Richard K Zimmerman

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (211)591.26 Total impact

  • The Journal of infectious diseases. 12/2014;
  • The Journal of infectious diseases. 11/2014;
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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; · 1.15 Impact Factor
  • Richard K Zimmerman
    Vaccine. 11/2014; 32(52):7040-7042.
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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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    Clinical Infectious Diseases 07/2014; · 9.37 Impact Factor
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    ABSTRACT: 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.
    BMC Public Health 07/2014; 14(1):718. · 2.08 Impact Factor
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    ABSTRACT: 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.
    Influenza and Other Respiratory Viruses 05/2014; · 1.47 Impact Factor
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    ABSTRACT: To increase childhood influenza vaccination rates using a toolkit and early vaccine delivery in a randomized cluster trial. 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. 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 (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. 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.
    Vaccine 04/2014; · 3.77 Impact Factor
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    ABSTRACT: Background: Concerns about influenza vaccine effectiveness in older adults and the role of influenza strains encountered earlier in life led to this study. : Methods: Antibody responses against antigens in the 2011-2012 influenza vaccine at 21 days post-vaccination were analyzed in 264 individuals aged 50-80 years. At Days 0 and 21, sera were tested for hemagglutination-inhibition titers against these vaccine strains and at Day 0 against a panel of 15 historical seasonal strains. Results: The proportions of participants with seroprotective titers ≥1:40 to the vaccine strains at Days 0 and 21, respectively, were 37% and 66% for A(H1N1) and 28% and 63% for A(H3N2). An increasing number of responses ≥1:40 against historical strains was associated with seroprotective responses after vaccination among participants with a titer<1:40 at Day 0 for A(H1N1) and A(H3N2) vaccine strains (P<0.01). In multivariable regression analyses among those with Day 0 titer<1:40, after controlling for age, sex, race, site and diabetes, Day 21 titers ≥ 1:40 for the vaccine A strains were significantly more likely as the number of seroprotective responses against historical strains increased (A(H1N1) odds ratio [OR] 1.41, 95% confidence interval [CI] = 1.09-1.82 and A(H3N2) OR = 1.32, 95% CI = 1.07-1.62). The likelihood of seroconversion was significantly higher with an increasing number of responses to historical strains for A(H3N2) only (OR = 1.24, 95% CI = 1.01-1.52). Seroconversion was significantly less likely as Day 0 vaccine strain titers increased. Conclusions: Seroprotective titers after influenza vaccination increased as the number of responses to historical strains increased.
    Human vaccines & immunotherapeutics. 03/2014; 10(5).
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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 to prevent influenza-associated, medically attended acute respiratory illness (ARI). This report uses data from 2,319 children and adults enrolled in the U.S. Influenza Vaccine Effectiveness (Flu VE) Network during December 2, 2013-January 23, 2014, to estimate an interim adjusted effectiveness of seasonal influenza vaccine for preventing laboratory-confirmed influenza virus infection associated with medically attended ARI. 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 influenza A and B virus infection associated with medically attended ARI was 61%. The influenza A (H1N1)pdm09 (pH1N1) virus that emerged to cause a pandemic in 2009 accounted for 98% of influenza viruses detected. VE was estimated to be 62% against pH1N1 virus infections and was similar across age groups. As of February 8, 2014, influenza activity remained elevated in the United States, the proportion of persons seeing their health-care provider for influenza-like illness was lower than in early January but remained above the national baseline, and activity still might be increasing in some parts of the country. CDC and the Advisory Committee on Immunization Practices routinely recommend that annual influenza vaccination efforts continue as long as influenza viruses are circulating. Persons aged ≥6 months who have not yet been vaccinated this season should be vaccinated. Antiviral medications are an important second line of defense to treat influenza illness and should be used as recommended among suspected or confirmed influenza patients, regardless of patient vaccination status. Early antiviral treatment is recommended for persons with suspected influenza with severe or progressive illness (e.g., hospitalized persons) and those at high risk for complications from influenza, no matter how severe the illness.
    MMWR. Morbidity and mortality weekly report 02/2014; 63(7):137-42.
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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. 01/2014;
