VoICE : Search Immunization Evidence

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The VoICE tool is a compendium of the many direct and downstream impacts of vaccine-preventable disease and immunization. The database contains summary explanations of the link between immunization and each impact, as well as sources of evidence for each link. You can browse the VoICE tool by topic, or use the filters to find results based on topic, disease or vaccine, location and published year.

41 Key Concepts, 51 Sources
Key Concept

Key Evidence: During the conflict in Yemen, efforts spearheaded by WHO, with coordination among partners and effective use of resources, especially GAVI, resulted in continued high pentavalent vaccine coverage decreasing only 3% from 2010 to 2015. Yemen also remained polio-free through 2015 and smoothly introduced two new vaccines (MR and IPV).

Key Evidence: During the humanitarian crisis in the Syrian Arab Republic, the constant support from WHO, UNICEF, and local NGOs resulted in immunizations against VPDs reaching over 90% of children.

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Key Concept

Key Evidence: In contrast to non-Somalis, family wealth did not significantly affect the likelihood of being fully vaccinated among Somali refugee children living in Kenya. This may point to systemic barriers to vaccination that cut across all socio-economic levels of the Somali refugee population.

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Key Evidence: Screening tests given to more than 300 newly-arrived economic migrants and asylum seekers in Italy — the majority from sub-Saharan Africa — found high rates of chronic hepatitis B infection and latent and active tuberculosis (with 8% having signs of current infection or active TB). These findings underscore the important of universal screening for infectious diseases for all newly-arrived migrants.

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Key Concept

Key Evidence: Mass displacement of people during a complex humanitarian emergency can trigger a “cascade” of risk factors for communicable disease outbreaks, including a breakdown in health services (such as disease surveillance and immunization services); over-crowding (increasing disease transmission rates); inadequate water, sanitation and hygiene; and exposure of displaced population to endemic diseases for which they have no immunity.

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Key Concept

Key Evidence: In a study of a 2003 outbreak of pertussis in the U.S., including 17 cases among healthcare workers, researchers estimated that vaccinating healthcare workers would result in a 2.4-fold return on investment for hospitals.

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Key Concept

Key Evidence: In a study of a 2003 outbreak of pertussis in the U.S., including 17 cases among healthcare workers, researchers estimated that vaccinating healthcare workers would prevent nearly 50% of disease exposures by healthcare workers per year.

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Key Evidence: Using data on the spread of Ebola from person to person during historical Ebola outbreaks to compare vaccination strategies, researchers found that prophylatically vaccinating all healthcare workers would have decreased the number of disease cases in the 2014 epidemics in Guinea and Nigeria by 60-80%.

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Key Concept

Key Evidence: In a study of nearly 40,000 recipients of PCV7 and control subjects in northern California, there was a 5.4% reduction in the number of antibiotic prescriptions and a 12.6% reduction in the use of “second-line antibiotics” among children who received the pneumococcal conjugate vaccine. Between the time the first dose was administered and the age of 3.5 years, use of the vaccine prevented 35 antibiotic prescriptions per 100 fully vaccinated children.

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Key Concept

Key Evidence: A 2006-07 meningococcal meningitis epidemic in Burkina Faso cost households an average of US$90 for each case of meningitis that occurred. These costs — representing nearly 2.5 months of the average per capita income for that year — included direct and indirect costs of treatment and lost income to caretakers.

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Key Concept

Key Evidence: Providing a birth dose of hepatitis B vaccine to all newborns (in addition to routine HepB immunization) was found to be a highly cost-effective means of preventing hepatitis B-related deaths in three refugee populations in Africa which are at extremely high risk of hepatitis B infection. Providing a birth dose only to newborns whose mothers test positive on a rapid diagnostic test was less cost-effective than vaccinating all newborns automatically. Thus, universal hepatitis B vaccination of newborns should remain a priority in refugee camps, despite competing humanitarian needs.

