Ceftaroline Fosamil for the Treatment of Methicillin-Resistant Staphylococcus Aureus Bacteremia: A Real-World Comparative Clinical Outcomes Study

BACKGROUND AND OBJECTIVE

Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia results in substantial morbidity and mortality. As current treatments often lead to unsatisfactory outcomes, evidence guiding alternative treatment options is needed. This study evaluated real-world clinical outcomes of ceftaroline fosamil for the treatment of MRSA bacteremia.

METHODS

This retrospective study included adults hospitalized with MRSA bacteremia between 2011 and 2019. Patients were classified according to treatment with ceftaroline fosamil (ceftaroline), vancomycin, or daptomycin: Group 1, ceftaroline; Group 2, vancomycin or daptomycin (without ceftaroline); Group 3, combination therapy with ≥ 2 of these three agents. Clinical outcomes were compared using propensity-score-adjusted odds ratios (ORs) from logistic regression models.

RESULTS

Overall, 24,479 patients were included (Group 1, n = 532; Group 2, n = 21,555; Group 3, n = 2392). Mean age was 59.6, 60.8, and 57.4 years in Groups 1, 2, and 3, respectively. Mean post-index treatment length of stay was 8.8, 8.8, and 8.0 days, respectively. The most frequent line of therapy was ceftaroline first-line (42.1%), vancomycin or daptomycin first-line (95.4%), and combination therapy third-line or later (67.8%) in Groups 1, 2, and 3, respectively. Compared with Group 2, Groups 1 and 3 had similar favorable clinical responses {odds ratio [OR] = 1.18 [95% confidence interval (CI) 0.98-1.44], p = 0.08; OR = 1.20 [95% CI 0.97-1.47], p = 0.09, respectively} and were less likely to switch treatment (both p < 0.001). Compared with Group 2, Group 1 was more likely to undergo 30-day all-cause readmission [OR = 1.38 (95% CI 1.06-1.80), p = 0.02], whereas this was less likely for Group 3 [OR = 0.77 (95% CI 0.58-1.00), p = 0.05].

CONCLUSIONS

Patients receiving ceftaroline more often had favorable clinical responses than those receiving vancomycin or daptomycin monotherapy. In the absence of large-scale randomized controlled trials, these real-world data provide insights into the potential role of ceftaroline for treating MRSA bacteremia.

Examining the association of rurality with opioid-related morbidity and mortality in Georgia: A geospatial analysis

INTRODUCTION

The US opioid epidemic continues to escalate, with overdose deaths being the most-used metric to quantify its burden. There is significant geographic variation in opioid-related outcomes. Rural areas experience unique challenges, yet many studies oversimplify rurality characterizations. Contextual factors, such as area deprivation, are also important to consider when understanding a community's need for treatment services and prevention programming. This study aims to provide a geospatial snapshot of the opioid epidemic in Georgia using several metrics of opioid-related morbidity and mortality and explore differences by rurality across counties.

METHODS

This was a spatial ecologic study. Negative binominal regression was used to model the relationship of county rurality with four opioid-related outcomes - overdose mortality, emergency department visits, inpatient hospitalizations, and overdose reversals - adjusting for county-level sex, racial/ethnic, and age distributions. Area Deprivation Index was also included.

RESULTS

There was significant geographic variation across the state for all four opioid-related outcomes. Counts remained highest among the metro areas. For rates, counties in the top quartile of rates varied by outcome and were often rural areas. In the final models, rurality designation was largely unrelated to opioid outcomes, with the exception of medium metro areas (inversely related to hospitalizations and overdose reversals) and non-core areas (inversely related to hospitalizations), as compared to large central metro areas. Higher deprivation was significantly related to increased ED visits and hospitalizations, but not overdose mortality and reversals.

CONCLUSIONS

When quantifying the burden of the opioid epidemic in a community, it is essential to consider multiple outcomes of morbidity and mortality. Understanding what outcomes are problematic for specific communities, in combination with their demographic and socioeconomic context, can provide insight into gaps in the treatment continuum and potential areas for intervention. Additionally, compared to demographic and socioeconomic factors, rurality may no longer be a salient predictor of the severity of the opioid epidemic in an area.

COVID-19-related work absenteeism and associated lost productivity cost in Germany: a population-based study

OBJECTIVE

To estimate COVID-19 absenteeism and indirect costs, by care setting.

METHODS

A population-based retrospective cohort study using data from the German Statutory Health Insurance (SHI) database to define outpatient (April 2020-December 2021) and hospitalized (April 2020-October 2022) cohorts of employed working-aged individuals.

RESULTS

In the outpatient cohort (n = 369,220) median absenteeism duration and associated cost was 10.0 (IQR: 5.0, 15.0) days and €1,061 (530, 1,591), respectively. In the hospitalized cohort (n = 20,687), median absenteeism and associated cost was 15.0 (7.0, 32.0) days and €1,591 (743, 3,394), respectively. Stratified analyses showed greater absenteeism in older workers, those at risk and those with severe disease.

CONCLUSIONS

The hospitalized cohort had longer absenteeism resulting in higher productivity loss. Being older, at risk of severe COVID-19 and higher disease severity during hospitalization were important drivers of higher absenteeism duration.

Health Care Resource Utilization and Costs Associated With COVID-19 Among Pediatrics Managed in the Community or Hospital Setting in England: A Population-based Cohort Study

BACKGROUND

Although COVID-19 morbidity is significantly lower in pediatrics than in adults, the risk of severe COVID-19 may still pose substantial health care resource burden. This study aimed to describe health care resource utilization (HCRU) and costs associated with COVID-19 in pediatrics 1-17 years old in England.

METHODS

A population-based retrospective cohort study of pediatrics with COVID-19 using Clinical Practice Research Datalink (CPRD Aurum) primary care data and, where available, linked Hospital Episode Statistics Admitted Patient Care secondary care data. HCRU and associated costs to the National Health Service were stratified by age, risk of severe COVID-19 and immunocompromised status, separately for those with and without hospitalization records (hospitalized cohort: COVID-19 diagnosis August 2020-March 2021; primary care cohort: COVID-19 diagnosis August 2020-January 2022).

RESULTS

This study included 564,644 patients in the primary care cohort and 60 in the hospitalized cohort. Primary care consultations were more common in those 1-4 years of age (face-to-face: 4.3%; telephone: 6.0%) compared with those 5-11 (2.0%; 2.1%) and 12-17 years of age (2.2%; 2.5%). In the hospitalized cohort, mean (SD) length of stay was longer [5.0 (5.8) days] among those 12-17 years old (n = 24) than those 1-4 [n = 15; 1.8 (0.9) days] and 5-11 years old [n = 21; 2.8 (2.1) days].

CONCLUSIONS

Most pediatrics diagnosed with COVID-19 were managed in the community. However, hospitalizations were an important driver of HCRU and costs, particularly for those 12-17 years old. Our results may help optimize the management and resource allocation of COVID-19 in this population.

Cost-Effectiveness of Oral Nirmatrelvir/Ritonavir in Patients at High Risk for Progression to Severe COVID-19 in the United States

OBJECTIVES

Nirmatrelvir/ritonavir (NMV/r) is an orally administered antiviral indicated for the outpatient treatment of patients with mild-to-moderate COVID-19 at high risk for disease progression to severe illness. We estimated the cost-effectiveness of NMV/r versus best supportive care for patients with mild-to-moderate COVID-19 at high risk for progression to severe illness from a US health sector perspective.

METHODS

A cost-effectiveness model was developed using a short-term decision-tree (1 year) followed by a lifetime 2-state Markov model (alive and dead). The short-term decision-tree captured costs and outcomes associated with the primary infection and healthcare utilization; survivors of the short-term decision-tree were followed until death assuming US quality-adjusted life years (QALYs), adjusted in the short-term for survivors of mechanical ventilation. Baseline rate of hospitalization and NMV/r effectiveness were taken from an Omicron-era US real-world study. Remaining inputs were informed by previous COVID-19 studies and publicly available US sources. Sensitivity analyses were conducted for all model inputs to test the robustness of model results.

RESULTS

NMV/r was found to decrease COVID-19 related hospitalizations (-0.027 per infected case) increase QALYs (+0.030), decrease hospitalization costs (-$1110), and increase total treatment cost (+$271), resulting in an incremental cost-effectiveness ratio of $8931/QALY. Results were most sensitive to baseline risk of hospitalization and NMV/r treatment effectiveness parameters. The probabilistic analysis indicated that NMV/r has a >99% probability of being cost-effective at a $100 000 willingness-to-pay threshold.

CONCLUSIONS

NMV/r is cost-effective vs best supportive care for patients at high risk for severe COVID-19 from a US health sector perspective.

Health-related quality of life in mild-to-moderate COVID-19 in the UK: a cross-sectional study from pre- to post-infection

BACKGROUND

The aim of this study was to estimate the impact of mild-to-moderate COVID-19 on health-related quality of life (HRQoL) over time among individuals in the United Kingdom, adding to the evidence base that had focussed on severe COVID-19.

