Commentary: Malaria vaccine can prevent millions of deaths in the world

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 6    June 2013

Malaria vaccine can prevent millions of deaths in the world
Ramesh Verma, Pardeep Khanna and Suraj Chawla
Malaria is a major public health problem, afflicting ~36% of the world’s population. The World Health Organization (WHO) has estimated that there were 216 million cases of malaria in 2010, and ~655,000 people died from the disease (~2000 per day), many under age five. Yet the disease, a killer for centuries, remains endemic in many poor nations, particularly in Africa, where it is blamed for retarding economic growth. India contributes ~70% of the 2.5 million reported cases in Southeast Asia. Malaria is also an important threat to travelers to the tropics, causing thousands of cases of illness and occasional deaths. The 5 Plasmodium species known to cause malaria are P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi. Most cases of malaria are uncomplicated, but some can quickly turn into severe, often fatal, episodes in vulnerable individuals if not promptly diagnosed and effectively treated. Malaria vaccines have been an area of intensive research, but there is no effective vaccine. Vaccines are among the most cost-effective tools for public health; they have historically contributed to a reduction in the spread and burden of infectious diseases. Many antigens present throughout the parasite life cycle that could be vaccine targets. More than 30 of these are being researched by teams worldwide in the hope of identifying a combination that can elicit protective immunity. Most vaccine research has focused on the P. falciparum strain due to its high mortality and the ease of conducting in vitro and in vivo studies. DNA-based vaccines are a new technology that may hold hope for an effective malaria vaccine.

A critical literature review of health economic evaluations of rotavirus vaccination

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 6    June 2013

A critical literature review of health economic evaluations of rotavirus vaccination
Volume 9, Issue 6   June 2013
Samuel Aballéa, Aurélie Millier, Sibilia Quilici, Stuart Caroll, Stavros Petrou and Mondher Toumi

Two licensed vaccines are available to prevent RVGE in infants. A worldwide critical review of economic evaluations of these vaccines was conducted. The objective was to describe differences in methodologies, assumptions and inputs and determine the key factors driving differences in conclusions. 68 economic evaluations were reviewed. RV vaccination was found to be cost-effective in developing countries, while conclusions varied between studies in developed countries. Many studies found that vaccination was likely to be cost-effective under some scenarios, such as lower prices scenarios, inclusion of herd protection, and/or adoption of a societal perspective. Other reasons for variability included uncertainty around healthcare visits incidence and lack of consensus on quality of life (QoL) valuation for infants and caregivers. New evidence on the vaccination effectiveness in real-world, new ways of modeling herd protection and assessments of QoL in children could help more precisely define the conditions under which RV vaccination would be cost-effective in developed countries.

Secular trends of chickenpox among military population in Israel in relation to introduction of varicella zoster vaccine 1979–2010

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 6    June 2013

Research Paper
Secular trends of chickenpox among military population in Israel in relation to introduction of varicella zoster vaccine 1979–2010
Volume 9, Issue 6   June 2013
Daniel Mimouni, Hagai Levine, Anat Tzurel Ferber, Inbal Rajuan-Galor and Michael Huerta-Hartal

Chickenpox is a contagious disease caused by the varicella zoster virus. There is scarce data on long-term trends of chickenpox and its relation to vaccinations practices. We aimed to evaluate trends of chickenpox in a military population during the period 1979–2010 and to assess temporal associations in relation with the introduction of varicella zoster vaccine to the civilian population in Israel in 2000. The archives of the Epidemiology Section of the Israel Defense Forces, where chickenpox is a notifiable disease, were reviewed for all cases of chickenpox from January 1, 1979–December 31, 2010. Annual and monthly incidence rates were calculated and analyzed in relation to vaccine introduction. Between 1979–2000, incidence rates fluctuated around 10 cases per 10,000 soldiers without a clear trend. Since 2000 there has been a dramatic 10-fold decline in incidence, especially notable since 2008, from eight per 10,000 soldiers in 2000 to the lowest rate ever recorded, in 2009, of 0.57 cases per 10,000 soldiers. A seasonal sinusoidal pattern was clearly demonstrated, with rising incidence from November to May followed by a gradual decline to October. The results of this long-term study suggest that the rates of chickenpox in the military population have significantly declined since the introduction of the vaccine to the civilian population in Israel and almost disappeared completely since 2008 as the vaccine was included in the state-funded routine childhood immunization schedule.

Evaluation of the frequency of immunization information system use for public health research

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 6    June 2013

Research Paper
Evaluation of the frequency of immunization information system use for public health research
Volume 9, Issue 6   June 2013
Eileen A. Curran, Robert A. Bednarczyk and Saad B. Omer

Immunization information systems (IIS) have been useful for consolidating immunization data and increasing coverage, and have the potential to be a valuable resource for immunization research, but the extent which IIS data are used for research purposes has not been evaluated. We reviewed studies conducted using data from federally supported state and city immunization program IIS, and categorized research type based on study objectives to evaluate patterns in the types of research conducted. Research papers using IIS data published between 1999 and July 3, 2012 were identified by searching the CDC IIS publication database and PubMed. These searches produced 304 and 884 papers, respectively, 44 of which were eligible to be included in this evaluation. The most common research category was evaluation of factors associated with vaccine coverage and vaccine coverage estimates (n = 20). This study shows that IIS may not be used to their full potential with regards to research. Further research is needed to determine barriers to using IIS data for research purposes.

NIC23 & Special Focus Reviews – Human Vaccines & Immunotherapuetics

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 6    June 2013

Special Section: NIC23
David Baxter and Martin J. Guppy
Full Text

The evidence for use of pneumococcal conjugate over polysaccharide in children
Ray Borrow
Abstract | Full Text

Meningococcal group B vaccines
Jamie Findlow
Abstract | Full Text

Should childhood MMR vaccination be compulsory? Rights, duties and the public interest
Julian Sheather
When children and young people lack the capacity to make decisions about their care and treatment, decisions have to be made on their behalf based on an assessment of their welfare or interests. In law, parents, or others with the relevant parental responsibility, are ordinarily regarded as the appropriate decision-makers. One way of framing this is to say that parents have certain decision-making rights with respect to their children. Such rights, however, are not generally regarded as absolute, rather they can be seen as secondary to and limited by the duties that parents have with regard to their children, duties to promote their welfare. It is against these parental duties that children could, at least in theory if not in practice, claim a right to certain kinds of protection. The legal rights of parents here, as opposed to the rights of the children, can be thought of as rights that secure for parents the freedom from interference necessary to fulfill the underlying duty.

Pneumococcal vaccination of older adults: conjugate or polysaccharide?
David S. Fedson
Abstract | Full Text

Accessing hard to reach groups, travelers and looked after children
Fiona Print

Improving vaccine uptake: An overview
Michelle Anne Falconer
Abstract | Full Text
A task group was formed with the aim to improve the quality of the service offered by ensuring that all children waiting for an appointment for vaccination would be offered one at the earliest opportunity. Children aged between 12 mo–5 y that were not completely immunized for their age were identified and included in a pilot catch-up session. Following evaluation of the pilot session, four further immunization sessions were delivered. A total of 398 children attended the four sessions, representing an improved attendance rate of 39%. Most parents brought their children between 11am–3pm and 728 vaccines were administered: 339 MMR; 255 Pre-school boosters; 53 Hib/MenC and 81 PCV. Uptake of MMR vaccine in the PCT at age 24 mo increased by 9% by Q3 2008. For children aged five years, uptake of the first dose of MMR vaccine increased from 91.9% to 94% for the first dose and from 82.3 to 82.5% for the second dose by Q3 2008. This project demonstrates that new ways of delivering immunization sessions can be successfully implemented which can enhance access through the use of alternative venues and subsequently lead to increased vaccine uptake.

The effect of ageing of the immune system on vaccination responses
Janet M. Lord
Abstract | Full Text | PDF

EV71 vaccine: protection from a previously neglected disease; Phase 3 Trial

The Lancet  
Jun 08, 2013  Volume 381  Number 9882  p1959 – 2054  e18 – 19

EV71 vaccine: protection from a previously neglected disease
Nigel W Crawford, Steve M Graham
Preview |
The eagerly awaited results of a phase 3 trial of an inactivated enterovirus 71 (EV71) vaccine are reported by Feng-Cai Zhu and colleagues in The Lancet.1 EV71 is an important cause of hand, foot, and mouth disease (HFMD), but is also associated with more severe diseases in young children (aged <5 years), including aseptic meningitis and encephalitis.2 This multicentre randomised controlled trial done in China is a notable advance in protection against EV71. It included more than 10 000 participants (aged 6–35 months), with a vaccine efficacy of 90·0% (95% CI 67·1–96·9) for EV71-associated HFMD and 80·4% (58·2–90·8) for EV71-associated disease (including herpangina, neurological complications, and non-specific illnesses caused by EV71).

Efficacy, safety, and immunology of an inactivated alum-adjuvant enterovirus 71 vaccine in children in China: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial
Feng-Cai Zhu, Fan-Yue Meng, Jing-Xin Li, Xiu-Ling Li, Qun-Ying Mao, Hong Tao, Yun-Tao Zhang, Xin Yao, Kai Chu, Qing-Hua Chen, Yue-Mei Hu, Xing Wu, Pei Liu, Lin-Yang Zhu, Fan Gao, Hui Jin, Yi-Juan Chen, Yu-Ying Dong, Yong-Chun Liang, Nian-Min Shi, Heng-Ming Ge, Lin Liu, Sheng-Gen Chen, Xing Ai, Zhen-Yu Zhang, Yu-Guo Ji, Feng-Ji Luo, Xiao-Qin Chen, Ya Zhang, Li-Wen Zhu, Zheng-Lun Liang, Xin-Liang Shen
A vaccine for enterovirus 71 (EV71) is needed to address the high burden of disease associated with infection. We assessed the efficacy, safety, immunogenicity, antibody persistence, and immunological correlates of an inactivated alum-adjuvant EV71 vaccine.

We did a randomised, double-blind, placebo-controlled, phase 3 trial. Healthy children aged 6—35 months from four centres in China were randomly assigned (1:1) to receive vaccine or alum-adjuvant placebo at day 0 and 28, according to a randomisation list (block size 30) generated by an independent statistician. Investigators and participants and their guardians were masked to the assignment. Primary endpoints were EV71-associated hand, foot, and mouth disease (HFMD) and EV71-associated disease during the surveillance period from day 56 to month 14, analysed in the per-protocol population. This study is registered with, number NCT01508247.

