Guidance on Public Reporting of Healthcare

8/2/2019 Guidance on Public Reporting of Healthcare

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Guidance on Public Reporting ofHealthcare-Associated Infections:

Recommendations of the HealthcareInfection Control Practices AdvisoryCommitteeLinda McKibben, MD,a Teresa Horan, MPH,b JeromeI. Tokars, MD, MPH,b Gabrielle Fowler,MPH,b Denise M. Cardo, MD,aMichele L. Pearson,MD,c Patrick J. Brennan, MD,d and the Healthcare

Infection Control Practices Advisory Committee*Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of theHICPAC PDF (150 KB / 10 pages) availabledownloadSince 2002, 4 states have enacted legislation thatrequires health care organizations to publicly

disclose health careassociated infection (HAI)

rates. Similar legislative efforts are underway inseveral other states. Advocates of mandatorypublic reporting of HAIs believe that making suchinformation publicly available will enableconsumers to make more informed choices abouttheir health care and improve overall health care

quality by reducing HAIs. Further, they believe thatpatients have a right to know this information.However, others have expressed concern that thereliability of public reporting systems may becompromised by institutional variability in the
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definitions used for HAIs, or in the methods andresources used to identify HAIs. Presently, there isinsufficient evidence on the merits and limitations

of an HAI public reporting system. Therefore, theHealthcare Infection Control Practices AdvisoryCommittee (HICPAC) has not recommended for oragainst mandatory public reporting of HAI rates.However, HICPAC has developed this guidancedocument based on established principles forpublic health and HAI reporting systems. This

document is intended to assist policymakers,program planners, consumer advocacyorganizations, and others tasked with designingand implementing public reporting systems forHAIs. The document provides a framework forlegislators, but does not provide model legislation.HICPAC recommends that persons who design and

implement such systems 1) use established publichealth surveillance methods when designing andimplementing mandatory HAI reporting systems;2) create multidisciplinary advisory panels,including persons with expertise in the preventionand control of HAIs, to monitor the planning andoversight of HAI public reporting systems; 3)

choose appropriate process and outcome measuresbased on facility type and phase in measures toallow time for facilities to adapt and to permitongoing evaluation of data validity; and 4) provideregular and confidential feedback of performance


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data to healthcare providers. Specifically, HICPACrecommends that states establishing publicreporting systems for HAIs select one or more of

the following process or outcome measures asappropriate for hospitals or long-term care facilitiesin their jurisdictions: 1) central-line insertionpractices; 2) surgical antimicrobial prophylaxis; 3)influenza vaccination coverage among patients andhealthcare personnel; 4) central line-associatedbloodstream infections; and 5) surgical site

infections following selected operations. HICPACwill update these recommendations as moreresearch and experience become available. (Am JInfect Control 2005;33:217-26.)

Consumer demand for health care information,including data about the performance of healthcare providers, has increased steadily over thepast decade. Many state and national initiativesare underway to mandate or induce health careorganizations to publicly disclose informationregarding institutional and physician performance.Mandatory public reporting of health careperformance is intended to enable stakeholders,including consumers, to make more informedchoices on health care issues.

Public reporting of health care performanceinformation has taken several forms. Health careperformance reports (report cards and honor rolls)


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typically describe the outcomes of medical care interms of mortality, selected complications, ormedical errors and, to a lesser extent, economic

outcomes. Increasingly, process measures (ie,measurement of adherence to recommendedhealth care practices, such as hand hygiene) arebeing used as an indicator of how well anorganization adheres to established standards ofpractice with the implicit assumption that goodprocesses lead to good health care outcomes.

National health care quality improvementinitiatives, notably those of the Joint Commissionon the Accreditation of Healthcare Organizations(JCAHO), the Centers for Medicare & MedicaidServices (CMS), and the Hospital Quality Alliance,use process measures in their public reportinginitiatives.

Health careassociated infections (HAIs) areinfections that patients acquire during the courseof receiving treatment for other conditions (seeAppendix 1 for full definition of this and otherterms used in this document). In hospitals alone,HAIs account for an estimated 2 million infections,90,000 deaths, and $4.5 billion in excess healthcare costs annually1; however, few of the existingreport cards on hospital performance use HAIs as aquality indicator. Since 2002, 4 states (Illinois,Pennsylvania, Missouri, and Florida) have enactedlegislation mandating hospitals and health care


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organizations to publicly disclose HAI rates. Similarlegislative efforts are underway in several otherstates.

Because of the increasing legislative and regulatoryinterest in this area, the Healthcare InfectionControl Practices Advisory Committee (HICPAC)conducted a scientific literature review to evaluatethe merits and limitations of HAI reportingsystems.We found no published information on theeffectiveness of public reporting systems inreducing HAIs. Therefore, HICPAC has concludedthat there is insufficient evidence at this time torecommend for or against public reporting of HAIs.

However, to assist those who will be tasked withdesigning and implementing such reportingsystems, HICPAC presents the following framework

for an HAI reporting system and recommendationsfor process and outcome measures to be includedin the system. The framework andrecommendations are based on establishedprinciples for public health and HAI surveillance.This document is intended primarily forpolicymakers, program planners, consumer

advocacy organizations, and others who will bedeveloping and maintaining public reportingsystems for HAI. The document does not providemodel legislation.


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This document represents the consensus opinion ofHICPAC. HICPAC is a federal advisory committeethat was established in 1991 to provide advice and

guidance to the Department of Health and HumanServices and CDC regarding surveillance,prevention, and control of HAIs and related eventsin healthcare settings(www.cdc.gov/HICPAC/).These recommendationsalso have been endorsed by the Association forProfessionals in Infection Control and

Epidemiology, the Council of State and TerritorialEpidemiologists, and the Society for HealthcareEpidemiology of America. These recommendationsalso have been endorsed by the Association forProfessionals in Infection Control andEpidemiology, the Council of State and TerritorialEpidemiologists, and the Society for Healthcare

Epidemiology of America. These recommendationswill be updated as new information becomesavailable.