METHODS

A bespoke online survey was administered to individuals who self-reported a positive COVID-19 test. An amended version of a validated generic HRQoL instrument (EQ-5D-5L) was used to measure HRQoL retrospectively at different timepoints over the course of an infection: pre-COVID-19, acute COVID-19, and long COVID. In addition, HRQoL post-COVID-19 was captured by the original EQ-5D-5L questionnaire. A mixed-effects model was used to estimate changes in HRQoL over time, adjusted for a range of variables correlated with HRQoL.

RESULTS

The study recruited 406 participants: (i) 300 adults and 53 adolescents with mild-to-moderate COVID-19 who had not been hospitalised for COVID-19 during acute COVID-19, and (ii) 53 adults who had been hospitalised for COVID-19 in the acute phase and who had been recruited for validation purposes. Data were collected between January and April 2022. Among participants included in the base-case analysis, EQ-5D-5L utility scores were lower during both acute COVID-19 (β=-0.080, p = 0.001) and long COVID (β=-0.072, p < 0.001) compared to pre COVID-19. In addition, EQ-5D-5L utility scores post-COVID-19 were found to be similar to the EQ-5D-5L utility scores before COVID-19, including for patients who had been hospitalised for COVID-19 during the acute phase or for those who had experienced long COVID. Moreover, being hospitalised in the acute phase was associated with additional utility decrements during both acute COVID-19 (β=-0.147, p = 0.026) and long (β=-0.186, p < 0.001) COVID.

CONCLUSION

Patients perceived their HRQoL to have varied significantly over the course of a mild-to-moderate COVID-19 infection. However, HRQoL was found to return to pre-COVID-19 levels, even for patients who had been hospitalised for COVID-19 during the acute phase or for those who had experienced long COVID.

Definition and measurement of post-COVID-19 conditions in real-world practice: a global systematic literature review

Post-COVID-19 conditions (PCC) is an umbrella term that encompasses a range of signs, symptoms and conditions present weeks after the acute phase of a SARS-CoV-2 infection. This systematic literature review summarises the heterogeneous methodology used to measure PCC across real-world studies and highlights trends by region, age group, PCC follow-up period and data source.

METHODS

Medline, EMBASE and the Cochrane Library were searched and supplemented with conference and grey literature searches. Eligible studies included individuals with (1) PCC or (2) a positive SARS-CoV-2 test or COVID-19 diagnosis who were followed over time. Included studies were published in English between 1 January 2020 and 14 November 2022.

FINDINGS

Of 291 publications included, 175 (60%) followed individuals with confirmed COVID-19 over time for PCC and 116 (40%) used a prespecified PCC definition. There was substantial heterogeneity in study design, geography, age group, PCC conditions/symptoms assessed and their classification and duration of follow-up. Among studies using a prespecified PCC definition, author-defined criteria (51%) were more common than criteria recommended by major public health organisations (19%). Measurement periods for PCC outcomes from date of acute COVID-19 test were primarily 3 to <6 months (39.2%), followed by 6 to <12 months (27.5%) and <3 months (22.9%). When classified by organ/system, constitutional-related PCC were the most frequently assessed in adult (86%) and paediatric (87%) populations. Within constitutional symptoms, fatigue was most frequently assessed in adult (91.6%) and paediatric (95.0%) populations, followed by fever/chills (37.9% and 55%, respectively).

CONCLUSIONS

PCC definitions are heterogenous across real-world studies, which limits reliable comparisons between studies. However, some similarities were observed in terms of the most frequently measured PCC-associated symptoms/conditions, which may aid clinical management of patients with PCC.CRD42022376111.

Persons diagnosed with COVID-19 in England in the Clinical Practice Research Datalink (CPRD): a cohort description

OBJECTIVE

To create case definitions for confirmed COVID-19 diagnoses, COVID-19 vaccination status and three separate definitions of high risk of severe COVID-19, as well as to assess whether the implementation of these definitions in a cohort reflected the sociodemographic and clinical characteristics of COVID-19 epidemiology in England.

DESIGN

Retrospective cohort study.

SETTING

Electronic healthcare records from primary care (Clinical Practice Research Datalink, CPRD) linked to secondary care data (Hospital Episode Statistics) data covering 24% of the population in England.

PARTICIPANTS

2 271 072 persons aged 1 year and older diagnosed with COVID-19 in CPRD Aurum between 1 August 2020 and 31 January 2022.

MAIN OUTCOME MEASURES

Age, sex and regional distribution of COVID-19 cases and COVID-19 vaccine doses received prior to diagnosis were assessed separately for the cohorts of cases identified in primary care and those hospitalised for COVID-19 (primary diagnosis code of ICD-10 U07.1 'COVID-19'). Smoking status, body mass index and Charlson Comorbidity Index were compared for the two cohorts, as well as for three separate definitions of high risk of severe disease used in the UK (National Health Service Highest Risk, PANORAMIC trial eligibility, UK Health Security Agency Clinical Risk prioritisation for vaccination).

RESULTS

Compared with national estimates, CPRD case estimates under-represented older adults in both the primary care (age 65-84: 6% in CPRD vs 9% nationally) and hospitalised (31% vs 40%) cohorts, and over-represented people living in regions with the highest median wealth areas of England (20% primary care and 20% hospital admitted cases in South East vs 15% nationally). The majority of non-hospitalised cases and all hospitalised cases had not completed primary series vaccination. In primary care, persons meeting high-risk definitions were older, more often smokers, overweight or obese, and had higher Charlson Comorbidity Index score.

CONCLUSIONS

CPRD primary care data are a robust real-world data source and can be used for some COVID-19 research questions, however, limitations of the data availability should be carefully considered. Included in this publication are supplemental files for a total of over 28 000 codes to define each of three definitions of high risk of severe disease.

Healthcare resource utilisation and costs of hospitalisation and primary care among adults with COVID-19 in England: a population-based cohort study

OBJECTIVES

To quantify direct costs and healthcare resource utilisation (HCRU) associated with acute COVID-19 in adults in England.

DESIGN

Population-based retrospective cohort study using Clinical Practice Research Datalink Aurum primary care electronic medical records linked to Hospital Episode Statistics secondary care administrative data.

SETTING

Patients registered to primary care practices in England.

POPULATION

1 706 368 adults with a positive SARS-CoV-2 PCR or antigen test from August 2020 to January 2022 were included; 13 105 within the hospitalised cohort indexed between August 2020 and March 2021, and 1 693 263 within the primary care cohort indexed between August 2020 and January 2022. Patients with a COVID-19-related hospitalisation within 84 days of a positive test were included in the hospitalised cohort.

MAIN OUTCOME MEASURES

Primary and secondary care HCRU and associated costs ≤4 weeks following positive COVID-19 test, stratified by age group, risk of severe COVID-19 and immunocompromised status.

RESULTS

Among the hospitalised cohort, average length of stay, including critical care stays, was longer in older adults. Median healthcare cost per hospitalisation was higher in those aged 75-84 (£8942) and ≥85 years (£8835) than in those aged <50 years (£7703). While few (6.0%) patients in critical care required mechanical ventilation, its use was higher in older adults (50-74 years: 8.3%; <50 years: 4.3%). HCRU and associated costs were often greater in those at higher risk of severe COVID-19 than in the overall cohort, although minimal differences in HCRU were found across the three different high-risk definitions. Among the primary care cohort, general practitioner or nurse consultations were more frequent among older adults and the immunocompromised.

CONCLUSIONS

COVID-19-related hospitalisations in older adults, particularly critical care stays, were the primary drivers of high COVID-19 resource use in England. These findings may inform health policy decisions and resource allocation in the prevention and management of COVID-19.

Impact of SARS-CoV-2 infective exacerbation of chronic obstructive pulmonary disease on clinical outcomes in a prospective cohort study of hospitalised adults

OBJECTIVES

To determine whether acute exacerbations of chronic obstructive pulmonary disease (AECOPD) triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have worse outcomes than AECOPD caused by other infectious agents or non-infective AECOPD (NI-COPD).

DESIGN

A two-hospital prospective cohort study of adults hospitalised with acute respiratory disease. We compared outcomes with AECOPD and a positive test for SARS-CoV-2 (n = 816), AECOPD triggered by other infections (n = 3038) and NI-COPD (n = 994). We used multivariable modelling to adjust for potential confounders and assessed variation by seasons associated with different SARS-CoV-2 variants.

SETTING

Bristol UK, August 2020-May 2022.

PARTICIPANTS

Adults (≥18 y) hospitalised with AECOPD.

MAIN OUTCOME MEASURES

We determined the risk of positive pressure support, longer hospital admission and mortality following hospitalisation with AECOPD due to non-SARS-CoV-2 infection compared with SARS-CoV-2 AECOPD and NI-COPD.