10 245 participants were enrolled and assigned: 5120 to vaccine versus 5125 to placebo. 4907 (with three cases of EV71-associated HFMD and eight cases of EV71-associated disease) versus 4939 (with 30 cases of EV71-associated HFMD and 41 cases of EV71-associated disease) were included in the primary efficacy analysis. Vaccine efficacy was 90·0% (95% CI 67·1—96·9) against EV71-associated HFMD (p=0·0001) and 80·4% (95% CI 58·2—90·8) against EV71-associated disease (p<0·0001). Serious adverse events were reported by 62 of 5117 (1·2%) participants in the vaccine group versus 75 of 5123 (1·5%) in the placebo group (p=0·27). Adverse events occurred in 3644 (71·2%) versus 3603 (70·3%; p=0·33).

EV71 vaccine provides high efficacy, satisfactory safety, and sustained immunogenicity.

China’s 12—5 National Major Infectious Disease Program, Beijing Vigoo Biological.

Opinion: An updated Declaration of Helsinki will provide more protection

Nature Medicine
June 2013, Volume 19 No 6 pp653-790

An updated Declaration of Helsinki will provide more protection – p664
Cecil B. Wilson

Almost 50 years ago, the World Medical Association adopted the Declaration of Helsinki as an ethical guide for research involving human subjects. There are now proposed revisions under consideration that will provide additional protection for study participants as well as increased clarity regarding the responsibilities of those conducting the research. Making these changes is important in a complex environment where what is ethical is not always self-evident.

Abstract – | Full Text – An updated Declaration of Helsinki will provide more protection | PDF (190 KB)

How AIDS Invented Global Health

New England Journal of Medicine
June 6, 2013  Vol. 368 No. 23

How AIDS Invented Global Health
A.M. Brandt
Excerpt [Free Full Text]
Over the past half-century, historians have used episodes of epidemic disease to investigate scientific, social, and cultural change. Underlying this approach is the recognition that disease, and especially responses to epidemics, offers fundamental insights into scientific and medical practices, as well as social and cultural values. As historian Charles Rosenberg wrote, “disease necessarily reflects and lays bare every aspect of the culture in which it occurs.”1

Many historians would consider it premature to write the history of the HIV epidemic. After all, more than 34 million people are currently infected with HIV. Even today, with long-standing public health campaigns and highly active antiretroviral therapy (HAART), HIV remains a major contributor to the burden of disease in many countries. As Piot and Quinn indicate in this issue of the Journal (pages 2210–2218), combating the epidemic remains a test of our expanding    knowledge and vigilance.

Nonetheless, the progress made in addressing this pandemic and its effects on science, medicine, and public health have been far-reaching (see timeline). The changes wrought by HIV have not only affected the course of the epidemic: they have had powerful effects on research and science, clinical practices, and broader policy. AIDS has reshaped conventional wisdoms in public health, research practice, cultural attitudes, and social behaviors. Most notably, the AIDS epidemic has provided the foundation for a revolution that upended traditional approaches to “international health,” replacing them with innovative global approaches to disease. Indeed, the HIV epidemic and the responses it generated have been crucial forces in “inventing” the new “global health.”…

Review Article
Global Health
Response to the AIDS Pandemic — A Global Health Model
Peter Piot, M.D., Ph.D., and Thomas C. Quinn, M.D.
N Engl J Med 2013; 368:2210-2218June 6, 2013DOI: 10.1056/NEJMra1201533

Excerpt [Free full text]
…International Response to AIDS — A Global Health Model

It was not until the third decade of the epidemic that the world’s public health officials, community leaders, and politicians united to combat AIDS. In 2001, the United Nations General Assembly endorsed a historic Declaration of Commitment on HIV/AIDS, a commitment that was renewed in 2011.7 These actions resulted in the formation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which was established to finance anti-AIDS activities in developing countries. In 2003, President George W. Bush announced the President’s Emergency Plan for AIDS Relief (PEPFAR), which allocated billions of dollars to the countries hardest hit by AIDS.

This unprecedented global response to the AIDS pandemic can serve as a model for the response to other global health threats. For example, the global AIDS response incorporated a multisectoral approach that involved public health officials, clinicians, politicians, and leaders in civil society, business and labor, the armed forces, and the law, working in concert and with financial resources in excess of $15 billion per year8 to reduce the incidence of HIV infection and associated mortality.    The response to the pandemic required a coordinated global effort, which has been led by the Joint United Nations Program on HIV/AIDS (UNAIDS) since 1996. This transformational response helped redefine what is meant by health diplomacy and led to a new culture of accountability in international development. Tiered pricing of medicines became commonplace, and renewed optimism provided a boost for research on other neglected global health issues. This response to the AIDS pandemic highlighted the shortage of health care workers, inadequate availability of essential medications, and weaknesses in primary health care and public health systems. The stigma of HIV infection and inequities in the care of those infected focused attention on social and medical equity and human rights…

Efficient Control of Epidemics Spreading on Networks: Balance between Treatment and Recovery

PLoS One
[Accessed 8 June 2013]

Efficient Control of Epidemics Spreading on Networks: Balance between Treatment and Recovery
Katarzyna Oleś, Ewa Gudowska-Nowak, Adam Kleczkowski
Research Article | published 04 Jun 2013 | PLOS ONE 10.1371/journal.pone.0063813

We analyse two models describing disease transmission and control on regular and small-world networks. We use simulations to find a control strategy that minimizes the total cost of an outbreak, thus balancing the costs of disease against that of the preventive treatment. The models are similar in their epidemiological part, but differ in how the removed/recovered individuals are treated. The differences in models affect choice of the strategy only for very cheap treatment and slow spreading disease. However for the combinations of parameters that are important from the epidemiological perspective (high infectiousness and expensive treatment) the models give similar results. Moreover, even where the choice of the strategy is different, the total cost spent on controlling the epidemic is very similar for both models.

Predictive Validation of an Influenza Spread Model

PLoS One
[Accessed 8 June 2013]

Predictive Validation of an Influenza Spread Model
Ayaz Hyder, David L. Buckeridge, Brian Leung
Research Article | published 03 Jun 2013 | PLOS ONE 10.1371/journal.pone.0065459
Modeling plays a critical role in mitigating impacts of seasonal influenza epidemics. Complex simulation models are currently at the forefront of evaluating optimal mitigation strategies at multiple scales and levels of organization. Given their evaluative role, these models remain limited in their ability to predict and forecast future epidemics leading some researchers and public-health practitioners to question their usefulness. The objective of this study is to evaluate the predictive ability of an existing complex simulation model of influenza spread.

Methods and Findings
We used extensive data on past epidemics to demonstrate the process of predictive validation. This involved generalizing an individual-based model for influenza spread and fitting it to laboratory-confirmed influenza infection data from a single observed epidemic (1998–1999). Next, we used the fitted model and modified two of its parameters based on data on real-world perturbations (vaccination coverage by age group and strain type). Simulating epidemics under these changes allowed us to estimate the deviation/error between the expected epidemic curve under perturbation and observed epidemics taking place from 1999 to 2006. Our model was able to forecast absolute intensity and epidemic peak week several weeks earlier with reasonable reliability and depended on the method of forecasting-static or dynamic.

Good predictive ability of influenza epidemics is critical for implementing mitigation strategies in an effective and timely manner. Through the process of predictive validation applied to a current complex simulation model of influenza spread, we provided users of the model (e.g. public-health officials and policy-makers) with quantitative metrics and practical recommendations on mitigating impacts of seasonal influenza epidemics. This methodology may be applied to other models of communicable infectious diseases to test and potentially improve their predictive ability.

Mother’s social capital and child health in Indonesia

Social Science & Medicine
Volume 91,   In Progress   (August 2013)

Mother’s social capital and child health in Indonesia
Original Research Article
Pages 1-9
Sujarwoto Sujarwoto, Gindo Tampubolon

Social capital has been shown to be positively associated with a range of health outcomes, yet few studies have explored the association between mother’s social capital and children’s health. This study examines the relation between mothers’ access to social capital (via participation in community activities) and child health. Instrumental variable estimation was applied to cross sectional data of the Indonesian Family Life Survey (IFLS) 2007 which consist of face-to-face interviews among the adult population in Indonesia (N/mothers = 3450, N/children = 4612, N/communities = 309, and participation rate at 92%). The findings show strong evidence for the causal flow running from a mother’s social capital to her children’s health. All instruments are highly correlated with mothers’ social capital but uncorrelated with child health. The findings are also robust to individual and community characteristics associated with child health, and suggest that enlarging mothers’ social capital through various community activities is a particularly relevant intervention for reducing child health disparities in Indonesia.

How do you measure trust in the health system? A systematic review of the literature

Social Science & Medicine
Volume 91,   In Progress   (August 2013)

How do you measure trust in the health system? A systematic review of the literature
Review Article
Pages 10-14
Sachiko Ozawa, Pooja Sripad

People’s trust in the health system plays a role in explaining one’s access to and utilization of medical care, adherence to medications, continuity of care, and even self-reported health status. Yet it is not easy to find trust measures and understand what they are measuring. A systematic review of scales and indices identified 45 measures of trust within the health system with an average of 12 questions each, which quantified levels of trust among various relationships across the health system. Existing evidence was narrow in scope, where half examined the relationship between doctors/nurses and patients, and the majority were designed, tested and validated in the United States. We developed a health systems trust content area framework, where we identified that honesty, communication, confidence and competence were captured frequently in these measures, with less focus on concepts such as fidelity, system trust, confidentiality and fairness. Half of the measures employed a qualitative method in the design of these measures and 33% were pilot tested. Reporting of test–retest reliability and inter-rater reliability were less common. This review identifies a need to develop measurements of trust beyond doctor–patient relationships and outside of U.S. contexts, and strengthen the rigor of existing trust measures. Greater development and use of trust measures in the health system could improve monitoring and evaluation efforts, which may in turn result in better health outcomes.

