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The seventh chapter, “An Era of Optimism,” analyzes the new culture of sanitation practices that helped to define modernity. In the late nineteenth and early twentieth centuries, those living in the developed world became accustomed to wearing shoes, using toilet paper, bathing regularly with soap, and utilizing refrigeration systems to extend the life of foods. In the mid-twentieth century, populations in the Global North benefited from population-wide vaccination programs against poliomyelitis, the prevalence of which seemed to have increased as a result of the implementation of better sanitation systems. Based on the "hygiene hypothesis," many specialists believed that poliomyelitis was rare in regions without modern sanitation. This was not the case. Regrettably, polio vaccination did not begin in the developing world until the 1970s. Oral rehydration therapy, a major breakthrough in the treatment of diarrheal disease, saved millions of lives.
Rotavirus (RV) is the main cause of acute gastroenteritis (AGE) in young children. The San Luis province of Argentina introduced RV vaccination in May 2013. We estimate vaccine impact (RVI) using real-world data. Data on all-cause AGE cases and AGE-related hospitalisations for San Luis and the adjacent Mendoza province (control group) were obtained and analysed by interrupted time-series methods. Regardless of the model used for counterfactual predictions, we estimated a reduction in the number of all-cause AGE cases of 20–25% and a reduction in AGE-related hospitalisations of 55–60%. The vaccine impact was similar for each age group considered (<1 year, <2 years and <5 years). RV vaccination was estimated to have reduced direct medical costs in the province by about 4.5 million pesos from May 2013 to December 2014. Similar to previous studies, we found a higher impact of RV vaccination in preventing severe all-cause AGE cases requiring hospitalisation than in preventing all-cases AGE cases presenting for medical care. An assessment of the economic value of RV vaccination could take other benefits into account in addition to the avoided medical costs and the costs of vaccination.
This study sets an example of an economic evaluation of a model dengue vaccination strategy for Sri Lanka, following a mandatory pre-vaccination screening strategy.
A decision analytic Markov model was developed to estimate the cost-effectiveness of a predicted dengue vaccination strategy over a time horizon of 10 years. The cost effectiveness of dengue vaccination strategy for seropositive individuals was estimated in terms of incremental cost effectiveness ratio (ICER) (cost per additional quality adjusted life-year [QALY]). District-specific ICER values and the budget impact for dengue vaccine were estimated with appropriate sensitivity analyses, also taking the variability of the pre-vaccination screening test performance into consideration.
The ICER for the predicted vaccination strategy following pre-vaccination screening was 4,382 USD/QALY for Sri Lanka. There was a significant regional variation in vaccine cost effectiveness. The disaggregated regional incidence of dengue and the need to perform pre-vaccination screening affects the cost effectiveness estimates significantly, where a safer version of the vaccine has the potential to become cost saving in high incidence districts.
The cost effectiveness of the predicted dengue vaccination strategy following pre-vaccination screening showed a significant regional variation across the districts of Sri Lanka. District-wise disease incidence and the need for pre-vaccination screening was found to be the most significant factors affecting the cost effectiveness of the vaccine.
Dogs harbor numerous zoonotic pathogens, many of which are controlled through vaccination programs. The delivery of these programs can be difficult where resources are limited. We developed a dynamic model to estimate vaccination coverage and cost-per-dog vaccinated. The model considers the main factors that affect vaccination programs: dog demographics, effectiveness of strategies, efficacy of interventions and cost. The model was evaluated on data from 18 vaccination programs representing eight countries. Sensitivity analysis was performed for dog confinement and vaccination strategies. The average difference between modelled vaccination coverage and field data was 3.8% (2.3%–5.3%). Central point vaccination was the most cost-effective vaccination strategy when >88% of the dog population was confined. More active methods of vaccination, such as door-to-door or capture-vaccinate-release, achieved higher vaccination coverage in free-roaming dog populations but were more costly. This open-access tool can aid in planning more efficient vaccination campaigns in countries with limited resources.
