Jennifer Barrett Assistant Editor

The recent resurgence of mumps in the United States may be linked to waning vaccine protection, according to a recent analysis from Harvard TH Chan School of Public Health.

Despite decades of declining mumps incidence, due to widespread vaccination, recent outbreaks in vaccinated adults and communities with high vaccine coverage have prompted concerns about the effectiveness of the current vaccine. According to the CDC, from January 1 to February 24, 2018, 32 states and the District of Columbia in the United States reported mumps infection in 304 people. Outbreaks have increased from 229 cases in 2012 to 6,366 cases in 2016.

Outbreaks are troubling, the researchers noted, because mumps infections can cause complications that can lead to infertility, meningitis, and deafness.

With many of the cases occurring in vaccinated individuals, the researchers aimed to determine whether the resurgence is due to waning immune protection or the emergence of new strains evading the vaccine.

, the researchers pooled and analyzed 6 epidemiological studies of mumps vaccine effectiveness conducted over past decades in the United States and Europe. The researchers estimated that vaccine-derived immune protection against mumps wanes on average 27 years after vaccination, with 25% of individuals in the United States vaccinated losing protection within 7.9 years, 50% within 19 years, and 75% within 38 years.

According to the researchers, a mathematical model of mumps transmission confirmed the central role of waning immunity to the vaccine in the recent resurgence of mumps cases, as well as in outbreaks that occurred in the late 1980s among adolescents. The researchers found no evidence that new strains of mumps virus are contributing to changes in vaccine effectiveness, as new strains would be expected to cause higher incidence among children, not adolescents and young adults.

“Vaccination is the centerpiece of current public health strategy against mumps,” Joseph Lewnard, postdoctoral research fellow at Harvard Chan School’s Center for Communicable Disease Dynamics, said in a press release about the study.

“Knowing that protection wanes in the long term can help inform how we deploy vaccines to prevent or contain future outbreaks.”

The researchers concluded that routine use of a third vaccine dose at 18 years of age, or booster dosing throughout adulthood, may be one strategy to prevent mumps re-emergence.

The study was funded by the National Institute of General Medical Sciences award U54GM088558 and a Doris Duke Charitable Foundation Clinical Scientist Development award.

Lewnard JA, Grad YH. Vaccine waning and mumps re-emergence in the United States. Science Translational Medicine. 2018. Doi: 10.1126/scitranslmed.aao5945

Mumps Cases and Outbreaks. CDC’s website.

Mumps resurgence likely due to waning vaccine-derived immunity [news release]. Boston. Harvard’s website.

https://www.hsph.harvard.edu/news/press-releases/mumps-resurgence-waning-immunity/

Articles

Despite decades of declining mumps incidence, due to widespread vaccination, recent outbreaks in vaccinated adults and communities with high vaccine coverage have prompted concerns about the effectiveness of the current vaccine. 

Study: Resurgence in Mumps Due to Waning Vaccine Protection in Adults

The number of nurse practitioners (NPs) has more than doubled over the past decade, reinforcing that the NP workforce is growing at an accelerated rate, according to new data released by the American Association of Nurse Practitioners (AANP).

The latest data is based on an annual survey conducted by the AANP and shows that more than 248,000 NPs are currently licensed to practice in the United States, compared with 120,000 NPs in 2007. According to the survey, the data showed an additional 23,000 new NPs graduated from programs in the 2015-2016 academic year, making up 15.5% of graduates from the 2014-2015 academic year. Out of these graduates, 85.5% have been trained in primary care, and nearly 2 out of 3 new NPs entering the workforce have graduated from family NP programs.

“Provider shortages, especially in primary care, have become a growing concern, but the growth of the NP profession is addressing that concern head-on,” Joyce Knestrick, PhD, APRN, CFNP, FAANP, President of AANP, said in a press release. “Couple that with news that NPs conducted an estimated 1.02 billion patient visits last year alone, and it’s easy to see why millions of Americans are making NPs their providers of choice.”

According to the press release, by 2026, the Bureau of Labor Statistics estimates that the NP profession will have grown by 36%, compared to 37% for physician assistants and 13% for physicians (excluding anesthesiologists and surgeons).

Based on the survey data, 74.1% of the NP workforce worked full-time (35+ hours per week), 58.6% of full-time NPs worked overtime, and 35.4% of full-time NPs took evening and weekend on-call shifts. Additionally, 25.5% of NPs who answered the survey work in private practice, 12.8% in hospital outpatient clinics, 10.3% in inpatient hospital units, 8.2% in community health centers and Federally Qualified Health Centers, and 5.9% in emergency rooms/urgent care.

An estimated 77.8% of all NPs deliver primary care.

Number of Nurse Practitioners Hits New Record High [news release]. Austin. AANP’s website.

https://www.aanp.org/press-room/press-releases/173-press-room/2018-press-releases/2190-number-of-nurse-practitioners-hits-new-record-high

The number of nurse practitioners has more than doubled over the past decade, reinforcing that the NP workforce is growing at an accelerated rate, according to new data released by the American Association of Nurse Practitioners.

