Health and Economic Impact of the United States Varicella Vaccination Program, 1996-2020.

BACKGROUND: The aim of this study was to evaluate the health and economic impact of the varicella vaccination program on varicella disease in the United States (US), 1996-2020. METHODS: Analysis was conducted using the Centers for Disease Control and Prevention or published annual population-based varicella incidence, and varicella-associated hospitalization, outpatient visit, and mortality rates in the US population aged 0-49 years during 1996-2020 (range, 199.5-214.2 million persons) compared to before vaccination (1990-1994). Disease costs were estimated using the societal perspective. Vaccination program costs included costs of vaccine, administration, postvaccination adverse events, and travel and work time lost to obtain vaccination. All costs were adjusted to 2020 US dollars using a 3% annual discount rate. The main outcome measures were the number of varicella-associated cases, hospitalizations, hospitalization days, and premature deaths prevented; life-years saved; and net societal savings from the US varicella vaccination program. RESULTS: Among US persons aged 0-49 years, during 1996-2020, it is estimated that more than 91 million varicella cases, 238 000 hospitalizations, 1.1 million hospitalization days, and almost 2000 deaths were prevented and 118 000 life-years were saved by the varicella vaccination program, at net societal savings of $23.4 billion. CONCLUSIONS: Varicella vaccination has resulted in substantial disease prevention and societal savings for the US over 25 years of program implementation.

The Advisory Committee on Immunization Practices' Updated Interim Recommendation for Allocation of COVID-19 Vaccine - United States, December 2020.

The first vaccines for prevention of coronavirus disease 2019 (COVID-19) in the United States were authorized for emergency use by the Food and Drug Administration (FDA) (1) and recommended by the Advisory Committee on Immunization Practices (ACIP) in December 2020.* However, demand for COVID-19 vaccines is expected to exceed supply during the first months of the national COVID-19 vaccination program. ACIP advises CDC on population groups and circumstances for vaccine use.† On December 1, ACIP recommended that 1) health care personnel§ and 2) residents of long-term care facilities¶ be offered COVID-19 vaccination first, in Phase 1a of the vaccination program (2). On December 20, 2020, ACIP recommended that in Phase 1b, vaccine should be offered to persons aged ≥75 years and frontline essential workers (non-health care workers), and that in Phase 1c, persons aged 65-74 years, persons aged 16-64 years with high-risk medical conditions, and essential workers not recommended for vaccination in Phase 1b should be offered vaccine.** These recommendations for phased allocation provide guidance for federal, state, and local jurisdictions while vaccine supply is limited. In its deliberations, ACIP considered scientific evidence regarding COVID-19 epidemiology, ethical principles, and vaccination program implementation considerations. ACIP's recommendations for COVID-19 vaccine allocation are interim and might be updated based on changes in conditions of FDA Emergency Use Authorization, FDA authorization for new COVID-19 vaccines, changes in vaccine supply, or changes in COVID-19 epidemiology.

The Advisory Committee on Immunization Practices' Interim Recommendation for Allocating Initial Supplies of COVID-19 Vaccine - United States, 2020.

The emergence of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), has led to a global pandemic that has disrupted all sectors of society. Less than 1 year after the SARS-CoV-2 genome was first sequenced, an application* for Emergency Use Authorization for a candidate vaccine has been filed with the Food and Drug Administration (FDA). However, even if one or more vaccine candidates receive authorization for emergency use, demand for COVID-19 vaccine is expected to exceed supply during the first months of the national vaccination program. The Advisory Committee on Immunization Practices (ACIP) advises CDC on population groups and circumstances for vaccine use.† ACIP convened on December 1, 2020, in advance of the completion of FDA's review of the Emergency Use Authorization application, to provide interim guidance to federal, state, and local jurisdictions on allocation of initial doses of COVID-19 vaccine. ACIP recommended that, when a COVID-19 vaccine is authorized by FDA and recommended by ACIP, both 1) health care personnel§ and 2) residents of long-term care facilities (LTCFs)¶ be offered vaccination in the initial phase of the COVID-19 vaccination program (Phase 1a**).†† In its deliberations, ACIP considered scientific evidence of SARS-CoV-2 epidemiology, vaccination program implementation, and ethical principles.§§ The interim recommendation might be updated over the coming weeks based on additional safety and efficacy data from phase III clinical trials and conditions of FDA Emergency Use Authorization.

