995 referred individuals, 74.9% were linked to PrEP care. Nearly all those linked to care were prescribed PrEP and filled a prescription, but only 47.4% of those who filled a prescription were persistent on PrEP. Individuals aged <25 years (vs ≥25 years), female subjects (vs males), and individuals with high-deductible insurance (vs no high deductible) were less likely to be linked to care. Individuals aged <25 years and Hispanics (vs non-Hispanic whites) were less likely to be persistent. Those with alcohol use disorder were more likely to be linked to PrEP care but less likely to be persistent. New HIV diagnoses occurred in 38 individuals, and only 1 had PrEP in possession at diagnosis. CONCLUSIONS We observed PrEP care gaps and disparities among individuals referred for PrEP. Patient-centered interventions are needed in primary care to address barriers to successful PrEP linkage and persistence.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Christina M Schumacher
- Center for Child and Community Health Research, John Hopkins University School of Medicine, Baltimore, MD
| | - William Towner
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Joyce Jones
- Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, MD; and
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Deborah Ling Grant
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Bruxvoort KJ, Bider-Canfield Z, Casey JA, Qian L, Pressman A, Liang AS, Robinson S, Jacobsen SJ, Tartof SY. Outpatient Urinary Tract Infections in an Era of Virtual Healthcare: Trends From 2008 to 2017. Clin Infect Dis 2021; 71:100-108. [PMID: 31437269 DOI: 10.1093/cid/ciz764] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/20/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) occur commonly, but recent data on UTI rates are scarce. It is unknown how the growth of virtual healthcare delivery affects outpatient UTI management and trends in the United States. METHODS From 1 January 2008 to 31 December 2017, UTIs from outpatient settings (office, emergency, and virtual visits) were identified from electronic health records at Kaiser Permanente Southern California using multiple UTI definitions. Annual rates estimated by Poisson regression were stratified by sex, care setting, age, and race/ethnicity. Annual trends were estimated by linear or piecewise Poisson regression. RESULTS UTIs occurred in 1 065 955 individuals. Rates per 1000 person-years were 53.7 (95% confidence interval [CI], 50.6-57.0) by diagnosis code with antibiotic and 25.8 (95% CI, 24.7-26.9) by positive culture. Compared to office and emergency visits, UTIs were increasingly diagnosed in virtual visits, where rates by diagnosis code with antibiotic increased annually by 21.2% (95% CI, 16.5%-26.2%) in females and 29.3% (95% CI, 23.7%-35.3%) in males. Only 32% of virtual care diagnoses had a culture order. Overall, UTI rates were highest and increased the most in older adults. Rates were also higher in Hispanic and white females and black and white males. CONCLUSIONS Outpatient UTI rates increased from 2008 to 2017, especially in virtual care and among older adults. Virtual care is important for expanding access to health services, but strategies are needed in all outpatient care settings to ensure accurate UTI diagnosis and reduce inappropriate antibiotic treatment.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Zoe Bider-Canfield
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Joan A Casey
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Alice Pressman
- Research, Development, and Dissemination Department, Sutter Health, Walnut Creek, California
| | - Anna S Liang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Sarah Robinson
- Research, Development, and Dissemination Department, Sutter Health, Walnut Creek, California
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
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Thomson R, Beshir KB, Cunningham J, Baiden F, Bharmal J, Bruxvoort KJ, Maiteki-Sebuguzi C, Owusu-Agyei S, Staedke SG, Hopkins H. pfhrp2 and pfhrp3 Gene Deletions That Affect Malaria Rapid Diagnostic Tests for Plasmodium falciparum: Analysis of Archived Blood Samples From 3 African Countries. J Infect Dis 2020; 220:1444-1452. [PMID: 31249999 PMCID: PMC6761929 DOI: 10.1093/infdis/jiz335] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/27/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malaria rapid diagnostic tests (mRDTs) that target histidine-rich protein 2 (HRP2) are important tools for Plasmodium falciparum diagnosis. Parasites with pfhrp2/3 gene deletions threaten the use of these mRDTs and have been reported in Africa, Asia, and South America. We studied blood samples from 3 African countries to determine if these gene deletions were present. METHODS We analyzed 911 dried blood spots from Ghana (n = 165), Tanzania (n = 176), and Uganda (n = 570). Plasmodium falciparum infection was confirmed by 18S rDNA polymerase chain reaction (PCR), and pfhrp2/3 genes were genotyped. True pfhrp2/3 gene deletions were confirmed if samples were (1) microscopy positive; (2) 18S rDNA PCR positive; (3) positive for merozoite surface protein genes by PCR or positive by loop-mediated isothermal amplification; or (4) quantitative PCR positive with >5 parasites/µL. RESULTS No pfhrp2/3 deletions were detected in samples from Ghana, but deletions were identified in Tanzania (3 pfhrp2; 2 pfhrp3) and Uganda (7 pfhrp2; 2 pfhrp3). Of the 10 samples with pfhrp2 deletions, 9 tested negative by HRP2-based mRDT. CONCLUSIONS The presence of pfhrp2/3 deletions in Tanzania and Uganda, along with reports of pfhrp2/3-deleted parasites in neighboring countries, reinforces the need for systematic surveillance to monitor the reliability of mRDTs in malaria-endemic countries.
