Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-30 (of 32 Records) |
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Population-level risk factors related to measles case fatality: A conceptual framework based on expert consultation and literature review
Sbarra AN , Jit M , Mosser JF , Ferrari M , Cutts F , Papania M , Kretsinger K , McCarthy KA , Thakkar N , Gaythorpe KAM , Gamage D , Krause LK , Dansereau E , Crowcroft N , Portnoy A . Vaccines (Basel) 2023 11 (8) A better understanding of population-level factors related to measles case fatality is needed to estimate measles mortality burden and impact of interventions such as vaccination. This study aimed to develop a conceptual framework of mechanisms associated with measles case fatality ratios (CFRs) and assess the scope of evidence available for related indicators. Using expert consultation, we developed a conceptual framework of mechanisms associated with measles CFR and identified population-level indicators potentially associated with each mechanism. We conducted a literature review by searching PubMed on 31 October 2021 to determine the scope of evidence for the expert-identified indicators. Studies were included if they contained evidence of an association between an indicator and CFR and were excluded if they were from non-human studies or reported non-original data. Included studies were assessed for study quality. Expert consultation identified five mechanisms in a conceptual framework of factors related to measles CFR. We identified 3772 studies for review and found 49 studies showing at least one significant association with CFR for 15 indicators (average household size, educational attainment, first- and second-dose coverage of measles-containing vaccine, human immunodeficiency virus prevalence, level of health care available, stunting prevalence, surrounding conflict, travel time to major city or settlement, travel time to nearest health care facility, under-five mortality rate, underweight prevalence, vitamin A deficiency prevalence, vitamin A treatment, and general malnutrition) and only non-significant associations for five indicators (antibiotic use for measles-related pneumonia, malaria prevalence, percent living in urban settings, pneumococcal conjugate vaccination coverage, vitamin A supplementation). Our study used expert consultation and a literature review to provide additional insights and a summary of the available evidence of these underlying mechanisms and indicators that could inform future measles CFR estimations. |
Combining serological and contact data to derive target immunity levels for achieving and maintaining measles elimination (preprint)
Funk S , Knapp JK , Lebo E , Reef SE , Dabbagh AJ , Kretsinger K , Jit M , Edmunds WJ , Strebel PM . bioRxiv 2019 201574 Background Vaccination has reduced the global incidence of measles to the lowest rates in history. However, local interruption of measles virus transmission requires sustained high levels of population immunity that can be challenging to achieve and maintain. The herd immunity threshold for measles is typically stipulated at 90–95%. This figure does not easily translate into age-specific immunity levels required to interrupt transmission. Previous estimates of such levels were based on speculative contact patterns based on historical data from high-income countries. The aim of this study was to determine age-specific immunity levels that would ensure elimination of measles when taking into account empirically observed contact patterns.Methods We combined estimated immunity levels from serological data in 17 countries with studies of age-specific mixing patterns to derive contact-adjusted immunity levels. We then compared these to case data from the 10 years following the seroprevalence studies to establish a contact-adjusted immunity threshold for elimination. We lastly combined a range of hypothetical immunity profiles with contact data from a wide range of socioeconomic and demographic settings to determine whether they would be sufficient for elimination.Results We found that contact-adjusted immunity levels were able to predict whether countries would experience outbreaks in the decade following the serological studies in about 70% of countries. The corresponding threshold level of contact-adjusted immunity was found to be 93%, corresponding to an average basic reproduction number of approximately 14. Testing different scenarios of immunity with this threshold level using contact studies from around the world, we found that 95% immunity would have to be achieved by the age of five and maintained across older age groups to guarantee elimination. This reflects a greater level of immunity required in 5–9 year olds than established previously.Conclusions The immunity levels we found necessary for measles elimination are higher than previous guidance. The importance of achieving high immunity levels in 5–9 year olds presents both a challenge and an opportunity. While such high levels can be difficult to achieve, school entry provides an opportunity to ensure sufficient vaccination coverage. Combined with observations of contact patterns, further national and sub-national serological studies could serve to highlight key gaps in immunity that need to be filled in order to achieve national and regional measles elimination.ESEN2European Sero-Epidemiology Network 2EUROEuropean RegionMCEMisclassification errorWHOWorld Health Organization |
Population-level risk factors related to measles case fatality: A conceptual framework based on expert consultation and literature review (preprint)
Sbarra AN , Jit M , Mosser JF , Ferrari M , Cutts F , Papania M , Kretsinger K , McCarthy KA , Thakkar N , Gaythorpe KAM , Gamage D , Krause LK , Dansereau E , Portnoy A . medRxiv 2022 01 Introduction: A better understanding of population-level factors related to measles case fatality is needed to estimate measles mortality burden and impact of interventions such as vaccination. This study aimed to develop a conceptual framework of mechanisms associated with measles case fatality ratios (CFRs) and assess the scope of evidence available for related indicators in the published literature. Method(s): Using expert consultation, we developed a conceptual framework of mechanisms associated with measles CFR and identified population-level indicators potentially associated with each mechanism. We then conducted a literature review by searching PubMed on October 31, 2021 to determine and classify the scope of evidence for the indicators identified by expert consultation. Studies were included if they contained evidence of an association between an indicator and measles CFR and were excluded if they were from non-human studies or reported non-original data. Result(s): Expert consultation identified five mechanisms in a conceptual framework of factors related to measles CFR: health system access and care-seeking behaviors, health system quality, measles control and epidemiology, nutritional status, and risk of secondary infection. Thirty-seven measurable population-level indicators were identified by expert consultation as proxies for the mechanisms. We identified 3772 studies for review and found 49 studies showing at least one significant association with CFR for 15 indicators and only non-significant associations for 5 indicators. Inadequate data were available to evaluate the remaining 17 indicators. A randomized controlled trial provided evidence for a relationship between vitamin A treatment and measles CFR. Average household size, educational attainment, first-dose coverage of measles-containing vaccine, human immunodeficiency virus prevalence, second-dose coverage of measles-containing vaccine, stunting prevalence, surrounding conflict, travel time to major city or settlement, travel time to nearest health care facility, under-five mortality rate, underweight prevalence, vitamin A deficiency prevalence, and wasting prevalence had quantitative observational level evidence. Level of health care available had qualitative evidence of a relationship with measles CFR. Conclusion(s): To reduce uncertainty in measles CFR estimation, population-level factors representative of underlying mechanisms associated with CFR could be used. Our study used expert consultation and literature review to provide additional insights and a summary of the available evidence of these underlying mechanisms and indicators that could inform future estimations of measles CFR. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license. |