2016-2017 Arkansas mumps outbreak in a close-knit community: Assessment of the economic impact and response strategies.

On August 8, 2016, a confirmed case of mumps was reported to the Arkansas Department of Health (ADH) in an adult resident of Springdale, Arkansas. By July 2017, nearly 3,000 cases of mumps were reported to ADH from 37 of the 75 counties in Arkansas. Over 50% of cases were in the Arkansas Marshallese community, a close-knit community characterized by large, and extended families sharing the same living space and communal activities. In a statewide effort, ADH collaborated with CDC, the Republic of the Marshall Island's (RMI) Ministry of Health, and the Arkansas Department of Education (ADE) to rapidly respond to and contain the outbreak. We assessed the economic burden to ADH of the outbreak response in terms of containment and vaccination costs, as well as response costs incurred by CDC, RMI, and ADE. The 2016-2017 Arkansas mumps outbreak was the second largest US mumps outbreak in over 30 years and was unique in size, spread, and population affected. Total public health response costs as a result of the outbreak were over $2.1 million, approximately $725 per case. The costs incurred to control this outbreak reflect the response strategies tailored to the affected populations, including consideration of social, cultural, and political factors in controlling transmission and requirements of distinctive strategies for public health outreach. Aside from the burden these outbreaks have on the affected population, we demonstrate the potential for high economic burden of these outbreaks to public health.

Cost of Responding to the 2017 University of Washington Mumps Outbreak: A Prospective Analysis.

OBJECTIVES: To estimate costs of labor and materials by the University of Washington (UW) and state and local public health departments (PHDs) to respond to the February to June 2017 UW mumps outbreak, where 42 cases were identified among students (primarily sorority and fraternity members), staff, and associated community members. DESIGN: We applied standard cost analysis methodology using a combined public health and university perspective to examine the cost of responding to the outbreak. SETTING: UW's Seattle campus encompasses 703 acres with approximately 32 000 undergraduate students. Nearly 15% of the undergraduate population are members of fraternities or sororities. Housing for the fraternities and sororities is adjacent to the UW campus and consists of 50 houses. PARTICIPANTS: During the outbreak, customized costing tools based on relevant staff or faculty positions and activities were provided to the UW and Public Health-Seattle & King County, populated by each person participating in the outbreak response, and then collected and analyzed. Laboratory hours and material costs were collected from the Washington Department of Health and the Minnesota Department of Health. MAIN OUTCOME MEASURE: Labor and material costs provided by the UW and PHDs during the outbreak were collected and categorized by payer and activity. RESULTS: Total costs to the UW and PHDs in responding to the outbreak were $282 762 ($6692 per case). Of these, the UW spent $160 064, while PHDs spent $122 098. Labor accounted for 77% of total outbreak costs, and UW response planning and coordination accounted for the largest amount of labor costs ($75 493) overall. CONCLUSIONS: Given the current university and public health department budget constraints, the response to the outbreak amounted to a significant use of resources. Labor was the largest driver of costs for the outbreak response; UW labor costs-related to campus response planning and coordination-dominated the total economic burden from public health and university perspectives.

Health Departments' Experience With Mumps Outbreak Response and Use of a Third Dose of Measles, Mumps, and Rubella Vaccine.

CONTEXT: During January 2016 to June 2017, US health departments (HDs) reported 150 mumps outbreaks. Most occurred among populations with high 2-dose measles, mumps, and rubella (MMR) vaccine coverage, prompting the Advisory Committee on Immunization Practices to examine the evidence for use of a third dose of MMR vaccine. OBJECTIVE: To evaluate HD experiences with mumps outbreak control and use of a third MMR dose during outbreaks. DESIGN: An online survey assessing mumps outbreak characteristics, outbreak response measures, challenges, and lessons learned from previous outbreaks was distributed to all 81 Council of State and Territorial Epidemiologists member HDs in August 2017. RESULTS: Sixty-one (75%) HDs responded; 46 (75%) had experience with ≥1 mumps outbreak(s) during January 2016 to August 2017. Twenty (43%) HDs recommended a third or outbreak MMR dose during mumps outbreaks; of these, 19 completed the section on use of a third dose and 8 (40%) rated the intervention "somewhat effective" or better. Health departments that used a third/outbreak dose suggested implementing the recommendation early and to a targeted group. Forty-three (73%) HDs reported having a policy for excluding persons without presumptive immunity from outbreak settings; of these, 37 (86%) had some degree of legal authority to implement this policy. Exclusion compliance improved with the use of personalized notification letters, focus groups of excluded persons and the community, and standardized messaging. Other outbreak control measures included cohorting of exposed or susceptible persons, mobile vaccination clinics and home visits, contact monitoring via text messaging, and facilitating student isolation with meal delivery and excused class absences. CONCLUSIONS: Our study revealed heterogeneity across HDs' mumps outbreak responses but also identified common challenges that will inform future Centers for Disease Control and Prevention guidance. These results were considered in the October 2017 Advisory Committee on Immunization Practices recommendation for use of a third dose of MMR vaccine for persons at increased risk for mumps during an outbreak and in the development of Centers for Disease Control and Prevention guidance for HDs when applying the Advisory Committee on Immunization Practices recommendation.

