Vaccines: The Week in Review 10 October 2011 Center for Vaccine Ethics & Policy (CVEP) http://centerforvaccineethicsandpolicy.wordpress.

com/ A program of - Center for Bioethics, University of Pennsylvania http://www.bioethics.upenn.edu/ - The Wistar Institute Vaccine Center http://www.wistar.org/vaccinecenter/default.html - Childrens Hospital of Philadelphia, Vaccine Education Center http://www.chop.edu/consumer/jsp/microsite/microsite.jsp This weekly summary targets news 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 now also posted in pdf form and as a set of blog posts at http://centerforvaccineethicsandpolicy.wordpress.com/. This blog allows fulltexting searching of some 2,000 content items. Comments and suggestions should be directed to David R. Curry, MS Editor and Executive Director Center for Vaccine Ethics & Policy david.r.curry@centerforvaccineethicsandpolicy.org

WHO reported on measles outbreak in Member States in the European and African regions, with several reported outbreaks in the Americas linked to Europe or Africa. [full text] Europe: As of 20 September 2011, 40 of 53 Member States in the WHO European Region have reported 26,025 confirmed measles cases for the period January July 2011 to the WHO European Regional Office through routine surveillance and outbreak reports. The highest number of cases was reported from France with 14,025 cases for the first six months of the year. In addition, eleven of all cases in the Region were lethal (6 in France and one in each of Germany, Kyrgyzstan, Romania, the Former Yugoslav Republic of Macedonia and the United Kingdom). The predominant genotype currently circulating in the European Region is D4, the same endemic genotype from the United Kingdom in 2008. The most recent outbreak was reported from Israel in September, with 12 cases. Member States have responded to the outbreak by modifying the vaccination schedule, like France, or by offering vaccination free of charge or in schools, to increase accessibility to and availability of vaccines. Africa: The Regional Office reports that as of September 2011 large measles outbreaks are being reported by the Democratic Republic of the Congo, with over 103,000 cases, Nigeria, with 17,428 cases, and Zambia,

with 5,397 cases, and Ethiopia, with 2 902 cases. Even though deaths are not routinely reported to the Regional Office, the WHO Country Office in the Democratic Republic of the Congo reports over 1100 measles-associated deaths in the country during 2011. Americas: The last case of endemic measles was reported from the region in 2002. In 2011 the Region has received reports of several outbreaks linked to importation of measles virus from other regions. The largest, in Quebec, Canada, involves 742 reported cases, 89 requiring hospitalization, but no measles-associated deaths. Other outbreaks have been reported from the United States (213 cases), Ecuador (41 cases), Brazil (18 cases), Columbia (7 cases), Mexico (3 cases), and Chile (6 cases). Most of these outbreaks are linked to importations from Europe, except for outbreaks in the United States and Chile linked to cases from Malaysia and the outbreak in Ecuador, linked to Kenya. Measles is a highly infectious disease that causes complications and deaths, even in previously-healthy individuals, but is fully preventable by vaccination. Countries need to ensure that they reach 95% coverage with two doses of measles vaccine across all age groups up to 15 years of age. Otherwise the country will experience measles outbreaks with large numbers of cases, associated hospitalizations and deaths. The recent outbreaks in countries with high volumes of international travellers can lead to measles exportation to regions previously free of measles, such as the Region of the Americas or certain African countries. These exportations can lead to large outbreaks and associated deaths. These outbreaks should remind travellers that they should ensure that they have had two doses of measles-containing vaccine before their trip. http://www.who.int/csr/don/2011_10_07/en/index.html

The Nobel Prize in Physiology or Medicine 2011 was awarded jointly to Bruce A. Beutler and Jules A. Hoffmann "for their discoveries concerning the activation of innate immunity" and to Ralph M. Steinman (posthumously) "for his discovery of the dendritic cell and its role in adaptive immunity". Extract from press release: Jules Hoffmann made his pioneering discovery in 1996, when he and his coworkers investigated how fruit flies combat infections. They had access to flies with mutations in several different genes including Toll, a gene previously found to be involved in embryonal development by Christiane Nsslein-Volhard (Nobel Prize 1995). When Hoffmann infected his fruit flies with bacteria or fungi, he discovered that Toll mutants died because they could not mount an effective defense. He was also able to conclude that the product of the Toll gene was involved in sensing pathogenic microorganisms and Toll activation was needed for successful defense against them. Bruce Beutler was searching for a receptor that could bind the bacterial product, lipopolysaccharide (LPS), which can cause septic shock, a life threatening condition that involves overstimulation of the immune system. In 1998, Beutler and his colleagues discovered that mice resistant to LPS had a mutation in a gene that was quite similar to the Toll gene of the fruit fly. This

Toll-like receptor (TLR) turned out to be the elusive LPS receptor. When it binds LPS, signals are activated that cause inflammation and, when LPS doses are excessive, septic shock. These findings showed that mammals and fruit flies use similar molecules to activate innate immunity when encountering pathogenic microorganisms. The sensors of innate immunity had finally been discovered. The discoveries of Hoffmann and Beutler triggered an explosion of research in innate immunity. Around a dozen different TLRs have now been identified in humans and mice. Each one of them recognizes certain types of molecules common in microorganisms. Individuals with certain mutations in these receptors carry an increased risk of infections while other genetic variants of TLR are associated with an increased risk for chronic inflammatory diseases Ralph Steinman discovered, in 1973, a new cell type that he called the dendritic cell. He speculated that it could be important in the immune system and went on to test whether dendritic cells could activate T cells, a cell type that has a key role in adaptive immunity and develops an immunologic memory against many different substances. In cell culture experiments, he showed that the presence of dendritic cells resulted in vivid responses of T cells to such substances. These findings were initially met with skepticism but subsequent work by Steinman demonstrated that dendritic cells have a unique capacity to activate T cells. Further studies by Steinman and other scientists went on to address the question of how the adaptive immune system decides whether or not it should be activated when encountering various substances. Signals arising from the innate immune response and sensed by dendritic cells were shown to control T cell activation. This makes it possible for the immune system to react towards pathogenic microorganisms while avoiding an attack on the body's own endogenous molecules. From fundamental research to medical use The discoveries that are awarded the 2011 Nobel Prize have provided novel insights into the activation and regulation of our immune system. They have made possible the development of new methods for preventing and treating disease, for instance with improved vaccines against infections and in attempts to stimulate the immune system to attack tumors. These discoveries also help us understand why the immune system can attack our own tissues, thus providing clues for novel treatment of inflammatory diseases http://www.nobelprize.org/nobel_prizes/medicine/laureates/2011/press.html

The GAVI Alliance praised la Caixa Foundations leadership and generosity in donating 4 million (US$5.7 million) to GAVIs new Matching Fund. GAVI described the matching programme as a major new effort with the private sector to raise US$260 million for immunisation by the end of 2015. Under the programme, the Gates Foundation has pledged US$50 million to match contributions to GAVI from primarily private sector companies, their customers and employees. In addition, pledges to the Matching Fund by UK companies and their customers and employees are being matched by the 50 million pledge from the UK Department for

