Computers and the effectiveness of the measles vaccination campaign in England and Wales

Summary Measles vaccination on a large scale began in England and Wales in 1968. We have compared the incidence of notified measles from 1968 to 1976 in the population whose vaccination programme was computer-assisted by 1971 with that in the population where computers were not used. The measles experience of both populations was similar from 1968 to 1970. Thereafter, all the incidence rates fell, the decline being most marked in the computer population. For the period 1971–6, the difference between the rates for the two populations is statistically significant, and the difference persists and remains significant when the urban and rural components of the populations are examined separately. We conclude that computers contributed to the lower incidence of measles in the computer population between 1971 and 1976 and suggest that the severity of measles epidemics may be further reduced by the nationwide use of computers.     

Hepatitis B vaccination coverage and uptake in prisons across England and Wales 2003-2010: a retrospective ecological study

Objective

To describe the custodial hepatitis B vaccination programme performance and examine these data by geographical region and prison category.

Design

Retrospective ecological study.

Data source

Health Protection Agency (HPA) published data.

Setting

Custodial primary healthcare providers located in prisons across England and Wales.

Participants

147 prisons which reported vaccination data between July 2003 and April 2010 to the HPA Prison Infection Prevention team.

Main outcome measures

Hepatitis B vaccination coverage (July 2003 to April 2010) and uptake (December 2007 to April 2010).

Results

Median hepatitis B vaccination coverage was 22% (interquartile range [IQR] 5–49%) and uptake was 36% (IQR 16–59%). Vaccination coverage varied significantly between July 2003 and November 2007 compared to December 2007 and April 2010 (median 12% [IQR 2–31%] versus median 48% [IQR 26–67%], Mann–Whitney W = 14,689,158.0, p < 0.001). There was significant variation between vaccination coverage (Kruskal–Wallis H = 613.44, DF = 9, p < 0.001) and uptake (Kruskal–Wallis H = 247.99, DF = 9, p < 0.001) across the HPA regions. Compared to England and Wales, estimated population median vaccination coverage was significantly (p ≤ 0.05) lower in three regions and one prison category and higher in four regions and seven prison categories; estimated population median vaccination uptake was significantly lower in three regions and three prison categories and higher in two regions and four prison categories.

Conclusion

Prisoners are a vulnerable group with a high prevalence of hepatitis B infection and the custodial setting plays an important role in the delivery of hepatitis B vaccination to this hard to reach group. This study suggests that variation in hepatitis B vaccination coverage and uptake may exist by geographical region and prison category. Further research is required to confirm and identify possible explanations for our findings.     

Hepatitis E in England and Wales

In 2005, 329 cases of hepatitis E virus infection were confirmed in England and Wales; 33 were confirmed indigenous infections, and a further 67 were estimated to be indigenous infections. Hepatitis E should be considered in the investigation of patients with hepatitis even if they have no history of travel.     

Hepatitis B vaccination in mentally retarded: effectiveness after 11 years

The long-term effectiveness of hepatitis B vaccination was determined in a high-risk group of 105 institutionalized mentally retarded. All individuals were vaccinated in 1986, with three (0, 1, 6 months), four (0, 1, 6 and 12 months) or more doses according to their immune response at month 7, resulting in group 1 (G1), group 2 (G2) and group 3 (G3). They were annually followed up for five years, after which they received a booster dose. Eleven years after the initial vaccination, they were again tested for the presence of hepatitis B virus (HBV) serologic markers. The decline in anti-HBs logtitre over the first five years was 51% for G1 and 45% for G2. From the booster on month 60 to year 11, the overall decline was 31%. Eleven years after the start of vaccination and six years after the booster, 92% of the individuals had protective antibody levels higher than 10 IU/L. G1 had a geometric mean titre of 2015 IU/L, for G2 this was 245 IU/L. The difference in response to vaccination between the groups did not affect their protection. Only two vaccinees seroconverted to anti-HBc positivity without becoming carrier or ill. Long-term protection against HBV by vaccination appears to be excellent.     

A simulation model to estimate the cost and effectiveness of alternative dialysis initiation strategies.

BACKGROUND: Patients with end-stage renal disease (ESRD) require dialysis to maintain survival. The optimal timing of dialysis initiation in terms of cost-effectiveness has not been established. METHODS: We developed a simulation model of individuals progressing towards ESRD and requiring dialysis. It can be used to analyze dialysis strategies and scenarios. It was embedded in an optimization frame worked to derive improved strategies. RESULTS: Actual (historical) and simulated survival curves and hospitalization rates were virtually indistinguishable. The model overestimated transplantation costs (10%) but it was related to confounding by Medicare coverage. To assess the model's robustness, we examined several dialysis strategies while input parameters were perturbed. Under all 38 scenarios, relative rankings remained unchanged. An improved policy for a hypothetical patient was derived using an optimization algorithm. CONCLUSION: The model produces reliable results and is robust. It enables the cost-effectiveness analysis of dialysis strategies.     

