International Conference on Emerging Infectious Diseases (ICEID 2012)

ATLANTA – Surveillance data from Minnesota and Wellington, New Zealand, underscore the extent of the racial and ethnic disparities in the rates of influenza and hospitalization for influenza that occurred during the 2009 H1N1 influenza pandemic, and some of those data demonstrate that these disparities persisted at similar levels in 2010-2011.

The findings underscore the need for improved public health strategies that alleviate the socioeconomic factors that contribute to the disparities, the investigators agreed.

Photo courtesy CDC/Cynthia Goldsmith

The combined incidence of hospitalization for influenza per 100,000 population in Minnesota during the pandemic influenza season in 2009 and the subsequent influenza season was 60.8 for blacks, 42.8 for Native Americans, 35.3 for Hispanics, 23.7 for Asians, and 17.8 for whites. Nonwhites accounted for 31% of cases during the pandemic period, and 23% during the following season, Craig Morin of the Minnesota Department of Health reported in a poster at the International Conference on Emerging Infectious Diseases.

The median age of hospitalized patients during the 2009 pandemic was 28.8 years; the median age in the 2010-2011 season was 52.6 years.

"After adjustment for age, the relative rates associated with nonwhite vs. white non-Hispanic race was 2.46 during the 2009 pandemic period, and 2.52 during the 2010-2011 season," Mr. Morin wrote. The differences were statistically significant.

Cases included in this study were laboratory-confirmed, hospitalized influenza cases. During the pandemic season, cases included Minnesota residents hospitalized between April 2009 and April 2010 for confirmed A (H1N1) pmd09 influenza. During the subsequent season, cases included Minnesota residents hospitalized between October 2010 and April 2011 for laboratory-confirmed A H3 or A (H1N1) pmd09 influenza.

Ethnicity information was available for 1,703 cases during the pandemic period and for 467 cases during the subsequent season.

The findings indicate that racial and ethnic disparities occurred to a similar degree during both seasons, and suggest that more study is needed to further delineate the relationship between race/ethnicity and socioeconomic factors, vaccine coverage, prevalence of chronic illnesses, and access to health care. A better understanding of these relationships would be helpful for designing public health interventions most likely to alleviate the disparities, Mr. Morin concluded.

Another study presented at the conference also demonstrated disparities in influenza rates and outcomes based on socioeconomic status. These findings among residents of New Zealand during the pandemic season also highlighted a need for public health interventions to reduce the factors contributing to disparities.

During the pandemic season, rates of infection were highest among the most socioeconomically deprived groups. For example, the rates were significantly higher among Pacific peoples than among European/other individuals (adjusted risk ratio, 1.49). Also, after the researchers adjusted for infection rates, they found that hospitalization rates were higher for Maori (adjusted risk ratio, 2.44), Pacific peoples (adjusted risk ratio, 4.16), and the most deprived socioeconomic status quintile of the population (adjusted risk ratio, 1.37). Mortality risk was also significantly higher for Pacific peoples (adjusted risk ratio, 3.28), Dr. Michael G. Baker of the University of Otaga, Wellington, reported at the conference.

Furthermore, general practitioner consultation rates were inversely associated with disease risk, and the rates of consultation were significantly lower for Maori and Pacific peoples and for those in more deprived quintiles after adjustment for infection rates, Dr. Baker said.

The findings reinforce the importance of identifying factors that contribute to elevated risk, reducing socioeconomic inequality, and improving access to primary care services for disadvantaged populations, he concluded.

Mr. Morin’s study was supported by the Centers for Disease Control and Prevention Emerging Infections Program. Neither Mr. Morin nor Dr. Baker had disclosures to report.

ATLANTA – Surveillance data from Minnesota and Wellington, New Zealand, underscore the extent of the racial and ethnic disparities in the rates of influenza and hospitalization for influenza that occurred during the 2009 H1N1 influenza pandemic, and some of those data demonstrate that these disparities persisted at similar levels in 2010-2011.

The findings underscore the need for improved public health strategies that alleviate the socioeconomic factors that contribute to the disparities, the investigators agreed.

Photo courtesy CDC/Cynthia Goldsmith

The combined incidence of hospitalization for influenza per 100,000 population in Minnesota during the pandemic influenza season in 2009 and the subsequent influenza season was 60.8 for blacks, 42.8 for Native Americans, 35.3 for Hispanics, 23.7 for Asians, and 17.8 for whites. Nonwhites accounted for 31% of cases during the pandemic period, and 23% during the following season, Craig Morin of the Minnesota Department of Health reported in a poster at the International Conference on Emerging Infectious Diseases.

The median age of hospitalized patients during the 2009 pandemic was 28.8 years; the median age in the 2010-2011 season was 52.6 years.

"After adjustment for age, the relative rates associated with nonwhite vs. white non-Hispanic race was 2.46 during the 2009 pandemic period, and 2.52 during the 2010-2011 season," Mr. Morin wrote. The differences were statistically significant.

Cases included in this study were laboratory-confirmed, hospitalized influenza cases. During the pandemic season, cases included Minnesota residents hospitalized between April 2009 and April 2010 for confirmed A (H1N1) pmd09 influenza. During the subsequent season, cases included Minnesota residents hospitalized between October 2010 and April 2011 for laboratory-confirmed A H3 or A (H1N1) pmd09 influenza.

Ethnicity information was available for 1,703 cases during the pandemic period and for 467 cases during the subsequent season.

The findings indicate that racial and ethnic disparities occurred to a similar degree during both seasons, and suggest that more study is needed to further delineate the relationship between race/ethnicity and socioeconomic factors, vaccine coverage, prevalence of chronic illnesses, and access to health care. A better understanding of these relationships would be helpful for designing public health interventions most likely to alleviate the disparities, Mr. Morin concluded.

Another study presented at the conference also demonstrated disparities in influenza rates and outcomes based on socioeconomic status. These findings among residents of New Zealand during the pandemic season also highlighted a need for public health interventions to reduce the factors contributing to disparities.

During the pandemic season, rates of infection were highest among the most socioeconomically deprived groups. For example, the rates were significantly higher among Pacific peoples than among European/other individuals (adjusted risk ratio, 1.49). Also, after the researchers adjusted for infection rates, they found that hospitalization rates were higher for Maori (adjusted risk ratio, 2.44), Pacific peoples (adjusted risk ratio, 4.16), and the most deprived socioeconomic status quintile of the population (adjusted risk ratio, 1.37). Mortality risk was also significantly higher for Pacific peoples (adjusted risk ratio, 3.28), Dr. Michael G. Baker of the University of Otaga, Wellington, reported at the conference.

Furthermore, general practitioner consultation rates were inversely associated with disease risk, and the rates of consultation were significantly lower for Maori and Pacific peoples and for those in more deprived quintiles after adjustment for infection rates, Dr. Baker said.

The findings reinforce the importance of identifying factors that contribute to elevated risk, reducing socioeconomic inequality, and improving access to primary care services for disadvantaged populations, he concluded.

Mr. Morin’s study was supported by the Centers for Disease Control and Prevention Emerging Infections Program. Neither Mr. Morin nor Dr. Baker had disclosures to report.

ATLANTA – Surveillance data from Minnesota and Wellington, New Zealand, underscore the extent of the racial and ethnic disparities in the rates of influenza and hospitalization for influenza that occurred during the 2009 H1N1 influenza pandemic, and some of those data demonstrate that these disparities persisted at similar levels in 2010-2011.

The findings underscore the need for improved public health strategies that alleviate the socioeconomic factors that contribute to the disparities, the investigators agreed.

Photo courtesy CDC/Cynthia Goldsmith

The combined incidence of hospitalization for influenza per 100,000 population in Minnesota during the pandemic influenza season in 2009 and the subsequent influenza season was 60.8 for blacks, 42.8 for Native Americans, 35.3 for Hispanics, 23.7 for Asians, and 17.8 for whites. Nonwhites accounted for 31% of cases during the pandemic period, and 23% during the following season, Craig Morin of the Minnesota Department of Health reported in a poster at the International Conference on Emerging Infectious Diseases.

The median age of hospitalized patients during the 2009 pandemic was 28.8 years; the median age in the 2010-2011 season was 52.6 years.

"After adjustment for age, the relative rates associated with nonwhite vs. white non-Hispanic race was 2.46 during the 2009 pandemic period, and 2.52 during the 2010-2011 season," Mr. Morin wrote. The differences were statistically significant.

Cases included in this study were laboratory-confirmed, hospitalized influenza cases. During the pandemic season, cases included Minnesota residents hospitalized between April 2009 and April 2010 for confirmed A (H1N1) pmd09 influenza. During the subsequent season, cases included Minnesota residents hospitalized between October 2010 and April 2011 for laboratory-confirmed A H3 or A (H1N1) pmd09 influenza.

Ethnicity information was available for 1,703 cases during the pandemic period and for 467 cases during the subsequent season.

The findings indicate that racial and ethnic disparities occurred to a similar degree during both seasons, and suggest that more study is needed to further delineate the relationship between race/ethnicity and socioeconomic factors, vaccine coverage, prevalence of chronic illnesses, and access to health care. A better understanding of these relationships would be helpful for designing public health interventions most likely to alleviate the disparities, Mr. Morin concluded.

Another study presented at the conference also demonstrated disparities in influenza rates and outcomes based on socioeconomic status. These findings among residents of New Zealand during the pandemic season also highlighted a need for public health interventions to reduce the factors contributing to disparities.

During the pandemic season, rates of infection were highest among the most socioeconomically deprived groups. For example, the rates were significantly higher among Pacific peoples than among European/other individuals (adjusted risk ratio, 1.49). Also, after the researchers adjusted for infection rates, they found that hospitalization rates were higher for Maori (adjusted risk ratio, 2.44), Pacific peoples (adjusted risk ratio, 4.16), and the most deprived socioeconomic status quintile of the population (adjusted risk ratio, 1.37). Mortality risk was also significantly higher for Pacific peoples (adjusted risk ratio, 3.28), Dr. Michael G. Baker of the University of Otaga, Wellington, reported at the conference.

Furthermore, general practitioner consultation rates were inversely associated with disease risk, and the rates of consultation were significantly lower for Maori and Pacific peoples and for those in more deprived quintiles after adjustment for infection rates, Dr. Baker said.

The findings reinforce the importance of identifying factors that contribute to elevated risk, reducing socioeconomic inequality, and improving access to primary care services for disadvantaged populations, he concluded.

Mr. Morin’s study was supported by the Centers for Disease Control and Prevention Emerging Infections Program. Neither Mr. Morin nor Dr. Baker had disclosures to report.

