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

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

Correction: Impact of the COVID-19 Pandemic on Health Care Utilization in a Large Integrated Health Care System: Retrospective Cohort Study

[This corrects the article DOI: 10.2196/26558.].

Impact of the COVID-19 Pandemic on Health Care Utilization in a Large Integrated Health Care System: Retrospective Cohort Study

Background

The COVID-19 pandemic has caused an abrupt reduction in the use of in-person health care, accompanied by a corresponding surge in the use of telehealth services. However, the extent and nature of changes in health care utilization during the pandemic may differ by care setting. Knowledge of the impact of the pandemic on health care utilization is important to health care organizations and policy makers.

Objective

The aims of this study are (1) to evaluate changes in in-person health care utilization and telehealth visits during the COVID-19 pandemic and (2) to assess the difference in changes in health care utilization between the pandemic year 2020 and the prepandemic year 2019.

Methods

We retrospectively assembled a cohort consisting of members of a large integrated health care organization, who were enrolled between January 6 and November 2, 2019 (prepandemic year), and between January 5 and October 31, 2020 (pandemic year). The rates of visits were calculated weekly for four settings: inpatient, emergency department (ED), outpatient, and telehealth. Using Poisson models, we assessed the impact of the pandemic on health care utilization during the early days of the pandemic and conducted difference-in-deference (DID) analyses to measure the changes in health care utilization, adjusting for the trend of health care utilization in the prepandemic year.

Results

In the early days of the pandemic, we observed significant reductions in inpatient, ED, and outpatient utilization (by 30.2%, 37.0%, and 80.9%, respectively). By contrast, there was a 4-fold increase in telehealth visits between weeks 8 (February 23) and 12 (March 22) in 2020. DID analyses revealed that after adjusting for prepandemic secular trends, the reductions in inpatient, ED, and outpatient visit rates in the early days of the pandemic were 1.6, 8.9, and 367.2 visits per 100 person-years (P<.001), respectively, while the increase in telehealth visits was 272.9 visits per 100 person-years (P<.001). Further analyses suggested that the increase in telehealth visits offset the reduction in outpatient visits by week 26 (June 28, 2020).

Conclusions

In-person health care utilization decreased drastically during the early period of the pandemic, but there was a corresponding increase in telehealth visits during the same period. By end-June 2020, the combined outpatient and telehealth visits had recovered to prepandemic levels.

Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study

OBJECTIVES

The aim of this study was to examine a large cohort of adults who received the zoster vaccine for evidence of an increased risk of prespecified adverse events requiring medical attention.

DESIGN

Two self-comparison approaches, including a case-centred approach and a self-controlled case series (SCCS) analysis were used.

SETTING

Eight managed-care organizations participating in the Vaccine Safety Datalink project in the United States.

SUBJECTS

A total of 193 083 adults aged 50 and older receiving a zoster vaccine from 1 January 2007 to 31 December 2008 were included.

MAIN OUTCOME MEASURES

Prespecified adverse events were identified by aggregated International Classification of Diseases, Ninth Revision (ICD-9) codes in automated health plan datasets.

RESULTS

The risk of allergic reaction was significantly increased within 1-7 days of vaccination [relative risk = 2.13, 95% confidence interval (CI): 1.87-2.40 by case-centred method and relative rate = 2.32, 95% CI: 1.85-2.91 by SCCS]. No increased risk was found for the following adverse event groupings: cerebrovascular events; cardiovascular events; meningitis; encephalitis; and encephalopathy; and Ramsay-Hunt syndrome and Bell's palsy.

CONCLUSIONS

The results of this study support the findings from the prelicensure clinical trials, providing reassurance that the zoster vaccine is generally safe and well-tolerated with a small increased risk of allergic reactions in 1-7 days after vaccination.

Monitoring vaccine safety using the Vaccine Safety Datalink: utilizing immunization registries for pandemic influenza

Mass vaccination campaigns during which new vaccines may be administered to many millions of people in a short period of time call for timely and accurate post-licensure surveillance to monitor vaccine safety. To address the need for timely H1N1 influenza vaccine safety information during the 2009-2010 H1N1 influenza pandemic, the Vaccine Safety Datalink (VSD) project assessed the feasibility and potential mechanisms for utilizing data from state and local immunization registries to capture vaccinations that would not otherwise be captured by the data systems of the participating VSD managed care organizations (MCOs). Three of the eight VSD sites were able to capture H1N1 immunization data electronically from the state and local registries, and one site was able to capture the immunizations through a paper-based system; however, the remaining four sites encountered various obstacles that prevented capture of such data. Additional work will be required at these sites to overcome the barriers, which included privacy and confidentiality laws, time constraints brought on by the pandemic, as well as data quality concerns.

