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Moehling KK, Zhai B, Schwarzmann WE, Chandran UR, Ortiz M, Nowalk MP, Nace D, Lin CJ, Susick M, Levine MZ, Alcorn JF, Zimmerman RK. The impact of physical frailty on the response to inactivated influenza vaccine in older adults. Aging (Albany NY) 2020; 12:24633-24650. [PMID: 33347425 PMCID: PMC7803506 DOI: 10.18632/aging.202207] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/27/2020] [Indexed: 11/25/2022]
Abstract
Physical frailty's impact on hemagglutination inhibition antibody titers (HAI) and peripheral blood mononuclear cell (PBMC) transcriptional responses after influenza vaccination is unclear. Physical frailty was assessed using the 5-item Fried frailty phenotype in 168 community- and assisted-living adults ≥55 years of age during an observational study. Blood was drawn before, 3, 7, and 28 days post-vaccination with the 2017-2018 inactivated influenza vaccine. HAI response to the A/H1N1 strain was measured at Days 0 and 28 using seropositivity, seroconversion, log2 HAI titers, and fold-rise in log2 HAI titers. RNA sequencing of PBMCs from Days 0, 3 and 7 was measured in 28 participants and compared using pathway analyses. Frailty was not significantly associated with any HAI outcome in multivariable models. Compared with non-frail participants, frail participants expressed decreased cell proliferation, metabolism, antibody production, and interferon signaling genes. Conversely, frail participants showed elevated gene expression in IL-8 signaling, T-cell exhaustion, and oxidative stress pathways compared with non-frail participants. These results suggest that reduced effectiveness of influenza vaccine among older, frail individuals may be attributed to immunosenescence-related changes in PBMCs that are not reflected in antibody levels.
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Affiliation(s)
- Krissy K. Moehling
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Bo Zhai
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - William E. Schwarzmann
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Uma R. Chandran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Marianna Ortiz
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - David Nace
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Chyongchiou J. Lin
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Ohio State University College of Nursing, Columbus, OH 43210, USA
| | - Michael Susick
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Min Z. Levine
- National Center for Immunization and Respiratory Diseases, Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA
| | - John F. Alcorn
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Richard K. Zimmerman
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Moehling KK, Zimmerman RK, Nowalk MP, Jeng Lin C, Martin JM, Alcorn JF, Susick M, Burroughs A, Holiday C, Flannery B, Levine MZ. A randomized controlled trial of antibody response to 2018-19 cell-based vs. egg-based quadrivalent inactivated influenza vaccine in children. Vaccine 2020; 38:5171-5177. [PMID: 32580919 DOI: 10.1016/j.vaccine.2020.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Current influenza vaccine effectiveness (VE) improvement efforts focus on minimizing egg adaptation mutations during manufacture. This study compared immune response of two FDA-approved quadrivalent inactivated influenza vaccines in an unblinded randomized controlled trial. METHODS Participants were 144 community dwelling, healthy children/adolescents aged 4-20 years, randomized 1:1 in blocks of 4 to a vaccine grown in cell culture (ccIIV4 [Flucelvax®]; n = 85); or in egg medium (IIV4 [Fluzone ®]; n = 83). Blood was drawn at day 0 prevaccination and at day 28 (19-35 days) post vaccination. Hemagglutination inhibition (HI) assays against A/H1N1 and both B strains and microneutralization (MN) assays against egg-based and cell-based A/H3N2 strains were conducted. The primary outcome measure was seroconversion (day 28/day 0 titer ratio ≥ 4 with day 28 titer ≥ 40). Secondary outcomes were elevated titers (day 28 HI titer ≥ 1:110), geometric mean titers (GMTs) and mean fold rise (MFR) in titers. Outcomes were compared for 74 ccIIV4 recipients and 70 IIV4 recipients, and for those vaccinated and unvaccinated the previous year. Only the HI and MN laboratory analysis team was blinded to group assignment. RESULTS In this racially diverse (81% non-white) group of children with a median age of 14 years, baseline demographics did not differ between vaccine groups. At day 0, half or more in each vaccine group had elevated HI or MN titers. Low seroconversion rates (14%-35%) were found; they did not differ between groups. Among 2018-19 ccIIV4 recipients, those unvaccinated in the previous season showed significantly higher MFR against A/H1N1 and A/H3N2 cell-grown virus than the previously vaccinated. Similar results were found for MFR against B/Victoria among 2018-2019 IIV4 recipients. CONCLUSION In mostly older children with high baseline titers, no differences in seroconversion or other measures of antibody titers were found between ccIIV4 and IIV4 recipients against egg- and cell-grown influenza vaccine viruses. CLINICAL TRIALS NO NCT03614975.
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Affiliation(s)
- Krissy K Moehling
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Judith M Martin
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - John F Alcorn
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Susick
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ashley Burroughs
- National Center Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta GA, USA
| | - Crystal Holiday
- National Center Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta GA, USA
| | - Brendan Flannery
- National Center Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta GA, USA
| | - Min Z Levine
- National Center Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta GA, USA
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Alcorn JF, Avula R, Chakka AB, Schwarzmann WE, Nowalk MP, Lin CJ, Ortiz MA, Horne WT, Chandran UR, Nagg JP, Zimmerman RK, Cole KS, Moehling KK, Martin JM. Differential gene expression in peripheral blood mononuclear cells from children immunized with inactivated influenza vaccine. Hum Vaccin Immunother 2020; 16:1782-1790. [PMID: 32298194 DOI: 10.1080/21645515.2020.1711677] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The human immune response to inactivated influenza vaccine is dynamic and impacted by age and preexisting immunity. Our goal was to identify postvaccination transcriptomic changes in peripheral blood mononuclear cells from children. Blood samples were obtained before and at 3 or 7 days postvaccination with 2016-2017 quadrivalent inactivated influenza vaccine and RNA sequencing was performed. There were 1,466 differentially expressed genes (DEGs) for the Day 0-Day 3 group and 513 DEGs for the Day 0-Day 7 group. Thirty-three genes were common between the two groups. The majority of the transcriptomic changes at Day 3 represented innate inflammation and apoptosis pathways. Day 7 DEGs were characterized by activation of cellular processes, including the regulation of cytoskeleton, junctions, and metabolism, and increased expression of immunoglobulin genes. DEGs at Day 3 were compared between older and younger children revealing increased inflammatory gene expression in the older group. Vaccine history in the year prior to the study was characterized by robust DEGs at Day 3 with decreased phagosome and dendritic cell maturation in those who had been vaccinated in the previous year. PBMC responses to inactivated influenza vaccination in children differed significantly by the timing of sampling, patient age, and vaccine history. These data provide insight into the expected molecular pathways to be temporally altered by influenza vaccination in children.
