Vaccine shortages: history, impact, and prospects for the future

Politics matters for individual attitudes toward vaccine donation: cross-national evidence from the United States and Taiwan

BACKGROUND

Vaccine equity has been a major concern during the COVID-19 pandemic. According to the principle of vaccine equity, donor countries should apply the criterion of needs to make decisions about vaccine donation instead of considering recipient countries' economic status. We examine whether people follow the same criterion or consider other factors to decide which country to donate vaccines and how many vaccines should be delivered.

METHODS

We conducted online surveys with the design of conjoint experiment in the United States and Taiwan in 2021. 1,532 American citizens and 1,587 Taiwanese citizens were interviewed. The respondents were broadly quota-matched to their respective demographic proportions on the dimensions of age, gender, and education. We estimated the average marginal component effects (AMCEs) of the conjoint attributes by using the OLS regression models with standard errors clustered at the respondent level.

RESULTS

15,320 and 15,870 decisions on vaccine donation generated by conjoint experiment respectively in the United States and Taiwan were included in the analysis. Both American and Taiwanese people tend to donate vaccines to countries that suffer severe consequences of COVID-19 and democracies compared to authoritarian countries. However, they are less willing to donate vaccines to those with higher levels of capability in response to COVID-19. Taiwanese people tend to donate vaccines to countries having formal diplomatic relations with Taiwan (AMCE 13.4%, 95% CI 11.8%-15.1%). Nonetheless, American people would rather donate vaccines to countries without formal diplomatic relations with the United States (AMCE - 4.0%, 95% CI -5.6%--2.4%).

CONCLUSIONS

The findings reveal that politics plays a significant role in people's decisions about vaccine donation. Under electoral pressure, political leaders must think about how to respond to the public's preferences over vaccine donation to achieve vaccine equity and address the global health crisis.

Incidence of acute otitis media in children in the United States before and after the introduction of 7- and 13-valent pneumococcal conjugate vaccines during 1998–2018

Background

Acute otitis media (AOM) is a leading cause of office visits and antibiotic prescriptions in children. Pneumococcal conjugate vaccines were introduced in the USA in 2000 (7-valent, PCV7) and 2010 (13-valent, PCV13). Expanded valency PCVs are currently under development. To describe the impact of PCVs and quantify the residual burden of AOM, this study estimated annual incidence rates (IRs) of AOM and AOM-related complications and surgical procedures in children < 18 years in the USA before and after the introduction of PCV7 and PCV13.

Methods

AOM episodes were identified in the IBM MarketScan® Commercial and Medicaid databases using diagnosis codes (ICD-9-CM: 382.x; ICD-10-CM: H66.xx and H67.xx). Annual IRs were calculated as the number of episodes per 1000 person-years (PYs) for all children < 18 years and by age group (< 2, 2–4, and 5–17 years). National estimates of annual AOM IRs were extrapolated using Census Bureau data. Interrupted time series analyses were used to assess immediate and gradual changes in monthly AOM IRs, controlling for seasonality.

Results

In the commercially insured population, AOM IRs declined between the pre-PCV7 period (1998–1999) and the late PCV13 period (2014–2018) from 1170.1 to 768.8 episodes per 1000 PY for children < 2 years, from 547.4 to 410.3 episodes per 1000 PY in children 2–4 years, and from 115.6 to 91.8 episodes per 1000 PY in children 5–17 years. The interrupted time series analyses indicated significant immediate or gradual decreases in the early PCV7 period (2001–2005), and gradual increases in the late PCV7 period (2006–2009) in children < 2 years; however, crude IRs trended downward in all time periods. In older children, IRs decreased in the early PCV7 and early PCV13 period (2011–2013), but gradually increased in the late PCV7 period. IRs of AOM-related surgical procedures decreased, and IRs of AOM-related complications increased during the study timeframe.

Conclusions

AOM disease burden remains high in children of all ages despite overall reductions in AOM IRs during 1998–2018 following the introduction of PCV7 and PCV13. The impact of investigational PCVs on the disease burden of AOM will likely depend on AOM etiology and circulating pneumococcal serotypes.

Replacing vaccine paper package inserts: a multi-country questionnaire study on the acceptability of an electronic replacement in different target groups

Background

In the European Union it is mandatory to include paper package leaflets (PPL) with all medicines, including vaccines, to inform the recipient. However, it is difficult to meet the necessity for localized PPLs in each of the 24 official European languages. Replacing PPLs with electronic versions offers many advantages including redistribution across nations, reduced storage space, accessibility by the visually impaired, easily updated information or the addition of video content. We wanted to assess the attitudes of patients (vaccine recipients or their parents) to the potential of replacing PPL with electronic versions.

Methods

We surveyed vaccinees or their parents in four European countries—Belgium, Italy, Bulgaria and France—for their actual use of vaccine PPLs and their opinions about switching to an electronic package leaflet. Our survey was conducted online because of the COVID-19 pandemic and resulted in 2518 responses to a questionnaire targeted at three specific groups with particular information needs: parents of young children, pregnant women and the elderly (≥ 60 years).

Results

Our main findings are that currently vaccine PPLs are rarely used and frequently unavailable for the vaccinee. Across the four countries surveyed 55–82% of vaccinees would accept an electronic version, as did 64% when there was an option to request a printout of the leaflet.

Conclusions

We found that switching to electronic versions of vaccine PPLs is an acceptable alternative for the public, potentially increasing the quality and amount of information reaching vaccinees while eliminating some barriers to redistribution of vaccines between countries.

