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Robertson SE, Steingrimsson JA, Dahabreh IJ. Cluster Randomized Trials Designed to Support Generalizable Inferences. EVALUATION REVIEW 2024:193841X231169557. [PMID: 38234059 DOI: 10.1177/0193841x231169557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
When planning a cluster randomized trial, evaluators often have access to an enumerated cohort representing the target population of clusters. Practicalities of conducting the trial, such as the need to oversample clusters with certain characteristics in order to improve trial economy or support inferences about subgroups of clusters, may preclude simple random sampling from the cohort into the trial, and thus interfere with the goal of producing generalizable inferences about the target population. We describe a nested trial design where the randomized clusters are embedded within a cohort of trial-eligible clusters from the target population and where clusters are selected for inclusion in the trial with known sampling probabilities that may depend on cluster characteristics (e.g., allowing clusters to be chosen to facilitate trial conduct or to examine hypotheses related to their characteristics). We develop and evaluate methods for analyzing data from this design to generalize causal inferences to the target population underlying the cohort. We present identification and estimation results for the expectation of the average potential outcome and for the average treatment effect, in the entire target population of clusters and in its non-randomized subset. In simulation studies, we show that all the estimators have low bias but markedly different precision. Cluster randomized trials where clusters are selected for inclusion with known sampling probabilities that depend on cluster characteristics, combined with efficient estimation methods, can precisely quantify treatment effects in the target population, while addressing objectives of trial conduct that require oversampling clusters on the basis of their characteristics.
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Affiliation(s)
- Sarah E Robertson
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jon A Steingrimsson
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Issa J Dahabreh
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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García-Zamora S, Pulido L. Vaccines in cardiology, an underutilized strategy to reduce the residual cardiovascular risk. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2024; 5:29-39. [PMID: 38596602 PMCID: PMC10999318 DOI: 10.47487/apcyccv.v5i1.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/22/2024] [Indexed: 04/11/2024]
Abstract
Cardiovascular diseases stand as the leading cause of mortality among adults globally. For decades, comprehensive evidence has underscored the correlation between infections, particularly those involving the respiratory system, and an elevated risk of cardiovascular and cerebrovascular events, as well as all-cause mortality. The mechanisms through which infections heighten cardiovascular events are intricate, encompassing immune system activation, systemic inflammation, hypercoagulable states, sympathetic system activation, and increased myocardial oxygen demand. Respiratory infections further contribute hypoxemia to this complex interplay. These mechanisms intertwine, giving rise to endothelial dysfunction, plaque ruptures, myocardial depression, and heart failure. They can either instigate de novo cardiovascular events or exacerbate pre-existing conditions. Compelling evidence supports the safety of influenza, pneumococcal, herpes zoster, COVID-19 and respiratory syncytial virus vaccines in individuals with cardiovascular risk factors or established cardiovascular disease. Notably, the influenza vaccine has demonstrated safety even when administered during the acute phase of a myocardial infarction in individuals undergoing angioplasty. Beyond safety, these vaccinations significantly reduce the incidence of cardiovascular events in individuals with an augmented cardiovascular risk. Nevertheless, vaccination rates remain markedly suboptimal. This manuscript delves into the intricate relationship between infections and cardiovascular events. Additionally, we highlight the role of vaccinations as a tool to mitigate these occurrences and reduce residual cardiovascular risk. Finally, we emphasize the imperative need to optimize vaccination rates among individuals with heart diseases.
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Affiliation(s)
- Sebastián García-Zamora
- Unidad Coronaria del Sanatorio Delta, Rosario, Argentina.Unidad Coronaria del Sanatorio DeltaRosarioArgentina
- Facultad de Medicina, Universidad Nacional de Rosario (UNR).Universidad Nacional de RosarioFacultad de MedicinaUniversidad Nacional de Rosario (UNR)Argentina
| | - Laura Pulido
- Servicio de Neumonología del Hospital Italiano de Rosario, Rosario, Argentina.Servicio de NeumonologíaHospital Italiano de RosarioRosarioArgentina
- Facultad de Medicina, Instituto Universitario Italiano de Rosario (IUNIR).Instituto Universitario Italiano de RosarioFacultad de MedicinaInstituto Universitario Italiano de Rosario (IUNIR)Argentina
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Moa A, Kunasekaran M, Akhtar Z, Costantino V, MacIntyre CR. Systematic review of influenza vaccine effectiveness against laboratory-confirmed influenza among older adults living in aged care facilities. Hum Vaccin Immunother 2023; 19:2271304. [PMID: 37929779 PMCID: PMC10629430 DOI: 10.1080/21645515.2023.2271304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023] Open
Abstract
We estimated the effectiveness of influenza vaccines in preventing laboratory-confirmed influenza among older adults in aged care. Electronic database searches were conducted using search terms, and studies were selected as per the selection criteria. Fourteen studies were included for final review. The studies exhibited considerable variation in reported vaccine effectiveness (VE) across different seasons. Among the observational studies, VE ranged from 7.2% to 89.8% against laboratory-confirmed influenza across different vaccines. Randomized clinical trials demonstrated a 17% reduction in infection rates with the adjuvanted trivalent vaccine. The limitations include the small number of included studies conducted in different countries or regions, varied seasons, variations in diagnostic testing methods, a focus on the A/H3N2 strain, and few studies available on the effectiveness of enhanced influenza vaccines in aged care settings. Despite challenges associated with achieving optimal protection, the studies showed the benefits of influenza vaccination in the elderly residents.
