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Montgomery MP, Morris SE, Rolfes MA, Kittikraisak W, Samuels AM, Biggerstaff M, Davis WW, Reed C, Olsen SJ. The role of asymptomatic infections in influenza transmission: what do we really know. THE LANCET. INFECTIOUS DISEASES 2024; 24:e394-e404. [PMID: 38128563 PMCID: PMC11127787 DOI: 10.1016/s1473-3099(23)00619-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/02/2023] [Accepted: 09/18/2023] [Indexed: 12/23/2023]
Abstract
Before the COVID-19 pandemic, the role of asymptomatic influenza virus infections in influenza transmission was uncertain. However, the importance of asymptomatic infection with SARS-CoV-2 for onward transmission of COVID-19 has led experts to question whether the role of asymptomatic influenza virus infections in transmission had been underappreciated. We discuss the existing evidence on the frequency of asymptomatic influenza virus infections, the extent to which they contribute to infection transmission, and remaining knowledge gaps. We propose priority areas for further evaluation, study designs, and case definitions to address existing knowledge gaps.
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Affiliation(s)
- Martha P Montgomery
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand.
| | - Sinead E Morris
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Melissa A Rolfes
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wanitchaya Kittikraisak
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand
| | - Aaron M Samuels
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Matthew Biggerstaff
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - William W Davis
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand
| | - Carrie Reed
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sonja J Olsen
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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Pahmeier K, Speckemeier C, Neusser S, Wasem J, Biermann-Stallwitz J. Vaccinating the German Population Aged 60 Years and Over with a Quadrivalent High-Dose Inactivated Influenza Vaccine Compared to Standard-Dose Vaccines: A Transmission and Budget Impact Model. PHARMACOECONOMICS 2023; 41:1539-1550. [PMID: 37434014 PMCID: PMC10570167 DOI: 10.1007/s40273-023-01299-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND AND OBJECTIVE In Germany, influenza vaccination is mainly advised for persons aged 60 years and over and individuals with health risks. Since 2021, an inactivated, quadrivalent high-dose influenza vaccine (IIV4-HD) has been recommended for persons aged 60 years and over. The aim of this study was to calculate the impact of vaccinating the German population aged 60 years and over with IIV4-HD compared to standard-dose influenza vaccines (IIV4-SD) with regard to health outcomes and costs. METHODS An age-stratified deterministic compartment model was built to simulate the course of influenza infection for the German population in the season 2019/20. Probabilities for health outcomes and cost data were searched from the literature and were used to compare the influenza-related health and economic effects for different scenarios. Perspectives were those of the statutory health insurance and the society. Deterministic sensitivity analyses were conducted. RESULTS From the statutory health insurance perspective, vaccinating the German population aged 60 years and over with IIV4-HD would have prevented 277,026 infections (- 1.1%) with an increase of overall direct costs of €224 million (+ 40.1%) compared with IIV4-SD. A separate analysis showed that increased vaccination of 75% (World Health Organization recommendation for older age groups) in persons aged 60 years and over using IIV4-SD only would prevent 1,289,648 infections (- 5.1%) and would save costs from a statutory health insurance perspective of €103 million (- 13.2%) compared with IIV4-HD at actual vaccination rates. CONCLUSIONS The modeling approach offers important insights into the epidemiological and budgetary impact of different vaccination scenarios. Achieving a higher vaccination coverage with IIV4-SD in persons aged 60 years and over would result in lower costs and fewer influenza infections compared with the scenario with IIV4-HD and actual vaccination rates.
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Affiliation(s)
- Kathrin Pahmeier
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany.
| | - Christian Speckemeier
- Essener Forschungsinstitut für Medizinmanagement (EsFoMed) GmbH, Bredeneyer Str. 2b, 45133, Essen, Germany
| | - Silke Neusser
- Essener Forschungsinstitut für Medizinmanagement (EsFoMed) GmbH, Bredeneyer Str. 2b, 45133, Essen, Germany
| | - Jürgen Wasem
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
| | - Janine Biermann-Stallwitz
- Essener Forschungsinstitut für Medizinmanagement (EsFoMed) GmbH, Bredeneyer Str. 2b, 45133, Essen, Germany
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Kohli MA, Maschio M, Cartier S, Mould-Quevedo J, Fricke FU. The Cost-Effectiveness of Vaccination of Older Adults with an MF59-Adjuvanted Quadrivalent Influenza Vaccine Compared to Other Available Quadrivalent Vaccines in Germany. Vaccines (Basel) 2022; 10:vaccines10091386. [PMID: 36146464 PMCID: PMC9503029 DOI: 10.3390/vaccines10091386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/24/2022] Open
Abstract
Enhanced quadrivalent influenza vaccines that include an adjuvant (aQIV) or a high dose of antigen (QIV-HD), which stimulate a stronger immune response in older adults than the standard vaccine (QIVe), are now approved. The objective of this research is to compare available vaccines and determine the cost-effectiveness of immunizing persons aged 65 years and above with aQIV compared to QIVe and QIV-HD in Germany. A compartmental transmission model calibrated to outpatient visits for influenza in Germany was used to predict the number of medically attended infections using the three vaccines. The rates of hospitalizations, deaths, and other economic consequences were estimated with a decision tree using German data where available. Based on meta-analysis, the rVE of −2.5% to 8.9% for aQIV versus QIV-HD, the vaccines are similar clinically, but aQIV is cost saving compared to QIV-HD (unit cost of EUR 40.55). All results were most sensitive to changes in vaccine effectiveness. aQIV may be cost-effective compared to QIVe depending on the willingness to pay for additional benefits in Germany. As aQIV and QIV-HD are similar in terms of effectiveness, aQIV is cost saving compared to QIV-HD at current unit prices.
