Estimating averted illnesses from influenza vaccination for children and pregnant women - El Salvador, Panama, and Peru, 2011-2018.

BACKGROUND: Estimating the burden of disease averted by vaccination can assist policymakers to implement, adjust, and communicate the value of vaccination programs. Demonstrating the use of a newly available modeling tool, we estimated the burden of influenza illnesses averted by seasonal influenza vaccination in El Salvador, Panama, and Peru during 2011-2017 among two influenza vaccine target populations: children aged 6-23 months and pregnant women. METHODS: We derived model inputs, including incidence, vaccine coverage, vaccine effectiveness, and multipliers from publicly available country-level influenza surveillance data and cohort studies. We also estimated changes in illnesses averted when countries' vaccine coverage was achieved using four different vaccine deployment strategies. RESULTS: Among children aged 6-23 months, influenza vaccination averted an estimated cumulative 2,161 hospitalizations, 81,907 medically-attended illnesses, and 126,987 overall illnesses during the study period, with a prevented fraction ranging from 0.3 % to 12.5 %. Among pregnant women, influenza vaccination averted an estimated cumulative 173 hospitalizations, 6,122 medically attended illnesses, and 16,412 overall illnesses, with a prevented fraction ranging from 0.2 % to 10.9 %. Compared to an influenza vaccine campaign with equal vaccine distribution during March-June, scenarios in which total cumulative coverage was achieved in March and April consistently resulted in the greatest increase in averted illness (23 %-3,129 % increase among young children and 22 %-3,260 % increase among pregnant women). DISCUSSION: Influenza vaccination campaigns in El Salvador, Panama, and Peru conducted between 2011 and 2018 prevented hundreds to thousands of influenza-associated hospitalizations and illnesses in young children and pregnant women. Existing vaccination programs could prevent additional illnesses, using the same number of vaccines, by achieving the highest possible coverage within the first two months of an influenza vaccine campaign.

Global Seasonal Influenza Mortality Estimates: A Comparison of 3 Different Approaches.

Prior to updating global influenza-associated mortality estimates, the World Health Organization convened a consultation in July 2017 to understand differences in methodology and implications for results of 3 influenza mortality projects from the US Centers for Disease Control and Prevention (CDC), the Netherlands Institute for Health Service Research's Global Pandemic Mortality Project II (GLaMOR), and the Institute for Health Metrics and Evaluation (IHME). The expert panel reviewed estimates and discussed differences in data sources, analysis, and modeling assumptions. We performed a comparison analysis of the estimates. Influenza-associated respiratory death counts were comparable between CDC and GLaMOR; the IHME estimate was considerably lower. The greatest country-specific influenza-associated fold differences in mortality rate between CDC and IHME estimates and between GLaMOR and IHME estimates were among countries in Southeast Asia and the Eastern Mediterranean region. The data envelope used for the calculation was one of the major differences (CDC and GLaMOR: all respiratory deaths; IHME: lower-respiratory infection deaths). With the assumption that there is only one cause of death for each death, IHME estimates a fraction of the full influenza-associated respiratory mortality that is measured by the other 2 groups. Wide variability of parameters was observed. Continued coordination between groups could assist with better understanding of methodological differences and new approaches to estimating influenza deaths globally.

Variability in published rates of influenza-associated hospitalizations: A systematic review, 2007-2018.

BACKGROUND: Influenza burden estimates help provide evidence to support influenza prevention and control programs at local and international levels. METHODS: Through a systematic review, we aimed to identify all published articles estimating rates of influenza-associated hospitalizations, describe methods and data sources used, and identify regions of the world where estimates are still lacking. We evaluated study heterogeneity to determine if we could pool published rates to generate global estimates of influenza-associated hospitalization. RESULTS: We identified 98 published articles estimating influenza-associated hospitalization rates from 2007-2018. Most articles (65%) identified were from high-income countries, with 34 of those (53%) presenting estimates from the United States. While we identified fewer publications (18%) from low- and lower-middle-income countries, 50% of those were published from 2015-2018, suggesting an increase in publications from lower-income countries in recent years. Eighty percent (n = 78) used a multiplier approach. Regression modelling techniques were only used with data from upper-middle or high-income countries where hospital administrative data was available. We identified variability in the methods, case definitions, and data sources used, including 91 different age groups and 11 different categories of case definitions. Due to the high observed heterogeneity across articles (I2 >99%), we were unable to pool published estimates. CONCLUSIONS: The variety of methods, data sources, and case definitions adapted locally suggests that the current literature cannot be synthesized to generate global estimates of influenza-associated hospitalization burden.

