Vaccines: The Week in Review 27 February 2012 Center for Vaccine Ethics & Policy (CVEP

This weekly summary targets news, announcements and events in global vaccines ethics and policy gathered from key governmental, NGO and industry sources, key journals and other sources. This summary supports ongoing initiatives of the Center for Vaccine Ethics & Policy, and is not intended to be exhaustive in its coverage. Vaccines: The Week in Review is also posted in pdf form and as a set of blog posts at This blog allows full-text searching of some 2,500 entries.. Comments and suggestions should be directed to David R. Curry, MS Editor and Executive Director Center for Vaccine Ethics & Policy

A pdf of this issue is available here:

UNICEF reported that the Central African Republic (CAR) launched a national immunization campaign to eradicate polio “aimed at reaching all children in the country, including hard-to-reach populations living in conflict and post-conflict zones with limited access to health services…in urgent response to four imported cases of polio discovered in CAR in 2011, the first in two years.” Mary Louise Eagleton Meaney, Deputy Representative for UNICEF, CAR, said “Routine data shows that only 68 per cent of children in CAR under five years of age are completely vaccinated against polio, which means that 260,000 children under five are at risk of contracting the virus.” UNICEF noted that health workers “will be going door-to-door to deliver polio vaccines starting February 24th to 806,825 children between the ages of 059 months; to administer vitamin A supplements to 725,102 children between 6-59 months; and to provide deworming for 643,595 children between 12-59 months of age.”

Interview: Voice of America interviews Dagfinn Høybråten GAVI Board Chair Dagfinn Høybråten talks to the official United States government broadcaster about the role of vaccines in achieving MDGs 4 and 5 Source: Health Alliance/2011 In an interview with Voice of America, GAVI Alliance Board Chairman Dagfinn Høybråten discusses a wide range of issues with VoA correspondent Linord Moudou. He traces GAVI’s history and explains that vaccines have created a moral imperative to act in order to save lives….Høybråten adds that without achieving high levels of vaccination, it will be impossible to reach Millennium Development Goals 4 and 5 to reduce child mortality and improve maternal health. By responding to country demand and prioritising uptake of new and underused vaccines, GAVI support has helped countries to avert more than five and a half million future deaths.

The MMWR weekly for February 24, 2012 / Vol. 61 / No. 7 includes: - Influenza Vaccination Coverage Among Pregnant Women — 29 States and New York City, 2009–10 Season - Update: Influenza Activity — United States, October 2, 2011–February 11, 2012 - Announcement: Release of Online U.S. and State Trend Data for HealthRelated Quality of Life

The Weekly Epidemiological Record (WER) for 24 February 2012, vol. 87, 7 (pp 65–72) includes WHO Quantitative Immunization and VaccineRelated Research meeting, October 2011 – summary; Dengue and severe dengue factsheet (Revised in January 2012)

Twitter Watch [accessed 26 February 17:35] Items of interest from a variety of twitter feeds associated with immunization, vaccines and global public health. This capture is highly selective and is by no means intended to be exhaustive. GAVI Alliance @GAVIAlliance Helen Evans - GAVI Deputy CEO - shares her insights into #GAVI's challenges and opportunities. 7:01 AM - 25 Feb 12 via web · Details EndPolioNow @EndPolioNow At Polio Summit, India just announces that WHO has removed India from the polio endemic list #polio 1:15 AM - 25 Feb 12 IHME at UW @IHME_UW Track #polio vaccination activities using Polio Campaign Monitoring Reports: #GHDxData #globalhealth 1:05 PM - 24 Feb 12 WHO @WHO If we eradicate polio, we'll save US$40-50b in the next 20yrs. We can use these $ to fight other diseases #poliochat 12:08 PM - 24 Feb 12 HarvardPublicHealth @HarvardHSPH

Today in #publichealth history: Children receive the first polio vaccine in 1954 #TodayinHistory EndPolioNow @EndPolioNow View a NEW infographic of the progress and current state of polio eradication. 1:46 PM - 23 Feb 12 Dagfinn Høybråten @Hoybraten Great opportunity to speak about the power of #vaccines to save lives at Voice of America: Retweeted by GAVI Alliance 9:26 AM - 21 Feb 12 PAHO/WHO @pahowho #PAHO Funds Training in Epidemiology for Health Officials in the Region 7:55 PM - 22 Feb 12 Sabin Vaccine Inst. @sabinvaccine Today on the blog: an update on sustainable immunization financing activities in Cambodia 3:42 PM - 22 Feb 12 GAVI Alliance @GAVIAlliance Nearly 70% of all vax consumed come from India; great potential 2 sustain growth momentum --RajeevDhere,SerumInstitute 8:20 AM - 22 Feb 12 Measles Initiative @MeaslesInit Why do measles outbreaks occur in middle- and higher-income communities? Retweeted by ECDC Eurovaccine 5:41 AM - 17 Feb 12 ECDC Eurovaccine @Eurovaccine Latest ECDC #measles monitoring provides 2011 analyses of surveillance data; 2011 cases is 4-fold increase from 2009. 10:47 AM - 21 Feb 12 GAVI Alliance @GAVIAlliance GAVI Board Chair, @Hoybraten talks about the role of vaccines in achieving MDGs 4 and 5: 8:28 AM - 21 Feb 12

Journal Watch Vaccines: The Week in Review continues its weekly scanning of key journals to identify and cite articles, commentary and editorials, books reviews and

other content supporting our focus on vaccine ethics and policy. Journal Watch is not intended to be exhaustive, but indicative of themes and issues the Center is actively tracking. We selectively provide full text of some editorial and comment articles that are specifically relevant to our work. Successful access to some of the links provided may require subscription or other access arrangement unique to the publisher. If you would like to suggest other journal titles to include in this service, please contact David Curry at: Annals of Internal Medicine February 21, 2012; 156 (4) [No relevant content] British Medical Bulletin Volume 100 Issue 1 December 2011 [Reviewed earlier; No relevant content] British Medical Journal 25 February 2012 (Vol 344, Issue 7845) [No relevant content] Cost Effectiveness and Resource Allocation (Accessed 26 February 2012) [No new relevant content] Emerging Infectious Diseases Volume 18, Number 3—March 2012 [No relevant content] Global Health Winter 2012 [Reviewed earlier] Globalization and Health [Accessed 26 February 2012] [No new relevant content]