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Affiliation(s)
- Michele A. Kohli
- Quadrant Health Economics Inc., 92 Cottonwood Crescent, Cambridge, ON N1T 2J1, Canada
| | - Michael Maschio
- Quadrant Health Economics Inc., 92 Cottonwood Crescent, Cambridge, ON N1T 2J1, Canada
| | - Shannon Cartier
- Quadrant Health Economics Inc., 92 Cottonwood Crescent, Cambridge, ON N1T 2J1, Canada
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Talantsev A, Fasth T, Wenner C, Wolff E, Larsson A. Evaluation of pharmaceutical intervention strategies against pandemics in Sweden: A scenario‐driven multiple criteria decision analysis study. JOURNAL OF MULTI-CRITERIA DECISION ANALYSIS 2022. [DOI: 10.1002/mcda.1779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anton Talantsev
- Department of Computer and Systems Sciences Stockholm University Stockholm Sweden
| | - Tobias Fasth
- Department of Computer and Systems Sciences Stockholm University Stockholm Sweden
- Public Health Analysis and Data Management Public Health Agency of Sweden Solna Sweden
| | - Cenny Wenner
- Public Health Analysis and Data Management Public Health Agency of Sweden Solna Sweden
| | - Ellen Wolff
- Public Health Analysis and Data Management Public Health Agency of Sweden Solna Sweden
| | - Aron Larsson
- Department of Computer and Systems Sciences Stockholm University Stockholm Sweden
- Risk and Crisis Research Centre Mid Sweden University Sundsvall Sweden
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Chen CM(J, Stanciu AC. Simulating influenza epidemics with waning vaccine immunity. Medicine (Baltimore) 2021; 100:e27169. [PMID: 34516511 PMCID: PMC8428734 DOI: 10.1097/md.0000000000027169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 08/20/2021] [Indexed: 01/05/2023] Open
Abstract
Observational studies indicate that vaccine-induced immunity can decline over time. However, few researchers have incorporated this kind of waning effect into their virus spread models. In this study, we simulate an influenza epidemic that considers the effects of waning immunity by fitting epidemiological models to CDC secondary historical data aggregated on a weekly basis, and derive the transmission rates at which susceptible individuals become infected over the course of the influenza season. Using a system of differential equations, we define four groups of individuals in a population: susceptible, vaccinated, infected, and recovered. We show that a larger number of initially infected individuals might not only bring the influenza season to an end sooner but also reduce the epidemic size. Moreover, any influenza virus that entails a faster recovery rate does not necessarily lead to a smaller epidemic size. We illustrate how simulation helps in understanding the effects of influenza epidemiological model in the presence of waning influenza vaccine immunity.
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A Call for a Reform of the Influenza Immunization Program in Mexico: Epidemiologic and Economic Evidence for Decision Making. Vaccines (Basel) 2021; 9:vaccines9030286. [PMID: 33808916 PMCID: PMC8003748 DOI: 10.3390/vaccines9030286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/03/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
Limited information is available to determine the effectiveness of Mexico's national influenza vaccination guidelines and inform policy updates. We aim to propose reforms to current influenza vaccination policies based on our analysis of cost-effectiveness studies. This cross-sectional epidemiological study used influenza case, death, discharge and hospitalization data from several influenza seasons and applied a one-year decision-analytic model to assess cost-effectiveness. The primary health outcome was influenza cases avoided; secondary health outcomes were influenza-related events associated with case reduction. By increasing vaccination coverage to 75% in the population aged 12-49 years with risk factors (diabetes, high blood pressure, morbid obesity, chronic renal failure, asthma, pregnancy), and expanding universal vaccination coverage to school-aged children (5-11 years) and adults aged 50-59 years, 7142-671,461 influenza cases; 1-15 deaths; 7615-262,812 healthcare visits; 2886-154,143 emergency room admissions and 2891-97,637 hospitalizations could be prevented (ranges correspond to separate age and risk factor groups), with a net annual savings of 3.90 to 111.99 million USD. Such changes to the current vaccination policy could potentially result in significant economic and health benefits. These data could be used to inform the revision of a vaccination policy in Mexico with substantial social value.
