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Takkinsatian P, Wannaphahoon K, Upapan P, Senawong S, Prommalikit O. Measles seroprevalence in Thailand: are adolescents and young adults at risk of measles? Singapore Med J 2024; 65:340-347. [PMID: 35651287 PMCID: PMC11232711 DOI: 10.11622/smedj.2022058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 01/06/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION During the last decade, measles has become an important re-emerging disease in Thailand. The objective of this study was to measure measles seroprevalence and its influencing factors so as to plan an improved vaccination programme. METHODS A total of 600 participants aged between 9 months and 50 years were divided into seven groups representing birth cohorts that experienced different measles vaccination policies. Participants' blood samples were obtained to measure measles immunoglobulin G (IgG) levels. RESULTS None of the participants in the age group of 9 months had measles IgG levels beyond a protective level. Participants in the age groups 2.5, 5-15, 16-29, 30-33, 34-40 and 41-50 years had 82% (95% confidence interval [CI] 73.3-90.7), 50% (95% CI 36.1-63.9), 52% (95% CI 42.3-62.7), 70% (95% CI 61.1-78.9), 88.8% (95% CI 84.1-93.5) and 98.8% (95% CI 96.4-100.0) measles seropositivity, respectively. The study did not find any significant factors affecting measles seropositivity. CONCLUSION Individuals aged 15-34 years are vulnerable to measles infections. Supplementary vaccination should be encouraged in special situations, including postexposure prophylaxis for young adults during an outbreak and for high-risk occupations such as healthcare personnel.
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Affiliation(s)
- Panit Takkinsatian
- Department of Pediatrics, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Kamolmart Wannaphahoon
- Department of Pediatrics, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Prasit Upapan
- Department of Medicine, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Sansnee Senawong
- Department of Immunology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Olarn Prommalikit
- Department of Pediatrics, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand
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Puthanakit T, Anugulruengkitt S, Angsuwatcharakon P, Bunjoungmanee P, Kowitdamrong E, Primsirikunawut A, Intarakhao S, Chetsonwisorn P, Sophonphan J, Tangsathapornpong A. Low Measles Seropositivity Rate among Thai Adolescents in the Thai National Immunization Program. Vaccines (Basel) 2022; 10:vaccines10081269. [PMID: 36016157 PMCID: PMC9412740 DOI: 10.3390/vaccines10081269] [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: 06/30/2022] [Revised: 08/02/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
To achieve the goal of measles elimination, herd immunity with 95% seroprotection in the community is required. This study aimed to describe the measles seropositivity rate among Thai children and adolescents. A cross-sectional study was conducted among children aged 3−18 years in Bangkok and its suburbs. Measles IgG antibodies were measured using a EUROIMMUN enzyme-linked immunosorbent assay kit. Seropositivity is defined as a measles IgG titer of ≥200 IU/L, due to a correlation with a >85% positive rate with a plaque reduction neutralizing titer of >120. Factors associated with seropositivity were analyzed using logistic regression analysis. From May to July 2020, 570 children with a median (IQR) age of 11.7 (9.4−14.8) years were enrolled. The geometric mean titer (GMT) of anti-measles IgG was 281 IU/L (95% CI; 257−306). The proportion of children with seropositivity was inversely correlated with age; 3−5 years 85.3%, 6−9 years 72.5%, 10−14 years 50.7%, and 15−18 years 56.3%. Adolescents aged 10−18 years had a lower measles seropositivity rate compared with young children; aOR 0.29 (95% CI 0.17−0.48). Only half of the adolescents who received two doses of measles-containing vaccine maintained measles IgG above the seropositive level. A measles booster dose for young adults may be needed to achieve the measles elimination goal.
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Affiliation(s)
- Thanyawee Puthanakit
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok 10330, Thailand
- Correspondence: ; Tel.: +66-22-564-930
| | - Suvaporn Anugulruengkitt
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok 10330, Thailand
| | | | - Pornumpa Bunjoungmanee
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
| | - Ekasit Kowitdamrong
- Division of Virology, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Athiwat Primsirikunawut
- National Institute of Thailand, Department of Medical Sciences, Ministry of Public Health, Nonthaburi 11000, Thailand
| | - Sukkrawan Intarakhao
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
| | - Panadda Chetsonwisorn
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok 10330, Thailand
| | - Jiratchaya Sophonphan
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok 10330, Thailand
| | - Auchara Tangsathapornpong
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
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The Concordance between Mumps and Rubella Sero-Positivity among the Israeli Population in 2015. Vaccines (Basel) 2022; 10:vaccines10070996. [PMID: 35891160 PMCID: PMC9319066 DOI: 10.3390/vaccines10070996] [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: 05/03/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 12/04/2022] Open
Abstract
Mumps and rubella are vaccine-preventable viral diseases through the measles-mumps-rubella-varicella (MMRV) vaccine, administered at 12 months and again at 6 years. We assessed the sero-prevalence of mumps and rubella, identified factors associated with sero-negativity, and evaluated concordance between mumps and rubella sero-positivity. A national cross-sectional sero-survey was conducted on samples collected in 2015 by the Israel National Sera Bank. Samples were tested for mumps and rubella IgG antibodies using an enzyme-linked immunosorbent assay. Of 3131 samples tested for mumps IgG, 84.8% (95%CI: 83.5–86.0%) were sero-positive. Sero-negativity for mumps was significantly associated with age (high odds ratios observed in infants younger than 4 years and 20–29 years old subjects). Of 3169 samples tested for rubella IgG antibodies, 95.2% (95%CI: 94.4–95.9%) were sero-positive. Rubella sero-negativity was significantly associated with age (high odds ratios observed in children younger than 4 years old and adults older than 30 years), males, Jews, and others. Concordant sero-positivity for both mumps and rubella viruses was observed in 83.9% of the tested samples. The Israeli population was sufficiently protected against rubella but not against mumps. Since both components are administered in the MMRV vaccine simultaneously, the mumps component has a lower uptake than rubella and quicker waning.