ATLANTA – Childhood immunization programs in the United States have been "a remarkable success" when it comes to vaccine coverage and disease prevention, but an increasing threat to this success is "vaccine hesitancy" – the term applied to concerns about safety and efficacy of vaccines that lead some parents to resist vaccination of their children as recommended, according to Dr. Arthur Reingold.

Although the vast majority of unimmunized children are unimmunized not as a result of vaccine hesitancy, but as a result of a failure of immunization programs to reach them (which itself is often a factor of socioeconomic status), there does exist a genuine anti-vaccine movement involving people who "see the world differently in terms of whether vaccines are a good thing or a bad thing," Dr. Reingold, professor of epidemiology and associate dean for research at the University of California, Berkeley, said at the International Conference on Emerging Infectious Diseases.

Photo credit: Sean Locke/iStockphoto.com

The problem of unreached children is something that increased resources and attention can certainly do a great deal to eliminate; the increasing problem of vaccine hesitancy requires something more – the building of trust, he said.

Some parents may be accepting of vaccines, but may have questions or concerns about safety. Others may reject vaccination due to religious or other personal beliefs, or they may accept some, but not all vaccinations because they believe the current schedule is "somehow an affront to the immune system," Dr. Reingold said.

"Increasingly, many parents are anxious and have questions, so we can’t assume that they will accept vaccination," he said, noting that addressing these concerns is time-consuming and challenging for the pediatrician or family doctor, but taking the time is an important aspect of building trust.

Trust-building is one of the best approaches to overcoming vaccine hesitancy, he said.

Lack of trust, along with misinformation, lack of information, and fear resulting from the belief that a child has died or been injured as a result of vaccination are the major contributors to vaccine hesitancy, he said.

Those most likely to refuse vaccination for their children are those with a higher income and mothers who are married and who have a college degree – and who have doubts about the effectiveness of vaccines, Dr. Reingold noted, adding that these are parents who "generally don’t necessarily trust the government or their physician to provide them with accurate information."

This is a very different group from those whose children are unimmunized due to lack of access, he said.

Adding to the concerns about vaccine hesitancy is the fact that several states already allow for exemptions based on religious or personal convictions, and a recent report said that seven states are weighing making it much easier to opt out.

Data show that rates of vaccine-preventable disease are higher in states that make it easy to opt out. Pertussis and measles are two examples of diseases that increase as vaccine rates decrease.

"Making it easier will certainly have effects," Dr. Reingold said.

Again, the key is trust-building, and there are approaches – as demonstrated world-wide through successful vaccination programs among initially resistant populations – that can be quite successful, he said.

He cited the polio vaccination program in India, where the disease has been eliminated.

Quite a bit of resistance was initially encountered among Muslim populations in North India, but a plan that involved community-level action and inclusion of local residents on leadership teams and as community organizers proved successful in winning support for the program.

The results in India show that compulsory vaccination – an approach that has been attempted periodically throughout the history of immunization programs – is not necessary for success.

"It is possible to build trust and to get people to accept vaccination, but it is hard work, and it takes resources," he said.

To build trust, a program requires transparency, accurate information, avoidance of financial conflicts of interest on the part of those promoting the program or a specific vaccine, a good system of monitoring and investigating adverse events, and a reasonable compensation program for those who are injured as a result of vaccination, he said.

The adverse event monitoring and investigation aspect is of particular importance given the fears that parents increasingly have regarding vaccines, and that means making the most of existing systems, including passive surveillance and the Vaccine Adverse Event Reporting System, he said.

"We know that when we give large numbers of vaccines to large numbers of children, sometimes bad things will happen shortly after they are vaccinated. ... It is very difficult to convince them, even with good epidemiologic data, that this is coincidence rather than a cause and effect relationship," Dr. Reingold said, adding, "So we do need very good programs in place to monitor adverse events, and we need to be in a position to study those events and determine whether or not there is a cause and effect relationship."

In the past, many such concerns about cause and effect have been debunked by solid, careful epidemiological study, he noted.

"But nevertheless, we need to be in a position to study these allegations and refute them with good data. ... Building and retaining trust in vaccines and their safety is critical for ensuring continued public support and acceptance of immunizations," he said.

Dr. Reingold said he had no disclosures to report.

ATLANTA – Childhood immunization programs in the United States have been "a remarkable success" when it comes to vaccine coverage and disease prevention, but an increasing threat to this success is "vaccine hesitancy" – the term applied to concerns about safety and efficacy of vaccines that lead some parents to resist vaccination of their children as recommended, according to Dr. Arthur Reingold.

Although the vast majority of unimmunized children are unimmunized not as a result of vaccine hesitancy, but as a result of a failure of immunization programs to reach them (which itself is often a factor of socioeconomic status), there does exist a genuine anti-vaccine movement involving people who "see the world differently in terms of whether vaccines are a good thing or a bad thing," Dr. Reingold, professor of epidemiology and associate dean for research at the University of California, Berkeley, said at the International Conference on Emerging Infectious Diseases.

Photo credit: Sean Locke/iStockphoto.com

The problem of unreached children is something that increased resources and attention can certainly do a great deal to eliminate; the increasing problem of vaccine hesitancy requires something more – the building of trust, he said.

Some parents may be accepting of vaccines, but may have questions or concerns about safety. Others may reject vaccination due to religious or other personal beliefs, or they may accept some, but not all vaccinations because they believe the current schedule is "somehow an affront to the immune system," Dr. Reingold said.

"Increasingly, many parents are anxious and have questions, so we can’t assume that they will accept vaccination," he said, noting that addressing these concerns is time-consuming and challenging for the pediatrician or family doctor, but taking the time is an important aspect of building trust.

Trust-building is one of the best approaches to overcoming vaccine hesitancy, he said.

Lack of trust, along with misinformation, lack of information, and fear resulting from the belief that a child has died or been injured as a result of vaccination are the major contributors to vaccine hesitancy, he said.

Those most likely to refuse vaccination for their children are those with a higher income and mothers who are married and who have a college degree – and who have doubts about the effectiveness of vaccines, Dr. Reingold noted, adding that these are parents who "generally don’t necessarily trust the government or their physician to provide them with accurate information."

This is a very different group from those whose children are unimmunized due to lack of access, he said.

Adding to the concerns about vaccine hesitancy is the fact that several states already allow for exemptions based on religious or personal convictions, and a recent report said that seven states are weighing making it much easier to opt out.

Data show that rates of vaccine-preventable disease are higher in states that make it easy to opt out. Pertussis and measles are two examples of diseases that increase as vaccine rates decrease.

"Making it easier will certainly have effects," Dr. Reingold said.

Again, the key is trust-building, and there are approaches – as demonstrated world-wide through successful vaccination programs among initially resistant populations – that can be quite successful, he said.

He cited the polio vaccination program in India, where the disease has been eliminated.

Quite a bit of resistance was initially encountered among Muslim populations in North India, but a plan that involved community-level action and inclusion of local residents on leadership teams and as community organizers proved successful in winning support for the program.

The results in India show that compulsory vaccination – an approach that has been attempted periodically throughout the history of immunization programs – is not necessary for success.

"It is possible to build trust and to get people to accept vaccination, but it is hard work, and it takes resources," he said.

To build trust, a program requires transparency, accurate information, avoidance of financial conflicts of interest on the part of those promoting the program or a specific vaccine, a good system of monitoring and investigating adverse events, and a reasonable compensation program for those who are injured as a result of vaccination, he said.

The adverse event monitoring and investigation aspect is of particular importance given the fears that parents increasingly have regarding vaccines, and that means making the most of existing systems, including passive surveillance and the Vaccine Adverse Event Reporting System, he said.

"We know that when we give large numbers of vaccines to large numbers of children, sometimes bad things will happen shortly after they are vaccinated. ... It is very difficult to convince them, even with good epidemiologic data, that this is coincidence rather than a cause and effect relationship," Dr. Reingold said, adding, "So we do need very good programs in place to monitor adverse events, and we need to be in a position to study those events and determine whether or not there is a cause and effect relationship."

In the past, many such concerns about cause and effect have been debunked by solid, careful epidemiological study, he noted.

"But nevertheless, we need to be in a position to study these allegations and refute them with good data. ... Building and retaining trust in vaccines and their safety is critical for ensuring continued public support and acceptance of immunizations," he said.

Dr. Reingold said he had no disclosures to report.

ATLANTA – Childhood immunization programs in the United States have been "a remarkable success" when it comes to vaccine coverage and disease prevention, but an increasing threat to this success is "vaccine hesitancy" – the term applied to concerns about safety and efficacy of vaccines that lead some parents to resist vaccination of their children as recommended, according to Dr. Arthur Reingold.

Although the vast majority of unimmunized children are unimmunized not as a result of vaccine hesitancy, but as a result of a failure of immunization programs to reach them (which itself is often a factor of socioeconomic status), there does exist a genuine anti-vaccine movement involving people who "see the world differently in terms of whether vaccines are a good thing or a bad thing," Dr. Reingold, professor of epidemiology and associate dean for research at the University of California, Berkeley, said at the International Conference on Emerging Infectious Diseases.

Photo credit: Sean Locke/iStockphoto.com

The problem of unreached children is something that increased resources and attention can certainly do a great deal to eliminate; the increasing problem of vaccine hesitancy requires something more – the building of trust, he said.

Some parents may be accepting of vaccines, but may have questions or concerns about safety. Others may reject vaccination due to religious or other personal beliefs, or they may accept some, but not all vaccinations because they believe the current schedule is "somehow an affront to the immune system," Dr. Reingold said.

"Increasingly, many parents are anxious and have questions, so we can’t assume that they will accept vaccination," he said, noting that addressing these concerns is time-consuming and challenging for the pediatrician or family doctor, but taking the time is an important aspect of building trust.

Trust-building is one of the best approaches to overcoming vaccine hesitancy, he said.

Lack of trust, along with misinformation, lack of information, and fear resulting from the belief that a child has died or been injured as a result of vaccination are the major contributors to vaccine hesitancy, he said.

Those most likely to refuse vaccination for their children are those with a higher income and mothers who are married and who have a college degree – and who have doubts about the effectiveness of vaccines, Dr. Reingold noted, adding that these are parents who "generally don’t necessarily trust the government or their physician to provide them with accurate information."

This is a very different group from those whose children are unimmunized due to lack of access, he said.

Adding to the concerns about vaccine hesitancy is the fact that several states already allow for exemptions based on religious or personal convictions, and a recent report said that seven states are weighing making it much easier to opt out.

Data show that rates of vaccine-preventable disease are higher in states that make it easy to opt out. Pertussis and measles are two examples of diseases that increase as vaccine rates decrease.

"Making it easier will certainly have effects," Dr. Reingold said.