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Affiliation(s)
- John F Alcorn
- Department of Pediatrics, University of Pittsburgh , Pittsburgh, PA, USA
| | - Raghunandan Avula
- Department of Biomedical Informatics, University of Pittsburgh , Pittsburgh, PA, USA
| | - Anish B Chakka
- Department of Biomedical Informatics, University of Pittsburgh , Pittsburgh, PA, USA
| | - William E Schwarzmann
- Department of Biomedical Informatics, University of Pittsburgh , Pittsburgh, PA, USA
| | | | | | - Marianna A Ortiz
- Department of Pediatrics, University of Pittsburgh , Pittsburgh, PA, USA.,Center for Vaccine Research, University of Pittsburgh , Pittsburgh, PA, USA
| | - William T Horne
- Department of Pediatrics, University of Pittsburgh , Pittsburgh, PA, USA
| | - Uma R Chandran
- Department of Biomedical Informatics, University of Pittsburgh , Pittsburgh, PA, USA
| | - Jennifer P Nagg
- Department of Pediatrics, University of Pittsburgh , Pittsburgh, PA, USA
| | - Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh , Pittsburgh, PA, USA
| | - Kelly S Cole
- Center for Vaccine Research, University of Pittsburgh , Pittsburgh, PA, USA
| | - Krissy K Moehling
- Department of Family Medicine, University of Pittsburgh , Pittsburgh, PA, USA
| | - Judith M Martin
- Department of Pediatrics, University of Pittsburgh , Pittsburgh, PA, USA
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Moehling KK, Nowalk MP, Lin CJ, Bertolet M, Ross TM, Carter CE, Susick M, Saul SG, Kaynar AM, Bromberger JT, Zimmerman RK. The effect of frailty on HAI response to influenza vaccine among community-dwelling adults ≥ 50 years of age. Hum Vaccin Immunother 2017; 14:361-367. [PMID: 29172948 DOI: 10.1080/21645515.2017.1405883] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The immune response to vaccine antigens is less robust in older adults because of changes in the aging immune system. Frailty, the multi-dimensional syndrome marked by losses in function and physiological reserve, is increasingly prevalent with advancing age. Frailty accelerates this immunosenescence but the consequence of frailty on immune response specific to influenza vaccine among older adults, is mixed. An observational, prospective study of 114 adults was conducted in the fall of 2013 to assess the association of physical frailty with immune response to standard dose influenza vaccine in community-dwelling adults ≥ 50 years of age. Participants were stratified by age (<65 years and ≥65 years), and vaccine strain (Influenza A/H1N1, A/H3N2 and B) was analyzed separately adjusting for body mass index (BMI) and baseline log2 hemagglutination inhibition (HAI) titers. Overall, immune responses were lower among those ≥65 years of age than those <65 years. Among those ≥65 years there were no significant differences between frail and non-frail individuals in seroprotection or seroconversion for any influenza strain. Frail individuals <65 years of age compared with non-frail individuals were more likely to be seroprotected and to seroconvert post vaccination. Linear regression models show the same pattern of significant differences between frail and non-frail for those <65 years but no significant differences between frailty groups for those ≥65 years. Additional research may elucidate the reasons for the differences observed between younger frail and non-frail adults.
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Affiliation(s)
- Krissy K Moehling
- a University of Pittsburgh, School of Medicine , Department of Family Medicine , Pittsburgh , PA , USA
| | - Mary Patricia Nowalk
- a University of Pittsburgh, School of Medicine , Department of Family Medicine , Pittsburgh , PA , USA
| | - Chyongchiou Jeng Lin
- a University of Pittsburgh, School of Medicine , Department of Family Medicine , Pittsburgh , PA , USA
| | - Marnie Bertolet
- b University of Pittsburgh, Graduate School of Public Health , Department of Epidemiology , Pittsburgh , PA , USA
| | - Ted M Ross
- c Center for Vaccines and Immunology, University of Georgia , Athens , GA , USA.,d University of Georgia, College of Veterinary Medicine , Department of Infectious Diseases , Athens , GA , USA
| | - Chalise E Carter
- c Center for Vaccines and Immunology, University of Georgia , Athens , GA , USA
| | - Michael Susick
- a University of Pittsburgh, School of Medicine , Department of Family Medicine , Pittsburgh , PA , USA
| | - Sean G Saul
- a University of Pittsburgh, School of Medicine , Department of Family Medicine , Pittsburgh , PA , USA
| | - A Murat Kaynar
- e University of Pittsburgh, School of Medicine , Department of Critical Care Medicine , Pittsburgh , PA , USA
| | - Joyce T Bromberger
- b University of Pittsburgh, Graduate School of Public Health , Department of Epidemiology , Pittsburgh , PA , USA
| | - Richard K Zimmerman
- a University of Pittsburgh, School of Medicine , Department of Family Medicine , Pittsburgh , PA , USA
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Nowalk MP, Moehling KK, Zhang S, Raviotta JM, Zimmerman RK, Lin CJ. Using the 4 Pillars to increase vaccination among high-risk adults: who benefits? Am J Manag Care 2017; 23:651-655. [PMID: 29182350 PMCID: PMC6166239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare changes in vaccination rates (pneumococcal polysaccharide vaccine [PPSV]; tetanus, diphtheria, and pertussis [Tdap] vaccine; and influenza vaccine) among high-risk adults following an intervention (June 1, 2013, to January 31, 2015) that used the 4 Pillars Practice Transformation Program (4 Pillars Program). STUDY DESIGN Post hoc analysis of data from a randomized controlled cluster trial. METHODS Eighteen primary care practices received staff education, guidance for using the 4 Pillars Program, and support for a practice immunization champion. Paired t tests were used to compare vaccination rates separately for those with diabetes, chronic lung or chronic heart disease, or other high-risk conditions. Student's t tests were used to compare vaccination rates across high-risk conditions. Generalized estimating equation modeling was used to determine the likelihood of vaccination. RESULTS Based on International Classification of Diseases, Ninth Revision, Clinical Modification codes, 4737 patients aged 18 to 64 years were identified as having diabetes (n = 1999), chronic heart disease (n = 658), chronic lung disease (n = 1682), or another high-risk condition (n = 764). PPSV uptake increased by 12.2 percentage points (PP), Tdap vaccination increased by 11.4 PP, and influenza vaccination increased by 4.8 PP. In regression analyses, patients with diabetes (odds ratio [OR], 2.2; 95% CI, 1.80-2.73), chronic lung disease (OR, 1.50; 95% CI, 1.21-1.87), or chronic heart disease (OR, 1.32; 95% CI, 1.02-1.71) were more likely to receive PPSV than those without the respective high-risk condition. Those with diabetes (OR, 1.14; 95% CI, 1.01-1.28) or chronic lung disease (OR, 1.14; 95% CI, 1.01-1.30) were more likely to receive an influenza vaccine than those without the respective condition. The likelihood of Tdap vaccination was not significantly associated with any of the chronic conditions tested. CONCLUSIONS An intervention including the 4 Pillars Program was associated with significant increases in vaccination of high-risk adults. However, the overall uptake of recommended vaccines for those with high-risk conditions remained below national goals.
