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de Waure C, Gärtner BC, Lopalco PL, Puig-Barbera J, Nguyen-Van-Tam JS. Real world evidence for public health decision-making on vaccination policies: perspectives from an expert roundtable. Expert Rev Vaccines 2024; 23:27-38. [PMID: 38084895 DOI: 10.1080/14760584.2023.2290194] [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: 11/04/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023]
Abstract
INTRODUCTION Influenza causes significant morbidity and mortality, but influenza vaccine uptake remains below most countries' targets. Vaccine policy recommendations vary, as do procedures for reviewing and appraising the evidence. AREAS COVERED During a series of roundtable discussions, we reviewed procedures and methodologies used by health ministries in four European countries to inform vaccine recommendations. We review the type of evidence currently recommended by each health ministry and the range of approaches toward considering randomized controlled trials (RCTs) and real-world evidence (RWE) studies when setting influenza vaccine recommendations. EXPERT OPINION Influenza vaccine recommendations should be based on data from both RCTs and RWE studies of efficacy, effectiveness, and safety. Such data should be considered alongside health-economic, cost-effectiveness, and budgetary factors. Although RCT data are more robust and less prone to bias, well-designed RWE studies permit timely evaluation of vaccine benefits, effectiveness comparisons over multiple seasons in large populations, and detection of rare adverse events, under real-world conditions. Given the variability of vaccine effectiveness due to influenza virus mutations and increasing diversification of influenza vaccines, we argue that consideration of both RWE and RCT evidence is the best approach to more nuanced and timely updates of influenza vaccine recommendations.
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Affiliation(s)
- Chiara de Waure
- Public Health, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Barbara C Gärtner
- Department and Institute of Microbiology, Saarland University Hospital, Homburg, Germany
| | | | - Joan Puig-Barbera
- Foundation for the Promotion of Health and Biomedical Research of the Valencian Region, Valencia, Spain
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Haupt R, Baracco L, Harberts EM, Loganathan M, Kerstetter LJ, Krammer F, Coughlan L, Ernst RK, Frieman MB. Enhancing the protection of influenza virus vaccines with BECC TLR4 adjuvant in aged mice. Sci Rep 2023; 13:715. [PMID: 36639569 PMCID: PMC9838488 DOI: 10.1038/s41598-023-27965-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Influenza A virus (IAV) is a leading cause of respiratory disease worldwide often resulting in severe morbidity and mortality. We have previously shown that the Bacterial Enzymatic Combinatorial Chemistry (BECC) adjuvants, BECC438 and BECC470, formulated with an influenza virus hemagglutinin (HA) protein vaccine, offer greater protection from influenza virus challenge in mouse respiratory models using adult mice than standard HA:adjuvant combinations. In this study, we determined that immunization with HA + BECC adjuvants also significantly broadened the epitopes targeted on HA as compared with other adjuvants, resulting in increased titers of antibodies directed against the highly conserved HA stalk domain. Importantly, we demonstrate that BECC470 combined with an influenza virus HA protein antigen in a prime-only immunization regimen was able to achieve complete protection from challenge in a ~ 12-month-old mouse aged model. Together, this demonstrates the heightened protection provided by the BECC470 adjuvant in an influenza virus vaccine model and shows the enhanced immune response, as compared to other adjuvants elicited by the formulation of HA with BECC470.
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Affiliation(s)
- Robert Haupt
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, MD, USA
- Center for Pathogen Research, School of Medicine, University of Maryland, Baltimore, MD, USA
- Therapeutic Discovery Branch, Molecular Biology Division, USAMRIID, Fort Detrick, MD, USA
| | - Lauren Baracco
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, MD, USA
- Center for Pathogen Research, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Erin M Harberts
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, MD, USA
| | | | - Lucas J Kerstetter
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine, New York, NY, USA
- Center for Vaccine Research and Pandemic Preparedness (C-VARPP), Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pathology, Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lynda Coughlan
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, MD, USA
- Center for Vaccine Development and Global Health (CVD), University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Robert K Ernst
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, MD, USA
| | - Matthew B Frieman
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, MD, USA.