Narratives are a powerful tool for transferring knowledge and culture. They have a profound effect on our psyche and our attitudes to messages and teachings. The transfer of information through traditional teaching and lectures is often less effective in changing a belief or understanding than using narrative. In this discussion paper, I explore this phenomenon and examine the persuasive effect of cultural narratives. The discussion also considers the impacts of cultural narrative as an educative tool on parental attitudes towards childhood immunisation. I explore the changing nature of the way parents with young children communicate and seek information and early childhood educators’ roles in their lives within the Australian context. Understanding the way humans are drawn to narrative may be beneficial to health workers, early childhood educators, family workers and those who plan health education programmes. To effectively target their messages, it would be of benefit to public health officials to have knowledge about how parents with young children inform themselves and develop health beliefs, and the extent to which parents’ ideas become fixed.
England has recently started a new paediatric influenza vaccine programme using a live-attenuated influenza vaccine (LAIV). There is uncertainty over how well the vaccine protects against more severe end-points. A test-negative case–control study was used to estimate vaccine effectiveness (VE) in vaccine-eligible children aged 2–16 years of age in preventing laboratory-confirmed influenza hospitalisation in England in the 2015–2016 season using a national sentinel laboratory surveillance system. Logistic regression was used to estimate the VE with adjustment for sex, risk-group, age group, region, ethnicity, deprivation and month of sample collection. A total of 977 individuals were included in the study (348 cases and 629 controls). The overall adjusted VE for all study ages and vaccine types was 33.4% (95% confidence interval (CI) 2.3–54.6) after adjusting for age group, sex, index of multiple deprivation, ethnicity, region, sample month and risk group. Risk group was shown to be an important confounder. The adjusted VE for all influenza types for the live-attenuated vaccine was 41.9% (95% CI 7.3–63.6) and 28.8% (95% CI −31.1 to 61.3) for the inactivated vaccine. The study provides evidence of the effectiveness of influenza vaccination in preventing hospitalisation due to laboratory-confirmed influenza in children in 2015–2016 and continues to support the rollout of the LAIV childhood programme.
Although the UK is the largest lamb meat producer in Europe, there are limited data available on sheep flock performance and on how sheep farmers manage their flocks. The aims of this study were to gather evidence on the types of disease control practices implemented in sheep flocks, and to explore husbandry factors associated with flock productivity. A questionnaire focusing on farm characteristics, general husbandry and flock health management was carried out in 648 farms located in the UK over summer 2016. Abattoir sales data (lamb sales over 12 months) was compared with the number of breeding ewes on farm to estimate flock productivity (number of lambs sold for meat per 100 ewes per farm per year). Results of a multivariable linear regression model, conducted on 615 farms with complete data, indicated that farms vaccinating ewes against abortion and clostridial agents and administering a group 4/5 anthelmintic to ewes (as recommended by the Sustainable Control of Parasites in Sheep Initiative) during quarantining had a greater flock productivity than farms not implementing these actions (P<0.01 and 0.02, respectively). Flocks with maternal breed types had higher productivity indexes compared with flocks with either pure hill or terminal breeds (P<0.01). Farms weighing lambs during lactation had greater productivity than those not weighing (P<0.01). Importantly, these actions were associated with other disease control practices, for example, treating individual lame ewes with an antibiotic injection, weaning lambs between 13 and 15 weeks of age and carrying out faecal egg counts, suggesting that an increase in productivity may be associated with the combined effect of these factors. This study provides new evidence on the positive relationship between sheep flock performance and disease control measures and demonstrates that lamb sales data can be used as a baseline source of information on flock performance and for farm benchmarking. Further research is needed to explore additional drivers of flock performance.
