Epidemiology of childhood tuberculosis after ceasing universal Bacillus Calmette–Guérin vaccination

Universal Bacillus Calmette–Guérin (BCG) vaccination is recommended in countries with high tuberculosis (TB) burden. Nevertheless, several countries have ceased universal BCG vaccination over the past 40 years, with scarce comparative epidemiological analyses regarding childhood TB after the policy change. We analysed data on childhood TB in countries that ceased universal BCG vaccination. Data sources included national/international databases, published papers, annual TB reports, and public health authority websites. Childhood TB notification rate increased in one of seven countries with available data. Pulmonary TB and TB lymphadenitis were the main causes of increasing childhood cases, while changes in severe forms of TB cases were minor. Maintaining high vaccine coverage for the target group was a common challenge after shifting selective vaccination. In some countries showing no increase in childhood TB after a BCG policy change, the majority of childhood TB cases were patients from abroad or those with overseas parents; these countries had changed immigration policies during the same period. Heterogeneity in childhood TB epidemiology was observed after ceasing universal BCG vaccination; several factors might obscure the influence of vaccination policy change. Lessons learned from these countries may aid in the development of better BCG vaccination strategies.

Herd immunity communication counters detrimental effects of selective vaccination mandates

Low vaccine uptake results in regular outbreaks of severe diseases, such as measles. Selective mandates, e.g. making measles vaccination mandatory (as currently implemented in Germany), could represent a viable solution to the problem. However, prior research has shown that making only some vaccinations mandatory while leaving the rest to voluntary decisions can result in psychological reactance (anger) and decreased uptake for voluntary vaccines. Since communicating the concept of herd immunity has been shown to increase the willingness to vaccinate, we assessed whether it can buffer such reactance effects. A total of 576 participants completed a preregistered 2 (policy: selective mandate vs. voluntary decision) × 2 (communication: herd immunity explained yes vs. no) factorial online experiment. In a first scenario, the concept of herd immunity was either introduced or not and vaccination was either mandatory or voluntary, depending on condition. The dependent variable was the intention to vaccinate in the second scenario where vaccination was always voluntary. Additionally, we explored the mediating role of anger between policies and intentions. Herd immunity communication generally increased vaccination intentions; selective mandates had no overall effect on intentions, and there was no interaction of the factors. However, selective mandates led to increased anger when herd immunity was not explained. This increased anger led to lower subsequent vaccination intentions. Consequently, explaining herd immunity can counter potential detrimental effects of selective mandates by preventing anger (reactance). Key messages When introducing selective mandates, the social benefits of herd immunity should be communicated. Otherwise, the uptake for still voluntary vaccines may decline, putting public health at risk.

The Effect of Selective and Mass Immunization Against Pneumococcal Infection on the Morbidity and Mortality due to Community-Acquired Pneumonia in Children Under 5 Years of Age

Background. It is required to perform estimation of epidemiological and cost efficacy (regarding morbidity rate) of mass routine vaccination against pneumococcal infection in Russian children and carried out earlier selective vaccination of children from high-risk groups on the basis of four-year experience. It is also important to estimate the rate of hospital admissions in this patient group, long-term and annual cycles, morbidity age and etiology structure, and mortality due to community-acquired pneumonia as one of the most common form of pneumococcal disease. The aim is to study the effect of selective and mass immunization against pneumococcal infection on the morbidity and mortality due to community-acquired pneumonia in children under 5 years of age. Methods. The analysis of communityacquired pneumonia morbidity (in 2003–2018) and mortality due to pneumonias (in 2003–2018) in children under the 14 years old in Perm was carried out. Serotypes of circulating pneumococcus, etiology of community-acquired pneumonias and immunization cost efficacy (direct expense on health care) were further studied. The analysis of study indexes was carried out following selective (vaccination of at-risk children in 2011–2014) and mass (vaccination of infants in 2015–2018) immunization strategies. Results. The morbidity rate of community-acquired pneumonias decreased by 4.0 times (from 267.0 to 66.7 for 1000) after performing selective vaccination (2011–2014) in at-risk children (frequently and chronically ill children). The morbidity rate of community-acquired pneumonias in non vaccinated children of the same group increased by 2.0 times (from 40.0 to 80.0 for 1000 non-vaccinated). The prophylactic efficacy index was 46.0. Whereby the antibacterial index among vaccinated frequently and chronically ill children was 0.11 on one child. This index has decreased by 2.6 times (from 0.11 to 0.04 on one child) in a year within the framework of prospective controlled randomized clinical study. The antibacterial index among non-vaccinated children of this group remained slightly the same: 0.09 and 0.12 respectively. During the selective vaccination the mortality rate among infants decreased by 2 times: long-term average index was 17.9 (2011–2014) against 35.2 (2003-2010) on 100 thousand children. Mass vaccination of infants against pneumococcal infection has reduced the incidence of community-acquired pneumonias among children under 2 years of age and has led to absence of multiple sites of pneumococcal infection in children’s organizations. It also has reduced the number of hospitalized children and achieved zero mortality due to pneumonias in infants by the third year of this immunization strategy implementation. The obtained results were achieved mainly due to circulation of 7 pneumococcal serotypes (6A, 6B, 9V, 14, 19A, 19F, 23F) in children under 5 years of age. The threshold level of vaccination against pneumococcal infection advancing morbidity and mortality due to pneumonias in children was specified. The strategy of mass vaccination of infants was cost-effective. Conclusion. The new data on epidemiological and cost efficacy of various immunization strategies against pneumococcal infection in children was obtained.

