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Background: Influenza vaccination coverage among nursing home residents has consistently been reported well below the Healthy People goals. We sought to determine if standing order programs (SOPs) in long-term care facilities are associated with greater influenza vaccination coverage among residents. Methods: The National Nursing Home Survey (2004) is cross-sectional. A total of 1152 US long-term care facilities were systematically sampled with probability proportional to number of beds. A total of 11,939 people aged 65 years or older residing in sampled long-term care facilities between August and December 2004 were randomly sampled. Influenza vaccination coverage of residents was obtained from facility records. Facility''s immunization program included standing orders versus other (preprinted admission order, advance physician order, personal physician order, and no program). Multinomial logistic regression was used to examine the relationship between type of influenza immunization program and receipt of vaccination, adjusted for resident and facility confounders. Results: The proportion of residents aged 65 years or older who received influenza vaccination was 64%; 41% of residents lived in a facility with an SOP. Influenza vaccination coverage among residents residing in facilities with standing orders was 68% compared with 59% to 63% of residents in facilities with other program types. Logistic regression showed that standing order programs were independently associated with greater influenza vaccination coverage (66.7% versus 62.0%, P < .01). Conclusion: This study indicates that residents in long-term care facilities having standing order programs for influenza were more likely to be immunized. More research needs to be done to understand how to facilitate adoption of these programs. [ABSTRACT FROM AUTHOR]

PURPOSE: The Health Plan Employer Data Information Set (HEDIS) provides comparative information across health plans to measure the quality of care and preventive services for health plan beneficiaries. We examined recent trends in adolescent immunizations recommended by the Advisory Committee for Immunization Practices (ACIP) measured through HEDIS and reported to the National Committee for Quality Assurance (NCQA). METHODS: The study was based on a longitudinal regression analysis of commercial managed care organizations' HEDIS measures from 1999-2002. HEDIS performance measures and plan characteristics include a sample of approximately 100-400 enrollees per plan each year. The outcome measures were the proportions of enrollees aged 13 years sampled in the plan who received measles-mumps-rubella vaccine (MMR), hepatitis B vaccine, and varicella vaccine. RESULTS: The immunization rates for all three antigens increased significantly from 1999 to 2002 (MMR: 57-68%; hepatitis B: 28-51%; and varicella: 21-38%). Factors in the final multivariable models that were found to be significantly associated with increased proportions immunized with MMR vaccine, hepatitis B vaccine, and varicella vaccine include year of report, presence of school entry laws, years in business up to 25 years, and operating in the northeastern U.S. region; the only factor associated with decreasing immunization rates for all antigens was the number of providers per 100 commercial enrollees. CONCLUSIONS: Consistent with previous reports, adolescent immunization rates are improving yet remain suboptimal. Strategies to increase immunization rates, as well as to improve documentation of immunization status, among commercial health insurance plans need to be developed and implemented. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine patterns of knowledge and attitudes among adults aged > 65 years unvaccinated for influenza. METHODS: Surveyed Medicare beneficiaries in 5 areas; clustered unvaccinated seniors by their immunization related knowledge and attitudes. RESULTS: Identified 4 clusters: Potentials (45%) would receive influenza vaccine to prevent disease; Fearful Uninformeds (9%) were unsure if influenza vaccine causes illness; Doubters (27%) were unsure if vaccine is efficacious; Misinformeds (19%) believed influenza vaccine causes illness. More Potentials (75%) and Misinformeds (70%) ever received influenza vaccine than did Fearful Uninformeds (18%) and Doubters (29%). CONCLUSION: Findings suggest that cluster analyses may be useful in identifying groups for targeted health messages. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Risk factors for underimmunization at 3 months of age are not well described. This study examines coverage rates and factors associated with under-immunization at 3 months of age in four medically underserved areas. METHODS: During 1997-1998, cross-sectional household surveys using a two-stage cluster sample design were conducted in four federally designated Health Professional Shortage Areas. Respondents were parents or caregivers of children ages 12-35 months: 847 from northern Manhattan, 843 from Detroit, 771 from San Diego, and 1,091 from rural Colorado. A child was considered up-to-date (UTD) with vaccinations at 3 months of age if documentation of receipt of diphtheria-tetanus-pertussis, polio, haemophilus influenzae type B, and hepatitis B vaccines was obtained from a provider or a hand-held vaccination card, or both. RESULTS: Household response rates ranged from 79% to 88% across sites. Vaccination coverage levels at 3 months of age varied across sites: 82.4% in northern Manhattan, 70.5% in Detroit, 82.3% in San Diego, and 75.8% in rural Colorado. Among children who were not UTD, the majority (65.7% to 71.5% per site) had missed vaccines due to missed opportunities. Factors associated with not being UTD varied by site and included having public or no insurance, >/=2 children living in the household, and the adult respondent being unmarried. At all sites, vaccination coverage among WIC enrollees was higher than coverage among children eligible for but not enrolled in WIC, but the association between UTD status and WIC enrollment was statistically significant for only one site and marginally significant for two other sites. CONCLUSIONS: Missed opportunities were a significant barrier to vaccinations, even at this early age. Practice-based strategies to reduce missed opportunities and prenatal WIC enrollment should be focused especially toward those at highest risk of underimmunization. [ABSTRACT FROM AUTHOR]

BACKGROUND: While many Complementary/Alternative Medicine (CAM) practitioners do not object to immunization, some discourage or even actively oppose vaccination among their patients. However, previous studies in this area have focused on childhood immunizations, and it is unknown whether and to what extent CAM practitioners may influence the vaccination behavior of their adult patients. The purpose of this study was to describe vaccination coverage levels of adults aged > or = 18 years according to their CAM use status and determine if there is an association between CAM use and adult vaccination coverage. METHODS: Data from the 2002 National Health Interview Survey, limited to 30,617 adults that provided at least one valid answer to the CAM supplement, were analyzed. Receipt of influenza vaccine during the past 12 months, pneumococcal vaccine (ever), and > or = 1 dose of hepatitis B vaccine was self-reported. Coverage levels for each vaccine by CAM use status were determined for adults who were considered high priority for vaccination because of the presence of a high risk condition and for non-priority adults. Multivariable analyses were conducted to evaluate the association between CAM users and vaccination status, adjusting for demographic and healthcare utilization characteristics. RESULTS: Overall, 36% were recent CAM users. Among priority adults, adjusted vaccination coverage levels were significantly different between recent and non-CAM users for influenza (44% vs 38%; p-value < 0.001) and pneumococcal (40% vs 33%; p-value < 0.001) vaccines but were not significantly different for hepatitis B (60% vs 56%; p-value = 0.36). Among non-priority adults, recent CAM users had significantly higher unadjusted and adjusted vaccination coverage levels compared to non-CAM users for all three vaccines (p-values < 0.001). CONCLUSION: Vaccination coverage levels among recent CAM users were found to be higher than non-CAM users. Because CAM use has been increasing over time in the U.S., it is important to continue monitoring CAM use and its possible influence on receipt of immunizations among adults. Since adult vaccination coverage levels remain below Healthy People 2010 goals, it may be beneficial to work with CAM practitioners to promote adult vaccines as preventive services in keeping with their commitment to maintaining good health. [ABSTRACT FROM AUTHOR]

Background: Racial disparities in receipt of high-dose influenza vaccine (HDV) have been documented nationally, but whether small-area geographic variation in such disparities exists remains unknown. We assessed the distribution of disparities in HDV receipt between Black and White traditional Medicare beneficiaries vaccinated against influenza within states and hospital referral regions (HRRs)., Methods: We conducted a nationally representative retrospective cohort study of 11,768,724 community-dwelling traditional Medicare beneficiaries vaccinated against influenza during the 2015-2016 influenza season (94.3% White and 5.7% Black). Our comparison was marginalized versus privileged racial group measured as Black versus White race. Vaccination and type of vaccine were obtained from Medicare Carrier and Outpatient files. Differences in the proportions of individuals who received HDV between Black and White beneficiaries within states and HRRs were used to measure age- and sex-standardized disparities in HDV receipt. We restricted to states and HRRs with ≥ 100 beneficiaries per age-sex strata per racial group., Results: We detected a national disparity in HDV receipt of 12.8 percentage points (pps). At the state level, the median standardized HDV receipt disparity was 10.7 pps (minimum, maximum: 2.9, 25.6; n = 30 states). The median standardized HDV receipt disparity among HRRs was 11.6 pps (minimum, maximum: 0.4, 24.7; n = 54 HRRs)., Conclusion: Black beneficiaries were less likely to receive HDV compared to White beneficiaries in almost every state and HRR in our analysis. The magnitudes of disparities varied substantially across states and HRRs. Local interventions and policies are needed to target geographic areas with the largest disparities to address these inequities., (© 2023. W. Montague Cobb-NMA Health Institute.)