Feasibility of measles and rubella vaccination programmes for disease elimination: a modelling study
Winter AK , Lambert B , Klein D , Klepac P , Papadopoulos T , Truelove S , Burgess C , Santos H , Knapp JK , Reef SE , Kayembe LK , Shendale S , Kretsinger K , Lessler J , Vynnycky E , McCarthy K , Ferrari M , Jit M . Lancet Glob Health 2022 10 (10) e1412-e1422 BACKGROUND: Marked reductions in the incidence of measles and rubella have been observed since the widespread use of the measles and rubella vaccines. Although no global goal for measles eradication has been established, all six WHO regions have set measles elimination targets. However, a gap remains between current control levels and elimination targets, as shown by large measles outbreaks between 2017 and 2019. We aimed to model the potential for measles and rubella elimination globally to inform a WHO report to the 73rd World Health Assembly on the feasibility of measles and rubella eradication. METHODS: In this study, we modelled the probability of measles and rubella elimination between 2020 and 2100 under different vaccination scenarios in 93 countries of interest. We evaluated measles and rubella burden and elimination across two national transmission models each (Dynamic Measles Immunisation Calculation Engine [DynaMICE], Pennsylvania State University [PSU], Johns Hopkins University, and Public Health England models), and one subnational measles transmission model (Institute for Disease Modeling model). The vaccination scenarios included a so-called business as usual approach, which continues present vaccination coverage, and an intensified investment approach, which increases coverage into the future. The annual numbers of infections projected by each model, country, and vaccination scenario were used to explore if, when, and for how long the infections would be below a threshold for elimination. FINDINGS: The intensified investment scenario led to large reductions in measles and rubella incidence and burden. Rubella elimination is likely to be achievable in all countries and measles elimination is likely in some countries, but not all. The PSU and DynaMICE national measles models estimated that by 2050, the probability of elimination would exceed 75% in 14 (16%) and 36 (39%) of 93 modelled countries, respectively. The subnational model of measles transmission highlighted inequity in routine coverage as a likely driver of the continuance of endemic measles transmission in a subset of countries. INTERPRETATION: To reach regional elimination goals, it will be necessary to innovate vaccination strategies and technologies that increase spatial equity of routine vaccination, in addition to investing in existing surveillance and outbreak response programmes. FUNDING: WHO, Gavi, the Vaccine Alliance, US Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation. |
Progress Toward Regional Measles Elimination - Worldwide, 2000-2020
Dixon MG , Ferrari M , Antoni S , Li X , Portnoy A , Lambert B , Hauryski S , Hatcher C , Nedelec Y , Patel M , Alexander JP Jr , Steulet C , Gacic-Dobo M , Rota PA , Mulders MN , Bose AS , Rosewell A , Kretsinger K , Crowcroft NS . MMWR Morb Mortal Wkly Rep 2021 70 (45) 1563-1569 In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan,* with the objective of eliminating measles(†) in five of the six World Health Organization (WHO) regions by 2020 (1). The Immunization Agenda 2021-2030 (IA2030)(§) uses measles incidence as an indicator of the strength of immunization systems. The Measles-Rubella Strategic Framework 2021-2030(¶) and the Measles Outbreaks Strategic Response Plan 2021-2023** are aligned with the IA2030 and highlight robust measles surveillance systems to document immunity gaps, identify root causes of undervaccination, and develop locally tailored solutions to ensure administration of 2 doses of measles-containing vaccine (MCV) to all children. This report describes progress toward World Health Assembly milestones and measles elimination objectives during 2000-2020 and updates a previous report (2). During 2000-2010, estimated MCV first dose (MCV1) coverage increased globally from 72% to 84%, peaked at 86% in 2019, but declined to 84% in 2020 during the COVID-19 pandemic. All countries conducted measles surveillance, although fewer than one third achieved the sensitivity indicator target of ≥2 discarded(††) cases per 100,000 population in 2020. Annual reported measles incidence decreased 88% during 2000-2016, from 145 to 18 cases per 1 million population, rebounded to 120 in 2019, before falling to 22 in 2020. During 2000-2020, the annual number of estimated measles deaths decreased 94%, from 1,072,800 to 60,700, averting an estimated 31.7 million measles deaths. To achieve regional measles elimination targets, enhanced efforts are needed to reach all children with 2 MCV doses, implement robust surveillance, and identify and close immunity gaps. |
Progress toward regional measles elimination - worldwide, 2000-2019
Patel MK , Goodson JL , Alexander JP Jr , Kretsinger K , Sodha SV , Steulet C , Gacic-Dobo M , Rota PA , McFarland J , Menning L , Mulders MN , Crowcroft NS . MMWR Morb Mortal Wkly Rep 2020 69 (45) 1700-1705 In 2010, the World Health Assembly (WHA) set the following three milestones for measles control to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district, 2) reduce global annual measles incidence to <5 cases per 1 million population, and 3) reduce global measles mortality by 95% from the 2000 estimate* (1). In 2012, WHA endorsed the Global Vaccine Action Plan,(†) with the objective of eliminating measles(§) in five of the six World Health Organization (WHO) regions by 2020. This report describes progress toward WHA milestones and regional measles elimination during 2000-2019 and updates a previous report (2). During 2000-2010, estimated MCV1 coverage increased globally from 72% to 84% but has since plateaued at 84%-85%. All countries conducted measles surveillance; however, approximately half did not achieve the sensitivity indicator target of two or more discarded measles and rubella cases per 100,000 population. Annual reported measles incidence decreased 88%, from 145 to 18 cases per 1 million population during 2000-2016; the lowest incidence occurred in 2016, but by 2019 incidence had risen to 120 cases per 1 million population. During 2000-2019, the annual number of estimated measles deaths decreased 62%, from 539,000 to 207,500; an estimated 25.5 million measles deaths were averted. To drive progress toward the regional measles elimination targets, additional strategies are needed to help countries reach all children with 2 doses of measles-containing vaccine, identify and close immunity gaps, and improve surveillance. |
Progress toward regional measles elimination - worldwide, 2000-2018
