Application of the revised WHO causality assessment protocol for adverse events following immunization in India

BackgroundIn 2013, the World Health Organization (WHO) and CIOMS introduced a revised Causality Assessment Protocol (CAP) for Adverse Events following Immunization (AEFI). India is one of the first countries to adopt the revised CAP. This study describes the application of the revised CAP in India.MethodsWe describe use of CAP by India’s AEFI surveillance program to assess reported AEFIs. Using publicly available results of causality assessment for reported AEFIs, we describe the results by demographic characteristics and review the trends for the results of the causality assessment.ResultsA total of 771 reports of AEFI between January 2012 and January 2015, completed causality review by August 2016. The cases were reported as belonging to a cluster (54%; n = 302), hospitalized or requiring hospitalization (41%; n = 270), death (25%; n = 195), or resulting in disability (0.4%; n = 3). The most common combinations of vaccines leading to report of an AEFI were DTwP, Hepatitis B, and OPV (14%; n = 106), followed by Pentavalent and OPV (13%; n = 103), and JE vaccine (13%; n = 101). Using the WHO Algorithm, most AEFI reports (89%, n = 683) were classifiable. Classifiable AEFI reports included those with a consistent causal association (53%; n = 407), an inconsistent causal association (29%; n = 226) or were indeterminate causal association with implicated vaccine(s) or vaccination process (6.5%; n = 50) (Fig. 1); 88 reports remained unclassifiable.ConclusionsThe revised CAP was informative and useful in classifying most of the reviewed AEFIs in India. Unclassifiable reports could be minimized with more complete information from health records. Improvements in causality assessment, and standardization in reporting between countries, can improve public confidence in vaccine system performance and identify important vaccine safety signals.     

Brief education to promote maternal influenza vaccine uptake: A randomized controlled trial

BackgroundAlthough pregnant women are the highest priority group for seasonal influenza vaccination, maternal influenza vaccination rates remain suboptimal. The purpose of this study was to evaluate the effect of a brief education intervention on maternal influenza vaccine uptake.MethodsDuring the 2013–14 and 2014–15 influenza seasons, we recruited 321 pregnant women from the antenatal clinics of 4 out of 8 public hospitals in Hong Kong with obstetric services. Hospitals were geographically dispersed and provided services to pregnant women with variable socioeconomic backgrounds. Participants were randomized to receive either standard antenatal care or brief one-to-one education. Participants received telephone follow-up at 2 weeks postpartum. The primary study outcome was self-reported receipt of influenza vaccination during pregnancy. The secondary outcomes were the proportion of participants who initiated discussion about influenza vaccination with a health care professional and the proportion of participants who attempted to get vaccinated.ResultsCompared with participants who received standard care, the vaccination rate was higher among participants who received brief education (21.1% vs. 10%; p = 0.006). More participants in the education group initiated discussion about influenza vaccination with their HCP (19.9% vs. 13.1%; p = 0.10), but the difference was not statistically significant. Of participants who did not receive the influenza vaccine (n = 271), 45 attempted to get vaccinated. A significantly higher proportion of participants who attempted to get vaccinated were in the intervention group (82.2% vs. 17.8%; p < 0.001). If participants who had attempted vaccination had received the vaccine, vaccination rates would have been substantially higher (44.1% vs. 15%; p < 0.001). Twenty-six participants were advised against influenza vaccination by a healthcare professional, including general practitioners, obstetricians, and nurses.ConclusionAlthough brief education was effective in improving vaccination uptake among pregnant women, overall vaccination rates remain suboptimal. Multicomponent approaches, including positive vaccination recommendations by healthcare professionals, are needed to promote maternal influenza vaccination.Clinical Trial Registration: www.clinicaltrials.gov (NCT01772901).     