Top of PageEssential Elements Of A Public Reporting System For HAIs

As a first step, the goals, objectives, and prioritiesof a public reporting system should be clearly

specified and the information to be monitoredshould be measurable to ensure that the systemcan be held accountable by stakeholders. Thereporting system should collect and reporthealthcare data that are useful not only to the
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public, but also to the facility for its qualityimprovement efforts. This can be achieved byselection of appropriate measures and patient

populations to monitor; use of standardized case-finding methods and data validity checks;adequate support for infrastructure, resources, andinfection control professionals; adjustment forunderlying infection risk; and production of usefuland accessible reports for stakeholders, withfeedback to healthcare providers. The planning and

oversight of the system should be monitored by amultidisciplinary group composed of public healthofficials, consumers, health care providers, andhealth care infection control professionals.

Top of PageIdentifying Appropriate Measures of Health CarePerformance

Monitoring both process and outcome measuresand assessing their correlation is a comprehensiveapproach to quality improvement. Standardizedprocess and outcome measures for national healthcare performance for hospitals, nursing homes,and other settings have been endorsed through theNational Quality Forum (NQF) voluntary consensusprocess.2-4 NQF also has developed a model policyon the endorsement of proprietary performancemeasures.5 Several other agencies andorganizations, including CDC, CMS, the Agency forHealthcare Quality and Research, JCAHO, the
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Leapfrog organization, and the National Committeefor Quality Assurance, also have developed healthcare quality measures. Health care performance

reports should identify the sources and endorsersof the measures and the sources of the data used(eg, administrative or clinical).

Process measures. Process measures aredesirable for inclusion in a public reporting systembecause the target adherence rate of 100% tothese practices is unambiguous. Furthermore,process measures do not require adjustment forthe patient's underlying risk of infection. Processmeasures that are selected for inclusion in a publicreporting system should be those that measurecommon practices, are valid for a variety of healthcare settings (eg, small, rural versus large, urbanhospitals); and can be clearly specified (eg,appropriate exclusion and inclusion criteria).Process measures meeting these criteria includeadherence rates of central line insertion practicesand surgical antimicrobial prophylaxis andcoverage rates of influenza vaccination for healthcare personnel and patients/residents (Table 1).Collection of data on one or more of these processmeasures already is recommended by the NQF andrequired by CMS and JCAHO for their purposes.Outcome measures. Outcome measures should bechosen for reporting based on the frequency,severity, and preventability of the outcomes and
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the likelihood that they can be detected andreported accurately.14 Outcome measures meetingthese criteria include central lineassociated,

laboratory-confirmed primary bloodstreaminfections (CLA-LCBI) in intensive care units (ICU)and surgical site infections (SSI) following selectedoperations (Table 2). Although CLA-LCBIs and SSIsoccur at relatively low rates, they are associatedwith substantial morbidity and mortality andexcess health care costs. Also, there are well-

established prevention strategies for CLA-LCBIsand SSIs.6,10 Therefore, highest priority should begiven to monitoring these two HAIs and providers'adherence to the related processes of care (ie,central-line insertion practices for CLA-LCBI andsurgical antimicrobial prophylaxis for SSIs).Use of other HAIs in public reporting systems may

be more difficult. For example, catheter-associatedurinary tract infections, though they may occurmore frequently than CLA-LCBIs or SSIs, areassociated with a lower morbidity and mortality;therefore, monitoring these infections likely hasless prevention effectiveness relative to the burdenof data collection and reporting. On the other

hand, HAIs such as ventilator-associatedpneumonia, which occur relatively infrequently buthave substantial morbidity and mortality, aredifficult to detect accurately. Including such HAIsin a reporting system may result in invalid
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comparisons of infection rates and be misleadingto consumers.

Monitoring of process and outcome measuresshould be phased in gradually to allow time forfacilities to adapt and to permit ongoing evaluationof data validity.

Top of PageIdentifying Patient Populations for Monitoring

CDC16 and other authorities17 no longer

recommend collection or reporting of hospital-wideoverall HAI rates because 1) HAI rates are low inmany hospital locations (which makes routineinclusion of these units unhelpful), 2) collectinghospital-wide data is labor intensive and maydivert resources from prevention activities, and 3)methods for hospital-wide risk adjustment have

not been developed. Rather than hospitalwiderates, reporting rates of specific HAI for specifichospital units or operation-specific rates of SSIs isrecommended.16 This practice can help ensurethat data collection is concentrated in populationswhere HAIs are more frequent and that rates arecalculated that are more useful for targeting

prevention and making comparisons amongfacilities or within facilities over time.

Top of PageCase-Finding
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Once the population at risk for HAIs has beenidentified, standardized methods for case-findingshould be adopted. Such methods help to reduce

surveillance bias (ie, the finding of higher rates atinstitutions that do a more complete job ofcasefinding). Incentives to find cases of HAI maybe helpful. Conversely, punitive measures forhospitals that report high rates may encourageunderreporting.

Traditional case-finding methods for HAIs includereview of medical records, laboratory reports, andantibiotic administration records. However, thesestandard case-finding methods can be enhanced.For example, substantially more SSIs are foundwhen administrative data sources (eg,International Classification of Diseases, 9thRevision [ICD-9], discharge codes) are used incombination with antimicrobial receipt to flagcharts for careful review.18,19 However, theaccuracy of case-finding using ICD-9 codes alonelikely varies by HAI type and by hospital.Therefore, ICD-9 discharge codes should not berelied upon as the sole source of case finding forHAI monitoring systems.

Traditional HAI case-finding methods weredeveloped in an era when patients' lengths ofhospitalization were much longer than they aretoday, allowing most HAIs to be detected during


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the hospital stay. However, for SSIs in particular,the current climate of short stays and rapidtransfers to other facilities makes accurate

detection difficult because as many as 50% of SSIsdo not become evident until after hospitaldischarge or transfer.20 Since there is noconsensus on which postdischarge surveillancemethods are the most accurate and practical fordetection of SSIs,10 the limitations of currentcase-finding methods should be recognized if SSIs

are selected for inclusion in mandatory reportingsystems.