Objectives: This study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs)., Design: Retrospective cohort study., Setting and Participants: We included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons., Methods: Our comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs., Results: The study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons., Conclusions and Implications: Our analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Resident and staff influenza and COVID-19 vaccination are critical components of infection prevention in nursing homes. Our study sought to characterize strategies that nursing home staff use to promote vaccination. Twenty-six telephone/videoconference interviews were conducted with administrators, directors of nursing, infection preventionists, and Minimum Data Set coordinators at 14 nursing homes across the US. Transcripts were analyzed using content analysis and a detailed audit trail was maintained. Staff described resident and staff influenza and COVID-19 vaccine hesitancy and confidence as well as varying approaches to promote vaccination. These included incentives, education efforts, and having a "vaccine champion" responsible for vaccine promotion. While many strategies had been in place prior to COVID-19 in support of improving influenza vaccination, participants reported implementing additional approaches to promote COVID-19 vaccination. Findings may inform future efforts to promote vaccination, which will be critical to mitigate the burden of influenza and COVID-19 in nursing homes., Competing Interests: Declaration of Competing Interest ARZ and BHB report conflicts with vaccine manufacturer, Sanofi, related to collaborative grants paid directly to Brown University. SG reports conflicts with vaccine manufacturers Sanofi, Seqirus, and Pfizer, related to grants, and these and Janssen, Merck, Novavax, and Moderna as consulting and/or speaking engagements. SG also has a grant with Genentech. HK and MML are full-time employees of Sanofi and may hold shares and/or stock options in the company. No other financial disclosures were reported., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Disparities in influenza vaccination exist between Hispanic and non-Hispanic White US nursing home (NH) residents, but the geographic areas with the largest disparities remain unknown. We examined how these racial/ethnic disparities differ across states and hospital referral regions (HRRs)., Methods: This retrospective cohort study included >14 million short-stay and long-stay US NH resident-seasons over 7 influenza seasons from October 1, 2011, to March 31, 2018, where residents could contribute to 1 or more seasons. Residents were aged ≥65 years and enrolled in Medicare fee-for-service. We used the Medicare Beneficiary Summary File to ascertain race/ethnicity and Minimum Data Set assessments for influenza vaccination. We calculated age- and sex-standardized percentage point (pp) differences in the proportions vaccinated between non-Hispanic White and Hispanic (any race) resident-seasons. Positive pp differences were considered disparities, where the proportion of non-Hispanic White residents vaccinated was greater than the proportion of Hispanic residents vaccinated. States and HRRs with ≥100 resident-seasons per age-sex stratum per racial/ethnic group were included in analyses., Results: Among 7 442 241 short-stay resident-seasons (94.1% non-Hispanic White, 5.9% Hispanic), the median standardized disparities in influenza vaccination were 4.3 pp (minimum, maximum: 0.3, 19.2; n = 22 states) and 2.8 pp (minimum, maximum: -3.6, 10.3; n = 49 HRRs). Among 6 758 616 long-stay resident-seasons (93.7% non-Hispanic White, 6.5% Hispanic), the median standardized differences were -0.1 pp (minimum, maximum: -4.1, 11.4; n = 18 states) and -1.8 pp (minimum, maximum: -6.5, 7.6; n = 34 HRRs)., Conclusions: Wide geographic variation in influenza vaccination disparities existed across US states and HRRs. Localized interventions targeted toward areas with high disparities may be a more effective strategy to promote health equity than one-size-fits-all national interventions., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

People living with dementia receive care from multiple caregivers, but little is known about the structure of their caregiving arrangements. This study used the Health and Retirement Study and latent class analyses to identify subgroups of caregiving arrangements based on caregiving hours received from spouses, children, other family/friends, and paid individuals among married (n = 361) and unmarried (n = 473) community-dwelling people with probable dementia. Three classes in the married sample (class 1 "low hours with shared care," class 2 "spouse-dominant care," and class 3 "children-dominant care") were identified. In class 1, spouses, children, and paid individuals provided 53%, 22%, and 26% of the caregiving hours, respectively. Three classes in the unmarried sample (class 1 "low hours with shared care," class 2 "children-dominant care," and class 3 "paid-dominant care") were identified. In unmarried class 1, children, other family/friends, and paid individuals provided 35%, 41% and 24% of the caregiving hours, respectively.

Objectives: Quantify the relationship between increasing influenza and respiratory syncytial virus (RSV) community viral activity and cardiorespiratory rehospitalizations among older adults discharged to skilled nursing facilities (SNFs)., Design: Retrospective cohort., Setting and Participants: Adults aged ≥65 years who were hospitalized and then discharged to a US SNF between 2012 and 2015., Methods: We linked Medicare Provider Analysis and Review claims to Minimum Data Set version 3.0 assessments, PRISM Climate Group data, and the Centers for Disease Control and Prevention viral testing data. All data were aggregated to US Department of Health and Human Services regions. Negative binomial regression models quantified the relationship between increasing viral activity for RSV and 3 influenza strains (H1N1pdm09, H3N2, and B) and cardiorespiratory rehospitalizations from SNFs. Incidence rate ratios described the relationship between a 5% increase in circulating virus and the rates of rehospitalization for cardiorespiratory outcomes. Analyses were repeated using the same model, but influenza and RSV were considered "in season" or "out of season" based on a 10% positive testing threshold., Results: Cardiorespiratory rehospitalization rates increased by approximately 1% for every 5% increase in circulating influenza A(H3N2), influenza B, and RSV, but decreased by 1% for every 5% increase in circulating influenza A(H1N1pdm09). When respiratory viruses were in season (vs out of season), cardiorespiratory rehospitalization rates increased by approximately 6% for influenza A(H3N2), 3% for influenza B, and 5% for RSV, but decreased by 6% for influenza A(H1N1pdm09)., Conclusions and Implications: The respiratory season is a particularly important period to implement interventions that reduce cardiorespiratory hospitalizations among SNF residents. Decreasing viral transmission in SNFs through practices such as influenza vaccination for residents and staff, use of personal protective equipment, improved environmental cleaning measures, screening and testing of residents and staff, surveillance of viral activity, and quarantining infected individuals may be potential strategies to limit viral infections and associated cardiorespiratory rehospitalizations., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Even small improvements in modifiable Alzheimer's disease and related dementias (ADRD) risk factors could lead to a substantial reduction of dementia cases., Aims: To determine if self-reported functional limitation associates with ADRD symptoms 4-18 years later., Methods: We conducted a prospective longitudinal study using the Health and Retirement Study of adults aged 51-59 years in 1998 without symptoms of ADRD by 2002 and followed them to 2016. Main exposure variables were difficulty with activities of daily living, mobility, large muscle strength, gross motor and upper limb activities. The outcome was incident ADRD identified by the Lange-Weir algorithm, death, or alive without ADRD. We fit two GEE multinomial models for each measure: (1) baseline measure of function and (2) change in function over time., Results: In the model with baseline only and outcome, only difficulty with mobility associated with future ADRD across levels of difficulty with near dose-response effect (risk ratios (RR) difficulty with 1-5 functions respectively, compared with no difficulty: 1.82; 2.70; 1.73 2.81; 4.03). Mobility also significantly associated with ADRD when allowing for change over time among those with 3, 4 or 5 versus no mobility limitations (RR 1.76; 2.36; 2.37)., Discussion: The results infer that an adult in midlife reporting difficulty with mobility as well as those with no mobility limitations in midlife but who later report severe limitations may be at increased risk of incident ADRD., Conclusions: Self-reported measures of mobility limitation may be early indicators of ADRD and may be useful for public health planning., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: We sought to compare rates of adverse events among nursing home residents who received an mRNA COVID-19 vaccine booster dose with those who had not yet received their booster., Methods: We assessed a prospective cohort of 11,200 nursing home residents who received a primary COVID-19 mRNA vaccine series at least 6 months prior to September 22, 2021 and received a third "booster dose" between September 22, 2021 and February 2, 2022. Residents lived in 239 nursing homes operated by Genesis HealthCare, spanning 21 U.S. states. We screened electronic health records for 20 serious vaccine-related adverse events that are monitored following receipt of COVID-19 vaccination by the CDC's Vaccine Safety Datalink. We matched boosted and yet-to-be boosted residents during the same time period, comparing rates of events occurring 14 days after booster administration with those occurring 14 days prior to booster administration. To supplement previously reported background rates of adverse events, we report background rates of medical conditions among nursing home residents during 2020, before COVID-19 vaccines were administered in nursing homes. Events occurring in 2021-2022 were confirmed by physician chart review. We report unadjusted rates of adverse events and used a false discovery rate procedure to adjust for multiplicity of events tested., Results: No adverse events were reported during the 14 days post-booster. A few adverse events occurred prior to booster (ischemic stroke: 49.4 per 100,000 residents, 95% CI: 21.2, 115.7; venous thromboembolism: 9.9 per 100,000 residents, 95% CI: 1.7, 56.0), though differences in event rates pre- versus post-booster were not statistically significant (p < 0.05) after adjusting for multiple comparisons. No significant differences were detected between post-booster vaccination rates and prior year 14-day background rates of medical conditions., Conclusions: No safety signals were detected following a COVID-19 mRNA vaccine booster dose in this large multi-state sample of nursing home residents., (© 2022 The American Geriatrics Society.)

