Developing a Framework for Public Involvement in Mathematical and Economic Modelling: Bringing New Dynamism to Vaccination Policy Recommendations

OBJECTIVES

The Mathematical and Economic Modelling for Vaccination and Immunisation Evaluation (MEMVIE) programme aimed to explore, capture and support the potential contribution of the public to mathematical and economic modelling, in order to identify the values that underpin public involvement (PI) in modelling and co-produce a framework that identifies the nature and type of PI in modelling and supports its implementation.

METHODS

We established a PI Reference Group, who worked collaboratively with the academic contributors to create a deliberative knowledge space, which valued different forms of knowledge, expertise and evidence. Together, we explored the key steps of mathematical and economic methods in 21 meetings during 2015-2020. These deliberations generated rich discussion, through which we identified potential points of public contribution and the values that underpin PI in modelling. We iteratively developed a framework to guide future practice of PI in modelling.

RESULTS

We present the MEMVIE Public Involvement Framework in two forms: a short form to summarise key elements, and a long form framework to provide a detailed description of each potential type of public contribution at each stage of the modelling process. At a macro level, the public can contribute to reviewing context, reviewing relevance, assessing data and justifying model choice, troubleshooting, and interpreting and reviewing outcomes and decision making. The underpinning values that drive involvement include the public contributing to the validity of the model, potentially enhancing its relevance, utility and transparency through diverse inputs, and enhancing the credibility, consistency and continuous development through scrutiny, in addition to contextualising the model within a wider societal view.

DISCUSSION AND CONCLUSION

PI in modelling is in its infancy. The MEMVIE Framework is the first attempt to identify potential points of collaborative public contribution to modelling, but it requires further evaluation and refinement that we are undertaking in a subsequent study.

Exploring the role of mass immunisation in influenza pandemic preparedness: A modelling study for the UK context

The nature and timing of the next influenza pandemic is unknown. This makes it difficult for policy makers to assess whether spending money now to prepare for mass immunisation in the event of a pandemic is worthwhile. We used simple epidemiological modelling and health economic analysis to identify the range of pandemic and policy scenarios under which plans to immunise the general UK population would have net benefit if a stockpiled vaccine or, alternatively, a responsively purchased vaccine were used. Each scenario we studied comprised a combination of pandemic, vaccine and immunisation programme characteristics in presence or absence of access to effective antivirals, with the chance of there being a pandemic each year fixed. Monetarised health benefits and cost savings from any influenza cases averted were set against the option, purchase, storage, distribution, administration, and disposal costs relevant for each scenario to give a discounted net present value over 10 years for planning to immunise, accounting for the possibility that there may be no pandemic over the period considered. To support understanding and exploration of model output, an interactive visualisation tool was devised and made available online. We evaluated over 29 million combinations of pandemic and policy characteristics. Preparedness plans incorporating mass immunisation show positive net present value for a wide range of scenarios, predominantly in the absence of effective antivirals. Plans based on the responsive purchase of vaccine have wider benefit than plans reliant on the purchase and maintenance of a stockpile if immunisation can start without extensive delays. This finding is not dependent on responsively purchased vaccine being more effective than stockpiled vaccine, but rather is driven by avoiding the costs of storing and replenishing a stockpile.

A method for evaluating the cost-benefit of different preparedness planning policies against pandemic influenza

•Our work presents a unifying method to calculate the net-benefit of different preparedness policies against different pandemic influeunza strains. Unlike previous methods, which have focused on evaluating specific strategies against specific pandemics, our method allows assessment of mass immunisation strategies in presence and absence of antiviral drugs for a large range of pandemic influenza strain characteristics and programme features. Overall, the model described here combines two parts to evaluate different preparedness planning policies against pandemic influenza.•The first part is adaptation of an existing transmission model for seasonal influenza to include generalisation across large number of pandemic influenza scenarios.•The second part is development of a tailor-made health economic model devised in collaboration with colleagues at the UK Department of Health and Social Care.

A method for evaluating and comparing immunisation schedules that cover multiple diseases: Illustrative application to the UK routine childhood vaccine schedule

BACKGROUND

In the UK, the childhood immunisation programme is given in the first 5 years of life and protects against 12 vaccine-preventable diseases. Recently, this programme has undergone changes with addition of vaccination against Meningitis B from September 2015 and the removal of the primary dose of protection against Meningitis C from July 2016. These hanges have direct impact on the associated diseases but in addition may induce indirect effects on the vaccines that are given simultaneously or later in the programme. In this work, we developed a novel formal method to evaluate the impact of vaccination changes to one aspect of the programme across an entire vaccine programme.