Top of PageValidation of Data

A method to validate data should be considered inany mandatory reporting system to ensure thatHAIs are being accurately and completely reportedand that rates are comparable from hospital tohospital or among all hospitals in the reportingsystem. The importance of validation wasemphasized by a CDC study of the accuracy ofreporting to the NNIS system, which found thatalthough hospitals identified and reported most ofthe HAIs that occurred, the accuracy varied byinfection site.15

Top of PageResources and Infrastructure Needed for a ReportingSystem


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A reporting system can not produce quality datawithout adequate resources. At the institutionlevel, trained personnel with dedicated time are

required, eg, infection control professionals toconduct HAI surveillance. At the system level, keyinfrastructure includes instruction manuals,training materials, data collection forms, methodsfor data entry and submission, databases toreceive and aggregate the data, appropriatequality checks, computer programs for data

analysis, and standardized reports fordissemination of results. Computer resourceswithin reporting systems must include bothhardware and software and a standard userinterface. In order to collect detailed data onfactors such as use of invasive devises (eg, centrallines), patient care location within the facility, type

of operation, and extensive data dictionaries andcoding schema must be developed and maintained.

Top of PageHAI Rates and Risk Adjustment

For optimal comparison purposes, HAI rates shouldbe adjusted for the potential differences in riskfactors.

For example, in the NNIS system, device-associated infections are risk adjusted bycalculating rates per 1,000 device-days (eg, CLA-LCBI per 1,000 central linedays) and stratifying


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by unit type.21-23 For that system, riskadjustment of SSIs is done by calculating ofoperation-specific rates stratified by a standardized

risk index.23-25 Although these methods do notincorporate all potential confounding variables,they provide an acceptable level of risk adjustmentthat avoids the data collection burden thatwould berequired to adjust for all variables.

Risk adjustment is labor intensive because datamust be collected on the entire population at risk(the denominator) rather than only the fractionwith HAIs (the numerator). Risk adjustment cannot correct for variability among data collectors inthe accuracy of finding and reporting events.Further, current riskadjustment methods improvebut do not guarantee the validity of inter-hospitalcomparisons, especially comparisons involvingfacilities with diverse patient populations (eg,community versus tertiary-care hospitals).

Valid event rates are facilitated by selecting eventsthat occur frequently enough and at-riskpopulations that are large enough to produceadequate sample sizes. Unfortunately, use of

stratification (eg, calculation of rates separately inmultiple categories) for risk adjustment may leadto small numbers of HAIs in any one category andthereby yield unstable rates, as is the case of asmall hospital with low surgical volume.


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Top of PageProducing Useful Reports and Feedback

Publicly released reports must convey scientific

meaning in a manner that is useful andinterpretable to a diverse audience. Collaborationbetween subject matter experts, statisticians, andcommunicators is necessary in developing thesereports. The reports should provide usefulinformation to the various users and highlightpotential limitations of both the data and the

methods used for risk adjustment. In a newreporting system, data should be examined andvalidated before initial release; in addition,sufficient sample size should be accumulated sothat rates are stable at the time of public release.Lastly, feedback of performance data should begiven to health care providers regularly so that

interventions to improve performance can beimplemented as quickly as possible. For example,feedback of SSI rates to surgeons has been shownto be an important component of strategies toreduce SSI risk.26

Top of PageAdapting Established Methods for Use In Mandatory

Reporting Systems

Where appropriate, developers of reportingsystems should avail themselves of establishedand proven methods of collecting and reportingsurveillance data. For example, many of the


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methods, attributes, and protocols of CDC's NNISsystem may be applicable for public reportingsystems. A detailed description of the NNIS

methodologies has been described elsewhere, 23and additional information on NNIS is availableatwww.cdc.gov/ncidod/hip/surveill/nnis.htm.Most reporting systems, such as NNIS, use manualdata collection methods. In most instances,information in computer databases, whenavailable, can be substituted for manually collected

data.27,28 However, when manual data collectionis necessary, alternate approaches include limitingreporting to well-defined and readily identifiableevents, using simpler and more objective eventdefinitions,29 and sampling to obtaindenominators.30 These approaches could decreasethe burden of data collection and improve the

consistency of reporting among facilities. If datacollection were simplified, expanding the numberof infection types and locations in which they aremonitored may become more feasible.

Top of PagePotential Consequences of Mandatory Public ReportingSystems

Mandatory reporting of HAIs will provideconsumers and stakeholders with additionalinformation for making informed health carechoices. Further, reports from private systemssuggest that participation in an organized, ongoing
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system for monitoring and reporting of HAIs mayreduce HAI rates.31,32 This same beneficialconsequence may apply to mandatory public

reporting systems. Conversely, as with voluntaryprivate reporting, mandatory public reporting thatdoesn't incorporate sound surveillance principlesand reasonable goals may divert resources toreporting infections and collecting data for riskadjustment and away from patient care andprevention; such reporting also could result in

unintended disincentives to treat patients at higherrisk for HAI. In addition, current standard methodsfor HAI surveillance were developed for voluntaryuse and may need to be modified for mandatoryreporting. Lastly, publicly reported HAI rates canmislead stakeholders if inaccurate information isdisseminated. Therefore, in a mandatory public

report of HAI information, the limitations of currentmethods should be clearly communicated withinthe publicly released report.

Top of PageResearch and Evaluation Needs

Research and evaluation of existing and future HAIreporting systems will be needed to answerquestions about 1) the comparative effectivenessand efficiency of public and private reportingsystems and 2) the incidence and prevention ofunintended consequences. Ongoing evaluation ofeach system will be needed to confirm the


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appropriateness of the methods used and thevalidity of the results.

Top of PageRecommendations

The Healthcare Infection Control Practices AdvisoryCommittee proposes four overarchingrecommendations regarding the mandatory publicreporting of HAIs. These recommendations areintended to guide policymakers in the creation ofstatewide reporting systems for health carefacilities in their jurisdictions.

1.Use established public health surveillancemethods when designing and implementingmandatory HAI reporting systems. This processinvolves:

a.selection of appropriate process and outcomemeasures to monitor;

b.selection of appropriate patient populations tomonitor;

c.use of standardized case-finding methods anddata validity checks;

d.provision of adequate support and resources;e.adjustment for underlying infection risk; andf.production of useful and accessible reports to

stakeholders.


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by all hospitals that conduct the operationsselected for monitoring.

iii. Influenza vaccination coverage rates forhealth care personnel and patients can bemeasured by all hospitals and long term carefacilities. For example:

Coverage rates for health care personnelcan be measured in all hospitals and longterm care facilities.