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Fens T, de Boer PT, van Puijenbroek EP, Postma MJ. Inclusion of Safety-Related Issues in Economic Evaluations for Seasonal Influenza Vaccines: A Systematic Review. Vaccines (Basel) 2021; 9:vaccines9020111. [PMID: 33540633 PMCID: PMC7913116 DOI: 10.3390/vaccines9020111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/18/2021] [Accepted: 01/26/2021] [Indexed: 11/18/2022] Open
Abstract
(1) Background: Vaccines for seasonal influenza are a good preventive and cost-effective strategy. However, it is unknown if and how these economic evaluations include the adverse events following immunization (AEFI), and what the impact of such inclusion is on the health economic outcomes. (2) Methods: We searched the literature, up to January 2020, to identify economic evaluations of seasonal influenza vaccines that considered AEFIs. The review protocol was published in PROSPERO (CDR42017058523). (3) Results: A total of 52 economic evaluations considered AEFI-related parameters in their analyses, reflecting 16% of the economic evaluations on seasonal influenza vaccines in the initial study selection. Most studies used the societal perspective (64%) and evaluated vaccination of children (37%). Where considered, studies included direct medical costs of AEFIs (90%), indirect costs (27%), and disutilities/quality-adjusted life years loss due to AEFIs (37%). The majority of these studies accounted for the effects of the costs of AEFI on cost-effectiveness for Guillain–Barré syndrome. In those papers allowing cost share estimation, direct medical cost of AFEIs was less than 2% of total direct costs. (4) Conclusions: Although the overall impact of AEFIs on the cost-effectiveness outcomes was found to be low, we urge their inclusion in economic evaluations of seasonal influenza vaccines to reflect comprehensive reports for the decision makers and end-users of the vaccination strategies.
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Affiliation(s)
- Tanja Fens
- Department of PharmacoTherapy, Epidemiology & -Economics (PTE2), Groningen Research Institute of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands; (P.T.d.B.); (E.P.v.P.); (M.J.P.)
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
- Correspondence:
| | - Pieter T. de Boer
- Department of PharmacoTherapy, Epidemiology & -Economics (PTE2), Groningen Research Institute of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands; (P.T.d.B.); (E.P.v.P.); (M.J.P.)
| | - Eugène P. van Puijenbroek
- Department of PharmacoTherapy, Epidemiology & -Economics (PTE2), Groningen Research Institute of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands; (P.T.d.B.); (E.P.v.P.); (M.J.P.)
- Netherlands Pharmacovigilance Centre Lareb, 5237 MH ’s-Hertogenbosch, The Netherlands
| | - Maarten J. Postma
- Department of PharmacoTherapy, Epidemiology & -Economics (PTE2), Groningen Research Institute of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands; (P.T.d.B.); (E.P.v.P.); (M.J.P.)
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, 9747 AE Groningen, The Netherlands
- Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung 45363, Indonesia
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Scholz SM, Weidemann F, Damm O, Ultsch B, Greiner W, Wichmann O. Cost-Effectiveness of Routine Childhood Vaccination Against Seasonal Influenza in Germany. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:32-40. [PMID: 33431151 DOI: 10.1016/j.jval.2020.05.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 04/23/2020] [Accepted: 05/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES In Germany, routine influenza vaccination with quadrivalent influenza vaccines (QIV) is recommended and reimbursed for individuals ≥60 years of age and individuals with underlying chronic conditions. The present study examines the cost-effectiveness of a possible extension of the recommendation to include strategies of childhood vaccination against seasonal influenza using QIV. METHODS A dynamic transmission model was used to examine the epidemiological impact of different childhood vaccination strategies. The outputs were used in a health economic decision tree to calculate the costs per quality-adjusted life year (QALY) gained from a societal and a third-party payer (TPP) perspective. Strain-specific epidemiology, vaccine uptake, and vaccine efficacy data from the 10 non-pandemic seasons from 2003/2004 to 2013/2014 were used, and cost data were drawn mainly from a health insurance claims data analysis and supplemented by estimates from literature. Uncertainty is explored via scenario, deterministic, and probabilistic sensitivity analyses. RESULTS Vaccinating 2- to 9-year-olds with QIV assuming a vaccine uptake of 40% is cost-saving with a benefit-cost ratio of 1.66 from a societal perspective and an incremental cost-effectiveness ratio of €998/QALY from a TPP perspective. Lower and higher vaccine uptakes show marginal effects, while extending the target group to 2- to 17-year-olds further increases the health benefits while still being below the willingness-to-pay (WTP) threshold. Assuming no vaccine-induced herd protection has a negative effect on the cost-effectiveness ratio, but childhood vaccination remains cost-effective. CONCLUSION Routine childhood vaccination against seasonal influenza in Germany is most likely to be cost-saving from a societal perspective and highly cost-effective from a TPP perspective.