Progress and Remaining Gaps in Estimating the Global Disease Burden of Influenza.

Influenza has long been a global public health priority because of the threat of another global pandemic. Although data are available for the annual burden of seasonal influenza in many developed countries, fewer disease burden data are available for low-income and tropical countries. In recent years, however, the surveillance systems created as part of national pandemic preparedness efforts have produced substantial data on the epidemiology and impact of influenza in countries where data were sparse. These data are leading to greater interest in seasonal influenza, including implementation of vaccination programs. However, a lack of quality data on severe influenza, nonrespiratory outcomes, and high-risk groups, as well as a need for better mathematical models and economic evaluations, are some of the major gaps that remain. These gaps are the focus of multilateral research and surveillance efforts that will strengthen global efforts in influenza control in the future.

Impact of Pneumococcal Conjugate Universal Routine Vaccination on Pneumococcal Disease in Italian Children.

In Italy, the effectiveness of pneumococcal universal vaccination in preventing vaccine-type invasive pneumococcal disease (IPD) in the PCV7/PCV13 shifting period was estimated to be 84.3% (95% CI: 84.0-84.6%) in children <5 years. This study aims at corroborating the estimation of both the effectiveness (VE) of PCVs and its impact in reducing pneumococcal diseases. A 1:3 matched-case-control study was conducted among children <5 years old hospitalized for IPD or pneumococcal pneumonia (PP) between 2006 and 2012 in the Puglia region. Moreover, hospitalizations for pneumococcal outcomes in the pre- and postvaccination period and the hospitalization risk ratios (HRRs) with 95% CIs were computed in Italy and in the first eight regions that introduced PCVs in 2006. The overall effectiveness of PCVs was 75% (95% CI: 61%-84%); it was 69% (95% CI: 30%-88%) against IPD and 77% (95% CI: 61%-87%) against PP. PCVs showed a significant impact on IPD and acute otitis media either at a national level or in those regions with a longer vaccination history, with a nearly 40% reduction of hospitalizations for both outcomes. Our findings provide further evidence of the effectiveness of PCVs against pneumococcal diseases and its impact on nasopharyngeal carriage in children <5 years, indicating the importance of maintaining high immunization coverage.

Estimation of the Impact of Meningococcal Serogroup C Universal Vaccination in Italy and Suggestions for the Multicomponent Serogroup B Vaccine Introduction.

In Italy, the meningococcal C conjugate vaccine (MenC) has been offered in most regions since 2009-2010. The incidence of Invasive Meningococcal Disease (IMD) was 0.25 confirmed cases per 100,000 in 2011, but this may be considerably underestimated due to underdetection and underreporting. This study estimates the impact of the MenC universal vaccination (URV) in the Puglia region by assessing the completeness of three registration sources (notifications, hospitalizations, and laboratory surveillance). Capture-recapture analysis was performed on meningococcal meningitis collected within 2001-2013. The impact of URV among ≤ 18-year-olds was assessed by attributable benefit, preventable fraction, and prevented fraction. Missed opportunities for vaccination were evaluated from surveillance of IMD. The proportion of detected serogroups was applied to the number of IMD in the postvaccination period to compute the cases still preventable. The sensitivity of the three sources was 36.7% (95% CI: 17.5%-57.9%) and registrations lost nearly 28 cases/year in the period. Attributable benefit of URV was -0.5 cases per 100,000, preventable fraction 19.6%, and prevented fraction 31.3%. Three adolescent cases missed the opportunity to be vaccinated. The multicomponent serogroup B meningococcal vaccine has the potential to further prevent at least three other cases/year. Vaccination strategy against serogroup B together with existing programmes makes IMD a 100% vaccine-preventable disease.

Promotion of influenza vaccination among health care workers: findings from a tertiary care children's hospital in Italy.