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Affiliation(s)
- Mary Patricia Nowalk
- University of Pittsburgh School of Medicine, 4420 Bayard St, Ste 520, Pittsburgh, PA 15260. E-mail:
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Nuñez IA, Carlock MA, Allen JD, Owino SO, Moehling KK, Nowalk P, Susick M, Diagle K, Sweeney K, Mundle S, Vogel TU, Delagrave S, Ramgopal M, Zimmerman RK, Kleanthous H, Ross TM. Impact of age and pre-existing influenza immune responses in humans receiving split inactivated influenza vaccine on the induction of the breadth of antibodies to influenza A strains. PLoS One 2017; 12:e0185666. [PMID: 29091724 PMCID: PMC5665503 DOI: 10.1371/journal.pone.0185666] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 09/14/2017] [Indexed: 12/28/2022] Open
Abstract
Most humans have pre-existing immunity to influenza viruses. In this study, volunteers (ages of 18-85 years) were vaccinated with split, inactivated Fluzone™ influenza vaccine in four consecutive influenza seasons from 2013 to 2016 seasons. The impact of repeated vaccination on breadth and durability of antibodies was assessed as a result of vaccine strain changes. Total IgG anti-hemagglutinin (HA) binding antibodies and hemagglutination-inhibition (HAI) activity increased in all age groups against both influenza A HA components in the vaccine post-vaccination (day 21). However, younger subjects maintained seroprotective titers to the vaccine strains, which resulted in higher seroconversion rates in the elderly, since the HAI titers in elderly subjects were more likely to decline prior to the next season. Young subjects had significant HAI activity against historical, as well as contemporary H1 and H3 vaccine strains from the mid-1980s to present. In contrast, elderly subjects had HAI activity to H1 strains from all years, but were more likely to have HAI activity to older strains from 1918-1950s. They also had a more restricted HAI profile against H3 viruses compared to young subjects recognizing H3N2 influenza viruses from the mid-2000s to present. Vaccine recipients were then categorized by whether subjects seroconverted from a seronegative or seropositive pre-vaccination state. Regardless of age, immunological recall or 'back-boosting' to antigenically related strains were associated with seroconversion to the vaccine strain. Overall, both younger and older people have the ability to mount a breadth of immune responses following influenza vaccination. This report describes how imprinting exposure differs across age groups, influences antibody cross-reactivity to past hemagglutinin antigenic variants, and shapes immune responses elicited by current split inactivated influenza vaccines. Understanding how current influenza vaccines are influenced by pre-existing immunity in people of different ages is critical for designing the next-generation of 'universal' or broadly-protective influenza vaccines.
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Affiliation(s)
- Ivette A. Nuñez
- Center for Vaccines and Immunology, University of Georgia, Athens, Georgia, United States of America
| | - Michael A. Carlock
- Center for Vaccines and Immunology, University of Georgia, Athens, Georgia, United States of America
| | - James D. Allen
- Center for Vaccines and Immunology, University of Georgia, Athens, Georgia, United States of America
| | - Simon O. Owino
- Center for Vaccines and Immunology, University of Georgia, Athens, Georgia, United States of America
| | - Krissy K. Moehling
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Michael Susick
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Kensington Diagle
- Martin Health System, Clinical Research Division, Stuart, Florida, United States of America
| | - Kristen Sweeney
- Martin Health System, Clinical Research Division, Stuart, Florida, United States of America
| | - Sophia Mundle
- Sanofi Pasteur, Inc., Research North America, Cambridge, Massachusetts, United States of America
| | - Thorsten U. Vogel
- Sanofi Pasteur, Inc., Research North America, Cambridge, Massachusetts, United States of America
| | - Simon Delagrave
- Sanofi Pasteur, Inc., Research North America, Cambridge, Massachusetts, United States of America
| | - Moti Ramgopal
- Martin Health System, Clinical Research Division, Stuart, Florida, United States of America
| | - Richard K. Zimmerman
- Department of Infectious Diseases, University of Georgia, Athens, Georgia, United States of America
| | - Harry Kleanthous
- Martin Health System, Clinical Research Division, Stuart, Florida, United States of America
| | - Ted M. Ross
- Center for Vaccines and Immunology, University of Georgia, Athens, Georgia, United States of America
- Department of Infectious Diseases, University of Georgia, Athens, Georgia, United States of America
- * E-mail:
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7
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Zimmerman RK, Raviotta JM, Nowalk MP, Moehling KK, Reis EC, Humiston SG, Lin CJ. Using the 4 Pillars™ Practice Transformation Program to increase adolescent human papillomavirus, meningococcal, tetanus-diphtheria-pertussis and influenza vaccination. Vaccine 2017; 35:6180-6186. [PMID: 28947346 DOI: 10.1016/j.vaccine.2017.09.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/27/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To report the results of an intervention using the 4 Pillars™ Practice Transformation Program (4 Pillars™ Program) to increase adolescent vaccinations including human papillomavirus vaccine (HPV) and influenza vaccines, which remain underutilized in this population. STUDY DESIGN Eleven pediatric and family medicine practices, previously control sites from a randomized controlled cluster trial, with ≥50 adolescent patients participated. The 4 Pillars™ Program was the foundation of the intervention. De-identified demographic, office visit and vaccination data were derived from electronic medical record extractions for patients whose date of birth was 4/1/1997 to 4/1/2004 (ages 11-17years at baseline). Vaccination rates for HPV, influenza, tetanus-pertussis-diphtheria (Tdap) and meningococcal (MenACWY) vaccines were determined for all eligible patients pre- and post intervention (i.e., vaccination rates on 4/1/2015 and 4/30/2016). RESULTS Among 9473 patients ages 11-17years at baseline (4/1/2015), mean pre-intervention vaccination rates for HPV initiation and completion, meningococcal, Tdap and influenza vaccines were below national levels. Rates increased significantly post intervention (P<0.001) for HPV initiation which increased 17.1 percentage points (PP) from 51.4%; HPV completion increased 14.8PP from 30.7%, meningococcal vaccine uptake increased 16.6PP from 79.1%, Tdap vaccine uptake increased 14.6PP from 76.9%. Influenza vaccine uptake did not increase significantly (2.3PP from 40.1%). In the regression using generalized estimating equations, odds of vaccination were higher for younger, non-white adolescents for all vaccines; being in a smaller practice decreased the odds of Tdap vaccination but increased the odds of influenza vaccination. CONCLUSION Clinically and statistically significant improvements in HPV series initiation and completion, and meningococcal and Tdap vaccinations were observed in primary care practices implementing the 4 Pillars™ Practice Transformation Program. Clinical Trial Registry Number: NCT02165722.
