title: impact of new vaccine introduction on the ......the introduction of a new vaccine can have...

Not$for$wide$distribution$

March$26,$2012$ 1$$

Title: Impact of New Vaccine Introduction on the Immunization and Health Systems: a Review

of the Published Literature

Authors: Terri Hyde1, Holly Dentz1,3, Susan Wang2, Sandra Mounier-Jack4, Helen Burchett4, W. Scott Gordon5, Logan Brenzel6, Jessica Shearer7, Michael Favin8, Susan Goldstein1, Jacqueline Gindler1 Carsten Mantel2 as a part of the SAGE ad hoc working group on the Impact of New Vaccine introduction on the Immunization and Health Systems

1. United States Centers for Disease Control and Prevention

2. World Health Organization

3. Innovations for Poverty Action, 101Whitney Ave, New Haven, CT 06510, USA

4. London School of Hygiene and Tropical Medicine, Global Health Development, Public Health and Policy, 15-17 Tavistock Place, London WC1H 9SH, UK

5. Program for Appropriate Technology in Health (PATH), Seattle, WA USA 6. Consultant, Bill & Melinda Gates Foundation, Seattle, Washington, US.

7. Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada

8. The Manoff Group, participation in this work through the USAID/MCHIP project.

Corresponding author: Terri Hyde, Global Immunization Division, Centers for Disease Control

and Prevention, 1600 Clifton Road NE; MS-A04, Atlanta, GA 30333. Tel: 1-404-639-8764.

Email: [email protected]


March$26,$2012$ 2$$

Abstract word count: (maximum allowed=300) Body word count: 3909 (maximum allowed for review article: 4000)

References: 137 (maximum allowed=100) Figures and Tables: 4 (maximum allowed=7)

Target journal: Vaccine

Date last updated: 26-MAR-2012

Acknowledgements: CDC, WHO, and PATH librarians, Cristina Averhoff (CDC student intern), Samantha Wu (WHO student intern), Steven Wassilak (Italian), Jacek Skarbinski (Polish), Adina Hirsch (Hebrew), Enbo Ma (Chinese), Ahmet Afsar (Turkish), David Durham, Narendra Arora, Maria Otelia Costales, Tracie Gardener, and Benjamin Dahl


March$26,$2012$ 3$$

Abstract

Introduction

The Expanded Program on Immunization (EPI) was established by the World Health

Organization (WHO) in 1974 to provide protection against six vaccine-preventable diseases

(tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis, and measles) through routine infant

immunization. Since then, many new vaccines have become available, and global public funding

for immunization, including the GAVI Alliance, has increased accessibility to these vaccines

[REF]. Most of the new vaccines, including hepatitis B (HepB), Haemophilus influenzae type B

(Hib) vaccine, pneumococcal conjugate vaccine (PCV), and rotavirus (RV) vaccines are intended

to be included in the routine infant program. Other new vaccines, such as human papilloma virus

(HPV), meningococcal meningitis, yellow fever, and typhoid vaccines are intended for older or

at-risk populations.

The introduction of a new vaccine can have both positive and negative impacts on the

immunization system and the broader health system. It may add stress to an already weak

infrastructure or, alternatively, it may provide opportunities and resources to strengthen an

existing system. Evidence of impact of new vaccine introduction on health and immunization

systems has not been systematically reviewed and summarized. Based on a request in 2010 from

the Strategic Advisory Group of Experts (SAGE) on Immunization that guides the World Health

Organization (WHO) on global immunization policies, we conducted a systematic review of the

published literature to examine these impacts.

Methods

Search strategy

We developed search terms to identify articles that included information describing the impact of

new vaccine introduction on immunization systems and health systems [1] (Table 1). The terms

were selected to be inclusive and were developed with input from immunization experts. The

search terms were divided into two broad categories: 1) vaccines, and 2) immunization and

health systems (Table 1).


March$26,$2012$ 4$$

We searched six publication databases (Medline, Embase, Nursing Update, West African Journal

of Nursing, CINAHL, Web of Science and Global Health) that are known to be relevant to

vaccines and immunization programs, and were likely to contain reports from developing

countries. We attempted to use identical terms to search each database; however, as each

database had certain specifications, it was sometimes necessary to modify some terms. We

limited the search to reports involving human subjects, published in any language. The final

search date was September 29, 2010 and was not limited to a beginning year.

Inclusion criteria

For an article to be included in the review process it had to be captured by at least one search

term in each of the two search categories (vaccines and immunization health systems), and had to

consider information and data from the first five years after vaccine introduction, unless the

assessed outcome manifested more than five years after vaccine introduction (e.g., HepB vaccine

and hepatocellular carcinoma or cirrhosis, HPV vaccine and cervical cancer). We reviewed the

title and abstract of each article meeting this criterion to determine whether the article was

potentially relevant, i.e., it contained quantitative or qualitative information on the impact of new

vaccine introduction on immunization or health system, or both. Articles that discussed disease

incidence, disease burden, vaccination coverage, serotype replacement, immunization

campaigns, or adverse events following immunization were included if they contained data or

discussion of vaccine impact on the health or immunization system. Cost effectiveness studies

were considered if they included real time data and real situations and savings. Expert opinion

pieces were included if they reported data. We excluded clinical trials, because they did not show

impact on the immunization and health systems following vaccine introduction. Potentially

relevant articles were recommended for a full abstraction.

Abstraction process

We used EndNote X3.0.1S (Thompson Reuters) to organize and track the articles, adding

databases sequentially beginning with Medline, and performing automated and manual de-

duplication following the inclusion of each subsequent database. Each article was reviewed to

determine if it addressed the impact of the vaccine introduction on the immunization and health

system. Sixteen expert reviewers from WHO, CDC, UNICEF, LSHTM and PATH participated


March$26,$2012$ 5$$

in the abstraction process. Information from relevant articles was abstracted using a standardized

MS Access 2007 data collection form. Non-English articles were abstracted by native speakers,

whenever possible. A random sample of 10% of the articles were abstracted and reviewed by a

second reviewer. If discordance was found, the article was reviewed by a principal reviewer to

resolve discrepancies. Published articles were reviewed and organized according to the WHO

Framework for Action (Figure 1); this framework was created by WHO in 2007 to promote a

common understanding of health systems by providing a systematic means for considering the

essential functions of a health care system [1]. The Framework comprises six building blocks:

service delivery; health workforce; information; medical products, vaccines and technologies;

financing; and leadership and governance.

Results

Search and abstraction

The search yielded 24,768 articles from 1911 through September 29, 2010, among which 8,925

(36%) were found to be duplicates (Figure 2). Reviewers applied the inclusion criteria to the

remaining 15,795 titles and abstracts. Among these, 654 (4%) articles met the inclusion criteria

and were referred for full abstraction; 49 (7%) of these were in languages other than English.

One hundred twenty-nine (20%) were found to be relevant for the analysis. In addition, one key

article known to the authors that were not identified by the systematic search of the published

literature were included, resulting in a total of 130.

General overview

Among the 130 studies included in this review (Table 2), the majority were from highly

industrialized countries: 97 (75%) were from high income countries (by World Bank Definition);

21 (16%) were from middle income countries; and only 4 (3%) were from GAVI countries.

Vaccines targeting 10 diseases (hepatitis A (3, [2%]), hepatitis B (24, [19%]), Haemophilus

influenzae type b disease (28, [22%]), human papilloma virus infection (13, [10%]), influenza (1,

[1%]), Japanese encephalitis (1, [1%]), meningococcal meningitis (17, [13%]), Streptococcus

pneumoniae disease (28, [22%]), Rotavirus diarrhea (14, [11%]) and typhoid (2, [2%])) with

multiple formulations and different combinations were represented in the studies. Over half of

the studies (64; [56%]) considered vaccine introductions that took place between 2000 and 2008.


