Interim Estimates of 2023-24 Seasonal Influenza Vaccine Effectiveness - United States

In the United States, annual influenza vaccination is recommended for all persons aged ≥6 months. Using data from four vaccine effectiveness (VE) networks during the 2023-24 influenza season, interim influenza VE was estimated among patients aged ≥6 months with acute respiratory illness-associated medical encounters using a test-negative case-control study design. Among children and adolescents aged 6 months-17 years, VE against influenza-associated outpatient visits ranged from 59% to 67% and against influenza-associated hospitalization ranged from 52% to 61%. Among adults aged ≥18 years, VE against influenza-associated outpatient visits ranged from 33% to 49% and against hospitalization from 41% to 44%. VE against influenza A ranged from 46% to 59% for children and adolescents and from 27% to 46% for adults across settings. VE against influenza B ranged from 64% to 89% for pediatric patients in outpatient settings and from 60% to 78% for all adults across settings. These findings demonstrate that the 2023-24 seasonal influenza vaccine is effective at reducing the risk for medically attended influenza virus infection. CDC recommends that all persons aged ≥6 months who have not yet been vaccinated this season get vaccinated while influenza circulates locally.

Influenza Vaccine Effectiveness Against Influenza A(H3N2)-Related Illness in the United States During the 2021-2022 Influenza Season

BACKGROUND

In the United States, influenza activity during the 2021-2022 season was modest and sufficient enough to estimate influenza vaccine effectiveness (VE) for the first time since the beginning of the coronavirus disease 2019 pandemic. We estimated influenza VE against laboratory-confirmed outpatient acute illness caused by predominant A(H3N2) viruses.

METHODS

Between October 2021 and April 2022, research staff across 7 sites enrolled patients aged ≥6 months seeking outpatient care for acute respiratory illness with cough. Using a test-negative design, we assessed VE against influenza A(H3N2). Due to strong correlation between influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, participants who tested positive for SARS-CoV-2 were excluded from VE estimations. Estimates were adjusted for site, age, month of illness, race/ethnicity, and general health status.

RESULTS

Among 6260 participants, 468 (7%) tested positive for influenza only, including 440 (94%) for A(H3N2). All 206 sequenced A(H3N2) viruses were characterized as belonging to genetic group 3C.2a1b subclade 2a.2, which has antigenic differences from the 2021-2022 season A(H3N2) vaccine component that belongs to clade 3C.2a1b subclade 2a.1. After excluding 1948 SARS-CoV-2-positive patients, 4312 patients were included in analyses of influenza VE; 2463 (57%) were vaccinated against influenza. Effectiveness against A(H3N2) for all ages was 36% (95% confidence interval, 20%-49%) overall.

CONCLUSIONS

Influenza vaccination in 2021-2022 provided protection against influenza A(H3N2)-related outpatient visits among young persons.

Factors Associated With COVID-19 Non-vaccination in Adolescents Hospitalized Without COVID-19

BACKGROUND

Pfizer-BioNTech COVID-19 vaccine received emergency use authorization for persons ≥ 16 years in December 2020 and for adolescents 12-15 years in May 2021. Despite the clear benefits and favorable safety profile, vaccine uptake in adolescents has been suboptimal. We sought to assess factors associated with COVID-19 non-vaccination in adolescents 12-18 years of age.

METHODS

Between June 1, 2021 and April 29, 2022, we assessed factors associated with COVID-19 non-vaccination in hospitalized adolescents ages 12-18 years enrolled in the Overcoming COVID-19 vaccine effectiveness network. Demographic characteristics and clinical information were captured through parent interviews and/or electronic medical record abstraction; COVID-19 vaccination was assessed through documented sources. We assessed associations between receipt of the COVID-19 vaccine and demographic and clinical factors using univariate and multivariable logistic regression and estimated adjusted odds ratios (aOR) for each factor associated with non-vaccination.

RESULTS

Among 1665 hospitalized adolescents without COVID-19, 56% were unvaccinated. Unvaccinated adolescents were younger (median age 15.1 years vs. 15.4 years, p < .01) and resided in areas with higher social vulnerability index (SVI) scores (median 0.6 vs 0.5, p < .001) than vaccinated adolescents. Residence in the Midwest [aOR 2.60 (95% CI: 1.80, 3.79)] or South [aOR 2.49 (95% CI: 1.77, 3.54)] US census regions, rarely or never receiving influenza vaccine [aOR 5.31 (95% CI: 3.81, 7.47)], and rarely or never taking precautions against COVID-19 [aOR 3.17 (95% CI: 1.94, 5.31)] were associated with non-vaccination against COVID-19.

CONCLUSIONS

Efforts to increase COVID-19 vaccination of adolescents should focus on persons with geographic, socioeconomic, and medical risk factors associated with non-vaccination.