RESULTS

Patients with SARS-CoV-2 AECOPD, in comparison to non-SARS-CoV-2 infective AECOPD or NI-COPD, more frequently required positive pressure support (18.5% and 7.5% vs. 11.7%, respectively), longer hospital stays (median [interquartile range, IQR]: 7 [3-15] and 5 [2-10] vs. 4 [2-9] days, respectively) and had higher 30-day mortality (16.9% and 11.1% vs. 5.9%, respectively) (all p < 0.001). In adjusted analyses, SARS-CoV-2 AECOPD was associated with a 55% (95% confidence interval [95% CI]: 24-93), 26% (95% CI: 15-37) and 35% (95% CI: 10-65) increase in the risk of positive pressure support, hospitalisation length and 30-day mortality, respectively, relative to non-SARS-CoV-2 infective AECOPD. The difference in risk remained similar during periods of wild-type, Alpha and Delta SARS-CoV-2 strain dominance, but diminished during Omicron dominance.

CONCLUSIONS

SARS-CoV-2-related AECOPD had worse patient outcomes compared with non-SARS-CoV-2 AECOPD or NI-AECOPD, although the difference in risks was less pronounced during Omicron dominance.

Incidence and clinical outcomes of pneumonia in persons with down syndrome in the United States

BACKGROUND

Persons with Down syndrome (DS) experience an increased risk of pneumonia. We determined the incidence and outcomes of pneumonia and relationship to underlying comorbidities in persons with and without DS in the United States.

METHODS

This retrospective matched cohort study used de-identified administrative claims data from Optum. Persons with DS were matched 1:4 to persons without DS on age, sex, and race/ethnicity. Pneumonia episodes were analyzed for incidence, rate ratios and 95 % confidence intervals, clinical outcomes, and comorbidities.

RESULTS

During 1-year follow-up among 33796 persons with and 135184 without DS, the incidence of all-cause pneumonia (pneumonia) was substantially higher among people with DS than those without DS (12427 vs. 2531 episodes/100000 person-years; 4.7-5.7 fold increase). Persons with DS and pneumonia were more likely to be hospitalized (39.4 % vs. 13.9 %) or admitted to the ICU (16.8 % vs. 4.8 %). Mortality was higher 1 year after first pneumonia (5.7 % vs. 2.4 %; P < 0.0001). Results were similar for episodes of pneumococcal pneumonia. Specific comorbidities were associated with pneumonia, particularly heart disease in children and neurologic disease in adults, which only partially mediated the effect of DS on pneumonia.

CONCLUSIONS

Among persons with DS, incidence of pneumonia and associated hospitalizations were increased; mortality among those with pneumonia was comparable at 30 days, but higher at 1 year. DS should be considered an independent risk condition for pneumonia.

Estimated global public health and economic impact of COVID-19 vaccines in the pre-omicron era using real-world empirical data

BACKGROUND

Limited data are available describing the global impact of COVID-19 vaccines. This study estimated the global public health and economic impact of COVID-19 vaccines before the emergence of the Omicron variant.

METHODS

A static model covering 215 countries/territories compared the direct effects of COVID-19 vaccination to no vaccination during 13 December 2020-30 September 2021. After adjusting for underreporting of cases and deaths, base case analyses estimated total cases and deaths averted, and direct outpatient and productivity costs saved through averted health outcomes. Sensitivity analyses applied alternative model assumptions.

RESULTS

COVID-19 vaccines prevented an estimated median (IQR) of 151.7 (133.7-226.1) million cases and 620.5 (411.1-698.1) thousand deaths globally through September 2021. In sensitivity analysis applying an alternative underreporting assumption, median deaths averted were 2.1 million. Estimated direct outpatient cost savings were $21.2 ($18.9-30.9) billion and indirect savings of avoided productivity loss were $135.1 ($121.1-206.4) billion, yielding a total cost savings of $155 billion globally through averted infections.

CONCLUSIONS

Using a conservative modeling approach that considered direct effects only, we estimated that COVID-19 vaccines have averted millions of infections and deaths, generating billions of cost savings worldwide, which underscore the continued importance of vaccination in public health response to COVID-19.

Public health impact of UK COVID-19 booster vaccination programs during Omicron predominance

BACKGROUND

We aimed to estimate the public health impact of booster vaccination against COVID-19 in the UK during an Omicron-predominant period.

RESEARCH DESIGN AND METHODS

A dynamic transmission model was developed to compare public health outcomes for actual and alternative UK booster vaccination programs. Input sources were publicly available data and targeted literature reviews. Base case analyses estimated outcomes from the UK's Autumn-Winter 2021-2022 booster program during January-March 2022, an Omicron-predominant period. Scenario analyses projected outcomes from Spring and in Autumn 2022 booster programs over an extended time horizon from April 2022-April 2023, assuming continued Omicron predominance, and explored hypothetical program alternatives with modified eligibility criteria and/or increased uptake.

RESULTS

Estimates predicted that the Autumn-Winter 2021-2022 booster program averted approximately 12.8 million cases, 1.1 million hospitalizations, and 290,000 deaths. Scenario analyses suggested that Spring and Autumn 2022 programs would avert approximately 6.2 million cases, 716,000 hospitalizations, and 125,000 deaths; alternatives extending eligibility or targeting risk groups would improve these benefits, and increasing uptake would further strengthen impact.

CONCLUSIONS

Boosters were estimated to provide substantial benefit to UK public health during Omicron predominance. Benefits of booster vaccination could be maximized by extending eligibility and increasing uptake.

Estimated BNT162b2 Vaccine Effectiveness Against Infection With Delta and Omicron Variants Among US Children 5 to 11 Years of Age

IMPORTANCE

Data describing the vaccine effectiveness (VE) and durability of BNT162b2 among children 5 to 11 years of age are needed.

OBJECTIVE

To estimate BNT162b2 VE against SARS-CoV-2 infection among children aged 5 to 11 years during Delta and Omicron variant-predominant periods and to further assess VE according to prior SARS-CoV-2 infection status and by sublineage during the Omicron variant-predominant period.

DESIGN, SETTING, AND PARTICIPANTS

This test-negative case-control study was conducted from November 2 to December 9, 2021 (Delta variant), and from January 16 to September 30, 2022 (Omicron variant), among 160 002 children tested at a large national US retail pharmacy chain, for SARS-CoV-2 via polymerase chain reaction (PCR); 62 719 children were tested during the Delta period, and 97 283 were tested during the Omicron period.

EXPOSURE

Vaccination with BNT162b2 before SARS-CoV-2 testing vs no vaccination.

MAIN OUTCOMES AND MEASURES

The primary outcome was SARS-CoV-2 infection confirmed by PCR (regardless of the presence of symptoms), and the secondary outcome was confirmed symptomatic infection. Adjusted estimated VE was calculated from multilevel logistic regression models.

RESULTS

A total of 39 117 children tested positive and 131 686 tested negative for SARS-CoV-2 (total, 170 803; 84 487 [49%] were boys; mean [SD] age was 9 [2] years; 74 236 [43%] were White non-Hispanic or non-Latino; and 37 318 [22%] were Hispanic or Latino). Final VE analyses included 160 002 children without SARS-CoV-2 infection less than 90 days prior. The VE of 2 doses of BNT162b2 against Delta was 85% (95% CI, 80%-89%; median follow-up, 1 month) compared with the Omicron period (20% [95% CI, 17%-23%]; median follow-up, 4 months). The adjusted VE of 2 doses against Omicron at less than 3 months was 39% (95% CI, 36%-42%), and at 3 months or more, it was -1% (95% CI, -6% to 3%). Protection against Omicron was higher among children with vs without infection 90 days or more prior but decreased in all children approximately 3 months after the second dose (58% [95% CI, 49%-66%] with infection vs 37% [95% CI, 34%-41%] without infection at <3 months; 27% [95% CI, 17%-35%] with infection vs -7% [95% CI, -12% to -1%] at ≥3 months without infection). The VE of 2 doses of BNT162b2 at less than 3 months by Omicron sublineage was 40% (95% CI, 36%-43%) for BA.1, 32% (95% CI, 21%-41%) for BA.2/BA.2.12.1, and 50% (95% CI, 37%-60%) for BA.4/BA.5. After 3 months or more, VE was nonsignificant for BA.2/BA.2.12.1 and BA.4/BA.5. The VE of a booster dose was 55% (95% CI, 50%-60%) against Omicron, with no evidence of waning at 3 months or more.

CONCLUSIONS AND RELEVANCE

This study suggests that, among children aged 5 to 11 years, 2 doses of BNT162b2 provided modest short-term protection against Omicron infection that was higher for those with prior infection; however, VE waned after approximately 3 months in all children. A booster dose restored protection against Omicron and was maintained for at least 3 months. These findings highlight the continued importance of booster vaccination regardless of history of prior COVID-19.

Trends in utilization and costs of migraine medications, 2017–2020

Objective

This study examines changes in utilization and costs trends associated with migraine medications.

