Defining and reporting adverse events of special interest in comparative maternal vaccine studies: a systematic review

Introduction

The GAIA (Global Alignment on Immunisation Safety Assessment in Pregnancy) consortium was established in 2014 with the aim of creating a standardised, globally coordinated approach to monitoring the safety of vaccines administered in pregnancy. The consortium developed twenty-six standardised definitions for classifying obstetric and infant adverse events. This systematic review sought to evaluate the current state of adverse event reporting in maternal vaccine trials following the publication of the case definitions by GAIA, and the extent to which these case definitions have been adopted in maternal vaccine safety research.

Methods

A comprehensive search of published literature was undertaken to identify maternal vaccine research studies. PubMed, EMBASE, Web of Science, and Cochrane were searched using a combination of MeSH terms and keyword searches to identify observational or interventional studies that examined vaccine safety in pregnant women with a comparator group. A two-reviewer screening process was undertaken, and a narrative synthesis of the results presented.

Results

14,737 titles were identified from database searches, 435 titles were selected as potentially relevant, 256 were excluded, the remaining 116 papers were included. Influenza vaccine was the most studied (25.0%), followed by TDaP (20.7%) and SARS-CoV-2 (12.9%).Ninety-one studies (78.4%) were conducted in high-income settings. Forty-eight (41.4%) utilised electronic health-records. The majority focused on reporting adverse events of special interest (AESI) in pregnancy (65.0%) alone or in addition to reactogenicity (27.6%). The most frequently reported AESI were preterm birth, small for gestational age and hypertensive disorders. Fewer than 10 studies reported use of GAIA definitions. Gestational age assessment was poorly described; of 39 studies reporting stillbirths 30.8% provided no description of the gestational age threshold.

Conclusions

Low-income settings remain under-represented in comparative maternal vaccine safety research. There has been poor uptake of GAIA case definitions. A lack of harmonisation and standardisation persists limiting comparability of the generated safety data.

Evaluation of Forced Expiratory Volume in One Second and Forced Vital Capacity from Age and Height for Pulmonary Function Test

BACKGROUND

Lung function tests (LFTs) are a collection of clinical examinations used to assess lung function and monitor potential declines in the lungs, respiratory muscles, and chest wall's mechanical performance. This cross-sectional study aimed to identify the relation of age and height to lung function.

MATERIAL AND METHODS

The study was conducted at AlHussein Medical City, 70 adult male subjects were enrolled in the study. All subjects were screened physically to ensure that they were normal and there were no respiratory disorders that could affect the lung function. Age and height were taken for these subjects, forced vital capacity (FVC), FEV1 (Forced expiratory volume in first second) as well as FEV1 /FVC ratio were measured.

RESULTS

The results of the study showed that the average values of FVC and FEV1 were 4.75 and 3.88 respectively. There was a significant negative correlation observed between age and FVC (r=0.48), FEV1 (r= 0.6). Also there was a significant positive correlation noticed between Height and FVC (r = 0.62), FEV1 (r =0.69). There was a very high correlation evidenced between FEV1 and FVC, the relation between FEV1 and FVC is practically height and age-independent.

CONCLUSION

Our study highlights a great interest in the study of the relation between age, height, and lung function. The study also creates simple and convenience equations that can be used for reference standards in clinical practice to give reasonable theoretical values for a large sector of the population.

Reflective practice in psychiatric training: Balint groups during COVID-19

Reflective practice is increasingly being recognized as an important component of doctors' professional development. Balint group practice is centered on the doctor-patient relationship: what it means, how it may be used to benefit patients, and why it commonly fails owing to a lack of understanding between doctor and patient. The COVID-19 pandemic led to unprecedented disruption to postgraduate medical training programs, including the mandatory Balint groups for psychiatric trainees. This editorial reports on the experience of online Balint groups in the North West of Ireland during the COVID-19 pandemic, and furthermore provides guidance for online Balint group practice into the future.

SARS-CoV-2 mRNA vaccines decouple anti-viral immunity from humoral autoimmunity

mRNA-based vaccines dramatically reduce the occurrence and severity of COVID-19, but are associated with rare vaccine-related adverse effects. These toxicities, coupled with observations that SARS-CoV-2 infection is associated with autoantibody development, raise questions whether COVID-19 vaccines may also promote the development of autoantibodies, particularly in autoimmune patients. Here we used Rapid Extracellular Antigen Profiling to characterize self- and viral-directed humoral responses after SARS-CoV-2 mRNA vaccination in 145 healthy individuals, 38 patients with autoimmune diseases, and 8 patients with mRNA vaccine-associated myocarditis. We confirm that most individuals generated robust virus-specific antibody responses post vaccination, but that the quality of this response is impaired in autoimmune patients on certain modes of immunosuppression. Autoantibody dynamics are remarkably stable in all vaccinated patients compared to COVID-19 patients that exhibit an increased prevalence of new autoantibody reactivities. Patients with vaccine-associated myocarditis do not have increased autoantibody reactivities relative to controls. In summary, our findings indicate that mRNA vaccines decouple SARS-CoV-2 immunity from autoantibody responses observed during acute COVID-19.