From Google Scholar+ [to 8 June 2013]

From Google Scholar & other sources: Selected Journal Articles, Dissertations, Theses, Commentary

Inactivated Influenza Vaccines for Prevention of Community-Acquired Pneumonia: The Limits of Using Nonspecific Outcomes in Vaccine Effectiveness Studies
Ferdinands, Jill M.a,b; Gargiullo, Paula; Haber, Michaelc; Moore, Matthewa; Belongia, Edward A.d; Shay, David K.a
July 2013 – Volume 24 – Issue 4 – p 530-537
doi: 10.1097/EDE.0b013e3182953065
Background: One to 4 million cases of community-acquired pneumonia (CAP) occur annually in the United States, resulting in 600,000 hospitalizations and 45,000 deaths. Influenza infection facilitates secondary bacterial infections, and influenza vaccination may prevent CAP directly by preventing influenza pneumonia or indirectly by preventing secondary bacterial CAP.
Methods: We investigated how influenza vaccination could affect incidence of CAP using deterministic probability and stochastic simulation models. The models included likely influential factors, including vaccine effectiveness (VE) against influenza, rates of influenza in the unvaccinated, vaccination coverage, and the relative risk (RR) of pneumonia, given influenza infection. To estimate effectiveness of influenza vaccine against CAP, we assumed mean VE against influenza of 55% and vaccine coverage of 38%.
Results: Given our baseline parameters, influenza vaccine had a mean effectiveness against CAP of 7% (95% confidence interval = 0–25%). Effectiveness of influenza vaccine against CAP increased as its effectiveness against influenza increased, as RR of pneumonia after influenza infection increased, and as rates of influenza among unvaccinated persons increased.
Conclusions: No matter how effective vaccine may be in preventing influenza infection, it is only modestly effective at preventing CAP. Because of the large annual burden of CAP, a vaccine that is only moderately effective in preventing influenza infection has the potential to prevent a substantial number of CAP cases. This modeling approach may be useful for planning influenza vaccine-probe studies and evaluating the effectiveness of other interventions targeted against infections that manifest in nonspecific outcomes.

A Licensed Combined Haemophilus influenzae Type b-Serogroups C and Y Meningococcal Conjugate Vaccine
KP Perrett, TM Nolan, J McVernon – Infectious Diseases and Therapy, 2013
The highest incidence of meningococcal disease occurs in infants younger than 1 year of age. However, in the US, prior to June 2012, there was no meningococcal vaccine licensed for use in this age group. In the US, where both serogroups C and Y contribute …

The physiological paradox: reframing the polypill as a vaccine for cardiovascular disease
MV Holmes, N Bhala – Journal of Epidemiology and Community Health, 2013
In his seminal work ‘Sick individuals, sick populations,’1 Geoffrey Rose postulated that reducing the population distribution of a causal risk factor would have a greater effect on population health than targeting only those at high risk (eg, as defined by a threshold …

A Morphine Conjugate Vaccine Attenuates the Behavioral Effects of Morphine in Rats
XY Shen, PW O’Malley, TA Kosten, BM Kinsey… – Progress in Neuro- …, 2013
Abstract Vaccines for opioid dependence may provide a treatment that would reduce or slow the distribution of the drug to brain, thus reducing the drug’s reinforcing effects. We tested whether a conjugate vaccine against morphine (keyhole limpet hemocyanin-6- …

Targovax AS Raises $3.6 Million in Private and Public Support for TG01 Pancreatic Cancer Vaccine Development
[Business Wire; June 05, 2013]
Cancer vaccine specialist Targovax today announced that it has raised a total of $3.6 million to accelerate development of its RAS mutation-targeted therapeutic cancer vaccine pipeline…

Vaccine exemptions rising, tied to whooping cough [New York State]

Accessed 8 June 2013

Vaccine exemptions rising, tied to whooping cough
NEW YORK | Mon Jun 3, 2013 12:10am EDT
(Reuters Health) – The number of New York parents who had their child skip at least one required vaccine due to religious reasons increased over the past decade, according to a new study.

What’s more, researchers found counties with high religious exemption rates also had more whooping cough cases – even among children that had been fully vaccinated.

States set their own requirements on which vaccines a child must have received to enter school. All allow exemptions for medical reasons, and most, including New York, also permit parents with a religious objection to forgo vaccination.

Less than half of states permit exemptions due to personal or philosophical beliefs. But those also can get counted under religious views in places with less strict exemption policies.

“Particularly in New York State, I do believe that parents are using religious exemptions for their personal beliefs,” said Dr. Jana Shaw, who worked on the study at SUNY Upstate Medical University in Syracuse…

UN Fighting Polio in Kenyan Refugee Camp

Voice of America

UN Fighting Polio in Kenyan Refugee Camp
June 01, 2013
The United Nations says it has completed the first phase of an aggressive vaccination campaign to contain a polio outbreak in Kenya’s largest refugee camp.
The U.N. High Commissioner for Refugees and the World Health Organization issued a statement Friday, saying 288,000 children up to age 15 are being immunized.
Officials says four people have contracted polio in the Dadaab complex in northeastern Kenya since the first case was discovered in mid-May….

Novavax Develops Vaccine Candidate for Recently Identified Coronavirus

Wall Street Journal

Novavax Develops Vaccine Candidate for Recently Identified Coronavirus
By Saabira Chaudhuri
June 6, 2013, 7:32 a.m. ET
Novavax Inc. (NVAX) said it has successfully produced a vaccine candidate designed to provide protection against the recently emerging Middle East Respiratory Syndrome Coronavirus…

…The vaccine candidate, which was made using Novavax’ recombinant nanoparticle vaccine technology, is based on the major surface spike protein.

Also called MERS-CoV, Middle East Respiratory Syndrome Coronavirus was first identified in September by an Egyptian virologist, who isolated the previously unknown coronavirus from the lungs of a 60-year-old patient with pneumonia and renal failure…

…Novavax had previously produced a recombinant nanoparticle vaccine candidate for the SARS-CoV virus which was similarly based on its major surface S protein.

Novavax’ SARS-CoV vaccine candidate study demonstrated immunogenicity and complete protection of animals in a live viral challenge.

Vaccines: The Week in Review 1 June 2013

Editor’s Notes:

Email Summary: Vaccines: The Week in Review is available as a weekly email summary: please send your request to

pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_1 June 2013

Twitter: Readers can also follow developments on twitter: @vaxethicspolicy.

Links: We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.

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WHO Director-General praises the World Health Assembly for its work (MERS-CoV assessment)

WHO Director-General praises the World Health Assembly for its work
Dr Margaret Chan, Director-General of the World Health Organization
Closing remarks at the Sixty-sixth World Health Assembly
Geneva, Switzerland
27 May 2013

Excerpt; Editor’s text bolding
“…Looking at the overall world health situation, my greatest concern right now is the novel coronavirus.

We understand too little about this virus when viewed against the magnitude of its potential threat.

Any new disease that is emerging faster than our understanding is never under control.

We do not know where the virus hides in nature. We do not know how people are getting infected. Until we answer these question, we are empty-handed when it comes to prevention.

These are alarm bells. And we must respond.

The novel coronavirus is not a problem that any single affected country can keep to itself or manage all by itself. The novel coronavirus is a threat to the entire world. As the Chair of committee A succinctly stated: this virus is something that can kill us.

Through WHO and the International Health Regulations, we need to bring together the assets of the entire world in order to adequately address this threat. We need more information, and we need it quickly, urgently.

As I have announced, joint WHO missions with the Kingdom of Saudi Arabia and Tunisia will take place just as soon as possible. The purpose is to gather all the facts needed to conduct a proper risk assessment. I thank these countries for their cooperation and collaboration.

I thank Member States for supporting my views on the seriousness of this situation….”

WHO: Global Alert and Response (GAR) [to 1 June 2013]

WHO: Global Alert and Response (GAR) – Disease Outbreak News

Middle East respiratory syndrome- coronavirus – update 31 May 2013
31 May 2013 – The Ministry of Health in Saudi Arabia has notified WHO of an additional laboratory-confirmed case with Middle East respiratory syndrome coronavirus (MERS-CoV).
The patient is a 61-year-old man with underlying medical conditions who became ill on 20 May 2013. The patient is from Al-Ahsa. Additionally, three patients earlier reported from Al-Ahsa have died.

The government is continuing to investigate the outbreaks in the country.

Globally, from September 2012 to date, WHO has been informed of a total of 50 laboratory-confirmed cases of infection with MERS-CoV, including 30 deaths.

Yellow fever in Ethiopia – update 31 May 2013
31 May 2013 – The Ministry of Health of Ethiopia is launching an emergency mass-vaccination campaign against yellow fever from 10 June 2013. This is in response to laboratory confirmation of six cases in the country on 7 May 2013.

The campaign aims to cover more than 527, 000 people in the following six districts: South Ari, North Ari, Benatsemay, Selamago, Hammer, and Gnangatom and one administrative town (Jinka) in South Omo Zone of the Southern Nations, Nationalities and Peoples’ region (SNNPR) of Ethiopia.

The International Coordinating Group on Yellow Fever Vaccine Provision (YF-ICG11) will provide over 585,800 doses of yellow fever vaccine for the mass vaccination campaign run by the Ministry of Health in Ethiopia, with support from the GAVI Alliance and other partners. WHO is closely supporting the outbreak investigation, capacity building for case management, resource mobilization for outbreak management, and monitoring preventive and control activities in the field…

Human infection with avian influenza A(H7N9) virus – update 29 May 2013
29 May 2013 – The National Health and Family Planning Commission, China notified WHO of an additional laboratory confirmed case of human infection with Avian Influenza A(H7N9) virus.

The patient is a six-year-old boy reported from Beijing who became ill on 21 May 2013 and is in stable condition.

To date, WHO has been informed of a total of 132 laboratory-confirmed cases, including 37 deaths.

Authorities in affected locations continue to maintain surveillance, epidemiological investigations, close contact tracing, clinical management, laboratory testing and sharing of samples as well as prevention and control measures. City and provincial governments have started to normalize their emergency operations into their routine surveillance and response activities.

So far, there is no evidence of sustained human-to-human transmission…

GPEI Update: Polio this week – As of 29 May 2013

Update: Polio this week – As of 29 May 2013
Global Polio Eradication Initiative

[Editor’s extract and bolded text]
. At last week’s World Health Assembly (WHA) in Geneva, Switzerland, health ministers from around the world acknowledged the progress achieved in the past year in bringing polio to its lowest ever levels, thanks to actions of Member States in placing polio eradication on an emergency footing. Delegates endorsed the new Polio Eradication and Endgame Strategic Plan 2013-2018 to secure a lasting polio-free world and urged for its full implementation and financing. For more, please click here.

. In the Horn of Africa, four new wild poliovirus (WPV) cases were reported in the past week (one in Kenya and three in Somalia). Outbreak response is continuing. See ‘Horn of Africa’ section for more.

