Effectiveness of COVID-19 mRNA vaccines in preventing COVID-19-associated outpatient visits and hospitalizations among American Indian and Alaska Native persons, January–November 2021: a test-negative case-control analysis using surveillance data

Background

Despite the disproportionate morbidity and mortality experienced by American Indian and Alaska Native (AI/AN) persons during the COVID-19 pandemic, few studies have reported vaccine effectiveness (VE) estimates among these communities.

Methods

We conducted a test-negative case-control analysis among AI/AN persons aged ≥12 years presenting for care from January 1, 2021 through November 30, 2021 to evaluate effectiveness of mRNA COVID-19 vaccines against COVID-19-associated outpatient visits and hospitalizations. Cases and controls were patients with ≥1 symptom consistent with COVID-19-like illness; cases were defined as those test-positive for SARS-CoV-2 and controls were defined as those test-negative for SARS-CoV-2. We used unconditional multivariable logistic regression to estimate VE, defined as 1 minus the adjusted odds ratio for vaccination among cases versus controls.

Results

The analysis included 207 cases and 267 test-negative controls. Forty-four percent of cases and 78% of controls received two doses of either BNT162b2 or mRNA-1273 vaccine. VE point estimates for two doses of mRNA vaccine were higher for hospitalized participants (94.6% [88.0–97.6]) than outpatient participants (86.5% [63.0–95.0]), but confidence intervals overlapped.

Conclusions

Among AI/AN persons, mRNA COVID-19 vaccines were highly effective in preventing COVID-associated outpatient visits and hospitalizations. Maintaining high vaccine coverage, including booster doses, will reduce the burden of disease in this population.

COVID-19 Case Investigation and Contact Tracing in the US, 2020

Importance

Contact tracing is a multistep process to limit SARS-CoV-2 transmission. Gaps in the process result in missed opportunities to prevent COVID-19.

Objective

To quantify proportions of cases and their contacts reached by public health authorities and the amount of time needed to reach them and to compare the risk of a positive COVID-19 test result between contacts and the general public during 4-week assessment periods.

Design, Setting, and Participants

This cross-sectional study took place at 13 health departments and 1 Indian Health Service Unit in 11 states and 1 tribal nation. Participants included all individuals with laboratory-confirmed COVID-19 and their named contacts. Local COVID-19 surveillance data were used to determine the numbers of persons reported to have laboratory-confirmed COVID-19 who were interviewed and named contacts between June and October 2020.

Main Outcomes and Measures

For contacts, the numbers who were identified, notified of their exposure, and agreed to monitoring were calculated. The median time from index case specimen collection to contact notification was calculated, as were numbers of named contacts subsequently notified of their exposure and monitored. The prevalence of a positive SARS-CoV-2 test among named and tested contacts was compared with that jurisdiction's general population during the same 4 weeks.

Results

The total number of cases reported was 74 185. Of these, 43 931 (59%) were interviewed, and 24 705 (33%) named any contacts. Among the 74 839 named contacts, 53 314 (71%) were notified of their exposure, and 34 345 (46%) agreed to monitoring. A mean of 0.7 contacts were reached by telephone by public health authorities, and only 0.5 contacts per case were monitored. In general, health departments reporting large case counts during the assessment (≥5000) conducted smaller proportions of case interviews and contact notifications. In 9 locations, the median time from specimen collection to contact notification was 6 days or less. In 6 of 8 locations with population comparison data, positive test prevalence was higher among named contacts than the general population.

Conclusions and Relevance

In this cross-sectional study of US local COVID-19 surveillance data, testing named contacts was a high-yield activity for case finding. However, this assessment suggests that contact tracing had suboptimal impact on SARS-CoV-2 transmission, largely because 2 of 3 cases were either not reached for interview or named no contacts when interviewed. These findings are relevant to decisions regarding the allocation of public health resources among the various prevention strategies and for the prioritization of case investigations and contact tracing efforts.

Evaluation of measurement error in 24-hour dietary recall for assessing sodium and potassium intake among US adults - National Health and Nutrition Examination Survey (NHANES), 2014

BACKGROUND

Understanding measurement error in sodium and potassium intake is essential for assessing population intake and studying associations with health outcomes.

