Childhood vaccination trends during 2019 to 2022 in Tanzania and the impact of the COVID-19 pandemic

The COVID-19 pandemic has significantly disrupted healthcare systems at all levels globally, notably affecting routine healthcare services, such as childhood vaccination. This study examined the impact of these disruptions on routine childhood vaccination programmes in Tanzania. We conducted a longitudinal study over four years in five Tanzanian regions: Mwanza, Dar es Salaam, Mtwara, Arusha, and Dodoma. This study analyzed the trends in the use of six essential vaccines: Bacille Calmette-Guérin (BCG), bivalent Oral Polio Vaccine (bOPV), Diphtheria Tetanus Pertussis, Hepatitis-B and Hib (DTP-HepB-Hib), measles-rubella (MR), Pneumococcal Conjugate Vaccine (PCV), and Rota vaccines. We evaluated annual and monthly vaccination trends using time-series and regression analyses. Predictive modeling was performed using an autoregressive integrated moving average (ARIMA) model. A total of 32,602,734 vaccination events were recorded across the regions from 2019 to 2022. Despite declining vaccination rates in 2020, there was a notable rebound in 2021, indicating the resilience of Tanzania's immunization program. The analysis also highlighted regional differences in vaccination rates when standardized per 1000 people. Seasonal fluctuations were observed in monthly vaccination rates, with BCG showing the most stable trend. Predictive modeling of BCG indicated stable and increasing vaccination coverage by 2023. These findings underscore the robustness of Tanzania's childhood immunization infrastructure in overcoming the challenges posed by the COVID-19 pandemic, as indicated by the strong recovery of vaccination rates post-2020. We provide valuable insights into the dynamics of vaccination during a global health crisis and highlight the importance of sustained immunization efforts to maintain public health.

Exploring future perspectives and pipeline progression in vaccine research and development

Introduction

The COVID-19 pandemic had a profound impact on vaccines' Research and Development, on vaccines' market, and on immunization programmes and policies. The need to promptly respond to the health emergency boostered resources' al-location and innovation, while new technologies were made available. Regulatory procedures were revised and expedited, and global production and distribution capacities significantly increased. Aim of this review is to outline the trajectory of research in vaccinology and vaccines' pipeline, highlighting major challenges and opportunities, and projecting future perspectives in vaccine preventables diseases' prevention and control.

Study Design

Narrative review.

Methods

We comprehensively consulted key biomedical databases including "Medline" and "Embase", preprint platforms, including"MedRxiv" and "BioRxiv", clinical trial registries, selected grey literature sources and scientific reports. Further data and insights were collected from experts in the field. We first reflect on the impact that the COVID-19 had on vaccines' Research and Development, regulatory frameworks, and market, we then present updated figures of vaccines pipeline, by different technologies, comparatively highlighting advantages and disadvantages. We conclude summarizing future perspectives in vaccines' development and immunizations strategies, outlining key challenges, knowledge gaps and opportunities for prevention strategies.

Results

COVID-19 vaccines' development has been largely supported by public funding. New technologies and expetited autho-rization and distribution processes allowed to control the pandemic, leading vaccines' market to grow exponentially. In the post-pandemic era investments in prevention are projected to decrease but advancements in technology offer great potential to future immunization strategies. As of 2023, the vaccine pipeline include almost 1,000 candidates, at different Research and Development phase, including innovative recombinant protein vaccines, nucleic acid vaccines and viral vector vaccines. Vaccines' technology platforms development varies by disease. Overall, vaccinology is progressing towards increasingly safe and effective products that are easily manufacturable and swiftly convertible.

Conclusions

Vaccine research is rapidly evolving, emerging technologies and new immunization models offer public health new tools and large potential to fight vaccines preventables diseases, with promising new platforms and broadened target populations. Real-life data analysis and operational research is needed to evaluate how such potential is exploited in public health practice to improve population health.

Trends and projections of age-appropriate vaccination coverage in 41 low- and middle- income countries in Asia and Sub-Saharan Africa, 2000-2030

Introduction

Routine immunization programs have focused on increasing vaccination coverage, which is equally important for decreasing vaccine-preventable diseases (VPDs), particularly in low- and lower-middle-income countries (LMICs). We estimated the trends and projections of age-appropriate vaccination coverage at the regional and national levels, as well as place of residence and wealth index in LMICs.

Methods

In total, 174 nationally representative household surveys from 2000 to 2020 from 41 LMICs were included in this study. Bayesian hierarchical regression models were used to estimate trends and projections of age-appropriate vaccination.

Results

The trend in coverage of age-appropriate Bacillus Calmette-Guérin (BCG), third dose of diphtheria, tetanus, and pertussis (DTP3), third dose of polio (polio3), and measles-containing vaccine (MCV) increased rapidly from 2000 to 2020 in LMICs. Findings indicate substantial increases at the regional and national levels, and by area of residence and socioeconomic status between 2000 and 2030. The largest rise was observed in East Africa, followed by South and Southeast Asia. However, out of the 41 countries, only 10 countries are estimated to achieve 90% coverage of the BCG vaccine by 2030, five of DTP3, three of polio3, and none of MCV. Additionally, by 2030, wider pro-urban and -rich inequalities are expected in several African countries.

Conclusion

Significant progress in age-appropriate vaccination coverage has been made in LMICs from 2000 to 2020. Despite this, projections show many countries will not meet the 2030 coverage goals, with persistent urban-rural and socioeconomic disparities. Therefore, LMICs must prioritize underperforming areas and reduce inequalities through stronger health systems and increased community engagement to ensure high coverage and equitable vaccine access.

Impact of the COVID-19 pandemic, its related social restriction measures and vaccination campaign on emergency department attendances for epileptic seizures: An interrupted time-series analysis

AIM

To investigate the impact of the outbreak of the COVID-19 pandemic, its related social restriction measure (national lockdown) and vaccination campaign on emergency department (ED) accesses for epileptic seizures.

METHODS

Retrospective observational analysis conducted on a consecutive cohort of patients who sought medical care at the ED of the General Hospital of Merano, Italy, from January 1, 2015, to December 31, 2021. We investigated the monthly ED attendances for epileptic seizures between the periods before and after the outbreak of the COVID-19 pandemic and the national lockdown (March 2020) using an interrupted time-series analysis with data standardized for 1000 accesses/month. As a further temporal cutoff, we used the start of the national vaccination campaign.

RESULTS

Between January 1, 2015, and December 31, 2021, a total of 415,005 ED attendances were recorded; 1,254 (0.3 %) were due to epileptic seizures. No significant difference was found in the rate of standardized ED accesses for epileptic seizures in March 2020 (time point of interest) to the pre-pandemic trend (0.33/1000; 95 %CI: -1.05 to 1.71; p = 0.637). Similarly, there was no difference between the pre- and post-pandemic trends (-0.02/1000; 95 %CI: -0.11 to 0.06; p = 0.600). When adopting January 2021 as time point of interest, we found no difference to the pre-vaccination trend (0.83/1000; 95 %CI: -0.48 to 2.15), and no difference in the pre- and post-vaccination trends (-0.12/1000; 95 %CI: -0.27 to 0.04).