Resilience is the ability of an animal to return soon to its initial productivity after facing diverse environmental challenges. This trait is directly related to animal welfare and it plays a key role in fluctuations of livestock productivity. A divergent selection experiment for environmental variance of litter size has been performed successfully in rabbits over ten generations. The objective of this study was to analyse resilience indicators of stress and disease in the divergent lines of this experiment. The high line showed a lower survival rate at birth than the low line (−4.1%). After correcting by litter size, the difference was −3.2%. Involuntary culling rate was higher in the high than in the low line (+12.4%). Before vaccination against viral haemorrhagic disease or myxomatosis, concentration of lymphocytes, C-reactive protein (CRP), complement C3, serum bilirubin, triglycerides and cholesterol were higher in the high line than in the low line (difference between lines +4.5%, +5.6 µg/ml, +4.6 mg/ml, +7.9 mmol/l, +0.3 mmol/l and +0.4 mmol/l). Immunological and biochemical responses to the two vaccines were similar. After vaccination, the percentage of lymphocytes and CRP concentration were higher in the low line than in the high one (difference between lines +4.0% and +13.1 µg/ml). The low line also showed a higher increment in bilirubin and triglycerides than the high line (+14.2 v. +8.7 mmol/l for bilirubin and +0.11 v. +0.01 mmol/l for triglycerides); these results would agree with the protective role of bilirubin and triglycerides against the larger inflammatory response found in this line. In relation to stress, the high line had higher basal concentration of cortisol than the low line (+0.2ng/ml); the difference between lines increased more than threefold after the injection of ACTH 1 to 24, the increase being greater in the high line (+0.9 ng/ml) than in the low line (+0.4 ng/ml). Selection for divergent environmental variability of litter size leads to dams with different culling rate for reproductive causes and different kits’ neonatal survival. These associations suggest that the observed fitness differences are related to differences in the inflammatory response and the corticotrope response to stress, which are two important components of physiological adaptation to environmental aggressions.
Immunization data are vital to support responses to vaccine-preventable disease outbreaks. The Oregon Immunization Program developed a unique prototype instrument—the Rapid Response Tool (RRT)—that provides population data to local responders within 2 hours of a request. Data outputs include vaccination coverage by age group and zip code; percentages of students with nonmedical exemptions to vaccination requirements, by school; and current, comprehensive lists of local vaccination providers.
The RRT was demonstrated to staff at 7 Oregon counties and feedback was solicited via comments and a structured survey.
The RRT received strong support. Attendees identified several uses for RRT data, including outbreak response and ongoing intervention efforts, and they pointed to areas for further development.
The success of the RRT demonstrations illustrates that a well-populated immunization information system can contribute to preparedness work well beyond current standards. (Disaster Med Public Health Preparedness. 2019;13:682–685)
This article explores the introduction of smallpox vaccination into Nepal in 1816 at the request of the Nepalese government; the king, however, was not vaccinated, contracted the disease and died. British hopes that vaccination would be extended throughout the country did not eventuate. The article examines the significance of this early appearance of vaccination in Nepal for both Nepalese and British, and relates it to the longer history of smallpox control and eventual eradication. When the Nepalese requested World Health Organization (WHO) assistance with communicable disease control in the mid-twentieth century little had changed for most Nepalese. We know about the events in 1816 through the letters of the newly imposed British Resident after Nepal’s military defeat in the Anglo-Nepal War (1814–16). By also drawing on other sources and foregrounding Nepal, it becomes possible to build up a more extensive picture of smallpox in Nepal that shows not only boundaries and limits to colonial authority and influence but also how governments may adopt and use technologies on their own terms and for their own purposes. Linking 1816 to the ultimately successful global eradication programme 150 years later reminds us of the need to think longer term as to why policies and programmes may or may not work as planned.