Trabajando con nuestros pacientes fumadores en atención primaria. Un análisis de coste-efectividad

ObjectiveThe aim of this work is to realize an economic evaluation of the smoking interventions in Primary Care (PC).DesignCost-Effectiveness Analysis comparing two intervention strategies; intensive and brief.SettingPatients in a general practitioner's list in a peri-urban Health Centre.ParticipantsAll the medical histories labelled as smokers; 235 and 37 in the group of brief and intensive intervention respectively.InterventionsThe brief intervention (BI) was made in the context of consultation for another purpose (1-5 minutes). The intensive intervention (II) was exclusively for smoking consultation (10-15 minutes).Main measurementsThe effectiveness data are obtained by the evaluation of intervention for smokers, in a general practitioner's list, after 6 years. We employ direct sanitary costs. We exclude drugs, non- sanitary and indirect costs. We apply the valuation of incremental cost-effectiveness ratio (ICER) of the brief interventions, intensive and total (brief + intensive) to compare not taking part with each type of intervention and II with regard to BI and probabilistic analysis to treat the uncertainty.ResultsThe total cost per abstinent patient was 406,74 €: 129,83 € for BI and 1.034,99 € for I.I.ICER Total intervention = €498, 87/patient who stops smoking.ICER BI = €235, 32/patient who stops smoking.ICER II = €1.232, 85/patient who stops smoking.ICER II/BI = €7.772,25/patient who stops smoking.ConclusionsSmoking interventions in PC are efficient. A proposal for smoking intervention in PC from an effective cost perspective could be an BI for smokers and an II on those who find more difficult to leave the habit.     

The doses of 10 μg should replace the doses of 5 μg in newborn hepatitis B vaccination in China: A cost-effectiveness analysis

ObjectiveTo identify whether Chinese current series of three 5 μg doses for newborn hepatitis B vaccination should be replaced by the series of three 10 μg doses.MethodsA cost-effectiveness analysis was conducted from the societal perspective based on the constructed decision tree-Markov model. Model parameters were estimated from published literatures, government documents and our surveys. The expected cost and effectiveness were compared between the 3-dose 5 μg series (the 5 μg strategy) and the 3-dose 10 μg series (the 10 μg strategy), and the incremental cost-effectiveness ratio (ICER, additional cost per quality-adjusted life-years gained) was calculated. Threshold values of the efficacy difference of the two series for the ICER = 0, 1 and 3 times per capita gross domestic product were analyzed under different scenarios to understand whether the 10 μg strategy should replace the 5 μg strategy according to the recommendation of World Health Organization.ResultsThe 10 μg strategy would be cost-saving compared with the 5 μg strategy under the base-case scenario. Under keeping all the other parameters at the base-case values or further adjusting any one of them to the value most unfavorable to the 10 μg strategy, as long as the efficacy of 3-dose 10 μg series was slightly higher than that of 3-dose 5 μg series, the 10 μg strategy would be cost-effective, highly cost-effective, or even cost-saving. Even under the most pessimistic scenario, i.e. all the other parameters, but the discount rate, at the values most unfavorable to the 10 μg strategy, the 10 μg strategy would be cost-effective if the efficacy difference reached higher than 1.23 percentage point.ConclusionFor newborn hepatitis B vaccination in China, the 10 μg strategy should be cost-effective, even more possibly highly cost-effective or cost-saving compared with the current 5 μg strategy. The doses of 10 μg should be considered to replace the doses of 5 μg in newborn hepatitis B vaccination in China.     

Androgen Deprivation Therapy for Prostate Cancer Prevention: What Impact Do Related Adverse Events Have on Quality of Life?

ObjectivesTo elicit utilities for health-related quality-of-life (HRQL) impact of adverse events (AEs) associated with androgen-deprivation therapy (ADT) for prostate cancer prevention.Study DesignCross-sectional, online survey of men aged ≥55 years, experiencing symptoms similar to one or more AEs related to ADT (erectile dysfunction [ED], loss of libido, gynecomastia, ejaculatory problems) outside the context of treatment for prostate cancer (n = 190, plus n = 10 had prostate cancer, included to allow greater representation of men with gynecomastia) and an age/sex equivalent control group (n = 100). Utilities were collected using the EQ-5D and a condition-specific measure of sexual HRQL from which a preference-based single index could be scored (SQoL-3D). Regression analysis was used to estimate the impact of the AE on utility values using a variety of model types.ResultsMany participants reported more than one symptom, including ED (most common at n = 139), reduced libido (n = 99), ejaculatory disorder (n = 98), and gynecomastia (n = 20). EQ-5D and SQoL-3D utilities were weakly correlated (r = 0.296). From the ordinary least squares regression, EQ-5D and SQoL-3D disutilities were estimated for ED (?0.042; ?0.074), reduced libido (?0.053; ?0.048), ejaculatory disorder (?0.047; ?0.028), and gynecomastia (?0.043; ? 0.038), respectively. The use of tobit regression did not improve model predictions.ConclusionsUtility values elicited in this study provide useful indicators of the impact of AEs related to ADT in older men for use in cost-effectiveness evaluation of prophylaxis for prostate cancer, and of benefits of treatments for sexual dysfunction or gynecomastia in older men.     