METHODS

Firstly, we combined transmission modelling (for four diseases) and historic data synthesis (for eight diseases) to project, for each disease, the disease burden at different levels of effective coverage against the associated disease. Secondly, we used a simulation model to determine the vector of effective coverage against each disease under three variations of the current childhood schedule. Combining these, we calculated the vector of disease burden across the programme under different scenarios, and assessed the direct and indirect effects of the schedule changes.

RESULTS

Through illustrative application of our novel framework to three scenarios of the current childhood immunisation programme in the UK, we demonstrated the feasibility of this unifying approach. For each disease in the programme, we successfully quantified the residual disease burden due to the change. For some diseases, the change was indirectly beneficial and reduced the burden, whereas for others the effect was adverse and the change increased the disease burden.

CONCLUSIONS

Our results demonstrate the potential benefit of considering the programme-wide impact of changes to an immunisation schedule, and our framework is an important step in the development of a means for systematically doing so.

A novel approach to evaluating the UK childhood immunisation schedule: estimating the effective coverage vector across the entire vaccine programme

Background

The availability of new vaccines can prompt policy makers to consider changes to the routine childhood immunisation programme in the UK. Alterations to one aspect of the schedule may have implications for other areas of the programme (e.g. adding more injections could reduce uptake of vaccines featuring later in the schedule). Colleagues at the Department of Health (DH) in the UK therefore wanted to know whether assessing the impact across the entire programme of a proposed change to the UK schedule could lead to different decisions than those made on the current case-by-case basis. This work is a first step towards addressing this question.

Methods

A novel framework for estimating the effective coverage against all of the diseases within a vaccination programme was developed. The framework was applied to the current (August 2015) UK childhood immunisation programme, plausible extensions to it in the foreseeable future (introducing vaccination against Meningitis B and/or Hepatitis B) and a “what-if” scenario regarding a Hepatitis B vaccine scare that was developed in close collaboration with DH.

Results

Our applications of the framework demonstrate that a programme-view of hypothetical changes to the schedule is important. For example, we show how introducing Hepatitis B vaccination could negatively impact aspects of the current programme by reducing uptake of vaccines featuring later in the schedule, and illustrate that the potential benefits of introducing any new vaccine are susceptible to behaviour changes affecting uptake (e.g. a vaccine scare). We show how it may be useful to consider the potential benefits and scheduling needs of all vaccinations on the horizon of interest rather than those of an individual vaccine in isolation, e.g. how introducing Meningitis B vaccination could saturate the early (2-month) visit, thereby potentially restricting scheduling options for Hepatitis B immunisation should it be introduced to the programme in the future.

Conclusions

Our results demonstrate the potential benefit of considering the programme-wide impact of changes to an immunisation schedule, and our framework is an important step in the development of a means for systematically doing so.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1299-8) contains supplementary material, which is available to authorized users.

School closures during the 2009 influenza pandemic: national and local experiences

BACKGROUND

School closure is a non-pharmaceutical intervention that was considered in many national pandemic plans developed prior to the start of the influenza A(H1N1)pdm09 pandemic, and received considerable attention during the event. Here, we retrospectively review and compare national and local experiences with school closures in several countries during the A(H1N1)pdm09 pandemic. Our intention is not to make a systematic review of country experiences; rather, it is to present the diversity of school closure experiences and provide examples from national and local perspectives.

METHODS

Data were gathered during and following a meeting, organized by the European Centres for Disease Control, on school closures held in October 2010 in Stockholm, Sweden. A standard data collection form was developed and sent to all participants. The twelve participating countries and administrative regions (Bulgaria, China, France, Hong Kong Special Administrative Region (SAR), Italy, Japan, New Zealand, Serbia, South Africa, Thailand, United Kingdom, and United States) provided data.

RESULTS

Our review highlights the very diverse national and local experiences on school closures during the A(H1N1)pdm09 pandemic. The processes including who was in charge of making recommendations and who was in charge of making the decision to close, the school-based control strategies, the extent of school closures, the public health tradition of responses and expectations on school closure varied greatly between countries. Our review also discusses the many challenges associated with the implementation of this intervention and makes recommendations for further practical work in this area.

CONCLUSIONS

The single most important factor to explain differences observed between countries may have been the different public health practises and public expectations concerning school closures and influenza in the selected countries.

