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OBJECTIVE--Influenza vaccine uptake remains low among the high-risk group of patients with diabetes, partly because of conflicting evidence regarding its potential benefits. We assessed the clinical effectiveness of influenza vaccination [...]

Study objective: Measures of health-related quality of life (HRQL) correlate with disease stage in persons with COPD. However, as their predictive capacity for mortality or medical utilization is less well [...]

Background: Influenza and pneumococcal vaccination rates remain too low. This survey assessed generalist and subspecialist physicians' knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for high-risk patients. Methods: A self-administered questionnaire was mailed to 6000 physicians randomly selected from a national database. Results: After 3 mailings, 1874 physicians (32%) of the 5858 eligible responded. Although most physicians thought that it was very important for their high-risk patients be current on influenza and pneumococcal vaccinations, only 86% and 75% of generalists and subspecialists, respectively, very strongly recommended influenza vaccinations to their elderly patients and only 81% and 64%, respectively, very strongly recommended pneumococcal vaccinations to their elderly patients (P Conclusions: Nontrivial proportions of generalist and subspecialist physicians fail to strongly recommend influenza and pneumococcal vaccinations to their elderly and high-risk patients. Other effective strategies for promoting vaccine delivery are also used relatively infrequently. These findings suggest areas for improvement if vaccination rates are to reach national goals. Arch Intern Med. 2001;161:2702-2708

Background: Vaccination rates for healthy senior citizens are lower than those for senior citizens with underlying medical conditions such as chronic heart or lung disease. Uncertainty about the benefits of influenza vaccination for healthy senior citizens may contribute to lower rates of utilization in this group. Objective: To clarify the benefits of influenza vaccination among low-risk senior citizens while concurrently assessing the benefits for intermediate- and high-risk senior citizens. Methods: All elderly members of a large health maintenance organization were included in each of 6 consecutive study cohorts. Subjects were grouped according to risk status: high risk (having heart or lung disease), intermediate risk (having diabetes, renal disease, stroke and/or dementia, or rheumatologic disease), and low risk. Outcomes were compared between vaccinated and unvaccinated subjects after controlling for baseline demographic and health characteristics. Results: There were more than 20 000 subjects in each of the 6 cohorts who provided 147 551 person-periods of observation. The pooled vaccination rate was 60%. There were 101 619 person-periods of observation for low-risk subjects, 15 482 for intermediate-risk, and 30 450 for high-risk subjects. Vaccination over the 6 seasons was associated with an overall reduction of 39% for pneumonia hospitalizations (P [is less than] .001), a 32% decrease in hospitalizations for all respiratory conditions (P [is less than] .001), and a 27% decrease in hospitalizations for congestive heart failure (P [is less than] .001). Immunization was also associated with a 50% reduction in all-cause mortality (P [is less than] .001). Within the risk subgroups, vaccine effectiveness was 29%, 32%, and 49% for high-, intermediate-, and low-risk senior citizens for reducing hospitalizations for pneumonia and influenza (for high and low risk, P [is less than or equal to] .002; for intermediate risk, P =. 11). Effectiveness was 19%, 39%, and 33% (for each, P [is less than or equal to] .008), respectively, for reducing hospitalizations for all respiratory conditions and 49%, 64%, and 55% for reducing deaths from all causes (for each, P [is less than] .001). Vaccination was also associated with direct medical care cost savings of $73 per individual vaccinated for all subjects combined (P = .002). Estimates of cost savings within each risk group suggest that vaccination would be cost saving for each subgroup (range of cost savings of $171 per individual vaccinated for high risk to $7 for low risk), although within the subgroups these findings did not reach statistical significance (for each, P [is greater than or equal to] .05). Conclusions: This study confirms that healthy senior citizens as well as senior citizens with underlying medical conditions are at risk for the serious complications of influenza and benefit from vaccination. All individuals 65 years or older should be immunized with this vaccine. Arch Intern Med. 1998;158:1769-1776

Background: Concern about side effects is a barrier to influenza vaccination. This randomized, double-blind, placebo-controlled trial assessed side effects following vaccination among healthy working adults. Methods: Healthy working adults were recruited during October and November 1994 and were randomized to receive influenza vaccine or placebo injections. Local and systemic symptoms during the week following the injection were evaluated through structured telephone interviews. Results: Of 849 subjects enrolled in the study, 425 received a placebo and 424 received influenza vaccine. Baseline characteristics were similar between the groups, and 99% of subjects completed interviews to assess side effects after the study injection. No differences were seen between the 2 groups for the systemic symptoms of fever, myalgias, fatigue, malaise, or headaches. Overall, 35.2% of placebo and 34.1% of vaccine recipients reported at least 1 of these systemic symptoms (P=.78, [x.sup.2]). Vaccine recipients reported a higher rate of arm soreness at the injection site than did placebo recipients (63.8% vs 24.1%, P

