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Tran Kiem C, Bosetti P, Paireau J, Crépey P, Salje H, Lefrancq N, Fontanet A, Benamouzig D, Boëlle PY, Desenclos JC, Opatowski L, Cauchemez S. SARS-CoV-2 transmission across age groups in France and implications for control. Nat Commun 2021; 12:6895. [PMID: 34824245 PMCID: PMC8617041 DOI: 10.1038/s41467-021-27163-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/28/2021] [Indexed: 12/16/2022] Open
Abstract
The shielding of older individuals has been proposed to limit COVID-19 hospitalizations while relaxing general social distancing in the absence of vaccines. Evaluating such approaches requires a deep understanding of transmission dynamics across ages. Here, we use detailed age-specific case and hospitalization data to model the rebound in the French epidemic in summer 2020, characterize age-specific transmission dynamics and critically evaluate different age-targeted intervention measures in the absence of vaccines. We find that while the rebound started in young adults, it reached individuals aged ≥80 y.o. after 4 weeks, despite substantial contact reductions, indicating substantial transmission flows across ages. We derive the contribution of each age group to transmission. While shielding older individuals reduces mortality, it is insufficient to allow major relaxations of social distancing. When the epidemic remains manageable (R close to 1), targeting those most contributing to transmission is better than shielding at-risk individuals. Pandemic control requires an effort from all age groups.
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Affiliation(s)
- Cécile Tran Kiem
- Institut Pasteur, Université de Paris, Mathematical Modelling of Infectious Diseases Unit, CNRS UMR 2000, Paris, France
- Collège Doctoral, Sorbonne Université, Paris, France
| | - Paolo Bosetti
- Institut Pasteur, Université de Paris, Mathematical Modelling of Infectious Diseases Unit, CNRS UMR 2000, Paris, France
| | - Juliette Paireau
- Institut Pasteur, Université de Paris, Mathematical Modelling of Infectious Diseases Unit, CNRS UMR 2000, Paris, France
- Santé publique France, French National Public Health Agency, Saint-Maurice, France
| | - Pascal Crépey
- Univ Rennes, EHESP, REPERES (Recherche en Pharmaco-Epidémiologie et Recours aux Soins), EA 7449, Rennes, France
| | - Henrik Salje
- Institut Pasteur, Université de Paris, Mathematical Modelling of Infectious Diseases Unit, CNRS UMR 2000, Paris, France
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - Noémie Lefrancq
- Institut Pasteur, Université de Paris, Mathematical Modelling of Infectious Diseases Unit, CNRS UMR 2000, Paris, France
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - Arnaud Fontanet
- Institut Pasteur, Université de Paris, Emerging Diseases Epidemiology Unit, Paris, France
- Conservatoire National des Arts et Métiers, PACRI Unit, Paris, France
| | - Daniel Benamouzig
- Sciences Po - Centre de sociologie des organisations and Chaire santé - CNRS, Paris, France
| | - Pierre-Yves Boëlle
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | | | - Lulla Opatowski
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, Gif-sur-Yvette, France
- Institut Pasteur, Université de Paris, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France
| | - Simon Cauchemez
- Institut Pasteur, Université de Paris, Mathematical Modelling of Infectious Diseases Unit, CNRS UMR 2000, Paris, France.
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2
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Vinh DN, Nhat NTD, de Bruin E, Vy NHT, Thao TTN, Phuong HT, Anh PH, Todd S, Quan TM, Thanh NTL, Lien NTN, Ha NTH, Hong TTK, Thai PQ, Choisy M, Nguyen TD, Simmons CP, Thwaites GE, Clapham HE, Chau NVV, Koopmans M, Boni MF. Age-seroprevalence curves for the multi-strain structure of influenza A virus. Nat Commun 2021; 12:6680. [PMID: 34795239 PMCID: PMC8602397 DOI: 10.1038/s41467-021-26948-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/27/2021] [Indexed: 11/21/2022] Open
Abstract
The relationship between age and seroprevalence can be used to estimate the annual attack rate of an infectious disease. For pathogens with multiple serologically distinct strains, there is a need to describe composite exposure to an antigenically variable group of pathogens. In this study, we assay 24,402 general-population serum samples, collected in Vietnam between 2009 to 2015, for antibodies to eleven human influenza A strains. We report that a principal components decomposition of antibody titer data gives the first principal component as an appropriate surrogate for seroprevalence; this results in annual attack rate estimates of 25.6% (95% CI: 24.1% - 27.1%) for subtype H3 and 16.0% (95% CI: 14.7% - 17.3%) for subtype H1. The remaining principal components separate the strains by serological similarity and associate birth cohorts with their particular influenza histories. Our work shows that dimensionality reduction can be used on human antibody profiles to construct an age-seroprevalence relationship for antigenically variable pathogens.
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MESH Headings
- Algorithms
- Antibodies, Viral/blood
- Antibodies, Viral/immunology
- Geography
- Hemagglutinin Glycoproteins, Influenza Virus/immunology
- Humans
- Immunoglobulin G/blood
- Immunoglobulin G/immunology
- Influenza A Virus, H1N1 Subtype/immunology
- Influenza A Virus, H1N1 Subtype/physiology
- Influenza A Virus, H3N2 Subtype/immunology
- Influenza A Virus, H3N2 Subtype/physiology
- Influenza A virus/classification
- Influenza A virus/immunology
- Influenza A virus/physiology
- Influenza, Human/epidemiology
- Influenza, Human/immunology
- Influenza, Human/virology
- Models, Theoretical
- Seroepidemiologic Studies
- Time Factors
- Vietnam/epidemiology
- Virus Replication/immunology
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Affiliation(s)
- Dao Nguyen Vinh
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Duy Nhat
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA
| | - Erwin de Bruin
- Department of Viroscience, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Nguyen Ha Thao Vy
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Tran Thi Nhu Thao
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Huynh Thi Phuong
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Pham Hong Anh
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Stacy Todd
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
- Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, England
| | - Tran Minh Quan
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Le Thanh
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | | | | | | | - Pham Quang Thai
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Marc Choisy
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tran Dang Nguyen
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA
| | - Cameron P Simmons
- Institute of Vector Borne Disease, Monash University, Melbourne, VIC, Australia
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Hannah E Clapham
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | | | - Marion Koopmans
- Department of Viroscience, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Maciej F Boni
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA.
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3
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Marriott AC, Gooch KE, Brown PJ, Ryan KA, Jones NJ, Merredew N, Wiblin N, Dibben O, Bright H, Hallis B, Whittaker CJ, Carroll MW. Severity of heterosubtypic influenza virus infection in ferrets is reduced by live attenuated influenza vaccine. NPJ Vaccines 2021; 6:43. [PMID: 33782409 PMCID: PMC8007727 DOI: 10.1038/s41541-021-00306-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/02/2021] [Indexed: 11/17/2022] Open
Abstract
Live attenuated influenza vaccine (LAIV) is widely used to protect humans from seasonal influenza infection, particularly in children. In contrast to inactivated vaccines, the LAIV can induce both mucosal and cellular immune responses. Here we show that a single dose of monovalent H1N1pdm09-specific LAIV in the ferret model is fully protective against a subsequent wild-type H1N1pdm09 challenge, and furthermore reduces the severity of disease following challenge with a different influenza A subtype (H3N2). The reduced severity comprised reductions in weight loss and fever, as well as more rapid clearance of virus, compared to non-vaccinated H3N2-challenged ferrets. No H3N2-neutralizing antibodies were detected in vaccinated ferret sera. Rather, heterosubtypic protection correlated with interferon-gamma+ (IFN-γ+) T-cell responses measured in peripheral blood and in lung lymphocytes. The IFN-γ+ cells were cross-reactive to H3N2 virus even when obtained from vaccinated animals that had never been exposed to H3N2 virus. We believe this study provides compelling evidence that the LAIV can provide a significant reduction in infection and symptoms when challenged with heterosubtypic influenza strains not included in the LAIV, highlighting the importance of cross-reactive T-cells in the design of a universal influenza vaccine.
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Affiliation(s)
- Anthony C Marriott
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK.
| | - Karen E Gooch
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK
| | - Phillip J Brown
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK
| | - Kathryn A Ryan
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK
| | - Nicola J Jones
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK
| | - Natasha Merredew
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK
| | - Nathan Wiblin
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK
| | - Oliver Dibben
- Flu-MSAT, Biopharmaceutical Development, R&D, AstraZeneca, Liverpool, UK
| | - Helen Bright
- Flu-MSAT, Biopharmaceutical Development, R&D, AstraZeneca, Liverpool, UK
| | - Bassam Hallis
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK
| | | | - Miles W Carroll
- National Infection Service, Public Health England, Porton Down, Wiltshire, UK
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4
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Benjamin-Chung J, Arnold BF, Kennedy CJ, Mishra K, Pokpongkiat N, Nguyen A, Jilek W, Holbrook K, Pan E, Kirley PD, Libby T, Hubbard AE, Reingold A, Colford JM. Evaluation of a city-wide school-located influenza vaccination program in Oakland, California, with respect to vaccination coverage, school absences, and laboratory-confirmed influenza: A matched cohort study. PLoS Med 2020; 17:e1003238. [PMID: 32810149 PMCID: PMC7433855 DOI: 10.1371/journal.pmed.1003238] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 07/14/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND It is estimated that vaccinating 50%-70% of school-aged children for influenza can produce population-wide indirect effects. We evaluated a city-wide school-located influenza vaccination (SLIV) intervention that aimed to increase influenza vaccination coverage. The intervention was implemented in ≥95 preschools and elementary schools in northern California from 2014 to 2018. Using a matched cohort design, we estimated intervention impacts on student influenza vaccination coverage, school absenteeism, and community-wide indirect effects on laboratory-confirmed influenza hospitalizations. METHODS AND FINDINGS We used a multivariate matching algorithm to identify a nearby comparison school district with pre-intervention characteristics similar to those of the intervention school district and matched schools in each district. To measure student influenza vaccination, we conducted cross-sectional surveys of student caregivers in 22 school pairs (2017 survey, N = 6,070; 2018 survey, N = 6,507). We estimated the incidence of laboratory-confirmed influenza hospitalization from 2011 to 2018 using surveillance data from school district zip codes. We analyzed student absenteeism data from 2011 to 2018 from each district (N = 42,487,816 student-days). To account for pre-intervention differences between districts, we estimated difference-in-differences (DID) in influenza hospitalization incidence and absenteeism rates using generalized linear and log-linear models with a population offset for incidence outcomes. Prior to the SLIV intervention, the median household income was $51,849 in the intervention site and $61,596 in the comparison site. The population in each site was predominately white (41% in the intervention site, 48% in the comparison site) and/or of Hispanic or Latino ethnicity (26% in the intervention site, 33% in the comparison site). The number of students vaccinated by the SLIV intervention ranged from 7,502 to 10,106 (22%-28% of eligible students) each year. During the intervention, influenza vaccination coverage among elementary students was 53%-66% in the comparison district. Coverage was similar between the intervention and comparison districts in influenza seasons 2014-2015 and 2015-2016 and was significantly higher in the intervention site in seasons 2016-2017 (7%; 95% CI 4, 11; p < 0.001) and 2017-2018 (11%; 95% CI 7, 15; p < 0.001). During seasons when vaccination coverage was higher among intervention schools and the vaccine was moderately effective, there was evidence of statistically significant indirect effects: The DID in the incidence of influenza hospitalization per 100,000 in the intervention versus comparison site was -17 (95% CI -30, -4; p = 0.008) in 2016-2017 and -37 (95% CI -54, -19; p < 0.001) in 2017-2018 among non-elementary-school-aged individuals and -73 (95% CI -147, 1; p = 0.054) in 2016-2017 and -160 (95% CI -267, -53; p = 0.004) in 2017-2018 among adults 65 years or older. The DID in illness-related school absences per 100 school days during the influenza season was -0.63 (95% CI -1.14, -0.13; p = 0.014) in 2016-2017 and -0.80 (95% CI -1.28, -0.31; p = 0.001) in 2017-2018. Limitations of this study include the use of an observational design, which may be subject to unmeasured confounding, and caregiver-reported vaccination status, which is subject to poor recall and low response rates. CONCLUSIONS A city-wide SLIV intervention in a large, diverse urban population was associated with a decrease in the incidence of laboratory-confirmed influenza hospitalization in all age groups and a decrease in illness-specific school absence rate among students in 2016-2017 and 2017-2018, seasons when the vaccine was moderately effective, suggesting that the intervention produced indirect effects. Our findings suggest that in populations with moderately high background levels of influenza vaccination coverage, SLIV programs are associated with further increases in coverage and reduced influenza across the community.