International Development (DFID). The la Caixa pledge 2 million in 2011 and 2 million in 2012 -- specifically goes toward the purchase of pneumococcal vaccine for GAVI-supported countries in Latin America. http://www.gavialliance.org/library/news/press-releases/2011/la-caixadonation-matching-fund/ The Bill & Melinda Gates Foundation announced a new initiative for Nigerias Executive Governors challenging them to deliver a dramatic improvement in polio and routine immunization by the end of 2012. The program will recognize those Executive Governors whose states pass a pre-defined threshold to improve routine immunization coverage and end polio. The states that meet the threshold criteria will be awarded a $500,000 grant from the Bill & Melinda Gates Foundation to support their top health priorities. The award will support winning governors priority initiatives in public health, such as malaria and tuberculosis, improving immunization, HIV prevention and treatment, or safe drinking water and hygiene promotion. In addition to the grant, those governors who achieve the goals will receive special recognition from Mr. Gates for their contribution to the elimination of polio. Winning governors will be highlighted in foundation communications, such as Mr. Gates annual letter or the foundations annual report, social media materials and Mr. Gates public engagements globally. In addition, if Governors choose, they also may contribute $250,000 to their chosen health project and the foundation will match that contribution, meaning a potential total $1 million towards improving health in their state. http://www.gatesfoundation.org/press-releases/Pages/governorsimmunization-leadership-challenge-111004.aspx Separately, the Gates Foundation announced that it is accepting nominations for the first Gates Vaccine Innovation Award to recognize, celebrate, and spur transformative ideas for achieving impact through the delivery of vaccines. Nominations will be accepted through 17 November 2011. The Gates Vaccine Innovation Award seeks to reward those who have achieved significant improvements in the prevention, control, or elimination of vaccine preventable disease through imaginative and pioneering approaches, and is unique in that it complements other awards already focused on scientific research and development. The winning person or team will receive $250,000 and earn special recognition by foundation leadership for their contribution. The Gates Vaccine Innovation Award application process is open to any individual or team from any discipline - academic institutions, governments, health care facilities, research institutions, non-profit organizations and for-profit companies. Nominations are being accepted online now at: www.gatesfoundation.org/gates-vaccine-innovation-award. http://www.gatesfoundation.org/press-releases/Pages/gates-vaccineinnovation-award-111006.aspx

The Weekly Epidemiological Record (WER) for 7 October 2011, vol. 86, 41 (pp 445456) includes: Hepatitis C; Monkeypox; Nipah virus; http://www.who.int/entity/wer/2011/wer8641.pdf

Twitter Watch A selection of items of interest from a variety of twitter feeds associated with immunization, vaccines and global public health. This capture is highly selective and by no means intended to be exhaustive. GAVIAlliance GAVI Alliance President Johnson Sirleaf is a tireless advocate for the right of all people to health and immunisation.-@GAVISeth http://ht.ly/6RKYR 21 hours ago gatesfoundation Gates Foundation Are we drawing closer to the end of #polio? @BillGates and @JeffRaikes meet with Nigeria's leaders: gates.ly/oYKDqL 8 Oct ShotAtLife Shot@Life by GAVIAlliance Committed to #vaccines: Ppl in Sierra Leone strap coolboxes of vaccines on backs & bike 2 remote villages @gavialliance bit.ly/p8fjO6 7 Oct GAVIAlliance GAVI Alliance Campaign to eradicate polio likely to fail unless combined w/vaccines that combat other deadly diseases such as measles http://ht.ly/6QjKX 7 Oct GAVISeth Seth Berkley #DavidCameron tells Conservative Party about the importance of vaccinating the world's children: http://ow.ly/6QcEE @Number10gov ShotAtLife Shot@Life by GAVIAlliance In 10 years, @MeaslesInit has protected 1 billion children from #measles with #vaccines. Read the story: bit.ly/n6yKO5 6 Oct MeaslesInit Measles Initiative by Eurovaccine New research on a measles outbreak in Japan shows vaccination much more cost-effective than containment and treatment bit.ly/pqs5Hh 7 Oct gatesfoundation Gates Foundation

Introducing the Gates Vaccine Innovation Award--Honoring revolutionary leaders in saving child lives: bit.ly/oISLRF #vaccines 6 Oct PATHtweets PATH START-UP project: Seeking to make prevention of cervical cancer available to all women, no matter where they live. http://ow.ly/6FkO2 6 Oct sabinvaccine Sabin Vaccine Inst. On this day in 1956 Dr. Albert Sabin introduced his live-virus oral #polio #vaccine, read more @wired bit.ly/r01vxA 6 Oct DofVC DoV Collaboration RT: @ISGLOBALorg "Access to safe and effective vaccines is a human right not currently enjoyed by everyone" @DofVC #ECTMIH bit.ly/q1hQ0q 5 Oct ImmunizeAction IAC CDC releases "Vaccine Storage & Handling Guide" - protect your vaccine, protect your patients: 1.usa.gov/qS6Inl 4 Oct UNICEF UNICEF UNICEF sends in experts to prevent #cholera epidemic in #Somalia -bit.ly/pE2oC2 -- #HornofAfrica @Refugees 4 Oct

Journal Watch [Editors Note] 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: david.r.curry@centerforvaccineethicsandpolicy.org Annals of Internal Medicine October 4, 2011; 155 (7) http://www.annals.org/content/current [No relevant content]

British Medical Bulletin Volume 99 Issue 1 September 2011 http://bmb.oxfordjournals.org/content/current [Reviewed earlier; No relevant content] British Medical Journal 8 October 2011 Volume 343, Issue 7826 http://www.bmj.com/content/current Practice Quality Improvement Report: Improving MMR vaccination rates: herd immunity is a realistic goal Philippa Cockman, Luise Dawson, Rohini Mathur, Sally Hull BMJ 2011;343:doi:10.1136/bmj.d5703 (Published 4 October 2011) Abstract Problem As measles is a highly infectious disease, the United Kingdom recommendation is for at least 95% of children to receive a first vaccination with the measles, mumps, and rubella (MMR) vaccine before age 2 years and a booster before age 5 years to achieve herd immunity and prevent outbreaks. Reported vaccination rates for England have improved since a low level in 2003-4. Coverage for London is consistently lower than for England, however, and concerns have been expressed that there could be an epidemic of measles in the capital. Design Observational time series study. Setting London Borough of Tower Hamlets. Key measurements for improvement Uptake rates for childhood vaccinations. The key target was to reach 95% coverage for the first MMR vaccine before age 2 years. Strategies for change Financial support for the development of geographically based networks of general practices. Commissioning of care packages, incentivising delivery of high quality integrated care with network level vaccination targets of 95%. Innovative use of information technology to enable robust call and recall processes, active follow-up of defaulters, and increased knowledge about the demography of the children most difficult to reach. Effects of change The development of networks of practices facilitated collaborative working among primary care clinicians and other stakeholders; peer review of achievements; and an element of healthy competition. Uptake improved for all childhood vaccinations, and to herd immunity levels for most. Uptake of the first MMR vaccine before age 2 years rose from 80% in September 2009 to 94% in March 2011. Lessons learnt Achieving herd immunity for childhood vaccinations is an achievable target in an ethnically mixed, socially deprived inner city borough. The ability to identify characteristics of the difficult to reach groups, including significant differences in uptake across different ethnicities, will allow targeted interventions that may further improve overall coverage. Cost Effectiveness and Resource Allocation

