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Lin TL, Fan YH, Chang YL, Ho HJ, Liang LL, Chen YJ, Wu CY. Early-Life Antibiotic Exposure Associated With Varicella Occurrence and Breakthrough Infections: Evidence From Nationwide Pre-Vaccination and Post-Vaccination Cohorts. Front Immunol 2022; 13:848835. [PMID: 35432330 PMCID: PMC9011717 DOI: 10.3389/fimmu.2022.848835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/10/2022] [Indexed: 12/02/2022] Open
Abstract
Background Antibiotic-driven dysbiosis may impair immune function and reduce vaccine-induced antibody titers. Objectives This study aims to investigate the impacts of early-life antibiotic exposure on subsequent varicella and breakthrough infections. Methods This is a nationwide matched cohort study. From Taiwan’s National Health Insurance Research Database, we initially enrolled 187,921 children born from 1997 to 2010. Since 2003, the Taiwan government has implemented a one-dose universal varicella vaccination program for children aged 1 year. We identified 82,716 children born during the period 1997 to 2003 (pre-vaccination era) and 48,254 children born from July 1, 2004, to 2009 (vaccination era). In the pre-vaccination era, 4,246 children exposed to antibiotics for at least 7 days within the first 2 years of life (Unvaccinated A-cohort) were compared with reference children not exposed to antibiotics (Unvaccinated R-cohort), with 1:1 matching for gender, propensity score, and non-antibiotic microbiota-altering medications. Using the same process, 9,531 children in the Vaccinated A-cohort and Vaccinated R-cohort were enrolled from the vaccination era and compared. The primary outcome was varicella. In each era, demographic characteristics were compared, and cumulative incidences of varicella were calculated. Cox proportional hazards model was used to examine associations. Results In the pre-vaccination era, the 5-year cumulative incidence of varicella in the Unvaccinated A-cohort (23.45%, 95% CI 22.20% to 24.70%) was significantly higher than in the Unvaccinated R-cohort (16.72%, 95% CI 15.62% to 17.82%) (p<.001). In the vaccination era, a significantly higher 5-year cumulative incidence of varicella was observed in the Vaccinated A-cohort (1.63%, 95% 1.32% to 1.93%) than in the Vaccinated R-cohort (1.19%, 95% CI 0.90% to 0.45%) (p=0.006). On multivariate analyses, early-life antibiotic exposure was an independent risk factor for varicella occurrence in the pre-vaccination (adjusted hazard ratio [aHR] 1.92, 95% CI 1.74 to 2.12) and vaccination eras (aHR 1.66, 95% CI 1.24 to 2.23). The use of penicillins, cephalosporins, macrolides, or sulfonamides in infancy was all positively associated with childhood varicella regardless of vaccine administration. Conclusions Antibiotic exposure in early life is associated with varicella occurrence and breakthrough infections.