Coverage rates for high-risk patients canbe measured in all hospitals.

Coverage rates for all residents can bemeasured in all long term care facilities.

b.Two outcome measures are appropriate forsome hospitals participating in a mandatory

HAI reporting system (Table 2).i. CLA-LCBIs.ii. SSIs following selected operations.

Hospitals for which these measures areappropriate are those in which the frequency

of the HAI is sufficient to achieve statisticallystable rates. To foster performanceimprovement, the HAI rate to be reportedshould be coupled with a process measure ofadherence to the prevention practice known


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to lower the rate (see 3ai and 3aii). Forexample, hospitals in states where reportingof SSIs is mandated should monitor and

report adherence to recommended standardsfor surgical prophylaxis (see 3aii).

4.Provide regular and confidential feedback ofperformance data to health care providers. Thispractice may encourage low performers toimplement targeted prevention activities andincrease the acceptability of the public reporting

systems within the health care sector.

HICPAC thanks the following subject-matterexperts for reviewing preliminary drafts of thisguidance document: Victoria Fraser, MD,Washington University School of Medicine, StLouis, MO; Lisa McGiffert, Consumers Union;

Richard Platt, MD, Harvard-Pilgrim Health, Boston,MA; Robert A Weinstein, MD, John J Stroger, Jr,Hospital of Cook County, Chicago, IL; and RichardP Wenzel, MD, Richmond, VA. HICPAC also thanksJ Shaw and Patricia Simone, MD, for exceptionaleditorial guidance during the development of thisdocument. The opinions of all the reviewers may

not be reflected in all the recommendationscontained in this document.


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Measles Vaccination

On this Page

For Those Getting Vaccinated

Clinical Information for Healthcare Professionals Vaccination Coverage

Measles can be prevented by the combination MMR (measles, mumps, and rubella) vaccine. Inthe decade before the measles vaccination program began, an estimated 34 million people in the

United States were infected each year, of whom 400500 died, 48,000 were hospitalized, and

another 1,000 developed chronic disability from measles encephalitis. Widespread use of

measles vaccine has led to a greater than 99% reduction in measles cases in the United Statescompared with the pre-vaccine era, and in 2009, only 71 cases of measles were reported in the

United States.

However, measles is still common in other countries. The virus is highly contagious and can

spread rapidly in areas where vaccination is not widespread. It is estimated that in 2008 there

were 164,000 measles deaths worldwidethat equals about 450 deaths every day or about 18deaths every hour.

For Those Getting Vaccinated

Vaccination recommendations and other useful information about the measles vaccine

Measles Vaccine Basics Beliefs & Concerns Vaccine Safety Who Should Not be Vaccinated?

Clinical Information for Healthcare Professionals

Measles references and resources, provider education tools, and materials for patients

Clinical Information on Measles Vaccine Recommendations References & Resources Provider Education Materials for Patients

Vaccination Coverage

Estimates of the number of people living in the U.S. who have been received particular vaccinesat the national, state, and local levels using results from the National Immunization Survey.
http://www.cdc.gov/measles/vaccination.html#basicshttp://www.cdc.gov/measles/vaccination.html#basicshttp://www.cdc.gov/measles/vaccination.html#clinicalhttp://www.cdc.gov/measles/vaccination.html#clinicalhttp://www.cdc.gov/measles/vaccination.html#coveragehttp://www.cdc.gov/measles/vaccination.html#coveragehttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#vacchttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#vacchttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#concernshttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#concernshttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#safetyhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#safetyhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#notvacchttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#notvacchttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#clinicalhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#clinicalhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#recshttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#recshttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#refhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#refhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#edhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#edhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#patienthttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#patienthttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#patienthttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#edhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#refhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#recshttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#clinicalhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#notvacchttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#safetyhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#concernshttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#vacchttp://www.cdc.gov/measles/vaccination.html#coveragehttp://www.cdc.gov/measles/vaccination.html#clinicalhttp://www.cdc.gov/measles/vaccination.html#basics


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Immunization Coverage in the U.S. School and Childcare Vaccination Surveys

Massachusetts releases report cards on

hospital-acquired infectionsE-mail|Print|Comments (0) 02/08/2012 8:58 PM

By Liz Kowalczyk, Globe Staff

Massachusetts public health officials have called together patient safety leaders to determine why

hospitals reported a high rate of surgical infections among women who received vaginal

hysterectomies over the past two years.

Hospitals reported 23 of these infections in 2010 and 25 in 2011 -- out of 4,313 procedures total -- about twice as many as expected based on national rates. Health officials said furtherinvestigation is needed to pinpoint the reasons.

The infection rates for vaginal hysterectomies emerged as health officials released report cardstoday for 71 hospitals, showing how many patients contract potentially serious infections from

surgery and other medical care that is intended to heal them.

By providing data on health care-associated infections for each hospital in an easy-to-read

format, Department of Public Health officials said they want to reach a new audience: consumers

and policy makers. Past reports have been geared more to hospital leaders.

The department plans to post one-page infection report cards for each hospital on its website,

http://www.mass.gov/eohhs/gov/departments/dph/, tomorrow.

Massachusetts does pretty well, but there are areas where there is room for improvement, said

Dr. Madeleine Biondolillo, director of the Bureau of Health Care Safety and Quality

Officials rated hospitals on the incidence of two types of infections: in surgical incisions for

coronary artery bypass surgery, knee replacement, hip replacement, vaginal hysterectomy, andabdominal hysterectomy; and bloodstream infections contracted from central lines -- tubing

inserted into veins, usually in intensive care units. The reports also show the rate of flu

vaccinations among hospital employees who provide patient care.