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    ABSTRACT: Quadrivalent human papillomavirus (HPV) vaccine, for protection against sexually transmitted HPV infection, is licensed for females and males 9-26 years on a 3-dose schedule (0, 2, and 6 months; Standard schedule). Vaccine uptake has been low and catch-up vaccination of older adolescents using an alternate dosing schedule may increase coverage. This study tested the non-inferiority of the immunogenicity of an alternate dosing schedule (0, 2, 12 months) among college age males. 220 18-25 year old males were randomly assigned to Standard or Alternate schedules. Blood samples were drawn immediately before Dose 1 and 2-6 weeks after Dose 3 and analyzed for antibody titers using a Luminex immunoassay. A value <1.5 for the upper 95% confidence interval (CI) bound of the Standard to Alternate schedule geometric mean titer (GMT) ratio was deemed non-inferior. Participants averaged 21.3 years old; 19.1% were non-white; completion rate was 93%. The anti-HPV titers for the Alternate schedule group were non-inferior to those of Standard schedule group for all four HPV vaccine virus types. Our results also demonstrated superiority of the Alternate schedule group for all four HPV vaccine virus types. A delayed third dose at 12 months is immunologically non-inferior and superior for four HPV virus types. Using an alternate dosing schedule offers more flexibility to receive the 3-dose HPV vaccine and may result in higher vaccination rates among college-age males.
    Vaccine 12/2013; · 3.77 Impact Factor
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    ABSTRACT: Two clinical trials suggest that procalcitonin-guided antibiotic therapy can safely reduce antibiotic prescribing in outpatient management of acute respiratory tract infections (ARTIs) in adults. Yet, it remains unclear whether procalcitonin testing is cost-effective in this setting. To evaluate the cost-effectiveness of procalcitonin-guided antibiotic therapy in outpatient management of ARTIs in adults. Cost-effectiveness model based on results from two published European clinical trials, with all parameters varied widely in sensitivity analyses. Two hypothetical cohorts were modeled in separate trial-based analyses: adults with ARTIs judged by their physicians to require antibiotics and all adults with ARTIs. Procalcitonin-guided antibiotic therapy protocols versus usual care. Costs and cost per antibiotic prescription safely avoided. We estimated the health care system willingness-to-pay threshold as $43 (range $0-$333) per antibiotic safely avoided, reflecting the estimated cost of antibiotic resistance per outpatient antibiotic prescribed. In the cohort including all adult ARTIs judged to require antibiotics by their physicians, procalcitonin cost $31 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored compared to usual care was 58.4 % in a probabilistic sensitivity analysis. In the analysis that included all adult ARTIs, procalcitonin cost $149 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored was 2.8 %. Procalcitonin-guided antibiotic therapy for outpatient management of ARTIs in adults would be cost-effective when the costs of antibiotic resistance are considered and procalcitonin testing is limited to adults with ARTIs judged by their physicians to require antibiotics.
    Journal of General Internal Medicine 11/2013; · 3.28 Impact Factor
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    ABSTRACT: Background. Each year, the US Flu VE Network examines the effectiveness of influenza vaccines in preventing medically-attended acute respiratory illnesses caused by influenza. Methods. Patients with acute respiratory illnesses of <7 days duration were enrolled at ambulatory care facilities in five communities. Specimens were collected and tested for influenza by real-time reverse transcriptase polymerase chain reaction. Receipt of influenza vaccine was defined based on documented evidence of vaccination in medical records or immunization registries. Vaccine effectiveness was estimated in adjusted logistic regression models by comparing the vaccination coverage in those who tested positive for influenza with those who tested negative. Results. The 2011-2012 season was mild and peaked late, with circulation of both type A viruses and both lineages of type B. Overall adjusted vaccine effectiveness was 47% (95% confidence interval [CI], 36 to 56) in preventing medically-attended influenza; vaccine effectiveness was 65% (95% CI, 44 to 79) against type A (H1N1) pdm09, but only 39% (95% CI, 23 to 52) against type A (H3N2). Estimates of vaccine effectiveness against both type B lineages were similar (overall 58%, 95% CI, 35 to 73). An apparent negative effect of prior year vaccination on current year effectiveness estimates was noted, particularly for A (H3N2) outcomes. Conclusions. Vaccine effectiveness in the 2011-2012 season was modest overall, with lower effectiveness against the predominant A (H3N2) virus. This may be related to modest antigenic drift, but past history of vaccination might also play a role.
    Clinical Infectious Diseases 11/2013; · 9.37 Impact Factor
  • Patricia Sweeney, Richard K. Zimmerman
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    ABSTRACT: For more than three decades, the Centers for Disease Control and Prevention (CDC) has recommended influenza vaccination for health care workers (HCWs). During that period, myriad interventions have been employed to increase HCW influenza vaccination rates have met limited success. Influenza immunization rates for this group remain far below the coverage goal of ≥90%. State legislatures have attempted to address this problem by enacting laws mandating a host of influenza vaccine activities across distinct categories of health care facilities and HCW disciplines. Concurrently, health care institutions, physician practices and health care systems nationwide have instituted policies to improve their HCW influenza vaccine rates. But the true impact of these state laws and institutional policies on HCW influenza immunization rates is unknown. This research set out to identify which, if any, components of state HCW influenza immunization law or institutional policy have the greatest impact on increasing HCW influenza immunization rates? To determine this, we used hierarchical linear modeling to analyze the relative impact of HCW demographic data (age, gender, race) and the precise components of state law and institutional policy (employee category, law/policy requirement, ease of law/policy opt out, and the penalties for non-compliance. Data analysis revealed that state laws and/or institutional policies that mandate offering immunizations to HCW staff or require education of HCW staff do not increase immunization rates among the intended population. However institutional policies which require influenza immunization and impose sanctions such as termination and/or reassignment yield the highest rates of HCW immunization rates.