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Affiliation(s)
- Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
| | - Benjamin F. Arnold
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
| | - Chris J. Kennedy
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
| | - Kunal Mishra
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
| | - Nolan Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
| | - Kate Holbrook
- Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, Oakland, California, United States of America
| | - Erica Pan
- Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, Oakland, California, United States of America
- Department of Pediatrics, Division of Infectious Diseases, University of California, San Francisco, San Francisco, California, United States of America
| | - Pam D. Kirley
- California Emerging Infections Program, Oakland, California, United States of America
| | - Tanya Libby
- California Emerging Infections Program, Oakland, California, United States of America
| | - Alan E. Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
| | - Arthur Reingold
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
| | - John M. Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, California, United States of America
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5
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Wang L, Chen J, Marathe A. A Framework for Discovering Health Disparities among Cohorts in an Influenza Epidemic. WORLD WIDE WEB 2019; 22:2997-3020. [PMID: 31777450 PMCID: PMC6880941 DOI: 10.1007/s11280-018-0608-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Infectious diseases such as Influenza and Ebola pose a serious threat to everyone but certain demographics and cohorts face a higher risk of infection than others. This research provides a computational framework for studying health disparities among cohorts based on individual level features, such as age, gender, income, etc. We apply this framework to find health disparities among subpopulations in an influenza epidemic and evaluate vaccination prioritization strategies to achieve specific objectives. We explore the heterogeneities in individuals' demographic and socioeconomic attributes as the potential cause of health disparities. An agent-based model is used to simulate an influenza epidemic over a synthetic social contact network of the Montgomery County in Southwest Virginia to identify infected cases which are then labeled with a specific clinical outcome by using a predefined probability distribution based on age and risk level. We divide the population into age and income based cohorts and measure the direct and indirect economic impact of vaccination for each cohort. Simulation-based results find strong health disparities across age and income groups. Various vaccine distribution strategies are considered and outcomes are measured through metrics such as death count, total number of infections, net return per capita, net return per dollar spent and net return per vaccinated person. The results, framework, and methodology developed here can assist public health policy makers in efficiently allocating limited pharmaceutical resources.
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Affiliation(s)
- Lijing Wang
- Department of Computer Science, Virginia Tech, Network Dynamics and Simulation Science Laboratory, Biocomplexity Institute of Virginia Tech, Blacksburg, VA 24061 USA
| | - Jiangzhuo Chen
- Network Dynamics and Simulation Science Laboratory, Biocomplexity Institute of Virginia Tech, Blacksburg, VA 24061, USA
| | - Achla Marathe
- Department of Agricultural and Applied Economics, Virginia Tech, Network Dynamics and Simulation Science Laboratory, Biocomplexity Institute of Virginia Tech, Blacksburg, VA 24061 USA
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6
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Germann TC, Gao H, Gambhir M, Plummer A, Biggerstaff M, Reed C, Uzicanin A. School dismissal as a pandemic influenza response: When, where and for how long? Epidemics 2019; 28:100348. [PMID: 31235334 PMCID: PMC6956848 DOI: 10.1016/j.epidem.2019.100348] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/06/2019] [Accepted: 06/03/2019] [Indexed: 01/02/2023] Open
Abstract
We used individual-based computer simulation models at community,
regional and national levels to evaluate the likely impact of coordinated
pre-emptive school dismissal policies during an influenza pandemic. Such
policies involve three key decisions: when, over what geographical scale, and
how long to keep schools closed. Our evaluation includes uncertainty and
sensitivity analyses, as well as model output uncertainties arising from
variability in serial intervals and presumed modifications of social contacts
during school dismissal periods. During the period before vaccines become widely
available, school dismissals are particularly effective in delaying the epidemic
peak, typically by 4–6 days for each additional week of dismissal.
Assuming the surveillance is able to correctly and promptly diagnose at least
5–10% of symptomatic individuals within the jurisdiction, dismissals at
the city or county level yield the greatest reduction in disease incidence for a
given dismissal duration for all but the most severe pandemic scenarios
considered here. Broader (multi-county) dismissals should be considered for the
most severe and fast-spreading (1918-like) pandemics, in which multi-month
closures may be necessary to delay the epidemic peak sufficiently to allow for
vaccines to be implemented.
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Affiliation(s)
- Timothy C Germann
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM 87545 USA
| | - Hongjiang Gao
- Community Interventions for Infection Control Unit, Centers for Disease Control and Prevention, Atlanta, GA 30329 USA.
| | - Manoj Gambhir
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA; School of Public Health and Preventive Medicine, Monash University, Victoria 3800 Australia
| | - Andrew Plummer
- Community Interventions for Infection Control Unit, Centers for Disease Control and Prevention, Atlanta, GA 30329 USA
| | - Matthew Biggerstaff
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA
| | - Carrie Reed
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA
| | - Amra Uzicanin
- Community Interventions for Infection Control Unit, Centers for Disease Control and Prevention, Atlanta, GA 30329 USA
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7
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Jefferson T, Rivetti A, Di Pietrantonj C, Demicheli V. Vaccines for preventing influenza in healthy children. Cochrane Database Syst Rev 2018; 2:CD004879. [PMID: 29388195 PMCID: PMC6491174 DOI: 10.1002/14651858.cd004879.pub5] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The consequences of influenza in children and adults are mainly absenteeism from school and work. However, the risk of complications is greatest in children and people over 65 years of age. This is an update of a review published in 2011. Future updates of this review will be made only when new trials or vaccines become available. Observational data included in previous versions of the review have been retained for historical reasons but have not been updated because of their lack of influence on the review conclusions. OBJECTIVES To assess the effects (efficacy, effectiveness, and harm) of vaccines against influenza in healthy children. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 12), which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE (1966 to 31 December 2016), Embase (1974 to 31 December 2016), WHO International Clinical Trials Registry Platform (ICTRP; 1 July 2017), and ClinicalTrials.gov (1 July 2017). SELECTION CRITERIA Randomised controlled trials comparing influenza vaccines with placebo or no intervention in naturally occurring influenza in healthy children under 16 years. Previous versions of this review included 19 cohort and 11 case-control studies. We are no longer updating the searches for these study designs but have retained the observational studies for historical purposes. DATA COLLECTION AND ANALYSIS Review authors independently assessed risk of bias and extracted data. We used GRADE to rate the certainty of evidence for the key outcomes of influenza, influenza-like illness (ILI), complications (hospitalisation, ear infection), and adverse events. Due to variation in control group risks for influenza and ILI, absolute effects are reported as the median control group risk, and numbers needed to vaccinate (NNVs) are reported accordingly. For other outcomes aggregate control group risks are used. MAIN RESULTS We included 41 clinical trials (> 200,000 children). Most of the studies were conducted in children over the age of two and compared live attenuated or inactivated vaccines with placebo or no vaccine. Studies were conducted over single influenza seasons in the USA, Western Europe, Russia, and Bangladesh between 1984 and 2013. Restricting analyses to studies at low risk of bias showed that influenza and otitis media were the only outcomes where the impact of bias was negligible. Variability in study design and reporting impeded meta-analysis of harms outcomes.Live attenuated vaccinesCompared with placebo or do nothing, live attenuated influenza vaccines probably reduce the risk of influenza infection in children aged 3 to 16 years from 18% to 4% (risk ratio (RR) 0.22, 95% confidence interval (CI) 0.11 to 0.41; 7718 children; moderate-certainty evidence), and they may reduce ILI by a smaller degree, from 17% to 12% (RR 0.69, 95% CI 0.60 to 0.80; 124,606 children; low-certainty evidence). Seven children would need to be vaccinated to prevent one case of influenza, and 20 children would need to be vaccinated to prevent one child experiencing an ILI. Acute otitis media is probably similar following vaccine or placebo during seasonal influenza, but this result comes from a single study with particularly high rates of acute otitis media (RR 0.98, 95% CI 0.95 to 1.01; moderate-certainty evidence). There was insufficient information available to determine the effect of vaccines on school absenteeism due to very low-certainty evidence from one study. Vaccinating children may lead to fewer parents taking time off work, although the CI includes no effect (RR 0.69, 95% CI 0.46 to 1.03; low-certainty evidence). Data on the most serious consequences of influenza complications leading to hospitalisation were not available. Data from four studies measuring fever following vaccination varied considerably, from 0.16% to 15% in children who had live vaccines, while in the placebo groups the proportions ranged from 0.71% to 22% (very low-certainty evidence). Data on nausea were not reported.Inactivated vaccinesCompared with placebo or no vaccination, inactivated vaccines reduce the risk of influenza in children aged 2 to 16 years from 30% to 11% (RR 0.36, 95% CI 0.28 to 0.48; 1628 children; high-certainty evidence), and they probably reduce ILI from 28% to 20% (RR 0.72, 95% CI 0.65 to 0.79; 19,044 children; moderate-certainty evidence). Five children would need to be vaccinated to prevent one case of influenza, and 12 children would need to be vaccinated to avoid one case of ILI. The risk of otitis media is probably similar between vaccinated children and unvaccinated children (31% versus 27%), although the CI does not exclude a meaningful increase in otitis media following vaccination (RR 1.15, 95% CI 0.95 to 1.40; 884 participants; moderate-certainty evidence). There was insufficient information available to determine the effect of vaccines on school absenteeism due to very low-certainty evidence from one study. We identified no data on parental working time lost, hospitalisation, fever, or nausea.We found limited evidence on secondary cases, requirement for treatment of lower respiratory tract disease, and drug prescriptions. One brand of monovalent pandemic vaccine was associated with a sudden loss of muscle tone triggered by the experience of an intense emotion (cataplexy) and a sleep disorder (narcolepsy) in children. Evidence of serious harms (such as febrile fits) was sparse. AUTHORS' CONCLUSIONS In children aged between 3 and 16 years, live influenza vaccines probably reduce influenza (moderate-certainty evidence) and may reduce ILI (low-certainty evidence) over a single influenza season. In this population inactivated vaccines also reduce influenza (high-certainty evidence) and may reduce ILI (low-certainty evidence). For both vaccine types, the absolute reduction in influenza and ILI varied considerably across the study populations, making it difficult to predict how these findings translate to different settings. We found very few randomised controlled trials in children under two years of age. Adverse event data were not well described in the available studies. Standardised approaches to the definition, ascertainment, and reporting of adverse events are needed. Identification of all global cases of potential harms is beyond the scope of this review.