The COVID-19 vaccination campaign in Bhutan: strategy and enablers

Bhutan has reported a total of 2596 COVID-19 cases and three deaths as of September 15, 2021. With support from India, the United States, Denmark, the People's Republic of China, Croatia and other countries, Bhutan was able to conduct two rounds of nationwide vaccination campaign. While many countries struggle to overcome vaccine refusal or hesitancy due to complacency, a lack of trust, inconvenience and fear, escalated in some countries by anti-vaccine groups, Bhutan managed to inoculate more than 95% of its eligible populations in two rounds of vaccination campaign. Enabling factors of this successful vaccination campaign were strong national leadership, a well-coordinated national preparedness plan, and high acceptability of vaccine due to effective mass communication and social engagement led by religious figures, volunteers and local leaders. In this short report, we described the national strategic plan and enabling factors that led to the success of this historical vaccination campaign.

COVID-19 outbreak and sectoral performance of the Australian stock market: An event study analysis

The outbreak of COVID-19 has weakened the economy of Australia and its capital market since early 2020. The overall stock market has declined. However, some sectors become highly vulnerable while others continue to perform well even in the crisis period. Given this new reality, we seek to investigate the initial volatility and the sectoral return. In this study, we analyse data for eight sectors such as, transportation, pharmaceuticals, healthcare, energy, food, real estate, telecommunications and technology of the Australian stock market. In doing so, we obtain data from Australian Securities Exchange (ASX) and analysed them based on 'Event Study' method. Here, we use the 10-days window for the event of official announcement of the COVID-19 outbreak in Australia on 27 February 2020. The findings of the study show that on the day of announcement, the indices for food, pharmaceuticals and healthcare exhibit impressive positive returns. Following the announcement, the telecommunications, pharmaceuticals and healthcare sectors exhibit good performance, while poor performance is demonstrated by the transportation industry. The findings are vital for investors, market participants, companies, private and public policymakers and governments to develop recovery action plans for vulnerable sectors and enable investors to regain their confidence to make better investment decisions.

Variability of in vivo potency tests of Diphtheria, Tetanus and acellular Pertussis (DTaP) vaccines

For batch release of legacy vaccines such as DTaP, in vivo potency release assays are required. We quantified the variability of in vivo potency release assays for four DTaP (Diphtheria, Tetanus, acellular Pertussis) products of different manufacturers. With their large CV (Coefficients of Variance) ranging from 16% to 132%, these in vivo assays are of limited value to ensure their potency is consistent and similar to the clinical batches used for the marketing authorisation. Our data show that, although individual potency test results show high variability, the DTaP batches are manufactured with great consistency, because repeated potency testing yields similar averages for the different batches. The economic impact of variability of in vivo tests is significant since it may result in the need for greater amount of antigen than may be required or for repeating a test. For monitoring the consistency of potency, in vitro assays are superior to in vivo assays. Animal-free potency determination is common practice for newly developed vaccines under modern GMP quality systems. However, replacement of in vivo potency tests for legacy vaccines like DTaP is challenging and would require a 'reverse characterisation' strategy in which the antigens are further characterised at the level of drug substance and drug product to identify critical quality attributes (CQA) that can be tested with in vitro assays. Based on these an updated set of release tests without animal tests can be proposed. Our data can serve as benchmark for the innovative methods.

Advances for the Hepatitis A Virus Antigen Production Using a Virus Strain With Codon Frequency Optimization Adjustments in Specific Locations

The available cell-adapted hepatitis A virus (HAV) strains show a very slow replication phenotype hampering the affordable production of antigen. A fast-growing strain characterized by the occurrence of mutations in the internal ribosome entry site (IRES), combined with changes in the codon composition has been selected in our laboratory. A characterization of the IRES activity of this fast-growing strain (HM175-HP; HP) vs. its parental strain (HM175; L0) was assessed in two cell substrates used in vaccine production (MRC-5 and Vero cells) compared with the FRhK-4 cell line in which its selection was performed. The HP-derived IRES was significantly more active than the L0-derived IRES in all cells tested and both IRES were more active in the FRhK-4 cells. The translation efficiency of the HP-derived IRES was also much higher than the L0-derived IRES, particularly, in genes with a HP codon usage background. These results correlated with a higher virus production in a shorter time for the HP strain compared to the L0 strain in any of the three cell lines tested, and of both strains in the FRhK-4 cells compared to Vero and MRC-5 cells. The addition of wortmannin resulted in the increase of infectious viruses and antigen in the supernatant of FRhK-4 infected cells, independently of the strain. Finally, the replication of both strains in a clone of FRhK-4 cells adapted to grow with synthetic sera was optimal and again the HP strain showed higher yields.

Visibility and Analytics Network (VAN) approach to improve immunization supply chain and management performance system in Pakistan

Background

Pakistan has been experiencing several immunization related challenges. The supply chain management information system (MIS) is considered an important component of immunization services as it can improve visibility in key areas such as vaccine shortages or wastage. This study assessed the effectiveness of the Visibility and Analytics Network (VAN) approach in improving vaccine supply and availability of stocks by comparing the situation in intervention and non-intervention districts in Sindh province of Pakistan.

Methods

We utilized a quantitative and qualitative approach to collect data to assess the VAN approach in two districts of Sindh province in Pakistan. The data were collected between August and October 2017. VAN is a systematic monitoring system which measures the performance of vaccine supply chain management based on a set of indicators. We assessed storage facilities of the Expanded Programme on Immunization (EPI) in Sindh and interviewed personnel involved using a pre-tested data collection tool. We also conducted in depth interviews with senior management to assess performance of VAN, adoption mechanism and needs to scale up the VAN approach.