Background

Migraine attacks are a burden to many patients. There are many pharmacotherapy options available with newer migraine drug classes entering the market in the past decade. Little is known about the use, associated costs, and the impact of the newer agents.

Methods

This retrospective, cross-sectional study examined 2017–2020 administrative claims from a large national pharmacy benefits manager. Patients aged ≥ 18 years enrolled in commercial, Medicare, Medicaid, or health insurance exchange insurance plans who filled ≥ 2 prescription claims for triptans, ergotamines, isometheptenes, gepants, ditans, and CGRP mABs were included. A two-sample t-test was conducted to estimate whether differences in mean utilization and costs between 2017 and 2020 were statistically significant for migraine drug classes, except for CGRP mABs, which were estimated between 2018 and 2020.

Results

The sample ranged from 161,369 (2017) to 240,330 (2020) patients. 84.5% (n = 203,110; 2020) of patients were women. The number of 30-day adjusted prescription fills for prophylaxis remained stable over the four-year period, except for CGRP mABs, which increased from 0.5% (n = 0.007; 2018) to 5.3% (n = 0.075; 2020). Antiepileptics, antidepressants and beta blockers were the most common prophylaxes, while triptans, non-steroidal anti-inflammatory drugs/non-narcotic analgesics and opioids were the most common treatments utilized. CGRP mABs were the most expensive, while utilization of triptans were the highest. CGRP mABs had the largest increase in utilization (177.5%) and costs (166.3%) PPPM in 2020 ($291.17) compared to 2018 ($109.35), the year they were first available (p < 0.001). Between 2018 and 2020, costs increased overall and for commercial and Medicare enrollees, but remained unchanged for Medicaid and HIX members.

Conclusion

Our study demonstrates a shift in migraine medication utilization from 2017–2020, where increased use of CGRP mABs had a significant contribution to increased costs. These increased pharmacy costs must be weighed against the improved tolerability of these agents likely resulting in other healthcare and indirect cost savings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-022-01476-y.

PCV13 Pediatric Routine Schedule Completion and Adherence Before and During the COVID-19 Pandemic in the United States

Introduction

A 13-valent pneumococcal conjugate vaccine (PCV13) was licensed to protect against emerging Streptococcus pneumoniae serotypes. Healthcare services, including routine childhood immunizations, were disrupted as a result of coronavirus disease 2019 (COVID-19). This study compared PCV13 routine vaccination completion and adherence among US infants before and during the COVID-19 pandemic and the relationship between primary and booster dose completion and adherence.

Methods

Retrospective data from Optum’s de-identified Clinformatics^® Data Mart were used to create three cohorts using data collected between January 2017 and December 2020: cohort 1 (C1), pre-COVID; cohort 2 (C2), cross-COVID; and cohort 3 (C3), during COVID. Study endpoints were completion and adherence to the primary PCV13 series (analyzed using univariate logistic regression) and completion of and adherence to the booster dose (analyzed descriptively).

Results

The analysis included 142,853 infants in C1, 27,211 infants in C2, and 53,306 infants in C3. Among infants with at least 8 months of follow-up from birth, three-primary-dose completion (receipt of all three doses within 8 months after birth) and adherence (receipt of doses at recommended times) were significantly higher before (C1 and C2) versus during (C3) COVID-19 (odds ratio [OR] 1.12 [95% confidence interval [CI] 1.07, 1.16] and OR 1.10 [95% CI 1.05, 1.15], respectively). A significantly higher percentage of infants received a booster dose before versus during COVID-19 (83.2% vs. 80.2%; OR 1.23; 95% CI 1.17, 1.29); similarly, booster dose adherence was higher before than during COVID-19 (51.2% vs. 47.4%; OR 1.17; 95% CI 1.13, 1.21). The odds of booster dose completion were 8.26 (95% CI 7.92, 8.60) and 7.90 (95% CI 7.14, 8.74) times as likely in infants who completed all three primary doses than in infants who did not complete primary doses before COVID-19 and during COVID-19, respectively.

Conclusions

PCV13 full completion was lower during the COVID-19 pandemic compared with pre-pandemic (79.0% vs. 77.1%).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-022-00699-5.

Coronavirus Disease 2019 Severity and Risk of Subsequent Cardiovascular Events

BACKGROUND

Little is known about the relationship between coronavirus disease 2019 (COVID-19) severity and subsequent risk of experiencing a cardiovascular event (CVE) after COVID-19 recovery. We evaluated this relationship in a large cohort of United States adults.

METHODS

Using a claims database, we performed a retrospective cohort study of adults diagnosed with COVID-19 between 1 April 2020 and 31 May 2021. We evaluated the association between COVID-19 severity and risk of CVE >30 days after COVID-19 diagnosis using inverse probability of treatment-weighted competing risks regression. Severity was based on level of care required for COVID-19 treatment: intensive care unit (ICU) admission, non-ICU hospitalization, or outpatient care only.

RESULTS

A total of 1 357 518 COVID-19 patients were included (2% ICU, 3% non-ICU hospitalization, and 95% outpatient only). Compared to outpatients, there was an increased risk of any CVE for patients requiring ICU admission (adjusted hazard ratio [aHR], 1.80 [95% confidence interval {CI}, 1.71-1.89]) or non-ICU hospitalization (aHR, 1.28 [95% CI, 1.24-1.33]). Risk of subsequent hospitalization for CVE was even higher (aHRs, 3.47 [95% CI, 3.20-3.76] for ICU and 1.96 [95% CI, 1.85-2.09] for non-ICU hospitalized vs outpatient only).

CONCLUSIONS

COVID-19 patients hospitalized or requiring critical care had a significantly higher risk of experiencing and being hospitalized for post-COVID-19 CVE than patients with milder COVID-19 who were managed solely in the outpatient setting, even after adjusting for differences between these groups. These findings underscore the continued importance of preventing severe acute respiratory syndrome coronavirus 2 infection from progressing to severe illness to reduce potential long-term cardiovascular complications.

Incidence, Attributable Mortality, and Healthcare and Out-of-Pocket Costs of Clostridioides difficile Infection in US Medicare Advantage Enrollees

BACKGROUND

US attributable Clostridioides difficile infection (CDI) mortality and cost data are primarily from Medicare fee-for-service populations, and little is known about Medicare Advantage Enrollees (MAEs). This study evaluated CDI incidence among MAEs from 2012 to 2019 and determined attributable mortality and costs by comparing MAEs with and without CDI occurring in 2018.

METHODS

This retrospective cohort study assessed CDI incidence and associated mortality and costs for eligible MAEs ≥65 years of age using the de-identified Optum Clinformatics Data Mart database (Optum; Eden Prairie, Minnesota, USA). Outcomes included mortality, healthcare utilization, and costs, which were assessed via a propensity score-matched cohort using 2018 as the index year. Outcome analyses were stratified by infection acquisition and hospitalization status.

RESULTS

From 2012 to 2019, overall annual CDI incidence declined from 609 to 442 per 100 000 person-years. Although the incidence of healthcare-associated CDI declined overall (2012, 53.2%; 2019, 47.2%), community-associated CDI increased (2012, 46.8%; 2019, 52.8%). The 1-year attributable mortality was 7.9% (CDI cases, 26.3%; non-CDI controls, 18.4%). At the 2-month follow-up, CDI-associated excess mean total healthcare and out-of-pocket costs were $13 476 and $396, respectively. Total excess mean healthcare costs were greater among hospitalized (healthcare-associated, $28 762; community-associated, $28 330) than nonhospitalized CDI patients ($5704 and $2320, respectively), whereas total excess mean out-of-pocket cost was highest among community-associated hospitalized CDI patients ($970).

CONCLUSIONS

CDI represents an important public health burden in the MAE population. Preventive strategies and treatments are needed to improve outcomes and reduce costs for healthcare systems and this growing population of older US adults.

Population attributable fractions of underlying medical conditions for COVID-19 diagnosis and COVID-19 hospitalizations, ventilations, and deaths among adults in the United States

Background

Several underlying medical conditions have been reported to be associated with an increased risk of coronavirus disease 2019 (COVID-19) and related hospitalization and death. Population attributable fractions (PAFs) describing the proportion of disease burden attributable to underlying medical conditions for COVID-19 diagnosis and outcomes have not been reported.

Methods

A retrospective population-based cohort study was conducted using Optum’s de-identified Clinformatics Data Mart database. Individuals were followed up from 20 January 2020 to 31 December 2020 for diagnosis and clinical progression, including hospitalization, intensive care unit admission, intubation and mechanical ventilation or extracorporeal membrane oxygenation, and death. Adjusted rate ratios and PAFs of underlying medical conditions for COVID-19 diagnosis and disease progression outcomes were estimated by age (18–49, 50–64, 65–74, or ≥75 years), sex, and race/ethnicity.