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Affiliation(s)
- Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan M Raviotta
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Krissy K Moehling
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Evelyn Cohen Reis
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sharon G Humiston
- Immunization Action Coalition, Minneapolis, MN, USA; Children's Mercy Hospital, Kansas City, MO, USA
| | - Chyongchiou Jeng Lin
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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8
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Lin CJ, Martin JM, Cole KS, Zimmerman RK, Susick M, Moehling KK, Levine MZ, Spencer S, Flannery B, Nowalk MP. Are children's vitamin D levels and BMI associated with antibody titers produced in response to 2014-2015 influenza vaccine? Hum Vaccin Immunother 2017; 13:1661-1665. [PMID: 28362550 DOI: 10.1080/21645515.2017.1299837] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Vitamin D is an immunomodulating hormone, which has been associated with susceptibility to infectious diseases. METHODS Serum vitamin D levels in 135 children ages 3-17 y were measured at baseline and hemagglutinin influenza antibody titers were measured pre- and 21 d post influenza vaccination with live attenuated influenza vaccine (LAIV) or inactivated influenza vaccine (IIV). Height and weight were derived from the electronic medical record and were used to calculate body mass index (BMI). RESULTS Thirty-nine percent of children were ages 3-8 years; 75% were black, 34% were obese (BMI ≥ 95th percentile); vitamin D levels were >20 ng/ml in 55%. In linear regression analyses, post vaccination antibody titers for LAIV B lineages (B Brisbane and B Massachusetts) were significantly higher among those with lower vitamin D levels and among younger participants (P < 0.05). No associations between vitamin D levels and responses to LAIV A strains (A/H1N1 and A/H3N2) or to any IIV strains or lineages were found. CONCLUSION Low vitamin D levels were associated with higher response to LAIV B lineages in the 2014-2015 LAIV, but not related to LAIV A or any IIV strains.
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Affiliation(s)
- Chyongchiou J Lin
- a Department of Family Medicine , University of Pittsburgh , Pittsburgh , PA , USA
| | - Judith M Martin
- b Department of Pediatrics , University of Pittsburgh , Pittsburgh , PA , USA
| | - Kelly Stefano Cole
- c Department of Immunology and Center for Vaccine Research , University of Pittsburgh , Pittsburgh , PA, USA
| | - Richard K Zimmerman
- a Department of Family Medicine , University of Pittsburgh , Pittsburgh , PA , USA
| | - Michael Susick
- a Department of Family Medicine , University of Pittsburgh , Pittsburgh , PA , USA
| | - Krissy K Moehling
- a Department of Family Medicine , University of Pittsburgh , Pittsburgh , PA , USA
| | - Min Z Levine
- d Influenza Division , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Sarah Spencer
- d Influenza Division , Centers for Disease Control and Prevention , Atlanta , GA , USA.,e Atlanta Research and Education Foundation , Atlanta , GA , USA
| | - Brendan Flannery
- d Influenza Division , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Mary Patricia Nowalk
- a Department of Family Medicine , University of Pittsburgh , Pittsburgh , PA , USA
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9
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Zimmerman RK, Moehling KK, Lin CJ, Zhang S, Raviotta JM, Reis EC, Humiston SG, Nowalk MP. Improving adolescent HPV vaccination in a randomized controlled cluster trial using the 4 Pillars™ practice Transformation Program. Vaccine 2017; 35:109-117. [PMID: 27876200 PMCID: PMC5836294 DOI: 10.1016/j.vaccine.2016.11.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/08/2016] [Accepted: 11/09/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Uptake of meningococcal vaccine (MCV) and tetanus, diphtheria and pertussis (Tdap) vaccine among adolescents has approached Healthy People 2020 goals, but human papillomavirus (HPV) vaccination has not. This study evaluated an intervention using the 4 Pillars™ Practice Transformation Program to increase HPV, MCV and Tdap uptake among adolescents in primary care practices. METHODS Practices with at least 50 patients 11-17years old with estimated vaccination rates less than national goals, were assigned to intervention (n=11) and control (n=11) groups in a randomized controlled cluster trial; 9 intervention and 11 control sites completed the study. The baseline and active study periods were 7/1/2013-6/30/2014 and 7/1/2014-3/31/2015, respectively. Vaccination and demographic data for patients who had a visit in both study periods were derived from de-identified EMR extractions. Primary outcomes were vaccination rates and percentage point (PP) changes. Data were analyzed in 2015-16. RESULTS Among the cohort of 10,861 adolescent patients, 38% were 11-13years old; 50% were female; 18% were non-white; and 64% were commercially insured. Average baseline HPV initiation rates were 52.5% for intervention and 61.8% for control groups. After 9months, the intervention sites increased HPV initiation 10.2PP compared with 7.3PP in control sites (P<0.001); HPV series completion rates did not differ between groups. Implementation of >10 strategies to improve rates significantly increased the likelihood of HPV series initiation (OR=2.06, 95% CI=1.43, 2.96). CONCLUSIONS Using >10 strategies from the 4 Pillars™ Practice Transformation Program is effective for increasing HPV series initiation among adolescents. Clinical trial registry number: NCT02165722.