Results

We assessed 52 EPI facilities of Sindh province government. In the intervention district 83.3% managers were using MIS data for decision making related to vaccine supplies whereas in the non- intervention district no MIS based data were available. Ninety percent of stores were maintaining a stock registry and 100% supplies matched with requisitions in the intervention district compared to 40% and 35% in the non-intervention district for the same variables. Vaccine wastage was high in the non- intervention district (BCG 46.7% vs 33.9; OPV 13.5% vs 9.5%; pneumococcal 11.4% vs 7.4%). In-depth interview findings suggested that the VAN approach provided data guided monitoring in Pakistan for the first time. The approach also enabled district managers to make timely decisions.

Conclusion

The VAN approach improves vaccine supply chain management. It should be scaled up and implemented at national or sub national especially in countries struggling with vaccine supply chain management.

Coronavirus (Covid-19) outbreak, investor sentiment, and medical portfolio: Evidence from China, Hong Kong, Korea, Japan, and U.S

This study explores whether investor sentiment, driven by Coronavirus-related news (CRNs) and economic-related announcements (ERAs) associated with the Coronavirus outbreak, is priced in medical stock portfolios in China, Hongkong, Korea, Japan, and U.S. We find that the CNRs and ERAs do not trigger irrational investment behaviours towards medical stocks. CRNs exert significant and positive effects on the five markets' medical portfolios. ERAs also pose positive and significant effects on five markets' medical portfolios. Furthermore, ERAs have stronger effects on the institutional investor sentiment than the individual investor sentiment. Total effects of CRNs and ERAs on five markets' medical stock portfolios are positive and significant, meaning the optimistic investor sentiment on the medical industry, which plays the critical role in preventing this unprecedented infectious disease.

Propagation and Molecular Characterization of Fowl Adenovirus Serotype 8b Isolates in Chicken Embryo Liver Cells Adapted on Cytodex™ 1 Microcarrier Using Stirred Tank Bioreactor

Large volume production of vaccine virus is essential for prevention and control of viral diseases. The objectives of this study were to propagate Fowl adenovirus (FAdV) isolate (UPM08136) in chicken embryo liver (CEL) cells adapted to Cytodex™ 1 microcarriers using stirred tank bioreactor (STB) and molecularly characterize the virus. CEL cells were prepared and seeded onto prepared Cytodex™ 1 microcarriers and incubated first in stationary phase for 3 h and in STB at 37 °C, 5% CO2, and 20 rpm for 24 h. The CEL cells were infected with FAdV isolate (UPM08136) passage 5 (UPM08136CELP5) or passage 20 (UPM08136CELP20) and monitored until cell detachment. Immunofluorescence, TCID50, sequencing, alignment of hexon and fiber genes, and phylogenetic analysis were carried out. CEL cells were adapted well to Cytodex™ 1 microcarriers and successfully propagated the FAdV isolates in STB with virus titer of 107.5 (UPM08136CELP5B1) and 106.5 (UPM08136CELP20B1) TCID50/mL. These isolates clustered with the reference FAdV serotype 8b in the same evolutionary clade. The molecular characteristics remained unchanged, except for a point substitution at position 4 of the hexon gene of UPM08136CELP20B1, suggesting that propagation of the FAdV isolate in STB is stable and suitable for large volume production and could be a breakthrough in the scale-up process.

The preparation of lipid-based drug delivery system using melt extrusion

Melt extrusion of lipids is versatile with high applicability in the pharmaceutical industry. The formulations prepared can be easily customized depending on the requirements, and have the potential to open a window on personalized medicine.

Prioritizing the vaccine supply chain issues of developing countries using an integrated ISM-fuzzy ANP framework

Purpose

Delivering vaccines to the children who need them requires a supply chain that is efficient and effective. In most of the developing countries, however, the unknown and unresolved supply chain issues are causing inefficiencies in distributing vaccines. There is, therefore, a great need in such countries to recognize the issues that cause delays in vaccine delivery. With this purpose, the present study aims to identify and analyze the key issues in the supply chain of basic vaccines required to immunize children in developing countries.

Design/methodology/approach

Based on a field survey of three states of India, in-depth review of relevant literature and experts’ opinions, 25 key issues were recognized as factors of the vaccine supply chain (VSC) and categorized into five main domains. Using integrated interpretive structural modeling and fuzzy analytic network process approaches, the issues have been prioritized to determine their relative importance in the VSC. In addition, a sensitivity analysis has been performed to investigate the priority stability of the issues.

Findings

The results of the analysis show that among the five domains of VSC issues, the economic domain with a weight of 0.4262 is the most important domain, followed by the management (0.2672), operational (0.2222), environmental (0.0532) and social (0.0312).

Research limitations/implications

This study focuses on the prioritization of VSC issues; therefore, the results of the present study can provide direction to the decision-makers of immunization programs of developing countries in driving their efforts and resources on eliminating the most important obstacles to design successful vaccination programs.

Originality/value

To the authors’ knowledge, this paper is first to provide a direction to the decision-makers in identifying and managing important issues through the use of an analytical approach.

