Correspondencia vacunación-inmunización como necesidad social y reto para la ciencia y la educación médica / Vaccination-immunization correspondence as a social need and challenge for science and medical education

Introducción: La vacunación constituye el arma preventiva más efectiva para las enfermedades trasmisibles que conoce la humanidad. Hacer que las vacunas aplicadas sean realmente inmunizantes resulta la responsabilidad de los profesionales de la atención primaria. Del mismo modo, es importante que se acepte, sin recelo, la vacunación, sobre todo en la situación epidemiológica actual. Objetivo: Describir las implicaciones sociales, económicas y éticas relacionadas con la existencia de vacunas teóricamente no inmunizantes. Métodos: Se emplearon los resultados de un programa de intervención educativa en edades pediátricas en el Policlínico 13 de marzo. Se utilizó la prueba de rangos con signo de Wilcoxon, con índice de confianza del 95 por ciento. Resultados: Inicialmente, predominó el nivel inadecuado de conocimiento, que luego mejoró significativamente. Se recuperaron 48 niños no vacunados y 29 vacunaciones no inmunizados. Conclusiones: No existe correspondencia entre las coberturas vacunales y la inmunización. Están instauradas, como correctas, falsas contraindicaciones para la vacunación. La intervención educativa fue efectiva, y se hizo patente la pertinencia de programas de pregrado y posgrado que perfeccionen la formación de los profesionales y la calidad en el desempeño profesional(AU)

Introduction: Vaccination is the most effective preventive weapon for communicable diseases known to humanity. It is the responsibility of primary health care professionals to ensure that the administered vaccines are truly immunizing. Likewise, it is important that vaccination be accepted without hesitations, especially in the current epidemiological situation. Objective: To describe the social, economic and ethical implications related to the existence of theoretically nonimmunizing vaccines. Methods: The results of an educational intervention program in pediatric ages at 13 de Marzo Policlinic were used. The Wilcoxon signed-rank test was used, with a confidence index of 95 percent. Results: Initially, an inadequate level of knowledge predominated, which later improved significantly. Forty-eight unvaccinated children and 29 unimmunized children recovered. Conclusions: There is no correspondence between vaccination coverage and immunization. False contraindications for vaccination are established as correct. The educational intervention was effective, while the relevance became evident for undergraduate and postgraduate programs to improve the training of professionals and the quality of professional performance(AU)

Cost-effectiveness evaluations of the 9-Valent human papillomavirus (HPV) vaccine: Evidence from a systematic review.

INTRODUCTION: The World Health Organization (WHO) recommends that human papillomavirus (HPV) vaccination programs are established to be cost-effective before implementation. WHO recommends HPV vaccination for girls aged 9-13 years to tackle the high burden of cervical cancer. This review examined the existing evidence on the cost-effectiveness of the 9-valent HPV vaccine within a global context. METHODS: The literature search covering a period of January 2000 to 31 July 2019 was conducted in PubMed and Scopus bibliographic databases. A combined checklist (i.e., WHO, Drummond and CHEERS) was used to examine the quality of eligible studies. A total of 12 studies were eligible for this review and most of them were conducted in developed countries. RESULTS: Despite some heterogeneity in approaches to measure cost-effectiveness, ten studies concluded that 9vHPV vaccination was cost-effective and two did not. The addition of adolescent boys into immunisation programs was cost effective when vaccine price and coverage was comparatively low. When vaccination coverage for females was more than 75%, gender neutral HPV vaccination was less cost-effective than vaccination targeting only girls aged 9-18 years. Multi cohort immunization approach was found cost-effective in the age range of 9-14 years. However, the upper age limit at which vaccination was found not cost-effective requires further evaluation. This review identified duration of vaccine protection, time horizon, vaccine price, coverage, healthcare costs, efficacy and discounting rates as the most dominating parameters in determining cost-effectiveness. CONCLUSIONS: These findings have implications in extending HPV immunization programs whether switching to the 9-valent vaccine or the inclusion of adolescent boys' vaccination or extending the age of vaccination. Further, this review also supports extending vaccination programs to low-resource settings where vaccine prices are competitive, donor funding is available, burden of cervical cancer is high and screening options are limited.

Immunization costs and programmatic barriers at an urban HIV clinic.