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Affiliation(s)
- Stefan M Scholz
- Immunization Unit, Robert Koch-Institute, Berlin, Germany; School of Public Health, Bielefeld University, Bielefeld, Germany.
| | | | - Oliver Damm
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | | | - Wolfgang Greiner
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Ole Wichmann
- Immunization Unit, Robert Koch-Institute, Berlin, Germany
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Thangarajah D, Malo JA, Field E, Andrews R, Ware RS, Lambert SB. Effectiveness of quadrivalent influenza vaccination in the first year of a funded childhood program in Queensland, Australia, 2018. Vaccine 2020; 39:729-737. [PMID: 33358414 DOI: 10.1016/j.vaccine.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/31/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Following high influenza activity in 2017, the state of Queensland, Australia, funded a quadrivalent inactivated influenza vaccination program for children aged 6 months to <5 years in 2018. We calculated influenza vaccine effectiveness (VE) among children eligible for this program. METHODS A matched case-control study was conducted. Cases were identified using Queensland 2018 influenza notification data among children age-eligible for funded vaccination. Controls were drawn from Australian Immunisation Register records of Queensland resident children age-eligible for funded influenza vaccine. Up to 10 controls per case were matched for location and birthdate. First dose vaccination was valid if received ≥14 days prior to specimen collection; a second dose was valid if received ≥28 days after first dose receipt. VE was calculated for vaccine doses and adherence to national recommendations for two doses in the first season (schedule completeness) and adjusted (VEadj) for sex and First Nations status. RESULTS There were 1,125 cases and 10,645 matched controls analysed. Overall VEadj against laboratory-confirmed influenza was 51% (95% confidence interval (CI) 41-60). VEadj was 60% (95% CI 46-70) for children who received two doses in 2018, and 60% (95% CI 48-69) for children vaccinated appropriately according to schedule completeness. VE increased with age. CONCLUSIONS Moderate vaccine effectiveness was observed for children eligible for the funded program in Queensland in 2018, adding to the sparse evidence for influenza vaccine use in Australian children. Adhering to the national first season two dose schedule for influenza vaccine receipt in children ensures maximum protection.
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Affiliation(s)
- Dharshi Thangarajah
- Communicable Diseases Branch, Queensland Health, Brisbane, Australia; National Centre for Epidemiology and Population Health, Australian National University, Canberra Australia.
| | - Jonathan A Malo
- Communicable Diseases Branch, Queensland Health, Brisbane, Australia.
| | - Emma Field
- National Centre for Epidemiology and Population Health, Australian National University, Canberra Australia; Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Ross Andrews
- National Centre for Epidemiology and Population Health, Australian National University, Canberra Australia; Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Robert S Ware
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia.
| | - Stephen B Lambert
- Communicable Diseases Branch, Queensland Health, Brisbane, Australia; National Centre for Epidemiology and Population Health, Australian National University, Canberra Australia.
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Falcón-Lezama JA, Saucedo-Martínez R, Betancourt-Cravioto M, Alfaro-Cortes MM, Bahena-González RI, Tapia-Conyer R. Influenza in the school-aged population in Mexico: burden of disease and cost-effectiveness of vaccination in children. BMC Infect Dis 2020; 20:240. [PMID: 32197591 PMCID: PMC7085158 DOI: 10.1186/s12879-020-4948-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 03/04/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The current national influenza vaccination schedule in Mexico does not recommend vaccination in the school-aged population (5-11 years). Currently, there are limited data from middle-income countries analysing the cost-effectiveness of influenza vaccination in this population. We explored the clinical effects and economic benefits of expanding the current national influenza vaccination schedule in Mexico to include the school-aged population. METHODS A static 1-year model incorporating herd effect was used to assess the cost-effectiveness of expanding the current national influenza vaccination schedule of Mexico to include the school-aged population. We performed a cross-sectional epidemiological study using influenza records (2009-2018), death records (2010-2015), and discharge and hospitalisation records (2010-2016), from the databases of Mexico's Influenza Surveillance System (SISVEFLU), the National Mortality Epidemiological and Statistical System (SEED), and the Automated Hospital Discharge System (SAEH), respectively. Cost estimates for influenza cases were based on 7 scenarios using data analysed from SISVEFLU; assumptions for clinical management of cases were defined according to Mexico's national clinical guidelines. The primary health outcome for this study was the number of influenza cases avoided. A sensitivity analysis was performed using conservative and optimistic parameters (vaccination coverage: 30% / 70%, Vaccine effectiveness: 19% / 68%). RESULTS It was estimated that expanding the influenza immunisation programme to cover school-aged population in Mexico over the 2018-2019 influenza season would result in 671,461 cases of influenza avoided (50% coverage and 50% effectiveness assumed). Associated with this were 262,800 fewer outpatient consultations; 154,100 fewer emergency room consultations; 97,600 fewer hospitalisations, and 15 fewer deaths. Analysis of cases avoided by age-group showed that 55.4% of them were in the school-aged population, and the decrease in outpatient consultations was largest in this population. There was an overall decrease in the economic burden for the Mexican health care system of 111.9 million US dollars; the immunization programme was determined to be cost-saving in the base, conservative and optimistic scenarios. CONCLUSIONS Vaccinating school-aged population in Mexico would be cost-effective; expansion of the current national vaccination schedule to this age group is supported.
