Model Comparisons of the Effectiveness and Cost-Effectiveness of Vaccination: A Systematic Review of the Literature.

OBJECTIVES: To describe all published articles that have conducted comparisons of model-based effectiveness and cost-effectiveness results in the field of vaccination. Specific objectives were to 1) describe the methodologies used and 2) identify the strengths and limitations of the studies. METHODS: We systematically searched MEDLINE and Embase databases for studies that compared predictions of effectiveness and cost-effectiveness of vaccination of two or more mathematical models. We categorized studies into two groups on the basis of their data source for comparison (previously published results or new simulation results) and performed a qualitative synthesis of study conclusions. RESULTS: We identified 115 eligible articles (only 5% generated new simulations from the reviewed models) examining the effectiveness and cost-effectiveness of vaccination against 14 pathogens (69% of studies examined human papillomavirus, influenza, and/or pneumococcal vaccines). The goal of most of studies was to summarize evidence for vaccination policy decisions, and cost-effectiveness was the most frequent outcome examined. Only 33%, 25%, and 3% of studies followed a systematic approach to identify eligible studies, assessed the quality of studies, and performed a quantitative synthesis of results, respectively. A greater proportion of model comparisons using published studies followed a systematic approach to identify eligible studies and to assess their quality, whereas more studies using new simulations performed quantitative synthesis of results and identified drivers of model conclusions. Most comparative modeling studies concluded that vaccination was cost-effective. CONCLUSIONS: Given the variability in methods used to conduct/report comparative modeling studies, guidelines are required to enhance their quality and transparency and to provide better tools for decision making

A scoping review protocol on social participation of indigenous elders, intergenerational solidarity and their influence on individual and community wellness

Introduction Indigenous elders have traditionally played an important role in maintaining social cohesion within their communities. Today, part of this role has been taken over by government social and healthcare services, but they are having limited success in addressing social challenges. Increasing elders’ social participation and intergenerational solidarity might foster community development and benefit young people, families, communities and the elders themselves. However, knowledge of the contribution of elders’ social participation and intergenerational solidarity to wellness is scattered and needs to be synthesised. This protocol presents a scoping review on the social participation of indigenous elders, intergenerational solidarity and their influence on individual and community wellness. Methods and analysis This scoping review protocol is based on an innovative methodological framework designed to gather information from the scientific and grey literature and from indigenous sources. It was developed by an interdisciplinary team including indigenous scholars/researchers, knowledge users and key informants. In addition to searching information databases in fields such as public health and indigenous studies, an advisory committee will ensure that information is gathered from grey literature and indigenous sources. Ethics The protocol was approved by the Ethics Review Board of the Université du Québec en Abitibi-Témiscamingue and the First Nations of Quebec and Labrador Health and Social Services Commission. Discussion The comprehensive synthesis of the scientific and grey literature and indigenous sources proposed in this protocol will not only raise awareness within indigenous communities and among healthcare professionals and community organisations, but will also enable decision-makers to better meet the needs of indigenous people. Conclusion The innovative methodological framework proposed in this scoping review protocol will yield richer information on the contribution of elders to community wellness. This work is an essential preliminary step towards developing research involving indigenous communities, drawing on the social participation of elders and intergenerational solidarity

Comparing the cost-effectiveness of two- and three-dose schedules of human papillomavirus vaccination: a transmission-dynamic modelling study.

BACKGROUND: Recent evidence suggests that two doses of HPV vaccines may be as protective as three doses in the short-term. We estimated the incremental cost-effectiveness of two- and three-dose schedules of girls-only and girls & boys HPV vaccination programmes in Canada. METHODS: We used HPV-ADVISE, an individual-based transmission-dynamic model of multi-type HPV infection and diseases (anogenital warts, and cancers of the cervix, vulva, vagina, anus, penis and oropharynx). We conducted the analysis from the health payer perspective, with a 70-year time horizon and 3% discount rate, and performed extensive sensitivity analyses, including duration of vaccine protection and vaccine cost. FINDINGS: Assuming 80% coverage and a vaccine cost per dose of $85, two-dose girls-only vaccination (vs. no vaccination) produced cost/quality-adjusted life-year (QALY)-gained varying between$7900-24,300. The incremental cost-effectiveness ratio of giving the third dose to girls (vs. two doses) was below $40,000/QALY-gained when: (i) three doses provide longer protection than two doses and (ii) two-dose protection was shorter than 30 years. Vaccinating boys (with two or three doses) was not cost-effective (vs. girls-only vaccination) under most scenarios investigated. INTERPRETATION: Two-dose HPV vaccination is likely to be cost-effective if its duration of protection is at least 10 years. A third dose of HPV vaccine is unlikely to be cost-effective if two-dose duration of protection is longer than 30 years. Finally, two-dose girls & boys HPV vaccination is unlikely to be cost-effective unless the cost per dose for boys is substantially lower than the cost for girls

