Incidence and Estimated Vaccine Effectiveness Against Hospitalizations for All-Cause Pneumonia Among Older US Adults Who Were Vaccinated and Not Vaccinated With 13-Valent Pneumococcal Conjugate Vaccine.

Importance: Following routine use of 13-valent pneumococcal conjugate vaccine (PCV13) in children in 2010, invasive pneumococcal disease rates have decreased substantially in children and adults. In 2014, the Advisory Committee for Immunization Practices recommended routine use of PCV13 among adults aged 65 years or older; previously only 23-valent pneumococcal polysaccharide vaccine (PPV23) was recommended. Objective: To estimate the association between the incidence of hospitalized all-cause pneumonia and lower respiratory tract infections (LRTI) and PCV13 vaccination among older adults at Kaiser Permanente Northern California (KPNC). Design, Setting, and Participants: This retrospective cohort study included adults at KPNC aged 65 years or older between July 1, 2015, and June 30, 2018, born after 1936 with no known history of PPV23 or PCV13 receipt before age 65. The study took place at an integrated health care system with an annual membership more than 4 million individuals, approximately 15% of whom are 65 years or older and broadly representative of the region. Data analysis took place from July 2018 to December 2021, and data collection took place from November 2016 to June 2018. Exposures: PCV13 vaccination status was ascertained from the electronic medical record (EMR). Individuals were considered vaccinated 14 days following immunization. Main Outcomes and Measures: First hospitalized all-cause pneumonia was identified in the EMR using primary/secondary discharge diagnosis International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. First hospitalized LRTI was identified using pneumonia codes and acute bronchitis codes. Relative risk (RR) of first pneumonia or LRTI hospitalization of individuals who were PCV13 vaccinated vs PCV13 unvaccinated was estimated using Poisson regressions adjusted for sex, race, ethnicity, age, influenza vaccine receipt, PPV23 receipt since age 65, pneumonia risk factors, health care use, and season. Vaccine effectiveness (VE) was estimated as (1-RR) × 100%. Results: Of 192 061 adults, 107 957 (56%) were female and 139 024 (72%) were White individuals. PCV13 coverage increased from 0 in 2014 to 135 608 (76.9%) by 2018. There were 3488 individuals with 3766 pneumonia hospitalizations and 3846 individuals with 4173 LRTI hospitalizations. PCV13 was associated with an adjusted VE of 10.0% (95% CI, 2.4-17.0; P = .01) against hospitalized pneumonia and 9.4% (95% CI, 2.1-16.1; P = .01) against hospitalized LRTI. Conclusions and Relevance: In the context of a robust pediatric PCV13 immunization program, PCV13 vaccination of adults aged 65 years or older was associated with significant reductions in hospitalizations for all-cause pneumonia and LRTI. Vaccinating older adults with PCVs may provide broader public health benefit against pneumonia hospitalizations.

Estimating the full public health value of vaccination.

There is an enhanced focus on considering the full public health value (FPHV) of vaccination when setting priorities, making regulatory decisions and establishing implementation policy for public health activities. Historically, a therapeutic paradigm has been applied to the evaluation of prophylactic vaccines and focuses on an individual benefit-risk assessment in prospective and individually-randomized phase III trials to assess safety and efficacy against etiologically-confirmed clinical outcomes. By contrast, a public health paradigm considers the population impact and encompasses measures of community benefits against a range of outcomes. For example, measurement of the FPHV of vaccination may incorporate health inequity, social and political disruption, disruption of household integrity, school absenteeism and work loss, health care utilization, long-term/on-going disability, the development of antibiotic resistance, and a range of non-etiologically and etiologically defined clinical outcomes. Following an initial conference at the Fondation Mérieux in mid-2015, a second conference (December 2016) was held to further describe the efficacy of using the FPHV of vaccination on a variety of prophylactic vaccines. The wider scope of vaccine benefits, improvement in risk assessment, and the need for partnership and coalition building across interventions has also been discussed during the 2014 and 2016 Global Vaccine and Immunization Research Forums and the 2016 Geneva Health Forum, as well as in numerous publications including a special issue of Health Affairs in February 2016. The December 2016 expert panel concluded that while progress has been made, additional efforts will be necessary to have a more fully formulated assessment of the FPHV of vaccines included into the evidence-base for the value proposition and analysis of unmet medical need to prioritize vaccine development, vaccine licensure, implementation policies and financing decisions. The desired outcomes of these efforts to establish an alternative framework for vaccine evaluation are a more robust vaccine pipeline, improved appreciation of vaccine value and hence of its relative affordability, and greater public access and acceptance of vaccines.

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

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

Rickets and vitamin D deficiency in Alaska native children.

BACKGROUND: Rickets and vitamin D deficiency appeared to increase in Alaskan children starting in the 1990s. We evaluated the epidemiology of rickets and vitamin D deficiency in Alaska native (AN) children in 2001-2010. METHODS: We analyzed 2001-2010 visits with rickets or vitamin D deficiency diagnosis for AN and American Indian children and the general US population aged <10 years. We conducted a case-control study of AN rickets/vitamin D deficient cases and age- and region-matched controls. RESULTS: In AN children, annual rickets-associated hospitalization rate (2.23/100,000 children/year) was higher than the general US rate (1.23; 95% CI 1.08-1.39). Rickets incidence increased with latitude. Rickets/vitamin D deficiency cases were more likely to have malnutrition (OR 38.1; 95% CI 4.9-294), had similar breast-feeding prevalence, and were less likely to have received vitamin D supplementation (OR 0.23; 95% CI 0.1-0.87) than controls. CONCLUSIONS: Our findings highlight the importance of latitude, malnutrition, and lack of vitamin D supplementation as risk factors for rickets.