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Key Evidence: Children living in the Yida refugee camp in South Sudan in 2013 were found to have an elevated rate of pneumonia infections likely due to malnutrition, overcrowding, and inadequate shelter. Using these data, the CDC estimated that the use of Hib and pneumococcal vaccines in children under 2 years of age in the camp would be cost-effective under all dosing scenarios evaluated. Medecines Sans Frontiers (MSF) provided medical services to this refugee camp and found delivery of these vaccines to be feasible and effective in this setting.

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Key Concept

Key Evidence: A large meningococcal meningitis epidemic in Burkina Faso cost the health system an estimated US$7.1 million, representing nearly 2% of the country’s entire annual health budget.

From the VoICE editors: In this study of a 2007 outbreak, 86% of the health system cost covered a reactive vaccination campaign using older polysaccharide vaccines. Routine vaccination with new, conjugate vaccines are expected to prevent or limit future outbreaks and thus reduce these costs.

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Key Evidence: A large measles outbreak in the Netherlands in 2013-14 resulted in 2700 cases of disease and cost an estimated US$4.7 million — or US$1,739 per case. Costs included outbreak response (including vaccination and enhanced surveillance), the cost of treatment (primarily hospitalizations), and the loss of productivity among caregivers ($365,000, less than 8% of total costs). Due to the likely under-reporting of the disease, the actual costs could be nearly 20% greater ($5.6 million).

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Key Evidence: Two meningococcal meningitis outbreaks in Brazil resulted in US$128,000 (9 cases, 2007) and US$34,000 (3 cases, 2011) in direct costs to the health system to investigate cases and manage the outbreak (including emergency vaccination). The investigation and response activities related to the 2011 outbreak alone cost $11,475 per case, and an additional $6,600 overall for supplemental disease surveillance activities.

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Key Evidence: According to the World Bank, the economic impact of the 2014-15 Ebola epidemic outlasted the epidemiological impact of outbreak, resulting in estimated losses of US$2.8 billion in Guinea, Liberia, and Sierra Leone (or 16% of their combined GDP).

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Key Evidence: The US state of Iowa incurred more than US$140,000 in direct costs of outbreak containment stemming from a single case of measles in an unvaccinated student infected overseas. Swift containment procedure limited the outbreak to 3 additional cases but included significant and costly steps including tracking down contacts of the infected student, establishing a measles information hotline, testing exposed medical staff for immunity, conducting measles vaccination clinics, and putting quarantines into effect.

From the VoICE editors: Although even small outbreaks of highly contagious diseases can be exceedingly costly to contain, the value of containment to society is very high. Traditional economic evaluations of outbreaks which include just the costs of illness to individuals should be expanded to include the costs and value of containing the outbreak required to protect society. 

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Key Evidence: In a comprehensive accounting of the costs of the 2014 Ebola outbreak in West Africa, Huber et al. estimate the economic and social costs to have been US$53 billion, of which US$18.8 billion was attributed to non-Ebola deaths.

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Key Concept

Key Evidence: A two-dose schedule of rotavirus vaccine was estimated to be cost-effective in Somalia, where more than 20 years of civil conflict have significantly damaged the health system and vaccine coverage is exceedingly low. Researchers estimate that in 2012, routine use of rotavirus vaccine, even at low coverage rates, would have averted nearly 25% of deaths due to rotavirus diarrhea in Somali children under one year of age.

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Key Evidence: Adding a birth dose of hepatitis B vaccine to routine immunization of refugees in Africa — who have particularly high infection rates — is a highly cost-effective means of reducing transmission of the infection thus strengthening the overall global health security among these mobile, vulnerable populations.

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Key Evidence: Children under 5 years of age bear the greatest burden of indirect conflict-associated mortality (indirect mortality results from disruption of health services including immunization, food insecurity, and high risk living conditions such as those found in refugee camps). The leading causes of child death in these circumstances include respiratory infections, diarrhea, measles, malaria, and malnutrition.