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High seroprevalence of rubella in Thai children with a 2-dose MMR national immunization policy. Vaccine 2021; 39:6206-6209. [PMID: 34556367 DOI: 10.1016/j.vaccine.2021.08.079] [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: 02/15/2021] [Revised: 07/14/2021] [Accepted: 08/22/2021] [Indexed: 11/20/2022]
Abstract
Rubella is generally a mild disease, but infection during pregnancy can cause congenital rubella syndrome. Thailand has implemented a two-dose MMR vaccination policy since 2010. This study aimed to describe the seroprevalence rate of rubella among children and adolescents in Thailand. We conducted a cross-sectional study of 132 healthy children (aged 3-9 years) who had received 2 doses of rubella vaccine and 424 adolescents (aged 10-18 years) who were expected to receive at least 1 dose of rubella vaccine. Stored serum samples from healthy children and recently drawn serum samples from adolescents were tested for rubella IgG antibody using a commercial enzyme-linked immunosorbent assay (ELISA) kit (EUROIMMUN). Seroprotection was defined as a rubella IgG level ≥ 10 IU/mL. The rubella seroprevalence rate among children and adolescents who had 2 documented doses of MMR was 97.0% (95 %CI 92.5-99.2%) and 85.4% (95% CI 78.8-90.6%, p < 0.01) respectively. The geometric mean titer of rubella was higher in children, 38.3 (95% CI 33.5-43.9) compared to adolescents, 22.5 (19.4-25.9) IU/mL. We observed an inverse correlation between the rubella titer and time interval from the second rubella containing vaccine dose (R = -0.30, p < 0.01). A 2-dose MMR vaccination course produces a high seroprevalence of rubella immunity in children, which decreases with time, suggesting waning of immunity. Thai clinical trials registry number TCTR20191120001.
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Seroprevalence of ToRCH Pathogens in Southeast Asia. Microorganisms 2021; 9:microorganisms9030574. [PMID: 33799699 PMCID: PMC7999562 DOI: 10.3390/microorganisms9030574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 11/17/2022] Open
Abstract
ToRCH is the acronym for several pathogens associated with pregnancy complications and sequelae in the unborn or newborn child. Particularly primary infections during pregnancy are associated with increased risk. Seroprevalence data of ToRCH infections are important, especially in countries with weak disease surveillance systems, to estimate immunity and vaccination levels, as well as exposure rates and thus the risk of infection during pregnancy. A systematic literature search spanning a 30-year time period was conducted to identify serosurveys on ToRCH pathogens in Southeast Asia. The 96 identified studies showed that some pathogens were well studied, while only limited data were available for others. Studies from the better-developed countries of the region were more abundant. Moreover, seroprevalence data were often limited to a certain geographical region within the country or to certain cohorts, there was an evident lack of recent serosurveys, and the study quality was often not adequate. Well-designed and area-wide serosurveys of ToRCH pathogens are clearly warranted. If combined with risk factor analysis, these studies may guide the development and implementation of effective measures for infection prevention, especially during pregnancy. In addition, educational programs for health care workers and for pregnant women during antenatal care are urgently needed.