Patel MK , Dumolard L , Nedelec Y , Sodha SV , Steulet C , Gacic-Dobo M , Kretsinger K , McFarland J , Rota PA , Goodson JL . MMWR Morb Mortal Wkly Rep 2019 68 (48) 1105-1111 In 2010, the World Health Assembly (WHA) set the following three milestones for measles control to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to >/=90% at the national level and to >/=80% in every district, 2) reduce global annual measles incidence to less than five cases per 1 million population, and 3) reduce global measles mortality by 95% from the 2000 estimate* (1). In 2012, WHA endorsed the Global Vaccine Action Plan,(dagger) with the objective of eliminating measles( section sign) in five of the six World Health Organization (WHO) regions by 2020. This report updates a previous report (2) and describes progress toward WHA milestones and regional measles elimination during 2000-2018. During 2000-2018, estimated MCV1 coverage increased globally from 72% to 86%; annual reported measles incidence decreased 66%, from 145 to 49 cases per 1 million population; and annual estimated measles deaths decreased 73%, from 535,600 to 142,300. During 2000-2018, measles vaccination averted an estimated 23.2 million deaths. However, the number of measles cases in 2018 increased 167% globally compared with 2016, and estimated global measles mortality has increased since 2017. To continue progress toward the regional measles elimination targets, resource commitments are needed to strengthen routine immunization systems, close historical immunity gaps, and improve surveillance. To achieve measles elimination, all communities and countries need coordinated efforts aiming to reach >/=95% coverage with 2 doses of measles vaccine (3). |
Progress toward rubella and congenital rubella syndrome control and elimination - worldwide, 2000-2018
Grant GB , Desai S , Dumolard L , Kretsinger K , Reef SE . MMWR Morb Mortal Wkly Rep 2019 68 (39) 855-859 Rubella is a leading cause of vaccine-preventable birth defects. Although rubella virus infection usually causes a mild febrile rash illness in children and adults, infection during pregnancy, especially during the first trimester, can result in miscarriage, fetal death, stillbirth, or a constellation of birth defects known as congenital rubella syndrome (CRS). A single dose of rubella-containing vaccine (RCV) can provide lifelong protection (1). In 2011, the World Health Organization (WHO) updated guidance on the use of RCV and recommended capitalizing on the accelerated measles elimination activities as an opportunity to introduce RCV (1). The Global Vaccine Action Plan 2011-2020 (GVAP) includes a target to achieve elimination of rubella in at least five of the six WHO regions by 2020 (2). This report on the progress toward rubella and CRS control and elimination updates the 2017 report (3), summarizing global progress toward the control and elimination of rubella and CRS from 2000 (the initiation of accelerated measles control activities) and 2012 (the initiation of accelerated rubella control activities) to 2018 (the most recent data) using WHO immunization and surveillance data. Among WHO Member States,* the number with RCV in their immunization schedules has increased from 99 (52% of 191) in 2000 to 168 (87% of 194) in 2018(dagger); 69% of the world's infants were vaccinated against rubella in 2018. Rubella elimination has been verified in 81 (42%) countries. To make further progress to control and eliminate rubella, and to reduce the equity gap, introduction of RCV in all countries is important. Likewise, countries that have introduced RCV can achieve and maintain elimination with high vaccination coverage and surveillance for rubella and CRS. The two WHO regions that have not established an elimination goal (African [AFR] and Eastern Mediterranean [EMR]) should consider establishing a goal.( section sign). |
Combining serological and contact data to derive target immunity levels for achieving and maintaining measles elimination
Funk S , Knapp JK , Lebo E , Reef SE , Dabbagh AJ , Kretsinger K , Jit M , Edmunds WJ , Strebel PM . BMC Med 2019 17 (1) 180 BACKGROUND: Vaccination has reduced the global incidence of measles to the lowest rates in history. However, local interruption of measles virus transmission requires sustained high levels of population immunity that can be challenging to achieve and maintain. The herd immunity threshold for measles is typically stipulated at 90-95%. This figure does not easily translate into age-specific immunity levels required to interrupt transmission. Previous estimates of such levels were based on speculative contact patterns based on historical data from high-income countries. The aim of this study was to determine age-specific immunity levels that would ensure elimination of measles when taking into account empirically observed contact patterns. METHODS: We combined estimated immunity levels from serological data in 17 countries with studies of age-specific mixing patterns to derive contact-adjusted immunity levels. We then compared these to case data from the 10 years following the seroprevalence studies to establish a contact-adjusted immunity threshold for elimination. We lastly combined a range of hypothetical immunity profiles with contact data from a wide range of socioeconomic and demographic settings to determine whether they would be sufficient for elimination. RESULTS: We found that contact-adjusted immunity levels were able to predict whether countries would experience outbreaks in the decade following the serological studies in about 70% of countries. The corresponding threshold level of contact-adjusted immunity was found to be 93%, corresponding to an average basic reproduction number of approximately 14. Testing different scenarios of immunity with this threshold level using contact studies from around the world, we found that 95% immunity would have to be achieved by the age of five and maintained across older age groups to guarantee elimination. This reflects a greater level of immunity required in 5-9-year-olds than established previously. CONCLUSIONS: The immunity levels we found necessary for measles elimination are higher than previous guidance. The importance of achieving high immunity levels in 5-9-year-olds presents both a challenge and an opportunity. While such high levels can be difficult to achieve, school entry provides an opportunity to ensure sufficient vaccination coverage. Combined with observations of contact patterns, further national and sub-national serological studies could serve to highlight key gaps in immunity that need to be filled in order to achieve national and regional measles elimination. |
Progress toward regional measles elimination - worldwide, 2000-2017
Dabbagh A , Laws RL , Steulet C , Dumolard L , Mulders MN , Kretsinger K , Alexander JP , Rota PA , Goodson JL . MMWR Morb Mortal Wkly Rep 2018 67 (47) 1323-1329 In 2010, the World Health Assembly set three milestones for measles prevention to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to >/=90% at the national level and to >/=80% in every district; 2) reduce global annual measles incidence to less than five cases per million population; and 3) reduce global measles mortality by 95% from the 2000 estimate (1). In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan (GVAP),(dagger) with the objective of eliminating measles( section sign) in four of the six World Health Organization (WHO) regions by 2015 and in five regions by 2020. Countries in all six WHO regions have adopted goals for measles elimination by 2020. This report describes progress toward global measles control milestones and regional measles elimination goals during 2000-2017 and updates a previous report (2). During 2000-2017, estimated MCV1 coverage increased globally from 72% to 85%; annual reported measles incidence decreased 83%, from 145 to 25 cases per million population; and annual estimated measles deaths decreased 80%, from 545,174 to 109,638. During this period, measles vaccination prevented an estimated 21.1 million deaths. However, measles elimination milestones have not been met, and three regions are experiencing a large measles resurgence. To make further progress, case-based surveillance needs to be strengthened, and coverage with MCV1 and the second dose of measles-containing vaccine (MCV2) needs to increase; in addition, it will be important to maintain political commitment and ensure substantial, sustained investments to achieve global and regional measles elimination goals. |