CONCLUSIONS

The COVID-19 pandemic and its related social restrictions (lockdown), as well as the COVID-19 national vaccination campaign, had little impact on ED accesses for epileptic seizures.

The impact of free vaccination policies under the Korean Influenza National Immunization Program: Trends in influenza vaccination rates in South Korea from 2010 to 2019

Background

Annual vaccination for influenza is recommended for high-risk populations for its high morbidity and mortality. South Korea provides free influenza vaccination to some target groups under the National Immunization Program (NIP), and discrepantly high vaccination rates are observed in such populations. In this study, we analyzed the trends in influenza vaccination rates and evaluated the impact of the recent expansion of financial coverage to children ≤12 years and pregnant women.

Methods

We conducted a cross-sectional study with nationwide survey data from Korea National Health and Nutrition Examination Survey (KNHANES). From 2010 to 2019, we evaluated the trends in influenza vaccination rates of the following four target groups: children ≤12 years, adults ≥65 years, pregnant women, and people with chronic diseases.

Results

In total, 80,861 individuals were analyzed. From 2017 to 2019, the vaccination coverage of children ≤12 years increased from 66.2% to 83.1%; pregnant women from 44.1% to 68.5% (comparing the mean of 2010–2017 and 2018–2019, P <0.001 for both). The elderly ≥65 years showed the highest rates (85.8% in 2019), while people with chronic diseases marked the lowest (41.9% in 2019). People with liver diseases showed the lowest vaccination rate of 27.8%, while that of other common diseases ranged between 31.7–44.1%.

Conclusion

The discrepancy between target groups corresponds to their financial coverage under NIP. The recent expansion of financial aids to children ≤12 years and pregnant women was followed by significant increases in vaccination rates in both groups. We suggest that free vaccination policy is one of the most effective strategies to enhance vaccination coverage, and we call for its expansion to other under-vaccinated target groups, especially people with chronic diseases.

Estimating COVID-19 Infections, Hospitalizations, and Deaths Following the US Vaccination Campaigns During the Pandemic

This decision analytic modeling study uses a simulation model to evaluate the association of US COVID-19 vaccination campaigns with infections, hospitalizations, and deaths.

The World of Immunization: Achievements, Challenges, and Strategic Vision for the Next Decade

Immunization is among the most cost-effective public health interventions available and is estimated to have averted at least 37 million deaths between 2000 and 2019. Since the establishment of the Expanded Programme on Immunization in 1974, global vaccination coverage increased and the coverage gap between rich and poor countries decreased. Creation of Gavi, the Vaccine Alliance, in 2000 allowed the poorest countries in the world to benefit from new, life-saving vaccines and expand the breadth of protection against an increasing number of vaccine-preventable diseases. Despite this progress, inequities in access to and uptake of vaccines persist. Opportunities to realize the full potential of vaccines are within reach but require focused, tailored and committed action by Governments and immunization stakeholders. The Immunization Agenda 2030 provides a framework for action during the next decade to attain a world where everyone, everywhere, at every age fully benefits from vaccines for good health and well-being.

Overview of the United States' Immunization Program

This manuscript describes the history, background, and current structure of the United States Immunization Program, founded upon public- and private-sector partnerships that include federal agencies, state and local health departments, tribal nations and organizations, healthcare providers, vaccine manufacturers, pharmacies, and a multitude of additional stakeholders. The Centers for Disease Control and Prevention sets the U.S. adult and childhood immunization schedules based on recommendations from the Advisory Committee on Immunization Practices. We review the current immunization schedules; describe the set of surveillance and other systems used to monitor the health impact, coverage levels, and safety of recommended vaccines; and note significant challenges. Vaccines have reduced the incidence of many diseases to historic lows in the US, and have potential to further reduce the burden of respiratory and other infectious diseases in the United States. Though the United States vaccination program has had notable successes in reducing morbidity and mortality from infectious disease, challenges-including disparities in access and vaccine hesitancy-remain. Supporting access to and confidence in vaccines as an essential public health intervention will not only protect individuals from vaccine-preventable diseases; it will also ensure the country is prepared for the next pandemic.

Long-term effectiveness of population-wide multifaceted interventions for hepatocellular carcinoma in Taiwan

BACKGROUND & AIMS

Taiwan has launched a series of population-wide interventions to prevent hepatocellular carcinoma (HCC) related to hepatitis B and C virus infection since 1984. We took this opportunity to investigate the impact of each intervention on the incidence and case-fatality rate of HCC, and assessed their relative contributions to the overall reduction in mortality during this period.

METHODS

Population-based registry data on HCC mortality and incidence from individuals aged 0 to 84 years between 1979 and 2016 were collected before (Period 1) and after universal hepatitis B vaccination from 1984 (Period 2), universal health care from 1995 (Period 3), and viral hepatitis therapy from 2003 (Period 4). A Bayesian Poisson regression model was used for mortality decomposition analysis to estimate the respective contributions of these interventions to the reduction in age-specific incidence and case-fatality rates.

RESULTS

Mortality declined substantially in children, young- and middle-aged groups, but only slightly decreased in the elderly group. The declining trends in mortality were in part explained by incidence reduction and in part by a remarkable decline in case-fatality rate attributed to universal health care. Hepatitis B vaccination led to a 35.9% (26.8% to 44.4%) reduction in incidence for individuals aged 30 years or below, whereas antiviral therapy reduced the incidence of HCC by 14.9% (11.8% to 17.9%) and 15.4% (14.1% to 16.6%) for individuals aged 30-49 years and 50-69 years, respectively.

CONCLUSIONS

Vaccination and antiviral therapy were effective in reducing HCC incidence and mortality for the young and middle-aged groups, while the case-fatality rate was improved by universal health care for all age groups.

LAY SUMMARY

Since 1984, a series of population-wide interventions have been launched in Taiwan to prevent viral hepatitis-related hepatocellular carcinoma, including a universal hepatitis B vaccination program (from 1984), universal health care (from 1995), and a national viral hepatitis therapy program (from 2004). Vaccination and antiviral therapy were effective in reducing HCC incidence and mortality for the young and middle-aged groups, while the case-fatality rate was improved by universal health care for all age groups.

