Seasonal influenza vaccination of healthy working-age adults: a review of economic evaluations

Assessing the impact of COVID-19 interventions on the hand, foot and mouth disease in Guangdong Province, China: a Bayesian modeling study

Background

The non-pharmaceutical interventions (NPIs) against COVID-19 may have affected the transmission of hand, foot and mouth disease (HFMD). We aimed to assess the impact of the NPIs on HFMD in the high epidemic area of HFMD, Guangdong Province.

Methods

The data of HFMD cases, etiological information, and meteorological factors in Guangdong from January 1, 2012, to December 31, 2021, were collected. Using a Bayesian structural time series (BSTS) model integrated counterfactual framework, we assessed the effect of NPIs on HFMD by different intervention periods, populations (gender, age, occupation), and cities. We further explored the correlation between the reduction of HFMD and socioeconomic factors in 21 cities.

Results

A total of 351,217 HFMD cases were reported and 455,327 cases were averted in Guangdong Province during 2020-2021 with a reduction of 84.94% (95%CI: 81.63-87.22%) in 2020 and 29.49% (95%CI: 15.26-39.54%) in 2021. The impact of NPIs on HFMD differed by age and gender. The effects of NPIs were more remarkable for children aged 0-2 years and scattered children. We found that the relative reductions in 21 cities were related to the composition ratio of children and COVID-19 incidence.

Conclusion

The reduction of HFMD incidence was significantly associated with COVID-19 NPIs, and school closure was an effective intervention to prevent HFMD outbreaks. Our findings will contribute to the development of HFMD prevention and control measures.

Cost-effectiveness of routine annual influenza vaccination by age and risk status

BACKGROUND

The epidemiology of circulating seasonal influenza strains changed following the 2009 pandemic influenza A(H1N1). A universal influenza vaccination recommendation has been implemented and new vaccine types have become available post-2009. The objective of this study was to evaluate the cost-effectiveness of routine annual influenza vaccination in the context of this new evidence.

METHODS

A state transition simulation model was constructed to estimate the health and economic outcomes of influenza vaccination compared to no vaccination for hypothetical US cohorts stratified by age and risk status. Model input parameters were derived from multiple sources, including post-2009 vaccine effectiveness data from the US Flu Vaccine Effectiveness Network. The analysis used societal and healthcare sector perspectives and a one-year time horizon, except permanent outcomes were also included. The primary outcome was the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life years (QALYs) gained.

RESULTS

Compared to no vaccination, vaccination yielded ICERs lower than $95,000/QALY for all age and risk groups, except for non-high-risk adults 18-49 years ($194,000/QALY). Vaccination was cost-saving for adults ≥50 years at higher risk for influenza-related complications. Results were most sensitive to changes in the probability of influenza illness. Performing the analysis from the healthcare sector perspective, excluding vaccination time costs, delivering vaccinations in lower-cost settings, and including productivity losses improved the cost-effectiveness of vaccination. Sensitivity analysis revealed that vaccination remains below $100,000/QALY for older persons ≥65 years at vaccine effectiveness estimates as low as 4 %.

CONCLUSIONS

Cost-effectiveness of influenza vaccination varied by age and risk status and was less than $95,000/QALY for all subgroups, except for non-high-risk working-age adults. Results were sensitive to the probability of influenza illness and vaccination was more favorable under certain scenarios. Vaccination for higher risk subgroups resulted in ICERs below $100,000/QALY even at low levels of vaccine effectiveness or circulating virus.

Social determinants of health and adult influenza vaccination: a nationwide claims analysis

BACKGROUND: The health and economic benefits of the annual influenza vaccine are well documented, yet vaccination rates in the United States missed the Healthy People 2020 goal and remain a focus of Healthy People 2030 efforts. By identifying underlying reasons for low annual influenza vaccination, social elements that need targeting may be identified and could guide future interventions or policy development to achieve vaccination goals and improve overall public health. OBJECTIVE: To determine the influence of certain social determinants of health on adherence to annual influenza vaccination in American adults. METHODS: This was a retrospective cohort analysis using data from IBM MarketScan Commercial Claims and Encounters Database and national Medicare 5% sample data from 2013 to 2016. Study eligibility criteria included adults (aged 18 years and older) who were continuously enrolled for 3 influenza seasons between 2013 and 2016. Receipt of the influenza vaccine was counted over 3 consecutive influenza seasons, and select social determinants were extracted from publicly available sources. Patient characteristics, health resource utilization, and selected social determinants of health were included in bivariate and multivariate logistic regression analyses to determine their association with annual influenza vaccination. RESULTS: 6,694,571 adults across employer-sponsored and Medicare coverage groups were analyzed, of which 14.7% of Medicare-enrolled adults and 9.2% of commercially enrolled adults were vaccinated in all 3 seasons. Higher proportions of vaccine adherence (ie, all 3 seasons) were observed among females (9.6% vs 8.7% [commercial], 15.0% vs 14.4% [Medicare]), the immunocompromised (11.8% vs 8.3% [commercial], 15.9% vs 13.6% [Medicare]), rural residents (10.5% vs 9.0% [commercial], 15.4% vs 14.6% [Medicare]; all P < 0.0001), and those enrolled in a high-deductible health plan (10.3%). Multivariable logistic regression models indicated that the odds of vaccine adherence tended to be higher in areas of higher poverty (OR=1.012; 95% CI = 1.01-1.02 [commercial], OR=1.01; 95% CI = 1.01-1.01 [Medicare]) yet lower in areas with higher proportions of Democratic voters (OR=0.998; 95% CI = 0.998-0.998 [commercial], OR = 0.996; 95% CI = 0.996-0.997 [Medicare]). Among commercially insured adults, the odds of vaccine adherence were higher in areas of higher health literacy (OR=1.036; 95% CI = 1.036-1.037), but this effect was not observed among Medicare members. Conversely, the odds of vaccine adherence increased as the proportion of those residing in areas of limited Internet access increased (OR=1.007; 95% CI = 1.004-1.010) among Medicare members only. CONCLUSIONS: Key social determinants of health are important factors of vaccine adherence and can guide policy and intervention efforts toward addressing potential hesitancy. A deeper assessment of other contributing social factors is needed in seasonal influenza and other vaccines to better interpret the vaccine-seeking behaviors of adults. DISCLOSURES: This study received no outside funding. Gatwood, Hagemann, Hohmeier, and Chiu declare vaccine-related grant funding from Merck & Co. and GlaxoSmithKline for vaccine research unrelated to the current study. Ramachandran declares vaccine-related grant funding from Glaxo-SmithKline for research unrelated to the current study. Shuvo and Behal have nothing to disclose. Findings described in this study were presented as a poster and podium at the Academy of Managed Care Pharmacy Nexus 2020 Virtual meeting, October 19-23, 2020.