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Affiliation(s)
- Teng-Li Lin
- Department of Dermatology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Hsuan Fan
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yi-Ling Chang
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsiu J Ho
- Institute of Biomedical Informatics and Research Center for Epidemic Prevention, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Li-Lin Liang
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Ju Chen
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Life Sciences, National Chung-Hsing University, Taichung, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Ying Wu
- Institute of Biomedical Informatics and Research Center for Epidemic Prevention, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Translational Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Public Health, China Medical University, Taichung, Taiwan.,National Institute of Cancer Research and Institute of Population Health Science, National Health Research Institutes, Miaoli, Taiwan
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Wang Y, Zhang L, Sun X, Cao Y, Wang Z, Liu L, Xu Y, Zhou M, Liu Y. Effectiveness and failure rate of the varicella vaccine in an outbreak in Jiangsu, China: a 1:2 matched case-control study. Hum Vaccin Immunother 2020; 16:506-512. [PMID: 31526231 DOI: 10.1080/21645515.2019.1665959] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: The varicella vaccine is not included in the national childhood immunization schedules in China, although one-dose varicella vaccine has been suggested for susceptible children aged 1-12 years in Jiangsu Province. However, varicella epidemics and outbreaks are frequently reported. We investigated a varicella outbreak in an elementary school to explore the risk factors for varicella transmission and vaccine failure.Methods: A 1:2 matched case-control study was carried out. Participant data were collected with standardized questionnaires. For each case, we enrolled two controls: a subject with high exposure in the same classroom as the case and a subject with low exposure in a different classroom. Data regarding vaccination status and medical and exposure histories were analyzed.Results: Fifty-one cases were reported during the outbreak; 26 cases (51%) were breakthrough varicella. Varicella vaccine immunization history (P < .001, OR = 0.19, 95% CI = 0.08-0.45) and the presence of siblings (P = .037, OR = 0.45, 95% CI = 0.21-0.95) were protective factors in preventing varicella infection. Contact with varicella patients increased the risk of varicella infection (P = .028, OR = 3.39, 95% CI = 1.14-10.09). Breakthrough varicella cases tended to present a milder rash (P = .049), fewer complications (P = .02), fewer rash sites (P = .02) and a shorter duration of active lesions (P = .001). One pneumonia case and one encephalitis case were reported in breakthrough cases. Age <15 months at the time of vaccination increased the risk of breakthrough varicella (P = .012). The adjusted vaccine effectiveness was 81%.Conclusions: One-dose varicella vaccine is effective at alleviating clinical manifestations. The moderate coverage provided by one dose cannot prevent varicella outbreaks, and vaccination after 15 months of age should be considered in the immunization schedule; a two-dose strategy is highly recommended.
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Affiliation(s)
- Yong Wang
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lei Zhang
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiang Sun
- Department of Expanded Programme on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu Province, China
| | - Yang Cao
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhiguo Wang
- Department of Expanded Programme on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu Province, China
| | - Li Liu
- Department of Expanded Programme on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu Province, China
| | - Yan Xu
- Department of Expanded Programme on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu Province, China
| | - Minghao Zhou
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu Province, China.,Department of Expanded Programme on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu Province, China
| | - Yuanbao Liu
- Department of Expanded Programme on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu Province, China
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Wutzler P, Bonanni P, Burgess M, Gershon A, Sáfadi MA, Casabona G. Varicella vaccination - the global experience. Expert Rev Vaccines 2017. [PMID: 28644696 DOI: 10.1080/14760584.2017.1343669] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Varicella, although a frequently benign childhood disease, nevertheless represents a considerable health burden. WHO recommends including varicella vaccines in universal routine vaccination programs, and maintaining coverage >80%. Many countries have successfully introduced varicella vaccination and have benefited from lower disease burden, but many others have not adopted the vaccine. Reasons include cost commitment for a 'mild childhood disease' or concerns that vaccination will shift varicella to older age groups or increase herpes zoster incidence. Areas covered: This literature review summarizes the effectiveness and epidemiological impact of varicella immunization programs. Expert commentary: Varicella vaccines are immunogenic with acceptable safety profiles. One and two dose schedules are highly effective against varicella and large reductions in disease incidence, particularly moderate-severe disease, have been widely reported. There is currently no evidence to suggest that the introduction of varicella vaccination results in a shift of varicella disease burden to older age groups. Although epidemiological studies have shown an increased incidence of herpes zoster since the vaccines were launched, there are many other contributing factors, and indeed, this secular trend was evident before their introduction. In conclusion, varicella vaccination easily fits into existing immunization programs and significantly reduces the often underestimated burden of varicella.