- Center for Pathogen Research, School of Medicine, University of Maryland, Baltimore, MD, USA.
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Jones-Gray E, Robinson EJ, Kucharski AJ, Fox A, Sullivan SG. Does repeated influenza vaccination attenuate effectiveness? A systematic review and meta-analysis. THE LANCET. RESPIRATORY MEDICINE 2023; 11:27-44. [PMID: 36152673 PMCID: PMC9780123 DOI: 10.1016/s2213-2600(22)00266-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Influenza vaccines require annual readministration; however, several reports have suggested that repeated vaccination might attenuate the vaccine's effectiveness. We aimed to estimate the reduction in vaccine effectiveness associated with repeated influenza vaccination. METHODS In this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and CINAHL Complete databases for articles published from Jan 1, 2016, to June 13, 2022, and Web of Science for studies published from database inception to June 13, 2022. For studies published before Jan 1, 2016, we consulted published systematic reviews. Two reviewers (EJ-G and EJR) independently screened, extracted data using a data collection form, assessed studies' risk of bias using the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) and evaluated the weight of evidence by Grading of Recommendations Assessment, Development, and Evaluation (GRADE). We included observational studies and randomised controlled trials that reported vaccine effectiveness against influenza A(H1N1)pdm09, influenza A(H3N2), or influenza B using four vaccination groups: current season; previous season; current and previous seasons; and neither season (reference). For each study, we calculated the absolute difference in vaccine effectiveness (ΔVE) for current season only and previous season only versus current and previous season vaccination to estimate attenuation associated with repeated vaccination. Pooled vaccine effectiveness and ∆VE were calculated by season, age group, and overall. This study is registered with PROSPERO, CRD42021260242. FINDINGS We identified 4979 publications, selected 681 for full review, and included 83 in the systematic review and 41 in meta-analyses. ΔVE for vaccination in both seasons compared with the current season was -9% (95% CI -16 to -1, I2=0%; low certainty) for influenza A(H1N1)pdm09, -18% (-26 to -11, I2=7%; low certainty) for influenza A(H3N2), and -7% (-14 to 0, I2=0%; low certainty) for influenza B, indicating lower protection with consecutive vaccination. However, for all types, A subtypes and B lineages, vaccination in both seasons afforded better protection than not being vaccinated. INTERPRETATION Our estimates suggest that, although vaccination in the previous year attenuates vaccine effectiveness, vaccination in two consecutive years provides better protection than does no vaccination. The estimated effects of vaccination in the previous year are concerning and warrant additional investigation, but are not consistent or severe enough to support an alternative vaccination regimen at this time. FUNDING WHO and the US National Institutes of Health.
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Affiliation(s)
- Elenor Jones-Gray
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC, Australia
| | - Elizabeth J Robinson
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC, Australia
| | - Adam J Kucharski
- Centre for the Mathematical Modelling of Infectious Diseases (CMMID), London School of Hygiene and Tropical Medicine, London, UK
| | - Annette Fox
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC, Australia; WHO Collaborating Centre for Reference and Research on Influenza, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Sheena G Sullivan
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC, Australia; WHO Collaborating Centre for Reference and Research on Influenza, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; Department of Epidemiology, University of California, Los Angeles, CA, USA.