Impact of the coronavirus disease 2019 interventions on the incidence of hand, foot, and mouth disease in mainland China

Background

In early 2020, non-pharmaceutical interventions (NPIs) were implemented in China to reduce and contain the coronavirus disease 2019 (COVID-19) transmission. These NPIs might have also reduced the incidence of hand, foot, and mouth disease (HFMD).

Methods

The weekly numbers of HFMD cases and meteorological factors in 31 provincial capital cities and municipalities in mainland China were obtained from Chinese Center for Disease Control and Prevention (CCDC) and National Meteorological Information Center of China from 2016 to 2020. The NPI data were collected from local CDCs. The incidence rate ratios (IRRs) were calculated for the entire year of 2020, and for January-July 2020 and August-December 2020. The expected case numbers were estimated using seasonal autoregressive integrated moving average models. The relationships between kindergarten closures and incidence of HFMD were quantified using a generalized additive model. The estimated associations from all cities were pooled using a multivariate meta-regression model.

Findings

Stringent NPIs were widely implemented for COVID-19 control from January to July 2020, and the IRRs for HFMD were less than 1 in all 31 cities, and less than 0·1 for 23 cities. Overall, the proportion of HFMD cases reduced by 52·9% (95% CI: 49·3-55·5%) after the implementation of kindergarten closures in 2020, and this effect was generally consistent across subgroups.

Interpretation

The decrease in HFMD incidence was strongly associated with the NPIs for COVID-19. HFMD epidemic peaks were either absent or delayed, and the final epidemic size was reduced. Kindergarten closure is an intervention to prevent HFMD outbreaks.

Funding

This research was supported by the National Natural Science Foundation of China (81973102 & 81773487), Public Health Talents Training Program of Shanghai Municipality (GWV-10.2-XD21), the Shanghai New Three-year Action Plan for Public Health (GWV-10.1-XK16), the Major Project of Scientific and Technical Winter Olympics from National Key Research and Development Program of China (2021YFF0306000), 13th Five-Year National Science and Technology Major Project for Infectious Diseases (2018ZX10725-509) and Key projects of the PLA logistics Scientific research Program (BHJ17J013).

Surveillance of Vaccination Coverage Among Adult Populations -United States, 2018

PROBLEM/CONDITION

Adults are at risk for illness, hospitalization, disability and, in some cases, death from vaccine-preventable diseases, particularly influenza and pneumococcal disease. CDC recommends vaccinations for adults on the basis of age, health conditions, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults remains low.

REPORTING PERIOD

August 2017-June 2018 (for influenza vaccination) and January-December 2018 (for pneumococcal, herpes zoster, tetanus and diphtheria [Td]/tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], hepatitis A, hepatitis B, and human papillomavirus [HPV] vaccination).

DESCRIPTION OF SYSTEM

The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. NHIS's objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. Adult receipt of influenza, pneumococcal, herpes zoster, Td/Tdap, hepatitis A, hepatitis B, and at least 1 dose of HPV vaccines was assessed. Estimates were derived for a new composite adult vaccination quality measure and by selected demographic and access-to-care characteristics (e.g., age, race/ethnicity, indication for vaccination, travel history [travel to countries where hepatitis infections are endemic], health insurance status, contacts with physicians, nativity, and citizenship). Trends in adult vaccination were assessed during 2010-2018.

RESULTS

Coverage for the adult age-appropriate composite measure was low in all age groups. Racial and ethnic differences in coverage persisted for all vaccinations, with lower coverage for most vaccinations among non-White compared with non-Hispanic White adults. Linear trend tests indicated coverage increased from 2010 to 2018 for most vaccines in this report. Few adults aged ≥19 years had received all age-appropriate vaccines, including influenza vaccination, regardless of whether inclusion of Tdap (13.5%) or inclusion of any tetanus toxoid-containing vaccine (20.2%) receipt was measured. Coverage among adults for influenza vaccination during the 2017-18 season (46.1%) was similar to the estimate for the 2016-17 season (45.4%), and coverage for pneumococcal (adults aged ≥65 years [69.0%]), herpes zoster (adults aged ≥50 years and aged ≥60 years [24.1% and 34.5%, respectively]), tetanus (adults aged ≥19 years [62.9%]), Tdap (adults aged ≥19 years [31.2%]), hepatitis A (adults aged ≥19 years [11.9%]), and HPV (females aged 19-26 years [52.8%]) vaccination in 2018 were similar to the estimates for 2017. Hepatitis B vaccination coverage among adults aged ≥19 years and health care personnel (HCP) aged ≥19 years increased 4.2 and 6.7 percentage points to 30.0% and 67.2%, respectively, from 2017. HPV vaccination coverage among males aged 19-26 years increased 5.2 percentage points to 26.3% from the 2017 estimate. Overall, HPV vaccination coverage among females aged 19-26 years did not increase, but coverage among Hispanic females aged 19-26 years increased 10.8 percentage points to 49.6% from the 2017 estimate. Coverage for the following vaccines was lower among adults without health insurance compared with those with health insurance: influenza vaccine (among adults aged ≥19 years, 19-49 years, and 50-64 years), pneumococcal vaccine (among adults aged 19-64 years at increased risk), Td vaccine (among all age groups), Tdap vaccine (among adults aged ≥19 years and 19-64 years), hepatitis A vaccine (among adults aged ≥19 years overall and among travelers aged ≥19 years), hepatitis B vaccine (among adults aged ≥19 years and 19-49 years and among travelers aged ≥19 years), herpes zoster vaccine (among adults aged ≥60 years), and HPV vaccine (among males and females aged 19-26 years). Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting ≥1 physician contact during the preceding year compared with those who had not visited a physician during the preceding year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts during the preceding year, depending on the vaccine, 20.1%-87.5% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was significantly higher than that of foreign-born adults, including influenza vaccination (aged ≥19 years), pneumococcal vaccination (all ages), tetanus vaccination (all ages), Tdap vaccination (all ages), hepatitis B vaccination (aged ≥19 years and 19-49 years and travelers aged ≥19 years), herpes zoster vaccination (all ages), and HPV vaccination among females aged 19-26 years. Vaccination coverage also varied by citizenship status and years living in the United States.

