Comparison of two vaccination programmes in preventing influenza-related hospitalization among the elderly during two consecutive seasons

The protective effect of influenza vaccine against influenza related hospitalization is well established at an individual level, but the effect of vaccination programme at the population level is unknown. In this study we compared a risk disease-based free-of-charge influenza vaccination programme in preventing hospitalizations due to influenza or pneumonia and cardiovascular diseases during 2 consecutive influenza seasons 1992/93 and 1993/94 in 43 municipalities in northern Finland. Vaccinations were carried out and reported by local staff in health centres. Data of hospital treatment periods were obtained from the National Hospital Discharge Register. During the influenza seasons the number of hospitalizations due to cardiovascular diseases and influenza/pneumonia increased by 13%. In the 1993/1994 season the increase in the study area with the risk disease-based vaccination programme was 22 per 1000 persons (95% CI 19-24), and with an age-based programme 3.3 per 1000 persons (95% CI 2.5-4.0), while the increase in the 1992/1993 season in both areas was 3-4 per 1000. The excess of hospitalization related to influenza epidemics is mostly due to cardiovascular diseases and varies from y to y, as do the benefits gained by vaccination.     

Hepatitis A virus vaccination in persons with hepatitis C virus infection: consequences of quality measure implementation

Hepatitis A virus (HAV) superinfection in persons with hepatitis C virus (HCV) infection has been associated with a high mortality rate, and vaccination is recommended. The incidence of HAV is low, and the aim of this study was to determine the mortality risk of HAV superinfection and the consequences of routine vaccination in persons with HCV infection. To determine the mortality risk of HAV superinfection, a meta-analysis including studies reporting mortality in HCV-infected persons was performed. Data were extracted independently by two investigators and recorded on a standardized spreadsheet. The pooled mortality estimate was used to determine the number needed to vaccinate (NNV) to prevent mortality from HAV superinfection. The total vaccine cost was also calculated. A total of 239 studies were identified using a defined search strategy. Of these, 11 appeared to be relevant, and of these, 10 were suitable for inclusion in the meta-analysis. The pooled odds ratio (OR) for mortality risk in HAV superinfection of HCV-infected persons was 7.23 (95% confidence interval: 1.24-42.12) with significant heterogeneity (I(2) = 56%; P = 0.03) between studies. Using the pooled OR for mortality, this translates to 1.4 deaths per 1,000,000 susceptible persons with HCV per year. The NNV to prevent one death per year is therefore 814,849, assuming 90% vaccine uptake and 94.3% vaccine efficiency. The vaccine cost for this totals $162 million, or $80.1 million per death prevented per year. CONCLUSION: These data challenge the use of routine HAV vaccination in HCV-infected persons and its incorporation into clinical practice guidelines. HAV vaccination of all HCV-infected persons is costly and likely to expose many individuals to an intervention that is of no direct benefit.     