Overall, hospitals reported 199 central line infections in the fiscal year that ended Sept. 30, 2011,

a 24 percent drop from the previous year. Health officials said, however, that while central lineinfection rates appear to be falling, a drop this steep is not statistically significant, meaning it

could have been random and due to normal year-to-year fluctuations. Depending on the type of

ICU, state rates were either equal to or better than national rates.
http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nishttp://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nishttp://www.cdc.gov/vaccines/stats-surv/schoolsurv/default.htmhttp://www.cdc.gov/vaccines/stats-surv/schoolsurv/default.htmhttp://void%280%29/http://void%280%29/http://www.boston.com/Boston/whitecoatnotes/2012/02/massachusetts-releases-report-cards-hospital-acquired-infections/nhyDkudOnnLhOBm1PlsDTL/index.htmlhttp://www.boston.com/Boston/whitecoatnotes/2012/02/massachusetts-releases-report-cards-hospital-acquired-infections/nhyDkudOnnLhOBm1PlsDTL/index.htmlhttp://www.boston.com/Boston/whitecoatnotes/2012/02/massachusetts-releases-report-cards-hospital-acquired-infections/nhyDkudOnnLhOBm1PlsDTL/index.htmlhttp://www.boston.com/Boston/whitecoatnotes/2012/02/massachusetts-releases-report-cards-hospital-acquired-infections/nhyDkudOnnLhOBm1PlsDTL/index.html?comments=all#readerCommhttp://www.boston.com/Boston/whitecoatnotes/2012/02/massachusetts-releases-report-cards-hospital-acquired-infections/nhyDkudOnnLhOBm1PlsDTL/index.html?comments=all#readerCommhttp://www.boston.com/Boston/whitecoatnotes/2012/02/massachusetts-releases-report-cards-hospital-acquired-infections/nhyDkudOnnLhOBm1PlsDTL/index.html?comments=all#readerCommhttp://www.mass.gov/eohhs/gov/departments/dph/http://www.mass.gov/eohhs/gov/departments/dph/http://www.mass.gov/eohhs/gov/departments/dph/http://www.boston.com/Boston/whitecoatnotes/2012/02/massachusetts-releases-report-cards-hospital-acquired-infections/nhyDkudOnnLhOBm1PlsDTL/index.html?comments=all#readerCommhttp://www.boston.com/Boston/whitecoatnotes/2012/02/massachusetts-releases-report-cards-hospital-acquired-infections/nhyDkudOnnLhOBm1PlsDTL/index.htmlhttp://void%280%29/http://www.cdc.gov/vaccines/stats-surv/schoolsurv/default.htmhttp://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis


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Surgical site infections were either similar to or lower than national rates -- except for vaginal

hysterectomies.

The department flagged six hospitals for high rates of surgical site infections since 2009

compared with the state average: Boston Medical Center and Baystate Medical Center in

Springfield for vaginal hysterectomy patients; Lawrence General Hospital for abdominalhysterectomy patients; Falmouth Hospital and Boston Medical Center for knee replacement

patients; and Beth Israel Deaconess Medical Center for coronary artery bypass patients.

Dr. Kenneth Sands, senior vice president of health care quality at Beth Israel Deaconess, said

that the hospital has intensified its infection-prevention efforts, including having heart surgerypatients wash their chests with a special disinfectant before coming to the hospital, and that there

has been just one surgical site infection in a bypass patient in the most recent 12 months. The

hospital had 19 such infections in 2009 and 2010.

The main thing is gathering a team together, from cardiac surgeons to anesthesia staff to our

support staff, to make sure we are doing everything to ensure that every step happens to thehighest standard.

Baystate Medical Center leaders said they have reduced infections after vaginal hysterectomies,and have not had any in the last three months, while Falmouth Hospital officials said just one

patient got an infection from a knee replacement in 2011, compared with seven in 2009 and 2010combined.

Boston Medical Center said it also made improvements, and no knee replacement patients had

infections in 2011 -- compared with eight in 2009 and 2010 combined -- and one patientexperienced an infection from a vaginal hysterectomy procedure. Lawrence General Hospital

said it had no infections in abdominal hysterectomy patients in 2011.

Biondolillo cautioned that consumers should not consider the infection data alone when deciding

where to get health care, and should not look at just the number of infections at a hospital, but at

the trend over time and how the hospital compares with the state.

Consumers increasingly are seeking information to help them make decisions about where to get

health care, while policy-makers are searching for ways to financially reward high-qualityhospitals and invest in prevention strategies that work.

Health care-associated infections are fertile ground for public reporting because of the large

number of patients affected and the high cost of providing additional care to these patients. TheCenters for Medicare and Medicaid Services this month posted on its website the rate of central

line infections at hospitals across the United States -- an area in which Massachusetts generally

has beat national rates.

Its almost been a competition around town to do better because of the public disclosure of thedata, said Dr. Barry Zuckerman, a member of the public health council and a pediatrician at

Boston Medical Center, during the councils meeting today.


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Biondolillo described the results to the council and said hospitals should laminate the reports and

widely distribute them as a way to push further improvement.

I am hoping every hospital brings this up to their board of directors, said council member Dr.

Alan Woodward, an emergency physician in Concord.

Liz Kowalczyk can be reached at [email protected].

How do we measure how well influenza vaccines work?

Two types of studies are used to determine how well influenza vaccines work. The first type ofstudy is called a randomized control trial (RCT). In a RCT, volunteers are assigned randomly to

either a group that receives vaccine or a group that receives a placebo (e.g., a shot of saline), and

vaccine efficacy is measured by comparing the frequency of influenza illness in the vaccinated

and the unvaccinated groups. RCTs are required before a new vaccine is licensed for routine useby a national regulatory authority, such as the Food and Drug Administration (FDA) in the

United States. The second type of study is called an observational study. In observational studiesthe study participants make their own decisions about whether or not to be vaccinated. In thistype of study, vaccine effectiveness is measured by comparing the frequency of influenza illness

in the vaccinated and unvaccinated groups, usually with adjustment for factors (like presence of

chronic medical conditions) that may vary between the groups. (See below for further details.)

What is 'vaccine effectiveness'?

Vaccine effectiveness is a measure of how well influenza vaccines work to protect againstinfluenza infection and illness when they are used in routine circumstances in the community,

and not specifically in a RCT. Effectiveness represents the percentage reduction in the frequency

of influenza infections among people vaccinated compared with the frequency among those whowere not vaccinated, assuming that the vaccine is the cause of this reduction. These studies are

conducted in community settings, and researchers have no control over those who choose to be

vaccinated or not.