Seasonal influenza vaccination in China: Landscape of diverse regional reimbursement policy,and budget impact analysis

BackgroundTo explore the current landscape of seasonal influenza vaccination across China, and estimate the budget of implementing a national “free-at-the-point-of-care” vaccination program for priority populations recommended by the World Health Organization.MethodsIn 2014 and 2016, we conducted a survey across provincial Centers for Disease Control and Prevention to collect information on regional reimbursement policies for influenza vaccination, estimated the national uptake using distributed doses of influenza vaccines, and evaluated the budget using population size and vaccine cost obtained from official websites and literatures.ResultsRegular reimbursement policies for influenza vaccination are available in 61 mutually exclusive regions, comprising 8 provinces, 45 prefectures, and 8 counties, which were reimbursed by the local Government Financial Department or Basic Social Medical Insurance (BSMI). Finance-reimbursed vaccination was offered mainly for the elderly, and school children for free in Beijing, Dongli district in Tianjin, Karamay, Shenzhen and Xinxiang cities. BSMI-reimbursement policies were limited to specific medical insurance beneficiaries with distinct differences in the reimbursement fractions. The average national vaccination coverage was just 1.5–2.2% between 2004 and 2014. A free national vaccination program for priority populations (n = 416 million), would cost government US$ 757 million (95% CI 726–789) annually (uptake rate = 20%).ConclusionsAn increasing number of regional governments have begun to pay, partially or fully, for influenza vaccination for selected groups. However, this small-scale policy approach has failed to increase national uptake. A free, nationwide vaccination program would require a substantial annual investment. A cost-effectiveness analysis is needed to identify the most efficient methods to improve coverage.     

Annual influenza vaccination reduces total hospitalization in patients with chronic hepatitis B virus infection: A population-based analysis

BackgroundThis study evaluated hospitalization and mortality in patients with chronic hepatitis B virus infection (HBV (+)) and matched comparison patients after stratifying the patients according to annual influenza vaccination (Vaccine (+)).MethodsData from Taiwan's National Health Insurance program from 2000 to 2009 were used to identify HBV(+)/vaccine(+) (n = 4434), HBV(+)/Vaccine(−) (n = 3646), HBV(−)/Vaccine(+) (n = 8868), and HBV(−)/Vaccine(−) (n = 8868) cohorts. The risk of pneumonia/influenza, respiratory failure, intensive care, hospitalization, and mortality in the four cohorts was evaluated.ResultsThe total hospitalization rate was significantly lower in patients with chronic HBV infection who received an annual influenza vaccination than in chronic HBV-infected patients who did not receive an influenza vaccination (16.29 vs. 24.02 per 100 person-years), contributing to an adjusted hazard ratio (HR) of 0.56 (95% confidence interval (CI) = 0.50–0.62). The HBV(+)/Vaccine(+) cohort also had lower risks than the HBV(+)/Vaccine(−) cohort for pneumonia and influenza (adjusted HR = 0.79, 95% CI = 0.67–0.92), intensive care unit admission (adjusted HR = 0.33, 95% CI = 0.25–0.43), and mortality (adjusted HR = 0.19, 95% CI = 0.15–0.24).ConclusionsOur results suggest that annual influenza vaccination can reduce the risk of hospitalization and mortality in patients with chronic HBV infection.     

The predominance of Ethiopian specific Mycobacterium tuberculosis families and minimal contribution of Mycobacterium bovis in tuberculous lymphadenitis patients in Southwest Ethiopia