INTERPRETATION

NHIS data indicate that many adults remain unprotected against vaccine-preventable diseases. Coverage for the adult age-appropriate composite measures was low in all age groups. Individual adult vaccination coverage remained low as well, but modest gains occurred in vaccination coverage for hepatitis B (among adults aged ≥19 years and HCP aged ≥19 years), and HPV (among males aged 19-26 years and Hispanic females aged 19-26 years). Coverage for other vaccines and groups with Advisory Committee on Immunization Practices vaccination indications did not improve from 2017. Although HPV vaccination coverage among males aged 19-26 years and Hispanic females aged 19-26 years increased, approximately 50% of females aged 19-26 years and 70% of males aged 19-26 years remained unvaccinated. Racial/ethnic vaccination differences persisted for routinely recommended adult vaccines. Having health insurance coverage, having a usual place for health care, and having ≥1 physician contacts during the preceding 12 months were associated with higher vaccination coverage; however, these factors alone were not associated with optimal adult vaccination coverage, and findings indicate missed opportunities to vaccinate remained.

PUBLIC HEALTH ACTIONS

Substantial improvement in adult vaccination uptake is needed to reduce the burden of vaccine-preventable diseases. Following the Standards for Adult Immunization Practice (https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html), all providers should routinely assess adults' vaccination status at every clinical encounter, strongly recommend appropriate vaccines, either offer needed vaccines or refer their patients to another provider who can administer the needed vaccines, and document vaccinations received by their patients in an immunization information system.

Inclusion of Safety-Related Issues in Economic Evaluations for Seasonal Influenza Vaccines: A Systematic Review

(1) Background: Vaccines for seasonal influenza are a good preventive and cost-effective strategy. However, it is unknown if and how these economic evaluations include the adverse events following immunization (AEFI), and what the impact of such inclusion is on the health economic outcomes. (2) Methods: We searched the literature, up to January 2020, to identify economic evaluations of seasonal influenza vaccines that considered AEFIs. The review protocol was published in PROSPERO (CDR42017058523). (3) Results: A total of 52 economic evaluations considered AEFI-related parameters in their analyses, reflecting 16% of the economic evaluations on seasonal influenza vaccines in the initial study selection. Most studies used the societal perspective (64%) and evaluated vaccination of children (37%). Where considered, studies included direct medical costs of AEFIs (90%), indirect costs (27%), and disutilities/quality-adjusted life years loss due to AEFIs (37%). The majority of these studies accounted for the effects of the costs of AEFI on cost-effectiveness for Guillain–Barré syndrome. In those papers allowing cost share estimation, direct medical cost of AFEIs was less than 2% of total direct costs. (4) Conclusions: Although the overall impact of AEFIs on the cost-effectiveness outcomes was found to be low, we urge their inclusion in economic evaluations of seasonal influenza vaccines to reflect comprehensive reports for the decision makers and end-users of the vaccination strategies.

Health Economic Evaluation of an Influenza Vaccination Program to Prevent Sick Leave in Employees: A Prospective Cohort Study

OBJECTIVE

To evaluate the cost-effectiveness of an influenza vaccination program (IVP) among employees.

METHODS

This health economic evaluation was embedded in a prospective cohort study of a voluntary IVP. Data on incidence, direct, and indirect costs were collected via questionnaires. Bootstrapping and modeling techniques were used to assess uncertainty of the results.

RESULTS

In the base-scenario, the IVP was less effective, more expensive and thus, neither cost-effective nor cost-beneficial. When applying a sensitivity analysis using published estimates of IVP effectiveness on the data, the IVP became cost-effective and cost-beneficial.

CONCLUSIONS

Like in many evaluations of real-world settings, lack of randomization may have caused selection bias which may explain the surprising results of the main analysis. This indicates the importance of sensitivity analyses and modeling approaches for future studies assessing the cost-effectiveness of IVP in a real-world setting.

A Perspective on Yoga as a Preventive Strategy for Coronavirus Disease 2019

The pandemic outbreak of coronavirus disease 2019 (COVID-19) infection caused by severe acute respiratory syndrome-coronavirus 2 has led to profound public health crisis. In particular, individuals with preexisting conditions of heart disease, diabetes, cerebrovascular diseases and the elderly are most vulnerable to succumb to this infection. The current COVID-19 emergency calls for rapid development of potential prevention and management strategies against this virus-mediated disease. There is a plethora of evidence that supports the add-on benefits of yoga in stress management, as well as prevention and management of chronic noncommunicable diseases. There are some studies on the effect of yoga in communicable diseases as well but very few for acute conditions and almost none for the rapidly spreading infections resulting in pandemics. Based on the available scientific evidences on yoga in improving respiratory and immune functions, we have formulated very simple doable integrated yoga modules in the form of videos to be practiced for prevention of the disease by children, adults, and the elderly.

Seasonal Influenza Vaccination Coverage Trends Among Adult Populations, U.S., 2010-2016

INTRODUCTION

Influenza is a major cause of morbidity and mortality among adults. The most effective strategy for preventing influenza is annual vaccination. However, vaccination coverage has been suboptimal among adult populations. The purpose of this study is to assess trends in influenza vaccination among adult populations.

METHODS

Data from the 2010-2016 National Health Interview Survey were analyzed in 2018 to estimate vaccination coverage during the 2010-2011 through 2015-2016 seasons. Trends of vaccination in recent years were assessed. Vaccination coverage by race/ethnicity within each group was examined. Multivariable logistic regression and predictive marginal models were conducted to identify factors associated with vaccination, and interactions between race/ethnicity and other demographic and access-to-care characteristics were assessed.