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O Murchu E, Comber L, Jordan K, Hawkshaw S, Marshall L, O'Neill M, Ryan M, Teljeur C, Carnahan A, Pérez JJ, Robertson AH, Johansen K, Jonge JD, Krause T, Nicolay N, Nohynek H, Pavlopoulou I, Pebody R, Penttinen P, Soler-Soneira M, Wichmann O, Harrington P. Systematic review of the efficacy, effectiveness and safety of MF59 ® adjuvanted seasonal influenza vaccines for the prevention of laboratory-confirmed influenza in individuals ≥18 years of age. Rev Med Virol 2022; 33:e2329. [PMID: 35142401 DOI: 10.1002/rmv.2329] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 01/18/2023]
Abstract
The most effective means of preventing seasonal influenza is through vaccination. In this systematic review, we investigated the efficacy, effectiveness and safety of MF59® adjuvanted trivalent and quadrivalent influenza vaccines to prevent laboratory-confirmed influenza. A systematic literature search was conducted in electronic databases and grey literature sources up to 7 February 2020. Randomised controlled trials and non-randomised studies of interventions (NRSIs) were eligible for inclusion. The search returned 28,846 records, of which 48 studies on MF59® adjuvanted vaccines met our inclusion criteria. No efficacy trials were identified. In terms of vaccine effectiveness (VE), MF59® adjuvanted trivalent influenza vaccines were effective in preventing laboratory-confirmed influenza in older adults (aged ≥65 years) compared with no vaccination (VE = 45%, 95% confidence interval (CI) 23%-61%, 5 NRSIs across 3 influenza seasons). By subtype, significant effect was found for influenza A(H1N1) (VE = 61%, 95% CI 44%-73%) and B (VE = 29%, 95% CI 5%-46%), but not for A(H3N2). In terms of relative VE, there was no significant difference comparing MF59® adjuvanted trivalent vaccines with either non-adjuvanted trivalent or quadrivalent vaccines. Compared with traditional trivalent influenza vaccines, MF59® adjuvanted trivalent influenza vaccines were associated with a greater number of local adverse events (RR = 1.90, 95% CI 1.50-2.39) and systemic reactions (RR = 1.18, 95% CI 1.02-1.38). In conclusion, MF59® adjuvanted trivalent influenza vaccines were found to be more effective than 'no vaccination'. Based on limited data, there was no significant difference comparing the effectiveness of MF59® adjuvanted vaccines with their non-adjuvanted counterparts.
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Affiliation(s)
- Eamon O Murchu
- Health Information and Quality Authority (HIQA), Dublin, Ireland.,Department of Health Policy & Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Laura Comber
- Health Information and Quality Authority (HIQA), Dublin, Ireland
| | - Karen Jordan
- Health Information and Quality Authority (HIQA), Dublin, Ireland
| | - Sarah Hawkshaw
- Health Information and Quality Authority (HIQA), Dublin, Ireland
| | - Liam Marshall
- Health Information and Quality Authority (HIQA), Dublin, Ireland
| | - Michelle O'Neill
- Health Information and Quality Authority (HIQA), Dublin, Ireland
| | - Máirín Ryan
- Health Information and Quality Authority (HIQA), Dublin, Ireland.,Department of Pharmacology & Therapeutics, Trinity College Dublin, Trinity Health Sciences, Dublin, Ireland
| | - Conor Teljeur
- Health Information and Quality Authority (HIQA), Dublin, Ireland
| | | | - Jaime Jesús Pérez
- General Directorate of Public Health and Addictions, IMIB-Arrixaca. Murcia University, Region of Murcia, Spain
| | - Anna Hayman Robertson
- Division of Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Kari Johansen
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Jorgen de Jonge
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | | | - Nathalie Nicolay
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Hanna Nohynek
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Ioanna Pavlopoulou
- Pediatric Research Laboratory, School of Health Sciences, Faculty of Nursing National and Kapodistrian University of Athens, Athens, Greece.,National Advisory Committee on Immunisation, Hellenic Ministry of Health, Athens, Greece
| | - Richard Pebody
- Institute of Epidemiology & Health, University College London, London, UK
| | - Pasi Penttinen
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Marta Soler-Soneira
- Vigilancia de Enfermedades Prevenibles por Vacunación, Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, Madrid, Spain