Background: Since PCV13 was recommended in 2014, the characteristics of nursing home (NH) residents (and their facilities) recorded by facilities as not up-to-date with pneumococcal vaccination upon admission were unknown, and it is unknown if they received PCV13 in the NH., Methods: We conducted a retrospective cohort of NH residents of Centers for Medicare and Medicaid (CMS)-certified skilled nursing facilities from October 1, 2014, through September 22, 2018. CMS' Minimum Data Set (MDS) was linked to Medicare Part B Carrier claims to corroborate pneumococcal vaccination up-to-date status in the MDS with pneumococcal vaccination claims. The primary outcome of interest was vaccination with PCV13 versus nonreceipt among those identified as "not up to date" according to facility MDS records. We estimated generalized estimating equation (GEE) models., Results: Of the 1,459,814 residents recorded not up-to-date, (78.2%) had no Part B claims for PCV13 before or in the NH, the majority of whom (71.5%) were reported to have refused the vaccine when offered. Only 1.3% subsequently received PCV13 within 99 days after NH admission. In adjusted analyses, residents less likely to receive PCV13 in the NH than those who did included: residence in a for-profit facility (OR: 0.94 [95% CI: 0.89, 0.99]); male (OR: 0.92 [95% CI:0.89, 0.95]); black race (OR: 0.71 (95%CI: 0.66, 0.77); Hispanic ethnicity (OR: 0.69 [95%CI: 0.59, 0.75]); severely cognitively impaired compared with any lesser degree of impairment; had diabetes (OR: 0.93 [95%CI: 0.89, 0.97]); long-stay (≥100 days) compared with short-stay residents (OR: 0.17 (95%CI: 0.15, 0.20); and did not receive the influenza vaccine (OR: 0.74 (95%CI: 0.71, 0.77)., Conclusions: Due to refusals, few NH residents recorded not up-to-date on pneumococcal vaccinations from 2014 to 2018 received PCV13 within three months of admission. Strategies to promote newly recommended PCV15 or PCV20 vaccination upon NH admission may be needed., (© 2022 The American Geriatrics Society.)

Background: More older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents., Methods: We analyzed 2014-2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination., Results: There were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.10 pp, 95% CL: -3.53 pp, -2.68 pp), or high (-4.63 pp, 95% CL: -5.11 pp, -4.15 pp) MA compared with NHs with the lowest prevalence of MA., Conclusion: A higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper: [EB, ARZ, BHB, and PM declare no conflicts of interest. RVA and AC are employed by Sanofi Pasteur. SG reports grants and personal fees from Seqirus, Sanofi; and consulting or speaker fees from Sanofi, Merck, Longeveron, and the Gerontological Society of America for research related to vaccines or NH care quality.]., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Pneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis., Methods and Findings: This national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up., Conclusion: Among older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: R.V.A. and A.C. are employed by Sanofi Pasteur and may hold shares and/or stock options in the company. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: To reduce the increasing societal and financial burden of Alzheimer's disease and related dementias (ADRD), prevention is critical. Even small improvements of the modifiable dementia risk factors on the individual level have the potential to lead to a substantial reduction of dementia cases at the population level., Objective: To determine if pattern(s) of functional decline in midlife associate with late-onset ADRD years later., Methods: Using a longitudinal study of adults aged 51-59 years in 1998 without symptoms of ADRD by 2002 and followed them from 2002 to 2016 (n = 5404). The outcome was incident ADRD identified by the Lange-Weir algorithm, death, or alive with no ADRD. We used cluster analysis to identify patterns of functional impairment at baseline and multinomial regression to assess their association with future ADRD., Results: Three groups of adults with differing patterns of functional impairment were at greater risk of future ADRD. Difficulty with climbing one flight of stairs was observed in all adults in two of these groups. In the third group, 100% had difficulty with lifting 10 pounds and pushing or pulling a large object, but only one-fourth had difficulty in climbing stairs., Conclusion: Results imply that improved large muscle strength could decrease future risk of ADRD. If confirmed in other studies, screening for four self-reported measures of function among adults in midlife may be used for targeted interventions.

Background: We sought to determine if racial differences in influenza vaccination among nursing home (NH) residents during the 2008-2009 influenza season persisted in 2018-2019., Methods: We conducted a cross-sectional study of NHs certified by the Centers for Medicare & Medicaid Services during the 2018-2019 influenza season in US states with ≥1% Black NH residents and a White-Black gap in influenza vaccination of NH residents (N = 2 233 392) of at least 1 percentage point (N = 40 states). NH residents during 1 October 2018 through 31 March 2019 aged ≥18 years and self-identified as being of Black or White race were included. Residents' influenza vaccination status (vaccinated, refused, and not offered) was assessed. Multilevel modeling was used to estimate facility-level vaccination status and inequities by state., Results: The White-Black gap in influenza vaccination was 9.9 percentage points. In adjusted analyses, racial inequities in vaccination were more prominent at the facility level than at the state level. Black residents disproportionately lived in NHs that had a majority of Blacks residents, which generally had the lowest vaccination. Inequities were most concentrated in the Midwestern region, also the most segregated. Not being offered the vaccine was negligible in absolute percentage points between White residents (2.6%) and Black residents (4.8%), whereas refusals were higher among Black (28.7%) than White residents (21.0%)., Conclusions: The increase in the White-Black vaccination gap among NH residents is occurring at the facility level in more states, especially those with the most segregation., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.)