Rabies is one of the major public health problems in China, and the mortality rate of rabies remains the highest among all notifiable infectious diseases. A meta-analysis was conducted to investigate the post-exposure prophylaxis (PEP) vaccination rate and risk factors for human rabies in mainland China. The PubMed, Web of Science, Chinese National Knowledge Infrastructure, Chinese Science and Technology Periodical and Wanfang databases were searched for articles on rabies vaccination status (published between 2007 and 2017). In total, 10 174 human rabies cases from 136 studies were included in this meta-analysis. Approximately 97.2% (95% confidence interval (CI) 95.1–98.7%) of rabies cases occurred in rural areas and 72.6% (95% CI 70.0–75.1%) occurred in farmers. Overall, the vaccination rate in the reported human rabies cases was 15.4% (95% CI 13.7–17.4%). However, among vaccinated individuals, 85.5% (95% CI 79.8%–83.4%) did not complete the vaccination regimen. In a subgroup analysis, the PEP vaccination rate in the eastern region (18.8%, 95% CI 15.9–22.1%) was higher than that in the western region (13.3%, 95% CI 11.1–15.8%) and this rate decreased after 2007. Approximately 68.9% (95% CI 63.6–73.8%) of rabies cases experienced category-III exposures, but their PEP vaccination rate was 27.0% (95% CI 14.4–44.9%) and only 6.1% (95% CI 4.4–8.4%) received rabies immunoglobulin. Together, these results suggested that the PEP vaccination rate among human rabies cases was low in mainland China. Therefore, standardised treatment and vaccination programs of dog bites need to be further strengthened, particularly in rural areas.
Determining whether, and when, to get one's children vaccinated has become an increasingly controversial decision, often leaving parents fearful of making the “wrong” choice. Part of the challenge stems from the fact that what is rationally optimal for an individual is inherently at odds with the best outcome for the community, meaning that if everyone acted out of self-interest with respect to pediatric vaccines, communal health would suffer significantly. Given these tensions, the issue of pediatric vaccines benefits greatly from the nuanced assessment of Catholic social teaching. Specifically, the Pontifical Council for Justice and Peace's “four permanent principles” of human dignity, the common good, subsidiarity, and solidarity highlight the issues involved and help parents navigate this significant medical choice with a more informed conscience and a greater sense of their moral responsibilities. The end result is a fruitful alignment between Catholic social teaching and ethics in ordinary life.
Bovine viral diarrhea virus (BVDV) is an important infectious agent affecting herd productivity and reproduction, and leading to massive economic losses. As such, BVD is the subject of a number of control and eradication schemes globally. The key elements of such schemes are: diagnosis and removal of persistently infected animals from herds; implementation of biosecurity practices aimed at preventing the introduction or re-introduction of BVDV in free herds; and ongoing surveillance to monitor the progress of the program and to detect new infections. The objective of this review is to examine the impact of BVD and the management of the disease in three countries: Scotland, Spain, and Argentina, where BVD control programs are in distinct phases: established, developing, and yet to be initiated. This work also sets out to highlight potential difficulties and formulate recommendations for successful BVD control. It concludes that a systematic, countrywide approach is needed to achieve a sustainable decrease in BVD prevalence. The role of vaccines in control programs is concluded to be a valuable additional biosecurity measure. This study also concludes that there are potential wider benefits to a systematic BVD control program, such as a reduction in antimicrobial use and increases in the competitiveness of the cattle industry.
When assessing hepatitis B virus (HBV) status in clinical settings, it is unclear whether self-reports on vaccination history and previous HBV-test results have any diagnostic capacity. Of 3997 participants in a multi-centre HBV-screening study in Paris, France, 1090 were asked questions on their last HBV-test result and vaccination history. Discordance between self-reported history compared with infection status (determined by serology) was calculated for participants claiming ‘negative’, ‘effective vaccine’, ‘past infection’, or ‘chronic infection’ HBV-status. Serological testing revealed that 320 (29.4%) were non-immunised, 576 (52.8%) were vaccinated, 173 (15.9%) had resolved the infection and 21 (1.9%) were hepatitis B surface antigen positive. In total 208/426 (48.8%) participants with a self-reported history of ‘negative’ infection had a discordant serological result, in whom 128 (61.5%) were vaccinated and 74 (35.6%) had resolved infections. A total of 153/599 (25.5%) participants self-reporting ‘effective vaccine’ had a discordant serological result, in whom 100 (65.4%) were non-immunised and 50 (32.7%) were resolved infections. Discordance for declaring ‘past’ or ‘chronic infection’ occurred in 9/55 (16.4%) and 3/10 (30.0%) individuals, respectively. In conclusion, self-reported HBV-status based on participant history is partially inadequate for determining serological HBV-status, especially between negative/vaccinated individuals. More adapted patient education about HBV-status might be helpful for certain key populations.