. Two new WPV cases were reported in the past week (WPV1s from Borno), bringing the total number of WPV cases for 2013 to 24. One of the new cases is the most recent WPV case in the country, with onset of paralysis on 25 April.

. One new WPV case was reported in the past week (WPV1 from Khyber Pakhtunkhwa – KP), bringing the total number of WPV cases for 2013 to nine. It is the most recent WPV case in the country, and had onset of paralysis on 3 May.

Horn of Africa
. Four new WPV cases were reported in the past week (one WPV1 from Dadaab, north-eastern Kenya, and three WPV1s from Somalia), bringing the total number of WPV1 cases in the region to six (two from Kenya and four from Somalia). These latest cases had onset of paralysis between 26 April and 14 May.

. Outbreak response activities are continuing in both countries this week. In Kenya, immunization activities began on 26 May, to reach nearly 440,000 children aged less than 15 years across Dadaab. Further SNIDs are planned for a wider area, including parts of Nairobi, on 9 June, followed by large-scale subnational immunization days (SNIDs) in late June.

. In Somalia, SNIDs are ongoing (26-29 May), including in Banadir region (which includes Mogadishu).

. Immunization campaigns are also planned and being conducted in other areas of the Horn of Africa, notably Ethiopia and Yemen, to urgently boost population immunity levels and minimize the risk of spread of the outbreak. In Ethiopia, in border areas with Kenya and Somalia, an immunization activity is planned to start on 31 May (targeting children aged less than 15 years). Focus will be particularly on reaching children in refugee camps. Broader activities are planned for late June.

. Yemen is planning two activities in early and late June.

Wall Street Journal: ASIA NEWS
Updated May 28, 2013, 5:21 p.m. ET
Polio Team Pulled From Pakistan City
World Health Organization Acts in Peshawar After Two Members of Vaccine Team Are Shot

UN Watch to 1 June 2013

UN Watch to 1 June 2013
Selected meetings, press releases, and press conferences relevant to immunization, vaccines, infectious diseases, global health, etc.

. Secretary-General Says Findings of Report on Post-2015 Agenda Fill Key Gaps in Millennium Development Goals (30 May 2013)

. Secretary-General Commends High-level Panel Report’s Call to Place Sustainability at Centre of Post-2015 Development Agenda (30 May 2013)

. Press Conference on Launch of Report on Post-2015 Development Agenda (30 May 2013)

Report: A New Global Partnership: Eradicate Poverty and Transform Economies through Sustainable Development –

Report: A New Global Partnership: Eradicate Poverty and Transform Economies through Sustainable DevelopmentThe Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda
May 2013, 81 pages
The High Level Panel on the Post-2015 Development Agenda released a report “which sets out a universal agenda to eradicate extreme poverty from the face of the earth by 2030, and deliver on the promise of sustainable development. The report calls upon the world to rally around a new Global Partnership that offers hope and a role to every person in the world.” The Panel was established by United Nations Secretary-General Ban Ki-moon and co-chaired by Indonesian President Susilo Bambang Yudhoyono, Liberian President Ellen Johnson Sirleaf and United Kingdom Prime Minister David Cameron.

GAVI Alliance welcomes priority given to health and immunisation in High Level Panel Report
Statement from Dr Seth Berkley, CEO of the GAVI Alliance, following the publication of the report of the UN High Level Panel of Eminent Persons on the Post-2015 Development Agenda.

Report: Accountability for Maternal, Newborn and Child Survival

Report:  Accountability for Maternal, Newborn and Child Survival
Countdown to 2015
27 May 2013
Summary report:
Full report:

The new Countdown report has been produced by a global collaboration of academics and health professionals from Johns Hopkins University, Aga Khan University, Federal University of Pelotas in Brazil, Harvard University, London School of Hygiene and Tropical Medicine, UNICEF, the World Health Organization, UNFPA, Family Care International, Save the Children, and other institutions from around the world. The secretariat of the Countdown to 2015 initiative ( is based at The Partnership for Maternal, Newborn & Child Health.

Countdown to 2015 assesses progress in the 75 countries that together account for more than 95% of all maternal and child deaths. This evidence is intended to support greater progress towards achieving UN Millennium Development Goals (MDGs) 4 and 5 by 2015. These MDGs call for reducing maternal deaths by three-quarters and the deaths of children under 5 years of age by two-thirds compared to 1990 levels.

Accountability for Maternal, Newborn and Child Survival reports on the extent to which women and children have access to key life-saving services in these 75 countries, including family planning, antenatal care, skilled birth attendance, post-natal care, vaccinations, and treatment for diarrhea, pneumonia and other leading killers of young children…

…The report also highlights areas where more progress is needed, including:
. Infectious Diseases. Malaria, pneumonia, diarrhea, sepsis, measles, AIDS, and other infectious diseases account for at least half of all young child deaths.  Many of these deaths can be prevented with cost-effective interventions. These priorities are highlighted by several recent efforts to scale up action to reduce child mortality, including the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea, launched last month by WHO and UNICEF; the Global Vaccine Action Plan, endorsed by the 194 member-states of the WHO in 2012; and Committing to Child Survival: A Promise Renewed, led by the governments of India, Ethiopia and the US, supported by UNICEF…

Report: Replenishing the Global Fund in 2013 – Options for U.S. Diplomatic Support

Report: Replenishing the Global Fund in 2013Options for U.S. Diplomatic Support
Katherine E. Bliss
CSIS, May 2013, 8 pages

Hopes are high for a successful outcome of the 2013 replenishment process, through which the Global Fund to Fight AIDS, Tuberculosis and Malaria seeks pledges of $15 billion to support planned activities for 2014–2016. The Fund is at a critical juncture. Established in 2002 to be an innovative multilateral organization, the Fund was designed as a partnership of the corporate, nonprofit, and government sectors and intended to be more flexible and attuned to country needs than traditional United Nations agencies in distributing donor monies. Following reports of grant mismanagement in some key recipient countries in 2011, the Fund went through an extensive, and at times difficult, yearlong reform process that has put new leadership in place, overhauled grant administration and accounting procedures, and positioned the organization to reengage with donors in securing financial support for its activities. Yet at a time when some experts argue it is finally possible to “turn the tide” on HIV/AIDS, malaria, and tuberculosis,2 it is an open question whether countries and other donors will pledge adequate funding to meet the revitalized Fund’s replenishment goal…

Meeting: The 8th Global Conference on Health Promotion

Meeting: The 8th Global Conference on Health Promotion
Finlandia Hall, Helsinki, Finland
10–14 June 2013
This conference is co-hosted by WHO and the Ministry of Social Affairs and Health, Finland. The main theme of the conference is “Health in All Policies” (HiAP) and its focus is on implementation, the “how-to”. It is structured around six themes.

The conference aims to:
–       facilitate the exchange of experiences and lessons learnt and give guidance on effective mechanisms for promoting intersectoral action;

–       review approaches to address barriers and build capacity for implementing Health in All Policies;

–       identify opportunities to implement the recommendations of the Commission on Social Determinants of Health through Health in All Policies;

–       establish and review economic, developmental and social case for investing in HiAP;

–       address the contribution of health promotion in the renewal and reform of primary health care; and

–       review progress, impact and achievements of health promotion since the Ottawa Conference.

WHO: Emergency Response Framework (ERF) [May 2013]

WHO: Emergency Response Framework (ERF)
May 2013, 51 pages

“ERF is to clarify WHO’s roles and responsibilities and to provide a common approach for its work in emergencies”

Executive Summary
WHO’s Member States face a broad range of emergencies resulting from various hazards and differing in scale, complexity and international consequences. These emergencies can have extensive political, economic, social and public health impacts, with potential long-term consequences sometimes persisting for years after the emergency. They may be caused by natural disasters, conflict, disease outbreaks, food contamination, or chemical or radio-nuclear spills, among other hazards. They can undermine decades of social development and hard-earned health gains, damage hospitals and other health infrastructure, weaken health systems and slow progress towards the Millennium Development Goals (MDGs). Preparing for and responding effectively to such emergencies are among the most pressing challenges facing the international community.

WHO has an essential role to play in supporting Member States to prepare for, respond to and recover from emergencies with public health consequences. WHO also has obligations to the Inter-Agency Standing Committee (IASC) as Health Cluster Lead Agency, to the international Health Regulations (2005) and to other international bodies and agreements related to emergency response.

The purpose of this Emergency Response Framework (ERF) is to clarify WHO’s roles and responsibilities in this regard and to provide a common approach for its work in emergencies. Ultimately, the ERF requires WHO to act with urgency and predictability to best serve and be accountable to populations affected by emergencies.

First, the ERF sets out WHO’s core commitments in emergency response which are those actions that WHO is committed to delivering in emergencies with public health consequences to minimize mortality and life-threatening morbidity by leading a coordinated and effective health sector response.

Second, the ERF elaborates the steps WHO will take between the initial alert of an event and its eventual emergency classification, including event verification and event risk assessment.

Third, the ERF describes WHO’s internal grading process for emergencies including the purpose of grading, the definitions of the various grades, the criteria for grading, and the steps to remove a grade.

Fourth, this paper describes WHO’s Performance Standards for emergency response: specific deliverables with timelines for completion that are used by WHO to measure its performance.

Fifth, the ERF outlines WHO’s four critical functions during emergency response: leadership, information, technical expertise and core services.

Sixth, the ERF states the role of WHO’s Global Emergency Management Team (GEMT) during emergency response, particularly related to the optimal use of Organization-wide resources, the monitoring of the implementation of relevant procedures and policies, and the management of WHO’s internal and external communications.

Seventh, the ERF outlines WHO’s Emergency Response Procedures (ERPs) that specify roles and responsibilities across the Organization to deliver on the four critical functions and the Performance Standards.

Finally, three essential emergency policies which will optimize WHO’s response are detailed: the surge policy, the Health Emergency Leader policy and the no-regrets policy.

At the end of the document there are six complementary annexes. Annex 1 provides a flow chart of the grading process and Annex 2 a country-level timeline during emergency response. Annex 3 states WHO’s obligations under an Inter-Agency Standing Committee Level 3 emergency; Annex 4 sets out WHO’s Performance Standards in protracted emergencies; Annex 5 defines WHO’s commitment to institutional readiness; and Annex 6 defines WHO’s commitment to emergency risk management.