How do vaccine effectiveness studies differ from vaccine efficacy studies?

Vaccine efficacy refers to studies of vaccine effects that occur under randomized, controlledconditions, where individuals are randomly assigned to either a group that is given influenza

vaccine or to a second group that is not given influenza vaccine, but instead, given a placebo. A

RCT is a study designed by researchers to minimize factors that could lead to invalid study

results. For example, vaccine allocation is usually double-blinded, which means neither the studyvolunteers nor the researchers know if a given person has received vaccine or placebo. This

methodology reduces bias that can occur if the researchers or the individuals receiving the

intervention know which study volunteers have received placebo versus vaccine. Bias is an

unintended systematic error in the way researchers select study participants, measure outcomes,or analyze data that can lead to inaccurate results.)

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When can vaccine effectiveness studies be conducted?

The most common approach now used to evaluate how well licensed influenza vaccines work isan observational or vaccine effectiveness study. Once an influenza vaccine has been licensed by

FDA, recommendations are typically made by CDC's Advisory Committee for Immunization

Practices (ACIP) for its routine use. For example, ACIP now recommends annual influenzavaccination for all U.S. residents aged 6 months and older. These universal vaccine

recommendations make it unethical to perform efficacy (i.e., experimental randomized) studies

with persons who are explicitly recommended to receive vaccine, especially because assigningpeople to a placebo group could place them at risk for serious complications from influenza.

What factors can affect the results of influenza vaccine effectiveness studies?

Effectiveness studies are subject to various forms of bias (see above for definition), more so than

are efficacy studies. Therefore, it is important when evaluating the results of an influenza vaccine

effectiveness study that researchers identify the potential biases and introduce methods to

minimize them. There are at least three forms of bias that are especially important in interpretingthe results of influenza vaccine effectiveness studies: confounding bias, selection bias, and

information bias.

Confounding bias occurs when the effect of vaccination on the risk of the outcome of interest(e.g., RT-PCR-confirmed influenza infection) is distorted by other factors associated both with

vaccination and influenza infection. For example, confounding bias would occur if the majority

of influenza cases in a case-control study have a chronic medical condition that places them at a

greater risk of influenza hospitalization and makes them more likely to receive an influenza

vaccine than non-cases. Not taking these associations into account for this study population

would lead to an estimate of effectiveness that is too low due to confounding bias caused by

cases having more chronic medical conditions than controls. Selection bias refers to errors introduced into a study because of differences between people

who are enrolled in a study compared with people who are not enrolled. For example, people

who are willing to participate in vaccine effectiveness studies might seek health care sooner,

exercise more, or live healthier lifestyles than people who don't participate in such studies. As a

result of this bias, study participants may not be representative of the general population, and

the study results may be biased towards finding higher vaccine effectiveness, if vaccination

worked better in such persons. Taking into account "health seeking behaviors" is especially

important in vaccine effectiveness studies conducted among the elderly.

Finally, information bias occurs when there are differences in the quality or accuracy ofmeasuring vaccination status or influenza illness in the groups of people being compared in a

study. For example, if researchers obtain information on vaccination for influenza cases from

medical records but use verbal interviews to get this information from non-cases, this difference

in data collection procedures could bias the results of the study.

The methods used to conduct observational studies of vaccine effectiveness must be reviewed

carefully to see if these and other possible forms of bias have been described and addressed by

adjustment for the factors that differ between groups.
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Top

What outcomes are measured in influenza vaccine effectiveness studies?

The interpretation of vaccine effectiveness studies depends on the outcomes measured in a

particular study. These outcomes may include prevention of laboratory-confirmed influenzaillness or hospitalization, prevention of medically attended, acute respiratory illness (MAARI),

prevention of influenza-like illness (or ILI, defined as an illness with fever and cough or sore

throat), and prevention of pneumonia requiring hospitalization. In general, the more specific theoutcome used (e.g., laboratory-confirmed influenza compared with ILI) the more accurate the

measurement of the effect of vaccination. A recent study suggests that using serology (a

laboratory test which measures the amount of antibody against a particular virus in a person's

body) to determine whether or not study participants have been infected with influenza maypotentially overestimate vaccine efficacy (Petrie et al, 2011). The reason for this is that following

an influenza vaccination, a person's immune system may produce a significant amount of

antibody against influenza. If that same person were to become infected with influenza despite

being vaccinated (i.e., a "vaccine failure"), it is possible that enough additional antibody may notbe produced to provide a positive result in a serology test. Diagnosis of influenza infection with

serology tests requires two blood samples: one taken prior to infection, and the second takenafter infection. Confirmation of influenza infection by serology tests requires a four-fold increase

in antibody in the post-infection serum as compared to the level in the pre-infection serum.

Because an influenza infection does not always produce a four-fold increase in antibody in

people who have received the flu vaccine, vaccine failures can be missed, thus increasingestimates of vaccine efficacy. Despite this potential for bias, studies using serology-confirmed

outcomes can still provide valid estimates of vaccine efficacy when considered with other

disease endpoints.

Which outcomes provide the best estimates of vaccine effectiveness?

Studies that use more specific outcomes, such as laboratory-confirmed influenza outcomes (e.g.,culture positive or reverse-transcriptase polymerase chain reaction (RT-PCR) positive results),

provide the best and most specific estimates of the impact of influenza vaccines in preventing

influenza. In general, when non-laboratory-confirmed outcomes are used (e.g., all pneumoniahospitalizations or influenza-like illness, which include many non-influenza illnesses), vaccine

effectiveness estimates are lower. For example, a study by Bridges et al (2000) among healthyadults found that the inactivated influenza vaccine was 86% effective against laboratory-

confirmed influenza, but only 10% effective against all respiratory illnesses in the samepopulation and season.

How can vaccine effectiveness against non-laboratory-confirmed outcomes be

interpreted?

