We sought to determine the preventive healthcare needs of incarcerated women in the following areas: cervical cancer and breast cancer screening, sexually transmitted infection (STI) screening, hepatitis screening and vaccination, and smoking cessation.
A cross-sectional interview survey of a random sample of 100 incarcerated women at the Rhode Island Department of Corrections (RIDOC) in Cranston, Rhode Island, was conducted.
Participants were 62% white, 11% African American, 13% Hispanic, and 14% of mixed race. Mean age was 35 years. Of those surveyed, 67% reported having had a Papanicolou (Pap) smear in the past year, the strongest predictor of which was having received a Pap smear while incarcerated. Of the inmates >40 years old, 58% reported having had a mammogram in the past 2 years. The majority (88%) reported testing for STIs in the past, and 39% desired testing during their current incarceration. As for hepatitis C, 70% had been tested previously and 37% of those reported testing positive. Hispanics were less likely than whites to have been tested for hepatitis C (OR 0.1). Over half (54%) of the women who reported testing positive for hepatitis C also reported having completed the hepatitis A and B vaccine series. Among smokers (80% of all survey participants), 61% were interested in quitting. Those who had been incarcerated multiple times were less likely to want to quit smoking (OR 0.1).
Incarceration presents a unique opportunity to provide preventive healthcare to high-risk, medically underserved women.
Hepatitis B remains a major public health problem in the United States, but public vaccination policy has targeted infants rather than the high-risk adults who constitute the vast majority of patients at imminent risk of infection. The effects of this policy were studied at a community health center in Boston. Adolescents and adults who attended a community health center between January 1, 1992 and May 31, 1993 and had human immunodeficiency virus (HIV) or another sexually transmitted disease (STD)--indications for vaccination according to the Centers for Disease Control and Prevention--were identified through chart review. The vaccination rate and missed opportunities were determined. In addition, directors of Boston health centers were surveyed on hepatitis B vaccine at their clinics. Of 178 individuals with HIV or another STD and without serologic evidence of prior exposure to hepatitis B, two (1.1%) received the vaccine. There were 342 missed opportunities. Only two of 14 medical directors said their clinics routinely offered vaccine to individuals with STDs. The medical directors rated financial barriers as more important obstacles to hepatitis B vaccination than nonfinancial barriers. These results indicate that many high-risk adolescents and adults do not receive a preventive intervention that is federally recommended, potentially life saving, and cost effective. Inadequate public funding for vaccine may be a key barrier for this population.
OBJECTIVE: To examine the clinical impact and financial cost of a vaccination program for the prevention of cholera in North Americans travelling to endemic and epidemic regions by means of the principles of decision analysis and a decision tree as well as to illustrate the effect of case attack rates on the cost per case prevented by vaccination. DESIGN: Review of the scientific literature to establish the probabilities of each significant outcome as well as a decision analysis and partial economic evaluation. OUTCOME MEASURES: Clinical impact (attack rates for cholera among vaccinated and nonvaccinated travellers), rates of death associated with cholera and vaccine-associated adverse events (VAAEs), and the number of VAAEs and the vaccine cost per case prevented. MAIN RESULTS: On the basis of our assumptions (including a rate of one case of cholera per 500,000 journeys to endemic regions), to prevent one case of cholera a vaccination program would cost $28.67 million and be associated with 105 VAAEs. CONCLUSION: Routine vaccination of travellers to endemic areas cannot be recommended; however, for people travelling to regions with a high transmission rate vaccination should be considered.
This study presents the results of a pilot study of mandatory pre-release testing for sexually transmitted disease (STD) and a behavioral risk survey for male inmates at an Ohio prison. Approximately 4–6 weeks prior to scheduled release, inmates took part in a mandatory blood test and optional genital swab and physical examination to test for STDs. At the time of testing, a voluntary behavioral and knowledge survey was administered to inmates. Pre-release testing identified 53 new cases of STDs among the 916 inmates (5.5%) scheduled for release during the pilot study period. Trichomoniasis and hepatitis C were the most common infections identified through pre-release testing. Nearly all inmates participated in the required blood test. Participation rates for the other testing methods averaged less than 45%. Inmates reported engaging in various risky behaviors during incarceration such as having sex (12.1%), tattooing (36.5%), and drug use (19.5%). Pre-release testing identified several new cases of STDs not identified through existing intake and for-cause testing procedures. Substantial useful information about the prevalence of STD risk behaviors can be obtained through a pre-release survey.
