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Ali M, Clemens J. Assessing Vaccine Herd Protection by Killed Whole-Cell Oral Cholera Vaccines Using Different Study Designs. Front Public Health 2019; 7:211. [PMID: 31417890 PMCID: PMC6685418 DOI: 10.3389/fpubh.2019.00211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 07/16/2019] [Indexed: 11/25/2022] Open
Abstract
The population level effectiveness of a vaccine may arise as the result of direct protection of vaccinees and vaccine herd protection, which may protect non-vaccinees, vaccinees, or both. Indirect, total, enhanced, and overall vaccine protection are measures of vaccine herd protection. The level of population level effectiveness induced by a vaccine is driven by several factors, including known vaccine-induced protective efficacy, the magnitude, and distribution of vaccine coverage at a point in time and the extent to which different groups mix with one another in the community. Data on vaccine herd protection are valuable in understanding the importance and cost-effectiveness in deploying the e vaccine in public health program. Killed whole-cell (WC) oral cholera vaccines (OCVs) have been evaluated for herd protection in various study settings, leveraging geographic information system (GIS) tools for the analyses. This article provides a brief description of the herd protective effects of killed WC OCVs measured using various study deigns that include (a) individually randomized, controlled clinical trials, (b) cluster randomized clinical trials, (c) observational cohort studies, and (d) observational case-control studies. In all of the study designs, significant herd protection was observed in unvaccinated persons as well as in the community as a whole. The findings of these studies suggest that using killed WC OCV as a public health tool for controlling cholera is impactful and cost-effective.
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Affiliation(s)
- Mohammad Ali
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - John Clemens
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
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Baldo V, Cocchio S, Baldovin T, Buja A, Furlan P, Bertoncello C, Russo F, Saia M. A population-based study on the impact of hospitalization for pneumonia in different age groups. BMC Infect Dis 2014; 14:485. [PMID: 25192701 PMCID: PMC4164793 DOI: 10.1186/1471-2334-14-485] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 09/03/2014] [Indexed: 01/08/2023] Open
Abstract
Background Pneumonia is an important cause of illness and death, particularly in elderly adults. This retrospective study was conducted to estimate the trend of hospitalization for pneumonia in the Veneto from the records of all hospitals in the region (serving a population of 4.81 million) during the years 2004 through 2012. Methods The cases of pneumonia identified in the hospital discharge records were all cases in which the first-listed diagnosis was pneumonia, or meningitis, septicemia or empyema associated with pneumonia. The annual total and age-specific hospitalization rates and trends were calculated and correlated with vaccine coverage. Total related costs were also calculated. Results There were 110,927 hospitalizations for pneumonia, meaning an annual rate of 256.3/100,000 population, with peaks in children and elderly people. The overall pneumonia-related hospitalization rate did not change significantly during the study period (AAPC: 1.3% [95% CI: −0.5, 3.1]). The rate dropped significantly among the 0- to 4-year-olds, however, from 617.3/100,000 in 2004 to 451.8/100,000 in 2012 (AAPC: −2.5% [95% CI: −4.5; −0.5]), while it increased slightly in adults aged 80+ (AAPC: 1.2% [95% CI: −0.9; 3.4]). The overall pneumonia-related mortality rate was 10.7%. The estimated cost per hospitalized patient was €3,090. Conclusion This study shows that hospitalization for pneumonia has a considerable impact on the health services, especially for children and the elderly. No decline in hospitalization rates was seen for the very elderly after the introduction of pneumococcal conjugate vaccination for children. Electronic supplementary material The online version of this article (doi:10.1186/1471-2334-14-485) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vincenzo Baldo
- Department of Molecular Medicine, Public Health Section, University of Padua, Istituto di Igiene, Via Loredan 18, 35130 Padova, Italy.
