Comparative Efficacy of Inactivated and Live Attenuated Influenza Vaccines

New England Journal of Medicine
Volume 361 — September 24, 2009 — Number 13
http://content.nejm.org/current.shtml

Original Articles
Comparative Efficacy of Inactivated and Live Attenuated Influenza Vaccines
A. S. Monto and Others

ABSTRACT
Background
The efficacy of influenza vaccines may vary from year to year, depending on a variety of factors, and may differ for inactivated and live attenuated vaccines.

Methods
We carried out a randomized, double-blind, placebo-controlled trial of licensed inactivated and live attenuated influenza vaccines in healthy adults during the 2007–2008 influenza season and estimated the absolute and relative efficacies of the two vaccines.

Results
A total of 1952 subjects were enrolled and received study vaccines in the fall of 2007. Influenza activity occurred from January through April 2008, with the circulation of influenza types A (H3N2) (about 90%) and B (about 9%). Absolute efficacy against both types of influenza, as measured by isolating the virus in culture, identifying it on real-time polymerase-chain-reaction assay, or both, was 68% (95% confidence interval [CI], 46 to 81) for the inactivated vaccine and 36% (95% CI, 0 to 59) for the live attenuated vaccine. In terms of relative efficacy, there was a 50% (95% CI, 20 to 69) reduction in laboratory-confirmed influenza among subjects who received inactivated vaccine as compared with those given live attenuated vaccine. The absolute efficacy against the influenza A virus was 72% (95% CI, 49 to 84) for the inactivated vaccine and 29% (95% CI, –14 to 55) for the live attenuated vaccine, with a relative efficacy of 60% (95% CI, 33 to 77) for the inactivated vaccine.

Conclusions
In the 2007–2008 season, the inactivated vaccine was efficacious in preventing laboratory-confirmed symptomatic influenza A (predominately H3N2) in healthy adults. The live attenuated vaccine also prevented influenza illnesses but was less efficacious. (ClinicalTrials.gov number, NCT00538512 [ClinicalTrials.gov] .)

Optimizing Influenza Vaccine Distribution

Science
25 September 2009  Vol 325, Issue 5948, Pages 1585-1740
http://www.sciencemag.org/current.dtl

Reports
Optimizing Influenza Vaccine Distribution
Jan Medlock1,2,* and Alison P. Galvani1

The criteria to assess public health policies are fundamental to policy optimization. Using a model parametrized with survey-based contact data and mortality data from influenza pandemics, we determined optimal vaccine allocation for five outcome measures: deaths, infections, years of life lost, contingent valuation, and economic costs. We find that optimal vaccination is achieved by prioritization of schoolchildren and adults aged 30 to 39 years. Schoolchildren are most responsible for transmission, and their parents serve as bridges to the rest of the population. Our results indicate that consideration of age-specific transmission dynamics is paramount to the optimal allocation of influenza vaccines. We also found that previous and new recommendations from the U.S. Centers for Disease Control and Prevention both for the novel swine-origin influenza and, particularly, for seasonal influenza, are suboptimal for all outcome measures.

1 Epidemiology and Public Health, Yale University School of Medicine, 60 College Street, New Haven, CT 06520–8034, USA.
2 Department of Mathematical Sciences, Clemson University, Box 340975, Clemson, SC 29634–0975, USA.

Decision support in vaccination policies

Vaccine
Volume 27, Issue 43, Pages 5921-6102 (9 October 2009)
http://www.sciencedirect.com/science/journal/0264410X

Review
Decision support in vaccination policies
Pages 5923-5928
B. Piso, C. Wild

Abstract
Background
Looking across boarders reveals that the national immunization programs of various countries differ in their vaccination schedules and decisions regarding the implementation and funding of new vaccines. The aim of this review is to identify decision aids and crucial criteria for a rational decision-making process on vaccine introduction and to develop a theoretical framework for decision-making based on available literature.

Methods
Systematic literature search supplemented by hand-search.

Results
We identified five published decision aids for vaccine introduction and program planning in industrialized countries. Their comparison revealed an overall similarity with some differences in the approach as well as criteria. Burden of disease and vaccine characteristics play a key role in all decision aids, but authors vary in their views on the significance of cost-effectiveness analyses. Other relevant factors that should be considered before vaccine introduction are discussed to highly differing extents. These factors include the immunization program itself as well as its conformity with other programs, its feasibility, acceptability, and equity, as well as ethical, legal and political considerations. Assuming that the most comprehensive framework possible will not provide a feasible tool for decision-makers, we suggest a stepwise procedure.