Results

Of 10 679 566 cohort members, 391 964 (3.7%) were diagnosed with COVID-19, of whom 87 526 (22.3%) were hospitalized. Of those hospitalized, 26 640 (30.4%) died. Overall, cardiovascular disease and diabetes had the highest PAFs for COVID-19 diagnosis and outcomes of increasing severity across age groups (up to 0.49 and 0.35, respectively). Among adults ≥75 years of age, neurologic disease had the second-highest PAFs (0.05‒0.27) after cardiovascular disease (0.26‒0.44). PAFs were generally higher in Black persons than in other race/ethnicity groups for the same conditions, particularly in the 2 younger age groups.

Conclusions

A substantial fraction of the COVID-19 disease burden in the United States is attributable to cardiovascular disease and diabetes, highlighting the continued importance of COVID-19 prevention ( eg, vaccination, mask wearing, social distancing) and disease management of patients with certain underlying medical conditions.

Bisphenol-A analogs induce lower urinary tract dysfunction in male mice

Bisphenol-A (BPA), an estrogenic endocrine disrupting chemical, significantly impacts numerous diseases and abnormalities in mammals. Estrogens are known to play an important role in the biology of the prostate; however, little is known about the role of bisphenols in the etiology of prostate pathologies, including benign prostate hyperplasia (BPH) and associated lower urinary tract dysfunction (LUTD). Bisphenol-F (BPF) and bisphenol-S (BPS) are analogs often used as substitutes for BPA; they are both reported to have in vitro and in vivo estrogenic effects similar to or more potent than BPA. The objective of this study was to assess the role of these bisphenols in the development of LUTD in adult male mice. In adult mice exposed to BPA, BPS or BPF, we examined urinary tract histopathology and physiological events associated with urinary dysfunction. Mice treated with bisphenols displayed increased bladder (p < 0.005) and prostate (p < 0.0001) mass, and there was an increased number of prostatic ducts in the prostatic urethra (p < 0.05) and decreased size of the urethra lumen (p < 0.05) compared to negative controls. After two months of bisphenol exposure, mice displayed notable differences in cystometric tracings compared to controls, consistent with LUTD. Treatment of male mice with all bisphenols also induced voiding dysfunction manifested by detrusor instability and histologic changes in the prostatic urethra of male rodents, consistent with LUTD. Our results implicate BPA and its replacements in the development and progression LUTD in mice and provide insights into the development and progression of BPH/LUTS in men.

COVID-19 vaccine effectiveness among immunocompromised populations: a targeted literature review of real-world studies

Introduction

From July through October of 2021, several countries issued recommendations for increased COVID-19 vaccine protection for individuals with one or more immunocompromised (IC) conditions. It is critically important to understand the vaccine effectiveness (VE) of COVID-19 vaccines among IC populations as recommendations are updated over time in response to the evolving COVID-19 pandemic.

Areas covered

A targeted literature review was conducted to identify real-world studies that assessed COVID-19 VE in IC populations between December 2020 and September 2021. A total of 10 studies from four countries were identified and summarized in this review.

Expert opinion

VE of the widely available COVID-19 vaccines, including BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), Ad26.COV2.S (Janssen), and ChAdOx1 nCoV-19 (Oxford/AstraZeneca), ranged from 64% to 90% against SARS-CoV-2 infection, 73% to 84% against symptomatic illness, 70% to 100% against severe illness, and 63% to 100% against COVID-19-related hospitalization among the fully vaccinated IC populations included in the studies. COVID-19 VE for most outcomes in the IC populations included in these studies were lower than in the general populations. These findings provide preliminary evidence that the IC population requires greater protective measures to prevent COVID-19 infection and associated illness, hence should be prioritized while implementing recommendations of additional COVID-19 vaccine doses.

Clinical and Pregnancy Outcomes of Coronavirus Disease 2019 Among Hospitalized Pregnant Women in the United States

Background

Pregnant women with coronavirus disease 2019 (COVID-19) may be at greater risk of poor maternal and pregnancy outcomes. This retrospective analysis reports clinical and pregnancy outcomes among hospitalized pregnant women with COVID-19 in the United States.

Methods

The Premier Healthcare Database-Special Release was used to examine the impact of COVID-19 among pregnant women aged 15-44 years who were hospitalized and who delivered compared with pregnant women without COVID-19. Outcomes evaluated were COVID-19 clinical progression, including the use of supplemental oxygen therapy, intensive care unit admission, critical illness, receipt of invasive mechanical ventilation/extracorporeal membrane oxygenation, maternal death, and pregnancy outcomes, including preterm delivery and stillbirth.

Results

Overall, 473 902 hospitalized pregnant women were included, 8584 (1.8%) of whom had a COVID-19 diagnosis (mean age = 28.4 [standard deviation = 6.1] years; 40% Hispanic). The risk of poor clinical and pregnancy outcomes was greater among pregnant women with COVID-19 compared with pregnant women without a COVID-19 diagnosis in 2020; the risk of poor clinical and pregnancy outcomes increased with increasing age. Hispanic and Black non-Hispanic women were consistently observed to have the highest relative risk of experiencing poor clinical or pregnancy outcomes across all age groups.

Conclusions

Overall, COVID-19 had a significant negative impact on maternal health and pregnancy outcomes. These data help inform clinical practice and counseling to pregnant women regarding the risks of COVID-19. Clinical studies evaluating the safety and efficacy of vaccines against severe acute respiratory syndrome coronavirus 2 in pregnant women are urgently needed.

Estimates of Presumed Population Immunity to SARS-CoV-2 by State in the United States, August 2021

Background

Information is needed to monitor progress toward a level of population immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sufficient to disrupt viral transmission. We estimated the percentage of the US population with presumed immunity to SARS-CoV-2 due to vaccination, natural infection, or both as of August 26, 2021.

Methods

Publicly available data as of August 26, 2021, from the Centers for Disease Control and Prevention were used to calculate presumed population immunity by state. Seroprevalence data were used to estimate the percentage of the population previously infected with SARS-CoV-2, with adjustments for underreporting. Vaccination coverage data for both fully and partially vaccinated persons were used to calculate presumed immunity from vaccination. Finally, we estimated the percentage of the total population in each state with presumed immunity to SARS-CoV-2, with a sensitivity analysis to account for waning immunity, and compared these estimates with a range of population immunity thresholds.

Results

In our main analysis, which was the most optimistic scenario, presumed population immunity varied among states (43.1% to 70.6%), with 19 states with ≤60% of their population having been infected or vaccinated. Four states had presumed immunity greater than thresholds estimated to be sufficient to disrupt transmission of less infectious variants (67%), and none were greater than the threshold estimated for more infectious variants (≥78%).

Conclusions

The United States remains a distance below the threshold sufficient to disrupt viral transmission, with some states remarkably low. As more infectious variants emerge, it is critical that vaccination efforts intensify across all states and ages for which the vaccines are approved.

Pandemic-related declines in hospitalization for non-COVID-19-related illness in the United States from January through July 2020

BACKGROUND

The COVID-19 pandemic, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has substantially impacted healthcare utilization worldwide. The objective of this retrospective analysis of a large hospital discharge database was to compare all-cause and cause-specific hospitalizations during the first six months of the pandemic in the United States with the same months in the previous four years.

METHODS

Data were collected from all hospitals in the Premier Healthcare Database (PHD) and PHD Special Release reporting hospitalizations from January through July for each year from 2016 through 2020. Hospitalization trends were analyzed stratified by age group, major diagnostic categories (MDCs), and geographic region.

RESULTS

The analysis included 286 hospitals from all 9 US Census divisions. The number of all-cause hospitalizations per month was relatively stable from 2016 through 2019 and then fell by 21% (57,281 fewer hospitalizations) between March and April 2020, particularly in hospitalizations for non-respiratory illnesses. From April onward there was a rise in the number of monthly hospitalizations per month. Hospitalizations per month, nationally and in each Census division, decreased for 20 of 25 MDCs between March and April 2020. There was also a decrease in hospitalizations per month for all age groups between March and April 2020 with the greatest decreases in hospitalizations observed for patients 50-64 and ≥65 years of age.

CONCLUSIONS

Rates of hospitalization declined substantially during the first months of the COVID-19 pandemic, suggesting delayed routine, elective, and emergency care in the United States. These lapses in care for illnesses not related to COVID-19 may lead to increases in morbidity and mortality for other conditions. Thus, in the current stage of the pandemic, clinicians and public-health officials should work, not only to prevent SARS-CoV-2 transmission, but also to ensure that care for non-COVID-19 conditions is not delayed.

COVID-19-associated hospitalizations among children less than 12 years of age in the United States

OBJECTIVES

To describe the characteristics, healthcare resource use and costs associated with initial hospitalization and readmissions among pediatric patients with COVID-19 in the US.