RESULTS

Vaccination coverage among adults aged ≥18 years increased from 38.3% in the 2010-2011 season to 43.4% in the 2015-2016 season, with an average increase of 1.3 percentage points annually. From the 2010-2011 through 2015-2016 seasons, coverage was stable for adults aged ≥65 years and changed by -0.1 to 9.9 percentage points for all other examined subgroups. Coverage in 2015-2016 was 70.4% for adults aged ≥65 years, 46.4% for those aged 50-64 years, and 32.3% for those aged 18-49 years; 47.9% for people aged 18-64 years with high-risk conditions; 64.8% for healthcare personnel; and 50.3% for pregnant women. Among adults aged ≥18 years for the 2015-2016 season, coverage was significantly lower among non-Hispanic blacks and Hispanics compared with non-Hispanic whites.

CONCLUSIONS

Overall, influenza vaccination coverage among adults aged ≥18 years increased during 2010-2016, but it remained below the national target of 70%. Vaccination coverage varied by age, risk status, race/ethnicity, healthcare personnel, and pregnancy status. Targeted efforts are needed to improve coverage and reduce disparities.

Cost-effectiveness of adult vaccinations: A systematic review

BACKGROUND

Coverage levels for many recommended adult vaccinations are low. The cost-effectiveness research literature on adult vaccinations has not been synthesized in recent years, which may contribute to low awareness of the value of adult vaccinations and to their under-utilization. We assessed research literature since 1980 to summarize economic evidence for adult vaccinations included on the adult immunization schedule.

METHODS

We searched PubMed, EMBASE, EconLit, and Cochrane Library from 1980 to 2016 and identified economic evaluation or cost-effectiveness analysis for vaccinations targeting persons aged ≥18 years in the U.S. or Canada. After excluding records based on title and abstract reviews, the remaining publications had a full-text review from two independent reviewers, who extracted economic values that compared vaccination to "no vaccination" scenarios.

RESULTS

The systematic searches yielded 1688 publications. After removing duplicates, off-topic publications, and publications without a "no vaccination" comparison, 78 publications were included in the final analysis (influenza = 25, pneumococcal = 18, human papillomavirus = 9, herpes zoster = 7, tetanus-diphtheria-pertussis = 9, hepatitis B = 9, and multiple vaccines = 1). Among outcomes assessing age-based vaccinations, the percent indicating cost-savings was 56% for influenza, 31% for pneumococcal, and 23% for tetanus-diphtheria-pertussis vaccinations. Among age-based vaccination outcomes reporting $/QALY, the percent of outcomes indicating a cost per QALY of ≤$100,000 was 100% for influenza, 100% for pneumococcal, 69% for human papillomavirus, 71% for herpes zoster, and 50% for tetanus-diphtheria-pertussis vaccinations.

CONCLUSIONS

The majority of published studies report favorable cost-effectiveness profiles for adult vaccinations, which supports efforts to improve the implementation of adult vaccination recommendations.

Model Comparisons of the Effectiveness and Cost-Effectiveness of Vaccination: A Systematic Review of the Literature

OBJECTIVES

To describe all published articles that have conducted comparisons of model-based effectiveness and cost-effectiveness results in the field of vaccination. Specific objectives were to 1) describe the methodologies used and 2) identify the strengths and limitations of the studies.

METHODS

We systematically searched MEDLINE and Embase databases for studies that compared predictions of effectiveness and cost-effectiveness of vaccination of two or more mathematical models. We categorized studies into two groups on the basis of their data source for comparison (previously published results or new simulation results) and performed a qualitative synthesis of study conclusions.

RESULTS

We identified 115 eligible articles (only 5% generated new simulations from the reviewed models) examining the effectiveness and cost-effectiveness of vaccination against 14 pathogens (69% of studies examined human papillomavirus, influenza, and/or pneumococcal vaccines). The goal of most of studies was to summarize evidence for vaccination policy decisions, and cost-effectiveness was the most frequent outcome examined. Only 33%, 25%, and 3% of studies followed a systematic approach to identify eligible studies, assessed the quality of studies, and performed a quantitative synthesis of results, respectively. A greater proportion of model comparisons using published studies followed a systematic approach to identify eligible studies and to assess their quality, whereas more studies using new simulations performed quantitative synthesis of results and identified drivers of model conclusions. Most comparative modeling studies concluded that vaccination was cost-effective.

CONCLUSIONS

Given the variability in methods used to conduct/report comparative modeling studies, guidelines are required to enhance their quality and transparency and to provide better tools for decision making.

Meditation or exercise for preventing acute respiratory infection (MEPARI-2): A randomized controlled trial

Background

Practice of meditation or exercise may enhance health to protect against acute infectious illness.

Objective

To assess preventive effects of meditation and exercise on acute respiratory infection (ARI) illness.

Design

Randomized controlled prevention trial with three parallel groups.

Setting

Madison, Wisconsin, USA.

Participants

Community-recruited adults who did not regularly exercise or meditate.

Methods

1) 8-week behavioral training in mindfulness-based stress reduction (MBSR); 2) matched 8-week training in moderate intensity sustained exercise (EX); or 3) observational waitlist control. Training classes occurred in September and October, with weekly ARI surveillance through May. Incidence, duration, and area-under-curve ARI global severity were measured using daily reports on the WURSS-24 during ARI illness. Viruses were identified multiplex PCR. Absenteeism, health care utilization, and psychosocial health self-report assessments were also employed.

Results

Of 413 participants randomized, 390 completed the trial. In the MBSR group, 74 experienced 112 ARI episodes with 1045 days of ARI illness. Among exercisers, 84 had 120 episodes totaling 1010 illness days. Eighty-two of the controls had 134 episodes with 1210 days of ARI illness. Mean global severity was 315 for MBSR (95% confidence interval 244, 386), 256 (193, 318) for EX, and 336 (268, 403) for controls. A prespecified multivariate zero-inflated regression model suggested reduced incidence for MBSR (p = 0.036) and lower global severity for EX (p = 0.042), compared to control, not quite attaining the p<0.025 prespecified cut-off for null hypothesis rejection. There were 73 ARI-related missed-work days and 22 ARI-related health care visits in the MBSR group, 82 days and 21 visits for exercisers, and 105 days and 24 visits among controls. Viruses were identified in 63 ARI episodes in the MBSR group, compared to 64 for EX and 72 for control. Statistically significant (p<0.05) improvements in general mental health, self-efficacy, mindful attention, sleep quality, perceived stress, and depressive symptoms were observed in the MBSR and/or EX groups, compared to control.