Parent willingness to remind health care workers to perform hand hygiene

American Journal of Infection Control
Vol 41 | No. 6 | June 2013 | Pages 481-574

Parent willingness to remind health care workers to perform hand hygiene
20 December 2012
Genevieve L. Buser, MDCM, MSHP, Brian T. Fisher, DO, MSCE, Judy A. Shea, PhD, Susan E. Coffin, MD, MPH

Health care worker (HCW) hand hygiene (HH) is the core strategy to prevent health care-associated infections (HAI). Suboptimal HCW HH rates continue despite hospital efforts to increase compliance.

To determine whether parents of hospitalized children perceive they have a role in preventing HAI and whether they are willing to remind HCW to perform HH, with and without an invitation.

We conducted structured interviews of parents of children admitted to a pediatric hospital. Questions assessed knowledge, attitudes, and behaviors about HAI and HH. The primary outcome was willingness to remind a HCW to do HH (5-point Likert scale).

We interviewed 115 parents, of whom 84% were aware of HAI. Most parents (78%) perceived HH as the most important practice to prevent HAI. However, only 67% would definitely remind a HCW to perform HH. Importantly, 92% said that an invitation from a HCW would make them more likely to remind a HCW to do HH in the future.

Our results suggest that parents of hospitalized children are willing to help prevent HAI; however one-third are still reluctant to remind HCW to perform HH. An invitation by HCW to parents to remind HCW to perform HH might effectively engage parents as partners in HAI prevention.

Twitter as a source of vaccination information: Content drivers and what they are saying

American Journal of Infection Control
Vol 41 | No. 6 | June 2013 | Pages 481-574

Twitter as a source of vaccination information: Content drivers and what they are saying
Brad Love, PhD, Itai Himelboim, PhD, Avery Holton, MA, Kristin Stewart, MBA

Twitter is a popular source of health information. This study reports a content analysis of posts about vaccinations, documenting sources, tone, and medical accuracy. Results can help explain patient knowledge and directions for educational campaigns. A set of 6,827 tweets indicates professional sources were shared most and treated positively. Two-thirds of shared medical content were substantiated. One-third of messages were positive, counter to other research and suggesting that users apply critical thinking when evaluating content.

The role of religious leaders in promoting acceptance of vaccination within a minority group: a qualitative study

BMC Public Health
(Accessed 1 June 2013)

Research article
The role of religious leaders in promoting acceptance of vaccination within a minority group: a qualitative study
Wilhelmina LM Ruijs1,2*, Jeannine LA Hautvast1, Said Kerrar1, Koos van der Velden1 and Marlies EJL Hulscher3

Although childhood vaccination programs have been very successful, vaccination coverage in minority groups may be considerably lower than in the general population. In order to increase vaccination coverage in such minority groups involvement of faith-based organizations and religious leaders has been advocated. We assessed the role of religious leaders in promoting acceptance or refusal of vaccination within an orthodox Protestant minority group with low vaccination coverage in The Netherlands.

Semi-structured interviews were conducted with orthodox Protestant religious leaders from various denominations, who were selected via purposeful sampling. Transcripts of the interviews were thematically analyzed, and emerging concepts were assessed for consistency using the constant comparative method from grounded theory.

Data saturation was reached after 12 interviews. Three subgroups of religious leaders stood out: those who fully accepted vaccination and did not address the subject, those who had religious objections to vaccination but focused on a deliberate choice, and those who had religious objections to vaccination and preached against vaccination. The various approaches of the religious leaders seemed to be determined by the acceptance of vaccination in their congregation as well as by their personal point of view. All religious leaders emphasized the importance of voluntary vaccination programs and religious exemptions from vaccination requirements. In case of an epidemic of a vaccine preventable disease, they would appreciate a dialogue with the authorities. However, they were not willing to promote vaccination on behalf of authorities.

Religious leaders’ attitudes towards vaccination vary from full acceptance to clear refusal. According to orthodox Protestant church order, local congregation members appoint their religious leaders themselves. Obviously they choose leaders whose views are compatible with the views of the congregation members. Moreover, the positions of orthodox Protestant religious leaders on vaccination will not change easily, as their objections to vaccination are rooted in religious doctrine and they owe their authority to their interpretation and application of this doctrine. Although the dialogue with religious leaders that is pursued by the Dutch government may be helpful in controlling epidemics by other means than vaccination, it is unlikely to increase vaccination coverage.

Loss of Passively Acquired Maternal Antibodies in Highly Vaccinated Populations: An Emerging Need to Define the Ontogeny of Infant Immune Responses

Journal of Infectious Diseases
Volume 208 Issue 1 July 1, 2013

Editor’s choice: Loss of Passively Acquired Maternal Antibodies in Highly Vaccinated Populations: An Emerging Need to Define the Ontogeny of Infant Immune Responses
Hayley A. Gans and  Yvonne A. Maldonado
J Infect Dis. (2013) 208(1): 1-3 doi:10.1093/infdis/jit144

Protection against infectious diseases is provided to young infants by passive immunity through the transplacental transfer of immunoglobulin G during pregnancy and through immunoglobulin A in breast milk [1–7]. Despite the obvious benefits of these antibodies to the youngest infants, their levels wane over time, necessitating the development of active immunity through vaccination. The timing of primary vaccination is complex, driven by the need to provide protection prior to a time when the infant is likely to be exposed to disease, by the possibility of interference with vaccine-induced immunity by passively acquired maternal antibodies, and, finally, by considerations of the developing infant immune system [7–9].

The titers of transplacentally transferred passive antibodies (PA) provided to infants are, in part, determined by antibody titers present in the mother during pregnancy. These maternal titers are affected by her nutritional and immune status, and evidence demonstrates that antibody titers induced by vaccination are typically lower than titers induced by natural disease [3, 5, 6, 10]. After decades of vaccination against childhood diseases, it is clear that successful vaccine programs have resulted in dramatic decreases in morbidity and mortality. However, the increasing prevalence of vaccine-derived maternal antibodies has also led to unexpected outcomes. This is most evident in the emergence of measles susceptibility in young infants living in highly vaccinated populations where the measles vaccine has been in use for decades [11–14]. Historically, in developed nations protection against measles among infants <12 months of age was provided by a combination of PA and herd immunity, supported by high population immunization rates. However, this barrier has been disrupted, to a certain extent, by global importation of measles …

Waning of Maternal Antibodies Against Measles, Mumps, Rubella, and Varicella in Communities With Contrasting Vaccination Coverage

Journal of Infectious Diseases
Volume 208 Issue 1 July 1, 2013

Editor’s choice: Waning of Maternal Antibodies Against Measles, Mumps, Rubella, and Varicella in Communities With Contrasting Vaccination Coverage
Sandra Waaijenborg, Susan J. M. Hahné, Liesbeth Mollema, Gaby P. Smits, Guy A. M. Berbers, Fiona R. M. van der Klis, Hester E. de Melker, and Jacco Wallinga
J Infect Dis. (2013) 208(1): 10-16 doi:10.1093/infdis/jit143

Background. The combined measles, mumps, and rubella (MMR) vaccine has been successfully administered for >20 years. Because of this, protection by maternal antibodies in infants born to vaccinated mothers might be negatively affected.

Methods. A large cross-sectional serologic survey was conducted in the Netherlands during 2006–2007. We compared the kinetics of antibody concentrations in children and women of childbearing age in the highly vaccinated general population with those in orthodox Protestant communities that were exposed to outbreaks.

Results. The estimated duration of protection by maternal antibodies among infants in the general population, most of whom were born to vaccinated mothers, was short: 3.3 months for measles, 2.7 months for mumps, 3.9 months for rubella, and 3.4 months for varicella. The duration of protection against measles was 2 months longer for infants born in the orthodox communities, most of whom had unvaccinated mothers. For rubella, mothers in the orthodox communities had higher concentrations of antibodies as compared to the general population.

Conclusion. Children of mothers vaccinated against measles and, possibly, rubella have lower concentrations of maternal antibodies and lose protection by maternal antibodies at an earlier age than children of mothers in communities that oppose vaccination. This increases the risk of disease transmission in highly vaccinated populations.

Lancet Editorial – Improving the health response to humanitarian crise

The Lancet  
Jun 01, 2013  Volume 381  Number 9881  p1877 – 1958  e16 – 17

Improving the health response to humanitarian crises
The Lancet
Earthquake in Haiti. Tsunami in Japan. Floods in Pakistan. When humanitarian crises happen, the natural response is to get help to those affected as quickly as possible. But when governments, agencies, and charities respond to a crisis, are they responding in the best way possible? In 2011, the UK’s Humanitarian Emergency Response Review, chaired by Paddy Ashdown, found that the evidence base for action in these settings was weak.

Lancet Comment: A H7N9

The Lancet  
Jun 01, 2013  Volume 381  Number 9881  p1877 – 1958  e16 – 17

Avian influenza A H7N9 in Zhejiang, China
Marion Koopmans, Menno D de Jong
On March 31, 2013, the China Health and Planning Commission notified WHO of three human infections in Shanghai and Anhui with a novel influenza virus characterised as avian influenza A H7N9 (illness onset between Feb 19 and March 15, 2013).1 Genetic characterisation2 showed that this virus resulted from recombination of genes between three parent viruses noted in Asia in poultry and wild birds. The severity of disease was remarkable, as was the fact that patients were from towns located 400 km apart, and had no epidemiological connection.

Genesis of avian-origin H7N9 influenza A viruses
Marc Van Ranst, Philippe Lemey
Since March, 2013, 126 laboratory-confirmed cases of avian influenza A H7N9 have been detected in ten provinces or municipalities in east and southeast China (as of April 30, 2013).1 Most H7N9-infected patients are older (approximate median age 62 years) urban men who reported exposure to chickens or captive-bred pigeons either professionally or through visits to live poultry markets.2,3 Patients rapidly develop progressive pneumonia leading to acute respiratory distress syndrome and multiorgan failure.