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Key Evidence: Respiratory infections and diarrhea are the leading causes of death during humanitarian emergencies according to a 2016 review of vaccine-preventable diseases and the use of immunizations during complex humanitarian emergencies.

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Key Concept

Key Evidence: The detection of H1N1 influenza virus in Mexico in 2009, and subsequently throughout other countries in the Americas, benefited from the laboratory experience with measles and rubella in the region, leading to the rapid detection of and response to what eventually became a novel pandemic virus.

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Key Concept

Key Evidence: Meningococcal meningitis epidemics in Burkina Faso “… disrupted all health services from national to operational levels,…” according to a 2011 study. Impacts included a shortage of available hospital beds and medicines, a reduction or delay in routine lab analyses for other diseases, longer wait times, and an increase in misdiagnoses by overtaxed health workers.

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Key Evidence: Fear of Ebola during the 2014-2016 epidemic in 3 West African countries had a major impact on the health sector in neighboring Nigeria, where hospitals reported sharp decreases in patient volume resulting in major financial losses. Some hospitals also turned away febrile patients to prevent being associated with Ebola while staff in other hospitals abandoned their posts.

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Key Evidence: A 2015 study projected that the crippling of immunization programs resulting from the 2014 Ebola epidemic in Guinea, Liberia, and Sierra Leone could double the number of people at risk of a measles outbreak, and could cause up to 16,000 measles deaths, surpassing the number of deaths caused by Ebola itself.

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Key Concept

Key Evidence: Kenyan children born outside of a health facility with the aid of a traditional birth attendant were around 80% more likely to be non-vaccinated or under-vaccinated than children born in a government health facility.

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Key Concept

Key Evidence: A meta-analysis of antimicrobial resistance (AMR) in migrant populations in Europe found that 25% of migrants carried or were infected with antibiotic resistant organisms. When considering all migrant types, refugees and asylum seekers had a higher rate (33%) of carrying or being infected with AMR organisms than other migrant groups (7%).

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Key Concept

Key Evidence: A meta-analysis of antimicrobial resistance (AMR) in migrant populations in Europe found that 25% of migrants carried or were infected with antibiotic resistant organisms. When considering all migrant types, refugees and asylum seekers had a higher rate (33%) of carrying or being infected with AMR organisms than other migrant groups (7%).

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Key Concept

Key Evidence: Somali refugee children in Kenya were nearly 60 times more likely than children of the main ethnic group in the study (Kikuyu) to not have received any childhood immunization and more than twice as likely to have not completed their vaccinations. Although Somali children made up less than 8% of the sample, they accounted for nearly half of all non-vaccinated children.

From the VoICE Editors: This study used data from Kenya’s Demographic and Health Survey data.

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Key Evidence: Girls from refugee families in Denmark were 40-56% less likely to receive HPV vaccine through 2 free-of-charge immunization programs than Danish-born girls, and the differences remained significant when income was taken into account. The odds of being vaccinated were lowest for refugees in the country ≤5 years and those from certain countries or regions, indicating the need to reduce cultural, social, and information barriers to immunization, as well as assess immunization programs across increasingly ethnically diverse societies.

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Key Concept

Key Evidence: Somali refugee children in Kenya were nearly 60 times more likely than children of the main ethnic group in the study (Kikuyu) to not have received any childhood immunization and more than twice as likely to have not completed their vaccinations. Although Somali children made up less than 8% of the sample, they accounted for nearly half of all non-vaccinated children.

From the VoICE Editors: This study used data from Kenya’s Demographic and Health Survey data.

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Key Evidence: Girls from refugee families in Denmark were 40-56% less likely to receive HPV vaccine through 2 free-of-charge immunization programs than Danish-born girls, and the differences remained significant when income was taken into account. The odds of being vaccinated were lowest for refugees in the country ≤5 years and those from certain countries or regions, indicating the need to reduce cultural, social, and information barriers to immunization, as well as assess immunization programs across increasingly ethnically diverse societies.