HIV testing; Inmates; Behavioral risk; Pre-release testing
Hepatitis B virus (HBV) is endemic worldwide. Given significant rates of infectivity, all infants born to Hepatitis B surface antigen positive mothers need to receive treatment at birth, immunization and post-vaccination serologic testing. However, not all infants complete these requirements.
We performed a retrospective review of the management of infants born to Hepatitis B infected mothers at two large military hospitals in the United States that use a global electronic medical record to track patient results. We then compared these results to those recently published by the National Perinatal Hepatitis B Prevention Program (PHBPP), which does not include hospitals in the United States Military Healthcare System. Our results show that although all infants were managed appropriately at birth and immunization rates were very high, post vaccination follow-up testing rates were much lower than those seen in centers participating in the PHBPP. The rates of post vaccination serological testing were significantly higher for infants born to Hepatitis B e antigen positive mothers and those referred to a pediatric infectious disease specialist.
Despite use of a global electronic medical record in the United States Military Healthcare System, management of HBV-exposed infants does not always follow recommended guidelines. These infants could benefit from a more systematic method of follow-up, similar to the PHBPP, to ensure HBV serologic testing is obtained after the vaccination series is complete.
Electronic health records; HBIG; Hepatitis B; Hepatitis B vaccines; Military; Newborns
We report the rationale, design, methods and details of participation of a community-based, double blind, randomized clinical trial of an HPV 16 and 18 vaccine conducted in two provinces of Costa Rica to investigate the efficacy and population impact of the vaccine in the prevention of cervical cancer precursors. More than 24,000 women between 18 and 25 years of age were invited to participate and pre-screened for eligibility, with recruitment of 7,466 women (30% of those prescreened, 59% of those eligible) who were randomized to receive 3 doses of the HPV vaccine or hepatitis A vaccine as control. A complex protocol of data and specimen collection was applied, including an interview, pelvic exam for sexually active women, blood for serology and cell-mediated immunity, cervical secretions for local immunity and cells for HPV, Chlamydia trachomatis and Gonorrhea testing. Eighty percent of the women received 3 doses, 12.4% two doses and 7.4% one dose. At visits, compliance with data and specimen collection was close to 100%. Baseline characteristics and age-specific prevalence of HPV and cervical neoplasia are reported. Overall prevalence of HPV was high (50%), with 8.3% of women having HPV 16 and 3.2% HPV 18. LSIL was detected in 12.7% of women at baseline and HSIL in 1.9%. Prevalence of Chlamydia was 14.2%. There was very good agreement in HPV detection between clinician-collected and self-collected specimens (89.4% agreement for all types, kappa 0.59). Follow up will continue with yearly or more frequent examinations for at least 4 years for each participant.
New-generation vaccines against typhoid fever have the potential to reduce the burden of disease in areas where the disease is endemic. The case for public expenditure on typhoid Vi polysaccharide vaccines for two low-income, high-incidence slums (Narkeldanga and Tiljala) in Kolkata, India, was examined. Three measures of the economic benefits of the vaccines were used: private and public cost-of-illness (COI) avoided; avoided COI plus mortality risk-reduction benefits; and willingness-to-pay (WTP) derived from stated preference (contingent valuation) studies conducted in Tiljala in 2004. Benefits and costs were examined from a social perspective. The study represents a unique opportunity to evaluate typhoid-vaccine programmes using a wealth of new site-specific epidemiological and economic data. Three typhoid-vaccination strategies (targeting only enrolled school children, targeting all children, and targeting adults and children) would most likely pass a social cost-benefit test, unless benefits are restricted to include only avoided COI. All three strategies would be considered ‘very cost-effective’ using the standard comparisons of cost per disability-adjusted life-year avoided with per-capita gross domestic product. However, at an average total cost per immunized person of ∼US$ 1.1, a typhoid-vaccination programme would absorb a sixth of existing public-sector spending on health (on a per-capita basis) in India. Because there appears to be significant private economic demand for typhoid vaccines, the Government could design a financially-sustainable programme with user-fees. The results show that a programme where adults pay a higher fee to subsidize vaccines for children (who have higher incidence) would avoid more cases than a uniform user-fee and still achieve revenue-neutrality.