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Affiliation(s)
- Tom Jefferson
- University of OxfordCentre for Evidence Based MedicineOxfordUKOX2 6GG
| | - Alessandro Rivetti
- ASL CN2 Alba BraDipartimento di Prevenzione ‐ S.Pre.S.A.LVia Vida 10AlbaPiemonteItaly12051
| | - Carlo Di Pietrantonj
- Local Health Unit Alessandria‐ ASL ALRegional Epidemiology Unit SeREMIVia Venezia 6AlessandriaAlessandriaItaly15121
| | - Vittorio Demicheli
- Azienda Sanitaria Locale ASL ALServizio Regionale di Riferimento per l'Epidemiologia, SSEpi‐SeREMIVia Venezia 6AlessandriaPiemonteItaly15121
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Norhayati MN, Ho JJ, Azman MY. Influenza vaccines for preventing acute otitis media in infants and children. Cochrane Database Syst Rev 2017; 10:CD010089. [PMID: 29039160 PMCID: PMC6485791 DOI: 10.1002/14651858.cd010089.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute otitis media (AOM) is one of the most common infectious diseases in children. It has been reported that 64% of infants have an episode of AOM by the age of six months and 86% by one year. Although most cases of AOM are due to bacterial infection, it is commonly triggered by a viral infection. In most children AOM is self limiting, but it does carry a risk of complications. Since antibiotic treatment increases the risk of antibiotic resistance, influenza vaccines might be an effective way of reducing this risk by preventing the development of AOM. OBJECTIVES To assess the effectiveness of influenza vaccine in reducing the occurrence of acute otitis media in infants and children. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, LILACS, Web of Science, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov (15 February 2017). We also searched the reference lists of included studies to identify any additional trials. SELECTION CRITERIA Randomised controlled trials comparing influenza vaccine with placebo or no treatment in infants and children aged younger than six years. We included children of either sex and of any ethnicity, with or without a history of recurrent AOM. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies, assessed trial quality, and extracted data. We performed statistical analyses using the random-effects and fixed-effect models and expressed the results as risk ratio (RR), risk difference (RD), and number needed to treat for an additional beneficial outcome (NNTB) for dichotomous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 11 trials (6 trials in high-income countries and 5 multicentre trials in high-, middle-, and low-income countries) involving 17,123 children aged 6 months to 6 years. Eight trials recruited participants from a healthcare setting. Ten trials (and all four trials that contributed to the primary outcome) declared funding from vaccine manufacturers. Four trials reported adequate allocation concealment, and 10 trials reported adequate blinding of participants and personnel. Attrition was low for eight trials included in the analysis.The primary outcome showed a small reduction in at least one episode of AOM over at least six months of follow-up (4 trials, 3134 children; RR 0.84, 95% CI 0.69 to 1.02; RD -0.04, 95% CI -0.08 to -0.00; NNTB 25, 95% CI 12.5 to 100; low-quality evidence).The subgroup analyses (i.e. number of courses and types of vaccine administered) showed no differences.There was a reduction in the use of antibiotics in vaccinated children (2 trials, 1223 children; RR 0.70, 95% CI 0.59 to 0.83; RD -0.11, 95% CI -0.16 to -0.06; moderate-quality evidence).We were unable to demonstrate whether there was any difference in the utilisation of health care. The use of influenza vaccine resulted in a significant increase in fever (7 trials, 10,615 children; RR 1.15, 95% CI 1.06 to 1.24; RD 0.02, 95% CI 0.00 to 0.04; low-quality evidence), rhinorrhoea (6 trials, 10,563 children; RR 1.17, 95% CI 1.07 to 1.29; RD 0.09, 95% CI 0.01 to 0.16; low-quality evidence), but no difference in pharyngitis. No major adverse events were reported.Differing from the protocol, the original publication of the review included a subgroup analysis of AOM episodes by season, and the secondary outcome 'types of influenza vaccine' was changed to a subgroup analysis. For this update, we removed the subgroup analyses for trial setting, season, and utilisation of health care due to the small number of trials involved. We removed Belshe 2000 from primary and secondary outcomes (courses of vaccine and types of vaccine) because it reported episodes of AOM per person. We did not perform a subgroup analysis by type of adverse event. We have reported each type of adverse event as a separate analysis. AUTHORS' CONCLUSIONS Influenza vaccine results in a small reduction in AOM. The observed reduction in the use of antibiotics needs to be considered in light of current recommended practices aimed at avoiding antibiotic overuse. Safety data from these trials were limited. The benefits may not justify the use of influenza vaccine without taking into account the vaccine efficacy in reducing influenza and safety data. We judged the quality of the evidence to be low to moderate. Additional research is needed.
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Affiliation(s)
- Mohd N Norhayati
- Universiti Sains MalaysiaDepartment of Family MedicineSchool of Medical SciencesHealth CampusKubang KerianKelantanMalaysia16150
| | - Jacqueline J Ho
- Penang Medical CollegeDepartment of Paediatrics4 Sepoy LinesPenangMalaysia10450
| | - Mohd Y Azman
- Raja Perempuan Zainab II HospitalKota BharuKelantanMalaysia15586
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Epidemiological and economic impact of pandemic influenza in Chicago: Priorities for vaccine interventions. PLoS Comput Biol 2017; 13:e1005521. [PMID: 28570660 PMCID: PMC5453424 DOI: 10.1371/journal.pcbi.1005521] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 04/14/2017] [Indexed: 11/19/2022] Open
Abstract
The study objective is to estimate the epidemiological and economic impact of vaccine interventions during influenza pandemics in Chicago, and assist in vaccine intervention priorities. Scenarios of delay in vaccine introduction with limited vaccine efficacy and limited supplies are not unlikely in future influenza pandemics, as in the 2009 H1N1 influenza pandemic. We simulated influenza pandemics in Chicago using agent-based transmission dynamic modeling. Population was distributed among high-risk and non-high risk among 0–19, 20–64 and 65+ years subpopulations. Different attack rate scenarios for catastrophic (30.15%), strong (21.96%), and moderate (11.73%) influenza pandemics were compared against vaccine intervention scenarios, at 40% coverage, 40% efficacy, and unit cost of $28.62. Sensitivity analysis for vaccine compliance, vaccine efficacy and vaccine start date was also conducted. Vaccine prioritization criteria include risk of death, total deaths, net benefits, and return on investment. The risk of death is the highest among the high-risk 65+ years subpopulation in the catastrophic influenza pandemic, and highest among the high-risk 0–19 years subpopulation in the strong and moderate influenza pandemics. The proportion of total deaths and net benefits are the highest among the high-risk 20–64 years subpopulation in the catastrophic, strong and moderate influenza pandemics. The return on investment is the highest in the high-risk 0–19 years subpopulation in the catastrophic, strong and moderate influenza pandemics. Based on risk of death and return on investment, high-risk groups of the three age group subpopulations can be prioritized for vaccination, and the vaccine interventions are cost saving for all age and risk groups. The attack rates among the children are higher than among the adults and seniors in the catastrophic, strong, and moderate influenza pandemic scenarios, due to their larger social contact network and homophilous interactions in school. Based on return on investment and higher attack rates among children, we recommend prioritizing children (0–19 years) and seniors (65+ years) after high-risk groups for influenza vaccination during times of limited vaccine supplies. Based on risk of death, we recommend prioritizing seniors (65+ years) after high-risk groups for influenza vaccination during times of limited vaccine supplies. The study objective is to estimate the epidemiological and economic impact of vaccine interventions during an influenza pandemic in Chicago, to assist in vaccine intervention priorities. Population dynamics play an important role in influenza pandemic planning and response. To optimally allocate limited vaccine resources, it is important to inform decision makers and public health officials about both the direct benefit among vaccinated population and the indirect benefit among non-vaccinated population. This study adds to the evidence of prior studies by using a detailed agent-based model for estimating the direct and indirect benefits of epidemiological and economic impact of vaccine-based interventions. This study can be extended to analyze for a range of vaccine compliance and efficacy values at different attack rates of influenza pandemics in different rural and urban areas of the United States and at the country level, to infer objective prioritization criteria for influenza vaccine interventions among different risk and age groups.
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Quantifying Protection Against Influenza Virus Infection Measured by Hemagglutination-inhibition Assays in Vaccine Trials. Epidemiology 2016; 27:143-51. [PMID: 26427723 PMCID: PMC4658669 DOI: 10.1097/ede.0000000000000402] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Correlations between hemagglutination-inhibition titers (hereafter “titers”) and protection against infection have been identified in historical studies. However, limited information is available about the dynamics of how titer influences protection.
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Andrews MA, Bauch CT. Disease Interventions Can Interfere with One Another through Disease-Behaviour Interactions. PLoS Comput Biol 2015; 11:e1004291. [PMID: 26047028 PMCID: PMC4457811 DOI: 10.1371/journal.pcbi.1004291] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 04/17/2015] [Indexed: 11/19/2022] Open
Abstract
Theoretical models of disease dynamics on networks can aid our understanding of how infectious diseases spread through a population. Models that incorporate decision-making mechanisms can furthermore capture how behaviour-driven aspects of transmission such as vaccination choices and the use of non-pharmaceutical interventions (NPIs) interact with disease dynamics. However, these two interventions are usually modelled separately. Here, we construct a simulation model of influenza transmission through a contact network, where individuals can choose whether to become vaccinated and/or practice NPIs. These decisions are based on previous experience with the disease, the current state of infection amongst one's contacts, and the personal and social impacts of the choices they make. We find that the interventions interfere with one another: because of negative feedback between intervention uptake and infection prevalence, it is difficult to simultaneously increase uptake of all interventions by changing utilities or perceived risks. However, on account of vaccine efficacy being higher than NPI efficacy, measures to expand NPI practice have only a small net impact on influenza incidence due to strongly mitigating feedback from vaccinating behaviour, whereas expanding vaccine uptake causes a significant net reduction in influenza incidence, despite the reduction of NPI practice in response. As a result, measures that support expansion of only vaccination (such as reducing vaccine cost), or measures that simultaneously support vaccination and NPIs (such as emphasizing harms of influenza infection, or satisfaction from preventing infection in others through both interventions) can significantly reduce influenza incidence, whereas measures that only support expansion of NPI practice (such as making hand sanitizers more available) have little net impact on influenza incidence. (However, measures that improve NPI efficacy may fare better.) We conclude that the impact of interference on programs relying on multiple interventions should be more carefully studied, for both influenza and other infectious diseases.
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Affiliation(s)
- Michael A. Andrews
- Department of Mathematics and Statistics, University of Guelph, Guelph, Ontario, Canada
| | - Chris T. Bauch
- Department of Mathematics and Statistics, University of Guelph, Guelph, Ontario, Canada
- Department of Applied Mathematics, University of Waterloo, Waterloo, Ontario, Canada
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Norhayati MN, Ho JJ, Azman MY. Influenza vaccines for preventing acute otitis media in infants and children. Cochrane Database Syst Rev 2015:CD010089. [PMID: 25803008 DOI: 10.1002/14651858.cd010089.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute otitis media (AOM) is one of the most common infectious diseases in children. It has been reported that 64% of infants have an episode of AOM by the age of six months and 86% by one year. Although most cases of AOM are due to bacterial infection, it is commonly triggered by a viral infection. In most children it is self limiting, but it does carry a risk of complications. Since antibiotic treatment increases the risk of antibiotic resistance, influenza vaccines might be an effective way of reducing this risk by preventing the development of AOM. OBJECTIVES To assess the effectiveness of influenza vaccine in reducing the occurrence of acute otitis media (AOM) in infants and children. SEARCH METHODS We searched CENTRAL (2014, Issue 6), MEDLINE (1946 to July week 1, 2014), EMBASE (2010 to July 2014), CINAHL (1981 to July 2014), LILACS (1982 to July 2014), Web of Science (1955 to July 2014) and reference lists of articles to July 2014. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing influenza vaccine with placebo or no treatment in infants and children aged younger than six years old. We included children of either sex and of any ethnicity, with or without a history of recurrent AOM. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies, assessed trial quality and extracted data. We performed statistical analyses using the random-effects and fixed-effect models and expressed the results as risk ratio (RR), risk difference (RD) and number needed to treat to benefit (NNTB) for dichotomous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 10 trials (six trials in high-income countries and four multicentre trials in high-, middle- and low-income countries) involving 16,707 children aged six months to six years. Eight trials recruited participants from a healthcare setting. Nine trials (and all five trials that contributed to the primary outcome) declared funding from vaccine manufacturers. Four trials reported adequate allocation concealment and nine trials reported adequate blinding of participants and personnel. Attrition was low for all trials included in the analysis.The primary outcome showed a small reduction in at least one episode of AOM over at least six months of follow-up (five trials, 4736 participants: RR 0.80, 95% CI 0.67 to 0.96; RD -0.04, 95% CI -0.07 to -0.02; NNTB 25, 95% CI 15 to 50).The subgroup analyses (i.e. number of courses, settings, seasons or types of vaccine administered) showed no differences.There was a reduction in the use of antibiotics in vaccinated children (two trials, 1223 participants: RR 0.70, 95% CI 0.59 to 0.83; RD -0.15, 95% CI -0.30 to -0.00).There was no significant difference in the utilisation of health care for the one trial that provided sufficient information to be included. The use of influenza vaccine resulted in a significant increase in fever (six trials, 10,199 participants: RR 1.15, 95% CI 1.06 to 1.24; RD 0.02, 95% CI -0.00 to 0.05) and rhinorrhoea (six trials, 10,563 children: RR 1.17, 95% CI 1.07 to 1.29; RD 0.09, 95% CI 0.01 to 0.16) but no difference in pharyngitis. No major adverse events were reported.Compared to the protocol, the review included a subgroup analysis of AOM episodes by season, and changed the types of influenza vaccine from a secondary outcome to a subgroup analysis. AUTHORS' CONCLUSIONS Influenza vaccine results in a small reduction in AOM. The observed reduction with the use of antibiotics needs to be considered in the light of current recommended practices aimed at avoiding antibiotic overuse. Safety data from these trials are limited. The benefits may not justify the use of influenza vaccine without taking into account the vaccine efficacy in reducing influenza and safety data. The quality of the evidence was high to moderate. Additional research is needed.
