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Bangs AC, Gastañaduy P, Neilan AM, Fiebelkorn AP, Walker AT, Rao SR, Ryan ET, LaRocque RC, Walensky RP, Hyle EP. The Clinical and Economic Impact of Measles-Mumps-Rubella Vaccinations to Prevent Measles Importations From US Pediatric Travelers Returning From Abroad. J Pediatric Infect Dis Soc 2022; 11:257-266. [PMID: 35333347 PMCID: PMC9214784 DOI: 10.1093/jpids/piac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/01/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric international travelers account for nearly half of measles importations in the United States. Over one third of pediatric international travelers depart the United States without the recommended measles-mumps-rubella (MMR) vaccinations: 2 doses for travelers ≥12 months and 1 dose for travelers 6 to <12 months. METHODS We developed a model to compare 2 strategies among a simulated cohort of international travelers (6 months to <6 years): (1) No pretravel health encounter (PHE): travelers depart with baseline MMR vaccination status; (2) PHE: MMR-eligible travelers are offered vaccination. All pediatric travelers experience a destination-specific risk of measles exposure (mean, 30 exposures/million travelers). If exposed to measles, travelers' age and MMR vaccination status determine the risk of infection (range, 3%-90%). We included costs of medical care, contact tracing, and lost wages from the societal perspective. We varied inputs in sensitivity analyses. Model outcomes included projected measles cases, costs, and incremental cost-effectiveness ratios ($/quality-adjusted life year [QALY], cost-effectiveness threshold ≤$100 000/QALY). RESULTS Compared with no PHE, PHE would avert 57 measles cases at $9.2 million/QALY among infant travelers and 7 measles cases at $15.0 million/QALY among preschool-aged travelers. Clinical benefits of PHE would be greatest for infants but cost-effective only for travelers to destinations with higher risk for measles exposure (ie, ≥160 exposures/million travelers) or if more US-acquired cases resulted from an infected traveler, such as in communities with limited MMR coverage. CONCLUSIONS Pretravel MMR vaccination provides the greatest clinical benefit for infant travelers and can be cost-effective before travel to destinations with high risk for measles exposure or from communities with low MMR vaccination coverage.
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Affiliation(s)
- Audrey C Bangs
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul Gastañaduy
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anne M Neilan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA,Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Parker Fiebelkorn
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Allison Taylor Walker
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sowmya R Rao
- MGH Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Edward T Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Regina C LaRocque
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA,Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily P Hyle
- Corresponding Author: Emily P. Hyle, MD, MSc, Division of Infectious Diseases, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA 02114, USA. E-mail:
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Hyle EP, Fields NF, Fiebelkorn AP, Walker AT, Gastañaduy P, Rao SR, Ryan ET, LaRocque RC, Walensky RP. The Clinical Impact and Cost-effectiveness of Measles-Mumps-Rubella Vaccination to Prevent Measles Importations Among International Travelers From the United States. Clin Infect Dis 2020; 69:306-315. [PMID: 30312374 DOI: 10.1093/cid/ciy861] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/05/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Measles importations and the subsequent spread from US travelers returning from abroad are responsible for most measles cases in the United States. Increasing measles-mumps-rubella (MMR) vaccination among departing US travelers could reduce the clinical impact and costs of measles in the United States. METHODS We designed a decision tree to evaluate MMR vaccination at a pretravel health encounter (PHE), compared with no encounter. We derived input parameters from Global TravEpiNet data and literature. We quantified Riskexposure to measles while traveling and the average number of US-acquired cases and contacts due to a measles importation. In sensitivity analyses, we examined the impact of destination-specific Riskexposure, including hot spots with active measles outbreaks; the percentage of previously-unvaccinated travelers; and the percentage of travelers returning to US communities with heterogeneous MMR coverage. RESULTS The no-encounter strategy projected 22 imported and 66 US-acquired measles cases, costing $14.8M per 10M travelers. The PHE strategy projected 15 imported and 35 US-acquired cases at $190.3M per 10M travelers. PHE was not cost effective for all international travelers (incremental cost-effectiveness ratio [ICER] $4.6M/measles case averted), but offered better value (ICER <$100 000/measles case averted) or was even cost saving for travelers to hot spots, especially if travelers were previously unvaccinated or returning to US communities with heterogeneous MMR coverage. CONCLUSIONS PHEs that improve MMR vaccination among US international travelers could reduce measles cases, but are costly. The best value is for travelers with a high likelihood of measles exposure, especially if the travelers are previously unvaccinated or will return to US communities with heterogeneous MMR coverage.