Costs and cost analysis; Cost-benefit analysis; Evaluation studies; Slums; Typhoid; Typhoid vaccine; India
Objectives To measure the seroprevalence of antibodies to hepatitis A virus (anti-HAV) in a health plan population of travelers and to determine whether prevaccination screening for anti-HAV can reduce unnecessary vaccination and thus promote the most effective, economic use of hepatitis A vaccine. Design Observational, cost-comparison study. Setting Central injection clinic of a health maintenance organization medical center. Subjects Five hundred twenty-seven adults who denied having previous hepatitis A or vaccination. Main outcome measures Subgroups with the greatest prevalence of anti-HAV seen between June 1995 and April 1996 for immunizations before traveling to nonindustrialized countries. Relative costs of their screening and immunization. Results The presence of anti-HAV precluded the need for vaccination in 148 subjects (28.1%). The highest prevalence of anti-HAV (82.7%) was found in subjects born in nonindustrialized countries (62/75), in subjects who had previously traveled to areas of endemic hepatitis A (32.1% [135/420]), and in subjects born before 1945 (29.2% [92/315]). Costs of screening and vaccinating travelers were cheapest if prevaccination antibody sera testing was limited to subjects born in nonindustrialized countries and those born before 1945. Conclusions Prevaccination screening of travelers for hepatitis A can be done selectively on the basis of age and country of origin. This strategy could lead to a more economic use of the vaccine and clinic resources.
Human papillomavirus (HPV) vaccines represent a remarkable opportunity for the primary prevention of cervical cancer and other HPV-related diseases. With almost four years of vaccine availability now accrued in the United States (US), data are beginning to accumulate about vaccine utilization patterns and how these may be affected by public opinions about the vaccines. This article describes the burden of HPV infection and related disease in the US, and reviews what is currently known about HPV vaccine utilization among adolescent and young adult females in this country. In addition, we report on emerging data on the personal and attitudinal factors that appear to influence HPV vaccine utilization and discuss how these data may be useful for designing future interventions to improve uptake of these vaccines. Finally, we re-examine cost-effectiveness studies of HPV vaccines, taking into account updated information on utilization of, and public attitudes about, these vaccines.
human papillomavirus; vaccine; adolescents; utilizations; adults; acceptability
Human papillomavirus (HPV) vaccines represent a remarkable opportunity for the primary prevention of cervical cancer and other HPV-related diseases. With almost four years of vaccine availability now accrued in the United States (U.S.), data are beginning to accumulate about vaccine utilization patterns and how these may be affected by public opinions about the vaccines. This article describes the burden of HPV infection and related disease in the U.S., and reviews what is currently known about HPV vaccine utilization among adolescent and young adult females in this country. In addition, we report on emerging data on the personal and attitudinal factors that appear to influence HPV vaccine utilization and discuss how these data may be useful for designing future interventions to improve uptake of these vaccines. Finally, we re-examine cost-effectiveness studies of HPV vaccines, taking into account updated information on utilization of, and public attitudes about, these vaccines.