BackgroundEthiopia has an extremely high rate of extrapulmonary tuberculosis, dominated by tuberculous lymphadenitis (TBLN). However, little is known about Mycobacterium tuberculosis complex (MTBc) lineages responsible for TBLN in Southwest Ethiopia.MethodsA total of 304 MTBc isolates from TBLN patients in Southwest Ethiopia were genotyped primarily by spoligotyping. Isolates of selected spoligotypes were further analyzed by 15-loci mycobacterial interspersed repetitive unit–variable number tandem repeat (MIRU-VNTR) (n = 167) and qPCR-based single nucleotide polymorphism (n = 38). Isolates were classified into main phylogenetic lineages and families by using the reference strain collections and identification tools available at MIRU-VNTRplus data base. Resistance to rifampicin was determined by Xpert MTB/RIF.ResultsThe majority of isolates (248; 81.6%) belonged to the Euro-American lineage (Lineage 4), with the ill-defined T and Haarlem as largest families comprising 116 (38.2%) and 43 (14.1%) isolates respectively. Of the T family, 108 isolates were classified as being part of the newly described Ethiopian families, namely Ethiopia_2 (n = 44), Ethiopia_3 (n = 34) and Ethiopia_H₃₇Rv-like (n = 30). Other sub-lineages included URAL (n = 18), S (n = 17), Uganda I (n = 16), LAM (n = 13), X (n = 5), TUR (n = 5), Uganda II (n = 4) and unknown (n = 19). Lineage 3 (Delhi/CAS) was the second most common lineage comprising 44 (14.5%) isolates. Interestingly, six isolates (2%) were belonged to Lineage 7, unique to Ethiopia. Lineage 1 (East-African Indian) and Lineage 2 (Beijing) were represented by 3 and 1 isolates respectively. M. bovis was identified in only two (0.7%) TBLN cases. The cluster rate was highest for Ethiopia_3 isolates showing clonal similarity with isolates from North Ethiopia. Lineage 3 was significantly associated with rifampicin resistance.ConclusionsIn TBLN in Southwest Ethiopia, the recently described Ethiopia specific Lineage 4 families were predominant, followed by Lineage 3 and Lineage 4-Haarlem. The contribution of M. bovis in TBLN infection is minimal.     

Association of both consistency and strength of self-reported clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children

PurposeWe tested the hypotheses that consistency and strength of clinician recommendation of the human papillomavirus (HPV) vaccination would be associated with vaccine delivery rates.MethodsFrom October 2015 through January 2016, we conducted a survey of primary care clinicians (n = 227) in Southeastern Minnesota to evaluate clinician behaviors regarding HPV vaccination. The survey response rate was 41.0% (51 clinical sites). We used the Rochester Epidemiology Project, a clinical data linkage infrastructure, to ascertain clinical site-level HPV vaccination rates. We examined associations of clinician self-reports of both the consistency and strength of their recommendations for HPV vaccination for patients aged 11–12 years (n = 14,406) with site-level vaccination rates.ResultsThe majority of clinicians reported consistently (always or usually) recommending the HPV vaccine to females (79.0%) and to males (62.2%); 71.9% of clinicians reported strongly recommending the vaccine to females while 58.6% reported strongly recommending to males. Consistency and strength of recommending the HPV vaccine was significantly higher among those practicing in pediatrics and board certified in pediatrics compared to family medicine. Higher rates of initiation (1 dose) [Incidence Rate Ratio (IRR) = 1.05; 95% CI (1.01–1.09)] and completion (3 doses) [IRR = 1.08; 95% CI (1.02–1.13)] were observed among clinical sites where, on average, clinicians more frequently reported always or usually recommending the vaccine for females compared to sites where, on average, clinicians reported recommending the vaccine less frequently. Similarly, higher rates of initiation [IRR = 1.03; 95% CI (1.00–1.06)] and completion [IRR = 1.04; CI (1.00, 1.08)] were observed among sites where clinicians reported strongly recommending the vaccine to females more frequently compared to sites where, on average, clinicians reported strongly recommending the HPV vaccine less frequently; similar associations were observed for male initiation [IRR = 1.05; CI (1.02,1.08)] and completion [IRR = 1.05; 95% CI (1.01, 1.09)].ConclusionsConsistency and strength of HPV vaccination recommendation was associated with higher vaccination rates.     