The interpretation of vaccine effectiveness against less specific, non-laboratory-confirmed

outcomes is influenced by the proportion of the outcome used that is actually caused by

influenza virus infections compared with other pathogens. One non-laboratory-confirmed


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outcome that is often used is influenza like illness (ILI). The proportion of ILI caused by

influenza viruses varies by year, and even varies within a specific year over the course of thewinter. For example, in the results of a theoretical study graphed below, vaccine was 75%

effective against laboratory-confirmed influenza, but it was only 30% effective against ILI when

influenza caused 40% of ILI in unvaccinated people (Figure). Influenza vaccine would be

estimated to be only 15% effective, however, if influenza viruses were responsible for only 20%of ILI at a particular point during the winter. This relationship is important because the

percentage of ILI caused by influenza varies widely over time and geography.

Figure: The effect of non-influenza illnesses on an estimate of influenza vaccine

effectiveness.

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Why do estimates of influenza vaccine effectiveness vary widely?

Estimates of influenza vaccine effectiveness are affected by several factors, including the

specific study biases discussed above, the match between the vaccine influenza strains and the

circulating strains, host factors and the sample size of a specific study. As noted above, the

specificity of the outcome measured in a study has an important influence on the observed

effectiveness. As more data are collected globally from annual studies that estimate effectivenessfor RT-PCR confirmed influenza, it is expected that our estimates will become more refined.

However, vaccine effectiveness will always vary from season to season, based upon the degreeof similarity between the viruses in the vaccine and those in circulation, as well as other factors.

In years when the vaccine strains are not well-matched to circulating strains, vaccine

effectiveness is generally lower. In addition, host factors also affect vaccine effectiveness. Ingeneral, influenza vaccines are less effective among people with chronic medical conditions and

among people age 65 and older, as compared to healthy young adults and older children.


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How well do inactivated influenza vaccines work in randomized control trials?

As noted above, effectiveness varies with vaccine match and the age and immune function of therecipient. In general, the greatest benefits of influenza vaccines have been reported in

randomized controlled trials (RCTs) conducted among healthy adults. For example, recent RCTs

of inactivated influenza vaccine among adults under 65 years of age have estimated 50-70%vaccine efficacy during seasons in which the vaccines' influenza A components were well

matched to circulating influenza A viruses (Beran et al., 2009, 2006-2007 season; Jackson et al.,

2010, 2005-2006 season; Monto et al., 2009, 2007-2008 season). As vaccine efficacy from arandomized clinical trial is the gold standard for how well a vaccine actually works, vaccine

effectiveness estimates obtained from observational studies can equal, but not exceed, estimates

of efficacy. Many factors that can result in substantial bias in effectiveness studies tend to bias

the vaccine effect downwards.

How well do influenza vaccines work during seasons in which the vaccine

strains are not well matched to circulating influenza viruses?

When vaccine strains are not well matched with circulating influenza viruses, the benefits ofvaccination may be reduced. For example, inactivated influenza vaccine effectiveness against

laboratory-confirmed influenza was 60% among healthy persons and 48% among those with

high-risk medical conditions in a case-control study among people 5064 years old during the2003-2004 influenza season, when the vaccine strains were not optimally matched to viruses in

circulation (Herrera et al., 2007). However, in a year when the influenza vaccine and

predominant circulating influenza viruses were poorly matched, researchers were not able to

measure an effect of influenza vaccination against the respective vaccine component (Bridges etal., 2000). It is not possible to predict how well the vaccine and circulating strains will be

matched in advance of the influenza season, and how this match may affect vaccine

effectiveness.

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How well do influenza vaccines work in people with chronic high-risk medical

conditions?

The presence of chronic medical conditions may also affect the effectiveness of influenza

vaccines. For example, in an observational study of people 5064 years of age, the vaccine was

60% effective in preventing laboratory-confirmed influenza among otherwise healthy adults 50

64 years of age, but only 48% effective among those who had high-risk medical conditions(Herrera et al., 2006). In general, vaccine efficacy and effectiveness estimates among people

with high-risk conditions may be somewhat lower than among people of similar age withouthigh-risk conditions. However, because the risk of influenza-related complications among this

group is much higher, vaccination still provides important benefits.

Adults 65 years or older


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Only one large randomized, controlled trial of influenza vaccine has been conducted among an

elderly population. During the 1991-1992 influenza season, a group of Dutch people 60 years ofage and older not living in long-term care facilities (e.g., nursing homes) was studied (Govaert et

al., 1994). In this study, vaccine efficacy was 58% in preventing clinically-defined influenza

with serologic confirmation of infection. There are no published studies of the efficacy or

effectiveness of influenza vaccines in preventing laboratory-confirmed, serious outcomes ofinfluenza such as hospitalization, primarily because the size of the study would be large, and

therefore, such a study is very expensive to conduct. Published observational studies conducted

among people 65 and older not living in long-term care facilities have used non-specificoutcomes, such as pneumonia hospitalizations or all-cause mortality. These studies may be

subject to substantial confounding and selection bias, and they use outcomes in which the

proportion of illness associated with influenza virus infections vary by season (as otherrespiratory viruses can cocirculate). As a result, it is difficult to interpret the results of these

studies.

Adults 65 years or older in long-term care facilities

All residents of long-term care facilities s (e.g., nursing homes) should receive annual influenza

vaccination, as outbreaks of influenza can be explosive and result in substantial morbidity andmortality among residents of such facilities. There is evidence that vaccination prevents

respiratory illnesses during periods of influenza circulation for elderly nursing home residents.

For example, one study conducted during the 1991-1992 influenza season found that vaccinationwas associated with a 34% reduction in total respiratory illnesses and a 55% reduction in

pneumonia during the two-week peak of influenza activity (Monto, 2001). In addition, one studyconducted in UK nursing homes found that vaccinating health care workers decreased deaths

during periods of influenza activity during one season with substantial influenza circulation, butnot during the next year, when influenza activity was low throughout the winter (Hayward,

2006).

Children

In a four-year randomized, placebo-controlled study of inactivated and live influenza vaccines

among children aged 115 years, vaccine efficacy was estimated at 77% against influenza A(H3N2) and 91% against influenza A (H1N1) virus infection (Neuzil et al., 2001). A two-year

study of children aged 624 months found that the vaccine was 66% effective in preventing

laboratory-confirmed influenza in one year of the study (Hoberman et al., 2003). Only childrenwho were fully vaccinated (i.e., had either two doses if not previously vaccinated, or one dose if

previously vaccinated) versus unvaccinated children were included in the analysis. In the other

year of this study, few cases of influenza occurred, making it difficult to assess the vaccine'sefficacy (Hoberman et al., 2003). Children younger than 9 years of age who have not beenvaccinated previously are recommended to receive two doses of vaccine the first year they get

vaccinated. In subsequent years, they need only one dose. This recommendation was made

because many children younger than 9 years of age have not been infected with influenza virusespreviously, and a booster dose is needed for them to produce a protective immune response.