OBJECTIVE: The goals of this study were to estimate seroprevalence of prior hepatitis B infection among high-risk adolescents and to determine the cost-effectiveness of prevaccination immunity screening. METHODS: The authors computed a "break-even" seroprevalence level calculated from current vaccine and administration costs. They then conducted a seroprevalence study of hepatitis B core antibody using sera previously submitted for syphilis serology from four-hundred adolescent and adult clients of sexually transmitted disease clinics. Finally, the authors compared age group-specific seroprevalence rates to the computed break-even seroprevalence. RESULTS: Levels of prior hepatitis B infection for all age groups were lower than the break-even seroprevalence standard from which cost-effectiveness was calculated. CONCLUSIONS: From the findings of this study, the authors concluded that routine preimmunization screening for prior hepatitis B infection would not be cost-effective for this population.
The aims of this study were to assess the seroprevalence of vaccine-preventable infections in Emirati medical students, and to provide scientific evidence for implementation of a cost-effective immunization guideline and policy for medical school admission.
This prospective cohort study involved 261 (61% female) Emirati medical students (preclinical and clinical) attending the College of Medicine and Health Sciences at UAE University. Data on vaccination and history of infectious diseases were collected from participants. Blood samples were collected between July 1, 2011 and May 30, 2012 for serological testing and QuantiFERON®-TB assay.
All students tested negative for infection with hepatitis C virus and human immunodeficiency virus. The prevalence of seropositivity to rubella virus was 97%, varicella–zoster virus 88%, mumps virus 84%, measles virus 54%, hepatitis B virus (HBV) 48%, and hepatitis A virus 21%. The QuantiFERON®-TB test was positive in 8% and indeterminate in 2%. Forty percent of students received HBV vaccine at birth; their HBV titers (mean ± SD) were 17.2 ± 62.9 mIU/mL (median = 1.64). The remaining 60% received it at school and their titers were 293.4 ± 371.0 mIU/mL (median = 107.7, p = 0.000).
About 50% of students were susceptible to HBV and measles virus; therefore, pre-matriculation screening for antibodies against these viruses is highly recommended. Moreover, tuberculosis screening is necessary because of the high influx of expatriates from endemic areas. Students with inadequate protection should be reimmunized prior to contact with patients.
Medical student; Immunization; Blood borne; Transmission; Prevention; UAE
Cervical cancer is a leading cause of cancer death among women in low-income countries, with ∼25% of cases worldwide occurring in India. We estimated the potential health and economic impact of different cervical cancer prevention strategies. After empirically calibrating a cervical cancer model to country-specific epidemiologic data, we projected cancer incidence, life expectancy, and lifetime costs (I$2005), and calculated incremental cost-effectiveness ratios (I$/YLS) for the following strategies: pre-adolescent vaccination of girls before age 12, screening of women over age 30, and combined vaccination and screening. Screening differed by test (cytology, visual inspection, HPV DNA testing), number of clinical visits (1, 2 or 3), frequency (1 × , 2 × , 3 × per lifetime), and age range (35–45). Vaccine efficacy, coverage, and costs were varied in sensitivity analyses. Assuming 70% coverage, mean reduction in lifetime cancer risk was 44% (range, 28–57%) with HPV 16,18 vaccination alone, and 21–33% with screening three times per lifetime. Combining vaccination and screening three times per lifetime provided a mean reduction of 56% (vaccination plus 3-visit conventional cytology) to 63% (vaccination plus 2-visit HPV DNA testing). At a cost per vaccinated girl of I$10 (per dose cost of $2), pre-adolescent vaccination followed by screening three times per lifetime using either VIA or HPV DNA testing, would be considered cost-effective using the country's per capita gross domestic product (I$3452) as a threshold. In India, if high coverage of pre-adolescent girls with a low-cost HPV vaccine that provides long-term protection is achievable, vaccination followed by screening three times per lifetime is expected to reduce cancer deaths by half, and be cost-effective.
HPV; cost-effectiveness; vaccination
The cost-effectiveness of prophylactic vaccination against human papillomavirus types 16 (HPV-16) and 18 (HPV-18) is an important consideration for guidelines for immunization in the United States.