Immune response to pneumococcal conjugate vaccine in patients with systemic vasculitis receiving standard of care therapy

AimTo study the effect of standard of care therapy on antibody response and functionality following immunization with 13-valent pneumococcal conjugate vaccine (PCV13) in patients with primary systemic vasculitis compared to healthy controls.Methods49 patients with vasculitis and 49 controls received a single dose (0.5 ml) PCV13 intramuscularly. Ongoing treatments: azathioprine (AZA; n = 11), cyclophosphamide (CYC; n = 6), methotrexate (MTX; n = 9), rituximab (n = 3); anti-TNF (n = 2), mycophenolate mofetil (n = 2), prednisolone alone (n = 15) and no active treatment (n = 2). Specific antibody concentrations for serotypes 6B and 23F were determined using ELISA and opsonophagocytic activity (OPA) assay (23F) was performed, on serum samples taken immediately before and 4–6 weeks after vaccination. Proportion of individuals with putative protective antibody concentration (≥1.0 µg/mL) and positive antibody response (≥2-fold increase from prevaccination concentration) for both serotypes were calculated and groups were compared.ResultsAt baseline, 6 patients (12%) and 12 controls (24%) had protective antibody levels for both serotypes. After vaccination, antibodies increased for both serotypes in patients and controls (p < 0.001), 32 patients (65%) and 35 controls (71%) reached protective level for 6B, and 32 patients (65%) and 37 controls (76%) for 23 F. Compared to controls, patients had lower prevaccination geometric mean concentration (23F, p = 0.01) and a numerical trend towards lower prevaccination level (6B) and postvaccination levels (both serotypes). Patients with prednisolone alone had lower prevaccination OPA (p < 0.01) compared to controls. OPA increased after vaccination in both patients and controls (p < 0.001), but improvement was better in controls (p = 0.001). AZA, CYC or MTX, but not prednisolone alone, tended towards a lower proportion of patients reaching protective antibody levels (p = 0.06), compared to controls.ConclusionsPneumococcal conjugate vaccine was safe and immunogenic in patients with established vasculitis. Treatment with DMARDs, mostly AZA, CYC and MTX but not systemic prednisolone may impair antibody response.Trial registration. ClinicalTrials.gov Identifier: NCT02240888. Registered 4 September, 2014     

Determinants of Bacillus Calmette–Guérin (BCG) vaccination among Québec children

ObjectivesTo identify determinants of Bacillus Calmette–Guérin (BCG) vaccination among children born in Québec, Canada, in 1974, the last year of the systematic vaccination campaign.MethodA retrospective birth cohort was assembled in 2011 through probabilistic linkage of administrative databases (n = 81,496). Potential determinants were documented from administrative databases and by interviewing a subset of subjects (n = 1643) in 2012. Analyses were conducted among subjects with complete data, 71,658 (88%) birth cohort subjects and 1154 (70%) interviewed subjects, then redone using multiple imputation. Determinants of BCG vaccination during the organized vaccination program (in 1974), and after the program (1975 onwards) were assessed separately. Logistic regression with backward elimination was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).ResultsOverall, 46% of subjects were BCG vaccinated, 43% during the program and 4% after it ended. BCG vaccination during the program was associated with parents' birthplace and urban or rural residence. BCG vaccination after the organized program was only related to ethnocultural origin of the child's grandparents.ConclusionDifferent factors were related to vaccination within and after the organized program. Determinants of BCG vaccination in Québec, Canada, have never been studied and will be useful for future research and vaccination campaigns.     

Lower vaccine uptake amongst older individuals living alone: A systematic review and meta-analysis of social determinants of vaccine uptake

IntroductionVaccination is a key intervention to reduce infectious disease mortality and morbidity amongst older individuals. Identifying social factors for vaccine uptake enables targeted interventions to reduce health inequalities.ObjectiveTo systematically appraise and quantify social factors associated with vaccine uptake amongst individuals aged ≥60 years from Europe.MethodsWe searched Medline and Embase from inception to 24/02/2016. The association of vaccine uptake was examined for social factors relevant at an individual level, to provide insight into individuals’ environment and enable development of targeted interventions by healthcare providers to deliver equitable healthcare. Factors included: living alone, marital status, education, income, vaccination costs, area-level deprivation, social class, urban versus rural residence, immigration status and religion. Between-study heterogeneity for each factor was identified using I²-statistics and Q-statistics, and investigated by stratification and meta-regression analysis. Meta-analysis was conducted, when appropriate, using fixed- or random-effects models.ResultsFrom 11,754 titles, 35 eligible studies were identified (uptake of: seasonal influenza vaccine (SIV) only (n = 27) or including pneumococcal vaccine (PV) (n = 5); herpes zoster vaccine (n = 1); pandemic influenza vaccine (n = 1); PV only (n = 1)). Higher SIV uptake was reported for individuals not living alone (summary odds ratios (OR) = 1.39 (95% confidence interval (CI): 1.16–1.68). Lower SIV uptake was observed in immigrants and in more deprived areas: summary OR = 0.57 (95%CI: 0.47–0.68) and risk ratio = 0.93 (95%CI: 0.92–0.94) respectively. Higher SIV uptake was associated with higher income (OR = 1.26 (95%CI: 1.08–1.47)) and higher education (OR = 1.05 (95%CI: 1–1.11)) in adequately adjusted studies. Between-study heterogeneity did not appear to result from variation in categorisation of social factors, but for education was partly explained by varying vaccination costs (meta-regression analysis p = <0.0001); individuals with higher education had higher vaccine uptake in countries without free vaccination.ConclusionsQuantification of associations between social factors and lower vaccine uptake, and notably living alone (an overlooked factor in vaccination programmes), should enable health professionals target specific social groups to tackle vaccine-related inequalities.     