Again, the key is trust-building, and there are approaches – as demonstrated world-wide through successful vaccination programs among initially resistant populations – that can be quite successful, he said.

He cited the polio vaccination program in India, where the disease has been eliminated.

Quite a bit of resistance was initially encountered among Muslim populations in North India, but a plan that involved community-level action and inclusion of local residents on leadership teams and as community organizers proved successful in winning support for the program.

The results in India show that compulsory vaccination – an approach that has been attempted periodically throughout the history of immunization programs – is not necessary for success.

"It is possible to build trust and to get people to accept vaccination, but it is hard work, and it takes resources," he said.

To build trust, a program requires transparency, accurate information, avoidance of financial conflicts of interest on the part of those promoting the program or a specific vaccine, a good system of monitoring and investigating adverse events, and a reasonable compensation program for those who are injured as a result of vaccination, he said.

The adverse event monitoring and investigation aspect is of particular importance given the fears that parents increasingly have regarding vaccines, and that means making the most of existing systems, including passive surveillance and the Vaccine Adverse Event Reporting System, he said.

"We know that when we give large numbers of vaccines to large numbers of children, sometimes bad things will happen shortly after they are vaccinated. ... It is very difficult to convince them, even with good epidemiologic data, that this is coincidence rather than a cause and effect relationship," Dr. Reingold said, adding, "So we do need very good programs in place to monitor adverse events, and we need to be in a position to study those events and determine whether or not there is a cause and effect relationship."

In the past, many such concerns about cause and effect have been debunked by solid, careful epidemiological study, he noted.

"But nevertheless, we need to be in a position to study these allegations and refute them with good data. ... Building and retaining trust in vaccines and their safety is critical for ensuring continued public support and acceptance of immunizations," he said.

Dr. Reingold said he had no disclosures to report.

ATLANTA – Rotavirus vaccination is significantly decreased among children without health insurance and among those whose parents did not graduate from college, according to data from the National Immunization Survey 2009.

The 2,174 children in the survey who did not have health insurance were 12% more likely to not be vaccinated than the 14,761 children in the survey who had health insurance, and the 9,322 children with a parent who did not graduate from college were 21% more likely to not be vaccinated than the 7,731 with a parent who did graduate from college, Koya C. Allen reported in a poster at the International Conference on Emerging Infectious Diseases.

The findings underscore the importance of developing educational strategies for improving access to health care among parents with lower income and lower educational attainment, said Ms. Allen, a PhD candidate at Kent (Ohio) State University.

The National Immunization Survey 2009 included more than 25,000 households. Of those, about 17,000 provided adequate data for this study, and those data indicated that rotavirus coverage among children aged 19-35 months between Jan. 6, 2009, and Feb. 10, 2010, was only 72%. Despite the unanticipated benefits of vaccination, including some herd immunity that reduced transmission and conferred protection to the unvaccinated population including older children not eligible for vaccination, it is necessary to ensure increased access to vaccine for age-appropriate children to reduce transmission rates even further, and to eliminate disparities in vaccine distribution, Ms. Allen noted.

In addition to insurance and education, the child’s age group, ethnicity, geographical region, and type of health care provider were found to be significantly associated with vaccination coverage. For example, children aged 24-29 months and 30-35 months were significantly more likely to not be vaccinated than those aged 19-23 months (odds ratios, 3.05 and 1.56, respectively), and non-Hispanic blacks, non-Hispanic whites, and multirace children all were significantly more likely to not be vaccinated than Hispanic children (OR, 1.21, 1.22, and 1.38, respectively). Those living in the South were significantly less likely to not be vaccinated than those in the Northeast (OR, 0.80), and those whose provider worked at a private facility were significantly less likely to not be vaccinated than those whose provider worked at a public facility (OR, 0.77).

The increased vaccination rate among Hispanics may be explained by geographic region or the way the categories for ethnicity were made for this study, Ms. Allen noted, adding, "The geographical region and age group associations both have plausible explanations to explain the increased probability for vaccination in the South and in younger children. The age restrictions on eligibility to receive the vaccine, in addition to introduction of the vaccine in 2006, make the highest likelihood for vaccination expected in the youngest age group. The increased probability of receiving the vaccine in the South during this time may be explained by an apparent increased incidence of rotavirus transmission in the South during the 2008-2009 seasons."

That outbreak in the South may have increased the probability of vaccination there, she explained.

This study also demonstrated interactions between the type of provider, income, and vaccination rates.

For example, individuals whose provider was at a hospital were 36% less likely to not have had insurance than those whose provider was a public facility, and individuals who had a private care provider were 52% less likely to not have insurance than those whose provider was a public facility.

"So, children whose health care provider is a public facility are more likely to have insurance and, therefore, more likely to receive the vaccination," she noted.

Also, insurance was associated with income level. Those from families making $75,000 or less per year were 4.6 times more likely not to have had insurance, compared with those making more than that, and those with an income below the poverty level were nearly 5.5 times more likely not to have had insurance than those with an income of more than $75,000 per year.

"Insurance proved to be a significant determinant of receiving vaccination, with income as a partial mediator when accounted for with other significant predictors. Further analysis should be conducted to see if this trend exists in the National Immunization Survey 2010," Ms. Allen wrote.

Further study should also look at the impact in the changing health insurance coverage for the United States on distribution of vaccine and alleviation of disparities in insurance type and access to vaccinations, she added.

In light of the Centers for Disease Control and Prevention’s recommendations that continued surveillance be conducted to determine the effects of rotavirus vaccine on rotavirus infection and disease in the United States, these findings are important, because in order to maintain adequate surveillance and to understand the effect of the vaccine, it is necessary to determine predictors for receiving the vaccine, she noted.

Ms. Allen said she had no relevant financial disclosures to report.

ATLANTA – Rotavirus vaccination is significantly decreased among children without health insurance and among those whose parents did not graduate from college, according to data from the National Immunization Survey 2009.

The 2,174 children in the survey who did not have health insurance were 12% more likely to not be vaccinated than the 14,761 children in the survey who had health insurance, and the 9,322 children with a parent who did not graduate from college were 21% more likely to not be vaccinated than the 7,731 with a parent who did graduate from college, Koya C. Allen reported in a poster at the International Conference on Emerging Infectious Diseases.

The findings underscore the importance of developing educational strategies for improving access to health care among parents with lower income and lower educational attainment, said Ms. Allen, a PhD candidate at Kent (Ohio) State University.

The National Immunization Survey 2009 included more than 25,000 households. Of those, about 17,000 provided adequate data for this study, and those data indicated that rotavirus coverage among children aged 19-35 months between Jan. 6, 2009, and Feb. 10, 2010, was only 72%. Despite the unanticipated benefits of vaccination, including some herd immunity that reduced transmission and conferred protection to the unvaccinated population including older children not eligible for vaccination, it is necessary to ensure increased access to vaccine for age-appropriate children to reduce transmission rates even further, and to eliminate disparities in vaccine distribution, Ms. Allen noted.

In addition to insurance and education, the child’s age group, ethnicity, geographical region, and type of health care provider were found to be significantly associated with vaccination coverage. For example, children aged 24-29 months and 30-35 months were significantly more likely to not be vaccinated than those aged 19-23 months (odds ratios, 3.05 and 1.56, respectively), and non-Hispanic blacks, non-Hispanic whites, and multirace children all were significantly more likely to not be vaccinated than Hispanic children (OR, 1.21, 1.22, and 1.38, respectively). Those living in the South were significantly less likely to not be vaccinated than those in the Northeast (OR, 0.80), and those whose provider worked at a private facility were significantly less likely to not be vaccinated than those whose provider worked at a public facility (OR, 0.77).

The increased vaccination rate among Hispanics may be explained by geographic region or the way the categories for ethnicity were made for this study, Ms. Allen noted, adding, "The geographical region and age group associations both have plausible explanations to explain the increased probability for vaccination in the South and in younger children. The age restrictions on eligibility to receive the vaccine, in addition to introduction of the vaccine in 2006, make the highest likelihood for vaccination expected in the youngest age group. The increased probability of receiving the vaccine in the South during this time may be explained by an apparent increased incidence of rotavirus transmission in the South during the 2008-2009 seasons."

That outbreak in the South may have increased the probability of vaccination there, she explained.

This study also demonstrated interactions between the type of provider, income, and vaccination rates.

For example, individuals whose provider was at a hospital were 36% less likely to not have had insurance than those whose provider was a public facility, and individuals who had a private care provider were 52% less likely to not have insurance than those whose provider was a public facility.

"So, children whose health care provider is a public facility are more likely to have insurance and, therefore, more likely to receive the vaccination," she noted.

Also, insurance was associated with income level. Those from families making $75,000 or less per year were 4.6 times more likely not to have had insurance, compared with those making more than that, and those with an income below the poverty level were nearly 5.5 times more likely not to have had insurance than those with an income of more than $75,000 per year.

"Insurance proved to be a significant determinant of receiving vaccination, with income as a partial mediator when accounted for with other significant predictors. Further analysis should be conducted to see if this trend exists in the National Immunization Survey 2010," Ms. Allen wrote.

Further study should also look at the impact in the changing health insurance coverage for the United States on distribution of vaccine and alleviation of disparities in insurance type and access to vaccinations, she added.

In light of the Centers for Disease Control and Prevention’s recommendations that continued surveillance be conducted to determine the effects of rotavirus vaccine on rotavirus infection and disease in the United States, these findings are important, because in order to maintain adequate surveillance and to understand the effect of the vaccine, it is necessary to determine predictors for receiving the vaccine, she noted.

Ms. Allen said she had no relevant financial disclosures to report.

ATLANTA – Rotavirus vaccination is significantly decreased among children without health insurance and among those whose parents did not graduate from college, according to data from the National Immunization Survey 2009.

The 2,174 children in the survey who did not have health insurance were 12% more likely to not be vaccinated than the 14,761 children in the survey who had health insurance, and the 9,322 children with a parent who did not graduate from college were 21% more likely to not be vaccinated than the 7,731 with a parent who did graduate from college, Koya C. Allen reported in a poster at the International Conference on Emerging Infectious Diseases.

The findings underscore the importance of developing educational strategies for improving access to health care among parents with lower income and lower educational attainment, said Ms. Allen, a PhD candidate at Kent (Ohio) State University.

The National Immunization Survey 2009 included more than 25,000 households. Of those, about 17,000 provided adequate data for this study, and those data indicated that rotavirus coverage among children aged 19-35 months between Jan. 6, 2009, and Feb. 10, 2010, was only 72%. Despite the unanticipated benefits of vaccination, including some herd immunity that reduced transmission and conferred protection to the unvaccinated population including older children not eligible for vaccination, it is necessary to ensure increased access to vaccine for age-appropriate children to reduce transmission rates even further, and to eliminate disparities in vaccine distribution, Ms. Allen noted.