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Affiliation(s)
- Rebecca Thomson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Khalid B Beshir
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Frank Baiden
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jameel Bharmal
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Katia J Bruxvoort
- London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Seth Owusu-Agyei
- London School of Hygiene and Tropical Medicine, London, United Kingdom.,University or Health and Allied Sciences, Kintampo Health Research Centre, Ghana
| | - Sarah G Staedke
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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O'Boyle S, Bruxvoort KJ, Ansah EK, Burchett HED, Chandler CIR, Clarke SE, Goodman C, Mbacham W, Mbonye AK, Onwujekwe OE, Staedke SG, Wiseman VL, Whitty CJM, Hopkins H. Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa. BMC Med 2020; 18:17. [PMID: 31996199 PMCID: PMC6990477 DOI: 10.1186/s12916-019-1483-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/17/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given. METHODS Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones. RESULTS Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDT-positive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial. CONCLUSIONS In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice. TRIAL REGISTRATION Reported in individual primary studies.
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Affiliation(s)
| | - Katia J Bruxvoort
- London School of Hygiene and Tropical Medicine, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Evelyn K Ansah
- Centre for Malaria Research, University of Health and Allied Sciences, Accra, Ghana
| | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Wilfred Mbacham
- Public Health Biotechnology, University of Yaoundé I, Yaoundé, Cameroon
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Virginia L Wiseman
- London School of Hygiene and Tropical Medicine, London, UK.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | | | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, UK
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Bruxvoort KJ, Liang AS, Harpaz R, Qian L, Sy LS, LaRussa P, Schmid DS, Luo Y, Takhar H, Tseng HF. Patient report of herpes zoster pain: Incremental benefits of zoster vaccine live. Vaccine 2019; 37:3478-3484. [PMID: 31088744 DOI: 10.1016/j.vaccine.2019.04.095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Pain following herpes zoster (HZ) can persist for months and negatively impact quality of life. To evaluate the effect of zoster vaccine live (ZVL) on progression of pain following HZ, we conducted a prospective cohort study of HZ cases at Kaiser Permanente Southern California. METHODS ZVL vaccinated and unvaccinated members aged ≥60 years with laboratory-confirmed HZ from January 18, 2012 to February 26, 2015 were followed up within 5 days of HZ diagnosis, and at 30, 60, and 90 days after diagnosis. Pain was assessed with the Zoster Brief Pain Inventory (ZBPI) on a 0-10 scale, using cut-points of ≥3, ≥5, and ≥7, with postherpetic neuralgia (PHN) defined as pain ≥3 at 90 days. Log binomial regression was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) associated with pain, comparing vaccinated versus unvaccinated HZ patients. RESULTS We interviewed 509 vaccinated and 509 unvaccinated HZ patients. ZVL was associated with significantly lower risks of HZ-related pain at all time-points. The risk of PHN in vaccinated and unvaccinated patients, respectively, was 9.2% and 15.4% (aRR = 0.594, 95% CI: 0.413, 0.854); 2.0% and 4.8% of these patients reported pain ≥7 (aRR = 0.332, 95% CI: 0.153, 0.721). Irrespective of vaccination, the risk of PHN was lower in adults aged <70 years versus those ≥70 years and was similar or lower in females versus males. CONCLUSION We used laboratory confirmation of HZ cases and patient survey to show that aside from preventing HZ, ZVL reduced HZ-related pain and prevented PHN among vaccine recipients who experienced HZ. Observational studies will be needed to evaluate long-term effectiveness of the new recombinant zoster vaccine and its benefits in protecting patients against PHN.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Anna S Liang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Rafael Harpaz
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Philip LaRussa
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York City, NY, United States.
