Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
September 2014 Volume 10, Issue 9
http://www.landesbioscience.com/journals/vaccines/toc/volume/10/issue/9/

Do current cost-effectiveness analyses reflect the full value of childhood vaccination in Europe?
A rotavirus case study
Bernd Brüggenjürgena, Mathie Lorrotb, Fiona R Sheppardc & Vanessa Rémyd*
DOI:10.4161/hv.29090
pages 2290-2294
Received: 22 Apr 2014
Accepted: 1 May 2014
Published online: 30 Oct 2014
Abstract
Economic evaluation of vaccination programs can be challenging and does not always fully capture the benefits provided. Reasons for this include the difficulties incurred in accurately capturing the health and economic impact of infectious diseases and how different diseases may interact with each other. Rotavirus infection, for example, peaks at a similar time than other infectious diseases, such as RSV and influenza, which can cause hospital overcrowding and disruption, and may pose a risk to more vulnerable children due to limited availability of isolation facilities. Another challenge, specific to evaluating childhood vaccination, is that QoL cannot be accurately measured in children due to a lack of validated instruments. Childhood diseases also incur a care giver burden, due to the need for parents to take time off work, and this is important to consider. Finally, for diseases such as RVGE, cost-effectiveness analyses in which longer time horizons are considered may not reflect the short-term benefits of vaccination. Further quantification of the economic impact of childhood diseases is thus required to fully highlight the true benefits of childhood vaccination that may be realized. Herein we explore the limitations of existing economic evaluations for childhood vaccination, and how economic analyses could be better adapted in future.

Cost-effectiveness of hepatitis A vaccination in Indonesia
Auliya A Suwantikaab*, Philippe Beutelsc & Maarten J Postmaa
DOI:10.4161/hv.29353
pages 2342-2349
Received: 7 Feb 2014
Accepted: 25 May 2014
Published online: 30 Oct 2014
Abstract
Objective
This study aims to assess the cost-effectiveness of hepatitis A immunization in Indonesia, including an explicit comparison between one-dose and two-dose vaccines.
Methods
An age-structured cohort model based on a decision tree was developed for the 2012 Indonesia birth cohort. Using the model, we made a comparison on the use of two-dose and one-dose vaccines. The model involved a 70-year time horizon with 1-month cycles for children less than 2 years old and annually thereafter. Monte Carlo simulations were used to examine the economic acceptability and affordability of the hepatitis A vaccination.
Results
Vaccination would save US$ 3 795 148 and US$ 2 892 920 from the societal perspective, for the two-dose and one-dose vaccine schedules, respectively, in the context of hepatitis A treatment. It also would save 8917 and 6614 discounted quality-adjusted-life-years (QALYs), respectively. With the vaccine price of US$ 3.21 per dose, the implementation of single dose vaccine would yield an incremental cost-effectiveness ratio (ICER) of US$ 4933 per QALY gained versus no vaccination, whereas the two-dose versus one-dose schedule would cost US$ 14 568 per QALY gained. Considering the 2012 gross-domestic-product (GDP) per capita in Indonesia of US$ 3557, the results indicate that hepatitis A vaccination would be a cost-effective intervention, both for the two-dose and one-dose vaccine schedules in isolation, but two-dose vaccination would no longer be cost-effective if one-dose vaccination is a feasible option. Vaccination would be 100% affordable at budgets of US$ 71 408 000 and US$ 37 690 000 for the implementation of the two-dose and one-dose vaccine schedules, respectively.
Conclusions
The implementation of hepatitis A vaccination in Indonesia would be a cost-effective health intervention under the market vaccine price. Given the budget limitations, the use of a one-dose-vaccine schedule would be more realistic to be applied than a two-dose schedule. The vaccine price, mortality rate and discount rate were the most influential parameters impacting the ICERs.