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Affiliation(s)
- Emily P Hyle
- Travelers' Advice and Immunization Center, Boston, Massachusetts.,Medical Practice Evaluation Center, Department of Medicine, Boston, Massachusetts.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Naomi F Fields
- Medical Practice Evaluation Center, Department of Medicine, Boston, Massachusetts
| | - Amy Parker Fiebelkorn
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Atlanta, Georgia
| | | | - Paul Gastañaduy
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sowmya R Rao
- 8Department of Global Health, Boston University School of Public Health, Massachusetts.,MGH Biostatistics Center, Massachusetts General Hospital, Boston
| | - Edward T Ryan
- Travelers' Advice and Immunization Center, Boston, Massachusetts.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Regina C LaRocque
- Travelers' Advice and Immunization Center, Boston, Massachusetts.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Department of Medicine, Boston, Massachusetts.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
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Hyle EP, Rao SR, Bangs AC, Gastañaduy P, Fiebelkorn AP, Hagmann SH, Walker AT, Walensky RP, Ryan ET, LaRocque RC. Clinical Practices for Measles-Mumps-Rubella Vaccination Among US Pediatric International Travelers. JAMA Pediatr 2020; 174:e194515. [PMID: 31816033 PMCID: PMC6902185 DOI: 10.1001/jamapediatrics.2019.4515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE The US population is experiencing a resurgence of measles, with more than 1000 cases during the first 6 months of 2019. Imported measles cases among returning international travelers are the source of most US measles outbreaks, and these importations can be reduced with pretravel measles-mumps-rubella (MMR) vaccination of pediatric travelers. Although it is estimated that children account for less than 10% of US international travelers, pediatric travelers account for 47% of all known measles importations. OBJECTIVE To examine clinical practice regarding MMR vaccination of pediatric international travelers and to identify reasons for nonvaccination of pediatric travelers identified as MMR eligible. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of pediatric travelers (ages ≥6 months and <18 years) attending pretravel consultation at 29 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-supported consortium of clinical sites that provide pretravel consultations, was performed from January 1, 2009, through December 31, 2018. MAIN OUTCOMES AND MEASURES Measles-mumps-rubella vaccination among MMR vaccination-eligible pediatric travelers. RESULTS Of 14 602 pretravel consultations for pediatric international travelers, 2864 travelers (19.6%; 1475 [51.5%] males; 1389 [48.5%] females) were eligible to receive pretravel MMR vaccination at the time of the consultation: 365 of 398 infants aged 6 to 12 months (91.7%), 2161 of 3623 preschool-aged travelers aged 1 to 6 years (59.6%), and 338 of 10 581 school-aged travelers aged 6 to 18 years (3.2%). Of 2864 total MMR vaccination-eligible travelers, 1182 (41.3%) received the MMR vaccine and 1682 (58.7%) did not. The MMR vaccination-eligible travelers who did not receive vaccine included 161 of 365 infants (44.1%), 1222 of 2161 preschool-aged travelers (56.5%), and 299 of 338 school-aged travelers (88.5%). We observed a diversity of clinical practice at different GTEN sites. In multivariable analysis, MMR vaccination-eligible pediatric travelers were less likely to be vaccinated at the pretravel consultation if they were school-aged (model 1: odds ratio [OR], 0.32 [95% CI, 0.24-0.42; P < .001]; model 2: OR, 0.26 [95% CI, 0.14-0.47; P < .001]) or evaluated at specific GTEN sites (South: OR, 0.06 [95% CI, 0.01-0.52; P < .001]; West: OR, 0.10 [95% CI, 0.02-0.47; P < .001]). The most common reasons for nonvaccination were clinician decision not to administer MMR vaccine (621 of 1682 travelers [36.9%]) and guardian refusal (612 [36.4%]). CONCLUSIONS AND RELEVANCE Although most infant and preschool-aged travelers evaluated at GTEN sites were eligible for pretravel MMR vaccination, only 41.3% were vaccinated during pretravel consultation, mostly because of clinician decision or guardian refusal. Strategies may be needed to improve MMR vaccination among pediatric travelers and to reduce measles importations and outbreaks in the United States.