Maternal SARS-CoV-2 vaccination and infant protection against SARS-CoV-2 during the first six months of life

We examined the effectiveness of maternal vaccination against SARS-CoV-2 infection in 30,311 infants born at Kaiser Permanente Northern California from December 15, 2020, to May 31, 2022. Using Cox regression, the effectiveness of ≥2 doses of COVID-19 vaccine received during pregnancy was 84% (95% confidence interval [CI]: 66, 93), 62% (CI: 39, 77) and 56% (CI: 34,71) during months 0-2, 0-4 and 0- 6 of a child's life, respectively, in the Delta variant period. In the Omicron variant period, the effectiveness of maternal vaccination in these three age intervals was 21% (CI: -21,48), 14% (CI: -9,32) and 13% (CI: -3,26), respectively. Over the entire study period, the incidence of hospitalization for COVID-19 was lower during the first 6 months of life among infants of vaccinated mothers compared with infants of unvaccinated mothers (21/100,000 person-years vs. 100/100,000 person-years). Maternal vaccination was protective, but protection was lower during Omicron than during Delta. Protection during both periods decreased as infants aged.

Resolving sex and gender bias in COVID-19 vaccines R&D and beyond

The influence of sex and gender in immune response and vaccine outcomes is established in many disease areas, including in COVID-19. Yet, there are notable gaps in the consideration of sex and gender in the analysis and reporting of COVID-19 vaccines clinical trial data. The push for stronger sex and gender integration in vaccines science should be championed by all researchers and stakeholders across the R&D and access ecosystem - not just gender experts. This requires joint action on the tactical framing of customized value propositions (based on stakeholder motivations), the stronger enforcement of existing regulation, tools, and commitments, and aligning the overall agenda to parallel calls on intersectionality, equity diversity and inclusion.

Maternal SARS-CoV-2 Vaccination and Infant Protection Against SARS-CoV-2 During the First 6 Months of Life

We examined the effectiveness of maternal vaccination against SARS-CoV-2 infection in 30,288 infants born at Kaiser Permanente Northern California from December 15, 2020, to May 31, 2022. Using Cox regression, the effectiveness of maternal vaccination was 85% (95% confidence interval [CI]: 67, 93), 64% (CI: 43, 78) and 57% (CI: 36,71) during the first 2, 4 and 6 months of life, respectively, in the Delta variant period. In the Omicron variant period, the effectiveness of maternal vaccination in these three age intervals was 22% (CI: -18,48), 14% (CI: -10,32) and 12% (CI: -4,26), respectively. Over the entire study period, the incidence of hospitalization for COVID-19 was lower during the first 6 months of life among infants of vaccinated mothers compared with infants of unvaccinated mothers (21/100,000 person-years vs. 100/100,000 person-years). Maternal vaccination was protective, but protection was lower during Omicron than during Delta. Protection during both periods decreased as infants aged.

The Impact of Australian Childhood Vaccination Mandates on Immunization Specialists and Their Interactions With Families

BACKGROUND

Recent global outbreaks of vaccine-preventable diseases, both before and since the coronavirus disease 2019 pandemic, have led to the introduction or strengthening of vaccine mandate policies to target vaccine refusal. Globally, there is wide variation in how governments and jurisdictions implement and enforce mandatory vaccination as well as the financial and educational consequences to those who fail to comply. We explored the impact of mandate vaccination policies on Australian Immunization Specialists who work in Specialist Immunization Clinics (SIC) for approving vaccine exemptions outside of the mandated criteria. In particular, their interactions with patients and families.

METHODS

A national, prospective, mixed methods, survey-based study conducted with members of the Australian Adverse Event Following Immunisation Clinical Assessment Network between February 2020 and June 2020.

RESULTS

Sixteen Immunization physicians and nurse practitioner specialists working in a SIC completed the survey. All sixteen respondents had been requested by parents to provide a Medical Exemptions at least once. 88% of respondents felt pressure to provide an exemption that was not medically justified according to legislation. Seventy-five percent of SIC consultants felt that the "No Jab" policies created a moderate or extreme amount of stress to both themselves and parents. All respondents reported experiencing hostility from parents with three respondents having received threats of violence.

CONCLUSIONS

Mandatory vaccination policies are associated with increased vaccination coverage but can result in widened financial and social inequity, and may harm families' relationships with health care providers. Countries considering the implementation of vaccination mandates should use the least restrictive health policies to ensure a balance between the public health and individual benefit whilst minimizing burdens on health care professionals, children and their parents.

COVID-19 vaccine perceptions in the initial phases of US vaccine roll-out: an observational study on reddit

Background

Open online forums like Reddit provide an opportunity to quantitatively examine COVID-19 vaccine perceptions early in the vaccine timeline. We examine COVID-19 misinformation on Reddit following vaccine scientific announcements, in the initial phases of the vaccine timeline.

Methods

We collected all posts on Reddit (reddit.com) from January 1 2020 - December 14 2020 (n=266,840) that contained both COVID-19 and vaccine-related keywords. We used topic modeling to understand changes in word prevalence within topics after the release of vaccine trial data. Social network analysis was also conducted to determine the relationship between Reddit communities (subreddits) that shared COVID-19 vaccine posts, and the movement of posts between subreddits.

Results

There was an association between a Pfizer press release reporting 90% efficacy and increased discussion on vaccine misinformation. We observed an association between Johnson and Johnson temporarily halting its vaccine trials and reduced misinformation. We found that information skeptical of vaccination was first posted in a subreddit (r/Coronavirus) which favored accurate information and then reposted in subreddits associated with antivaccine beliefs and conspiracy theories (e.g. conspiracy, NoNewNormal).

Conclusions

Our findings can inform the development of interventions where individuals determine the accuracy of vaccine information, and communications campaigns to improve COVID-19 vaccine perceptions, early in the vaccine timeline. Such efforts can increase individual- and population-level awareness of accurate and scientifically sound information regarding vaccines and thereby improve attitudes about vaccines, especially in the early phases of vaccine roll-out. Further research is needed to understand how social media can contribute to COVID-19 vaccination services.