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Key Evidence: Screening tests given to more than 300 newly-arrived economic migrants and asylum seekers in Italy — the majority from sub-Saharan Africa — found high rates of chronic hepatitis B infection and latent and active tuberculosis (with 8% having signs of current infection or active TB). These findings underscore the important of universal screening for infectious diseases for all newly-arrived migrants.

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Key Evidence: Antibody screening of asylum seekers arriving in Germany found that few subgroups, such as people from the same country, were sufficiently protected against measles, rubella, and varicella, and that the majority of adolescents and adults would benefit from immunizations. The serology screening results were used to target specific high-risk groups (for example, people from certain countries and age groups) for vaccination as a cost-savings measure, which proved successful in managing varicella outbreaks at refugee reception centers.

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Key Evidence: Nearly one-third of children and adolescents seeking asylum in Denmark were not adequately vaccinated upon their arrival, with Afghans and Eritreans having the lowest vaccination rates. This points to the need for initiatives targeted to this population to promote immunization and improve access to health services.

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Key Concept

Key Evidence: Although the upfront investment in preparedness is costly – severe influenza pandemic preparedness is US$4.5bn a year – the estimated annual economic benefits would total US$60bn and US$490bn through averted deaths. “Even if only one tenth of these benefits were to materialize, the returns to public investment in preparedness would still be extraordinarily high.”

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Key Concept

Key Evidence: An analysis conducted in areas of Ethiopia with high proportions of refugees found that high measles vaccination coverage was linked to lower rates of acute malnutrition (wasting) in children under five. For each percentage point increase in measles vaccination coverage, there was a 0.65% decrease in the rate of acute malnutrition in these areas.

From the VoICE Editors: The analysis was conducted on data from more than 150 nutrition surveys.

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Key Evidence: Malnutrition is a leading contributor to morbidity and mortality during humanitarian emergencies, and a cyclical relationship exists between malnutrition and infectious diseases. Universal immunization programs have been shown to improve the height and weight measurement markers associated with malnutrition.

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Key Concept

Key Evidence: An analysis conducted in areas of Ethiopia with high proportions of refugees found that high measles vaccination coverage was linked to lower rates of acute malnutrition (wasting) in children under five. For each percentage point increase in measles vaccination coverage, there was a 0.65% decrease in the rate of acute malnutrition in these areas.

From the VoICE Editors: The analysis was conducted on data from more than 150 nutrition surveys.

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Key Concept

Key Evidence: A measles outbreak in the Federated States of Micronesia (FSM) in 2014, causing nearly 400 confirmed cases, cost nearly US$4 million (around US$10,000 per case), 88% of which was for a mass vaccination campaign, outbreak investigations, and other containment costs. While the U.S. government covered 2/3 of the costs, the economic burden to FSM — in labor and other costs of containing the outbreak, the direct costs of illness, and productivity losses — were the equivalent of the country’s entire education budget for one year.

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Key Evidence: In an analysis of a hypothetical disease outbreak scenario, based on data from the Ebola epidemic in West Africa, researchers estimated that a large-scale disease outbreak spreading to nine Asian countries could cost the US economy $8-41 billion in lost exports and put almost 1.4 million export-related US jobs at risk.

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Key Evidence: During the 2014-2016 Ebola epidemic in 3 West African countries, fear of the disease in neighboring Nigeria and misperceptions on how disease spreads negatively affected many sectors of the economy – retail, hospitality, airline industries, and certain agricultural sectors.

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Key Evidence: A study of a cholera outbreak in Peru in 1991-92 estimates that the national economy conservatively suffered more than US$50 million in economic losses due to reduced tourism revenue, reduced revenue on export of goods and lower domestic consumption as a result of the outbreak of cholera.