OBJECTIVE

The aim of this study was to compare sodium and potassium intake derived from 24-h dietary recall (24HDR) with intake derived from 24-h urinary excretion (24HUE).

DESIGN

Data were analyzed from 776 nonpregnant, noninstitutionalized US adults aged 20-69 y who completed 1-to-2 24HUE and 24HDR measures in the 2014 NHANES. A total of 1190 urine specimens and 1414 dietary recalls were analyzed. Mean bias was estimated as mean of the differences between individual mean 24HDR and 24HUE measurements. Correlations and attenuation factors were estimated using the Kipnis joint-mixed effects model accounting for within-person day-to-day variability in sodium excretion. The attenuation factor reflects the degree to which true associations between long-term intake (estimated using 24HUEs) and a hypothetical health outcome would be approximated using a single 24HDR: values near 1 indicate close approximation and near 0 indicate bias toward null. Estimates are reported for sodium, potassium, and the sodium: potassium (Na/K) ratio. Model parameters can be used to estimate correlations/attenuation factors when multiple 24HDRs are available.

RESULTS

Overall, mean bias for sodium was -452 mg (95% CI: -646, -259), for potassium -315 mg (CI: -450, -179), and for the Na/K ratio -0.04 (CI: -0.15, 0.07, NS). Using 1 24HDR, the attenuation factor for sodium was 0.16 (CI: 0.09, 0.21), for potassium 0.25 (CI:0.16, 0.36), and for the Na/K ratio 0.20 (CI: 0.10, 0.25). The correlation for sodium was 0.27 (CI: 0.16, 0.37), for potassium 0.35 (CI: 0.26, 0.55), and for the Na/K ratio 0.27 (CI: 0.13, 0.32).

CONCLUSIONS

Compared with 24HUE, using 24HDR underestimates mean sodium and potassium intake but is unbiased for the Na/K ratio. Additionally, using 24HDR as a measure of exposure in observational studies attenuates the true associations of sodium and potassium intake with health outcomes.

1723. Mumps Attack Rates Following Administration of a Third Dose of MMR Vaccine to School-Aged Children, Arkansas, 2016–2017

Background

During the 2016–2017 school year, the largest mumps outbreak in the United States since 2006 occurred in Arkansas with nearly 3,000 cases. As part of outbreak response, a third dose of measles–mumps–rubella vaccine (MMR3) was offered at 27 schools with mumps attack rates ≥5 cases/1,000 students. We compared attack rates after vaccination clinics among students who received MMR3 and students with 2 MMR vaccine doses.

Methods

We obtained information on school enrollment and student immunization status from school registries, and mumps case status from Arkansas’s National Electronic Disease Surveillance System database. We included students aged 6–21 years who had previously received ≥2 doses of MMR vaccine. We used Arkansas’s Immunization Information System to identify students who received MMR3.

We included schools with at least 1 mumps case after their vaccination clinic. We calculated mumps attack rates by 2- and 3-dose MMR vaccine recipients. Observation time started 14 days after each clinic to allow for development of an immune response to MMR3, and continued to the end of the 2016–2017 school year. Observation time varied by school as schools held clinics on different dates.

Results

A total of 18 schools (10 elementary, 8 middle/junior high) with 10,275 students who had previously received ≥2 doses of MMR (85% of total enrolled) met inclusion criteria. Median number of students per school was 553. Median student age was 11 years (range, 6–18) and 1,525 students received MMR3. MMR3 uptake varied by school (median, 12%; range, 2–33%; interquartile range, 7–22%). A total of 12 mumps cases occurred among MMR3 recipients and 122 cases among 2-dose recipients. School-specific attack rates ranged from 0 to 23 cases/1,000 students among 3-dose recipients, and 2–41 cases/1,000 students among 2-dose recipients. Mumps attack rates within each school were lower for 3-dose recipients vs. 2-dose recipients in all but one school (P < .05). The differences in attack rates between 2- and 2-dose recipients ranged from −5 to 23 cases/1,000 students (median, 5/1,000).