Use of the revised World Health Organization cluster survey methodology to classify measles-rubella vaccination campaign coverage in 47 counties in Kenya, 2016
Subaiya S , Tabu C , N'Ganga J , Awes AA , Sergon K , Cosmas L , Styczynski A , Thuo S , Lebo E , Kaiser R , Perry R , Ademba P , Kretsinger K , Onuekwusi I , Gary H , Scobie HM . PLoS One 2018 13 (7) e0199786 INTRODUCTION: To achieve measles elimination, two doses of measles-containing vaccine (MCV) are provided through routine immunization services or vaccination campaigns. In May 2016, Kenya conducted a measles-rubella (MR) vaccination campaign targeting 19 million children aged 9 months-14 years, with a goal of achieving >/=95% coverage. We conducted a post-campaign cluster survey to estimate national coverage and classify coverage in Kenya's 47 counties. METHODS: The stratified multi-stage cluster survey included data from 20,011 children in 8,253 households sampled using the recently revised World Health Organization coverage survey methodology (2015). Point estimates and 95% confidence intervals (95% CI) of national campaign coverage were calculated, accounting for study design. County vaccination coverage was classified as 'pass,' 'fail,' or 'intermediate,' using one-sided hypothesis tests against a 95% threshold. RESULTS: Estimated national MR campaign coverage was 95% (95% CI: 94%-96%). Coverage differed significantly (p < 0.05) by child's school attendance, mother's education, household wealth, and other factors. In classifying coverage, 20 counties passed (>/=95%), two failed (<95%), and 25 were intermediate (unable to classify either way). Reported campaign awareness among caretakers was 92%. After the 2016 MR campaign, an estimated 93% (95% CI: 92%-94%) of children aged 9 months to 14 years had received >/=2 MCV doses; 6% (95% CI: 6%-7%) had 1 MCV dose; and 0.7% (95% CI: 0.6%-0.9%) remained unvaccinated. CONCLUSIONS: Kenya reached the MR campaign target of 95% vaccination coverage, representing a substantial achievement towards increasing population immunity. High campaign awareness reflected the comprehensive social mobilization strategy implemented in Kenya and supports the importance of including strong communications platforms in future vaccination campaigns. In counties with sub-optimal MR campaign coverage, further efforts are needed to increase MCV coverage to achieve the national goal of measles elimination by 2020. |
Progress toward rubella and congenital rubella syndrome control - South-East Asia Region, 2000-2016
Khanal S , Bahl S , Sharifuzzaman M , Dhongde D , Pattamadilok S , Reef S , Morales M , Dabbagh A , Kretsinger K , Patel M . MMWR Morb Mortal Wkly Rep 2018 67 (21) 602-606 In 2013, the 66th session of the Regional Committee of the World Health Organization (WHO) South-East Asia Region (SEAR)* adopted the goal of elimination of measles and control(dagger) of rubella and congenital rubella syndrome (CRS) by 2020 (1). Rubella is the leading vaccine-preventable cause of birth defects. Although rubella typically causes a mild fever and rash in children and adults, rubella virus infection during pregnancy, especially during the first trimester, can result in miscarriage, fetal death, or a constellation of congenital malformations known as CRS, commonly including visual, auditory, and/or cardiac defects, and developmental delay (2). Rubella and CRS control capitalizes on the momentum created by pursuing measles elimination because the efforts are programmatically linked. Rubella-containing vaccine (RCV) is administered as a combined measles and rubella vaccine, and rubella cases are detected through case-based surveillance for measles or fever and rash illness (3). This report summarizes progress toward rubella and CRS control in SEAR during 2000-2016. Estimated coverage with a first RCV dose (RCV1) increased from 3% of the birth cohort in 2000 to 15% in 2016 because of RCV introduction in six countries. RCV1 coverage is expected to increase rapidly with the phased introduction of RCV in India and Indonesia beginning in 2017; these countries are home to 83% of the SEAR birth cohort. During 2000-2016, approximately 83 million persons were vaccinated through 13 supplemental immunization activities (SIAs) conducted in eight countries. During 2010-2016, reported rubella incidence decreased by 37%, from 8.6 to 5.4 cases per 1 million population, and four countries (Bangladesh, Maldives, Sri Lanka, and Thailand) reported a decrease in incidence of >/=95% since 2010. To achieve rubella and CRS control in SEAR, sustained investment to increase routine RCV coverage, periodic high-quality SIAs to close immunity gaps, and strengthened rubella and CRS surveillance are needed. |
Progress toward regional measles elimination - worldwide, 2000-2016
Dabbagh A , Patel MK , Dumolard L , Gacic-Dobo M , Mulders MN , Okwo-Bele JM , Kretsinger K , Papania MJ , Rota PA , Goodson JL . MMWR Morb Mortal Wkly Rep 2017 66 (42) 1148-1153 The fourth United Nations Millennium Development Goal, adopted in 2000, set a target to reduce child mortality by two thirds by 2015. One indicator of progress toward this target was measles vaccination coverage (1). In 2010, the World Health Assembly (WHA) set three milestones for measles control by 2015: 1) increase routine coverage with the first dose of a measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district; 2) reduce global annual measles incidence to <5 cases per million population; and 3) reduce global measles mortality by 95% from the 2000 estimate (2).* In 2012, WHA endorsed the Global Vaccine Action Plan,dagger with the objective of eliminating measles in four World Health Organization (WHO) regions by 2015 and in five regions by 2020. Countries in all six WHO regions have adopted goals for measles elimination by or before 2020. Measles elimination is defined as the absence of endemic measles virus transmission in a region or other defined geographic area for ≥12 months, in the presence of a high quality surveillance system that meets targets of key performance indicators. This report updates a previous report (3) and describes progress toward global measles control milestones and regional measles elimination goals during 2000-2016. During this period, annual reported measles incidence decreased 87%, from 145 to 19 cases per million persons, and annual estimated measles deaths decreased 84%, from 550,100 to 89,780; measles vaccination prevented an estimated 20.4 million deaths. However, the 2015 milestones have not yet been met; only one WHO region has been verified as having eliminated measles. Improved implementation of elimination strategies by countries and their partners is needed, with focus on increasing vaccination coverage through substantial and sustained additional investments in health systems, strengthening surveillance systems, using surveillance data to drive programmatic actions, securing political commitment, and raising the visibility of measles elimination goals. |
Transitioning lessons learned and assets of the Global Polio Eradication Initiative to global and regional measles and rubella elimination