Conclusions

Training in mindfulness meditation or exercise may help protect against ARI illness.

Limitations

This trial was likely underpowered.

Trial registration

Clinicaltrials.gov NCT01654289

WHO guide on the economic evaluation of influenza vaccination

Influenza is responsible for substantial morbidity and mortality across the globe, with a large share of the total disease burden occurring in low- and middle-income countries (LMICs). There have been relatively few economic evaluations assessing the value of seasonal influenza vaccination in LMICs. The purpose of this guide is to outline the key theoretical concepts and best practice in methodologies and to provide guidance on the economic evaluation of influenza vaccination in LMICs. It outlines many of the influenza vaccine-specific challenges and should help to provide a framework for future evaluations in the area to build upon.

Association of provider recommendation and offer and influenza vaccination among adults aged ≥18 years - United States

BACKGROUND

Influenza vaccination has been recommended for all persons aged ≥6 months since 2010.

METHODS

Data from the 2016 National Internet Flu Survey were analyzed to assess provider vaccination recommendations and early influenza vaccination during the 2016-17 season among adults aged ≥18 years. Predictive marginals from a multivariable logistic regression model were used to identify factors independently associated with early vaccine uptake by provider vaccination recommendation status.

RESULTS

Overall, 24.0% visited a provider who both recommended and offered influenza vaccination, 9.0% visited a provider who only recommended but did not offer, 25.1% visited a provider who neither recommended nor offered, and 41.9% did not visit a doctor from July 1 through date of interview. Adults who reported that a provider both recommended and offered vaccine had significantly higher vaccination coverage (66.6%) compared with those who reported that a provider only recommended but did not offer (48.4%), those who neither received recommendation nor offer (32.0%), and those who did not visit a doctor during the vaccination period (28.8%). Results of multivariable logistic regression indicated that having received a provider recommendation, with or without an offer for vaccination, was significantly associated with higher vaccination coverage after controlling for demographic and access-to-care factors.

CONCLUSIONS

Provider recommendation was significantly associated with influenza vaccination. However, overall, 67.0% of adults did not visit a doctor during the vaccination period or did visit a doctor but did not receive a provider recommendation. Evidence-based strategies such as client reminder/recall, standing orders, provider reminders, or health systems interventions in combination should be undertaken to improve provider recommendation and influenza vaccination coverage. Other factors significantly associated with a higher level of influenza vaccination included age ≥50 years, being Hispanic, having a college or higher education, having a usual place for medical care, and having public health insurance.

Knowledge of influenza vaccination recommendation and early vaccination uptake during the 2015-16 season among adults aged ≥18years - United States

BACKGROUND

Since 2010, the Advisory Committee on Immunization Practices (ACIP) has recommended that all persons aged ≥6months receive annual influenza vaccination.

METHODS

We analyzed data from the 2015 National Internet Flu Survey (NIFS), to assess knowledge and awareness of the influenza vaccination recommendation and early influenza vaccination coverage during the 2015-16 season among adults. Predictive marginals from a multivariable logistic regression model were used to identify factors independently associated with adults' knowledge and awareness of the vaccination recommendation and early vaccine uptake during the 2015-16 influenza season.

RESULTS

Among the 3301 respondents aged ≥18years, 19.6% indicated knowing that influenza vaccination is recommended for all persons aged ≥6months. Of respondents, 62.3% indicated awareness that there was a recommendation for influenza vaccination, but did not indicate correct knowledge of the recommended age group. Overall, 39.9% of adults aged ≥18years reported having an influenza vaccination. Age 65years and older, being female, having a college or higher education, not being in work force, having annual household income ≥$75,000, reporting having received an influenza vaccination early in the 2015-16 season, having children aged ≤17years in the household, and having high-risk conditions were independently associated with a higher correct knowledge of the influenza vaccination recommendation.

CONCLUSIONS

Approximately 1 in 5 had correct knowledge of the recommendation that all persons aged ≥6months should receive an influenza vaccination annually, with some socio-economic groups being even less aware. Clinic based education in combination with strategies known to increase uptake of recommended vaccines, such as patient reminder/recall systems and other healthcare system-based interventions are needed to improve vaccination, which could also improve awareness.

Community Mitigation Guidelines to Prevent Pandemic Influenza - United States, 2017

When a novel influenza A virus with pandemic potential emerges, nonpharmaceutical interventions (NPIs) often are the most readily available interventions to help slow transmission of the virus in communities, which is especially important before a pandemic vaccine becomes widely available. NPIs, also known as community mitigation measures, are actions that persons and communities can take to help slow the spread of respiratory virus infections, including seasonal and pandemic influenza viruses.These guidelines replace the 2007 Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States - Early, Targeted, Layered Use of Nonpharmaceutical Interventions (https://stacks.cdc.gov/view/cdc/11425). Several elements remain unchanged from the 2007 guidance, which described recommended NPIs and the supporting rationale and key concepts for the use of these interventions during influenza pandemics. NPIs can be phased in, or layered, on the basis of pandemic severity and local transmission patterns over time. Categories of NPIs include personal protective measures for everyday use (e.g., voluntary home isolation of ill persons, respiratory etiquette, and hand hygiene); personal protective measures reserved for influenza pandemics (e.g., voluntary home quarantine of exposed household members and use of face masks in community settings when ill); community measures aimed at increasing social distancing (e.g., school closures and dismissals, social distancing in workplaces, and postponing or cancelling mass gatherings); and environmental measures (e.g., routine cleaning of frequently touched surfaces).Several new elements have been incorporated into the 2017 guidelines. First, to support updated recommendations on the use of NPIs, the latest scientific evidence available since the influenza A (H1N1)pdm09 pandemic has been added. Second, a summary of lessons learned from the 2009 H1N1 pandemic response is presented to underscore the importance of broad and flexible prepandemic planning. Third, a new section on community engagement has been included to highlight that the timely and effective use of NPIs depends on community acceptance and active participation. Fourth, to provide new or updated pandemic assessment and planning tools, the novel influenza virus pandemic intervals tool, the Influenza Risk Assessment Tool, the Pandemic Severity Assessment Framework, and a set of prepandemic planning scenarios are described. Finally, to facilitate implementation of the updated guidelines and to assist states and localities with prepandemic planning and decision-making, this report links to six supplemental prepandemic NPI planning guides for different community settings that are available online (https://www.cdc.gov/nonpharmaceutical-interventions).