A H7N9 virus – viral genome, phylogenetic, structural, and coalescent analyses

The Lancet  
Jun 01, 2013  Volume 381  Number 9881  p1877 – 1958  e16 – 17

Human infections with the emerging avian influenza A H7N9 virus from wet market poultry: clinical analysis and characterisation of viral genome
Yu Chen, Weifeng Liang, Shigui Yang, Nanping Wu, Hainv Gao, Jifang Sheng, Hangping Yao, Jianer Wo, Qiang Fang, Dawei Cui, Yongcheng Li, Xing Yao, Yuntao Zhang, Haibo Wu, Shufa Zheng, Hongyan Diao, Shichang Xia, Yanjun Zhang, Kwok-Hung Chan, Hoi-Wah Tsoi, Jade Lee-Lee Teng, Wenjun Song, Pui Wang, Siu-Ying Lau, Min Zheng, Jasper Fuk-Woo Chan, Kelvin Kai-Wang To, Honglin Chen, Lanjuan Li, Kwok-Yung Yuen

Preview |
Cross species poultry-to-person transmission of this new reassortant H7N9 virus is associated with severe pneumonia and multiorgan dysfunction in human beings. Monitoring of the viral evolution and further study of disease pathogenesis will improve disease management, epidemic control, and pandemic preparedness.

Origin and diversity of novel avian influenza A H7N9 viruses causing human infection: phylogenetic, structural, and coalescent analyses
Di Liu, Weifeng Shi, Yi Shi, Dayan Wang, Haixia Xiao, Wei Li, Yuhai Bi, Ying Wu, Xianbin Li, Jinghua Yan, Wenjun Liu, Guoping Zhao, Weizhong Yang, Yu Wang, Juncai Ma, Yuelong Shu, Fumin Lei, George F Gao

Preview |
The novel avian influenza A H7N9 virus might have evolved from at least four origins. Diversity among isolates implies that the H7N9 virus has evolved into at least two different lineages. Unknown intermediate hosts involved might be implicated, extensive global surveillance is needed, and domestic-poultry-to-person transmission should be closely watched in the future.

Comparative Effectiveness of Acellular Versus Whole-Cell Pertussis Vaccines in Teenagers

June 2013, VOLUME 131 / ISSUE 6

Comparative Effectiveness of Acellular Versus Whole-Cell Pertussis Vaccines in Teenagers
Nicola P. Klein, MD, PhD, Joan Bartlett, MPH, MPP, Bruce Fireman, MA, Ali Rowhani-Rahbar, MD, MPH, PhD, and Roger Baxter, MD

BACKGROUND: During the 1990s, the United States switched from combined diphtheria, tetanus toxoids, whole-cell pertussis (DTwP) vaccines to combined acellular pertussis (DTaP) vaccines because of safety concerns. After a 2010–2011 pertussis outbreak, we sought to evaluate whether disease risk in 10 to 17 year olds differed between those who previously received DTwP from those who received DTaP.

METHODS: A case-control study among individuals born from 1994 to 1999 who received 4 pertussis-containing vaccines during the first 2 years of life at Kaiser Permanente Northern California (KPNC). We separately compared pertussis polymerase chain reaction (PCR)-positive cases with PCR-negative and KPNC-matched controls. We assessed risk of pertussis relative to vaccine type in early childhood (4 DTwPs, mixed DTwP/DTaP, or 4 DTaPs) by using conditional logistic regression stratified for calendar time and adjusted for gender, race, medical clinic, and receipt of reduced antigen content acellular pertussis (Tdap) vaccine.

RESULTS: We compared 138 PCR-positive cases with 899 PCR-negative and 54 339 KPNC-matched controls. Teenagers who had received 4 DTwPs were much less likely to be pertussis PCR-positive than those who had received 4 DTaPs (odds ratio 5.63, 95% confidence interval 2.55–12.46) or mixed DTwP/DTaP vaccines (odds ratio 3.77, 95% confidence interval 1.57–9.07). Decreasing number of DTwP doses was significantly associated with increased pertussis risk (P < .0001).

CONCLUSIONS: Teenagers who received DTwP vaccines in childhood were more protected during a pertussis outbreak than were those who received DTaP vaccines.

Pregnancy Dose Tdap and Postpartum Cocooning to Prevent Infant Pertussis: A Decision Analysis

June 2013, VOLUME 131 / ISSUE 6

Pregnancy Dose Tdap and Postpartum Cocooning to Prevent Infant Pertussis: A Decision Analysis
Andrew Terranella, MD, MPH, Garrett R. Beeler Asay, PhD, Mark L. Messonnier, PhD, Thomas A. Clark, MD, MPH, and Jennifer L. Liang, DVM, MPVM

BACKGROUND: Infants <2 months of age are at highest risk of pertussis morbidity and mortality. Until recently, the US Advisory Committee on Immunization Practices (ACIP) recommended protecting young infants by “cocooning” or vaccination of postpartum mothers and other close contacts with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap) booster vaccine. ACIP recommends pregnancy vaccination as a preferred and safe alternative to postpartum vaccination. The ACIP cocooning recommendation has not changed.

METHODS: We used a cohort model reflecting US 2009 births and the diphtheria-tetanus-acellular pertussis schedule to simulate a decision and cost-effectiveness analysis of Tdap vaccination during pregnancy compared with postpartum vaccination with or without vaccination of other close contacts (ie, cocooning). We analyzed infant pertussis cases, hospitalizations, and deaths, as well as direct disease, indirect, and public health costs for infants in the first year of life. All costs were updated to 2011 US dollars.

RESULTS: Pregnancy vaccination could reduce annual infant pertussis incidence by more than postpartum vaccination, reducing cases by 33% versus 20%, hospitalizations by 38% versus 19%, and deaths by 49% versus 16%. Additional cocooning doses in a father and 1 grandparent could avert an additional 16% of cases but at higher cost. The cost per quality-adjusted life-year saved for pregnancy vaccination was substantially less than postpartum vaccination ($414 523 vs $1 172 825).

CONCLUSIONS: Tdap vaccination during pregnancy could avert more infant cases and deaths at lower cost than postpartum vaccination, even when postpartum vaccination is combined with additional cocooning doses. Pregnancy dose vaccination is the preferred alternative to postpartum vaccination for preventing infant pertussis.

Intussusception After Rotavirus Vaccines Reported to US VAERS, 2006–2012

June 2013, VOLUME 131 / ISSUE 6

Intussusception After Rotavirus Vaccines Reported to US VAERS, 2006–2012
Penina Haber, MPH, Manish Patel, MD, Yi Pan, PhD, James Baggs, PhD, Michael Haber, PhD, Oidda Museru, MPH, Xin Yue, MS, Paige Lewis, MSPH, Frank DeStefano, MD, MPH, and Umesh D. Parashar, MBBS, MPH

BACKGROUND: In 2006 and 2008, 2 new rotavirus vaccines (RotaTeq [RV5] and Rotarix [RV1]) were introduced in the United States.

METHODS: We assessed intussusception events reported to the Vaccine Adverse Event Reporting System from February 2006 through April 2012 for RV5 and from April 2008 through April 2012 for RV1. For RV5, we conducted a self-controlled risk interval analysis using Poisson regression to estimate the daily reporting ratio (DRR) of intussusception comparing average daily reports 3 to 6 versus 0 to 2 days after vaccination. We calculated reporting rate differences based on DRRs and background rates of intussusception. Sensitivity analyses were conducted to assess effects of differential reporting completeness and inaccuracy of baseline rates. Few reports were submitted after RV1, allowing only a descriptive analysis.

RESULTS: The Vaccine Adverse Event Reporting System received 584 confirmed intussusception reports after RV5 and 52 after RV1, with clustering 3 to 6 days after both vaccines. The DRR comparing the 3- to 6-day and the 0- to 2-day periods after RV5 dose 1 was 3.75 (95% confidence interval = 1.90 to 7.39). There was no significant increase in reporting after dose 2 or dose 3. Over all 3 doses, the excess risk of intussusception was 0.79 events (95% confidence interval = –0.04 to 1.62) per 100 000 vaccinations. From the sensitivity analyses, we conclude that under a worst-case scenario, the DRR could be 5.00 and excess risk per 100 000 doses could be 1.36.

CONCLUSIONS: We observed a persistent clustering of reported intussusception events 3 to 6 days after the first dose of RV5 vaccination. This clustering could translate to a small increased risk of intussusception, which is outweighed by the benefits of rotavirus vaccination.

Effectiveness of Decision Support for Families, Clinicians, or Both on HPV Vaccine Receipt

June 2013, VOLUME 131 / ISSUE 6

Effectiveness of Decision Support for Families, Clinicians, or Both on HPV Vaccine Receipt
Alexander G. Fiks, MD, MSCE; Robert W. Grundmeier, MD; Lihai Song, MS; Kristen Feemster, MD, MPH, MSHP; Dean Karavite, MSI; Cayce C. Hughes, MPH; James Massey, RN; Ron Keren, MD, MPH; Louis M. Bell, MD; Richard Wasserman, MD, and A. Russell Localio, PhD

OBJECTIVE: To improve human papillomavirus (HPV) vaccination rates, we studied the effectiveness of targeting automated decision support to families, clinicians, or both.

METHODS: Twenty-two primary care practices were cluster-randomized to receive a 3-part clinician-focused intervention (education, electronic health record-based alerts, and audit and feedback) or none. Overall, 22 486 girls aged 11 to 17 years due for HPV vaccine dose 1, 2, or 3 were randomly assigned within each practice to receive family-focused decision support with educational telephone calls. Randomization established 4 groups: family-focused, clinician-focused, combined, and no intervention. We measured decision support effectiveness by final vaccination rates and time to vaccine receipt, standardized for covariates and limited to those having received the previous dose for HPV #2 and 3. The 1-year study began in May 2010.

RESULTS: Final vaccination rates for HPV #1, 2, and 3 were 16%, 65%, and 63% among controls. The combined intervention increased vaccination rates by 9, 8, and 13 percentage points, respectively. The control group achieved 15% vaccination for HPV #1 and 50% vaccination for HPV #2 and 3 after 318, 178, and 215 days. The combined intervention significantly accelerated vaccination by 151, 68, and 93 days. The clinician-focused intervention was more effective than the family-focused intervention for HPV #1, but less effective for HPV #2 and 3.

CONCLUSIONS: A clinician-focused intervention was most effective for initiating the HPV vaccination series, whereas a family-focused intervention promoted completion. Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt.

Meningococcal Serogroup A, C, W135 and Y Conjugated Vaccine: A Cost-Effectiveness Analysis in the Netherland

PLoS One
[Accessed 1 June 2013]

Meningococcal Serogroup A, C, W135 and Y Conjugated Vaccine: A Cost-Effectiveness Analysis in the Netherlands
Hiltsje Hepkema, Koen B. Pouwels, Arie van der Ende, Tjalke A. Westra, Maarten J. Postma

In 2002, vaccination with a serogroup C meningococcal conjugate vaccine (MenC) was introduced in the Netherlands for all children aged 14 months. Despite its success, herd immunity may wane over time. Recently, a serogroup A,C,W135,Y meningococcal conjugate vaccine (MenACWY) was licensed for use in subjects of 12 months of age and above.