Background: This study was conducted to assess medical students' immunity to vaccine-preventable diseases, their exposure to these diseases, and their attitudes toward immunity to vaccine-preventable diseases. Methods: A cross-sectional, mailed survey was conducted of all 249 senior medical students in the 1991 graduating class at the University of Minnesota, Mirmeapolis. Two mailings were sent during the autumn of their senior year. Results: The response rate was 77.5%. More than 90% of the students reported that they were immune to measles, mumps, rubella, and hepatitis B but only 23% were immune to influenza. Fewer than half of the students had ever been queried about their immune status prior to clinical clerkships. One third of the students had had a needlestick exposure during their clinical training (including 8% to a known hepatitis B carrier) and only 52% of these were reported by the student. Ten percent to 20% of the students felt that immunity to measles, mumps, and rubella was only somewhat or not very important. Less than one third of the students felt that immunity to influenza was important for themselves as health care providers. Conclusion: This study documented inadequate levels of immunity among medical students to certain vaccine-preventable diseases, that exposure to vaccine-preventable diseases was fairly common during clinical training, and that medical students often had inadequate attitudes about immunity.to vaccine-preventable diseases. These findings have implications for medical school immunization policies and curriculum content. (Arch Intern Med. 1993;153:1913-1916)

* The Minneapolis and Pittsburgh Veterans Affairs Medical Centers conduct virtually identical institution-wide influenza vaccination programs that include annual educational and publicity mailings to all outpatients. Despite these efforts, 40% to 50% of high-risk outpatients at both centers fail to receive influenza vaccine each year. To assess differences between high-risk vaccine recipients and nonrecipients, a self-administered questionnaire was mailed to 500 randomly selected outpatients from each site. The questionnaire asked about risk factors, vaccination status, and knowledge and attitudes regarding influenza and 'flu shots.' Patient risk characteristics and vaccination rates in Minneapolis and Pittsburgh were similar with 75.6% and 76.3% reporting high-risk conditions and 65.6% and 56.1% of high-risk respondents reporting influenza vaccination, respectively. High-risk vaccine recipients and nonrecipients had similar knowledge but different attitudes about influenza and 'flu shots.' Using stepwise logistic regression, factors positively associated with vaccination behavior were: intention to follow physician or nurse recommendations for 'flu shots' (odds ratio [OR] = 7.09); previous vaccination behavior (OR = 6.36); and physician or nurse recommendations for a 'flu shot' (OR = 4.29). Factors negatively associated with vaccination behavior were difficulty in coming to the medical center (OR = 0.42) and previous side effects from the vaccine (OR = 0.19). These findings suggest areas in need of additional emphasis if influenza vaccination rates are to be improved. (Arch Intern Med. 1992;152:106-110)

This report presents data concerning the effectiveness of an inpatient ''flu shot'' program established in 1989 at the Minneapolis Veterans Affairs (VA) Medical Center. The program was an adaptation of an outpatient vaccination program at the same facility. Patients without contraindications were given a shot upon discharge from the hospital or ward (if nonambulatory). Special inservice training was conducted for ward nurses. A sample of 274 patients was selected from the list of 547 patients over 64 years who were discharged during a 2-month period and surveyed by postcard questionnaire regarding receipt of the flu shot, medical condition, and demographic variables. A randomly selected group of outpatients received the same questionnaire. In- and outpatient response rates were 78.3 percent and 76.6 percent, respectively. Elderly inpatients reported more serious illness than elderly outpatients; 75.7 percent of the inpatients had lung disease, heart disease, diabetes, or other serious illness, compared with 52.2 percent of outpatients. The vaccination rate for the inpatients was 78.6 percent, higher than the goal of the immunization program. Inpatients were more likely than outpatients to have been vaccinated at the VA Medical Center. The results show that an outpatient vaccination program can be effectively adapted to inpatients. (Consumer Summary produced by Reliance Medical Information, Inc.)