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Affiliation(s)
- Mohd N Norhayati
- Department of Family Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia, 16150
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Andersohn F, Bornemann R, Damm O, Frank M, Mittendorf T, Theidel U. Vaccination of children with a live-attenuated, intranasal influenza vaccine - analysis and evaluation through a Health Technology Assessment. GMS HEALTH TECHNOLOGY ASSESSMENT 2014; 10:Doc03. [PMID: 25371764 PMCID: PMC4219018 DOI: 10.3205/hta000119] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Influenza is a worldwide prevalent infectious disease of the respiratory tract annually causing high morbidity and mortality in Germany. Influenza is preventable by vaccination and this vaccination is so far recommended by the The German Standing Committee on Vaccination (STIKO) as a standard vaccination for people from the age of 60 onwards. Up to date a parenterally administered trivalent inactivated vaccine (TIV) has been in use almost exclusively. Since 2011 however a live-attenuated vaccine (LAIV) has been approved additionally. Consecutively, since 2013 the STIKO recommends LAIV (besides TIV) for children from 2 to 17 years of age, within the scope of vaccination by specified indications. LAIV should be preferred administered in children from 2 to 6 of age. The objective of this Health Technology Assessment (HTA) is to address various research issues regarding the vaccination of children with LAIV. The analysis was performed from a medical, epidemiological and health economic perspective, as well as from an ethical, social and legal point of view. METHOD An extensive systematic database research was performed to obtain relevant information. In addition a supplementary research by hand was done. Identified literature was screened in two passes by two independent reviewers using predefined inclusion and exclusion criteria. Included literature was evaluated in full-text using acknowledged standards. Studies were graded with the highest level of evidence (1++), if they met the criteria of European Medicines Agency (EMA)-Guidance: Points to consider on applications with 1. meta-analyses; 2. one pivotal study. RESULTS For the medical section, the age of the study participants ranges from 6 months to 17 years. Regarding study efficacy, in children aged 6 months to ≤7 years, LAIV is superior to placebo as well as to a vac-cination with TIV (Relative Risk Reduction - RRR - of laboratory confirmed influenza infection approx. 80% and 50%, respectively). In children aged >7 to 17 years (= 18th year of their lives), LAIV is superior to a vaccination with TIV (RRR 32%). For this age group, no studies that compared LAIV with placebo were identified. It can be concluded that there is high evidence for superior efficacy of LAIV (compared to placebo or TIV) among children aged 6 months to ≤7 years. For children from >7 to 17 years, there is moderate evidence for superiority of LAIV for children with asthma, while direct evidence for children from the general population is lacking for this age group. Due to the efficacy of LAIV in children aged 6 months to ≤7 years (high evidence) and the efficacy of LAIV in children with asthma aged >7 to 17 years (moderate evidence), LAIV is also very likely to be efficacious among children in the general population aged >7 to 17 years (indirect evidence). In the included studies with children aged 2 to 17 years, LAIV was safe and well-tolerated; while in younger children LAIV may increase the risk of obstruction of the airways (e.g. wheezing). In the majority of the evaluated epidemiological studies, LAIV proved to be effective in the prevention of influenza among children aged 2-17 years under everyday conditions (effectiveness). The trend appears to indicate that LAIV is more effective than TIV, although this can only be based on limited evidence for methodological reasons (observational studies). In addition to a direct protective effect for vaccinated children themselves, indirect protective ("herd protection") effects were reported among non-vaccinated elderly population groups, even at relatively low vaccination coverage of children. With regard to safety, LAIV generally can be considered equivalent to TIV. This also applies to the use among children with mild chronically obstructive conditions, from whom LAIV therefore does not have to be withheld. In all included epidemiological studies, there was some risk of bias identified, e.g. due to residual confounding or other methodology-related sources of error. In the evaluated studies, both the vaccination of children with previous illnesses and the routine vaccination of (healthy) children frequently involve cost savings. This is especially the case if one includes indirect costs from a societal perspective. From a payer perspective, a routine vaccination of children is often regarded as a highly cost-effective intervention. However, not all of the studies arrive at consistent results. In isolated cases, relatively high levels of cost-effectiveness are reported that make it difficult to perform a conclusive assessment from an economic perspective. Based on the included studies, it is not possible to make a clear statement about the budget impact of using LAIV. None of the evaluated studies provides results for the context of the German healthcare setting. The efficacy of the vaccine, physicians' recommendations, and a potential reduction in influenza symptoms appear to play a role in the vaccination decision taken by parents/custodians on behalf of their children. Major barriers to the utilization of influenza vaccination services are a low level of perception and an underestimation of the disease risk, reservations concerning the safety and efficacy of the vaccine, and potential side effects of the vaccine. For some of the parents surveyed, the question as to whether the vaccine is administered as an injection or nasal spray might also be important. CONCLUSION In children aged 2 to 17 years, the use of LAIV can lead to a reduction of the number of influenza cases and the associated burden of disease. In addition, indirect preventive effects may be expected, especially among elderly age groups. Currently there are no data available for the German healthcare setting. Long-term direct and indirect effectiveness and safety should be supported by surveillance programs with a broader use of LAIV. Since there is no general model available for the German healthcare setting, statements concerning the cost-effectiveness can be made only with precaution. Beside this there is a need to conduct health eco-nomic studies to show the impact of influenza vaccination for children in Germany. Such studies should be based on a dynamic transmission model. Only these models are able to include the indirect protective effects of vaccination correctly. With regard to ethical, social and legal aspects, physicians should discuss with parents the motivations for vaccinating their children and upcoming barriers in order to achieve broader vaccination coverage. The present HTA provides an extensive basis for further scientific approaches and pending decisions relating to health policy.
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Affiliation(s)
- Frank Andersohn
- Institut für Sozialmedizin, Epidemiologie und Gesundheitsökonomie, Charité - Universitätsmedizin Berlin, Germany ; Frank Andersohn Consulting & Research Services, Berlin, Germany
| | - Reinhard Bornemann
- Universität Bielefeld, Fakultät für Gesundheitswissenschaften, Bielefeld, Germany
| | - Oliver Damm
- Universität Bielefeld, Fakultät für Gesundheitswissenschaften, Bielefeld, Germany
| | - Martin Frank
- Center for Health Economics Research Hannover, Germany
| | - Thomas Mittendorf
- Herescon GmbH - health economic research & consulting, Hannover, Germany
| | - Ulrike Theidel
- Center for Health Economics Research Hannover, Germany ; Herescon GmbH - health economic research & consulting, Hannover, Germany
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Kramer VG, Byrareddy SN. The value of HIV protective epitope research for informed vaccine design against diverse viral pathogens. Expert Rev Vaccines 2014; 13:935-7. [PMID: 24964950 DOI: 10.1586/14760584.2014.928597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The success of vaccine regimens against viral pathogens hinges on the elicitation of protective responses. Hypervariable pathogens such as HIV avoid neutralization by masking protective epitopes with more immunogenic decoys. The identification of protective, conserved epitopes is crucial for future vaccine candidate design. The strategies employed for identification of HIV protective epitopes will also aid towards rational vaccine design for other viral pathogens.
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Affiliation(s)
- Victor G Kramer
- McGill AIDS Centre, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
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Abstract
Influenza is a worldwide public health concern. Since the introduction of trivalent influenza vaccine in 1978, vaccination has been the primary means of prevention and control of influenza. Current influenza vaccines have moderate efficacy, good safety, and acceptable tolerability; however, they have unsatisfactory efficacy in older adults, are dependent on egg supply for production, and are time-consuming to manufacture. This review outlines the unmet medical needs of current influenza vaccines. Recent developments in influenza vaccines are also described.
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Affiliation(s)
- Ji Yun Noh
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea. ; Asian Pacific Influenza Institute, Korea University College of Medicine, Seoul, Korea
| | - Woo Joo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea. ; Asian Pacific Influenza Institute, Korea University College of Medicine, Seoul, Korea. ; Transgovernmental Enterprise for Pandemic Influenza in Korea, Seoul, Korea
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Lukšić I, Clay S, Falconer R, Pulanic D, Rudan I, Campbell H, Nair H. Effectiveness of seasonal influenza vaccines in children -- a systematic review and meta-analysis. Croat Med J 2013; 54:135-45. [PMID: 23630141 PMCID: PMC3662362 DOI: 10.3325/cmj.2013.54.135] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aim To assess the efficacy and effectiveness of seasonal influenza vaccines in healthy children up to the age of 18 years. Methods MedLine, EMBASE, CENTRAL, CINAHL, WHOLIS, LILACS, and Global Health were searched for randomized controlled trials and cohort and case-control studies investigating the efficacy or effectiveness of influenza vaccines in healthy children up to the age of 18 years. The studies were assessed for their quality and data on the outcomes of influenza-like illness, laboratory-confirmed influenza, and hospitalizations were extracted. Seven meta-analyses were performed for different vaccines and different study outcomes. Results Vaccine efficacy for live vaccines, using random effects model, was as follows: (i) for similar antigen, using per-protocol analysis: 83.4% (78.3%-88.8%); (ii) for similar antigen, using intention to treat analysis: 82.5 (76.7%-88.6%); (iii) for any antigen, using per protocol analysis: 76.4% (68.7%-85.0%); (iv) for any antigen, using intention to treat analysis: 76.7% (68.8%-85.6%). Vaccine efficacy for inactivated vaccines, for similar antigen, using random effects model, was 67.3% (58.2%-77.9%). Vaccine effectiveness against influenza-like illness for live vaccines, using random effects model, was 31.4% (24.8%-39.6%) and using fixed-effect model 44.3% (42.6%-45.9%). Vaccine effectiveness against influenza-like illness for inactivated vaccines, using random effects model, was 32.5% (20.0%-52.9%) and using fixed-effect model 42.6% (38.3%-47.5%). Conclusions Influenza vaccines showed high efficacy in children, particularly live vaccines. Effectiveness was lower and the data on hospitalizations were very limited.
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Affiliation(s)
- Ivana Lukšić
- Ivana Luksic, Institute of Public Health, Dr Andrija Štampar, Department of Microbiology, Mirogojska 16, 10000 Zagreb, Croatia.
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Wells CR, Klein EY, Bauch CT. Policy resistance undermines superspreader vaccination strategies for influenza. PLoS Comput Biol 2013; 9:e1002945. [PMID: 23505357 PMCID: PMC3591296 DOI: 10.1371/journal.pcbi.1002945] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 01/11/2013] [Indexed: 11/19/2022] Open
Abstract
Theoretical models of infection spread on networks predict that targeting vaccination at individuals with a very large number of contacts (superspreaders) can reduce infection incidence by a significant margin. These models generally assume that superspreaders will always agree to be vaccinated. Hence, they cannot capture unintended consequences such as policy resistance, where the behavioral response induced by a new vaccine policy tends to reduce the expected benefits of the policy. Here, we couple a model of influenza transmission on an empirically-based contact network with a psychologically structured model of influenza vaccinating behavior, where individual vaccinating decisions depend on social learning and past experiences of perceived infections, vaccine complications and vaccine failures. We find that policy resistance almost completely undermines the effectiveness of superspreader strategies: the most commonly explored approaches that target a randomly chosen neighbor of an individual, or that preferentially choose neighbors with many contacts, provide at best a 2% relative improvement over their non-targeted counterpart as compared to 12% when behavioral feedbacks are ignored. Increased vaccine coverage in super spreaders is offset by decreased coverage in non-superspreaders, and superspreaders also have a higher rate of perceived vaccine failures on account of being infected more often. Including incentives for vaccination provides modest improvements in outcomes. We conclude that the design of influenza vaccine strategies involving widespread incentive use and/or targeting of superspreaders should account for policy resistance, and mitigate it whenever possible.
