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PubMed1997

Impact of a new universal purchase vaccine program in North Carolina.

OBJECTIVE: To explore the effects of state universal purchase (UP) of vaccines for all children, regardless of income or insurance status, on North Carolina physicians and families. DESIGN: Cross-sectional survey. PARTICIPANTS: Pediatricians and family physicians (N = 2163) were surveyed in 1995 to compare immunization charges in North Carolina (new UP) with those of Massachusetts (UP) and Texas (free market). MAIN OUTCOME MEASURES: Patient charges for immunizations and well-child visits and physician perceptions of the effects of state immunization programs. Models were devised to simulate the net effect of the North Carolina UP program on immunization revenue for physicians and on families' out-of-pocket costs for well-child care. RESULTS: Physician participation rates in the 2 UP programs were very high. North Carolina physicians reported substantial decreases in immunization charges and reduced referrals to public clinics, but thought that UP increased their administrative burden. Sixty percent of North Carolina physicians increased charges for well-child visits, nearly twice that in the 2 control states. Families who previously had received immunizations from public clinics but chose to remain in the private-sector "medical home" for immunizations after implementation of UP had increased out-of-pocket expenses that varied by their insurance status. CONCLUSIONS: The North Carolina UP program is effective in decreasing patient immunization charges and reducing referrals to public clinics. However, UP does not eliminate cost as a barrier to immunization, nor does it enable all children to remain in their medical homes. Underinsured children still may face considerable financial barriers to immunization in a UP system.

Cross-Sectional Studies↗

PubMed2007

The economics of routine childhood hepatitis A immunization in the United States: the impact of herd immunity.

OBJECTIVES: Because of the herd-immunity phenomenon, the benefits of immunization against hepatitis A extend beyond those received by those who are vaccinated. This analysis estimates the impact of herd immunity on the cost-effectiveness of routine hepatitis A immunization among US children. PATIENTS AND METHODS: In an economic model, the costs and benefits of hepatitis A immunization were estimated for immunizing all US children at age 1 year over a 10-year period starting in 2005. The future burden of disease from hepatitis A was also estimated with this model, and the fraction that would be prevented by herd immunity was modeled by using a previously published analysis of the relationship between hepatitis A vaccination coverage and declines in hepatitis A incidence. RESULTS: Without accounting for herd-immunity effects, the costs of routine immunization would average 32,000 dollars per quality-adjusted life-year gained for the first 10 cohorts immunized starting with the 2005 birth cohort. Herd-immunity effects would be expected to produce substantial additional benefits, lowering the cost of the immunization program to 1000 dollars per quality-adjusted life-year gained for the first 10 cohorts. Herd-immunity benefits would be greatest for the first few cohorts, more than doubling the benefits of immunization, and would decline over time. In a univariate sensitivity analysis, estimates were most sensitive to vaccination costs but remained below 20,000 dollars per quality-adjusted life-year under all of the assumptions. CONCLUSIONS: Herd-immunity effects more than double the savings from hepatitis A immunization during the first 10 years of the program. After accounting for these effects, immunization is close to cost-neutral on a cost-per-quality-adjusted-life-year basis.

Child, Preschool↗

PubMed1997

Increasing immunization: a Medicaid managed care model.

OBJECTIVE: To evaluate the impact of an immunization outreach program on immunization rates. SETTING: A Pennsylvania independent practice association model managed care organization (100% Medicaid). DESIGN: Retrospective cohort study (N = 2511) of children 30 to 35 months of age from two age cohorts that compared immunization rates for Advisory Committee on Immunization Practices schedules for diphtheria-tetanus-pertussis, oral polio vaccine, measles-mumps-rubella, and Haemophilus influenza type b. An evaluation of the outreach component of the program compared treatment and nontreatment subgroups of one age cohort (N = 1002). INTERVENTION: The immunization program targeted approximately 19 000 members from birth to 6 years of age. The program components included computerized tracking and reminders, member and provider education, provider incentives, member incentives, and home visiting outreach. RESULTS: Data indicate that the treatment group has higher completed immunization rates at 35 months of age than does the control group. Furthermore, data show that members with home visits have significantly higher completed immunization rates than do other members. The corresponding comparisons for age-appropriate immunizations by 24 months indicate a nonsignificant trend of increased rates. CONCLUSION: The data provide evidence supporting a correlation between comprehensive strategies (computerized tracking, member and provider education and incentives, and home visiting) and increased immunization rates. Those individuals who received home visits were more likely to complete an immunization series by 35 months of age than those who did not. However, within the Mercy Health Plan program, age-appropriate immunizations are not significantly affected by home-visiting outreach.