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Affiliation(s)
- Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Krissy K Moehling
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Chyongchiou J Lin
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Song Zhang
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jonathan M Raviotta
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Evelyn C Reis
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Sharon G Humiston
- Immunization Action Coalition, Minneapolis, MN, United States; Children's Mercy Hospital, Kansas City, MO, United States
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
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Lin CJ, Nowalk MP, Pavlik VN, Brown AE, Zhang S, Raviotta JM, Moehling KK, Hawk M, Ricci EM, Middleton DB, Patel S, South-Paul JE, Zimmerman RK. Using the 4 pillars™ practice transformation program to increase adult influenza vaccination and reduce missed opportunities in a randomized cluster trial. BMC Infect Dis 2016; 16:623. [PMID: 27809793 PMCID: PMC5094034 DOI: 10.1186/s12879-016-1940-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/18/2016] [Indexed: 11/17/2022] Open
Abstract
Background An evidence-based, step-by-step guide, the 4 Pillars™ Practice Transformation Program, was the foundation of an intervention to increase adult immunizations in primary care and was tested in a randomized controlled cluster trial. The purpose of this study is to report changes in influenza immunization rates and on factors related to receipt of influenza vaccine. Methods Twenty five primary care practices were recruited in 2013, stratified by city (Houston, Pittsburgh), location (rural, urban, suburban) and type (family medicine, internal medicine), and randomized to the intervention (n = 13) or control (n = 12) in Year 1 (2013-14). A follow-up intervention occurred in Year 2 (2014-15). Demographic and vaccination data were derived from de-identified electronic medical record extractions. Results A cohort of 70,549 adults seen in their respective practices (n = 24 with 1 drop out) at least once each year was followed. Baseline mean age was 55.1 years, 35 % were men, 21 % were non-white and 35 % were Hispanic. After one year, both intervention and control arms significantly (P < 0.001) increased influenza vaccination, with average increases of 2.7 to 6.5 percentage points. In regression analyses, likelihood of influenza vaccination was significantly higher in sites with lower percentages of patients with missed opportunities (P < 0.001) and, after adjusting for missed opportunities, the intervention further improved vaccination rates in Houston (lower baseline rates) but not Pittsburgh (higher baseline rates). In the follow-up intervention, the likelihood of vaccination increased for both intervention sites and those that reduced missed opportunities (P < 0.005). Conclusions Reducing missed opportunities across the practice increases likelihood of influenza vaccination of adults. The 4 Pillars™ Practice Transformation Program provides strategies for reducing missed opportunities to vaccinate adults. Trial registration This study was registered as a clinical trial on 03/20/2013 at ClinicalTrials.gov, Clinical Trial Registry Number: NCT01868334, with a date of enrollment of the first participant to the trial of April 1, 2013.
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Affiliation(s)
- Chyongchiou J Lin
- Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.
| | - Valory N Pavlik
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Anthony E Brown
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.,Current address: Houston Methodist Primary Care Group, Houston, TX, USA
| | - Song Zhang
- Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA
| | - Jonathan M Raviotta
- Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA
| | - Krissy K Moehling
- Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA
| | - Mary Hawk
- Department of Behavioral and Community Health Sciences (MH, EMR), University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA, 15261, USA
| | - Edmund M Ricci
- Department of Behavioral and Community Health Sciences (MH, EMR), University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA, 15261, USA
| | - Donald B Middleton
- Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA
| | - Suchita Patel
- Centers for Disease Control and Prevention (SP), Atlanta, GA, USA
| | - Jeannette E South-Paul
- Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA
| | - Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.,Department of Behavioral and Community Health Sciences (MH, EMR), University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA, 15261, USA
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11
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Zimmerman RK, Brown AE, Pavlik VN, Moehling KK, Raviotta JM, Lin CJ, Zhang S, Hawk M, Kyle S, Patel S, Ahmed F, Nowalk MP. Using the 4 Pillars Practice Transformation Program to Increase Pneumococcal Immunizations for Older Adults: A Cluster-Randomized Trial. J Am Geriatr Soc 2016; 65:114-122. [PMID: 27755655 DOI: 10.1111/jgs.14451] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To test the effectiveness of a step-by step, evidence-based guide, the 4 Pillars Practice Transformation Program, to increase adult pneumococcal vaccination. DESIGN Randomized controlled cluster trial (RCCT) in Year 1 (June 1, 2013 to May 31, 2014) and pre-post study in Year 2 (June 1, 2014 to January 31, 2015) with data analyzed in 2016. Baseline year was June 1, 2012, to May 31, 2013. Demographic and vaccination data were derived from deidentified electronic medical record extractions. SETTING Primary care practices (n = 25) stratified according to metropolitan area (Houston, Pittsburgh), location (rural, urban, suburban), and type (family medicine, internal medicine), randomized to receive the intervention in Year 1 (n = 13) or Year 2 (n = 12). PARTICIPANTS Individuals aged 65 and older at baseline (N = 18,107; mean age 74.2; 60.7% female, 16.5% non-white, 15.7% Hispanic). INTERVENTION The 4 Pillars Program, provider education, and one-on-one coaching of practice-based immunization champions. Outcome measures were 23-valent pneumococcal polysaccharide vaccine (PPSV) and pneumococcal conjugate vaccine (PCV) vaccination rates and percentage point (PP) changes in vaccination rates. RESULTS In the Year 1 RCCT, PPSV vaccination rates increased significantly in all intervention and control groups, with average increases ranging from 6.5 to 8.7 PP (P < .001). The intervention was not related to greater likelihood of PPSV vaccination. In the Year 2 pre-post study, the likelihood of PPSV and PCV vaccination was significantly higher in the active intervention sites than the maintenance sites in Pittsburgh but not in Houston. CONCLUSION In a RCCT, PPSV vaccination rates increased in the intervention and control groups in Year 1. In a pre-post study, private primary care practices actively participating in the 4 Pillars Practice Transformation Program improved PPSV and PCV uptake significantly more than practices that were in the maintenance phase of the study.
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Affiliation(s)
- Richard K Zimmerman
- Department of Family Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony E Brown
- Department of Family Medicine, Baylor College of Medicine, Houston, Texas
| | - Valory N Pavlik
- Department of Family Medicine, Baylor College of Medicine, Houston, Texas
| | - Krissy K Moehling
- Department of Family Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan M Raviotta
- Department of Family Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chyongchiou J Lin
- Department of Family Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Song Zhang
- Department of Family Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Hawk
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shakala Kyle
- Department of Family Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Suchita Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Faruque Ahmed
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary Patricia Nowalk
- Department of Family Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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12
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Lin CJ, Nowalk MP, Zimmerman RK, Moehling KK, Conti T, Allred NJ, Reis EC. Reducing Racial Disparities in Influenza Vaccination Among Children With Asthma. J Pediatr Health Care 2016; 30:208-15. [PMID: 26254743 PMCID: PMC4744151 DOI: 10.1016/j.pedhc.2015.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/12/2015] [Accepted: 06/21/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION A multifaceted intervention to raise influenza vaccination rates was tested among children with asthma. METHODS In a pre/post study design, 18 primary care practices implemented the 4 Pillars Immunization Toolkit along with other strategies. The primary outcome was the difference in influenza vaccination rates at each practice among children with asthma between the baseline year (before the intervention) and at the end of year 2 (after the intervention), both overall and by race (White vs. non-White). RESULTS Influenza vaccination rates increased significantly in 13 of 18 practices. The percentage of vaccinated non-White children increased from 46% to 61% (p < .01), and the percentage of vaccinated White children increased from 58% to 65% (p < .001). Likelihood of vaccination was significantly lower for non-White children before the intervention (odds ratio = 0.66; 95% confidence interval = 0.59-0.73; p < .001), but this difference was eliminated after the intervention (odds ratio = 0.95; 95% confidence interval = 0.85-1.05; p = .289). DISCUSSION A multi-strategy, evidence-based intervention significantly increased influenza vaccination uptake and reduced racial disparities among children with asthma.
