Richard K Zimmerman

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (227)757.59 Total impact

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    ABSTRACT: Background: Influenza causes significant morbidity and mortality with considerable economic costs, including lost work productivity. Influenza vaccines may reduce the economic burden through primary prevention of influenza and reduction in illness severity. Methods: We examined illness severity and work productivity loss among working adults with medically-attended acute respiratory illnesses, and compared outcomes for patients with and without laboratory-confirmed influenza, and by influenza vaccination status among patients with influenza during the 2012-2013 influenza season. Results: Illnesses laboratory-confirmed as influenza (i.e. Cases) were subjectively assessed as more severe than illnesses not caused by influenza (i.e. Non-Cases) based on multiple measures, including current health status at study enrollment (<7 days from illness onset), and current activity and sleep quality status relative to usual. Influenza Cases reported missing 45% more work hours (20.5 vs. 15.0, P<.001) than Non-Cases, and subjectively assessed their work productivity as impeded to a greater degree (6.0 vs. 5.4, P<.001). Current health status and current activity relative to usual were subjectively assessed as modestly, but significantly, better for vaccinated influenza Cases compared with unvaccinated Cases; however, no significant modifications of sleep quality, missed work hours, or work productivity loss were noted for vaccinated subjects. Conclusions: . Influenza illnesses were more severe and resulted in more missed work hours and productivity loss than illnesses not confirmed as influenza. Modest reductions in illness severity for vaccinated influenza cases were observed. These findings highlight the burden of influenza illnesses and illustrate the importance of laboratory-confirmation of influenza outcomes in evaluations of vaccine effectiveness.
    Clinical Infectious Diseases 11/2015; DOI:10.1093/cid/civ952 · 8.89 Impact Factor

  • 37th Annual Meeting of the Society for Medical Decision Making, St. Louis, MO; 10/2015
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    ABSTRACT: We estimated the burden of outpatient influenza and cases prevented by vaccination during the 2011/2012 and 2012/2013 influenza seasons using data from the United States Influenza Vaccine Effectiveness (US Flu VE) Network. We defined source populations of persons who could seek care for acute respiratory illness (ARI) at each of the five US Flu VE Network sites. We identified all members of the source population who were tested for influenza during US Flu VE influenza surveillance. Each influenza-positive subject received a sampling weight based on the proportion of source population members who were tested for influenza, stratified by site, age, and other factors. We used the sampling weights to estimate the cumulative incidence of medically attended influenza in the source populations. We estimated cases averted by vaccination using estimates of cumulative incidence, vaccine coverage, and vaccine effectiveness. Cumulative incidence of medically attended influenza ranged from 0.8% to 2.8% across sites during 2011/2012 and from 2.6% to 6.5% during the 2012/2013 season. Stratified by age, incidence ranged from 1.2% among adults 50 years of age and older in 2011/2012 to 10.9% among children 6 months to 8 years of age in 2012/2013. Cases averted by vaccination ranged from 4 to 41 per 1000 vaccinees, depending on the study site and year. The incidence of medically attended influenza varies greatly by year and even by geographic region within the same year. The number of cases averted by vaccination varies greatly based on overall incidence and on vaccine coverage. Copyright © 2015. Published by Elsevier Ltd.
    Vaccine 08/2015; 33(39). DOI:10.1016/j.vaccine.2015.07.098 · 3.62 Impact Factor
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    ABSTRACT: A multifaceted intervention to raise influenza vaccination rates was tested among children with asthma. 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). 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). A multi-strategy, evidence-based intervention significantly increased influenza vaccination uptake and reduced racial disparities among children with asthma. Copyright © 2015 National Association of Pediatric Nurse Practitioners. All rights reserved.
    Journal of Pediatric Health Care 08/2015; DOI:10.1016/j.pedhc.2015.06.006 · 1.44 Impact Factor
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    ABSTRACT: In addition to its well-known effects on bone metabolism, vitamin D is an immunomodulating hormone. Serum vitamin D levels in males 18-25 years were measured at baseline, and HPV antibody titers were measured one month following the third quadrivalent HPV vaccine dose. Vitamin D levels were >30 ng/ml (normal) in 60 males and <30 ng/ml (low) in 113 males. Reverse cumulative distribution curves and scatter plots showed higher antibody titers with low vitamin D for all vaccine strains (P<0.05). In linear regression analyses, antibody titers for all HPV strains were significantly higher among those with lower vitamin D levels and among younger participants (P<0.05). These relationships add to the body of knowledge of the complex role of vitamin D in immunoregulation.