Assessing the Importance of Domestic Vaccine Manufacturing Centers: An Overview of Immunization Programs, Vaccine Manufacture, and Distribution

Vaccines have significantly reduced the detrimental effects of numerous human infectious diseases worldwide, helped to reduce drastically child mortality rates and even achieved eradication of major pathogens, such as smallpox. These achievements have been possible due to a dedicated effort for vaccine research and development, as well as an effective transfer of these vaccines to public health care systems globally. Either public or private institutions have committed to developing and manufacturing vaccines for local or international population supply. However, current vaccine manufacturers worldwide might not be able to guarantee sufficient vaccine supplies for all nations when epidemics or pandemics events could take place. Currently, different countries produce their own vaccine supplies under Good Manufacturing Practices, which include the USA, Canada, China, India, some nations in Europe and South America, such as Germany, the Netherlands, Italy, France, Argentina, and Brazil, respectively. Here, we discuss some of the vaccine programs and manufacturing capacities, comparing the current models of vaccine management between industrialized and developing countries. Because local vaccine production undoubtedly provides significant benefits for the respective population, the manufacture capacity of these prophylactic products should be included in every country as a matter of national safety.

A fuzzy MICMAC analysis for improving supply chain performance of basic vaccines in developing countries

INTRODUCTION

In recent years, demand to improve child immunization coverage globally, and the development of the latest vaccines and technology has made the vaccine market very complex. The rise in such complexities often gives birth to numerous issues in the vaccine supply chain, which are the primary cause of its poor performance. Figuring out the cause of the performance problem can help you decide how to address it. The goal of the present study is to identify and analyze important issues in the supply chain of basic vaccines required for child immunization in the developing countries.

RESEARCH DESIGN & METHODS

Twenty-five key issues as various factors of the vaccine supply chain have been presented in this paper. Fuzzy MICMAC analysis has been carried out to classify the factors based on their driving and dependence power and to develop a hierarchy based model. Further, the findings have been discussed with the field experts to identify the critical factors.

RESULTS & CONCLUSION

Three factors: better demand forecast, communication between the supply chain members, and proper planning and scheduling have been identified as the critical factors of vaccine supply chain. These factors should be given special care to improve vaccine supply chain performance.

Dangerous infectious diseases: Bad news for Main Street, good news for Wall Street?

We examine whether investor mood, driven by World Health Organization (WHO) alerts and media news on dangerous infectious diseases, is priced in pharmaceutical companies' stocks in the United States. We argue that disease-related news (DRNs) should not trigger rational trading. We find that DRNs have a positive and significant sentiment effect among investors (on Wall Street). The effect is stronger (weaker) for small (large) companies, who are less (more) likely to engage in the development of new vaccines. A potential negative investor climate (on Main Street) – induced by disease-related fear – does not alter the positive sentiment effect.

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We examine whether investor mood, driven by World Health Organization alerts on infectious diseases, is priced in pharmaceutical stocks in the U.S.

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Disease-related fear has a negative and significant effect on returns on pharmaceutical stocks.

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Disease-related news (DRN) has a positive and significant effect on returns on pharmaceutical stocks.

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The effect of DRN persists over several days following a WHO alert on infectious diseases.

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The effect of DRN is stronger for smaller companies and is weaker for larger companies.

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Our findings give rise to profitable trading strategies.

Emergence of event cascades in inhomogeneous networks

There is a commonality among contagious diseases, tweets, and neuronal firings that past events facilitate the future occurrence of events. The spread of events has been extensively studied such that the systems exhibit catastrophic chain reactions if the interaction represented by the ratio of reproduction exceeds unity; however, their subthreshold states are not fully understood. Here, we report that these systems are possessed by nonstationary cascades of event-occurrences already in the subthreshold regime. Event cascades can be harmful in some contexts, when the peak-demand causes vaccine shortages, heavy traffic on communication lines, but may be beneficial in other contexts, such that spontaneous activity in neural networks may be used to generate motion or store memory. Thus it is important to comprehend the mechanism by which such cascades appear, and consider controlling a system to tame or facilitate fluctuations in the event-occurrences. The critical interaction for the emergence of cascades depends greatly on the network structure in which individuals are connected. We demonstrate that we can predict whether cascades may emerge, given information about the interactions between individuals. Furthermore, we develop a method of reallocating connections among individuals so that event cascades may be either impeded or impelled in a network.

Introduction of pentavalent vaccine in Indonesia: a policy analysis

The introduction of pentavalent vaccine containing Haemophilus influenzae type b antigen in Indonesia's National Immunization Program occurred nearly three decades after the vaccine was first available in the United States and 16 years after Indonesia added hepatitis B vaccine into the program. In this study, we analyzed the process that led to the decision to introduce pentavalent vaccine in Indonesia. Using process tracing and case comparison, we used qualitative data gathered through interviews with key informants and data extracted from written sources to identify four distinct but interrelated processes that were involved in the decision making: (a) pentavalent vaccine use policy process, (b) financing process, (c) domestic vaccine development process and (d) political process. We hypothesized that each process is associated with four necessary conditions that are jointly sufficient for the successful introduction of pentavalent vaccine in Indonesia, namely (a) an evidence-based vaccine use recommendation, (b) sufficient domestic financing capacity, (c) sufficient domestic vaccine manufacturing capacity and (d) political support for introduction. This analysis of four processes that led to the decision to introduce a new vaccine in Indonesia may help policy makers and other stakeholders understand and manage activities that can accelerate vaccine introduction in the future.

Lessons Learned From Making and Implementing Vaccine Recommendations in the U.S

After publication of certain vaccine recommendations made by the Advisory Committee on Immunization Practices, several unexpected events have occurred during implementation of these recommendations. These have included changes in recommendations following adverse events involved with a particular vaccine and the conferral of community protection as an offshoot of vaccination of a specific population. Vaccine shortages and hesitancy have also been proven impediments to full implementation, and vaccine recommendations have not gone unaffected by either public perception of a vaccine or by cost considerations.