386. A Systematic Review of COVID-19 Transmission Dynamics and Clinical Response on Cruise Ships Globally Between January and October 2020

Background

Cruise ships provide an ideal setting for efficient transmission of SARS-CoV- 2 given a socially dense exposure environment. No systematic review of transmission of COVID-19 on cruise ships to date has been completed.

Methods

MEDLINE was searched in accordance with PRIMSA guidelines for COVID-19 cases associated with cruise ships. A list of cruise ships with COVID-19 was crossed referenced with the Centers for Disease Controls’ list of cruise ships that had at least one COVID-19 case associated with them within 14 days of disembarkation. News articles were also searched for epidemiologic information. 43 full text articles from MEDLINE and 177 from news sources were included in the final analysis. Narratives of the outbreak in ships with over 100 cases are presented.

PRISMA Flow Diagram

PRISMA Flow diagram of articles screened, reviewed, and analyzed

Results

A total of 80 ships and 104 unique voyages on cruise ships were identified with at least one COVID-19 case before 30 October 2020. Nineteen ships had more than one voyage with a case of COVID-19. The median number of cases per ship was three (intraquartile range (IQR) 1–17.8), with two notable outliers the Diamond Princess and Ruby Princess which had 712 and 907 cases respectively. The median attack rate for COVID-19 was 0.2% (IQR 0.03% -1.5%), though this distribution was skewed to the right with a mean attack rate of 3.7%. 25.9% of voyages had at least one associated death. Outbreaks involving only crew were later than outbreaks with guests and crew.

Cases of COVID-19 on cruise ships in 2020

Number of cases of COVID-19 on cruise ships by date COVID-19 outbreak identified and if case was a guest or crew member. Percent of COVID-19 cases that were crew in 2020

Percent of COVID-19 cases that were in crew members by date outbreak identified in 2020

Percent of passengers on cruise ships that were crew

Percentage of passengers on cruise ships that were crew members in 2020 by date outbreak identified

Conclusion

COVID-19 can spread easily on cruise ships in a susceptible population when there is an absence of mitigation measures due to the confined space and high-density of contact networks. This can not only create super spreader events but also facilitate

international spread.

Disclosures

All Authors: No reported disclosures

572. Real-world Effectiveness of COVID-19 mRNA Vaccines against Hospitalizations and Deaths in a Retrospective Cohort

Background

The effectiveness of Severe Acute Respiratory Syndrome Coronavirus 2 vaccines after two doses needs to be demonstrated beyond clinical trials.

Methods

In a retrospective cohort assembled from a cross-institution comprehensive data repository, established patients of the health care system were categorized as having received no doses, one dose or two doses of SARS-CoV-2 mRNA vaccine through April 4, 2021. Outcomes were COVID-19 related hospitalization and death.

Results

Of 94,018 patients 27.7% had completed two doses and 3.1% had completed one dose of a COVID-19 mRNA vaccine. The two dose group was older with more comorbidities. 1.0% of the two dose group had a COVID-19 hospitalization, compared to 4.0% and 2.7% in the one dose and no dose groups respectively. The adjusted Cox proportional-hazards model based vaccine effectiveness after two doses (vs. no dose) was 96%(95% confidence interval(CI):95–97), compared to 78%(95%CI:76–82) after one dose. After two doses, vaccine effectiveness for COVID-19 mortality was 97.9%(95%CI:91.7–99.5), and 53.5%(95%CI:0.28–80.8) after one dose. Vaccine effectiveness at preventing hospitalization was conserved across age, race, ethnicity, Area Deprivation Index and Charlson Comorbidity Indices.

Cohort Enrollment and Distribution by Immunization Status and Vaccine effectiveness against mortality

Cohort members are described by their immunization status and hospitalization at the end of the study period ending April 4th, 2021. Percentages compare this population to the total established patients. Each group is then divided into when hospitalized events occurred across immunization status. These percentages compare the number of events to the population in the immunization status at the end of the analysis period. Odds ratios for mortality were calculated and vaccine effectiveness calculated as 1 minus odds ratio times 100%.

Conclusion

In a large, diverse US cohort, receipt of two doses of an mRNA vaccine was highly effective in the real-world at preventing COVID-19 related hospitalizations and deaths with a substantive difference in effectiveness between one and two doses.

Disclosures

All Authors: No reported disclosures

Global Respiratory Syncytial Virus-Related Infant Community Deaths

BACKGROUND

Respiratory syncytial virus (RSV) is a leading cause of pediatric death, with >99% of mortality occurring in low- and lower middle-income countries. At least half of RSV-related deaths are estimated to occur in the community, but clinical characteristics of this group of children remain poorly characterized.

METHODS

The RSV Global Online Mortality Database (RSV GOLD), a global registry of under-5 children who have died with RSV-related illness, describes clinical characteristics of children dying of RSV through global data sharing. RSV GOLD acts as a collaborative platform for global deaths, including community mortality studies described in this supplement. We aimed to compare the age distribution of infant deaths <6 months occurring in the community with in-hospital.

RESULTS

We studied 829 RSV-related deaths <1 year of age from 38 developing countries, including 166 community deaths from 12 countries. There were 629 deaths that occurred <6 months, of which 156 (25%) occurred in the community. Among infants who died before 6 months of age, median age at death in the community (1.5 months; IQR: 0.8-3.3) was lower than in-hospital (2.4 months; IQR: 1.5-4.0; P < .0001). The proportion of neonatal deaths was higher in the community (29%, 46/156) than in-hospital (12%, 57/473, P < 0.0001).