The accuracy of external blood loss estimation by ambulance and hospital personnel

OBJECTIVE

To determine if emergency personnel, either ambulance or hospital based, can estimate the volume of external blood loss accurately enough to be of potential clinical use in guiding fluid resuscitation.

METHODS

A total of 61 ambulance and 35 hospital personnel viewed nine scenarios consisting of volumes of blood (100 mL, 400 mL and 700 mL) spilt onto three surfaces--carpet, vinyl and a clothed manikin. They were asked to estimate the blood loss in each case.

RESULTS

Estimates of volumes of blood loss on all surfaces were generally inaccurate. Both ambulance and hospital groups were comparable in this regard. Hospital personnel had higher mean estimates than those of ambulance personnel. Of particular clinical relevance were the findings that blood loss on carpet was underestimated and small volumes on a clothed manikin were overestimated.

CONCLUSION

External blood loss estimation by ambulance and hospital personnel is generally too inaccurate to be of clinical use.

The impact of trauma case management on patient outcomes

BACKGROUND

Previous investigations demonstrate that nursing case management in the acute care setting improves patient outcomes. However, these findings provide limited information specific to trauma patients.

METHOD

The effect of trauma case management (TCM) was measured using practice-specific variables such as in-hospital complications, missed injury rates, and length of stay. Other measures included staff satisfaction and use of allied health services. Data from 148 patients with an Injury Severity Score < 16 in the 5 months after the introduction of TCM were compared with 327 patients from the previous 12 months.

RESULTS

Results demonstrated a trend toward reduced length of stay overall, more so in the older and more severely injured. TCM greatly improved missed injury detection rates (p < 0.0015) and coordinated allied health use more efficiently (p < 0.0001). Staff surveys exhibited a perceived dramatic improvement in the effectiveness of patient care (p < 0.0001).

CONCLUSION

The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution.

Refractory hypotension in trauma: a case study

In the patient with blunt trauma, diagnosis of the cause of ongoing hypotension may be difficult. A number of causes may contribute to refractory hypotension, either alone or in combination. However, by following standard algorithms for the management of these patients, causes can be excluded or identified, then managed appropriately. The following case study highlights one of the diagnoses of exclusion for refractory hypotension in the blunt trauma victim. Ongoing considerations and implications for the nursing care of spinal injured patients are also discussed.

Endotracheal tube stability in the resuscitation environment

Evidence presented in the anaesthetic and emergency medical services literature warns of the possibility of accidental or insidious displacement of endotracheal tubes in intubated patients. In particular, there is evidence that head movement in intubated patients can lead to displacement of the distal tip of an endotracheal tube in the trachea while its depth markings remain fixed in relation to the patient's lips or teeth. Immobilisation of the heads of all intubated patients should be considered, to prevent the possibility of accidental endotracheal tube displacement. In addition, all intubated patients must be clinically assessed for proper endotracheal tube placement and maintenance of adequate ventilation after every movement during resuscitation and diagnostic measures.

Monoclonal immunoglobulin G1-kappa fibrillary glomerulonephritis

We report here a case of fibrillary glomerulonephritis arising in a 43-year-old man with a polyclonal gammopathy, who presented with progressive renal insufficiency, microscopic hematuria, and mild proteinuria (0.7 g/d). Ultrastructural studies showed deposits of randomly oriented fibrils in the glomerular mesangium and adjacent portions of some glomerular basement membranes, with a mean fibril thickness of 14.3 nm, highly consistent with fibrillary glomerulonephritis. The Congo red stain was negative on histologic sections. Immunofluorescence studies revealed strong mesangial and focal glomerular capillary staining for immunoglobulin (Ig) G, complement (C) 3, and kappa light chains, with minimal staining for IgA, IgM, C1q, or lambda light chains. The IgG present was entirely of the IgG1 subclass. This case is quite unusual for fibrillary glomerulonephritis, which typically presents with polyclonal IgG deposits and IgG4 as the dominant IgG subclass present. Monoclonal deposits are more frequently associated with immunotactoid glomerulopathy, characterized ultrastructurally by microtubule-like structures 30 to 50 nmn thick, often in parallel arrays. The present case illustrates that although fibrillary glomerulonephritis and immunotactoid glomerulopathy might be distinguishable on ultrastructural grounds, there is overlap between these two entities with respect to the potential composition of the glomerular deposits present.