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Keck PC, Ynalvez MA, Gonzalez HF, Castillo KD. School-located influenza vaccination and absenteeism among elementary school students in a Hispanic community. J Sch Nurs 2013; 29:271-83. [PMID: 23598571 DOI: 10.1177/1059840513486008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Seasonal influenza is recognized as a significant health burden to children and is a cause of excess school absenteeism in children. In 2008, the Advisory Committee on Immunization Practices recommended annual influenza vaccination for all children 6 months to 18 years of age. School nurses influence participation in this recommendation by conducting school-located influenza vaccination (SLIV) programs at their campuses. Knowing the effect of SLIV programs on student absenteeism may motivate school nurses and district administrators to conduct such vaccination programs. This study examines the impact of an SLIV program on elementary school absenteeism in an inner city school district with a predominantly Hispanic population. Using Poisson regression models with robust standard errors, we analyzed data from 3,775 records obtained by stratified random sampling. Results of the study indicate that students vaccinated through an SLIV program have fewer absences than unvaccinated students. A surprising result of the study shows that students vaccinated through an SLIV program had fewer absences than students vaccinated elsewhere. These results are of particular importance to school nurses who work with large Hispanic populations. Our study illustrates one way that a school nurse can assess the effect of an SLIV program on absenteeism.
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Abstract
The term "herd immunity" is widely used but carries a variety of meanings. Some authors use it to describe the proportion immune among individuals in a population. Others use it with reference to a particular threshold proportion of immune individuals that should lead to a decline in incidence of infection. Still others use it to refer to a pattern of immunity that should protect a population from invasion of a new infection. A common implication of the term is that the risk of infection among susceptible individuals in a population is reduced by the presence and proximity of immune individuals (this is sometimes referred to as "indirect protection" or a "herd effect"). We provide brief historical, epidemiologic, theoretical, and pragmatic public health perspectives on this concept.
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Affiliation(s)
- Paul Fine
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Nelson EJ, Harris JB, Morris JG, Calderwood SB, Camilli A. Cholera transmission: the host, pathogen and bacteriophage dynamic. Nat Rev Microbiol 2009; 7:693-702. [PMID: 19756008 PMCID: PMC3842031 DOI: 10.1038/nrmicro2204] [Citation(s) in RCA: 343] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Zimbabwe offers the most recent example of the tragedy that befalls a country and its people when cholera strikes. The 2008-2009 outbreak rapidly spread across every province and brought rates of mortality similar to those witnessed as a consequence of cholera infections a hundred years ago. In this Review we highlight the advances that will help to unravel how interactions between the host, the bacterial pathogen and the lytic bacteriophage might propel and quench cholera outbreaks in endemic settings and in emergent epidemic regions such as Zimbabwe.
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Affiliation(s)
- Eric J Nelson
- Howard Hughes Medical Institute, Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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Barlow JW, White LJ, Zadoks RN, Schukken YH. A mathematical model demonstrating indirect and overall effects of lactation therapy targeting subclinical mastitis in dairy herds. Prev Vet Med 2009; 90:31-42. [DOI: 10.1016/j.prevetmed.2009.03.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 03/29/2009] [Accepted: 03/31/2009] [Indexed: 11/27/2022]
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Charvat B, Brookmeyer R, Herson J. The Effects of Herd Immunity on the Power of Vaccine Trials. Stat Biopharm Res 2009. [DOI: 10.1198/sbr.2009.0011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
A fundamental assumption usually made in causal inference is that of no interference between individuals (or units); that is, the potential outcomes of one individual are assumed to be unaffected by the treatment assignment of other individuals. However, in many settings, this assumption obviously does not hold. For example, in the dependent happenings of infectious diseases, whether one person becomes infected depends on who else in the population is vaccinated. In this article, we consider a population of groups of individuals where interference is possible between individuals within the same group. We propose estimands for direct, indirect, total, and overall causal effects of treatment strategies in this setting. Relations among the estimands are established; for example, the total causal effect is shown to equal the sum of direct and indirect causal effects. Using an experimental design with a two-stage randomization procedure (first at the group level, then at the individual level within groups), unbiased estimators of the proposed estimands are presented. Variances of the estimators are also developed. The methodology is illustrated in two different settings where interference is likely: assessing causal effects of housing vouchers and of vaccines.