(accessed 10 October 2011) http://www.resource-allocation.com/ [No new relevant content] Emerging Infectious Diseases Volume 17, Number 10October 2011 http://www.cdc.gov/ncidod/EID/index.htm [No relevant content] Health Affairs October 2011; Volume 30, Issue 10 Agenda For Fighting Disparities http://content.healthaffairs.org/content/current From The Editor-in-Chief A Nation At Risk For Wider Health Disparities Susan Dentzer Health Aff October 2011 30:1818; doi:10.1377/hlthaff.2011.1091 Extract Among the well-documented deficiencies of US health care is its pronounced lack of equitynot just in access, but also in the quality of care provided whites versus ethnic and racial minorities. We shouldnt be surprised, because our society is inequitable, a fact that gives rise to inequities in health. This months issue of Health Affairs, produced with the support of the Aetna Foundation, provides a progress report on where we are as a nation in addressing these health and health care disparities. It also underscores that a change agenda will have to tackle the very fundamentals of existence that characterize the lives of millions of people in twenty-first-century America Health Economics, Policy and Law Volume 6 - Issue 04 - 01 October 2011 http://journals.cambridge.org/action/displayIssue?jid=HEP&tab=currentissue [Reviewed earlier] Human Vaccines Volume 7, Issue 10 October 2011 http://www.landesbioscience.com/journals/vaccines/toc/volume/7/issue/10/ Research Papers Cost-effectiveness analysis of pneumococcal polysaccharide vaccination from age 60 in So Paulo State, Brazil Open Access Article Joao Tonolio Neto, Gabriela Tannus Branco de Araujo, Anna Gagliardi, Amanda Pinho, Laure Durand and Marcelo Fonseca Vaccination of adults aged 60 years and older against Streptococcus pneumonia is not recommended in Brazil. The 23-valent polysaccharide pneumococcal vaccine (PPV23) is only available for institutionalized persons

or with underlying diseases despite the substantial medical and economic burden related to pneumococcal infections in adults over than 59 years. The study aimed at evaluating the cost effectiveness of implementing a large PPV program in this population. This analysis was performed using a static decision tree model. Demographic and epidemiological data were obtained from Brazilian official sources and international literature. Economic data were obtained from a study performed in 2007 in a public and a private hospital located in Sao Paulo. Vaccination was assumed to protect for 5 years with 60% effectiveness against bacteremic pneumococcal pneumonia (BPP) and 21% effectiveness against non bacteremic pneumococcal pneumonia (NBPP). Deterministic and sensitivity analyses were performed. The pneumococcal polysaccharide vaccination saved 5,218 life year gained (LYG). The vaccination program was found to be cost effective in the social security and public health care perspectives with a mean incremental costeffectiveness ratio of R$10,887 and R$8,281 per LYG respectively. Results were sensitive to the vaccine effectiveness against NBPP, the incidence and case-fatality rate of NBPP. From a societal perspective, PPV23 program for adults 60 and older was found to be cost-saving. Pneumococcal polysaccharide vaccination is clinically and economically favored over the present vaccination strategy, in which persons aged over 59 years in Sao Paulo, have not been vaccinated. Attitudes of seasonal influenza vaccination among healthcare worker and general community population after pandemic influenza A/H1N1 in Hangzhou Shijun Liu, Hanyan Yuan, Yan Liu, Jian Du, Xiaoping Zhang, Jun Wang, Xinren Che and Erping Xu Objective To know the attitude towards seasonal influenza vaccination among healthcare worker (HCWs) and general community population (GCPs) in the post-pandemic influenza A/H1N1 period. Method We conducted a crosssectional investigation in the beginning of seasonal influenza vaccination between 2010 and 2011, employed logistic regression analysis to compute the relationship between the willingness of seasonal influenza vaccination and variables after pandemic influenza A/H1N1. Results A total of 489 participants including 126 HCWs and 363 GCPs completed the investigation. 33.33% individuals (34.92% HCWs vs 32.78% GCPs, p0.05) intended to accept the seasonal influenza vaccination after pandemic influenza A/H1N1. Individuals received seasonal influenza vaccination in the prior 3 years and monovalent A/H1N1 vaccination in 2009 were aggressive to vaccinate seasonal influenza vaccine with adjusted OR= 5.21(3.20~8.49) and 1.97(1.18~3.30).. According to the results of multivariable logistic regression model, the safety not efficacy of influenza vaccine was the significant factor for acceptability of seasonal influenza vaccination (OR: 3.11, 95%CI: 1.76~5.50). The positive attitude of serious degree of influenza A/H1N1 and occupational factor were also associated with the willingness of seasonal influenza vaccination and the adjusted ORs were 2.09(1.14~3.83) and 1.62(1.00~2.64). Conclusion Participants showed low acceptability of seasonal influenza vaccination after pandemic influenza A/H1N1. Need educational program concerning the advantages of vaccine, comprehensible information about possible adverse effects and the hazards

of seasonal influenza disease, which might motivate individuals to accept seasonal influenza vaccination. Challenges and opportunities in the Israeli 2009 Pandemic Influenza Vaccination Program Hagai Levine, Ran D Balicer, Daniel Laor and Itamar Grotto Abstract Vaccines are a cornerstone in any pandemic influenza preparedness plan. Successful supplementary mass vaccination programs require proper advance planning. We aimed to identify general, and Israeli specific, challenges and opportunities before initiating the Israeli pandemic influenza vaccination program in order to better plan implementation of the program. Following the vaccination campaign the analysis was retrospectively examined in order to determine whether the challenges were properly identified and whether the opportunities were indeed realized. The major challenges identified were prioritization; ongoing communication with the public; balancing between central management and accessibility; and preventing vaccination errors. The major opportunity was expected to be the chance to enhance cooperation and communication between different organizations both within and outside of the health system at local, national and international levels. The vaccination program was planned based on this analysis. In retrospect, the analysis identified the key challenges and opportunities and appropriate measures were taken. However, the criticalness of acceptance of the vaccine among health care practitioners was not given sufficient attention and should be addressed in future vaccination programs. Analysis of global and local challenges and opportunities served as a useful tool for planning a pandemic influenza vaccination program. Lessons learned from this analysis could serve to foster cooperation and communication between various agencies in the event of planning rapid mass vaccination programs as well as for more routine public health vaccination campaigns. Commentary Perceptions of malaria and vaccines in Kenya David Ojakaa, Emmanuel Yamo, Yvette Collymore, Antoinette Ba-Nguz and Allison Bingham Abstract Malaria is a leading cause of morbidity and mortality in Kenya. To confront malaria, the Government of Kenya has been implementing and coordinating three approaches - vector control by distributing insecticide-treated bed nets and indoor residual spraying, case management, and the management of malaria during pregnancy. Immunization is recognized as one of the most cost-effective public health interventions. Efforts are underway to develop a malaria vaccine. The most advanced (RTS,S), is currently going through phase 3 trials. Although recent studies show the overwhelming support in the community for the introduction of a malaria vaccine, two issues - culture and the delivery of child immunization services - need to be considered. Alongside the modern methods of malaria control described above, traditional methods coexist and act as barriers to attainment of universal immunization. The gender dimension of the immunization programme (where women are the main child caretakers) will also need to be addressed. There is an age dimension to child immunization programmes. Two age cohorts of