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Ng Y, Chua LAV, Cui L, Ang LW, Tee NWS, Lin RTP, Ma S, Lee VJM. Seroprevalence of vaccine-preventable diseases among children and adolescents in Singapore: Results from the National Paediatric Seroprevalence Survey 2018. Int J Infect Dis 2019; 92:234-240. [PMID: 31843668 DOI: 10.1016/j.ijid.2019.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The Ministry of Health (MOH), Singapore, conducted the National Paediatric Seroprevalence Survey 2018 (NPSS 2018) to estimate the latest immunity levels against measles, rubella, varicella, diphtheria, tetanus and hepatitis B, and the seroprevalence of chronic hepatitis B virus (HBV) carriage in children and adolescents in Singapore. METHODS The survey involved prospective collection of residual sera from 1,200 children and adolescents aged 1-17 years in two public acute hospitals. Enzyme-linked immunosorbent assays (EIA) or plague reduction neutralisation tests (PRNT) were used to determine the seroprevalence of the vaccine-preventable diseases. RESULTS Overall prevalence of measles and rubella antibodies among Singaporean children and adolescents aged 1-17 years were 98.2% (95% CI: 91.2-98.8%) and 94.8% (95% CI: 93.4-95.9%) respectively. 97.1% (95% CI: 96.0-97.9%) of subjects had at least basic protection against diphtheria, while 89.3% (95% CI: 87.5-91.0%) were protected against tetanus. The prevalence of chronic HBV carriage was 0.4% (95% CI: 0.2-1.0%), while 45.7% (95% CI: 42.9-48.5%) were immune against HBV. The seroprevalence for varicella antibodies was 52.9% (95% CI: 50.1-55.7%). Concordance between vaccination status and seroprevalence was observed for measles, rubella, diphtheria and tetanus. CONCLUSION Singapore's children and adolescents are well-protected against measles, rubella, diphtheria and tetanus. Continual efforts in ensuring high vaccination coverage should be sustained.
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Affiliation(s)
- Yixiang Ng
- Epidemiology and Disease Control Division, Ministry of Health, Singapore
| | - Lily Ai Vee Chua
- Epidemiology and Disease Control Division, Ministry of Health, Singapore.
| | - Lin Cui
- National Public Health Laboratory, National Centre for Infectious Diseases, Singapore
| | - Li Wei Ang
- National Public Health and Epidemiology Unit, National Centre for Infectious Diseases, Singapore
| | - Nancy Wen Sim Tee
- National Public Health Laboratory, National Centre for Infectious Diseases, Singapore
| | - Raymond Tzer Pin Lin
- National Public Health Laboratory, National Centre for Infectious Diseases, Singapore
| | - Stefan Ma
- Epidemiology and Disease Control Division, Ministry of Health, Singapore
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Wanlapakorn N, Wasitthankasem R, Vichaiwattana P, Auphimai C, Yoocharoen P, Vongpunsawad S, Poovorawan Y. Antibodies against measles and rubella virus among different age groups in Thailand: A population-based serological survey. PLoS One 2019; 14:e0225606. [PMID: 31770412 PMCID: PMC6879141 DOI: 10.1371/journal.pone.0225606] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/07/2019] [Indexed: 12/16/2022] Open
Abstract
Measles and rubella are highly contagious viral diseases transmitted via respiratory secretions and aerosolized droplets. Thailand has implemented universal vaccination against measles using the monovalent measles (M) or the trivalent measles-mumps-rubella (MMR) vaccine for the past 30 years. Nevertheless, incidence of measles and rubella remains in some parts of the country. We conducted a seroprevalence study to evaluate the antibodies to measles and rubella virus among Thais of all ages and to determine pre-existing immunity resulting from either vaccination and/or natural exposure. A total of 1,781 serum samples collected in 2014 was tested for IgG to measles and rubella virus by commercial enzyme-linked immunosorbent assays (ELISA). Percentages of individuals with protective antibody levels and the geometric mean concentrations (GMC) of IgG in each age group were analysed. The GMC of anti-measles IgG and anti-rubella IgG were 653.7 IU/L (95% confidence interval (CI); 555.9–751.4) and 39.5 IU/mL (95% CI;35.0–43.9), respectively. Thais between the ages of six months and 25 years did not demonstrate sufficient protective herd immunity for measles. This observation is consistent with the recent measles outbreaks in this age group. Lower prevalence of immunity against rubella was found among children ages 5–6 years who may not have completed vaccination as infants. Our findings identify gaps in rubella and measles immunity in specific age groups and support recommendations for catch-up MMR vaccination in individuals 30 years of age or younger.
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Affiliation(s)
- Nasamon Wanlapakorn
- Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Academic Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Rujipat Wasitthankasem
- Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- National Biobank of Thailand, National Science and Technology Development Agency, Pathum Thani, Thailand
| | - Preeyaporn Vichaiwattana
- Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chompoonut Auphimai
- Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pornsak Yoocharoen
- Department of Disease Control, Division of Vaccine Preventable Diseases, Ministry of Public Health, Nonthaburi, Thailand
| | - Sompong Vongpunsawad
- Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yong Poovorawan
- Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- * E-mail:
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Ödemiş İ, Köse Ş, Akbulut İ, Albayrak H. Seroprevalence of measles, mumps, rubella, and varicella zoster virus antibodies among healthcare students: analysis of vaccine efficacy and cost-effectiveness. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32:525-531. [PMID: 31642641 PMCID: PMC6913082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aims of this study are to determine the seroprevalence for measles, mumps, rubella, and varicella zoster virus (VZV) in a cohort of nursing students, to evaluate vaccination response rates of nonimmune students, and to calculate the cost of vaccinating students based on seroprevalence screening. METHODS A cross-sectional study was conducted August 2015-November 2016 among 326 healthy nursing students aged 14.1-18.1 years. Serum IgG antibodies were measured by ELISA. Results were analyzed by the Chi-square test; a p-value of < 0.05 was considered statistically significant. RESULTS The number of seropositive participants (%) was 308 (94.5%) for rubella, 295 (90.5%) for VZV, 244 (74.9%) for measles, and 219 (67.2%) for mumps. A significant correlation was found between measles IgG and age. A relationship was also observed between VZV IgG and kindergarten attendance. Response rates to measles, rubella, VZV, and mumps vaccination were 96%, 92.3%, 87.5%, 78.8%, respectively. The total cost of vaccination after IgG screening was less than vaccination without screening. CONCLUSIONS In this study, participants' immunity to measles and VZV was low. Prevaccination serological screening was cost-effectiveness method for preventing measles, mumps, rubella, and varicella infections. We believe that administering booster measles, mumps, and rubella (MMR) vaccine doses or developing a special MMR vaccination strategy for at-risk groups may prevent MMR outbreaks.