Kretsinger K , Strebel P , Kezaala R , Goodson JL . J Infect Dis 2017 216 S308-S315 The Global Polio Eradication Initiative has built an extensive infrastructure with capabilities and resources that should be transitioned to measles and rubella elimination efforts. Measles continues to be a major cause of child mortality globally, and rubella continues to be the leading infectious cause of birth defects. Measles and rubella eradication is feasible and cost saving. The obvious similarities in strategies between polio elimination and measles and rubella elimination include the use of an extensive surveillance and laboratory network, outbreak preparedness and response, extensive communications and social mobilization networks, and the need for periodic supplementary immunization activities. Polio staff and resources are already connected with those of measles and rubella, and transitioning existing capabilities to measles and rubella elimination efforts allows for optimized use of resources and the best opportunity to incorporate important lessons learned from polio eradication, and polio resources are concentrated in the countries with the highest burden of measles and rubella. Measles and rubella elimination strategies rely heavily on achieving and maintaining high vaccination coverage through the routine immunization activity infrastructure, thus creating synergies with immunization systems approaches, in what is termed a "diagonal approach." |
Polio legacy in action: Using the polio eradication infrastructure for measles elimination in Nigeria - the National Stop Transmission of Polio Program
Michael CA , Waziri N , Gunnala R , Biya O , Kretsinger K , Wiesen E , Goodson JL , Esapa L , Gidado S , Uba B , Nguku P , Cochi S . J Infect Dis 2017 216 S373-S379 From 2012 to date, Nigeria has been the focus of intensified polio eradication efforts. Large investments made by multiple partner organizations and the federal Ministry of Health to support strategies and resources, including personnel, for increasing vaccination coverage and improved performance monitoring paid off, as the number of wild poliovirus (WPV) cases detected in Nigeria were reduced significantly, from 122 in 2012 to 6 in 2014. No WPV cases were detected in Nigeria in 2015 and as at March 2017, only 4 WPV cases had been detected. Given the momentum gained toward polio eradication, these resources seem well positioned to help advance other priority health agendas in Nigeria, particularly the control of vaccine-preventable diseases, such as measles. Despite implementation of mass measles vaccination campaigns, measles outbreaks continue to occur regularly in Nigeria, leading to high morbidity and mortality rates for children <5 years of age. The National Stop Transmission of Polio (NSTOP) program was collaboratively established in 2012 to create a network of staff working at national, state, and district levels in areas deemed high risk for vaccine-preventable disease outbreaks. As an example of how the polio legacy can create long-lasting improvements to public health beyond polio, the Centers for Disease Control and Prevention will transition >180 NSTOP officers to provide technical experience to improve measles surveillance, routine vaccination coverage, and outbreak investigation and response in high-risk areas. |
Progress toward measles elimination - Bangladesh, 2000-2016
Khanal S , Bohara R , Chacko S , Sharifuzzaman M , Shamsuzzaman M , Goodson JL , Dabbagh A , Kretsinger K , Dhongde D , Liyanage J , Bahl S , Thapa A . MMWR Morb Mortal Wkly Rep 2017 66 (28) 753-757 In 2013, at the 66th session of the Regional Committee of the World Health Organization (WHO) South-East Asia Region (SEAR), a regional goal was established to eliminate measles and control rubella and congenital rubella syndrome* by 2020 (1). WHO-recommended measles elimination strategies in SEAR countries include 1) achieving and maintaining ≥95% coverage with 2 doses of measles-containing vaccine (MCV) in every district, delivered through the routine immunization program or through supplementary immunization activities (SIAs)dagger; 2) developing and sustaining a sensitive and timely measles case-based surveillance system that meets targets for recommended performance indicators; and 3) developing and maintaining an accredited measles laboratory network (2). In 2014, Bangladesh, one of 11 countries in SEAR, adopted a national goal for measles elimination by 2018 (2,3). This report describes progress and challenges toward measles elimination in Bangladesh during 2000-2016. Estimated coverage with the first MCV dose (MCV1) increased from 74% in 2000 to 94% in 2016. The second MCV dose (MCV2) was introduced in 2012, and MCV2 coverage increased from 35% in 2013 to 93% in 2016. During 2000-2016, approximately 108.9 million children received MCV during three nationwide SIAs conducted in phases. During 2000-2016, reported confirmed measles incidence decreased 82%, from 34.2 to 6.1 per million population. However, in 2016, 56% of districts did not meet the surveillance performance target of ≥2 discarded nonmeasles, nonrubella cases section sign per 100,000 population. Additional measures that include increasing MCV1 and MCV2 coverage to ≥95% in all districts with additional strategies for hard-to-reach populations, increasing sensitivity of measles case-based surveillance, and ensuring timely transport of specimens to the national laboratory will help achieve measles elimination. |
Progress toward regional measles elimination - worldwide, 2000-2015
Patel MK , Gacic-Dobo M , Strebel PM , Dabbagh A , Mulders MN , Okwo-Bele JM , Dumolard L , Rota PA , Kretsinger K , Goodson JL . MMWR Morb Mortal Wkly Rep 2016 65 (44) 1228-1233 Adopted in 2000, United Nations Millennium Development Goal 4 set a target to reduce child mortality by two thirds by 2015, with measles vaccination coverage as one of the progress indicators. In 2010, the World Health Assembly (WHA) set three milestones for measles control by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) for children aged 1 year to ≥90% nationally and ≥80% in every district; 2) reduce global annual measles incidence to <5 cases per 1 million population; and 3) reduce global measles mortality by 95% from the 2000 estimate (1,2).* In 2012, WHA endorsed the Global Vaccine Action Plandagger with the objective to eliminate measles in four World Health Organization (WHO) regions by 2015. Countries in all six WHO regions have adopted measles elimination goals. Measles elimination is the absence of endemic measles transmission in a region or other defined geographical area for ≥12 months in the presence of a well performing surveillance system. This report updates a previous report (3) and describes progress toward global measles control milestones and regional measles elimination goals during 2000-2015. During this period, annual reported measles incidence decreased 75%, from 146 to 36 cases per 1 million persons, and annual estimated measles deaths decreased 79%, from 651,600 to 134,200. However, none of the 2015 milestones or elimination goals were met. Countries and their partners need to act urgently to secure political commitment, raise the visibility of measles, increase vaccination coverage, strengthen surveillance, and mitigate the threat of decreasing resources for immunization once polio eradication is achieved. |
Antecedent causes of a measles resurgence in the Democratic Republic of the Congo