    Human Vaccines & Immunotherapeutics 07/2015; DOI:10.1080/21645515.2015.1062955 · 2.37 Impact Factor
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    ABSTRACT: To determine the effects of symptoms and presence of confirmed influenza on intention to receive an influenza vaccine, specifically in patients recovering from a medically-attended acute (≤ 7 days' duration) respiratory illness (ARI). During the 2013-14 influenza season individuals seeking outpatient care for an ARI that included cough were tested for influenza using reverse transcription polymerase chain reaction assays (PCR) and completed surveys. Children (6 months-18 years) and adults (≥ 18 years) were grouped by their combined current season's influenza vaccination status (vaccinated/not vaccinated) and their vaccination intentions for next season (intend/do not intend). Overall, 41% (323/786) were unvaccinated at enrollment; of those, nearly half (151/323) intended to be vaccinated next season. When adjusting for demographic, health, and other factors, unvaccinated individuals who intended to be vaccinated next season were approximately 1.5 times more likely to have PCR-confirmed influenza compared with vaccinated individuals who intended to be vaccinated next season. The combined experience of not being vaccinated against influenza and seeking medical attention for an ARI seemed to influence approximately one-half of unvaccinated participants to consider influenza vaccination for next season.
    American journal of health behavior 07/2015; 39(4). DOI:10.5993/AJHB.39.4.14 · 1.31 Impact Factor
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    ABSTRACT: During the 2013-14 influenza season, we analyzed data from 6,004 outpatients aged ≥6 months with acute respiratory illness (ARI). Among the 2,786 ARI patients at higher risk for influenza complications, 835 (30%) presented to care ≤2 days from symptom onset; among those, 126 (15%) were prescribed an antiviral medication. Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.
    Clinical Infectious Diseases 02/2015; 60(11). DOI:10.1093/cid/civ146 · 8.89 Impact Factor
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    ABSTRACT: In the United States, annual vaccination against seasonal influenza is recommended for all persons aged ≥6 months. Each season since 2004-05, CDC has estimated the effectiveness of seasonal influenza vaccine in preventing medically attended acute respiratory illness (ARI) associated with laboratory-confirmed influenza. This season, early estimates of influenza vaccine effectiveness are possible because of widespread, early circulation of influenza viruses. By January 3, 2015, 46 states were experiencing widespread flu activity, with predominance of influenza A (H3N2) viruses. This report presents an initial estimate of seasonal influenza vaccine effectiveness at preventing laboratory-confirmed influenza virus infection associated with medically attended ARI based on data from 2,321 children and adults enrolled in the U.S. Influenza Vaccine Effectiveness Network (Flu VE) during November 10, 2014-January 2, 2015. During this period, overall vaccine effectiveness (VE) (adjusted for study site, age, sex, race/ethnicity, self-rated health, and days from illness onset to enrollment) against laboratory-confirmed influenza associated with medically attended ARI was 23% (95% confidence interval [CI] = 8%-36%). Most influenza infections were due to A (H3N2) viruses. This interim VE estimate is relatively low compared with previous seasons when circulating viruses and vaccine viruses were well-matched and likely reflects the fact that more than two-thirds of circulating A (H3N2) viruses are antigenically and genetically different (drifted) from the A (H3N2) vaccine component of 2014-15 Northern Hemisphere seasonal influenza vaccines. These early, low VE estimates underscore the need for ongoing influenza prevention and treatment measures. CDC continues to recommend influenza vaccination because the vaccine can still prevent some infections with the currently circulating A (H3N2) viruses as well as other viruses that might circulate later in the season, including influenza B viruses. Even when VE is reduced, vaccination still prevents some illness and serious influenza-related complications, including thousands of hospitalizations and deaths. Persons aged ≥6 months who have not yet been vaccinated this season should be vaccinated, including persons who might already have been ill with influenza this season.
    MMWR. Morbidity and mortality weekly report 01/2015; 64(1):10-5.