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Affiliation(s)
- İlker Ödemiş
- Nigde Omer Halisdemir University, Training and Research Hospital, Infectious Diseases and Clinical Microbiology Clinic, Nigde, Turkey,Correspondence: İlker ÖdemişAşagi Kayabasi mah. Nigde Omer Halisdemir Universitesi, Egitim ve Arastirma Hastanesi Intaniye Poliklinigi Merkez/Nigde Phone: +90 505 416 30 35 Fax: +90 388 212 1411 E-mail:
| | - Şükran Köse
- University Of Health Sciences, Tepecik Training and Research Hospital, Infectious Diseases and Clinical Microbiology Clinic, İzmir, Turkey
| | - İlkay Akbulut
- University Of Health Sciences, Tepecik Training and Research Hospital, Infectious Diseases and Clinical Microbiology Clinic, İzmir, Turkey
| | - Hazal Albayrak
- University Of Health Sciences, Tepecik Training and Research Hospital, Infectious Diseases and Clinical Microbiology Clinic, İzmir, Turkey
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Caldera F, Misch EA, Saha S, Wald A, Zhang Y, Hubers J, Megna B, Ley D, Reichelderfer M, Hayney MS. Immunosuppression Does Not Affect Antibody Concentrations to Measles, Mumps, and Rubella in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2019; 64:189-195. [PMID: 30317494 DOI: 10.1007/s10620-018-5321-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 10/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Advisory Committee on Immunization Practices (ACIP) recommends using the immunization record and not serologic testing to determine immunity against measles and rubella in the general population, due to potential false negatives. However, it is unknown whether the immune response is less durable among patients who are immunosuppressed. AIMS The primary aim of this study was to evaluate sustained vaccine-induced measles, mumps, and rubella (MMR) antibody concentrations in immunosuppressed patients with inflammatory bowel disease (IBD). METHODS We performed a cross-sectional study to compare antibody concentrations following the two-dose (MMR) vaccine among 46 patients with IBD and 20 healthy controls (HC). Three IBD groups stratified by the immunosuppressive regimen that preceded study entry for at least 3 months: (1) thiopurine monotherapy, (2) anti-TNF monotherapy, or (3) combination therapy (anti-TNF agent combined with an immunomodulator) were enrolled. RESULTS All subjects had measurable antibody concentrations to the three vaccine viruses. Age and time since receipt of MMR series were similar in both groups. There were no difference in the antibody concentration of measles (IBD 667 mIU/ml vs HC 744 mIU/ml; p = 0.45), mumps (IBD 339 EU/ml vs HC 402 EU/ml; p = 0.62), or rubella (IBD 25 mIU/ml vs HC 62 mIU/ml; p = 0.11) among the groups. No differences in antibody concentrations were found among the IBD treatment groups. CONCLUSION Immunosuppressed patients with IBD have sustained antibody concentrations comparable to healthy controls. Thus, gastroenterologist should follow the ACIP recommendations and use the immunization record when available to determine immunity to measles and rubella in patients with IBD. Clinical Trials Registry # NCT02434133.
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Affiliation(s)
- Freddy Caldera
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin-Madison, 1685 Highland Avenue, Madison, WI, 53705-2281, USA.