parents, caregivers, or family members deserve particular attention. These are the youth who are about to initiate childbearing, and the elderly (particularly mother-in-laws who often play a role in child-rearing). Mothers who are less privileged and socially disadvantaged need particular attention when it comes to child immunization. Access to immunization services is often characterized in some Kenyan rural communities in terms of living near the main road, or in the remote inaccessible areas. Should a malaria vaccine become available in the future, a strategy to integrate it into the immunization programme in Kenya should take into account at least two issues. First, it must address the fact that alongside the formal approach in malaria control, there exist the informal traditional practices among communities. Secondly, it must address particular issues in the delivery of immunization services. Introduction of a second dose of measles in National immunization program in India: A major step towards eradication Ramesh Verma, Pardeep Khanna, Mohan Bairwa, Suraj Chawla, Shankar Prinja and Meena Rajput Abstract Measles is a highly infectious, acute respiratory illness that is caused by a virus of the genus Morbillivirus. The disease infects nearly 30 million children each year, and deaths usually occur from complications related to pneumonia, diarrhoea and malnutrition. A systematic review of published Indian literature depicts the median case fatality ratio (CFR) of measles to be 1.6%. Through immunization, measles deaths dropped a remarkable 78% from 733,000 in 2000 to 164,000 in 2008. As of 2008, 192 of 193 Member States of WHO use 2 doses of measles vaccine in their National immunization programs, India being the only exception. The Millennium Development Goal (MDG) 4 aims to reduce by two-thirds between 1990 and 2015 the under-five mortality rate (U5MR) in the world. Per the draft comprehensive Multi Year Strategic Plan (cMYP, 2010-17) for immunization of India, the country aims to reduce measles-related mortality by 90% by 2013 when compared to 2000. As recommended by the National Technical Advisory Group on Immunization (NTAGI), the implementation strategy of the second dose of measles vaccine at the state level is determined by the underlying performance of the routine immunization program. The second dose in the national immunization schedule gives extra immunity against measles infection that renders children more susceptible to secondary pneumonia and diarrhoeal diseases, which are the primary causes of under-5 child mortality in India. International Journal of Infectious Diseases Volume 15, Issue 10 pp. e655-e730 (October 2011) http://www.sciencedirect.com/science/journal/12019712 [Reviewed earlier] JAMA October 5, 2011, Vol 306, No. 13, pp 1407-1501 http://jama.ama-assn.org/current.dtl [No relevant content]

Journal of Infectious Diseases Volume 204 Issue 9 November 1, 2011 http://www.journals.uchicago.edu/toc/jid/current [Reviewed earlier] The Lancet Oct 08, 2011 Volume 378 Number 9799 p1275 - 1354 http://www.thelancet.com/journals/lancet/issue/current Editorial Early child developmenta winning combination The Lancet Preview 4 years ago, a Lancet Series on child development reported that worldwide, more than 200 million children younger than 5 years were failing to reach their developmental potential. In today's issue a follow-up Series documents progress in reduction of risk factors for poor development, such as inadequate cognitive stimulation, intrauterine growth restriction, HIV infection, and societal violence. The poorest and most vulnerable children benefit most from interventions, such as preschool programmes, because risk factors accumulated over a child's short life produce greater inequality in educational achievements and development. Series Inequality in early childhood: risk and protective factors for early child development Susan P Walker, Theodore D Wachs, Sally Grantham-McGregor, Maureen M Black, Charles A Nelson, Sandra L Huffman, Helen Baker-Henningham, Susan M Chang, Jena D Hamadani, Betsy Lozoff, Julie M Meeks Gardner, Christine A Powell, Atif Rahman, Linda Richter Summary Inequality between and within populations has origins in adverse early experiences. Developmental neuroscience shows how early biological and psychosocial experiences affect brain development. We previously identified inadequate cognitive stimulation, stunting, iodine deficiency, and irondeficiency anaemia as key risks that prevent millions of young children from attaining their developmental potential. Recent research emphasises the importance of these risks, strengthens the evidence for other risk factors including intrauterine growth restriction, malaria, lead exposure, HIV infection, maternal depression, institutionalisation, and exposure to societal violence, and identifies protective factors such as breastfeeding and maternal education. Evidence on risks resulting from prenatal maternal nutrition, maternal stress, and families affected with HIV is emerging. Interventions are urgently needed to reduce children's risk exposure and to promote development in affected children. Our goal is to provide information to help the setting of priorities for early child development programmes and policies to benefit the world's poorest children and reduce persistent inequalities.

Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries Patrice L Engle, Lia CH Fernald, Harold Alderman, Jere Behrman, Chloe O'Gara, Aisha Yousafzai, Meena Cabral de Mello, Melissa Hidrobo, Nurper Ulkuer, Ilgi Ertem, Selim Iltus, the Global Child Development Steering Group Summary This report is the second in a Series on early child development in low-income and middle-income countries and assesses the effectiveness of early child development interventions, such as parenting support and preschool enrolment. The evidence reviewed suggests that early child development can be improved through these interventions, with effects greater for programmes of higher quality and for the most vulnerable children. Other promising interventions for the promotion of early child development include children's educational media, interventions with children at high risk, and combining the promotion of early child development with conditional cash transfer programmes. Effective investments in early child development have the potential to reduce inequalities perpetuated by poverty, poor nutrition, and restricted learning opportunities. A simulation model of the potential long-term economic effects of increasing preschool enrolment to 25% or 50% in every low-income and middle-income country showed a benefit-to-cost ratio ranging from 64 to 176, depending on preschool enrolment rate and discount rate. The Lancet Infectious Disease Oct 2011 Volume 11 Number 10 p721 - 800 http://www.thelancet.com/journals/laninf/issue/current [Reviewed earlier] Medical Decision Making (MDM) September/October 2011; 31 (5) http://mdm.sagepub.com/content/current [Reviewed earlier] Nature Volume 478 Number 7367 pp5-148 6 October 2011 http://www.nature.com/nature/current_issue.html [No relevant content] Nature Medicine September 2011, Volume 17 No 9 http://www.nature.com/nm/index.html [Reviewed earlier] New England Journal of Medicine