The Societal Value of Vaccination in the Age of COVID-19

In recent years, academics and policymakers have increasingly recognized that the full societal value of vaccination encompasses broad health, economic, and social benefits beyond avoided morbidity and mortality due to infection by the targeted pathogen and limited health care costs. Nevertheless, standard economic evaluations of vaccines continue to focus on a relatively narrow set of health-centric benefits, with consequences for vaccination policies and public investments.The COVID-19 pandemic illustrates in stark terms the multiplicity and magnitude of harms that infectious diseases may inflict on society. COVID-19 has overtaxed health systems, disrupted routine immunization programs, forced school and workplace closures, impeded the operation of international supply chains, suppressed aggregate demand, and exacerbated existing social inequities.The obvious nature of the pandemic's broad effects could conceivably convince more policymakers to identify and account for the full societal impacts of infectious disease when evaluating the potential benefits of vaccination. Such a shift could make a big difference in how we allocate societal resources in the service of population health and in how much we stand to gain from that spending.

Progress towards Eradication of Peste des Petits Ruminants through Vaccination

Peste des petits ruminants (PPR) is a transboundary viral disease that threatens more than 1.74 billion goats and sheep in approximately 70 countries globally. In 2015, the international community set the goal of eradicating PPR by 2030, and, since then, Food and Agriculture Organization of the United Nations (FAO) and World Organization for Animal Health (OIE) have jointly developed and implemented the Global Control and Eradication Strategy for PPR. Here, data from the United Nations Food and Agriculture Organization Statistical Database (FAOSTAT), the OIE World Animal Health Information System (WAHIS), Regional Roadmap Meetings, and countries' responses to PPR Monitoring and Assessment Tool (PMAT) questionnaires were analyzed to inform on current progress towards PPR eradication. OIE recorded the use of over 333 million doses of vaccine in 12 countries from 2015 to 2018, 41.8% of which were used in Asia and 58.2% in Africa. Between 2015 and 2019, a total of 12,757 PPR outbreaks were reported to OIE: 75.1% in Asia, 24.8% in Africa, and 0.1% in Europe. The number of global outbreaks in 2019 fell to 1218, compared with 3688 in 2015. Analysis of vaccine use and PPR outbreaks in countries indicates that disease control strategies, particularly vaccination campaigns and vaccine distribution strategies, still require scientific evaluation. It is imperative that vaccination is undertaken based on the epidemiology of the disease in a region and is coordinated between neighboring countries to restrict transboundary movements. Strengthening surveillance and post-vaccination sero-monitoring at the national level is also essential. The PPR vaccine stock/bank established by FAO, OIE, and other partners have improved the quality assurance and supply of vaccines. However, to achieve PPR eradication, filling the funding gap for vaccination campaigns and other program activities will be critical.

Dynamic changes in paediatric invasive pneumococcal disease after sequential switches of conjugate vaccine in Belgium: a national retrospective observational study

BACKGROUND

Ten-valent and 13-valent pneumococcal conjugate vaccines (PCVs) have shown important benefits by decreasing invasive pneumococcal disease caused by vaccine serotypes. Belgium had an uncommon situation with sequential use of PCV7, PCV13, and PCV10 in the childhood vaccination programmes between 2007 and 2018. We aimed to analyse the changes in incidence of invasive pneumococcal disease and serotype distribution in children throughout this period.

METHODS

Streptococcus pneumoniae isolates were obtained from patients with invasive pneumococcal disease in Belgium between 2007 and 2018 by the national laboratory-based surveillance. Paediatric invasive pneumococcal disease incidence, serotype distribution, and antimicrobial susceptibility were analysed in periods during which PCV7 (2009-10), PCV13 (2013-14), both PCV13 and PCV10 (2015-16), and PCV10 (2017-18) were used. Incidence rates and trends were compared. Vaccination status was collected. For a subset of serotype 19A isolates, multilocus sequence type was identified.

FINDINGS

After a decrease in PCV7 serotype invasive pneumococcal disease was observed during the PCV7 period, total paediatric invasive pneumococcal disease incidence significantly declined during the PCV13 period (-2·6% monthly, p<0·0001). During the PCV13-PCV10 period (2015-16), the lowest mean in paediatric invasive pneumococcal disease incidence was achieved, but the incidence increased again during the PCV10 period (2017-18), especially in children younger than 2 years (+1·7% monthly; p=0·028). This increase was mainly due to a significant rise in serotype 19A invasive pneumococcal disease incidence in the PCV10 period compared with the PCV13 period (p<0·0001), making serotype 19A the predominant serotype in paediatric invasive pneumococcal disease in the PCV10 period. Genetic diversity within the 2017-18 serotype 19A collection was seen, with two predominant clones, ST416 and ST994, that were infrequently observed before PCV10 introduction. In 2018, among children younger than 5 years with invasive pneumococcal disease who were correctly vaccinated, 37% (37 of 100) had PCV13 serotype invasive pneumococcal disease, all caused by serotype 19A and serotype 3.

INTERPRETATION

After a significant decrease during the PCV13 period, paediatric invasive pneumococcal disease incidence increased again during the PCV10 period. This observation mainly resulted from a significant increase of serotype 19A cases. During the PCV10 period, dominant serotype 19A clones differed from those detected during previous vaccine periods. Whether changes in epidemiology resulted from the vaccine switch or also from natural evolution remains to be further elucidated.

FUNDING

The Belgian National Reference is funded by the Belgian National Institute for Health and Disability Insurance and the whole genome sequencing by an investigator-initiated research grant from Pfizer.

Contextualised strategies to increase childhood and adolescent vaccination coverage in South Africa: a mixed-methods study

INTRODUCTION

Despite the unparalleled success of immunisation in the control of vaccine preventable diseases, immunisation coverage in South Africa remains suboptimal. While many evidence-based interventions have successfully improved vaccination coverage in other countries, they are not necessarily appropriate to the immunisation needs, barriers and facilitators of South Africa. The aim of this research is to investigate barriers and facilitators to optimal vaccination uptake, and develop contextualised strategies and implementation plans to increase childhood and adolescent vaccination coverage in South Africa.

METHODS

The study will employ a mixed-methods research design. It will be conducted over three iterative phases and use the Adopt, Contextualise or Adapt (ACA) model as an overarching conceptual framework. Phase 1 will identify, and develop a sampling frame of, immunisation stakeholders involved in the design, planning and implementation of childhood and human papillomavirus immunisation programmes in South Africa. Phase 2 will identify the main barriers and facilitators to, and solutions for, increasing vaccination coverage. This phase will comprise exploratory qualitative research with stakeholders and a review of existing systematic reviews on interventions for improving vaccination coverage. Using the findings from Phase 2 and the ACA model, Phase 3 will develop a set of proposed interventions and implementation action plans for improving immunisation coverage in South Africa. These plans will be discussed, revised and finalised through a series of participatory stakeholder workshops and an online questionnaire, conducted as part of Phase 3.