To evaluate the cost-effectiveness of meningococcal vaccination at 14 months and an additional vaccination at the age of 12 years, both with the MenACWY vaccine.

A decision analysis cohort model, with 185,000 Dutch newborns, was used to evaluate the cost-effectiveness of different immunization strategies. For strategies including a vaccination at 12 years of age, an additional cohort with adolescents aged 12 years was followed. The incremental cost-effectiveness ratio (ICER) was estimated for the current disease incidence and for a scenario when herd immunity is lost.

Vaccination with MenACWY at 14 months is cost-saving. Vaccinating with MenACWY at 14 months and at 12 years would prevent 7 additional cases of meningococcal serogroup A,C,W135,Y disease in the birth cohort and adolescent cohort followed for 99 years compared to the current vaccine schedule of a single vaccination with MenC at 14 months. With the current incidence, this strategy resulted in an ICER of €635,334 per quality adjusted life year. When serogroup C disease incidence returns to pre-vaccination levels due to a loss of vaccine-induced herd-immunity, vaccination with MenACWY at 14 months and at 12 years would be cost-saving.

Routine vaccination with MenACWY is cost-saving. With the current epidemiology, a booster-dose with MenACWY is not likely cost-effective. When herd immunity is lost, a booster-dose has the potential of being cost-effective. A dynamic model should be developed for more precise estimation of the cost-effectiveness of the prevention of disappearance of herd immunity.

Accelerating Next-Generation Vaccine Development for Global Disease Prevention

31 May 2013 vol 340, issue 6136, pages 1005-1132

Accelerating Next-Generation Vaccine Development for Global Disease Prevention
Wayne C. Koff, Dennis R. Burton, Philip R. Johnson, Bruce D. Walker, Charles R. King, Gary J. Nabel, Rafi Ahmed, Maharaj K. Bhan, Stanley A. Plotkin

Vaccines have provided some of the greatest successes in the history of medicine, including the eradication of smallpox, the near eradication of polio, and the prevention of considerable morbidity and mortality from numerous infectious diseases each year. However, past strategies for vaccine development are unlikely to succeed in the future against major global diseases such as AIDS, tuberculosis, and malaria. For such diseases, the correlates of protection are poorly defined, and the pathogens evade immune detection and/or exhibit extensive genetic variability. Limitations of animal models to predict human immune responses to vaccines, coupled with low success rates for vaccine development compared with biopharmaceuticals, suggest that new paradigms must be implemented for accelerating vaccine development.

Recent technological advances in molecular genetics, molecular and cellular immunology, structural biology, bioinformatics, computational biology, nanotechnology, formulation methods, and systems biology are ushering in a new era of vaccine discovery. For example, genomic-based antigen discovery is being exploited for the design of vaccines against multiple bacterial pathogens. Similarly, interrogation of the memory B cell and antibody repertoires from virus-infected subjects has led to the identification of broadly neutralizing antibodies against HIV, influenza, and other viruses, which are now being exploited as tools to design highly conserved epitope-based vaccines. Advances in adjuvant and vector delivery technologies are providing novel approaches for immune potentiation of vaccines, offering new strategies for improving vaccine response rates in neonates and the elderly. However, translation of these advances into vaccines remains impeded by major gaps in our knowledge of human immune responses, including methods to focus immune responses on subdominant protective epitopes, to elicit long-term memory responses, and to drive antibody maturation processes. These gaps can now be addressed given the technological advances described, including the development of approaches to analyze immune responses at the single-cell and systems levels.

Successful development of vaccines against the major global diseases for which vaccines do not currently exist would be transformational for public health, with huge benefits across society. To accelerate next-generation vaccine development, we propose that new human immunology–based clinical research initiatives be established, with the goal of elucidating and more effectively generating vaccine-induced protective immune responses. Collectively, such a “Human Vaccines Project” holds the potential to greatly accelerate the development of next-generation vaccines against major global killers such as AIDS, tuberculosis, malaria, and other infectious diseases; enable more successful vaccine development against allergies, autoimmune diseases, and cancers; and provide a foundation for vaccine development against new and emerging diseases.

Teenagers’ understandings of and attitudes towards vaccines and vaccine-preventable diseases: A qualitative study

Volume 31, Issue 22, Pages 2539-2598 (24 May 2013)
Teenagers’ understandings of and attitudes towards vaccines and vaccine-preventable diseases: A qualitative study
Original Research Article
Pages 2543-2550
S. Hilton, C. Patterson, E. Smith, H. Bedford, K. H

To examine immunisation information needs of teenagers we explored understandings of vaccination and vaccine-preventable diseases, attitudes towards immunisation and experiences of immunisation. Diseases discussed included nine for which vaccines are currently offered in the UK (human papillomavirus, meningitis, tetanus, diphtheria, polio, whooping cough, measles, mumps and rubella), and two not currently included in the routine UK schedule (hepatitis B and chickenpox).

Twelve focus groups conducted between November 2010 and March 2011 with 59 teenagers (29 girls and 30 boys) living in various parts of Scotland.

Teenagers exhibited limited knowledge and experience of the diseases, excluding chickenpox. Measles, mumps and rubella were perceived as severe forms of chickenpox-like illness, and rubella was not associated with foetal damage. Boys commonly believed that human papillomavirus only affects girls, and both genders exhibited confusion about its relationship with cancer. Participants considered two key factors when assessing the threat of diseases: their prevalence in the UK, and their potential to cause fatal or long-term harm. Meningitis was seen as a threat, but primarily to babies. Participants explained their limited knowledge as a result of mass immunisation making once-common diseases rare in the UK, and acknowledged immunisation’s role in reducing disease prevalence.

While it is welcome that fewer teenagers have experienced vaccine-preventable diseases, this presents public health advocates with the challenge of communicating benefits of immunisation when advantages are less visible. The findings are timely in view of the Joint Committee on Vaccination and Immunisation’s recommendation that a booster of meningitis C vaccine should be offered to teenagers; that teenagers did not perceive meningitis C as a significant threat should be a key concern of promotional information. While teenagers’ experiences of immunisation in school were not always positive, they seemed enthusiastic at the prospect of introducing more vaccines for their age group.

Cost–benefit analysis of hospital based postpartum vaccination with combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap)

Volume 31, Issue 22, Pages 2539-2598 (24 May 2013)
Cost–benefit analysis of hospital based postpartum vaccination with combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap)
Original Research Article
Pages 2558-2564
Yao Ding, Sylvia H. Yeh, Chris Anna M. Mink, Kenneth M. Zangwill, Norma J. Allred, Joel W. Ha

To assess the economic benefits associated with hospital-based postpartum Tdap (combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccination.

A decision tree model was constructed to calculate the potential cost–benefit of this strategy from both a health care system and a societal perspective. Probabilities and costs were derived from published literature, data reported to Centers for Disease Control and Prevention, and recommendations from expert panels. The maternal vaccination protection period for infants was defined as 7 months, and 10 years of waning immunity following Tdap for birth mothers was estimated in the model. All cost estimates were inflated to year 2012 US dollars and discounted at a 3% annual discount rate.

In the base case from a societal perspective, the expected costs per vaccinated and unvaccinated mother were estimated at $129.27 and $187.97, respectively, suggesting an expected net benefit of $58.70 per vaccinated mother. The overall societal benefits in the cohort of 3.6 million U.S. birth mothers ranged from $52.8–126.8 million, depending on the vaccination coverage level. If including direct medical costs only, the strategy would not generate net savings from a health care system perspective. Annual incidence of pertussis in birth mothers and Tdap efficacy exhibited substantial impact on the model as shown in one-way and two-way sensitivity analyses.

Although postpartum Tdap vaccination is not cost-beneficial from a health care system perspective in the base case, this strategy is likely to generate net benefits from a societal perspective

Postlicensure surveillance for pre-specified adverse events following the 13-valent pneumococcal conjugate vaccine in children

Volume 31, Issue 22, Pages 2539-2598 (24 May 2013)
Postlicensure surveillance for pre-specified adverse events following the 13-valent pneumococcal conjugate vaccine in children
Original Research Article
Pages 2578-2583
Hung Fu Tseng, Lina S. Sy, In-Lu Amy Liu, Lei Qian, S. Michael Marcy, Eric Weintraub, Katherine Yih, Roger Baxter, Jason M. Glanz, James Donahue, Allison Naleway, James Nordin, Steven J. Jacobsen

Although no increased risk was detected for serious adverse events in the prelicensure trials for the 13-valent pneumococcal vaccine, Prevnar 13® (PCV13), continued monitoring of rare but serious adverse events is necessary. A surveillance system using cohort study design was set up to monitor safety of PCV13 immediately after it was included in the childhood immunization program in the United States. The exposed population included children of 1 month to 2 years old who received PCV13 from April, 2010 to January, 2012 from the eight managed care organizations participating in the Vaccine Safety Datalink Project in the United States. The historical unexposed population was children of the same age who received the 7-valent pneumococcal conjugate vaccine Prevnar 7® (PCV7) in 2007 (or 2005 depending on the outcome of interest) to 2009. The risk of pre-specified adverse events in the risk window following PCV13 was repeatedly compared to that in the historical comparison group. The number of doses included in the study was 599,229. No increased risk was found for febrile seizures, urticaria or angioneurotic edema, asthma, thrombocytopenia, or anaphylaxis. An increased risk for encephalopathy was not confirmed following the medical record review. The relative risk for Kawasaki disease in 0–28 days following vaccination was 1.94 (95% confidence interval: 0.79–4.86), comparing PCV13 to PCV7. Comparing to PCV7 vaccine, we identified no significant increased risk of pre-specified adverse events in the Vaccine Safety Datalink study cohort. The possible association between PCV13 and Kawasaki disease may deserve further investigation.