BNT162b2 mRNA Vaccination Against Coronavirus Disease 2019 is Associated With a Decreased Likelihood of Multisystem Inflammatory Syndrome in Children Aged 5-18 Years-United States, July 2021 - April 2022

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C), linked to antecedent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is associated with considerable morbidity. Prevention of SARS-CoV-2 infection or coronavirus disease 2019 (COVID-19) by vaccination might also decrease MIS-C likelihood.

METHODS

In a multicenter, case-control, public health investigation of children ages 5-18 years hospitalized from 1 July 2021 to 7 April 2022, we compared the odds of being fully vaccinated (2 doses of BNT162b2 vaccine ≥28 days before hospital admission) between MIS-C case-patients and hospital-based controls who tested negative for SARS-CoV-2. These associations were examined by age group, timing of vaccination, and periods of Delta and Omicron variant predominance using multivariable logistic regression.

RESULTS

We compared 304 MIS-C case-patients (280 [92%] unvaccinated) with 502 controls (346 [69%] unvaccinated). MIS-C was associated with decreased likelihood of vaccination (adjusted OR [aOR]: .16; 95% CI: .10-.26), including among children ages 5-11 years (aOR: .22; 95% CI: .10-.52), ages 12-18 years (aOR: .10; 95% CI: .05-.19), and during the Delta (aOR: .06; 95% CI: .02-.15) and Omicron (aOR: .22; 95% CI: .11-.42) variant-predominant periods. This association persisted beyond 120 days after the second dose (aOR: .08; 95% CI: .03-.22) in 12-18-year-olds. Among all MIS-C case-patients, 187 (62%) required intensive care unit admission and 280 (92%) vaccine-eligible case-patients were unvaccinated.

CONCLUSIONS

Vaccination with 2 doses of BNT162b2 is associated with reduced likelihood of MIS-C in children ages 5-18 years. Most vaccine-eligible hospitalized patients with MIS-C were unvaccinated.

Maternal Vaccination and Risk of Hospitalization for Covid-19 among Infants

BACKGROUND

Infants younger than 6 months of age are at high risk for complications of coronavirus disease 2019 (Covid-19) and are not eligible for vaccination. Transplacental transfer of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) after maternal Covid-19 vaccination may confer protection against Covid-19 in infants.

METHODS

We used a case-control test-negative design to assess the effectiveness of maternal vaccination during pregnancy against hospitalization for Covid-19 among infants younger than 6 months of age. Between July 1, 2021, and March 8, 2022, we enrolled infants hospitalized for Covid-19 (case infants) and infants hospitalized without Covid-19 (control infants) at 30 hospitals in 22 states. We estimated vaccine effectiveness by comparing the odds of full maternal vaccination (two doses of mRNA vaccine) among case infants and control infants during circulation of the B.1.617.2 (delta) variant (July 1, 2021, to December 18, 2021) and the B.1.1.259 (omicron) variant (December 19, 2021, to March 8, 2022).

RESULTS

A total of 537 case infants (181 of whom had been admitted to a hospital during the delta period and 356 during the omicron period; median age, 2 months) and 512 control infants were enrolled and included in the analyses; 16% of the case infants and 29% of the control infants had been born to mothers who had been fully vaccinated against Covid-19 during pregnancy. Among the case infants, 113 (21%) received intensive care (64 [12%] received mechanical ventilation or vasoactive infusions). Two case infants died from Covid-19; neither infant's mother had been vaccinated during pregnancy. The effectiveness of maternal vaccination against hospitalization for Covid-19 among infants was 52% (95% confidence interval [CI], 33 to 65) overall, 80% (95% CI, 60 to 90) during the delta period, and 38% (95% CI, 8 to 58) during the omicron period. Effectiveness was 69% (95% CI, 50 to 80) when maternal vaccination occurred after 20 weeks of pregnancy and 38% (95% CI, 3 to 60) during the first 20 weeks of pregnancy.

CONCLUSIONS

Maternal vaccination with two doses of mRNA vaccine was associated with a reduced risk of hospitalization for Covid-19, including for critical illness, among infants younger than 6 months of age. (Funded by the Centers for Disease Control and Prevention.).

A-03 Physical Therapy Compared to a Home Exercise Program for Protracted Pediatric Sport-Related Concussion Rehabilitation