PURPOSE: TO enhance influenza vaccination rates for high-risk outpatients at the DePartment of Veterans Affairs Medical Center (VAMC) in Minneapolis, Minnesota, an institution-wide immunization Program was implemented during 1987. PATIENTS AND METHODS: The program consisted of: (1) a hospital policy allowing nurses to vaccinate without a signed physician's order, (2) stamped reminders on aH clinic progress notes; (3) a 2-week walk-in flu shot clinic; (4) influenza vaccination 'stations' in the busiest clinic areas; and (5) a mailing to aD outpatients. Risk characteristics and vaccination rates for patients were estimated from a validated self-administered postcard questionnaire mailed to 500 randomly selected outpatients. For comparison, 500 patients were surveyed from each of three other Midwestern VAMCs without similar programs. RESULTS: Overall, 70.6 % of Minneapolis patients were high-risk and 58.3% of them were vaccinated. In contrast, 69.9% of patients at the comparison medical centers were high-risk, but only 29.9% of them were vaccinated. CONCLUSION: The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization., Influenza is an acute, contagious respiratory infection with the influenza virus that is characterized by sudden onset, fever, chills, headache, muscle pain, and absolute exhaustion. The infection usually lasts from two to seven days. An immunization program was developed to increase the rates of vaccination against influenza among patients with a high risk of developing this illness. The program was carried out at the Veterans Affairs Medical Center (VAMC) in Minneapolis, Minnesota in 1987. According to the program, nurses were permitted to give the influenza vaccination without a signed physician's order; reminders were stamped on all clinic progress notes; flu shots were available over a two-week period in a walk-in clinic; influenza vaccine stations were established in the busiest clinic areas; and outpatients were provided information about the influenza vaccine through the mail. Risk characteristics and vaccination rates were assessed by questionnaires given to 500 patients. The results were compared with data from three other VAMCs without immunization programs. The findings showed that almost 71 percent of patients were considered high-risk and about 58 percent were vaccinated against influenza. At the medical centers without immunization programs, almost 70 percent of patients were high-risk, but only about 30 percent were vaccinated. The Minneapolis VAMC vaccination program was thus very effective and may serve as a useful model for attaining the national health objective of influenza vaccination for high-risk individuals. (Consumer Summary produced by Reliance Medical Information, Inc.)

Influenza is a respiratory infection that occurs suddenly and is characterized by symptoms of fever, chills, headache, muscle pain and intense exhaustion. Nasal inflammation and discharge, cough, and sore throat are also common symptoms, and the infection usually lasts from two to seven days. In the elderly and chronically ill, influenza can cause more serious illness and death, although fewer than one-third of those at high risk are vaccinated in the United States, because of the fear of unfavorable side effects of the influenza vaccination. This study examined the frequency of adverse side effects from influenza vaccination in 650 elderly, chronically ill subjects. The patients, averaging 63 years in age, were divided into two groups: group I was interviewed a week after vaccination, and group II was interviewed three weeks after vaccination regarding the presence of fever, disability and flu-like illness. The occurrence of fever and disability was similar in both groups, although a higher proportion of group I patients reported flu-like symptoms. The results show that there is a low incidence of symptoms, although flu-like illness was higher during the first week after influenza vaccination than at three weeks after receiving the vaccine. The symptoms did not affect the ability of any patient to perform daily activities.

A study of the health aspects of veterans receiving care from a veterans integrated service network is presented. It is observed that the VA patients have low quality of life coupled with high rates of health services utilization implying the need to improve the health-related quality of life and functional abilities of veterans.

Background: Influenza is a major cause of illness, disruption to daily life, and work absenteeism among healthy working adults aged between 18 and 64 years. This group is not included among the traditional priority groups for annual vaccination. Immunization rates remain low. Objective: To assess the economic implications of a strategy for annual vaccination of this group. Methods: Using the societal perspective, this cost-benefit analysis included the direct and indirect costs associated with vaccination as well as the direct and indirect costs prevented by vaccination. Clinical and economic variable estimates were derived primarily from the published literature. For this model, it was assumed that vaccination occurred in efficient, low-cost settings such as at the work site. Monte Carlo simulation was used to calculate the mean net costs or savings along with the 95% probability interval, and sensitivity analyses explored the sensitivity of the cost model to different values of the input variables. Results: Vaccinating healthy working adults was on average cost saving, with mean savings of $13.66 per person vaccinated (95% probability interval: net savings of $32.97 to net costs of $2.18), with vaccination generating net savings 95% of the time. The model was most sensitive to the influenza illness rate, the work absenteeism rate due to influenza, and hourly wages. In the worst-case scenario vaccination was not cost saving. Vaccination also generated net costs to society during years with a poor vaccine--circulating virus strain match. In all of the other sensitivity analysis scenarios, vaccination was cost saving. Conclusion: Influenza vaccination of healthy working adults on average is cost saving. These findings support a strategy of routine, annual vaccination for this group, especially when vaccination occurs in efficient and low-cost sites.

