EARLY PEANUT INTRODUCTION IN INFANTS TO PREVENT PEANUT ALLERGY: IMPROVING GUIDELINE ADHERENCE THROUGH EMR STANDARDIZATION

Background: Peanut allergy in children is a population health problem affecting individuals, families, and healthcare systems. Strong evidence from the Learning Early About Peanut (LEAP) study suggests that early peanut introduction (EPI) for infants after four months of age but before 12 months can reduce the risk of developing peanut allergy (Du Toit et al., 2015; Fleischer et al., 2021; Obbagy et al., 2019; Togias et al., 2017). The success of peanut allergy prevention in infants is highly dependent on primary care providers (PCPs) incorporating the addendum guidelines into routine well-child check (WCC) encounters (Bilaver et al., 2019; Lai & Sicherer, 2019). Addendum guidelines recommending EPI have not been widely adopted in primary care settings. The Children's Primary and Specialty Clinic at UNC had notably low adoption of the addendum guidelines for EPI.Methods: Using quality improvement (QI) methodology and the model for improvement, researchers developed and implemented a workflow protocol and clinical decision support (CDS) tools to improve guideline adherence through standardization. These tools, available in the electronic medical record (EMR), included smart lists, visit templates, and patient education handouts for home peanut introduction at 4, 6, and 9-month WCC encounters. Through plan-do-study-act (PDSA) cycles, the team executed changes and modifications to improve outcomes.Results: The team collected data from 292 WCC encounters during the QI project. EMR documentation of clinically appropriate EPI guidance at 4, 6, and 9-month WCCs shifted from a mean of 8.8% at baseline to 74.7% after 18 weeks of PDSA cycles (p<0.001). Mean provider adoption of smart lists and templates was 67.3%, and distribution of home peanut introduction handouts was 50.2% after 18 weeks of project implementation. There were no statistically significant changes in patient time-in-room (p=0.795). Rates of DTaP vaccination remained at 100% for 6M visits during the intervention. Conclusion: QI methodology, PDSA cycles, and interprofessional collaboration in primary care settings improved documentation of EPI guidance at routine WCC encounters without impacting other measures. Broader PCP use of bundled CDS tools and EMR standardization could further improve guideline adherence to prevent peanut allergy in infants.Doctor of Nursing Practic

Racial/ethnic and Socioeconomic Differences in Screening Toddlers for Autism Spectrum Disorders Using the M-CHAT

Universal screening for autism spectrum disorder (ASD) is recommended to reduce disparities in timing of diagnosis. Early diagnosis of ASD has been associated with higher parent education and income in some studies, while others report that economically disadvantaged children and African American and Latino children are diagnosed later or not at all (Fombonne, 2003; Fountain, King, & Bearman, 2011; Liptak et al., 2008). A sample of 18,669 children was drawn from screening sites at the University of Connecticut (n = 9587, 51.4%) or Georgia State University (n = 9082, 48.6%). Socioeconomic status (SES) was estimated by Census Tract median income data. Participants included Majority group (White children; n= 6169) and the Minority group (all other racial/ethnic groups; n= 2789). There were small but significant disparities by race/ethnicity, controlling for income, in child age at M-CHAT screening, age at M-CHAT Follow-up Interview (FUI), and time from M-CHAT to FUI. African American and Latino children were older at screening and follow-up, but not evaluation, likely due to differential attrition. Minority and lower income children screened positive more frequently on certain screener items, including all reverse-scored items. Finally, positive predictive value (PPV) of the M-CHAT did not differ by race/ethnicity. In conclusion, standardized screening procedures employed in the current study largely eliminated disparities in screening, follow-up, and evaluation for ASD in toddlers. Item response patterns also differed by both race/ethnicity and SES, underscoring the need for support for parent understanding of M-CHAT items in pediatric practice

Racial/ethnic and Socioeconomic Differences in Screening Toddlers for Autism Spectrum Disorders Using the M-CHAT