    141st APHA Annual Meeting and Exposition 2013; 11/2013
  • Richard K Zimmerman
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    ABSTRACT: Health care worker (HCW) influenza vaccination rates are modest. This paper provides a detailed ethical analysis of the major options to increase HCW vaccination rates, comparing how major ethical theories would address the options. The main categories of interventions to raise rates include education, incentives, easy access, competition with rewards, assessment and feedback, declination, mandates with alternative infection control measures, and mandates with administrative action as consequences. The aforementioned interventions, except mandates, arouse little ethical controversy. However, these efforts are time and work intensive and rarely achieve vaccination rates higher than about 70%. The primary concerns voiced about mandates are loss of autonomy, injustice, lack of due process, and subsuming the individual for institutional ends. Proponents of mandates argue that they are ethical based on beneficence, non-maleficence, and duty. A number of professional associations support mandates. Arguments by analogy can be made by mandates for HCW vaccination against other diseases. The ethical systems used in the analyses include evolutionary ethics, utilitarianism, principalism (autonomy, beneficence, non-maleficence, and justice), Kantism, and altruism. Across these systems, the most commonly preferred options are easy access, assessment and feedback, declinations, and mandates with infection control measures as consequences for non-compliance. Given the ethical imperatives of non-maleficence and beneficence, the limited success of lower intensive interventions, and the need for putting patient safety ahead of HCW convenience, mandates with additional infection control measures as consequences for non-compliance are preferred. For those who opt out of vaccination due to conscience concerns, such mandates provide a means to remain employed but not put patient safety at risk.
    Vaccine 11/2013; · 3.77 Impact Factor
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    ABSTRACT: Purpose: To evaluate the cost-effectiveness of procalcitonin-guided antibiotic therapy in outpatient management of ARTIs in adults. Method: We developed a cost-effectiveness model based on data from two randomized controlled trials and modeled the different cohorts in two separate analyses. Cohort one comprised all adults with ARTIs presenting in the outpatient setting. Cohort two comprised all adults with ARTIs presenting in the outpatient setting and judged by their providers to require antibiotics after clinical evaluation. Both analyses assumed a societal perspective and a clinic visit time horizon. We compared two strategies: usual care and procalcitonin-guided antibiotic therapy. The primary differences between strategies were the procalcitonin testing costs and fewer antibiotic prescriptions in the procalcitonin strategy. The primary outcome was cost per antibiotic avoided. Because there is not an accepted societal willingness-to-pay threshold for this outcome, we developed an estimate for this threshold based on the societal cost of antibiotic resistance per outpatient antibiotic prescription. For each cohort, we performed base case cost-effectiveness analyses and examined model robustness to parameter variation in sensitivity analyses. Result: We estimated the willingness-to-pay threshold as $43 (range $0–$333) per antibiotic avoided, reflecting the estimated societal cost of antibiotic resistance per outpatient antibiotic prescription. In the cohort including all adults with ARTIs, the procalcitonin strategy cost more ($49 vs. $15 per patient) and reduced the number of antibiotic prescriptions (0.14 vs. 0.37 antibiotic prescriptions per patient) compared to usual care, resulting in an incremental cost-effectiveness ratio (ICER) of $149 per antibiotic prescription avoided. In a probabilistic sensitivity analysis, the likelihood of procalcitonin being favored over usual care was 2.8%. In the cohort including adult ARTIs judged by their providers to require antibiotics, the procalcitonin strategy cost more ($51 vs. $29 per patient) and reduced the number of antibiotic prescriptions (0.25 vs. 0.97 antibiotic prescriptions per patient) compared to usual care, resulting in an ICER of $31 per antibiotic prescription avoided. In a probabilistic sensitivity analysis, the likelihood of procalcitonin being favored over usual care was 58.4%. Conclusion: Procalcitonin-guided antibiotic therapy for outpatient management of ARTIs in adults is cost-effective compared to usual care when the societal costs of antibiotic resistance are considered and procalcitonin testing is limited to adults with ARTIs judged by their providers to require antibiotics after clinical evaluation.
    The 35th Annual Meeting of the Society for Medical Decision Making; 10/2013

Publication Stats

2k Citations
591.26 Total Impact Points

Institutions

  • 1996–2014
    • University of Pittsburgh
      • • Department of Family Medicine
      • • School of Medicine
      • • Department of Medicine
      Pittsburgh, Pennsylvania, United States
  • 2009
    • Centers for Disease Control and Prevention
      Atlanta, Michigan, United States
  • 2007
    • University of Toledo
      • Department of Family Medicine
      Toledo, OH, United States
  • 2003
    • University of Louisville
      • School of Public Health and Information Sciences
      Louisville, KY, United States
    • TAS Energy
      Houston, Texas, United States
    • Medical University of Ohio at Toledo
      Toledo, Ohio, United States
  • 1991
    • University of Minnesota Duluth
      Duluth, Minnesota, United States