Afriflu2--second international workshop on influenza vaccination in the African continent--8 November 2012, Cape Town (South Africa).

The second meeting of the Afriflu conferences took place in Cape Town, South Africa, with over 60 participants from 15 countries in Africa and also outside the continent. Significant progress in surveillance has been made in better understanding the illness burden of influenza on the continent, which limited evidence suggests is greater than that in the developed world. In southern Africa HIV and TB coinfections play a major role in increasing hospitalisation and mortality, while elsewhere in Africa other cofactors still need to be determined. There is currently no indigenous vaccine production in sub-Saharan Africa and only one facility, based in South Africa, capable of filling imported bulk. Innovative vaccine strategies will need to be explored, such as maternal immunisation, and also the possibility of other influenza vaccine options, such as live attenuated influenza vaccine for young children. Sustained indigenous vaccine production is essential for the continent to have vaccine security in the event of a pandemic even though establishing local production faces considerable challenges especially ensuring adequate markets on the continent. There is an urgent need to develop effective communication messages for decision makers as well as healthcare workers addressing the importance of influenza even in the face of the major competing health burdens of the continent.

Early childhood hemoglobin level is a strong predictor of hemoglobin levels during later childhood among low-income Alaska children.

OBJECTIVES: For unknown reasons, Arctic Indigenous children have iron deficiency and anemia prevalences up to 10 times higher than national reference populations. The current study sought to identify the importance of Alaska Native status, residence and hemoglobin (Hb) level at age 10 to 23 months for predicting Hb levels at age 24 to 59 months when controlling for potential confounders. STUDY DESIGN: Retrospective cohort. METHODS: A birth certificate database was linked to a database containing hemoglobin levels determined through the U.S. Supplemental Nutrition Program for Women, Infants and Children (WIC) among Alaskan children age 10 to 59 months evaluated from 1999-2006. RESULTS: Of children with a birth certificate matched to WIC data, Alaska Native status and residence in western and northern Alaska were associated strongly with anemia at both ages. Nevertheless, of 5,796 children with Hb levels determined at both ages, the single strongest predictor of Hb level at age 24 to 59 months was Hb level at age 10 to 23 months. The community-level anemia prevalence among children age 10 to 23 months was predictive of community-level anemia prevalence among children age 24 to 59 months. CONCLUSIONS: The early onset of anemia and the strong association between earlier and later Hb levels or anemia at both the individual and community levels suggest a role for prenatal effects that remain until at least age 5 years. This is true particularly of Yupik and Inupiat children, who make up the primary residents of western and northern Alaska.

A controlled, household-randomized, open-label trial of the effect that treatment of Helicobacter pylori infection has on iron deficiency in children in rural Alaska.

BACKGROUND: Helicobacter pylori infection and iron deficiency are prevalent in disadvantaged populations worldwide. Previous small or uncontrolled studies have reported that successful treatment of H. pylori infection may resolve iron deficiency or anemia. METHODS: We screened 68% of children 7-11 years old living in 10 western Alaska villages. The 219 children with iron deficiency (serum ferritin level, <22.5 pmol/L [<10 microg/L]) and H. pylori infection (diagnosed on the basis of (13)C-labeled urea breath tests) were enrolled in a household-randomized, unblinded trial. All children received iron supplementation for 6 weeks; children in the intervention group also received a 2-week course of treatment for H. pylori infection plus another 2-week course of treatment if the infection had not resolved at 2 months after treatment initiation. RESULTS: At 2 months after treatment initiation, 32% of children in the intervention group and 39% of children in the control group had iron deficiency. At 14 months after treatment initiation, 65% of children in the intervention group and 72% of children in the control group had iron deficiency (adjusted relative risk [ARR], 0.90 [95% confidence interval [CI], 0.74-1.1]); in addition, 22% of children in the intervention group and 14% of children in the control group had anemia (ARR, 1.6 [95% CI, 0.86-2.9]). Results were similar when children were compared by H. pylori infection status. CONCLUSIONS: In a high-prevalence population, treatment and resolution of H. pylori infection did not improve isolated iron deficiency or mild anemia up to 14 months after treatment initiation.

25-hydroxyvitamin D levels among healthy children in Alaska.

OBJECTIVE: To determine vitamin D levels among children 6 to 23 months old receiving services from Women, Infants, and Children (WIC) programs in Alaska. Study design During 2001 and 2002, we recruited 133 children receiving services at seven WIC clinics, administered a risk factor questionnaire, and collected blood. RESULTS: Fifteen (11%) and 26 (20%) children, respectively, had vitamin D levels <15 (considered abnormal) and 15 to <25 ng/mL (low normal). Compared with other children, children who still breast-fed were more likely to have a vitamin D level <15 ng/mL (relative risk [RR], 12; 95% confidence interval [CI], 3.6-39) or 15 to <25 ng/mL (RR, 3.6; 95% CI, 1.9-6.8) than > or =25 ng/mL. Among 41 still breast-feeding children, 14 (34%) took supplemental vitamins, and six (18%) were reported to have received vitamins every day. CONCLUSIONS: Vitamin D deficiency is prevalent in Alaska. Breast-feeding in the absence of adequate vitamin D supplementation is the greatest risk factor.