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13
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Kaynar AM, Nowalk MP, Lin CJ, Moehling KK, Susick M, Bakalov V, Pitt BR, Bain DJ, Ross TM, Saul SG, Raymund M, Zimmerman RK. Are plasma mineral levels related to antibody response to influenza vaccination in older adults? Hum Vaccin Immunother 2016; 12:1003-8. [PMID: 26751915 DOI: 10.1080/21645515.2015.1113358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION An effective immune response to vaccination may be related to nutritional status. This study examined the association of plasma mineral levels with hemagglutination inhibition (HI) titers produced in response to influenza vaccine in older adults. METHODS Prior to (Day 0) and 21 (range = 19-28) days after receiving the 2013-14 influenza vaccine, 109 adults ages 51-81 years, provided blood samples. Serum samples were tested for HI activity against the A/H1N1 and A/H3N2 2013-2014 vaccine virus strains. Plasma minerals were collected in zinc-free tubes and assayed by inductively coupled plasma mass spectrometry. HI titers were reported as seroprotection (≥1:40) and seroconversion (≥ 4-fold rise from Day 0 (minimum HI = 1:10) to Day 21). Both HI titers and mineral values were skewed and thus log2 transformed. Magnesium (Mg), phosphorus (P), zinc (Zn), copper (Cu), iron (Fe), potassium (K) and the Cu to Zn ratio were tested. Logistic regression analyses were used to determine the associations between mineral levels and seroconversion and seroprotection of HI titers for each influenza A strain. RESULTS Participants were 61% white, 28% male, 39% diabetic, and 81% overweight/obese with a mean age of 62.6 y. In logistic regression, Day 21 A/H1N1 seroprotection was associated with P and Zn at Day 21(P < 0.05). Seroconversion of A/H1N1 was associated with Day 21 Cu, P, and Mg (P < 0.03). Day 21 A/H3N2 seroprotection and seroconversion were associated with Day 21 P (P < 0.05). CONCLUSIONS Phosphorus was associated with seroprotection and seroconversion to influenza A after vaccination; these associations warrant additional studies with larger, more diverse population groups.
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Affiliation(s)
- Ata Murat Kaynar
- a Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, Department of Critical Care Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA.,b Department of Environmental and Occupational Health , University of Pittsburgh Graduate School of Public Health , Pittsburgh , PA , USA
| | - Mary Patricia Nowalk
- c Department of Family Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Chyongchiou Jeng Lin
- c Department of Family Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Krissy K Moehling
- c Department of Family Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Michael Susick
- c Department of Family Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Veli Bakalov
- d Department of Critical Care Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Bruce R Pitt
- d Department of Critical Care Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Daniel J Bain
- e Department of Geology and Environmental Science , University of Pittsburgh , Pittsburgh , PA , USA
| | - Ted M Ross
- f Vaccine and Gene Therapy Institute of Florida , Port St. Lucie , FL , USA
| | - Sean G Saul
- c Department of Family Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Mahlon Raymund
- c Department of Family Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Richard K Zimmerman
- c Department of Family Medicine , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
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14
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Nowalk MP, Zimmerman RK, Lin CJ, Reis EC, Huang HH, Moehling KK, Hannibal KM, Matambanadzo A, Shenouda EM, Allred NJ. Maintenance of Increased Childhood Influenza Vaccination Rates 1 Year After an Intervention in Primary Care Practices. Acad Pediatr 2016; 16:57-63. [PMID: 26767508 PMCID: PMC8311666 DOI: 10.1016/j.acap.2015.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Influenza vaccination rates among some groups of children remain below the Healthy People 2020 goal of 70%. Multistrategy interventions to increase childhood influenza vaccination have not been evaluated recently. METHODS Twenty pediatric and family medicine practices were randomly assigned to receive the intervention in either year 1 or year 2. This study focuses on influenza vaccine uptake in the 10 year 1 intervention sites during intervention and the following maintenance year. The intervention included the 4 Pillars Immunization Toolkit-a practice improvement toolkit, early delivery of donated vaccine for disadvantaged children, staff education, and feedback on progress. During the maintenance year, practices were not assisted or contacted, except to complete follow-up surveys. Student's t tests assessed vaccine uptake of children aged 6 months to 18 years, and multilevel regression modeling in repeated measures determined variables related to the likelihood of vaccination. RESULTS Influenza vaccine uptake increased 12.4 percentage points (PP; P < .01) during active intervention and uptake was sustained (+0.4 PP; P > .05) during maintenance, for an average change of 12.7 PP over all sites, increasing from 42.2% at baseline to 54.9% (P < .001) during maintenance. In regression modeling that controlled for age, race, and insurance, likelihood of vaccination was greater during intervention than baseline (odds ratio 1.47; 95% confidence interval 1.44-1.50; P < .001) and greater during maintenance than baseline (odds ratio 1.50; 95% confidence interval 1.47-1.54; P < .001). CONCLUSIONS In primary care practices, a multistrategy intervention that included the 4 Pillars Immunization Toolkit, early delivery of vaccine, and feedback was associated with significant improvements in childhood influenza vaccination rates that were maintained 1 year after active intervention.
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Affiliation(s)
- Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
| | - Richard K. Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Chyongchiou Jeng Lin
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Evelyn Cohen Reis
- Department of Pediatrics, University of Pittsburgh School of Medicine, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Hsin-Hui Huang
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Krissy K. Moehling
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Kristin M. Hannibal
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Annamore Matambanadzo
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | | | - Norma J. Allred
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
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15
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Zimmerman RK, Rinaldo CR, Nowalk MP, Balasubramani GK, Moehling KK, Bullotta A, Eng HF, Raviotta JM, Sax TM, Wisniewski S. Viral infections in outpatients with medically attended acute respiratory illness during the 2012-2013 influenza season. BMC Infect Dis 2015; 15:87. [PMID: 25887948 PMCID: PMC4344779 DOI: 10.1186/s12879-015-0806-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/04/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While it is known that acute respiratory illness (ARI) is caused by an array of viruses, less is known about co-detections and the resultant comparative symptoms and illness burden. This study examined the co-detections, the distribution of viruses, symptoms, and illness burden associated with ARI between December 2012 and March 2013. METHODS Outpatients with ARI were assayed for presence of 18 viruses using multiplex reverse transcriptase polymerase chain reaction (MRT-PCR) to simultaneously detect multiple viruses. RESULTS Among 935 patients, 60% tested positive for a single virus, 9% tested positive for ≥1 virus and 287 (31%) tested negative. Among children (<18 years), the respective distributions were 63%, 14%, and 23%; whereas for younger adults (18-49 years), the distributions were 58%, 8%, and 34% and for older adults (≥50 years) the distributions were 61%, 5%, and 32% (P < 0.001). Co-detections were more common in children than older adults (P = 0.01), and less frequent in households without children (P = 0.003). Most frequently co-detected viruses were coronavirus, respiratory syncytial virus, and influenza A virus. Compared with single viral infections, those with co-detections less frequently reported sore throat (P = 0.01), missed fewer days of school (1.1 vs. 2 days; P = 0.04), or work (2 vs. 3 days; P = 0.03); other measures of illness severity did not vary. CONCLUSIONS Among outpatients with ARI, 69% of visits were associated with a viral etiology. Co-detections of specific clusters of viruses were observed in 9% of ARI cases particularly in children, were less frequent in households without children, and were less symptomatic (e.g., lower fever) than single infections.
