A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Introduction: Thousands of people die from influenza or its complications each year despite the fact that it is one of the few vaccine preventable diseases. Immunocompromised cancer patients are among the most vulnerable to this infection and flu‐related complications, and therefore vaccination is highly recommended in these patients; however, current vaccination rates and attitudes towards vaccination remain unknown. We hypothesize that immunization rates are lower than the 100% recommendation rate, and hope to understand the reasoning behind the discrepancy. The purpose of this study is to assess cancer patient attitudes towards influenza vaccination in an effort to minimize barriers to vaccination and eventually increase vaccination rates in this immunocompromised population. Methods: Cancer patients enrolled in phase I clinical oncology trials at the Virginia G Piper Cancer Center at Scottsdale Healthcare were invited to participate in a voluntary survey. The 15‐item survey consisted of demographic information, knowledge regarding the flu vaccine, vaccination status after cancer diagnosis and while on treatment, and general attitudes towards vaccination. A total of 84 cancer patients completed the survey. Results were stratified by age, gender, education level, and vaccination status. As this was a descriptive study, no statistical analyses were performed. Results: A total of 84 (n=84) advanced cancer patients enrolled in phase I clinical oncology trials completed the survey. Results indicate that although 71% of patients received the vaccine prior to cancer diagnosis, only 58% of patients have received the vaccine since their cancer diagnosis, and only 48% have been vaccinated while on cancer treatment. Of those vaccinated since cancer diagnosis, 94% reported doctor recommendation of the vaccine and most vaccinate to protect themselves from the virus. Of those not vaccinated since cancer diagnosis, only 37% report their doctor recommends the vaccine and the majority avoid vaccination because they believe the vaccine can cause the flu, they do not feel at risk of infection, and they do not believe the vaccine is effective. Conclusion: Our findings suggest that although the CDC strongly recommends influenza vaccination in cancer patients due to the risk of secondary complications and even death in these immunocompromised individuals, vaccination rates remain low. Our data demonstrates that patients who receive a doctor recommendation for the vaccine are more likely to be vaccinated, but not all doctors recommend the vaccine. Furthermore, false information regarding the vaccine, its efficacy, and its ability to cause infection continues to deter patients from vaccination. Together, this information offers profound insight into the cancer patient population and suggests the need for increased physician and patient education regarding the benefits of annual influenza vaccination to improve vaccination rates and decrease influenza infection and complications in the future.

Class of 2011 Abstract / OBJECTIVES: The purpose of this study was to create and evaluate the usability and credibility of an informational website about the influenza vaccination. METHODS: This was a descriptive study of user’s reactions to a website. Questionnaires administered during a regularly scheduled class collected ratings of the usability and credibility of an informational website about the influenza vaccination; data on vaccination status, year in pharmacy school and plans for future vaccination were also collected. RESULTS: Questionnaires were completed by 8 students. Eighty-eight percent of participants were in their 3rd year of pharmacy school and 62% received the influenza vaccination in the past season. Only one participant had used the internet to access information about vaccines in the past. The means scores for the 9 usability and credibility statements were between 2 to 2.9 indicating agreement with the statements. CONCLUSION: The influenza website is easy to navigate and provides a source of credible information about the influenza vaccination.

Seasonal influenza outbreaks are associated with morbidity and mortality in the United States. Though children are the most susceptible to influenza infection and are most likely to transmit the illness to others, many children are not vaccinated. The purpose of this study was to examine the relationship between seasonal influenza vaccination Advisory Committee on Immunization Practices (ACIP) recommendations, demographic characteristics, socioeconomic factors, and vaccine type among children over 3 consecutive flu seasons. This quantitative cross-sectional study was guided by the social ecology of health model. Secondary data from 3 consecutive flu seasons (2014-2015, 2015-2016, and 2016-2017) provided by the National Health Interview Survey was used for this study. Binary logistic regression and chi-square were used to analyze the data. A relationship between socioeconomic status, demographics (age, race, and family income) and vaccine type (live-attenuated influenza vaccine [LAIV]/inactivated influenza vaccine) was established among U.S. children; those who received LAIV were most likely to be White elementary school age children with a higher family income. Demographic and socioeconomic status was not considered influential in LAIV uptake for race, health insurance status, or family income. ACIP recommendations by age and year had the greatest impact on flu vaccine choice for this sample population. The results of this study can lead to social change by providing information for policy that can increase vaccine uptake, which can result in lower health cost and reduced illness and death rates associated with the flu, especially for those most at risk.