March$26,$2012$ 6$$

Service delivery

New vaccine introduction may affect the delivery of other immunization and health services. In

many high and upper middle income countries including China, Germany, Singapore, Thailand

and the US, coverage with vaccines administered through routine childhood or school-based

programs increased or remained the same when new vaccines were introduced [2-10]. PCV

introduction in two US counties was not associated with delays in other childhood vaccinations

or additional primary care visits [2]. In Canada, offering HepB vaccine and PCV at no cost

removed existing inequities in PCV distribution [11], increased uptake and improved on-time

vaccination [11, 12].

New vaccines have been introduced using a number of delivery modalities, including routine

immunization programs, one-time catch up schemes, mass campaigns, school-based programs, or

a combination of these, depending on the vaccine and age recommendation for vaccination [13-

20]. For instance, Australia’s government-funded HPV vaccination program included school-

based routine vaccination of 12 year-old girls with a 2-year adolescent catch-up program and

general practice-based vaccination of women aged 18-26 [15].The vaccination visit for 18-26

year old women was also intended to provide provided an opportunity for general practitioners to

broaden sexual health education and discuss cervical cancer prevention [15]. Ensuring

completion of the series for those who missed school-based vaccination required additional

effort, including coordination with general practitioners, additional mop-up campaigns at the end

of the year, or establishing an individual recall system. To facilitate school-based vaccination in

Canada, a new consent procedure – sending the consent form home for parental signature before

the school vaccination clinic – was implemented in some settings [12].

Delivery of new vaccines was often coupled with communication and education activities. Social

mobilization to publicize the vaccination activity – including through mothers’ clubs and

professional organizations – was part of successful efforts to ensure wide acceptance of HepB

vaccine in Singapore [5], China [21], Taiwan [22] and Peru [9], and of Hib in Uruguay, Chile,

Qatar, and Kuwait [23]. Introduction of HPV vaccine in the UK involved engagement of

multiple stakeholders and was facilitated through the establishment of an HPV implementation


March$26,$2012$ 7$$

group [24]. Knowledge and education about the disease and the vaccine, including safety issues,

aided the successful introduction of Hib [25] and HepB vaccine [26] in Canada and the UK [27],

and in Zimbabwe the program included training of health care workers, development of HepB

communication materials and community mobilization activities [28]. In the US and Canada, in

contrast to other routinely recommended childhood immunizations, HPV vaccine was actively

marketed through direct consumer advertising and public awareness campaigns that targeted

legislators and policy makers in addition to consumers [29]. In the UK, funding for media

communication about meningococcal conjugate C vaccine was included in the budget for

vaccine introduction [30]. In Israel, immunization planners chose a Hib vaccine with a 2-dose

primary series rather than one with a 3-dose series, in part, to avoid three injections at the 6

month visit [31]. In settings where there was insufficient information or provider concern about

safety or number of injections, implementation was less successful. Reluctance by vaccine

providers to administer three injections at one time was observed with PCV introduction in

Australia [32].

Health workforce

There was variability in the impact of new vaccine introduction on health workforce. In settings

where vaccination was introduced into regularly-scheduled clinics, there was little impact on

staffing and appointment times, as was the case with Hib vaccine introduction in Sweden [33],

HPV vaccine introduction in Australia [34], and PCV7 introduction in the United States [2].

Vaccine introduction into adolescent and adult immunization programs sometimes required

additional staff or adjustment of appointment times: in Scotland, adding pneumococcal vaccine

to appointments for influenza vaccination among older adults increased consultation times by

about 2 minutes [35]. Additional staff were also needed for HPV vaccine introduction in the UK

[36], where public health nurses, pediatric nurses, health visitors, and managers were recruited

into teams, and additional funding was made available to address a shortage of school nurse

vaccinators; as well as in remote areas of Australia [15], and in juvenile justice facilities in the

United States [37].

Additional training of health staff at national, regional and local levels was required for

successful HepB vaccine introduction in China [38] and Zimbabwe [28], hepatitis A and


March$26,$2012$ 8$$

Japanese encephalitis (JE) vaccine in China [39], Hib vaccine in the Americas [40, 41], and

meningococcal polysaccharide vaccine in Egypt [13]. When the new vaccine was introduced as a

combination product that included a vaccine already used in the program [23], training was

relatively straightforward. In Indonesia, training, and periodic re-training in the local language

were needed to successfully implement the school-based typhoid program [20]. Continuing

education was also conducted in Italy to promote the birth dose of HepB vaccine [42].

To ensure funding for training, the vaccine introduction budget for HepB and Hib vaccines in

Ethiopia included a training and education component [43]. In Australia’s HPV vaccination

program, a time-limited incentive payment of $6 per notification of vaccination was offered to

general practitioners to improve completeness of the vaccine register [44].

Information

In China [4, 45], Malawi [46], South Africa [47], Nicaragua [48], Canada [49] and Egypt [13],

existing disease surveillance systems were used for impact evaluation, policy formulation, and

program advocacy related to immunization against HepB [4], JE [45], invasive Hib disease [46,

47], rotavirus [48], pneumococcal pneumonia [49] and meningococcal meningitis [13]. In other

countries, vaccine introduction stimulated the development of new surveillance or vaccine

registry systems, including comprehensive surveillance for meningococcal meningitis in the UK

[14], pediatric invasive pneumococcal disease in Canada [50], hepatitis B virus-associated

nephropathy in South Africa [51], and an HPV immunization registry in Australia [10, 44]. In

Chile and Uruguay, Hib case definitions and reporting forms were standardized, and a

technology transfer program was developed following Hib vaccine introduction [40]. A national

immunization register, implemented at the same time as a meningococcal conjugate B

vaccination campaign in New Zealand, was used to monitor coverage, safety and effectiveness

assessments [52].

Medical products, vaccines and technologies

The availability of new technologies, including combination vaccines and auto-disable syringes,

had an impact on the immunization system. In Chile [53], the USA [6] and Zimbabwe [28], use


March$26,$2012$ 9$$

of combination vaccines resulted in fewer injections, and the need for fewer needles and

syringes; lower administrative costs; and reduced storage capacity, compared with introducing it

as a separate vaccine [6, 28, 53]. Introduction of DTP-Hib vaccine in The Gambia, however,

resulted in initial interruption of routine DTP immunization due to irregular supply of the

combination vaccine at that time [54].

In other instances, introduction of new vaccines created additional requirements for cold chain

and logistics systems. In Ethiopia, the replacement of 10-dose vials of whole cell dipththeria-

tetanus-pertussis vaccine (DTwP) with single-dose vials of pentavalent DTwP–Hep B–Hib

increased transport and cold chain requirements [43]. The need for additional cold chain capacity

was also reported for rotavirus in several Latin American countries [55], hepatitis A and B

vaccine introduction in China [21, 39], HPV vaccine introduction in the US [37], and 23-valent

pneumococcal polysaccharide vaccine (PPV23) for older adults in Scotland [35]. In contrast,

introduction of Hib vaccine in Chile and Uruguay did not require additional cold chain capacity

[40].

As part of new vaccine introduction, auto-disable (AD) syringes were introduced into GAVI-

eligible countries. AD syringes were bundled with new vaccines, and, through a time-limited

program, GAVI provided support for AD syringes for all vaccines for infants and women in the

country’s immunization program. Most countries were able to continue the use of AD syringes

after GAVI funding ended. Some countries reported that GAVI support for AD syringes for

immunization influenced their decision to expand AD syringes into non-immunization services,

and to develop injection safety policies for the health sector. [56, 57].

Financing and sustainability

Cost was a consideration in planning new vaccine introduction, including introduction in

developed countries [58]. Utilizing existing infrastructure or combination vaccines reduced the

costs for introduction, as was documented with introduction of DTP-Hib in the US [6],

combination HepA/HepB vaccines in Spain [59], and Hib vaccine in Sweden [33]. In a number

of settings, cost concerns about new vaccine introduction [23] and loss of donor support [28]

resulted in vaccine shortages and program interruptions.