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Affiliation(s)
| | - Rodrigo Saucedo-Martínez
- Sociedad Mexicana de Salud Pública, Herschel 109, Anzures, Miguel Hidalgo, 11590, Mexico City, Mexico
| | | | - Myrna María Alfaro-Cortes
- Sociedad Mexicana de Salud Pública, Herschel 109, Anzures, Miguel Hidalgo, 11590, Mexico City, Mexico
| | | | - Roberto Tapia-Conyer
- Sociedad Mexicana de Salud Pública, Herschel 109, Anzures, Miguel Hidalgo, 11590, Mexico City, Mexico.
- Universidad Nacional Autónoma de México, Av. Universidad 3000, Circuito Escolar CU, Edificio B 1er Piso, Coyoacan, 04510, Mexico City, Mexico.
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Zhang Y, Muscatello DJ, Cao Z, Chughtai AA, Costantino V, Zhang D, Yang P, Wang Q, MacIntyre CR. A model of influenza infection and vaccination in children aged under 5 years in Beijing, China. Hum Vaccin Immunother 2020; 16:1685-1690. [PMID: 31995439 DOI: 10.1080/21645515.2019.1705692] [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: 10/25/2022] Open
Abstract
BACKGROUND Children aged under 5 years are particularly vulnerable to influenza infection. In this study, we aim to estimate the number and incidence of influenza among young children and estimate the impact of childhood vaccination in different scenarios from 2013/14 to 2016/17 seasons. METHODS The number and incidence rate of influenza infections among children aged under 5 years in Beijing was estimated by scaling up observed surveillance data. Then, we used a susceptible-exposed-infected-recovery (SEIR) model to reproduce the weekly number of influenza infections estimated in Beijing during the study seasons, and to estimate the number and proportion of influenza-attributed medically attended acute respiratory infections (I-MAARI) averted by vaccination in each season. Finally, we evaluated the impact of alternative childhood vaccination programs with different coverage and speed of vaccine distribution. RESULTS The estimated average annual incidence of influenza in children aged under 5 years was 33.9% (95% confidence interval (CI): 27.5%, 47.2%) during the study period. With the actual coverage during the included seasons at around 2.9%, an average of 3.9% (95%CI: 3.5%, 4.4%) I-MAARI was reduced compared to a no-vaccination scenario. Reaching 20%, 40%, 50%, 60%, 80% and 100% vaccine coverage would lead to an overall I-MAARI reduction of 25.3%, 42.7%, 51.9%, 57.0%, 65.3% and 71.2%. At 20% coverage scenario, an average of 28.8% I-MAARI will be prevented if intensive vaccination implemented in 2 months since the vaccine released. CONCLUSION In Beijing, the introduction of a program for vaccinating young children, even at relatively low vaccine coverage rates, would considerably reduce I-MAARI, particularly if the vaccines can be quickly delivered.
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Affiliation(s)
- Yi Zhang
- Institute for Infectious Diseases and Endemic Diseases Control, Beijing Municipal Center for Disease Prevention and Control & Beijing Research Center for Preventive Medicine , Beijing, China.,School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia
| | - David J Muscatello
- School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia
| | - Zhidong Cao
- The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences , Beijing, China
| | - Abrar A Chughtai
- School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia
| | - Valentina Costantino
- School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia
| | - Daitao Zhang
- Institute for Infectious Diseases and Endemic Diseases Control, Beijing Municipal Center for Disease Prevention and Control & Beijing Research Center for Preventive Medicine , Beijing, China
| | - Peng Yang
- Institute for Infectious Diseases and Endemic Diseases Control, Beijing Municipal Center for Disease Prevention and Control & Beijing Research Center for Preventive Medicine , Beijing, China
| | - Quanyi Wang
- Institute for Infectious Diseases and Endemic Diseases Control, Beijing Municipal Center for Disease Prevention and Control & Beijing Research Center for Preventive Medicine , Beijing, China
| | - C Raina MacIntyre
- Kirby Institute, Faculty of Medicine, The University of New South Wales , Sydney, Australia.,College of Public Service & Community Solutions and College of Health Solutions, Arizona State University , Phoenix, AZ, USA
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12
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de Boer PT, Backer JA, van Hoek AJ, Wallinga J. Vaccinating children against influenza: overall cost-effective with potential for undesirable outcomes. BMC Med 2020; 18:11. [PMID: 31931789 PMCID: PMC6958762 DOI: 10.1186/s12916-019-1471-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 11/20/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The present study aims to assess the cost-effectiveness of an influenza vaccination program for children in the Netherlands. This requires an evaluation of the long-term impact of such a program on the burden of influenza across all age groups, using a transmission model that accounts for the seasonal variability in vaccine effectiveness and the shorter duration of protection following vaccination as compared to natural infection. METHODS We performed a cost-effectiveness analysis based on a stochastic dynamic transmission model that has been calibrated to reported GP visits with influenza-like illness in the Netherlands over 11 seasons (2003/2004 to 2014/2015). We analyzed the costs and effects of extending the current program with vaccination of children aged 2-16 years at 50% coverage over 20 consecutive seasons. We measured the effects in quality-adjusted life-years (QALYs) and we adopted a societal