Health Affairs February 2012; Volume 31, Issue 2 Theme: The Future of The Small Business Insurance Exchange [No relevant content] Health and Human Rights Vol 13, No 2 (2011) [Reviewed earlier] Health Economics, Policy and Law Volume 7 - Special Issue 01 - January 2012 [Reviewed earlier] Health Policy and Planning Volume 27 Issue 1 January 2012 [Reviewed earlier] Advanced access February 13, 2012 Original Paper: Marko Vujicic, Stephanie E Weber, Irina A Nikolic, Rifat Atun, and Ranjana Kumar An analysis of GAVI, the Global Fund and World Bank support for human resources for health in developing countries Health Policy Plan. first published online February 13, 2012 doi:10.1093/heapol/czs012 (9 pages) Abstract Shortages, geographic imbalances and poor performance of health workers pose major challenges for improving health service delivery in developing countries. In response, multilateral agencies have increasingly recognized the need to invest in human resources for health (HRH) to assist countries in achieving their health system goals. In this paper we analyse the HRH-related activities of three agencies: the Global Alliance for Vaccines and Immunisation (GAVI); the Global Fund for Aids, Tuberculosis, and Malaria (the Global Fund); and the World Bank. First, we reviewed the type of HRH-related activities that are eligible for financing within each agency. Second, we reviewed the HRH-related activities that each agency is actually financing. Third, we reviewed the literature to understand the impact that GAVI, Global Fund and World Bank investments in HRH have had on the health workforce in developing countries. Our analysis found that by far the most common activity supported across all agencies is short-term, in-service training. There is relatively little investment in expanding pre-service training capacity, despite large health worker shortages in developing countries. We also found

that the majority of GAVI and the Global Fund grants finance health worker remuneration, largely through supplemental allowances, with little information available on how payment rates are determined, how the potential negative consequences are mitigated, and how payments are to be sustained at the end of the grant period. Based on the analysis, we argue there is an opportunity for improved co-ordination between the three agencies at the country level in supporting HRH-related activities. Existing initiatives, such as the International Health Partnership and the Health Systems Funding Platform, could present viable and timely vehicles for the three agencies to implement this improved co-ordination. Human Vaccines & Immunotherapeutics (formerly Human Vaccines) Volume 8, Issue 2 February 2012 [Reviewed earlier] International Journal of Infectious Diseases Volume 16, Issue 3 pp. e151-e224 (March 2012) [Reviewed last week] JAMA February 22/29, 2012, Vol 307, No. 8, pp 749-874 Original Contributions Cost-effectiveness of Adult Vaccination Strategies Using Pneumococcal Conjugate Vaccine Compared With Pneumococcal Polysaccharide Vaccine Kenneth J. Smith, Angela R. Wateska, Mary Patricia Nowalk, Mahlon Raymund, J. Pekka Nuorti, Richard K. Zimmerman JAMA. 2012;307(8):804-812.doi:10.1001/jama.2012.169 Abstract Context The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear. Objective To estimate the cost-effectiveness of PCV13 vaccination strategies in adults. Design, Setting, and Participants A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included Centers for Disease Control and Prevention Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey.

Main Outcome Measures Pneumococcal disease cases prevented and incremental costs per quality-adjusted life-year (QALY) gained. Results In the base case scenario, administration of PCV13 as a substitute for PPSV23 in current recommendations (ie, vaccination at age 65 years and at younger ages if comorbidities are present) cost $28 900 per QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost $45 100 per QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 years to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing $496 000 per QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored. Conclusion Overall, PCV13 vaccination was favored compared with PPSV23, but the analysis was sensitive to assumptions about PCV13 effectiveness against nonbacteremic pneumococcal pneumonia and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution. Risk of Febrile Seizures and Epilepsy After Vaccination With Diphtheria, Tetanus, Acellular Pertussis, Inactivated Poliovirus, and Haemophilus Influenzae Type b Yuelian Sun, Jakob Christensen, Anders Hviid, Jiong Li, Peter Vedsted, Jørn Olsen, Mogens Vestergaard JAMA. 2012;307(8):823-831.doi:10.1001/jama.2012.165 Abstract Context Vaccination with whole-cell pertussis vaccine carries an increased risk of febrile seizures, but whether this risk applies to the acellular pertussis vaccine is not known. In Denmark, acellular pertussis vaccine has been included in the combined diphtheria-tetanus toxoids-acellular pertussis– inactivated poliovirus– Haemophilus influenzae type b (DTaP-IPV-Hib) vaccine since September 2002. Objective To estimate the risk of febrile seizures and epilepsy after DTaPIPV-Hib vaccination given at 3, 5, and 12 months. Design, Setting, and Participants A population-based cohort study of 378 834 children who were born in Denmark between January 1, 2003, and December 31, 2008, and followed up through December 31, 2009; and a selfcontrolled case series (SCCS) study based on children with febrile seizures during follow-up of the cohort. Main Outcome Measures Hazard ratio (HR) of febrile seizures within 0 to 7 days (0, 1-3, and 4-7 days) after each vaccination and HR of epilepsy after first vaccination in the cohort study. Relative incidence of febrile seizures within 0 to 7 days (0, 1-3, and 4-7 days) after each vaccination in the SCCS study. Results A total of 7811 children were diagnosed with febrile seizures before 18 months, of whom 17 were diagnosed within 0 to 7 days after the first (incidence rate, 0.8 per 100 000 person-days), 32 children after the second (1.3 per 100 000 person-days), and 201 children after the third (8.5 per 100 000 person-days) vaccinations. Overall, children did not have higher risks

of febrile seizures during the 0 to 7 days after the 3 vaccinations vs a reference cohort of children who were not within 0 to 7 days of vaccination. However, a higher risk of febrile seizures was found on the day of the first (HR, 6.02; 95% CI, 2.86-12.65) and on the day of the second (HR, 3.94; 95% CI, 2.18-7.10), but not on the day of the third vaccination (HR, 1.07; 95% CI, 0.73-1.57) vs the reference cohort. On the day of vaccination, 9 children were diagnosed with febrile seizures after the first (5.5 per 100 000 person-days), 12 children after the second (5.7 per 100 000 person-days), and 27 children after the third (13.1 per 100 000 person-days) vaccinations. The relative incidences from the SCCS study design were similar to the cohort study design. Within 7 years of follow-up, 131 unvaccinated children and 2117 vaccinated children were diagnosed with epilepsy, 813 diagnosed between 3 and 15 months (2.4 per 1000 person-years) and 1304 diagnosed later in life (1.3 per 1000 person-years). After vaccination, children had a lower risk of epilepsy between 3 and 15 months (HR, 0.63; 95% CI, 0.50-0.79) and a similar risk for epilepsy later in life (HR, 1.01; 95% CI, 0.66-1.56) vs unvaccinated children. Conclusions DTaP-IPV-Hib vaccination was associated with an increased risk of febrile seizures on the day of the first 2 vaccinations given at 3 and 5 months, although the absolute risk was small. Vaccination with DTaP-IPV-Hib was not associated with an increased risk of epilepsy. Editorials Prevention of Pneumococcal Infection With Vaccines: An Evolving Story Eugene D. Shapiro JAMA. 2012;307(8):847-849.doi:10.1001/jama.2012.194 Extract [first 150 words per JAMA convention] The first vaccines to prevent pneumococcal infections, crude preparations of killed bacteria, were developed by Sir Almroth Wright in 1911 to try to alleviate the high mortality and morbidity among gold miners in South Africa.1 Discovery that antibodies against purified polysaccharides of the capsular surface of pneumococci were protective led to development of polysaccharide vaccines that were marketed in the 1940s. These vaccines were commercial failures because the advent of antimicrobials led to a perception that pneumococcal infections were no longer a major threat.2 Subsequent evidence of the persistence of significant morbidity from pneumococcal infections, as well as mortality rates of 25% to 30% in patients with invasive (including bacteremic) pneumococcal infections despite early treatment with antimicrobials, led to redevelopment of a polysaccharide vaccine, approved in the United States in 1977, that contained 14 of the more than 90 serotypes of pneumococci (responsible for about 80% of invasive … Journal of Infectious Diseases Volume 205 Issue 6 March 15, 2012 [No relevant content]