Cost effectiveness of a targeted age-based West Nile virus vaccination program

BackgroundWest Nile virus (WNV) is the leading cause of domestically-acquired arboviral disease in the United States. Several WNV vaccines are in various stages of development. We estimate the cost-effectiveness of WNV vaccination programs targeting groups at increased risk for severe WNV disease.MethodsWe used a mathematical model to estimate costs and health outcomes of vaccination with WNV vaccine compared to no vaccination among seven cohorts, spaced at 10 year intervals from ages 10 to 70 years, each followed until 90-years-old. U.S. surveillance data were used to estimate WNV neuroinvasive disease incidence. Data for WNV seroprevalence, acute and long-term care costs of WNV disease patients, quality-adjusted life-years (QALYs), and vaccine characteristics were obtained from published reports. We assumed vaccine efficacy to either last lifelong or for 10 years with booster doses given every 10 years.ResultsThere was a statistically significant difference in cost-effectiveness ratios across cohorts in both models and all outcomes assessed (Kruskal-Wallis test p < 0.0001). The 60-year-cohort had a mean cost per neuroinvasive disease case prevented of $664,000 and disability averted of $1,421,000 in lifelong model and $882,000 and $1,887,000, respectively in 10-year immunity model; these costs were statistically significantly lower than costs for other cohorts (p < 0.0001). Vaccinating 70-year-olds had the lowest cost per death averted in both models at around $4.7 million (95%CI $2–$8 million). Cost per disease case averted was lowest among 40- and 50-year-old cohorts and cost per QALY saved lowest among 60-year cohorts in lifelong immunity model. The models were most sensitive to disease incidence, vaccine cost, and proportion of persons developing disease among infected.ConclusionsAge-based WNV vaccination program targeting those at higher risk for severe disease is more cost-effective than universal vaccination. Annual variation in WNV disease incidence, QALY weights, and vaccine costs impact the cost effectiveness ratios.     

Predictors of reported influenza vaccination in HIV-infected women in the United States, 2006–2007 and 2007–2008 seasons

ObjectiveTo estimate the cumulative incidence of self-reported influenza vaccination (“vaccination coverage”) and investigate predictors in HIV-infected women.MethodsIn an ongoing cohort study of HIV-infected women in five US cities, data from two influenza seasons (2006–2007 n = 1209 and 2007–2008 n = 1161) were used to estimate crude and adjusted prevalence ratios (aPR) and 95% confidence intervals ([,]) from Poisson regression with robust variance models using generalized estimating equations (GEE).ResultsIn our study, 55% and 57% of HIV-infected women reported vaccination during the 2006–2007 and 2007–2008 seasons, respectively. Using data from both seasons, older age, non-smoking status, CD4 T-lymphocyte (CD4) count ≥ 200 cells/mm³, and reporting at least one recent healthcare visit was associated with increased vaccination coverage. In the 2007–2008 season, a belief in the protection of the vaccine (aPR = 1.38 [1.18, 1.61]) and influenza vaccination in the previous season (aPR = 1.66 [1.44, 1.91]) most strongly predicted vaccination status.ConclusionInterventions to reach unvaccinated HIV-infected women should focus on changing beliefs about the effectiveness of influenza vaccination and target younger women, current smokers, those without recent healthcare visits, or a CD4 count < 200 cells/mm³.     