Background: Anecdotal reports suggest that influenza-related morbidity may be high among persons with acquired immunodeficiency syndrome (AIDS), but little information is available concerning the population-level impact of influenza on mortality in persons with AIDS. Methods: Using the Multiple Cause-of-Death data files, which contain information on all deaths occurring in the United States each year, we calculated the numbers of excess deaths and rates of excess death due to pneumonia or influenza among persons with AIDS aged 13 years and older during the influenza seasons 1991-1992 through 1993-1994. For comparison, numbers of excess deaths and excess death rates were also calculated for several other groups including the general US population aged 13 years and older and the general US population aged 65 years and older. Results: During the 1991-1992, 1992-1993, and 1993-1994 influenza seasons, there were 261,254, and 191 excess deaths due to pneumonia or influenza in persons with AIDS and excess death rates of 19.74, 15.38, and 10.17 deaths per 10000 persons, respectively, compared with a summer baseline period. For the same seasons, we observed excess death rates of 1.40, 1.62, and 1.48 for the general US population aged 13 years and older and 8.10, 9.28, and 8.54 for the general US population aged 65 years and older. Thus, persons with AIDS had excess death rates substantially higher than the general US population and similar to, if not somewhat higher than, the general US population aged 65 years and older, a group that is already targeted for annual vaccination. The findings were similar when we compared the preinfluenza season with the influenza season. Conclusions: Persons with AIDS have significant excess mortality due to pneumonia or influenza during influenza seasons and should be considered a high-risk group that is targeted for the prevention of influenza. Arch Intern Med. 200.1;161:441-446

Background: Decline in immune function has been reported to predictably accompany advancing age. However, to our knowledge, few studies have specifically characterized the rapidly expanding advanced elderly population or controlled adequately for concurrent diseases. Objective: To assess whether successfully reaching an advanced age in good health is associated with preserved immune function. Methods: We prospectively compared in vivo with in vitro variables of immune function in 29 healthy, independently living elderly subjects (mean age, 80 years; age range, 75-103 years) and in 21 healthy young control subjects (mean age, 29 years; age range, 25-35 years) in a Veterans Affairs Medical Center. Results: In vivo, among elderly and young subjects, numbers of total white blood cells, monocytes, lymphocytes, and lymphocyte subsets ([CD4.sup.+] and [CD8.sup.+] T lymphocytes and [CD20.sup.+] B cells) were similar, as were levels of total se rum IgG and IgM. Only levels of serum IgA were higher in the elderly subjects (3.0 vs 1.7 g/L; P=.001). Functionally, both groups showed vigorous responses to protein (tetanus and diphtheria toxoids) and polysaccharide (23-valent pneumococcal) vaccines. Although levels varied, the fold increases in vaccine antigen-specific IgG were not significantly different in young and elderly subjects, and the avidities of IgG to pneumococcal polysaccharides 14 and 19F were similar before and after vaccination. In vitro, proliferative responses of blood mononuclear cells to T-lymphocyte and B-cell mitogens (pokeweed mitogen, Staphylococcus aureus Cowan strain I, and S aureus Cowan strain I plus interleukin 2), and lipopolysaccharide-induced production of tumor necrosis factor [Alpha], were comparable in elderly vs young subjects. Conclusion: Successful aging, defined by reaching an advanced age with one's overall health intact, may be associated with preserved immune function and adequate responses to vaccines. Arch Intern Med. 2000;160:2017-2024

Background: More than 50% of the elderly population has not received pneumococcal vaccination. Uncertainty regarding the benefits of immunization, particularly for noninvasive disease, may contribute to the underuse of pneumococcal vaccine. Objective: To assess the health and economic benefits associated with pneumococcal vaccination. Methods: We conducted a 2-year retrospective cohort study among all elderly members of a staff-model managed care organization who had a baseline diagnosis of chronic lung disease. The study outcomes were assessed over 2 years, from November 15, 1993, through November 14, 1995, and included hospitalizations for pneumonia and influenza, death, and hospitalization costs. Using administrative data, we compared these outcomes for vaccinated and unvaccinated subjects using multivariate models to control for subjects' baseline demographic and health characteristics. The additive benefits of combined influenza and pneumococcal vaccination were also assessed for the 2 influenza seasons included in the study. Results: There were 1898 subjects. Pneumococcal vaccination was associated with significantly lower risks for pneumonia hospitalizations (adjusted risk ratio [RR], 0.57; 95% confidence interval [CI], 0.38-0.84; P = .005) and for death (adjusted RR, 0.71; 95% CI, 0.56-0.91; P = .008). For the control outcome of all nonpneumonia hospitalizations, rates did not differ significantly between the 2 groups (adjusted RR, 0.91; 95% CI, 0.77-1.07; P = .24). During the influenza seasons included in the study, the benefits of pneumococcal and influenza vaccinations were additive, with an adjusted RR of 0.28 (95% CI, 0.14-0.58; P [is less than] .001) for the number of hospitalizations for pneumonia and influenza among persons who had received both vaccinations compared with those who had received neither and an adjusted odds ratio of 0.18 (95% CI, 0.11-0.31; P [is less than] .001) for death. Over the 2-year outcome period, pneumococcal vaccination was also associated with direct medical care cost savings. Conclusions: Pneumococcal vaccination of elderly persons with chronic lung disease was associated with fewer hospitalizations for pneumonia, fewer deaths, and direct medical care cost savings. Arch Intern Med. 1999; 159:243 7-2442