March$26,$2012$ 10$$

A decrease in ambulatory consultations and hospitalizations, disease-related complications, and

long-term sequelae associated with new vaccine introduction was reported from developing and

industrialized countries; these led to reductions in health care utilization, and in some cases

resulted in changes in treatment recommendations, [33, 51, 54, 60-90] (Table 3). Mortality in

sickle cell patients in the US decreased; however, guidelines for penicillin prophylaxis remained

unchanged, because not all pneumococcal serotypes are covered by currently available vaccines

[91]. In Brazil, all-cause diarrhea costs declined following introduction of RV vaccine, but they

were not sufficient to offset the costs of program implementation [83]. Racial and ethnic

disparities in rates of Hib disease incidence in Israel [92] and Australia [93, 94] and of

pneumococcal disease in the US [95] were decreased or eliminated following vaccine

introduction. Populations not targeted by the vaccine experienced reductions in morbidity and

mortality associated with Hib disease [25, 40, 92, 96-101], Streptococcus pneumoniae [50, 84,

102-108], meningococcal disease [13, 19, 109-115], hepatitis A [59], hepatitis B [116], typhoid

fever [16], rotavirus [117-124], human papilloma virus [125, 126], and Japanese encephalitis

[45]; these reductions were attributed to a herd protective effect.

An analysis of 50 country financial sustainability plans [127] developed between 2000 and 2006

in the poorest countries, found that program costs increased from $6.0 per infant before new

vaccine introduction to an average of $17.5 per infant after new vaccine introduction.

Expenditures per infant doubled in countries that introduced tetravalent HepB vaccine, and

increased by a factor of three to four after pentavalent vaccine was introduced. While national

government funding accounts for 42% of overall funding, the study showed funding gaps of $4.3

per infant per year,with some 25% of the expenditure needs remain largely unmet.

Funding sources for immunization are diversifying, including development of innovative

mechanisms such as bridge funding from the Vaccine Fund [46]; World Bank, UNICEF, USAID

and WHO [43]; and the GAVI alliance [127]. An evaluation of four African countries that

applied for early GAVI funding suggested that there was little planning at the country level to

ensure financial sustainability after GAVI funding ended [128]. The government of Malawi

committed to paying 20% of Hib vaccine introduction, but could not sustain a higher financial

share without external support [46].


March$26,$2012$ 11$$

Leadership and governance

New vaccine introduction requires a framework for vaccine licensing, purchasing, legislative

issues, development of introduction plans and national recommendations, public awareness

campaigns, impact evaluation, and safety monitoring. In many countries, including Australia,

Belgium, Canada, Chile, Greece, Taiwan, UK, US, and Uruguay [14, 22, 29, 40, 129, 130],

existing national regulatory institutions and advisory committees were used to license and

develop recommendations for new vaccines. Frequently, subcommittees were formed to develop

the recommendations for the specific vaccine, often in collaboration with academic pediatric and

infectious disease organizations [40] and disease- specific societies [22, 130].

Planning of vaccination campaigns has gone beyond the immunization program to include the

departments of education, health, and defense; academic institutions and local government [20,

22]. In some countries, legislation was enacted to promote vaccine implementation or evaluation.

For example, Italy had a law requiring routine infant HepB vaccination and catch-up vaccination

of unvaccinated adolescents [131], and failure to comply had the potential to result in the

temporary suspension of paternal authority to ensure immunization of the minor [132]. In

Australia, legislation enabled the establishment of the National HPV Vaccination Program

Register, a national registry to collect data to assess HPV vaccination coverage [44].

DISCUSSION

In this comprehensive review of the published literature, we found that new vaccine introduction

had a mixed effect on – and often provided opportunities to strengthen – existing components of

the immunization system. Findings related to impact on the larger health system, however, were

limited. Few reviewed papers were designed to evaluate impacts on immunization systems or

health systems. The information relevant to our review was frequently an incidental finding

noted in the discussion section of the papers. In addition, most of the reviewed papers were from

high- or middle-income countries, whose experiences may not represent those from lower-

income countries, where the impact related to new vaccine introduction – both positive and

negative – is likely to be greater. Our conclusions, therefore, need to be interpreted in the context

of these caveats.


March$26,$2012$ 12$$

The impact on costs and efficiency of introduction differed according to the delivery platform

and vaccine formulation. When vaccine introduction made use of existing delivery strategies,

such as the routine infant immunization program, costs and impact on staffing needs were

substantially less than when vaccines were introduced through newly-created platforms. School-

based programs were documented to be effective platforms for introducing new vaccines to

school-aged children and adolescents, although additional staff was required, even for existing

programs. Venues outside the school were sometimes needed to complete the vaccination series

in a timely fashion. Combination vaccines that added the new antigen or antigens to an existing

vaccine were less costly and more efficiently introduced than those that required an additional

injection.

New vaccine introduction also had an impact on vaccine program logistics and technology.

Disruptions in routine vaccination services were reported, related to insufficient on-hand stock of

vaccine when programs commenced, and in lower-income countries, to funding shortfalls.

Disruptions have also been reported related to global vaccine shortages [133]. A commonly-

reported impact of new vaccine introduction was the need for increased cold chain capacity, such

as was common with the introduction of the early formulations of rotavirus vaccine. [55, 134]. A

comprehensive assessment of cold chain capacity should be included in all pre-vaccine

introduction assessments. New vaccine introductions have highlighted existing shortfalls in the

cold chain and logistics systems. These shortfalls are being resolved through partner and donor

contributions and infrastructure strengthening. As a result of early introduction experiences with

inadequate infrastructure, effective vaccine management (EVM)[135] assessments and regular

cold chain inventories are now a precondition for new GAVI support in order to assure system

readiness for the new vaccine.

Reduced disease incidence following new vaccine introduction led to reported declines in the use

of vaccine preventable disease-related curative health services. Decreased use of antibiotics

resulted in reduced antimicrobial resistance, and herd immunity extended these benefits to

populations not targeted by the vaccines. There was some evidence in high-income countries that

new vaccine introduction was associated with lower use of ambulatory and hospital services and

reduced costs. An important benefit to the health system that has been facilitated by new vaccine

introduction has been the widespread use of AD syringes and awareness of injection safety.


March$26,$2012$ 13$$

Existing infrastructures were utilized and often strengthened to provide information for vaccine

introduction. For example, in many countries, established health information and disease

surveillance systems were enhanced to collect data for policy development, program advocacy,

and impact assessment. In other countries, new systems were developed, especially to monitor

vaccination coverage, safety and effectiveness. These new or enhanced systems can be expanded

and adapted to facilitate introduction of other vaccines, and to improve disease surveillance.

The importance of social mobilization for the public and training and education for health care

workers was frequently noted. The introduction of new vaccines led to the establishment of

legislation intended to improve vaccine delivery or program assessment, including mandatory

newborn vaccination or school entry laws and national vaccine registries.

This review was subject to a number of limitations. Only published papers were included in the

review, although much of the information about the impact of new vaccine introduction is, in

fact, contained in the grey literature [133]. In addition, because the information related to the

impact of new vaccine introduction was rarely the main focus of the reviewed studies, we were

unable to compare studies or evaluate the quality of the data. Because most papers were from

high-income countries, it is difficult to generalize those experiences to low-income countries,

which often have weaker infrastructure, and require donor support to fund their immunization

programs. Although the majority of papers we reviewed were published during the past decade,

we also included reports of introductions from more than 20 years ago; these reports may be less

relevant to current introductions of new vaccines. While it is likely that the impact of vaccine

introduction on a country’s existing immunization and health system reflected the underlying

system strength, evaluating this was beyond the scope of this review.

Health programs in developing countries rarely have predictable, long-term funding from donors.