The seasonal influenza (flu) vaccine has been shown to prevent flu outbreaks that can cause debilitating effects on the body and even death. Underserved members of Black communities are more likely to refuse the flu vaccine than are persons of other ethnicities. The purpose of the project was to determine from a needs assessment the reasons for flu vaccine refusal in the Black population of an inner city clinic in order to develop tailored communication and nursing actions that promote awareness of the flu vaccine's importance and safety. The health belief model constructs (perceived susceptibility, perceived severity, perceived benefits, and perceived barriers) were used to guide the project. A survey based on the constructs of the health belief model was administered to a convenience sample of 40 adult patients in an inner city clinic who completed the anonymous survey while they waited for the physician. Descriptive statistics showed that adults ages 18 to 36, who were the largest group of respondents (n = 33), agreed to be vaccinated and believed the flu to be a serious disease for their age group. Reported barriers to vaccination included finding time to get vaccinated and the belief that the vaccine causes the flu. The findings supported development of an annual seasonal flu vaccine campaign that included verbal and written education, informational posters, social media messages, and a standing order to offer and administer the injection to all adults served by the practice. Social change implications are expected to include decreased morbidity and mortality from flu among the Black inner city patients and closer alignment of the clinic with the Healthy People 2020 vaccination goals.

Background: Vaccination is one of the most cost-effective preventive measures against infectious diseases. A proper administration of the vaccine is critical. Therefore, only authorized and trained health care personnel including pharmacists can administrate vaccines safely and effectively. However, in Sweden, several laws and regulations prevent pharmacists to perform vaccinations. Aim: The aim was to elucidate the conditions and regulations of influenza vaccination administration by pharmacists at pharmacies in other countries compared to Sweden. Methods: A literature review were performed. Two different databases, PubMed and Web of Science were used. In addition, reports of governmental and various organizations were used. Interviews have been used as a complement. Results: Involving pharmacists in vaccination administration improves the vaccine coverage. This result was confirmed by pharmacist performing vaccine administration in other countries such as the USA, Canada, UK and Norway. However, these benefits are limited in Sweden due to the regulation HSLF-FS 2017:37, which hampers vaccines administration by pharmacists. Nevertheless, the regulation SOSFS 1997:14 could be interpreted as allowing clinical doctors to delegate vaccination to pharmacists. However, this needs to be further investigated. All Swedish representatives interviewed in this report, supported the idea that pharmacists should be able to perform vaccines at Swedish pharmacies. Conclusions: Modification of the regulation HSLF-FS 2017: 37 as well as proper education and training are required to allow pharmacists to perform vaccinations in Swedish pharmacies.

abstract: Influenza is a deadly disease that poses a major threat to global health. The surface proteins of influenza A, the type most often associated with epidemics and pandemics, mutate at a very high frequency from season to season, reducing the efficacy of seasonal influenza vaccines. However, certain regions of these proteins are conserved between strains of influenza A, making them attractive targets for the development of a ‘universal’ influenza vaccine. One of these highly conserved regions is the ectodomain of the influenza matrix 2 protein (M2e). Studies have shown that M2e is poorly immunogenic on its own, but when properly adjuvanted it can be used to induce protective immune responses against many strains of influenza A. In this thesis, M2e was fused to a pair experimental ‘vaccine platforms’: an antibody fusion protein designed to assemble into a recombinant immune complex (RIC) and the hepatitis B core antigen (HBc) that can assemble into virus-like particles (VLP). The two antigens were produced in Nicotiana benthamiana plants through the use of geminiviral vectors and were subsequently evaluated in mouse trials. Mice were administered three doses of either the VLP alone or a 1:1 combination of the VLP and the RIC, and recipients of both the VLP and RIC exhibited endpoint anti-M2e antibody titers that were 2 to 3 times higher than mice that received the VLP alone. While IgG2a:IgG1 ratios, which can suggest the type of immune response (TH1 vs TH2) an antigen will elicit, were higher in mice vaccinated solely with the VLP, the higher overall titers are encouraging and demonstrate a degree of interaction between the RIC and VLP vaccines. Further research is necessary to determine the optimal balance of VLP and RIC to maximize IgG2a:IGg1 ratios as well as whether such interaction would be observed through the use of a variety of diverse antigens, though the results of other studies conducted in this lab suggests that this is indeed the case. The results of this study demonstrate not only the successful development of a promising new universal influenza A vaccine, but also that co-delivering different types of recombinant vaccines could reduce the total number of vaccine doses needed to achieve a protective immune response. / Dissertation/Thesis / Masters Thesis Molecular and Cellular Biology 2019