The Lancet Feb 25, 2012 Volume 379 Number 9817 p685 - 776 Comment Community-based treatment of severe childhood pneumonia Robert E Black, Shams El Arifeen In 2010, an estimated 7·6 million children died before their fifth birthday, and more than a million of these deaths were due to pneumonia.1 Although progress is being made in expanding the use of vaccines to prevent pneumonia, many countries have yet to introduce these vaccines, especially the pneumococcal vaccine.2 Correct breastfeeding of children can also help prevent pneumonia deaths, but a high prevalence of suboptimum breastfeeding practices (eg, low rates of exclusive breastfeeding up to 6 months of age) is seen in all regions of the world. The Lancet Infectious Disease Mar 2012 Volume 12 Number 3 p167 - 254 Editorial Avian influenza and the dual-use research debate The Lancet Infectious Diseases Preview Since the first human cases of infection with avian influenza H5N1 were reported 15 years ago, the disease has caused 344 deaths among 583 known cases—a case fatality of nearly 60%. Despite the highly lethal nature of this virus, it is very rarely transmitted from birds to people, and even less frequently, if ever, transmitted from person to person. Nonetheless, the possibility of the virus mutating or recombining with another to develop pandemic potential is a bleak prospect for public health. So it is not surprising that the news that two groups of researchers have purposefully generated H5N1 strains that are transmitted easily in aerosols among ferrets, a widely used model of human influenza transmission, has generated a fierce debate about the conduct and dissemination of dual-use research, as reported in this month's Newsdesk. Series Infectious disease surveillance and modelling across geographic frontiers and scientific specialties Kamran Khan, Scott JN McNabb, Ziad A Memish, Rose Eckhardt, Wei Hu, David Kossowsky, Jennifer Sears, Julien Arino, Anders Johansson, Maurizio Barbeschi, Brian McCloskey, Bonnie Henry, Martin Cetron, John S Brownstein Summary Infectious disease surveillance for mass gatherings (MGs) can be directed locally and globally; however, epidemic intelligence from these two levels is not well integrated. Modelling activities related to MGs have historically focused on crowd behaviours around MG focal points and their relation to the safety of attendees. The integration of developments in internet-based global infectious disease surveillance, transportation modelling of populations travelling to and from MGs, mobile phone technology for surveillance during MGs, metapopulation epidemic modelling, and crowd behaviour modelling is

important for progress in MG health. Integration of surveillance across geographic frontiers and modelling across scientific specialties could produce the first real-time risk monitoring and assessment platform that could strengthen awareness of global infectious disease threats before, during, and immediately after MGs. An integrated platform of this kind could help identify infectious disease threats of international concern at the earliest stages possible; provide insights into which diseases are most likely to spread into the MG; help with anticipatory surveillance at the MG; enable mathematical modelling to predict the spread of infectious diseases to and from MGs; simulate the effect of public health interventions aimed at different local and global levels; serve as a foundation for scientific research and innovation in MG health; and strengthen engagement between the scientific community and stakeholders at local, national, and global levels. Research agenda for mass gatherings: a call to action John S Tam, Maurizio Barbeschi, Natasha Shapovalova, Sylvie Briand, Ziad A Memish, Marie-Paule Kieny Summary Public health research is essential for the development of effective policies and planning to address health security and risks associated with mass gatherings (MGs). Crucial research topics related to MGs and their effects on global health security are discussed in this review. The research agenda for MGs consists of a framework of five major public health research directions that address issues related to reducing the risk of public health emergencies during MGs; restricting the occurrence of non-communicable and communicable diseases; minimisation of the effect of public health events associated with MGs; optimisation of the medical services and treatment of diseases during MGs; and development and application of modern public health measures. Implementation of the proposed research topics would be expected to provide benefits over the medium to long term in planning for MGs. Review Antiviral resistance during the 2009 influenza A H1N1 pandemic: public health, laboratory, and clinical perspectives Aeron C Hurt, Tawee Chotpitayasunondh, Nancy J Cox, Rod Daniels, Alicia M Fry, Larisa V Gubareva, Frederick G Hayden, David S Hui, Olav Hungnes, Angie Lackenby, Wilina Lim, Adam Meijer, Charles Penn, Masato Tashiro, Timothy M Uyeki, Maria Zambon, on behalf of the WHO Consultation on Pandemic Influenza A (H1N1) 2009 Virus Resistance to Antivirals Summary Influenza A H1N1 2009 virus caused the first pandemic in an era when neuraminidase inhibitor antiviral drugs were available in many countries. The experiences of detecting and responding to resistance during the pandemic provided important lessons for public health, laboratory testing, and clinical management. We propose recommendations for antiviral susceptibility testing, reporting results, and management of patients infected with 2009 pandemic influenza A H1N1. Sustained global monitoring for antiviral resistance among circulating influenza viruses is crucial to inform public health and clinical recommendations for antiviral use, especially since community spread of oseltamivir-resistant A H1N1 2009 virus remains a concern. Further studies are needed to better understand influenza