Scobie HM , Ilunga BK , Mulumba A , Shidi C , Coulibaly T , Obama R , Tamfum JJM , Simbu EP , Smit SB , Masresha B , Perry RT , Alleman MM , Kretsinger K , Goodson J . Pan Afr Med J 2015 21 (30) 30 INTRODUCTION: Despite accelerated measles control efforts, a massive measles resurgence occurred in the Democratic Republic of the Congo (DRC) starting in mid-2010, prompting an investigation into likely causes. METHODS: We conducted a descriptive epidemiological analysis using measles immunization and surveillance data to understand the causes of the measles resurgence and to develop recommendations for elimination efforts in DRC. RESULTS: During 2004-2012, performance indicator targets for case-based surveillance and routine measles vaccination were not met. Estimated coverage with the routine first dose of measles-containing vaccine (MCV1) increased from 57% to 73%. Phased supplementary immunization activities (SIAs) were conducted starting in 2002, in some cases with sub-optimal coverage (≤95%). In 2010, SIAs in five of 11 provinces were not implemented as planned, resulting in a prolonged interval between SIAs, and a missed birth cohort in one province. During July 1, 2010-December 30, 2012, high measles attack rates (>100 cases per 100,000 population) occurred in provinces that had estimated MCV1 coverage lower than the national estimate and did not implement planned 2010 SIAs. The majority of confirmed case-patients were aged <10 years (87%) and unvaccinated or with unknown vaccination status (75%). Surveillance detected two genotype B3 and one genotype B2 measles virus strains that were previously identified in the region. CONCLUSION: The resurgence was likely caused by an accumulation of unvaccinated, measles-susceptible children due to low MCV1 coverage and suboptimal SIA implementation. To achieve the regional goal of measles elimination by 2020, efforts are needed in DRC to improve case-based surveillance and increase two-dose measles vaccination coverage through routine services and SIAs. |
Regional variations in home canning practices and the risk of foodborne botulism in the Republic of Georgia, 2003
Tarkhashvili N , Chokheli M , Chubinidze M , Abazashvili N , Chakvetadze N , Imnadze P , Kretsinger K , Varma J , Sobel J . J Food Prot 2015 78 (4) 746-50 Foodborne botulism is a severe, paralytic illness caused by ingestion of preformed neurotoxins produced by Clostridium botulinum. In 2003, we conducted a population-based household survey of home canning practices to explore marked regional variations in botulism incidence in the Republic of Georgia (ROG). We designed a cluster sampling scheme and subdivided each of the 10 regions of the ROG into a variable number of strata. Households were selected from each stratum using a two-step cluster sampling methodology. We administered a questionnaire about home canning practices to household members responsible for food preparation. Using multivariate logistic regression analysis, we modeled high (eastern ROG) against low (western ROG) incidence areas. Overall, we surveyed 2,742 households nationwide. Home canning with a capping device hermetically sealing the lid covering the jar was practiced by 1,909 households (65.9%; 95% confidence interval [CI]: 59.8 to 72.1%). Canning was more prevalent in regions of low botulism incidence (34 versus 32%; P < 0.01). When compared with low-botulism areas, the following practices were associated with an increased risk in high-botulism areas: ≥6 months between canning vegetables and consuming them (adjusted odds ratio [aOR] = 2.1; 95% CI: 1.3 to 3.5) and adding any of the following ingredients to the jar at time of preparation: >1 tablespoon of salt per liter (aOR = 5.1; 95% CI: 1.2 to 22.6); vinegar (aOR = 2.2; 95% CI: 1.3 to 3.7), and greens (aOR = 5.6; 95% CI: 1.7 to 18.2). The following practices were associated with a decreased risk in high-botulism areas: >57 jars canned per household annually (aOR = 0.5; 95% CI: 0.3 to 0.9), covering or immersing vegetables in boiling water before placing them into the jar (aOR = 0.3 95% CI: 0.2 to 0.6), covering or immersing vegetables in boiling water after placing them into the jar (aOR = 0.4; 95% CI: 0.2 to 0.9), or adding garlic (aOR = 0.2; 95% CI: 0.1 to 0.5) or aspirin (aOR = 0.1; 95% CI: 0.1 to 0.2) to the jar at the time of preparation. |
Polio outbreak among nomads in Chad: outbreak response and lessons learned
Ndiaye SM , Ahmed MA , Denson M , Craig AS , Kretsinger K , Cherif B , Kandolo P , Moto DD , Richelot A , Tuma J . J Infect Dis 2014 210 Suppl 1 S74-84 BACKGROUND: In response to the 2011 and 2012 polio epidemic in Chad, Chad's Ministry of Public Health, with support from Global Polio Eradication Initiative partners, took steps to increase vaccination coverage of nomadic children with targeted polio campaigns. This article describes the strategies we used to vaccinate nomads in 3 districts of Chad. METHODS: Our targeted interventions involved using mobile vaccination teams, recruiting local nomads to identify settlements, using social mobilization, and offering vaccinations to children, women, and animals. RESULTS: Vaccination coverage of nomadic children 0-59 months of age increased, particularly among those never before vaccinated against polio. These increases occurred mostly in the intervention districts of Dourbali, from 2956 to 8164 vaccinated children, and Kyabe, from 7319 to 15 868. The number of first-time vaccinated nomadic children also increased the most in these districts, from 60 to 131 in Dourbali and from 1302 to 2973 in Kyabe. Coverage in the Massaguet district was only 37.7%. CONCLUSIONS: Our success was probably due to (1) appointment of staff to oversee implementation, (2) engagement of the national government and its partners, (3) participation of nomadic community leaders, (4) intersectoral collaboration between human and animal health services, and (5) flexibility and capacity of vaccinators to vaccinate when and where nomads were available. |
Polio eradication in the World Health Organization African region, 2008-2012
Kretsinger K , Gasasira A , Poy A , Porter KA , Everts J , Salla M , Brown KH , Wassilak SG , Nshimirimana D . J Infect Dis 2014 210 Suppl 1 S23-39 A renewed commitment at the regional and the global levels led to substantial progress in the fight for polio eradication in the African Region (AFR) of the World Health Organization (WHO) during 2008-2012. In 2008, there were 912 reported cases of wild poliovirus (WPV) infection in 12 countries in the region. This number had been reduced to 128 cases in 3 countries in 2012, of which 122 were in Nigeria, the only remaining country with endemic circulation of WPV in AFR. During 2008-2012, circulation apparently ceased in the 3 AFR countries with reestablished WPV transmission-Angola, the Democratic Republic of the Congo, and Chad. Outbreaks in West Africa continued to occur in 2008-2010 but were more rapidly contained, with fewer cases than during earlier years. This progress has been attributed to better implementation of core strategies, increased accountability, and implementation of innovative approaches. During this period, routine coverage with 3 doses of oral polio vaccine in AFR, as measured by WHO-United Nations Children's Fund estimates, increased slightly, from 72% to 74%. Despite this progress, challenges persist in AFR, and 2013 was marked by new setbacks and importations. High population immunity and strong surveillance are essential to sustain progress and assure that AFR reaches its goal of eradicating WPV. |
Forewarning of poliovirus outbreaks in the horn of Africa: an assessment of acute flaccid paralysis surveillance and routine immunization systems in Kenya