The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease

BACKGROUND: More than 50% of the elderly population has not received pneumococcal vaccination. Uncertainty regarding the benefits of immunization, particularly for noninvasive disease, may contribute to the underuse of pneumococcal vaccine. OBJECTIVE: To assess the health and economic benefits associated with pneumococcal vaccination. METHODS: We conducted a 2-year retrospective cohort study among all elderly members of a staff-model managed care organization who had a baseline diagnosis of chronic lung disease. The study outcomes were assessed over 2 years, from November 15, 1993, through November 14, 1995, and included hospitalizations for pneumonia and influenza, death, and hospitalization costs. Using administrative data, we compared these outcomes for vaccinated and unvaccinated subjects using multivariate models to control for subjects' baseline demographic and health characteristics. The additive benefits of combined influenza and pneumococcal vaccination were also assessed for the 2 influenza seasons included in the study. RESULTS: There were 1898 subjects. Pneumococcal vaccination was associated with significantly lower risks for pneumonia hospitalizations (adjusted risk ratio [RR], 0.57; 95% confidence interval [CI], 0.38-0.84; P=.005) and for death (adjusted RR, 0.71; 95% CI, 0.56-0.91; P = .008). For the control outcome of all nonpneumonia hospitalizations, rates did not differ significantly between the 2 groups (adjusted RR, 0.91; 95% CI, 0.77-1.07; P= .24). During the influenza seasons included in the study, the benefits of pneumococcal and influenza vaccinations were additive, with an adjusted RR of 0.28 (95% CI, 0.14-0.58; P<.001) for the number of hospitalizations for pneumonia and influenza among persons who had received both vaccinations compared with those who had received neither and an adjusted odds ratio of 0.18 (95% CI, 0.11-0.31; P<.001) for death. Over the 2-year outcome period, pneumococcal vaccination was also associated with direct medical care cost savings. CONCLUSIONS: Pneumococcal vaccination of elderly persons with chronic lung disease was associated with fewer hospitalizations for pneumonia, fewer deaths, and direct medical care cost savings.     

Involvement of Workers in Closed and Semiclosed Institutions in Outbreaks of Acute Gastroenteritis Due to Norovirus

Norovirus outbreaks frequently occur in closed or semiclosed institutions. Recent studies in Catalonia and various countries indicate that, during outbreaks in these institutions, norovirus is detected in between 23% and 60% of workers, and the prevalence of infection in asymptomatic workers involved in outbreaks ranges from 17% to 40%. In this work, we carried out a prospective study to investigate the involvement of workers in closed and semiclosed institutions during outbreaks. The attack rates (ARs) and the rate ratios (RRs) were calculated according to the type of transmission and occupational category. The RRs and 95% confidence intervals (CIs) between workers and users were calculated. The mean cycle of quantification (Cq) values were compared according to the genogroup and the presence of symptoms. ARs were higher in person-to-person transmission than in common vehicle outbreaks, and 38.8% of workers were symptomatic. The RR between workers and users was 0.46 (95% CI 0.41–0.52). The ARs in workers were high, particularly in workers with closer contact with users. The mean Cq was lower in patients than in asymptomatic infected persons, although the difference was only significant for genogroup I (GI). The frequency of asymptomatic infected persons suggests that personal hygiene measures should be followed by all workers in the centers affected.     

Clinical effectiveness of influenza vaccination in persons younger than 65 years with high-risk medical conditions: the PRISMA study

BACKGROUND: Influenza vaccination has consistently been shown to prevent all-cause death and hospitalizations during influenza epidemics among seniors. However, such benefits have not yet been demonstrated among younger individuals with high-risk medical conditions. In the present study, we evaluated the effectiveness of influenza vaccine in persons recommended for vaccination of any age during an epidemic. METHODS: We conducted a case-control study during the 1999-2000 influenza A epidemic nested in a cohort of 75,227 primary care patients. End points were all-cause mortality and episodes of hospitalizations or general practitioner (GP) visits for influenza, pneumonia, other acute respiratory disease, acute otitis media, myocardial infarction, heart failure, and stroke. The effectiveness of vaccination was evaluated by means of logistic regression analysis with adjustments for age, sex, prior health care use, medication use, and comorbid conditions. RESULTS: Among high-risk children and adolescents younger than 18 years (n=5933; 8% of the study population), 1 death, 3 hospitalizations for pneumonia, and 160 GP visits occurred. After adjustments, 43% (95% confidence interval [CI], 10%-64%) of visits were prevented. Among high-risk adults aged between 18 and 64 years (n=24 928; 33% of the study population), 47 deaths, 23 hospitalizations, and 363 GP visits occurred. After adjustments, vaccination prevented 78% of deaths (95% CI, 39%-92%), 87% of hospitalizations (95% CI, 39%-97%), and 26% of GP visits (95% CI, 7%-47%). Among elderly persons (n=44 366; 59% of the study population), 272 deaths and 166 hospitalizations occurred, and after adjustments the vaccine prevented these end points by 50% (95% CI, 23%-68%) and 48% (95% CI, 7%-71%), respectively. CONCLUSION: Persons with high-risk medical conditions of any age can substantially benefit from annual influenza vaccination during an epidemic.     