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Affiliation(s)
- Emily P. Hyle
- Travelers’ Advice and Immunization Center, Massachusetts General Hospital, Boston,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston,Division of Infectious Diseases, Massachusetts General Hospital, Boston,Harvard Medical School, Boston, Massachusetts
| | - Sowmya R. Rao
- Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Audrey C. Bangs
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston
| | - Paul Gastañaduy
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amy Parker Fiebelkorn
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan H.F. Hagmann
- Division of Pediatric Infectious Diseases, Steven and Alexandra Cohen Children’s Medical Center of New York, New Hyde Park,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Allison Taylor Walker
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston,Division of Infectious Diseases, Massachusetts General Hospital, Boston,Harvard Medical School, Boston, Massachusetts
| | - Edward T. Ryan
- Travelers’ Advice and Immunization Center, Massachusetts General Hospital, Boston,Division of Infectious Diseases, Massachusetts General Hospital, Boston,Harvard Medical School, Boston, Massachusetts
| | - Regina C. LaRocque
- Travelers’ Advice and Immunization Center, Massachusetts General Hospital, Boston,Division of Infectious Diseases, Massachusetts General Hospital, Boston,Harvard Medical School, Boston, Massachusetts
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Carlson A, Riethman M, Gastañaduy P, Lee A, Leung J, Holshue M, DeBolt C, Melnick A. Notes from the field:
Community outbreak of measles - Clark County, Washington, 2018-2019. Am J Transplant 2019. [DOI: 10.1111/ajt.15479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | | | - Paul Gastañaduy
- Division of Viral Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta Georgia
| | - Adria Lee
- Division of Viral Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta Georgia
| | - Jessica Leung
- Division of Viral Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta Georgia
| | | | - Chas DeBolt
- Office of Communicable Disease Epidemiology; Washington State Department of Health; Spokane Washington
| | - Alan Melnick
- Clark County Public Health; Vancouver Washington
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Carlson A, Riethman M, Gastañaduy P, Lee A, Leung J, Holshue M, DeBolt C, Melnick A. Notes from the Field: Community Outbreak of Measles - Clark County, Washington, 2018-2019. MMWR Morb Mortal Wkly Rep 2019; 68:446-447. [PMID: 31095534 PMCID: PMC6522079 DOI: 10.15585/mmwr.mm6819a5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Venkat H, Kassem AM, Su CP, Hill C, Timme E, Briggs G, Komatsu K, Robinson S, Sunenshine R, Patel M, Elson D, Gastañaduy P, Brady S. Notes from the Field: Measles Outbreak at a United States Immigration and Customs Enforcement Facility - Arizona, May-June 2016. MMWR Morb Mortal Wkly Rep 2017; 66:543-544. [PMID: 28542125 PMCID: PMC5657873 DOI: 10.15585/mmwr.mm6620a5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Munir N, Liu P, Gastañaduy P, Montes J, Shane A, Moe C. Norovirus infection in immunocompromised children and children with hospital-acquired acute gastroenteritis. J Med Virol 2013; 86:1203-9. [DOI: 10.1002/jmv.23774] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2013] [Indexed: 12/13/2022]
Affiliation(s)
- Naeemah Munir
- Center for Global Safe Water, Rollins School of Public Health; Emory University; Atlanta Georgia
| | - Pengbo Liu
- Center for Global Safe Water, Rollins School of Public Health; Emory University; Atlanta Georgia
| | - Paul Gastañaduy
- Division of Infectious Diseases, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Julia Montes
- Center for Global Safe Water, Rollins School of Public Health; Emory University; Atlanta Georgia
| | - Andi Shane
- Division of Infectious Diseases, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Christine Moe
- Center for Global Safe Water, Rollins School of Public Health; Emory University; Atlanta Georgia
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Lopman B, Gastañaduy P, Park GW, Hall AJ, Parashar UD, Vinjé J. Environmental transmission of norovirus gastroenteritis. Curr Opin Virol 2012; 2:96-102. [DOI: 10.1016/j.coviro.2011.11.005] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 11/03/2011] [Accepted: 11/11/2011] [Indexed: 12/12/2022]
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