In addition to insurance and education, the child’s age group, ethnicity, geographical region, and type of health care provider were found to be significantly associated with vaccination coverage. For example, children aged 24-29 months and 30-35 months were significantly more likely to not be vaccinated than those aged 19-23 months (odds ratios, 3.05 and 1.56, respectively), and non-Hispanic blacks, non-Hispanic whites, and multirace children all were significantly more likely to not be vaccinated than Hispanic children (OR, 1.21, 1.22, and 1.38, respectively). Those living in the South were significantly less likely to not be vaccinated than those in the Northeast (OR, 0.80), and those whose provider worked at a private facility were significantly less likely to not be vaccinated than those whose provider worked at a public facility (OR, 0.77).

The increased vaccination rate among Hispanics may be explained by geographic region or the way the categories for ethnicity were made for this study, Ms. Allen noted, adding, "The geographical region and age group associations both have plausible explanations to explain the increased probability for vaccination in the South and in younger children. The age restrictions on eligibility to receive the vaccine, in addition to introduction of the vaccine in 2006, make the highest likelihood for vaccination expected in the youngest age group. The increased probability of receiving the vaccine in the South during this time may be explained by an apparent increased incidence of rotavirus transmission in the South during the 2008-2009 seasons."

That outbreak in the South may have increased the probability of vaccination there, she explained.

This study also demonstrated interactions between the type of provider, income, and vaccination rates.

For example, individuals whose provider was at a hospital were 36% less likely to not have had insurance than those whose provider was a public facility, and individuals who had a private care provider were 52% less likely to not have insurance than those whose provider was a public facility.

"So, children whose health care provider is a public facility are more likely to have insurance and, therefore, more likely to receive the vaccination," she noted.

Also, insurance was associated with income level. Those from families making $75,000 or less per year were 4.6 times more likely not to have had insurance, compared with those making more than that, and those with an income below the poverty level were nearly 5.5 times more likely not to have had insurance than those with an income of more than $75,000 per year.

"Insurance proved to be a significant determinant of receiving vaccination, with income as a partial mediator when accounted for with other significant predictors. Further analysis should be conducted to see if this trend exists in the National Immunization Survey 2010," Ms. Allen wrote.

Further study should also look at the impact in the changing health insurance coverage for the United States on distribution of vaccine and alleviation of disparities in insurance type and access to vaccinations, she added.

In light of the Centers for Disease Control and Prevention’s recommendations that continued surveillance be conducted to determine the effects of rotavirus vaccine on rotavirus infection and disease in the United States, these findings are important, because in order to maintain adequate surveillance and to understand the effect of the vaccine, it is necessary to determine predictors for receiving the vaccine, she noted.

Ms. Allen said she had no relevant financial disclosures to report.

Improving immunization rates in adults is going to require a public relations overhaul.

It’s time for new approaches. We devote hundreds of millions of dollars to programs to increasing immunizations, and most are neither highly innovative nor highly successful, and yet we keep doing the same things.

In some cases, immunization coverage is actually on the decline and outbreaks of previously controlled diseases, such as measles, are occurring.

Part of the problem is a failure to recognize that people form beliefs about vaccination often on the basis of emotional and psychological reasons.

By contrast, current materials used to educate patients about immunizations rely on the language of logic and consciousness, and ignore issues of perception and reality construction. These decisions about whether an individual gets vaccinated often are made by emotional projection, rather than by reason.

Our traditional messages aimed at promoting vaccination are challenged by myths circulating on the Internet and books written by celebrities who use emotional engagement to make their arguments against vaccination.

We’re all about figures and probability; patients are about figurative language and possibilities.

The problem is particularly apparent among health care workers. Only about a third of health care workers were vaccinated against the 2009-2010 pandemic influenza virus. Many remembered the H1N1 outbreak in 1976, when some people developed Guillain-Barré syndrome after being vaccinated. The perception was that new flu vaccines are dangerous. Yet none of our educational materials about vaccines addressed this perception.

Here are 10 suggestions for improving communication with and vaccination coverage of adults:

• Make transformation, not incrementalism, the new metanarrative. There is a whole science and methodology behind innovation and transformation, and we don’t use it. Public health could formally partner with academia to design and fund Requests for Applications for explicit vaccine priority areas for which transformation is the goal.

• Build trust. No sustained progress will be made without trust. We’re clearly losing the new generation of health care providers.

Increased transparency about the process for making recommendations – including what information is and isn’t available – would be a step in the right direction for trust building.

• Use new emotive education methods. Some argue this is manipulative and "not very scientific."

We have a choice. We can continue in our analytic framework and get the results that we always have, or we can use a more of the emotive framework like the anti-vaccine group does, and get the results that they have. This may mean abandoning much of what is currently being done in favor of using more emotionally compelling advertisements instead.

Many people are innumerate, make fear-based decisions, or use heuristics. Giving these people a standard vaccine information sheet is useless.

• Move from pediatrics to geriatrics. Vaccine-preventable mortality is about 166-fold higher in adults than it is in children, and yet this fact continues to be ignored.

We are becoming a nation of older people, and we had better focus our priorities, time, and resources on understanding immunosenescence, designing vaccines against diseases that primarily afflict the elderly, improving vaccine immunogenicity and efficacy in the elderly, and funding vaccine delivery for the elderly.

• Develop a priority matrix. This matrix should be displayed on a single page, mapping strategies and tactics in an explicit fashion as informed by risks, current status, feasibility, and over-the-horizon threats.

We should develop a doctrine for how vaccines get developed and delivered. It should help us focus priorities with periodic outside review, and include progress milestones with incentives and disincentives for achieving them.

A military model, in which someone is put in charge and given authority, would be useful in this scenario.

• Build 21st-century transformation teams. Entities that are successful in achieving transformation do so by building teams of experts from relevant fields, such as designers, anthropologists, sociologists, psychologists, communication experts, and social media experts. Success also is achieved by embracing cultural trends. Take for example, the popularity of iPods and MP3 players among college students. A podcast should be developed to promote HPV vaccination in this age group.

We have to stop being afraid to stand up to celebrities who promote misinformation and pseudoscience. These people should be exposed as being dangerous to the public health. It would be useful to develop something akin to a consumer report for antivaccine websites. We need to learn how to harness social media as effectively as they have.

• Tread carefully and use incentives. Not everyone is at equal risk for every disease, so mandates in the general public should tread carefully.

In addition, real incentives and disincentives (economic or legal, for example) for acceptance or rejection of vaccines among institutions, individuals, and payors, should be considered.

• Give some attention to the concept of "personalized vaccinomics." This is a concept of personalized vaccination based on the idea that one size and dose does not fit all.

Eventually, phenotype/genotype databases will be large enough to make predictions about dosing needs (such as predicting which young women might respond to one dose of HPV vaccine, eliminating the need for all three doses), for example, so that the approach can be personalized.

• Ensure health care worker vaccine competency and compliance. Vaccine requirements for transmissible diseases among health care workers are needed, as are educational requirements for workers. A "nursing paradox" also needs to be addressed; studies suggest that while nurses spend the most time with patients and are the greatest influencers, they still tend to question the safety of vaccines more than any other health care worker category.

Several studies, including ones that I have conducted, show that there is very little in the way of vaccine education in nursing schools. It’s time to change that trend.

• Learn and utilize the science of motivation, change, and communication. This involves learning how people learn, how they think, and how they make decisions, and applying this through innovation. It also requires relentlessly exposing and rebutting dangerous and uniformed opinions for what they are.

Ample data demonstrate that we make fundamentally flawed decisions because of unconscious biases. It’s the way we’re wired. I think we would be wise to understand the role of cognitive bias and preferred cognitive styles in educating the public, and the power of emotive stories and parables.

Dr. Poland is director of the Mayo Clinic Vaccine Research Group, Rochester, Minn. He reported having relationships with the following companies: Merck, Avianax, Theraclone Sciences, Liquidia Technologies, Dynavax, PaxVax, and Novartis Vaccines and Diagnostics.

Improving immunization rates in adults is going to require a public relations overhaul.

It’s time for new approaches. We devote hundreds of millions of dollars to programs to increasing immunizations, and most are neither highly innovative nor highly successful, and yet we keep doing the same things.

In some cases, immunization coverage is actually on the decline and outbreaks of previously controlled diseases, such as measles, are occurring.

Part of the problem is a failure to recognize that people form beliefs about vaccination often on the basis of emotional and psychological reasons.

By contrast, current materials used to educate patients about immunizations rely on the language of logic and consciousness, and ignore issues of perception and reality construction. These decisions about whether an individual gets vaccinated often are made by emotional projection, rather than by reason.

Our traditional messages aimed at promoting vaccination are challenged by myths circulating on the Internet and books written by celebrities who use emotional engagement to make their arguments against vaccination.

We’re all about figures and probability; patients are about figurative language and possibilities.

The problem is particularly apparent among health care workers. Only about a third of health care workers were vaccinated against the 2009-2010 pandemic influenza virus. Many remembered the H1N1 outbreak in 1976, when some people developed Guillain-Barré syndrome after being vaccinated. The perception was that new flu vaccines are dangerous. Yet none of our educational materials about vaccines addressed this perception.

Here are 10 suggestions for improving communication with and vaccination coverage of adults:

• Make transformation, not incrementalism, the new metanarrative. There is a whole science and methodology behind innovation and transformation, and we don’t use it. Public health could formally partner with academia to design and fund Requests for Applications for explicit vaccine priority areas for which transformation is the goal.

• Build trust. No sustained progress will be made without trust. We’re clearly losing the new generation of health care providers.

Increased transparency about the process for making recommendations – including what information is and isn’t available – would be a step in the right direction for trust building.

• Use new emotive education methods. Some argue this is manipulative and "not very scientific."

We have a choice. We can continue in our analytic framework and get the results that we always have, or we can use a more of the emotive framework like the anti-vaccine group does, and get the results that they have. This may mean abandoning much of what is currently being done in favor of using more emotionally compelling advertisements instead.

Many people are innumerate, make fear-based decisions, or use heuristics. Giving these people a standard vaccine information sheet is useless.

• Move from pediatrics to geriatrics. Vaccine-preventable mortality is about 166-fold higher in adults than it is in children, and yet this fact continues to be ignored.

We are becoming a nation of older people, and we had better focus our priorities, time, and resources on understanding immunosenescence, designing vaccines against diseases that primarily afflict the elderly, improving vaccine immunogenicity and efficacy in the elderly, and funding vaccine delivery for the elderly.