management in specific patient groups, such as severely immunocompromised hosts, including optimisation of antiviral treatment, rapid sample testing, and timely reporting of susceptibility results. Medical Decision Making (MDM) January–February 2012; 32 (1) [Reviewed earlier] Nature Volume 482 Number 7386 pp439-562 23 February 2012 Editorial Flu papers warrant full publication Nature 482, 439 (23 February 2012) doi:10.1038/482439a Published online 22 February 2012 Although more debate is needed, the benefits of publishing sensitive data outweigh the risks that have so far been made public. “No one should presume to know all the ways in which influenza virus could be misused, and the motivations for doing so, but the consequences could be catastrophic. There are many scenarios to consider, ranging from mad lone scientists, desperate despots and members of millennial doomsday cults to nation states wanting mutually assured destruction options, bioterrorists or a single person's random acts of craziness. These are low-probability events, but they could introduce a new evolutionary H5N1 seed into the environment that seems not to exist in nature. This might not cause a pandemic instantly, but it could start the virus on a new path for pandemic evolution.” That is the rationale provided by Paul Keim, acting chair of the US National Science Advisory Board for Biosecurity (NSABB), in response to questions posed by Nature (P. S. Keim Nature 482, 156–157; 2012) about the NSABB's recommendation that recent work on the transmissibility in mammals of artificial strains of avian H5N1 influenza virus should not be published in full. The work was conducted in ferrets — generally considered the best animal models for human transmission — and shows that avian H5N1 viruses have a greater potential to evolve into transmissible forms in mammals, including humans, than had been thought. The work is reported in two papers accepted but not yet published in Nature and Science. Last week, a group of flu and public-health experts gathered at the World Health Organization (WHO) headquarters in Geneva, Switzerland, to discuss the matter (see And it was clear at the meeting that the above opening quote expresses the only rationale that attendees had received. To its credit and that of the US government, the NSABB is the only body in the world set up to review these issues in a systematic fashion. It includes exofficio representatives of all relevant government departments (including intelligence and security agencies), as well as independent researchers. The NSABB's guidance was an important first step in public consideration of the

impacts and potential regulation of such research. The second step was last week's meeting at the WHO — again, like the NSABB, a body empowered only to make recommendations. Some context is important in considering the issues surrounding publication. In 2003, Nature and many other journals met to establish editorial procedures for considering papers that have public-health and scientific benefits but that might also have biosecurity risks (see Nature 421, 771; 2003). The statement that emerged from that meeting envisaged the possibility that a journal would reject a paper if it was clear that the risks of publication outweighed the benefits. Nature accordingly used independent advisers in considering the submission of the latest paper, and most of the advisers recommended publication in full. This is also the first paper submitted to any Nature journal for which recommendations have been made against publication on biosecurity grounds. Rather than simply reject the papers, given also the NSABB's opinion, both Nature and Science decided to investigate another option: to publish a redacted version omitting key methods and data. But a condition of such an approach was that a method should exist for distributing a full version to those in need of the results for public-health reasons and those capable of pursuing the science. Both journals accordingly prepared full and redacted versions. “There is already a substantial immediate risk to humans.” Those at the WHO meeting, under conditions of strict security, examined both versions of the two papers. It had already been said in blogs and news coverage that, because the methods used are not novel, and because one of the papers had been presented at an open meeting, redaction would be pointless. As one WHO participant said: “It was only when I'd seen both versions that I realized how ineffective redaction would be.” What was also concluded was that a system for distributing the full paper only to selected individuals would be impossible to set up on any relevant timescale. But what also became clear, partly from unpublished data, was that not only does the mammalian transmissibility threat seem greater than previously thought, but also that current avian viruses have some of the mutations identified in the new work. In other words, there is already a substantial immediate risk to humans. The meeting also concluded that the new data are of value for surveillance, and that the results should be built on to explore the mechanisms underlying transmissibility and the high fatality rate observed in humans infected by H5N1. Given the inadequacy of redaction, and the immediate risks to global public health, the biosecurity objections expressed above seem too general and hypothetical to justify obstructing publication and further research. Moreover, with regard to the NSABB's recommendations and the recommendations of the WHO meeting (see, neither of the discussions that preceded them were sufficiently inclusive of the security, societal and research interests at stake. Therefore, further discussion is essential. That must include a review of the safety regimes (lab equipment, buildings and practices) in which future work should be conducted. The two laboratories in which the latest research originated are categorized as 'BSL-3 enhanced' (see Nature 480, 421–422; 2011), a classification that, although rigorous in these cases, is not well

defined in general. The Public Health Agency of Canada has deemed the highest level of BSL-4 to be required (see page 447). Safety-standards committees in the United States and Europe are currently assessing required safety levels, and may report within a few weeks. As was agreed by the journals and the lead authors at the meeting, publication of the papers must wait at least for the outcome of those discussions. There may yet be regulatory or legal obstacles to publication, or biosecurity or biosafety risks sufficient to outweigh the health risks. Otherwise, it is Nature's view that the papers should ultimately be published in full. Nature Medicine February 2012, Volume 18 No 2 pp179-321 [Reviewed last week] Nature Reviews Immunology March 2012 Vol 12 No 3 [No relevant content] New England Journal of Medicine February 23, 2012 Vol. 366 No. 8 [No relevant content] OMICS: A Journal of Integrative Biology January/February 2012, 16(1-2): 1-2 [No relevant content] The Pediatric Infectious Disease Journal March 2012 - Volume 31 - Issue 3 pp: 217-286,e52-e58,A11-A12 Original Studies Comparative Coverage of Supplementary and Universally Recommended Immunizations in Children at 24 Months of Age Hug, Salome; Weibel, Daniel; Delaporte, Elisabeth; Gervaix, Alain; Heininger, Ulrich Pediatric Infectious Disease Journal. 31(3):217-220, March 2012. doi: 10.1097/INF.0b013e31823cbaa5 Abstract: Background: The introduction of pneumococcal and meningococcal group C conjugate vaccinations as supplementary (a new category in Swiss