Epidemiology of Herpes Zoster in the pre-vaccination era: establishing the baseline for vaccination programme’s impact in Spain

BackgroundHerpes zoster (HZ) affects 1 in 3 persons in their lifetime, and the risk of HZ increases with increasing age and the presence of immunocompromising conditions. In Spain, vaccination guidelines were recently updated to include the recommendation of the new recombinant zoster vaccine (RZV) for certain risk groups.AimTo describe the epidemiology of HZ-related hospitalisations in Spain in order to prioritise vaccination recommendations and define a baseline to monitor the effectiveness of vaccination policies.MethodsRetrospective study using the National Health System’s Hospital Discharge Records Database, including all HZ-related hospitalisations from 1998 to 2018.ResultsThe 65,401 HZ-related hospitalisations, corresponded to an annual mean hospitalisation rate of 6.75 per 100,000 population. There was an increasing trend of HZ hospitalisations over the study period. This rate was higher in males and older age groups, particularly over 65 years. Comorbidities with higher risk of readmission were leukaemia/lymphoma (RR 2.4; 95% CI: 2.3–2.6) and solid malignant neoplasm (RR 2.2; 95% CI: 2.1–2.4). Comorbidities associated with higher risk of mortality were leukaemia/lymphoma (RR 2.9; 95% CI: 2.7–3.2), solid malignant neoplasm (RR 2.9; 95% CI: 2.7–3.1) and HIV infection (RR 2.2; 95% CI: 1.8–2.7).ConclusionOf all patients hospitalised with HZ, those with greater risk of mortality or readmission belonged to the groups prioritised by the current vaccination recommendations of the Spanish Ministry of Health. Our study provided relevant information on clinical aspects of HZ and established the base for future assessments of vaccination policies.     

Impacto de la vacunación de las embarazadas frente a la tosferina en las hospitalizaciones de menores de un año en un hospital de tercer nivel de Cataluña

IntroductionThe recommendation for pertussis vaccination in pregnancy was established in Catalonia in February 2014. The objective of this study was to compare the hospitalization rate for pertussis in children under one year of age before and after the implementation of the vaccination program.MethodsObservational and retrospective study of patients under one year of age admitted to hospital with a diagnosis of pertussis. The hospitalization rate of patients under one year of age of the period prior to the vaccination program (2008-2013) was compared with the period with vaccination program (2014-2019) in the total of children under one year of age and in 2 subgroups: children under 3 months and between 3-11 months.ResultsHospitalization rate was significantly lower in the period with vaccination program in children under one year of age and specifically in children under 3 months (2.43 vs. 4.72 per 1,000 person-years and 6.47 vs. 13.11 per 1,000 person-years, respectively). The rate ratios were: 0.51 (95% CI 0.36-0.73) for children under one year of age; 0.49 (95% CI 0.32-0.75) for those younger than 3 months and 0.56 (95% CI 0.30-1.03) for those with 3-11 months. No statistically significant differences were observed in the clinical severity between both periods.ConclusionThe introduction of the pertussis vaccination program in pregnancy was associated with a global lower hospitalization rate for pertussis in children under one year of age and specifically in those under 3 months of age.     