Enabling implementation of the Global Vaccine Action Plan: developing investment cases to achieve targets for measles and rubella prevention

Global prevention and control of infectious diseases requires significant investment of financial and human resources and well-functioning leadership and management structures. The reality of competing demands for limited resources leads to trade-offs and questions about the relative value of specific investments. Developing investment cases can help to provide stakeholders with information about the benefits, costs, and risks associated with available options, including examination of social, political, governance, and ethical issues. We describe the process of developing investment cases for globally coordinated management of action plans for measles and rubella as tools for enabling the implementation of the Global Vaccine Action Plan (GVAP). We focus on considerations related to the timing of efforts to achieve measles and rubella goals independently and within the context of ongoing polio eradication efforts, other immunization priorities, and other efforts to control communicable diseases or child survival initiatives. Our analysis suggests that the interactions between the availability and sustainability of financial support, sufficient supplies of vaccines, capacity of vaccine delivery systems, and commitments at all levels will impact the feasibility and timing of achieving national, regional, and global goals. The timing of investments and achievements will determine the net financial and health benefits obtained. The methodology, framing, and assumptions used to characterize net benefits and uncertainties in the investment cases will impact estimates and perceptions about the value of prevention achieved overall by the GVAP. We suggest that appropriately valuing the benefits of investments of measles and rubella prevention will require the use of integrated dynamic disease, economic, risk, and decision analytic models in combination with consideration of qualitative factors, and that synthesizing information in the form of investment cases may help stakeholders manage expectations as they chart the course ahead and navigate the decade of vaccines.

Barriers to the vaccination of children and adolescents and possible solutions

The benefits of vaccination are clearly demonstrated by the eradication or enormous decline in the incidence of many vaccine-preventable diseases, but the coverage of many highly recommended vaccines is still frequently inadequate and children continue to suffer from diseases that could have been prevented. The main aim of this paper is to discuss the recognized barriers to the vaccination of children and adolescents confronting national health systems, providers and parents, and the ways in which they can be overcome. Most of the problems underlying limited vaccination coverage among children are due to a lack of understanding on the part of healthcare providers and parents, which underlines the need for educational programmes specifically addressed to each of these groups. It is also essential that all of the physicians providing immunization develop approaches that acknowledge parents' concerns and respectfully try to correct any misinformation. Other means of extending vaccine coverage include the implementation of adequate systems for recording vaccine administration and the activation of effective reminder/recall systems, the provision of immunization services in some medical care specialties or by integrating healthcare sites, and the elimination or reduction of all the problems that currently limit access to vaccination services. However, it will take the combined efforts of healthcare systems and providers to pull down all of the barriers.

Identifying the relative priorities of subpopulations for containing infectious disease spread

In response to the outbreak of an emerging infectious disease, e.g., H1N1 influenza, public health authorities will take timely and effective intervention measures to contain disease spread. However, due to the scarcity of required resources and the consequent social-economic impacts, interventions may be suggested to cover only certain subpopulations, e.g., immunizing vulnerable children and the elderly as well as closing schools or workplaces for social distancing. Here we are interested in addressing the question of how to identify the relative priorities of subpopulations for two measures of disease intervention, namely vaccination and contact reduction, especially when these measures are implemented together at the same time. We consider the measure of vaccination that immunizes susceptible individuals in different age subpopulations and the measure of contact reduction that cuts down individuals’ effective contacts in different social settings, e.g., schools, households, workplaces, and general communities. In addition, we construct individuals’ cross-age contact frequency matrix by inferring basic contact patterns respectively for different social settings from the socio-demographical census data. By doing so, we present a prioritization approach to identifying the target subpopulations that will lead to the greatest reduction in the number of disease transmissions. We calculate the relative priorities of subpopulations by considering the marginal effects of reducing the reproduction number for the cases of vaccine allocation by age and contact reduction by social setting. We examine the proposed approach by revisiting the real-world scenario of the 2009 Hong Kong H1N1 influenza epidemic and determine the relative priorities of subpopulations for age-specific vaccination and setting-specific contact reduction. We simulate the influenza-like disease spread under different settings of intervention. The results have shown that the proposed approach can improve the effectiveness of disease control by containing disease transmissions in a host population.

The impact of anti-infective drug shortages on hospitals in the United States: trends and causes

Anti-infective shortages pose significant logistical and clinical challenges to hospitals and may be considered a public health emergency. Anti-infectives often represent irreplaceable life-saving treatments. Furthermore, few new agents are available to treat increasingly prevalent multidrug-resistant pathogens. Frequent anti-infective shortages have substantially altered patient care and may lead to inferior patient outcomes. Because many of the shortages stem from problems with manufacturing and distribution, federal legislation has been introduced but not yet enacted to provide oversight for the adequate supply of critical medications. At the local level, hospitals should develop strategies to anticipate the impact and extent of shortages, to identify therapeutic alternatives, and to mitigate potential adverse outcomes. Here we describe the scope of recent anti-infective shortages in the United States and explore the reasons for inadequate drug supply.

To give or not to give: Approaches to early childhood immunization delivery in Oregon rural primary care practices

CONTEXT

Little is known about rural clinicians' perspectives regarding early childhood immunization delivery, their adherence to recommended best immunization practices, or the specific barriers they confront.

PURPOSE

To examine immunization practices, beliefs, and barriers among rural primary care clinicians for children in Oregon and compare those who deliver all recommended immunizations in their practices with those who do not.

METHODS

A mailed questionnaire was sent to all physicians, nurse practitioners, and physician assistants practicing primary care in rural communities throughout Oregon.