BACKGROUND: The aims of this study were: a) to evaluate attitudes and practices of health care workers (HCWs) towards influenza vaccination and their opinion regarding a vaccination promotion toolkit; b) to estimate hospital HCWs' influenza vaccination coverage rates (VC). METHODS: The Bambino Gesù Children's Hospital (OPBG) is an academic hospital in Italy. Since 2009, free influenza vaccination is offered to HCWs during working hours. In October-December 2013, a communication campaign based on a standardized toolkit was conducted. In December 2013, we performed a cross-sectional survey in a sample of hospital wards, based on a self-administered questionnaire including participants' characteristics; self-reported influenza vaccination history; reasons for vaccination or missed vaccination; opinion regarding the toolkit. Multivariable logistic analysis was used to assess independent predictors of influenza vaccination status. Annual VC for years 2009-2013 was estimated by using the number of seasonal influenza vaccine doses administered to HCWs as numerator, and the number of hospital HCWs as denominator. RESULTS: Out of 191 HCWs who participated in the survey, 35.6% reported at least one influenza vaccination during their life; 6.8% adhered to annual revaccination. Years of service and professional category were significantly and independently associated with vaccination (adjusted-OR: 2.4 for > 10 years of service, compared to < 5 years of service; adjusted-OR: 2.6 for physicians compared to nurses). Patient protection was the main reported reason for vaccination (34.3%); considering influenza a mild disease was the main reason for non-vaccination (36.9%); poor vaccine effectiveness was the main reason for missed annual revaccination (28.8%). Overall, 75% of respondents saw at least one promotion tool; 65.6% of them found the information useful. Hospital VC decreased from 30% in 2009, to 5% in 2012. In 2013, VC was 14%. CONCLUSIONS: Satisfactory influenza VC in HCWs is hard to achieve. In 2013, along with the toolkit implementation, we observed an increase in HCWs' vaccination coverage, nevertheless, it remained unsatisfactory. Tailored information strategies targeting nurses and recently employed HCWs should be implemented. Institution of declination statements, adding influenza vaccination to financial incentive systems, or vaccination requirements should also be considered to increase influenza VC among HCWs.

Low vaccination coverage among italian healthcare workers in 2013.

Vaccination of healthcare workers (HCWs) reduces the risk of occupational infections, prevents nosocomial transmission and maintains healthcare delivery during outbreaks. Despite the European directive and national legislation on workers' protection, immunization coverage among HCWs has often been very low. In light of Italian National Vaccination Plan 2012-2014 recommendations, the aim of this study was to assess levels of immunization and factors influencing adherence to vaccinations needed for HCWs in Puglia region, South Italy. The study was conducted using an interview-based standardized anonymous questionnaire administered to hospital employees in the period November 2009-March 2011. A total of 2198 health professionals responded in 51/69 Apulian hospitals (median age: 45 years; 65.2% nurses, 22.6% doctors and 12.2% other hospital personnel). Vaccination coverage was 24.8% for influenza, 70.1% for hepatitis B, 9.7% for MMR, 3.6% for varicella, and 15.5% for Td booster. Receiving counselling from occupational health physicians (OHPs) was associated with influenza (OR = 1.8; 95%CI = 1.5-2.2; P < 0.001), hepatitis B (OR = 4.9; 95%CI = 3.9-6.3; P < 0.001), varicella (OR = 43.7; 95%CI = 18.9-101.7; P < 0.001), MMR (OR = 8.8; 95%CI = 4.1-18.6; P < 0.001) and tetanus (OR = 50.5; 95%CI = 30.1-88.3; P < 0.001) vaccine uptake.   OHPs should be trained with standard guidelines specific for healthcare settings and HCWs' risk groups to facilitate their crucial role in improving vaccine coverage among HCWs and increase awareness on the duty to protect both employees and patients.

Are we ready to abrogate compulsory vaccinations for children?

In Italy, vaccination against diphtheria, tetanus, polio and hepatitis B is compulsory for infants countrywide, except in Veneto region where since 2007 Health Authorities have experimented the suspension of mandatory vaccination. In light of the recent discussion on the potential abrogation in other regions, we explored the opinion of family pediatricians who play a crucial role in promoting immunization programmes in Italy. In November 2009, we interviewed by phone the family pediatricians working in Puglia region using a standardised, ad hoc and piloted questionnaire. Of the 596 contacted, 502 (84.2%) completed the questionnaire (54% female, median age = 52 y). Among the respondents, 72 (14.3%) would agree on the hypothesis of abrogation. This judgment was associated with having a good opinion on the level of awareness of the importance of vaccinations in the general public (OR = 6.6; 95% CI: 3.6-12.1) and having the perception of adequate organization of Vaccination Services in supporting the abrogation (OR = 3.6; 95% CI: 1.7-5.9). Family pediatricians appeared really sceptical about the abrogation of compulsory vaccination that could be hypothesized only increasing public awareness, communication skills and capability of Vaccination Services personnel in offering vaccinations.

Effectiveness of vaccination against varicella in children under 5 years in Puglia, Italy 2006-2012.