BACKGROUND: Although the increasing number of recommended immunizations is essential for patients infected with human immunodeficiency virus (HIV), the potentially uncompensated costs of expanded immunizations will present significant challenges for clinics and health systems serving HIV-infected patients. METHODS: We estimated costs of providing Gardasil, Prevnar, and Zostavax to eligible patients at a US Ryan White Part C academically affiliated HIV clinic in 2013. Clinic expenditures were calculated using vaccine price and administrative fees. Revenue was calculated using insurance reimbursement data for vaccination and administration. Three scenarios were used: 100% uptake of vaccines, adjusted uptake based on published rates, and adjusted reimbursement according to pre-Affordable Care Act (ACA) insurance status. RESULTS: 2887 patients (27% Medicare, 13% Alabama Medicaid, 26% Commercial, 34% Uninsured), received care with wide variation in immunization reimbursement ($0 to $210) by insurance and vaccine. The net yield (revenue minus expenditure) was calculated for each vaccine. Prevnar was most costly: annual net yield of -$60 691. Provision of all 3 vaccines would lead to a net yield of -$97 122. Adjusting for reduced uptake led to annual clinic losses of $44 119. Using pre-ACA reimbursement for immunization of the uninsured led to reduced clinic losses (-$62 326), attributable to reimbursement via Ryan White funds. CONCLUSIONS: A cost analysis of 3 vaccines shows great variation in insurance coverage, with potential losses of almost $100 000 for one HIV clinic if eligible patients received vaccinations in one calendar year. Adequate, cost neutral reimbursement should be instituted if medical providers and health systems are to achieve Advisory Committee on Immunization Practices immunization recommendations for both HIV positive and negative adults.

Validation of infant immunization billing codes in administrative data.

Ontario has a single payer provincial health insurance program. Administrative data may provide a potentially robust source of information for post-marketing vaccine studies. Vaccine-specific immunization billing codes were introduced in 2011. Our objective was to validate Ontario's universal health care administrative datasets to assess infant immunization status. Electronic medical record data from the Electronic Medical Record Administrative data Linked Database (EMRALD) was used as the reference standard to calculate performance characteristics of the Ontario Health Insurance Plan (OHIP) database vaccine-specific and general immunization codes for 4 primary infant immunizations: diphtheria, tetanus, acellular pertussis, inactivated polio, Haemophilus influenzae type B (DTaP-IPV-Hib) combination vaccine, pneumococcal conjugate vaccine, measles, mumps, rubella (MMR) vaccine, and meningococcal conjugate serogroup C vaccine. OHIP billing claims had specificity ranging from 81% to 92%, sensitivity 70% to 83%, positive predictive value (PPV) 97% to 99%, and negative predictive value (NPV) 13% to 46% for identifying the various specific vaccines in administrative data. For cohorts vaccinated in the new code introduction phase, using both the vaccine-specific and general codes had higher sensitivity than the vaccine-specific codes alone. In conclusion, immunization billing claims from administrative data in Ontario had high specificity and PPV, moderate sensitivity, and low NPV. This study identifies some of the applications of utilizing administrative data for post-marketing vaccine studies. However, limitations of these data decrease their utility for measuring vaccine coverage and effectiveness. Therefore, the establishment of a comprehensive and linkable immunization registry should be a provincial priority.

Inmunización para influenza y neumococo en prevención cardiovascular / [Influenza and pneumococcal immunization in cardiovascular prevention]

A group of interdisciplinary experts (cardiologists, clinicians, infectologists met with the purpose of analyzing the evidence revealed by the relationship between respiratory diseases caused by influenza, pneumococcal diseases and cardiovascular events, and the role played by immunization strategies applied in cardiovascular prevention. The present statement summarizes the conclusions reached by the expertise of the aforementioned professionals. Systematic revisions imply consistent evidence that influenza and pneumococcal infection lead to acute myocardial infarction and cardiovascular death. Studies published during the last 15 years suggest that vaccination against influenza and S. pneumoniae reduce the risk of acute coronary syndromes. With the current evidence, and considering cost-effectiveness, reducing operating expenses and safety profile of the vaccines, scientific societies, national and international government health agencies strongly recommend incorporating immunization programs in those patients with chronic cardiovascular disease.