FINDINGS

While 39% of rural clinicians reported delivering all childhood immunizations in their clinic, 43% of clinicians reported that they refer patients elsewhere for some vaccinations, and 18% provided no immunizations in the clinic whatsoever. Leading reasons for referral include inadequate reimbursement, parental request, and storage and stocking difficulties. Nearly a third of respondents reported that they had some level of concern about the safety of immunizations, and 14% reported that concerns about safety were a specific reason for referring. Clinicians who delivered only some of the recommended immunizations were less likely than nonreferring clinicians to have adopted evidence-based best immunization practices.

CONCLUSIONS

This study of rural clinicians in Oregon demonstrates the prevalence of barriers to primary care based immunization delivery in rural regions. While some barriers may be difficult to overcome, others may be amenable to educational outreach and support. Thus, efforts to improve population immunization rates should focus on promoting immunization "best practices" and enhancing the capacity of practices to provide immunizations and ensuring that any alternative means of delivering immunizations are effective.

Antigen-expressing immunostimulatory liposomes as a genetically programmable synthetic vaccine

Liposomes are versatile (sub)micron-sized membrane vesicles that can be used for a variety of applications, including drug delivery and in vivo imaging but they also represent excellent models for artificial membranes or cells. Several studies have demonstrated that in vitro transcription and translation can take place inside liposomes to obtain compartmentalized production of functional proteins within the liposomes (Kita et al. in Chembiochem 9(15):2403–2410, 2008; Moritani et al.in FEBS J, 2010; Kuruma et al. in Methods Mol Biol 607:161–171, 2010; Murtas et al. in Biochem Biophys Res Commun 363(1):12–17, 2007; Sunami et al. in Anal Biochem 357(1):128–136, 2006; Ishikawa et al. in FEBS Lett 576(3):387–390, 2004; Oberholzer et al. in Biochem Biophys Res Commun 261(2):238–241, 1999). Such a minimal artificial cell-based model is ideal for synthetic biology based applications. In this study, we propose the use of liposomes as artificial microbes for vaccination. These artificial microbes can be genetically programmed to produce specific antigens at will. To show proof-of-concept for this artificial cell-based platform, a bacterial in vitro transcription and translation system together with a gene construct encoding the model antigen β-galactosidase were entrapped inside multilamellar liposomes. Vaccination studies in mice showed that such antigen-expressing immunostimulatory liposomes (AnExILs) elicited higher specific humoral immune responses against the produced antigen (β-galactosidase) than control vaccines (i.e. AnExILs without genetic input, liposomal β-galactosidase or pDNA encoding β-galactosidase). In conclusion, AnExILs present a new platform for DNA-based vaccines which combines antigen production, adjuvanticity and delivery in one system and which offer several advantages over existing vaccine formulations.

Formulation of microneedles coated with influenza virus-like particle vaccine

Mortality due to seasonal and pandemic influenza could be reduced by increasing the speed of influenza vaccine production and distribution. We propose that vaccination can be expedited by (1) immunizing with influenza virus-like particle (VLP) vaccines, which are simpler and faster to manufacture than conventional egg-based inactivated virus vaccines, and (2) administering vaccines using microneedle patches, which should simplify vaccine distribution due to their small package size and possible self-administration. In this study, we coated microneedle patches with influenza VLP vaccine, which was released into skin by dissolution within minutes. Optimizing the coating formulation required balancing factors affecting the coating dose and vaccine antigen stability. Vaccine stability, as measured by an in vitro hemagglutination assay, was increased by formulation with increased concentration of trehalose or other stabilizing carbohydrate compounds and decreased concentration of carboxymethylcellulose (CMC) or other viscosity-enhancing compounds. Coating dose was increased by formulation with increased VLP concentration, increased CMC concentration, and decreased trehalose concentration, as well as increased number of dip coating cycles. Finally, vaccination of mice using microneedles stabilized by trehalose generated strong antibody responses and provided full protection against high-dose lethal challenge infection. In summary, this study provides detailed analysis to guide formulation of microneedle patches coated with influenza VLP vaccine and demonstrates effective vaccination in vivo using this system.

Effects of an ongoing epidemic on the annual influenza vaccination rate and vaccination timing among the Medicare elderly: 2000-2005

OBJECTIVES

We assessed short-term responsiveness of influenza vaccine demand to variation in timing and severity of influenza epidemics since 2000. We tested the hypothesis that weekly influenza epidemic activity is associated with annual and daily influenza vaccine receipt.

METHODS

We conducted cross-sectional survival analyses from the 2000-2001 to 2004-2005 influenza seasons among community-dwelling elderly using the Medicare Current Beneficiary Survey (unweighted n = 2280-2822 per season; weighted n = 7.7-9.7 million per season). The outcome variable was daily vaccine receipt. Covariates included the biweekly changes of epidemic and vaccine supply at 9 census-region levels.

RESULTS

In all 5 seasons, biweekly epidemic change was positively associated with overall annual vaccination (e.g., 2.7% increase in 2003-2004 season) as well as earlier vaccination timing (P < .01). For example, unvaccinated individuals were 5%-29% more likely to receive vaccination after a 100% biweekly epidemic increase.

CONCLUSIONS

Accounting for short-term epidemic responsiveness in predicting demand for influenza vaccination may improve vaccine distribution and the annual vaccination rate, and might assist pandemic preparedness planning.