| | - Elizabeth Ann Misch
- Department of Medicine, Division of Infectious Disease, School of Medicine and Public Health, University of Wisconsin-Madison, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - Sumona Saha
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin-Madison, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - Arnold Wald
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin-Madison, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - Youqi Zhang
- School of Pharmacy, School of Medicine and Public Health, University of Wisconsin-Madison, 777 Highland Avenue, Madison, WI, 53705, USA
| | - Jeffrey Hubers
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin-Madison, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - Bryant Megna
- School of Medicine and Public Health, University of Wisconsin-Madison, 750 Highland Avenue, Madison, WI, 53705, USA
| | - Dana Ley
- School of Medicine and Public Health, University of Wisconsin-Madison, 750 Highland Avenue, Madison, WI, 53705, USA
| | - Mark Reichelderfer
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin-Madison, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - Mary S Hayney
- School of Pharmacy, School of Medicine and Public Health, University of Wisconsin-Madison, 777 Highland Avenue, Madison, WI, 53705, USA
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Tang L, Zhou Y, Pan Y, Zhu H. Measles epidemics and seroepidemiology of population in Wujin, Changzhou city, Jiangsu province, China 2015. Vaccine 2017; 35:2925-2929. [PMID: 28433329 DOI: 10.1016/j.vaccine.2017.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/08/2017] [Accepted: 04/11/2017] [Indexed: 11/18/2022]
Abstract
The measles epidemic was rather severe in Wujin 2015, and a seroprevalence survey of measles antibody was conducted during June to September 2015 in Wjin district of Changzhou city. Blood samples were collected from community health population and convenient samples of residual blood from hospitals. Measles-specific IgG levels were measured by ELISA assay. A total of 122 measles cases were reported 2015 in Wujin district with an incidence of 8.31 per 100000 populations. A large proportion of measles cases were adults ≥20years (62.30%) and infants aged <18months (28.69%). Floating population accounted for 68.57% of all cases. 1070 blood samples aged from 9months to 49years old were collected and the overall seroprevalence and geometric mean titer (GMT) of measles were 82.71% and 551.19mIU/ml, respectively. Although the seroprevalence among children aged 9months to 4years was consistently over 90%, it began to decrease since 24months, and till the age of ≥10years, the seroprevalences were all <80%, however, the seroprevalence rised to above 80% in people over 40years. There were no significant differences between the two blood sample sources in the level of seroprevalence and GMT. Also no significant differences were observed in the seroprevalence of measles and GMT levels between genders. The seroprevalence and GMT in people with measles vaccination were higher than those without measles vaccination or people whose measles vaccination are unknown (P<0.001). Our study indicated that the adult measles cases have become a serious problem in Wujin district, which may mainly relate to the increasing size of the floating population with low measles vaccine coverage. The seroprevalence of measles decreased dramatically with increasing age since teenagers, which may mainly caused by waning vaccine-induced immunity. Therefore, it is necessary to strengthen measles vaccine in these people especially floating population.
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Affiliation(s)
- Lingyan Tang
- Department of Epidemic Prevention, Wujin District Center for Disease Control and Prevention, Changzhou 213164, Jiangsu Province, China.
| | - Yihong Zhou
- Department of Epidemic Prevention, Wujin District Center for Disease Control and Prevention, Changzhou 213164, Jiangsu Province, China
| | - Yingzi Pan
- Department of Epidemic Prevention, Wujin District Center for Disease Control and Prevention, Changzhou 213164, Jiangsu Province, China
| | - Hongming Zhu
- Department of Epidemic Prevention, Wujin District Center for Disease Control and Prevention, Changzhou 213164, Jiangsu Province, China
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Thompson KM, Odahowski CL, Goodson JL, Reef SE, Perry RT. Synthesis of Evidence to Characterize National Measles and Rubella Exposure and Immunization Histories. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2016; 36:1427-1458. [PMID: 26249328 DOI: 10.1111/risa.12454] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 06/04/2023]
Abstract
Population immunity depends on the dynamic levels of immunization coverage that countries achieve over time and any transmission of viruses that occur within the population that induce immunity. In the context of developing a dynamic transmission model for measles and rubella to support analyses of future immunization policy options, we assessed the model inputs required to reproduce past behavior and to provide some confidence about model performance at the national level. We reviewed the data available from the World Health Organization (WHO) and existing measles and rubella literature for evidence of historical reported routine and supplemental immunization activities and reported cases and outbreaks. We constructed model input profiles for 180 WHO member states and three other areas to support disease transmission model development and calibration. The profiles demonstrate the significant variability in immunization strategies used historically by regions and member states and the epidemiological implications of these historical choices. The profiles provide a historical perspective on measles and rubella immunization globally at the national level, and they may help immunization program managers identify existing immunity and/or knowledge gaps.
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Affiliation(s)
- Kimberly M Thompson
- Kid Risk, Inc, Orlando, FL, USA
- University of Central Florida, College of Medicine, Orlando, FL, USA
| | | | - James L Goodson
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Susan E Reef
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Thompson KM, Odahowski CL. Systematic Review of Measles and Rubella Serology Studies. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2016; 36:1459-1486. [PMID: 26077609 DOI: 10.1111/risa.12430] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Serological tests provide information about individual immunity from historical infection or immunization. Cross-sectional serological studies provide data about the age- and sex-specific immunity levels for individuals in the studied population, and these data can provide a point of comparison for the results of transmission models. In the context of developing an integrated model for measles and rubella transmission, we reviewed the existing measles and rubella literature to identify the results of national serological studies that provided cross-sectional estimates of population immunity at the time of data collection. We systematically searched PubMed, the Science Citation Index, and references we identified from relevant articles published in English. We extracted serological data for comparison to transmission model outputs. For rubella, serological studies of women of child-bearing age provide information about the potential risks of infants born with congenital rubella syndrome. Serological studies also document the loss of maternal antibodies, which occurs at different rates for the different viruses and according to the nature of the induced immunity (i.e., infection or vaccine). The serological evidence remains limited for some areas, with studies from developed countries representing a disproportionate part of the evidence. The collection and review of serological evidence can help program managers identify immunity gaps in the population, which may help them better understand the characteristics of individuals within their populations who may participate in transmission and manage risks.