Cost of Public Health Response and Outbreak Control With a Third Dose of Measles-Mumps-Rubella Vaccine During a University Mumps Outbreak-Iowa, 2015-2016.

BACKGROUND: The United States is experiencing mumps outbreaks in settings with high 2-dose measles-mumps-rubella (MMR) vaccine coverage, mainly universities. The economic impact of mumps outbreaks on public health systems is largely unknown. During a 2015-2016 mumps outbreak at the University of Iowa, we estimated the cost of public health response that included a third dose of MMR vaccine. METHODS: Data on activities performed, personnel hours spent, MMR vaccine doses administered, miles traveled, hourly earnings, and unitary costs were collected using a customized data tool. These data were then used to calculate associated costs. RESULTS: Approximately 6300 hours of personnel time were required from state and local public health institutions and the university, including for vaccination and laboratory work. Among activities demanding time were case/contact investigation (36%), response planning/coordination (20%), and specimen testing and report preparation (13% each). A total of 4736 MMR doses were administered and 1920 miles traveled. The total cost was >$649 000, roughly equally distributed between standard outbreak control activities and third-dose MMR vaccination (55% and 45%, respectively). CONCLUSIONS: Public health response to the mumps outbreak at the University of Iowa required important amounts of personnel time and other resources. Associated costs were sizable enough to affect other public health activities.

Guidance for Assessment of Poliovirus Vaccination Status and Vaccination of Children Who Have Received Poliovirus Vaccine Outside the United States.

In 1988, the World Health Assembly resolved to eradicate poliomyelitis (polio). Since then, wild poliovirus (WPV) cases have declined by >99.9%, from an estimated 350,000 cases of polio each year to 74 cases in two countries in 2015 (1). This decrease was achieved primarily through the use of trivalent oral poliovirus vaccine (tOPV), which contains types 1, 2, and 3 live, attenuated polioviruses. Since 2000, the United States has exclusively used inactivated polio vaccine (IPV), which contains all three poliovirus types (2,3). In 2013, the World Health Organization (WHO) set a target of a polio-free world by 2018 (4). Of the three WPV types, type 2 was declared eradicated in September 2015. To remove the risk for infection with circulating type 2 vaccine-derived polioviruses (cVDPV), which can lead to paralysis similar to that caused by WPV, all OPV-using countries simultaneously switched in April 2016 from tOPV to bivalent OPV (bOPV), which contains only types 1 and 3 polioviruses (5). This report summarizes current Advisory Committee on Immunization Practices (ACIP) recommendations for poliovirus vaccination and provides CDC guidance, in the context of the switch from tOPV to bOPV, regarding assessment of vaccination status and vaccination of children who might have received poliovirus vaccine outside the United States, to ensure that children living in the United States (including immigrants and refugees) are protected against all three poliovirus types. This guidance is not new policy and does not change the recommendations of ACIP for poliovirus vaccination in the United States. Children living in the United States who might have received poliovirus vaccination outside the United States should meet ACIP recommendations for poliovirus vaccination, which require protection against all three poliovirus types by age-appropriate vaccination with IPV or tOPV. In the absence of vaccination records indicating receipt of these vaccines, only vaccination or revaccination in accordance with the age-appropriate U.S. IPV schedule is recommended. Serology to assess immunity for children with no or questionable documentation of poliovirus vaccination will no longer be an available option and therefore is no longer recommended, because of increasingly limited availability of antibody testing against type 2 poliovirus.