immunization recommendations) to universally recommended vaccinations in 2006 prompted this study to investigate their acceptance. Methods: The study was performed in 24-month-old healthy children born in the Geneva or Basel areas in Switzerland between January and April 2007. After informed consent had been obtained from caregivers (for this particular study in Basel and in general for providing immunization data in Geneva on an ongoing basis), all universally recommended and supplementary vaccinations administered by ≤24 months of age were analyzed for completeness and timeliness according to set definitions. Sample size calculations and standard statistical tests were applied for comparative data analyses. Results: Of 592 children at the age of 12 months, 94% and 73% had received complete diphtheria-tetanus-pertussis component combination and pneumococcal conjugate vaccinations, respectively. At the age of 24 months, coverage rates for complete booster doses were 77% and 70%, respectively. Rates for MMR doses 1 and 2 at 24 months were 92% and 72%, respectively, and the rate for meningococcal conjugate vaccine (single dose) was 62%. On an average, coverage rates were similar in the 2 study regions except those for pneumococcal conjugate and second dose of MMR, which were approximately 10% higher in Geneva. Conclusions: Compliance with supplementary vaccinations was lower than that with universally recommended vaccinations. This can be explained by the recent introduction of supplementary vaccinations or by the public perception that they are less important than universal vaccinations. The Changing Epidemiology of Invasive Pneumococcal Disease at a Tertiary Children's Hospital Through the 7-valent Pneumococcal Conjugate Vaccine Era: A Case for Continuous Surveillance Ampofo, Krow; Pavia, Andrew T.; Stockmann, Chris; Hersh, Adam L.; Bender, Jeffrey M.; Blaschke, Anne J.; Weng, Hsin Yi Cindy; Korgenski, Kent E.; Daly, Judy; Mason, Edward O.; Byington, Carrie L. Pediatric Infectious Disease Journal. 31(3):228-234, March 2012. doi: 10.1097/INF.0b013e31823dcc72 Abstract: Background: In 2000, a 7-valent pneumococcal conjugate vaccine (PCV7) was licensed for use among US children. Many sites have since reported changes in invasive pneumococcal disease (IPD). We recognized an opportunity to describe the changes in epidemiology, clinical syndromes, and serotype distribution during a 14-year period including 4 years before vaccine introduction and spanning the entire PCV7 era. Methods: Cases were defined as children <18 years of age who were cared for at Primary Children's Medical Center for culture-confirmed IPD. We defined the prevaccine period as the time frame spanning from 1997 to 2000 and the postvaccine period from 2001 to 2010. Demographics, clinical data, and outcomes were collected through electronic query and chart review. Streptococcus pneumoniae serotyping was performed using the capsular swelling method. Results: The median age of children with IPD increased from 19 months during the prevaccine period to 27 months during postvaccine period (P = 0.02), with a larger proportion of IPD among children older than 5 years. The proportion of IPD associated with pneumonia increased substantially from

29% to 50% (P < 0.001). This increase was primarily attributable to an increase in complicated pneumonia (17% to 33%, P < 0.001). Nonvaccine serotypes 7F, 19A, 22F, and 3 emerged as the dominant serotypes in the postvaccine period. In children with IPD who were younger than 5 years, for whom vaccine is recommended, 67% of the cases were caused by serotypes in 13-valent PCV during 2005 to 2010. Conclusions: After PCV7 was introduced, significant changes in IPD were noted. One-third of IPD occurred in children older than 5 years, who were outside the age-group for which PCV is recommended. Continued surveillance is warranted to identify further evolution of the epidemiology, clinical syndromes, and serotype distribution of S. pneumoniae after 13-valent PCV licensure. Vaccine Reports Incidence of Intussusception Among Infants in a Large Commercially Insured Population in the United States Mona Eng, Patricia; Mast, T. Christopher; Loughlin, Jeanne; Clifford, C. Robin; Wong, Judy; Seeger, John D. Pediatric Infectious Disease Journal. 31(3):287-291, March 2012. doi: 10.1097/INF.0b013e31824213b1 Abstract: Background: To estimate the incidence of intussusception among infants treated in inpatient and emergency department settings during the period preceding the US launch of second-generation rotavirus vaccines. Methods: From a large US health insurance claims database, we sampled 100,000 infants aged 1 to 3 months at first diphtheria-tetanus-acellular pertussis vaccination between 2001 and 2005. Potential intussusception cases were identified on the basis of claims and were confirmed by medical record review. Incidence rates (IRs) and 95% confidence intervals (CIs) were estimated based on follow-up from first diphtheria-tetanus-acellular pertussis dose to up to 1 year of age, and within 21, 30, and 60 days after each dose. Results: The IR of intussusception in the first year of life was 0.33/1000 person-years based on 22 confirmed cases (95% CI: 0.21–0.50/1000 personyears). The age-specific incidence peaked among infants aged 5 months (IR: 0.82/1000 person-years; 95% CI: 0.30–1.78/1000 person-years). During the 21, 30, and 60 days following any dose, the incidence per 1000 person-years was 0.27, 0.24, and 0.33, respectively. Conclusion: The rates described in this study can serve as a benchmark for comparison with incidences observed after the introduction of the secondgeneration rotavirus vaccines. Postmarketing Evaluation of the Short-term Safety of the Pentavalent Rotavirus Vaccine Loughlin, Jeanne; Mast, T. Christopher; Doherty, Michael C.; Wang, Florence T.; Wong, Judy; Seeger, John D. Pediatric Infectious Disease Journal. 31(3):292-296, March 2012. doi: 10.1097/INF.0b013e3182421390 Abstract: Background: A pentavalent rotavirus vaccine (RV5) demonstrated efficacy and safety in a large clinical trial before US licensure in 2006. The primary objective of this observational study was to assess the occurrence of intussusception (IS) among infants who received RV5 in routine use.

Secondary objectives assessed the occurrence of Kawasaki disease (KD) and general safety. Methods: We identified and followed infants with a health insurance claim for RV5 during the first 2 years of RV5 availability. Concurrent and historical cohorts receiving diphtheria-tetanus-acellular pertussis (DTaP) vaccine were used as comparators; the historical DTaP cohort informed sequential monitoring boundaries for IS and KD. Medical records from potential IS and KD cases were reviewed to confirm outcomes. General safety was evaluated across a wide range of outcomes using prespecified criteria. Incidence rates for outcomes along with relative risks and 95% confidence intervals (CIs) were estimated. Results: The 85,397 RV5 and 62,820 DTaP recipients contributed 17,433 and 12,339 person-years, resulting in 6 and 5 confirmed cases of IS, respectively, within 30 days following any dose. The relative risk of IS was 0.8 (95% confidence interval: 0.22–3.52). The number of IS or KD cases did not cross the monitoring boundaries. The general safety evaluation did not identify any specific diagnoses or patterns of diagnoses that might suggest other safety concerns. Conclusion: RV5 was not associated with an increased risk of IS, KD, or any other recognized health outcome. Pediatrics February 2012, VOLUME 129 / ISSUE 2 [Reviewed earlier] Pharmacoeconomics March 1, 2012 - Volume 30 - Issue 3 pp: 171-256 [Reviewed last week] PLoS One [Accessed 26 February 2012];jsessionid=577FD8B9E1F322DA A533C413369CD6F3.ambra01?field=date [No new relevant content] PLoS Medicine (Accessed 26 February 2012) Mobile Phone Text Messaging: Tool for Malaria Control in Africa Dejan Zurovac, Ambrose O. Talisuna, Robert W. Snow Essay, published 21 Feb 2012 doi:10.1371/journal.pmed.1001176 Summary Points