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Key Concept

Key Evidence: Among both HIV positive and HIV negative parents in a study in Kenya, 99% of pneumococcal strains found and tested were resistant to one or more antibiotics. HIV positive parents carried 16% more strains that were resistant to penicillin than those carried by HIV negative parents.

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Key Concept

Key Evidence: Two years after the introduction of 10-strain pneumococcal conjugate vaccine (PCV-10) in Kenya, the percent of HIV-positive adults who carried pneumococcal bacteria declined significantly (from 43% to 28%), but did not decline in HIV-negative adults. However, the reduction in carriage of pneumococcal strains that are in PCV10 declined significantly in both HIV-positive and HIV-negative adults. This reduction was still four times higher in HI- positive vs. HIV-negative adults (2.8% vs. 0.7%), indicating that HIV positive adults continue to be at considerably higher risk of invasive pneumococcal disease than HIV-uninfected adults.

From the VoICE Editors: Nasopharyngeal carriage is an indicator of the risk for invasive pneumococcal disease and pneumonia. 

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Key Concept

Key Evidence: Non-Somali children in Kenya in the poorest households were nearly three times as likely to be unvaccinated than children from middle-income households, while wealthier children were significantly less likely to be unvaccinated.

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Key Concept

Key Evidence: A large U.S. study of surveillance data examining the impact of switching from PCV7 to PCV13 for infants demonstrated how important vaccination is in combating antimicrobial resistance. While the incidence of antibiotic-resistant invasive pneumococcal disease (IPD) was increasing before the introduction of PCV13, drug resistant IPD declined 78-96% in children under five after the vaccine introduction.

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Key Evidence: This study from South Africa demonstrates significant declines in invasive pneumococcal disease cases caused by bacteria that are resistant to one or more antibiotics. In fact, the rate of infections resistant to two different antibiotics declined nearly twice as much as infections that could be treated with antibiotics.

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Key Evidence: Studies in several countries have shown that, following the introduction of pneumococcal conjugate vaccine, there was a reduction in the number and percent of drug-resistant cases of pneumococcal diseases in children, and in some countries in adults, due to herd effects. In Japan there was a 10-fold decline in the proportion of penicillin-resistance among cases of invasive pneumococcal disease (from 56% to 5%), and in the U.S. there were reductions of 81% and 49% in the proportion of penicillin-resistant cases in children less than two years and in adults more than 65 years old, respectively.

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Key Concept

Key Evidence: A study of sickle cell disease patients in Ghana found that pneumoccocus bacteria found in their noses and throats had high rates of drug resistance with 37% of positive samples resistant to penicillin and 34% resistant to multiple drugs (typically penicillin + tetracycline + cotrimoxazole).

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Key Concept

Key Evidence: Among both HIV positive and HIV negative parents in a study in Kenya, 99% of pneumococcal strains found and tested were resistant to one or more antibiotics. HIV positive parents carried 16% more strains that were resistant to penicillin than those carried by HIV negative parents.

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Key Evidence: Two years after the introduction of 10-strain pneumococcal conjugate vaccine (PCV-10) in Kenya, the percent of HIV-positive adults who carried pneumococcal bacteria declined significantly (from 43% to 28%), but did not decline in HIV-negative adults. However, the reduction in carriage of pneumococcal strains that are in PCV10 declined significantly in both HIV-positive and HIV-negative adults. This reduction was still four times higher in HI- positive vs. HIV-negative adults (2.8% vs. 0.7%), indicating that HIV positive adults continue to be at considerably higher risk of invasive pneumococcal disease than HIV-uninfected adults.

From the VoICE Editors: Nasopharyngeal carriage is an indicator of the risk for invasive pneumococcal disease and pneumonia. 