ETHICS

Ethical approval was obtained from the South African Medical Research Council (EC018-11/2018). No risks to participants are expected. Various steps will be taken to ensure the anonymity and confidentiality of participants.

DISSEMINATION

The study findings will be shared at stakeholder workshops, the website of Cochrane South Africa and academic publications and conferences.

[Measles vaccination: why and how?]

The measles virus is highly contagious and may hit non-immune populations very hard, as observed on remote islands. The first live-attenuated measles virus vaccine was registered in the United States in 1963, and was imported to the Netherlands from 1968 onwards. Production was taken over by the National Institute for Public Health (RIV). Because the burden of disease was still high, measles vaccination was introduced into the Dutch National Immunisation Programme in 1976; since 1987 this has been in the form of the combined measles, mumps and rubella (MMR) vaccination. The MMR vaccine was also initially imported and later manufactured by the National Institute for Public Health and the Environment (RIVM). Since then, measles epidemics have almost exclusively affected unvaccinated populations. Vaccinated individuals are thus well-protected, as are unvaccinated individuals as long as the rate of vaccination in the surrounding population is sufficiently high. Unvaccinated individuals who travel to countries where measles is endemic are still at a higher risk. Recent studies show that measles not only has the classical symptoms, but also damages the immune system.

[Routine vaccinations during SARS-CoV-2 epidemics]

The circulation of SARS-CoV-2 required the deplacement of resources from routine preventive activities to pandemic-related interventions. The vaccination services have been adapted to the individual territorial realities on the basis of virus circulation and restrictive measures put in place. The reduction of coverage with the consequent accumulation of susceptible subjects increases the risk of vaccine-preventable diseases' epidemics. Catch-up programs and strategies to optimize sessions, such as carrying out co-administrations, are in place on the national territory in order to reduce the risk.

Conscientious vaccination exemptions in kindergarten to eighth-grade children across Texas schools from 2012 to 2018: A regression analysis

BACKGROUND

As conscientious vaccination exemption (CVE) percentages rise across the United States, so does the risk and occurrence of outbreaks of vaccine-preventable diseases such as measles. In the state of Texas, the median CVE percentage across school systems more than doubled between 2012 and 2018. During this period, the proportion of schools surpassing a CVE percentage of 3% rose from 2% to 6% for public schools, 20% to 26% for private schools, and 17% to 22% for charter schools. The aim of this study was to investigate this phenomenon at a fine scale.

METHODS AND FINDINGS

Here, we use beta regression models to study the socioeconomic and geographic drivers of CVE trends in Texas. Using annual counts of CVEs at the school system level from the 2012-2013 to the 2017-2018 school year, we identified county-level predictors of median CVE percentage among public, private, and charter schools, the proportion of schools below a high-risk threshold for vaccination coverage, and five-year trends in CVEs. Since the 2012-2013 school year, CVE percentages have increased in 41 out of 46 counties in the top 10 metropolitan areas of Texas. We find that 77.6% of the variation in CVE percentages across metropolitan counties is explained by median income, the proportion of the population that holds a bachelor's degree, the proportion of the population that self-reports as ethnically white, the proportion of the population that is English speaking, and the proportion of the population that is under the age of five years old. Across the 10 top metropolitan areas in Texas, counties vary considerably in the proportion of school systems reporting CVE percentages above 3%. Sixty-six percent of that variation is explained by the proportion of the population that holds a bachelor's degree and the proportion of the population affiliated with a religious congregation. Three of the largest metropolitan areas-Austin, Dallas-Fort Worth, and Houston-are potential vaccination exemption "hotspots," with over 13% of local school systems above this risk threshold. The major limitations of this study are inconsistent school-system-level CVE reporting during the study period and a lack of geographic and socioeconomic data for individual private schools.

CONCLUSIONS

In this study, we have identified high-risk communities that are typically obscured in county-level risk assessments and found that public schools, like private schools, are exhibiting predictable increases in vaccination exemption percentages. As public health agencies confront the reemerging threat of measles and other vaccine-preventable diseases, findings such as ours can guide targeted interventions and surveillance within schools, cities, counties, and sociodemographic subgroups.

Global trends in measles publications

INTRODUCTION

Beginning with the 1960s, this review analyzes trends in publications on measles indexed by the National Library of Medicine from January 1960 to mid-2018. It notes both the growth in numbers of published papers, and the increasing number and proportion of publications, in the current century, of articles on such items as costing, measles elimination, and determinants of coverage.

METHODS

A two-person team extracted from the National Library of Medicine (NLM) homepage all citations on measles beginning in 1960 and continuing through mid-2018. These were then classified both by overall number and by subject matter, with tabular summaries of both by decade and by subject matter. The tabular presentation forms the basis for a discussion of the ten most frequently cited subjects, and publication trends, with a special emphasis on the current century.

RESULTS

As in the past, the most often currently published items have been on coverage and its determinants, measles elimination, outbreak reports, SSPE, and SIAs. The putative relationship between vaccination and autism saw a spurt of articles in the 1990s, rapidly declining after the IOM report rejecting the causative hypothesis.

CONCLUSION

There is a discussion on the sequencing of polio and measles eradication, the former unlikely before 2022, and an examination of likely research priorities as the world moves from measles control to measles eradication. There is a key role for social science in combatting vaccination reticence. The role of technical innovations, such as micropatch vaccination, is discussed.

Applying a Constrained Optimization Portfolio Model to Aid Prioritization of Public Health Interventions in Malaysia

OBJECTIVES

Countries have constrained healthcare budgets and must prioritize new interventions depending on health goals and time frame. This situation is relevant in the sphere of national immunization programs, for which many different vaccines are proposed, budgets are limited, and efficient choices must be made in the order of vaccine introduction.

METHODS

A constrained optimization (CO) model for infectious diseases was developed in which different intervention types (prophylaxis and treatment) were combined for consideration in Malaysia. Local experts defined their priority public health issues: pneumococcal disease, dengue, hepatitis B and C, rotavirus, neonatal pertussis, and cholera. Epidemiological, cost, and effectiveness data were informed from local or regionally published literature. The model aimed to maximize quality-adjusted life-year (QALY) gain through the reduction of events in each of the different diseases, under budget and intervention coverage constraints. The QALY impact of the interventions was assessed over 2 periods: lifetime and 20 years. The period of investment was limited to 15 years.

RESULTS

The assessment time horizon influenced the prioritization of interventions maximizing QALY gain. The incremental health gains compared with a uninformed prioritization were large for the first 8 years and declined thereafter. Rotaviral and pneumococcal vaccines were identified as key priorities irrespective of time horizon, hepatitis B immune prophylaxis and hepatitis C treatment were priorities with the lifetime horizon, and dengue vaccination replaced these with the 20-year horizon.