In Italy, between 2003 and 2010, 8/21 Regions recommended varicella routine vaccination (URV). The National Immunization Plan (PNPV) 2012-2014 scheduled the introduction of URV nationwide in 2015, following the results achieved by the eight Regions.   Puglia adopted varicella URV in 2006. This study describes epidemiology and costs of varicella in Puglia between 2003 and 2012. One-dose Vaccine Effectiveness (VE) against varicella of any severity and severe hospitalized cases in children was also evaluated. Vaccination coverage (VC) was estimated from the regional immunization registry. Incidence and hospitalization rates were calculated from computerised surveillance system for communicable diseases and hospital discharge registry (ICD9-CM codes: 052.x), respectively. URV impact was assessed by Incidence Rate Ratios (IIRs) and Hospitalization Risk Ratios (HRRs). Hospitalization costs were also evaluated. VE was estimated using the screening method, where PPV was VC in children aged <72 months and PCV was the proportion of cases vaccinated among notified or hospitalized cases, respectively. One-dose VC in children aged ≤ 24 months increased from 49% in the birth cohort 2006 to 91.1% in the cohort 2010; 2-dose VC was 64.8% and 28.8% in the 2005 and 1997 cohort, respectively. Comparing pre and post-vaccination era, incidence declined from 122.5 ×100 000 in 2003-2005 to 13.7 in 2009-2012 (IRR = 0.11, 95% CI = 0.10-0.12), hospitalization rate from 3.9 ×100 000 to 1.1 (HRR = 0.29, 95% CI = 0.21-0.4), hospitalization costs from 319 000 Euros/year to 106 000. One-dose VE against varicella of any severity and severe hospitalized disease was 98.8% and 99%, respectively. Our findings strongly support varicella URV introduction into the Italian Essential Health Interventions, as scheduled by 2015.

Further efforts in the achievement of congenital rubella syndrome/rubella elimination.

The Italian National Plan of Measles and Rubella Elimination 2010-2015 has deferred the objective to reduce congenital rubella syndrome (CRS) to <1 case per 100 000 live births to 2015 and has highlighted the need to reduce to <5% susceptibility to rubella among women in childbearing-age. In Puglia region, MMR vaccine coverage is 93% in newborns (cohort 2010; one dose), 85% in children 5-6 years old and 77% in adolescents (cohort 2005 and 1997, respectively; two doses). Combining available seroepidemiological data and results of a survey on the attitude towards rubella vaccination and rubella testing before pregnancy, we could estimate that 5.7% of Apulian women in childbearing-age are currently susceptible to rubella infection. The regional infectious disease routine notification system reported no cases of CRS and rubella in pregnancy in 2001-2010 period. The inconsistency among the mentioned data triggered the evaluation of the reliability of disease reporting. We performed a retrospective case-finding for the years 2003-2011. We scanned the regional hospital discharge registry to identify hospitalizations for rubella in pregnancy and CRS and retrieve individual records. We also searched for clinical history of CRS mothers in the delivery assistance certificate registry. We identified one CRS, two confirmed and four suspected congenital infections, and seven cases of rubella in pregnancy. Passive surveillance of CRS and rubella in pregnancy appears not to be reliable in the light of strengthening rubella elimination strategies.

Italian family paediatricians' approach and management of celiac disease: a cross-sectional study in Puglia Region, 2012.

BACKGROUND: Celiac disease (CD) is a chronic autoimmune illness of the small intestine triggered by gluten consumption in genetically predisposed individuals. CD presentation is not limited to the gastrointestinal tract and it is still under-diagnosed. Complete resolution of clinical manifestations follows if a gluten-free diet is adopted. In western countries, CD prevalence is approximately 1%. Age of onset is often between 6 months and 7 years.We assessed the approach to diagnosis and management of celiac patients by the paediatricians in Puglia Region, Italy. METHODS: We conducted a cross-sectional survey among the 589 Apulian Family Paediatricians (FPs) during January 2011-January 2012 using a self-administered web-based standardized questionnaire including self-assessment of their knowledge, diagnostic path and type of management they would follow for CD, clinical information on their celiac patients. We assessed associations among the explored variables by defining double-entry contingency tables and calculating Odds Ratio (OR) with 95% Confidence Intervals (CIs). RESULTS: The 218 (37%) FPs participating in the study reported 1,020 CD patients (representing approximately 1% of the child population covered by the enrolled FPs). Of them, 55% were female; 45% were aged 5-10 years. Weight loss and stunting were the main reported symptoms at diagnosis (41%). The majority (98%) of FPs requested anti-transglutaminase antibody (tTG-Ab) titres for CD diagnosis. Approximately 78% of FPs recommended gluten introduction in the diet of infants at the age of 6 months; 12% and 8% recommended introduction of gluten before and after 6 months of age respectively.The degree of knowledge for either CD diagnosis making process or CD related diseases was medium/high in 97% and 82% of the participating FPs respectively. FPs (83%) who had a medium or high degree of knowledge of CD patients' diet were more likely to experience low or no difficulty in providing their patients with dietary advices (OR:5.5; 95%CI:1.7-17.5). CONCLUSIONS: Apulian FPs report a good degree of knowledge of CD, its diagnosis and its management. We will diffuse results and recommendations to all paediatricians in the Region. Actions aiming to continued education on CD in medical under and postgraduate trainings are crucial to prevent under-diagnosis.