Public health requirements for rapid progress in global health

Effective public health interventions can save hundreds of millions of lives in developing countries, as well as create broad social and economic benefits. Unfortunately, public health approaches and solutions applied in developed countries are often assumed to be inappropriate or unattainable in developing countries. This has sometimes forestalled effective interventions in parts of the world where they are most needed, despite conditions that now facilitate lasting solutions to both long-standing and emerging global public health problems. Core public health functions are similar regardless of a country's income level. Although some resource-intensive approaches from industrialised nations are inappropriate in less developed countries, many basic public health measures achieved decades ago in developed countries are urgently needed, highly appropriate, extremely cost-effective and eminently attainable in developing countries today. About half of the disease burden in low and middle-income countries is now from non-communicable diseases, but non-communicable disease epidemics that will otherwise increase rapidly in the developing world can be avoided or reversed. Progress of public health in developing countries is possible, but will require sufficient funding and human resources; improved physical plant and information systems; effective programme implementation and regulatory capacity; and, most importantly, political will at the highest levels of government.

Vaccine supply, demand, and policy: a primer

OBJECTIVE

To provide an overview of supply and demand issues in the vaccine industry and the policy options that have been implemented to resolve these issues.

DATA SOURCES

Medline, Policy File, and International Pharmaceutical Abstracts were searched to locate academic journal articles. Other sources reviewed included texts on the topics of vaccine history and policy, government agency reports, and reports from independent think tanks. Keywords included vaccines, immunizations, supply, demand, and policy.

STUDY SELECTION

Search criteria were limited to English language and human studies. Articles pertaining to vaccine demand, supply, and public policy were selected and reviewed for inclusion.

DATA EXTRACTION

By the authors.

DATA SYNTHESIS

Vaccines are biologic medications, therefore making their development and production more difficult and costly compared with "small-molecule" drugs. Research and development costs for vaccines can exceed $800 million, and development may require 10 years or more. Strict manufacturing regulations and facility upgrades add to these costs. Policy options to increase and stabilize the supply of vaccines include those aimed at increasing supply, such as government subsidies for basic vaccine research, liability protection for manufacturers, and fast-track approval for new vaccines. Options to increase vaccine demand include advance purchase commitments, government stockpiles, and government financing for select populations.

CONCLUSION

High development costs and multiple barriers to entry have led to a decline in the number of vaccine manufacturers. Although a number of vaccine policies have met with mixed success in increasing the supply of and demand for vaccines, a variety of concerns remain, including developing vaccines for complex pathogens and increasing immunization rates with available vaccines. New policy innovations such as advance market commitments and Medicare Part D vaccine coverage have been implemented and may aid in resolving some of the problems in the vaccine industry.

A duty to participate in research: does social context matter?

Because of the important benefits that biomedical research offers to humans, some have argued that people have a general moral obligation to participate in research. Although the defense of such a putative moral duty has raised controversy, few scholars, on either side of the debate, have attended to the social context in which research takes place and where such an obligation will be discharged. By reflecting on the social context in which a presumed duty to participate in research will obtain, this article shows that decontextualized discussions of this putative moral obligation are problematic.

Preclinical evaluation of microneedle technology for intradermal delivery of influenza vaccines

Recent clinical studies have suggested that, for certain strains of influenza virus, intradermal (i.d.) delivery may enable protective immune responses using a lower dose of vaccine than required by intramuscular (i.m.) injection. Here, we describe the first preclinical use of microneedle technology for i.d. administration of three different types of influenza vaccines: (i) a whole inactivated influenza virus, (ii) a trivalent split-virion human vaccine, and (iii) a plasmid DNA encoding the influenza virus hemagglutinin. In a rat model, i.d. delivery of the whole inactivated virus provided up to 100-fold dose sparing compared to i.m. injection. In addition, i.d. delivery of the trivalent human vaccine enabled at least 10-fold dose sparing for the H1N1 strain and elicited levels of response across the dose range similar to those of i.m. injection for the H3N2 and B strains. Furthermore, at least fivefold dose sparing from i.d. delivery was evident in animals treated with multiple doses of DNA plasmid vaccine, although such effects were not apparent after the first immunization. Altogether, the results demonstrate that microneedle-based i.d. delivery elicits antibody responses that are at least as strong as via i.m. injection and that, in many cases, dose sparing can be achieved by this new immunization method.

Network structure, and vaccination strategy and effort interact to affect the dynamics of influenza epidemics

There is growing interest in understanding and controlling the spread of diseases through realistically structured host populations. We investigate how network structures, ranging from circulant, through small-world networks, to random networks, and vaccination strategy and effort interact to influence the proportion of the population infected, the size and timing of the epidemic peak, and the duration of the epidemic. We found these three factors, and their higher-order interactions, significantly influenced epidemic development and extent. Increasing vaccination effort (from 0% to 90%) decreased the number of hosts infected while increasing network randomness worked to increase disease spread. On average, vaccinating hosts based on degree (hubs) resulted in the smallest epidemics while vaccinating hosts with the highest clustering coefficient resulted in the largest epidemics. In a targeted test of five vaccination strategies on a small-world network (probability of rewiring edges=5%) with 10% vaccination effort we found that vaccinating hosts preferentially with high-clustering coefficients (similar to real-world strategies) resulted in twice the number of hosts infected as random vaccinations and nearly a 30-fold higher number of cases than our strategy targeting hubs (highest degree hosts). Our model suggests how vaccinations might be implemented to minimize the extent of an epidemic (e.g., duration and total number infected) as well as the timing and number of hosts infected at a given time over a wide range of structured host networks.