Purpose: The purpose of this study was to compare the recovery time in days between protracted recovery (greater than or equal to 28 days since injury) patients who were prescribed physical therapy and those who were prescribed a home exercise program. We hypothesized that physical therapy would be associated with shorter recovery times relative to the home exercise program. Methods: The 159 participants (aged 8–18) were drawn from an ongoing study. This study was a retrospective cohort design of sports-related concussion patients with a protracted recovery who presented to an outpatient specialty concussion clinic between 2018 and 2021, with data collected from electronic medical records. Both prescribed physical therapy (PPT) and home exercise program (HEP) patients were provided vestibular/ocular motor rehabilitation exercises to be completed at home three times per day. PPT participants must have completed at least three PPT sessions, or they were excluded from the study. Multi-variable zero-truncated negative binomial regressions were used to evaluate associations between groups. Results: Among the 48 (30.2%) PPT and 111 (69.8%) HEP participants, the majority were female (57.9%), age was 15.3 ± 1.4 (PPT) and 14.2 ± 2.8 (HEP), and days to clinic was a median 6.0 (IQR = 3.0–27.0; PPT) and 7.0 (IQR = 3.0–23.0; HEP). After adjusting for demographic (age, sex) and clinical measures (concussion history, convergence, VOMS score, and days to clinic), PPT was associated with an additional 1.21 days (95% CI: 1.06, 1.39) than HEP. Conclusions: We unexpectedly found that PPT was not associated with a shorter recovery time relative to HEP. Future research should explore this hypothesis while aiming to evaluate the effect of PPT versus HEP using a randomized design.

A-05 Retrospective Comparison of Concussion Recovery Between School and All Star Cheerleaders

Purpose: Though often categorized together, All Star and school cheerleading are vastly different in concussion risk due to competitiveness and skill difficulty. The purpose of the current study was to compare concussion rate and recovery in school and All Star cheerleaders diagnosed with sports-related concussions (SRC). Methods: This study was a retrospective comparison of cheerleaders (aged 8–18 years) who were evaluated in a specialty concussion clinic and diagnosed with SRC from 2020–2022. A total of 64 female cheerleaders were included (33 school and 31 All Star). We compared days to clinic, prior history of concussion, Post-Concussion Symptom Scale (PCSS) total score, symptom provocation on the Vestibular Ocular Motor Screen, and recovery time in days for each group. Results: Reports of at least one prior concussion were higher in All Star cheerleaders (61%) compared to school cheerleaders (39%). Initial evaluation occurred an average of 4.0 ± 5.8 days post injury for All Star cheerleaders, with recovery occurring in 23.6 ± 17.4 days compared to school cheerleaders who were evaluated for initial evaluation an average of 4.2 ± 4.3 days post injury and recovered in 27.6 ± 19.7 days (P &gt; 0.05). All Star cheerleaders experienced greater symptom provocation (P = 0.05) on horizontal vestibular-ocular reflex compared to school cheerleaders. There was no difference in symptom reporting on the PCSS (P = 0.23). Conclusions: Higher rates of prior concussion were reported in All Star cheerleaders. This may be a function of the more difficult skills being performed. Future research should investigate the impact of skill level and mechanism of injury on SRCs in All Star Cheerleading.

A-32 Association Between Adolescent Patient Emotional Factors and Adherence to a Sport-Related Concussion Treatment

Purpose: To determine the association between Anxiety Sensitivity Index (ASI) and Positive and Negative Affect Schedule (PANAS) and adherence to an exercise treatment for sport-related concussion (SRC). We hypothesized Positive Affect (PA) score would be positively associated, while ASI and Negative Affect (NA) score would be negatively associated with odds of treatment adherence. Methods: This was a prospective (2020–2021) analysis of adolescents (aged 14–17) diagnosed with SRC by a pediatric specialty concussion clinic and subsequently prescribed daily exercise. Adherence to the exercise protocol was defined as consistently increasing physical activity volume (measured by accelerometer) during recovery. Multivariable logistic regressions evaluated the independent associations between treatment adherence and ASI; PA score; NA score. Results: The mean (standard deviation [SD]) recovery time was 16.1 (9.0) days. Among the 32 (56.1%) adherent and 25 (43.9%) not adherent participants, the majority were aged 15 years (29.8%), male (50.9%), non-Hispanic White (70.2%), and had no concussion history (61.4%). After adjusting for age and sex, the odds of treatment adherence for each additional unit increase in ASI, PA score, and NA score was 1.03 (95% CI: 0.96–1.10), 1.14 (95% CI: 0.97–1.35), and 1.18 (95% CI: 0.95–1.47), respectively. Conclusions: Despite lack of statistical significance, it appears that PA score and NA score may contribute to exercise treatment adherence for SRC. As this study may be underpowered, future studies should aim to have a larger sample and investigate the discriminate utility of PANAS to identify those who may or may not adhere to SRC exercise treatments.

A-36 Tracking Compliance To A Home Exercise Program For Concussion Using Ecological Momentary Assessment: A Pilot Study