perspective. RESULTS The childhood vaccination program is estimated to have an average incremental cost-effectiveness ratio (ICER) of €3944 per QALY gained and is cost-effective in the general population (across 1000 simulations; conventional Dutch threshold of €20,000 per QALY gained). The childhood vaccination program is not estimated to be cost-effective for the target-group itself with an average ICER of €57,054 per QALY gained. Uncertainty analyses reveal that these ICERs hide a wide range of outcomes. Even though introduction of a childhood vaccination program decreases the number of infections, it tends to lead to larger epidemics: in 23.3% of 1000 simulations, the childhood vaccination program results in an increase in seasons with a symptomatic attack rate larger than 5%, which is expected to cause serious strain on the health care system. In 6.4% of 1000 simulations, the childhood vaccination program leads to a net loss of QALYs. These findings are robust across different targeted age groups and vaccination coverages. CONCLUSIONS Modeling indicates that childhood influenza vaccination is cost-effective in the Netherlands. However, childhood influenza vaccination is not cost-effective when only outcomes for the children themselves are considered. In approximately a quarter of the simulations, the introduction of a childhood vaccination program increases the frequency of seasons with a symptomatic attack rate larger than 5%. The possibility of an overall health loss cannot be excluded.
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Affiliation(s)
- Pieter T de Boer
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie Van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands.
| | - Jantien A Backer
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie Van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
| | - Albert Jan van Hoek
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie Van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jacco Wallinga
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie Van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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13
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Schmidt-Ott R, Molnar D, Anastassopoulou A, Yanni E, Krumm C, Bekkat-Berkani R, Dos Santos G, Henneke P, Knuf M, Schwehm M, Eichner M. Assessing direct and indirect effects of pediatric influenza vaccination in Germany by individual-based simulations. Hum Vaccin Immunother 2019; 16:836-845. [PMID: 31647348 PMCID: PMC7227695 DOI: 10.1080/21645515.2019.1682843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Children have a high burden of influenza and play a central role in spreading influenza. Routinely vaccinating children against influenza may, thus, not only reduce their disease burden, but also that of the general population, including the elderly who frequently suffer severe complications. Using the published individual-based tool 4Flu, we simulated how pediatric vaccination would change infection incidence in Germany. Transmission of four influenza strains was simulated in 100,000 individuals with German demography and contact structure. After initialization with the recorded trivalent influenza vaccination coverage for 20 years (1997-2016), all vaccinations were switched to quadrivalent influenza vaccine (QIV). Scenarios where vaccination coverage of children (0.5-17-year-old) was increased from the current value (4.3%) to a maximum of 10-60% were compared to baseline with unchanged coverage, averaging results of 1,000 pairs of simulations over a 20-year evaluation period (2017-2036). Pediatric vaccination coverage of 10-60% annually prevented 218-1,732 (6.3-50.5%) infections in children, 204-1,961 (2.9-28.2%) in young adults and 95-868 (3.1-28.9%) in the elderly in a population of 100,000 inhabitants; overall, 34.1% of infections in the total population (3.7 million infections per year in Germany) can be prevented if 60% of all children are vaccinated annually. 4.4-4.6 vaccinations were needed to prevent one infection among children; 1.7-1.8 were needed to prevent one in the population. Enhanced pediatric vaccination prevents many infections in children and even more in young adults and the elderly.
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Affiliation(s)
| | | | | | | | | | | | | | - Philipp Henneke
- Center for Chronic Immunodeficiency and Center for Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Markus Knuf
- Helios Dr Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | | | - Martin Eichner
- Epimos GmbH, Dusslingen, Germany.,University of Tübingen, Tübingen, Germany
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14
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Backer J, Wallinga J, Meijer A, Donker G, van der Hoek W, van Boven M. The impact of influenza vaccination on infection, hospitalisation and mortality in the Netherlands between 2003 and 2015. Epidemics 2019; 26:77-85. [DOI: 10.1016/j.epidem.2018.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 08/23/2018] [Accepted: 10/03/2018] [Indexed: 12/22/2022] Open
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15
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Do LAH, Mulholland K. How long are children protected by influenza vaccination? THE LANCET RESPIRATORY MEDICINE 2018; 6:889-891. [PMID: 30442591 DOI: 10.1016/s2213-2600(18)30463-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Lien Anh Ha Do
- Murdoch Children's Research Institute, Flemington Road, Parkville 3051, VIC, Australia
| | - Kim Mulholland
- Murdoch Children's Research Institute, Flemington Road, Parkville 3051, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; London School of Hygiene & Tropical Medicine, London, UK.