However, many new mechanisms have been developed to improve financing such as the Vaccine

Independence Initiative [136], the Advanced Market Commitments (AMC) [137] to bring new

vaccines such as pneumococcal vaccine to market sooner with committed donor support and the

International Finance Facility for Immunisation (IFFIms) [138] which uses long-term donor

support to sell ‘vaccine bonds’ have created an unprecedented inflow of funding to global

immunization through GAVI replenishments, improved focus on accountability as part of the

GAVI Alliance, and the Decade of Vaccines Global Action Plan. Another review of country


March$26,$2012$ 14$$

strategies for sustaining immunization and new vaccines [139] found that countries sought to

mobilize additional resources, improve the reliability of existing resources and funding sources,

and increase the efficiency of service delivery. However, even if countries were to fully

implement these strategies, funding gaps would remain and financial sustainability would be far

from assured in most cases. In addition to new funding initiatives, priorities for new vaccine

introduction have expanded include focus on interdepartmental (MoH, MoE) approaches to

vaccine delivery for HPV vaccine, a new UNICEF communications framework, further emphasis

on cold chain readiness before introducing a new vaccine, new and improved adapted vaccine,

presentations with substantially reduced cold chain volume, additional work on out-of-cold-chain

use of vaccines for outreach sessions, new delivery technologies (e.g. jet injectors, films), and

enhanced training of health care workers.

This review of the published literature summarizes the impact of new vaccine introduction on the

immunization system and the larger health system through 2010. While new vaccine

introduction often includes an assessment of disease burden and impact on morbidity and

mortality, a component of future evaluations should include the systematic and objective

assessment of how the vaccine introduction affects the country’s immunization system and

broader health system, especially in lower-income countries.


March$26,$2012$ 15$$

Figure$1:$Health$Systems$Framework$

Source: World$Health$Organization,$Everybody)business):)strengthening)health)systems)to)improve)health)outcomes):)WHO’s)framework))for)action.,$2007,$WHO$Press:$Geneva.$$http://www.who.int/healthsystems/strategy/everybodys_business.pdf$$


March$26,$2012$ 16$$

Table&1:&Search&terms&used&for&systematic&literature&review&of&the&impact&of&new&vaccine&introduction&on&the&immunization&and&health&system&

Vaccine&search&term&category&1$ exp$*Hepatitis$B$Vaccines/$2$ exp$*Haemophilus$Vaccines/$3$ exp$*Pneumococcal$Vaccines/$4$ exp$*Rotavirus$Vaccines/$5$ exp$*Meningococcal$Vaccines/$6$ exp$*Yellow$Fever$Vaccine/$7$ exp$*Japanese$Encephalitis$Vaccines/$8$ exp$*Papillomavirus$Vaccines/$9$ exp$*TyphoidZParatyphoid$Vaccines/$10$ exp$*Cholera$Vaccines/$11$ (HPV$vaccine$or$HPV$vaccines).ab,ti.$12$ (HBV$vaccine$or$HBV$vaccines).ab,ti.$13$ $(hib$vaccine$or$Hib$vaccines).ab,ti.$14$ $new$vaccine.ab,ti.$15$ new$vaccines.ab,ti.$

16$ ((under$utilised$or$underZutilised$or$under$utilized$or$underZutilized$or$underutilised$or$underutilized)$and$(vaccine$or$vaccines)).ab,ti.$

$ &Immunization&and&health&system&search&term&category&17$ exp$Immunization$Programs/$

18$health$planning/$or$health$care$rationing/$or$health$plan$implementation/$or$health$planning$guidelines/$or$health$planning$technical$assistance/$or$health$priorities/$or$health$resources/$or$national$health$programs/$or$exp$regional$health$planning/$

19$ Capacity$Building/$20$ exp$Inservice$Training/$21$ capacity$building.ab,ti.$22$ building$capacity.ab,ti.$23$ skill$development.ab,ti.$24$ "delivery$of$health$care"/$or$health$services$accessibility/$or$healthcare$disparities/$25$ equity.ab,ti$

$$$26$"quality$of$health$care"/$or$clinical$competence/$or$guideline$adherence/$or$exp$"outcome$and$process$assessment$(health$care)"/$or$program$evaluation/$or$quality$assurance,$health$care/$or$benchmarking/$or$clinical$audit/$or$medical$audit/$or$nursing$audit/$or$total$quality$management/$

27$ health$system.ab,ti.$28$ health$systems.ab,ti.$29$ (health$service$or$health$services).ab,ti.$30$ Health$Manpower/$31$ exp$"Patient$Acceptance$of$Health$Care"/$32$ (community$mobilisation$or$community$mobilization).ab,ti.$33$ community$advocacy.ab,ti.$


March$26,$2012$ 17$$

34$

information$systems/$or$integrated$advanced$information$management$systems/$or$management$information$systems/$or$ambulatory$care$information$systems/$or$clinical$pharmacy$information$systems/$or$database$management$systems/$or$healthcare$common$procedure$coding$system/$or$"personnel$staffing$and$scheduling$information$systems"/$

35$ safety.ab,ti.$36$ systems$integration/$

$$$37$ employee$incentive$plans/$or$personnel$loyalty/$or$"personnel$staffing$and$scheduling"/$or$personnel$turnover/$or$physician$incentive$plans/$or$"salaries$and$fringe$benefits"/$or$workload/$

38$ Curriculum/$39$ Forecasting/$40$ Group$Purchasing/$41$ procurement.ab,ti.$42$ logistics.ab,ti.$43$ cold$chain.ab,ti.$44$ financial$management/$or$exp$budgets/$or$fund$raising/$or$risk$management/$or$financial$support/$45$ Health$Services/$46$ Health$Personnel/$47$ Social$Change/$48$ "Organization$and$Administration"/$49$ Product$Surveillance,$Postmarketing/$50$ medical$waste/$or$medical$waste$disposal/$51$ Decision$Making,$Organizational/$52$ policy$making/$or$advisory$committees/$53$ Government$Regulation/$54$ stock.ab,ti.$55$ $Immunologic$Surveillance/$56$ $population$surveillance/$or$sentinel$surveillance/$

57$ $(strain$surveillance$or$serotype$surveillance$or$virological$surveillance$or$epidemiological$surveillance).ab,ti.$

58$ access$to$services.ab,ti.$59$ $(affordability$or$affordable).ab,ti.$60$ $((timeliness$or$timely)$adj3$vaccination).ab,ti.$61$ delivery$strateg*.ab,ti.$62$ integrated$disease$control.ab,ti.$63$ social$mobilization.ab,ti.$64$ (incentiv*$adj3$health$care$worker*).ab,ti.$65$ preZtraining.ab,ti.$66$ (inZservice$training$or$inservice$training).ab,ti.$67$ (career$path$or$career$paths).ab,ti.$68$ wages.ab,ti.$69$ supportive$supervision.ab,ti.$70$ data$quality.ab,ti.$71$ data$collection.ab,ti.$72$ data$management.ab,ti.$


March$26,$2012$ 18$$

73$ health$management$information$system.ab,ti.$74$ impact$monitoring.ab,ti.$75$ adverse$events$following$immunization.ab,ti.$76$ AEFI.ab,ti.$77$ (post$marketing$adj3$evaluation).ab,ti.$78$ (demand$and$supply$forecasting).ab,ti.$79$ (demand$adj3$forecasting).ab,ti.$80$ (supply$adj3$forecasting).ab,ti.$81$ (stock*$adj3$manag*).ab,ti.$82$ pooled$procurement*.ab,ti.$83$ (effective$adj3$vaccine$management).ab,ti.$84$ financing.ab,ti.$85$ (vaccine*$adj3$price*).ab,ti.$86$ healthy$market*.ab,ti.$87$ fiscal$space.ab,ti.$88$ budget$support.ab,ti.$89$ (donor*$adj3$pool*).ab,ti.$90$ SWAp.ab,ti.$91$ opportunity$cost*.ab,ti.$

92$

(national$regulatory$agenc*$or$national$immunization$technical$advisory$group*$or$national$immunisation$technical$advisory$group*$or$legislation$or$governance$or$accountability$or$interZagency$coordinating$committee*$or$interagency$coordinating$committee*).ti,ab.$