Walker AT , Sodha S , Warren WC , Sergon K , Kiptoon S , Ogange J , Ahmeda AH , Eshetu M , Corkum M , Pillai S , Scobie H , Mdodo R , Tack DM , Halldin C , Appelgren K , Kretsinger K , Bensyl DM , Njeru I , Kolongei T , Muigai J , Ismail A , Okiror SO . J Infect Dis 2014 210 Suppl 1 S85-90 BACKGROUND: Although the Horn of Africa region has successfully eliminated endemic poliovirus circulation, it remains at risk for reintroduction. International partners assisted Kenya in identifying gaps in the polio surveillance and routine immunization programs, and provided recommendations for improved surveillance and routine immunization during the health system decentralization process. METHODS: Structured questionnaires collected information about acute flaccid paralysis (AFP) surveillance resources, training, data monitoring, and supervision at provincial, district, and health facility levels. The routine immunization program information collected included questions about vaccine and resource availability, cold chain, logistics, health-care services and access, outreach coverage data, microplanning, and management and monitoring of AFP surveillance. RESULTS: Although AFP surveillance met national performance standards, widespread deficiencies and limited resources were observed and reported at all levels. Deficiencies were related to provider knowledge, funding, training, and supervision, and were particularly evident at the health facility level. CONCLUSIONS: Gap analysis assists in maximizing resources and capacity building in countries where surveillance and routine immunization lag behind other health priorities. Limited resources for surveillance and routine immunization systems in the region indicate a risk for additional outbreaks of wild poliovirus and other vaccine-preventable illnesses. Monitoring and evaluation of program strengthening activities are needed. |
Progress toward measles preelimination - African Region, 2011-2012
Masresha BG , Kaiser R , Eshetu M , Katsande R , Luce R , Fall A , Dosseh AR , Naouri B , Byabamazima CR , Perry R , Dabbagh AJ , Strebel P , Kretsinger K , Goodson JL , Nshimirimana D . MMWR Morb Mortal Wkly Rep 2014 63 (13) 285-91 In 2008, the 46 member states of the World Health Organization (WHO) African Region (AFR) adopted a measles preelimination goal to reach by the end of 2012 with the following targets: 1) >98% reduction in estimated regional measles mortality compared with 2000, 2) annual measles incidence of fewer than five reported cases per million population nationally, 3) >90% national first dose of measles-containing vaccine (MCV1) coverage and >80% MCV1 coverage in all districts, and 4) >95% MCV coverage in all districts by supplementary immunization activities (SIAs). Surveillance performance objectives were to report two or more cases of nonmeasles febrile rash illness per 100,000 population, one or more suspected measles cases investigated with blood specimens in ≥80% of districts, and 100% completeness of surveillance reporting from all districts. This report updates previous reports and describes progress toward the measles preelimination goal during 2011-2012. In 2012, 13 (28%) member states had >90% MCV1 coverage, and three (7%) reported >90% MCV1 coverage nationally and >80% coverage in all districts. During 2011-2012, four (15%) of 27 SIAs with available information met the target of >95% coverage in all districts. In 2012, 16 of 43 (37%) member states met the incidence target of fewer than five cases per million, and 19 of 43 (44%) met both surveillance performance targets. In 2011, the WHO Regional Committee for AFR established a goal to achieve measles elimination by 2020. To achieve this goal, intensified efforts to identify and close population immunity gaps and improve surveillance quality are needed, as well as committed leadership and ownership of the measles elimination activities and mobilization of adequate resources to complement funding from global partners. |
Maternal, fetal, and neonatal outcomes associated with measles during pregnancy: Namibia, 2009-2010
Ogbuanu IU , Zeko S , Chu SY , Muroua C , Gerber S , De Wee R , Kretsinger K , Wannemuehler K , Gerndt K , Allies M , Sandhu HS , Goodson JL . Clin Infect Dis 2014 58 (8) 1086-92 BACKGROUND: Previous studies of maternal, fetal, and neonatal complications of measles during pregnancy suggest the possibility of increased risk for morbidity and mortality. In 2009-2011, a nationwide laboratory-confirmed measles outbreak occurred in Namibia, with 38% of reported cases among adults. This outbreak provided an opportunity to describe clinical features of measles in pregnant women and assess the relative risk for adverse maternal, fetal and neonatal outcomes. METHODS: A cohort of pregnant women with clinical measles was identified retrospectively from six district hospitals and clinics over a 12-month period. Each pregnant woman with measles was matched with three pregnant women without measles, randomly selected from antenatal clinic registers at the same hospital during the same time interval. We reviewed hospital and clinic records and conducted in-person interviews to collect demographic and clinical information on the pregnant women and their infants. FINDINGS: Of 55 pregnant women with measles, 53 (96%) were hospitalized; measles-related complications included diarrhea (60%), pneumonia (40%), and encephalitis (5%). Among pregnant women with known HIV status, 15% of those without measles and 19% of those with measles were HIV-positive. Of 42 measles-related pregnancies with known outcomes, 25 (60%) had ≥1 adverse maternal, fetal or neonatal outcome and five women (12%) died. Compared with 172 pregnancies without measles, after adjusting for age, pregnancies with measles had significantly increased risks for neonatal low birth weight (adjusted relative risk [aRR]=3.5; 95% CI=1.5,8.2), spontaneous abortion (aRR=5.9; 95% CI=1.8,19.7), intra-uterine fetal death (aRR=9.0; 95% CI=1.2,65.5), and maternal death (aRR=9.6; 95% CI=1.2,70.0). INTERPRETATION: Our findings suggest that measles virus infection during pregnancy confers a high risk of adverse maternal, fetal and neonatal outcomes, including maternal death. Maximizing measles immunity among women of childbearing age would decrease the incidence of gestational measles and the attendant maternal, fetal, and neonatal morbidity and mortality. |
Need for physician education on the benefits and risks of male circumcision in the United States
Carbery B , Zhu J , Gust DA , Chen RT , Kretsinger K , Kilmarx PH . AIDS Educ Prev 2012 24 (4) 377-87 Physicians may be called upon to counsel male patients or parents of newborn males regarding their decision to circumcise their newborn sons. The purpose of the present study was to describe physicians who do not understand the benefits and risks associated with male circumcision well enough to counsel parents of newborn male infants and adult men. A self-administered, cross-sectional electronic survey of physicians was conducted in 2008. We analyzed responses from 1,500 physicians (510 family practitioners, 490 internists, 250 pediatricians, and 250 obstetricians/gynecologists). Nearly 22% (n = 327/1500) reported they did not understand the risks and benefits of newborn male circumcision well enough to counsel parents and 40.3% (n = 504/1250) reported not understanding the risks and benefits well enough to counsel adult men. A substantial minority of physicians may need additional training and/or information about current male circumcision research to feel comfortable counseling parents of newborn male infants or adult men. |
An outbreak of wild poliovirus in the Republic of Congo, 2010 - 2011