Knowledge of and attitudes to influenza in unvaccinated primary care physicians and nurses
A cross-sectional study
Angela Domínguezab*, Pere Godoybc, Jesús Castillabd, José María Mayorale, Núria Soldevilab, Núria Tornerabc, Diana Toledobf, Jenaro Astrayg, Sonia Tamamesh, Susana García-Gutiérrezi, Fernando González-Candelasj, Vicente Martínk, José Díazl, the CIBERESP Working Group & for the Survey on Influenza Vaccination in Primary Health Care Workers
Open access
DOI:10.4161/hv.29142
pages 2378-2386
Received: 28 Feb 2014
Accepted: 7 May 2014
Published online: 30 Oct 2014
Abstract
Primary healthcare workers, especially nurses, are exposed to the vast majority of patients with influenza and play an important role in vaccinating patients. Healthcare workers’ misconceptions about influenza and influenza vaccination have been reported as possible factors associated with lack of vaccination. The objective of this study was to compare the characteristics of unvaccinated physicians and unvaccinated nurses in the 2011–2012 influenza season. We performed an anonymous web survey of Spanish primary healthcare workers in 2012. Information was collected on vaccination and knowledge of and attitudes to the influenza vaccine. Multivariate analysis was performed using unconditional logistic regression. We included 461 unvaccinated physicians and 402 unvaccinated nurses. Compared with unvaccinated nurses, unvaccinated physicians had more frequently received seasonal influenza vaccination in the preceding seasons (aOR 1.58; 95% CI 1.11–2.25), and more frequently believed that vaccination of high risk individuals is effective in reducing complications (aOR 2.53; 95% CI 1.30–4.95) and that influenza can be a serious illness (aOR 1.65; 95% CI 1.17–2.32). In contrast, unvaccinated physicians were less concerned about infecting patients (aOR 0.62; 95% CI 0.40–0.96). Unvaccinated nurses had more misconceptions than physicians about influenza and the influenza vaccine and more doubts about the severity of annual influenza epidemics in patients with high risk conditions and the prevention of complications by means of the influenza vaccination. For unvaccinated physicians, strategies to improve vaccination coverage should stress the importance of physicians as a possible source of infection of their patients. The effectiveness of influenza vaccination of high risk persons should be emphasized in nurses.

Inequalities in vaccination coverage for young females whose parents are informal caregivers
Tabatha N Offutt-Powella*, Rohit P Ojhab, Tara M Brinkmanb, Joseph E Totac, Bradford E Jacksond, Karan P Singhd & Jennifer S Smithe
DOI:10.4161/hv.29096
pages 2454-2459
Received: 1 Mar 2014
Accepted: 2 May 2014
Published online: 30 Oct 2014
Abstract
The effects of caregiver strain and stress on preventive health service utilization among adult family members are well-established, but the effects of informal caregiving on children of caregivers are unknown. We aimed to assess whether inequalities in vaccination coverage (specifically human papillomavirus [HPV] and influenza) exist for females aged 9 to 17 years whose parents are informal caregivers (i.e., care providers for family members or others who are not functionally independent) compared with females whose parents are not informal caregivers. Data from the 2009 Behavioral Risk Factor Surveillance System were analyzed using Poisson regression with robust variance to estimate overall and subgroup-specific HPV and influenza vaccination prevalence ratios (PRs) and corresponding 95% confidence limits (CL) comparing females whose parents were informal caregivers with females whose parents were not informal caregivers. Our unweighted study populations comprised 1645 and 1279 females aged 9 to 17 years for the HPV and influenza vaccination analyses, respectively. Overall, both HPV and influenza vaccination coverage were lower among females whose parents were informal caregivers (HPV: PR = 0.72, 95% CL: 0.53, 0.97; Influenza: PR = 0.89, 95% CL: 0.66, 1.2). Our results suggest consistently lower HPV and influenza vaccination coverage for young females whose parents are informal caregivers. Our study provides new evidence about the potential implications of caregiving on the utilization of preventive health services among children of caregivers.

Parents’ attitude toward multiple vaccinations at a single visit with alternative delivery methods
Patricia Kaaijk*a, Deborah E Kleijnea, Mirjam J Knola, Irene A Harmsena, Olga JAE Ophorsta & Nynke Y Rotsa
Open access
DOI:10.4161/hv.29361
pages 2483-2489
Received: 11 Apr 2014
Accepted: 26 May 2014
Published online: 30 Oct 2014
Abstract
Last decades, the number of routine childhood vaccinations has increased considerably, which consequently has led to multiple vaccine injections per consultation. Implementation of additional vaccines will probably lead to more than 2 vaccine injections per consult, which might be a barrier for parents to vaccinate their child. A decrease in vaccination coverage, however, increases the risk of disease outbreaks. Less stressful alternative methods for vaccine delivery might lead to an increased acceptance of multiple childhood vaccinations by parents. The present questionnaire study was set up to explore the maximum number of vaccine injections per visit that is acceptable for parents, as well as to gauge parents’ attitude toward alternative needle-free methods for vaccine delivery. For this purpose, the parents’ opinion toward a jet injector, a patch, a microneedle system, and nasal spray device as methods for vaccine delivery was assessed. The majority of the 1154 participating parents indicated that 3 vaccine injections per visit was perceived as too much. Most participants had a positive attitude with respect to the jet injector and the patch as alternative vaccine delivery method, whereas the microneedle device and an intranasal spray device were not perceived as better than the conventional syringe by the parents. Parents indicated that both the jet injector and the patch might increase their acceptance of giving their children more than 2 vaccinations at the same time. This should encourage vaccine developers and manufacturers to put efforts in developing these delivery methods for their vaccines.