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Affiliation(s)
- Michael G. Hudgens
- Michael G. Hudgens is Research Associate Professor, Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27599 (E-mail: ). M. Elizabeth Halloran is Professor, Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, and Department of Biostatistics, University of Washington, Seattle, WA 98185 (E-mail: )
| | - M. Elizabeth Halloran
- Michael G. Hudgens is Research Associate Professor, Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27599 (E-mail: ). M. Elizabeth Halloran is Professor, Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, and Department of Biostatistics, University of Washington, Seattle, WA 98185 (E-mail: )
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Fine PE, Mulholland K. Community immunity. Vaccines (Basel) 2008. [DOI: 10.1016/b978-1-4160-3611-1.50075-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Vaccine Protection of Bangladeshi infants and young children against cholera: implications for vaccine deployment and person-to-person transmission. Pediatr Infect Dis J 2008; 27:33-7. [PMID: 18162935 DOI: 10.1097/inf.0b013e318149dffd] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Killed oral cholera vaccines are internationally licensed for older children and adults, but not for infants and young children. We investigated whether mass immunization of older children and adults can confer herd protection to children too young to be vaccinated. METHODS We analyzed the first year of surveillance of an individually randomized, placebo-controlled trial of killed oral cholera vaccines in 89,596 older Bangladeshi children and adult women. Vaccine herd protection of children less than 2 years of age, who were too young to participate in the trial, was evaluated by determining whether the incidence of cholera during the first year of follow-up of this age group was lower in residential clusters with higher levels of vaccine coverage than in clusters with lower levels of vaccine coverage. RESULTS Vaccine coverage of the targeted population ranged from 4% to 65% in different clusters. The incidence (cases per 1000) of cholera among children less than 2 years of age ranged from 18.9 in clusters in the lowest quintile of vaccine coverage to 8.6 in clusters in the highest quintile (P = 0.004 for the inverse association between vaccine coverage and risk of cholera) Vaccine coverage of adult women (relative risk of cholera = 0.95 for each percent increase in vaccine coverage; 95% confidence interval: 0.92-0.99; P < 0.01), but not of older children, was independently associated with a lower risk of cholera in children less than 2 years of age. CONCLUSIONS Vaccination of older age groups was associated with protection of children too young to be vaccinated. The pronounced herd protection of young children associated with vaccination of adult women suggests that adult women may play a prominent role in the transmission of cholera to young children in this setting.
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Abstract
BACKGROUND We describe important findings in theoretical epidemiology related to mass vaccination, including herd immunity and vaccine efficacy measures. POINTS Through a review of recent publications, we address the following questions: is there optimal vaccine coverage? Is it possible to achieve optimal coverage through individual choice? What are the consequences of a suboptimal vaccination? What is vaccine efficacy and how is it measured? PERSPECTIVES These results define a framework for analysing how successful mass vaccination may be from a public health perspective.
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Affiliation(s)
- P-Y Boëlle
- Inserm, UMR S 707, Faculté de Médecine Saint-Antoine, 27, rue Chaligny, 75571 Paris cedex 12, France.
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Becker N, Lefèvre C, Utev S. Estimating protective vaccine efficacy from large trials with recruitment. J Stat Plan Inference 2007. [DOI: 10.1016/j.jspi.2006.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lin X, Koopman JS, Chick SE. Mathematical model comparisons of potential non-typeable Haemophilus influenzae vaccine effects. J Theor Biol 2007; 245:66-76. [PMID: 17098258 PMCID: PMC1852514 DOI: 10.1016/j.jtbi.2006.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Revised: 09/28/2006] [Accepted: 09/28/2006] [Indexed: 11/22/2022]
Abstract
Vaccines to prevent acute otitis media (AOM) caused by non-typeable Haemophilus influenzae (NTHi) are under development. Because NTHi is highly variable and colonization rates are high, special vaccine characteristics and trial designs might be needed. We examined in mathematical models the equilibrium NTHi-caused AOM rate given hypothetical vaccines that generated immunity identical to corresponding maximal naturally acquired immunity. Vaccines were examined with single effects and combinations of immunity affecting (1) AOM rates given colonization (pathogenicity), (2) susceptibility to colonization, and (3) contagiousness given colonization. Percent reductions in AOM across all preschool children were (1) 34%, (2) 31%, (3) 9%, (1 and 2) 57%, (2 and 3) 50%, and (1, 2, and 3) 75%. Effects on children in daycare vs. not in daycare were (1) 18 vs. 48%, (2) -1 vs. 57%, (3) 13 vs. 5%, (1 and 2) 30 vs. 79%, (2 and 3) 33 vs. 60%, and (1, 2, and 3) 64 vs. 85%. Pure pathogenicity effects (1 alone) will need to be supplemented by transmission effects. The effects of susceptibility (2 alone) are diminished or negative because children protected against colonization have lower levels of immunity to (1) and (3) than unvaccinated children. For trials to predict population effects, both colonization and AOM outcomes must be studied and all three effects must be evaluated. This need arises because, unlike H. influenzae type B, high NTHi exposure diminishes cumulative vaccine effects and high colonization rates generate rapid accumulation of natural immunity that alters the indirect effects of vaccine immunity on transmission differently by age and daycare status.