We synthesized epidemiologic and demographic data using models of HPV-16 and HPV-18 transmission and cervical carcinogenesis to compare the health and economic outcomes of vaccinating preadolescent girls (at 12 years of age) and vaccinating older girls and women in catch-up programs (to 18, 21, or 26 years of age). We examined the health benefits of averting other HPV-16–related and HPV-18–related cancers, the prevention of HPV-6–related and HPV-11–related genital warts and juvenile-onset recurrent respiratory papillomatosis by means of the quadrivalent vaccine, the duration of immunity, and future screening practices.
On the assumption that the vaccine provided lifelong immunity, the cost-effectiveness ratio of vaccination of 12-year-old girls was $43,600 per quality-adjusted life-year (QALY) gained, as compared with the current screening practice. Under baseline assumptions, the cost-effectiveness ratio for extending a temporary catch-up program for girls to 18 years of age was $97,300 per QALY; the cost of extending vaccination of girls and women to the age of 21 years was $120,400 per QALY, and the cost for extension to the age of 26 years was $152,700 per QALY. The results were sensitive to the duration of vaccine-induced immunity; if immunity waned after 10 years, the cost of vaccination of preadolescent girls exceeded $140,000 per QALY, and catch-up strategies were less cost-effective than screening alone. The cost-effectiveness ratios for vaccination strategies were more favorable if the benefits of averting other health conditions were included or if screening was delayed and performed at less frequent intervals and with more sensitive tests; they were less favorable if vaccinated girls were preferentially screened more frequently in adulthood.
The cost-effectiveness of HPV vaccination will depend on the duration of vaccine immunity and will be optimized by achieving high coverage in preadolescent girls, targeting initial catch-up efforts to women up to 18 or 21 years of age, and revising screening policies.
Pap screening combined with loop electrosurgical excision procedures (LEEP) is almost 100% effective in preventing cervical cancer mortality yet many countries with these procedures have now implemented broad HPV vaccination programs. HPV vaccines have not been demonstrated to be more effective or safer than Pap screening in the prevention of cervical cancer and Pap screening will still be required even in vaccinated women. The HPV vaccine costs Au$450 per person and it does not protect against ~30% of cancer. This investigation analyses the cost-effectiveness of using the HPV vaccine in countries where Pap screening and surgical procedures have already reduced cervical cancer mortality to very low rates. Cost-effectiveness of vaccination programs is being determined by mathematical models which are founded on many assumptions. It is necessary to examine the rigor of these assumptions to be certain of the health benefits that are predicted. In 2002 scientists concluded that HPV 16 and 18 were the central and independent cause of most cervical cancer. This conclusion was based on molecular technology. If HPV 16 and 18 infections are the central and independent cause of most cervical cancer then the incidence of HPV 16 and 18 should vary with the incidence and mortality of cervical cancer worldwide. This correlation does not exist. It is also observed that the majority of HPV 16/18 infections do not lead to cervical cancer. This indicates that other etiological or ‘risk’ factors are necessary for persistent HPV infection to progress to cancer. The benefits of HPV vaccines have been determined by using pre-cancerous lesions in young women as a surrogate for cervical cancer. This surrogate is found to be inadequate as an end-point for cervical cancer. Clinical trials have only provided speculative benefits for the efficacy of HPV vaccines against cancer and the long-term risks of the vaccine have not been established. Pap screening will still be required in vaccinated women hence HPV vaccination programs are not cost-effective, and may do more harm than good, in countries where regular Pap screening and surgery has already reduced the burden of this disease.