Newcastle disease is one of the most important diseases of poultry with wide distribution and high fatalities. An infection with a virulent strain can cause up to 100% fatality in a susceptible flock, with devastating economic losses. In-feed antibiotics are not directly effective against Newcastle disease virus (NDV), but they may assist in prevent associated production problems. With in-feed antibiotics being controlled or banned, prebiotics, particularly those sourced from spices, and probiotics have been investigated as potential alternatives for maintaining seroconversion in poultry vaccinated against NDV. Certain prebiotics have a positive effect on anti-NDV antibodies but using spices as sources of prebiotics gave no clearly defined results. Garlic extract was reported to increase the mean haemagglutination inhibition (HI) titre of NDV by 0.6 after two weeks of supplementation, increasing titres by 4.0 in the vaccinated group compared to an increase of 3.4 in vaccinated unsupplemented group. However, onion-based compounds did not improve anti-NDV antibodies. The majority of studies have found that probiotics improved antibody levels and seroconversion to NDV vaccines in poultry. A commercial probiotic, containing a mixture of Bacillus species and Saccharomyces boulardii when used at a concentration of 100 g/ton was found to significantly increase the anti-NDV titre (log2) from 5.00 to 5.50. Another commercial probiotic, consisting of a combination of bacteria, reduced mortality by 6.6% at a concentration of 1 g/kg. Additional studies are needed to define the conditions and forms in which both the pre- and pro-biotics work best with respect to NDV control.
Schizophrenia affects 1% of the population. Clozapine is the only medication licensed for treatment-resistant schizophrenia and is intensively monitored to prevent harm from neutropenia. Clozapine is also associated with increased risk of pneumonia although the mechanism is poorly understood.
To investigate the potential association between clozapine and antibody deficiency.
Patients taking clozapine and patients who were clozapine-naive and receiving alternative antipsychotics were recruited and completed a lifestyle, medication and infection-burden questionnaire. Serum total immunoglobulins (immunoglobulin (Ig)G, IgA, IgM) and specific IgG antibodies to haemophilus influenzae type B, tetanus and IgG, IgA and IgM to pneumococcus were measured.
Immunoglobulins were all significantly reduced in the clozapine-treated group (n = 123) compared with the clozapine-naive group (n = 111). Odds ratios (ORs) for a reduction in clozapine:control immunoglobulin values below the fifth percentile were IgG, OR = 6.00 (95% CI 1.31–27.44); IgA, OR = 16.75 (95% CI 2.18–128.60); and IgM, OR = 3.26 (95% CI 1.75–6.08). These findings remained significant despite exclusion of other potential causes of hypogammaglobulinaemia. In addition, duration on clozapine was associated with decline in IgG. A higher proportion of the clozapine-treated group reported taking more than five courses of antibiotics in the preceding year (5.3% (n = 5) versus 1% (n = 1).
Clozapine use was associated with significantly reduced immunoglobulin levels and an increased proportion of patients using more than five antibiotic courses in a year. Antibody testing is not included in existing clozapine monitoring programmes but may represent a mechanistic explanation and modifiable risk factor for the increased rates of pneumonia and sepsis-related mortality previously reported in this vulnerable cohort.
Declaration of interest
S.J. has received support from CSL Behring, Shire, LFB, Biotest, Binding Site, Sanofi, GSK, UCB Pharma, Grifols, BPL SOBI, Weatherden, Zarodex and Octapharma for projects, advisory boards, meetings, studies, speaker and clinical trials.
Due to the European measles epidemic and the increased number of imported cases, it can be theorised that the risk of exposure among Hungarian healthcare workers (HCWs) has increased. In 2017, the increased measles circulation in the region led to the emergence of smaller local and hospital epidemics. Therefore, our objective was to determine the herd immunity in the high-risk group of HCWs. A hospital-based study of detecting anti-measles IgG activity was performed in 2017 and included 2167 employees of the Military Medical Centre (Hungary). The screening of HCWs presented a good general seropositivity (90.6%). The highest seroprevalence value (99.1%) was found in the age group of 60 years or older. The lowest number of seropositive individuals was seen in the 41–45 years (86.2%) age group, indicating a significant herd immunity gap between groups. Regarding the Hungarian data, there might be gaps in the seroprevalence of the analysed HCWs, implying that susceptible HCWs may generate healthcare-associated infections. This study suggests that despite the extensive vaccination and high vaccine coverage, it is still important to monitor the level of protective antibodies in HCWs, or in a representative group of the whole population of Hungary, and possibly in other countries as well.