• Develop a priority matrix. This matrix should be displayed on a single page, mapping strategies and tactics in an explicit fashion as informed by risks, current status, feasibility, and over-the-horizon threats.

We should develop a doctrine for how vaccines get developed and delivered. It should help us focus priorities with periodic outside review, and include progress milestones with incentives and disincentives for achieving them.

A military model, in which someone is put in charge and given authority, would be useful in this scenario.

• Build 21st-century transformation teams. Entities that are successful in achieving transformation do so by building teams of experts from relevant fields, such as designers, anthropologists, sociologists, psychologists, communication experts, and social media experts. Success also is achieved by embracing cultural trends. Take for example, the popularity of iPods and MP3 players among college students. A podcast should be developed to promote HPV vaccination in this age group.

We have to stop being afraid to stand up to celebrities who promote misinformation and pseudoscience. These people should be exposed as being dangerous to the public health. It would be useful to develop something akin to a consumer report for antivaccine websites. We need to learn how to harness social media as effectively as they have.

• Tread carefully and use incentives. Not everyone is at equal risk for every disease, so mandates in the general public should tread carefully.

In addition, real incentives and disincentives (economic or legal, for example) for acceptance or rejection of vaccines among institutions, individuals, and payors, should be considered.

• Give some attention to the concept of "personalized vaccinomics." This is a concept of personalized vaccination based on the idea that one size and dose does not fit all.

Eventually, phenotype/genotype databases will be large enough to make predictions about dosing needs (such as predicting which young women might respond to one dose of HPV vaccine, eliminating the need for all three doses), for example, so that the approach can be personalized.

• Ensure health care worker vaccine competency and compliance. Vaccine requirements for transmissible diseases among health care workers are needed, as are educational requirements for workers. A "nursing paradox" also needs to be addressed; studies suggest that while nurses spend the most time with patients and are the greatest influencers, they still tend to question the safety of vaccines more than any other health care worker category.

Several studies, including ones that I have conducted, show that there is very little in the way of vaccine education in nursing schools. It’s time to change that trend.

• Learn and utilize the science of motivation, change, and communication. This involves learning how people learn, how they think, and how they make decisions, and applying this through innovation. It also requires relentlessly exposing and rebutting dangerous and uniformed opinions for what they are.

Ample data demonstrate that we make fundamentally flawed decisions because of unconscious biases. It’s the way we’re wired. I think we would be wise to understand the role of cognitive bias and preferred cognitive styles in educating the public, and the power of emotive stories and parables.

Dr. Poland is director of the Mayo Clinic Vaccine Research Group, Rochester, Minn. He reported having relationships with the following companies: Merck, Avianax, Theraclone Sciences, Liquidia Technologies, Dynavax, PaxVax, and Novartis Vaccines and Diagnostics.

Improving immunization rates in adults is going to require a public relations overhaul.

It’s time for new approaches. We devote hundreds of millions of dollars to programs to increasing immunizations, and most are neither highly innovative nor highly successful, and yet we keep doing the same things.

In some cases, immunization coverage is actually on the decline and outbreaks of previously controlled diseases, such as measles, are occurring.

Part of the problem is a failure to recognize that people form beliefs about vaccination often on the basis of emotional and psychological reasons.

By contrast, current materials used to educate patients about immunizations rely on the language of logic and consciousness, and ignore issues of perception and reality construction. These decisions about whether an individual gets vaccinated often are made by emotional projection, rather than by reason.

Our traditional messages aimed at promoting vaccination are challenged by myths circulating on the Internet and books written by celebrities who use emotional engagement to make their arguments against vaccination.

We’re all about figures and probability; patients are about figurative language and possibilities.

The problem is particularly apparent among health care workers. Only about a third of health care workers were vaccinated against the 2009-2010 pandemic influenza virus. Many remembered the H1N1 outbreak in 1976, when some people developed Guillain-Barré syndrome after being vaccinated. The perception was that new flu vaccines are dangerous. Yet none of our educational materials about vaccines addressed this perception.

Here are 10 suggestions for improving communication with and vaccination coverage of adults:

• Make transformation, not incrementalism, the new metanarrative. There is a whole science and methodology behind innovation and transformation, and we don’t use it. Public health could formally partner with academia to design and fund Requests for Applications for explicit vaccine priority areas for which transformation is the goal.

• Build trust. No sustained progress will be made without trust. We’re clearly losing the new generation of health care providers.

Increased transparency about the process for making recommendations – including what information is and isn’t available – would be a step in the right direction for trust building.

• Use new emotive education methods. Some argue this is manipulative and "not very scientific."

We have a choice. We can continue in our analytic framework and get the results that we always have, or we can use a more of the emotive framework like the anti-vaccine group does, and get the results that they have. This may mean abandoning much of what is currently being done in favor of using more emotionally compelling advertisements instead.

Many people are innumerate, make fear-based decisions, or use heuristics. Giving these people a standard vaccine information sheet is useless.

• Move from pediatrics to geriatrics. Vaccine-preventable mortality is about 166-fold higher in adults than it is in children, and yet this fact continues to be ignored.

We are becoming a nation of older people, and we had better focus our priorities, time, and resources on understanding immunosenescence, designing vaccines against diseases that primarily afflict the elderly, improving vaccine immunogenicity and efficacy in the elderly, and funding vaccine delivery for the elderly.

• Develop a priority matrix. This matrix should be displayed on a single page, mapping strategies and tactics in an explicit fashion as informed by risks, current status, feasibility, and over-the-horizon threats.

We should develop a doctrine for how vaccines get developed and delivered. It should help us focus priorities with periodic outside review, and include progress milestones with incentives and disincentives for achieving them.

A military model, in which someone is put in charge and given authority, would be useful in this scenario.

• Build 21st-century transformation teams. Entities that are successful in achieving transformation do so by building teams of experts from relevant fields, such as designers, anthropologists, sociologists, psychologists, communication experts, and social media experts. Success also is achieved by embracing cultural trends. Take for example, the popularity of iPods and MP3 players among college students. A podcast should be developed to promote HPV vaccination in this age group.

We have to stop being afraid to stand up to celebrities who promote misinformation and pseudoscience. These people should be exposed as being dangerous to the public health. It would be useful to develop something akin to a consumer report for antivaccine websites. We need to learn how to harness social media as effectively as they have.

• Tread carefully and use incentives. Not everyone is at equal risk for every disease, so mandates in the general public should tread carefully.

In addition, real incentives and disincentives (economic or legal, for example) for acceptance or rejection of vaccines among institutions, individuals, and payors, should be considered.

• Give some attention to the concept of "personalized vaccinomics." This is a concept of personalized vaccination based on the idea that one size and dose does not fit all.

Eventually, phenotype/genotype databases will be large enough to make predictions about dosing needs (such as predicting which young women might respond to one dose of HPV vaccine, eliminating the need for all three doses), for example, so that the approach can be personalized.

• Ensure health care worker vaccine competency and compliance. Vaccine requirements for transmissible diseases among health care workers are needed, as are educational requirements for workers. A "nursing paradox" also needs to be addressed; studies suggest that while nurses spend the most time with patients and are the greatest influencers, they still tend to question the safety of vaccines more than any other health care worker category.

Several studies, including ones that I have conducted, show that there is very little in the way of vaccine education in nursing schools. It’s time to change that trend.

• Learn and utilize the science of motivation, change, and communication. This involves learning how people learn, how they think, and how they make decisions, and applying this through innovation. It also requires relentlessly exposing and rebutting dangerous and uniformed opinions for what they are.

Ample data demonstrate that we make fundamentally flawed decisions because of unconscious biases. It’s the way we’re wired. I think we would be wise to understand the role of cognitive bias and preferred cognitive styles in educating the public, and the power of emotive stories and parables.

Dr. Poland is director of the Mayo Clinic Vaccine Research Group, Rochester, Minn. He reported having relationships with the following companies: Merck, Avianax, Theraclone Sciences, Liquidia Technologies, Dynavax, PaxVax, and Novartis Vaccines and Diagnostics.

ATLANTA – Vaccination rates increased dramatically and influenza rates decreased dramatically in children aged 6 months to 4 years in Connecticut following institution of a 2011 influenza vaccination requirement for children enrolled in day care, according to surveillance data.

Vaccination rates in this age group during the 2010-2011 influenza season, which was an H3N2-dominant season, were 85%, compared with 54% in 2009-2010, Kimberly Yousey-Hindes reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo © Yarinca/istockphoto.com

Also, the proportion of all emergency department visits for influenza and influenzalike illness was 30% in 2011, compared with 34% in 2008 (the most recent prior H3N2 dominant influenza season), representing a significant decrease, said Ms. Yousey-Hindes, influenza program coordinator for the Connecticut Emerging Infectious Program at Yale University.

"When compared to the 2007-2008 season, among those hospitalized with influenza, the proportion of patients 6 months to 4 years decreased as well (13% vs. 10%)," she wrote, noting that the proportion of laboratory-confirmed influenza cases also decreased ... during the same time period. Both declines were statistically significant.

Vaccination was required effective Jan. 1, 2011, for all children aged 6 months to 59 months who were enrolled in a licensed Connecticut day care. This study used data from the Connecticut Hospital Emergency Department Syndromic Surveillance system, the Connecticut Emerging Infectious Programs’ Influenza-Associated Hospitalization Surveillance system, and influenza reports to the state reportable disease database to measure the impact of the new rule.

An estimated 60% of preschool-age children receive nonparental care each week, mostly in child care centers, suggesting that vaccination of these children could have population-level effects, Ms. Yousey-Hindes noted.

Ms. Yousey-Hindes had no conflicts of interest to report.

ATLANTA – Vaccination rates increased dramatically and influenza rates decreased dramatically in children aged 6 months to 4 years in Connecticut following institution of a 2011 influenza vaccination requirement for children enrolled in day care, according to surveillance data.

Vaccination rates in this age group during the 2010-2011 influenza season, which was an H3N2-dominant season, were 85%, compared with 54% in 2009-2010, Kimberly Yousey-Hindes reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo © Yarinca/istockphoto.com

Also, the proportion of all emergency department visits for influenza and influenzalike illness was 30% in 2011, compared with 34% in 2008 (the most recent prior H3N2 dominant influenza season), representing a significant decrease, said Ms. Yousey-Hindes, influenza program coordinator for the Connecticut Emerging Infectious Program at Yale University.

"When compared to the 2007-2008 season, among those hospitalized with influenza, the proportion of patients 6 months to 4 years decreased as well (13% vs. 10%)," she wrote, noting that the proportion of laboratory-confirmed influenza cases also decreased ... during the same time period. Both declines were statistically significant.