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Affiliation(s)
- Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Charles R Rinaldo
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Departments of Infectious Disease and Microbiology, and Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - G K Balasubramani
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Krissy K Moehling
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Arlene Bullotta
- Departments of Infectious Disease and Microbiology, and Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Heather F Eng
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Jonathan M Raviotta
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Theresa M Sax
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Stephen Wisniewski
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
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Baker NA, Moehling KK, Park SY. The effect of an alternative keyboard on musculoskeletal discomfort: A randomized cross-over trial. Work 2015; 50:677-86. [DOI: 10.3233/wor-131797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nancy A. Baker
- Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Krissy K. Moehling
- Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Seo Young Park
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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17
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Nowalk MP, Lin CJ, Hannibal K, Reis EC, Gallik G, Moehling KK, Huang HH, Allred NJ, Wolfson DH, Zimmerman RK. Increasing childhood influenza vaccination: a cluster randomized trial. Am J Prev Med 2014; 47:435-43. [PMID: 25113138 PMCID: PMC4208625 DOI: 10.1016/j.amepre.2014.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 05/13/2014] [Accepted: 07/03/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Since the 2008 inception of universal childhood influenza vaccination, national rates have risen more dramatically among younger children than older children and reported rates across racial/ethnic groups are inconsistent. Interventions may be needed to address age and racial disparities to achieve the recommended childhood influenza vaccination target of 70%. PURPOSE To evaluate an intervention to increase childhood influenza vaccination across age and racial groups. METHODS In 2011-2012, a total of 20 primary care practices treating children were randomly assigned to the intervention and control arms of a cluster randomized controlled trial to increase childhood influenza vaccination uptake using a toolkit and other strategies including early delivery of donated vaccine, in-service staff meetings, and publicity. RESULTS The average vaccination differences from pre-intervention to the intervention year were significantly larger in the intervention arm (n=10 practices) than the control arm (n=10 practices); for children aged 9-18 years (11.1 pct pts intervention vs 4.3 pct pts control, p<0.05); for non-white children (16.7 pct pts intervention vs 4.6 pct pts control, p<0.001); and overall (9.9 pct pts intervention vs 4.2 pct pts control, p<0.01). In multi-level modeling that accounted for person- and practice-level variables and the interactions among age, race, and intervention, the likelihood of vaccination increased with younger age group (6-23 months); white race; commercial insurance; the practice's pre-intervention vaccination rate; and being in the intervention arm. Estimates of the interaction terms indicated that the intervention increased the likelihood of vaccination for non-white children in all age groups and white children aged 9-18 years. CONCLUSIONS A multi-strategy intervention that includes a practice improvement toolkit can significantly improve influenza vaccination uptake across age and racial groups without targeting specific groups, especially in practices with large percentages of minority children.
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Affiliation(s)
| | | | | | | | - Gregory Gallik
- University of Pittsburgh School of Medicine Shadyside Family Health Center, Pittsburgh, Pennsylvania
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Havers F, Thaker S, Clippard JR, Jackson M, McLean HQ, Gaglani M, Monto AS, Zimmerman RK, Jackson L, Petrie JG, Nowalk MP, Moehling KK, Flannery B, Thompson MG, Fry AM. Use of influenza antiviral agents by ambulatory care clinicians during the 2012-2013 influenza season. Clin Infect Dis 2014; 59:774-82. [PMID: 25034419 DOI: 10.1093/cid/ciu422] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Early antiviral treatment (≤2 days since illness onset) of influenza reduces the probability of influenza-associated complications. Early empiric antiviral treatment is recommended for those with suspected influenza at higher risk for influenza complications regardless of their illness severity. We describe antiviral receipt among outpatients with acute respiratory illness (ARI) and antibiotic receipt among patients with influenza. METHODS We analyzed data from 5 sites in the US Influenza Vaccine Effectiveness Network Study during the 2012-2013 influenza season. Subjects were outpatients aged ≥6 months with ARI defined by cough of ≤7 days' duration; all were tested for influenza by polymerase chain reaction (PCR). Medical history and prescription information were collected by medical and pharmacy records. Four sites collected prescribing data on 3 common antibiotics (amoxicillin-clavulanate, amoxicillin, and azithromycin). RESULTS Of 6766 enrolled ARI patients, 509 (7.5%) received an antiviral prescription. Overall, 2366 (35%) had PCR-confirmed influenza; 355 (15%) of those received an antiviral prescription. Among 1021 ARI patients at high risk for influenza complications (eg, aged <2 years or ≥65 years or with ≥1 chronic medical condition) presenting to care ≤2 days from symptom onset, 195 (19%) were prescribed an antiviral medication. Among participants with PCR-confirmed influenza and antibiotic data, 540 of 1825 (30%) were prescribed 1 of 3 antibiotics; 297 of 1825 (16%) were prescribed antiviral medications. CONCLUSIONS Antiviral treatment was prescribed infrequently among outpatients with influenza for whom therapy would be most beneficial; in contrast, antibiotic prescribing was more frequent. Continued efforts to educate clinicians on appropriate antibiotic and antiviral use are essential to improve healthcare quality.