Objectives: To compare rates of adverse events following Coronavirus Disease 2019 (COVID-19) vaccination among nursing home residents with and without previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection., Design: Prospective cohort., Setting and Participants: A total of 20,918 nursing home residents who received the first dose of messenger RNA COVID-19 vaccine from December 18, 2020, through February 14, 2021, in 284 facilities within Genesis Healthcare, a large nursing home provider spanning 24 US states., Methods: We screened the electronic health record for adverse events, classified by the Brighton Collaboration, occurring within 15 days of a resident's first COVID-19 vaccine dose. All events were confirmed by physician chart review. To obtain risk ratios, multilevel logistic regression model that accounted for clustering (variability) across nursing homes was implemented. To balance the probability of prior SARS-CoV-2 infection (previous positive test or diagnosis by the International Classification of Diseases, 10 th Revision, Clinical Modification) more than 20 days before vaccination, we used inverse probability weighting. To adjust for multiplicity of adverse events tested, we used a false discovery rate procedure., Results: Statistically significant differences existed between those without (n = 13,163) and with previous SARS-CoV-2 infection [symptomatic (n = 5617) and asymptomatic (n = 2138)] for all baseline characteristics assessed. Only 1 adverse event was reported among those with previous SARS-CoV-2 infection (asymptomatic), venous thromboembolism [46.8 per 100,000 residents 95% confidence interval (CI) 8.3-264.5], which was not significantly different from the rate reported for those without previous infection (30.4 per 100,000 95% CI 11.8-78.1). Several other adverse events were observed for those with no previous infection, but were not statistically significantly higher than those reported with previous infection after adjustments for multiple comparisons., Conclusions and Implications: Although reactogenicity increases with preexisting immunity, we did not find that vaccination among those with previous SARS-CoV-2 infection resulted in higher rates of adverse events than those without previous infection. This study stresses the importance of monitoring novel vaccines for adverse events in this vulnerable population., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Estimates of influenza vaccine use are not available at the county level for U.S. nursing home (NH) residents but are critically necessary to guide the implementation of quality improvement programs aimed at increasing vaccination. Furthermore, estimates that account for differences in resident characteristics between counties are unavailable. We estimated risk-standardized vaccination rates (RSVRs) among short- and long-stay NH residents by U.S. county and identified drivers of geographic variation., Methods: We conducted a retrospective cohort study utilizing 100% of 2013-2015 fee-for-service Medicare claims, Minimum Data Set assessments, Certification and Survey Provider Enhanced Reports, and Long-Term Care: Facts on Care in the U.S. We separately evaluated short-stay (<100 days) and long-stay (≥100 days) residents aged 65 and older across the 2013-2014 and 2014-2015 influenza seasons. We estimated RSVRs via hierarchical logistic regression adjusting for 32 resident-level covariates. We then used multivariable linear regression models to assess associations between county-level NHs predictors and RSVRs., Results: The study cohort consisted of 2,817,217 residents in 14,658 NHs across 2798 counties. Short-stay residents had lower RSVRs than long-stay residents (2013-2014: median [interquartile range], 69.6% [62.8-74.5] vs 84.0% [80.8-86.4]), and there was wide variation within each population (range, 11.4-89.8 vs 49.1-92.6). Several modifiable facility-level characteristics were associated with increased RSVRs, including higher registered nurse to total nurse ratio and higher total staffing for licensed practical nurses, speech-language pathologists, and social workers. Characteristics associated with lower RSVRs included higher percentage of residents restrained, with a pressure ulcer, and NH-level hospitalizations per resident-year., Conclusions: Substantial county-level variation in influenza vaccine use exists among short- and long-stay NH residents. Quality improvement interventions to improve vaccination rates can leverage these results to target NHs located in counties with lower risk-standardized vaccine use., (© 2021 The American Geriatrics Society.)

Objective: To compare rates of incident SARS-CoV-2 infection and 30-day hospitalization or death among residents with confirmed infection in nursing homes with earlier versus later SARS-CoV-2 vaccine clinics., Design: Matched pairs analysis of nursing homes that had their initial vaccine clinics between December 18, 2020, and January 2, 2021, versus between January 3, 2021, and January 18, 2021. Matched facilities had their initial vaccine clinics between 12 and 16 days apart., Setting and Participants: Two hundred and eighty nursing homes in 21 states owned and operated by the largest long-term care provider in the United States., Measurements: Incident SARS-CoV-2 infections per 100 at-risk residents per week; hospital transfers and/or deaths per 100 residents with confirmed SARS-CoV-2 infection per day, averaged over a week., Results: The early vaccinated group included 136 facilities with 12,157 residents; the late vaccinated group included 144 facilities with 13,221 residents. After 1 week, early vaccinated facilities had a predicted 2.5 fewer incident SARS-CoV-2 infections per 100 at-risk residents per week (95% CI: 1.2-4.0) compared with what would have been expected based on the experience of the late vaccinated facilities. The rates remained significantly lower for several weeks. Cumulatively over 5 weeks, the predicted reduction in new infections was 5.2 cases per 100 at-risk residents (95% CI: 3.2-7.3). By 5 to 8 weeks post-vaccine clinic, early vaccinated facilities had a predicted 1.1 to 3.8 fewer hospitalizations and/or deaths per 100 infected residents per day, averaged by week than expected based on late vaccinated facilities' experience for a cumulative on average difference of 5 events per 100 infected residents per day., Conclusions: The SARS-CoV-2 vaccines seem to have accelerated the rate of decline of incident infections, morbidity, and mortality in this large multi-state nursing home population., (© 2021 The American Geriatrics Society.)