CONCLUSIONS

We observed that children in the community die at a younger age. We expect that maternal vaccination or immunoprophylaxis against RSV will have a larger impact on RSV-related mortality in the community than in-hospital. This case series of RSV-related community deaths, made possible through global data sharing, allowed us to assess the potential impact of future RSV vaccines.

Saliva viral load is a dynamic unifying correlate of COVID-19 severity and mortality

While several clinical and immunological parameters correlate with disease severity and mortality in SARS-CoV-2 infection, work remains in identifying unifying correlates of coronavirus disease 2019 (COVID-19) that can be used to guide clinical practice. Here, we examine saliva and nasopharyngeal (NP) viral load over time and correlate them with patient demographics, and cellular and immune profiling. We found that saliva viral load was significantly higher in those with COVID-19 risk factors; that it correlated with increasing levels of disease severity and showed a superior ability over nasopharyngeal viral load as a predictor of mortality over time (AUC=0.90). A comprehensive analysis of immune factors and cell subsets revealed strong predictors of high and low saliva viral load, which were associated with increased disease severity or better overall outcomes, respectively. Saliva viral load was positively associated with many known COVID-19 inflammatory markers such as IL-6, IL-18, IL-10, and CXCL10, as well as type 1 immune response cytokines. Higher saliva viral loads strongly correlated with the progressive depletion of platelets, lymphocytes, and effector T cell subsets including circulating follicular CD4 T cells (cTfh). Anti-spike (S) and anti-receptor binding domain (RBD) IgG levels were negatively correlated with saliva viral load showing a strong temporal association that could help distinguish severity and mortality in COVID-19. Finally, patients with fatal COVID-19 exhibited higher viral loads, which correlated with the depletion of cTfh cells, and lower production of anti-RBD and anti-S IgG levels. Together these results demonstrated that viral load - as measured by saliva but not nasopharyngeal - is a dynamic unifying correlate of disease presentation, severity, and mortality over time.

1125. Innovative Virtual Learning in the Midst of a Pandemic - Patients, Populations, and Pandemics: Responding to COVID-19

Background

The COVID-19 pandemic has posed a unique challenge to undergraduate medical education. Medical schools postponed student participation in direct patient care in mid-March 2020, creating the need for rapidly-designed, virtual, and innovative learning experiences.

Methods

Utilizing Kern’s six-step approach to curriculum development, faculty and medical student liaisons rapidly designed a six-week online and interactive course for clerkship-year students and above, launched on March 30th, 2020. “Patients, Populations, and Pandemics: Responding to COVID-19” emphasized honing higher level skills of Bloom’s taxonomy, namely evaluating, synthesizing, and creating. Following weekly faculty-led lectures, student groups identified research questions, analyzed literature, presented data, critiqued peer presentations, and created infographics for the public.

Results

We aimed to maintain quality and interactiveness despite challenges posed by our timeframe, the evolving COVID-19 literature, and the virtual setting. We recruited frontline faculty and designed the course to facilitate discussion, thereby promoting real-time exploration of public health and clinical challenges. Encouraging student participation, we incorporated group synthesis sessions and instructed use of video, hand-raising, and chat features. In a survey administered at the end of the first week, 85.7% (18/21) of students strongly agreed or agreed that small group presentations successfully enabled synthesis of new and emerging data. Among the 29 enrolled students, 82.8% (24/29) of students completed final course evaluations, with 87.5% (21/24) agreeing that the learning activities “usually” or “always” helped meet the learning objectives identified at the beginning of the course. The course was rated as “excellent” or “very good” by 83.3% (20/24) of students.

Conclusion

Lessons learned include providing students with increased direction on critically reviewing peer presentations and imparting guidance on best practices for data synthesis. This course model will be disseminated throughout our institution and beyond to address challenges in remote learning and to serve as a paradigm during future health crises.

Disclosures

All Authors: No reported disclosures

68. Active Monitoring of a Healthcare Worker Cohort During the COVID-19 Epidemic

Background

Initial CDC recommendations for passive monitoring of COVID-19 related symptoms among staff may not be sufficient in preventing the introduction and transmission of SARS-CoV-2 in healthcare settings. We therefore implemented active monitoring for SARS-CoV-2 infection in healthcare workers (HCWs) at an academic medical center during the COVID-19 epidemic in northeast US.

Methods

We recruited a cohort of HCWs at Yale New Haven Hospital who worked in COVID-19 units and did not have COVID-19 related symptoms between March 28 and June 1, 2020. During follow-up, participants provided daily information on symptoms by responding to a web-based questionnaire, self-administered nasopharyngeal (NP) and saliva specimens every 3 days, and blood specimens every 14 days. We performed SARS-CoV-2 RT-PCR and an anti-spike protein IgM and IgG ELISA to identify virological and serological-confirmed infection, respectively.

Results

We enrolled 525 (13%) amongst 4,136 HCW of whom daily information on symptoms and NP, saliva, and blood specimens were obtained for 66% (of 13208), 42% (or 1977), 44% (of 2071) and 65% (of 1099), respectively, of the follow-up measurement points. We identified 16 (3.0% of 525) HCWs with PCR-confirmed SARS-CoV-2 infection and an additional 12 (2.3% of 525) who were not tested by PCR or had negative PCR results but had serological evidence of infection. The overall cumulative incidence of SARS-CoV-2 infection was 5.3% (28 of 525) amongst HCWs. Cases were not identified by hospital protocols for passive staff self-monitoring for symptoms. Amongst 16 PCR-confirmed cases, 9 (56%) of the 16 PCR-confirmed HCW had symptoms during or after the date of initial detection. We did not identify an epidemiological link between the 28 confirmed cases.