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    ABSTRACT: Influenza vaccination is administered throughout the influenza disease season, even as late as March. Given such timing, what is the value of vaccinating the population earlier than currently being practiced? We used real data on when individuals were vaccinated in Allegheny County, Pennsylvania, and the following 2 models to determine the value of vaccinating individuals earlier (by the end of September, October, and November): Framework for Reconstructing Epidemiological Dynamics (FRED), an agent-based model (ABM), and FluEcon, our influenza economic model that translates cases from the ABM to outcomes and costs [health care and lost productivity costs and quality-adjusted life-years (QALYs)]. We varied the reproductive number (R0) from 1.2 to 1.6. Applying the current timing of vaccinations averted 223,761 influenza cases, $16.3 million in direct health care costs, $50.0 million in productivity losses, and 804 in QALYs, compared with no vaccination (February peak, R0 1.2). When the population does not have preexisting immunity and the influenza season peaks in February (R0 1.2-1.6), moving individuals who currently received the vaccine after September to the end of September could avert an additional 9634-17,794 influenza cases, $0.6-$1.4 million in direct costs, $2.1-$4.0 million in productivity losses, and 35-64 QALYs. Moving the vaccination of just children to September (R0 1.2-1.6) averted 11,366-1660 influenza cases, $0.6-$0.03 million in direct costs, $2.3-$0.2 million in productivity losses, and 42-8 QALYs. Moving the season peak to December increased these benefits, whereas increasing preexisting immunity reduced these benefits. Even though many people are vaccinated well after September/October, they likely are still vaccinated early enough to provide substantial cost-savings.
    Medical Care 01/2015; 53(3). DOI:10.1097/MLR.0000000000000302 · 3.23 Impact Factor
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    ABSTRACT: Background. Despite vaccination, residents of long-term-care facilities (LTCFs) remain at high risk of influenza-related morbidity and mortality. More-effective vaccine options for this population are needed. Methods. We conducted a single-blinded, randomized, controlled trial comparing high-dose (HD) to standard-dose (SD) inactivated influenza vaccine (IIV) in 205 frail, elderly residents of LTCFs during the 2011-2012 and 2012-2013 influenza seasons. Hemagglutination inhibition (HI) antibody titers were measured at baseline and 30 and 180 days following vaccination. Results. A total of 187 subjects (91%) completed the study. The mean age was 86.7 years. Geometric mean titers (GMTs) were significantly higher (P < .05) at day 30 for HD recipients, compared with SD recipients, for all comparisons except influenza A(H1N1) during 2012-2013 (the HD formulation was noninferior to the SD formulation for influenza A[H1N1] during 2012-2013). GMTs for HD and SD recipients during 2011-2012 were as follows: influenza A(H1N1), 78 (95% confidence interval [CI], 45-136) and 27 (95% CI, 17-44), respectively; influenza A(H3N2), 26 (95% CI, 17-40) and 10 (95% CI, 7-15), respectively; and influenza B, 26 (95% CI, 19-35) and 14 (95% CI, 11-18), respectively. During 2012-2013, GMTs for HD and SD recipients were as follows: influenza A(H1N1), 46 (95% CI, 33-63) and 50 (95% CI, 37-67); influenza A(H3N2), 23 (95% CI, 18-31) and 14 (95% CI, 11-18), respectively; and influenza B, 26 (95% CI, 21-32) and 17 (95% CI, 14-22), respectively. GMTs were significantly higher at day 180 for HD recipients, compared with SD recipients, for influenza A(H3N2) in both years (P < .001). Conclusions. Among frail, elderly residents of LTCFs, HD influenza vaccine produced superior responses for all strains except influenza A(H1N1) in 2012-2013. Clinical Trials Registration. NCT01654224.
    The Journal of Infectious Diseases 12/2014; 211(12). DOI:10.1093/infdis/jiu622 · 6.00 Impact Factor
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    ABSTRACT: Rapid, accurate, and cost-effective methods to identify the cause of respiratory tract infections are needed to maximize clinical benefit. Outpatients with acute respiratory illness were tested for influenza using a singleplex reverse transcriptase polymerase chain reaction (SRT-PCR) method. A multiplex RT-PCR (MRT-PCR) method tested for influenza and 17 other viruses and was compared with SRT-PCR using chi-square tests. Among 935 patients, 335 (36%) tested positive for influenza A and influenza B using SRT-PCR. Using MRT-PCR, 320 (34.2%) tested positive for influenza A and influenza B. This study supports MRT-PCR as a comparable method for detecting influenza among patients seeking outpatient care for acute respiratory illnesses.