Child, Preschool↗

PubMed2001

Ethics and immunization policy: promoting dialogue to sustain consensus.

The societal consensus that has supported the United States' universal childhood immunization programs for the past 50 years shows signs of eroding. This article proposes a systematic approach to evaluate immunization policy options. Through a unifying framework that combines epidemiologic, economic, and ethical concerns, this approach promotes a clearer understanding of underlying issues and inherent tradeoffs between alternative policies. Such a systematic examination of policy options could facilitate the public dialogue necessary to continually recreate a broad consensus on immunization practices and enable us to choose policies most in accord with our fundamental values.

Ethics, Medical↗

PubMed1997

[How to manage vaccinations in the elderly traveler].

Along with the growth of travels, the ageing of the population multiplies the number of older travellers. 13% of travellers could be at least 65 years old. It is admitted that there is no upper age limit to perform immunizations. Immunizations are all the more useful for older people because age generally aggravates infectious diseases. With age the immune response decreases definitely, especially that depending on cellular immunity, as well as the humoral response, as it has been observed with vaccinations against tetanus, flu, pneumococcal infections and hepatitis B. The first series of immunizations could be more affected by age than boosters. But a lot of questions still remain unanswered. Is there a maximum age beyond which the immune response would be unadapted to such an extent that it would be necessary to modify the immunization protocols as well as the periodicity of boosters? 75 years? 80 years? Is this age the same for all individuals? Is that a matter of a lower level of the antibody response, or rather of a slower, delayed response? The planning of older travellers immunizations meets another difficulty: their often vague knowledge of past immunization records and infectious diseases. One is often reduced to conjectures. Thus men, who have served in the army since the beginning of World War II are supposed to have got the first series of immunization against tetanus and diphtheria, but how can we restore their immunity (once we have defined the maximum age) when boosters have been either insufficient or missing? Conversely for women born before 1945, who were probably never immunized, a first series of immunization is warranted. On the other hand, since the immunization against poliomyelitis only came into effect in the sixties, most older adults have never been immunized but have acquired in the past a natural immunity from their contact with wild polio viruses. Naturally acquired antipoliovirus immunity doesn't seem to have decreased with age, unlike antidiphtheria and antitetanus immunity, as shown by recent serologic studies. Thus would a single booster with inactivated polio vaccine be sufficient to reinforce the immunity of most older travellers who have never been immunized? Considering these uncertainties, one could think of carrying out a serologic assessment prior to establishing an immunization program, as it has already been recommended for the immunization against hepatitis A. What would its feasibility be? There are quite a lot of questions to discuss. May this round table help define these questions and specify which investigations would be necessary to solve them, as well as program more rationally the immunizations of the older traveller.

Aged↗

PubMed1986

Antibody determination in an ongoing hepatitis B vaccination program.

In an interim analysis of our ongoing immunization program against hepatitis B (HB), started in early 1982, we tested 283 serum samples from 77 female and 110 male vaccinees for antibody to HB surface antigen (anti-HBs). We compared two methods, Anti-HBs EIA (ROCHE) (method 1), which is a neutralization test, and AUSABR EIA (method 2), which is a double-antigen-sandwich test. The nonresponder rate (after the 12-month booster dose of Hevac B Pasteur) was 4% in females with both methods, in males 15% measured with method 1 and 11% measured with method 2. Five healthy HBsAg carriers were detected only by method 1. When the samples were grouped according to their anti-HBs titers, method 1 measured higher in samples taken after three vaccine doses and method 2 did so in samples collected after the 12-month booster dose. This tendency was confirmed with samples from slow responders who received a 4th vaccine dose soon after the initial three doses. We therefore confirm the efficacy of the plasma-derived HBsAg vaccine and validate the assay systems used to measure anti-HBs, one parameter of immunity to HB virus infection.

Adult↗

PubMed2006

Hepatitis B virus infection: epidemiology and vaccination.

Worldwide, two billion people have been infected with hepatitis B virus (HBV), 360 million have chronic infection, and 600,000 die each year from HBV-related liver disease or hepatocellular carcinoma. This comprehensive review of hepatitis B epidemiology and vaccines focuses on definitive and influential studies and highlights current trends, policies, and directions. HBV can be transmitted vertically, through sexual or household contact, or by unsafe injections, but chronic infections acquired during infancy or childhood account for a disproportionately large share of worldwide morbidity and mortality. Vaccination against HBV infection can be started at birth and provides long-term protection against infection in more than 90% of healthy people. In the 1990s, many industrialized countries and a few less-developed countries implemented universal hepatitis B immunization and experienced measurable reductions in HBV-related disease. For example, in Taiwan, the prevalence of chronic infection in children declined by more than 90%. Many resource-poor nations have recently initiated universal hepatitis B immunization programs with assistance from the Global Alliance for Vaccines and Immunization. Further progress towards the elimination of HBV transmission will require sustainable vaccination programs with improved vaccination coverage, practical methods of measuring the impact of vaccination programs, and targeted vaccination efforts for communities at high risk of infection.