Vaccination was required effective Jan. 1, 2011, for all children aged 6 months to 59 months who were enrolled in a licensed Connecticut day care. This study used data from the Connecticut Hospital Emergency Department Syndromic Surveillance system, the Connecticut Emerging Infectious Programs’ Influenza-Associated Hospitalization Surveillance system, and influenza reports to the state reportable disease database to measure the impact of the new rule.

An estimated 60% of preschool-age children receive nonparental care each week, mostly in child care centers, suggesting that vaccination of these children could have population-level effects, Ms. Yousey-Hindes noted.

Ms. Yousey-Hindes had no conflicts of interest to report.

ATLANTA – Vaccination rates increased dramatically and influenza rates decreased dramatically in children aged 6 months to 4 years in Connecticut following institution of a 2011 influenza vaccination requirement for children enrolled in day care, according to surveillance data.

Vaccination rates in this age group during the 2010-2011 influenza season, which was an H3N2-dominant season, were 85%, compared with 54% in 2009-2010, Kimberly Yousey-Hindes reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo © Yarinca/istockphoto.com

Also, the proportion of all emergency department visits for influenza and influenzalike illness was 30% in 2011, compared with 34% in 2008 (the most recent prior H3N2 dominant influenza season), representing a significant decrease, said Ms. Yousey-Hindes, influenza program coordinator for the Connecticut Emerging Infectious Program at Yale University.

"When compared to the 2007-2008 season, among those hospitalized with influenza, the proportion of patients 6 months to 4 years decreased as well (13% vs. 10%)," she wrote, noting that the proportion of laboratory-confirmed influenza cases also decreased ... during the same time period. Both declines were statistically significant.

Vaccination was required effective Jan. 1, 2011, for all children aged 6 months to 59 months who were enrolled in a licensed Connecticut day care. This study used data from the Connecticut Hospital Emergency Department Syndromic Surveillance system, the Connecticut Emerging Infectious Programs’ Influenza-Associated Hospitalization Surveillance system, and influenza reports to the state reportable disease database to measure the impact of the new rule.

An estimated 60% of preschool-age children receive nonparental care each week, mostly in child care centers, suggesting that vaccination of these children could have population-level effects, Ms. Yousey-Hindes noted.

Ms. Yousey-Hindes had no conflicts of interest to report.

ATLANTA – Initiation and completion of the human papillomavirus quadrivalent vaccination series is very low among active servicewomen in the United States Armed Forces, according to findings from the Defense Medical Surveillance System.

The findings are concerning, because HPV is the most common sexually transmitted infection among U.S. service members, Dr. Hala Nsouli-Maktabi reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo courtesy National Cancer Institute

Of 270,257 active servicewoman who were eligible for vaccination between January, 2006 and June, 2011, only 60,807 (22.5%) initiated the vaccination series, receiving at least one of three doses. Of the 51,924 who remained active and eligible for vaccination at least 6 months after the initial dose, 31.8% received only the first dose, 22.7% received only two doses and 45.5% completed the series, said Dr. Nsouli-Maktabi of the Henry M. Jackson Foundation, Bethesda, Md.

Of those who did not complete the series by 6 months, 47,250 (16.8%) did complete it at 1 year. Those most likely to complete the series, either at 6 months or at 1 year, included Hispanics, blacks, never-married women, officers, younger women, women with higher education, and women with fewer sexually transmitted infections, she noted.

"Consistent with the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommendations, the Department of Defense recommends routine HPV vaccination of eligible service members aged 17-26 years with the three-dose series administered over 6 months," Dr. Nsouli-Maktabi wrote.

This study was undertaken in response to anecdotal reports that vaccination remained low despite the availability of HPV4 vaccine, and the findings confirm these reports, she said, concluding that the findings indicate a need for increased education of servicewomen and providers about the benefits of vaccination.

Such education may increase HPV4 coverage and enhance series completion, she concluded.

ATLANTA – Initiation and completion of the human papillomavirus quadrivalent vaccination series is very low among active servicewomen in the United States Armed Forces, according to findings from the Defense Medical Surveillance System.

The findings are concerning, because HPV is the most common sexually transmitted infection among U.S. service members, Dr. Hala Nsouli-Maktabi reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo courtesy National Cancer Institute

Of 270,257 active servicewoman who were eligible for vaccination between January, 2006 and June, 2011, only 60,807 (22.5%) initiated the vaccination series, receiving at least one of three doses. Of the 51,924 who remained active and eligible for vaccination at least 6 months after the initial dose, 31.8% received only the first dose, 22.7% received only two doses and 45.5% completed the series, said Dr. Nsouli-Maktabi of the Henry M. Jackson Foundation, Bethesda, Md.

Of those who did not complete the series by 6 months, 47,250 (16.8%) did complete it at 1 year. Those most likely to complete the series, either at 6 months or at 1 year, included Hispanics, blacks, never-married women, officers, younger women, women with higher education, and women with fewer sexually transmitted infections, she noted.

"Consistent with the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommendations, the Department of Defense recommends routine HPV vaccination of eligible service members aged 17-26 years with the three-dose series administered over 6 months," Dr. Nsouli-Maktabi wrote.

This study was undertaken in response to anecdotal reports that vaccination remained low despite the availability of HPV4 vaccine, and the findings confirm these reports, she said, concluding that the findings indicate a need for increased education of servicewomen and providers about the benefits of vaccination.

Such education may increase HPV4 coverage and enhance series completion, she concluded.

ATLANTA – Initiation and completion of the human papillomavirus quadrivalent vaccination series is very low among active servicewomen in the United States Armed Forces, according to findings from the Defense Medical Surveillance System.

The findings are concerning, because HPV is the most common sexually transmitted infection among U.S. service members, Dr. Hala Nsouli-Maktabi reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo courtesy National Cancer Institute

Of 270,257 active servicewoman who were eligible for vaccination between January, 2006 and June, 2011, only 60,807 (22.5%) initiated the vaccination series, receiving at least one of three doses. Of the 51,924 who remained active and eligible for vaccination at least 6 months after the initial dose, 31.8% received only the first dose, 22.7% received only two doses and 45.5% completed the series, said Dr. Nsouli-Maktabi of the Henry M. Jackson Foundation, Bethesda, Md.

Of those who did not complete the series by 6 months, 47,250 (16.8%) did complete it at 1 year. Those most likely to complete the series, either at 6 months or at 1 year, included Hispanics, blacks, never-married women, officers, younger women, women with higher education, and women with fewer sexually transmitted infections, she noted.

"Consistent with the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommendations, the Department of Defense recommends routine HPV vaccination of eligible service members aged 17-26 years with the three-dose series administered over 6 months," Dr. Nsouli-Maktabi wrote.

This study was undertaken in response to anecdotal reports that vaccination remained low despite the availability of HPV4 vaccine, and the findings confirm these reports, she said, concluding that the findings indicate a need for increased education of servicewomen and providers about the benefits of vaccination.

Such education may increase HPV4 coverage and enhance series completion, she concluded.

ATLANTA – A large proportion of children apparently are not receiving the 13-valent pneumococcal conjugate vaccine as recommended by the Advisory Committee on Immunization Practices, surveillance data from the Centers for Disease Control and Prevention suggest.

According to the data from an ongoing evaluation of PCV13 vaccine effectiveness, 86 (78%) vaccine-eligible children out of 110 diagnosed with invasive pneumococcal disease secondary to serotypes unique to PCV13 in the year after the vaccine was introduced had not received the dosing recommended by the Advisory Committee on Immunization Practices (ACIP), Dr. Chad M. Cox reported at the International Conference on Emerging Infectious Diseases.

The ACIP recommendations, published March 12, 2010, call for the same dosing schedule used for PCV7 (immunizations at ages 2, 4, and 6 months, with a booster dose at age 12-15 months). ACIP also called for a single supplemental dose of PCV13 in all children aged 14-59 months who previously received an age-appropriate series of PCV7, and for use of PCV13 for the fourth dose in those who had received only three of the four previously recommended doses of PCV7.

PCV13 includes six additional serotypes not included in PCV7, which was introduced in 2000 using the seven most commonly circulating serotypes.

After the introduction of PCV7, a sharp decrease occurred in disease caused by these seven serotypes, but in more recent years an increase was seen in disease caused by serotypes not covered by PC7. Because of the emergence of this "replacement disease," PCV13 was introduced, Dr. Cox explained.

"The [PCV13] vaccine was readily available soon after [the March 2010 ACIP recommendations], and quickly replaced PCV7 in most provider’s offices," said Dr. Cox of the CDC in Atlanta.

Nonetheless, in June 2011 the California Department of Health reported a fatal case of invasive pneumococcal disease in a 2-year-old, which was caused by a serotype in the PCV13 vaccine; 30 additional cases were identified in counties not included in the CDC surveillance area.

This led to a health advisory issued in August 2011 – reminding providers of the ACIP recommendations – and to this study of outcomes in 10 participating surveillance areas representing 3.8 million children under age 5 years.

The hospitalized children in this study included those from the surveillance areas for whom complete vaccination information was available. About two-thirds were aged 2-4 years, Dr. Cox said.

About two-thirds of patients in the study were noncompliant because they had not received a supplemental PCV13 dose after completion of the PCV7 series, and about one-fifth had not received the fourth dose in the series, which should have been a PCV13 dose, he noted.

The majority of the children (93%) had no underlying medical conditions, and 79% were hospitalized. No deaths occurred.

These findings demonstrate that invasive pneumococcal disease resulting from pneumococcal serotyopes unique to PCV13 continued to occur in those who did not receive the recommended dose of PCV13 in the year after it became available, Dr. Cox said.

Prevention of invasive pneumococcal disease requires that a single supplemental dose of PCV13 be given to all children aged 14-59 months who have received an age-appropriate series of PCV7, he said. Efforts have been made, using these and other CDC data, to better educate health care professionals about the ACIP recommendations.

"This is something we continue to watch," he said, noting that the vaccine effectiveness evaluation will continue for 2 more years.

Dr. Cox said that he had no relevant financial disclosures to report.

ATLANTA – A large proportion of children apparently are not receiving the 13-valent pneumococcal conjugate vaccine as recommended by the Advisory Committee on Immunization Practices, surveillance data from the Centers for Disease Control and Prevention suggest.

According to the data from an ongoing evaluation of PCV13 vaccine effectiveness, 86 (78%) vaccine-eligible children out of 110 diagnosed with invasive pneumococcal disease secondary to serotypes unique to PCV13 in the year after the vaccine was introduced had not received the dosing recommended by the Advisory Committee on Immunization Practices (ACIP), Dr. Chad M. Cox reported at the International Conference on Emerging Infectious Diseases.