Anti-rheumatic drug use and risk of hospitalization for congestive heart failure in rheumatoid arthritis

OBJECTIVE: To assess the risk of hospitalization for congestive heart failure (CHF) associated with the use of disease-modifying anti-rheumatic drugs (DMARDs) and other medications used in RA. METHODS: We used a case-control design nested within an administrative database cohort of patients with rheumatoid arthritis (RA) who were dispensed a DMARD between September 1998 and December 2001. Subjects identified with a prior history of CHF were excluded. For each hospitalized case of CHF identified during follow-up, 10 controls matched on age and time were randomly selected from the cohort. Conditional logistic regression was used to estimate the rate ratio (RR) of hospitalizations for CHF associated with the current use of specific drugs, adjusted for sex and co-morbidity. RESULTS: The cohort included 41 885 patients; 75% were women, with an average age at cohort entry of 51 yr. During follow-up, 520 hospitalizations for CHF occurred, for a rate of 10.1 per 1000 per year. The adjusted RR of CHF for current use of any DMARD was 0.7 (95% CI 0.6-0.9) relative to no current use. By DMARD category, there was evidence of a beneficial effect for both tumour necrosis factor-alpha antagonists (RR 0.5, 95% CI 0.2-0.9) and methotrexate monotherapy (RR 0.8, 95% CI 0.6-1.0). For non-DMARD medications, the rate of CHF was not clearly increased or decreased, except for COX-2 inhibitors. The data suggested an increased risk of CHF with rofecoxib (RR 1.3, 95% CI 1.0-3.1) and a decreased risk of CHF with celecoxib (RR 0.6, 95% CI 0.4, 1.0). CONCLUSIONS: The use of DMARDs was associated with a reduction in the risk of hospitalizations for CHF in this RA cohort. The increased risk with rofecoxib alongside a decreased risk with celecoxib suggests the absence of a class effect with respect to COX-II inhibitors for some types of cardiovascular morbidity.     

A cohort study of the effectiveness of influenza vaccine in older people, performed using the United Kingdom general practice research database

BACKGROUND: The effectiveness of influenza vaccination against hospitalization and death can only ethically be assessed in observational studies. A concern is that individuals who are vaccinated are healthier than individuals who are not vaccinated, potentially biasing estimates of effectiveness upward. METHODS: We conducted a historical cohort study of individuals >64 years of age, for whom there were data available in the General Practice Research Database for 1989 to 1999 in England and Wales. Rates of admissions for acute respiratory diseases and rates of death due to respiratory disease were compared over 692,819 person-years in vaccine recipients and 1,534,280 person-years in vaccine nonrecipients. RESULTS: The pooled effectiveness of vaccine against hospitalizations for acute respiratory disease was 21% (95% confidence interval [CI], 17%-26%). The rate reduction attributable to vaccination was 4.15 hospitalizations/100,000 person-weeks in the influenza season. Among vaccine recipients, no important reduction in the number of admissions to the hospital was seen outside influenza seasons. The pooled effectiveness of vaccine against deaths due to respiratory disease was 12% (95% CI, 8%-16%). A greater proportionate reduction was seen among people without medical disorders, but absolute rate reduction was higher in individuals with medical disorders, compared with individuals without such disorders (6.14 deaths due to respiratory disease/100,000 person-weeks vs. 3.12 deaths due to respiratory disease/100,000 person-weeks). Clear protection against death due to all causes was not seen. CONCLUSIONS: Influenza vaccination reduces the number of hospitalizations and deaths due to respiratory disease, after correction for confounding in individuals >64 years of age who had a high risk or a low risk for influenza. For elderly people, untargeted influenza vaccination is of confirmed benefit against serious outcomes.     

Prevalence of chronic hepatitis B and incidence of acute hepatitis B infection in human immunodeficiency virus-infected subjects