The development of alcohol strategies in England and Wales.

Alcohol has become a major public health problem in the UK. In order to coordinate the work of both statutory and non-statutory agencies more efficiently and effectively, a government circular HN(89)4 has emphasized the need for development of local multi-agency alcohol misuse prevention strategies. Despite expressed enthusiasm for alcohol strategies, information about their development, effectiveness and overall national progress is scarce and needs to be improved. This national survey reports the most recent and accurate information about the development of district and regional alcohol strategies in England and Wales. Although only 51 (27%) districts stated they had a strategy, it was encouraging to find 90 (47%) other districts that were in the process of, or planning to develop such a document. Of the 51 districts with a strategy, the following key findings were noted: (1) Forty-three (84%) districts stated that they had started to implement their strategy, but none claimed to have fully implemented it. (2) Thirty-six (71%) districts stated that their strategy had an action plan. (3) Thirty-four (67%) districts stated that their strategy had been officially endorsed by the district health authority. (4) Thirty-eight (76%) districts stated that they had identified an individual or group to monitor the strategies' implementation. The results of the survey could be of interest to the Department of Health, the Faculty of Public Health Medicine, the Health Education Authority and the regional alcohol coordinators.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluating rotavirus vaccination in England and Wales. Part II. The potential cost-effectiveness of vaccination

AIM: Rotavirus is the leading cause of acute gastroenteritis in children. Two rotavirus vaccines (RotaTeq and Rotarix) have recently completed clinical trials. We investigated whether routine infant immunisation with either vaccine can be cost effective. METHODS: We compared costs and outcomes of vaccination using a cohort model, following children over the first 5 years of life. We estimated health provider costs, economic costs and quality adjusted life years (QALYs) lost due to rotavirus-related deaths, hospital admissions, nosocomial infections, accident and emergency attendances, general practice consultations and calls to NHS Direct. RESULTS: Under base case assumptions, a programme using RotaTeq (priced at pound 25 a dose) would cost the health provider pound 79,900 per QALY gained. Using Rotarix (priced at pound 35 a dose) would cost pound 61,000 per QALY gained. Univariate and multivariate sensitivity analysis indicate that at these prices an immunisation programme would be unlikely to be cost-effective for any realistic value of the key parameters. CONCLUSIONS: Rotavirus immunisation could reduce the substantial short-term morbidity burden due to rotavirus, but is unlikely to be deemed cost effective unless the vaccine is competitively priced.     

Cost effectiveness of hepatitis B vaccination strategies in Ireland: an economic evaluation

BACKGROUND: In accordance with World Health Organization recommendations, many European countries have introduced universal hepatitis B vaccination policies. The UK and Ireland are exceptions. In this study, we conducted an economic evaluation of a universal infant hepatitis B vaccination programme, using a six-component vaccine, compared with the current selective strategy of vaccinating high-risk infants with a monovalent hepatitis B vaccine. METHODS: A cost effectiveness analysis was conducted using a Markov model. The perspective of the analysis was the Irish Health Service Executive. Unit cost and resource utilization data were derived from expert clinical opinion, published sources, diagnosis-related group costs for hospital admissions and local cost estimates for medical fees and laboratory investigations. A full probabilistic sensitivity analysis was undertaken. Both costs and outcomes were modelled over a period of 80 years and discounted at 3.5%. RESULTS: Assuming an incidence of acute hepatitis B virus (HBV) infection in Ireland of 8.4 per 100,000 population, the incremental cost effectiveness ratio ranged from euro10,992/life years gained (LYG) to euro67 200/LYG, at the lowest and highest price estimates for the six-component vaccine, respectively. The cost effectiveness of universal versus selective hepatitis B vaccination was sensitive to the risk of acute HBV infection, the cost of the universal infant vaccination programme and the discount rate. CONCLUSION: At a cost of euro29.00 per dose of the six-component vaccine, universal infant hepatitis B vaccination is cost effective at euro37 018/LYG. This compares favourably with other preventive programmes in Ireland.     