Survey: Nurse Practitioner Workforce Sees Substantial Growth

Emergency department (ED) visits in the United States for opioid overdoses are up, signaling that the epidemic is worsening, according to a recent CDC report.

, the report analyzes data available from ED visits for opioid overdoses across multiple states. Data from 16 states in the CDC’s Enhanced State Opioid Overdose Surveillance Program were examined to identify trends by state and rural/urban differences. The researchers also analyzed data from the National Syndromic Surveillance Program BioSense Platform covering 52 jurisdictions in 45 states.

Overall, the researchers found that visits for suspected opioid overdoses rose 30% in the United States from July 2016 to September 2017 across 45 states, and 35% across the 16 states.

These were the key findings from the report:

Eight states from 3 US regions reported substantial increases (25% or greater) in the rate of opioid overdose ED visits.

Significant increases in all states reporting in the Midwest, including Wisconsin (109%), Illinois (66%), Indiana (35%), Ohio (28%), and Missouri (21%).

There was considerable variation among states in the Northeast and Southeast, with some states reporting substantial increases and others reporting modest decreases.

The highest rate of increases (54%) were seen in large central metropolitan areas.

From July 2016 to September 2017, opioid overdoses increased for:

Individuals aged 25-34 (31%), 35-54 (36%), and 55 and over (32%).

Most states (30% average), especially in the Midwest (70% average).

“Long before we receive data from death certificates, emergency department data can point to alarming increases in opioid overdoses,” CDC Acting Director Anne Schuchat, MD, said in a press release.

In an accompanying editorial published in the

, the authors noted that EDs typically do not have consistent protocols or guidelines for what to do after the overdose is resolved. “The CDC

report signaled that the ED is a critical entry point for primary and secondary prevention of opioid overdose,” they said.

The authors suggested that innovative systems-based protocols can promote overdose education and naloxone distribution. Additionally, initiating medication-assisted treatment with buprenorphine for patients presenting with opioid use disorder, with continuation in primary care, can reduce opioid use.

According to the CDC’s report, health care providers can help by prescribing opioids only when benefits are likely to outweigh risks, determining a patient’s prescription drug history and level of risk by accessing data from their state PDMP, and identifying mental health, social services, and treatment options for patients with opioid use disorder.

Opioid Overdoses Treated in Emergency Departments.

https://www.cdc.gov/vitalsigns/opioid-overdoses/index.html

Emergency Data Show Rapid Increases in Opioid Overdoses [news release]. CDC’s website.

https://www.cdc.gov/media/releases/2018/p0306-vs-opioids-overdoses.html

Houry DE, Haegerich TM, Vivolo-Kantor A. Opportunities for Prevention and Intervention of Opioid Overdose in the Emergency Department.

https://doi.org/10.1016/j.annemergmed.2018.01.052

Emergency department (ED) visits in the United States for opioid overdoses are up, a sign that the epidemic is worsening, according to a recent CDC report.

CDC's Emergency Department Data Points to Worsening Opioid Epidemic

In oral testimony before the US House Committee on Energy and Commerce Subcommittee on Oversight and Investigations, FDA Commissioner Scott Gottlieb, MD, addressed influenza response efforts and preparedness, and urged for immediate steps to be taken to enhance vaccine development.

The testimony was given hearing on US public health preparedness and response efforts to seasonal influenza.

Exploring alternatives to egg-based vaccines is one way to address strain drift or newly emerging strains that make existing vaccines less effective, Dr. Gottlieb said. Many manufacturers are continuing to produce egg-based vaccines, largely because more investment would be needed to fundamentally change manufacturing. Despite this, Dr. Gottlieb indicated that it is worth better understanding the potential of these alternative vaccines.

“Some studies have found that cell-based and recombinant vaccines are more efficacious, or could be more efficacious, than egg-based vaccines; but, more data and analyses are needed,” he said, adding that the FDA is looking at how to develop a more robust recombinant vaccine manufacturing process to increase yield while reducing cost. Additionally, the agency intends to help industry make investments in new manufacturing technologies and develop regulatory tools and guidances for these products.

Data presented at a recent FDA advisory committee meeting suggested that the strains selected for the 2017-2018 vaccine reasonably matched circulating strains, even the H3N2 strain. Past vaccines have also been less effective against H3N2, and Dr. Gottlieb stated that the FDA is trying to better understand why effectiveness tends to be lower against this strain.

Until then, Dr. Gottlieb noted that improving vaccine uptake and preventing shortages of flu treatments, such as antivirals and IV saline, remain essential.

“As we continue to invest in the future of manufacturing and vaccine technology, we also need to remember the importance of simply ensuring that more people are vaccinated with available vaccines each flu seasons,” he explained.