We determined incidence and risk factors for acute and chronic hepatitis B virus (HBV) infection and HBV vaccination rates among human immunodeficiency virus (HIV)-infected subjects from the Adult/Adolescent Spectrum of HIV Disease Project, during 1998-2001. Among 16,248 HIV-infected patients receiving care, the incidence of acute HBV was 12.2 cases/1000 person-years (316 cases), was higher among black subjects (rate ratio [RR], 1.4; 95% confidence interval [CI], 1.0-2.0), subjects with alcoholism (RR, 1.7; 95% CI, 1.2-2.3), subjects who had recently injected drugs (RR, 1.6; 95% CI, 1.1-2.4), and subjects with a history of AIDS-defining conditions (RR, 1.5; 95% CI, 1.2-1.9) and was lower in those taking either antiretroviral therapy (ART) with lamivudine (RR, 0.5; 95% CI, 0.4-0.6), ART without lamivudine (RR, 0.5; 95% CI, 0.3-0.7), or >/=1 dose of HBV vaccine (14% of subjects) (RR, 0.6; 95% CI, 0.4-0.9). Prevalence of chronic HBV was 7.6% among unvaccinated subjects. HBV rates in this population were much higher than those in the general population, and vaccination levels were low. HBV remains an important cause of comorbidity in HIV-infected persons, but ART and vaccination are associated with decreased disease.     

Would vaccination against nicotine be a cost‐effective way to prevent smoking uptake in adolescents?

Aims We used epidemiological modelling to assess whether nicotine vaccines would be a cost‐effective way of preventing smoking uptake in adolescents. Design, Setting, Participants and Measurements We built an epidemiological model using Australian data on age‐specific smoking prevalence; smoking cessation and relapse rates; life‐time sex‐specific disability‐adjusted life years lived for cohorts of 100 000 smokers and non‐smokers; government data on the costs of delivering a vaccination programme by general practitioners; and a range of plausible and optimistic estimates of vaccine cost, efficacy and immune response rates based on clinical trial results. We first estimated the smoking uptake rates for Australians aged 12–19 years. We then used these estimates to predict the expected smoking prevalence in a birth cohort aged 12 in 2003 by age 20 under (i) current policy and (ii) different vaccination scenarios that varied in cost, initial vaccination uptake, yearly re‐vaccination rates, efficacy and a favourable vaccine immune response rate. Findings Under the most optimistic assumptions, the cost to avert a smoker at age 20 was $44 431 [95% confidence interval (CI) $40 023–49 250]. This increased to $296 019 (95% CI $252 307–$355 930) under more plausible scenarios. The vaccine programme was not cost‐effective under any scenario. Conclusions A preventive nicotine vaccination programme is unlikely to be cost‐effective. The total cost of a universal vaccination programme would be high and its impact on population smoking prevalence negligible. For these reasons, such a programme is unlikely to be publicly funded in Australia or any other developed country.     

Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study

BACKGROUND: An increasing proportion of deaths among human immunodeficiency virus (HIV)-infected persons with access to combination antiretroviral therapy (cART) are due to complications of liver diseases. METHODS: We investigated the frequency of and risk factors associated with liver-related deaths in the Data Collection on Adverse Events of Anti-HIV Drugs study, which prospectively evaluated 76 893 person-years of follow-up in 23 441 HIV-infected persons. Multivariable Poisson regression analyses identified factors associated with liver-related, AIDS-related, and other causes of death. RESULTS: There were 1246 deaths (5.3%; 1.6 per 100 person-years); 14.5% were from liver-related causes. Of these, 16.9% had active hepatitis B virus (HBV), 66.1% had hepatitis C virus (HCV), and 7.1% had dual viral hepatitis co-infections. Predictors of liver-related deaths were latest CD4 cell count (adjusted relative rate [RR], 16.1; 95% confidence interval [CI], 8.1-31.7 for <50 vs > or =500/microL), age (RR, 1.3; 95% CI, 1.2-1.4 per 5 years older), intravenous drug use (RR, 2.0; 95% CI, 1.2-3.4), HCV infection (RR, 6.7; 95% CI, 4.0-11.2), and active HBV infection (RR, 3.7; 95% CI, 2.4-5.9). Univariable analyses showed no relationship between cumulative years patients were receiving cART and liver-related death (RR, 1.00; 95% CI, 0.93-1.07). Adjustment for the most recent CD4 cell count and patient characteristics resulted in an increased risk of liver-related mortality per year of mono or dual antiretroviral therapy before cART (RR, 1.09; 95% CI, 1.02-1.16; P = .008) and per year of cART (RR, 1.11; 95% CI, 1.02-1.21; P = .02). CONCLUSIONS: Liver-related death was the most frequent cause of non-AIDS-related death. We found a strong association between immunodeficiency and risk of liver-related death. Longer follow-up is required to investigate whether clinically significant treatment-associated liver-related mortality will develop.     