JABS FOR THE BOYS

The human papillomavirus (HPV) can cause a range of cancers as well as genital warts and recurrent respiratory papillomatosis in men and women. Most cases can be prevented by vaccination in adolescence. Many countries vaccinate girls and an increasing number, although still a minority, vaccinate both boys and girls. The case for vaccinating boys is based on arguments of public health, equity, ethics and cost-effectiveness. The selective vaccination of females does not protect males sufficiently and provides no protection at all for men who have sex with men. In the United Kingdom (UK), the government’s vaccination advisory committee (Joint Committee on Vaccination and Immunisation [JCVI]) began to consider whether boys should be vaccinated as well as girls in 2013 and made clear in draft statements that it considered this not to be cost-effective. A campaign group, HPV Action, was established to advocate gender-neutral vaccination. This group became a coalition of over 50 organisations and used evidence-based arguments, political advocacy and media campaigning to make its case. One of its members initiated legal action against the government on the grounds of sex discrimination. In July 2018, the government agreed that boys in the UK should be vaccinated. The lessons for other campaigns in the men’s and public health fields include: be prepared for the long haul, focus on clear and specific goals, build alliances, align the objectives with existing policies, make a financial case for a change of policy, and use all legitimate means to exert pressure.

VP48 The Costs And Cost-Effectiveness Of Bacillus Calmette-Guérin (BCG) Vaccination In Estonia

INTRODUCTION:Many countries that have used Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis (TB) have switched from universal vaccination of infants and children to selective vaccination, or discontinued with vaccination at all. The aim of the study is to assess the costs and cost-effectiveness of BCG vaccination in Estonia.METHODS:A Markov cohort model and budget impact analysis were used to compare the current, universal BCG vaccination to selective and non-vaccination strategies. The epidemiological and economic impact of BCG vaccination were estimated for the period 2018–2032 following the hypothetical change in the vaccination policy in 2018. The results were presented as the cost per case of TB adverted, changes in the occurrence of TB and yearly (undiscounted) costs associated with vaccination and TB treatment.RESULTS:In a cohort of 13,500 infants over a time-period of 15 years Estonian universal BCG vaccination prevents around two TB cases compared to selective or non-vaccination strategies. The cost per one TB case averted for the universal strategy compared to non-vaccination strategy was EUR12,234 (EUR4,059–28,748 in sensitivity analysis) and compared to selective vaccination EUR3,847 (EUR504–10,568). The number of TB cases in 0–14-year old children in 2032 was estimated to be 1.3 for universal vaccination, 2.7 for selective and 2.9 for non-vaccination strategy. The total costs of vaccination and TB treatment in 2032 were estimated to be EUR23,764, EUR16,459 and EUR7,553 respectively.CONCLUSIONS:The cost per case of TB averted is dependent on vaccine efficacy, and is high compared with the cost of treating one case of TB. At the same time, the total costs of BCG vaccination and TB treatment are marginal compared to other vaccination programs used in Estonia. Despite the limited budget impact, several organizational challenges need to be addressed if the universal program is replaced with selective BCG vaccination.

Varicella-zoster immunoglobulin treatment in pregnant women in Denmark from 2005 to 2015: descriptive epidemiology and follow-up

SUMMARYPrimary infection with varicella-zoster virus in pregnancy poses a risk of severe infection and embryopathies. Upon exposure, seronegative women are candidates for varicella-zoster immunoglobulin (VZIG). The aim of this paper was to describe risk factors for VZIG treatment including sources of varicella exposure and to study how many women developed clinical infection and received postpartum vaccination. We identified all pregnant women who received VZIG from December 2005 to March 2015. Additional information was obtained from Danish registers and a follow-up questionnaire. A total of 104 women were included and 88 completed the questionnaire. Significantly more women had ‘other country of origin’ than Denmark. They were more often second para (57%) and had most commonly been exposed to varicella by their own child (58%). Five women developed clinical varicella infection, and only 26·5% were vaccinated after delivery. The study concludes that few women developed infection after VZIG and none developed pneumonia. General practitioners should be particularly aware of obtaining varicella anamnesis in parous women from non-temperate countries in order to perform selective vaccination prior to pregnancy. In case of varicella exposure during pregnancy in a seronegative woman, postpartum vaccination is crucial.