Universal screening for autism spectrum disorder (ASD) is recommended to reduce disparities in timing of diagnosis. Early diagnosis of ASD has been associated with higher parent education and income in some studies, while others report that economically disadvantaged children and African American and Latino children are diagnosed later or not at all (Fombonne, 2003; Fountain, King, & Bearman, 2011; Liptak et al., 2008). A sample of 18,669 children was drawn from screening sites at the University of Connecticut (n = 9587, 51.4%) or Georgia State University (n = 9082, 48.6%). Socioeconomic status (SES) was estimated by Census Tract median income data. Participants included Majority group (White children; n= 6169) and the Minority group (all other racial/ethnic groups; n= 2789). There were small but significant disparities by race/ethnicity, controlling for income, in child age at M-CHAT screening, age at M-CHAT Follow-up Interview (FUI), and time from M-CHAT to FUI. African American and Latino children were older at screening and follow-up, but not evaluation, likely due to differential attrition. Minority and lower income children screened positive more frequently on certain screener items, including all reverse-scored items. Finally, positive predictive value (PPV) of the M-CHAT did not differ by race/ethnicity. In conclusion, standardized screening procedures employed in the current study largely eliminated disparities in screening, follow-up, and evaluation for ASD in toddlers. Item response patterns also differed by both race/ethnicity and SES, underscoring the need for support for parent understanding of M-CHAT items in pediatric practice

Estimated Effectiveness of JYNNEOS Vaccine in Preventing Mpox: A Multijurisdictional Case-Control Study — United States, August 19, 2022–March 31, 2023

As of March 31, 2023, more than 30,000 monkeypox (mpox) cases had been reported in the United States in an outbreak that has disproportionately affected gay, bisexual, and other men who have sex with men (MSM) and transgender persons (1). JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic) was approved by the Food and Drug Administration (FDA) in 2019 for the prevention of smallpox and mpox via subcutaneous injection as a 2-dose series (0.5 mL per dose, administered 4 weeks apart) (2). To expand vaccine access, an Emergency Use Authorization was issued by FDA on August 9, 2022, for dose-sparing intradermal injection of JYNNEOS as a 2-dose series (0.1 mL per dose, administered 4 weeks apart) (3). Vaccination was available to persons with known or presumed exposure to a person with mpox (postexposure prophylaxis [PEP]), as well as persons at increased risk for mpox or who might benefit from vaccination (preexposure mpox prophylaxis [PrEP]) (4). Because information on JYNNEOS vaccine effectiveness (VE) is limited, a matched case-control study was conducted in 12 U.S. jurisdictions,† including nine Emerging Infections Program sites and three Epidemiology and Laboratory Capacity sites,§ to evaluate VE against mpox among MSM and transgender adults aged 18-49 years. During August 19, 2022-March 31, 2023, a total of 309 case-patients were matched to 608 control patients. Adjusted VE was 75.2% (95% CI&nbsp;=&nbsp;61.2% to 84.2%) for partial vaccination (1 dose) and 85.9% (95% CI&nbsp;=&nbsp;73.8% to 92.4%) for full vaccination (2 doses). Adjusted VE for full vaccination by subcutaneous, intradermal, and heterologous routes of administration was 88.9% (95% CI&nbsp;=&nbsp;56.0% to 97.2%), 80.3% (95% CI&nbsp;=&nbsp;22.9% to 95.0%), and 86.9% (95% CI&nbsp;=&nbsp;69.1% to 94.5%), respectively. Adjusted VE for full vaccination among immunocompromised participants was 70.2% (95% CI&nbsp;=&nbsp;-37.9% to 93.6%) and among immunocompetent participants was 87.8% (95% CI&nbsp;=&nbsp;57.5% to 96.5%). JYNNEOS is effective at reducing the risk for mpox. Because duration of protection of 1 versus 2 doses remains unknown, persons at increased risk for mpox exposure should receive the 2-dose series as recommended by the Advisory Committee on Immunization Practices (ACIP),¶ regardless of administration route or immunocompromise status