93$((treatment$adj3$cost*)$or$(hospitalization$adj3$cost*)$or$(hospitalisation$adj3$cost*)$or$(norms$adj3$standards)).ti,ab.$

94$ (storage$adj3$capacity).ab,ti.$$95$ (storage$adj3$volume).ab,ti.$$$96$ (vaccine*$adj3$stor*).ab,ti.$97$ (vaccine*$adj3$handl*).ab,ti.$$98$ (vaccine*$adj5$distribut*).ab,ti.$$$$99$ (vaccine*$adj5$transport*).ab,ti.$$$$100$ $((supply$or$supplies)$adj5$(frequen*$or$interval*)).ab,ti.$$$$101$ $logistic*.ab,ti.$$$102$ $((immunization$adj3$expenditure*)$or$(immunisation$adj3$expenditure*)).ab,ti.$103$ exp$"health$care$economics$and$organizations"/$$104$ $(economics$or$legislation$jurisprudence).fs.$$


March$26,$2012$ 19$$

Figure&2:&&Search&method&algorithm&used&for&systematic&literature&review&of&the&impact&of&new&vaccine&introduction&on&the&immunization&and&health&system


March$26,$2012$ 20$$

Table 2. Literature cited according to World Bank income level, country, and vaccine(s) discussed for vaccines introduced 1980-2008*

World Bank income level‡

Country No. references

Vaccine(s) [reference]

High Australia 10 Hib [93, 94]; HPV [10, 15, 34, 44, 125]; PCV [32, 107]; Rota [124]

Austria 1 Rota [118]

Belgium 1 HPV [129]

Canada 15 HBV [12, 26]; Hib [25, 96]; Influenza [71]; MenPS/Conj [19, 111-113]; PCV [11, 50, 78, 140]; PPV23 [49]

Finland 1 Hib [67]

Germany 2 HAV [3]; PCV [103]

Great Britain 13 Hib [27, 64, 97]; HPV [24, 36]; MenPS/Conj [14, 17, 30, 110, 114, 115]; PCV [73]; PPV23 [35]

Greece 1 HBV [130]

Israel 2 Hib [31, 92]

Italy 9 HBV [42, 57, 79, 80, 131, 132]; PCV [89]; PPV23 [88], Rota [76]

New Zealand 1 MenB [52]

Singapore 1 HBV [5]

Spain 3 HAV/HBV [59]; Hib [98]; Mening [109]

Sweden 1 Hib [33]

Taiwan 4 HBV [22, 81, 82, 116]

USA 27 Combo (DTP/Hib/HB/IPV) [6]; Hib [86]; HPV [37]; PCV [2, 60, 61, 63, 65, 66, 68, 69, 72, 75, 84, 87, 90, 91, 95, 102, 104, 105, 108]; PPV23 [77]; Rota [85, 120-123]

Multi1 1 Hib [70]

Multi2,3,4 3 HPV [18, 29, 126]

Total refs, (% of total) high income countries

97 (75)

Middle Brazil 1 Rota [83]

Chile 1 Hib [53]

Cuba 1 Hib [99]

Egypt 1 Mening PS [13]

El Salvador 1 Rota [119]

Indonesia 1 Typhoid [20]

Mexico 1 Rota [117]

Nicaragua 1 Rota [48]

Peru 1 HBV [9]

People's Republic of China

5 HBV [4, 21, 38]; JE [45]; HAV/JE [39]

Senegal 1 Combo (DTP/Hib/HB/IPV) [100]

South Africa 2 HBV [51]; Hib [47]


March$26,$2012$ 21$$

Thailand 1 HBV [7]

Multi5,6 1 Hib [40]

Multi7 1 Typhoid [16]

Multi8 1 Rota [55]

Total refs, (% of total) lower and upper middle income countries

21 [16]

Low Ethiopia 1 Combo (DTP/Hib/HB/IPV) [43]

Gambia 1 Hib [54]

Malawi 1 Hib [46]

Zimbabwe 1 HBV [28]

Total refs, (% of total) low income countries

4 (3)

Not classified§ 18 European countries 1 HPV [58]

50 GAVI-eligible countries

1 HBV & Hib [127]

Americas 1 Hib [41]

Multi9, 10 2 Hib [23, 128]

Global 1 HBV [8]

Global11 1 Hib [101]

Total refs, (% of total) not classified 7 (5)

Literature review Multi12 1 PCV [74]

Total literature reviews (% of total)

1 (0.8)

Total refs 129**

*Year of vaccine introduction (Number [%] of references): 1980-1989 - 14 (12%); 1990-1999 - 37 (32%); 2000-2007 - 64 (56%); 115/129 (89%) specified studies the year of introduction

‡Based on Gross National Income (GNI) per capita. Low:≤USD1005; Middle: USD1006-12,275 (includes lower middle [USD1006-3975] and upper middle [USD3976-12275]); High:≥USD12,276

§Studies done in multiple countries with different World Bank income levels **1 reference which came were identified by the authors and not by the literature search for inclusion are not included in the table

1Finland, Iceland, Germany, Switzerland 2USA & Canada 3USA, Puerto Rico, Canada 4Italy & Belgium 5Chile & Uruguay 6South Africa & Argentina 7Thailand, China, Vietnam, India, Indonesia, Pakistan 8Brazil, Ecuador, El Salvador, Panama, Mexico, Nicaragua, Venezuela 9Ghana, Mozambique, Tanzania, Lesotho 10Qatar, Uruguay, Chile, Kuwait 11US Army beneficiaries 12US, UK, Norway, Netherlands, Germany, Canada, Switzerland, Spain, Australia


March$26,$2012$ 22$$

Table 3. Impact on health care utilization and economic impact (where documented) following new vaccine introduction in selected countries.

Vaccine(s) Outcome(s) Country(ies) Reference(s) Reported economic impact

HBV Decrease in acute hepatitis B; hepatocellular carcinoma, HBV-associated glomerulonephritis

Italy, South Africa, Taiwan [51, 79-82] Estimated US$224M savings in acute health care costs [79, 80] per year

Hib Decrease in ambulatory consultations and hospitalizations for meningitis, epiglottitis, orbital and periorbital cellulitis and septic arthritis; change in empiric antibiotic recommendations

Gambia, Sweden, Finland, Wales, US, Iceland, Germany, Switzerland, Canada, UK, Netherlands, Australia, New Zealand

[33, 54, 64, 67, 70, 86] Modeled cost savings to society [33]

Influenza Decrease in hospitalizations Canada [71] PCV7,10,13 Fewer antibiotic-resistant infections; decrease in

hospitalizations for pneumonia, outpatient and emergency department visits for otitis media, pneumonia, and other respiratory infections, fever; invasive pneumococcal disease in HIV-infected persons; decrease in antibiotic prescriptions, insurance claims for otitis media, tympanostomy tube placement; change in recommendations for fever evaluation among vaccinated children

US, Canada, Italy, England, multi-country literature review

[60, 63, 65, 66, 68, 69, 72-75, 78, 84, 87, 89, 90, 140]

Vaccine cost-effective, and in some cases, cost-saving [84]

PPV23 Decrease in otitis media and pneumonia Italy, US [77, 88] Vaccination cost-saving [88]

Rotavirus Decrease in hospitalizations, outpatient and emergency department visit for all-cause and rotavirus gastroenteritis

Brazil, Italy, US [61, 76, 83, 85] Decreased curative health care costs [61, 76, 83]; increase [83] or no decrease [76] in health system costs.