Work and productivity loss related to herpes zoster

OBJECTIVE

To estimate absenteeism and presenteeism-related work loss due to herpes zoster (HZ) among working individuals of 50-64 years of age.

METHODS

This telephone survey included individuals with ≥1 insurance claim for HZ in the past year in administrative claims data from five US commercial health plans. Demographic information, characteristics of the HZ episode; impact of HZ on activities of daily living (ADL), and work days loss and productivity were surveyed.

RESULTS

Responses were obtained from 153 of 1654 individuals who were contacted and were eligible for the survey (9.3%). Most had moderate or severe HZ (72.6%). Close to two-thirds reported some impact of HZ on ADL such as shopping, housework/chores, and social engagement. About half (51%) reported missing work due to HZ, and about an equal percentage reported little or much worse productivity than usual due to HZ while at work. On average, age-adjusted absenteeism- and presenteeism-related work loss was estimated at 31.6 hours, and 84.4 hours, respectively, with a combined work loss of 116.0 hours per HZ episode in a working person of 50-64 years of age. Work loss tended to increase with age and the duration and severity of the HZ episode.

CONCLUSIONS

The study documents a substantial societal burden of HZ-related work and productivity loss. This is important information to take into consideration, in addition to the direct medical burden, when making policy decisions around vaccine prevention of HZ.

LIMITATIONS

The study may potentially be subject to selection bias due to low survey response rate and since only those cases who sought care for a HZ episode were captured. The study may also be subject to respondent recall bias. Finally, since some respondents could still be having the HZ episode at the time of survey, the study may potentially have under-estimated the work and productivity loss.

Contribution of potential EF hand motifs to the calcium-dependent gating of a mouse brain large conductance, calcium-sensitive K(+) channel

1. The large conductance, calcium-sensitive K(+) channel (BK(Ca) channel) is a unique member of the K(+)-selective ion channel family in that activation is dependent upon both direct calcium binding and membrane depolarization. Calcium binding acts to dynamically shift voltage-dependent gating in a negative or left-ward direction, thereby adjusting channel opening to changes in cellular membrane potential. 2. We hypothesized that the intrinsic calcium-binding site within the BK(Ca) channel alpha subunit may contain an EF hand motif, the most common, naturally occurring calcium binding structure. Following identification of six potential sites, we introduced a single amino acid substitution (D/E to N/Q or A) at the equivalent of the -z position of a bona fide EF hand that would be predicted to lower calcium binding affinity at each of the six sites. 3. Using macroscopic current recordings of wild-type and mutant BK(Ca) channels in excised inside-out membrane patches from HEK 293 cells, we observed that a single point mutation in the C-terminus (Site 6, FLD(923)QD to N), adjacent to the 'calcium bowl' described by Salkoff and colleagues, shifted calcium-sensitive gating right-ward by 50--65 mV over the range of 2--12 microM free calcium, but had little effect on voltage-dependent gating in the absence of calcium. Combining this mutation at Site 6 with a similar mutation at Site 1 (PVD(81)EK to N) in the N-terminus produced a greater shift (70--90 mV) in calcium-sensitive gating over the same range of calcium. We calculated that these combined mutations decreased the apparent calcium binding affinity approximately 11-fold (129.5 microM vs. 11.3 microm) compared to the wild-type channel. 4. We further observed that a bacterially expressed protein encompassing Site 6 of the BK(Ca) channel C-terminus and bovine brain calmodulin were both able to directly bind (45)Ca(2+) following denaturation and polyacrylamide gel electrophoresis (e.g. SDS-PAGE). 5. Our results suggest that two regions within the mammalian BK(Ca) channel alpha subunit, with sequence similarities to an EF hand motif, functionally contribute to the calcium-sensitive gating of this channel.

Enhanced activity of a large conductance, calcium-sensitive K+ channel in the presence of Src tyrosine kinase