Purpose: The management of pediatric concussions creates a clinical challenge due to unknown patient compliance with prescribed therapies and interventions. The purpose of this pilot study was to describe the logistical use of ecological momentary assessment (EMA) to track compliance to a physical therapy facilitated vestibular/ocular motor home exercise program (HEP) in patients diagnosed with concussion. Methods: A convenience sample of 20 concussed patients (aged 13–18 years [mdn = 14.5, IQR = 14.0–16.8]) was included in this initial pilot study. All participants were evaluated within seven days of injury. Participants were instructed to complete one daily HEP compliance log until medical clearance on their parent or guardians’ mobile device using an EMA application. Results: Participants were evaluated a median 3.5 (IQR = 1.3–6.5) days post injury, recovered in a median 15.5 (IQR = 11.0–25.0) days, and completed a mean 5.85 (SD = 3.9) total EMA logs representing a 47% completion rate. Participants reported completing a mean 1.21 (SD = 0.77) HEPs per day with a range of 0.0 to 3.0. Self-reported HEP compliance did not significantly correlate with recovery time in days (P = 0.26). Conclusions: The overall response rate for EMA logs was 47% and participants reported completing 1.2 HEPs per day. Analysis of this preliminary data did not reveal a correlation between HEP compliance and recovery time in days. Participants reported the primary barrier to completing daily questionnaires was access to their parent or guardians’ mobile device at the time of the prompt. Overall, the data derived from EMA appears useful for tracking the progression of this heterogenous injury.

BNT162b2 Protection against the Omicron Variant in Children and Adolescents

BACKGROUND

Spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) B.1.1.529 (omicron) variant, which led to increased U.S. hospitalizations for coronavirus disease 2019 (Covid-19), generated concern about immune evasion and the duration of protection from vaccines in children and adolescents.

METHODS

Using a case-control, test-negative design, we assessed vaccine effectiveness against laboratory-confirmed Covid-19 leading to hospitalization and against critical Covid-19 (i.e., leading to receipt of life support or to death). From July 1, 2021, to February 17, 2022, we enrolled case patients with Covid-19 and controls without Covid-19 at 31 hospitals in 23 states. We estimated vaccine effectiveness by comparing the odds of antecedent full vaccination (two doses of BNT162b2 messenger RNA vaccine) at least 14 days before illness among case patients and controls, according to time since vaccination for patients 12 to 18 years of age and in periods coinciding with circulation of B.1.617.2 (delta) (July 1, 2021, to December 18, 2021) and omicron (December 19, 2021, to February 17, 2022) among patients 5 to 11 and 12 to 18 years of age.

RESULTS

We enrolled 1185 case patients (1043 [88%] of whom were unvaccinated, 291 [25%] of whom received life support, and 14 of whom died) and 1627 controls. During the delta-predominant period, vaccine effectiveness against hospitalization for Covid-19 among adolescents 12 to 18 years of age was 93% (95% confidence interval [CI], 89 to 95) 2 to 22 weeks after vaccination and was 92% (95% CI, 80 to 97) at 23 to 44 weeks. Among adolescents 12 to 18 years of age (median interval since vaccination, 162 days) during the omicron-predominant period, vaccine effectiveness was 40% (95% CI, 9 to 60) against hospitalization for Covid-19, 79% (95% CI, 51 to 91) against critical Covid-19, and 20% (95% CI, -25 to 49) against noncritical Covid-19. During the omicron period, vaccine effectiveness against hospitalization among children 5 to 11 years of age was 68% (95% CI, 42 to 82; median interval since vaccination, 34 days).

CONCLUSIONS

BNT162b2 vaccination reduced the risk of omicron-associated hospitalization by two thirds among children 5 to 11 years of age. Although two doses provided lower protection against omicron-associated hospitalization than against delta-associated hospitalization among adolescents 12 to 18 years of age, vaccination prevented critical illness caused by either variant. (Funded by the Centers for Disease Control and Prevention.).

Effectiveness of BNT162b2 Vaccine against Critical Covid-19 in Adolescents

BACKGROUND

The increasing incidence of pediatric hospitalizations associated with coronavirus disease 2019 (Covid-19) caused by the B.1.617.2 (delta) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the United States has offered an opportunity to assess the real-world effectiveness of the BNT162b2 messenger RNA vaccine in adolescents between 12 and 18 years of age.

METHODS

We used a case-control, test-negative design to assess vaccine effectiveness against Covid-19 resulting in hospitalization, admission to an intensive care unit (ICU), the use of life-supporting interventions (mechanical ventilation, vasopressors, and extracorporeal membrane oxygenation), or death. Between July 1 and October 25, 2021, we screened admission logs for eligible case patients with laboratory-confirmed Covid-19 at 31 hospitals in 23 states. We estimated vaccine effectiveness by comparing the odds of antecedent full vaccination (two doses of BNT162b2) in case patients as compared with two hospital-based control groups: patients who had Covid-19-like symptoms but negative results on testing for SARS-CoV-2 (test-negative) and patients who did not have Covid-19-like symptoms (syndrome-negative).

RESULTS

A total of 445 case patients and 777 controls were enrolled. Overall, 17 case patients (4%) and 282 controls (36%) had been fully vaccinated. Of the case patients, 180 (40%) were admitted to the ICU, and 127 (29%) required life support; only 2 patients in the ICU had been fully vaccinated. The overall effectiveness of the BNT162b2 vaccine against hospitalization for Covid-19 was 94% (95% confidence interval [CI], 90 to 96); the effectiveness was 95% (95% CI, 91 to 97) among test-negative controls and 94% (95% CI, 89 to 96) among syndrome-negative controls. The effectiveness was 98% against ICU admission and 98% against Covid-19 resulting in the receipt of life support. All 7 deaths occurred in patients who were unvaccinated.