March$26,$2012$ 23$$

References

1.$ World$Health$Organization,$Everybody)business):)strengthening)health)systems)to)improve)health)outcomes):)WHO’s)framework)

for)action.,$2007,$WHO$Press:$Geneva.$2.$ Szilagyi,$P.G.,$et$al.,$The)impact)of)conjugate)pneumococcal)vaccination)on)routine)childhood)

vaccination)and)primary)care)use)in)2)counties.$Pediatrics,$2006.$118(4):$p.$1394L1402.$3.$ Kalies,$H.,$et$al.,$The)use)of)combination)vaccines)has)improved)timeliness)of)vaccination)in)

children.$Pediatric$Infectious$Disease$Journal,$2006.$25(6):$p.$507L12.$4.$ Gong,$J.,$et$al.,$[LongDterm)efficacy)of)infant)hepatitis)B)immunization)program].$Chung$Hua$Kan$

Tsang$Ping$Tsa$Chih,$2003.$11(4):$p.$203L5.$5.$ Goh,$K.T.,$Prevention)and)control)of)hepatitis)B)virus)infection)in)Singapore.$Annals$of$the$

Academy$of$Medicine$Singapore,$1997.$26(5):$p.$671L681.$6.$ Freed,$G.L.,$et$al.,$Factors)affecting)physicians')early)adoption)of)combined)DTPDHib)vaccine.$

Ambulatory$Child$Health,$1997.$3(1$I):$p.$27L33.$7.$ Chunsuttiwat,$S.,$et$al.,$Integration)of)hepatitis)B)vaccination)into)the)expanded)programme)on)

immunization)in)Chonburi)and)Chiangmai)provinces,)Thailand.$Vaccine,$1997.$15(6L7):$p.$769L74.$8.$ Centers$for$Disease,$C.$and$Prevention,$Global)progress)toward)universal)childhood)hepatitis)B)

vaccination,)2003.$MMWR$L$Morbidity$&$Mortality$Weekly$Report,$2003.$52(36):$p.$868L70.$9.$ Cabezas,$C.,$et$al.,$[Pilot)program)of)immunization)against)viral)hepatitis)B,)integrated)in)the)

extended)immunization)program)in)Abancay)(peru)].$Revista$de$Gastroenterologia$del$Peru,$1995.$15(3):$p.$215L22.$

10.$ Brotherton,$J.M.L.,$et$al.,$Interim)estimates)of)human)papillomavirus)vaccination)coverage)in)the)schoolDbased)program)in)Australia.$Communicable$Diseases$Intelligence,$2008.$32(4):$p.$457L61.$

11.$ De$Wals,$P.,$et$al.$,$Uptake)of)Pneumococcal)Conjugate)Vaccine:)Methodological)Issues)in)Measurement)and)Impact)of)Publicly)Funded)Programs.$Canadian$Journal$of$Public$Health$Revue$Canadienne$de$Sante$Publique,$2009.$100(6):$p.$413L6.$

12.$ Dobson,$S.,$D.$Scheifele,$and$A.$Bell,$Assessment)of)a)universal,)schoolDbased)hepatitis)B)vaccination)program.$JAMA,$1995.$274(15):$p.$1209L13.$

13.$ Nakhla,$I.,$et$al.,$The)changing)epidemiology)of)meningococcal)meningitis)after)introduction)of)bivalent)A/C)polysaccharide)vaccine)into)schoolDbased)vaccination)programs)in)Egypt.$Vaccine,$2005.$23(25):$p.$3288L93.$

14.$ Miller,$E.,$D.$Salisbury,$and$M.$Ramsay,$Planning,)registration,)and)implementation)of)an)immunisation)campaign)against)meningococcal)serogroup)C)disease)in)the)UK:)a)success)story.$Vaccine,$2001.$20*Suppl*1:$p.$S58L67.$

15.$ Leask,$J.,$et$al.,$Implementation)of)the)Australian)HPV)vaccination)program)for)adult)women:)qualitative)key)informant)interviews.$Vaccine,$2009.$27(40):$p.$5505L12.$

16.$ DeRoeck,$D.,$et$al.,$Typhoid)vaccination:)the)Asian)experience.$Expert$Review$of$Vaccines,$2008.$7(5):$p.$547L60.$

17.$ Campbell,$H.,$et$al.,$Meningococcal)C)conjugate)vaccine:)the)experience)in)England)and)Wales.$Vaccine,$2009.$27*Suppl*2:$p.$B20L9.$

18.$ Borruto,$F.$and$K.$Hoppenbrouwers,$HPV)vaccination)in)adolescents:)From)clinical)data)to)implementation)and)practice.$Current$Cancer$Therapy$Reviews,$2010.$6(2):$p.$138L142.$

19.$ Bettinger,$J.A.,$et$al.,$The)impact)of)childhood)meningococcal)serogroup)C)conjugate)vaccine)programs)in)Canada.$Pediatric$Infectious$Disease$Journal,$2009.$28(3):$p.$220L4.$


March$26,$2012$ 24$$

20.$ Agtini,$M.D.,$et$al.,$Introducing)Vi)polysaccharide)typhoid)fever)vaccine)to)primary)school)children)in)North)Jakarta,)Indonesia,)via)an)existent)schoolDbased)vaccination)platform.$Public$Health,$2006.$120(11):$p.$1081L7.$

21.$ Jiang,$H.,$et$al.,$Evaluation)on)immunization)effect)of)hepatitis)B)vaccine)of)GAVI)project)in)Fukang)City,)Xinjiang.$Endemic$Diseases$Bulletin$/$Di$Fang$Bing$Tong$Bao,$2010.$25(2):$p.$27L28.$

22.$ Chien,$Y.LC.,$et$al.,$Nationwide)hepatitis)B)vaccination)program)in)Taiwan:)effectiveness)in)the)20)years)after)it)was)launched.$Epidemiologic$Reviews,$2006.$28:$p.$126L35.$

23.$ Wenger,$J.D.,$et$al.,$Introduction)of)Hib)conjugate)vaccines)in)the)nonDindustrialized)world:)experience)in)four)'newly)adopting')countries.$Vaccine,$1999.$18(7L8):$p.$736L42.$

24.$ Green,$D.$and$D.$Catlow,$Immunisation)against)human)papilloma)virus)in)a)primary)care)trust:)a)report)on)the)first)three)months)of)the)national)campaign.$Journal$of$Infection$Prevention,$2009.$10(3):$p.$112L115.$

25.$ Scheifele,$D.,$Hib)conjugate)vaccines:)lessons)learned.$International$Journal$of$Clinical$Practice,$2001.$Supplement.(118):$p.$8L9.$

26.$ Bigham,$M.,$et$al.,$Uptake)and)behavioural)and)attitudinal)determinants)of)immunization)in)an)expanded)routine)infant)hepatitis)B)vaccination)program)in)British)Columbia.$Canadian$Journal$of$Public$Health$Revue$Canadienne$de$Sante$Publique,$2006.$97(2):$p.$90L5.$

27.$ Salisbury,$D.M.,$The)introduction)of)Haemophilus)influenzae)type)b)immunization)into)the)United)Kingdom:)practical)steps)to)assure)success.$Pediatric$Infectious$Disease$Journal,$1998.$17(9$Suppl):$p.$S136L9.$

28.$ Chihota,$V.$and$S.A.$Tswana,$Hepatitis)B)prevention)and)vaccination)in)Zimbabwe.$Southern$African$Journal$of$Epidemiology$&$Infection,$2002.$17(3/4(Supplement)):$p.$60L62.$

29.$ Shefer,$A.,$et$al.,$Early)experience)with)human)papillomavirus)vaccine)introduction)in)the)United)States,)Canada)and)Australia.$Vaccine,$2008.$26*Suppl*10:$p.$K68L75.$

30.$ Salisbury,$D.,$Introduction)of)a)conjugate)meningococcal)type)C)vaccine)programme)in)the)UK.$Journal$of$Paediatrics$&$Child$Health,$2001.$37(5):$p.$S34L6;$discussion$37.$

31.$ Dagan,$R.,$et$al.,$Effectiveness)of)a)nationwide)infant)immunization)program)against)Haemophilus)influenzae)b.)The)Israeli)Pediatric)Bacteremia)and)Meningitis)Group.$Vaccine,$1999.$17(2):$p.$134L41.$