| | - D Scott Schmid
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Harpreet Takhar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
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Bruxvoort KJ, Leurent B, Chandler CIR, Ansah EK, Baiden F, Björkman A, Burchett HED, Clarke SE, Cundill B, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Mangham-Jefferies L, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Rowland MW, Shakely D, Staedke SG, Vestergaard LS, Webster J, Whitty CJM, Wiseman VL, Yeung S, Schellenberg D, Hopkins H. The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium. Am J Trop Med Hyg 2017; 97:1170-1179. [PMID: 28820705 PMCID: PMC5637593 DOI: 10.4269/ajtmh.16-0955] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400-432,513). mRDTs were associated with significantly lower ACT prescription (range 8-69% versus 20-100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.
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Affiliation(s)
- Katia J Bruxvoort
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Baptiste Leurent
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bonnie Cundill
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | | | | | - Catherine Goodman
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kristian S Hansen
- University of Copenhagen, Copenhagen, Denmark.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Sham Lal
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Toby Leslie
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pascal Magnussen
- Department for Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Makerere University School of Public Health, Kampala, Uganda.,Ministry of Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Mark W Rowland
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden.,Karolinska Institutet, Stockholm, Sweden.,Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sarah G Staedke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Virginia L Wiseman
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shunmay Yeung
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Heidi Hopkins
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Hopkins H, Bruxvoort KJ, Cairns ME, Chandler CIR, Leurent B, Ansah EK, Baiden F, Baltzell KA, Björkman A, Burchett HED, Clarke SE, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Jefferies LM, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Reyburn H, Rowland MW, Shakely D, Vestergaard LS, Webster J, Wiseman VL, Yeung S, Schellenberg D, Staedke SG, Whitty CJM. Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings. BMJ 2017; 356:j1054. [PMID: 28356302 PMCID: PMC5370398 DOI: 10.1136/bmj.j1054] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 01/21/2023]
Abstract
Objectives To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia.Design Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).Setting Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants 522 480 children and adults with acute febrile illness.Interventions Rapid diagnostic tests for malaria.Main outcome measures Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.Results Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined.