Participation sociale et solidarités intergénérationnelles : une synthèse des connaissances sur la contribution des aînés autochtones au mieux-être des personnes et des communautés

Les services publics actuels montrent des effets limités dans leur réponse aux besoins et aux enjeux complexes de mieux-être vécus par les peuples autochtones. Afin d’utiliser des approches holistiques misant sur les forces des individus et des communautés, l’implication des aînés autochtones peut contribuer à répondre à ces besoins, à surmonter leurs enjeux vécus et à développer le mieux-être. L’objectif de cette synthèse des connaissances visait à mieux comprendre les caractéristiques de la participation sociale des aînés autochtones et des solidarités intergénérationnelles ainsi que leurs influences sur les différentes dimensions du mieux-être des personnes et des communautés. Un comité consultatif composé d’utilisateurs de connaissances a été impliqué tout au long de la recherche. En plus de la recherche dans les bases de données, 17 entrevues individuelles avec des aînés autochtones et six café-rencontres ont été réalisés dans des communautés de huit nations (Abénaquis, Anishnabek, Atikamekw, Huronne-Wendat, Innue, Mohawk, Inuite, Crie) notamment pour l’identification de documents. Pour la recherche d’écrits scientifiques, quatorze banques de données ont été utilisées à partir de 58 mots-clés. Deux étudiantes de recherche supervisées par la chercheure principale ont vérifié l’admissibilité de chacun des documents. Sur les 143 documents rencontrant les critères d’inclusion, 73 proviennent des écrits scientifiques. La plupart des articles scientifiques recensés ont utilisé une méthodologie qualitative (n=60). Six revues systématiques ou recensions d’écrits ont été incluses. Parmi les autres écrits scientifiques, à l’exception d’un article ayant utilisé un devis pré-expérimental pour évaluer l’efficacité d’une intervention, tous avaient utilisé un devis transversal. Les documents de la littérature grise sont des rapports gouvernementaux ou d’organismes ainsi que des livres, des courts métrages, des entrevues audios et des jeux vidéos produits par des communautés autochtones ou des organismes autochtones ou oeuvrant avec les peuples autochtones. Une grille d’analyse bâtie à partir de la Classification internationale du fonctionnement, de l’incapacité et du handicap de l’Organisation mondiale de la santé a été développée pour codifier les documents. Enfin, plusieurs stratégies de mobilisation des connaissances rejoignant les différents profils d’utilisateurs sont utilisées (p. ex., articles scientifiques et non scientifiques, présentations dans des colloques et congrès ainsi que dans des activités auprès d’un public non scientifique, boîte à outils). Bien que les contextes de contribution des aînés au mieux-être des communautés varient entre les nations et les communautés autochtones, cette synthèse des connaissances montre que dans l’ensemble, la participation sociale des aînés autochtones ainsi que les solidarités intergénérationnelles se réalisent dans les domaines de la vie sociale, communautaire et civique, par l’implication dans des emplois ou du bénévolat ainsi que par la réalisation d’activités traditionnelles. La contribution des aînés autochtones se manifeste à travers leurs relations et interactions par différentes formes de communication. En effet, les aînés contribuent au mieux-être individuel et collectif entre autres par leur participation en tant que conférenciers et écrivains, par leur implication dans les écoles et des comités ainsi que par la transmission des savoirs et savoir-faire traditionnels (p. ex., pêche, chasse, artisanat, danse, utilisation de plantes médicinales). Ils contribuent à la transmission des connaissances et des valeurs traditionnelles par des enregistrements vidéos, la sensibilisation dans les milieux de travail et les écoles avec les allochtones, des témoignages ainsi que la transmission de contes et légendes. Enfin, ils organisent et participent aux cérémonies, aux journées culturelles, à l’enseignement spirituel et à des manifestations. Les aînés autochtones contribuent sur le plan familial et participent aux instances locales, régionales, provinciales et nationales. Les principaux bénéfices de la contribution des aînés autochtones concernent le maintien des relations interpersonnelles, familiales et conjugales, le soutien formel et informel ainsi que la santé physique et mentale. Plus spécifiquement, les bénéfices répertoriés concernent la cohésion sociale, la réciprocité, le fait de bénéficier de conseils ainsi que la promotion de la santé et la prévention des maladies. Les aînés autochtones contribuent à influencer le développement de la résilience, des forces, de l’autonomie et de la persévérance, ainsi qu’à l’enseignement de la langue, des valeurs, des règles de vie et de savoir-faire traditionnels. Enfin, la participation sociale des aînés autochtones contribue au développement de produits notamment didactiques (p. ex., DVD d’artisanat), culturels (p. ex., courts métrages) et spirituels (p. ex., tente de sudation) ainsi qu’aux services, aux systèmes et aux politiques (p. ex., revendication territoriales et défense des droits, création d’un réseau télévisé). Certaines contributions des aînés ressortent davantage dans la littérature grise que dans les écrits scientifiques, alors que d’autres n’apparaissent que dans la littérature grise. Par exemple, en santé et services sociaux, la co-animation de thérapies et la contribution des aînés aux grossesses et aux accouchements ainsi qu’à la prévention des abus sexuels ne ressortent que dans la littérature grise. Sur les plans juridique et politique, leur contribution au développement des programmes de réinsertion en emploi pour les prisonniers, à des associations de défense des droits ainsi que leur apport en tant qu’expert pour les ministères ou lors de crises sont d’autres exemples uniquement mentionnés dans la littérature grise. Leur contribution à l’approche philosophique des programmes d’enseignement ne ressort pas non plus dans les écrits scientifiques. Sur les plans environnemental et communautaire, leur implication dans des instances visant la délimitation des aires protégées et l’aménagement des espaces ruraux, le développement de politiques de sécurité sociale et de protection civile ainsi que la sensibilisation du public aux réalités autochtones ne ressortent que dans la littérature grise. Enfin, certains bénéfices que la contribution des aînés autochtones entraîne sur le plan des attitudes et des comportements (gestion de la colère, conscience collective, patience, dignité, capacités d’adaptation) sont uniquement documentés dans la littérature grise. Bien que plusieurs documents aient été inclus dans cette synthèse des connaissances, peu d’écrits scientifiques ont utilisé des dispositifs permettant de démonter l’effet de la contribution des aînés autochtones au mieux-être des personnes et des communautés. De plus, plusieurs variables signifiantes pour les peuples autochtones notamment relatives au développement d’attitudes positives pour le mieux-être n’ont pas été incluses dans ces recherches. Ainsi, les organismes prestataires de services, les décideurs et les chercheurs devraient établir des partenariats avec les communautés pour évaluer des contributions des aînés autochtones qui n’apparaissent que dans la littérature grise sans avoir été évaluées en recherche. Pour ce faire, des opportunités accrues en recherche partenariale doivent mesurer les variables les plus signifiantes pour les peuples autochtones en regard des différentes composantes du mieux-être. Puisque les peuples autochtones accordent autant d’importance aux processus qu’aux résultats, les recherches futures devraient utiliser davantage des devis mixtes permettant non seulement d’évaluer les effets de la contribution des aînés (volet quantitatif), mais également d’en comprendre les processus (volet qualitatif). De plus, comme la langue et l’identité sont des enjeux importants pour lemieux-être, ces deux aspects devraient toujours être considérés dans les recherches et dans les actions concrètes. Par ailleurs, afin de bien comprendre l’évolution du mieux-être en fonction de la contribution des aînés autochtones, les opportunités de recherche doivent privilégier des devis longitudinaux. Ainsi, des approches partenariales avec les peuples autochtones soutiendraient leurs savoirs, leur créativité et leurs forces et leur apporteraient des retombées concrètes puisqu’ils ont souvent participé à des recherches, sans avoir l’opportunité d’en bénéficier directement. Afin de miser sur le partage de pratiques exemplaires reconnues et valorisées par les peuples autochtones, les instances oeuvrant auprès d’eux devraient davantage se concerter. Conséquemment, dans le développement, l’implantation et la prestation de soins, de services et d’interventions pour les peuples autochtones, les organisations des secteurs publics et communautaires devraient inclure des aînés ou représentants autochtones. Les services devraient être développés dans une approche holistique du mieux-être en misant sur le développement des forces plutôt que de cibler des enjeux de façon décontextualisée. Ainsi, les aînés et représentants autochtones devraient être impliqués dans la formation du personnel gestionnaire ou intervenant auprès des individus et des groupes afin d’assurer une offre de services favorisant la compétence culturelle des intervenants et la sécurité culturelle des peuples autochtones. De plus, afin d’assurer la continuité dans la transmission des savoirs ainsi que des valeurs, de la langue et de l’identité culturelle collective, les aînés devraient également travailler en collaboration avec les plus jeunes. Pour ce faire, les enjeux de communication intergénérationnelle et transculturelle méritent une importance particulière. Enfin, il s’avère essentiel d’assurer la pérennité d’actions ayant montré des effets positifs au plan du mieux-être et qui actuellement, faute de ressources financières, ne sont pas poursuivies