Long-term safety assessment of live attenuated tetravalent dengue vaccines: Deliberations from a WHO technical consultation

Volume 31, Issue 23, Pages 2599-2658 (28 May 2013)
Long-term safety assessment of live attenuated tetravalent dengue vaccines: Deliberations from a WHO technical consultation
Original Research Article
Pages 2603-2609
Live Dengue Vaccines Technical Consultation Reporting Group, Adwoa D. Bentsi-Enchill, Julia Schmitz, Robert Edelman, Anna Durbin, John T. Roehrig, Peter G. Smith, Joachim Hombach, Jeremy Farrar

Dengue is a rapidly growing public health threat with approximately 2.5 billion people estimated to be at risk. Several vaccine candidates are at various stages of pre-clinical and clinical development. Thus far, live dengue vaccine candidates have been administered to several thousands of volunteers and were well-tolerated, with minimal short-term safety effects reported in Phase I and Phase II clinical trials. Based on the natural history of dengue, a theoretical possibility of an increased risk of severe dengue as a consequence of vaccination has been hypothesized but not yet observed. In October 2011, the World Health Organization (WHO) convened a consultation of experts in dengue, vaccine regulation and vaccine safety to review the current scientific evidence regarding safety concerns associated with live attenuated dengue vaccines and, in particular, to consider methodological approaches for their long-term evaluation. In this paper we summarize the scientific background and methodological considerations relevant to the safety assessment of these vaccines. Careful planning and a coordinated approach to safety assessment are recommended to ensure adequate long-term evaluation of dengue vaccines that will support their introduction and continued use.

Introducing vaccination against serogroup B meningococcal disease: An economic and mathematical modelling study of potential impact

Volume 31, Issue 23, Pages 2599-2658 (28 May 2013)
Introducing vaccination against serogroup B meningococcal disease: An economic and mathematical modelling study of potential impact
Original Research Article
Pages 2638-2646
Hannah Christensen, Matthew Hickman, W. John Edmunds, Caroline L. Trotter

Meningococcal disease remains an important cause of morbidity and mortality worldwide. The first broadly effective vaccine against group B disease (which causes considerable meningococcal disease in Europe, the Americas and Australasia) was licensed in the EU in January 2013; our objective was to estimate the potential impact of introducing such a vaccine in England.

We developed two models to estimate the impact of introducing a new ‘MenB’ vaccine. The cohort model assumes the vaccine protects against disease only; the transmission dynamic model also allows the vaccine to protect against carriage (accounting for herd effects). We used these, and economic models, to estimate the case reduction and cost-effectiveness of a number of different vaccine strategies.

We estimate 27% of meningococcal disease cases could be prevented over the lifetime of an English birth cohort by vaccinating infants at 2,3,4 and 12 months of age with a vaccine that prevents disease only; this strategy could be cost-effective at £9 per vaccine dose. Substantial reductions in disease (71%) can be produced after 10 years by routinely vaccinating infants in combination with a large-scale catch-up campaign, using a vaccine which protects against carriage as well as disease; this could be cost-effective at £17 per vaccine dose.

New ‘MenB’ vaccines could substantially reduce disease in England and be cost-effective if competitively priced, particularly if the vaccines can prevent carriage as well as disease. These results are relevant to other countries, with a similar epidemiology to England, considering the introduction of a new ‘MenB’ vaccine.

Indicators to assess National Immunization Technical Advisory Groups (NITAGs)

Volume 31, Issue 23, Pages 2599-2658 (28 May 2013)
Indicators to assess National Immunization Technical Advisory Groups (NITAGs)
Original Research Article
Pages 2653-2657
Julia Blau, Nahad Sadr-Azodi, Marine Clementz, Nihal Abeysinghe, Niyazi Cakmak, Philippe Duclos, Cara Janusz, Barbara Jauregui, Richard Mihigo, Liudmila Mosina, Yoshihiro Takashima, Kamel Senouci

A National Immunization Technical Advisory Group (NITAG) is an expert advisory committee that provides evidence-based recommendations to the Ministry of Health (MoH) to guide immunization programs and policies. The World Health Organization (WHO), the Initiative for Supporting National Independent Immunization and Vaccine Advisory Committees (SIVAC) at Agence de Médecine Préventive (AMP) and the US Centers for Disease Control and Prevention (US CDC) engaged NITAG stakeholders and technical partners in the development of indicators to assess the effectiveness of NITAGs. A list of 17 process, output and outcome indicators was developed and tested in 14 countries to determine whether they were understandable, feasible to collect, and useful for the countries. Based on the findings, a revised version of the indicators is proposed for self-assessment in the countries, as well as for global monitoring of the NITAGs.

Economic analysis of measles elimination program in the Republic of Korea, 2001: A cost benefit analysis study

Volume 31, Issue 24, Pages 2659-2722 (31 May 2013)
Economic analysis of measles elimination program in the Republic of Korea, 2001: A cost benefit analysis study
Original Research Article
Pages 2661-2666
Geun-Ryang Bae, Young June Choe, Un Yeong Go, Yong-Ik Kim, Jong-Koo Lee

In this study, we modeled the cost benefit analysis for three different measles vaccination strategies based upon three different measles-containing vaccines in Korea, 2001. We employed an economic analysis model using vaccination coverage data and population-based measles surveillance data, along with available estimates of the costs for the different strategies. In addition, we have included analysis on benefit of reduction of complication by mumps and rubella.

We evaluated four different strategies: strategy 1, keep-up program with a second dose measles-mumps-rubella (MMR) vaccine at 4–6 years without catch-up campaign; strategy 2, additional catch-up campaign with measles (M) vaccine; strategy 3, catch-up campaign with measles-rubella (MR) vaccine; and strategy 4, catch-up campaign with MMR vaccine. The cost of vaccination included cost for vaccines, vaccination practices and other administrative expenses. The direct benefit of estimated using data from National Health Insurance Company, a government-operated system that reimburses all medical costs spent on designated illness in Korea.

With the routine one-dose MMR vaccination program, we estimated a baseline of 178,560 measles cases over the 20 years; when the catch-up campaign with M, MR or MMR vaccines was conducted, we estimated the measles cases would decrease to 5936 cases. Among all strategies, the two-dose MMR keep-up program with MR catch-up campaign showed the highest benefit-cost ratio of 1.27 with a net benefit of 51.6 billion KRW.

Across different vaccination strategies, our finding suggest that MR catch-up campaign in conjunction with two-dose MMR keep-up program was the most appropriate option in terms of economic costs and public health effects associated with measles elimination strategy in Korea.

Who is unlikely to report adverse events after vaccinations to the Vaccine Adverse Event Reporting System (VAERS)?

Volume 31, Issue 24, Pages 2659-2722 (31 May 2013)
Who is unlikely to report adverse events after vaccinations to the Vaccine Adverse Event Reporting System (VAERS)?
Original Research Article
Pages 2673-2679
Michael M. McNeil, Rongxia Li, Susanne Pickering, Theresa M. Real, Philip J. Smith, Michael R. Pemberton

Healthcare provider (HCP) reporting to the Vaccine Adverse Event Reporting System (VAERS) is important to assuring the safety of U.S. licensed vaccines. HCP awareness of and practices regarding reporting of adverse events following immunization (AEFI) is understudied.

A large, nationally representative sample of U.S. office-based HCP across three occupational groups (physicians, mid-level providers [physician assistants, advanced practice nurses] and nurses) and three primary care practice areas (pediatrics, family medicine, internal medicine) were surveyed utilizing standardized methodology. We assessed HCP familiarity with VAERS, the situations under which they were likely to report an AEFI, and the methods they used and preferred for reporting. We used logistic regression to determine factors associated with HCP not reporting AEFI to VAERS.

Our survey response rate was 54.9%. The percentage of HCP aware of VAERS (71%) varied by occupation and primary care practice area. About 37% of HCP had identified at least one AEFI with only 17% of these indicating that they had ever reported to VAERS. More serious events were more likely to be reported. Factors associated with HCP not reporting AEFI included: HCP not familiar versus very familiar with filing a paper VAERS report (OR = 12.84; p < 0.0001), primary care practice area of internal medicine versus pediatrics (OR = 4.22; p = 0.0005), and HCP not familiar versus very familiar with when it was required to file a VAERS report (OR = 5.52; p = 0.0013).

Specific educational interventions targeted to HCP likely to see AEFI but not currently reporting may improve vaccine safety reporting practices.

Have changing pneumococcal vaccination programmes impacted disease in Ontario?

Volume 31, Issue 24, Pages 2659-2722 (31 May 2013)
Have changing pneumococcal vaccination programmes impacted disease in Ontario?
Original Research Article
Pages 2680-2685
Gillian H. Lim, Anne E. Wormsbecker, Allison McGeer, Dylan R. Pillai, Jonathan B. Gubbay, Wallis Rudnick, Don E. Low, Karen Green, Natasha S. Crowcroft, Shelley L. Deeks

Publicly funded infant 7-valent pneumococcal conjugate vaccine (PCV7) was introduced in Ontario, Canada in 2005 and was replaced by 10- and 13-valent vaccines (PCV10, PCV13) in October 2009 and November 2010, respectively. Among adults ≥ 65 years, a 23-valent polysaccharide vaccine (PPV23) has been universally available since 1996. In January 2012, PCV13 was approved for adults  ≥ 50 years. This study examines the impact of publicly funded vaccination programmes on invasive pneumococcal disease (IPD).

Laboratory data from population-based surveillance for IPD conducted at the Toronto Invasive Bacterial Disease Network and from Public Health Ontario Laboratories between January 1, 2008 and December 31, 2010 were analyzed.

Between 2008 and 2010 there were 3259 cases of IPD; overall incidence was 7.4/9.3/8.3 per 100,000 in 2008/9/10, respectively. Incidence increased significantly among adults 65+ years during the period; this group had the highest incidence (21.5–25.6/100,000). The second highest incidence in 2008 and 2009 was in infants <1 year, whereas in 2010 it was in children 1–4 years. Among children <5 years, 68% and 19% of serotypes were covered by PCV13 and PCV10, respectively, between 2008 and 2010. In 2009, 6 cases with the 3 additional PCV10 serotypes were reported in infants compared with 2 in 2010. Among persons eligible for PCV7 (born ≥ 2004), there was a 77% decrease in the rate of IPD due to PCV7 serotypes between 2008 and 2010 and a 60% decrease in PCV7 serotypes among persons not vaccine-eligible (born < 2004). There was a 15% difference in serotype coverage between PCV13 and the 23-valent polysaccharide vaccine in adults ≥ 50 years.

During Ontario’s PCV7 programme, serotype-specific decreases in IPD were observed, suggesting vaccine programme success, including herd immunity. Our results also suggest some early impact among infants from PCV10 introduction. A substantial burden of disease was also observed among older adults.