Community Mitigation Guidelines to Prevent Pandemic Influenza - United States, 2017

When a novel influenza A virus with pandemic potential emerges, nonpharmaceutical interventions (NPIs) often are the most readily available interventions to help slow transmission of the virus in communities, which is especially important before a pandemic vaccine becomes widely available. NPIs, also known as community mitigation measures, are actions that persons and communities can take to help slow the spread of respiratory virus infections, including seasonal and pandemic influenza viruses.These guidelines replace the 2007 Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States - Early, Targeted, Layered Use of Nonpharmaceutical Interventions (https://stacks.cdc.gov/view/cdc/11425). Several elements remain unchanged from the 2007 guidance, which described recommended NPIs and the supporting rationale and key concepts for the use of these interventions during influenza pandemics. NPIs can be phased in, or layered, on the basis of pandemic severity and local transmission patterns over time. Categories of NPIs include personal protective measures for everyday use (e.g., voluntary home isolation of ill persons, respiratory etiquette, and hand hygiene); personal protective measures reserved for influenza pandemics (e.g., voluntary home quarantine of exposed household members and use of face masks in community settings when ill); community measures aimed at increasing social distancing (e.g., school closures and dismissals, social distancing in workplaces, and postponing or cancelling mass gatherings); and environmental measures (e.g., routine cleaning of frequently touched surfaces).Several new elements have been incorporated into the 2017 guidelines. First, to support updated recommendations on the use of NPIs, the latest scientific evidence available since the influenza A (H1N1)pdm09 pandemic has been added. Second, a summary of lessons learned from the 2009 H1N1 pandemic response is presented to underscore the importance of broad and flexible prepandemic planning. Third, a new section on community engagement has been included to highlight that the timely and effective use of NPIs depends on community acceptance and active participation. Fourth, to provide new or updated pandemic assessment and planning tools, the novel influenza virus pandemic intervals tool, the Influenza Risk Assessment Tool, the Pandemic Severity Assessment Framework, and a set of prepandemic planning scenarios are described. Finally, to facilitate implementation of the updated guidelines and to assist states and localities with prepandemic planning and decision-making, this report links to six supplemental prepandemic NPI planning guides for different community settings that are available online (https://www.cdc.gov/nonpharmaceutical-interventions).

Systematic review of the cost-effectiveness of influenza immunization programs

BACKGROUND

Seasonal influenza immunization programs vary widely across jurisdictions. In Canada, some provinces offer universal programs while others target specific population groups. However, whether targeted or universal programs provide more benefit and value-for-money is unclear. The cost-effectiveness of influenza immunization programs was systematically reviewed to inform policy.

METHODS

Citation databases and the grey literature were searched for economic evaluations of influenza immunization programs. Eligible studies were appraised using the Scottish Intercollegiate Guidelines Network (SIGN) checklist with supplemental WHO vaccine-related questions. Data from high quality studies was extracted and the studies reviewed.

RESULTS

A total of 41influenza immunization studies were identified. Of these, 31 were high quality. For pregnant and postpartum women, vaccinating all versus only high risk women study results ranged from dominance (less costly and more effective) to $9773 per QALY gained (societal) and from dominance to $58,000 per QALY gained (healthcare system). Studies of vaccinating all versus only high risk children found vaccination to be dominant to $47,000 per QALY gained (societal), and dominant to $18,000 per QALY gained (healthcare system). Vaccinating high risk adults was highly cost-effective and vaccinating health care workers resulted in $35,000 per QALY gained. Results for healthy working adults were mixed and sensitive to vaccine uptake, efficacy, and productivity loss.

CONCLUSIONS

From the societal perspective, vaccination was cost-effective for children, pregnant and postpartum women, high risk groups, and in some cases, healthy working age adults. Immunization programs using group administration are more cost-effective than programs using individual administration. The perspective, programmatic design, setting, and inclusion of herd immunity affects cost-effectiveness. In regions with targeted programs, re-evaluating "high risk" criteria and consideration of a universal program is warranted.

Cost for physician-diagnosed influenza and influenza-like illnesses on primary care level in Germany--results of a database analysis from May 2010 to April 2012

BACKGROUND

Seasonal influenza is one of the most significant infectious diseases in Germany; epidemic outbreaks occur every winter and cause substantial morbidity and mortality. However, published data from Germany on the current economic burden of influenza and the costs per episode are lacking.

METHODS

A retrospective database analysis was conducted using a longitudinal electronic medical records database (IMS Disease Analyzer). Patients with influenza, diagnosed by German office-based physicians using ICD-10 J09-11 (International Classification of Diseases, 10(th) revision), who were observable in the database from 12 months before the index (diagnosis) date until 1 month afterwards, were included. The selection window, defined to cover two influenza seasons, was May 2010 to April 2012. Direct and indirect costs were evaluated from payer, patient and societal perspectives. Published unit costs and tariffs from Germany (2012) were used for the analysis.

RESULTS

A total of 21,039 influenza-attributable episodes in 17,836 adults, managed by primary care physicians (PCP) and 7,107 episodes in 6,288 children, managed by pediatricians, were eligible for analysis. The mean (±Standard Deviation (SD)) age of the adults with at least one episode was 46 (±18) years and 7 (±4) years in the children. The presence of clinical risk factors was documented for 39% episodes in adults and 24% episodes in children, with the most common being cardiovascular diseases in adults (29%) and chronic respiratory diseases in children (23%). Complications and severe symptoms accompanied the influenza-attributable episode (adults: 37%, children: 54%), bronchitis (adults: 16%, children: 19%) and acute upper respiratory infection (adults: 15%, children: 21%) being the most frequent. From a societal perspective, the total average mean cost (±SD) per episode was €514 (±609) in adults, where work days lost were the main cost driver (82%), and €105 (±224) in children. Complications and severe symptoms increased the cost per episode versus episodes without by 1.7 times in adults (€684 (±713) vs. €413 (±510)) and nearly 3 times in children (€149 (±278) vs. €55 (±116)).