Child Health Services↗

PubMed2003

The cost-effectiveness of routine childhood varicella vaccination in Germany.

This study explores the economic value of a routine varicella vaccination program for Germany. An age-structured decision analytic model was used to assess the benefits, costs and cost-effectiveness of an immunization program for a period of 30 years. Three interventions were compared with no vaccination: universal vaccination of around 15 months old healthy children, vaccination of susceptible adolescents (11-12 years of age), and the combined strategy. The analysis was conducted from both the societal perspective and the payers', i.e. sickness funds, perspective. Input data were mainly derived from a retrospective survey (analyzed were 1334 patient records) and from a seroprevalence study (n = 4602 sera). Using a coverage rate of 85% and a vaccine efficacy rate of 86% routine children vaccination could prevent around 611,000 varicella cases and over 4700 major complications per year. Average yearly cost savings for the society are 51.3 million Euro. The benefit-cost ratio (BCR) is 4.12. From the third-party payer's perspective, the BCR is 1.75 which is a consequence of significant reimbursement of parent's lost earnings by German sickness funds. The adolescent vaccination strategy has a favorable BCR ratio of 8.44 from the societal perspective, but clearly inferior medical effects. The combined vaccination strategy showed similar results as the children strategy. Routine childhood varicella vaccination appears to be a highly efficient strategy to reduce the burden of varicella and results in significant savings for both the society and the payers.

Adolescent↗

PubMed2001

Effectiveness of a mass immunization campaign against serogroup C meningococcal disease in Quebec.

CONTEXT: An outbreak of meningococcal disease in Quebec province prompted a mass immunization program. The impact of this campaign on the epidemiology of meningococcal disease has not been studied. OBJECTIVES: To study the impact of a mass immunization campaign using polysaccharide vaccine on the epidemiology of meningococcal disease (MCD) and to assess serogroup C vaccine effectiveness (VE). DESIGN, SETTING, AND SUBJECTS: Analysis of MCD cases reported in Quebec from 1990 to 1998, before and after the mass immunization campaign was conducted during the winter of 1992-1993, when 84% of residents aged 6 months to 20 years (the target population, approximately 1.9 million individuals) were vaccinated. MAIN OUTCOME MEASURES: Incidence of MCD in 1990-1998; incidence of culture-proven serogroup C MCD between April 1, 1993, and March 31, 1998, compared among vaccinated and unvaccinated persons in the target population. RESULTS: The incidence of serogroup C disease decreased after the mass immunization campaign, from 1.4 per 100 000 in 1990-1992 to 0.3 per 100 000 in 1993-1998, and the overall incidence of other serogroups remained stable at 0.7 per 100 000, with a small increase in the proportion of cases caused by serogroup Y (P =.009). Protection from serogroup C MCD was indicated in the first 2 years after vaccine administration (VE, 65%; 95% confidence interval [CI], 20%-84%), but not in the next 3 years (VE, 0%; 95% CI, -5% to 65%). Vaccine effectiveness was strongly related to age at vaccination: 83% (95% CI, 39%-96%) for ages 15 through 20 years, 75% (95% CI, - 17% to 93%) for ages 10 through 14 years, and 41% (95% CI, -106% to 79%) for ages 2 through 9 years. There was no evidence of protection in children younger than 2 years; all 8 MCD cases in this age group occurred in vaccinees. CONCLUSIONS: Serogroup C polysaccharide vaccine is effective for controlling outbreaks in teenaged individuals but should not be used in children younger than 2 years. The mass campaign did not induce significant serogroup switching.

Adolescent↗

PubMed1992

Neutrophil, glass-adherent, nitroblue tetrazolium assay gives early indication of immunization effectiveness in rainbow trout.