CONCLUSIONS

CO modeling is a useful tool for making economically efficient decisions within public health programs for the control of infectious diseases by helping prioritize the selection of interventions to maximize health gain under annual budget constraints.

Trends in vaccine investment in middle income countries

Although a proven and effective preventive health measure, childhood immunization programs remain vulnerable to budgetary pressures. Sustainable financing of immunization programs is an important issue that presents a challenge for middle-income countries (MIC) in particular, in part due to technological advances meaning more vaccines are available. This study aimed to analyse trends in immunization program investment across 15 MIC selected based on availability of data, income level classification, and regional representativeness. We assessed investment trends in relation to vaccine coverage, vaccine access, and broader health indicators. Immunization and expenditure data were obtained from the World Health Organisation (WHO) database and the WHO UNICEF Joint Reporting Form and WHO Vaccine Product, Price and Procurement from 2006-2016. We calculated a weighted average index of vaccine commitment (WAIVC) based on vaccine coverage, vaccine scope, and weighted by vaccine innovation measured by approximating vaccine expenditure. Correlation analyses were conducted between immunization expenditure per-capita and each WAIVC, infant mortality and life expectancy. Correlation analyses at a global and individual country level indicate an improvement in immunization access, vaccination commitment measured by WAIVC, and scope of available vaccines in countries with sustained increases in vaccination funding. Increases in national immunization expenditure were correlated with reduced infant mortality and increased life expectancy. Vaccine expenditure comprises a small proportion (less than 2%) of total healthcare spending and has not uniformly increased in accordance with the scope of available vaccines. The present analysis supports the premise that countries with consistent increases in vaccine expenditure have increased vaccine coverage and commitment measured by WAIVC and improved broader health outcomes, indicating the value of sustained investment in vaccination for improved population health. The benefits of vaccine expenditure in this holistic fashion are critical to inform policy decisions on national budget allocation for vaccine funding.

Four Italian experiences on vaccination policies: results and lessons

INTRODUCTION

In 2018 the Council of Europe adopted a Recommendation on strengthened cooperation against vaccine preventable diseases. Among EU Member States, Italy has a long-lasting tradition of immunization policies implemented in the context of the National Health Service over the last forty years.

METHODS

We identify, report and critically appraise four immunization strategies implemented in Italy in recent years and quantitatively assess their impact on coverage rates and other selected indicators.

RESULTS

First: the regional law that suspended mandatory vaccination in the Veneto Region in 2007 to stimulate a proactive approach to vaccine uptake was not successful. Second: a strengthened political commitment started in 2014 brought to the release of an innovative and updated National Immunization Prevention Plan and to encouraging increase in vaccine confidence and vaccination uptake. Third: the success of social media influencers is exemplified by the case of Roberto Burioni, professor of microbiology, who in 2015 started a personal social media campaign to contrast anti-vaccinists. Fourth: The new 2017 Italian law extending mandatory vaccinations has successfully impacted on vaccine coverage which increased by more than 1% and 4% for polio and MMR vaccines, respectively, in the first six months since its entering into force, and has continued to raise in 2018.

CONCLUSION

Our data and real-life case studies offer to the broader European public health community a solid basis for discussion and ground to evaluate similar polices implemented in different European settings, with the common goal to share best practices and promote the culture of immunization.

360 Years of Measles: Limiting Liberty Now for a Healthier Future

The United States Supreme Court has upheld state vaccination mandates as a condition of entry to schools by relying on their police power in protecting public health and safety. Despite this broad authority, many state mandates include exemptions that permit parents to refuse vaccination on behalf of their children for nonmedical reasons, like religious, philosophical, or personal beliefs. A spectrum of these laws currently exists, ranging from California's ban of all nonmedical claims to Ohio's extremely permissive grant of exemptions. This article discusses each of these states' mandates and the relationship between relaxed exemption laws and measles outbreaks using statistical analyses. To curb the spread of this vaccine-preventable disease, states should consider the threat to public health paramount to individual liberty infringement by restricting access to nonmedical exemptions. This approach aligns with a century of case law that has rejected vaccination mandate challenges based on fundamental rights, religious freedom, equal protection, and due process. Now states must act within that authority to safeguard against the persistence of this potentially fatal disease.

Lessons learned from the 2009-2010 H1N1 outbreak for the management of the 2013 silent polio outbreak

BACKGROUND

The Israeli Ministry of Health (MoH) encountered two substantial outbreaks during the past decade: the H1N1 swine flu outbreak during 2009-2010 and the silent polio outbreak during 2013. Although both outbreaks share several similar characteristics, the functioning of the Israeli MoH was different for each case. The aim of this study was to identify factors that contributed to the change in the MoH response to the polio outbreak in light of the previous 2009-2010 H1N1 outbreak.

METHODS

We conducted a qualitative research using semi-structured interviews with 18 Israeli policymakers from the MoH, relevant specialists and politicians. Each interview was transcribed and a thematic analysis was conducted independently by two researchers.

RESULTS

Three main themes were found in the interview analysis, which reflect major differences in the MoH management policy during the polio outbreak. 1) clinical and epidemiological differences between the two disease courses, 2) differences in the functioning of the MoH during the outbreaks, 3) differences in the risk communication strategies used to reach out to the local health community and the general public. Most interviewees felt that the experience of the 2009-2010 H1N1 outbreak which was perceived as unsuccessful, fueled the MoH engagement and proactiveness in the later polio outbreak.

CONCLUSION

These findings highlight the importance of learning processes within health care organizations during outbreaks and may contribute to better performance and higher immunization rates.

Impact of Pharmacist Immunization Authority on Seasonal Influenza Immunization Rates Across States

PURPOSE

The goal of this study was to investigate the impact on immunization rates of policy changes that allowed pharmacists to administer influenza immunizations across the United States.

METHODS

Influenza immunization rates across states were compared before and after policy changes permitting pharmacists to administer influenza immunizations. The study used Behavioral Risk Factor Surveillance System (BRFSS) survey data on influenza immunization rates between 2003 and 2013. Logistic regression models were constructed and incorporated adjustments for the complex sample design of the BRFSS to predict the likelihood of a person receiving an influenza immunization based on various patient health, demographic, and access to care factors.

FINDINGS

Overall, as states moved to allow pharmacists to administer influenza immunizations, the odds that an adult resident received an influenza immunization rose, with the effect increasing over time. The average percentage of people receiving influenza immunizations in states was 35.1%, rising from 32.2% in 2003 to 40.3% in 2013. The policy changes were associated with a long-term increase of 2.2% to 7.6% in the number of adults aged 25 to 59 years receiving an influenza immunization (largest for those aged 35-39 years) and no significant change for those younger or older.

IMPLICATIONS

These findings suggest that pharmacies and other nontraditional settings may offer accessible venues for patients when implementing other public health initiatives.