Conclusion

Mumps attack rates were lower in 3-dose vs. 2-dose MMR vaccine recipients after MMR3 vaccination clinics, supporting a benefit of MMR3 for persons in outbreak settings. Further analysis is needed to determine impact of MMR3 on duration and size of mumps outbreaks.

Disclosures

All authors: No reported disclosures.

Self-Reported Receipt of Advice and Action Taken To Reduce Dietary Sodium Among Adults With and Without Hypertension - Nine States and Puerto Rico, 2015

Hypertension is a major cardiovascular disease risk factor (1,2). Advice given by health professionals can result in lower sodium intake and lower blood pressure (3).The 2017 Hypertension Guideline released by the American College of Cardiology and the American Heart Association emphasizes nonpharmacologic approaches, including sodium reduction, as important components of hypertension prevention and treatment (4). Data from 50,576 participants in the sodium module of the 2015 Behavioral Risk Factor Surveillance System (BRFSS) in nine states and Puerto Rico were analyzed to determine the prevalence of reported sodium reduction advice and action among participants with and without self-reported hypertension. Among participants with self-reported hypertension, adjusted prevalence of receiving sodium reduction advice from a health professional was 41.9%, compared with 12.8% among participants without hypertension. Among those with hypertension, adjusted prevalence of reported action to reduce sodium intake was 80.9% among participants who received advice and 55.7% among those who did not receive advice. Among participants without hypertension, adjusted prevalence of taking action to reduce sodium intake was 72.7% among those who received advice and 46.9% among those who did not receive advice. The provision of advice on sodium reduction by health professionals is associated with respondent action to watch or reduce sodium intake. Fewer than half of patients with hypertension received this advice from their health professionals, a circumstance that represents a substantial missed opportunity to promote hypertension prevention and treatment.

Home return following invasive mechanical ventilation for the oldest-old patients in medical intensive care units from two US hospitals

Background:

The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50–70-year olds.

Methods:

Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50–70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards’ regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home.

Results:

A total of 375 patients were included in the analysis: 279 (74%) patients aged 50–70 years and 96 (26%) patients aged ≥80 years. Compared to 50–70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96; 95% CI 1.43–2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19; 95% CI 1.33–3.59) as well as of dying in the hospital (adjusted HR: 1.81; 95% CI 1.21–2.71).

Conclusion:

Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50–70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population.

The role of pre-existing diabetes mellitus on hepatocellular carcinoma occurrence and prognosis: a meta-analysis of prospective cohort studies

Background

The impact of pre-existing diabetes mellitus (DM) on hepatocellular carcinoma (HCC) occurrence and prognosis is complex and unclear. The aim of this meta-analysis is to evaluate the association between pre-existing diabetes mellitus and hepatocellular carcinoma occurrence and prognosis.

Methods

We searched PubMed, Embase and the Cochrane Library from their inception to January, 2011 for prospective epidemiological studies assessing the effect of pre-existing diabetes mellitus on hepatocellular carcinoma occurrence, mortality outcomes, cancer recurrence, and treatment-related complications. Study-specific risk estimates were combined by using fixed effect or random effect models.

Results

The database search generated a total of 28 prospective studies that met the inclusion criteria. Among these studies, 14 reported the risk of HCC incidence and 6 studies reported risk of HCC specific mortality. Six studies provided a total of 8 results for all-cause mortality in HCC patients. Four studies documented HCC recurrence risks and 2 studies reported risks for hepatic decomposition occurrence in HCC patients. Meta-analysis indicated that pre-existing diabetes mellitus (DM) was significantly associated with increased risk of HCC incidence [meta-relative risk (RR) = 1.87, 95% confidence interval (CI): 1.15–2.27] and HCC-specific mortality (meta-RR = 1.88, 95%CI: 1.39–2.55) compared with their non-DM counterparts. HCC patients with pre-existing DM had a 38% increased (95% CI: 1.13–1.48) risk of death from all-causes and 91% increased (95%CI: 1.41–2.57) risk of hepatic decomposition occurrence compared to those without DM. In DM patients, the meta-RR for HCC recurrence-free survival was 1.93(95%CI: 1.12–3.33) compared with non-diabetic patients.