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Affiliation(s)
- Ximin Lin
- Department of Epidemiology, the University of Michigan, 109 Observatory Street, Ann Arbor, Michigan, 48109, USA (X. Lin: ; J.S. Koopman: )
- * Corresponding author: 2200 Hedgerow Road Unit A, Columbus, OH 43220, USA, , Phone: 1-614-218-3823, FAX: 1-734-764-3192
| | - James S. Koopman
- Department of Epidemiology, the University of Michigan, 109 Observatory Street, Ann Arbor, Michigan, 48109, USA (X. Lin: ; J.S. Koopman: )
| | - Stephen E. Chick
- Technology and Operations Management, INSEAD, Boulevard de Constance, 77305 Fontainebleau Cedex, FRANCE ()
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Yang Y, Longini IM, Halloran ME. Design and Evaluation of Prophylactic Interventions Using Infectious Disease Incidence Data from Close Contact Groups. J R Stat Soc Ser C Appl Stat 2006; 55:317-330. [PMID: 22457545 DOI: 10.1111/j.1467-9876.2006.00539.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Prophylaxis of contacts of infectious cases such as household members and treatment of infectious cases are methods to prevent spread of infectious diseases. We develop a method based on maximum likelihood to estimate the efficacy of such interventions and the transmission probabilities. We consider both the design with prospective follow-up of close contact groups and the design with ascertainment of close contact groups by an index case as well as randomization by groups and by individuals. We compare the designs using simulations. We estimate the efficacy of the influenza antiviral agent oseltamivir in reducing susceptibility and infectiousness in two case-ascertained household trials.
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Affiliation(s)
- Yang Yang
- Department of Biostatistics, The Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, U.S.A
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Abstract
BACKGROUND For nontransmissible diseases, decisions between interventions focused on high-risk groups and unfocused interventions can be based on attributable-risk calculations. The assumptions of those calculations, however, are violated for infectious diseases. METHODS We used deterministic compartmental models of infection transmission having both high- and low-risk groups and both susceptible and infected states to examine intervention effects on endemic infection levels. High risk is generated by increased susceptibility or contagiousness-factors that can be reduced by interventions. Population effects of focused and unfocused interventions are compared at settings where these would be equal if there were no transmission. RESULTS In the most likely range of mixing between high- and low-risk groups, focused interventions have considerably larger effects than unfocused interventions. At all mixing levels, both interventions have greater effects on infectious than noninfectious diseases because a change in risk factor for one individual alters risk in others. Interventions on contagiousness in high-risk groups have greater effects than comparable interventions on susceptibility. CONCLUSIONS Risk assessment for infectious disease requires analysis of the population system that is circulating the infection. Vaccine trials on individuals will miss important effects that trials on transmission units will detect. Focusing HIV control on contagiousness factors in high-risk groups will be especially productive.
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Affiliation(s)
- James S Koopman
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA.
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Ali M, Emch M, von Seidlein L, Yunus M, Sack DA, Rao M, Holmgren J, Clemens JD. Herd immunity conferred by killed oral cholera vaccines in Bangladesh: a reanalysis. Lancet 2005; 366:44-9. [PMID: 15993232 DOI: 10.1016/s0140-6736(05)66550-6] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Decisions about the use of killed oral cholera vaccines, which confer moderate levels of direct protection to vaccinees, can depend on whether the vaccines also provide indirect (herd) protection when high levels of vaccine coverage are attained. We reanalysed data from a field trial in Bangladesh to ascertain whether there is evidence of indirect protection from killed oral cholera vaccines. METHODS We analysed the first year of surveillance data from a placebo-controlled trial of B subunit-killed whole-cell and killed whole-cell-only oral cholera vaccines in children and adult women in Bangladesh. We calculated whether there was an inverse, monotonic trend for the relation between the level of vaccine coverage in a residential cluster and the incidence of cholera in individual vaccine recipients or placebo recipients residing in the cluster after controlling for potential confounding variables. FINDINGS Vaccine coverage of the targeted population ranged from 4% to 65%. Incidence rates of cholera among placebo recipients were inversely related to levels of vaccine coverage (7.01 cases per 1000 in the lowest quintile of coverage vs 1.47 cases per 1000 in the highest quintile; p<0.0001 for trend). Receipt of vaccine by an individual and the level of vaccine coverage of the individual's cluster were independently related to a reduced risk of cholera. Moreover, after adjustment for the level of vaccine coverage of the cluster, vaccine protective efficacy remained significant (55% [95% CI 41-66], p<0.0001). INTERPRETATION In addition to providing direct protection to vaccine recipients, killed oral cholera vaccines confer significant herd protection to neighbouring non-vaccinated individuals. Use of these vaccines could have a major effect on the burden of cholera in endemic settings.