    Advances in Virology 12/2014; 2014:274679. DOI:10.1155/2014/274679
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    ABSTRACT: Background: During the 2012-2013 influenza season, there was cocirculation of influenza A(H3N2) and 2 influenza B lineage viruses in the United States. Methods: Patients with acute cough illness for ≤7 days were prospectively enrolled and had swab samples obtained at outpatient clinics in 5 states. Influenza vaccination dates were confirmed by medical records. The vaccine effectiveness (VE) was estimated as [100% × (1 - adjusted odds ratio)] for vaccination in cases versus test-negative controls. Results: Influenza was detected in 2307 of 6452 patients (36%); 1292 (56%) had influenza A(H3N2), 582 (25%) had influenza B/Yamagata, and 303 (13%) had influenza B/Victoria. VE was 49% (95% confidence interval [CI], 43%-55%) overall, 39% (95% CI, 29%-47%) against influenza A(H3N2), 66% (95% CI, 58%-73%) against influenza B/Yamagata (vaccine lineage), and 51% (95% CI, 36%-63%) against influenza B/Victoria. VE against influenza A(H3N2) was highest among persons aged 50-64 years (52%; 95% CI, 33%-65%) and persons aged 6 months-8 years (51%; 95% CI, 32%-64%) and lowest among persons aged ≥65 years (11%; 95% CI, -41% to 43%). In younger age groups, there was evidence of residual protection from receipt of the 2011-2012 vaccine 1 year earlier. Conclusions: The 2012-2013 vaccines were moderately effective in most age groups. Cross-lineage protection and residual effects from prior vaccination were observed and warrant further investigation.
    The Journal of Infectious Diseases 11/2014; 211(10). DOI:10.1093/infdis/jiu647 · 6.00 Impact Factor
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    ABSTRACT: College-age men were recruited using Facebook™ advertisements (ads), as well as traditional recruitment methods, for a randomized controlled trial to compare immunological responses to human papillomavirus vaccine administered in two dosing schedules. This study compares enrollees who were recruited through traditional recruitment methods versus social networking sites (SNSs), including Facebook. Potential participants were recruited using flyers posted on and off campus(es), and distributed at health fairs, classes, sporting, and other campus events; e-mails to students and student organizations; and print advertisements in student newspapers and on city buses. Facebook ads were displayed to users with specific age, geographic, and interest characteristics; ads were monitored daily to make adjustments to improve response. A total of 220 males, aged 18 to 25 years enrolled between October 2010 and May 2011. The majority of participants (51%) reported print advertisements as the method by which they first heard about the study, followed by personal contact (29%) and Facebook or other SNSs (20%). The likelihood of a SNS being the source by which the participant first heard about the study compared with traditional methods was increased if the participant reported (a) being homosexual or bisexual or (b) posting daily updates on SNSs. Facebook and other SNSs are a viable recruitment strategy for reaching potential clinical trial participants among groups who typically use social media to stay connected with their friends and hard-to-reach groups such as young men who self-identify as homosexual or bisexual.
    American journal of men's health 11/2014; DOI:10.1177/1557988314557563 · 1.15 Impact Factor
  • Richard K Zimmerman ·

    Vaccine 11/2014; 32(52):7040-7042. DOI:10.1016/j.vaccine.2014.10.028 · 3.62 Impact Factor
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    ABSTRACT: Background: Randomized trials indicate superior effectiveness of live attenuated influenza vaccine (LAIV) compared to inactivated influenza vaccines (IIV) in children aged 2 -6 years. We compared relative effectiveness of LAIV versus IIV in preventing medically attended influenza illness in children 2–18 years enrolled in an observational study of influenza vaccine effectiveness (VE) over two seasons. Methods: We analyzed data from 1468 children aged 2-18 years, considered fully vaccinated with either LAIV or IIV, who presented for treatment of acute respiratory illnesses (ARI) during the 2011-12 or 2012-13 influenza seasons. Specimens from participants were tested for influenza infection by real-time reverse-transcription PCR. Relative VE was calculated by comparing LAIV versus IIV receipt in those patients who tested positive for influenza and those who tested negative and calculated as 100 x (1- adjusted odds ratio) in logistic