The effectiveness of the national hepatitis B vaccination program 25 years after its introduction in Iran: a historical cohort study

IntroductionHepatitis B virus (HBV) is responsible for one of the most common human viral infections. An estimated 257 million people are living with chronic HBV infection worldwide, and mortality has reached 900,000 deaths in recent years. In 2001, the World Health Organization reported a prevalence of chronic hepatitis B infection in Iran between 2–7%.ObjectiveTo assess the effect of the national HBV mass vaccination program after 25 years.MethodsA retrospective cohort study was conducted in vaccinated and unvaccinated people according to the year of birth. Blood samples were obtained from each enrolled person and data about demographic variables, and medical and vaccination history were collected using a standardized questionnaire. Persons were considered uninfected if they were negative for both HBsAg and anti-HBc. Also, Vaccine effectiveness was measured by calculating the risk of disease among vaccinated and unvaccinated persons and defining the percentage risk reduction of infection in the vaccinated group.ResultsA total of 2720 persons were interviewed. The rate of HBV breakthrough infection among the vaccinated group was significantly lower than in unvaccinated group. One hundred ninety-four cases with positive HBV markers of infection were identified. The risk ratio of HBV infection was 0.71, 95% CI: 0.54–0.94 (vaccinated/unvaccinated). The estimated vaccination effectiveness against Hepatitis B infection was 29% (95% CI: 6%–46%).ConclusionsIran has successfully combined hepatitis B vaccination into regular immunization programs. The WHO goal of reducing HBsAg prevalence to an equivalent of 1% by 2020 has been reached. With respect to vaccination effectiveness and low prevalence of the disease in the country, catch-up hepatitis B vaccination programs for adolescents can guarantee the immunity of the population.     

The epidemiology of sepsis in patients with malignancy

STUDY OBJECTIVES: To evaluate the longitudinal epidemiology of sepsis in patients with a history of cancer and to specifically examine sepsis-related disparities in risk or outcome. DESIGN: Sepsis cases from 1979 through 2001 using a nationally representative sample of nonfederal acute-care hospitalizations in the United States (the National Hospital Discharge Survey) integrated with cancer prevalence from the Surveillance, Epidemiology, and End Results database. SETTING: Eight hundred fifty-four million acute-care hospitalizations and 8.9 million patients with cancer. Patients or participants: Patients with a history of cancer hospitalized with a diagnosis of sepsis. MEASUREMENTS AND RESULTS: From 1979 to 2001, there were a total of 1,781,445 cases of sepsis in patients with cancer, yielding a mean annual incidence rate of 1,465 cases per 100,000 cancer patients and a relative risk [RR] of 9.77 compared to noncancer patients (95% confidence interval [95% CI], 9.67 to 9.88). In contrast to the absolute number of cases, the incidence rate of sepsis decreased over time, from a peak of 1,959 cases per 100,000 cancer patients in 1987 to 995 cases per 100,000 in 2001. The distribution of infectious sources causing sepsis was associated with the type of malignancy. White cancer patients had a lower risk for sepsis compared to nonwhites (African-American RR, 1.28; 95% CI, 1.16 to 1.40) and other races (RR, 1.47; 95% CI, 1.22 to 1.72); and male cancer patients had a higher risk for sepsis compared to female cancer patients (male RR, 1.17; 95% CI, 1.10 to 1.23). Cancer was an independent predictor of death among sepsis patients by multivariable analysis (adjusted odds ratio for death, 1.98; 95% CI, 1.97 to 1.99). CONCLUSIONS: Patients with a history of cancer are at increased risk for acquiring and subsequently dying from sepsis, compared to the general population, although incidence and fatality rates are decreasing over time. There are significant racial and gender disparities in the incidence and outcome of sepsis among cancer patients that require explanation.     