Cost-effectiveness analysis of MMR immunization in health care workers.

BACKGROUND: Assessment of measles, mumps and rubella (MMR) status is an essential part of occupational health clearance for new health care workers (HCWs). At the time of this study the policy at Sheffield Occupational Health Service (SOHS) was to perform serological testing of HCWs without evidence of previous immunization prior to MMR vaccination. AIMS: To identify the cost implications of changing policy to offer vaccination without prior serological testing to HCWs without evidence of previous immunization. METHODS: A retrospective cohort analysis of all MMR serological results from individuals attending SOHS for pre-placement assessment between 1 April 2010 and 31 March 2012. RESULTS: Seven thousand five hundred and sixty-nine individuals attended SOHS for pre-placement screening. Of these, 52% (3921) had no evidence of prior vaccination to at least one MMR disease and underwent serological testing. Thirty-three per cent (1204) of these HCWs were sero-negative to at least one condition requiring vaccination. With the suggested change in policy, our data indicate a cost-saving of over £105 000 per year may currently be achieved at SOHS. CONCLUSIONS: Our findings highlight significant savings through offering vaccination without prior serology for HCWs with no evidence of prior immunization to MMR. An awareness of costs associated with serology, vaccination and staff clinics, as well as the wider impact of population vaccination campaigns, are important factors determining the most cost-effective strategy in this area.

A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents.

OBJECTIVE: To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents. METHODS: We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices. The main outcome measures were immunization rates for routine vaccines (meningococcus, pertussis, HPV) and preventive visit rates at study end. RESULTS: Intervention and control groups were similar at baseline for demographics, immunization rates, and preventive visits. Among adolescents who were behind at the start, immunization rates at study end increased by 21% for mailed (P < .01 vs control), 17% for telephone (P < .05), and 13% for control groups. The proportion of adolescents with a preventive visit (within 12 months) was: mailed (65%; P < .01), telephone (63%; P < .05), and controls (59%). The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders; for an additional preventive visit, it was 17 and 29. The intervention cost $18.78 (mailed) or $16.68 (phone) per adolescent per year to deliver. The cost per additional adolescent fully vaccinated was $463.99 for mailed and $714.98 for telephone; the cost per additional adolescent receiving a preventive visit was $324.75 and $487.03. CONCLUSIONS: Managed care-based mail or telephone reminder/recall improved adolescent immunizations and preventive visits, with modest costs and modest impact.

Effectiveness and cost of immunization recall at school-based health centers.

BACKGROUND AND OBJECTIVE: Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers (SBHCs). We assessed (1) immunization rates achieved with recall among sixth-grade girls (demonstration study); (2) effectiveness of recall among sixth-grade boys (randomized controlled trial [RCT]); and (3) cost of conducting recall in SBHCs. METHODS: During October 2008 through March 2009, in 4 Denver public SBHCs, we conducted (1) a demonstration study among 265 girls needing ≥ 1 recommended adolescent vaccine and (2) an RCT among 264 boys needing vaccines, with half randomized to recall and half receiving usual care. Immunization rates for recommended adolescent vaccines were assessed 6 months after recall. First dose costs were assessed by direct observation and examining invoices. RESULTS: At the end of the demonstration study, 77% of girls had received ≥ 1 vaccine and 45% had received all needed adolescent vaccines. Rates of receipt among those needing each of the vaccines were 68% (160/236) for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, 57% (142/248) for quadrivalent meningococcal conjugate vaccine, and 59% (149/253) for the first human papillomavirus vaccine. At the end of the RCT, 66% of recalled boys had received ≥ 1 vaccine and 59% had received all study vaccines, compared with 45% and 36%, respectively, of the control group (P < .001). Cost of conducting recall ranged from $1.12 to $6.87 per recalled child immunized. CONCLUSIONS: SBHC-based recall was effective in improving immunization rates for all adolescent vaccines, with effects sizes exceeding those achieved with younger children in practice settings.

Effectiveness and net cost of reminder/recall for adolescent immunizations.

OBJECTIVE: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues. METHODS: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines. RESULTS: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses. CONCLUSIONS: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

Vaccines and future global health needs.