Conclusion

We found that a significant proportion (5.3%) of HCWs were infected with SARS-CoV-2 during the COVID-19 epidemic. In the setting of universal PPE use, infections were possibly acquired in the community rather than stemming from patient-HCW or HCW-HCW transmission. Passive monitoring of symptoms is inadequate in preventing introductions of SARS-CoV-2 into the healthcare setting due to asymptomatic and oligosymptomatic presentations.

Disclosures

All Authors: No reported disclosures

Kinetics of antibody responses dictate COVID-19 outcome

Recent studies have provided insights into innate and adaptive immune dynamics in coronavirus disease 2019 (COVID-19). Yet, the exact feature of antibody responses that governs COVID-19 disease outcomes remain unclear. Here, we analysed humoral immune responses in 209 asymptomatic, mild, moderate and severe COVID-19 patients over time to probe the nature of antibody responses in disease severity and mortality. We observed a correlation between anti-Spike (S) IgG levels, length of hospitalization and clinical parameters associated with worse clinical progression. While high anti-S IgG levels correlated with worse disease severity, such correlation was time-dependent. Deceased patients did not have higher overall humoral response than live discharged patients. However, they mounted a robust, yet delayed response, measured by anti-S, anti-RBD IgG, and neutralizing antibody (NAb) levels, compared to survivors. Delayed seroconversion kinetics correlated with impaired viral control in deceased patients. Finally, while sera from 89% of patients displayed some neutralization capacity during their disease course, NAb generation prior to 14 days of disease onset emerged as a key factor for recovery. These data indicate that COVID-19 mortality does not correlate with the cross-sectional antiviral antibody levels per se, but rather with the delayed kinetics of NAb production.

Kinetics of antibody responses dictate COVID-19 outcome

Recent studies have provided insights into innate and adaptive immune dynamics in coronavirus disease 2019 (COVID-19). Yet, the exact feature of antibody responses that governs COVID-19 disease outcomes remain unclear. Here, we analysed humoral immune responses in 209 asymptomatic, mild, moderate and severe COVID-19 patients over time to probe the nature of antibody responses in disease severity and mortality. We observed a correlation between anti-Spike (S) IgG levels, length of hospitalization and clinical parameters associated with worse clinical progression. While high anti-S IgG levels correlated with worse disease severity, such correlation was time-dependent. Deceased patients did not have higher overall humoral response than live discharged patients. However, they mounted a robust, yet delayed response, measured by anti-S, anti-RBD IgG, and neutralizing antibody (NAb) levels, compared to survivors. Delayed seroconversion kinetics correlated with impaired viral control in deceased patients. Finally, while sera from 89% of patients displayed some neutralization capacity during their disease course, NAb generation prior to 14 days of disease onset emerged as a key factor for recovery. These data indicate that COVID-19 mortality does not correlate with the cross-sectional antiviral antibody levels per se , but rather with the delayed kinetics of NAb production.

Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru

BACKGROUND

Maternal immunization has the potential to reduce both maternal and infant morbidity and mortality by protecting women from complications during pregnancy as well as conferring protection for babies who are too young to be vaccinated. Limited evidence is available about the drivers of maternal immunization in middle-income countries such as Peru. Vaccines against tetanus, diphtheria and influenza are recommended beginning in the second trimester in Peru; however, vaccination coverage has remained low in Peru compared to other countries in the region. As additional vaccines are recommended for administration in pregnancy, a better understanding of the perceptions and attitudes of pregnant women that influence vaccination are needed to design communication materials.

METHODS

We conducted an exploratory qualitative study to understand the individual level factors influencing pregnant women's vaccine uptake. We interviewed pregnant women about their knowledge, perceptions and experiences with vaccination during pregnancy. Community health workers recruited women in a peri urban area of Peru in April 2018.

RESULTS

Twelve women were interviewed, the majority of which had received vaccination during the current pregnancy. The most common reasons for vaccination were to protect the baby and because vaccines are effective. Concerns included vaccine safety during pregnancy and adverse effects on the unborn baby. Some women mentioned that because vaccines are given later in pregnancy, the unborn baby is stronger, so vaccines will not harm them. Women highlighted that the main reason for not being vaccinated was lack of information. They also noted that they were the decision-maker in whether or not they were vaccinated. Most women said that they trusted healthcare providers and that trust was linked to providing information through open communication.

CONCLUSIONS

Overall, participants were supportive of maternal vaccination. They believed that vaccines were effective in protecting both their unborn baby and themselves. The main reason given for non-vaccination was lack of knowledge about vaccination in pregnancy. The strong desire expressed by study participants to get more information presents an opportunity for immunization programs to develop interventions that facilitate better information dissemination to pregnant women to increase vaccination uptake.