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16
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Backer JA, van Boven M, van der Hoek W, Wallinga J. Vaccinating children against influenza increases variability in epidemic size. Epidemics 2018; 26:95-103. [PMID: 30529023 DOI: 10.1016/j.epidem.2018.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/28/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023] Open
Abstract
Seasonal influenza causes a high disease burden. Many influenza vaccination programmes target the elderly and persons at high risk of complications. Some countries have recommended or even implemented a paediatric vaccination programme. Such a programme is expected to reduce influenza transmission in the population, offering direct protection to the vaccinated children and indirect protection to the elderly. We study the impact of a child vaccination programme with an age- and risk-structured transmission model, calibrated to data of 11 influenza seasons in the Netherlands. The model tracks the build-up of immunes and susceptibles in each age cohort over time, and it allows for seasonal variation in vaccine match and antigenic drift. Different vaccination strategies are evaluated for three target age groups (2-3, 2-12 and 2-16 year olds) over the full range of vaccination coverages (0-100%). The results show that the paediatric vaccination programme has only a limited impact on the elderly age groups, which account for most influenza morbidity and mortality. This is due to two notable changes in infection dynamics. First, an age shift is observed: influenza infections are reduced in vaccinated children, but are increased in young adults with limited natural immunity after years of vaccination. These young adults assume the role of driving the epidemic. Second, a year with low influenza activity can be followed by a large epidemic due to build-up of susceptibles. This variation of the infection attack rate increases with increasing vaccination coverage. The increased variability in the infection attack rate implies that health care facilities should be prepared for rare but larger peaks in influenza patients. Moreover, vaccinating the group with the highest transmission potential, results in a larger dependency on a secure vaccine supply. These arguments should be taken into account in the decision to introduce mass vaccination of school-aged children against influenza.
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Affiliation(s)
- J A Backer
- Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
| | - M van Boven
- Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - W van der Hoek
- Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - J Wallinga
- Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands; Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
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17
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López Trigo JA, López Mongil R, Mariano Lázaro A, Mato Chaín G, Moreno Villajos N, Ramos Cordero P. [Seasonal flu vaccination for older people: Evaluation of the quadrivalent vaccine. Positioning report]. Rev Esp Geriatr Gerontol 2018; 53 Suppl 2:185-202. [PMID: 30107941 DOI: 10.1016/j.regg.2018.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/22/2018] [Indexed: 01/08/2023]
Abstract
Influenza is a significant health problem, particularly in those persons susceptible to having associated complications, older people, children less than 2 years, patients with chronic diseases, immunocompromised patients, and pregnant women. But influenza also has a large impact on the health system, with an increase in the healthcare demand and a spectacular increase in outpatient visits, overloading the emergency and hospital services. During epidemic outbreaks, the hospital admission rates of people over 65 years are at a maximum, and the mortality notified for the 2017/2018 influenza season was 960 deaths. The seasonal anti-influenza vaccine is the method with a better cost-effective ratio of primary prevention of influenza, reducing associated respiratory diseases, the number of hospital admissions, and deaths in high risk individuals, as well as work absenteeism in adults. In the last few years, influenza B has received little attention in the scientific literature, although in the periods between epidemics influenza B can be one of the main causes of seasonal epidemics, causing considerable morbidity and mortality and an increase in costs. The quadrivalent vaccine has a second-line immunological protection against influenza B, and according to a critical review of the scientific literature, it provides wider protection without affecting immunogenicity of the other three vaccine strains common to the trivalent and tetravalent vaccine. The quadrivalent vaccine is cost-effective in reducing the number of influenza cases, and is always a worthwhile intervention, with a significant cost saving for the health system and for society, by reducing the hospital admission rates and mortality associated with the complications of influenza. Supplement information: This article is part of a supplement entitled 'Seasonal flu vaccination for older people: Evaluation of the quadrivalent vaccine' which is sponsored by Sanofi-Aventis, S.A.