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Key Concept

Key Evidence: Evaluation of the ability of pneumococcal conjugate vaccine to reduce the occurrence of respiratory infections and the resultant antibiotic drug use was conducted among day care attendees in Israel. It was observed that children who had received the 9-valent conjugate vaccine showed a 17% overall reduction in antibiotic usage. In particular, a 10% reduction in days of antibiotic usage for upper respiratory tract infections, 47% fewer days of antibiotic usage for lower respiratory tract infections, and 20% fewer days of antibiotic usage for otitis media (ear infections) when compared to children who did not receive PCV.

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Key Evidence: Several studies have shown a 13-50% reduction in the use of antibiotics by children who have received influenza vaccine compared with unvaccinated controls. This is due to a decline in febrile illnesses causes by influenza — for which antibiotics are often prescribed inappropriately — as well as a decline in secondary bacterial infections requiring antibiotic treatment, such as pneumonia and middle ear infections, that are triggered by influenza.

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Key Evidence: In a study evaluating the impact of PCV7 on 40,000 recipients and control subjects in northern California revealed that the vaccine could significantly decrease the need for antibiotics to treat the disease. The children who had received the vaccine displayed a 5.4% reduction in the number of antibiotic prescriptions and a 12.6% reduction in the use of “second-line antibiotics” compared to the controls. Additionally, when looking at children in the time period between their first dose and attainment of the age of 3.5 years, receiving the vaccine had prevented 35 antibiotic prescriptions per 100 fully vaccinated children.

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Key Evidence: Vaccines against influenza reduce the use of antibiotics that drive drug resistance in bacteria in two ways. First, they prevent secondary bacterial infections caused by influenza, such as pneumonia and otitis media; in Ontario, Canada, the rate of prescribing for influenza-associated antibiotics declined around 64% after universal introduction of influenza vaccination compared to other Canadian provinces with more limited use of the vaccine. Second, they help prevent inappropriate antibiotic prescriptions for respiratory tract infections caused by influenza and other viruses, which account for half of all respiratory illnesses for which antibiotics are prescribed in the U.S.

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Key Concept

Key Evidence: A community-based study in Vietnam found a high percent of children under five years of age were carrying pneumococcal bacteria in their noses and throats that were non-susceptible to commonly-used antibiotics. Of the strains tested, 18% were not susceptible to penicillin, 26% weren’t susceptible to cefotaxime, 76% were not susceptible to meropenem and 14% were not susceptible to all three nor to any of the “macrolide” drugs (e.g., erthromycin and azithromycin). However, 90% of the multi-drug resistant strains are serotypes that are in the 13-strain pneumococcal conjugate vaccine (PCV-13) and thus the introduction of a vaccine is expected to increase the susceptibility of circulating strains of the bacteria.

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Key Evidence: The US CDC identifies the use of vaccines as one of the 4 critical steps for controlling the spread of antibiotic resistance.

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Key Evidence: According to a study in a hypothetical endemic population, vaccination using typhoid conjugate vaccine will reverse the current increase in the percent of chronic carriers of the disease who are antibiotic resistant, if at least 50% of the target population is vaccinated. This would deplete an important “reservoir” of antibiotic resistant typhoid.

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Key Evidence: A systematic review of studies from India found that prior to widespread use of the pneumococcal conjugate vaccine, antibiotic resistance in serious pneumoccocal infections among Indian children has been common. Penicillin resistance was found in 10% of invasive pneumococcal disease (IPD) cases, while trimethoprim/sulfamethoxazole resistance was found in more than 80% of these cases.

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Key Evidence: Shortly after its introduction of Hib vaccine in the United Kingdom, a decrease in resistant (ᵝ-lactamase-positive) strains were documented. In the U.S., following introduction of pneumococcal conjugate vaccines, including PCV13, there was a decrease in both antibiotic use and in the prevalence of pneumococcal strains not susceptible to antibiotics.