Prevention and control of influenza in persons with chronic obstructive pulmonary disease

Despite recommendations for annual vaccination against influenza, more than half of patients with chronic obstructive pulmonary disease (COPD) in developed countries do not receive this vaccine. Influenza is characterized by its potentially of causing epidemics and by excess morbidity and mortality in patients with COPD and other chronic medical conditions. Good evidence of the efficacy, effectiveness, and cost-effectiveness of influenza vaccination underlines the recommendation of use in patients with COPD. Influenza vaccination could reduce influenza-related complications and exacerbations in patients with COPD, therefore reducing hospitalizations and deaths. Each year, all persons with COPD should be vaccinated with the inactivated trivalent influenza vaccine containing the most frequent two influenza A viral strains and one influenza B viral strain detected in the influenza season of the previous year. To achieve a 100% vaccination rate in patients with COPD, all patients with COPD registered in health insurance companies and attended in health centers and specialized clinics should be vaccinated during the immunization period (October–December). Antiviral therapies could be used as an adjunct to vaccination and to reduce influenza transmission in outbreaks. Antiviral therapies could reduce the duration and complications of influenza when administered within two days of the onset of illness. Research is necessary for new antiviral therapies that could prevent influenza with cost-effectiveness similar to the influenza vaccine.     

Non-preventable mumps outbreaks in schoolchildren in Catalonia

Various doses of the combined MMR vaccine containing the Rubini mumps strain were distributed in Catalonia in 1994 and 1995. We studied outbreaks of mumps reported from 1997 to 2002 to determine the possible involvement of this vaccine in the appearance of non-preventable mumps outbreaks. A total of 17 mumps outbreaks were declared in the period 1997-2000, 14 of which were in schoolchildren. In 11, it was determined that children were correctly vaccinated. Of these, 10 were non-preventable outbreaks. 66% of cases investigated had ages which coincided with vaccination in the period 1994-1996, during which the MMR vaccine containing the Rubini mumps strain was administered. In Catalonia, during the period 1997-2000, at least two-thirds of mumps cases in schoolchildren could be explained by vaccination with the combined MMR vaccine containing the Rubini strain, which has also been associated with mumps outbreaks amongst vaccinated people in other countries.     

The impact of antiretroviral treatment on mortality trends of HIV‐positive adults in rural Uganda: a longitudinal population‐based study, 1999–2009

Objective To investigate trends in all‐cause adult mortality after the roll‐out of an antiretroviral therapy (ART) programme in rural Uganda. Methods Longitudinal population‐based cohort study of approximately 20 000 residents in rural Uganda. Mortality in adults aged 15–59 years was determined for the 5‐year period (1999–2003) before introduction of ART in January 2004 and for the 5‐year period afterwards. Poisson regression was used to estimate mortality rate ratios (RRs) for the period before ART, 1 year after ART introduction (from January 2004 to January 2005) and more than 1 year after ART introduction. Trends in mortality were analysed by HIV status, age and sex. Results Before ART became available, the mortality rate (deaths per 1000 person‐years) was 4.0 (95% CI = 3.3–4.8) among HIV‐negative individuals and 116.4 (95% CI = 101.9–133.0) among HIV‐positive individuals. During the period January 2004–end November 2009, 279 individuals accessed ART. In the year after ART was introduced, the mortality rate (deaths per 1000 person‐years) among HIV‐negative individuals did not change significantly (adjusted RR = 0.95, 95% CI = 0.61–1.47), but among HIV‐positive individuals dropped by 25% to 87.4 (adjusted RR = 0.75, 95% CI = 0.53–1.06). In the period 2005–2009, the mortality rate (deaths per 1000 person‐years) among HIV‐positive individuals fell further to 39.9 (adjusted RR = 0.33, 95% CI = 0.26–0.43). The effect was greatest among individuals aged 30–44 years, and trends were similar in men and women. Conclusion The substantially reduced mortality rate among HIV‐positive individuals after ART roll‐out lends further support to the intensification of efforts to ensure universal access to ART.     