Background: The devastating impact of the SARS-CoV-2 pandemic prompted the development and emergency use authorization of two mRNA vaccines in early 2020. Vaccine trials excluded nursing home (NH) residents, limiting adverse event data that directly apply to this population., Methods: To prospectively monitor for potential adverse events associated with vaccination, we used Electronic Health Record (EHR) data from Genesis HealthCare, the largest NH provider in the United States. EHR data on vaccinations and pre-specified adverse events were updated daily and monitored for signal detection among residents of 147 facilities who received the first dose of vaccine between December 18, 2020 and January 3, 2021. For comparison, unvaccinated residents during the same time period were included from 137 facilities that started vaccinating at least 15 days after the vaccinating-facilities., Results: As of January 3, 2021, 8553 NH residents had received one dose of SARS-CoV-2 vaccine and by February 20, 2021, 8371 residents had received their second dose of vaccine; 11,072 were included in the unvaccinated comparator group. No significant associations were noted for neurologic outcomes, anaphylaxis, or cardiac events., Conclusions: No major safety problems were detected following the first or second dose of the vaccine to prevent COVID-19 in the study cohort from December 18, 2020 through March 7, 2021., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: BHB reports conflicts with vaccine manufacturers Sanofi and Pfizer related with grants. RAF and CB are employed by Genesis HealthCare. S. G. reports conflicts with vaccine manufacturers Sanofi, Seqirus, Pfizer related to grants, consulting, and speaking engagements. S. G. also consults with other pharmaceutical companies including Janssen, and Merck and has grants with Sunovion. KM reports conflicts with vaccine manufacturers Sanofi, Pfizer, and Sequiris related with grants. RG has served as an expert witness to Johnson & Johnson/Janssen in the opioid litigation. EMW, AN, VM, and INS have no conflicts., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: Quantify how observable characteristics contribute to influenza vaccination disparities among White, Black, and Hispanic nursing home (NH) residents., Design: Retrospective cohort., Setting and Participants: Short- and long-stay U.S. NH residents aged ≥65 years., Methods: We linked Minimum Data Set (MDS) and Medicare data to LTCFocUS and other facility data. We included residents with 6-month continuous enrollment in Medicare and an MDS assessment between October 1, 2013, and March 31, 2014. Residents were classified as short-stay (<100 days in NH) or long-stay (≥100 days in NH). We fit multivariable logistic regression models to assess the relationships between 27 resident and NH-level characteristics and receipt of influenza vaccination. Using nonlinear Oaxaca-Blinder decomposition, we decomposed the disparity in influenza vaccination between White versus Black and White versus Hispanic NH residents. Analyses were repeated separately for short- and long-stay residents., Results: Our study included 630,373 short-stay and 1,029,593 long-stay residents. Proportions vaccinated against influenza included 67.2% of White, 55.1% of Black, and 54.5% of Hispanic individuals among short-stay residents and 84.2%, 76.7%, and 80.8%, respectively among long-stay residents. Across 4 comparisons, the crude disparity in influenza vaccination ranged from 3.4 to 12.7 percentage points. By equalizing 27 prespecified characteristics, these disparities could be reduced 37.7% to 59.2%. Living in a predominantly White facility and proxies for NH quality were important contributors across all analyses. Characteristics unmeasured in our data (eg, NH staff attitudes and beliefs) may have also contributed significantly to the disparity., Conclusions and Implications: The racial/ethnic disparity in influenza vaccination was most dramatic among short-stay residents. Intervening on factors associated with NH quality would likely reduce these disparities; however, future qualitative research is essential to explore potential contributors that were unmeasured in our data and to understand the degree to which these factors contribute to the overall disparity in influenza vaccination., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims: Primary prevention studies have indicated that structured lifestyle change programs in adults with an annual diabetes risk of 4.7% are cost-effective. However, few population-based studies have quantified the risk of diabetes among adults with prediabetes., Methods: We used the nationally representative U.S. Health and Retirement Study to identify adults aged ≥ 52 years with prediabetes (A1c: 5.7% - 6.4%) in 2006 and followed them to 2014 to assess diabetes status defined by A1c ≥ 6.5% in 2010 or 2014 or by self-report of a diabetes diagnosis by various risk factors., Results: Among the 1,406 adults with prediabetes (average 4.7 years of follow-up), risk factors significantly associated with subsequent incident diabetes with adjusted annual risk of diabetes ≥ 4.7% were: male gender (4.8%); aged 52-64 years (5.0%); Black race (5.5%); obesity (body mass index (kg/m 2 ) ≥ 30.0, 6.8%); large waist circumference (women: > 35 in.; men: > 40 in., 4.9%); C-reactive protein levels ≥ 3 ug/L (5.5%); treated for high cholesterol (4.7%); treated for hypertension (5.3%); and moderate mobility loss (4.8%)., Conclusions: Primary prevention interventions among adults with prediabetes who also have moderate mobility loss or well-known risk factors for diabetes are likely to be cost-effective., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background/objectives: We sought to compare the post-acute and long-term care experience of Medicare beneficiaries with and without Alzheimer Disease and Related Dementias (ADRD), and whether differences changed from January 1, 2007 to September 30, 2015., Design: Retrospective cross-sectional trend study using Medicare claims linked to the Centers for Medicare & Medicaid Services' (CMS) Minimum Data Set., Setting: CMS-certified skilled nursing facilities (skilled nursing facility (SNF), n = 17,043)., Participants: Fee-for-service Medicare beneficiaries aged ≥66 years (n = 6,614,939) discharged from a hospital to a SNF who had not lived in a nursing home during the year before hospitalization., Measurements: ADRD was defined by the Chronic Condition Data Warehouse. Outcome measures included: (1) successful discharge defined as being in SNF less than 90 days, then discharged back to the community, alive without subsequent inpatient health care for 30 continuous days; (2) became long-stay resident in SNF; (3) death in SNF within 90 days; (4) hospital readmission within 30 days of entering SNF; and (5) transferred to another nursing home within 30 days of entering SNF., Results: Successful discharge of beneficiaries with ADRD increased from 43.4% in 2007 to 53.9% in 2015 (average annual percent change (AAPC) = 2.1 (95% CI = 2.0-2.2)); those without ADRD also increased (from 59.1% to 63.6%, AAPC = 0.9 (95% CI = 0.7-1.1)) but not as fast as those with ADRD (P < .01). The proportion of all beneficiaries who became long-stay or were readmitted to the hospital decreased (P < .05). The proportion with ADRD who became long-stay was nearly three times higher than those without throughout the study (15.0% vs 5.5% in 2007; 11.3% vs 4.3% in 2015)., Conclusion: Though disparity in ADRD in becoming long-stay residents remains, the increase in successful discharges among those with ADRD also stresses the increasing importance of community as a care setting for adults with ADRD., (© 2020 The American Geriatrics Society.)

Introduction: Annual influenza vaccination is associated with reduced mortality among older adults and lower overall public health burden of influenza. This study seeks to identify the characteristics associated with repeat influenza vaccination and determine whether age-group (51-59, 60-69, ≥70 years) differences exist., Methods: Using the nationally representative, longitudinal Health and Retirement Study waves 2004, 2008, 2012, and 2016, adults aged >50 years were followed from 2004 to 2016. In 2020, age-stratified, multinomial regression models were estimated to identify the factors associated with respondents receiving the vaccine repeatedly (every time point), occasionally (some years), or never, with censoring for death., Results: The overall proportion of adults repeatedly receiving influenza vaccine monotonically increased across age groups from 25.9% among adults aged 51-59 years to 62.4% among those aged ≥70 years. Black, non-Hispanics and smokers were less likely to repeatedly receive an influenza vaccine than white, non-Hispanics and nonsmokers (RR=0.40-0.61 and RR=0.60-0.75, respectively, p<0.05 for all). Those who had 1‒4 medical doctor visits in the past 2 years (RR=1.60-2.99) or cholesterol screening (RR=2.67-3.48) in the past 2 years were significantly more likely to repeatedly receive influenza vaccine than those who had none., Conclusions: Although adults aged 60-69 years and ≥70 years are more likely to receive influenza vaccine repeatedly than adults aged 51-59 years, age-specific interventions for repeat influenza vaccination may not be as effective as interventions targeted to certain subgroups among adults aged ≥51 years., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to identify patterns of knowledge, attitudes, and behaviors (KABs) about influenza and influenza vaccination among healthcare personnel (HCP) and define characteristics associated with these patterns. Methods: We used an Internet panel survey of HCP (N = 2265) during March 27-April 17, 2018; clustered HCP by their vaccination-related KABs. Results: Four clusters were identified: Immunization Champions (61.1% of the sample) received influenza vaccine to prevent disease; Unworried Vaccinators (15.4%) received the influenza vaccine but did not believe influenza is a serious threat to themselves; Fence Sitters (8.1%) believed the vaccine is safe and worth the time and expense but is not effective; Skeptics (15.4%) did not believe the vaccine is safe or effective. Influenza vaccination coverage was 78.4% overall and higher among Immunization Champions (90.2%) and Unworried Vaccinators (87.0%) than Fence Sitters (61.6%) or Skeptics (32.2%). Conclusions: Findings suggest that based on KABs, the 3 clusters comprising 85% of HCP might be vaccinated in the future. Using messages specific to each group may improve vaccination coverage among HCP.

The association between chronic kidney disease (CKD) and tuberculosis disease (TB) has been recognized for decades. Recently CKD prevalence is increasing in low- to middle-income countries with high TB burden. Using data from the required overseas medical exam and the recommended US follow-up exam for 444,356 US-bound refugees aged ≥ 18 during 2009-2017, we ran Poisson regression to assess the prevalence of TB among refugees with and without CKD, controlling for sex, age, diabetes, tobacco use, body mass index ( kg/m 2 ), prior residence in camp or non-camp setting, and region of birth country. Of the 1117 (0.3%) with CKD, 21 (1.9%) had TB disease; of the 443,239 who did not have CKD, 3380 (0.8%) had TB. In adjusted analyses, TB was significantly higher among those with than without CKD (prevalence ratio 1.93, 95% CI: 1.26, 2.98, p < 0.01). Healthcare providers attending to refugees need to be aware of this association.