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Key Concept

Key Evidence: In a study modeling the cost-effectiveness of vaccination campaigns in Somalia – the country with the second largest number of refugees in 2012 – the use of Hib vaccine, PCV10, or both Hib and PCV10 were all found to be cost effective means to prevent excess morbidity and mortality from pneumonia in young Somali children. Such a vaccination campaign could conservatively reduce pneumonia cases and deaths by nearly 20%.

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Key Evidence: Children living in the Yida refugee camp in South Sudan in 2013 were found to have an elevated rate of pneumonia infections likely due to malnutrition, overcrowding, and inadequate shelter. Using these data, the CDC estimated that the use of Hib and pneumococcal vaccines in children under 2 years of age in the camp would be cost-effective under all dosing scenarios evaluated. Medecines Sans Frontiers (MSF) provided medical services to this refugee camp and found delivery of these vaccines to be feasible and effective in this setting.

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Key Concept

Key Evidence: The ongoing conflict in Syria has caused the breakdown of immunization services, leading to outbreaks of vaccine preventable diseases in the region and the re-emergence of polio in Syria for the first time in 15 years. The potential for polio to re-emerge in neighboring areas with low coverage of inactivated polio vaccine (IPV) threatens the success of global efforts to eradicate polio.

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Key Evidence: Researchers investigating the causes of a measles outbreak in Burkina Faso that occurred despite a recent mass vaccination campaign found that migration to and from Cote d’Ivoire was a major risk factor for children. Unvaccinated children who developed measles were 8.5x more likely to have recently traveled to Cote d’Ivoire than unvaccinated children who had not traveled across the border. Children returning to Burkina Faso after a period of time in Cote d’Ivoire were less likely to have been vaccinated due to low routine coverage of measles vaccines in Cote d’Ivoire. Conversely, unvaccinated children from Burkina Faso who traveled to Cote d’Ivoire and returned were more likely to be exposed to measles and thus had a higher rate of disease than children who never visited Cote d’Ivoire.

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Key Evidence: In a study of the overlap between complex humanitarian emergencies and disease outbreaks, researchers found that more than 40% of complex emergencies that occurred between 2005-2014 were associated with an outbreak of infectious disease, with a high likelihood that the outbreak was vaccine-preventable.

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Key Evidence: The influx of Syrian refugees into Turkey as a result of the Syrian civil war has led to a re-emergence of several infectious diseases in Turkey, including vaccine-preventable diseases, such as measles (930 cases reported among refugees over 4 years), tuberculosis and hepatitis A.

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Key Evidence: An outbreak of wild polio virus began two years after the onset of the civil war in Syria and subsequently spread to Iraq, causing a total of 38 cases (36 in Syria). Factors leading to the outbreak included a decline in polio surveillance and in polio vaccination coverage (from 83% for 3 doses of oral polio vaccine pre-war in Syria to 47-52%).

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Key Evidence: The humanitarian emergency in Venezuela, and resulting collapse of its primary health care infrastructure, has caused measles and diphtheria to reemerge — disproportionately affecting indigenous populations — and to spread to neighboring countries. This sets the stage for the potential reemergence of polio. The re-establishment of measles as an endemic disease in Venezuela (with >5,500 confirmed cases) and its spread to neighboring countries threaten the measles-free status.

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Key Evidence: Insecurity resulting from armed conflict, political instability, or social disruption increases the risk of communicable disease outbreaks during complex humanitarian emergencies by inhibiting populations’ access to health services, disrupting activities such as immunization and surveillance that prevent the spread of diseases, and making adequate humanitarian responses more difficult.

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Key Evidence: Large measles outbreaks occurred in Lebanon and Jordan, following an influx of Syrian refuges migrating to escape conflict. In Lebanon, the measles incidence increased 200-fold in one year following high migration. There were 2.1 measles cases per million population in Lebanon in 2012; this increased to 411 cases per million in 2013.