Increased international support for both research into new vaccines and their deployment in developing countries has been evident over the past decade. In particular, the GAVI Alliance has had a major impact in increasing uptake of the six common infant vaccines as well as those against hepatitis B and yellow fever. It further aims to introduce pneumococcal and rotavirus vaccines in the near future and several others, including those against human papillomavirus, meningococcal disease, rubella and typhoid not long after that. In addition, there is advanced research into vaccines against malaria, HIV/AIDS and tuberculosis. By 2030, we may have about 20 vaccines that need to be used in the developing world. Finding the requisite funds to achieve this will pose a major problem. A second and urgent question is how to complete the job of global polio eradication. The new strategic plan calls for completion by 2013, but both pre-eradication and post-eradication challenges remain. Vaccines will eventually become available beyond the field of infectious diseases. Much interesting work is being done in both autoimmunity and cancer. Cutting across disease groupings, there are issues in methods of delivery and new adjuvant formulations.

The future of immunisation policy, implementation, and financing.

Vaccines have already saved many lives and they have the potential to save many more as increasingly elaborate technologies deliver new and effective vaccines against both infectious diseases--for which there are currently no effective licensed vaccines--such as malaria, tuberculosis, and HIV and non-infectious diseases such as hypertension and diabetes. However, these new vaccines are likely to be more complex and expensive than those that have been used so effectively in the past, and they could have a multifaceted effect on the disease that they are designed to prevent, as has already been seen with pneumococcal conjugate vaccines. Deciding which new vaccines a country should invest in requires not only sound advice from international organisations such as WHO but also a well informed national immunisation advisory committee with access to appropriate data for local disease burden. Introduction of vaccines might need modification of immunisation schedules and delivery procedures. Novel methods are needed to finance the increasing number of new vaccines that have the potential to save lives in countries that are too poor to afford them. Here, we discuss some options.

Targeted human papillomavirus vaccination of men who have sex with men in the USA: a cost-effectiveness modelling analysis.

BACKGROUND: A vaccine targeting human papillomavirus (HPV) types 16 and 18, which are associated with 80% of anal cancers, is efficacious in men. High-risk populations such as men who have sex with men (MSM) might especially benefit from vaccination. I aimed to estimate the cost-effectiveness of HPV vaccination of MSM in the USA. METHODS: I constructed decision-analytic models to estimate the direct health and economic outcomes of HPV vaccination (against types 6, 11, 16, and 18) for prevention of HPV-related anal cancer and genital warts. The model parameters that were varied were age at vaccination (12 years, 20 years, and 26 years), previous exposure to vaccine-targeted HPV types, and prevalence of HIV-1. I used the models to conduct sensitivity analyses, including duration of vaccine protection, vaccine cost, and burden of anal cancer and genital warts. FINDINGS: In a scenario of HPV vaccination of MSM at 12 years of age without previous exposure to HPV, compared with no vaccination, vaccination cost US$15,290 per quality-adjusted life-year gained. In scenarios where MSM are vaccinated at 20 years or 26 years of age, after exposure to HPV infections, the cost-effectiveness ratios worsened, but were less than $50,000 per quality-adjusted life-year under most scenarios. For example, HPV vaccination of MSM at 26 years cost $37,830 per quality-adjusted life-year when previous exposure to all vaccine-targeted HPV types was assumed to be 50%. Outcomes were most sensitive to variations in anal cancer incidence, duration of vaccine protection, and HIV prevalence in MSM. INTERPRETATION: HPV vaccination of MSM is likely to be a cost-effective intervention for the prevention of genital warts and anal cancer. FUNDING: US National Cancer Institute.

Varicella among seafarers: a case study on testing and vaccination as a cost-effective method of prevention.