METHODS

Hospitalized pediatric patients, 0-11 years of age, with a primary or secondary discharge diagnosis code for COVID-19 (ICD-10 code U07.1) were selected from 1 April 2020 to 30 September 2021 in the US Premier Healthcare Database Special Release (PHD SR). Patient characteristics, hospital length of stay (LOS), in-hospital mortality, hospital costs, hospital charges, and COVID-19-associated readmission outcomes were evaluated and stratified by age groups (0-4, 5-11), four COVID-19 disease progression states based on intensive care unit (ICU) and invasive mechanical ventilation (IMV) usage, and three sequential calendar periods. Sensitivity analyses were performed using the US HealthVerity claims database and restricting the analyses to the primary discharge code.

RESULTS

Among 4,573 hospitalized pediatric patients aged 0-11 years, 68.0% were 0-4 years and 32.0% were 5-11 years, with a mean (median) age of 3.2 (1) years; 56.0% were male, and 67.2% were covered by Medicaid. Among the overall study population, 25.7% had immunocompromised condition(s), 23.1% were admitted to the ICU and 7.3% received IMV. The mean (median) hospital LOS was 4.3 (2) days, hospital costs and charges were $14,760 ($6,164) and $58,418 ($21,622), respectively; in-hospital mortality was 0.5%. LOS, costs, charges, and in-hospital mortality increased with ICU admission and/or IMV usage. In total, 2.1% had a COVID-19-associated readmission. Study outcomes appeared relatively more frequent and/or higher among those 5-11 than those 0-4. Results using the HealthVerity data source were generally consistent with main analyses.

LIMITATIONS

This retrospective administrative database analysis relied on coding accuracy and inpatient admissions with validated hospital costs.

CONCLUSIONS

These findings underscore that children aged 0-11 years can experience severe COVID-19 illness requiring hospitalization and substantial hospital resource use, further supporting recommendations for COVID-19 vaccination.

Public health impact of booster vaccination against COVID-19 in the UK during Delta variant dominance in autumn 2021

AIM

To evaluate the public health impact of the UK COVID-19 booster vaccination program in autumn 2021, during a period of SARS-CoV-2 Delta variant predominance.

MATERIALS AND METHODS

A compartmental Susceptible-Exposed-Infectious-Recovered model was used to compare age-stratified health outcomes for adult booster vaccination versus no booster vaccination in the UK over a time horizon of September-December 2021, when boosters were introduced in the UK and the SARS-CoV-2 Delta variant was predominant. Model input data were sourced from targeted literature reviews and publicly available data. Outcomes were predicted COVID-19 cases, hospitalizations, post-acute sequelae of COVID-19 (PASC) cases, deaths, and productivity losses averted, and predicted healthcare resources saved. Scenario analyses varied booster coverage, virus infectivity and severity, and time horizon parameters.

RESULTS

Booster vaccination was estimated to have averted approximately 547,000 COVID-19 cases, 36,000 hospitalizations, 147,000 PASC cases, and 4,200 deaths in the UK between September and December 2021. It saved over 316,000 hospital bed-days and prevented the loss of approximately 16.5 million paid and unpaid patient work days. In a scenario of accelerated uptake, the booster rollout would have averted approximately 3,400 additional deaths and 25,500 additional hospitalizations versus the base case. A scenario analysis assuming four-fold greater virus infectivity and lower severity estimated that booster vaccination would have averted over 105,000 deaths and over 41,000 hospitalizations versus the base case. A scenario analysis assuming pediatric primary series vaccination prior to adult booster vaccination estimated that expanding vaccination to children aged ≥5 years would have averted approximately 51,000 additional hospitalizations and 5,400 additional deaths relative to adult booster vaccination only.

LIMITATIONS

The model did not include the wider economic burden of COVID-19, hospital capacity constraints, booster implementation costs, or non-pharmaceutical interventions.

CONCLUSIONS

Booster vaccination during Delta variant predominance reduced the health burden of SARS-CoV-2 in the UK, releasing substantial NHS capacity.

101. PCV13 Pediatric Vaccination Disparity and Impact Due to COVID-19 Pandemic in the US

Background

Existing disparities in vaccination rates across different social and demographic groups in the US may have been exacerbated during the Coronavirus Disease 2019 (COVID) pandemic, leaving some children at risk for vaccine-preventable diseases. This study examined sociodemographic and risk factors of PCV13 infant primary series vaccination completion, before and during COVID.

Methods

Retrospective data from the Optum’s de-identified Clinformatics Data Mart Database were used to create 3 cohorts: C1, Pre-COVID; C2, During COVID; C3, Cross-COVID (Figure 1). C1 and C3 (C1&3) were combined and compared with C2 for primary dosing completion before and during COVID according to infant/caregiver characteristics. Full completion (FC) was defined as receipt of 3 doses of PCV13 within 8 months of birth. Multivariable logistic regression was used to compare FC vs. partial completion or no vaccine. Descriptive analyses were used to compare FC before and during COVID within subgroups.

Figure 1: Study population and inclusion criteria

Results

A total of 132,183 and 16,522 infants with at least 8 months of follow up time were enrolled in C1&3 and C2, respectively. FC was significantly higher before COVID-19 (adjusted odds ratio = 1.12, 95% CI: 1.07-1.17). Adjusting for COVID, FC was significantly lower in infants who were Black, with co-morbidities or risk factors, living in households with &gt;1 children or no children, household annual income &lt; &99k, residing in a neighborhood with median education of high school or below, and whose primary caregiver was aged &lt;25 years (Table 1). Comparing FC before and during COVID, the % decline relative to pre-COVID was &gt; 2% among infants who were White, residing in the Mountain, New England or Pacific regions, in a household with 2 children, &gt;&100k annual income, employer-based insurance or HMO, and median neighborhood education of bachelor degree plus (Table 2).

Table 1. Multivariable binomial logistic regression results for PCV13 full primary dosing completion vs. not full completion (partial or no vaccine), N=144,799*

Conclusion

Health inequities in PCV13 primary series completion existed prior to COVID-19 and have remained during the pandemic. Our results, however, suggest that during the pandemic, groups traditionally considered to have better healthcare access (Whites, higher income, more education) had more impact on vaccine uptake. Further research is needed to confirm these trends as COVID mitigation measures subside.

Disclosures

Liping Huang, MD, MA, MS, Pfizer Inc (Employee) Jennifer L Nguyen, ScD, MPH, Pfizer Inc. (Employee) Johnna Perdrizet, MPH, Pfizer Inc (Employee) Tamuno Alfred, PhD, Pfizer Inc. (Employee) Adriano Arguedas, MD, Pfizer (Employee)

1179. PCV13 Pediatric Routine Schedule Completion and Adherence Before and During the COVID-19 Pandemic in the US

Background

Coronavirus Disease 2019 (COVID) mitigation measures may have unintended consequences, such as reduced or delayed access to routine immunizations. This study examined (1) PCV13 routine vaccination completion and adherence (C&A) among US infants before and during the COVID pandemic and (2) the relationship between primary dose C&A and booster dose C&A.

Methods

Retrospective data from the Optum’s de-identified Clinformatics Data Mart Database were used to create 3 cohorts: C1, Pre-COVID; C2, During COVID; C3, Cross-COVID (Figure 1). The completion was defined as number of PCV13 doses received within 8 months of birth, and the adherence was defined number of doses received at ACIP recommended time (@2, 4, 6 months, +/- 5 days). Univariable logistic regression was used to compare the odds of primary dose C&A in cohorts C1 and C3 vs C2 and descriptive analyses were used to explore primary dose C&A in relation to booster dose C&A.

Figure 1: Study population and inclusion criteria

Results

A total of 172,916, 70,049, and 34,854 infants were included in C1, C2, and C3. Among infants with &gt; 8 months of follow-up from birth (N=132,183 for C1&C3, 16,522 for C3), 3-primary dose completion was statistically significantly higher before COVID than during COVID (crude OR = 1.10, 95% CI: 1.06-1.15). The 3-primary dose adherence was also higher before COVID than during COVID (crude OR = 1.10, 95% CI: 1.05-1.15). Among infants with ≥2, 4 and 6 months of follow-up, adherence of each individual dose was consistently higher before COVID than during COVID (1st dose: OR = 1.03, 95% CI: 1.01–1.04; 2nd dose: OR = 1.04, 95% CI: 1.01 – 1.06; 3rd dose: OR = 1.12, 95% CI: 1.08 – 1.15) (Table 1). Booster dose completion was higher in infants who completed or adhered to 3 primary doses than infants who completed or adhered to only 1 or 2 primary doses (Figure 2, Overall) and booster dose C&A was generally higher before COVID than during COVID (Figure 2, Cohort 1 vs. Cohort 3).

Table 1. Comparison of completion and adherence of primary dosing series per-COVID vs. during-COVID era

Conclusion

These results indicated that PCV13 full completion was statistically lower during COVID, but the magnitude of the difference in infants was not extensive. Infants who completed or adhered to all three primary doses were more likely to complete or adhere to the booster dose. Further research is warranted as structured datasets mature to capture the full time span of COVID-19 mitigation measures.