Introduction: Vaccinating pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can reduce influenza and pertussis risk for themselves and their infants., Methods: Surveillance data were analyzed to ascertain influenza-associated hospitalization among pregnant women and infant hospitalization and death associated with influenza and pertussis. An Internet panel survey was conducted during March 27-April 8, 2019, among women aged 18-49 years who reported being pregnant any time since August 1, 2018. Influenza vaccination before or during pregnancy was assessed among respondents with known influenza vaccination status who were pregnant any time during October 2018-January 2019 (2,097). Tdap receipt during pregnancy was assessed among respondents with known Tdap status who reported a live birth by their survey date (817)., Results: From 2010-11 to 2017-18, pregnant women accounted for 24%-34% of influenza-associated hospitalizations per season among females aged 15-44 years. From 2010 to 2017, a total of 3,928 pertussis-related hospitalizations were reported among infants aged <2 months (annual range = 262-743). Maternal influenza and Tdap vaccination coverage rates reported as of April 2019 were 53.7% and 54.9%, respectively. Among women whose health care providers offered vaccination or provided referrals, 65.7% received influenza vaccine and 70.5% received Tdap. The most commonly reported reasons for nonvaccination were believing the vaccine is not effective (influenza; 17.6%) and not knowing that vaccination is needed during each pregnancy (Tdap; 37.9%), followed by safety concerns for the infant (influenza =15.9%; Tdap = 17.1%)., Conclusions and Implications for Public Health Practice: Many pregnant women do not receive the vaccines recommended to protect themselves and their infants, even when vaccination is offered. CDC and provider organizations' resources are available to help providers convey strong, specific recommendations for influenza and Tdap vaccination that are responsive to pregnant women's concerns., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

We examined changes in the prevalence of chronic health conditions among US-bound refugees originating from Burma resettling over 8 years by the type of living arrangement before resettlement, either in camps (Thailand) or in urban areas (Malaysia). Using data from the required overseas medical exam for 73,251 adult (≥ 18 years) refugees originating from Burma resettling to the United States during 2009-2016, we assessed average annual percent change (AAPC) in proportion ≥ 45 years and age- and sex-standardized prevalence of obesity, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and musculoskeletal disease, by camps versus urban areas. Compared with refugees resettling from camps, those coming from urban settings had higher prevalence of obesity (mean 18.0 vs. 5.9%), diabetes (mean 6.5 vs. 0.8%), and hypertension (mean 12.7 vs. 8.1%). Compared with those resettling from camps, those from urban areas saw greater increases in the proportion with COPD (AAPC: 109.4 vs. 9.9) and musculoskeletal disease (AAPC: 34.6 vs. 1.6). Chronic conditions and their related risk factors increased among refugees originating from Burma resettling to the United States whether they had lived in camps or in urban areas, though the prevalence of such conditions was higher among refugees who had lived in urban settings.

Objectives: To assess changes in US tuberculosis (TB) incidence rates by age, period, and cohort effects, stratified according to race/ethnicity and nativity., Methods: We used US National Tuberculosis Surveillance System data for 1996 to 2016 to estimate trends through age-period-cohort models., Results: Controlling for cohort and period effects indicated that the highest rates of TB incidence occurred among those 0 to 5 and 20 to 30 years of age. The incidence decreased by age for successive birth cohorts. There were greater estimated annual percentage decreases among US-born individuals (-7.3%; 95% confidence interval [CI] = -7.5, -7.1) than among non-US-born individuals (-4.3%; 95% CI = -4.5, -4.1). US-born individuals older than 25 years exhibited the largest decreases, a pattern that was not reflected among non-US-born adults. In the case of race/ethnicity, the greatest decreases by nativity were among US-born Blacks (-9.3%; 95% CI = -9.6, -9.1) and non-US-born Hispanics (-5.7%; 95% CI = -6.0, -5.5)., Conclusions: TB has been decreasing among all ages, races and ethnicities, and consecutive cohorts, although these decreases are less pronounced among non-US-born individuals.

Background: Recent studies have shown that some vaccines have beneficial effects that cannot be explained solely by the prevention of their respective targeted disease(s)., Methods: We used the MarketScan US Commercial Claims Databases for 2005 to 2014 to assess the risk of hospital admission for nontargeted infectious (NTI) diseases in children aged 16 through 24 months according to the last vaccine type (live and/or inactivated). We included children continuously enrolled within a month of birth through 15 months who received at least 3 doses of diphtheria-tetanus-acellular pertussis vaccine by the end of 15 months of age. We used Cox regression to estimate hazard ratios (HRs), stratifying by birthdate to control for age, year, and seasonality and adjusting for sex, chronic diseases, prior hospitalizations, number of outpatient visits, region of residence, urban/rural area of domicile, prematurity, low birth weight, and mother's age., Results: 311663 children were included. In adjusted analyses, risk of hospitalization for NTI from ages 16 through 24 months was reduced for those who received live vaccine alone compared with inactivated alone or concurrent live and inactivated vaccines (HR, 0.50; 95% confidence interval [CI], 0.43, 0.57 and HR, 0.78; 95% CI, 0.67, 0.91, respectively) and for those who received live and inactivated vaccines concurrently compared with inactivated-only (HR, 0.64; 95% CI, 0.58, 0.70)., Conclusions: We found lower risk of NTI disease hospitalizations from age 16 through 24 months among children whose last vaccine received was live compared with inactivated vaccine, as well as concurrent receipt compared with inactivated vaccine., (Published by Oxford University Press for the Infectious Diseases Society of America 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

U.S. military personnel assigned to areas deemed to be at high risk for anthrax attack receive Anthrax Vaccine Adsorbed (AVA). Few cases of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have been reported in persons who received AVA. Using a matched case-control study design, we assessed the relationship of RA and SLE with AVA vaccination using the Defense Medical Surveillance System. We identified potential cases using International Classification of Diseases, 9th Revision, Clinical Modification codes and confirmed cases with medical record review and rheumatologist adjudication. Using conditional logistic regression, we estimated odds ratios (OR) for AVA exposure during time intervals ranging from 90 to 1,095 days before disease onset. Among 77 RA cases, 13 (17%) had ever received AVA. RA cases were no more likely than controls to have received AVA when looking back 1,095 days (OR: 1.03; 95% confidence interval [CI]: 0.48-2.19) but had greater odds of exposure in the prior 90 days (OR: 3.93; 95% CI: 1.08-14.27). Among the 39 SLE cases, 5 (13%) had ever received AVA; no significant difference in receipt of AVA was found when compared with controls (OR: 0.91; 95% CI: 0.26-3.25). AVA was associated with recent onset RA, but did not increase the risk of developing RA in the long term., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Background: No comparative review of Vaccine Adverse Event Reporting System (VAERS) submissions following pandemic influenza A (H1N1) 2009 and seasonal influenza vaccinations during the pandemic season among U.S. military personnel has been published., Methods: We compared military vs. civilian adverse event reporting rates. Adverse events (AEs) following vaccination were identified from VAERS for adults aged 17-44years after pandemic (monovalent influenza [MIV], and seasonal (trivalent inactivated influenza [IIV3], live attenuated influenza [LAIV3]) vaccines. Military vaccination coverage was provided by the Department of Defense's Defense Medical Surveillance System. Civilian vaccination coverage was estimated using data from the National 2009 H1N1 Flu Survey and the Behavioral Risk Factor Surveillance System survey., Results: Vaccination coverage was more than four times higher for MIV and more than twenty times higher for LAIV3 in the military than in the civilian population. The reporting rate of serious AE reports following MIV in service personnel (1.19 per 100,000) was about half that reported by the civilian population (2.45 per 100,000). Conversely, the rate of serious AE reports following LAIV3 among service personnel (1.32 per 100,000) was more than twice that of the civilian population. Although fewer military AEs following MIV were reported overall, the rate of Guillain-Barré Syndrome (GBS) (4.01 per million) was four times greater than that in the civilian population. (1.04 per million)., Conclusions: Despite higher vaccination coverage in service personnel, the rate of serious AEs following MIV was about half that in civilians. The rate of GBS reported following MIV was higher in the military., (Published by Elsevier Ltd.)