From current vaccine recommendations to everyday practices: An analysis in five sub-Saharan African countries

BackgroundEstimates of WHO and UNICEF vaccination coverage may provide little insight into the extent to which vaccinations are administered on time. Yet, lack of adherence to the recommended age to receive a specific vaccination may have detrimental health consequences. For example, delays in receiving vaccination will prolong the risk of lack of protection, often when disease risk is highest, such as during early infancy. We estimated the reported age at vaccination, and vaccine coverage at different ages in children from five sub-Saharan African countries.MethodsWe analyzed data from the latest Demographic and Health Programme databases available for Burkina Faso 2010 (n = 15,044 observations), Ghana 2008 (n = 2992), Kenya 2008–9 (n = 6079), Senegal 2010–11 (n = 12,326), and Tanzania 2010 (n = 8023). We assessed, amongst vaccinees, the exact age when vaccine was administered for the three infant doses of pentavalent vaccine (DTP) and the first dose of measles-containing-vaccine (MCV), as well as the proportion of children immunized with these antigens by a certain age. Vitamin A supplementation (VAS) coverage was evaluated as a potential contact visit for vaccine introduction.ResultsFor all DTP doses, the median intervals between recommended and actual ages of receiving vaccination ranged from 12, 17 and 23 days in Kenya, to 22, 33 and 45 days in Senegal. MCV was mostly given during the recommended age of 9 months. In each country, there was a large discrepancy in the median age at DTP vaccination between regions. VAS coverage in young children ranged from 30.3% in Kenya to 78.4% in Senegal, with large variations observed between areas within each study country.ConclusionIn the context of new vaccine introduction, age of children at vaccination should be monitored to interpret data on vaccine-preventable disease burden, vaccine effectiveness, and vaccine safety, and to adapt targeted interventions and messages.     

Evaluación de una intervención comunitaria para incrementar la cobertura vacunal de la gripe en mujeres embarazadas

ObjectiveTo know the impact of the educational intervention carried out on the professionals of a basic health area and their community participation group, which make up the intervention group (IG), and to analyze its repercussion on the vaccination coverage achieved for influenza in the risk group (pregnant and puerperal women) comparing it with its neighboring basic zone, which makes up the control group (CG), during the 2019/20 vaccination season.DesignQuasi-experimental study of community intervention.SiteTwo basic health zones belonging to the Elche-Crevillente health department, Spain.ParticipantsPregnant and postpartum women from 2 basic health areas and the community participation group. Health professionals directly related to the flu vaccination campaign.InterventionsTraining session for the IG prior to the 2019/20 flu campaign.Main measurementsAttitudes towards influenza vaccination in health professionals through the validated CAPSVA questionnaire and the vaccination coverage of pregnant and postpartum women through the Nominal Vaccine Registry and their acceptance of the vaccine in the midwife's office.ResultsThe influenza vaccination coverage data recorded in Nominal Vaccine Registry for pregnant and puerperal women was 26.4% (n = 207) in the IG and 19.7% (n = 144) in the CG (p = 0.001), with an incidence ratio of 1.34, thus achieving 34% more vaccination in the IG. Acceptance for vaccination in the midwife's office was also high, with 96.5% immunization in IG vs. 89.0% in CG, with a RR = 1.09 (95% CI 1.01-1.62).ConclusionsJoint training strategies for professionals and community assets improve the results of vaccination coverage.     

Clinician knowledge,clinician barriers,and perceived parental barriers regarding human papillomavirus vaccination: Association with initiation and completion rates