October 6, 2011 Vol. 365 No. 14 http://content.nejm.org/current.shtml Perspective Routine HIV Screening What Counts in Evidence-Based Policy? R. Bayer and G.M. Oppenheimer [Free full-text] The Pediatric Infectious Disease Journal October 2011 - Volume 30 - Issue 10 pp: A7-A8,821-918,e179-e202 http://journals.lww.com/pidj/pages/currenttoc.aspx [Reviewed earlier] Pediatrics October 2011, VOLUME 128 / ISSUE 4 http://pediatrics.aappublications.org/current.shtml [No relevant content] Advance Online Multicomponent Interventions to Enhance Influenza Vaccine Delivery to Adolescents Lisa M. Gargano, Karen Pazol, Jessica M. Sales, Julia E. Painter, Christopher Morfaw, LaDawna M. Jones, Paul Weiss, James W. Buehler, Dennis L. Murray, Gina M. Wingood, Walter A. Orenstein, Ralph J. DiClemente, and James M. Hughes Pediatrics 2011; peds.2011-0453; Published online October 10, 2011 (10.1542/peds.2011-0453) Abstract Objective: To compare school- versus provider-based approaches to improving influenza vaccination coverage among adolescents in rural Georgia. Methods: We used a nonrandomized, 3-armed design: (1) a middle- and high school-based influenza vaccination intervention in 1 county; (2) a providerbased influenza vaccination intervention in a second county; and (3) a standard-of-care condition in a third county. Interventions also included distribution of an educational brochure, school presentations, and community-based outreach to enhance vaccine knowledge and awareness among adolescents and their parents. Results: During the 20082009 influenza season, 70 (19%) of 370 students were vaccinated in the school-based county and 110 (15%) of 736 students were vaccinated in the provider-based county, compared with 71 (8%) of 889 students in the standard-of-care county (risk ratio [RR]school: 2.4 [95% confidence interval (CI): 1.73.2]; RRprovider: 1.9 [95% CI: 1.42.5]). During 20092010, seasonal influenza vaccination coverage was 114 (30.4%) of 375 of students in the school-based county, 122 (16.9%) of 663 of students in the provider-based county, and 131 (15.2%) of 861 students in the standard-ofcare county (RRschool: 2.3 [95% CI: 1.92.9]; RRprovider: 1.2 [95% CI: 0.97 1.5]).

Conclusions: Special efforts to promote influenza vaccination among rural, predominantly black students were associated with increased vaccination coverage. The school-based influenza vaccination intervention was associated with the highest levels of vaccination coverage. This study revealed the efficacy of school-based influenza education to improve vaccination rates among adolescents. Alternative Vaccination Schedule Preferences Among Parents of Young Children Amanda F. Dempsey, Sarah Schaffer, Dianne Singer, Amy Butchart, Matthew Davis, and Gary L. Freed Pediatrics 2011; peds.2011-0400; Published online October 3, 2011 (10.1542/peds.2011-0400) Abstract Objective: Increasing numbers of parents use alternative vaccination schedules that differ from the recommended childhood vaccination schedule for their children. We sought to describe national patterns of alternative vaccination schedule use and the potential malleability of parents' current vaccination schedule choices. Methods: We performed a cross-sectional, Internet-based survey of a nationally representative sample of parents of children 6 months to 6 years of age. Bivariate and multivariate analyses determined associations between demographic and attitudinal factors and alternative vaccination schedule use. Results: The response rate was 61% (N = 748). Of the 13% of parents who reported following an alternative vaccination schedule, most refused only certain vaccines (53%) and/or delayed some vaccines until the child was older (55%). Only 17% reported refusing all vaccines. In multivariate models, nonblack race and not having a regular health care provider for the child were the only factors significantly associated with higher odds of using an alternative schedule. A large proportion of alternative vaccinators (30%) reported having initially followed the recommended vaccination schedule. Among parents following the recommended vaccination schedule, 28% thought that delaying vaccine doses was safer than the schedule they used, and 22% disagreed that the best vaccination schedule to follow was the one recommended by vaccination experts. Conclusions: More than 1 of 10 parents of young children currently use an alternative vaccination schedule. In addition, a large proportion of parents currently following the recommended schedule seem to be at risk for switching to an alternative schedule. Pharmacoeconomics October 1, 2011 - Volume 29 - Issue 10 pp: 823-911 http://adisonline.com/pharmacoeconomics/pages/currenttoc.aspx [Reviewed earlier] PLoS One [Accessed 10 October 2011] http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DA A533C413369CD6F3.ambra01?field=date

Meningococcal Disease in Children in Merseyside, England: A 31 Year Descriptive Study Michelle C. Stanton, David Taylor-Robinson, David Harris, Fauzia Paize, Nick Makwana, Scott J. Hackett, Paul B. Baines, F. Andrew I. Riordan, Omnia Marzouk, Alistair P. J. Thomson, Peter J. Diggle, C. Anthony Hart, Enitan D. Carrol of the meningococcal C conjugate (MCC) vaccine. The proportion ... ] , and the introduction of the meningococcal C conjugate vaccine [8 ... in the introduction of the Meningococcal C vaccine in November 1999 PLoS ONE: Research Article, published 07 Oct 2011 10.1371/journal.pone.0025957 Abstract Meningococcal disease (MCD) is the leading infectious cause of death in early childhood in the United Kingdom, making it a public health priority. MCD most commonly presents as meningococcal meningitis (MM), septicaemia (MS), or as a combination of the two syndromes (MM/MS). We describe the changing epidemiology and clinical presentation of MCD, and explore associations with socioeconomic status and other risk factors. A hospital-based study of children admitted to a tertiary children's centre, Alder Hey Children's Foundation Trust, with MCD, was undertaken between 1977 to 2007 (n = 1157). Demographics, clinical presentations, microbiological confirmation and measures of deprivation were described. The majority of cases occurred in the 14 year age group and there was a dramatic fall in serogroup C cases observed with the introduction of the meningococcal C conjugate (MCC) vaccine. The proportion of MS cases increased over the study period, from 11% in the first quarter to 35% in the final quarter. Presentation with MS (compared to MM) and serogroup C disease (compared to serogroup B) were demonstrated to be independent risk factors for mortality, with odds ratios of 3.5 (95% CI 1.18 to 10.08) and 2.18 (95% CI 1.26 to 3.80) respectively. Cases admitted to Alder Hey were from a relatively more deprived population (mean Townsend score 1.25, 95% CI 1.09 to 1.41) than the Merseyside reference population. Our findings represent one of the largest single-centre studies of MCD. The presentation of MS is confirmed to be a risk factor of mortality from MCD. Our study supports the association between social deprivation and MCD. Communicable Diseases Prioritized for Surveillance and Epidemiological Research: Results of a Standardized Prioritization Procedure in Germany, 2011 Yanina Balabanova, Andreas Gilsdorf, Silke Buda, Reinhard Burger, Tim Eckmanns, Barbara Grtner, Uwe Gro, Walter Haas, Osamah Hamouda, Johannes Hbner, Thomas Jnisch, Manfred Kist, Michael H. Kramer, Thomas Ledig, Martin Mielke, Matthias Pulz, Klaus Stark, Norbert Suttorp, Uta Ulbrich, Ole Wichmann, Grard Krause possibilities and needs (including vaccines) ** Preventive ... of a routine childhood Varicella vaccination program in 2004 ... trends of vaccine-preventable diseases that followed PLoS ONE: Research Article, published 04 Oct 2011 10.1371/journal.pone.00256 Abstract Introduction To establish strategic priorities for the German national public health institute (RKI) and guide the institute's mid-term strategic decisions, we prioritized infectious pathogens in accordance with their importance for national surveillance and epidemiological research.