Conclusions
Though even the best rational approach and most comprehensive evaluation is limited by remaining uncertainties, frameworks provide at least a structured approach to evaluate the various aspects of vaccine implementation decision-making. This process is essential in making consistently sound decisions and will facilitate the public’s confidence in the decision and its realization.

Safety and efficacy of rotavirus vaccine: Asian infants

Vaccine
Volume 27, Issue 43, Pages 5921-6102 (9 October 2009)
http://www.sciencedirect.com/science/journal/0264410X

Safety and efficacy of human rotavirus vaccine during the first 2 years of life in Asian infants: Randomised, double-blind, controlled study
Pages 5936-5941
K.B. Phua, F.S. Lim, Y.L. Lau, E.A.S. Nelson, L.M. Huang, S.H. Quak, B.W. Lee, Y.L. Teoh, H. Tang, I. Boudville, L.C. Oostvogels, P.V. Suryakiran, I.V. Smolenov, H.H. Han, H.L. Bock

Abstract
This study evaluates the safety and efficacy against severe rotavirus gastroenteritis of the oral live attenuated human rotavirus vaccine RIX4414 (Rotarix™) during the first 2 years of life in Asian infants from high-income countries. Healthy infants were enrolled to receive 2 doses of RIX4414 (N = 5359) or placebo (N = 5349). From 2 weeks post-dose 2 to 2 years of age, vaccine efficacy was 96.1% (95%CI:85.1%; 99.5%) against severe rotavirus gastroenteritis, 100% (95%CI:80.8%; 100%) against wild-type G1P[8] and 93.6% (95%CI:74.7%; 99.3%) against circulating non-G1 rotavirus types. No intussusception cases were reported within 31 days post-vaccination. RIX4414 shows a good safety profile and offers high protection during the first 2 years of life with potentially significant public health impact in this population.

Cost-effectiveness analysis: Screening, prevention and treatment of cervical cancer

Vaccine
Volume 27, Issue 43, Pages 5921-6102 (9 October 2009)
http://www.sciencedirect.com/science/journal/0264410X

Screening, prevention and treatment of cervical cancer—A global and regional generalized cost-effectiveness analysis
Pages 6060-6079
Gary Michael Ginsberg, Tessa Tan-Torres Edejer, Jeremy A. Lauer, Cecilia Sepulveda

Abstract
The paper calculates regional generalized cost-effectiveness estimates of screening, prevention, treatment and combined interventions for cervical cancer.

Using standardised WHO-CHOICE methodology, a cervical cancer model was employed to provide estimates of screening, vaccination and treatment effectiveness. Intervention effectiveness was determined via a population state-transition model (PopMod) that simulates the evolution of a sub-regional population accounting for births, deaths and disease epidemiology. Economic costs of procedures and treatment were estimated, including programme overhead and training costs.

In regions characterized by high income, low mortality and high existing treatment coverage, the addition of any screening programme to the current high treatment levels is very cost-effective. However, based on projections of the future price per dose (representing the economic costs of the vaccination excluding monopolistic rents and vaccine development cost) vaccination is the most cost-effective intervention.

In regions characterized by low income, low mortality and existing treatment coverage around 50%, expanding treatment with or without combining it with screening appears to be cost-effective or very cost-effective. Abandoning treatment in favour of screening in a no-treatment scenario would not be cost-effective. Vaccination is usually the most cost-effective intervention. Penta or tri-annual PAP smears appear to be cost-effective, though when combined with HPV-DNA testing they are not cost-effective.

In regions characterized by low income, high mortality and low treatment levels, expanding treatment with or without adding screening would be very cost-effective. A one off vaccination plus expanding treatment was usually very cost-effective. One-off PAP or VIA screening at age 40 are more cost-effective than other interventions though less effective overall.

From a cost-effectiveness perspective, consideration should be given to implementing vaccination (depending on cost per dose and longevity of efficacy) and screening programmes on a worldwide basis to reduce the burden of disease from cervical cancer. Treatment should also be increased where coverage is low.