Cost effectiveness and cost benefit of viral hepatitis B vaccination in the Slovak Republic

In our work we tried to evaluate the cost effectiveness (CEA) and cost benefit (CBA) of the vaccination strategy of viral hepatitis B (VHB) vaccination in Slovakia. Retrospectively we analysed the incidence of VHB before and after the vaccination against VHB. From the calculated yearly cost (direct and indirect)--treatment costs and vaccination costs--we tried to calculate the estimated financial costs of vaccination strategy in 2000 (89.4 mil. SK), the saved costs (92 mil. SK), cost effectiveness (201 642 SK) and cost benefit (2.70 SK). First a decrease of the incidence (after introduction of measures to prevent nosocomial transmission) had been achieved by vaccination of selected risk groups of the population. A significant positive impact on the incidence of VHB is expected from mass preventive vaccination of infants, introduced in Slovakia in 1998.     

Hepatitis B vaccination strategies tailored to different endemicity levels: Some considerations

Hepatitis B is a serious public health problem. Worldwide three different levels of hepatitis B endemicity (high, intermediate and low) can be distinguished. Areas with different levels of endemicity require tailored vaccination strategies to fit the needs for individuals at risk and/or countries, depending on the infection risk per age group, vaccination rate, duration of protection after vaccination, cost effectiveness of vaccination strategies and ease of implementation in the national immunization schedules.This opinion paper evaluates these factors and proposes a combination of infant risk group and universal adolescent vaccination for low endemic countries thus targeting the different groups at risk. A universal infant vaccination schedule starting with a newborn vaccination within 24 h after birth is more appropriate in intermediate- and high-endemic regions.     

Cost-effectiveness analysis of pneumococcal conjugate vaccination in England and Wales

AIM: To establish whether universal vaccination of infants with the pneumococcal conjugate vaccine is likely to be cost-effective from the perspective of the health care provider (NHS). METHOD: Two hypothetical cohorts--one vaccinated and one unvaccinated--were followed over their lifetime, and the expected net costs and benefits (measured in terms of life-years and quality adjusted life years (QALY) gained) were compared in the two cohorts. The impact of indirect effects of the vaccine, such as herd immunity and serotype replacement, were investigated and their relative importance was assessed by performing univariate sensitivity analysis and multivariate Monte Carlo simulations. RESULTS: Under base-case assumptions (no herd immunity and no serotype replacement) the programme is not expected to be cost-effective from the NHS perspective at the current price of the vaccine (assumed 30 pounds per dose, three-dose programme). A reduction of the cost of the vaccine to half of its current level could bring the cost per QALY gained within normally acceptable ranges. If the burden of disease is significantly underestimated by current surveillance systems, then the cost per QALY gained approaches acceptable levels at the current vaccine price. Herd immunity may substantially reduce the burden of pneumococcal disease, particularly of pneumonia among the elderly, leading to a significant improvement in the cost per life year and QALY gained. Serotype replacement would partly offset these benefits, although only with a complete substitution of vaccine types with non-vaccine types and a low level of herd immunity, would pneumococcal vaccination programme would not be cost-effective. CONCLUSIONS: Conclusions on the cost-effectiveness of pneumococcal conjugate vaccine are sensitive to assumptions regarding the current burden of pneumococcal disease and the future impact that vaccination will have in the unvaccinated and on the future serotype distribution. This study quantifies, for the first time, how these indirect effects may change the cost-effectiveness of pneumococcal vaccination.     

The cost-effectiveness of pentavalent rotavirus vaccination in England and Wales

Rotavirus vaccines have shown great potential for reducing the disease burden of the major cause of severe childhood gastroenteritis. The decision regarding whether rotavirus vaccination will be introduced into the national immunization program is currently being reviewed. The conclusions of previous evaluations of rotavirus vaccination cost-effectiveness contradict each other. This is the first analysis to incorporate a dynamic transmission model to assess the cost-effectiveness of rotavirus vaccination in England and Wales. Most previously reported models do not include herd protection, and thus may underestimate the cost-effectiveness of vaccination against rotavirus. We incorporate a dynamic model of rotavirus transmission in England and Wales into a cost-effectiveness analysis to determine the probability that the pentavalent rotavirus vaccination will be cost-effective over a range of full-course vaccine prices. This novel approach allows the cost-effectiveness analysis to include a feasible level of herd protection provided by a vaccination program. Our base case model predicts that pentavalent rotavirus vaccination is likely to be cost-effective in England and Wales at £60 per course. In some scenarios the vaccination is predicted to be not only cost-effective but also cost-saving. These savings could be generated within ten years after vaccine introduction. Our budget impact analysis demonstrates that for the realistic base case scenarios, 58–96% of the cost outlay for vaccination will be recouped within the first four years of a program. Our results indicate that rotavirus vaccination would be beneficial to public health and could be economically sound. Since rotavirus vaccination is not presently on the immunization schedule for England and Wales but is currently under review, this study can inform policymakers of the cost-effectiveness and budget impact of implementing a mass rotavirus vaccine strategy.     