CONCLUSIONS

Among hospitalized adolescent patients, two doses of the BNT162b2 vaccine were highly effective against Covid-19-related hospitalization and ICU admission or the receipt of life support. (Funded by the Centers for Disease Control and Prevention.).

Effectiveness of Maternal Vaccination with mRNA COVID-19 Vaccine During Pregnancy Against COVID-19-Associated Hospitalization in Infants Aged <6 Months - 17 States, July 2021-January 2022

COVID-19 vaccination is recommended for persons who are pregnant, breastfeeding, trying to get pregnant now, or who might become pregnant in the future, to protect them from COVID-19.§ Infants are at risk for life-threatening complications from COVID-19, including acute respiratory failure (1). Evidence from other vaccine-preventable diseases suggests that maternal immunization can provide protection to infants, especially during the high-risk first 6 months of life, through passive transplacental antibody transfer (2). Recent studies of COVID-19 vaccination during pregnancy suggest the possibility of transplacental transfer of SARS-CoV-2-specific antibodies that might provide protection to infants (3-5); however, no epidemiologic evidence currently exists for the protective benefits of maternal immunization during pregnancy against COVID-19 in infants. The Overcoming COVID-19 network conducted a test-negative, case-control study at 20 pediatric hospitals in 17 states during July 1, 2021-January 17, 2022, to assess effectiveness of maternal completion of a 2-dose primary mRNA COVID-19 vaccination series during pregnancy against COVID-19 hospitalization in infants. Among 379 hospitalized infants aged <6 months (176 with COVID-19 [case-infants] and 203 without COVID-19 [control-infants]), the median age was 2 months, 21% had at least one underlying medical condition, and 22% of case- and control-infants were born premature (<37 weeks gestation). Effectiveness of maternal vaccination during pregnancy against COVID-19 hospitalization in infants aged <6 months was 61% (95% CI = 31%-78%). Completion of a 2-dose mRNA COVID-19 vaccination series during pregnancy might help prevent COVID-19 hospitalization among infants aged <6 months.

Effectiveness of BNT162b2 (Pfizer-BioNTech) mRNA Vaccination Against Multisystem Inflammatory Syndrome in Children Among Persons Aged 12-18 Years - United States, July-December 2021

Multisystem inflammatory syndrome in children (MIS-C) is a severe postinfectious hyperinflammatory condition, which generally occurs 2-6 weeks after a typically mild or asymptomatic infection with SARS-CoV-2, the virus that causes COVID-19 (1-3). In the United States, the BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine is currently authorized for use in children and adolescents aged 5-15 years under an Emergency Use Authorization and is fully licensed by the Food and Drug Administration for persons aged ≥16 years (4). Prelicensure randomized trials in persons aged ≥5 years documented high vaccine efficacy and immunogenicity (5),§ and real-world studies in persons aged 12-18 years demonstrated high vaccine effectiveness (VE) against severe COVID-19 (6). Recent evidence suggests that COVID-19 vaccination is associated with lower MIS-C incidence among adolescents (7); however, VE of the 2-dose Pfizer-BioNTech regimen against MIS-C has not been evaluated. The effectiveness of 2 doses of Pfizer-BioNTech vaccine received ≥28 days before hospital admission in preventing MIS-C was assessed using a test-negative case-control design¶ among hospitalized patients aged 12-18 years at 24 pediatric hospitals in 20 states** during July 1-December 9, 2021, the period when most MIS-C patients could be temporally linked to SARS-CoV-2 B.1.617.2 (Delta) variant predominance. Patients with MIS-C (case-patients) and two groups of hospitalized controls matched to case-patients were evaluated: test-negative controls had at least one COVID-19-like symptom and negative SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) or antigen-based assay results, and syndrome-negative controls were hospitalized patients without COVID-19-like illness. Among 102 MIS-C case-patients and 181 hospitalized controls, estimated effectiveness of 2 doses of Pfizer-BioNTech vaccine against MIS-C was 91% (95% CI = 78%-97%). All 38 MIS-C patients requiring life support were unvaccinated. Receipt of 2 doses of the Pfizer-BioNTech vaccine is associated with a high level of protection against MIS-C in persons aged 12-18 years, highlighting the importance of vaccination among all eligible children.