32.$ Hanna,$J.N.,$et$al.,$An)assessment)of)the)implementation)of)the)pneumococcal)conjugate)vaccination)program)for)Aboriginal)and)Torres)Strait)infants)in)north)Queensland.$Communicable$Diseases$Intelligence,$2003.$27(2):$p.$262L6.$

33.$ Garpenholt,$O.,$S.A.$Silfverdal,$and$L.A.$Levin,$Economic)evaluation)of)general)childhood)vaccination)against)Haemophilus)influenzae)type)b)in)Sweden.$Scandinavian$Journal$of$Infectious$Diseases,$1998.$30(1):$p.$5L10.$

34.$ Brotherton,$J.M.L.,$et$al.,$National)survey)of)general)practitioners)experience)of)delivering)the)national)human)papillomavirus)vaccination)program.$Sexual$Health,$2010.$7(3):$p.$291L298.$

35.$ Breen,$D.,$Pneumococcal)vaccination)programme)in)over)65s)and)atDrisk)groups:)the)Dumfries)and)Galloway)experience.$Communicable$Disease$&$Public$Health,$2003.$6(3):$p.$228L30.$

36.$ More)Nurses)Needed)for)HPV)Scheme.$Community$Practitioner,$2008.$81(10):$p.$4L7.$37.$ Henderson,$C.E.,$et$al.,$HPV)vaccination)practices)among)juvenile)justice)facilities)in)the)United)

States.$Journal$of$Adolescent$Health,$2010.$46(5):$p.$495L8.$38.$ Ushiur,$F.,$Patigul,$and$Q.$Liu,$Survey)and)analysis)of)hepatitis)B)virus)vaccine)application)in)

Xinjiang)from)2003)to)2006.$Endemic$Diseases$Bulletin$/$Di$Fang$Bing$Tong$Bao,$2008.$23(6):$p.$25L26,$29.$

39.$ Yuan,$J.,$et$al.,$Analysis)of)the)vaccination)program)after)Wenchuan)earthquake)in)Sichuan,)2008.$Journal$of$Tropical$Medicine$(Guangzhou),$2008.$8(8):$p.$833L835.$


March$26,$2012$ 25$$

40.$ Landaverde,$M.,$et$al.,$[Introduction)of)a)conjugate)vaccine)against)Hib)in)Chile)and)Uruguay].$Pan$American$Journal$of$Public$Health,$1999.$5(3):$p.$200L6.$

41.$ DanovaroLHolliday,$M.C.,$et$al.,$Progress)in)vaccination)against)Haemophilus)influenzae)type)b)in)the)Americas.$PLoS$Medicine$/$Public$Library$of$Science,$2008.$5(4):$p.$e87.$

42.$ Stroffolini,$T.,$P.$Pasquini,$and$A.$Mele,$A)nationwide)vaccination)programme)in)Italy)against)hepatitis)B)virus)infection)in)infants)of)hepatitis)B)surface)antigenDcarrier)mothers.$Vaccine,$1989.$7(2):$p.$152L154.$

43.$ Griffiths,$U.K.,$et$al.,$Incremental)system)costs)of)introducing)combined)DTwPDhepatitis)BDHib)vaccine)into)national)immunization)services)in)Ethiopia.$Vaccine,$2009.$27(9):$p.$1426L32.$

44.$ Brotherton,$J.M.L.$and$R.M.$Mullins,$Estimating)coverage)of)the)National)HPV)Vaccination)Program:)where)are)we)at?$Medical$Journal$of$Australia,$2009.$191(3):$p.$188.$

45.$ Pan,$X.H.,$et$al.,$Epidemiological)characteristics)and)related)influencing)factors)on)Japanese)encephalitis)in)Hainan)Province.)[Chinese].$Zhonghua$liu$xing$bing$xue$za$zhi$=$Zhonghua$liuxingbingxue$zazhi,$2009.$30(5):$p.$471L474.$

46.$ Daza,$P.,$et$al.,$The)impact)of)routine)infant)immunization)with)Haemophilus)influenzae)type)b)conjugate)vaccine)in)Malawi,)a)country)with)high)human)immunodeficiency)virus)prevalence.$Vaccine,$2006.$24(37L39):$p.$6232L6239.$

47.$ von$Gottberg,$A.,$et$al.,$Impact)of)conjugate)Haemophilus)influenzae)type)b)(Hib))vaccine)introduction)in)South)Africa.$Bulletin$of$the$World$Health$Organization,$2006.$84(10):$p.$811L8.$

48.$ Patel,$M.,$et$al.,$Association)between)pentavalent)rotavirus)vaccine)and)severe)rotavirus)diarrhea)among)children)in)Nicaragua.$JAMA,$2009.$301(21):$p.$2243L51.$

49.$ Ndiaye,$A.A.,$et$al.,$Impact)of)a)mass)immunization)campaign)to)control)an)outbreak)of)severe)respiratory)infections)in)Nunavik,)northern)Canada.$International$Journal$of$Circumpolar$Health,$2006.$65(4):$p.$297L304.$

50.$ Bettinger,$J.A.,$et$al.,$The)effect)of)routine)vaccination)on)invasive)pneumococcal)infections)in)Canadian)children,)Immunization)Monitoring)Program,)Active)2000D2007.$Vaccine,$2010.$28(9):$p.$2130L6.$

51.$ Bhimma,$R.,$et$al.,$The)impact)of)the)hepatitis)B)virus)vaccine)on)the)incidence)of)hepatitis)B)virusDassociated)membranous)nephropathy.$Archives$of$Pediatrics$&$Adolescent$Medicine,$2003.$157(10):$p.$1025L30.$

52.$ O'Hallahan,$J.,$et$al.,$Delivering)a)safe)and)effective)strainDspecific)vaccine)to)control)an)epidemic)of)group)B)meningococcal)disease.$New$Zealand$Medical$Journal,$2009.$122(1291):$p.$48L59.$

53.$ Lagos,$R.,$et$al.,$The)introduction)of)routine)Haemophilus)influenzae)type)b)conjugate)vaccine)in)Chile:)a)framework)for)evaluating)new)vaccines)in)newly)industrializing)countries.$Pediatric$Infectious$Disease$Journal,$1998.$17(9$Suppl):$p.$S139L48.$

54.$ Adegbola,$R.A.,$et$al.,$Elimination)of)Haemophilus)influenzae)type)b)(Hib))disease)from)The)Gambia)after)the)introduction)of)routine)immunisation)with)a)Hib)conjugate)vaccine:)a)prospective)study.$Lancet,$2005.$366(9480):$p.$144L50.$

55.$ de$Oliveira,$L.H.,$et$al.,$Rotavirus)vaccine)introduction)in)the)Americas:)progress)and)lessons)learned.$Expert$Review$of$Vaccines,$2008.$7(3):$p.$345L53.$

56.$ Levin,$A.,$et$al.,$A)global)health)partnership's)use)of)timeDlimited)support)to)catalyze)health)practice)change:)the)case)of)GAVI's)Injection)Safety)Support.$PloS$one,$2010.$5(9):$p.$e12986.$

57.$ Cui,$F.LQ.,$X.LH.$Gong,$and$Y.LS.$Chen,$[Evaluation)on)impact)of)hepatitis)B)vaccine)integrated)into)routine)immunization)in)the)areas)of)Ministry)of)Health/Global)Alliance)for)Vaccine)and)Immunization)(GAVI))Cooperation)Project)P.R.)China].$Zhongguo$Jihua$Mianyi,$2009.$15(4):$p.$289L93.$


March$26,$2012$ 26$$

58.$ Dorleans,$F.,$et$al.,$The)current)state)of)introduction)of)human)papillomavirus)vaccination)into)national)immunisation)schedules)in)Europe:)first)results)of)the)VENICE2)2010)survey.$Eurosurveillance,$2010.$15(47):$p.$19730.$