CONCLUSIONS

Based on a large patient sample derived from representative PCP and pediatricians panels, our results demonstrate that seasonal influenza is associated with substantial clinical and economic burden in Germany.

Amantadine and rimantadine for influenza A in children and the elderly

BACKGROUND

Influenza is an acute respiratory illness caused by influenza A and B viruses. Complications may occur, especially among children and the elderly.

OBJECTIVES

To assess the effectiveness and safety of amantadine and rimantadine in preventing, treating and shortening the duration of influenza A in children and the elderly.

SEARCH METHODS

We searched CENTRAL (2014, Issue 9), MEDLINE (1966 to September week 4, 2014) and EMBASE (1980 to October 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing amantadine and/or rimantadine with no intervention, placebo, other antivirals or different doses or schedules of amantadine or rimantadine in children and the elderly with influenza A.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the search results. We extracted and analysed data using the standard Cochrane methodology.

MAIN RESULTS

We identified 12 studies (2494 participants: 1586 children and 908 elderly) comparing amantadine and rimantadine with placebo, paracetamol (one trial: 69 children) or zanamivir (two trials: 545 elderly) to treat influenza A.Amantadine was effective in preventing influenza A in children (773 participants, risk ratio (RR) 0.11; 95% confidence interval (CI) 0.04 to 0.30). The assumed risk of influenza A in the control group was 10 per 100. The corresponding risk in the rimantadine group was one per 100 (95% CI 0 to 3). Nevertheless, the quality of the evidence was low and the safety of the drug was not well established.For treatment, rimantadine was beneficial in abating fever on day three of treatment in children: one selected study with low risk of bias, moderate evidence quality and 69 participants (RR 0.36; 95% CI 0.14 to 0.91). The assumed risk was 38 per 100. The corresponding risk in the rimantadine group was 14 per 100 (95% CI 5 to 34).Rimantadine did not show any prophylactic effect in the elderly. The quality of evidence was very low: 103 participants (RR 0.45; 95% CI 0.14 to 1.41). The assumed risk was 17 per 100. The corresponding risk in the rimantadine group was 7 per 100 (95% CI 2 to 23).There was no evidence of adverse effects caused by treatment with amantadine or rimantadine.We found no studies assessing amantadine in the elderly.

AUTHORS' CONCLUSIONS

The quality of the evidence combined with a lack of knowledge about the safety of amantadine and the limited benefits of rimantadine, do not indicate that amantadine and rimantadine compared to control (placebo or paracetamol) could be useful in preventing, treating and shortening the duration of influenza A in children and the elderly.

Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patient safety and nonmaleficent practice

A growing body of literature defends the efficacy of seasonal influenza vaccination for health care workers in reducing the mortality of hospitalized patients. I review the evidence concerning influenza vaccination, concluding that universal vaccination of health care workers against influenza should be considered standard patient care and that nonvaccination represents maleficent care. I further argue that the ethical responsibility to ensure universal vaccination of staff against seasonal influenza lies not only with individual health care providers but with each individual health care institution.

Can increasing adult vaccination rates reduce lost time and increase productivity?

This article addresses limited vaccination coverage by providing an overview of the epidemiology of influenza, pertussis, and pneumonia, and the impact these diseases have on work attendance for the worker, the worker's family, and employer profit. Studies focused on the cost of vaccination programs, lost work time, lost employee productivity and acute disease treatment are discussed, as well as strategies for increasing vaccination coverage to reduce overall health care costs for employers. Communicating the benefits of universal vaccination for employees and their families and combating vaccine misinformation among employees are outlined.

Socioeconomic impact of seasonal (epidemic) influenza and the role of over-the-counter medicines

The substantial economic impact of influenza on society results primarily from lost work time and reduced productivity of patients and caregivers and increased use of medical resources. Additionally, since the 1980s, aging of the US population has meant rising influenza-related morbidity and mortality. According to the most current published data on this topic, in 2003 the total economic burden of influenza epidemics in the USA across all age groups was US$87.1 billion. As of February 2013, overall vaccine effectiveness for the 2012/2013 season was estimated to be 56 %. The Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases has concluded that more effective vaccines and vaccination strategies are needed. Moderate efficacy of the influenza vaccine, continued questions regarding the value of treatment with antivirals, and a growing self-care movement have led to increased use of over-the-counter (OTC) medicines, which play a vital role in managing symptoms associated with mild to moderate influenza and provide an estimated US$102 billion in annual savings for the US healthcare system. A primary benefit to society of using OTC medicines to manage influenza is decreased use of the healthcare system, thereby mitigating the socioeconomic burden of influenza. Considering the stresses placed on the US healthcare system and the substantial productivity losses resulting from seasonal influenza as well as the growing self-care movement, OTC medicines will play an important role in the course of future influenza epidemics.

Trends in racial/ethnic disparities in influenza vaccination coverage among adults during the 2007-08 through 2011-12 seasons

BACKGROUND

Annual influenza vaccination is recommended for all persons aged ≥6 months. The objective of this study was to assess trends in racial/ethnic disparities in influenza vaccination coverage among adults in the United States.

METHODS

We analyzed data from the 2007-2012 National Health Interview Survey (NHIS) and Behavioral Risk Factor Surveillance System (BRFSS) using Kaplan-Meier survival analysis to assess influenza vaccination coverage by age, presence of medical conditions, and racial/ethnic groups during the 2007-08 through 2011-12 seasons.

RESULTS

During the 2011-12 season, influenza vaccination coverage was significantly lower among non-Hispanic blacks and Hispanics compared with non-Hispanic whites among most of the adult subgroups, with smaller disparities observed for adults age 18-49 years compared with other age groups. Vaccination coverage for non-Hispanic white, non-Hispanic black, and Hispanic adults increased significantly from the 2007-08 through the 2011-12 season for most of the adult subgroups based on the NHIS (test for trend, P < .05). Coverage gaps between racial/ethnic minorities and non-Hispanic whites persisted at similar levels from the 2007-08 through the 2011-12 seasons, with similar results from the NHIS and BRFSS.