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How effective is the live attenuated influenza vaccine (LAIV)?

This vaccine currently is licensed only for healthy, non-pregnant people between 2 and 49 yearsof age.

Healthy Children

Because LAIV (nasal spray) vaccine was licensed more recently than inactivated vaccines, there

are more data available on its effects from large randomized trials. For example, a RCTconducted among 1,602 healthy children initially aged 1571 months assessed the efficacy of

trivalent LAIV against culture-confirmed influenza during two seasons (Belshe et al., 1998;

2000). In season one, when vaccine and circulating virus strains were well-matched, efficacy in

preventing laboratory-confirmed illness from influenza was 93% for participants who receivedtwo doses of LAIV. In season two, when the A (H3N2) component was not well-matched

between vaccine and circulating virus strains, efficacy was 86% overall.

Healthy Adults

A randomized, double-blind, placebo-controlled trial among 4,561 healthy working adults aged

1864 years assessed multiple endpoints (i.e., targeted outcome measures), including reductionsin self-reported respiratory tract illness without laboratory confirmation, absenteeism, health care

visits, use of antibiotics, and use of over-the-counter medications for illness symptoms during

peak and total influenza outbreak periods (Nichol et al., 1999). The study was conducted duringthe 1997-1998 influenza season, when the influenza vaccine and circulating A (H3N2) viruses

were poorly matched. Vaccination was associated with reductions in severe febrile illnesses of

19%, and febrile upper respiratory tract illnesses of 24%.

Vaccination was also associated with fewer days of illness, fewer days of work lost, fewer dayswith health care provider visits, and reduced use of prescription antibiotics and over-the-countermedications. Among a subset of 3,637 healthy adults aged 1849 years, LAIV recipients (n =

2,411) had 26% fewer febrile upper-respiratory illness episodes; 27% fewer lost work days as a

result of febrile upper respiratory illness; and 18%37% fewer days of health care provider visits

caused by febrile illness, compared with placebo recipients (n = 1,226). Days of antibiotic usewere reduced by 41%45% in this age subset.

A randomized, double-blind, placebo-controlled influenza virus challenge study among 92

healthy adults (LAIV, n = 29; placebo, n = 31; inactivated influenza vaccine, n = 32) aged 1841

years assessed the efficacy of both LAIV and inactivated vaccine (Treanor et al., 1999). The

overall efficacy of LAIV and inactivated influenza vaccine in preventing laboratory-documentedinfluenza from all three influenza strains combined was 85% and 71%, respectively. These

results were obtained after study participants, all of whom were susceptible to recently

circulating influenza viruses before vaccination, were experimentally exposed to viruses. The

difference in efficacy between the two vaccines was not statistically significant.
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How do live attenuated vaccine and inactivated vaccines compare in vaccine

efficacy and effectiveness studies?

Few studies that directly compare live attenuated influenza vaccine (LAIV) and trivalentinactivated influenza vaccine (TIV) have been conducted, and results appear to differ for adults

and children. More data are available for children than for adults. Among children, each of threeRCTs comparing inactivated and live vaccines demonstrated that live vaccine offered betterprotection than inactivated vaccine. However, none of the studies included a placebo group, so

the absolute efficacies of the two vaccines could not be assessed. One study included 2,187

children aged 671 months who had recurrent respiratory tract infections (Ashkenazi et al.,

2006) and found overall influenza rates of 2.3% among live vaccine recipients and 4.8% for TIV,for a 52.7% decrease in children receiving live vaccine compared to those receiving inactivated

vaccine. In a randomized study of 2,229 children aged 617 years with asthma, 4.1% of live

vaccine recipients and 6.2% of TIV recipients developed influenza, for a relative reduction of

34.7% (Fleming et al., 2006). Finally, in 2004-2005 a multinational RCT was conducted among8,352 children aged 659 months (Belshe et al., 2007). For the primary endpoint in this trial,

culture-confirmed influenza-like illness, there were 45% fewer cases of influenza for well-matched influenza strains and 58% fewer for mismatched strains among live versus inactivatedvaccine recipients.

In contrast to the studies in young children described above, a RCT conducted among primarilycollege age healthy adults was conducted during three influenza seasons using three assignment

groups, including a placebo group. Overall, the results suggested that inactivated vaccine may be

more efficacious than live vaccine for this age group. For example, in the final season of the

study, absolute efficacy against the influenza A virus was 72% for the inactivated vaccine and29% (not significant) for the live attenuated vaccine. Therefore, the relative improvement in

efficacy offered by the inactivated vaccine was 60% (Monto et al., 2009).

The above studies taken together indicate that live and inactivated influenza viruses perform

differently relative to each other in children and young adults.

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What information is necessary to make assessments of vaccine effectiveness?

Ideally, influenza vaccine effectiveness should be assessed on an annual basis, using a consistent

methodology and similar populations. Use of a laboratory-confirmed outcome to assess vaccineeffectiveness is important to provide the most specific results of the benefits of vaccination and

to limit the impact of the co-circulation of non-influenza respiratory pathogens on estimates of

vaccine effectiveness. Because the current recommendation for the United States is that allpersons aged 6 months and older receive a vaccine each season, it is ideal if estimates of

effectiveness can be made for children, adults and older adults. Because a proportion of older

adults have chronic medical conditions and most in this age group seek vaccination, it is difficult

to conduct and interpret influenza vaccine effectiveness in this population. CDC currentlyconducts annual vaccine effectiveness studies among people of all age groups recommended for

annual vaccination (i.e., all aged 6 months and older). In addition, CDC conducts special studies
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targeted at answering more specific questions, such as estimating the effectiveness of inactivated

vaccine in preventing laboratory-confirmed influenza hospitalizations among older U.S.residents.

Guidance on Public Reporting of Healthcare

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