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Affiliation(s)
- Chad R Wells
- Department of Mathematics and Statistics, University of Guelph, Guelph, Ontario, Canada.
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Jefferson T, Rivetti A, Di Pietrantonj C, Demicheli V, Ferroni E. Vaccines for preventing influenza in healthy children. Cochrane Database Syst Rev 2012; 2012:CD004879. [PMID: 22895945 PMCID: PMC6478137 DOI: 10.1002/14651858.cd004879.pub4] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The consequences of influenza in children and adults are mainly absenteeism from school and work. However, the risk of complications is greatest in children and people over 65 years of age. OBJECTIVES To appraise all comparative studies evaluating the effects of influenza vaccines in healthy children, assess vaccine efficacy (prevention of confirmed influenza) and effectiveness (prevention of influenza-like illness (ILI)) and document adverse events associated with influenza vaccines. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3) which includes the Acute Respiratory Infections Group's Specialised Register, OLD MEDLINE (1950 to 1965), MEDLINE (1966 to November 2011), EMBASE (1974 to November 2011), Biological Abstracts (1969 to September 2007), and Science Citation Index (1974 to September 2007). SELECTION CRITERIA Randomised controlled trials (RCTs), cohort and case-control studies of any influenza vaccine in healthy children under 16 years of age. DATA COLLECTION AND ANALYSIS Four review authors independently assessed trial quality and extracted data. MAIN RESULTS We included 75 studies with about 300,000 observations. We included 17 RCTs, 19 cohort studies and 11 case-control studies in the analysis of vaccine efficacy and effectiveness. Evidence from RCTs shows that six children under the age of six need to be vaccinated with live attenuated vaccine to prevent one case of influenza (infection and symptoms). We could find no usable data for those aged two years or younger.Inactivated vaccines in children aged two years or younger are not significantly more efficacious than placebo. Twenty-eight children over the age of six need to be vaccinated to prevent one case of influenza (infection and symptoms). Eight need to be vaccinated to prevent one case of influenza-like-illness (ILI). We could find no evidence of effect on secondary cases, lower respiratory tract disease, drug prescriptions, otitis media and its consequences and socioeconomic impact. We found weak single-study evidence of effect on school absenteeism by children and caring parents from work. Variability in study design and presentation of data was such that a meta-analysis of safety outcome data was not feasible. Extensive evidence of reporting bias of safety outcomes from trials of live attenuated influenza vaccines (LAIVs) impeded meaningful analysis. One specific brand of monovalent pandemic vaccine is associated with cataplexy and narcolepsy in children and there is sparse evidence of serious harms (such as febrile convulsions) in specific situations. AUTHORS' CONCLUSIONS Influenza vaccines are efficacious in preventing cases of influenza in children older than two years of age, but little evidence is available for children younger than two years of age. There was a difference between vaccine efficacy and effectiveness, partly due to differing datasets, settings and viral circulation patterns. No safety comparisons could be carried out, emphasising the need for standardisation of methods and presentation of vaccine safety data in future studies. In specific cases, influenza vaccines were associated with serious harms such as narcolepsy and febrile convulsions. It was surprising to find only one study of inactivated vaccine in children under two years, given current recommendations to vaccinate healthy children from six months of age in the USA, Canada, parts of Europe and Australia. If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes, and directly comparing vaccine types are urgently required. The degree of scrutiny needed to identify all global cases of potential harms is beyond the resources of this review. This review includes trials funded by industry. An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry-funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favourable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in the light of this finding.
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The impact of personal experiences with infection and vaccination on behaviour-incidence dynamics of seasonal influenza. Epidemics 2012; 4:139-51. [PMID: 22939311 DOI: 10.1016/j.epidem.2012.06.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 06/12/2012] [Accepted: 06/25/2012] [Indexed: 11/24/2022] Open
Abstract
Personal experiences with past infection events, or perceived vaccine failures and complications, are known to drive vaccine uptake. We coupled a model of individual vaccinating decisions, influenced by these drivers, with a contact network model of influenza transmission dynamics. The impact of non-influenzal influenza-like illness (niILI) on decision-making was also incorporated: it was possible for individuals to mistake niILI for true influenza. Our objectives were to (1) evaluate the impact of personal experiences on vaccine coverage; (2) understand the impact of niILI on behaviour-incidence dynamics; (3) determine which factors influence vaccine coverage stability; and (4) determine whether vaccination strategies can become correlated on the network in the absence of social influence. We found that certain aspects of personal experience can significantly impact behaviour-incidence dynamics. For instance, longer term memory for past events had a strong stabilising effect on vaccine coverage dynamics, although it could either increase or decrease average vaccine coverage depending on whether memory of past infections or past vaccine failures dominated. When vaccine immunity wanes slowly, vaccine coverage is low and stable, and infection incidence is also very low, unless the effects of niILI are ignored. Strategy correlations can occur in the absence of imitation, on account of the neighbour-neighbour transmission of infection and history-dependent decision making. Finally, niILI weakens the behaviour-incidence coupling and therefore tends to stabilise dynamics, as well as breaking up strategy correlations. Behavioural feedbacks, and the quality of self-diagnosis of niILI, may need to be considered in future programs adopting "universal" flu vaccines conferring long-term immunity. Public health interventions that focus on reminding individuals about their previous influenza infections, as well as communicating facts about vaccine efficacy and the difference between influenza and niILI, may be an effective way to increase vaccine coverage and prevent unexpected drops in coverage.
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Giglio N, Gentile A, Lees L, Micone P, Armoni J, Reygrobellet C, Crépey P. Public health and economic benefits of new pediatric influenza vaccination programs in Argentina. Hum Vaccin Immunother 2012; 8:312-22. [PMID: 22330959 PMCID: PMC3426079 DOI: 10.4161/hv.18569] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Argentina’s population was heavily affected by the 2009 influenza pandemic, particularly children, in whom incidence of seasonal influenza is consistently high. Following the pandemic, Argentinean national recommendations for pediatric vaccination against A/H1N1 influenza were defined for all children aged up to five years, in line with programs implemented by national authorities elsewhere. Economic evaluations have found that vaccination programs for this population against seasonal influenza are cost-effective, if not cost-saving in many countries. Recently, Argentina decided to routinely vaccinate against influenza children aged 6–23 mo-old. But, the economic value of such strategies for the country has never been assessed.
Methods: A model was developed to assess the value of four different vaccination strategies: (1) no pediatric vaccination; (2) vaccination of 6–23 mo-old children; (3) vaccination of 6–36 mo-old children; (4) vaccination of 6 mo−5 y-old children. We first estimated community health benefits of vaccination then we evaluated the economic and quality-of-life impact of these strategies on the population. Data used in the model come from surveillance networks, published literature, national databases and retrospective hospital-based data. Results: Pediatric influenza vaccination benefited not only children but also the overall community, due to decreased disease transmission. Our results showed that the recent decision by Argentina to vaccinate 6–23 mo-old children is cost-effective as would be the incremental vaccination of broader age groups. Conclusions: Results from this study are consistent with previous analyses in other countries confirming that implementing influenza pediatric vaccination programs can be highly cost-effective through individual- and community protection against the disease.
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Affiliation(s)
- Norberto Giglio
- Epidemiología Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
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22
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Glaser MS, Chui S, Webber MP, Gustave J, Lee R, McLaughlin MT, Ortiz V, Prezant D, Kelly K. Predictors of acceptance of H1N1 influenza vaccination by FDNY firefighters and EMS workers. Vaccine 2011; 29:5675-80. [PMID: 21693157 DOI: 10.1016/j.vaccine.2011.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 05/24/2011] [Accepted: 06/07/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a widely recognized need for vaccination of health care workers (HCWs). We undertook this study to assess the 2009-2010 H1N1 vaccination rates in ∼14,000 firefighters and emergency medical service (EMS) workers at the Fire Department of New York (FDNY) and to determine predictors of H1N1 vaccine acceptance. METHODS After 9/11/01, FDNY developed a bio-preparedness drill where units are dispatched to FDNY-BIOPOD (biologic points of distributions) for rapid distribution of medications/vaccines in the event of a biological disaster. Since 2005, FDNY offers free, voluntary seasonal influenza vaccination during routine medical monitoring/treatment examinations and at FDNY-BIOPOD. In 2009, FDNY-BIOPOD instead offered the H1N1 vaccine. We report on FDNY H1N1 vaccination rates and on predictors of acceptance using bivariate and multivariable techniques. RESULTS Overall, 10,612 (77%) FDNY workers were offered H1N1 vaccination, of whom 5831 (55%) accepted. Acceptance was 57.2% during FDNY-BIOPOD compared with 34.4% during medical monitoring/treatment exams (p=0.0001). Workers who accepted prior seasonal influenza vaccinations were 4 times more likely to accept H1N1 vaccination (AOR=4.4, CI(95)=4.0-4.8). CONCLUSION FDNY offered H1N1 vaccination to 77% of its workforce during the 2009-2010 season. Prior seasonal vaccine acceptance and vaccination in a group setting such as FDNY-BIOPOD dramatically increased acceptance of the H1N1 vaccine. However, within a voluntary program, additional strategies are needed to further increase vaccine acceptance in first responders and other HCWs.
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Affiliation(s)
- Michelle S Glaser
- Department of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
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Cohen SA, Chui KKH, Naumova EN. Influenza vaccination in young children reduces influenza-associated hospitalizations in older adults, 2002-2006. J Am Geriatr Soc 2011; 59:327-32. [PMID: 21275932 DOI: 10.1111/j.1532-5415.2010.03271.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess how influenza vaccination coverage in children is related to pneumonia and influenza (P&I) in older adults and whether sociodemographic factors modify these associations. DESIGN Approximately 5 million hospitalization records from the Centers for Medicare and Medicaid Services for four influenza years (2002-2006) were abstracted. A single-year age distribution of rates of P&I hospitalization was estimated according to state for each influenza season; an exponential acceleration in the P&I rates with age was observed for each influenza season. State- and season-specific P&I rate accelerations were regressed against the percentage of vaccinated children, older adults, or both using mixed effects models. SETTING U.S. population, 2002 to 2006. PARTICIPANTS U.S. population aged 65 and older. MEASUREMENTS State-level influenza annual vaccination coverage data in children and older adults were obtained from the National Immunization Survey and the Behavioral Risk Factor Surveillance System, respectively. RESULTS Child influenza vaccination coverage was negatively associated with age acceleration in P&I, whereas influenza vaccination in the older adults themselves was not significantly associated with P&I in older adults. CONCLUSION Vaccination of children against influenza may induce herd immunity against influenza for older adults and has the potential to be more beneficial to older adults than the existing policy of preventing influenza by vaccinating older adults themselves.
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Affiliation(s)
- Steven A Cohen
- Initiative for the Forecasting and Modeling of Infectious Disease, Tufts University, Boston, Massachusetts, USA.