Individual and Neighborhood Factors Associated With Failure to Vaccinate Against Influenza During Pregnancy

Uptake of influenza vaccine among pregnant women remains low. We investigated whether unvaccinated pregnant women were clustered geographically and determined factors associated with failure to vaccinate using spatial and multivariate logistic regression analyses. Pregnant women who were members of Kaiser Permanente Northern California in 2015 or 2016 were included in the study. More than half (53%) of the 77,607 included pregnant women were unvaccinated. Spatial analysis identified 5 clusters with a high prevalence of unvaccinated pregnant women. The proportion of unvaccinated women ranged from 57% to 75% within clusters as compared with 51% outside clusters. In covariate-adjusted analyses, residence in a cluster was associated with a 41% increase in the odds of being unvaccinated (odds ratio (OR) = 1.41, 95% confidence interval (CI): 1.36, 1.46). The odds of being unvaccinated were greater for Black women (OR = 1.58, 95% CI: 1.49, 1.69), Hispanic women (OR = 1.15, 95% CI: 1.05, 1.25), women with subsidized health insurance (OR = 1.18, 95% CI: 1.11, 1.24), women with fewer than 5 prenatal-care visits (OR = 1.85, 95% CI: 1.60, 2.16), and neighborhoods with a high deprivation index (fourth quartile vs. first: OR = 1.14, 95% CI: 1.07, 1.21). In conclusion, unvaccinated pregnant women were clustered geographically and by key sociodemographic factors. These findings suggest that interventions to increase influenza vaccine coverage among pregnant women are needed, particularly in vulnerable populations.

Coronavirus Disease-19: An Interim Evidence Synthesis of the World Association for Infectious Diseases and Immunological Disorders (Waidid)

Coronavirus disease 2019 (COVID-19) is a rapidly evolving, highly transmissible, and potentially lethal pandemic caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of June 11 2020, more than 7,000,000 COVID-19 cases have been reported worldwide, and more than 400,000 patients have died, affecting at least 188 countries. While literature on the disease is rapidly accumulating, an integrated, multinational perspective on clinical manifestations, immunological effects, diagnosis, prevention, and treatment of COVID-19 can be of global benefit. We aimed to synthesize the most relevant literature and experiences in different parts of the world through our global consortium of experts to provide a consensus-based document at this early stage of the pandemic.

Health care providers perspectives about maternal immunization in Latin America

BACKGROUND

Antenatal care providers have a key role in providing appropriate information and immunization recommendations to improve pregnant women's vaccine uptake. The objective of this study is to describe health care providers' perspectives and experience regarding the implementation of maternal immunization programs in Latin America.

METHODS

We conducted 33 in-depth interviews of health care providers from Argentina, Brazil, Honduras, Mexico, and Peru (6-7 per country). Qualitative data analysis was conducted using a combination of both manual techniques and the computer software program NVivo. We identified and coded main themes related to maternal immunization.

RESULTS

The main themes identified in this analysis were practices related to maternal immunization, knowledge and training, resource availability and interactions with pregnant women. Healthcare providers knew that recommendations exists but some did not know their content; they expressed concerns about insufficient training. Providers from all five countries expressed the need for additional human resources and supplies. They also expressed a desire for women to be more proactive and ask more questions during the health visits.

CONCLUSION

This is the first multi-country study assessing the perspectives of health care providers about maternal immunization practices at the facility level in Latin America. Recommendations based on the results from this study include implementing additional trainings around maternal immunization, especially targeting obstetricians and midwives. These trainings should be conducted in coordination with improvements to supply chain and other structural issues.

Prevalence of and Sociodemographic Disparities in Influenza Vaccination Among Adults With Diabetes in the United States

National estimates describing the overall prevalence of and disparities in influenza vaccination among patients with diabetes mellitus (DM) in United States are not well described. Therefore, we analyzed the prevalence of influenza vaccination among adults with DM, overall and by sociodemographic characteristics, using the Medical Expenditure Panel Survey database from 2008 to 2016. Associations between sociodemographic factors and lack of vaccination were examined using adjusted logistic regression. Among adults with DM, 36% lacked influenza vaccination. Independent predictors of lacking influenza vaccination included age 18 to 39 years (odds ratio [OR] 2.54; 95% confidence interval [CI], 2.14-3.00), Black race/ethnicity (OR 1.29; 95% CI, 1.14-1.46), uninsured status (OR 1.88; 95% CI, 1.59-2.21), and no usual source of care (OR 1.61; 95% CI, 1.39-1.85). Nearly 64% individuals with ≥ 4 higher-risk sociodemographic characteristics lacked influenza vaccination (OR 3.50; 95% CI 2.79-4.39). One-third of adults with DM in the United States lack influenza vaccination, with younger age, Black race, and lower socioeconomic status serving as strong predictors. These findings highlight the continued need for focused public health interventions to increase vaccine coverage and utilization among disadvantaged communities.

Pregnant women's perspectives about maternal immunization in Latin America

BACKGROUND

Maternal immunization rates and vaccine uptake in Latin America vary from country to country. This variability stems from factors related to pregnant women, vaccine recommendations from healthcare providers and the health system. The aim of this paper is to describe women's knowledge and attitudes to maternal immunziation, and barriers to access and vaccination related decision-making processes in Latin American countries.

METHODS

We conducted focus group discussions (FGD) with pregnant women in five middle-income countries: Argentina, Brazil, Honduras, Mexico and Peru, between July 2016 and July 2018. The FGDs were conducted by trained qualitative researchers in diverse clinics located in the capital cities of these countries.

RESULTS

A total of 162 pregnant women participated in the FGDs. In general, participants were aware of the recommendation to receive vaccines during pregnancy but lacked knowledge regarding the diseases prevented by these vaccines. Pregnant women expressed a desire for clearer and more detailed communication on maternal vaccines by their healthcare professionals instead of relying on other sources of information such as the internet. Overall, participants had positive attitudes towards maternal immunization and were open to receiving vaccines in pregnancy based on general trust they have in recommendations made by their healthcare providers. The main obstacles pregnant women said they encounter were mainly centered around their clinical experience: long waiting times, vaccine shortages, and impolite behavior of healthcare providers or clinical staff.