Cervical cancer; Human papillomavirus virus (HPV); Genotype; Infectious diseases; Gardasil®; Public health policy; Vaccination programs
Vaccination against hepatitis B virus (HBV) immediately after birth prevents neonatal infection by vertical transmission from HBV carrier mothers. There is an ongoing debate whether infant vaccination is sufficient to protect against infection when exposed to HBV later in life. We studied 222 Thai infants born to HBsAg −/+ and HBeAg −/+ mothers who were vaccinated with recombinant hepatitis B vaccine at 0-1-2-12 months of age. A subset of 100 subjects received a booster dose at age 5 years. Blood samples collected yearly for 20 years were examined for anti-HBs antibodies and serological markers of hepatitis B infection (anti-HBc, HBsAg, and in selected cases HBeAg, anti-HBe, HBV DNA). During the 20-year follow-up, no subject acquired new chronic HBV infection or clinical hepatitis B disease. During the first decade, possible subclinical breakthrough HBV infection (anti-HBc seroconversion) was only observed in subjects born to HBsAg +/HBeAg + mothers (6/49 [12.2%]). During the second decade, breakthrough HBV infections were detected in all groups (18/140 [12.8%]). Increases in anti-HBs concentrations that were unrelated to additional HBV vaccination or infection were detected in approximately 10% of subjects in each decade. Primary infant vaccination with a recombinant hepatitis B vaccine confers long-term protection against clinical disease and new chronic hepatitis B infection despite confirmed hepatitis B exposure. (http://www.clinicaltrials.gov NCT00240500 and NCT00456625)
efficacy; hepatitis B; vaccine
To assess the economic aspects of HBV (hepatitis B virus) transmission prevention for premarriage individuals in a country with cultural backgrounds like Iran and intermediate endemicity of HBV infection.
A cost-effectiveness analysis model was used from the health care system and society perspectives. The effectiveness was defined as the number of chronic HBV infections averted owing to one of the following strategies:
1) HBsAg screening to find those would-be couples one of whom is HBsAg positive and putting seronegative subjects on a protection protocol comprising HBV vaccination, single dose HBIG and condom protection.
2) HBsAg screening as above, in addition to performing HBcAb screening in the HBsAg negative spouses of the HBsAg positive persons and giving the protocol only to HBcAb negative ones.
Sensitivity and threshold analyses were conducted.
The cost of each chronic infection averted was 202$ and 197$ for the strategies 1 and 2, respectively. Sensitivity analysis showed that strategy 2 was always slightly cheaper than strategy 1. The discounted threshold value for the lifetime costs of chronic liver disease, above which the model was cost saving was 2818$ in strategy 1 and 2747$ in strategy 2.
Though premarriage prevention of HBV transmission in the countries with cultural backgrounds similar to Iran seems cost saving, further studies determining precise costs of HBV infection in Iran can lead to a better analysis.
Human papillomavirus (HPV), a sexually transmitted infection and
the etiologic cause of genital warts and cervical cancer, is
highly prevalent in sexually active men and women. Although
cervical screening procedures have significantly reduced the
disease burden associated with HPV infection, they are expensive
and abnormal results cause significant emotional distress.
Therefore, prevention may be an effective strategy for reducing
the economic, psychosocial, and disease burden of HPV infection.
Multivalent vaccines are now in clinical development. A bivalent
vaccine that protects against HPV 16 and 18, and a quadrivalent
vaccine which protects against HPV types 6, 11, 16, and 18, have
been shown to significantly reduce the occurrence of incident and
persistent HPV infections in phase 2 clinical trials; phase 3
trials are currently underway. HPV vaccines will be most effective
when administered prior to initiation of sexual activity, and
vaccination campaigns should aggressively target preadolescent and
This study assessed the long-term economic implications of a national program to vaccinate all adults treated at sexually transmitted disease (STD) clinics in a single year.
A model was developed to track the long-term disease outcomes and costs among a hypothetical cohort of 2 million STD clinic clients accessing services in one year, using data from published sources and demonstration projects at STD clinics in San Diego (California), Illinois, and Denver (Colorado). The model estimated net economic benefits of a routine hepatitis B vaccination policy at STD clinics nationwide compared with no vaccination.