Disclosures

Liping Huang, MD, MA, MS, Pfizer Inc (Employee) Jennifer L Nguyen, ScD, MPH, Pfizer Inc. (Employee) Johnna Perdrizet, MPH, Pfizer Inc (Employee) Tamuno Alfred, PhD, Pfizer Inc. (Employee) Adriano Arguedas, MD, Pfizer (Employee)

16. Attributable Mortality, Healthcare Costs and Out-of-Pocket Costs of Clostridioides difficile Infection in US Medicare Advantage Enrollees

Background

US attributable CDI mortality and cost data are primarily from Medicare fee-for-service populations. Little is known about Medicare Advantage Enrollees (MAEs), who comprise about 39% of the Medicare population.

Methods

Using 2017‒2019 Optum’s de-identified Clinformatics® Data Mart database, this retrospective cohort study identified first C difficile infection (CDI) episodes occurring in 2018 among eligible MAEs ≥66 y of age who were continuously enrolled for 12 mo before CDI diagnosis (baseline period). CDI was defined via ICD10 diagnosis codes or evidence of toxin testing with CDI antibiotic treatment. To assess all-cause mortality and CDI-associated healthcare and patient out-of-pocket (OOP) costs, CDI+ cases were matched 1:1 to CDI– controls using propensity scores (PS) and were followed through the earliest of death, disenrollment or end of the 12 mo followup. Additionally, outcome analyses were stratified by infection acquisition and hospitalization status.

Results

Among 3,450,354 eligible MAEs, 15,195 (0.4%) had a CDI episode in 2018. Using PS generated from &gt;60 variables collected in the baseline period, 14,928 CDI+ cases were matched to CDI– controls.

Over 12 mo of follow-up, the difference in 1-y attributable mortality was 7.9% in the CDI+ (26.3%) vs CDI– (18.4%) cohort (Figure 1). CDI-attributable mortality was higher among hospitalized CDI+ cases (18.4% for healthcare associated [HA]; 13.1% for community associated [CA]) vs nonhospitalized CDI+ cases (HA, 4.5%; CA, 1.0%).

Similarly, healthcare costs were higher for CDI+ vs CDI– patients, with excess mean total cost of &13,363 at the 2-mo follow-up (Figure 2). Total excess mean healthcare costs were greater among hospitalized CDI+ patients (HA, &28,139; CA, &28,136) than for nonhospitalized CDI+ patients (HA, &5741; CA, &2503). CDI-associated excess mean OOP cost was &409 for CDI+ cases at the 2 mo followup. Total excess mean OOP cost was highest in CA hospitalized CDI+ cases, followed by HA hospitalized CDI+ cases, HA nonhospitalized CDI+ cases and finally CA nonhospitalized CDI+ cases (&964, &574, &231 and &197, respectively).

Conclusion

CDI is associated with major mortality and total healthcare and OOP costs. Preventing CDI in the elderly may improve outcomes and reduce costs for healthcare systems and patients.

Disclosures

Holly Yu, MSPH, Pfizer Inc (Employee, Shareholder) Jennifer L Nguyen, ScD, MPH, Pfizer Inc. (Employee) Tamuno Alfred, PhD, Pfizer Inc. (Employee) Jingying Zhou, MA, MEd, Pfizer Inc (Employee, Shareholder) Margaret A. Olsen, PhD, MPH, Pfizer (Consultant, Research Grant or Support)

Hospitalization and mortality trends among patients with confirmed COVID-19 in the United States, April through August 2020

Background: The United States has experienced high COVID- 19 case counts, hospitalizations, and death rates. This retrospective analysis reports changing trends in the demographics and clinical outcomes of hospitalized US COVID-19 patients between April and August 2020.

Design and methods: The Premier Healthcare Database Special Release was used to examine patient demographics of hospitalized COVID-19 patients from all US Census Bureau divisions. Demographics included age, sex, race, and ethnicity. Clinical outcomes included in-hospital mortality, intensive care unit (ICU) admission, and receipt of invasive mechanical ventilation.

Results: Overall, 146,491 hospitalized COVID-19 patients were included (mean [SD] age, 61.0 [18.4] years; 51.7% male; 29.6% White non-Hispanic). Monthly total hospitalizations decreased from 44,854 in April to 18,533 in August; ICU admissions increased from 19.8% to 23.6%, and ventilator use and inpatient mortality decreased from 18.6% to 14.5% and 21.0% to 11.4%, respectively. Inpatient mortality was highest in the Middle Atlantic division (20.3%), followed by the New England (19.0%), East North Central (14.2%), and Mountain (13.7%) divisions. Black non-Hispanic patients were overrepresented among hospitalizations (19.0%); this group comprises 12.2% of the US population. Patients aged <65 years made up 53% of hospitalizations and had lower inpatient mortality than those aged ≥65 years.

Conclusions: Hospitalizations, ventilator use, and mortality decreased, while ICU admission rates increased from April to August 2020. Older individuals and Black non-Hispanics were found to be at elevated risk of severe outcomes. These trends could inform ongoing patient care and US public health policies to limit the further spread of SARS-CoV-2.

Effect of an intensive lifestyle intervention on the prevalence of metabolic syndrome and its components among overweight and obese adults

Background

Despite the fact that up to a third of the global population has metabolic syndrome (MetS), it has been overlooked in clinical settings. This study assesses the impact of a physician-supervised nonsurgical weight management program on the prevalence of MetS and its key indicators.

Methods

Four-hundred seventy-nine overweight and obese participants aged 19 years or older were included in a prospective longitudinal study. Changes in MetS and its key indicators were assessed using the binomial exact, chi-square and Wilcoxon signed-rank tests in an intent-to-treat study population. Differences in age strata were assessed using a generalized linear model.

Results

Fifty-two percent of participants (n = 249) had MetS at baseline. Prevalence of MetS decreased steadily with significant changes from baseline observed at weeks 13 (31.8%, P < 0.0001), 26 (28.7%, P < 0.0012) and 39 (21.6%, P < 0.0002); changes from baseline were observed at week 52 as statistically significant (16.7%, P < 0.0012). Improvements in anthropometrics and levels of key indicators of MetS were observed throughout the study.

Conclusion

These findings confirm that weight loss is inversely associated with prevalence of MetS and its key indicators among overweight and obese individuals. Future studies may benefit from a larger sample size and better retention (ClinicalTrials.gov ID: NCT03588117).

Evaluation of COVID-19 vaccine breakthrough infections among immunocompromised patients fully vaccinated with BNT162b2

OBJECTIVE

To evaluate COVID-19 vaccine breakthrough infections among immunocompromised (IC) individuals.

METHODS

Individuals vaccinated with BNT162b2 were selected from the US HealthVerity database (10 December 2020 to 8  July 2021). COVID-19 vaccine breakthrough infections were examined in fully vaccinated (≥14 days after 2nd dose) IC individuals (IC cohort), 12 mutually exclusive IC condition groups, and a non-IC cohort. IC conditions were identified using an algorithm based on diagnosis codes and immunosuppressive (IS) medication usage.

RESULTS

Of 1,277,747 individuals ≥16 years of age who received 2 BNT162b2 doses, 225,796 (17.7%) were identified as IC (median age: 58 years; 56.3% female). The most prevalent IC conditions were solid malignancy (32.0%), kidney disease (19.5%), and rheumatologic/inflammatory conditions (16.7%). Among the fully vaccinated IC and non-IC cohorts, a total of 978 breakthrough infections were observed during the study period; 124 (12.7%) resulted in hospitalization and 2 (0.2%) were inpatient deaths. IC individuals accounted for 38.2% (N = 374) of all breakthrough infections, 59.7% (N = 74) of all hospitalizations, and 100% (N = 2) of inpatient deaths. The proportion with breakthrough infections was 3 times higher in the IC cohort compared to the non-IC cohort (N = 374 [0.18%] vs. N = 604 [0.06%]; unadjusted incidence rates were 0.89 and 0.34 per 100 person-years, respectively. Organ transplant recipients had the highest incidence rate; those with >1 IC condition, antimetabolite usage, primary immunodeficiencies, and hematologic malignancies also had higher incidence rates compared to the overall IC cohort. Incidence rates in older (≥65 years old) IC individuals were generally higher versus younger IC individuals (<65).

LIMITATIONS

This retrospective analysis relied on coding accuracy and had limited capture of COVID-19 vaccine receipt.

CONCLUSIONS

COVID-19 vaccine breakthrough infections are rare but are more common and severe in IC individuals. The findings from this large study support the FDA authorization and CDC recommendations to offer a 3rd vaccine dose to increase protection among IC individuals.

Health outcomes and economic burden of hospitalized COVID-19 patients in the United States

OBJECTIVE

The aims of this study were to evaluate health outcomes and the economic burden of hospitalized COVID-19 patients in the United States.