- Across many malaria-endemic areas in rural Africa, the communication gap between managers, health workers, and patients is a significant barrier to efficient malaria control. - The rapid expansion of mobile network coverage and the widespread availability of basic handsets have the potential to substantively bridge the communication gap. - Text messaging, as the least-expensive mobile phone function found on all handsets, could improve the delivery of health services and health outcomes. - Six major areas of malaria control in which deficiencies are apparent and text messaging interventions could be beneficial are: (1) disease and treatment effectiveness surveillance, (2) monitoring of the availability of health commodities, (3) pharmacovigilance and post-marketing surveillance of the safety and quality of antimalarial drugs, (4) health worker adherence to guidelines, (5) patient adherence to medication regimens, and (6) posttreatment review. - Text messages transmitting information from the periphery of the health systems to malaria control managers are in the first three malaria control areas: (1) disease and treatment effectiveness surveillance, (2) monitoring of the availability of health commodities, and (3) pharmacovigilance and postmarketing surveillance of the safety and quality of antimalarial medicines. Future projects in these three areas should demonstrate responses to data signals and comparative advantages with routine information systems. - Text messages in the second three areas transmit information to health workers and patients to support the management of malaria patients by improving (4) health workers' adherence to guidelines, (5) patient adherence to medicines, and (6) post-treatment review. Future priorities in these areas are cost-effectiveness evaluations, qualitative research, and studies measuring impact on the processes of care and health outcomes. PNAS - Proceedings of the National Academy of Sciences of the United States of America (Accessed 26 February 2012) [No new relevant content] Science 24 February 2012 vol 335, issue 6071, pages 881-1008 [No relevant content] Tropical Medicine & International Health March 2012 Volume 17, Issue 3 Pages 263–403 Child Health Expanding and improving urban outreach immunization in Patna, India

Narottam Pradhan, Tove K. Ryman, Sherin Varkey, Alok Ranjan, Satish K. Gupta, Gopal Krishna, R. P. Swetanki and Randall Young Article first published online: 14 DEC 2011 | DOI: 10.1111/j.13653156.2011.02916.x Abstract  Objectives We conducted a case study of an urban immunization outreach strategy to determine the feasibility of the intervention and to measure administrative immunization coverage outcomes.  Methods A multipronged strategy for improving immunization coverage in Urban Patna, India, was implemented for 1 year (2009/2010). The strategy was designed to increase immunization sites, shift human resources, plan logistics, improve community mobilization, provide supervision, strengthen data flow and implement special vaccination drives.  Results Over 1 year, the coverage of all primary vaccines of the Universal Immunization Program improved by over 100%.  Conclusion Coverage can be rapidly improved through outreach immunization in low socioeconomic areas if existing opportunities are carefully utilized. Malaria Acceptability of coupling Intermittent Preventive Treatment in infants with the Expanded Programme on Immunization in three francophone countries in Africa Alexandra de Sousa, Leon P. Rabarijaona, Jean L. Ndiaye, Doudou Sow, Mouhamed Ndyiae, Jacques Hassan, Nilda Lambo, Paul Adovohekpe, Flavia Guidetti, Judith Recht and Alphonse Affo Article first published online: 29 NOV 2011 | DOI: 10.1111/j.13653156.2011.02915.x Abstract  Objective Intermittent preventive treatment in infants (IPTi) is a malaria control strategy currently recommended by WHO for implementation at scale in Africa, consisting of administration of sulphadoxine-pyrimethamine (SP) coupled with routine immunizations offered to children under 1 year. In this study, we analysed IPTi acceptability by communities and health staff.  Methods Direct observation, in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in Benin, Madagascar and Senegal during IPTi pilot implementation. Villages were stratified by immunization coverage. Data were transcribed and analysed using NVivo7 software.  Results Communities’ knowledge of malaria aetiology and diagnosis was good, although generally villagers did not seek treatment at health centres as their first choice. Perceptions and attitudes towards IPTi were very positive among communities and health workers. A misconception that SP was an antipyretic that prevents post-vaccinal fever contributed to IPTi’s acceptability. No refusals or negative rumours related to IPTi coupling with immunizations were identified, and IPTi did not negatively influence attitudes towards other malaria control strategies. Healthcare decisions about children, normatively made by the father, are starting to shift to educated and financially independent mothers.  Discussion Intermittent preventive treatment in infants is well accepted by providers and communities, showing a synergic acceptability when coupled

with routine immunizations. However, a misconception that SP alleviates fever should be addressed when scaling up implementation. Vaccine Volume 30, Issue 12 pp. 2037-2236 (9 March 2012) Regular Papers Knowledge, attitude and practice in primary and secondary cervical cancer prevention among young adult Italian women Original Research Article Pages 2075-2082 Serena Donati, Cristina Giambi, Silvia Declich, Stefania Salmaso, Antonietta Filia, Marta Luisa Ciofi degli Atti, Maria Pia Alibrandi, Silvia Brezzi, Francesca Carozzi, Natalina Collina, Daniela Franchi, Amedeo Lattanzi, Margherita Meda, Maria Carmela Minna, Roberto Nannini, Giuseppina Gallicchio, Antonino Bella, The PreGio Working group Abstract In Italy since 2007 vaccination against human papillomavirus (HPV) is offered to 11-year-old females, whereas vaccination for older age groups is still a matter of debate. To assess Italian young women's knowledge, attitudes and practice regarding primary and secondary cervical cancer prevention a crosssectional study among young women aged 18–26 years was conducted in 2008. The survey collected information on in-depth awareness and knowledge regarding Pap testing, HPV infection, HPV vaccine and cervical cancer. The response rate was 57.7% with a wide range of variability (34– 84%) amongst local health units. Among 667 women who participated in the survey poor awareness and various misconceptions regarding HPV and cervical cancer prevention were detected. Overall women were found to be more knowledgeable about Pap smears and cervical cancer than about HPV infection and the HPV vaccine. Respondents pointed to their healthcare providers as their most trusted source for medical information. Understanding women's knowledge on cervical cancer prevention, as well as related factors is important in helping to achieve and maintain adherence to cervical cancer preventive strategies. Moreover in order to minimize cervical cancer risk by improving women's adherence to preventive strategies, appropriate and adequate information dissemination, and guidance from health professionals appear to be crucial elements. Risk factors of underutilization of childhood immunizations in ultraorthodox Jewish communities in Israel despite high access to health care services Original Research Article Pages 2109-2115 Khitam Muhsen, Reem Abed El-Hai, Anat Amit-Aharon, Haim Nehama, Mervat Gondia, Nadav Davidovitch, Sophy Goren, Dani Cohen Abstract Background The risk factors of underutilization of childhood vaccines in populations with high access to health services are not fully understood.