Subjective and Objective Risk as Predictors of Influenza Vaccination during the Vaccine Shortage of 2004-2005

BACKGROUND

We aimed to identify the role of objective risk status and subjective risk beliefs in influenza vaccination decisions during the recent rationing of influenza vaccine.

METHOD

A random sample of 300 Americans, obtained through random-digit dialing, was interviewed regarding influenza vaccination practices and beliefs in September 2004 and again in March 2005.

RESULTS

One-half of individuals at high risk of influenza did not know that they were at high risk and, therefore, were not vaccinated. Respondents at high objective risk were more likely to report having been vaccinated than respondents who were not at high objective risk (36% vs. 6%, respectively; odds ratio, 8.31; 95% confidence interval, 3.65-18.88). However, a more powerful predictor of self-reported vaccination was subjective risk (64% vs. 7%, respectively; odds ratio, 24.02; 95% confidence interval, 12.18-48.09). Subjective risk fully mediated the relationship between objective risk and vaccination. Other predictors of vaccination included physician recommendation, habit, prior vaccination intention, belief that the influenza vaccine is safe and effective, perceived likelihood of getting influenza, and trait neuroticism.

CONCLUSION

Health communication efforts must be more effective in persuading adults with chronic illness and individuals in contact with persons at risk that they should be vaccinated against influenza.

The role of measles elimination in development of a national immunization program

The U.S. Immunization Program has been one of the most successful efforts in preventive medicine. Since its beginning with passage of the Vaccination Assistance Act in 1962, polio, measles and rubella have been eliminated and many other vaccine-preventable diseases are at record or near record lows. In 1966, 3 years after licensure of the first measles vaccines, the Centers for Disease Control and Prevention began an effort to eliminate measles within the United States, an on-and-off effort that was to last more than 30 years. With measles elimination as the primary driver, fundamental components of today's immunization program were built that affected not only measles, but all of the vaccines and vaccine-preventable diseases of childhood. Some of the major contributions were the enactment and enforcement of immunization requirements for school attendance in all 50 states, enactment of an entitlement program for vaccine purchase, the Vaccines for Children Program, support for health services research to determine reasons for nonimmunization and interventions to improve coverage, development of standards for immunization practices and the measurement system for immunization coverage in all 50 states and 28 major urban areas. Key lessons have been: (1) the program must rest on a sound base of vaccine science and health services science; (2) having a limited number of measurable goals allows program focus, but consider strategies that have crosscutting impact; (3) accountability is critical to program performance at all levels-state, local and individual practice; and (4) establishing and maintaining political support is essential.

Variation in hepatitis B immunization coverage rates associated with provider practices after the temporary suspension of the birth dose

Background

In 1999, the American Academy of Pediatrics and U.S. Public Health Service recommended suspending the birth dose of hepatitis B vaccine due to concerns about potential mercury exposure. A previous report found that overall national hepatitis B vaccination coverage rates decreased in association with the suspension. It is unknown whether this underimmunization occurred uniformly or was associated with how providers changed their practices for the timing of hepatitis B vaccine doses. We evaluate the impact of the birth dose suspension on underimmunization for the hepatitis B vaccine series among 24-month-olds in five large provider groups and describe provider practices potentially associated with underimmunization following the suspension.

Methods

Retrospective cohort study of children enrolled in five large provider groups in the United States (A-E). Logistic regression was used to evaluate the association between the birth dose suspension and a child's probability of being underimmunized at 24 months for the hepatitis B vaccine series.

Results

Prior to July 1999, the percent of children who received a hepatitis B vaccination at birth varied widely (3% to 90%) across the five provider groups. After the national recommendation to suspend the hepatitis B birth dose, the percent of children who received a hepatitis B vaccination at birth decreased in all provider groups, and this trend persisted after the policy was reversed. The most substantial decreases were observed in the two provider groups that shifted the first hepatitis B dose from birth to 5–6 months of age. Accounting for temporal trend, children in these two provider groups were significantly more likely to be underimmunized for the hepatitis B series at 24 months of age if they were in the birth dose suspension cohort compared with baseline (Group D OR 2.7, 95% CI 1.7 – 4.4; Group E OR 3.1, 95% CI 2.3 – 4.2). This represented 6% more children in Group D and 9% more children in Group E who were underimmunized in the suspension cohort compared with baseline. Children in the reversal cohort in these groups remained significantly more likely to be underimmunized compared with baseline. In contrast, in a third provider group where the typical timing of the third dose was unchanged and in two other provider groups whose hepatitis B vaccination schedules were unaffected by the birth dose suspension, hepatitis B vaccination coverage either was maintained or improved.

Conclusion

When the hepatitis B birth dose was suspended, provider groups that moved the first dose of vaccination to 5–6 months of age or later had decreases in hepatitis B vaccine coverage at 24 months. These findings suggest that as vaccine policy changes occur, providers could attempt to minimize underimmunization by adopting vaccination schedules that minimize delays in the recommended timing of vaccine doses.

Keys to strengthening the supply of routinely recommended vaccines: view from industry

The vaccine enterprise in the United States is a remarkable success story that has resulted in freedom from disease for millions of children. Although some persons believe that this success is in danger because of recent vaccine shortages, the reality is otherwise. The existing system fundamentally works and should be strengthened and stabilized, to improve delivery of current vaccines and to establish a firm structure into which a new generation of vaccines can be integrated. Ten practical actions to strengthen supplies of vaccine and ensure the stability of these supplies were presented to the National Vaccine Advisory Committee in February 2002. The present article has been updated to include progress made since that time. By building on what is already in place and on what we know works, we can continue to ensure success for years to come.