Effectiveness of Pfizer-BioNTech mRNA Vaccination Against COVID-19 Hospitalization Among Persons Aged 12-18 Years - United States, June-September 2021

Pfizer-BioNTech COVID-19 vaccine is authorized for use in children and adolescents aged 12-15 years and is licensed by the Food and Drug Administration (FDA) for persons aged ≥16 (1). A randomized placebo-controlled trial demonstrated an efficacy of 100% (95% confidence interval [CI] = 75.3%-100%) in preventing outpatient COVID-19 in persons aged 12-15 years (2); however, data among adolescents on vaccine effectiveness (VE) against COVID-19 in real-world settings are limited, especially among hospitalized patients. In early September 2021, U.S. pediatric COVID-19 hospitalizations reached the highest level during the pandemic (3,4). In a test-negative, case-control study at 19 pediatric hospitals in 16 states during June 1-September 30, 2021, the effectiveness of 2 doses of Pfizer-BioNTech vaccine against COVID-19 hospitalization was assessed among children and adolescents aged 12-18 years. Among 464 hospitalized persons aged 12-18 years (179 case-patients and 285 controls), the median age was 15 years, 72% had at least one underlying condition, including obesity, and 68% attended in-person school. Effectiveness of 2 doses of Pfizer-BioNTech vaccine against COVID-19 hospitalization was 93% (95% CI = 83%-97%), during the period when B.1.617.2 (Delta) was the predominant variant. This evaluation demonstrated that 2 doses of Pfizer-BioNTech vaccine are highly effective at preventing COVID-19 hospitalization among persons aged 12-18 years and reinforces the importance of vaccination to protect U.S. youths against severe COVID-19.

Anaemia and coronary microvascular dysfunction in end-stage renal disease

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): (1) University Hospitals Birmingham Charity (2) Metchley Park Medical Society

Introduction

 

Coronary microvascular dysfunction (CMD) is common among patients with end-stage renal disease (ESRD) and confers poor prognosis. Coronary flow velocity reserve (CFVR) is a marker of coronary microvascular function and can be reliably measured using Doppler echocardiography. Reduced CFVR in ESRD has been attributed to factors such as hypertension and left ventricular hypertrophy (LVH). Anaemia is prevalent in ESRD but the association between haemoglobin and CFVR in ESRD has not been studied. 

Purpose

 

To assess if CFVR is related to haemoglobin among patients with ESRD. 

Methods

 

22 subjects with ESRD and awaiting kidney transplant (8 pre-dialysis and 14 on peritoneal dialysis) were studied with adenosine myocardial contrast echocardiography, Doppler CFVR assessment and serum multiplex immunoassay analysis. Individuals with diabetes, uncontrolled hypertension or ischaemic heart disease were excluded.

Results 

7/22 (32%) of subjects had CMD (defined as CFVR &lt;2). Age (47 years ± 15 vs 55 ± 10, p = 0.177), estimated glomerular filtration rate [7ml/min/1.73m² (5-11) vs 9 (7-10), p = 0.837], systolic blood pressure (129mmHg ± 25 vs 137 ± 20, p = 0.398) and left ventricular mass index (98g/m² ± 31 vs 98 ± 28, p = 0.936) did not significantly differ between subjects with or without CMD. There were no significant differences in other demographic, haemodynamic, laboratory or echocardiographic variables between the two groups.  A panel of biomarkers of inflammation, myocardial stretch, cardiac fibrosis and LVH studied by multiplex immunoassay also did not show any significant differences between the two groups. No subjects had wall motion abnormalities or perfusion defects on myocardial contrast echocardiography.

CFVR was significantly lower in subjects with CMD (1.6 ± 0.2 vs 3.2 ± 0.9, p &lt; 0.001). Subjects with CMD had significantly lower haemoglobin than subjects without CMD (102g/L ± 12 vs 117g/L ± 11, p = 0.008). There was a moderate positive correlation between haemoglobin and CFVR (r = 0.65, p = 0.001) – figure 1. In a stepwise multiple regression model with CFVR as the dependent variable and age, haemoglobin, systolic blood pressure, left ventricular mass index and estimated glomerular filtration rate as independent variables, only haemoglobin was an independent predictor of CFVR (β=0.051 95%CI 0.023-0.079, p = 0.001). 

Conclusions 

Among our cohort of ESRD patients awaiting kidney transplant, there was a high prevalence of CMD despite well controlled blood pressure and no significant LVH. Subjects with CMD had significantly lower haemoglobin than subjects without CMD. Reduced haemoglobin causes impaired oxygen carrying capacity to the myocardium, which may lead to microvascular ischaemia and adverse microvascular remodelling, causing CMD. Thus, anaemia may be a potentially correctible driver of CMD in ESRD.  This association needs to be confirmed in larger studies.

Abstract Figure 1

A-33 VOMS Scores Relationship to C3 Logix Trail Scores in Females

Objective

Burkhart and colleagues (2020) showed that positive screening on the Vestibular Ocular Motor Screening (VOMS) and slower C3 Logix Trails (C3LT) were predictive of protracted recovery in female adolescents. The purpose of this study was to see if there was a relationship between positive screening on the VOMS and slower C3LT times in a similar population.