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Affiliation(s)
- Fiona Havers
- Epidemic Intelligence Service assigned to the Influenza Division
| | - Swathi Thaker
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jessie R Clippard
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Manjusha Gaglani
- Baylor Scott & White Health, Texas A&M University Health Science Center College of Medicine, Temple, Texas
| | - Arnold S Monto
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | | | - Lisa Jackson
- Group Health Research Institute, Seattle, Washington
| | - Josh G Petrie
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | | | - Krissy K Moehling
- Department of Family Medicine, University of Pittsburgh, Pennsylvania
| | - Brendan Flannery
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mark G Thompson
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alicia M Fry
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
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19
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Zimmerman RK, Rinaldo CR, Nowalk MP, Gk B, Thompson MG, Moehling KK, Bullotta A, Wisniewski S. Influenza and other respiratory virus infections in outpatients with medically attended acute respiratory infection during the 2011-12 influenza season. Influenza Other Respir Viruses 2014; 8:397-405. [PMID: 24852890 PMCID: PMC4057994 DOI: 10.1111/irv.12247] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2014] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Respiratory tract infections are a major cause of outpatient visits, yet only a portion is tested to determine the etiologic organism. Multiplex reverse transcriptase polymerase chain reaction (MRT-PCR) assays for detection of multiple viruses are being used increasingly in clinical settings. METHODS During January-April 2012, outpatients with acute respiratory illness (≤ 7 days) were tested for influenza using singleplex RT-PCR (SRT-PCR). A subset was assayed for 18 viruses using MRT-PCR to compare detection of influenza and examine the distribution of viruses and characteristics of patients using multinomial logistic regression. RESULTS Among 662 participants (6 months-82 years), detection of influenza was similar between the MRT-PCR and SRT-PCR (κ = 0.83). No virus was identified in 267 (40.3%) samples. Commonly detected viruses were human rhinovirus (HRV, 15.4%), coronavirus (CoV, 10.4%), respiratory syncytial virus (RSV, 8.4%), human metapneumovirus (hMPV, 8.3%), and influenza (6%). Co-detections were infrequent (6.9%) and most commonly occurred among those <18 years old. In regression analyses, compared with non-viral illnesses, RSV and hMPV were significantly more frequent in children and less frequent in 18- to 49-year-olds than in those ≥ 50 years (P = 0.01), fever was more common in hMPV and influenza infections (P = 0.008), nasal congestion was more frequent in CoV, HRV, hMPV, influenza and RSV infections (P = 0.001), and body mass index was higher among those with influenza (P = 0.036). CONCLUSIONS Using MRT-PCR, a viral etiology was found in three-fifths of patients with medically attended outpatient visits for acute respiratory illness during the influenza season; co-detected viruses were infrequent. Symptoms varied by viral etiology.
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Affiliation(s)
- Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Zimmerman RK, Nowalk MP, Lin CJ, Hannibal K, Moehling KK, Huang HH, Matambanadzo A, Troy J, Allred NJ, Gallik G, Reis EC. Cluster randomized trial of a toolkit and early vaccine delivery to improve childhood influenza vaccination rates in primary care. Vaccine 2014; 32:3656-63. [PMID: 24793941 DOI: 10.1016/j.vaccine.2014.04.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/11/2014] [Accepted: 04/17/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE To increase childhood influenza vaccination rates using a toolkit and early vaccine delivery in a randomized cluster trial. METHODS Twenty primary care practices treating children (range for n=536-8183) were randomly assigned to Intervention and Control arms to test the effectiveness of an evidence-based practice improvement toolkit (4 Pillars Toolkit) and early vaccine supplies for use among disadvantaged children on influenza vaccination rates among children 6 months-18 years. Follow-up staff meetings and surveys were used to assess use and acceptability of the intervention strategies in the Intervention arm. Rates for the 2010-2011 and 2011-2012 influenza seasons were compared. Two-level generalized linear mixed modeling was used to evaluate outcomes. RESULTS Overall increases in influenza vaccination rates were significantly greater in the Intervention arm (7.9 percentage points) compared with the Control arm (4.4 percentage points; P<0.034). These rate changes represent 4522 additional doses in the Intervention arm vs. 1390 additional doses in the Control arm. This effect of the intervention was observed despite the fact that rates increased significantly in both arms - 8/10 Intervention (all P<0.001) and 7/10 Control sites (P-values=0.04 to <0.001). Rates in two Intervention sites with pre-intervention vaccination rates >58% did not significantly increase. In regression analyses, a child's likelihood of being vaccinated was significantly higher with: younger age, white race (Odds ratio [OR]=1.29; 95% confidence interval [CI]=1.23-1.34), having commercial insurance (OR=1.30; 95%CI=1.25-1.35), higher pre-intervention practice vaccination rate (OR=1.25; 95%CI=1.16-1.34), and being in the Intervention arm (OR=1.23; 95%CI=1.01-1.50). Early delivery of influenza vaccine was rated by Intervention practices as an effective strategy for raising rates. CONCLUSIONS Implementation of a multi-strategy toolkit and early vaccine supplies can significantly improve influenza vaccination rates among children in primary care practices but the effect may be less pronounced in practices with moderate to high existing vaccination rates. Clinical trial registry name/number: From Innovation to Solutions: Childhood Influenza/NCT01664793.
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Affiliation(s)
- Richard K Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
| | - Chyongchiou Jeng Lin
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kristin Hannibal
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Krissy K Moehling
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Hsin-Hui Huang
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Annamore Matambanadzo
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Judith Troy
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Norma J Allred
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Greg Gallik
- Shadyside Family Health Center, Pittsburgh, PA, United States
| | - Evelyn C Reis
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Baker NA, Moehling KK, Desai AR, Gustafson NP. Effect of carpal tunnel syndrome on grip and pinch strength compared with sex- and age-matched normative data. Arthritis Care Res (Hoboken) 2014; 65:2041-5. [PMID: 23925936 DOI: 10.1002/acr.22089] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 07/15/2013] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To compare grip and pinch strength of individuals with carpal tunnel syndrome (CTS) to normative values before and after a combined splint/stretching intervention. METHODS Data collected on grip and pinch strength on 124 subjects with CTS were compared to age- and sex-matched normative data. RESULTS In general, our sample had significantly lower strength than the normative sample at baseline. Although there were significant improvements in strength after 4 weeks of splinting/exercise, subjects continued to have significant deficits in comparison to the normative data. CONCLUSION Patients with CTS have moderate to large deficits in grip and pinch strength in comparison to normative data. Splinting/stretching may reduce these deficits; however, CTS patients are often left with residual problems at 4 weeks.
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Baker NA, Moehling KK, Rubinstein EN, Wollstein R, Gustafson NP, Baratz M. The Comparative Effectiveness of Combined Lumbrical Muscle Splints and Stretches on Symptoms and Function in Carpal Tunnel Syndrome. Arch Phys Med Rehabil 2012; 93:1-10. [DOI: 10.1016/j.apmr.2011.08.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 08/01/2011] [Accepted: 08/07/2011] [Indexed: 12/21/2022]
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