regression models adjusted for age, race/ethnicity, sex, subjective health status, presence of high risk conditions, enrollment site, interval from illness onset to enrollment (days), and week of enrollment. Results: 576 fully vaccinated children aged 2-18 years were enrolled during medically attended ARI episodes in 2011-12 and 892 in 2012-13. In 2011-12, among 72 (13%) children with laboratory-confirmed influenza, 12 (17%) had received LAIV and 60 (83%) IIV; among 504 influenza test-negative children, 100 (20%) had received LAIV and 404 (80%) IIV. Relative effectiveness of LAIV vs. IIV in 2011-12 was 4% (95% CI, -106, 55). In 2012-13, among 289 (32%) children with laboratory confirmed influenza, 65 (22%) had received LAIV and 224 (78%) IIV; among 603 influenza test-negative children, 148 (25%) had received LAIV and 455 (75%) IIV. Relative effectiveness in 2012-13 was 4% (95% CI, -40, 34). In children aged 2–8 years, relative effectiveness of LAIV vs. IIV was 43% (95% CI: -80, 82) in 2011-12 and 35% (95% CI -8, 61) in 2012-13. In children aged 9–18 years, relative effectiveness of LAIV vs. IIV was -16% (95% CI, -277, 64) in 2011-12 and -21%, (95% CI, -134, 38) in 2012-13. Conclusion: We observed nonsignificant results that did not indicate a difference in effectiveness of LAIV compared to IIV in preventing medically attended influenza illness in children and adolescents.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: We compared antibody responses to influenza vaccine in adults ≥50 years old in two consecutive seasons. In 2011-12, all participants received trivalent inactivated influenza vaccine (IIV3). In 2012-13, those age 50-64 received intradermal (ID) and those age ≥65 received high-dose vaccine (HD). In 2012-13, the WHO-recommended vaccine strains were modified for H3N2 and B. Methods: Participants were recruited in 2011 and vaccinated in the fall of 2011 and 2012. In both years, pre- and post (21-28 days)-vaccination sera were tested for antibody response to vaccine [measured by hemagglutination inhibition (HI) titer]. We compared geometric mean titers (GMT) and titer fold rise from pre- to post-vaccination in 2012, among 2011-12 responders (≥4-fold rise in HI titer from pre-to post-vaccination) and 2011-12 non-responders (<4-fold rise in HI titer) to the corresponding vaccine strain. Results: 183 adults received IIV3 in 2011 and either HD (N = 82) or ID (N = 101) in 2012. For the 2011-12 vaccine, 56 (31%) responded to the H1N1 strain, 68 (37%) responded to H3N2, and 28 (15%) responded to B. Among HD recipients, post-vaccination GMT for H3N2 was higher among 2011-12 responders vs. non-responders (p = 0.04). Fold rise did not differ significantly for any vaccine strains between responders vs. non-responders. HD recipients ID recipients Strain 2012-13 Response 2011-12 Non-responders 2011-12 Responders 2011-12 Non-responders 2011-12 Responders H1N1 Post-vaccination GMT (IQR) 93 (57, 160) 128 (80, 320) 78 (40, 226) 105 (40, 160) Median fold rise (IQR) 4 (2, 8) 4 (1, 8) 2 (1, 4) 2 (2, 4) H3N2 Post-vaccination GMT (IQR) 154 (80, 320)* 242 (160, 452) 120 (57, 320) 118 (40, 226) Median fold rise (IQR) 4 (2, 8) 4 (2, 11) 2 (1, 4) 2 (1, 8) B Post-vaccination GMT (IQR) 185 (80, 320) 180 (80, 320) 137 (80, 320) 163 (80, 320) Median fold rise (IQR) 3 (1, 8) 2 (2, 11) 2 (1, 6) 3 (1, 16) * p < 0.05 for comparison of 2011-12 responders and non-responders. Conclusion: Prior response to 2011-12 vaccine antigen was not associated with response to the new H3N2 or B antigens in 2012-13, nor was it associated with response to the H1N1 antigen used in both the 2011-12 and 2012-13 vaccines.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Influenza A (H1N1)pdm09 (pH1N1) virus has circulated at different levels during each U.S. influenza season since the 2009 pandemic, with highest levels during the 2013-14 season. A pH1N1 virus (A/California/7/2009) has been included as the H1N1 component of seasonal influenza vaccines since 2010. We investigated effectiveness of seasonal influenza vaccines against medically attended influenza illness due to pH1N1 infection over 3 seasons with varying pH1N1 virus circulation. Methods: We analyzed data from 9665 patients with medically attended acute respiratory illnesses enrolled at five U.S. Flu VE Network study sites during the 2011-12, 2012-13 and 2013-14 influenza seasons, during periods when pH1N1 virus was identified at ≥1 study site. Respiratory specimens from all enrollees were tested for influenza viruses using reverse transcription PCR. Vaccination was defined as documented or reported receipt