Epidemiology of Diphtheria in India, 1996-2016: Implications for Prevention and Control

Diphtheria is an acute disease caused by exotoxin-producing Corynebacterium diphtheriae. Globally, diphtheria has been showing a declining trend due to effective childhood vaccination programs. A substantial proportion of global burden of diphtheria is contributed by India. Hospital-based surveillance studies as well as diphtheria outbreaks published in last 20 years (1996-2016) indicate that diphtheria cases are frequent among school-going children and adolescents. In some Indian states, Muslim children are affected more. As per the national level health surveys, coverage of three doses of diphtheria vaccine was 80% during 2015-2016. Information about coverage of diphtheria boosters is not routinely collected through these surveys, but is expected to be low. Few studies also indicate low diphtheria immunity among school-going children and adults. The strategies for prevention of diphtheria need to focus on improving coverage of primary and booster doses of diphtheria vaccines administered as a part of Universal Immunization Program as well as introducing diphtheria vaccine for school-going children.

Differences in Human Papillomavirus Vaccination Among Adolescent Girls in Metropolitan Versus Non-metropolitan Areas: Considering the Moderating Roles of Maternal Socioeconomic Status and Health Care Access

OBJECTIVES

This study is among the first to examine metropolitan status differences in human papillomavirus (HPV) vaccine initiation and completion among United States adolescent girls and is unique in its focus on how maternal socioeconomic status and health care access moderate metropolitan status differences in HPV vaccination.

METHODS

Using cross-sectional data from 3573 girls aged 12-17 in the U.S. from the 2008-2010 Behavioral Risk Factor Surveillance System, we estimate main and interaction effects from binary logistic regression models to identify subgroups of girls for which there are metropolitan versus non-metropolitan differences in HPV vaccination.

RESULTS

Overall 34 % of girls initiated vaccination, and 19 % completed all three shots. On average, there were no metropolitan status differences in vaccination odds. However, there were important subgroup differences. Among low-income girls and girls whose mothers did not complete high school, those in non-metropolitan areas had significantly higher probability of vaccine initiation than those in metropolitan areas. Among high-income girls and girls whose mothers completed college, those in metropolitan areas had significantly higher odds of vaccine initiation than those in non-metropolitan areas. Moreover, among girls whose mothers experienced a medical cost barrier, non-metropolitan girls were less likely to initiate vaccination compared to metropolitan girls.

CONCLUSIONS

Mothers remain essential targets for public health efforts to increase HPV vaccination and combat cervical cancer. Public health experts who study barriers to HPV vaccination and physicians who come into contact with mothers should be aware of group-specific barriers to vaccination and employ more tailored efforts to increase vaccination.

[Review of the 2016 Swiss immunization schedule and technology update for improving vaccine management]

The 2016 immunization schedule published by the Swiss Federal Office of Public Health includes three new clauses: reimbursement of the additional Human Papillomavirus (HPV) vaccination in young males (11-26 years) as recommended by local canton programs, the end of franchise exemption for the measles, mumps and rubella (MMR) vaccination, and the creation of a new system of indemnities and moral compensation in the event of personal injury resulting from vaccinations. This article presents the main features of the 2016 immunization schedule with details of the technology available to physicians to improve vaccine management.

The Future of the RTS,S/AS01 Malaria Vaccine: An Alternative Development Plan

Roly Gosling and Lorenz von Seidlein consider a potential future development plan for the RTS,S/AS01 malaria vaccine.

VACCINATION--COLLECTIVE RESPONSIBILITY OR VIOLATION OF RIGHTS?

Vaccination is considered to be the most effective and the cheapest medical intervention through which individual and collective immunisation is achieved. Statistics show that, at present, immunisation annually saves 400 million lives and protects approximately 750,000 children against disabilities of varying degrees. Approximately 80% of worldwide children are vaccinated against diphtheria, tetanus, pertussis, polio, measles, etc.; these diseases used to be considered incurable in the past. Vaccines help the body to produce antibodies; they help the immune system to detect germs and inactivate their cells. The immunological protection is installed after a variable period of time following the inoculation and is long lasting. Immunisations can be achieved in several ways: through national immunisation campaigns with general recommendation--they may be compulsory, optional or prophylactic (for the diseases for which a vaccine is available); vaccinations not included in the compulsory immunisation programmes; they may also be targeted to the contagious infectious outbreaks or to groups of population in certain situations. There is no guarantee that a vaccine will provide 100% protection. However, it will significantly reduce the risk of getting an infection. Vaccines have side effects which can be divided into reactions triggered by the vaccine or reactions exacerbated by it, without a causal relationship to the vaccine.

National Immunization Program: Computerized System as a tool for new challenges

The scope and coverage of the Brazilian Immunization Program can be compared with those in developed countries because it provides a large number of vaccines and has a considerable coverage. The increasing complexity of the program brings challenges regarding its development, high coverage levels, access equality, and safety. The Immunization Information System, with nominal data, is an innovative tool that can more accurately monitor these indicators and allows the evaluation of the impact of new vaccination strategies. The main difficulties for such a system are in its implementation process, training of professionals, mastering its use, its constant maintenance needs and ensuring the information contained remain confidential. Therefore, encouraging the development of this tool should be part of public health policies and should also be involved in the three spheres of government as well as the public and private vaccination services.

After 2015: infectious diseases in a new era of health and development

Running over timescales that span decades or centuries, the epidemiological transition provides the central narrative of global health. In this transition, a reduction in mortality is followed by a reduction in fertility, creating larger, older populations in which the main causes of illness and death are no longer acute infections of children but chronic diseases of adults. Since the year 2000, the Millennium Development Goals (MDGs) have provided a framework for accelerating the decline of infectious diseases, backed by a massive injection of foreign investment to low-income countries. Despite the successes of the MDGs era, the inhabitants of low-income countries still suffer an enormous burden of disease owing to diarrhoea, pneumonia, HIV/AIDS, tuberculosis, malaria and other pathogens. Adding to the predictable burden of endemic disease, the threat of pandemics is ever-present and global. With a view to the future, this review spotlights five aspects of the fight against infection beyond 2015, when the MDGs will be replaced by a new set of goals for poverty reduction and sustainable development. These aspects are: exploiting the biological links between infectious and non-infectious diseases; controlling infections among the new urban majority; enhancing the response to international health threats; expanding childhood immunization programmes to prevent acute and chronic diseases in adults; and working towards universal health coverage. By scanning the wider horizon now, infectious disease specialists have the chance to shape the post-2015 era of health and development.