| | - Ole Wichmann
- Immunization Unit, Robert Koch-Institute, Berlin, Germany
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Mira-Iglesias A, Demont C, López-Labrador FX, Mengual-Chuliá B, García-Rubio J, Carballido-Fernández M, Tortajada-Girbés M, Mollar-Maseres J, Schwarz-Chavarri G, Puig-Barberà J, Díez-Domingo J. Role of age and birth month in infants hospitalized with RSV-confirmed disease in the Valencia Region, Spain. Influenza Other Respir Viruses 2021; 16:328-339. [PMID: 34821055 PMCID: PMC8818825 DOI: 10.1111/irv.12937] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background RSV is the leading cause of hospital admissions in infants and the principal cause of bronchiolitis in young children. There is a lack of granular data on RSV‐associated hospitalization per season using laboratory confirmed results. Our current study addresses this issue and intends to fill this gap. Methods The study was conducted from 2014 through 2018, in 4 to 10 hospitals in the Valencia Region, Spain. Infants included in this study were admitted in hospital through the Emergency Department with a respiratory complaint and tested by RT‐PCR for RSV in a central laboratory. Results Incidence rates of RSV‐associated hospitalization varied by season and hospital. Overall, the highest incidence rates were observed in 2017/2018. RSV‐associated hospitalization was highest in infants below 3 months of age and in those born before or at the beginning of the RSV season. Almost 54% of total infants hospitalized with laboratory confirmed RSV were found to be born outside the season, from April to October. The RSV positivity rate by ICD‐10 discharged codes varied by season and age with results from 48% to 57% among LRI (J09‐J22). Conclusion The study was instrumental in bringing forth the time unpredictability of RSV epidemics, the critical impact of age, and the comparable distribution of RSV‐associated hospitalization in infants born on either side of the RSV season. These data could help in better characterization of the population that drives the healthcare burden and is crucial for the development of future immunization strategies, especially with upcoming vaccines in against RSV.
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Affiliation(s)
- Ainara Mira-Iglesias
- Área de Investigación en Vacunas, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO-Public Health), Valencia, Spain
| | - Clarisse Demont
- RSV Medical Evidence Generation, Sanofi Pasteur, Lyon, France
| | - F Xavier López-Labrador
- Laboratorio de Virología, Área de Genómica y Salud. Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO-Public Health), Valencia, Spain.,Consorcio de Investigación Biomédica de Epidemiología y Salud Pública (CIBER-ESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Mengual-Chuliá
- Laboratorio de Virología, Área de Genómica y Salud. Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO-Public Health), Valencia, Spain
| | - Javier García-Rubio
- Área de Investigación en Vacunas, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO-Public Health), Valencia, Spain
| | - Mario Carballido-Fernández
- Preventive Medicine, Hospital General Universitario de Castellón, Castellón de la Plana, Spain.,Medicine Department, Universidad CEU Cardenal Herrera, Castellón de la Plana, Spain
| | | | - Juan Mollar-Maseres
- Preventive Medicine, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Germán Schwarz-Chavarri
- Out-of-Hospital Family and Community Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Joan Puig-Barberà
- Área de Investigación en Vacunas, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO-Public Health), Valencia, Spain
| | - Javier Díez-Domingo
- Área de Investigación en Vacunas, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO-Public Health), Valencia, Spain
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- Área de Investigación en Vacunas, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO-Public Health), Valencia, Spain
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6