Importance of Indigenous elders’ contributions to individual and community wellness: results from a scoping review on social participation and intergenerational solidarity

Objective: Wellness is a challenge for Indigenous peoples, partly because Western services do not adopt a holistic approach. By devaluing traditional knowledge, Indigenous values and beliefs, these services lower Indigenous power and affect cultural identities. Indigenous elders participate in intergenerational solidarity by transmitting knowledge, values, and culture in a holistic approach. Despite widespread acceptance of the importance of Indigenous elders’ contributions to wellness, a rigorous synthesis of knowledge has never been done. This study aimed to provide a comprehensive understanding of how Indigenous elders’ social participation contributes to individual and community wellness. Method: A scoping review was conducted with Indigenous elders and stakeholders in Québec (Canada). Sixteen databases were searched with 57 keywords. Data from the documents retrieved were analyzed, organized, and synthesized based on the International Classification of Functioning, Disability and Health. Synthesis: A total of 144 documents were examined, comprising 74 scientific papers and 70 sources from the gray literature. Indigenous elders contributed to wellness mainly through relationships and interactions with other community members and non-Indigenous people (72.2%); intergenerational oral and written communications (70.1%); community, social and civic life (45.8%); volunteering and jobs (35.4%); and family life (29.9%). Elders transmit traditional knowledge, strengthen social cohesion, and help to develop positive attitudes such as reciprocity. Their actions favour disease prevention and health promotion, as including traditional approaches increases the acceptability of health and social services. Conclusion: This scoping review highlights the need for longitudinal studies with mixed-method designs involving Indigenous communities at all stages of the research to deepen understanding of the contributions of Indigenous elders to individual and community wellness. © 2020, The Author(s)

Efficacy and immunogenicity of a single dose of human papillomavirus vaccine compared to no vaccination or standard three and two-dose vaccination regimens: A systematic review of evidence from clinical trials.

OBJECTIVES: This study aimed to systematically review the literature on the efficacy and immunogenicity of single-dose HPV vaccination compared to no vaccination or multi-dose schedules among vaccine trial participants. METHODS: Medline, EMBASE, Global Health Database and Cochrane Central Register of Controlled Trials were searched for publications and conference abstracts (dated January 1999-August 2018) using MeSH and non-MeSH terms for human papillomavirus AND vaccines AND (immunogenicity OR efficacy/effectiveness) AND dosage. Search results were screened against pre-specified eligibility criteria. Data were extracted from included articles, and a narrative synthesis conducted on efficacy against HPV16/18 infection and humoral immunogenicity. RESULTS: Seven of 6,523 unique records identified were included in the review. Six were nested observational studies of participants randomised to receive two or three doses in three large HPV vaccine trials, in which some participants did not complete their allocated schedules. One small pilot study prospectively allocated participants to receive one or no vaccine dose. Frequency of HPV16/18 infection was low (e.g.  0.05 in all cases). Frequency of infection was significantly lower in one-dose recipients compared to unvaccinated controls (p < 0.01 for all infection endpoints in each study). HPV16/18 seropositivity rates were high in all HPV vaccine recipients (100% in three of four studies reporting this endpoint), though antibody levels were lower with one compared to two or three doses. CONCLUSIONS: This review supports the premise that one HPV vaccine dose may be as effective in preventing HPV infection as multi-dose schedules in healthy young women. However, it also highlights the paucity of available evidence from purpose-designed, prospectively-randomised trials. Results from ongoing clinical trials assessing the efficacy and immunogenicity of single-dose HPV vaccination compared to currently-recommended schedules are awaited

Optimal human papillomavirus vaccination strategies to prevent cervical cancer in low-income and middle-income countries in the context of limited resources: a mathematical modelling analysis