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Affiliation(s)
- Kimberly M Thompson
- Kid Risk, Inc, Orlando, FL, USA
- University of Central Florida, College of Medicine, Orlando, FL, USA
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A 16-year review of seroprevalence studies on measles and rubella. Vaccine 2016; 34:4110-4118. [PMID: 27340097 DOI: 10.1016/j.vaccine.2016.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 05/15/2016] [Accepted: 06/01/2016] [Indexed: 01/31/2023]
Abstract
The determination of the seroprevalence of vaccine-preventable diseases is critical in monitoring the efficacy of vaccination programmes and to assess the gaps in population immunity but requires extensive organisation and is time and resource intensive. The results of the studies are frequently reported in peer-reviewed scientific, government and non-government publications. A review of scientific literature was undertaken to advise the development of WHO guidelines for the assessment of measles and rubella seroprevalence. A search of the National Library of Medicine's PubMed online publications using key words of 'measles', 'rubella', combined with 'serosurvey', 'seroprevalence', 'immunity' and 'population immunity' was conducted. A total of 97 articles published between January 1998 and June 2014 were retrieved, 68 describing serosurveys for measles and 58 serosurveys for rubella, conducted in 37 and 36 different countries respectively. Only 13 (19%) and 8 (14%) respectively were UN classified "least developed countries". The study sample varied markedly and included combinations of male and female infants, children, adolescents and adults. The study sizes also varied with 28% and 33% of measles and rubella studies respectively, having greater than 2000 participants. Microtitre plate enzyme immunoassays were used in 52 (76%) measles studies and 40 (69%) rubella studies. A total of 39 (57%) measles and 44 (76%) rubella studies reported quantitative test results. Seroprevalence ranged from 60.8% to 95.9% for measles and 53.0% to 99.3% for rubella studies. The review highlighted that infants lost maternally-acquired immunity within 9months of birth and were unprotected until vaccination. Two groups at higher risk of infection were identified: young adults between the ages of 15 and 30years and immigrants.
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Seroprevalence of antibodies to measles, mumps, and rubella, and serologic responses after vaccination among human immunodeficiency virus (HIV)-1 infected adults in Northern Thailand. BMC Infect Dis 2016; 16:190. [PMID: 27138005 PMCID: PMC4852403 DOI: 10.1186/s12879-016-1499-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 04/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND After the global implementation of national immunization programs for prevention of measles, mumps, and rubella (MMR), the prevalences of protective antibodies to these viruses are high in general population. However, there are limited data among human immunodeficiency virus (HIV)-1 infected individuals. This study aimed to determine the seroprevalence of antibodies to these viruses, and the serologic responses after vaccination among HIV-infected adults in Northern Thailand. METHODS A cross-sectional study was conducted in 500 HIV-infected adults, aged 20-59 years, receiving combination antiretroviral therapy, CD4 cell count ≥200 cells/mm(3), and plasma HIV-1 RNA <50 copies/mL, and 132 HIV-uninfected controls, aged 20-59 years, at Chiang Mai University Hospital during July and August 2011. Prevalences of protective antibodies to these viruses as well as serologic responses after MMR vaccination in those without protective antibody to at least one of the three viruses were compared between groups. RESULTS The prevalences of protective antibodies to measles, mumps, and rubella were 94.2, 55.0, and 84.6 % among HIV-infected adults, and 97.7, 67.5, and 89.4 % among HIV-uninfected controls, respectively. The prevalence of protective antibody to mumps was significantly lower in HIV-infected adults (p-value = 0.010). MMR vaccination was done in 249 HIV-infected and 46 HIV-uninfected controls; at week 8 to 12 after vaccination, the seroprotective rates against measles, mumps, and rubella in HIV-infected adults were 96.4, 70.7, and 98.0 %, respectively, whereas those in HIV-uninfected controls were 100, 87, and 100 %, respectively. No serious adverse effects were observed. CONCLUSIONS In contrast to measles and rubella, the prevalence of protective antibody to mumps was low in both HIV-infected adults and HIV-uninfected controls in northern Thailand. The seroprotective rates after MMR vaccination in both groups were considerably high, except only for mumps. Therefore, MMR vaccination should be considered in all HIV-infected adults receiving antiretroviral therapy with undetectable plasma HIV-1 RNA and CD4 cell count ≥200 cells/mm(3). TRIAL REGISTRATION ClinicalTrials.gov: NCT02724852 , registered on March 31, 2016.