Methods We used the Delphi process with internal (RKI) and external experts and a metric-consensus approach to score pathogens according to ten three-tiered criteria. Additional experts were invited to weight each criterion, leading to the calculation of a median weight by which each score was multiplied. We ranked the pathogens according to the total weighted score and divided them into four priority groups. Results 127 pathogens were scored. Eighty-six experts participated in the weighting; Case fatality rate was rated as the most important criterion. Twenty-six pathogens were ranked in the highest priority group; among those were pathogens with internationally recognised importance (e.g., Human Immunodeficiency Virus, Mycobacterium tuberculosis, Influenza virus, Hepatitis C virus, Neisseria meningitides), pathogens frequently causing large outbreaks (e.g., Campylobacter spp.), and nosocomial pathogens associated with antimicrobial resistance. Other pathogens in the highest priority group included Helicobacter pylori, Respiratory Syncytial Virus, Varicella zoster virus and Hantavirus. Discussion While several pathogens from the highest priority group already have a high profile in national and international health policy documents, high scores for other pathogens (e.g., Helicobacter pylori, Respiratory syncytial virus or Hantavirus) indicate a possible under-recognised importance within the current German public health framework. A process to strengthen respective surveillance systems and research has been started. The prioritization methodology has worked well; its modular structure makes it potentially useful for other settings. PLoS Medicine (Accessed 10 October 2011) http://www.plosmedicine.org/article/browse.action?field=date [No relevant content] Proceedings of the National Academy of Sciences of the United States of America (Accessed 10 October 2011) http://www.pnas.org/content/early/recent [No new relevant content] Science 7 October 2011 vol 334, issue 6052, pages 1-144 http://www.sciencemag.org/current.dtl EDITORIAL: Genomics Is Not Enough Aravinda Chakravarti Science 7 October 2011: 15.

Next week, the international congress of human genetics convenes in Montreal, where genomic science, its technologies, genetic disease, and personalized medicine will be discussed. Translating current knowledge into medical practice is an important goal for the public who support medical research, and for the scientists and clinicians who articulate the critical research needs of our time. However, despite innumerable successful gene discoveries through genomics, a major impediment is our lack of knowledge of how these genes affect the fundamental biological mechanisms that are dysregulated in disease. If genomic medicine is to prosper, we need to turn our attention to this gaping hole. Science Translational Medicine 5 October 2011 vol 3, issue 103 http://stm.sciencemag.org/content/current Commentary Science and Health Policy The Changing Burden of Infectious Disease in Europe Robin Fears, Jos W. M. van der Meer, and Volker ter Meulen 5 October 2011: 103cm30 Abstract Infectious diseases continue to pose major public health challenges in developed, as well as developing, countries. The European Academies Science Advisory Council aims to integrate multidisciplinary analyses to define priorities for European surveillance of new, growing, or potential threats from antimicrobial resistance, vector-borne disease, and pandemic influenza. There is a concomitant need to apply such knowledge toward the development of improved health care and robust policies. We discuss how translational medicine can bridge these global issues by helping to mobilize resources between academia, industry, health care services, and policymakers.

Tropical Medicine & International Health November 2011 Volume 16, Issue 11 Pages 13531464 http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-3156/currentissue [No relevant content] Vaccine http://www.sciencedirect.com/science/journal/0264410X Volume 29, Issue 45 pp. 7875-8174 (19 October 2011) Regular Papers GuillainBarr syndrome and H1N1 (2009) pandemic influenza vaccination using an AS03 adjuvanted vaccine in the United Kingdom: Self-controlled case series Pages 7878-7882 Nick Andrews, Julia Stowe, Rustam Al-Shahi Salman, Elizabeth Miller Abstract

In 1976 a swine influenza vaccine was associated with an increased risk of GuillainBarr syndrome (GBS). Although subsequent studies did not find an increased risk of GBS following seasonal influenza vaccine, there was concern that the monovalent H1N1 vaccines developed against the swine influenza pandemic of 2009 might increase the risk of GBS. In the UK a split-virion AS03 oil-in-water adjuvanted vaccine (Pandemrix) was predominantly used. To determine whether the risk of GBS increased after Pandemrix administration, we sought GBS cases during the period of vaccine use from neurologists and a patient support group, and following the vaccination period from hospital episode statistics (HES) in England. We obtained cases vaccination histories and illness onset dates from general practitioners. We determined the relative incidence of GBS in the 6 weeks after vaccination using the self-controlled case series method on the cases identified in HES. We included 327 GBS cases, of whom 37 received pandemic vaccine in the study period, nine of whom developed GBS within 6 weeks of vaccination (relative incidence 1.05 [95% confidence interval (CI) 0.37 to 2.24]). We found no evidence of an increased risk of GBS in the 6 weeks following pandemic influenza vaccination. MMR vaccine effectiveness in an outbreak that involved day-care and primary schools Pages 8024-8031 Irene Barrabeig, Ariadna Rovira, Pilar Muoz, Joan Batalla, Cristina Rius, Josep Anton Snchez, ngela Domnguez Abstract Objective In 2006, a large measles outbreak occurred in Catalonia (Spain), where the immunization schedule included two doses of MMR vaccine at 15 months and 4 years. The aim of this study was to investigate the vaccine effectiveness (VE) of MMR in children attending day-care and pre-school centres and to estimate the number of cases that would have been avoided by administering the first dose of MMR at 12 months. Methods A retrospective cohort study was carried out between October 2006 and January 2007 in day-care and pre-school centres with confirmed measles cases. VE was calculated in children aged 15 months without previous measles infection. Cases avoided by advancing the first dose of MMR to 12 months were estimated by calculating the basic and effective reproduction number in centres where transmission outside the class was observed. Results Fifteen centres and 1394 children were included. There were 77 confirmed cases (attack rate = 5.5%). Vaccination coverage of the 1121 children aged 15 months was 91.6% and VE was 96% (95%CI 8998%). There were 33 (41%) cases in the 81 children aged 1214 months. Advancing the first dose to 12 months would have prevented 74 cases (91.5%) and lowered the attack rate from 41% to 8.6%. Conclusions Over 90% of cases in children aged 1214 months would have been avoided by MMR administration at 12 rather than 15 months. We strongly recommend advancing the first dose of MMR to 12 months in order to reduce the risk of measles outbreaks.