PurposeWe tested the hypothesis that clinician knowledge, clinician barriers, and perceived parental barriers relevant to the human papillomavirus (HPV) vaccination account for the variation in vaccine delivery at the practice-site level.MethodsWe conducted a survey from October 2015 through January 2016 among primary care clinicians (n = 280) in a 27-county geographic region to assess clinician knowledge, clinician barriers, and perceived parental barriers regarding HPV vaccination. Primary care clinicians included family medicine physicians, general pediatricians, and family and pediatric nurse-practitioners. We also used the Rochester Epidemiology Project to measure HPV vaccination delivery. Specifically we used administrative data to measure receipt of at least one valid HPV vaccine dose (initiation) and receipt of three valid HPV vaccine doses (completion) among 9–18 year old patients residing in the same 27-county geographic region. We assessed associations of clinician survey data with variation in vaccine delivery at the clinical site using administrative data on patients aged 9–18 years (n = 68,272).ResultsConsistent with our hypothesis, we found that greater knowledge of HPV and the HPV vaccination was associated with higher rates of HPV vaccination initiation (Incidence rate ratio [IRR] = 1.05) and completion of three doses (IRR = 1.28). We also found support for the hypothesis that greater perceived parental barriers to the HPV vaccination were associated with lower rates of initiation (IRR = 0.94) and completion (IRR = 0.90). These IRRs were statistically significant even after adjustment for site-level characteristics including percent white, percent female, percent ages 9–13, and percent with government insurance or self-pay at each site.ConclusionsClinician knowledge and their report of the frequency of experiencing parental barriers are associated with HPV vaccine delivery rates—initiation and completion. Higher measures of knowledge correlated with higher rates. Fewer perceived occurrences of parental barriers correlated with lower rates. These data can guide efforts to improve HPV vaccine delivery in clinical settings.     

Genetically predicted 17beta-estradiol,cognitive function and depressive symptoms in women: A Mendelian randomization in the Guangzhou Biobank Cohort Study

ObjectiveThe role of estrogen in cognitive function and depressive symptoms is controversial due to discrepancies between results from randomized controlled trials (RCT) and observational studies. Mendelian randomization analysis may provide further insights concerning the role of estrogen in these outcomes as it assesses the effect of lifelong endogenous exposure but is less vulnerable to confounding than observational studies.MethodWe used separate sample instrumental variable analysis to estimate the association of log 17β estradiol with cognitive function (Delayed 10 word recall, and Mini Mental State Examination (MMSE)) and depressive symptoms (Geriatric Depression Scale (GDS)) in older Chinese women of the Guangzhou Biobank Cohort Study (GBCS, n = 3086). The estimate was derived based on the Wald estimator, the ratio of the association of genetic determinants (rs1008805 and rs2175898) of log 17β-estradiol with cognitive function and depressive symptoms in GBCS and the association of log 17β-estradiol with genetic determinants in the sample of young women in Hong Kong (n = 236).ResultsGenetically predicted 17β-estradiol was not associated with delayed 10-word recall (0.42 words per log increase in 17β-estradiol (pmol/L), 95% confidence interval (CI) − 0.49 to 1.34) MMSE (0.39 per log increase in 17β-estradiol (pmol/L), 95% CI − 0.87 to 1.65) or GDS (0.24 per log increase in 17β-estradiol (pmol/L), 95% CI − 0.57 to 1.05).ConclusionThese results were largely consistent with evidence from RCTs and did not show any beneficial effect of estrogen on cognitive function and depressive symptoms. However, larger Mendelian randomization analyses are needed to identify any minor effects.     

Varicella vaccination elicits a humoral and cellular response in children with rheumatic diseases using immune suppressive treatment

ObjectiveTo assess humoral and cellular responses to live-attenuated varicella zoster virus (VZV) vaccination of patients with juvenile idiopathic arthritis (JIA), juvenile dermatomyositis (JDM) or juvenile scleroderma (JScle) compared to those of healthy controls (HC).MethodsBefore, 4–6 weeks and one year after VZV vaccination, blood samples of patients and HC were collected. VZV-specific antibody concentrations were measured by ELISA and multiplex immune-assay. IFN-γ ELISpot assays were performed to assess VZV-specific T-cell responses. Cytokine production upon VZV stimulation were measured with a Luminex-assay.Results49 patients (39 JIA, 5 JDM, 5 JScle) and 18 HC were included. All patients used methotrexate (MTX), 16 also used corticosteroids, 3 patients used biologics. No disease flares were reported after vaccination. Antibody response to the vaccine was similar in patients and controls (p = 0.139). Use of immunosuppressive drugs did not affect the response (p = 0.203). A second vaccination (n = 21) increased VZV-specific antibody concentrations (p = 0.02). VZV-specific T-cells increased after vaccination (p = 0.043), with a cytokine profile suggesting a VZV-specific Th1 and cytotoxic T-cell response.ConclusionThe humoral response to VZV vaccination in patients with pediatric rheumatic diseases (PRD) is similar to that of HC. Generally, patients are able to mount a VZV-specific cellular response.This study has been registered in the Brazilian Clinical Trials Registry under number U1111-1189-9837.