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Gonwong S, Chuenchitra T, Khantapura P, Islam D, Mason CJ. Measles susceptibility in young Thai men suggests need for young adult measles vaccination: a cross sectional study. BMC Public Health 2016; 16:309. [PMID: 27067256 PMCID: PMC4827213 DOI: 10.1186/s12889-016-2987-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 03/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background Measles remains a major public health concern in Thailand despite the introduction of vaccination since 1984. Similar to other countries, Thailand has experienced numerous measles outbreaks including adult communities such as university student dormitories, prisons, refugee camps, and military recruit camps. These outbreaks raise questions on the seroprotective antibody level in Thai adults. Methods To better understand measles susceptibility in young Thai adults, a retrospective measles seroprevalence study on repository serum specimens obtained with informed consent from young Thai men entering the Royal Thai Army (RTA) during 2007–2008 was conducted. A total of 7760 stratified randomized samples were chosen by residence province. Measles IgG titer was measured using a commercial IgG quantitative ELISA kit following the manufacturer’s instructions. An antibody level ≥ 250 International Units per Liter (IU/L) was interpreted as seropositive. Results The overall measles seroprevalence was 78.5 % (95 % Confidence Interval: 77.6–79.4 %) with geometric mean titer of 738 IU/L (95 % Confidence Interval: 716–760 IU/L). The measles seroprevalence by province ranged from 59.6 % to 93.1 %. A trend of decreasing seroprevalence in the younger cohorts despite increasing immunization coverage was found. Lower seroprevalence than vaccination coverage was observed in the youngest age group. Conclusions To achieve long term measles control and elimination, an integrated two doses vaccination strategy has been implemented in children in Thailand. This nationwide measles seroprevalence study in young adult RTA recruits found a measles seroprevalence lower than WHO’s recommendation for measles outbreak prevention and elimination. These results raise concerns for measles control in Thailand. Supplementary immunization in young adults is essential especially in high-risk and densely populated communities to establish herd immunity for outbreak prevention and elimination.
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Affiliation(s)
- Siriphan Gonwong
- Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand.
| | - Thippawan Chuenchitra
- Division of Research, Armed Forces Research Institute of Medical Sciences, Bangkok, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Patchariya Khantapura
- Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Dilara Islam
- Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Carl J Mason
- Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
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Santacruz-Sanmartín E, Hincapié-Palacio D, Ospina MC, Perez-Toro O, Bernal-Restrepo LM, Buitrago-Giraldo S, Lenis-Ballesteros V, Díaz FJ. Seroprevalence of mumps in an epidemic period in Medellín, Colombia. Vaccine 2015; 33:5606-5612. [DOI: 10.1016/j.vaccine.2015.08.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 11/30/2022]
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Olaitan AE, Ella EE, Ameh JB. Comparative seroprevalence of measles virus immunoglobulin M antibodies in children aged 0-8 months and a control population aged 9-23 months presenting with measles-like symptoms in selected hospitals in Kaduna State. Int J Gen Med 2015; 8:101-8. [PMID: 25792852 PMCID: PMC4362903 DOI: 10.2147/ijgm.s79423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Measles remains the leading cause of vaccine-preventable childhood mortality in developing countries, with its greatest incidence in children younger than 2 years of age. The aim of this study was to determine the seroprevalence of measles virus in children (aged 0–8 months) and older children (aged 9–23 months) presenting with measles-like symptoms. Methods A total of 273 blood samples comprising 200 from children aged 0–8 months and 73 from children aged 9–23 months were collected and analyzed for measles virus IgM antibodies by enzyme-linked immunosorbent assay. Results An overall prevalence of 21.2% was obtained, with a prevalence of 6.5% in children aged 0–8 months and 61.6% in children aged 9–23 months. The prevalence of measles virus increased with age in children aged 0–8 months and decreased with age in older children (aged 9–23 months), showing a significant association between measles virus and age of the child (P=0.000). A higher prevalence was found in females (27.5%) than in males (16.3%) and this difference was significant (odds ratio 1.942, P=0.025). There was no significant association with the level of parental education, parental occupation, or number of children in the family (P>0.05). With respect to children’s vaccination status and breastfeeding, there was a significant association (P<0.05). The marital status of the family, place of residence, and household size showed no significant association with the prevalence of measles virus. However, a significant association was observed in relation to maternal measles history (odds ratio 2.535, P=0.005) and maternal vaccination status (odds ratio 1.791, P=0.049), as well as between measles virus infection and all presenting symptoms, except for vomiting, malaria, typhoid, and pneumonia, which showed no significant association (P>0.05). Conclusion The findings of this study confirm the presence of measles virus infection in children aged 0–8 months.