Objectives To determine vaccination coverage and factors associated with underutilization of childhood vaccines in a population with sub-optimal vaccination compliance, despite a high health care access. Methods The study was conducted among 430 children from ultraorthodox Jewish communities in the Bnei Brak city and Jerusalem district. Data on immunization status, socio-demographic factors and on parents’ attitudes regarding vaccines were obtained from medical records and through parents’ interviews. Results The proportion of fully vaccinated children was 65% in 2- to 5-year-old ultraorthodox children from Jerusalem district, and 86% in 2.5-year-old children from Bnei Brak city. The factors that were significantly associated with vaccines underutilization in Bnei Brak were having >6 siblings, maternal academic education, parental religious beliefs against vaccination, perceived risk of vaccine preventable diseases as low, and mistrust in the Ministry of Health (MOH). Similarly, in Jerusalem, religious beliefs against vaccination, and the perceived low risk of vaccine preventable diseases significantly increased the likelihood of under-immunization, while having a complementary health insurance was inversely related with vaccines underutilization. Conclusions The risk factors of under-immunization are in part modifiable, by means of health education on the risks of vaccine preventable diseases and by improving the trust in the MOH. The leaders of the ultraorthodox communities could play an important role in such interventions. Pneumococcal disease in South Australia: Vaccine success but no time for complacency Original Research Article Pages 2206-2211 David R. Johnson, Katina D’Onise, Ros A. Holland, Jane C.A. Raupach, Ann P. Koehler Abstract Background Trends in age specific and serotype specific incidence rates for invasive pneumococcal disease (IPD) were examined in South Australia 4 years before and 5 years after the commencement of the Australian universal childhood 7 valent pneumococcal conjugate vaccine (7vPCV) program. Methods IPD cases were identified by routine enhanced surveillance. IPD serotypes were grouped according to those covered by the 7vPCV, the six serotypes specific to the 13 valent pneumococcal conjugate vaccine (13vPCV), the 11 serotypes specific to the 23 valent pneumococcal polysaccharide vaccine (23vPPV), as well as non-13vPCV and non-23vPPV groups. Poisson regression was used to calculate age-specific and serotype-specific incident rate ratios (IRRs) comparing pre (2002–2004) and post (2007–2009) universal childhood 7vPCV periods. Results

Following the introduction of the 7vPCV program, the rate of IPD in children aged <2 years decreased by 81% for all serotypes (IRR 0.19, 95% CI, 0.13– 0.28) and by 98% for 7vPCV serotypes (IRR 0.02, 95% CI, 0.007–0.07). At the same time, there was some evidence for an increase in IPD caused by 13vPCV specific serotypes (IRR 1.58, 95% CI, 0.78–3.21) and non-13vPCV serotypes (IRR 1.80, 95% CI, 0.45–7.21). Among adults aged ≥65 years, overall there was a 27% reduction in IPD caused by all serotypes following introduction of the 7vPCV program (IRR 0.73, 95% CI, 0.58–0.93). However, the rate of IPD increased in the last 2 years of the study period. The initial decrease was a result of a 74% reduction in the rate of IPD due to 7vPCV serotypes (IRR 0.26, 95% CI, 0.17–0.40). At the same time, the rate of IPD increased for 13vPCV specific serotypes (IRR 1.55, 95% CI, 0.94–2.54), 23vPPV specific serotypes (IRR 1.91, 95% CI, 0.99–3.71) and particularly non23vPPV serotypes (IRR 5.3, 95% CI, 1.83–15.34). Conclusion There has been a large direct and sustained benefit from the universal 7vPCV program in children, particularly those aged <2 years, with some evidence for serotype replacement. There is also good evidence that the childhood program has provided indirect benefits to adults aged ≥65 years, although serotype replacement has reduced the initial benefits. Volume 30, Issue 11 pp. 1911-2036 (2 March 2012) Regular Papers Cost-effectiveness of pneumococcal conjugate vaccines of 7, 10, and 13 valences in Colombian children Original Research Article Pages 1936-1943 Carlos Castañeda-Orjuela, Nelson Alvis-Guzmán, Martha Velandia-González, Fernando De la Hoz-Restrepo Abstract Background Currently there are three pneumococcal conjugate vaccines with different coverage of serotypes for use in children under one year. We evaluate the cost-effectiveness of the introduction of pneumococcal conjugate vaccines of 7, 10, and 13 valences in the Colombian EPI. Methods A Markov model, which followed a cohort of children under one year to life expectancy, was developed. Parameters of occurrence and care costs were based on data from National Health System and literature review. PCV-7 is a dominated strategy. PCV-10 and PCV-13 were each compared to no vaccination or PCV-10 vaccination, respectively. A 2 + 1 schedule and a vaccination price of US$ 14.00, US$ 14.85 and US$ 16.34 per dose were assumed in the base case for PCV-7, -10, and PCV-13 vaccines. Results Introduction of PCV-13 rather than PCV-10 increases the number of life years gained (LYG). From the societal perspective, in the ‘competing choice’ framework cost per LYG was US$ 1837 with PCV-10 and US$ 9514 with PCV13, while PCV-7 is a dominated strategy. The ICER of PCV-13 is above the per capita Gross Domestic Product. Incremental cost-effectiveness ratios (ICERs)

were influenced mainly by effectiveness against radiologically-confirmed pneumonia and AOM, vaccine price, and discount rate. Conclusion Routine vaccination against Streptococcus pneumoniae in Colombia would be cost-effective with PCV-10, with ICER below the per-capita GDP, but its inclusion requires evaluating the budget impact. PCV-13 would prevent more disease and deaths with a higher LYG, but PCV-10 would save more cost to the healthcare system due its higher impact in the prevention of AOM. There is limitation in the clinical evidence of both strategies. Toward rubella elimination in Europe: An epidemiological assessment Original Research Article Pages 1999-2007 Mark Muscat, Laura Zimmerman, Sabrina Bacci, Henrik Bang, Steffen Glismann, Kåre Mølbak, Susan Reef, the EUVAC.NET group Abstract Background The elimination of rubella and prevention of congenital rubella syndrome (CRS) by 2015 are established goals for Europe. Our aim was to review the epidemiology of rubella in relation to this goal. Material and methods National surveillance institutions from 32 European countries provided information on rubella and CRS surveillance systems and data for 2000–08. We reported the number of notified rubella cases by year for countries with a national mandatory notification system for rubella covering total country population consistently throughout 2000–08 and analysed rubella surveillance data for 2008. Results Throughout 2000–08, 24 countries conducted passive routine surveillance based on mandatory reporting rubella covering total country population. Altogether these countries reported 526,751 rubella cases. The median incidence per million inhabitants declined from 7.2 in 2000 to 0.3 in 2008. By 2008, the number of countries with mandatory notification systems for rubella increased to 28. These countries reported 21,475 rubella cases of which 1.5% (n = 317) were laboratory-confirmed. Most cases (n = 21,075; 98%) were reported from Poland, Italy and Romania. Ten countries reported zero rubella cases and five others reported an incidence of <1 per million inhabitants. In 2008, 20 CRS cases were reported from five countries. Conclusion The overall decline in rubella incidence and increase in the number of countries conducting rubella surveillance through a mandatory notification system are notable achievements toward the goal of rubella elimination in Europe. However, in a few countries with high rubella incidence the risk for CRS still exists. Achievement and maintenance of the required high vaccination coverage and high-quality surveillance of rubella and CRS including laboratory testing of all suspected cases are fundamental to eliminate rubella and prevent CRS in Europe. Febrile seizures after 2010–2011 influenza vaccine in young children, United States: A vaccine safety signal from the vaccine adverse event reporting system