Without a vaccination program, an estimated 237,021 new hepatitis B virus (HBV) infections would occur over the lifetimes of the 2 million STD clinic clients seen in a single year. HBV-related medical costs and productivity losses would be $1.6 billion. In a national program for routine vaccination at STD clinics, 1.3 million adults would be expected to receive at least one vaccine dose, and an estimated 45% of the new HBV infections expected without vaccination would be prevented. The vaccination program would cost $138 million, HBV infections occurring despite the program would cost $878 million, and clients' time and travel would cost $45 million. The net economic benefit (savings) of routine vaccination would be $526 million. If the indirect costs of lost productivity due to HBV infection are not considered, routine vaccination would have a net cost of $28 million.
Estimates from this model suggest a national program for routine hepatitis B vaccination of adults at STD clinics would be a cost saving to society.
Bluetongue (BT) is a vector-borne disease of ruminants caused by bluetongue virus that is transmitted by biting midges (Culicoides spp.). In 2006, the introduction of BTV serotype 8 (BTV-8) caused a severe epidemic in Western and Central Europe. The principal effective veterinary measure in response to BT was believed to be vaccination accompanied by other measures such as movement restrictions and surveillance. As the number of vaccine doses available at the start of the vaccination campaign was rather uncertain, the Dutch Ministry of Agriculture, Nature and Food Quality and the Dutch agricultural industry wanted to evaluate several different vaccination strategies. This study aimed to rank eight vaccination strategies based on their efficiency (i.e. net costs in relation to prevented losses or benefits) for controlling the bluetongue virus serotype 8 epidemic in 2008.
An economic model was developed that included the Dutch professional cattle, sheep and goat sectors together with the hobby farms. Strategies were evaluated based on the least cost - highest benefit frontier, the benefit-cost ratio and the total net returns. Strategy F, where all adult sheep at professional farms in the Netherlands would be vaccinated was very efficient at lowest costs, whereas strategy D, where additional to all adult sheep at professional farms also all adult cattle in the four Northern provinces would be vaccinated, was also very efficient but at a little higher costs. Strategy C, where all adult sheep and cattle at professional farms in the whole of the Netherlands would be vaccinated was also efficient but again at higher costs.
This study demonstrates that a financial analysis differentiates between vaccination strategies and indicates important decision rules based on efficiency.
OBJECTIVE: Incarcerated populations are a group at high risk for hepatitis B. About 30% of people experiencing acute hepatitis B virus infection (HBV) have a history of incarceration. Offering routine HBV vaccinations to incarcerated individuals could have a significant effect on public health. The objective of this study is to identify current vaccine practices and the perceived feasibility of routine vaccinations for hepatitis B within correctional settings. METHOD: The authors surveyed the medical directors of state correctional facilities in all 50 states and the federal prison system regarding current HBV vaccine practices. Surveys were faxed or mailed between July 1 and September 1, 2000. RESULTS: Thirty-five states and the federal system responded (response rate = 70.6%). These systems account for 77% of all inmates in federal or state prisons and jails. Two states give hepatitis B vaccine routinely, nine states offer no hepatitis B vaccine, and 26 states and the Federal Bureau of Prisons offer hepatitis vaccine to some inmates. Most states do not spend enough money to vaccinate even those prisoners at highest risk. Under the Vaccine for Children program, 19,520 youths could receive vaccine immediately. According to the respondents, if vaccine were available at no-cost, 25 states and the Federal Bureau of Prisons would routinely offer vaccination to all inmates. CONCLUSIONS: Most correctional systems do not routinely offer vaccine to their incarcerated populations, but would if funds were available. There exists now a unique public health opportunity to prevent a significant proportion of new hepatitis B infections.
Purpose of review
To review recent findings on immunity and vaccine development to Chlamydia trachomatis.
There is increasing knowledge on the interactions between Chlamydia trachomatis and infected host cells. During genital infection the organism avoids generating protective immunity but immune responses to a number of chlamydial proteins have been associated with reproductive tract pathology. Various vaccine and adjuvant preparations have been tried experimentally. Information generated by proteomics and complex studies of serological and T-lymphocyte immune responses points to novel vaccine candidates.