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Affiliation(s)
- José Antonio López Trigo
- Geriatría, Ayuntamiento de Málaga. Presidencia de la Sociedad Española de Geriatría y Gerontología (SEGG), Málaga, España.
| | | | - Alberto Mariano Lázaro
- Medicina Preventiva y Salud Pública, Unidad de Epidemiología, Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Madrid, España
| | - Gloria Mato Chaín
- Medicina Preventiva y Salud Pública, Unidad de Vacunación del Adulto, Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Madrid, España
| | | | - Primitivo Ramos Cordero
- Coordinación médico-asistencial, Servicio Regional de Bienestar Social, Comunidad de Madrid, Madrid, España
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18
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Zhang N, Huang H, Su B, Ma X, Li Y. A human behavior integrated hierarchical model of airborne disease transmission in a large city. BUILDING AND ENVIRONMENT 2018; 127:211-220. [PMID: 32287976 PMCID: PMC7115769 DOI: 10.1016/j.buildenv.2017.11.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/06/2017] [Accepted: 11/06/2017] [Indexed: 05/19/2023]
Abstract
Epidemics of infectious diseases such as SARS, H1N1, and MERS threaten public health, particularly in large cities such as Hong Kong. We constructed a human behavior integrated hierarchical (HiHi) model based on the SIR (Susceptible, Infectious, and Recovered) model, the Wells-Riley equation, and population movement considering both spatial and temporal dimensions. The model considers more than 7 million people, 3 million indoor environments, and 2566 public transport routes in Hong Kong. Smallpox, which could be spread through airborne routes, is studied as an example. The simulation is based on people's daily commutes and indoor human behaviors, which were summarized by mathematical patterns. We found that 59.6%, 18.1%, and 13.4% of patients become infected in their homes, offices, and schools, respectively. If both work stoppage and school closure measures are taken when the number of infected people is greater than 1000, an infectious disease will be effectively controlled after 2 months. The peak number of infected people will be reduced by 25% compared to taking no action, and the time of peak infections will be delayed by about 40 days if 90% of the infected people go to hospital during the infectious period. When ventilation rates in indoor environments increase to five times their default settings, smallpox will be naturally controlled. Residents of Kowloon and the north part of Hong Kong Island have a high risk of infection from airborne infectious diseases. Our HiHi model reduces the calculation time for infection rates to an acceptable level while preserving accuracy.
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Affiliation(s)
- Nan Zhang
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong SAR, China
- Institute of Public Safety Research, Department of Engineering Physics, Tsinghua University, Beijing, China
| | - Hong Huang
- Institute of Public Safety Research, Department of Engineering Physics, Tsinghua University, Beijing, China
| | - Boni Su
- Electric Power Planning & Engineering Institute, Beijing, China
| | - Xun Ma
- Institute of Public Safety Research, Department of Engineering Physics, Tsinghua University, Beijing, China
| | - Yuguo Li
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong SAR, China
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19
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de Boer PT, van Maanen BM, Damm O, Ultsch B, Dolk FCK, Crépey P, Pitman R, Wilschut JC, Postma MJ. A systematic review of the health economic consequences of quadrivalent influenza vaccination. Expert Rev Pharmacoecon Outcomes Res 2017; 17:249-265. [PMID: 28613092 DOI: 10.1080/14737167.2017.1343145] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Quadrivalent influenza vaccines (QIVs) contain antigens derived from an additional influenza type B virus as compared with currently used trivalent influenza vaccines (TIVs). This should overcome a potential reduced vaccine protection due to mismatches between TIV and circulating B viruses. In this study, we systematically reviewed the available literature on health economic evaluations of switching from TIV to QIV. Areas covered: The databases of Medline and Embase were searched systematically to identify health economic evaluations of QIV versus TIV published before September 2016.A total of sixteen studies were included, thirteen cost-effectiveness analyses and three cost-comparisons. Expert commentary: Published evidence on the cost-effectiveness of QIV suggests that switching from TIV to QIV would be a valuable intervention from both the public health and economic viewpoint. However, more research seems mandatory. Our main recommendations for future research include: 1) more extensive use of dynamic models in order to estimate the full impact of QIV on influenza transmission including indirect effects, 2) improved availability of data on disease outcomes and costs related to influenza type B viruses, and 3) more research on immunogenicity of natural influenza infection and vaccination, with emphasis on cross-reactivity between different influenza B viruses and duration of protection.
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Affiliation(s)
- Pieter T de Boer
- a Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), Groningen Research Institute of Pharmacy , University of Groningen , Groningen , The Netherlands
| | - Britt M van Maanen
- a Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), Groningen Research Institute of Pharmacy , University of Groningen , Groningen , The Netherlands
| | - Oliver Damm
- b Department of Health Economics and Health Care Management, School of Public Health , Bielefeld University , Bielefeld , Germany
| | - Bernhard Ultsch
- c Immunisation Unit , Robert Koch Institute , Berlin , Germany
| | - Franklin C K Dolk
- a Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), Groningen Research Institute of Pharmacy , University of Groningen , Groningen , The Netherlands
| | - Pascal Crépey
- d Department of Quantitative Methods in Public Health , EHESP Rennes , Sorbonne Paris Cité, Rennes , France.,e UPRES-EA-7449 Reperes, University of Rennes 1 , Rennes , France
| | | | - Jan C Wilschut
- g Department of Medical Microbiology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Maarten J Postma
- a Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), Groningen Research Institute of Pharmacy , University of Groningen , Groningen , The Netherlands.,h Department of Epidemiology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands.,i Institute of Science in Healthy Aging & healthcaRE (SHARE) , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
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