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Affiliation(s)
- Peter Wutzler
- a Institute of Virology and Antiviral Therapy , Friedrich Schiller University , Jena , Germany
| | - Paolo Bonanni
- b Department of Health Sciences , University of Florence , Florence , Italy
| | - Margaret Burgess
- c The Discipline of Paediatrics and Adolescent Health , University of Sydney , Sydney , Australia
| | - Anne Gershon
- d Division of Infectious Disease , Columbia University , New York , NY , USA
| | - Marco Aurélio Sáfadi
- e Department of Pediatrics , Santa Casa de Sao Paulo School of Medical Sciences , Sao Paulo , Brazil
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Romera-Guirado F, Molina-Salas Y, Pérez-Martín J, Ruzafa-Martínez M. Varicella vaccine effectiveness in schoolchildren in outbreaks in a semi-urban area. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Romera-Guirado F, Molina-Salas Y, Pérez-Martín J, Ruzafa-Martínez M. Efectividad de la vacuna de la varicela en el contexto de brotes escolares en una zona semiurbana. An Pediatr (Barc) 2016; 84:30-8. [DOI: 10.1016/j.anpedi.2015.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/16/2015] [Accepted: 02/20/2015] [Indexed: 10/23/2022] Open
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Germinario C, Gallone MS, Cappelli MG, Tafuri S. Clinical benefits of routine varicella vaccination for adults. Hum Vaccin Immunother 2015; 11:1426-8. [PMID: 25970524 PMCID: PMC4514254 DOI: 10.1080/21645515.2015.1030559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/12/2015] [Indexed: 10/23/2022] Open
Abstract
Varicella is a highly contagious disease caused by varicella zoster virus. In children, it is generally a mild to moderate illness while it is often more severe in adults, with serious complications as dehydration, pneumonia, bleeding problems, infection or inflammation of the brain, secondary bacterial infections, sepsis, toxic shock syndrome, bone infections, joint infections and deaths. Some groups of adults are at major risk of complications, in particular immunocompromised persons as subjects with impaired humoral immunity and who is receiving systemic steroids, persons who live or work in environments in which transmission of varicella is likely, health-care personnel and pregnant women. After the introduction of Universal Mass Vaccination (UMV), the first mathematical models suggested that vaccination will lead to a shift in the average age at infection from children to adults with an increasing numbers of complicated forms, nevertheless new models predicted that, although an upward shift in the age at infection may occur, the overall morbidity due to varicella is likely to decrease. Current literature seems to suggest that for public health authorities the key action to prevent an increase of varicella incidence among adults is to achieve high vaccination coverage among babies and adolescents in countries who adopted UMV.
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Affiliation(s)
- Cinzia Germinario
- Department of Biomedical Science and Human Oncology; “Aldo Moro” University of Bari; Bari, Italy
| | - Maria Serena Gallone
- Department of Biomedical Science and Human Oncology; “Aldo Moro” University of Bari; Bari, Italy
| | - Maria Giovanna Cappelli
- Department of Biomedical Science and Human Oncology; “Aldo Moro” University of Bari; Bari, Italy
| | - Silvio Tafuri
- Department of Biomedical Science and Human Oncology; “Aldo Moro” University of Bari; Bari, Italy
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Vink MA, Bootsma MCJ, Wallinga J. Serial intervals of respiratory infectious diseases: a systematic review and analysis. Am J Epidemiol 2014; 180:865-75. [PMID: 25294601 DOI: 10.1093/aje/kwu209] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The serial interval of an infectious disease represents the duration between symptom onset of a primary case and symptom onset of its secondary cases. A good evidence base for such values is essential, because they allow investigators to identify epidemiologic links between cases and serve as an important parameter in epidemic transmission models used to design infection control strategies. We reviewed the literature for available data sets containing serial intervals and for reported values of serial intervals. We were able to collect data on outbreaks within households, which we reanalyzed to infer a mean serial interval using a common statistical method. We estimated the mean serial intervals for influenza A(H3N2) (2.2 days), pandemic influenza A(H1N1)pdm09 (2.8 days), respiratory syncytial virus (7.5 days), measles (11.7 days), varicella (14.0 days), smallpox (17.7 days), mumps (18.0 days), rubella (18.3 days), and pertussis (22.8 days). For varicella, we found an evidence-based value that deviates substantially from the 21 days commonly used in transmission models. This value of the serial interval for pertussis is, to the best of our knowledge, the first that is based on observations. Our review reveals that, for most infectious diseases, there is very limited evidence to support the serial intervals that are often cited.