Pages 2020-2023 Z. Leroy, K. Broder, D. Menschik, T. Shimabukuro, D. Martin Signal identification and evaluation for risk of febrile seizures in children following trivalent inactivated influenza vaccine in the Vaccine Safety Datalink Project, 2010–2011 Original Research Article Pages 2024-2031 Alison Tse, Hung Fu Tseng, Sharon K. Greene, Claudia Vellozzi, Grace M. Lee, On behalf of the VSD Rapid Cycle Analysis Influenza Working Group Bridging the gap between data and public health needs. In the heat of a signal: Responding to a vaccine safety signal for febrile seizures after 2010–11 influenza vaccine in young children, United States Pages 2032-2034 Karen R. Broder, David B. Martin, Claudia Vellozzi Volume 30, Issue 10 pp. 1753-1910 (27 February 2012) Editorials The nursing profession and patient safety and healthcare provider influenza immunization: The puzzling stance of the American Nursing Association Pages 1753-1755 Gregory A. Poland, Sharon Tucker [No abstract] Nursing leadership to ensure patient and health worker protection from influenza Pages 1756-1758 Jo Anne Bennett, Derryl Block [No abstract] Regular Papers Impact of vaccine protection against multiple HPV types on the costeffectiveness of cervical screening Original Research Article Pages 1813-1822 Veerle M.H. Coupé, Johannes A. Bogaards, Chris J.L.M. Meijer, Johannes Berkhof Abstract Cross-protection against non-HPV16/18 types and the emergence of broad spectrum vaccines protecting against multiple HPV types will influence the cost-effectiveness of future screening. To assess this influence we used an individual-based simulation model describing the relation between 14 HPV types and cervical disease, allowing the occurrence of multiple type infections. Screening scenarios for vaccinated women were evaluated, firstly for HPV16/18 vaccination with partial crossprotection against HPV 31, 33, 45 and 58 and secondly, for broad spectrum vaccination against 5–13 HPV types. The vaccine-induced incidence reduction of type-specific infection was varied from 0 to 95% in the cross-protection setting and set at 100% in the setting of broad spectrum vaccines. Scenarios of either cytology or HPV DNA screening were considered under varying lifetime number of screening rounds. At a cost-effectiveness threshold of €20,000/QALY, four times HPV DNA screening between 30 and 60 years was

the selected scenario in addition to HPV16/18 vaccination, whether or not cross-protection was conferred (€6707 and €9994/QALY, respectively). In the absence of cross-protection, a fifth screening round might be considered (ICER €22,967/QALY). In addition to broad spectrum vaccination, one screen during lifetime was cost-effective up to an 11-valent vaccine. If the vaccineinduced type-specific incidence reduction was lowered to 99%, one screen during lifetime was cost-effective even in addition to 13-valent vaccination. In conclusion, in a cohort of HPV16/18 vaccinated women, four rounds of HPV DNA screening is cost-effective. One screen during lifetime remains costeffective in addition to broad spectrum vaccination offering protection against many high-risk HPV types. UK parents’ decision-making about measles–mumps–rubella (MMR) vaccine 10 years after the MMR-autism controversy: A qualitative analysis Original Research Article Pages 1855-1864 Katrina F. Brown, Susannah J. Long, Mary Ramsay, Michael J. Hudson, John Green, Charles A. Vincent, J. Simon Kroll, Graham Fraser, Nick Sevdalis Abstract Background and objectives Public concern about an unsubstantiated link between MMR vaccine and autism stemmed from a 1998 paper by Dr Andrew Wakefield and colleagues, and the substantial media coverage which that work attracted. Though the Wakefield paper is now discredited and an MMR-autism link has never been demonstrated empirically, this concern has manifested in over a decade of suboptimal MMR uptake. Few qualitative studies have explored parents’ MMR decision-making since uptake began to improve in 2004. This study updates and adds methodological rigour to the evidence base. Methods 24 mothers planning to accept, postpone or decline the first MMR dose (MMR1) for their 11–36 month-old children, described their decision-making in semi-structured interviews. Mothers were recruited via General Practice, parents’ groups/online forums, and chain referral. MMR1 status was obtained from General Practice records 6 months post-interview. Interview transcripts were coded and interpreted using a modified Grounded Theory approach. Results Five themes were identified: MMR vaccine and controversy; Social and personal consequences of MMR decision; Health professionals and policy; Severity and prevalence of measles, mumps and rubella infections; Information about MMR and alternatives. Results indicated that MMR1 acceptors were sympathetic toward Wakefield as a person, but universally rejected his study which sparked the controversy; parents opting for single vaccines expressed the sense that immune overload is not a consideration but that not all three components of MMR are warranted by disease severity; and MMR1 rejectors openly criticised other parents’ MMR decisions and decision-making. Conclusions This study corroborated some previous qualitative work but indicated that the shrinking group of parents now rejecting MMR comprises mainly those with more extreme and complex anti-immunisation views, whilst parents opting

for single vaccines may use second-hand information about the controversy. In response, policymakers and practitioners should revise their expectations of today's MMR decision-makers, and their methods for supporting them. The population based socioeconomic burden of pediatric influenzaassociated hospitalization in Hong Kong Original Research Article Pages 1895-1900 Susan S. Chiu, Kwok-Hung Chan, Lok Yee So, Robin Chen, Eunice L.Y. Chan, J.S.M. Peiris Abstract We described the monetary and non-monetary cost incurred by children hospitalized for virologically confirmed influenza virus infection in a population-based prospective 3-year study. The mean direct and indirect cost of each child hospitalized was $1217.82 (95% CI, 1111.54–1324.23) and $1328.33 (95% CI, $1136.79–1520.00) for influenza A and B, respectively. School age patients took a mean (SD) of 4.70 (3.05) days and 5.31 (3.62) days of sick leave for influenza A and B infection, respectively. Pediatric influenza A and B hospitalization was associated with 662–1046 days of school absenteeism and 214–336 days of parental work loss per 10,000 population <18 years of age per year. We showed that the cost incurred by hospitalization alone, was comparable to the cost of annual universal pediatric influenza vaccination especially in children 6 months to under 6 years of age and vaccination would result in much larger cost-savings when non-monetary costs are included. Value in Health Vol 15 | No. 1 | January-February 2012 | Pages 1-214 [Reviewed earlier]





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