Large conductance, calcium-sensitive K(+) channels (BK(Ca) channels) contribute to the control of membrane potential in a variety of tissues, including smooth muscle, where they act as the target effector for intracellular "calcium sparks" and the endothelium-derived vasodilator nitric oxide. Various signal transduction pathways, including protein phosphorylation can regulate the activity of BK(Ca) channels, along with many other membrane ion channels. In our study, we have examined the regulation of BK(Ca) channels by the cellular Src gene product (cSrc), a soluble tyrosine kinase that has been implicated in the regulation of both voltage- and ligand-gated ion channels. Using a heterologous expression system, we observed that co-expression of murine BK(Ca) channel and the human cSrc tyrosine kinase in HEK 293 cells led to a calcium-sensitive enhancement of BK(Ca) channel activity in excised membrane patches. In contrast, co-expression with a catalytically inactive cSrc mutant produced no change in BK(Ca) channel activity, demonstrating the requirement for a functional cSrc molecule. Furthermore, we observed that BK(Ca) channels underwent direct tyrosine phosphorylation in cells co-transfected with BK(Ca) channels and active cSrc but not in cells co-transfected with the kinase inactive form of the enzyme. A single Tyr to Phe substitution in the C-terminal half of the channel largely prevented this observed phosphorylation. Given that cSrc may become activated by receptor tyrosine kinases or G-protein-coupled receptors, these findings suggest that cSrc-dependent tyrosine phosphorylation of BK(Ca) channels in situ may represent a novel regulatory mechanism for altering membrane potential and calcium entry.

Generation of cytotoxic T lymphocytes from peripheral blood

BACKGROUND

Cytotoxic T lymphocytes (CTL) have been shown to be useful for adoptive immunotherapy in malignancy. Traditional sources for CTL, such as tumor-infiltrating lymphocytes, have limitations. It would therefore be useful to develop a method of generating antitumor CTL from a renewable source such as peripheral blood.

METHODS

DBA/2 mice were injected intradermally in the abdominal wall with the murine tumor PHS-5 and killed 14 days later. Peripheral blood lymphocytes were harvested and cultured with 20 units/ml interleukin-2 and autologous tumor-stimulator cells treated with mitomycin C. Cultures were split when greater than 2 x 10(6) cells/well, fed every 3 days and stimulated weekly.

RESULTS

Lymphocytes expanded greater than 130,000-fold during 8 weeks. Specific cytotoxicity was shown with 51Cr release assay. Withdrawal of repeated stimulation with autologous tumor resulted in failure of cells to expand in culture and loss of cytotoxicity. In vivo administration showed marked reduction of 10-day liver metastases, indicating therapeutic efficacy.

CONCLUSIONS

These data demonstrate a successful animal model of adoptive immunotherapy with CTL generated from peripheral blood lymphocytes.

Prolactin, estradiol, and thyroid hormones in umbilical cord blood of neonates with and without hyaline membrane disease: a study of 405 neonates from midpregnancy to term

Concentrations of prolactin (PRL), estradiol (E2), thyroxine (T4), triiodothyronine (T3), and reverse T3 in umbilical cord blood were measured by radioimmunoassay in neonates with (n = 60) and in a control group without (n = 345) hyaline membrane disease. Mean levels of all hormones assayed were not significantly different between the two groups at various stages of gestation. In the control group, gestational age correlated positively with PRL and inversely with reverse T3, whereas birth weight correlated positively with PRL, T4, and T3, but inversely with reverse T3 levels. Thus, larger, more mature neonates tended to have higher cord levels of PRL, T4, T3 and lower concentrations of reverse T3. The data also suggest that, in the premature neonate, various obstetric complications and exposure in utero to beta-mimetic drugs and glucocorticoids may be important determinants of the concentrations of E2 and thyroid hormone in cord blood.

Regression of pituitary microadenoma during and following bromocriptine therapy: persistent defect in prolactin regulation before and throughout pregnancy

During 5 years of clinical, endocrinologic, and radiologic observations in a woman with a microprolactinoma treated medically with bromocriptine for 29 months, serial hypothalamic-pituitary studies revealed a defect in lactotrope function after prolactin (PRL) concentrations and ovulation were restored to normal. This defect persisted throughout a spontaneously conceived pregnancy in which the PRL, estradiol, and progesterone levels were subnormal, while, the dehydroepiandrosterone sulfate levels were normal and estriol concentrations were elevated. Levels of the beta subunit of human chorionic gonadotropin (hCG) were close to and slightly above the normal ranges. These observations are consistent with a role for PRL, interacting with hCG, in the control of estrogen and progesterone secretion by the fetoplacental unit. Lactation was initiated and maintained post partum. Pituitary function and PrL responses to suckling suggested improved lactotrope function 22 to 25 months after withdrawal of bromocriptine. The impaired lactotrope function, therefore, did not preclude normal implantation, pregnancy maintenance, onset of parturition, fetal development, and lactation.