Chlamydia trachomatis, an obligate intracellular bacterium, is the commonest sexually transmitted infection worldwide and is associated with reproductive pathology. To develop rational vaccines it is necessary to understand the complex life-cycle of the organism, the host immune response to infection and how these relate to disease. Infection does not prevent reinfection and antibiotic treatment prevents antibody production at a population level. It remains unclear what type of immune response would be sufficient to prevent infection and/or reinfection. Although the prevalence and demographics of infection and the severity of disease associations suggest it would be desirable, there is no vaccine currently available. A number of studies have identified novel vaccine candidates.
Chlamydia trachomatis; Immunity; Vaccination
Hepatitis B vaccination is recommended for all clients of sexually transmitted disease (STD) clinics. Hepatitis A vaccination and hepatitis C testing are recommended for STD clinic clients who report specific risks for those viruses. In 1999, the Illinois Department of Public Health began working with local health departments in Illinois (excluding Chicago) to introduce hepatitis B testing and vaccination in public STD clinics. Hepatitis A vaccination and hepatitis C counseling and testing were introduced in 2001. Illinois state funding has covered more than one-third of the costs of offering these integrated viral hepatitis services to STD clients. Hepatitis A and B vaccination and hepatitis C counseling and testing are now the standard of care in almost all (35 of 41) Illinois public STD clinics (excluding Chicago). In 2005, 29.4% of STD client visits included a hepatitis B vaccination. In public STD clinics in Illinois, hepatitis A and B vaccinations and hepatitis C counseling and testing have increased from essentially no activity in 1999 to substantial levels of service in 2005.
OBJECTIVE--To assess the cost effectiveness of adding universal hepatitis B vaccination in infancy or pre-adolescence to a policy of selective vaccination of at risk groups. DESIGN--Costs of a selective policy and additional costs of universal vaccination policies were estimated from costs of vaccine delivery and published data on target populations. Additional years of life gained were calculated for each policy by applying life tables to estimates of mortality attributable to hepatitis B. SETTING--England and Wales. RESULTS--Compared with no vaccination, vaccination in infancy was the most cost effective followed by vaccination in preadolescence. Selective vaccination was the least effective (cost per year of life gained 2568 pounds, 2824 pounds, and 8564 pounds respectively). Adding vaccination in infancy or at pre-adolescence to a selective policy cost 1537 pounds or 1658 pounds per year of life gained. Discounting years gained in the future at 6% per annum, however, made pre-adolescent vaccination more cost effective than infant or selective vaccination (51,817 pounds, 94,821 pounds, and 124,779 pounds per discounted year of life gained). Adding pre-adolescent vaccination to a selective policy cost 32,125 pounds per discounted year of life gained and infant vaccination, 77,085 pounds. CONCLUSIONS--Universal vaccination against hepatitis B was more cost effective than selective vaccination in a low prevalence country. Discounting future health gain, however, made universal infant vaccination lest cost effective than universal pre-adolescent vaccination. If future health gained is as important as present gain the addition of universal vaccination to a selective policy is equivalent to the cost per quality adjusted year of life from renal transplantation or breast cancer screening.
We assessed the cost-effectiveness of adding a quadrivalent (6/11/16/18) human papillomavirus (HPV) vaccine to the current screening programme in the UK compared to screening alone.
A Markov model of the natural history of HPV infection incorporating screening and vaccination was developed. A vaccine that prevents 98% of HPV 6, 11, 16 and 18-associated disease, with a lifetime duration and 85% coverage, in conjunction with current screening was considered.
Vaccination with screening, compared to screening alone, was associated with an incremental cost-effectiveness ratio of £21,059 per quality adjusted life year (QALY) and £34,687 per life year saved (LYS). More than 400 cases of cervical cancer, 6700 cases of cervical intraepithelial neoplasia and 4750 cases of genital warts could be avoided per 100,000 vaccinated girls. Results were sensitive to assumptions about the need for a booster, the duration of vaccine efficacy and discount rate.
These analyses suggest that adding a quadrivalent HPV vaccine to current screening in the UK could be a cost-effective method for further reducing the burden of cervical cancer.