Neutrophil activity in rainbow trout (Oncorhynchus mykiss) is increased upon antigenic stimulation with the Yersinia ruckeri O-antigen bacterin. The characteristics of neutrophil attachment to glass and nitroblue tetrazolium (NBT) staining were used to determine the effectiveness of immunization programs with fingerling rainbow trout. Fish immunized by intraperitoneal injection with doses of 100, 10, or 1 microgram of the bacterin showed the highest responses in that order in numbers of glass adherent, NBT-positive neutrophils. Studies on the kinetics of the occurrence of numbers of glass-adherent, NBT-positive staining cells from the fish injected with the 10 micrograms dose showed the numbers of positive cells were largest on Day 2 after injection. The specific immune response was confirmed by demonstrating the presence of plaque-forming cells by the passive hemolytic plaque assay and the rise in humoral antibody titers by passive hemagglutination 12 days after injection. The effects of immunization in trout could be detected earlier by using the neutrophil glass adherence and NBT reduction assays than by using assays based on observations of the specific immune response.

Animals↗

PubMed1994

Health cards, maternal reports and the measurement of immunization coverage: the example of Guatemala.

Immunization against major childhood diseases has been an essential component of health policies in developing countries. However, despite its importance and the efforts invested by many organizations in promoting immunization programs, consistent and accurate measurement of immunization coverage has not yet been achieved. In this paper, we explore the implications of alternative methods of measuring immunization coverage rates in Guatemala, using data from the 1987 Encuesta Nacional de Salud Materno Infantil, and we consider the dangers of making inferences about levels and trends in coverage from cross-sectional data. The results indicate that (1) service statistics may well lead to overestimates of coverage; (2) survey estimates derived from health cards can also produce severely biased estimates; and (3) in spite of problems associated with maternal recall, mothers' reports of their children's vaccination status probably result in substantially improved estimates of immunization coverage.

Bias↗

PubMed2003

Monitoring vaccine safety during measles mass immunization campaigns: clinical and programmatic issues.

In the planning and implementation of mass immunization campaigns, vaccine delivery has always been a priority. However, safety issues have gained increasingly more attention and grown in importance, and campaign planners must now take them into prime consideration. The World Health Organization has released guidelines to assist with the design and implementation of safety surveillance systems, primarily for developing countries, and these include a new monograph for measles mass campaigns. Experience in the past decade with mass campaigns (primarily in developed countries) shows that measles vaccine performs in these settings as anticipated from pre- and post-licensure studies. Serious adverse events are rare, even under the increased scrutiny extended during a campaign. The experience in developing country settings is growing. The implementation of safety surveillance for mass campaigns offers a unique opportunity for countries to avoid crisis situations and to begin vaccine safety monitoring in routine immunization programs.

Adolescent↗

PubMed1999

Indications for acellular pertussis vaccines in adults: the case for selective, rather than universal, recommendations.

The availability of acellular pertussis vaccines, which appear to be both safe and immunogenic in adults, will require that vaccine advisory groups make recommendations regarding their use. Pertussis in adults has negligible mortality but is responsible for about one-quarter of cases of chronic cough syndrome in young adults. Parents and other infant caregivers are important transmitters of pertussis to infants, the group who have the highest morbidity and mortality. Assuming that further studies confirm the immunogenicity and safety profile of acellular pertussis vaccines in adults, recommendations can be made for its use for universal immunization of adolescents, epidemic control, and strongly considered targeted adults who give care to infants. Factors that mitigate against including acellular pertussis vaccine in the recommended decennial tetanus-diphtheria toxoids booster include the short duration of the immune response to the acellular pertussis vaccine, increased cost and reactogenicity, and the lack of vaccine delivery systems to most adults. The elderly and the infirm, who are the current focus of adult immunization programs, are unlikely candidates for pertussis immunization. Therefore, recommendations for use of acellular pertussis vaccine in adults should be selective, rather than universal.

Adult↗

PubMed2006

Linking practices with community programs to improve immunization rates.

Pediatricians should be knowledgeable about programs available in their community and support efforts to collaborate with other providers, public health departments and immunization coalitions in their community. Through immunization coalitions and widespread use of an immunization registry, together with participating private providers, case management and home visitation programs can improve immunization rates among the highest risk children.

Child↗

PubMed2006

Meningococcal conjugate vaccines: efficacy and new combinations.