The ACIP recommendations, published March 12, 2010, call for the same dosing schedule used for PCV7 (immunizations at ages 2, 4, and 6 months, with a booster dose at age 12-15 months). ACIP also called for a single supplemental dose of PCV13 in all children aged 14-59 months who previously received an age-appropriate series of PCV7, and for use of PCV13 for the fourth dose in those who had received only three of the four previously recommended doses of PCV7.

PCV13 includes six additional serotypes not included in PCV7, which was introduced in 2000 using the seven most commonly circulating serotypes.

After the introduction of PCV7, a sharp decrease occurred in disease caused by these seven serotypes, but in more recent years an increase was seen in disease caused by serotypes not covered by PC7. Because of the emergence of this "replacement disease," PCV13 was introduced, Dr. Cox explained.

"The [PCV13] vaccine was readily available soon after [the March 2010 ACIP recommendations], and quickly replaced PCV7 in most provider’s offices," said Dr. Cox of the CDC in Atlanta.

Nonetheless, in June 2011 the California Department of Health reported a fatal case of invasive pneumococcal disease in a 2-year-old, which was caused by a serotype in the PCV13 vaccine; 30 additional cases were identified in counties not included in the CDC surveillance area.

This led to a health advisory issued in August 2011 – reminding providers of the ACIP recommendations – and to this study of outcomes in 10 participating surveillance areas representing 3.8 million children under age 5 years.

The hospitalized children in this study included those from the surveillance areas for whom complete vaccination information was available. About two-thirds were aged 2-4 years, Dr. Cox said.

About two-thirds of patients in the study were noncompliant because they had not received a supplemental PCV13 dose after completion of the PCV7 series, and about one-fifth had not received the fourth dose in the series, which should have been a PCV13 dose, he noted.

The majority of the children (93%) had no underlying medical conditions, and 79% were hospitalized. No deaths occurred.

These findings demonstrate that invasive pneumococcal disease resulting from pneumococcal serotyopes unique to PCV13 continued to occur in those who did not receive the recommended dose of PCV13 in the year after it became available, Dr. Cox said.

Prevention of invasive pneumococcal disease requires that a single supplemental dose of PCV13 be given to all children aged 14-59 months who have received an age-appropriate series of PCV7, he said. Efforts have been made, using these and other CDC data, to better educate health care professionals about the ACIP recommendations.

"This is something we continue to watch," he said, noting that the vaccine effectiveness evaluation will continue for 2 more years.

Dr. Cox said that he had no relevant financial disclosures to report.

ATLANTA – A large proportion of children apparently are not receiving the 13-valent pneumococcal conjugate vaccine as recommended by the Advisory Committee on Immunization Practices, surveillance data from the Centers for Disease Control and Prevention suggest.

According to the data from an ongoing evaluation of PCV13 vaccine effectiveness, 86 (78%) vaccine-eligible children out of 110 diagnosed with invasive pneumococcal disease secondary to serotypes unique to PCV13 in the year after the vaccine was introduced had not received the dosing recommended by the Advisory Committee on Immunization Practices (ACIP), Dr. Chad M. Cox reported at the International Conference on Emerging Infectious Diseases.

The ACIP recommendations, published March 12, 2010, call for the same dosing schedule used for PCV7 (immunizations at ages 2, 4, and 6 months, with a booster dose at age 12-15 months). ACIP also called for a single supplemental dose of PCV13 in all children aged 14-59 months who previously received an age-appropriate series of PCV7, and for use of PCV13 for the fourth dose in those who had received only three of the four previously recommended doses of PCV7.

PCV13 includes six additional serotypes not included in PCV7, which was introduced in 2000 using the seven most commonly circulating serotypes.

After the introduction of PCV7, a sharp decrease occurred in disease caused by these seven serotypes, but in more recent years an increase was seen in disease caused by serotypes not covered by PC7. Because of the emergence of this "replacement disease," PCV13 was introduced, Dr. Cox explained.

"The [PCV13] vaccine was readily available soon after [the March 2010 ACIP recommendations], and quickly replaced PCV7 in most provider’s offices," said Dr. Cox of the CDC in Atlanta.

Nonetheless, in June 2011 the California Department of Health reported a fatal case of invasive pneumococcal disease in a 2-year-old, which was caused by a serotype in the PCV13 vaccine; 30 additional cases were identified in counties not included in the CDC surveillance area.

This led to a health advisory issued in August 2011 – reminding providers of the ACIP recommendations – and to this study of outcomes in 10 participating surveillance areas representing 3.8 million children under age 5 years.

The hospitalized children in this study included those from the surveillance areas for whom complete vaccination information was available. About two-thirds were aged 2-4 years, Dr. Cox said.

About two-thirds of patients in the study were noncompliant because they had not received a supplemental PCV13 dose after completion of the PCV7 series, and about one-fifth had not received the fourth dose in the series, which should have been a PCV13 dose, he noted.

The majority of the children (93%) had no underlying medical conditions, and 79% were hospitalized. No deaths occurred.

These findings demonstrate that invasive pneumococcal disease resulting from pneumococcal serotyopes unique to PCV13 continued to occur in those who did not receive the recommended dose of PCV13 in the year after it became available, Dr. Cox said.

Prevention of invasive pneumococcal disease requires that a single supplemental dose of PCV13 be given to all children aged 14-59 months who have received an age-appropriate series of PCV7, he said. Efforts have been made, using these and other CDC data, to better educate health care professionals about the ACIP recommendations.

"This is something we continue to watch," he said, noting that the vaccine effectiveness evaluation will continue for 2 more years.

Dr. Cox said that he had no relevant financial disclosures to report.

ATLANTA – The risk of dengue remains a concern for residents of the United States who travel to the tropics, and the disease burden may be underestimated, surveillance data suggest.

Between 2005 and 2010, 1,697 laboratory-positive cases were reported to the Centers for Disease Control and Prevention’s arbovirus surveillance system (ArboNET) and/or to the CDC dengue branch, for an annual average of 285 cases. A substantial number of cases occurred in New York City and in Florida, and most travelers failed to take precautionary measures when traveling to endemic areas, according to data presented at the International Conference on Emerging Infectious Diseases.

CDC/James Gathany

Furthermore, when the estimated number of cases derived from laboratory testing data was compared with the number of laboratory-positive cases, there was a fourfold degree of underreporting, Dr. D. Fermin Arguello of the CDC, San Juan, Puerto Rico reported in a poster at the conference.

The CDC data indicated that half of the cases occurred in travelers to the Dominican Republic, Puerto Rico, India, Mexico, or Haiti.

Data from the New York City Department of Health and Mental Hygiene showed that between 2001 and 2009 the annual average was 36 cases, but that in 2010, when a global dengue epidemic occurred, 144 cases were identified, according to Brooke Bregman of the department.

This was more than any other single year, she pointed out.

Cases in New York also frequently occurred in travelers to the Dominican Republic and Puerto Rico. In fact, most cases there (68%) were associated with travel to the Caribbean. Others were associated with travel to Southeast Asia (13%), and South America (10%), Ms. Bregman said.

The New York data indicated that, although 81% of patients recalled being bitten by mosquitoes, only 29% reported using mosquito repellent and only 14% used a bed net.

Only 10% sought medical advice before traveling, Ms. Bregman said, noting that effective strategies are needed to encourage travelers to adopt protective measures.

Dr. Arguello agreed, noting also that travelers should seek pre-travel consultation, minimize mosquito exposure while traveling, and seek medical attention if they develop a fever either during travel or soon after return from travel.

He also noted a need for improvements in national surveillance reporting to determine the risk and impact of dengue in U.S. travelers.

In another poster presented at the conference, researchers noted that educational strategies do have a beneficial impact.

A 2011 population-based evaluation of knowledge, attitudes, and behaviors toward dengue prevention in Key West showed that of 526 households evaluated, more than 80% were able to identify infected mosquitoes as the transition mode for dengue, and standing water as an important source for the mosquito vector, according to Emily Zielinski-Gutiérrez, DrPH of the CDC, Fort Collins, Colo.

Respondents who reported being exposed to dengue educational messages were significantly more knowledgeable about the disease than were those with no recall of exposure to such messages, according to scores on a dengue knowledge scale, she said.

The Florida Keys Mosquito Control District and local newspaper articles were the most frequently cited sources of information about dengue.

This study highlighted areas where more effort is needed, however; less than half of the respondents were aware that some patients in Key West had been hospitalized for dengue, and a third could not name specific symptoms of dengue illness, Dr. Zielinski-Gutiérrez reported.

None of the authors had disclosures to report.

ATLANTA – The risk of dengue remains a concern for residents of the United States who travel to the tropics, and the disease burden may be underestimated, surveillance data suggest.

Between 2005 and 2010, 1,697 laboratory-positive cases were reported to the Centers for Disease Control and Prevention’s arbovirus surveillance system (ArboNET) and/or to the CDC dengue branch, for an annual average of 285 cases. A substantial number of cases occurred in New York City and in Florida, and most travelers failed to take precautionary measures when traveling to endemic areas, according to data presented at the International Conference on Emerging Infectious Diseases.

CDC/James Gathany

Furthermore, when the estimated number of cases derived from laboratory testing data was compared with the number of laboratory-positive cases, there was a fourfold degree of underreporting, Dr. D. Fermin Arguello of the CDC, San Juan, Puerto Rico reported in a poster at the conference.

The CDC data indicated that half of the cases occurred in travelers to the Dominican Republic, Puerto Rico, India, Mexico, or Haiti.

Data from the New York City Department of Health and Mental Hygiene showed that between 2001 and 2009 the annual average was 36 cases, but that in 2010, when a global dengue epidemic occurred, 144 cases were identified, according to Brooke Bregman of the department.

This was more than any other single year, she pointed out.

Cases in New York also frequently occurred in travelers to the Dominican Republic and Puerto Rico. In fact, most cases there (68%) were associated with travel to the Caribbean. Others were associated with travel to Southeast Asia (13%), and South America (10%), Ms. Bregman said.

The New York data indicated that, although 81% of patients recalled being bitten by mosquitoes, only 29% reported using mosquito repellent and only 14% used a bed net.

Only 10% sought medical advice before traveling, Ms. Bregman said, noting that effective strategies are needed to encourage travelers to adopt protective measures.

Dr. Arguello agreed, noting also that travelers should seek pre-travel consultation, minimize mosquito exposure while traveling, and seek medical attention if they develop a fever either during travel or soon after return from travel.

He also noted a need for improvements in national surveillance reporting to determine the risk and impact of dengue in U.S. travelers.

In another poster presented at the conference, researchers noted that educational strategies do have a beneficial impact.