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Key Concept

Key Evidence: The latest International Health Regulations (IHR) of the World Health Organization updated in 2005 contained several major changes compared to earlier versions. However, the need to report cases of cholera and yellow fever has remained along with an expansion of the concerned disease list. These diseases continue to be critical threats to national and international health security, making immunization against them a vital disease control approach.

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Key Evidence: The development and successful implementation of a coordinated, multi-country plan in response to a wild polio outbreak in Syria and Iraq halted the outbreak within 6 months. The response, which involved strengthening acute flaccid paralysis surveillance and more than 70 synchronized mass polio vaccination campaigns in 8 Middle Eastern countries (reaching >27 million children), could serve as a model for responding to disease outbreaks in areas affected by conflict and political instability.

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Key Evidence: Conflict in the Eastern Mediterranean Region impacted health infrastructure and compromised the success of the region’s measles elimination goal. At the same time that rates of migration and displacement skyrocketed, the number of measles cases in the region doubled, from 10,072 cases in 2010 to 20,898 in 2015.  

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Key Concept

Key Evidence: In 2013 nearly all of the 175 cases of measles in the US could be traced back to international importations.

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Key Evidence: The humanitarian emergency in Venezuela, and resulting collapse of its primary health care infrastructure, has caused measles and diphtheria to reemerge — disproportionately affecting indigenous populations — and spread to neighboring countries. This sets the stage for the potential reemergence of polio. The re-establishment of measles as an endemic disease in Venezuela (with >5,500 confirmed cases) and its spread to neighboring countries threaten the measles-free status.

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Key Concept

Key Evidence: TB and pneumococcal infections are two of 18 drug-resistant threats to US health security identified by the CDC in 2013 and are potentially vaccine-preventable. Most antibiotic resistant TB infections in the US occur in people born outside the US.

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Key Concept

Key Evidence: After PCV13 replaced PCV7 in the U.S. infant immunization program in 2010, the incidence of invasive pneumococcal disease (IPD) caused by the 6 additional serotypes in the new vaccine declined by 75% in children too old to be vaccinated (5-17 years) by the third year following the switch, and by 58-72% in adults, compared to the expected incidence if PCV7 alone had been continued. This led to overall reductions in IPD incidence of 53% in 5-17 year olds and of 12-32% in adults within three years of the switch from PCV7 to PCV13.

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Key Concept

Key Evidence: Mothers infected with rubella virus during the first trimester of pregnancy can give birth to children with permanent disabilities such as intellectual impairment, autism, blindness, deafness, and cardiac defects. The infection is completely preventable if mothers are vaccinated before pregnancy.

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Key Concept

Key Evidence: In the Americas, a platform built to secure polio eradication has been expanded to help track, control, prevent, and monitor immunization impact for measles and rubella. In India, highly trained polio health workers have become the basis for a trained workforce working towards the elimination of measles and rubella and helping ensure India’s certification by WHO for having eliminated maternal and neonatal tetanus.

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Key Concept

Key Evidence: The American Academy of Pediatrics and the International Pediatric Association were included as partners in the measles and rubella elimination initiative, allowing for more direct collaboration around the interactions of primary health and immunization services and concerns.

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Key Concept

Key Evidence: The detection of H1N1 influenza virus in Mexico in 2009, and subsequently throughout other countries in the Americas, benefited from the laboratory experience with measles and rubella in the region, leading to the rapid detection of, and response to, what eventually became a novel pandemic virus.

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Key Concept

Key Evidence: A study based on population- and lab-based surveillance of bacterial infections in the U.S. estimated that, of the estimated 400,000 cases and 30,000 deaths from invasive pneumococcal disease (IPD) that were likely prevented from 2001 to 2012 with the introduction of PCV7 (in 2000) and PCV13 (in 2010) in the infant immunization schedule, more than half of cases prevented and nearly 90% of prevented deaths were among people older than 5 years of age.

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Key Concept

Key Evidence: The US CDC estimates that antibiotic resistant pneumococcal infections in the US add $96 million to the costs of treatment each year.

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