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Tran CH, McElrath J, Hughes P, Ryan K, Munden J, Castleman JB, Johnson J, Doty R, McKay DR, Stringfellow J, Holmes RA, Myers PD, Small PA, Morris JG. Implementing a Community-Supported School-Based Influenza Immunization Program. Biosecur Bioterror 2010; 8:331-41. [DOI: 10.1089/bsp.2010.0029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Cuc H. Tran
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Josephine McElrath
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Patricia Hughes
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Kathleen Ryan
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Jean Munden
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Joan B. Castleman
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Jackie Johnson
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Randell Doty
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Dallas R. McKay
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Jim Stringfellow
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Rosalee A. Holmes
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Paul D. Myers
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - Parker A. Small
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
| | - J. Glenn Morris
- Cuc H. Tran, MPH, is Program Coordinator; Rosalee A. Holmes, BS, is Assistant Program Coordinator; and J. Glenn Morris, Jr., MD, is Professor and Director; all in the Emerging Pathogens Institute, University of Florida, Gainesville. Kathleen Ryan, MD, is Assistant Professor and Community Liaison, Department of Pediatrics; Joan B. Castleman, MS, is Clinical Associate Professor, College of Nursing; Dallas R. McKay, DO, is a pediatric resident; and Parker A. Small, Jr., MD, is Professor Emeritus, Department
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Chi RC, Reiber GE, Lipsky BA, Boyko EJ, Neuzil KM. Influenza vaccination rates of children in households with high-risk adults. Public Health Rep 2010; 125:192-8. [PMID: 20297745 DOI: 10.1177/003335491012500207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Household contacts of people at high risk for influenza complications should receive yearly influenza vaccination to reduce potential viral transmission. We evaluated influenza vaccine coverage among children to determine whether or not living with a high-risk adult predicts the likelihood of being vaccinated. METHODS Using the 2006 National Health Interview Survey, we examined influenza vaccination rates among children (aged 1-17 years) who did and did not reside in a household with an adult at high risk for influenza-related complications. RESULTS Among 24,195 sampled families, there were 8,976 high-risk adults, 18.9% of whom reported living with a person 17 years of age of younger. Influenza vaccination rates by age group among children living with high-risk adults were 41.7% (1 year), 30.3% (2-4 years), and 20.0% (5-17 years). Unadjusted influenza vaccination rates were significantly higher for school-aged children who lived with a high-risk adult compared with those who did not (20.0% vs. 15.0%, p < 0.001). Among children younger than 5 years of age, for whom vaccination was universally recommended at the time of the survey, the rates did not differ. After adjusting for the child's age, gender, race, insurance coverage, medical visits, and chronic conditions, children who lived with a high-risk adult were not statistically more likely than those who did not live with a high-risk adult to receive influenza vaccination (odds ratio = 1.16, 95% confidence interval 0.99, 1.36). CONCLUSIONS Children had low rates of influenza vaccination, and those who lived with high-risk adults were not significantly more likely to be vaccinated. Clinicians caring for high-risk adults should remind eligible household contacts to receive influenza vaccine.
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Affiliation(s)
- Ru-Chien Chi
- Veterans Administration Puget Sound Health Care System, Seattle, WA, USA.
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Adalja A, Crooke P, Hotchkiss J. Influenza Transmission in Preschools: Modulation by contact landscapes and interventions. MATHEMATICAL MODELLING OF NATURAL PHENOMENA 2010; 5:3-14. [PMID: 20967134 PMCID: PMC2956988 DOI: 10.1051/mmnp/20105301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Epidemiologic data suggest that schools and daycare facilities likely play a major role in the dissemination of influenza. Pathogen transmission within such small, inhomogenously mixed populations is difficult to model using traditional approaches. We developed simulation based mathematical tool to investigate the effects of social contact networks on pathogen dissemination in a setting analogous to a daycare center or grade school. Here we show that interventions that decrease mixing within child care facilities, including limiting the size of social clusters, reducing the contact frequency between social clusters, and eliminating large gatherings, could diminish pathogen dissemination. Moreover, these measures may amplify the effectiveness of vaccination or antiviral prophylaxis, even if the vaccine is not uniformly effective or antiviral compliance is incomplete. Similar considerations should apply to other small, imperfectly mixed populations, such as offices and schools.
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Affiliation(s)
- A.A. Adalja
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh
| | - P.S. Crooke
- Department of Mathematics, Vanderbilt University
| | - J.R. Hotchkiss
- Departments of Critical Care Medicine and Medicine, University of Pittsburgh
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Goldstein E, Apolloni A, Lewis B, Miller JC, Macauley M, Eubank S, Lipsitch M, Wallinga J. Distribution of vaccine/antivirals and the 'least spread line' in a stratified population. J R Soc Interface 2009; 7:755-64. [PMID: 19828505 DOI: 10.1098/rsif.2009.0393] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We describe a prioritization scheme for an allocation of a sizeable quantity of vaccine or antivirals in a stratified population. The scheme builds on an optimal strategy for reducing the epidemic's initial growth rate in a stratified mass-action model. The strategy is tested on the EpiSims network describing interactions and influenza dynamics in the population of Utah, where the stratification we have chosen is by age (0-6, 7-13, 14-18, adults). No prior immunity information is available, thus everyone is assumed to be susceptible-this may be relevant, possibly with the exception of persons over 50, to the 2009 H1N1 influenza outbreak. We have found that the top priority in an allocation of a sizeable quantity of seasonal influenza vaccinations goes to young children (0-6), followed by teens (14-18), then children (7-13), with the adult share being quite low. These results, which rely on the structure of the EpiSims network, are compared with the current influenza vaccination coverage levels in the US population.
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Affiliation(s)
- E Goldstein
- Harvard School of Public Health, Boston, MA 02115, USA.
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Basta NE, Halloran ME, Matrajt L, Longini IM. Estimating influenza vaccine efficacy from challenge and community-based study data. Am J Epidemiol 2008; 168:1343-52. [PMID: 18974084 PMCID: PMC2638553 DOI: 10.1093/aje/kwn259] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In this paper, the authors provide estimates of 4 measures of vaccine efficacy for live, attenuated and inactivated influenza vaccine based on secondary analysis of 5 experimental influenza challenge studies in seronegative adults and community-based vaccine trials. The 4 vaccine efficacy measures are for susceptibility (VES), symptomatic illness given infection (VEP), infection and illness (VESP), and infectiousness (VEI). The authors also propose a combined (VEC) measure of the reduction in transmission in the entire population based on all of the above efficacy measures. Live influenza vaccine and inactivated vaccine provided similar protection against laboratory-confirmed infection (for live vaccine: VES = 41%, 95% confidence interval (CI): 15, 66; for inactivated vaccine: VES = 43%, 95% CI: 8, 79). Live vaccine had a higher efficacy for illness given infection (VEP = 67%, 95% CI: 24, 100) than inactivated vaccine (VEP = 29%, 95% CI: −19, 76), although the difference was not statistically significant. VESP for the live vaccine was higher than for the inactivated vaccine. VEI estimates were particularly low for these influenza vaccines. VESP and VEC can remain high for both vaccines, even when VEI is relatively low, as long as the other 2 measures of vaccine efficacy are relatively high.
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Affiliation(s)
- Nicole E Basta
- Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, Washington, USA
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Safety of the intranasal, trivalent, live attenuated influenza vaccine (LAIV) in children with intermittent wheezing in an open-label field trial. Pediatr Infect Dis J 2008; 27:444-52. [PMID: 18401289 DOI: 10.1097/inf.0b013e3181660c2e] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Safety of the intranasal, trivalent, live attenuated influenza vaccine (LAIV) in children with asthma is unknown. A previous report showed an "asthma signal" in children aged 18-35 months. METHODS Healthy children aged 1.5-18 years with history of intermittent wheezing received single annual LAIV doses during a 4-year trial. Rates of medically-attended acute respiratory illnesses, including acute asthma exacerbation, during 0-14 and 0-42 days post-LAIV were compared with respective reference periods (before day 0 and after 14 or 42 days). To assess the risk of new-onset asthma, LAIV recipients without history of wheezing were analyzed. RESULTS During each of the 4 years, 454, 656, 656, and 430 children, respectively, with intermittent wheezing who received LAIV had no increased risk for medically-attended acute respiratory illnesses, including asthma exacerbation. First-dose LAIV recipients, including those aged 1.5-4 years, and those receiving 2-4 consecutive annual doses had no increased risk. Children with parents' report of intermittent wheezing and those with administrative database codes for asthma during 2 prior years had no increased risk. During the 4 years, 2952, 3092, 2953, and 2478 children without history of wheezing had no increased risk of new-onset asthma. CONCLUSIONS LAIV administration in children aged 1.5-18 years with history of intermittent wheezing was safe, and was not associated with increased risk for medically-attended acute respiratory illnesses, including acute asthma exacerbation. This was true for the first and 2-4 consecutive annual doses. Parents' report of intermittent wheezing was reliable. First-dose LAIV was not associated with new-onset asthma in children without history of wheezing.
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Jefferson T, Rivetti A, Harnden A, Di Pietrantonj C, Demicheli V. Vaccines for preventing influenza in healthy children. Cochrane Database Syst Rev 2008:CD004879. [PMID: 18425905 DOI: 10.1002/14651858.cd004879.pub3] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The consequences of influenza in children and adults are mainly absenteeism from school and work. However, the risk of complications is greatest in children and people over 65 years old. OBJECTIVES To appraise all comparative studies evaluating the effects of influenza vaccines in healthy children; assess vaccine efficacy (prevention of confirmed influenza) and effectiveness (prevention of influenza-like illness) and document adverse events associated with influenza vaccines. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 3); OLD MEDLINE (1950 to 1965); MEDLINE (1966 to September 2007); EMBASE (1974 to September 2007); Biological Abstracts (1969 to September 2007); and Science Citation Index (1974 to September 2007). SELECTION CRITERIA Randomised controlled trials (RCTs), cohort and case-control studies of any influenza vaccine in healthy children under 16 years of age. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. MAIN RESULTS Fifty-one studies with 294,159 observations were included. Sixteen RCTs and 18 cohort studies were included in the analysis of vaccine efficacy and effectiveness. From RCTs, live vaccines showed an efficacy of 82% (95% confidence interval (CI) 71% to 89%) and an effectiveness of 33% (95% CI 28% to 38%) in children older than two compared with placebo or no intervention. Inactivated vaccines had a lower efficacy of 59% (95% CI 41% to 71%) than live vaccines but similar effectiveness: 36% (95% CI 24% to 46%). In children under two, the efficacy of inactivated vaccine was similar to placebo. Variability in study design and presentation of data was such that a meta-analysis of safety outcome data was not feasible. Extensive evidence of reporting bias of safety outcomes from trials of live attenuated vaccines impeded meaningful analysis. AUTHORS' CONCLUSIONS Influenza vaccines are efficacious in children older than two but little evidence is available for children under two. There was a marked difference between vaccine efficacy and effectiveness. No safety comparisons could be carried out, emphasizing the need for standardisation of methods and presentation of vaccine safety data in future studies. It was surprising to find only one study of inactivated vaccine in children under two years, given current recommendations to vaccinate healthy children from six months old in the USA and Canada. If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes and directly comparing vaccine types are urgently required.
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Affiliation(s)
- Tom Jefferson
- Vaccines Field, Cochrane Collaboration, Via Adige 28a, Anguillara Sabazia, Roma, Italy, 00061
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The challenges of eliciting neutralizing antibodies to HIV-1 and to influenza virus. Nat Rev Microbiol 2008; 6:143-55. [PMID: 18197170 DOI: 10.1038/nrmicro1819] [Citation(s) in RCA: 247] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The ability to elicit broadly neutralizing antibody responses against HIV-1 is a crucial goal for a prophylactic HIV-1 vaccine. Here, we discuss the difficulties of achieving broad HIV-1 neutralization in the context of both the effective annual human influenza virus vaccine and the need to develop a pandemic influenza vaccine. Immunogen-design strategies are underway to target functionally conserved regions of the HIV-1 envelope glycoproteins, and similar strategies might be applicable to pandemic influenza virus vaccine development. Efforts to develop broadly neutralizing vaccines against either HIV-1 or influenza virus might establish a paradigm for future vaccines against highly variable pathogens.
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Belshe RB, Walker R, Stoddard JJ, Kemble G, Maassab HF, Mendelman PM. Influenza vaccine-live. Vaccines (Basel) 2008. [DOI: 10.1016/b978-1-4160-3611-1.50020-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Radonovich, Jr. LJ, Bender BS, Small, Jr. PA. Children Should Be Among the Highest Priority Groups to Receive Immunization for Seasonal and Pandemic Influenza. Biosecur Bioterror 2007; 5:363-5. [DOI: 10.1089/bsp.2007.0060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lewis J. Radonovich, Jr.
- Director, Biosecurity Programs, Office of Program Development, North Florida/South Georgia Veterans Health System, Adjunct Assistant Professor of Medicine, University of Florida, College of Medicine, Mailstop 151B, Gainesville, FL 32608.
| | - Bradley S. Bender
- Chief of Staff, North Florida/South Georgia, Veterans Health System, Professor of Medicine, University of Florida, College of Medicine, Gainesville, FL.