OBJECTIVE: Meningococcal disease continues to be a serious public health concern, being associated with high morbidity and mortality rates worldwide, particularly in Brazil. In addition to discussing recent changes in the global epidemiology of meningococcal disease, we also analyze the development and impact of new conjugate vaccines on the prevention of meningococcal disease, with emphasis on the different immunization strategies implemented with these vaccines. SOURCES OF DATA: MEDLINE databases were searched from 1996 to 2006, with emphasis on review articles, clinical trials and epidemiological studies. Information was also sought on the Centers for Disease Control and Prevention, Brazilian Ministry of Health and Centro de Vigilância Epidemiológica do Estado de São Paulo websites. SUMMARY OF THE FINDINGS: Five serogroups (A, B, C, W135 and Y) are responsible for virtually all cases of the disease worldwide, with marked regional and temporal differences. The new meningococcal serogroup C conjugate vaccines (MCC) offer unmistakable advantages over polysaccharide vaccines. MCC vaccines generate a more efficient and long-lasting antibody response, inducing immunologic memory and reduction of nasopharyngeal carriage. The immediate results of introducing these vaccines into immunization programs have been encouraging, with a dramatic reduction in the incidence of serogroup C disease, not only in vaccinated, but also in unvaccinated individuals (herd immunity). However, concerns have arisen regarding the long-term effectiveness of these vaccines, especially for infants vaccinated in the routine schedule. CONCLUSIONS: The reported waning of efficacy more than 1 year after routine infant immunization supports alternative schedules incorporating a booster dose of MCC vaccine given at 12-18 months of age, in order to maintain long-term protection. The recent licensure of the tetravalent meningococcal conjugate vaccine represents, at last, a real possibility of a broader protection against meningococcal disease, although the need to develop an effective vaccine against serogroup B remains.

Adult↗

PubMedDate not supplied

Keeping up-to-date on immunizations: a framework and review for pharmacists.

OBJECTIVE: To provide a framework for keeping current in the immunizations field; an update on changes in adult and pediatric vaccine delivery since 2003; and an update on new immunization guidelines, new approved vaccines, and changes in uses for current vaccines. DATA SOURCES: Published guidelines identified from the Centers for Disease Control National Immunization Program Web site. In addition, published articles were identified through Medline (January 2003-November 2005) using specific vaccine names as search terms. Additional sources were identified from the bibliographies of retrieved articles. STUDY SELECTION: By the authors. DATA EXTRACTION: By the authors. DATA SYNTHESIS: To implement the immunization services now permitted under law in 44 states, many pharmacists receive initial training through the American Pharmacists Association Pharmacy-Based Immunization Delivery CERTIFICATE PROGRAM. To remain up-to-date in this field, pharmacists can apply the process described in this article, which includes regular monitoring of the Web site and publications of the Centers for Disease Control and Prevention and participation in one or more listservs. Specific information is presented on new vaccines marketed in the United States since 2003 along with updates on standards for adult and adolescent immunizations and changes in guidelines during this time frame. CONCLUSION: As increasingly committed health professionals in the immunizations field, pharmacists are responsible for keeping updated on the constantly changing recommendations for vaccines and related products. By incorporating the recent information presented in this article and applying the process described for tracking changes in this field, pharmacists can fulfill their emerging vaccine-related roles on the health care team.

Adolescent↗

PubMed1983

Achieving optimal immunization levels in school-age children.

In a school-based immunization program in four states, 70% of the students were fully immunized by the end of the first year and 85% by the end of the second year. Because of student turnover, 20% of the immunization levels achieved by the end of a school year were not sustained into the subsequent year. Levels reported by the state immunization officers were higher than those recorded by school personnel. Completed immunization series for students requiring immunizations were 33% to 40% higher for students enrolled at the start of the year than for students who entered during the school year. Students who were unimmunized at the beginning of the year had a better change (P less than 0.001) of being immunized by the end of the year than those whose immunization status was unknown. To maintain high levels, a program must be sustained and continuing, provide immunizations, and have careful administrative monitoring of child-specific population-based data. Schools are uniquely able to provide all of these elements, which can augment the efforts of private practitioners.

Child↗

PubMed2006

The impact of mass school immunization on school attendance.

The purpose of this study was to assess the impact a free, on-site influenza immunization program could have on attendance in Title 1 schools. Four Title 1 elementary schools participated in the study. Students at 2 schools were offered free FluMist immunizations on site, and students at 2 control schools were not. Compliance on receiving FluMist was measured on the percentage of students participating after evaluating for medical exclusions. Documentation on the reason for absences at all 4 schools included self- or parent-reported influenza. Attendance rates for the year also were compared with the previous year for all 4 schools. A comparison was done of total days absent versus total days enrolled between schools receiving FluMist and schools not receiving the vaccine. Despite the fact that FluMist is a new vaccine and is not required for children, 57% of those medically eligible to receive it had parental permission and received the vaccine. The 2 schools receiving FluMist increased their attendance rates from 95.3% and 93.9% to 96.1% and 95.8%. Previously, the comparison schools each had a 94.6% attendance rate; one fell to 94.4% and the other rose very slightly to 94.7%. The differences in self- or parent-reported influenza absences were not significant. However, the difference in days absent between individual vaccinated and nonvaccinated schools was statistically significant.

Absenteeism↗