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Affiliation(s)
- Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Matthew E Cairns
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Baptiste Leurent
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | - Kristian S Hansen
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- University of Copenhagen, Copenhagen, DK1014, Denmark
| | | | - Sham Lal
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Toby Leslie
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Pascal Magnussen
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, and Department for Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | - Seth Owusu-Agyei
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Kintampo Health Research Centre, Kintampo, Ghana
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Mark W Rowland
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden, and Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Virginia L Wiseman
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Shunmay Yeung
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Sarah G Staedke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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48
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Bruxvoort KJ, Charbonneau HM, Giambernardi TA, Goolsby JC, Qian CN, Zylstra CR, Robinson DR, Roy-Burman P, Shaw AK, Buckner-Berghuis BD, Sigler RE, Resau JH, Sullivan R, Bushman W, Williams BO. Inactivation of Apc in the mouse prostate causes prostate carcinoma. Cancer Res 2007; 67:2490-6. [PMID: 17363566 DOI: 10.1158/0008-5472.can-06-3028] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Alterations of the Wnt/beta-catenin signaling pathway are positively associated with the development and progression of human cancer, including carcinoma of the prostate. To determine the role of activated Wnt/beta-catenin signaling in mouse prostate carcinogenesis, we created a mouse prostate tumor model using probasin-Cre-mediated deletion of Apc. Prostate tumors induced by the deletion of Apc have elevated levels of beta-catenin protein and are highly proliferative. Tumor formation is fully penetrant and follows a consistent pattern of progression. Hyperplasia is observed as early as 4.5 weeks of age, and adenocarcinoma is observed by 7 months. Continued tumor growth usually necessitated sacrifice between 12 and 15 months of age. Despite the high proliferation rate, we have not observed metastasis of these tumors to the lymph nodes or other organs. Surgical castration of 6-week-old mice inhibited tumor formation, and castration of mice with more advanced tumors resulted in the partial regression of specific prostate glands. However, significant areas of carcinoma remained 2 months postcastration, suggesting that tumors induced by Apc loss of function are capable of growth under conditions of androgen depletion. We conclude that the prostate-specific deletion of Apc and the increased expression of beta-catenin associated with prostate carcinoma suggests a role for beta-catenin in prostate cancer and offers an appropriate animal model to investigate the interaction of Wnt signaling with other genetic and epigenetic signals in prostate carcinogenesis.
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Affiliation(s)
- Katia J Bruxvoort
- Laboratory of Cell Signaling and Carcinogenesis, Van Andel Research Institute, Grand Rapids, Michigan 49503-2518, USA
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49
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Liu X, Bruxvoort KJ, Zylstra CR, Liu J, Cichowski R, Faugere MC, Bouxsein ML, Wan C, Williams BO, Clemens TL. Lifelong accumulation of bone in mice lacking Pten in osteoblasts. Proc Natl Acad Sci U S A 2007; 104:2259-64. [PMID: 17287359 PMCID: PMC1892939 DOI: 10.1073/pnas.0604153104] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Bone formation is carried out by the osteoblast, a mesenchymal cell whose lifespan and activity are regulated by growth factor signaling networks. Growth factors activate phosphatidylinositol 3-kinase (PI3K), which enhances cell survival and antagonizes apoptosis through activation of Akt/PKB. This process is negatively regulated by the Pten phosphatase, which inhibits the activity of PI3K. In this study, we investigated the effects of Akt activation in bone in vivo by conditionally disrupting the Pten gene in osteoblasts by using Cre-mediated recombination. Mice deficient in Pten in osteoblasts were of normal size but demonstrated a dramatic and progressively increasing bone mineral density throughout life. In vitro osteoblasts lacking Pten differentiated more rapidly than controls and exhibited greatly reduced apoptosis in association with markedly increased levels of phosphorylated Akt and activation of signaling pathways downstream of activated Akt. These findings support a critical role for this tumor-suppressor gene in regulating osteoblast lifespan and likely explain the skeletal abnormalities in patients carrying germ-line mutations of PTEN.
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Affiliation(s)
- Ximeng Liu
- *Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Katia J. Bruxvoort
- Laboratory of Cell Signaling and Carcinogenesis, Van Andel Research Institute, Grand Rapids, MI 49503
| | - Cassandra R. Zylstra
- Laboratory of Cell Signaling and Carcinogenesis, Van Andel Research Institute, Grand Rapids, MI 49503
| | - Jiarong Liu
- *Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Rachel Cichowski
- Laboratory of Cell Signaling and Carcinogenesis, Van Andel Research Institute, Grand Rapids, MI 49503
| | | | - Mary L. Bouxsein
- Orthopedic Biomechanics Laboratory, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Chao Wan
- *Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Bart O. Williams
- Laboratory of Cell Signaling and Carcinogenesis, Van Andel Research Institute, Grand Rapids, MI 49503
- To whom correspondence may be addressed. E-mail:
or
| | - Thomas L. Clemens
- *Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294
- To whom correspondence may be addressed. E-mail:
or
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