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Pros and Cons of Universal Vaccination of the Healthy 19-49 Year-old Population

Pros and Cons of Universal Vaccination of the Healthy 19-49 Year-old Population. Critical Information Needs Richard K Zimmerman MD MPH Dept. Family Medicine and Clinical Epidemiology, University of Pittsburgh. Information Needs in the Evidence Base Medicine Era.

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Pros and Cons of Universal Vaccination of the Healthy 19-49 Year-old Population

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  1. Pros and Cons of Universal Vaccination of the Healthy 19-49 Year-old Population Critical Information Needs Richard K Zimmerman MD MPH Dept. Family Medicine and Clinical Epidemiology, University of Pittsburgh

  2. Information Needs in the Evidence Base Medicine Era • Systematic evidence reviews of efficacy and of effectiveness in the age group • USPSTF review is dated (1996 publication) • Cochrane review on adults is available • Updated from review published in Vaccine in 2000 – vol 18:957-1030 • Does not look at age subgroups • Healthy individuals aged 14 to 60 irrespective of influenza immune status. Studies with > 25% of individuals outside this age range excluded

  3. Cochrane Review • 25 reports involving 59,566 people were included. • LAIV reduced cases of serologically confirmed influenza by 48% (95% confidence interval (CI) 24% to 64%), • Inactivated parenteral vaccines had efficacy of 70% (95% CI 56% to 80%). • Effectiveness against clinical influenza (not serologically confirmed) low: LAIV: 15% (95% CI 8% to 21%) and for TIV, 25% (95% CI 13% to 35%) respectively. Overall, clinical influenza decreased by 6%. • Use of the vaccine significantly reduced time off work but only by 0.16 days for each influenza episode (95% CI 0.04 to 0.29 days); • Analysis of vaccines matching the circulating strain gave higher efficacy.

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  6. Cochrane Review Conclusions • “Conclusions: Influenza vaccines are effective in reducing serologically confirmed cases of influenza. However, they are not as effective in reducing cases of clinical influenza and number of working days lost. Universal immunisation of healthy adults is not supported by the results of this review.” • From Vaccine 2000: “However, when safety and quality of life considerations are included, parenteral vaccines have such low effectiveness and high incidence of trivial local adverse effects that the trade-off is unfavourable.” • Note evidence-based medicine preference for effectiveness data

  7. Data Need • Need a systematic review that accounts for age, match, and vaccine manufactured • Vaccines currently produced for US may differ from some in Cochrane review as may the setting; this could lead to different efficacy estimates • I personally doubt that Cochrane estimates apply to US vaccines when match is good; but we need systematic evidence review published on vaccines used in US

  8. Bioethical Theories and Influenza Vaccine • Deontologic: Do I have a duty to be vaccinated? • Contribution to decreased transmission and herd immunity • Contribution to personal health – does it reduce work loss and hospitalizations?

  9. Bioethical Theories and Influenza Vaccine -2 • Principle Approach: • Autonomy – freedom to accept or refuse Implication is knowing consumer preferences • Beneficence – implication is for recipients to know personal benefits and reduced transmission • Non-maleficence – “do no harm” - implications are vaccine safety and quick appraisal via VAERs of potential adverse reactions, coverage in VICP (Guillian Barre) Justice – access so all can afford vaccination and continued safety research so that no group bears extra burden of adverse effects

  10. Bioethical Theories and Influenza Vaccine - 3 • Utilitarian: Will my vaccination bring the most happiness • Cost-effectiveness needs clarified • Quality of life issue – adverse local effects and hassle versus personal and societal benefit • Therefore, acceptability data needed

  11. Disease Burden in 18-49 Year Olds • Mortality in healthy persons in this age group is low and therefore not reason for policy change • Decision rests of benefits to morbidity and society including herd immunity

  12. Conclusions • I advocated for routine vaccination of persons aged 50-64 due to increased disease burden, cost-effectiveness/ reduced absenteeism, and pragmatic issue of low vaccination rates among high risk persons 50-64. • I advocated for vaccination of healthy children 6-23 months of age due to hospitalization burden • But for 19-49 year olds, negligible mortality, limited hospitalizations, disagreement about cost-effectiveness, and limited US vaccine supplies call for caution. • Need more data on herd immunity, cost-effectiveness, and acceptability • Need continued emphasis on vaccine safety • Need a systematic review using data relevant to US • Need a vaccine economic system for adults that is just

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