Background: The life expectancy of the average American with diabetes has increased, but the quality of health and functioning during those extra years are unknown. We aimed to investigate the net effect of recent trends in diabetes incidence, disability, and mortality on the average age of disability onset and the number of healthy and disabled years lived by adults with and without diabetes in the USA. We assessed whether disability expanded or was compressed in the population with diabetes and compared the findings with those for the population without diabetes in two consecutive US birth cohorts aged 50-70 years., Methods: In this prospective longitudinal analysis, we analysed data for two cohorts of US adults aged 50-70 years from the Health and Retirement Study, including 1367 people with diabetes and 11 414 without diabetes. We assessed incident disability, remission from disability, and mortality between population-based cohort 1 (born 1931-41, follow-up 1992-2002) and cohort 2 (born 1942-47, follow up 2002-12). Disability was defined by mobility loss, difficulty with one or more instrumental activities of daily living, and difficulty with one or more activities of daily living. We entered age-specific probabilities representing the two birth cohorts into a five-state Markov model to estimate the number of years of disabled and disability-free life and life-years lost by age 70 years., Findings: In people with diabetes, compared with cohort 1 (n=1067), cohort 2 (n=300) had more disability-free and total years of life, later onset of disability, and fewer disabled years. Simulations of the Markov models suggest that in men with diabetes aged 50 years, this difference between cohorts amounted to a 0·8-2·3 year delay in disability across the three metrics (mobility, 63·0 [95% CI 62·3-63·6] to 64·8 [63·6-65·7], p=0·01; instrumental activities of daily living, 63·5 [63·0-64·0] to 64·3 [63·0-65·3], p=0·24; activities of daily living, 62·7 [62·1-63·3] to 65·0 [63·5-65·9], p<0·0001) and 1·3 fewer life-years lost (ie, fewer remaining life-years up to age 70 years; from 2·8 [2·5-3·2] to 1·5 [1·3-1·9]; p<0·0001 for all three measures of disability). Among women with diabetes aged 50 years, this difference between cohorts amounted to a 1·1-2·3 year delay in disability across the three metrics (mobility, 61·3 [95% CI 60·5-62·1] to 63·2 [61·5-64·5], p=0·0416; instrumental activities of daily living, 63·0 [62·4-63·7] to 64·1 [62·7-65·2], p=0·16; activities of daily living, 62·3 [61·6-63·0] to 64·6 [63·1-65·6], p<0·0001) and 0·8 fewer life-years lost by age 70 years (1·9 [1·7-2·2] to 1·1 [0·9-1·5]; p<0·0001 for all three measures of disability). Parallel improvements were gained between cohorts of adults without diabetes (cohort 1, n=8687; cohort 2, n=2727); within both cohorts, those without diabetes had significantly more disability-free years than those with diabetes (p<0·0001 for all comparisons)., Interpretation: Irrespective of diabetes status, US adults saw a compression of disability and gains in disability-free life-years. The decrease in disability onset due to primary prevention of diabetes could play an important part in achieving longer disability-free life-years., Funding: US Department of Health & Human Services and the US Centers for Disease Control and Prevention., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: To quantify the impact of diabetes status on healthy and disabled years of life for older adults in the U.S. and provide a baseline from which to evaluate ongoing national public health efforts to prevent and control diabetes and disability., Research Design and Methods: Adults (n = 20,008) aged 50 years and older were followed from 1998 to 2012 in the Health and Retirement Study, a prospective biannual survey of a nationally representative sample of adults. Diabetes and disability status (defined by mobility loss, difficulty with instrumental activities of daily living [IADL], and/or difficulty with activities of daily living [ADL]) were self-reported. We estimated incidence of disability, remission to nondisability, and mortality. We developed a discrete-time Markov simulation model with a 1-year transition cycle to predict and compare lifetime disability-related outcomes between people with and without diabetes. Data represent the U.S. population in 1998., Results: From age 50 years, adults with diabetes died 4.6 years earlier, developed disability 6-7 years earlier, and spent about 1-2 more years in a disabled state than adults without diabetes. With increasing baseline age, diabetes was associated with significant (P < 0.05) reductions in the number of total and disability-free life-years, but the absolute difference in years between those with and without diabetes was less than at younger baseline age. Men with diabetes spent about twice as many of their remaining years disabled (20-24% of remaining life across the three disability definitions) as men without diabetes (12-16% of remaining life across the three disability definitions). Similar associations between diabetes status and disability-free and disabled years were observed among women., Conclusions: Diabetes is associated with a substantial reduction in nondisabled years, to a greater extent than the reduction of longevity., (© 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Unlabelled: To determine rates of diabetes, hypertension, and hyperlipidemia in Cambodian refugees, and to assess the proportion whose conditions are satisfactorily managed in comparison to the general population. Self-report and laboratory/physical health assessment data obtained from a household probability sample of U.S.-residing Cambodian refugees (N = 331) in 2010-2011 were compared to a probability sample of the adult U.S. population (N = 6,360) from the 2009-2010 National Health and Nutrition Examination Survey. Prevalence of diabetes, hypertension and hyperlipidemia in Cambodian refugees greatly exceeded rates found in the age- and gender-adjusted U.S., Population: Cambodian refugees with diagnosed hypertension or hyperlipidemia were less likely than their counterparts in the general U.S. population to have blood pressure and total cholesterol within recommended levels. Increased attention should be paid to prevention and management of diabetes and cardiovascular disease risk factors in the Cambodian refugee community. Research is needed to determine whether this pattern extends to other refugee groups.

Background: Estimation of incidence of the state of undiagnosed chronic disease provides a crucial missing link for the monitoring of chronic disease epidemics and determining the degree to which changes in prevalence are affected or biased by detection., Methods: We developed a four-part compartment model for undiagnosed cases of irreversible chronic diseases with a preclinical state that precedes the diagnosis. Applicability of the model is tested in a simulation study of a hypothetical chronic disease and using diabetes data from the Health and Retirement Study (HRS)., Results: A two dimensional system of partial differential equations forms the basis for estimating incidence of the undiagnosed and diagnosed disease states from the prevalence of the associated states. In the simulation study we reach very good agreement between the estimates and the true values. Application to the HRS data demonstrates practical relevance of the methods., Discussion: We have demonstrated the applicability of the modeling framework in a simulation study and in the analysis of the Health and Retirement Study. The model provides insight into the epidemiology of undiagnosed chronic diseases.

Introduction: Diabetes is one of the most common and fastest-growing comorbidities of pregnancy. Temporal trends in gestational diabetes mellitus (GDM) have not been examined at the state level. This study examines GDM prevalence trends overall and by age, state, and region for 19 states, and by race/ethnicity for 12 states. Sub-analysis assesses trends among GDM deliveries by insurance type and comorbid hypertension in pregnancy., Methods: Using the Agency for Healthcare Research and Quality's National and State Inpatient Databases, deliveries were identified using diagnosis-related group codes for GDM and comorbidities using ICD-9-CM diagnosis codes among all community hospitals. General linear regression with a log-link and binomial distribution was used in 2014 to assess annual change in GDM prevalence from 2000 through 2010., Results: The age-standardized prevalence of GDM increased from 3.71 in 2000 to 5.77 per 100 deliveries in 2010 (relative increase, 56%). From 2000 through 2010, GDM deliveries increased significantly in all states (p<0.01), with relative increases ranging from 36% to 88%. GDM among deliveries in 12 states reporting race and ethnicity increased among all groups (p<0.01), with the highest relative increase in Hispanics (66%). Among GDM deliveries in 19 states, those with pre-pregnancy hypertension increased significantly from 2.5% to 4.1% (relative increase, 64%). The burden of GDM delivery payment shifted from private insurers (absolute decrease of 13.5 percentage points) to Medicaid/Medicare (13.2-percentage point increase)., Conclusions: Results suggest that GDM deliveries are increasing. The highest rates of increase are among Hispanics and among GDM deliveries complicated by pre-pregnancy hypertension., (Published by Elsevier Inc.)