Health beliefs and attitudes associated with HPV vaccine intention among young gay and bisexual men in the southeastern United States Pages 8060-8065 Christopher W. Wheldon, Ellen M. Daley, Eric R. Buhi, Alan G. Nyitray, Anna R. Giuliano Abstract Gay and bisexual men are at increased risk of anal cancer as a result of human papillomavirus (HPV) infection. Prophylactic vaccination is a potentially effective strategy for preventing anal cancer in this population. The purpose of this study was to identify factors associated with gay and bisexual men's intention to receive HPV vaccine. In the fall of 2010, 179 selfidentified gay and bisexual men (mean age 22 years) completed an Internetbased questionnaire assessing beliefs and attitudes toward HPV vaccination. Men were recruited from college-based and Internet venues throughout the southeastern United States. The probability of intent to receive HPV vaccine was modeled using logistic regression. A majority of men (93%) had heard of HPV prior to participation but were generally unaware of the association of HPV with anal, penile, and oral cancers. Only 26% were aware of an HPV vaccine for males. Of the 179 participants, 64 (36%) were likely to be vaccinated. Men most likely to receive HPV vaccine perceived stronger physical and psychological benefits from vaccination and had more positive attitudes toward the vaccine. Conversely, intent to be vaccinated was negatively associated with concern over the financial cost of vaccination. Findings from this study can inform college-based health education programs aimed at increasing vaccine uptake among gay and bisexual men. Pharmacists as providers: Targeting pneumococcal vaccinations to high risk populations Pages 8073-8076 Michael Taitel, Ed Cohen, Ian Duncan, Cheryl Pegus Abstract Background Older adults and persons with chronic conditions are at increased risk for pneumococcal disease. Severe pneumococcal disease represents a substantial humanistic and economic burden to society. Although pneumococcal vaccination (PPSV) can decrease risk for serious consequences, vaccination rates are suboptimal. As more people seek annual influenza vaccinations at community pharmacies, pharmacists have the ability to identify at-risk patients and provide PPSV. Objectives The objective of this study was to evaluate the impact of pharmacists educating at-risk patients on the importance of receiving a pneumococcal vaccination. Methods Using de-identified claims from a large, national pharmacy chain, all patients who had received an influenza vaccination between August 1, 2010 and November 14, 2010 and who were eligible for PPSV were identified for the analysis. Based on the Advisory Committee on Immunization Practices recommendations, at-risk patients were identified as over 65 years of age or as aged 264 with a comorbid conditions. A benchmark medical and

pharmacy claims database of commercial and Medicare health plan members was used to derive a PPSV vaccination rate typical of traditional care delivery to compare to pharmacy-based vaccination. Period incidence of PPSV was calculated and compared. Results Among the 1.3 million at-risk patients who were vaccinated by a pharmacist during the study period, 65,598 (4.88%) also received a pneumococcal vaccine. This vaccination rate was significantly higher than the benchmark rate of 2.90% (34,917/1,204,104; p < .001) representing traditional care. Patients aged 6070 years had the highest vaccination rate (6.60%; 26,430/400,454) of any age group. Conclusions Pharmacists were successful at identifying at-risk patients and providing additional immunization services. Concurrent immunization of PPSV with influenza vaccination by pharmacists has potential to improve PPSV coverage. These results support the expanding role of community pharmacists in the provision of wellness and prevention services. The potential cost-effectiveness of infant pneumococcal vaccines in Australia Pages 8077-8085 Anthony T. Newall, Prudence Creighton, David J. Philp, James G. Wood, C. Raina MacIntyre Abstract Over the last decade infant pneumococcal vaccination has been adopted as part of routine immunisation schedules in many developed countries. Although highly successful in many settings such as Australia and the United States, rapid serotype replacement has occurred in some European countries. Recently two pneumococcal conjugate vaccines (PCVs) with extended serotype coverage have been licensed for use, a 10-valent (PHiD-CV) and a 13-valent (PCV-13) vaccine, and offer potential replacements for the existing vaccine (PCV-7) in Australia. To evaluate the cost-effectiveness of PCV programs we developed a static, deterministic state-transition model. The perspective for costs included those to the government and healthcare system. When compared to current practice (PCV-7) both vaccines offered potential benefits, with those estimated for PHiD-CV due primarily to prevention of otitis media and PCV-13 due to a further reduction in invasive disease in Australia. At equivalent total cost to vaccinate an infant, compared to no PCV the base-case cost per QALY saved were estimated at A$64,900 (current practice, PCV-7; 3 + 0), A$50,200 (PHiD-CV; 3 + 1) and A$55,300 (PCV-13; 3 + 0), respectively. However, assumptions regarding herd protection, serotype protection, otitis media efficacy, and vaccination cost changed the relative cost-effectiveness of alternative PCV programs. The high proportion of current invasive disease caused by serotype 19A (as included in PCV-13) may be a decisive factor in determining vaccine policy in Australia. Healthy-days time equivalents for outcomes of acute rotavirus infections Pages 8086-8093 A. Brett Hauber, Robbin Itzler, F. Reed Johnson, Ateesha F. Mohamed, Juan Marcos Gonzlez, John R. Cook, Emmanuel B. Walter Abstract

Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide. Health-state utility measures used in economic evaluations of rotavirus vaccines do not reflect differences between mild and severe symptoms of rotavirus gastroenteritis and, therefore, do not adequately capture preferences for non-fatal outcomes associated with rotavirus common in industrialized countries. This paper describes the development and results of a survey specifically designed to develop qualityadjusted time equivalents for rotavirus gastroenteritis among a sample of parents with young children in the United States as an alternative to conventional QALY measures in assessing cost-effectiveness. Dentists awareness toward vaccine preventable diseases Pages 8108-8112 Stefano Petti, Giuseppe A. Messano, Antonella Polimeni Abstract Effective infection control in dentistry is unfeasible without an adequate immunization program for dental health care providers (DHCPs). Such an assumption is demonstrated for some vaccine preventable infectious diseases (VPIDs), such as Hepatitis B, Influenza and Varicella. However, excluding Hepatitis B vaccine, immunization programs for DHCPs are few and often unclear about which vaccinations are recommended, thus leading to generally low awareness and consequent low vaccination rates. This survey investigated dentists awareness toward VPIDs. At the moment of registration to a dental congress, a questionnaire regarding the immunization status toward VPIDs was anonymously filled in by 379 Italian dentists (86% of the contacted dentists), with at least fifteen years of activity. DHCP specific awareness was considered high if dentists reported to have controlled the serum level of anti-HBs during the last ten years and have received seasonal influenza vaccine annually. Awareness toward VPIDs was classified high if dentists reported to be immune against six or seven of the following VIPDs, Hepatitis B, Influenza, Varicella, Measles, Mumps, Rubella and Tetanus. DHCP specific awareness resulted high for 32.5% of subjects and low for 31.1%. None of the subjects reported high awareness toward VPIDs, while for 60% of them, such awareness was low (immunization status reported for none or one of the seven VPIDs). Low dentists awareness stresses the need for a transparent immunization program which is effective in controlling VPID transmission in the dental health care settings and focuses on those VPIDs which pose a true risk of infection for DHCPs and patients Vaccine http://www.sciencedirect.com/science/journal/0264410X Volume 29, Issue 44 pp. 7577-7874 (13 October 2011) Editorial Developing vaccine policy: Attributes of just policy and a proposed template to guide decision and policy making Pages 7577-7578 Gregory A. Poland, Edgar K. Marcuse [No abstract] Short Communications College students perceptions of H1N1 flu risk and attitudes toward vaccination