CONCLUSION

Important advances have been made in Latin America to promote maternal immunization. Results from this study show that an important aspect that remains to be addressed, and is crucial in improving vaccine uptake in pregnancy, is women's clinical experience. We recommend pregnant women to be treated as a priority population for providing immunization and related healthcare education. It is imperative to train healthcare providers in health communication so they can effectively communicate with pregnant women regarding maternal vaccines and can fill knowledge gaps that otherwise might be covered by unreliable sources dispensing inaccurate information.

2735. Improving Uptake of Maternal Immunizations in the Obstetric Care Setting Through an Adaptation of the CDC’s Immunization Quality Improvement Program (AFIX)

Background

Methods

Results

Conclusion

Disclosures

2461. Safety of Quadrivalent Meningococcal Polysaccharide Diphtheria Toxoid-Conjugate Vaccine in Adolescents

Background

The first quadrivalent meningococcal conjugate vaccine (MenACWY-D) was recommended for use in adolescents in 2005. Soon after, case reports of Guillain-Barre syndrome (GBS) following vaccination prompted subsequent studies, with a meta-analysis concluding that the attributable risk of GBS after MenACWY-D is unlikely to exceed 1 case per million vaccinations. We conducted a retrospective cohort study in the Vaccine Safety Datalink to assess the risk of 10 outcomes, including GBS, following MenACWY-D.

Methods

We included adolescents (aged 11–18 years) vaccinated with MenACWY-D during the years 2005–2014. We identified pre-specified outcomes using ICD-9 (International Classification of Disease, version 9) codes. We used automated data only for Bell’s palsy, fever, seizure and syncope, and we confirmed incident cases by medical record review for acute disseminated encephalomyelitis (ADEM), acute transverse myelitis (ATM), anaphylaxis, chronic inflammatory demyelinating polyneuropathy (CIDP), GBS and Henoch-Schönlein purpura (HSP). We used a self-controlled risk interval design to estimate relative risk (RR).

Results

Following 1.4 million doses of MenACWY-D, we detected increased risks for fever in the 1–6 days following vaccination (RR 1.5, 95% confidence interval [CI] 1.3–1.7) and syncope on the day of vaccination (RR 5.8, 95% CI 4.1–8.3), but not for seizures (RR 1.1, 95% CI 0.7–1.9) or Bell’s palsy (RR 1.1, 95% CI 0.8–1.5). We detected no cases in the post-vaccination risk intervals for CIDP, ADEM or ATM. We detected few cases of the other outcomes resulting in relatively unstable RR estimates: anaphylaxis (RR 1.9, 95% CI 0.5–7.1), GBS (RR 2.5, 95% CI 0.6–10.0) and HSP (RR 1.6, 95% CI 0.7–3.3). We estimated that the attributable risk of GBS was 1.5 cases per million vaccinations (upper bound of one-sided 95% CI, 4.9).

Conclusion

In a large retrospective cohort, we detected increased risks for syncope and fever, but not seizures or Bell’s palsy, following vaccination with MenACWY-D. Other outcomes were rare. Our findings, consistent with previous studies, suggest that the increased risk of GBS, if any, is likely small (<5 excess cases of GBS per million vaccinations).

Disclosures

N. P. Klein, Sanofi Pasteur: Investigator, Research grant. Merck: Investigator, Research grant. GSK: Investigator, Research grant. Pfizer: Investigator, Research support. Protein Science: Investigator, Research grant. MedImmune: Investigator, Research grant. Dynavax: Research Contractor, Grant recipient. M. L. Jackson, Novartis: Grant Investigator, Research support.

Hurdles to herd immunity: Distrust of government and vaccine refusal in the US, 2002-2003

High rates of nonmedical exemptions (NMEs) from required childhood vaccinations have contributed to outbreaks of vaccine-preventable diseases, such as measles and pertussis. Understanding the parental decision to obtain an NME could help health professionals and public health programs improve vaccination rates in areas with high vaccine refusal. Using a 2002-2003 multi-state survey of parents of school age children (​n=2445), this study found that parental distrust of the government and of healthcare providers is a significant factor related to a number of vaccine-related beliefs and behaviors. The odds that parents who distrust the government have seen a complementary/alternative medicine (CAM) provider were 2.11 times greater than those of parents who trust the government (70.1% vs 52.6%; OR, 2.11; 95% CI, 1.59-2.84; P<0.01). Parents who distrust the government had increased odds of trusting vaccine information from CAM providers compared to trusting parents (57.9% vs 46.3%; OR, 1.53; 95% CI, 1.16-2.01; P<0.01). Parents who distrust the government also had increased odds of distrusting vaccine information acquired at their healthcare providers' offices (12.6% vs 4.7%; OR, 2.64; 95% CI, 1.64-4.24; P<0.01). Distrustful parents had increased odds of thinking government sources of information about vaccines were unreliable, categorizing the CDC, the Food and Drug Administration (FDA), or local and state health departments as poor or very poor sources (distrust government vs trust government: 25.2% vs 11.7%; OR, 2.39; 95% CI, 1.70-3.36; P<0.01; distrust healthcare providers vs trust healthcare providers: 24.4% vs 11.4%; OR, 2.44; 95% CI, 1.75-3.38; P<0.01). These findings indicate that distrustful parent populations may need to be reached through modalities outside of traditional government and healthcare provider communications. Research into new and more effective techniques for delivering pro-vaccine messages is warranted.