Remarks from FDA Commissioner Scott Gottlieb, M.D., as prepared for oral testimony before the U.S. House Committee on Energy and Commerce Subcommittee on Oversight and Investigations hearing “Examining U.S. Public Health Preparedness for and Response Efforts to Seasonal Influenza.” [FDA Statement]. FDA’s website.

https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm600244.htm?utm_campaign=03082018_Statement_Oral%20testimony%20flu&utm_medium=email&utm_source=Eloqua

In oral testimony before the US House Committee on Energy and Commerce Subcommittee on Oversight and Investigations, FDA Commissioner Scott Gottlieb, MD, addressed influenza response efforts and preparedness. 

FDA Commissioner Discusses Seasonal Flu Preparedness, Response Efforts

The American College of Physicians (ACP) recently issued new guidelines aimed at assisting clinicians in making decisions about targets when using pharmacologic therapy in adults with type 2 diabetes.

Based on evaluation of existing guidelines and clinical studies, the ACP has recommended that clinicians use less intensive treatment target strategies. Studies showed no evidence that lowering HbA

levels less than 7% provided any additional benefit. The guidelines also suggested de-intensifying treatment for patients with HbA

“The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7% and 8% will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs,” said Jack Ende, MD, President, ACP, in a press release.

The ACP published the 4 evidence-based statement guidelines to assist health care providers in making treatment decisions:

Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, and costs of care.

level between 7% and 8% in most patients with type 2 diabetes.

Clinicians should consider de-intensifying pharmacologic therapy in patients who achieve HbA

Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA

level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions because the harms outweigh the benefits in this population.

The authors analyzed 5 large, long-term controlled trials from existing guidelines that investigated intensive versus less intensive treatment target strategies in adults. Throughout the studies, patients randomly assigned to more intensive therapy required more antiglycemic medications at higher doses, leading to more adverse events than the less intensive groups.

According to the guidelines, the studies demonstrated that no evidence has consistently shown that intensive glycemic control to HbA

levels below 7% reduces clinical microvascular events, and that only reductions were seen in surrogate microvascular complications.

“Although ACP’s guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate if it can be achieved with diet and lifestyle modifications such as exercise, dietary changes, and weight loss,” said Dr. Ende.

Although several guidelines differ on recommended treatment target strategies, all guidelines consistently recommend individualizing HbA

targets on the basis of patient characteristics, such as comorbid conditions and risk for hypoglycemia.

Qaseem A, Wilt TJ, Kansagara D, et al. Hemoglobin A

targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians.

ACP recommends moderate blood sugar control targets for most patients with type 2 diabetes [news release]. Philadelphia. ACP’s website.

https://www.acponline.org/acp-newsroom/acp-recommends-moderate-blood-sugar-control-targets-for-most-patients-with-type-2-diabetes

The American College of Physicians recently issued new guidelines aimed at assisting clinicians in making decisions about targets when using pharmacologic therapy in adults with type 2 diabetes.

ACP Guidelines Recommend Less-Intensive Treatment Targets for Type 2 Diabetes

Although obesity has been considered a risk factor for severe acute respiratory illness, including more severe cases of the flu, a recently-published study found that weight may not be associated with increased illness severity.

Study data from the 2009 pandemic flu season had shown obesity as an independent risk factor for hospitalized adults, but few studies have investigated the association between weight and severity of respiratory illnesses seeking care in the emergency department during other winter respiratory seasons.

“We undertook this study thinking that obesity would put patients at greater risk for other respiratory illnesses,” Elizabeth Halvorson, MD, assistant professor of pediatrics at Wake Forest Baptist and study author, said in a press release.

Unexpectedly, the study found no evidence of obesity as a risk factor for more severe acute respiratory illnesses, including the flu, in children or adults.

the researchers examined 3,560 children and adults who came to the emergency department with acute respiratory illness over consecutive winter respiratory seasons from 2010 to 2014. The researchers defined acute respiratory illness as any illness that included symptoms such as fever, cough, runny nose, sore throat, and difficulty breathing.

The researchers looked at data based on division of weight category, such as normal-weight, overweight, and obese. Severity was determined based on several different measures, such as admission to hospital, treatment with antibiotics, length of stay after being admitted, and the need for extra oxygen during hospitalization.

Study limitations included a relatively small sample size for children and the exclusion of patients who received care at outpatient clinics and urgent care centers.

Overall, the researchers found no increased risk of hospitalization based on weight in either children or adults, but noted that further study is needed with more participants in different regions of the country.

The study was supported by the National Institutes of Health.

Halvorson E, Peters TR, Skelton JA, et al. Is weight associated with severity of acute respiratory illness?

Obesity Not a Risk Factor for Acute Respiratory [news release]. North Carolina. Wake Forest’s website.

www.wakehealth.edu/News-Releases/2018/Obesity_Not_a_Risk_Factor_for_Acute_Respiratory_Illnesses_Study_Finds.htm