Pages 7599-7601 Meagan A. Ramsey, Cecile A. Marczinski Abstract College students are highly susceptible to the H1N1 virus, yet previous studies suggest that college students perceive themselves at low risk for the flu. We surveyed 514 undergraduates to assess their perceptions of H1N1 flu risk and opinions about flu vaccines. A third of respondents stated that they were not at risk of getting the H1N1 flu because they were young. Responses indicated a distrust of the safety and effectiveness of influenza vaccinations; only 15.8% of participants planned on receiving H1N1 vaccination. Top reasons for refusing the H1N1 vaccine included questioning vaccine safety and effectiveness, and concerns about potential serious and/or benign side effects. Top reasons for H1N1 vaccination acceptance included receiving a doctor recommendation for the vaccine, having previously gotten a seasonal vaccine, and being at high-risk for influenza. Our findings suggest that college students are inaccurate in assessing their risk level and are unlikely to seek vaccinations. Regular Papers Cost-effectiveness of the introduction of the pneumococcal polysaccharide vaccine in elderly Colombian population Pages 7644-7650 Carlos Castaeda-Orjuela, Nelson Alvis-Guzmn, ngel Jos Paternina, Fernando De la Hoz-Restrepo Abstract Background Streptococcus pneumoniae causes community-acquired pneumonia, otitis media and meningitis, with higher incidences at the extremes of life. PPV-23 vaccine is widely used in prevention of pneumonia and invasive pneumococcal disease in older adults in developed countries. We developed an evaluation of cost-effectiveness of implementing PPV-23 in Colombian population over 60 years. Methods The number of cases of pneumonia and meningitis in patients over 60 years and the proportion by S. pneumoniae was estimated based on a review of literature. A decision tree model with a 5-year time horizon was built to evaluate the cost-effectiveness of the implementation of the PPV-23 in this population. Direct health care costs of out- and in-patients were calculated based on expenditure records from the Bogota public health system. Incremental cost-effectiveness ratios per life saved and per year of life gained were estimated based on the decision tree model. Deterministic and probabilistic sensitivity analyses were performed. Results Without vaccination 4460 (range 23848162) bacteremic pneumococcal pneumonias and 141 (range 73183) pneumococcal meningitis would occur among people over 60 years old in Colombia. In the first year, vaccination with PPV-23 at US$8/dose would save 480 (range 1001753) deaths due to Invasive and non-invasive pneumococcal disease. Vaccination would results in US$3400/deaths averted (range US$102810,862) and US$1514/life years gained (range US$4085404). Conclusion

Vaccination with PPV-23 in over 60 years is a highly cost-effective public health measure in Colombia. Despite some limitations, the results are robust, and may help developing countries to perform informed decisions about the introduction of the vaccine. Parent and adolescent perspectives about adolescent vaccine delivery: Practical considerations for vaccine communication Pages 7651-7658 Cynthia M. Rand, Sharon G. Humiston, Stanley J. Schaffer, Christina S. Albertin, Laura P. Shone, Aaron K. Blumkin, Shannon Stokley, Peter G. Szilagyi Abstract We surveyed parents of adolescents (n = 430) and their adolescents ages 1517 years (n = 208) in 9 primary-care settings in Monroe County, NY to assess perceptions about adolescent vaccine delivery. Parents and adolescents most wanted to discuss vaccine side effects and the diseases prevented with the adolescents provider. Those who perceived vaccines as very safe were more accepting of adolescent vaccines. Most participants agreed with vaccinating the teen during a mild illness and with providing multiple vaccines concomitantly. Participants most preferred medical, as opposed to other settings, for receipt of adolescent vaccines. For parents and adolescents who are wary of vaccination, strategies are needed to enhance communication about risks and benefits of vaccinations. Parental acceptance of human papillomavirus (HPV) vaccination in Indonesia: A cross-sectional study Pages 7785-7793 L. Jaspers, S. Budiningsih, R. Wolterbeek, F.C. Henderson, A.A.W. Peters Abstract Background Cervical cancer ranks the second most frequent cancer in Indonesian women. In Indonesia, human papillomavirus (HPV) vaccine acceptance has not been studied before. Objective To determine parental HPV vaccine acceptance in Indonesia, and factors that influence their decision. Factors include sociodemographic factors, knowledge of HPV, HPV vaccination and cervical cancer, health beliefs about cervical cancer, and attitudes towards vaccination in general. Methods 746 parents, with at least 1 daughter aged 014, were interviewed using questionnaires based on published and adjusted interviews. Interviews were done in sub district public health centers, general governmental hospitals, and via house-visits, in 5 Indonesian provinces. Results Parental HPV vaccine acceptance was 96.1%. Logistic regression revealed that age, beliefs regarding cervical cancer, and attitudes towards vaccination in general were significantly associated with HPV vaccine acceptance. Of the participants, 66.0%, 16.6%, and 15.8% had heard about cervical cancer, HPV, and HPV vaccination respectively. The mean total knowledge score was 1.91(Standard Deviation 2.31) on a 08 scale. Health beliefs about cervical cancer and attitudes towards vaccination in general were positive. Participants named the high cost of the vaccine, fear for side-effects, and

chosen vaccination locations as possible barriers towards HPV vaccine implementation. Discussion Parental HPV vaccine acceptance is high, but knowledge about HPV and cervical cancer is low. During HPV vaccination programs, focus should not only be on providing information, but also on existing beliefs and attitudes towards cervical cancer and vaccination in general. If HPV vaccination programs were to be implemented in Indonesia, the indicated barriers should be taken into account. Hospital-based study of the economic burden associated with rotavirus diarrhea in eastern China Pages 7801-7806 Hui Jin, Bei Wang, Zhaoyin Fang, Zhaojun Duan, Qian Gao, Na Liu, Lijie Zhang, Yuan Qian, Sitang Gong, Qirong Zhu, Xiaona Shen, Qingbin Wu Abstract Rotavirus infection is one of the most common causes of severe diarrhea in China. To evaluate the economic burden associated with rotavirus infection of children in China, we combined data on the disease burden of rotavirusassociated costs for samples comprising 832 outpatients and 604 inpatients from five seaside cities. The average social costs and direct medical costs for rotavirus-associated admissions were calculated to be US $61.64 and US $40.73 for outpatients, and US $684.15 and US $559.48 for inpatients, respectively, from October 1, 2006 to December 1, 2007. On average, the private cost ranged from US $54.64 for outpatients to US $454.24 for inpatients when children suffered from rotavirus infection. Accordingly, this cost accounted for 35.19293% of the monthly income of an unskilled or service worker. We estimated that the annual number of children with rotavirus diarrhea was 12.10 million. Consequently, the total annual direct cost, total annual social cost, and total annual private cost were US $271.4 million, US $365.0 million, and US $290.0 million, respectively. Furthermore, rotavirus diarrhea affected children's behavior and emotions, which had a great influence on the caretakers quality of life. These data indicate the potential requirement for a safe and effective rotavirus vaccine to reduce the economic burden associated with rotavirus disease. Value in Health September 2011, Vol. 14, No. 6 http://www.valueinhealthjournal.com/home [No relevant content]