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Hibbert CL, Piedra PA, McLaurin KK, Vesikari T, Mauskopf J, Mahadevia PJ. Cost-effectiveness of live-attenuated influenza vaccine, trivalent in preventing influenza in young children attending day-care centres. Vaccine 2007; 25:8010-20. [PMID: 17936446 DOI: 10.1016/j.vaccine.2007.09.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Revised: 08/29/2007] [Accepted: 09/06/2007] [Indexed: 11/16/2022]
Abstract
Vaccinating children at day-care may be a cost-effective approach for improving influenza immunization rates in this high-risk group. This study uses influenza attack-rate data from a randomized, blinded, placebo-controlled clinical trial of live-attenuated influenza vaccine, trivalent in day-care centres from two consecutive influenza seasons, one with a moderate attack rate (H1N1 dominant) and one with a high attack rate (H3N2 dominant). Costs were measured in US dollars. In the moderate attack-rate season (vaccinated, 2.2%; placebo, 13.4%), vaccination saved US$ 5.47 per child in societal costs. In the high attack-rate season (vaccinated, 4.7%; placebo, 32.1%), vaccination led to a societal costs savings of US$ 144.44 per child.
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Affiliation(s)
- Clare L Hibbert
- RTI Health Solutions, Williams House, Manchester Science Park, Lloyd Street North, Manchester M15 6SE, United Kingdom.
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37
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Halloran ME, Piedra PA, Longini IM, Gaglani MJ, Schmotzer B, Fewlass C, Herschler GB, Glezen WP. Efficacy of trivalent, cold-adapted, influenza virus vaccine against influenza A (Fujian), a drift variant, during 2003-2004. Vaccine 2007; 25:4038-45. [PMID: 17395338 PMCID: PMC2883284 DOI: 10.1016/j.vaccine.2007.02.060] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 02/07/2007] [Accepted: 02/15/2007] [Indexed: 11/26/2022]
Abstract
In the 2003-2004 influenza season, the predominant circulating influenza A (H3N2) virus in the United States was similar antigenically to A/Fujian/411/2002 (H3N2), a drift variant of A/Panama/2007/99 (H3N2), the vaccine strain. That year, a field study of trivalent live-attenuated influenza vaccine (LAIV-T) was conducted in Temple-Belton, Texas, as part of a larger community-based, non-randomized, open-label study in three communities that began in August 1998 [Gaglani MJ, Piedra PA, Herschler GB, Griffith ME, Kozinetz CA, Riggs MW, et al. Direct effectiveness of the trivalent, cold-adapted, influenza virus vaccine (CAIV-T) against the 2000-2001 influenza A (H1N1) and B epidemic in healthy children. Arch Pediatr Adolesc Med 2004;158:65-73; Piedra PA, Gaglani MJ, Kozinetz CA, Herschler G, Riggs M, Griffith M, et al. Herd immunity in adults against influenza-related illnesses with use of the trivalent-live attenuated influenza vaccine (CAIV-T) in children. Vaccine 2005;23:1540-8; Piedra PA, Gaglani MJ, Riggs M, Herschler G, Fewlass C, Watts M, et al. Live attenuated influenza vaccine, trivalent, is safe in healthy children 18 months to 4 years, 5 to 9 years, and 10 to 18 years of age in a community-based, nonrandomized, open-label trial. Pediatrics 2005;116:397-407]. Participants were healthy children aged 5-18 years. The analysis here concerns 6403 children in the Scott & White Health Plan (SWHP) database living within zip codes of the Temple-Belton area, of whom 1706 received LAIV-T and 548 received trivalent inactivated vaccine (TIV) in 2003, 983 had been previously vaccinated in 1998-2001, but not in 2002-2003 or 2003, and 3166 had never been vaccinated. The main outcome measure was medically-attended acute respiratory illness (MAARI). Surveillance culture results were incorporated into the analysis to estimate efficacy against culture-confirmed influenza illness. Vaccine effectiveness of LAIV-T against MAARI was 26% (95% confidence interval (CI) 11, 39). Vaccine efficacy of LAIV-T against culture-confirmed influenza illness including surveillance cultures of children in the SWHP database in the validation calculation was 56% (95% CI 24, 84). LAIV-T was cross-protective with a drift variant strain in 2003-2004, evidence that such vaccines could be important for preparing for a pandemic and for annual influenza.
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Affiliation(s)
- M Elizabeth Halloran
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA.
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Mair M, Grow RW, Mair JS, Radonovich LJ. Universal influenza vaccination: the time to act is now. Biosecur Bioterror 2006; 4:20-40. [PMID: 16545022 DOI: 10.1089/bsp.2006.4.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Annual influenza epidemics create a significant public health burden each year in the United States. That influenza continues to pose a public health threat despite being largely preventable through vaccination is indicative of continuing weaknesses in the U.S.'s public health system. Moreover, the burden of annual influenza epidemics and the fragility and instability of the capacity to respond to them underscore the U.S.'s ongoing vulnerability to pandemic influenza and highlights gaps in bioterrorism preparedness and response efforts. This article examines the burden of annual influenza epidemics in the U.S., efforts to combat that burden with vaccination, shortcomings of influenza vaccination efforts, and how those shortcomings exemplify weaknesses in pandemic influenza and bioterrorism preparedness efforts. We make the case for establishing an annual universal influenza vaccination program to assure access to influenza vaccination to anyone who can safely receive vaccination and desires it. Such a program could greatly reduce the annual burden of influenza while advancing and maintaining U.S. pandemic influenza and bioterrorism preparedness and response efforts.
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Affiliation(s)
- Michael Mair
- Center for Biosecurity of the University of Pittsburgh Medical Center, Baltimore, Maryland 21202, USA.
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39
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Mair M, Grow RW, Mair JS, Radonovich LJ. Universal Influenza Vaccination: The Time to Act Is Now. Biosecur Bioterror 2006. [DOI: 10.1089/bsp.2006.4.ft-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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40
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Carrat F, Lavenu A, Cauchemez S, Deleger S. Repeated influenza vaccination of healthy children and adults: borrow now, pay later? Epidemiol Infect 2006; 134:63-70. [PMID: 16409652 PMCID: PMC2870374 DOI: 10.1017/s0950268805005479] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2005] [Indexed: 11/05/2022] Open
Abstract
A growing number of publications are recommending annual influenza vaccination of healthy children and adults. However, the long-term consequences of repeated influenza vaccination are unknown. We used a simple model of recurrent influenza infection to assess the likely impact of various repeated influenza vaccination scenarios. The model was based on a Markovian framework and was fitted on annual incidence rates of influenza infection by age. We found that natural influenza infection reduced the risk of being re-infected by 15.4% (95% confidence interval 7.1-23.0). Various scenarios of repeated influenza vaccination were then simulated and compared with a reference scenario where vaccination is given from age 65 years onwards. We show that repeated vaccination at a young age substantially increases the risk of influenza in older age, by a factor ranging between 1.2 (vaccination after 50 years) to 2.4 (vaccination from birth). These findings have important implications for influenza vaccination policies.
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Affiliation(s)
- F Carrat
- Epidemiology and Information Sciences, U707, Institut national de la Santé et de la Recherche Médicale, Paris, France.
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41
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Smith S, Demicheli V, Di Pietrantonj C, Harnden AR, Jefferson T, Matheson NJ, Rivetti A. Vaccines for preventing influenza in healthy children. Cochrane Database Syst Rev 2006:CD004879. [PMID: 16437500 DOI: 10.1002/14651858.cd004879.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In children and adults the consequences of influenza are mainly absences from school and work, however the risk of complications is greatest in children and people over 65 years old. OBJECTIVES To appraise all comparative studies evaluating the effects of influenza vaccines in healthy children; assess vaccine efficacy (prevention of confirmed influenza) and effectiveness (prevention of influenza-like illness) and document adverse events associated with receiving influenza vaccines. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005); OLD MEDLINE (1966 to 1969); MEDLINE (1969 to December 2004); EMBASE (1974 to December 2004); Biological Abstracts (1969 to December 2004); and Science Citation Index (1974 to December 2004). We wrote to vaccine manufacturers and a number of corresponding authors of studies in the review. SELECTION CRITERIA Any randomised controlled trials (RCTs), cohort and case-control studies of any influenza vaccine in healthy children under 16 years old. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS Fifty-one studies involving 263,987 children were included. Seventeen papers were translated from Russian. Fourteen RCTs and 11 cohort studies were included in the analysis of vaccine efficacy and effectiveness. From RCTs, live vaccines showed an efficacy of 79% (95% confidence interval (CI) 48% to 92%) and an effectiveness of 33% (95% CI 28% to 38%) in children older than two years compared with placebo or no intervention. Inactivated vaccines had a lower efficacy of 59% (95% CI 41% to 71%) than live vaccines but similar effectiveness: 36% (95% CI 24% to 46%). In children under two, the efficacy of inactivated vaccine was similar to placebo. Thirty-four reports containing safety outcomes were included, 22 including live vaccines, 8 inactivated vaccines and 4 both types. The most commonly presented short-term outcomes were temperature and local reactions. The variability in design of studies and presentation of data was such that meta-analysis of safety outcome data was not feasible. AUTHORS' CONCLUSIONS Influenza vaccines are efficacious in children older than two years but little evidence is available for children under two. There was a marked difference between vaccine efficacy and effectiveness. That no safety comparisons could be carried out emphasizes the need for standardisation of methods and presentation of vaccine safety data in future studies. It was surprising to find only one study of inactivated vaccine in children under two years, given recent recommendations to vaccinate healthy children from six months old in the USA and Canada. If immunisation in children is to be recommended as public-health policy, large-scale studies assessing important outcomes and directly comparing vaccine types are urgently required.
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Affiliation(s)
- S Smith
- Oxford University, Institute of Health Sciences, Old Road Headington, Oxford, UK, OX3 7LF.
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42
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Brownstein JS, Kleinman KP, Mandl KD. Identifying pediatric age groups for influenza vaccination using a real-time regional surveillance system. Am J Epidemiol 2005; 162:686-93. [PMID: 16107568 PMCID: PMC1266301 DOI: 10.1093/aje/kwi257] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Evidence is accumulating that universal vaccination of schoolchildren would reduce the transmission of influenza. The authors sought to identify target age groups within the pediatric population that develop influenza the earliest and are most strongly linked with mortality in the population. Patient visits for respiratory illness were monitored, using real-time syndromic surveillance systems, in six Massachusetts health-care settings, including ambulatory care sites and emergency departments at tertiary-care and community hospitals. Visits from January 1, 2000, to September 30, 2004, were segmented into age group subpopulations. Timeliness and prediction of each subpopulation were measured against pneumonia and influenza mortality in New England with time-series analyses and regression models. Study results show that patient age significantly influences timeliness (p = 0.026), with pediatric age groups arriving first (p < 0.001); children aged 3-4 years are consistently the earliest (p = 0.0058). Age also influences the degree of prediction of mortality (p = 0.036), with illness among children under age 5 years, compared with all other patients, most strongly associated with mortality (p < 0.001). Study findings add to a growing body of support for a strategy to vaccinate children older than the currently targeted age of 6-23 months and specifically suggest that there may be value in vaccinating preschool-age children.
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Affiliation(s)
- John S Brownstein
- Division of Emergency Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA 02215, USA.
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43
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Reina J. Nuevas indicaciones de la vacuna inactivada antigripal en la población infantil (2004-2005). An Pediatr (Barc) 2005; 63:45-9. [PMID: 15989871 DOI: 10.1157/13076767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Several epidemiological studies have indicated that, in all countries and in distinct epidemic years, the highest rates of influenza infection (between 15% and 42%) occur in the pediatric population, especially in school-aged children. Over various influenza seasons, the rates of annual outpatient visits attributable to influenza vary from 6-29% of children. Influenza and its complications have been reported to result in a 10-30% increase in the number of antibiotic courses prescribed to children during the influenza season. Current percentages of influenza vaccination in children are very low, although the hospitalization rates for infectious complications in children under 5 years are at least equal to those observed in individuals aged more than 65 years. The reasons for these low immunization rates are unknown, but many factors could be involved, especially the need for annual revaccination. In 2003 the Advisory Committee on Immunization Practices (ACIP) recommended influenza immunization only in children at high risk for influenza complications and in those living with someone in a high-risk group. However, they encouraged vaccination of all children aged 6-23 months old. After a review of various epidemiological studies, in 2004 both the ACIP and the American Academy of Pediatrics recommended systematic immunization of all healthy children within this age group. However, both institutions advise that before the routine introduction of influenza immunization in all children aged 6-23 months old, immunization programs in high-risk children need to be implemented.