A 2011 population-based evaluation of knowledge, attitudes, and behaviors toward dengue prevention in Key West showed that of 526 households evaluated, more than 80% were able to identify infected mosquitoes as the transition mode for dengue, and standing water as an important source for the mosquito vector, according to Emily Zielinski-Gutiérrez, DrPH of the CDC, Fort Collins, Colo.

Respondents who reported being exposed to dengue educational messages were significantly more knowledgeable about the disease than were those with no recall of exposure to such messages, according to scores on a dengue knowledge scale, she said.

The Florida Keys Mosquito Control District and local newspaper articles were the most frequently cited sources of information about dengue.

This study highlighted areas where more effort is needed, however; less than half of the respondents were aware that some patients in Key West had been hospitalized for dengue, and a third could not name specific symptoms of dengue illness, Dr. Zielinski-Gutiérrez reported.

None of the authors had disclosures to report.

ATLANTA – The risk of dengue remains a concern for residents of the United States who travel to the tropics, and the disease burden may be underestimated, surveillance data suggest.

Between 2005 and 2010, 1,697 laboratory-positive cases were reported to the Centers for Disease Control and Prevention’s arbovirus surveillance system (ArboNET) and/or to the CDC dengue branch, for an annual average of 285 cases. A substantial number of cases occurred in New York City and in Florida, and most travelers failed to take precautionary measures when traveling to endemic areas, according to data presented at the International Conference on Emerging Infectious Diseases.

CDC/James Gathany

Furthermore, when the estimated number of cases derived from laboratory testing data was compared with the number of laboratory-positive cases, there was a fourfold degree of underreporting, Dr. D. Fermin Arguello of the CDC, San Juan, Puerto Rico reported in a poster at the conference.

The CDC data indicated that half of the cases occurred in travelers to the Dominican Republic, Puerto Rico, India, Mexico, or Haiti.

Data from the New York City Department of Health and Mental Hygiene showed that between 2001 and 2009 the annual average was 36 cases, but that in 2010, when a global dengue epidemic occurred, 144 cases were identified, according to Brooke Bregman of the department.

This was more than any other single year, she pointed out.

Cases in New York also frequently occurred in travelers to the Dominican Republic and Puerto Rico. In fact, most cases there (68%) were associated with travel to the Caribbean. Others were associated with travel to Southeast Asia (13%), and South America (10%), Ms. Bregman said.

The New York data indicated that, although 81% of patients recalled being bitten by mosquitoes, only 29% reported using mosquito repellent and only 14% used a bed net.

Only 10% sought medical advice before traveling, Ms. Bregman said, noting that effective strategies are needed to encourage travelers to adopt protective measures.

Dr. Arguello agreed, noting also that travelers should seek pre-travel consultation, minimize mosquito exposure while traveling, and seek medical attention if they develop a fever either during travel or soon after return from travel.

He also noted a need for improvements in national surveillance reporting to determine the risk and impact of dengue in U.S. travelers.

In another poster presented at the conference, researchers noted that educational strategies do have a beneficial impact.

A 2011 population-based evaluation of knowledge, attitudes, and behaviors toward dengue prevention in Key West showed that of 526 households evaluated, more than 80% were able to identify infected mosquitoes as the transition mode for dengue, and standing water as an important source for the mosquito vector, according to Emily Zielinski-Gutiérrez, DrPH of the CDC, Fort Collins, Colo.

Respondents who reported being exposed to dengue educational messages were significantly more knowledgeable about the disease than were those with no recall of exposure to such messages, according to scores on a dengue knowledge scale, she said.

The Florida Keys Mosquito Control District and local newspaper articles were the most frequently cited sources of information about dengue.

This study highlighted areas where more effort is needed, however; less than half of the respondents were aware that some patients in Key West had been hospitalized for dengue, and a third could not name specific symptoms of dengue illness, Dr. Zielinski-Gutiérrez reported.

None of the authors had disclosures to report.

ATLANTA – People who take antacid therapy, the elderly, and individuals who reside in long-term care facilities are at increased risk of recurrent Clostridium difficile infections, according to data from the Connecticut Emerging Infections Program.

Of 826 children and adults with an initial incident episode of C. difficile infection, 130 (16%) had at least one recurrence. Those with vs. without recurrence were significantly older (75.1 vs. 69.9 years), and significantly more likely to reside in a long-term care facility (53% vs. 40%), Blanca Paccha reported in a poster at the International Conference on Emerging Infectious Diseases.

Individuals with recurrence were more likely than those without recurrence to be taking H₂ blockers (10% vs. 3%), reported Ms. Paccha, a research assistant and student working on her master’s in Public Health at Yale University, New Haven, Conn.

When stratified based on whether the C. difficile infection was acquired in the health care setting or in the community, the only difference between the recurrence and nonrecurrence groups in those with health care–associated infection was the use of H₂ blockers, which appeared to increase the risk for recurrence in this population. This finding contradicts those from previous studies that suggested a protective effect of antacid therapy, Ms. Paccha noted.

In those with community-associated infection, those with recurrence were older than those without recurrence (68.9 vs. 56.6 years). They also were significantly more likely to have used immunosuppressants (36% vs. 13%), and less likely to have used antimicrobials (73% vs. 43%), Ms. Paccha said in an interview.

C. difficile, which is often preceded by antibiotic use, has been a growing concern in the past decade because of the emergence of increasingly toxigenic strains. The Connecticut Emerging Infections Program has been conducting surveillance for the infection since 2009, she said.

Case patients were at least 1 year of age and were diagnosed on the basis of a positive C. difficile infection laboratory test. Those with health care–associated infection included patients with onset 3 days after hospital or long-term care facility admission (health care facility onset patients); patients with onset within 3 months of hospital discharge, outpatient surgery or long-term care facility residency (community-onset health care facility-associated patients); and patients with onset without prior health care exposure (community-associated infection patients). Information on the patients was obtained by chart review.

The study was limited by the use of a nonclinical definition of recurrence and by a lack of treatment data for the initial C. difficile infection.

Additional research to determine if those at risk for recurrence tend to harbor more toxigenic diseases is warranted, she said.

Ms. Paccha reported having no relevant conflicts of interest.

ATLANTA – People who take antacid therapy, the elderly, and individuals who reside in long-term care facilities are at increased risk of recurrent Clostridium difficile infections, according to data from the Connecticut Emerging Infections Program.

Of 826 children and adults with an initial incident episode of C. difficile infection, 130 (16%) had at least one recurrence. Those with vs. without recurrence were significantly older (75.1 vs. 69.9 years), and significantly more likely to reside in a long-term care facility (53% vs. 40%), Blanca Paccha reported in a poster at the International Conference on Emerging Infectious Diseases.

Individuals with recurrence were more likely than those without recurrence to be taking H₂ blockers (10% vs. 3%), reported Ms. Paccha, a research assistant and student working on her master’s in Public Health at Yale University, New Haven, Conn.

When stratified based on whether the C. difficile infection was acquired in the health care setting or in the community, the only difference between the recurrence and nonrecurrence groups in those with health care–associated infection was the use of H₂ blockers, which appeared to increase the risk for recurrence in this population. This finding contradicts those from previous studies that suggested a protective effect of antacid therapy, Ms. Paccha noted.

In those with community-associated infection, those with recurrence were older than those without recurrence (68.9 vs. 56.6 years). They also were significantly more likely to have used immunosuppressants (36% vs. 13%), and less likely to have used antimicrobials (73% vs. 43%), Ms. Paccha said in an interview.

C. difficile, which is often preceded by antibiotic use, has been a growing concern in the past decade because of the emergence of increasingly toxigenic strains. The Connecticut Emerging Infections Program has been conducting surveillance for the infection since 2009, she said.

Case patients were at least 1 year of age and were diagnosed on the basis of a positive C. difficile infection laboratory test. Those with health care–associated infection included patients with onset 3 days after hospital or long-term care facility admission (health care facility onset patients); patients with onset within 3 months of hospital discharge, outpatient surgery or long-term care facility residency (community-onset health care facility-associated patients); and patients with onset without prior health care exposure (community-associated infection patients). Information on the patients was obtained by chart review.

The study was limited by the use of a nonclinical definition of recurrence and by a lack of treatment data for the initial C. difficile infection.

Additional research to determine if those at risk for recurrence tend to harbor more toxigenic diseases is warranted, she said.

Ms. Paccha reported having no relevant conflicts of interest.

ATLANTA – People who take antacid therapy, the elderly, and individuals who reside in long-term care facilities are at increased risk of recurrent Clostridium difficile infections, according to data from the Connecticut Emerging Infections Program.

Of 826 children and adults with an initial incident episode of C. difficile infection, 130 (16%) had at least one recurrence. Those with vs. without recurrence were significantly older (75.1 vs. 69.9 years), and significantly more likely to reside in a long-term care facility (53% vs. 40%), Blanca Paccha reported in a poster at the International Conference on Emerging Infectious Diseases.

Individuals with recurrence were more likely than those without recurrence to be taking H₂ blockers (10% vs. 3%), reported Ms. Paccha, a research assistant and student working on her master’s in Public Health at Yale University, New Haven, Conn.

When stratified based on whether the C. difficile infection was acquired in the health care setting or in the community, the only difference between the recurrence and nonrecurrence groups in those with health care–associated infection was the use of H₂ blockers, which appeared to increase the risk for recurrence in this population. This finding contradicts those from previous studies that suggested a protective effect of antacid therapy, Ms. Paccha noted.

In those with community-associated infection, those with recurrence were older than those without recurrence (68.9 vs. 56.6 years). They also were significantly more likely to have used immunosuppressants (36% vs. 13%), and less likely to have used antimicrobials (73% vs. 43%), Ms. Paccha said in an interview.

C. difficile, which is often preceded by antibiotic use, has been a growing concern in the past decade because of the emergence of increasingly toxigenic strains. The Connecticut Emerging Infections Program has been conducting surveillance for the infection since 2009, she said.

Case patients were at least 1 year of age and were diagnosed on the basis of a positive C. difficile infection laboratory test. Those with health care–associated infection included patients with onset 3 days after hospital or long-term care facility admission (health care facility onset patients); patients with onset within 3 months of hospital discharge, outpatient surgery or long-term care facility residency (community-onset health care facility-associated patients); and patients with onset without prior health care exposure (community-associated infection patients). Information on the patients was obtained by chart review.

The study was limited by the use of a nonclinical definition of recurrence and by a lack of treatment data for the initial C. difficile infection.

Additional research to determine if those at risk for recurrence tend to harbor more toxigenic diseases is warranted, she said.

Ms. Paccha reported having no relevant conflicts of interest.