Varicella immunization requirements for US colleges: 2014-2015 academic year.

OBJECTIVE: To obtain information on varicella prematriculation requirements in US colleges for undergraduate students during the 2014-2015 academic year. PARTICIPANTS: Health care professionals and member schools of the American College Health Association (ACHA). METHODS: An electronic survey was sent to ACHA members regarding school characteristics and whether schools had policies in place requiring that students show proof of 2 doses of varicella vaccination for school attendance. RESULTS: Only 27% (101/370) of schools had a varicella prematriculation requirement for undergraduate students. Only 68% of schools always enforced this requirement. Private schools, 4-year schools, northeastern schools, those with <5,000 students, and schools located in a state with a 2-dose varicella vaccine mandate were significantly more likely to have a varicella prematriculation requirement. CONCLUSIONS: A small proportion of US colleges have a varicella prematriculation requirement for varicella immunity. College vaccination requirements are an important tool for controlling varicella in these settings.

Challenges with controlling varicella in prison settings: experience of California, 2010 to 2011.

This article describes the epidemiology of varicella in one state prison in California during 2010 and 2011, control measures implemented, and associated costs. Eleven varicella cases were reported, of which nine were associated with two outbreaks. One outbreak consisted of three cases and the second consisted of six cases with two generations of spread. Among exposed inmates serologically tested, 98% (643/656) were varicella-zoster virus seropositive. The outbreaks resulted in > 1,000 inmates exposed, 444 staff exposures, and > $160,000 in costs. The authors documented the challenges and costs associated with controlling and managing varicella in a prison setting. A screening policy for evidence of varicella immunity for incoming inmates and staff and vaccination of susceptible persons has the potential to mitigate the impact of future outbreaks and reduce resources necessary to manage cases and outbreaks.

Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP).

Two live, attenuated varicella zoster virus-containing vaccines are available in the United States for prevention of varicella: 1) a single-antigen varicella vaccine (VARIVAX, Merck & Co., Inc., Whitehouse Station, New Jersey), which was licensed in the United States in 1995 for use among healthy children aged > or = 12 months, adolescents, and adults; and 2) a combination measles, mumps, rubella, and varicella vaccine (ProQuad, Merck & Co., Inc., Whitehouse Station, New Jersey), which was licensed in the United States in 2005 for use among healthy children aged 12 months-12 years. Initial Advisory Committee on Immunization Practices (ACIP) recommendations for prevention of varicella issued in 1995 (CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 1996;45 [No. RR-11]) included routine vaccination of children aged 12-18 months, catch-up vaccination of susceptible children aged 19 months-12 years, and vaccination of susceptible persons who have close contact with persons at high risk for serious complications (e.g., health-care personnel and family contacts of immunocompromised persons). One dose of vaccine was recommended for children aged 12 months-12 years and 2 doses, 4-8 weeks apart, for persons aged > or = 13 years. In 1999, ACIP updated the recommendations (CDC. Prevention of varicella: updated recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 1999;48 [No. RR-6]) to include establishing child care and school entry requirements, use of the vaccine following exposure and for outbreak control, use of the vaccine for certain children infected with human immunodeficiency virus, and vaccination of adolescents and adults at high risk for exposure or transmission. In June 2005 and June 2006, ACIP adopted new recommendations regarding the use of live, attenuated varicella vaccines for prevention of varicella. This report revises, updates, and replaces the 1996 and 1999 ACIP statements for prevention of varicella. The new recommendations include 1) implementation of a routine 2-dose varicella vaccination program for children, with the first dose administered at age 12-15 months and the second dose at age 4-6 years; 2) a second dose catch-up varicella vaccination for children, adolescents, and adults who previously had received 1 dose; 3) routine vaccination of all healthy persons aged > or = 13 years without evidence of immunity; 4) prenatal assessment and postpartum vaccination; 5) expanding the use of the varicella vaccine for HIV-infected children with age-specific CD4+ T lymphocyte percentages of 15%-24% and adolescents and adults with CD4+ T lymphocyte counts > or = 200 cells/microL; and 6) establishing middle school, high school, and college entry vaccination requirements. ACIP also approved criteria for evidence of immunity to varicella.