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Affiliation(s)
- J Reina
- Centro Referencia Gripe Illes Balears, Unidad de Virología, Servicio de Microbiología, Hospital Universitario Son Dureta, Palma de Mallorca, España.
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44
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Negri E, Colombo C, Giordano L, Groth N, Apolone G, La Vecchia C. Influenza vaccine in healthy children: a meta-analysis. Vaccine 2005; 23:2851-61. [PMID: 15780733 DOI: 10.1016/j.vaccine.2004.11.053] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2004] [Revised: 11/18/2004] [Accepted: 11/26/2004] [Indexed: 10/26/2022]
Abstract
We conducted a meta-analysis of 13 randomised clinical trials evaluating the efficacy of influenza vaccine in healthy children. Against culture-confirmed influenza the overall efficacy was 74% (95% confidence interval, CI, 57%-84%), 65% for inactivated and 80% for live-attenuated vaccine. Corresponding figures were 59% (95% CI 43%-71%), 63% and 54% for serologically-confirmed influenza, and 33% (95% CI 29%-36%), 33% and 34% for clinical illness. Influenza vaccine is effective in preventing laboratory-confirmed and clinical influenza in healthy children, with no clear difference between inactivated and live-attenuated vaccine. Data on infants and younger children were too scanty to allow separate assessment.
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Affiliation(s)
- Eva Negri
- Istituto di Ricerche Farmacologiche Mario Negri, Via Eritrea 62, 20157 Milan, Italy.
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45
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Patel R, Longini IM, Halloran ME. Finding optimal vaccination strategies for pandemic influenza using genetic algorithms. J Theor Biol 2005; 234:201-12. [PMID: 15757679 DOI: 10.1016/j.jtbi.2004.11.032] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2004] [Revised: 09/23/2004] [Accepted: 11/22/2004] [Indexed: 11/16/2022]
Abstract
In the event of pandemic influenza, only limited supplies of vaccine may be available. We use stochastic epidemic simulations, genetic algorithms (GA), and random mutation hill climbing (RMHC) to find optimal vaccine distributions to minimize the number of illnesses or deaths in the population, given limited quantities of vaccine. Due to the non-linearity, complexity and stochasticity of the epidemic process, it is not possible to solve for optimal vaccine distributions mathematically. However, we use GA and RMHC to find near optimal vaccine distributions. We model an influenza pandemic that has age-specific illness attack rates similar to the Asian pandemic in 1957-1958 caused by influenza A(H2N2), as well as a distribution similar to the Hong Kong pandemic in 1968-1969 caused by influenza A(H3N2). We find the optimal vaccine distributions given that the number of doses is limited over the range of 10-90% of the population. While GA and RMHC work well in finding optimal vaccine distributions, GA is significantly more efficient than RMHC. We show that the optimal vaccine distribution found by GA and RMHC is up to 84% more effective than random mass vaccination in the mid range of vaccine availability. GA is generalizable to the optimization of stochastic model parameters for other infectious diseases and population structures.
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Affiliation(s)
- Rajan Patel
- Department of Biostatistics, The Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA
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46
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Piedra PA, Gaglani MJ, Kozinetz CA, Herschler G, Riggs M, Griffith M, Fewlass C, Watts M, Hessel C, Cordova J, Glezen WP. Herd immunity in adults against influenza-related illnesses with use of the trivalent-live attenuated influenza vaccine (CAIV-T) in children. Vaccine 2005; 23:1540-8. [PMID: 15694506 DOI: 10.1016/j.vaccine.2004.09.025] [Citation(s) in RCA: 214] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Revised: 07/21/2004] [Accepted: 09/28/2004] [Indexed: 11/18/2022]
Abstract
Highest attack rates for influenza occur in children. Immunization of schoolchildren with inactivated influenza vaccine in Michigan and Japan was associated with decreased morbidity and mortality, respectively, in older community contacts. An open-labeled, non-randomized, community-based trial in children with the cold adapted influenza vaccine, trivalent (CAIV-T) was initiated to determine the coverage necessary to reduce spread of influenza in the community. Age-specific baseline rates of medically attended acute respiratory illness (MAARI) for Scott and White Health Plan (SWHP) members at intervention (Temple and Belton) and comparison communities (Waco, Bryan, and College Station) were obtained in 1997-1998. During three subsequent vaccination years, 4298, 5251 and 5150 children received one dose per season of CAIV-T. Vaccinees represented 20-25% of the age-eligible children. Age-specific MAARI rates were compared for SWHP members in the intervention and comparison sites during the influenza outbreaks. Baseline age-specific MAARI rates per 100 persons for the influenza season were comparable between the intervention and comparison communities. In the subsequent three influenza seasons, the age groups 35-44, 45-54, 55-65 and >64 years experienced reductions in MAARI rates in the intervention communities. In adults > or =35 years of age, significant reductions in MAARI of 0.08 (95% CI: 0.04, 0.13), 0.18 (95% CI: 0.14, 0.22) and 0.15 (95% CI: 0.12, 0.19), were observed in the influenza seasons for vaccination years 1, 2 and 3, respectively. No consistent reduction in MAARI rates was detected in the younger age groups. Vaccination of approximately 20-25% of children, 1.5-18 years of age in the intervention communities resulted in an indirect protection of 8-18% against MAARI in adults > or =35 years of age.
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Affiliation(s)
- Pedro A Piedra
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Rm 248E, One Baylor Plaza, Houston, TX 77030, USA.
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Weycker D, Edelsberg J, Halloran ME, Longini IM, Nizam A, Ciuryla V, Oster G. Population-wide benefits of routine vaccination of children against influenza. Vaccine 2005; 23:1284-93. [PMID: 15652671 DOI: 10.1016/j.vaccine.2004.08.044] [Citation(s) in RCA: 223] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2004] [Revised: 06/23/2004] [Accepted: 08/16/2004] [Indexed: 11/16/2022]
Abstract
Using a stochastic simulation model of influenza transmission, clinical illness, and economic costs, we estimated the population-wide benefits of routinely vaccinating US children (ages 6 months to 18 years) against influenza. Disease burden was projected to decline as a result of both reduced susceptibility to infection among vaccinees and reductions in disease transmission to others in the community. Vaccination of 20% of children would reduce the total number of influenza cases in the US by 46%; 80% coverage would reduce the total number of cases by 91%. Similar reductions were estimated to occur in influenza-related mortality and economic costs.
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Affiliation(s)
- Derek Weycker
- Policy Analysis Inc., Four Davis Court, Brookline, MA 02445, USA
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48
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Meltzer MI, Neuzil KM, Griffin MR, Fukuda K. An economic analysis of annual influenza vaccination of children. Vaccine 2005; 23:1004-14. [PMID: 15620473 DOI: 10.1016/j.vaccine.2004.07.040] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2004] [Revised: 06/29/2004] [Accepted: 07/26/2004] [Indexed: 11/22/2022]
Abstract
We used a Monte Carlo mathematical model to calculate the net economic returns (cost-benefit analysis) from annually vaccinating children against influenza. The model included cohorts of 1000 children in three different age groups (6-23 months, 6-59 months, and 5-14 years), with different proportions of children with high risk conditions (100, 10, and 0%). Vaccinating cohorts of 100% high risk children in all three age groups produced median net savings, regardless of cost of vaccination examined (US dollar 30-60/dose administered). Median threshold vaccination costs for cohorts containing 10% high risk children were US dollar 48, 46, and 45 per dose administered for age groups 6-23 months, 6-59 months, and 5-14 years, respectively (US dollar/dose administered below these thresholds generate net savings). For all cohorts, for the range of cost per dose administered examined, the 5th percentiles were net costs. The probability of death, though rare, was the most influential distribution in the model. The number of high-risk children that receive influenza vaccine should be maximized to achieve improved health outcomes as well as cost savings.
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Affiliation(s)
- Martin I Meltzer
- Mailstop D-59, OS/OD/NCID/CDC, 1600 Clifton Road, Atlanta, GA 30333, USA.
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49
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Greenbaum E, Engelhard D, Levy R, Schlezinger M, Morag A, Zakay-Rones Z. Mucosal (SIgA) and serum (IgG) immunologic responses in young adults following intranasal administration of one or two doses of inactivated, trivalent anti-influenza vaccine. Vaccine 2004; 22:2566-77. [PMID: 15193382 DOI: 10.1016/j.vaccine.2003.12.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2003] [Accepted: 12/15/2003] [Indexed: 11/20/2022]
Abstract
Influenza morbidity affects the entire population and has an enormous impact upon the economic burden and the health care systems. Available vaccines are often unsatisfactory and many individuals are reluctant to receive injections. Intranasal immunization is painless, side effect free and may encourage a large number of individuals to participate in the vaccination programs. Ninety-two students were immunized intranasally once or twice, 21 days apart, with a trivalent inactivated whole influenza vaccine during three separate seasons (1996/1997, 1997/1998 and 1998/1999) with the recommended seasonal strains. The vaccine was well tolerated, without adverse effect and morbidity in the vaccinees during the winter season was low. Serum antibody response was determined by the hemagglutination inhibition (HI) test and nasal response by the enzyme-linked immunoadsorbant assay (ELISA). Following the second dose, mucosal antibody response was detected in 48.1-73.3% of immunized subjects. Serum and mucosal antibody levels (GMT) increased significantly to all the strains, with the exception of A/H3N2 in the mucosal response in 1997/1998. At the end of the trial, the percentage of immune subjects was over 93% to A/H1N1 strains, 60-71% to A/H3N2 and 64-66% to B/Harbin in 1996/1997 and 1997/1998, and 75-91% following one dose in 1998/1999. When serum and mucosal responses were combined, a higher percentage of responders was found (60-86%). Repeated vaccination does not seem to interfere with serum or mucosal response. The double barrier of mucosal and serum antibody may inhibit infection and decrease morbidity when infection occurs, thus limiting the spread of influenza in the community.
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MESH Headings
- Administration, Intranasal
- Adult
- Antibodies, Viral/analysis
- Antibodies, Viral/blood
- Female
- Humans
- Immunity, Mucosal
- Immunoglobulin A, Secretory/analysis
- Immunoglobulin A, Secretory/biosynthesis
- Immunoglobulin G/blood
- Influenza A virus/immunology
- Influenza Vaccines/administration & dosage
- Influenza Vaccines/immunology
- Influenza, Human/immunology
- Influenza, Human/prevention & control
- Male
- Nasal Mucosa/immunology
- Vaccination
- Vaccines, Inactivated/administration & dosage
- Vaccines, Inactivated/immunology
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Affiliation(s)
- Evgenia Greenbaum
- Department of Virology, Faculty of Medicine, The Hebrew University Hadassah-Medical School, Hebrew University of Jerusalem, P O Box 12272, Jerusalem, Israel
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Glezen WP. The changing epidemiology of respiratory syncytial virus and influenza: impetus for new control measures. Pediatr Infect Dis J 2004; 23:S202-6. [PMID: 15577574 DOI: 10.1097/01.inf.0000144662.86396.07] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Influenza and respiratory syncytial virus (RSV) are the most important causes of medically attended acute respiratory illnesses. Medical encounters for acute respiratory illness peak each winter, coinciding with the peak of influenza activity. RSV is the most important cause of hospitalization of infants for acute lower respiratory illness. METHODS Surveillance of influenza and RSV have been maintained in Houston since 1974. Hospitalization rates during that period were compared with national data. U.S. influenza mortality rates and population dynamics were reviewed. RESULTS The number of deaths attributed to influenza in the United States have increased from approximately 15,000 per year for the period from 1972 through 1984 to >50,000 from 1990 to 1999. RSV hospitalization rates for infants have more than doubled during the same period. Influenza epidemics have tended to occur earlier in Texas, with epidemic disease evident in early November in 3 of the last 4 years. CONCLUSIONS Population dynamics with increased population density and urbanization probably are responsible for worsening of epidemics of the major respiratory viruses. New approaches to control will be necessary to reduce impact of these infections. These include earlier availability of influenza vaccine each autumn and use of antivirals and new vaccines for RSV.
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Affiliation(s)
- W Paul Glezen
- Departments of Molecular Virology and Microbiology and of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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