Introduction of human papillomavirus (HPV) vaccination has been slow in low-income and middle-income countries (LMICs) because of resource constraints and worldwide shortage of vaccine supplies. To help inform WHO recommendations, we modelled various HPV vaccination strategies to examine the optimal use of limited vaccine supplies and best allocation of scarce resources in LMICs in the context of the WHO global call to eliminate cervical cancer as a public health problem. Methods In this mathematical modelling analysis, we developed HPV-ADVISE LMIC, a transmission-dynamic model of HPV infection and diseases calibrated to four LMICs: India, Vietnam, Uganda, and Nigeria. For different vaccination strategies that encompassed use of a nine-valent vaccine (or a two-valent or four-valent vaccine assuming high cross-protection), we estimated three outcomes: reduction in the age-standardised rate of cervical cancer, number of doses needed to prevent one case of cervical cancer (NNV; as a measure of efficiency), and the incremental cost-effectiveness ratio (ICER; in 2017 international $per disability-adjusted life-year [DALY] averted). We examined different vaccination strategies by varying the ages of routine HPV vaccination and number of age cohorts vaccinated, the population targeted, and the number of doses used. In our base case, we assumed 100 Findings We predicted that HPV vaccination could lead to cervical cancer elimination in Vietnam, India, and Nigeria, but not in Uganda. Compared with no vaccination, strategies that involved vaccinating girls aged 9-14 years with two doses were predicted to be the most efficient and cost-effective in all four LMICs. NNV ranged from 78 to 381 and ICER ranged from$28 per DALY averted to $1406 per DALY averted depending on the country. The most efficient and cost-effective strategies were routine vaccination of girls aged 14 years, with or without a later switch to routine vaccination of girls aged 9 years, and routine vaccination of girls aged 9 years with a 5-year extended interval between doses and a catch-up programme at age 14 years. Vaccinating boys (aged 9-14 years) or women aged 18 years or older resulted in substantially higher NNVs and ICERs. Interpretation We identified two strategies that could maximise efforts to prevent cervical cancer in LMICs given constraints on vaccine supplies and costs and that would allow a maximum of LMICs to introduce HPV vaccination. Funding World Health Organization, Canadian Institute of Health Research, Fonds de recherche du Québec-Santé, Compute Canada, PATH, and The Bill & Melinda Gates Foundation. Translations For the French and Spanish translations of the abstract see Supplementary Materials section

Human papillomavirus vaccine effectiveness by number of doses: Updated systematic review of data from national immunization programs.

BACKGROUND: Human papillomavirus (HPV) vaccines were first licensed as a three-dose series. Two doses are now widely recommended in some age groups; there are data suggesting high efficacy with one dose. We updated a systematic literature review of HPV vaccine effectiveness by number of doses in observational studies. METHODS: We searched Medline and Embase databases from January 1, 2007, through September 29, 2021. Data were extracted and summarized in a narrative synthesis. We also conducted quality assessments for bias due to selection, information, and confounding. RESULTS: Overall, 35 studies were included; all except one were conducted within the context of a recommended three-dose schedule. Evaluations were in countries that used bivalent HPV vaccine (seven), quadrivalent HPV vaccine (27) or both (one). Nine evaluated effectiveness against HPV infection, ten anogenital warts, and 16 cervical abnormalities. All studies were judged to have moderate or serious risk of bias. The biases rated as serious would likely result in lower effectiveness with fewer doses. Investigators attempted to control for or stratify by potentially important variables, such as age at vaccination. Eight studies evaluated impact of buffer periods (lag time) for case counting and 10 evaluated different intervals between doses for two-dose vaccine recipients. Studies that stratified by vaccination age found higher effectiveness with younger age at vaccination, although differences were not all formally tested. Most studies found highest estimates of effectiveness with three doses; significant effectiveness was found among 28/29 studies that evaluated three doses, 19/29 that evaluated two doses, and 18/30 that evaluated one dose. Some studies that adjusted or stratified analyses by age at vaccination found similar effectiveness with three, two and one doses. CONCLUSION: Observational studies of HPV vaccine effectiveness have many biases. Studies examining persons vaccinated prior to sexual activity and using methods to reduce sources of bias are needed for valid effectiveness estimates

Population-level effects of human papillomavirus vaccination programs on infections with nonvaccine genotypes

We analyzed human papillomavirus (HPV) prevalences during prevaccination and postvaccination periods to consider possible changes in nonvaccine HPV genotypes after introduction of vaccines that confer protection against 2 high-risk types, HPV16 and HPV18. Our meta-analysis included 9 studies with data for 13,886 girls and women ≤19 years of age and 23,340 women 20–24 years of age. We found evidence of cross-protection for HPV31 among the younger age group after vaccine introduction but little evidence for reductions of HPV33 and HPV45. For the group this same age group, we also found slight increases in 2 nonvaccine high-risk HPV types (HPV39 and HPV52) and in 2 possible high-risk types (HPV53 and HPV73). However, results between age groups and vaccines used were inconsistent, and the increases had possible alternative explanations; consequently, these data provided no clear evidence for type replacement. Continued monitoring of these HPV genotypes is important