METHODS

Hospitalized patients with a primary or secondary discharge diagnosis code for COVID-19 (ICD-10 code U07.1) from 1 April to 31 October 2020 were identified in the Premier Healthcare COVID-19 Database. Patient demographics, hospitalization characteristics, and concomitant medical conditions were assessed. Hospital length of stay (LOS), in-hospital mortality, hospital charges, and hospital costs were evaluated overall and stratified by age groups, insurance types, and 4 COVID-19 disease progression states based on intensive care unit (ICU) and invasive mechanical ventilation (IMV) usage.

RESULTS

Of the 173,942 hospitalized COVID-19 patients, the median age was 63 years, 51.0% were male, and 48.5% were covered by Medicare. The most prevalent concomitant medical conditions were cardiovascular disease (73.5%), hypertension (64.8%), diabetes (40.7%), obesity (27.0%), and chronic kidney disease (24.2%). Approximately one-fifth (21.9%) of the hospitalized COVID-19 patients were admitted to the ICU and 16.9% received IMV; most patients (73.6%) did not require ICU admission or IMV, and 12.4% required both. The median hospital LOS was 5 days, in-hospital mortality was 13.6%, median hospital charges were $43,986, and median hospital costs were $12,046. Hospital LOS and in-hospital mortality increased with ICU and/or IMV usage and age; hospital charges and costs increased with ICU and/or IMV usage. Patients with both ICU and IMV usage had the longest median hospital LOS (15 days), highest in-hospital mortality (53.8%), and highest hospital charges ($198,394) and hospital costs ($54,402).

LIMITATIONS

This retrospective administrative database analysis relied on coding accuracy and a subset of admissions with validated/reconciled hospital costs.

CONCLUSIONS

This study summarizes the severe health outcomes and substantial hospital costs of hospitalized COVID-19 patients in the US. The findings support the urgent need for rapid implementation of effective interventions, including safe and efficacious vaccines.

Seasonal Influenza Infections and Cardiovascular Disease Mortality

IMPORTANCE

Cardiovascular deaths and influenza epidemics peak during winter in temperate regions.

OBJECTIVES

To quantify the temporal association between population increases in seasonal influenza infections and mortality due to cardiovascular causes and to test if influenza incidence indicators are predictive of cardiovascular mortality during the influenza season.

DESIGN, SETTING, AND PARTICIPANTS

Time-series analysis of vital statistics records and emergency department visits in New York City, among cardiovascular deaths that occurred during influenza seasons between January 1, 2006, and December 31, 2012. The 2009 novel influenza A(H1N1) pandemic period was excluded from temporal analyses.

EXPOSURES

Emergency department visits for influenza-like illness, grouped by age (≥0 years and ≥65 years) and scaled by laboratory surveillance data for viral types and subtypes, in the previous 28 days.

MAIN OUTCOMES AND MEASURES

Mortality due to cardiovascular disease, ischemic heart disease, and myocardial infarction.

RESULTS

Among adults 65 years and older, who accounted for 83.0% (73 363 deaths) of nonpandemic cardiovascular mortality during influenza seasons, seasonal average influenza incidence was correlated year to year with excess cardiovascular mortality (Pearson correlation coefficients ≥0.75, P ≤ .05 for 4 different influenza indicators). In daily time-series analyses using 4 different influenza metrics, interquartile range increases in influenza incidence during the previous 21 days were associated with an increase between 2.3% (95% CI, 0.7%-3.9%) and 6.3% (95% CI, 3.7%-8.9%) for cardiovascular disease mortality and between 2.4% (95% CI, 1.1%-3.6%) and 6.9% (95% CI, 4.0%-9.9%) for ischemic heart disease mortality among adults 65 years and older. The associations were most acute and strongest for myocardial infarction mortality, with each interquartile range increase in influenza incidence during the previous 14 days associated with mortality increases between 5.8% (95% CI, 2.5%-9.1%) and 13.1% (95% CI, 5.3%-20.9%). Out-of-sample prediction of cardiovascular mortality among adults 65 years and older during the 2009-2010 influenza season yielded average estimates with 94.0% accuracy using 4 different influenza metrics.

CONCLUSIONS AND RELEVANCE

Emergency department visits for influenza-like illness were associated with and predictive of cardiovascular disease mortality. Retrospective estimation of influenza-attributable cardiovascular mortality burden combined with accurate and reliable influenza forecasts could predict the timing and burden of seasonal increases in cardiovascular mortality.

Daily indoor-to-outdoor temperature and humidity relationships: a sample across seasons and diverse climatic regions

The health consequences of heat and cold are usually evaluated based on associations with outdoor measurements collected at a nearby weather reporting station. However, people in the developed world spend little time outdoors, especially during extreme temperature events. We examined the association between indoor and outdoor temperature and humidity in a range of climates. We measured indoor temperature, apparent temperature, relative humidity, dew point, and specific humidity (a measure of moisture content in air) for one calendar year (2012) in a convenience sample of eight diverse locations ranging from the equatorial region (10 °N) to the Arctic (64 °N). We then compared the indoor conditions to outdoor values recorded at the nearest airport weather station. We found that the shape of the indoor-to-outdoor temperature and humidity relationships varied across seasons and locations. Indoor temperatures showed little variation across season and location. There was large variation in indoor relative humidity between seasons and between locations which was independent of outdoor airport measurements. On the other hand, indoor specific humidity, and to a lesser extent dew point, tracked with outdoor, airport measurements both seasonally and between climates, across a wide range of outdoor temperatures. These results suggest that, in general, outdoor measures of actual moisture content in air better capture indoor conditions than outdoor temperature and relative humidity. Therefore, in studies where water vapor is among the parameters of interest for examining weather-related health effects, outdoor measurements of actual moisture content can be more reliably used as a proxy for indoor exposure than the more commonly examined variables of temperature and relative humidity.

Weather and triggering of ventricular arrhythmias in patients with implantable cardioverter-defibrillators

Outdoor ambient weather has been hypothesized to be responsible for the seasonal distribution of cardiac arrhythmias. Because people spend most of their time indoors, we hypothesized that weather-related arrhythmia risk would be better estimated using an indoor measure or an outdoor measure that correlates well with indoor conditions, such as absolute humidity. The clinical records of 203 patients in eastern Massachusetts, USA, with an implantable cardioverter-defibrillator were abstracted for arrhythmias between 1995 and 2002. We used case-crossover methods to examine the association between weather and ventricular arrhythmia (VA). Among 84 patients who experienced 787 VAs, lower estimated indoor temperature (odds ratio (OR)=1.16, 95% confidence interval (CI) 1.05-1.27 for a 1 °C decrease in the 24-h average) and lower absolute humidity (OR=1.06, 95% CI 1.03-1.08 for a 0.5 g/m(3) decrease in the 96-h average) were associated with increased risk. Lower outdoor temperature increased risk only in warmer months, likely attributable to the poor correlation between outdoor and indoor temperature during cooler months. These results suggest that lower temperature and drier air are associated with increased risk of VA onset among implantable cardioverter-defibrillator patients.

The relationship between indoor and outdoor temperature, apparent temperature, relative humidity, and absolute humidity

Many studies report an association between outdoor ambient weather and health. Outdoor conditions may be a poor indicator of personal exposure because people spend most of their time indoors. Few studies have examined how indoor conditions relate to outdoor ambient weather. The average indoor temperature, apparent temperature, relative humidity (RH), and absolute humidity (AH) measured in 16 homes in Greater Boston, Massachusetts, from May 2011 to April 2012 was compared to measurements taken at Boston Logan airport. The relationship between indoor and outdoor temperatures is nonlinear. At warmer outdoor temperatures, there is a strong correlation between indoor and outdoor temperature (Pearson correlation coefficient, r = 0.91, slope, β = 0.41), but at cooler temperatures, the association is weak (r = 0.40, β = 0.04). Results were similar for outdoor apparent temperature. The relationships were linear for RH and AH. The correlation for RH was modest (r = 0.55, β = 0.39). Absolute humidity exhibited the strongest indoor-to-outdoor correlation (r = 0.96, β = 0.69). Indoor and outdoor temperatures correlate well only at warmer outdoor temperatures. Outdoor RH is a poor indicator of indoor RH, while indoor AH has a strong correlation with outdoor AH year-round.

Early changes of guanylate cyclase and cGMP phosphodiesterase activities in glomeruli and tubules isolated from the remaining kidney after unilateral nephrectomy in the rabbit

Guanylate cyclase (GCase) and cyclic guanosine 3'5'-monophosphate-phosphodiesterase (cGMP-PDE) activities were measured in the medulla, glomeruli and cortical tubules isolated from the remaining kidney 5-120 min after unilateral nephrectomy. The results showed that cGMP-PDE-specific activities were unchanged in all the fractions isolated from the contralateral kidney when compared with the nephrectomized control kidney. The GCase-specific activity in the cortical and medullary tubules isolated from the remaining kidney reached a maximum by 10 min after unilateral nephrectomy and then returned to control values. On the other hand the glomerular GCase activity decreased for 10 min after unilateral nephrectomy, then rebound activity reached a maximum by 30 min and after 120 min had returned to the control value. The possible physiological signification of such variations is discussed.