Compliance with hepatitis B vaccination in 1175 heroin users and risk factors associated with lack of vaccine response

Aims To investigate the feasibility of hepatitis B vaccination among heroin users, assessing adherence to the vaccination schedules and identifying factors associated with antibody response. Design and participants A large cohort study in nine public centres for drug users (PCDUs) in north‐eastern Italy, with data collected between January 1989 and December 1998. A total of 1175 heroin users were selected and vaccinated with a recombinant vaccine using two schedules (0–1–6 months and 0–1–2 months). Findings Eighty‐eight per cent of patients completed the vaccination series and a protective antibody response occurred in 77% of subjects. Completion of the vaccination series was not related to the length of the vaccination schedule or whether the patient was still in drug abuse treatment at the end of the series, but was related strongly to the number of patients enrolled at each PCDU (Spearman correlation = – 0.93, P < 0.001). Four variables were significantly associated with lack of seroconversion in response to vaccination: older age (AOR = 0.91 per year, 95% CI 0.88–0.94, P < 0.001), 2‐month vaccination schedule (AOR = 3.10, 95% CI 2.06–4.68, P < 0.001), HCV seropositivity (AOR = 0.69, 95% CI 0.47–0.99, P = 0.04), HIV seropositivity (AOR = 0.27, 95% CI 0.10–0.77, P = 0.01). Conclusions A large‐scale, multi‐site hepatitis B vaccination programme for heroin users proved feasible and effective. The factors associated with a lack of antibody response may be useful in identifying patients who would benefit most from routine post‐vaccination testing, with booster doses for non‐responders. These results suggest that hepatitis B vaccination for drug users should become a routine public health practice.     

Effect of influenza vaccination on disease progression among HIV-infected persons

OBJECTIVE: To describe the effect of influenza vaccination on long-term change in CD4 count and HIV RNA level, and on progression to AIDS or death. DESIGN AND SETTING: A longitudinal medical record review set in 113 medical clinics in 10 United States cities. PATIENTS: A total of 36,050 HIV-infected persons aged > or = 13 years in care for HIV infection. MAIN OUTCOME MEASURES: Change in CD4 count and HIV RNA level at follow-up (3-12 months after vaccination); hazard ratios (HR) for association of influenza vaccine with progression from baseline CD4 or HIV RNA level to AIDS and to death. RESULTS: The median CD4 count among all persons decreased 28 cells/year during follow-up, with no difference in change in CD4 count between the 8007 (40%) vaccinated (median = 6 months, vaccine to follow-up CD4 count) and the 11,794 unvaccinated persons. In a viral load subanalysis, median HIV RNA level decreased 90 copies/ml per year among all persons during follow-up; decreases were not different between vaccinated and unvaccinated persons (median = 7 months, vaccine to follow-up HIV RNA level determination). Influenza vaccination was weakly associated with decreased risk of progression to clinical AIDS [HR 0.93; 95% confidence interval (CI), 0.87-0.99], but not associated with time to death (HR, 0.97; CI, 0.93-1.01). CONCLUSIONS: No negative long-term effect of influenza vaccination on CD4 counts, HIV RNA levels, or progression to AIDS or death was found in this HIV-infected population. These data suggest that physicians should not withhold influenza vaccine because of concerns about long-term detrimental effects of increased viral replication.