Towards the 13-valent pneumococcal conjugate universal vaccination: effectiveness in the transition era between PCV7 and PCV13 in Italy, 2010-2013.

Pneumococcal disease epidemiology has changed after introduction of pneumococcal conjugate vaccines. Seven-valent vaccine (PCV7) has been effective in reducing invasive pneumococcal disease (IPD). In Europe, PCV13 effectiveness was estimated at 78% (95% CI: -18-96%) for 2-priming doses. In Italy, PCV7 was introduced in 2006 in the childhood immunization schedule and replaced with PCV13 in 2010. In Apulia, vaccination coverage has reached 95.1% (birth-cohort 2010). We estimated PCV program effectiveness and its impact on S. pneumoniae diseases. PCV EFFECTIVENESS: We used the screening method. We calculated the Proportion of Population Vaccinated from immunization registries and detected cases through a laboratory-confirmed surveillance among hospitalized children≤60 months. A confirmed IPD case was a child with PCR positive for S. pneumoniae. Differences among children were assessed with the Chi-square or the Fisher exact test (P value<0.05). PCV IMPACT: We constructed time series using outcome-specific Poisson regression models: hospitalization rate in pre-PCV era and hospitalization risk ratios (RRs) with 95% CIs for both PCV7 and PCV7/PCV13 shifting era. We calculated hospitalization RR with 95% CIs comparing pre-PCV years with vaccination period. The PCV effectiveness was 84.3% (95% CI: 84.0-84.6%). In May 2010-January 2013, we enrolled 159 suspected IPD of whom 4 were confirmed. Two (fully vaccinated) were caused by serotype 9V, 1 (not vaccinated) by serotype 3, 1 (vaccinated with 2 PCV13 doses) by 15B/C. The most important reduction was for pneumococcal pneumonia (RR: 0.43, 95% CI: 0.21-0.90). The PCV program show promising results in terms of both PCV13 effectiveness and its impact in reducing IPD in children<5 years.

[Attitude and compliance towards influenza vaccination among health care workersin two Italian hospitals after a vaccination promotion campaign]. / Atteggiamento degli operatori sanitari di due ospedali italiani nell'ambito di una campagna di promozione della vaccinazione antinfluenzale.

In the season 2013-2014, a campaign to promote influenza vaccination among health care workers (HCWs) was conducted in two Italian hospitals, based on an educational toolkit and attitude and compliance towards vaccination were investigated. Overall, 36% of the HCWs get vaccinated almost once, 2.3% in 2013-14 season for the first time, 57% never, 7% do not know or not remember. The main reason for vaccination was reportedly to avoid taking sick-leave (29.7%); while refusal was guided by the low risk-perception associated with influenza (38.5%). Interventions based only on education and communication seem not to be sufficient; an integrated approach with multiple components is needed to achieve higher coverage rates and to ensure a successful vaccination campaign.

Lessons learnt from a birthday party: a Bacillus cereus outbreak, Bari, Italy, January 2012.

INTRODUCTION: Bacillus cereus, a ubiquitous bacterium, can be isolated in various starchy food items, causing both emetic and diarrhoeal disease. The real burden of B. cereus outbreaks is actually poorly known in Italy. We report a B. cereus foodborne outbreak that occurred in a pub in Bari (Italy) on January 22nd 2012 during a birthday party, promptly reported by the pub owner. MATERIALS AND METHODS: Between January 22nd and 24th 2012, we performed a retrospective cohort study among the guests of the party to identify risk factors associated with illness. Leftovers of different meals were available for microbiological analysis. Faecal specimens were collected from cases. RESULTS: A total of 12 cases among the 13 customers (attack rate: 92%) were reported. All cases had consumed basmati rice and sweet and sour vegetables (aetiological fraction: 100%). B. cereus was isolated from both basmati rice served during the party and faecal specimens. DISCUSSION: The close collaboration between the pub owner and the public health officers and the possibility to test food leftovers and stool samples contributed to prevent further cases.