This study assessed smallholder finances and their attitudes towards the Foot and Mouth Disease (FMD) vaccination programme, when 1 620 000 vaccine doses were provided for strategic administration in large ruminants in FMD ‘high-risk’ areas in Laos between 2012 and 2016. Farmers (n = 168) in the provinces of Xayyabouli (XYL), Xiengkhoung (XK) and Huaphan (HP), were interviewed. Over 91% of the farmers responded that their livestock were vaccinated for FMD, with over 86% ranking FMD vaccination as a good or very good intervention. No FMD cases were reported from the vaccinated provinces after May 2013. Examination of the total income per household in XYL, XK and HP indicated earnings of US$5060(±650), US$4260(±294) and US$1691(±676), respectively (P = 0.001), with 23%, 28% and 68% of the total incomes from annual sales of large ruminant, respectively. Of the farmers in XYL, XK and HP, 83%, 93% and 70% (P = 0.009) said their annual income increased compared with 2012, and 47%, 64% and 41%, respectively (P = 0.005), indicated this increase was from additional large ruminant sales. The study indicated that this large FMD vaccination programme was well regarded by participating farmers and may have provided satisfactory suppression of the disease in Laos, despite not achieving the preferred vaccination coverage. Continuation of the vaccination programme in FMD high-risk areas is suggested as desirable.
An evaluation of the relationship between predictors and immune response was conducted using data obtained from a clinical trial in 200 Czech healthy adults aged 24–65 years receiving a booster dose of a monovalent tetanus vaccine in 2017. The response was determined from ELISA antibody concentrations of paired sera obtained before and 4 weeks after the immunisation. While all subjects with initial antibody levels <1.2 IU/ml achieved a 100% seroconversion rate (at least a fourfold rise in antibodies), only 8% seroconversion was documented in subjects with initial levels >2.2 IU/ml. The immune response was not affected by sex, age, tetanus vaccine type, concomitant medication, related adverse events or post-vaccination period since there were no significant differences in geometric mean concentrations or seroconversion rates. The seroconversion rate of 56% in smokers was significantly lower than that of 73% achieved in non-smokers. Although the seroconversion rates did not differ between individuals with normal or higher body weight, the adjusted odds ratio (1.3; 95% Cl 1.08–1.60) revealed a positive correlation between seroconversion rate and body mass index (BMI). Although the vaccine-induced response was influenced by pre-vaccination antibody levels, smoking or BMI, the booster immunisation against tetanus produced a sufficient response regardless the predictors.
Tick-borne encephalitis (TBE) is an emerging vector-borne disease in Europe. The aim of the study was to evaluate sequelae and to analyse the potential risk factors predisposing to sequelae development. We performed a retrospective analysis of medical records of 1072 patients who received a 1-month follow-up appointment after hospital discharge. Medical data, such as patients’ age, gender, place of living, subjective complaints, neurological and psychiatric sequelae were evaluated twice: at the moment of discharge and at follow-up visits 1 month after discharge. We observed that sequelae may affect 20.6% of TBE patients. Subjective sequelae were more frequent than subjective complaints during the hospitalisation (P < 0.001), while objective neurological symptoms during the hospitalisation were more pronounced than neurological sequelae (P < 0.001). Patients with meningoencephalomyelitis were predisposed to neurological complications, while subjective symptoms were more common in meningoencephalitis. Independent risk factors for sequelae development were: age and cerebrospinal fluid (CSF) protein concentration. The risk of late neurological complications persisting was increased in patients with higher CSF protein concentration. Based on the results of our study we concluded that, there is a need for a better vaccination program, which would prevent the development of sequelae.