Evaluating rotavirus vaccination in England and Wales. Part I. Estimating the burden of disease

Rotavirus is a major cause of gastroenteritis in young children. New vaccines for rotavirus are now available and countries need to establish the health and economic burden of rotavirus disease to assess whether vaccine introduction is advisable. This study assesses the fraction of acute gastroenteritis in children under 5 years that may be attributable to rotavirus using multiple linear regression. Results suggest around 45% of hospitalisations, 25% of GP consultations, 27% of NHS Direct calls and 20% of accident and emergency (A&E) attendances for acute gastroenteritis in this age group may be attributable to rotavirus. The annual incidence is estimated to be 4.5 hospitalisations, 9.3 A&E consultations, and 28-44 GP consultations per 1000 children under five years of age. The cost to the health service is estimated to be pound 14.2m per annum. Rotavirus vaccination has the potential to reduce this burden of disease. This study provides a sound basis on which to make this assessment and serves as a baseline against which any reductions that do occur if vaccination is introduced can be measured against.     

Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales

A live-attenuated vaccine against herpes zoster (HZ) has been approved for use, on the basis of a large-scale clinical trial that suggests that the vaccine is safe and efficacious. This study uses a Markov cohort model to estimate whether routine vaccination of the elderly (60+) would be cost-effective, when compared with other uses of health care resources. Vaccine efficacy parameters are estimated by fitting a model to clinical trial data. Estimates of QALY losses due to acute HZ and post-herpetic neuralgia were derived by fitting models to data on the duration of pain by severity and the QoL detriment associated with different severity categories, as reported in a number of different studies. Other parameters (such as cost and incidence estimates) were based on the literature, or UK data sources. The results suggest that vaccination of 65 year olds is likely to be cost-effective (base-case ICER = £20,400 per QALY gained). If the vaccine does offer additional protection against either the severity of disease or the likelihood of developing PHN (as suggested by the clinical trial), then vaccination of all elderly age groups is highly likely to be deemed cost-effective. Vaccination at either 65 or 70 years (depending on assumptions of the vaccine action) is most cost-effective. Including a booster dose at a later age is unlikely to be cost-effective.     

Estimating the impact of childhood influenza vaccination programmes in England and Wales

There is increasing interest in routine vaccination of children against influenza. We use an age-structured model to demonstrate that the long-term incidence of influenza A could decrease by 11-21% in the overall population by vaccinating individuals aged 6 to <24 months, and by 22-38% and 65-97% through targeting those aged 6 to <60 months and 6 months to 16 years, respectively. The corresponding reductions predicted for influenza B were 25-35%, 44-69% and 85-96%, respectively. These results are sensitive to assumptions about contact patterns and several parameters, including the vaccine efficacy among those aged <24 months, require further study. Consistently high levels of vaccination coverage among pre-school children has the potential to bring benefits to both those vaccinated and the community.     

Hepatitis B vaccination in prisons

The opportunities and problems for hepatitis B vaccination programmes in prison settings are discussed. In particular, the advantages of modelling are stressed and an active case-finding approach is advocated. Measures for maintaining good case-holding are also discussed, and a 0, 1, 2 months vaccination regimen with 20 microg doses of vaccine is advocated for prison settings. A higher reference level for inferring adequate immunization is also recommended, with booster injections for inmates who do not meet the higher reference after a primary course of vaccination.     

Effectiveness and cost comparison of two strategies for hepatitis B vaccination of schoolchildren

CONTEXT: In 1994, immunization against hepatitis B was implemented in schools in Quebec, targeting grade 4 students. In 1996-1997 and 1997-1998, one Local Community Service Centre (CLSC) replaced the school-based program in its district with vaccination offered in community clinics after school hours. The aim of the current study was to compare the effectiveness and costs of school-based and clinic-based programs. METHODS: Vaccination coverage data were collected in the CLSC with the clinic-based program (CBP), and in three matched CLSCs with a school-based program (SBP), from 1994 to 2000. Surveys were conducted to estimate costs to parents, to schools and to CLSCs in 1997-1998. RESULTS: With the implementation of the CBP, the vaccination coverage fell to 73%, compared with over 90% in the SBPs. Coverage increased to 90% when the CBP was abandoned. Costs to the CLSC were not much lower in the CBP. Societal costs were $63 per student vaccinated in the CBP, and < or = $40 in the SBPs. CONCLUSION: Results demonstrate the advantage of a SBP over a CBP for the immunization of schoolchildren.