CONCLUSIONS

Influenza vaccination coverage among most racial/ethnic groups increased from the 2007-08 through the 2011-12 seasons, but substantial racial and ethnic disparities remained in most age groups. Targeted efforts are needed to improve coverage and reduce these disparities.

Seasonal influenza vaccination coverage among adult populations in the United States, 2005-2011

The most effective strategy for preventing influenza is annual vaccination. We analyzed 2005-2011 data from the National Health Interview Survey (NHIS), using Kaplan-Meier survival analysis to estimate cumulative proportions of persons reporting influenza vaccination in the 2004-2005 through 2010-2011 seasons for persons aged ≥18, 18-49, 50-64, and ≥65 years, persons with high-risk conditions, and health-care personnel. We compared vaccination coverage by race/ethnicity within each age and high-risk group. Vaccination coverage among adults aged ≥18 years increased from 27.4% during the 2005-2006 influenza season to 38.1% during the 2010-2011 season, with an average increase of 2.2% annually. From the 2005-2006 season to the 2010-2011 season, coverage increased by 10-12 percentage points for all groups except adults aged ≥65 years. Coverage for the 2010-2011 season was 70.2% for adults aged ≥65 years, 43.7% for adults aged 50-64 years, 36.7% for persons aged 18-49 years with high-risk conditions, and 55.8% for health-care personnel. In most subgroups, coverage during the 2010-2011 season was significantly lower among non-Hispanic blacks and Hispanics than among non-Hispanic whites. Vaccination coverage among adults under age 65 years increased from 2005-2006 through 2010-2011, but substantial racial/ethnic disparities remained in most age groups. Targeted efforts are needed to improve influenza vaccination coverage and reduce disparities.

Influenza vaccines in low and middle income countries: a systematic review of economic evaluations

OBJECTIVES

Economic evaluations on influenza vaccination from low resource settings are scarce and have not been evaluated using a systematic approach. Our objective was to conduct a systematic review on the value for money of influenza vaccination in low- and middle-income countries.

METHODS

PubMed and EMBASE were searched for economic evaluations published in any language between 1960 and 2011. Main outcome measures were costs per influenza outcome averted, costs per quality-adjusted life years gained or disability-adjusted life years averted, costs per benefit in monetary units or cost-benefit ratios.

RESULTS

Nine economic evaluations on seasonal influenza vaccine met the inclusion criteria. These were model- or randomized-controlled-trial (RCT)-based economic evaluations from middle-income countries. Influenza vaccination provided value for money for elderly, infants, adults and children with high-risk conditions. Vaccination was cost-effective and cost-saving for chronic obstructive pulmonary disease patients and in elderly above 65 y from model-based evaluations, but conclusions from RCTs on elderly varied.

CONCLUSION

Economic evaluations from middle income regions differed in population studied, outcomes and definitions used. Most findings are in line with evidence from high-income countries highlighting that influenza vaccine is likely to provide value for money. However, serious methodological limitations do not allow drawing conclusions on cost-effectiveness of influenza vaccination in middle income countries. Evidence on cost-effectiveness from low-income countries is lacking altogether, and more information is needed from full economic evaluations that are conducted in a standardized manner.

Key issues for estimating the impact and cost-effectiveness of seasonal influenza vaccination strategies

Many countries have considered or are considering modifying their seasonal influenza immunization policies. Estimating the impact of such changes requires understanding the existing clinical and economic burden of influenza, as well as the potential impact of different vaccination options. Previous studies suggest that vaccinating clinical risk groups, health care workers, children and the elderly may be cost-effective. However, challenges in such estimation include: (1) potential cases are not usually virologically tested; (2) cases have non-specific symptoms and are rarely reported to surveillance systems; (3) endpoints for influenza proxies (such as influenza-like illness) need to be matched to case definitions for treatment costs, (4) disease burden estimates vary from year to year with strain transmissibility, virulence and prior immunity, (5) methods to estimate productivity losses due to influenza vary, (6) vaccine efficacy estimates from trials differ due to variation in subtype prevalence, vaccine match and case ascertainment, and (7) indirect (herd) protection from vaccination depends on setting-specific variables that are difficult to directly measure. Given the importance of knowing the impact of changes to influenza policy, such complexities need careful treatment using tools such as population-based trial designs, meta-analyses, time-series analyses and transmission dynamic models.

Employer-incurred health care costs and productivity losses associated with influenza

The primary objective of this study was to assess trends in employer expenditures for both direct medical costs and indirect productivity losses associated with influenza. A retrospective analysis was performed using two of the MarketScan family of databases for 2005-2009. Patients with at least one diagnosis claim for influenza during an influenza season were selected. We estimated seasonal incidence of influenza in the employed population from the MarketScan Commercial Claims and Encounters database. Health care utilization and costs and productivity losses were assessed during the 21-d period following the influenza diagnosis date. Compared with the 2005-2006 season (493 per 100,000 plan members), influenza incidence increased during the 2006-2007 (598 per 100,000 plan members) and 2007-2008 (1,142 per 100,000 plan members) seasons and had a dramatic increase during the pandemic season of 2008-2009 (1,715 per 100,000 plan members) . The total influenza-related employer spending per 100,000 plan members also increased by over 400% during the 2008-2009 influenza season [$623,248; confidence interval (CI]):$601,518-$644,991], compared with 2005-2006 ($145,834; 95% CI: $135,067-$156,603). The primary drivers of the increased costs were emergency room, outpatient and inpatient visits. Total costs associated with influenza-related missed work time per 100,000 plan members increased over 4-fold from $26,479 in the 2005-2006 influenza season to $122,811 in 2008-2009. Overall, as expected, considerably higher direct and indirect costs were observed during the 2008-2009 influenza pandemic season than during other influenza seasons. In recent years, the influenza-related employer burden has increased considerably. In future, employers may need efficient resource allocation in order to address the productivity losses and increasing direct medical costs associated with increased influenza incidence. One of the strategies that employers may consider is increasing influenza vaccination rates among employees, which likely will help lower the influenza incidence and the associated downstream direct and indirect costs.