Measuring the hepatic venous pressure gradient in the upper digestive hemorrhages

The upper digestive hemorrhage is one of the main causes of mortality from liver cirrhosis (CH). The measurement of the hepatic venous pressure gradient (HVPG) by angiographic way can be used for the determination of the risk of hemorrhage. The aim of this study is to verify the influence of the HVPG measurement upon the survival in patients with CH and upper digestive hemorrhage. A retrospective pilot study on 33 patients with upper digestive hemorrhage divided into two groups according to the therapeutic attitude followed, was carried out. One group was classically treated, with variceal band ligation, non-elective beta-blockers and in emergency Octreotide. The other group was treated depending on the value of HVPG. From the moment of the first episode of digestive hemorrhage, the survival period was in average of 8.1 months for the patients with viral etiology and for those with alcoholic etiology it was of 19.7 months. In patients treated after HVPG measurement, the average survival period was of 34.2 months and in patients "classically" treated, the average survival period was of 15.5 months (significant difference). In conclusion, the measurement of HVPG allowed the selection of a high-risk group of patients. This permitted the making of a therapeutical decision with a significant prolongation of life in these patients.

Continuity across inpatient and outpatient mental health care or specialisation of teams? A systematic review

BACKGROUND

A central question for the organisation of mental health care is whether the same clinicians should be responsible for a patient's care across inpatient and outpatient settings (continuity of care) or if there should be separate teams (specialisation). Current reforms in Europe are inconsistent on which to favour, and are based on little research evidence. This review is the first systematic appraisal of the existing evidence comparing continuity of care and specialisation across inpatient and outpatient mental health care.

METHOD

A systematic search for studies of any design comparing mental health care systems based on continuity or specialisation of care was performed. Differences in clinical, social and cost-effective outcomes, and the views and experiences of patients and staff were assessed using narrative synthesis.

RESULTS

Seventeen studies met the inclusion criteria. All studies had methodological shortcomings, but findings point towards reduced length and number of hospitalisations, and faster or more flexible transitions between services in continuity systems. Survey and qualitative findings suggest advantages of both systems, whilst patients and staff appear to prefer a continuity system.

CONCLUSION

The evidence base suggests better outcomes and stakeholder preferences for continuity of care systems, but the quality of existing studies is insufficient to draw definitive conclusions. Higher quality comparative studies across various settings and population groups are urgently needed.

Vascular endothelial growth factor secretion from pituitary folliculostellate cells: role of KATP channels

Vascular endothelial growth factor (VEGF) is an endothelial cell mitogen responsible for physiological and pathological angiogenesis. Abnormal regulation of VEGF expression in anterior pituitary folliculostellate (FS) cells has been implicated in pituitary tumour progression. FS and endocrine cells express VEGF, which is considered to be secreted by the constitutive pathway. The present study investigated the mechanism of VEGF secretion in TtT/GF cells, a mouse FS cell line. TtT/GF cells were shown to express VEGF(164), the most potent and bioavailable isoform of VEGF. Immunofluorescence and immunogold electron microscopy localised VEGF to the cytoplasm and small electron-lucent vesicles. Pituitary adenylate cyclase-activating polypeptide (PACAP), a well-documented stimulant of VEGF secretion, caused a robust increase in VEGF secretion over 24 h. Glyburide, an ABCA1 and K(ATP) channel blocker, also caused an increase in VEGF secretion when applied alone, and amplified the response to PACAP. Other ABCA1 transport blockers did not affect VEGF secretion. Exposure of TtT/GF cells to cycloheximide with PACAP or glyburide inhibited the increased secretion of VEGF, consistent with control of secretion at the transcription level. The SUR2B/Kir6.1 form of K(ATP) channels was shown to be expressed by TtT/GF cells. Diazoxide, a K(ATP) activator, inhibited PACAP- and PACAP + glyburide-stimulated VEGF secretion but not that of glyburide alone. These data suggest that K(ATP) channels are expressed by FS cells and play a significant role in the control of VEGF secretion, and also that activation of K(ATP) channels inhibits the secretion of VEGF at the level of transcription.

Hypertrophic olivary degeneration on magnetic resonance imaging in mitochondrial syndromes associated with POLG and SURF1 mutations

Hypertrophic olivary degeneration (HOD) is associated with lesions within the dento-rubro-olivary pathway or Guillain-Mollaret triangle and may be associated clinically with palatal tremor. Here we report HOD on brain magnetic resonance (MR) imaging in three patients with progressive mitochondrial syndromes in the absence of palatal tremor. Two of the patients were found to have identical compound heterozygous mutations in the POLG gene, encoding the catalytic subunit of the mitochondrial DNA polymerase-γ, but presented with different clinical phenotypes. The first patient displayed the clinical syndrome of sensory ataxia, neuropathy, dysarthria, and ophthalmoparesis (SANDO), while the second patient was affected by a neurological disorder consisting of an ophthalmoplegia, myopathy, and neuropathy. The third case was a child with Leigh syndrome due to SURF1 gene mutations, who presented with a generalized tremor. We discuss the brain MR imaging findings in these three cases along with a literature review on the MR features of previously reported cases of patients with POLG gene mutations and Leigh disease due to SURF1 gene mutations. Our findings suggest that the presence of HOD, in the appropriate clinical setting, should alert the clinician to the possibility of a mitochondrial disorder and the need to screen for mutations in POLG and SURF1 genes.