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Affiliation(s)
- A E Olaitan
- Department of Microbiology, Ahmadu Bello University, Zaria, Nigeria
| | - E E Ella
- Department of Microbiology, Ahmadu Bello University, Zaria, Nigeria
| | - J B Ameh
- Department of Microbiology, Ahmadu Bello University, Zaria, Nigeria
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Xiong Y, Wang D, Lin W, Tang H, Chen S, Ni J. Age-related changes in serological susceptibility patterns to measles: results from a seroepidemiological study in Dongguan, China. Hum Vaccin Immunother 2014; 10:1097-03. [PMID: 24448194 DOI: 10.4161/hv.27734] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The present study was performed to determine the seroprevalence of IgG measles antibodies in Dongguan residents (irrespective of vaccination status), to analyze the changes in age-related serological susceptibility patterns. A total of 1960 residents aged 0-60 years and 315 mother-infant pairs were studied. Serum IgG antibodies against measles virus were measured by ELISA. The overall seroprevalence was 93.4% in the general population in Dongguan, China. In subgroups aged 1-29 years who were likely vaccinated, there was a declining trend of seropositivity with age from 98.6% at 1-4 years to 85.7% at 20-29 years (P<0.0001). Seroprevalence were near or>95% in the older population (30-39 years and ≥ 40 years) who had not been immunized against measles. Age and sex were independent factors associated with seropositivity. Seroprevalence in pregnant women and their newborns was 87.0% and 84.1%, respectively. Our results suggest that the waning vaccine-induced immunity may be the main cause of increased serological susceptibility in young adults and young infants. An additional vaccination strategy that targets young adults is important for elimination of measles.
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Affiliation(s)
- Yongzhen Xiong
- School Clinic; Guangdong Medical College; Dongguan, PR China
| | - Dong Wang
- Department of Immunization Program; Dongguan Center for Disease Control and Prevention; Dongguan, PR China
| | - Weiyan Lin
- Department of Epidemiology and Biostatistics; Guangdong Medical College; Dongguan, PR China
| | - Hao Tang
- Department of Epidemiology and Biostatistics; Guangdong Medical College; Dongguan, PR China
| | - Shaoli Chen
- Department of Immunization Program; Dongguan Center for Disease Control and Prevention; Dongguan, PR China
| | - Jindong Ni
- Department of Epidemiology and Biostatistics; Guangdong Medical College; Dongguan, PR China
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Seroprevalence survey on measles, mumps, rubella and varicella antibodies in healthcare workers in Japan: sex, age, occupational-related differences and vaccine efficacy. Epidemiol Infect 2013; 142:12-9. [PMID: 23574767 PMCID: PMC3857110 DOI: 10.1017/s0950268813000393] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A seroprevalence survey on measles, mumps, rubella and varicella was conducted on healthcare workers (HCWs) at Shimane University Hospital, Japan utilizing an enzyme immunoassay. Of 1811 HCWs tested, 91.8% were seropositive to measles, 92.1% to mumps, 89.5% to rubella and 96.3% to varicella. Sex-related differences in seroprevalence were found in rubella (males vs. females: 84.7 vs. 92.2%, P < 0.001). Moreover, males aged 30-39 years were most susceptible to rubella (22.4%), which may be attributed to the design of childhood immunization programmes in Japan. Individuals aged ≤ 29 years were more susceptible to measles (14.3%) and mumps (10.9%), compared to other age groups. There were no significant sex- and age-related differences in varicella seroprevalence. The physician occupational group was more susceptible to rubella, but no significant occupational-related difference was observed in the other diseases. Susceptible subjects, with negative or equivocal serological results were given a vaccine which induced seroconversion in most vaccinees. Seroconversion occurred more frequently in the equivocal group than in the negative group. These findings provide a new insight for the seroprevalence survey of vaccine-preventable diseases in Japanese HCWs with special reference to vaccine efficacy.
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Waning population immunity to measles in Taiwan. Vaccine 2012; 30:6721-7. [DOI: 10.1016/j.vaccine.2012.05.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 04/30/2012] [Accepted: 05/02/2012] [Indexed: 11/20/2022]
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Seroprevalence of measles, mumps and rubella Antibodies in 18 months and 6.5 years old children: 6 months after measles-mumps-rubella (MMR) vaccination. Jundishapur J Microbiol 2012. [DOI: 10.5812/jjm.4563] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Replacing the measles ten-dose vaccine presentation with the single-dose presentation in Thailand. Vaccine 2011; 29:3811-7. [PMID: 21439313 DOI: 10.1016/j.vaccine.2011.03.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 03/02/2011] [Accepted: 03/04/2011] [Indexed: 11/23/2022]
Abstract
Introduced to minimize open vial wastage, single-dose vaccine vials require more storage space and therefore may affect vaccine supply chains (i.e., the series of steps and processes involved in distributing vaccines from manufacturers to patients). We developed a computational model of Thailand's Trang province vaccine supply chain to analyze the effects of switching from a ten-dose measles vaccine presentation to each of the following: a single-dose measles-mumps-rubella vaccine (which Thailand is currently considering) or a single-dose measles vaccine. While the Trang province vaccine supply chain would generally have enough storage and transport capacity to accommodate the switches, the added volume could push some locations' storage and transport space utilization close to their limits. Single-dose vaccines would allow for more precise ordering and decrease open vial waste, but decrease reserves for unanticipated demand. Moreover, the added disposal and administration costs could far outweigh the costs saved from preventing open vial wastage.
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