of ≥1 dose of current season influenza vaccines at least 14 days before illness onset. Vaccine effectiveness was estimated as 100 x (1 – adjusted odds ratio) from multivariable logistic regression comparing odds of vaccination among pH1N1-positive cases versus influenza-negative patients. Results: pH1N1 virus accounted for 112 (25%) of 440 confirmed influenza A virus cases enrolled in 2011-12, 51 (4%) of 1380 cases in 2012-13 and 742 (95%) of 778 cases in 2013-14. Over three seasons, 4401 (50%) of 8760 influenza-negative patients had received ≥1 dose of current season influenza vaccine versus 240 (27%) of 905 pH1N1 cases. After adjusting for season, study site, age, self-reported health status and days from illness onset to enrollment, overall VE against pH1N1 virus infection during three influenza seasons was 65% (95% confidence interval [CI]: 59%, 70%), varying from 62% (95% CI: 53%, 69%) in 2013-14 to 81% (95% CI: 61%, 91%) in 2012-13, with no statistically significant difference in VE by season. After combining seasons, adjusted age-group specific VE estimates against pH1N1 ranged from 56% (95% CI:16%, 77%) among patients ≥65 years to 79% (95% CI: 54%, 91%) among 9-17 year olds. Conclusion: The pH1N1 virus included in seasonal influenza vaccines since 2009 provided consistent protection against medically-attended pH1N1 illness 2-4 years after the pandemic despite varying pH1N1 circulation.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    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.
    American Journal of Preventive Medicine 10/2014; 47(4). DOI:10.1016/j.amepre.2014.07.003 · 4.53 Impact Factor
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    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.
    Clinical Infectious Diseases 07/2014; 59(6). DOI:10.1093/cid/ciu422 · 8.89 Impact Factor
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    ABSTRACT: Background There are disparities in influenza and pneumococcal vaccination rates among elderly minority groups and little guidance as to which intervention or combination of interventions to eliminate these disparities is likely to be most cost-effective. Here, we evaluate the cost-effectiveness of four hypothetical vaccination programs designed to eliminate disparities in elderly vaccination rates and differing in the number of interventions. Methods We developed a Markov model in which we assumed a healthcare system perspective, 10-year vaccination program and lifetime time horizon. The cohort was the combined African-American and Hispanic 65 year-old birth cohort in the United States in 2009. We evaluated five different vaccination strategies: no vaccination program and four vaccination programs that varied from “low intensity” to “very high intensity” based on the number of interventions deployed in each program, their cumulative cost and their cumulative impact on elderly minority influenza and pneumococcal vaccination rates. Results The very high intensity vaccination program ($24,479/quality-adjusted life year; QALY) was preferred at willingness-to-pay-thresholds of $50,000 and $100,000/QALY and prevented 37,178 influenza cases, 342 influenza deaths, 1,158 invasive pneumococcal disease (IPD) cases and 174 IPD deaths over the birth cohort’s lifetime. In one-way sensitivity analyses, the very high intensity program only became cost-prohibitive (>$100,000/QALY) at less likely values for the influenza vaccination rates achieved in year 10 of the high intensity (>73.5%) or very high intensity (<76.8%) vaccination programs. Conclusions A practice-based vaccination program designed to eliminate disparities in elderly minority vaccination rates and including four interventions would be cost-effective.
    BMC Public Health 07/2014; 14(1):718. DOI:10.1186/1471-2458-14-718 · 2.26 Impact Factor

Publication Stats

3k Citations
757.59 Total Impact Points


  • 1995-2015
    • University of Pittsburgh
      • • Department of Family Medicine
      • • Department of Medicine
      • • Department of Pediatrics
      Pittsburgh, Pennsylvania, United States
  • 2009
    • Centers for Disease Control and Prevention
      • National Center for Immunization and Respiratory Diseases
      Atlanta, MI, United States
  • 2003-2007
    • Medical University of Ohio at Toledo
      Toledo, Ohio, United States
    • TAS Energy
      Houston, Texas, United States
    • University of Louisville
      • School of Public Health and Information Sciences
      Louisville, KY, United States
  • 1991-1993
    • University of Minnesota Duluth
      Duluth, Minnesota, United States