BACKGROUND: Many individuals together in semi-confined settings increase the risk of outbreaks of infectious diseases. A single case of varicella on a cruise ship can thus result in rapid spread and elevated costs for the cruise provider in terms of repatriation, ship diversion, law suits, and loss in current and potential future revenue. Control of varicella involves attention to good personal hygiene, safe food and water handling, and use of vaccine. OBJECTIVES: To test crewmembers during their pre-employment medical examination to determine who might be susceptible to contract varicella if exposed, to vaccinate those at risk, and to see whether the benefits of testing and vaccination outweigh the costs. MATERIAL AND METHODS: Tests were conducted on 121 Indian seafarers for varicella IgG and IgM antibodies during their pre-employment medical examination in Mumbai and Goa from December 1st to December 23rd 2008. Cases without IgG antibodies to varicella (IgG negative) were administered vaccine. RESULTS: Twenty (16.5%) seafarers who tested IgG negative and one who tested equivocally were administered the vaccine. One hundred (82.7%) tested positive for IgG antibodies and were therefore not vaccinated. None tested positive for IgM antibodies, indicating no active infection. CONCLUSIONS: One in six Indian seafarers tested IgG negative and was thus at risk to contract varicella if exposed. Testing for varicella IgG and IgM antibodies, followed by vaccination when necessary, is a costeffective method to prevent an expensive outbreak in the semi-confined setting of a cruise ship and is recommended as a mandatory part of the pre-employment medical examination for Indian seafarers.

Cost-effectiveness of influenza immunization in adult cancer patients in Taiwan.

The aim of this study was to investigate the efficacy of the influenza vaccine among cancer patients in Taiwan. We determined the effect of immunization on the following outcomes of disease: hospitalizations, emergency department visits, hospital outpatient visits, physician office visits, and deaths. Cost-effectiveness was analysed from the perspectives of the healthcare system and society. A decision tree was used, with estimates of disease burden and costs based on data from published and unpublished sources. The model followed 34 112 cancer patients aged 20-64 years who were registered by the Taiwan National Cancer Registry in 2002. An influenza immunization programme for the cancer population would prevent 2555 cases of all types of influenza infection, 660 of which would be serious cases involving hospitalization, emergency department visits and death. From the perspective of the healthcare system, the programme would cost US$7.7 million, providing net savings of US$5.4 million. From a societal perspective, the programme would cost US$28.6 million, providing net savings of US$22.3 million. This corresponds to savings of US$2107 and US$6338 per case averted, from healthcare and societal perspectives, respectively, as well as 110 lives saved. Lesser disease burden, greater vaccine efficacy and lower cost of hospitalizations increased cost-effectiveness. Influenza immunization for cancer patients is cost-saving and cost-effective from a healthcare and societal perspective in Taiwan. We highly recommend annual influenza vaccinations for this patient group.

Immunizing school-age children and adolescents: experience from low- and middle-income countries.

OBJECTIVE: Given the increased attention on the need for booster immunizations of older children and adolescents, as well as new primary vaccine series that specifically target school-age children and adolescents, we reviewed the current state of vaccine delivery to school-age children and adolescents in low- and middle-income countries. METHODS: We searched the published literature and unpublished sources for articles, meeting presentations, technical reports and program documents related to immunization policies and programs for school-age children and/or adolescents between 6 and 19 years of age in low- and middle-income countries. FINDINGS: We found several examples of ongoing school-age children and adolescent immunization in low- and middle-income countries. Reasons to vaccinate this age group include vaccines specifically targeted for this age group, waning immunity from prior vaccination, "catch-up" vaccination, acceleration of disease control or elimination efforts, and age distribution shift in the incidence of vaccine-preventable diseases. Multiple delivery strategies are currently in use: routine immunization, supplementary immunization activities, and Child Health Days and similar activities. Vaccines can be delivered in fixed sites, or through outreach. Most immunization programs that target adolescents and school-aged children are providing boosters of infant vaccines at school entry age, with scant experience in delivery of primary vaccination series in adolescents. Few of these programs have been formally evaluated and dissemination of lessons learned is limited. CONCLUSIONS: This baseline description may facilitate immunization program planning in countries considering vaccinating this age group. Additionally, this summary may inform plans for operational research and program evaluation designed to expand vaccine delivery to school-age children and adolescents in low- and middle-income countries.

Financing immunization of adults in the United States.

Immunization is one of the most effective and cost-effective prevention measures available. As a result of universal vaccination of children, polio has been eliminated in the United States and much of the world, measles and rubella are no longer endemic diseases in the United States, and most of the other vaccine-preventable diseases of childhood are at or near record lows. A recent review of clinical preventive services by Partnership for Prevention gave childhood immunization a perfect score of 10, based on clinically preventable burden and cost-effectiveness.