Patel MK , Konde MK , Didi-Ngossaki BH , Ndinga E , Yogolelo R , Salla M , Shaba K , Everts J , Armstrong GL , Daniels D , Burns C , Wassilak S , Pallansch M , Kretsinger K . Clin Infect Dis 2012 55 (10) 1291-8 BACKGROUND: The Republic of Congo has had no cases of wild poliovirus type 1 (WPV1) since 2000. In October 2010, a neurologist noted an abnormal number of cases of acute flaccid paralysis (AFP) among adults which were later confirmed to be caused by WPV1. METHODS: Those presenting with AFP underwent clinical history, physical examination, and clinical specimen collection to determine if they had polio. AFP cases were classified as laboratory-confirmed, clinical, or non-polio AFP. Epidemiologic features of the outbreak were analyzed. RESULTS: From September 19, 2010 to January 22, 2011, 445 WPV1 cases were reported in the ROC; 390 cases were from Pointe Noire. Overall, 331 cases were among adults; 378 cases were clinically confirmed and 64 cases were laboratory confirmed. The case fatality ratio (CFR) was 43%. Epidemiologic characteristics differed among polio cases reported in Pointe Noire and cases reported in the rest of ROC, including age distribution and CFR. The outbreak stopped after multiple vaccination rounds with oral poliovirus vaccine which targeted the entire population. CONCLUSIONS: This outbreak underscores the need to maintain high vaccination coverage to prevent outbreaks, the need to maintain timely high quality surveillance to rapidly identify and respond to any potential cases before an outbreak escalates, and the need to perform ongoing risk assessments of immunity gaps in polio-free countries. |
Investigation of elevated case-fatality rate in poliomyelitis outbreak in Pointe Noire, Republic of Congo - 2010
Gregory CJ , Ndiaye S , Patel M , Hakizamana E , Wannemuehler K , Ndinga E , Chu S , Talani P , Kretsinger K . Clin Infect Dis 2012 55 (10) 1299-306 BACKGROUND: Multiple cases of paralysis, often resulting in death, occurred among young adults during a wild poliovirus (WPV) type 1 outbreak in Pointe Noire, the Republic of Congo in 2010. We conducted an investigation to identify factors associated with fatal outcomes among persons with poliomyelitis in Pointe Noire. METHODS: Polio cases were defined as AFP cases reported from October 7 to December 7, 2010 with either a stool specimen positive for WPV or clinically classified as polio-compatible. Data were obtained from medical records, hospital databases, AFP case investigation forms and, when possible, via interviews with persons with polio or surrogates using a standard questionnaire. RESULTS: Three hundred and sixty nine polio cases occurred in Pointe Noire between October 7 to December 7, 2010. Median age was 22 years for non-survivors and 18 years for survivors (P=0.01). Small home size, as defined by ≤ 2 rooms, use of a well for drinking water during a water shortage and age ≥15 years were risk factors for death in multivariate analysis. CONCLUSIONS: Consideration should be given during polio risk assessment planning and outbreak response to water/sanitation status and potential susceptibility to polio in older children and adults. Serosurveys to estimate immunity gaps in older age groups in countries at high risk of polio importation might be useful to guide preparedness and response planning. |
Coverage of newborn and adult male circumcision varies among public and private US payers despite health benefits
Clark SJ , Kilmarx PH , Kretsinger K . Health Aff (Millwood) 2011 30 (12) 2355-61 Studies have shown that male circumcision greatly reduces the risk for heterosexual transmission of HIV, other sexually transmitted infections, infant urinary tract infections, penile cancer, and other adverse health outcomes. Given recent data regarding these health benefits and the cost-effectiveness of newborn male circumcision, national policy makers are developing new recommendations regarding circumcision for newborn, adolescent, and adult males. To investigate the implications, this study assessed insurance coverage and reimbursement for routine newborn and adult male circumcision in private and public health plans in 2009. We found that coverage varies across private and public payers. Private insurance provides far broader coverage than state Medicaid programs for routine newborn male circumcision. Specifically, Medicaid programs in seventeen states do not cover it, even though low-income populations have a higher risk of HIV and other sexually transmitted diseases compared to higher-income groups. For adult male circumcision, coverage is generally sparse across public and private plans. Presentation of evidence-based recommendations--for example, from the Centers for Disease Control and Prevention--may be necessary if coverage for newborn and adult male circumcision is to be expanded. |
Acceptability of newborn circumcision to prevent HIV infection in the United States
Gust DA , Kretsinger K , Gaul Z , Pals S , Heffelfinger JD , Begley E , Chen RT , Kilmarx PH . Sex Transm Dis 2011 38 (6) 536-42 BACKGROUND/PURPOSE: To understand whether information from the African clinical trials about the partially protective effect of male circumcision against human immunodeficiency virus (HIV) infection could influence adults to circumcise a newborn son. METHODS: Using the 2008 ConsumerStyles panel survey data, multiple regression analysis was performed to identify correlates of (1) inclination toward circumcising a newborn son and (2) being influenced to have a newborn son circumcised if it would reduce the chance of becoming HIV infected later in life. RESULTS: Response rate was 50.6% (10,108/19,996). Approximately 12% reported not being inclined to circumcise a newborn son. Higher odds of not being inclined to circumcise a newborn son were associated with Hispanic and "other" race/ethnicity, being an uncircumcised man and a man not reporting circumcision status, postgraduate education, region, and negative health-related attitudes. Lower odds were associated with black race and less number of household members. Fifty-three percent of respondents reported that information about the protective effect of circumcision would make them more likely to have a newborn son circumcised. Higher odds of being influenced to have a newborn son circumcised were associated with being ≥45 years of age, black race, living in a household with fewer than 5 members, having high school or some college education, region, and positive health-related attitudes; lower odds were associated with being an uncircumcised man and lower income. CONCLUSIONS: Our findings suggest that providing educational information about the HIV prevention and benefit of circumcision may increase the inclination to circumcise a newborn son for some people. |
Barriers to early uptake of tetanus, diphtheria and acellular pertussis vaccine (Tdap) among adults-United States, 2005-2007
Miller BL , Kretsinger K , Euler GL , Lu PJ , Ahmed F . Vaccine 2011 29 (22) 3850-6 BACKGROUND: The tetanus, diphtheria and acellular pertussis vaccine (Tdap) was recommended by the Advisory Committee on Immunization Practices (ACIP) for U.S. adults in 2005. Our objective was to identify barriers to early uptake of Tdap among adult populations. METHODS: The 2007 National Immunization Survey (NIS)-Adult was a telephone survey sponsored by the Centers for Disease Control and Prevention (CDC). Immunization information was collected for persons aged ≥18 years on all ACIP-recommended vaccines. A weighted analysis accounted for the complex survey design and non-response. RESULTS: Overall, 3.6% of adults aged 18-64 years reported receipt of a Tdap vaccination. Of unvaccinated respondents, 18.8% had heard of Tdap, of which 9.4% reported that a healthcare provider had recommended it. A low perceived risk of contracting pertussis was the single most common reason for either not vaccinating with Tdap or being unwilling to do so (44.7%). Most unvaccinated respondents (81.8%) indicated a willingness to receive Tdap if it was recommended by a provider. CONCLUSIONS: During the first two years of availability, Tdap uptake was likely inhibited by a low collective awareness of Tdap and a low perceived risk of contracting pertussis among U.S. adults, as well as a paucity of provider-to-patient vaccination recommendations. Significant potential exists for improved coverage, as many adults were receptive to vaccination. |
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