Conclusion

The findings from the current meta-analysis suggest that DM may be both associated with elevated risks of both HCC incidence and mortality. Furthermore, HCC patients with pre-existing diabetes have a poorer prognosis relative to their non-diabetic counterparts.

Declining rates of hepatocellular carcinoma in urban Shanghai: incidence trends in 1976-2005

In China, hepatocellular carcinoma (HCC) incidence rates in several registry catchment populations are amongst the highest worldwide. The incidence rates in urban Shanghai were analyzed between 1976 and 2005 to describe and interpret the time trends. Age-specific and age-standardized rates were calculated and graphically presented. An age-period-cohort model was fitted to assess the effects of age at diagnosis, calendar period, and birth cohort on the changing HCC incidence rates. In total, 35,241 and 13,931 men and women were diagnosed with HCC during 1976-2005 in urban Shanghai. The age-standardized incidence rates in urban Shanghai were 33.9 per 10(5) among men and 11.4 per 10(5) among women in 1976-1980, but decreased in both sexes to 25.8 per 10(5) and 8.5 per 10(5), respectively by 2001-2005. Accelerating rates in birth cohorts born in the early-1930s and decelerating rates circa 1945 were observed in both sexes, with further accelerations noted in the late-1950s (in women) and early-1960s (in men). Given the parameterization, increases in risk of HCC were seen in successive male and female generations between 1900 and 1935, followed by a further increase among successive cohorts born around 1960, with a reduction in risk in the most recent generations. The incidence rates of HCC in urban Shanghai from 1976 to 2005 have declined in both sexes, with the complex but similar patterns observed in successive generations suggestive of a shared changing prevalence in risk factors in men and women, with a role possibly for HBV interventions reducing risk of HCC in cohorts born after 1960.

Soy intake is associated with lower lung cancer risk: results from a meta-analysis of epidemiologic studies

BACKGROUND

Although several in vitro and animal in vivo studies have suggested that soy or soy isoflavones may exert inhibitory effects on lung carcinogenesis, epidemiologic studies have reported inconclusive results on the association between soy intake and lung cancer.

OBJECTIVE

The aim of this meta-analysis was to investigate whether an association exists between soy and lung cancer in epidemiologic studies.

DESIGN

We searched PubMed, EMBASE, and the Cochrane Library from their inception to February 2011 for both case-control and cohort studies that assessed soy consumption and lung cancer risk. Study-specific risk estimates were combined by using fixed-effect or random-effect models.

RESULTS

A total of 11 epidemiologic studies that consisted of 8 case-control and 3 prospective cohort studies were included. A significantly inverse association was shown between soy intake and lung cancer with an overall RR of 0.77 (95% CI: 0.65, 0.92). Findings were slightly different when analyses were restricted to 5 high-quality studies (RR: 0.70; 95% CI: 0.45, 0.99). In a subgroup meta-analysis, a statistically significant protective effect of soy consumption was observed in women (RR: 0.79; 95% CI: 0.67, 0.93), never smokers (RR: 0.62; 95% CI: 0.51, 0.76), and Asian populations (RR: 0.86; 95% CI: 0.74, 0.98).

CONCLUSIONS

Our findings indicate that the consumption of soy food is associated with lower lung cancer risk. Because of different methods used to assess soy consumption across studies, more well-designed cohort studies or intervention studies that use unified measures of soy intake are needed to fully characterize such an association.

Marital status and mortality among middle age and elderly men and women in urban Shanghai

BACKGROUND

Previous studies have suggested that marital status is associated with mortality, but few studies have been conducted in China where increasing aging population and divorce rates may have major impact on health and total mortality.

METHODS

We examined the association of marital status with mortality using data from the Shanghai Women's Health Study (1996-2009) and Shanghai Men's Health Study (2002-2009), two population-based cohort studies of 74,942 women aged 40-70 years and 61,500 men aged 40-74 years at the study enrollment. Deaths were identified by biennial home visits and record linkage with the vital statistics registry. Marital status was categorized as married, never married, divorced, widowed, and all unmarried categories combined. Cox regression models were used to derive hazard ratios (HR) and 95% confidence interval (CI).