Method

220 females aged 10–18 were administered the VOMS and C3LT between 2017–2019. We hypothesized that positive screening on the VOMS (i.e. symptom provocation of +2, convergence of &gt; 6 mm) would be related to slower speeds on C3LT A and B. Odds ratios were calculated to estimate the likelihood of screening positive on the VOMS based on C3LT times.

Results

Slower times on C3LT A and B, one to two standard deviations (SD) above the mean, was not related to a positive screening on the VOMS. However, performing a faster C3LT A time, one SD below the mean, was 68% less likely to screen positively on the VOMS (OR = 0.32, 95%CI = 0.16–0.62, p = 0.001) compared to those not 1 SD below the mean.

Conclusions

Though C3LT has a visual scanning component, positive screening on the VOMS was not related to slower processing speeds on the C3LT in females age 10–18.

A-08 VOMS Scores Relationship to King-Devick Scores in Males

Objective

Burkhart and colleagues (2020) showed that positive screening on the Vestibular Ocular Motor Screening (VOMS) and slower King Devick scores were predictive of protracted recovery in male adolescents. The purpose of this study was to examine the relationship between positive VOMS screening and King-Devick Trial 1 scores in a similar population.

Method

300 male participants age 10–18 were administered VOMS and King-Devick Trial 1 within 7-days of their injury at a specialty concussion clinic between 2017–2019. We hypothesized that slower speeds on King-Devick Trial 1 would be related to a positive screening on the VOMS (i.e. symptom provocation of +2, convergence of &gt; 6 mm). Odds ratios were calculated to estimate the likelihood of screening positive on the VOMS among those with a King-Devick Trial 1 score above the median compared to those with a score below the median.

Results

Those scoring above the median on King-Devick Trial 1 (i.e. slower times) were 74% more likely to have a positive screening on the VOMS, OR = 1.74, 95% CI [1.10–2.78], p = 0.02, relative to those with a King-Devick Trial 1 above the median.

Conclusions

The VOMS was created to be a symptom provocation tool sensitive to concussion. However, this study demonstrated that the VOMS is also related to performance on objective visual scanning task. Specifically, adolescent males with slower scores on the King-Devick Trial 1 were more likely to have a positive screening on the VOMS.

Premature coronary artery disease and early stage chronic kidney disease

A 30 year old asymptomatic male with stage 3 chronic kidney disease (CKD) secondary to Focal Segmental Glomerulosclerosis was found to have features of CKD associated cardiomyopathy including left ventricular hypertrophy (LVH) and focal sub-endocardial scarring on cardiac magnetic resonance imaging. There was also a significantly raised CT coronary calcium score and evidence of non-flow limiting coronary artery disease (CAD) on a CT coronary angiogram. Early stage CKD is a major risk factor for cardiovascular risk causing myocardial hypertrophy and fibrosis and coronary artery atheroma. Cardiovascular risk begins to increase from an eGFR of around 75ml/min/1.73m2. The pathophysiology of cardiovascular disease in CKD is under investigation but to date, treatment options are limited. Blood pressure control and statins have the strongest supportive evidence.

Nurse-led weaning from mechanical ventilation: where's the evidence?

BACKGROUND

Several authors have suggested clinical protocols as a means of shortening ventilation time and the important role of the nurse in reducing ventilation time has also been highlighted. Despite the many references in the literature to reducing weaning times using clinical protocols, it is not clear whether nurse-led weaning strategies hasten weaning from mechanical ventilation compared with physician-led care.

OBJECTIVE

to systematically review the published literature to answer the question: Does nurse-led weaning from mechanical ventilation reduce duration of ventilation compared with doctor-led care?

DATA SOURCES

MEDLINE, CINHAL, EMBASE, Cochrane Library, Best Evidence, hand search, expert opinion, controlled trials register.

STUDY SELECTION

randomized controlled trials (RCTs) and cohort studies where nurses or respiratory therapists lead the weaning from mechanical ventilation; duration of ventilation must be stated.

DATA EXTRACTION

performed by the author, who extracted data on statistical significance of the difference in duration of ventilation between control and trial groups, complication rates (such as reintubation) and mortality.

DATA SYNTHESIS

statistical synthesis was not attempted but narrative synthesis was performed.

RESULTS

only 1 randomized controlled trial and 2 cohort studies were found where nurses or respiratory therapists led weaning using a protocol. Two studies showed reduction in ventilation time without additional complications; the third study had the weakest evidence, because it was retrospective, and showed no difference between control and treatment groups.

CONCLUSIONS

There is limited evidence suggesting that nurse-led weaning may reduce ventilation time; however, it is not clear whether it was the nurse-led aspect or the clinical protocol that produced the effect.