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Affiliation(s)
- Roger I Glass
- Viral Gastroenteritis Section, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Huang SS, Finkelstein JA, Lipsitch M. Modeling Community- and Individual-Level Effects of Child-Care Center Attendance on Pneumococcal Carriage. Clin Infect Dis 2005; 40:1215-22. [PMID: 15825020 DOI: 10.1086/428580] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2004] [Accepted: 11/15/2004] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The prevalence of pneumococcal carriage varies widely across communities. This variation is not fully explained by risk factors at the individual level but may be explained by factors producing effects at both the individual and community levels, such as child-care center (CCC) attendance. METHODS We developed a transmission model to evaluate whether the combined risks of attending CCCs and associating with playmates who attend CCCs account for a large proportion of the variability in the prevalence of pneumococcal carriage across communities. We based parameters for the model on data from a multicommunity study. RESULTS According to our model, differences in the proportion of children who attend CCCs can account for a range of 4%-56% in the prevalence of pneumococcal carriage across communities. Our model, which was based on data collected from 16 Massachusetts communities, predicts that the odds of carriage associated with CCC attendance are 2-3 times the odds associated with no CCC attendance (individual-level effect). The model also predicts that the odds of carriage for nonattendees in a community with CCCs are up to 6 times the odds for children in a community without CCCs (community-level effect). In addition, the mean number of hours spent at CCCs by a single attendee appears to exert effects on pneumococcal carriage that are independent of either the proportion of CCC attendance in the community or the mean number of hours these attendees spend in child care. CONCLUSIONS We used data from multiple communities to develop a transmission model that explains marked differences in pneumococcal carriage across communities by variations in CCC attendance. This model only accounts for CCC attendance among young children and does not include other known risk factors for pneumococcal carriage.
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Affiliation(s)
- Susan S Huang
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA.
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Abstract
In this paper we discuss statistical considerations regarding endpoints in preventive vaccine trials. Brief discussion is given to preclinical, Phase I, and Phase II trials, with the bulk of attention paid to endpoint choice and analysis in Phase III efficacy trials. In addition to traditional efficacy measures of vaccine effects for immunized individuals, consideration is given to waning, strain specific efficacy, correlates of protective immunity, postinfection endpoints, and cluster randomized trials.
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Affiliation(s)
- Michael G Hudgens
- Statistical Center For HIV/AIDS Research and Prevention, Program in Biostatistics, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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Oakes JM. The (mis)estimation of neighborhood effects: causal inference for a practicable social epidemiology. Soc Sci Med 2004; 58:1929-52. [PMID: 15020009 DOI: 10.1016/j.socscimed.2003.08.004] [Citation(s) in RCA: 439] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The resurgence of interest in the effect of neighborhood contexts on health outcomes, motivated by advances in social epidemiology, multilevel theories and sophisticated statistical models, too often fails to confront the enormous methodological problems associated with causal inference. This paper employs the counterfactual causal framework to illuminate fundamental obstacles in the identification, explanation, and usefulness of multilevel neighborhood effect studies. We show that identifying useful independent neighborhood effect parameters, as currently conceptualized with observational data, to be impossible. Along with the development of a dependency-based methodology and theories of social interaction, randomized community trials are advocated as a superior research strategy, one that may help social epidemiology answer the causal questions necessary for remediating disparities and otherwise improving the public's health.
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Affiliation(s)
- J Michael Oakes
- Division of Epidemiology and Population Research Center, University of Minnesota, 1300 South 2nd Street, Minneapolis, MN 55454, USA.
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