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Affiliation(s)
- Aye Moa
- Biosecurity Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
| | - Mohana Kunasekaran
- Biosecurity Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
| | - Zubair Akhtar
- Biosecurity Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
| | - Valentina Costantino
- Biosecurity Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
| | - C. Raina MacIntyre
- Biosecurity Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
- College of Public Service and Community Solutions, Arizona State University, Phoenix, AZ, USA
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Simon S, Joean O, Welte T, Rademacher J. The role of vaccination in COPD: influenza, SARS-CoV-2, pneumococcus, pertussis, RSV and varicella zoster virus. Eur Respir Rev 2023; 32:230034. [PMID: 37673427 PMCID: PMC10481333 DOI: 10.1183/16000617.0034-2023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/20/2023] [Indexed: 09/08/2023] Open
Abstract
Exacerbations of COPD are associated with worsening of the airflow obstruction, hospitalisation, reduced quality of life, disease progression and death. At least 70% of COPD exacerbations are infectious in origin, with respiratory viruses identified in approximately 30% of cases. Despite long-standing recommendations to vaccinate patients with COPD, vaccination rates remain suboptimal in this population.Streptococcus pneumoniae is one of the leading morbidity and mortality causes of lower respiratory tract infections. The Food and Drug Administration recently approved pneumococcal conjugate vaccines that showed strong immunogenicity against all 20 included serotypes. Influenza is the second most common virus linked to severe acute exacerbations of COPD. The variable vaccine efficacy across virus subtypes and the impaired immune response are significant drawbacks in the influenza vaccination strategy. High-dose and adjuvant vaccines are new approaches to tackle these problems. Respiratory syncytial virus is another virus known to cause acute exacerbations of COPD. The vaccine candidate RSVPreF3 is the first authorised for the prevention of RSV in adults ≥60 years and might help to reduce acute exacerbations of COPD. The 2023 Global Initiative for Chronic Lung Disease report recommends zoster vaccination to protect against shingles for people with COPD over 50 years.
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Affiliation(s)
- Susanne Simon
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
| | - Oana Joean
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany
| | - Jessica Rademacher
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany
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Smith CL, Bednarchik B, Aung H, Wilk DJ, Boxer RS, Daddato AE, Wilson BM, Gravenstein S, Canaday DH. Humoral and Cellular Immunity Induced by Adjuvanted and Standard Trivalent Influenza Vaccine in Older Nursing Home Residents. J Infect Dis 2023; 228:704-714. [PMID: 36951196 DOI: 10.1093/infdis/jiad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/07/2023] [Accepted: 03/21/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Despite wide use of adjuvanted influenza vaccine in nursing home residents (NHR), little immunogenicity data exist for this population. METHODS We collected blood from NHR (n = 85) living in nursing homes participating in a cluster randomized clinical trial comparing MF59-adjuvanted trivalent inactivated influenza vaccine (aTIV) with nonadjuvanted vaccine (TIV) (parent trial, NCT02882100). NHR received either vaccine during the 2016-2017 influenza season. We assessed cellular and humoral immunity using flow cytometry and hemagglutinin inhibition, antineuraminidase (enzyme-linked lectin assay), and microneutralization assays. RESULTS Both vaccines were similarly immunogenic and induced antigen-specific antibodies and T cells, but aTIV specifically induced significantly larger 28 days after vaccination (D28) titers against A/H3N2 neuraminidase than TIV. CONCLUSIONS NHRs respond immunologically to TIV and aTIV. From these data, the larger aTIV-induced antineuraminidase response at D28 may help explain the increased clinical protection observed in the parent clinical trial for aTIV over TIV in NHR during the A/H3N2-dominant 2016-2017 influenza season. Additionally, a decline back to prevaccination titers at 6 months after vaccination emphasizes the importance of annual vaccination against influenza. CLINICAL TRIALS REGISTRATION NCT02882100.
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Affiliation(s)
- Carson L Smith
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Beth Bednarchik
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Htin Aung
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Dennis J Wilk
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente of Colorado, Aurora, CO, USA
| | - Andrea E Daddato
- Institute for Health Research, Kaiser Permanente of Colorado, Aurora, CO, USA
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Stefan Gravenstein
- Division of Geriatrics and Palliative Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, USA
| | - David H Canaday
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA
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Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remains asymptomatic in 33% to 90% of older adults depending on their immune status from prior infection, vaccination, and circulating strain. Older adults symptomatic with SARS-CoV-2 often both present atypically, such as with a blunted fever response, and develop more severe disease. Early and late reports showed that older adults have increased severity of coronavirus disease 2019 (COVID-19) with higher case fatality rates and higher intensive care needs compared with younger adults. Infection and vaccine-induced antibody response and long-term effects of COVID-19 also differ in older adults.