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Rose AMC, Kissling E, Gherasim A, Casado I, Bella A, Launay O, Lazăr M, Marbus S, Kuliese M, Syrjänen R, Machado A, Kurečić Filipović S, Larrauri A, Castilla J, Alfonsi V, Galtier F, Ivanciuc A, Meijer A, Mickiene A, Ikonen N, Gómez V, Lovrić Makarić Z, Moren A, Valenciano M. Vaccine effectiveness against influenza A(H3N2) and B among laboratory-confirmed, hospitalised older adults, Europe, 2017-18: A season of B lineage mismatched to the trivalent vaccine. Influenza Other Respir Viruses 2020; 14:302-310. [PMID: 32022450 PMCID: PMC7182608 DOI: 10.1111/irv.12714] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/09/2019] [Accepted: 12/15/2019] [Indexed: 01/22/2023] Open
Abstract
Background Influenza A(H3N2), A(H1N1)pdm09 and B viruses co‐circulated in Europe in 2017‐18, predominated by influenza B. WHO‐recommended, trivalent vaccine components were lineage‐mismatched for B. The I‐MOVE hospital network measured 2017‐18 seasonal influenza vaccine effectiveness (IVE) against influenza A(H3N2) and B among hospitalised patients (≥65 years) in Europe. Methods Following the same generic protocol for test‐negative design, hospital teams in nine countries swabbed patients ≥65 years with recent onset (≤7 days) severe acute respiratory infection (SARI), collecting information on demographics, vaccination status and underlying conditions. Cases were RT‐PCR positive for influenza A(H3N2) or B; controls: negative for any influenza. “Vaccinated” patients had SARI onset >14 days after vaccination. We measured pooled IVE against influenza, adjusted for study site, age, sex, onset date and chronic conditions. Results We included 3483 patients: 376 influenza A(H3N2) and 928 B cases, and 2028 controls. Most (>99%) vaccinated patients received the B lineage‐mismatched trivalent vaccine. IVE against influenza A(H3N2) was 24% (95% CI: 2 to 40); 35% (95% CI: 6 to 55) in 65‐ to 79‐year‐olds and 14% (95% CI: −22 to 39) in ≥80‐year‐olds. Against influenza B, IVE was 30% (95% CI: 16 to 41); 37% (95% CI: 19 to 51) in 65‐ to 79‐year‐olds and 19% (95% CI: −7 to 38) in ≥80‐year‐olds. Conclusions IVE against influenza B was similar to A(H3N2) in hospitalised older adults, despite trivalent vaccine and circulating B lineage mismatch, suggesting some cross‐protection. IVE was lower in those ≥80 than 65‐79 years. We reinforce the importance of influenza vaccination in older adults as, even with a poorly matched vaccine, it still protects one in three to four of this population from severe influenza.
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Affiliation(s)
| | | | - Alin Gherasim
- National Centre of Epidemiology, CIBERESP, Institute of Health Carlos III, Madrid, Spain
| | - Itziar Casado
- Navarra Public Health Institute, IdiSNA-CIBERESP, Pamplona, Spain
| | - Antonino Bella
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Odile Launay
- Inserm, F-CRIN, Innovative clinical research network in vaccinology (I-REIVAC), Paris, France.,CIC Cochin Pasteur, université Paris Descartes, Sorbonne Paris Cité, hôpital Cochin, AP-HP, Paris, France
| | - Mihaela Lazăr
- National Military-Medical Institute for Research and Development, Bucharest, Romania
| | - Sierk Marbus
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Monika Kuliese
- Department of Infectious diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ritva Syrjänen
- Finnish Institute for Health and Welfare, Tampere, Finland
| | - Ausenda Machado
- Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisbon, Portugal
| | - Sanja Kurečić Filipović
- Division for epidemiology of communicable diseases, Croatian Institute of Public Health, Zagreb, Croatia
| | - Amparo Larrauri
- National Centre of Epidemiology, CIBERESP, Institute of Health Carlos III, Madrid, Spain
| | - Jesús Castilla
- Navarra Public Health Institute, IdiSNA-CIBERESP, Pamplona, Spain
| | - Valeria Alfonsi
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Florence Galtier
- Inserm, F-CRIN, Innovative clinical research network in vaccinology (I-REIVAC), Paris, France.,CHU de Montpellier, Inserm CIC 1411, Hôpital Saint-Eloi, Montpellier, France
| | - Alina Ivanciuc
- National Military-Medical Institute for Research and Development, Bucharest, Romania
| | - Adam Meijer
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Aukse Mickiene
- Department of Infectious diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Niina Ikonen
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Verónica Gómez
- Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisbon, Portugal
| | - Zvjezdana Lovrić Makarić
- Division for epidemiology of communicable diseases, Croatian Institute of Public Health, Zagreb, Croatia
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