PURPOSE: Influenza and pneumococcal vaccines are underused. Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates. Little has been published on the long-term success and durability of such efforts. METHODS: We performed a 10-year time-series study to examine the durability and success of an ongoing, multifaceted, institution-wide influenza and pneumococcal vaccination program. The program was first implemented at the Minneapolis Department of Veterans Affairs (VA) Medical Center in 1987-88 following the demonstration that a clinic-based standing order policy was much more successful than provider education for improving vaccine delivery. The program ensures that vaccine is offered to all high-risk patients followed up at the medical center, promotes convenient access for patients, and facilitates efficient administration of vaccine. Specific elements include an annual mailing to patients, standing orders for nurses, walk-in clinics, and the use of standardized, preprinted documentation forms. Initially the program targeted high-risk outpatients for influenza vaccination. It was extended to include inpatients in 1989-90. Pneumococcal vaccinations were added to the program in 1994-95. Vaccination rates are estimated each year from surveys mailed to randomly selected patients, and vaccine utilization is monitored through pharmacy logs. RESULTS: The survey response rates have exceeded 75% each year. Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58% following the 1987-88 vaccination season to 84% in 1996-97 (P [is less than] 0.001). Pneumococcal vaccination rates have also increased from 34% in 1994-95 to 63% in 1996-97 (P [is less than] 0.001). Vaccination rates are similar for inpatients and outpatients, but rates for high-risk patients [is less than] 65 years of age remain lower than for the elderly: 69% versus 89% for influenza, 1996-97 (P [is less than] 0.001); 52% versus 66% for pneumococcal, 1996-97 (P = 0.05). For elderly patients followed up at the medical center, influenza (89% versus 67%, P [is less than] 0.0001) and pneumococcal (66% versus 43%, P [is less than] 0.0001) vaccination rates significantly exceeded those for the state of Minnesota in 1996-97. The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987-88 to more than 22,000 in 1996-97; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994-95 through 1996-97. CONCLUSION: This simple, multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid. Similar strategies if implemented in other settings may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized. Am J Med. 1998;105:385-392. [C] 1998 by Excerpta Medica, Inc.

Omega-3 polyunsaturated fatty acids found in certain fish have been said to decrease the risk of coronary heart disease. When the blood vessels supplying the heart become narrowed with atherosclerotic plaques, the blood supply to the heart is compromised. This results in coronary heart disease which increases the risk for myocardial infarction, or heart attack. High blood cholesterol contributes to the development of atherosclerosis. It is thought that the fatty acids in fish oil prevent blood clotting platelet cells from aggregating, lower blood pressure and improve the lipid (fats) levels in the blood. To see if diets rich in fish oil reduce high blood cholesterol, 38 men with cholesterol levels between 220 and 300 milligrams were given fish oil for 12 weeks and then plain safflower oil for 12 weeks. A four-week interval separated the two testing periods. Compared with the period of safflower oil ingestion, total cholesterol levels increased by 4.8 percent and low density lipoprotein (LDL) cholesterol increased by 9.1 percent after consuming fish oil. Low density lipoprotein was significantly higher and triglycerides (blood lipids) were lower after fish oil. Total cholesterol and high density lipoprotein (HDL) cholesterol, however, remained unchanged. Blood cholesterol should be lowered by at least five percent to produce effective therapeutic results. Fish oil failed to lower high blood cholesterol levels in men without high triglyceride levels. (Consumer Summary produced by Reliance Medical Information, Inc.)

Although the pandemic influenza A(HlNl) virus is capturing much of the public's attention, we need to remind our patients and ourselves that many also need protection from pneumococcal disease. Pneumococcal [...]