Regulation of ovarian follicular and luteal function during treatment with exogenous gonadotropins in anovulatory infertility

The dosage, duration of treatment, and plasma hormone levels were analyzed statistically between and within groups of treatment cycles with (n = 46) and without (n = 10) ovulation. A significant difference was observed in the dosage of human menopausal gonadotropins (hMG) over various days of treatment, but not in the mean dosage of hMG and human chorionic gonadotropin (hCG) administered per cycle. Follicle-stimulating hormone (FSH):luteinizing hormone (LH) ratios, prolactin (PRL) levels, and the magnitude and the duration of the estradiol response were greater in the ovulatory cycles. Additionally, in the ovulatory cycles, the dose of hMG correlated with the plasma levels of estradiol, FSH, and LH, while in the anovulatory cycles, hMG dosage correlated only with the LH concentrations. After administration of hCG, the mean plasma concentrations of its beta subunit peaked within 1 day and remained detectable for up to 10 days thereafter. In the ovulatory cycles, the mean progesterone level was maximal 6 days following hCG administration. In these cycles, luteal phase progesterone levels correlated positively with the preovulatory estradiol and inversely with concentrations of the beta subunit of hCG. The data demonstrate that, in contrast to anovulatory follicles, ovulatory follicles were exposed to a relative "dominance" of FSH over LH, with higher concentrations of estradiol and PRL for several days before hCG was administered. Apart from hMG dosage, the endogenous discharge of LH appeared to be an important determinant of the ovarian response. A single 10,000 IU dose of hCG was adequate for inducing ovulation and maintaining luteal function.

Human chorionic gonadotropin, estradiol, progesterone, prolactin, and B-scan ultrasound monitoring of complications in early pregnancy

In a prospective study of women in the first trimester who were at risk for recurrent abortion, data from 20 pregnancies with normal outcomes were contrasted with those of 9 pregnancies that aborted spontaneously between 7 and 12 weeks. In pregnancies in which an embryo was present before abortion, the mean concentrations of human chorionic gonadotropin beta-subunit (hCG-beta) were low with a steady decline in progesterone levels, whereas estradiol (E2) and prolactin concentrations approximated those in normal pregnancies. With growth disorganization, mean hCG-beta, E2, and progesterone levels were significantly lower than normal. In 87.5% of embryopathic pregnancies, conclusive evidence of this disorder was obtained with ultrasound monitoring. Subnormal levels of hCG-beta, E2, and progesterone were observed in 88.9, 100, and 57.1%, respectively. The karyotype was abnormal in 80% of embryopathic pregnancies successfully cultured. The normal production of E2 appeared dependent on the presence of the embryo in the first trimester of pregnancy. Endocrine failure of the trophoblast and/or the corpus luteum in embryopathic pregnancy is suggested by diminished hCG-beta and progesterone concentrations. Serial ultrasound scanning and hormone assay, particularly of hCG-beta and E2, may be useful in assessing pregnancy at risk for recurrent abortion. However, because subnormal hormone levels may occur relatively late in the clinical course of embryopathic gestation, ultrasound scanning may yield more useful results as compared with hormone assay. Further studies are required to define more clearly the mechanisms of endocrine failure in embryopathic pregnancy.

A possible role for prolactin in the control of human chorionic gonadotropin and estrogen secretion by the fetoplacental unit

The effects of prolactin (PRL) on fetoplacental function were studied by measuring the beta subunit of human chorionic gonadotropin (hCG-beta), estradiol (E2), progesterone (P), and PRL concentrations throughout seven pregnancies in a control group (N = 6 women) and in three pregnant women with prolactinomas, who were receiving bromocriptine. In one of the latter, estriol (E3) was also assayed. Long-term suppression of PRL was associated with augmentation of hCG-beta at the first-treimester peak and in late pregnancy. Concomitant augmentation of E3 (in late gestation) and possibly E2, but not P, levels was also observed. This effect on hCG appeared dependent on PRL rather than the dopaminergic effect of bromocriptine. Short-term drug induced alterations in PRL (over 3 hours) during early pregnancy did not result in significant changes in hCG-beta or steroid concentrations. In each control pregnancy, a significant negative correlation (p less than 0.05) was observed between hCG-beta and PRL, while a significant positive correlation between the latter and E2 concentrations in these women was also demonstrated. Apart from its effect on lactation, osmoregulation, and gonadal and adrenal function, a further role for PRL during reproduction appears to be in the control of hCG and estrogen secretion in the fetoplacental unit.

Plasma prolactin, human chorionic gonadotropin, estradiol, testosterone, and progesterone in the ovarian hyperstimulation syndrome

Plasma prolactin, estradiol, progesterone, and testosterone, but not HCG-beta levels, were higher in a patient who developed the ovarian hyperstimulation syndrome while undergoing ovulation induction with human gonadotropins than in two other women who also became pregnant after similar treatment without complications. These results suggest that hyperprolactinema, in association with elevated ovarian steroid levels, may be factors in the pathogenesis of this disorder.