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Single-dose varicella vaccine effectiveness in school settings in China. Vaccine 2013; 31:3834-8. [PMID: 23845816 DOI: 10.1016/j.vaccine.2013.06.075] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 06/25/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Varicella vaccine has been available in the private sector in China for a decade as a single-dose regimen, but varicella vaccine effectiveness (VE) has not been fully examined in school settings yet. METHODS A matched case-control study was carried out in elementary schools and daycares in Tai'an prefecture, Shandong province, China. Clinical diagnosis of varicella and breakthrough disease was used for this study. Four controls were randomly selected from classmates; two from classmates of the case and two from another class of the same grade without cases. Vaccination status, date of vaccination, and vaccine product received if vaccinated were collected from home and clinic immunization records. Vaccination status of all students in schools/daycares with varicella cases from home immunization records or parental recall was used to calculate vaccination coverage. RESULTS The overall varicella VE was 83.4% (95% confidence interval 71.4-90.3%). Receipt of varicella vaccine five years or more years before the outbreak was significantly associated with breakthrough varicella (odds ratio=4.7, P<0.001), while age at vaccination (<15 vs. ≥15 months) was not (odds ratio=1.5, P=0.62). Varicella vaccination coverage was 41% with substantial variation across schools (range of 0-93.8%). CONCLUSIONS Single-dose varicella vaccine is highly effective in school settings. Maintaining limited vaccination coverage might shift varicella disease burden to older individuals, who are more prone to develop severe outcomes if varicella occurs.
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Bonanni P, Gershon A, Gershon M, Kulcsár A, Papaevangelou V, Rentier B, Sadzot-Delvaux C, Usonis V, Vesikari T, Weil-Olivier C, de Winter P, Wutzler P. Primary versus secondary failure after varicella vaccination: implications for interval between 2 doses. Pediatr Infect Dis J 2013; 32:e305-13. [PMID: 23838789 PMCID: PMC5500254 DOI: 10.1097/inf.0b013e31828b7def] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Two-dose varicella vaccination is recommended for optimal control of varicella in populations with high (>90%) 1-dose coverage. Optimal timing of the second dose may depend on whether breakthrough varicella results from primary vaccine failure (no protective immunity after vaccination) or secondary vaccine failure (waning protective immunity). METHODS Published literature (1995 to 2012) on vaccine failure after varicella vaccination cited in PubMed and other online sources was reviewed. RESULTS Nineteen publications detailed 21 varicella outbreaks with breakthrough varicella rates ranging from 0% to 42%; the publications showed no consistent trend between breakthrough varicella rate and time since vaccination. CONCLUSIONS Literature to date indicates a relatively high rate of primary vaccine failure and limited evidence of secondary vaccine failure among 1-dose varicella vaccine recipients, suggesting that a short interval between 2 doses might be preferable in countries considering implementation of universal varicella vaccination to reduce breakthrough varicella. However, any potential disruption to well-established vaccination schedules should be considered.
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Affiliation(s)
- Paolo Bonanni
- Department of Public Health, University of Florence, Florence, Italy
| | - Anne Gershon
- Department of Pediatrics, Division of Pediatric Infectious Disease, New York, NY, USA
| | - Michael Gershon
- Faculty of Anatomy and Cell Biology, Columbia University, New York, NY, USA
| | - Andrea Kulcsár
- Ward for Pediatric Infectious Diseases, Szent László Hospital, Budapest, Hungary
| | - Vassiliki Papaevangelou
- Second Department of Pediatrics, University of Athens Medical School, “P & A Kyriakou” Children's Hospital, Athens, Greece
| | - Bernard Rentier
- IGIGA-Virology and Immunology-CHU Liège, University of Liège, Liège, Belgium
| | | | - Vytautas Usonis
- Clinic of Paediatrics, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Timo Vesikari
- Vaccine Research Center, University of Tampere Medical School, Tampere, Finland
| | | | - Peter de Winter
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Peter Wutzler
- Institute of Virology and Antiviral Therapy, Jena University Hospital Friedrich-Schiller University, Jena, Germany
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