Monitoring what governments "give for" and "spend on" vaccine procurement: Vaccine Procurement Assistance and Vaccine Procurement Baseline

Background

The Global Vaccine Action Plan will require, inter alia, the mobilization of financial resources from donors and national governments – both rich and poor. Vaccine Procurement Assistance (VPA) and Vaccine Procurement Baseline (VPB) are two metrics that could measure government performance and track resources in this arena. VPA is proposed as a new subcategory of Official Development Assistance (ODA) given for the procurement of vaccines and VPB is a previously suggested measure of the share of Gross Domestic Product (GDP) that governments spend on their own vaccine procurement.

Objective

To determine realistic targets for VPA and VPB.

Methods

Organization for Economic Co-Operation and Development (OECD) and World Bank data for 2009 were analyzed to determine the proportions of bilateral ODA from the 23 Development Assistance Committee (DAC) countries disbursed (as % of GDP in current US$) for infectious disease control. DAC country contributions to the GAVI Alliance for 2009 were assessed as a measure of multilateral donor support for vaccines and immunization programs.

Findings

In 2009, total DAC bilateral ODA was 0.16% of global GDP and 0.25% of DAC GDP. As a percentage of GDP, Norway (0.013%) and United Kingdom (0.0085%) disbursed the greatest proportion of bilateral ODA for infectious disease control, and Norway (0.024%) and Canada (0.008%) made the greatest contributions to the GAVI Alliance. In 2009 0.02% of DAC GDP was US$7.61 billion and 0.02% of the GDP of the poorest 117 countries was US$2.88 billion.

Conclusions

Adopting 0.02% GDP as minimum targets for both VPA and VPB is based on realistic estimates of what both developed and developing countries should spend, and can afford to spend, to jointly ensure procurement of vaccines recommended by national and global bodies. New OECD purpose codes are needed to specifically track ODA disbursed for a) vaccine procurement; and b) immunization programs.

Paving the way for the introduction of new vaccines into developing countries

The great advances in vaccine R&D over the last 20 years have not been paralleled by the regular introduction of new vaccines into the market thus far. This situation acquires more dramatic proportions in developing countries, where preventable infectious diseases still impose a major public health problem. Furthermore, most of the new developments are being conceived to target the market of industrialized countries and it is foreseeable that their introduction in low-to-middle income countries will be difficult if at any time possible. Strengthening their own capacities for R&D and production is likely to be the most reasonable avenue to ensure that new vaccines will become a sustainable reality for developing countries. Concerted efforts that draw together local capacities (industry and academy) with the experience of large global manufacturers, could have a major impact and provide a great example of an effective partnership to achieve this.

New hepatitis B vaccine formulated with an improved adjuvant system

A new hepatitis B vaccine (FENDrix, GlaxoSmithKline Biologicals) containing as active substance 20 microg of recombinant hepatitis B virus surface antigen produced in Saccharomyces cerevisiae has recently been licensed in Europe. It is prepared with a novel adjuvant system: aluminum phosphate and 3-O-desacyl-4 -monophosphoryl lipid A. It is intended for use in adults from the age of 15 years onwards for active immunization against hepatitis B virus infection for patients with renal insufficiency (including prehemodialysis and hemodialysis patients). It is applied in a four-dose scheme: day 0, month 1, 2 and 6 after day 0. Due to the improved adjuvant system it induces higher antibody concentrations that reach protective levels in a faster fashion. Furthermore, due to higher titers reached after the primary immunization course, protective levels are retained for a longer period of time. Vaccination with FENDrix induces more transient local symptoms, with pain at the injection site being the most frequently reported solicited local symptom. Other symptoms such as fatigue, gastrointestinal disorders and headaches were also frequently observed but resolved without sequelae. The higher risk of hepatitis B transmission in patients with end-stage renal disease and the often immunocompromised status of these patients afford a tailored vaccination strategy that, up to now, has consisted of injecting double doses of ordinary hepatitis B vaccines. With the introduction of FENDrix there now exists an efficient alternative with superior immunogenicity that is, despite comparatively higher reactogenicity, well tolerated.

Postlicensure epidemiology of childhood vaccination: the Danish experience

The efficacy, the ability to confer protection against a target disease and the safety of a vaccine are assessed in great detail before licensure. However, inherent limitations in the prelicensure assessment necessitate continued epidemiological evaluations of efficacy and safety issues after the introduction of vaccines into use. In Denmark, the opportunities available for epidemiological research are unique. In 2001, an initiative was undertaken to take advantage of these opportunities to study the postlicensure epidemiology of childhood vaccination with respect to effectiveness and safety. First, we describe the unique opportunities for postlicensure research in Denmark with respect to the data sources available and the epidemiological and statistical methods used. We then describe a number of recent postlicensure studies of effectiveness and safety that took advantage of these opportunities. Specifically, studies on the effectiveness of Haemophilus influenzae type b vaccination, the effectiveness of pertussis vaccination, the impact of a preschool pertussis booster on infant pertussis, measles-mumps-rubella vaccine and autism, thimerosal-containing vaccine and autism, measles-mumps-rubella vaccine and febrile seizures, childhood vaccination and Type 1 diabetes, and childhood vaccination and nontargeted infectious disease are discussed.

Heptavalent pneumococcal conjugate vaccine: current and future impact

Diseases caused by Streptococcus pneumoniae contribute significantly to worldwide morbidity and mortality. S. pneumoniae is now the number one cause of invasive bacterial disease in children in countries where Haemophilus influenzae type b (Hib) disease has been conquered by use of the Hib conjugate vaccine. Licensure of a heptavalent pneumococcal conjugate vaccine for prevention of invasive pneumococcal disease in children less than 5 years old in the USA represents the culmination of more than five decades of pneumococcal vaccine development. This review will: highlight safety, immunogenicity and efficacy studies that led to US Food and Drug Administration approval of this PCV7; summarize data about the incidence of childhood pneumococcal disease in the USA subsequent to licensure; review PCV7 treatment guidelines currently in place in the USA, Canada and Australia; and consider future directions in pneumococcal vaccine research.

Acellular pertussis vaccines in Japan: past, present and future

An antivaccine movement developed in Japan as a consequence of increasing numbers of adverse reactions to whole-cell pertussis vaccines in the mid-1970s. After two infants died within 24 h of the vaccination from 1974 to 1975, the Japanese government temporarily suspended vaccinations. Subsequently, the public and the government witnessed the re-emergence of whooping cough, with 41 deaths in 1979. This series of unfortunate events revealed to the public that the vaccine had, in fact, been beneficial. Furthermore, researchers and the Japanese government proceeded to develop safer pertussis vaccines. Japan now has the most experience worldwide with acellular pertussis vaccines, being the first country to have approved their use. This review describes the major events associated with the Japanese vaccination program. The Japanese experience should be valuable to other countries that are considering the development and use of such vaccines.

Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development

By disaggregating gains in child health in Bangladesh over the past several decades, significant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the country's development experience can be identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain significant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to effectively promote inclusive and equitable development within and beyond the health system.

Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh

In Bangladesh, rapid advancements in coverage of many health interventions have coincided with impressive reductions in fertility and rates of maternal, infant, and childhood mortality. These advances, which have taken place despite such challenges as widespread poverty, political instability, and frequent natural disasters, warrant careful analysis of Bangladesh's approach to health-service delivery in the past four decades. With reference to success stories, we explore strategies in health-service delivery that have maximised reach and improved health outcomes. We identify three distinctive features that have enabled Bangladesh to improve health-service coverage and health outcomes: (1) experimentation with, and widespread application of, large-scale community-based approaches, especially investment in community health workers using a doorstep delivery approach; (2) experimentation with informal and contractual partnership arrangements that capitalise on the ability of non-governmental organisations to generate community trust, reach the most deprived populations, and address service gaps; and (3) rapid adoption of context-specific innovative technologies and policies that identify country-specific systems and mechanisms. Continued development of innovative, community-based strategies of health-service delivery, and adaptation of new technologies, are needed to address neglected and emerging health challenges, such as increasing access to skilled birth attendance, improvement of coverage of antenatal care and of nutritional status, the effects of climate change, and chronic disease. Past experience should guide future efforts to address rising public health concerns for Bangladesh and other underdeveloped countries.

Different vaccination strategies in Spain and its impact on severe varicella and zoster

Varicella vaccines available in Spain were marketed in 1998 and 2003 for non-routine use. Since 2006 some regions decided to include varicella vaccination in their regional routine vaccination programmes at 15-18 months of age. Other regions chose the strategy of vaccinating susceptible adolescents. This study shows the trends in severe varicella zoster virus infections through the analysis of the hospital discharges related to varicella and herpes zoster in the general population from 2005 to 2010 in Spain. A total of 11,125 hospital discharges related to varicella and 27,736 related to herpes zoster were reported during the study period. The overall annual rate of hospitalization was 4.14 cases per 100,000 for varicella and 10.33 cases per 100,000 for herpes zoster. In children younger than 5 years old varicella hospitalization rate significantly decreased from 46.77 in 2005 to 26.55 per 100,000 in 2010. The hospitalization rate related to herpes zoster slightly increased from 9.71 in 2005 to 10.90 per 100,000 in 2010. This increase was mainly due to the significant increase occurring in the >84 age group, from 69.55 to 97.68 per 100,000. When gathering for regions taking into account varicella vaccine strategy, varicella related hospitalizations decreased significantly more in those regions which included the vaccine at 15-18 months of age as a routine vaccine comparing with those vaccinating at 10-14 years old. No significant differences were found in herpes zoster hospitalization rates regarding the varicella vaccination strategy among regions. Severe varicella infections decreased after implementation of varicella vaccination in Spain. This decrease was significantly higher in regions including the vaccine at 15-18 months of age compared with those vaccinating susceptible adolescents.

NSW annual immunisation coverage report, 2011

This annual report, the third in the series, documents trends in immunisation coverage in NSW for children, adolescents and the elderly, to the end of 2011.

METHODS

Data from the Australian Childhood Immunisation Register, the NSW School Immunisation Program and the NSW Population Health Survey were used to calculate various measures of population coverage.

RESULTS

During 2011, greater than 90% coverage was maintained for children at 12 and 24 months of age. For children at 5 years of age the improvement seen in 2010 was sustained, with coverage at or near 90%. For adolescents, there was improved coverage for all doses of human papillomavirus vaccine, both doses of hepatitis B vaccine, varicella vaccine and the dose of diphtheria, tetanus and acellular pertussis given to school attendees in Years 7 and 10. Pneumococcal vaccination coverage in the elderly has been steadily rising, although it has remained lower than the influenza coverage estimates.

CONCLUSION

This report provides trends in immunisation coverage in NSW across the age spectrum. The inclusion of coverage estimates for the pneumococcal conjugate, varicella and meningococcal C vaccines in the official coverage assessments for 'fully immunised' in 2013 is a welcome initiative.

Trends in HPV vaccine initiation among adolescent females in North Carolina, 2008-2010

BACKGROUND

To better target future immunization efforts, we assessed trends and disparities in human papillomavirus (HPV) vaccine initiation among female adolescents in North Carolina over 3 years.

METHODS

We analyzed data from a stratified random sample of 1,427 parents who, between 2008 and 2010, completed two linked telephone surveys: the Behavioral Risk Factor Surveillance System and the Child Health Assessment and Monitoring Program surveys. Weighted analyses examined HPV vaccine initiation for girls ages 11 to 17 years.

RESULTS

HPV vaccine initiation increased modestly over time (2008, 34%; 2009, 41%; 2010, 44%). This upward trend was present within 11 subpopulations of girls, including those who lived in rural areas, were of minority (non-black/non-white) race, or had not recently received a preventive check-up. Looking at differences between groups, HPV vaccine initiation was less common among girls who attended private versus public school, were younger, or lacked a recent check-up. However, the latter difference narrowed over time. The low level of initiation among girls without recent check-ups increased substantially (from 11% to 41%), whereas initiation among girls with recent visits improved little (from 39% to 44%, P(interaction) = 0.007).

CONCLUSIONS

Although HPV vaccine initiation improved among several groups typically at higher risk for cervical cancer, the lack of progress among girls with recent check-ups suggests that missed opportunities for administration have hampered broader improvements.

IMPACT

Achieving widespread coverage of HPV vaccine will require redoubled efforts to vaccinate adolescents during routine care.

Communication in crisis situations in the process of immunization

Immunization is one of the most effective medical interventions in the prevention of the disease and represents the easiest and most cost-effective investment in health. The strategy of controlling contagious diseases that can be prevented through immunization has a long tradition in B&H. Mandatory immunizations are administered against ten diseases. Although the development of new technologies, the efforts of the pharmaceutical industry, the development of new vaccines provides better vaccines in terms of greater safety and effectiveness it should be pointed out that no vaccine is "absolutely effective and safe", and it will not achieve the immune response in 100% vaccinated, also there are possible side effects and unexpected reactions that could occur. Vaccination is often a media issue because previously unnoticed local, isolated events-side effects and complications of vaccination are now accompanied by media attention as there are now numerous and fast communication channels (internet, e-mail, TV1 etc.) and media evolved from being less "controlled" to more "commercial". Doubt in benefit of vaccination is growing even among health professionals who are expected to provide up-to-date, understandable information, and issue information about immunization benefits and potential risks. It is therefore important for health professionals to be well informed, to be a good source of authoritative, scientific and reasonable advice, and to speak openly about the benefits and risks of vaccination so that consumers fully understand both possible outcomes of vaccination. This takes communication skills, particularly in crisis situations connected with vaccination. Health professionals are thus faced with a changing attitude toward importance of immunization in the social climate where risk is less tolerated than ever before.