RESULTS

Unmarried and widowed women had an increased all-cause HR = 1.11, 95% CI: 1.03, 1.21 and HR = 1.10, 95% CI: 1.02, 1.20 respectively) and cancer (HR = 1.17, 95% CI: 1.04, 1.32 and HR = 1.18, 95% CI: 1.04, 1.34 respectively) mortality. Never married women had excess all-cause mortality (HR = 1.46, 95% CI: 1.03, 2.09). Divorce was associated with elevated cardiovascular disease (CVD) mortality in women (HR = 1.47, 95% CI: 1.01, 2.13) and elevated all-cause mortality (HR = 2.45, 95% CI: 1.55, 3.86) in men. Amongst men, not being married was associated with excess all-cause (HR = 1.45, 95% CI: 1.12, 1.88) and CVD (HR = 1.65, 95% CI: 1.07, 2.54) mortality.

CONCLUSIONS

Marriage is associated with decreased all cause mortality and CVD mortality, in particular, among both Chinese men and women.

Changes in cancer incidence patterns among a northeastern American Indian population: 1955-1969 versus 1990-2004

PURPOSE

This manuscript examines shifts in patterns of cancer incidence among the Seneca Nation of Indians (SNI) for the interval 1955-1969 compared to 1990-2004.

METHODS

A retrospective cohort design was used to examine cancer incidence among the SNI during 2 time intervals: 1955-1969 and 1990-2004. Person-years at risk were multiplied by cancer incidence rates for New York State, exclusive of New York City, over 5-year intervals. A computer-aided match with the New York State Cancer Registry was used to identify incident cancers. Overall and site-specific standardized incidence ratios (SIRs = observed/expected x 100), and 95% confidence intervals (CIs), were calculated for both time periods.

RESULTS

During the earlier interval, deficits in overall cancer incidence were noted among males (SIR = 56, CI 36-82) and females (SIR = 71, CI 50-98), and for female breast cancers (SIR = 21, CI 4-62). During the more recent intervals, deficits in overall cancer incidence persisted among both genders (males SIR = 63, CI 52-77; females SIR = 67, CI 55-80). Deficits were also noted among males for cancers of the lung (SIR = 60, CI 33-98), prostate (SIR = 51, CI = 33-76) and bladder (SIR = 17, CI = 2-61) and among females for breast (SIR = 33, CI = 20-53) and uterus (SIR = 36, CI = 10-92). No cancer sites demonstrated increased incidence. Persons ages 60-69 years, 70-79 years, and ages 80+ years tended to exhibit deficits in overall incidence.

CONCLUSIONS

Despite marked changes over time, deficits in overall cancer incidence have persisted between the time intervals studied. Tribal-specific cancer data are important for the development and implementation of comprehensive cancer control plans which align with local needs.

Fifty years of cancer in an American Indian population

BACKGROUND

A clear understanding of cancer patterns among American Indian tribal groups has been complicated by a variety of issues. A retrospective cohort study design was applied to a Seneca Nation of Indians (SNI) cohort for the period from 1955 through 2004.

METHODS

Incident cancers were identified through a computer match with the New York State Cancer Registry. Standardized incidence ratios (SIRs) and 95% confidence intervals were calculated for the overall interval as well as for each of the 5 10-year intervals. The SNI cohort consisted of 3935 men and 4193 women with a total of 120,403 person-years.

RESULTS

Significant deficits in cancer incidence were noted among men for all sites combined (SIR, 69), and for lung (SIR, 59), prostate (SIR, 54), urinary bladder (SIR, 8), and Hodgkin lymphoma (SIR, 0); no cancer sites were identified with significantly elevated incidence. Women demonstrated significantly reduced cancer incidence for all sites combined (SIR, 70) and for breast (SIR, 39), colorectal (SIR, 72), ovary (SIR, 37), uterus (SIR, 42), bladder (SIR, 20), pancreas (SIR, 10), and non-Hodgkin lymphoma (SIR, 39); elevated incidence was noted for cancers of the lung (SIR, 139) and liver (SIR, 405).

CONCLUSIONS

To the authors' knowledge, the current study represents the most comprehensive investigation to date of cancer patterns among an American Indian tribal group and provides insights for the development of tribal cancer control programming.