Objective: Diabetes care has changed substantially in the past 2 decades. We examined the change in medical spending and use related to diabetes between 1987 and 2011., Research Design and Methods: Using the 1987 National Medical Expenditure Survey and the Medical Expenditure Panel Surveys in 2000-2001 and 2010-2011, we compared per person medical expenditures and uses among adults ≥ 18 years of age with or without diabetes at the three time points. Types of medical services included inpatient care, emergency room (ER) visits, outpatient visits, prescription drugs, and others. We also examined the changes in unit cost, defined by the expenditure per encounter for medical services., Results: The excess medical spending attributed to diabetes was $2,588 (95% CI, $2,265 to $3,104), $4,205 ($3,746 to $4,920), and $5,378 ($5,129 to $5,688) per person, respectively, in 1987, 2000-2001, and 2010-2011. Of the $2,790 increase, prescription medication accounted for 55%; inpatient visits accounted for 24%; outpatient visits accounted for 15%; and ER visits and other medical spending accounted for 6%. The growth in prescription medication spending was due to the increase in both the volume of use and unit cost, whereas the increase in outpatient expenditure was almost entirely driven by more visits. In contrast, the increase in inpatient and ER expenditures was caused by the rise of unit costs., Conclusions: In the past 2 decades, managing diabetes has become more expensive, mostly due to the higher spending on drugs. Further studies are needed to assess the cost-effectiveness of increased spending on drugs., (© 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Context: Maternal pregestational diabetes (PGDM) is a risk factor for development of congenital heart defects (CHDs). Glycemic control before pregnancy reduces the risk of CHDs. A meta-analysis was used to estimate summary ORs and mathematical modeling was used to estimate population attributable fractions (PAFs) and the annual number of CHDs in the U.S. potentially preventable by establishing glycemic control before pregnancy., Evidence Acquisition: A systematic search of the literature through December 2012 was conducted in 2012 and 2013. Case-control or cohort studies were included. Data were abstracted from 12 studies for a meta-analysis of all CHDs., Evidence Synthesis: Summary estimates of the association between PGDM and CHDs and 95% credible intervals (95% CrIs) were developed using Bayesian random-effects meta-analyses for all CHDs and specific CHD subtypes. Posterior estimates of this association were combined with estimates of CHD prevalence to produce estimates of PAFs and annual prevented cases. Ninety-five percent uncertainty intervals (95% UIs) for estimates of the annual number of preventable cases were developed using Monte Carlo simulation. Analyses were conducted in 2013. The summary OR estimate for the association between PGDM and CHDs was 3.8 (95% CrI=3.0, 4.9). Approximately 2670 (95% UI=1795, 3795) cases of CHDs could potentially be prevented annually if all women in the U.S. with PGDM achieved glycemic control before pregnancy., Conclusions: Estimates from this analysis suggest that preconception care of women with PGDM could have a measureable impact by reducing the number of infants born with CHDs., (Published by Elsevier Inc.)

Background: Trends in state-level prevalence of pre-pregnancy diabetes mellitus (PDM; i.e., type 1 or type 2 diabetes diagnosed before pregnancy) among delivery hospitalizations are needed to inform healthcare delivery planning and prevention programs., Purpose: To examine PDM trends overall, by age group, race/ethnicity, primary payer, and with comorbidities such as pre-eclampsia and pre-pregnancy hypertension, and to report changes in prevalence over 11 years., Methods: In 2014, State Inpatient Databases from the Agency for Healthcare Research and Quality were analyzed to identify deliveries with PDM and comorbidities using diagnosis-related group codes and ICD-9-CM codes. General linear regression with a log-link and binomial distribution was used to assess the annual change., Results: Between 2000 and 2010, PDM deliveries increased significantly in all age groups, all race/ethnicity groups, and in all states examined (p<0.01). The age-standardized prevalence of PDM increased from 0.65 per 100 deliveries in 2000 to 0.89 per 100 deliveries in 2010, with a relative change of 37% (p<0.01). Although PDM rates were highest in the South, some of the largest relative increases occurred in five Western states (≥69%). Non-Hispanic blacks had the highest PDM rates and the highest absolute increase (0.26 per 100 deliveries). From 2000 to 2010, the proportion of PDM deliveries with pre-pregnancy hypertension increased significantly (p<0.01) from 7.4% to 14.1%., Conclusions: PDM deliveries are increasing overall and particularly among those with PDM who have hypertension. Effective diabetes prevention and control strategies for women of childbearing age may help protect their health and that of their newborns., (Published by Elsevier Inc.)

Objective: To determine whether macronutrient intake differs by awareness of glycemic status among people with diabetes and prediabetes., Research Design and Methods: We used 24-h dietary recall and other data from 3,725 nonpregnant adults with diabetes or prediabetes aged ≥20 years from the morning fasting sample of the 2005-2010 National Health and Nutrition Examination Survey. Diabetes and prediabetes awareness were self-reported; those unaware of diabetes and prediabetes were defined by fasting plasma glucose (FPG) ≥126 mg/dL or HbA1c ≥6.5% and FPG 100-125 mg/dL or HbA1c of 5.7%-6.4%, respectively. Components of nutrient intake on a given day assessed were total calories, sugar, carbohydrates, fiber, protein, fat, and total cholesterol, stratified by sex and glycemic status awareness. Estimates of nutrient intake were adjusted for age, race/ethnicity, education level, BMI, smoking status, and family history of diabetes., Results: Men with diagnosed diabetes consumed less sugar (mean 86.8 vs. 116.8 g) and carbohydrates (mean 235.0 vs. 262.1 g) and more protein (mean 92.3 vs. 89.7 g) than men with undiagnosed diabetes. Similarly, women with diagnosed diabetes consumed less sugar (mean 79.1 vs. 95.7 g) and more protein (mean 67.4 vs. 56.6 g) than women with undiagnosed diabetes. No significant differences in macronutrient intake were found by awareness of prediabetes. All participants, regardless of sex or glycemic status, consumed on average less than the American Diabetes Association recommendations for fiber intake (i.e., 14 g/1,000 kcal) and slightly more saturated fat than recommended (>10% of total kcal)., Conclusions: Screening and subsequent knowledge of glycemic status may favorably affect some dietary patterns for people with diabetes., (© 2014 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

OBJECTIVE We assessed whether functional decline and physical disability increase the subsequent risk of diabetes. RESEARCH DESIGN AND METHODS We used a subsample of adults aged 51 years and older with no diabetes at baseline who were followed up to 12 years (1998-2010) in the Health and Retirement Study, an observational study of a nationally representative survey. We assessed baseline disability status and incident disability with subsequent risk of diabetes, accounting for death as a competing risk and controlling for BMI, age, sex, race/ethnicity, net wealth, mother's level of education, respondents' level of education, and time of follow-up. Disability was defined as none, mild, moderate, and severe, based on a validated scale of mobility measures. Diabetes was identified by self-report of a diagnosis from a doctor. Population attributable fraction (PAF) was calculated to assess the percentage of diabetes cases that were attributable to mobility disability. RESULTS The sample included 22,878 adults with an average of 8.7 years of follow-up; 9,649 (41.2%) reported some level of disability at baseline, and 8,175 (35.7%) additional participants developed disability during follow-up; 3,546 (15.5%) participants developed diabetes; and 5,869 (25.6%) died. Regression analyses found a statistically significant dose-response relationship of increased risk of diabetes (28-95%) among those with any level of functional decline, prevalent or incident. Among the subanalytic sample, including incident disability only, the PAF was 6.9% (CI 4.2-9.5). CONCLUSIONS Our findings suggest those who become disabled, even mildly, are at increased risk of developing diabetes. This finding raises the possibility that approaches to prevent disability in older adults could also reduce diabetes incidence.

Objective: To use structural modeling to test a hypothesized model of causal pathways related with prediabetes among older adults in the U.S., Research Design and Methods: Cross-sectional study of 2,230 older adults (≥ 50 years) without diabetes included in the morning fasting sample of the 2001-2006 National Health and Nutrition Examination Surveys. Demographic data included age, income, marital status, race/ethnicity, and education. Behavioral data included physical activity (metabolic equivalent hours per week for vigorous or moderate muscle strengthening, walking/biking, and house/yard work), and poor diet (refined grains, red meat, added sugars, solid fats, and high-fat dairy). Structural-equation modeling was performed to examine the interrelationships among these variables with family history of diabetes, high blood pressure, BMI, large waist (waist circumference: women, ≥ 35 inches; men, ≥ 40 inches), triglycerides ≥ 200 mg/dL, and total and HDL (≥ 60 mg/dL) cholesterol., Results: After dropping BMI and total cholesterol, our best-fit model included three single factors: socioeconomic position (SEP), physical activity, and poor diet. Large waist had the strongest direct effect on prediabetes (0.279), followed by male sex (0.270), SEP (-0.157), high blood pressure (0.122), family history of diabetes (0.070), and age (0.033). Physical activity had direct effects on HDL (0.137), triglycerides (-0.136), high blood pressure (-0.132), and large waist (-0.067); poor diet had direct effects on large waist (0.146) and triglycerides (0.148)., Conclusions: Our results confirmed that, while including factors known to be associated with high risk of developing prediabetes, large waist circumference had the strongest direct effect. The direct effect of SEP on prediabetes suggests mediation by some unmeasured factor(s).