Distribution of 8-oxygenated leaf-surface flavones in the genus Ocimum

Nine species of Ocimum (Lamiaceae) were surveyed for leaf-surface flavonoids by means of HPLC with diode array detection and atmospheric pressure chemical ionisation (APCI) mass spectrometry. The analysis revealed the presence of 23 different flavones, most of which were identified by comparing their UV and mass spectra with those of standards. Almost all taxa investigated contained flavones methoxylated in the 6- and 8-positions, such as nevadensin, xanthomicrol and gardenin B. The same taxa also produced flavones methoxylated in the 6-position but hydroxylated in the 8-position, including isothymusin (5,8,4'-trihydroxy-6,7-dimethoxyflavone), pedunculin (5,8-dihydroxy-6,7,4'-trimethoxyflavone) and a new flavone, 5,7,8-trihydroxy-6,4'-dimethoxyflavone, which was given the trivial name pilosin. This compound was isolated from O. americanum var. pilosum and also detected as a minor constituent in O. x citriodorum leaf extracts. Its molecular structure was elucidated by means of NMR spectroscopy. 8-Oxygenated flavones were absent only from O. lamiifolium. APCI mass spectrometry of the flavonoids revealed that the product ions formed by collision induced dissociation of the protonated molecule provided structural information about the substitution pattern of the A-ring. The chemotaxonomic and biogenetic implications of the results are discussed.

Our journey with clinical supervision in an intensive care unit

In 1991, the nursing profession began to pursue the idea of reflective practice with vigour, despite little evidence that reflective practice improved nursing care (Burnard 1991; Hunt 1993). A small qualitative study on the experiences of nurses writing reflective journals was undertaken in the intensive care unit at Newham General Hospital. (A Price 1995). This highlighted the need for clear initial guidance and support when introducing reflective practice. It also demonstrated a lack of knowledge about reflection within the unit. During this time, a group of nurses who were interested in developing clinical supervision as a method of support for staff was formed. Kohner's (1994) definition of clinical supervision, adopted by the group after review of literature, makes it clear that this involves reflection on practice. Johns' (1993) Model of Structured Reflection was amended and used to promote in-depth analysis of situations, and journal writing was encouraged within the group. A continuing process of group clinical supervision was started, initially with the help of a facilitator experienced in it. On the basis of this experience, a strategy for implementation of clinical supervision in the intensive care unit was developed and put into action by the group members. Consideration of the progress and problems experienced leads to the conclusion that continuing staff motivation and commitment, and adequate time are essential for implementation of clinical supervision.

Osmolality affects ion and water fluxes and secretion in the ferret trachea

Nonisosmolar solutions were placed in the lumen of the ferret trachea in vitro in an organ bath. Hyposmolar (150 mmol/kg) solutions progressively increased in osmolarity over 1 h. Increases in luminal concentration of impermeant blue dextran occurred only after 5 min, suggesting that the initial changes were due to ion rather than water fluxes. With hyperosmolar solutions the osmolarity decreased over 1 h with no change in blue dextran concentration, indicating that ion but not water fluxes were taking place. Cooling the preparation to 4 degrees C greatly reduced the osmolaity changes with hyperosmolar solutions and halved those with hyposmolar solutions, suggesting that active ion transport was involved. Hyposmolar (75-150 mmol/kg) and hyperosmolar (450-900 mmol/kg) solutions both increased albumin output into the lumen, but the response was prevented by cooling the trachea to 4 degrees C. Hyposmolar and hyperosmolar solutions both increased the output of lysozyme from glandular serous cells into the lumen. The response to hyposmolar solutions was stronger. Cooling the trachea abolished the lysozyme response to hyperosmolar solutions. Thus hypo- and hyperosmolar solutions promote ion transport in directions to restore isosmolarity. Both nonisosmolar solutions promote albumin movement by active transport across the mucosa and lysozyme secretion from submucosal glands, responses inhibited by tracheal cooling and therefore dependent on metabolically active processes.

Transport of albumin by the rabbit trachea in vitro

The rabbit whole trachea was mounted in vitro in an organ bath containing Krebs-Henseleit (KH) solution. When the trachea was air filled there was no resting secretion and none was induced by methacholine (0.02 mM). Histology showed that the trachea has very few submucosal glands. When the trachea was filled with KH, with fluorescent bovine serum albumin in the surrounding KH solution, the rate of transport of albumin into the lumen was measured. Methacholine (0.02 mM) and phenylephrine (0.1 mM) more than doubled the output of albumin, and albuterol (0.1 mM) increased it more than fourfold. Cooling the preparation to 4 degrees C decreased the spontaneous output of albumin to less than one-half control and abolished the increase in output due to albuterol. Addition of sodium cyanide (1 mM) to the preparation abolished the increase in albumin transport due to albuterol. Serosal-to-mucosal transport of fluorescent dextran (mol wt 70,000) was less than one-third that of albumin and was not enhanced by methacholine, phenylephrine, or albuterol. Lysozyme output, an index of serous cell secretion, was barely detectable in controls and was not enhanced by any of the drugs. We conclude that the rabbit trachea has no measurable submucosal gland secretion and that it can actively transport albumin into the lumen via the epithelium. The transport rate is enhanced by methacholine, phenylephrine, and especially by albuterol.