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Joean O, Welte T. Vaccination and modern management of chronic obstructive pulmonary disease - a narrative review. Expert Rev Respir Med 2022; 16:605-614. [PMID: 35713962 DOI: 10.1080/17476348.2022.2092099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) carries a tremendous societal and individual burden, posing significant challenges for public health systems worldwide due to its high morbidity and mortality. Due to aging and multimorbidity but also in the wake of important progress in deciphering the heterogeneous disease endotypes, an individualized approach to the prevention and management of COPD is necessary. AREAS COVERED This article tackles relevant immunization strategies that are available or still under development with a focus on the latest evidence but also controversies around different regional immunization approaches. Further, we present the crossover between chronic lung inflammation and lung microbiome disturbance as well as its role in delineating COPD endotypes. Moreover, the article attempts to underline endotype-specific treatment approaches. Lastly, we highlight non-pharmacologic prevention and management programs in view of the challenges and opportunities of the COVID-19 era. EXPERT OPINION Despite the remaining challenges, personalized medicine has the potential to offer tailored approaches to prevention and therapy and promises to improve the care of patients living with COPD.
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Affiliation(s)
- Oana Joean
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany
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Berry SD, Goldfeld KS, McConeghy K, Gifford D, Davidson HE, Han L, Syme M, Gandhi A, Mitchell SL, Harrison J, Recker A, Johnson KS, Gravenstein S, Mor V. Evaluating the Findings of the IMPACT-C Randomized Clinical Trial to Improve COVID-19 Vaccine Coverage in Skilled Nursing Facilities. JAMA Intern Med 2022; 182:324-331. [PMID: 35099523 PMCID: PMC8804975 DOI: 10.1001/jamainternmed.2021.8067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Identifying successful strategies to increase COVID-19 vaccination among skilled nursing facility (SNF) residents and staff is integral to preventing future outbreaks in a continually overwhelmed system. OBJECTIVE To determine whether a multicomponent vaccine campaign would increase vaccine rates among SNF residents and staff. DESIGN, SETTING, AND PARTICIPANTS This was a cluster randomized trial with a rapid timeline (December 2020-March 2021) coinciding with the Pharmacy Partnership Program (PPP). It included 133 SNFs in 4 health care systems across 16 states: 63 and 70 facilities in the intervention and control arms, respectively, and participants included 7496 long-stay residents (>100 days) and 17 963 staff. INTERVENTIONS Multicomponent interventions were introduced at the facility level that included: (1) educational material and electronic messaging for staff; (2) town hall meetings with frontline staff (nurses, nurse aides, dietary, housekeeping); (3) messaging from community leaders; (4) gifts (eg, T-shirts) with socially concerned messaging; (5) use of a specialist to facilitate consent with residents' proxies; and (6) funds for additional COVID-19 testing of staff/residents. MAIN OUTCOMES AND MEASURES The primary outcomes of this study were the proportion of residents (from electronic medical records) and staff (from facility logs) who received a COVID-19 vaccine (any), examined as 2 separate outcomes. Mixed-effects generalized linear models with a binomial distribution were used to compare outcomes between arms, using intent-to-treat approach. Race was examined as an effect modifier in the resident outcome model. RESULTS Most facilities were for-profit (95; 71.4%), and 1973 (26.3%) of residents were Black. Among residents, 82.5% (95% CI, 81.2%-83.7%) were vaccinated in the intervention arm, compared with 79.8% (95% CI, 78.5%-81.0%) in the usual care arm (marginal difference 0.8%; 95% CI, -1.9% to 3.7%). Among staff, 49.5% (95% CI, 48.4%-50.6%) were vaccinated in the intervention arm, compared with 47.9% (95% CI, 46.9%-48.9%) in usual care arm (marginal difference: -0.4%; 95% CI, -4.2% to 3.1%). There was no association of race with the outcome among residents. CONCLUSIONS AND RELEVANCE A multicomponent vaccine campaign did not have a significant effect on vaccination rates among SNF residents or staff. Among residents, vaccination rates were high. However, half the staff remained unvaccinated despite these efforts. Vaccination campaigns to target SNF staff will likely need to use additional approaches. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04732819.
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Affiliation(s)
- Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Keith S Goldfeld
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Kevin McConeghy
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Providence Veteran's Administration Medical Center, Providence, Rhode Island
| | - David Gifford
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC
| | | | - Lisa Han
- Insight Therapeutics, Norfolk, Virginia
| | - Maggie Syme
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Ashvin Gandhi
- University of California, Los Angeles Anderson School of Management, Los Angeles
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jill Harrison
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Amy Recker
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Kimberly S Johnson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Stefan Gravenstein
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Vincent Mor
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Providence Veteran's Administration Medical Center, Providence, Rhode Island
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Kwetkat A, Heppner HJ, Endres AS, Leischker AH. Aktuelles zur Grippeimpfung und COVID-19-Auffrischimpfung. GERIATRIE-REPORT 2021. [PMCID: PMC8592671 DOI: 10.1007/s42090-021-1300-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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