59.$ Dominguez,$A.,$et$al.,$Effectiveness)of)a)mass)hepatitis)A)vaccination)program)in)preadolescents.$Vaccine,$2003.$21(7L8):$p.$698L701.$

60.$ Zhou,$F.,$et$al.,$Trends)in)acute)otitis)mediaDrelated)health)care)utilization)by)privately)insured)young)children)in)the)United)States,)1997D2004.$Pediatrics,$2008.$121(2):$p.$253L60.$

61.$ Wang,$F.T.,$et$al.,$Effectiveness)of)the)pentavalent)rotavirus)vaccine)in)preventing)gastroenteritis)in)the)United)States.$Pediatrics,$2010.$125(2):$p.$e208L13.$

62.$ De$Wals,$P.D.,$et$al.$$ $ ,$Reduced)Physician)Claims)for)Otitis)Media)after)Implementation)of)Pneumococcal)Conjugate)Vaccine)Program)in)the)Province)of)Quebec,)Canada.$Pediatric$Infectious$Disease$Journal,$2009.$28(9):$p.$e271L5.$

63.$ Talbot,$T.R.,$et$al.,$Reduction)in)high)rates)of)antibioticDnonsusceptible)invasive)pneumococcal)disease)in)tennessee)after)introduction)of)the)pneumococcal)conjugate)vaccine.$Clinical$Infectious$Diseases,$2004.$39(5):$p.$641L8.$

64.$ Shoaib,$A.,$et$al.,$The)effects)of)mass)immunization)on)Haemophilus)influenzae)type)BDrelated)orthopaedic)disease.$Journal$of$Pediatric$Orthopaedics,$Part$B,$2007.$16(3):$p.$236L8.$

65.$ Ramilo,$O.,$et$al.,$PCVD7)vaccine:)Changing)the)epidemiology)of)acute)otitis)media.$Advanced$Studies$in$Medicine,$2004.$4(10$E):$p.$S928LS936+S952LS953.$

66.$ Poehling,$K.A.,$et$al.,$PopulationDbased)impact)of)pneumococcal)conjugate)vaccine)in)young)children.$Pediatrics,$2004.$114(3):$p.$755L761.$

67.$ Peltola,$H.,$M.J.$Kallio,$and$L.$UnkilaLKallio,$Reduced)incidence)of)septic)arthritis)in)children)by)Haemophilus)influenzae)typeDb)vaccination.)Implications)for)treatment.$Journal$of$Bone$&$Joint$Surgery$L$British$Volume,$1998.$80(3):$p.$471L3.$

68.$ Nigrovic,$L.E.$and$R.$Malley,$Evaluation)of)the)febrile)child)3)to)36)months)old)in)the)era)of)pneumococcal)conjugate)vaccine:)Focus)on)occult)bacteremia.$Clinical$Pediatric$Emergency$Medicine,$2004.$5(1):$p.$13L19.$

69.$ Nelson,$J.C.,$et$al.,$Impact)of)the)introduction)of)pneumococcal)conjugate)vaccine)on)rates)of)community)acquired)pneumonia)in)children)and)adults.$Vaccine,$2008.$26(38):$p.$4947L54.$

70.$ Madore,$D.V.,$Impact)of)immunization)on)Haemophilus)influenzae)type)b)disease.$Infectious$Agents$and$Disease,$1996.$5(1):$p.$8L20.$

71.$ Kwong,$J.C.,$et$al.,$The)Effect)of)Universal)Influenza)Immunization)on)Mortality)and)Health)Care)Use.$Plos$Medicine,$2008.$5(10):$p.$1440L1452.$

72.$ Kourtis,$A.P.,$et$al.,$Hospitalizations)for)invasive)pneumococcal)disease)among)human)immunodeficiency)virusD1)infected)children,)adolescents)and)young)adults)in)the)United)States)in)the)era)of)highly)active)antiretroviral)therapy)and)the)conjugate)pneumococcal)vaccine.$Pediatric$Infectious$Disease$Journal,$2010.$29(6):$p.$561L563.$

73.$ Koshy,$E.,$et$al.,$Impact)of)the)sevenDvalent)pneumococcal)conjugate)vaccination)(PCV7))programme)on)childhood)hospital)admissions)for)bacterial)pneumonia)and)empyema)in)England:)National)timeDtrends)study,)1997D2008.$Thorax,$2010.$65(9):$p.$770L774.$

74.$ Isaacman,$D.J.,$et$al.,$Indirect)effects)associated)with)widespread)vaccination)of)infants)with)heptavalent)pneumococcal)conjugate)vaccine)(PCV7;)Prevnar).$Vaccine,$2007.$25(13):$p.$2420L7.$

75.$ Grijalva,$C.G.,$et$al.,$Decline)in)pneumonia)admissions)after)routine)childhood)immunisation)with)pneumococcal)conjugate)vaccine)in)the)USA:)a)timeDseries)analysis.$Lancet,$2007.$369(9568):$p.$1179L1186.$

76.$ Giammanco,$M.D.,$et$al.,$An)economic)analysis)of)rotavirus)vaccination)in)Italy.$Vaccine,$2009.$27(29):$p.$3904L11.$


March$26,$2012$ 27$$

77.$ Gable,$C.B.,$et$al.,$Pneumococcal)vaccine.)Efficacy)and)associated)cost)savings.$Journal$of$the$American$Medical$Association,$1990.$264(22):$p.$2910L2915.$

78.$ De$Wals,$P.,$et$al.,$Pneumonia)after)implementation)of)the)pneumococcal)conjugate)vaccine)program)in)the)province)of)Quebec,)Canada.$Pediatric$Infectious$Disease$Journal,$2008.$27(11):$p.$963L8.$

79.$ Da$Villa,$G.$and$A.$Sepe,$Immunization)programme)against)hepatitis)B)virus)infection)in)Italy:)CostDeffectiveness.$Vaccine,$1999.$17(13L14):$p.$1734L1738.$

80.$ Da$Villa,$G.,$Rationale)for)the)infant)and)adolescent)vaccination)programmes)in)Italy.$Vaccine,$2000.$18*Suppl*1:$p.$S31L4.$

81.$ Chang,$M.H.,$et$al.,$Hepatitis)B)vaccination)and)hepatocellular)carcinoma)rates)in)boys)and)girls.$JAMA,$2000.$284(23):$p.$3040L2.$

82.$ Chang,$M.H.,$et$al.,$Universal)hepatitis)B)vaccination)in)Taiwan)and)the)incidence)of)hepatocellular)carcinoma)in)children.)Taiwan)Childhood)Hepatoma)Study)Group.$New$England$Journal$of$Medicine,$1997.$336(26):$p.$1855L9.$

83.$ Centenari,$C.,$et$al.,$Rotavirus)vaccination)in)northeast)Brazil:)a)laudable)intervention,)but)can)it)lead)to)costDsavings?$Vaccine,$2010.$28(25):$p.$4162L8.$

84.$ Black,$S.,$et$al.,$Postlicensure)surveillance)for)pneumococcal)invasive)disease)after)use)of)heptavalent)pneumococcal)conjugate)vaccine)in)Northern)California)Kaiser)Permanente.$Pediatric$Infectious$Disease$Journal,$2004.$23(6):$p.$485L9.$

85.$ Bégué,$R.E.$and$K.$Perrin,$Reduction)in)gastroenteritis)with)the)use)of)pentavalent)rotavirus)vaccine)in)a)primary)practice.$Pediatrics,$2010.$126(1):$p.$e40L5.$

86.$ Barone,$S.R.$and$L.T.$Aiuto,$Periorbital)and)orbital)cellulitis)in)the)Haemophilus)influenzae)vaccine)era.$Journal$of$Pediatric$Ophthalmology$and$Strabismus,$1997.$34(5):$p.$293L296.$

87.$ Balazs,$G.C.,$F.J.$Garcia,$and$L.G.$Yamamoto,$Conjugate)heptavalent)pneumococcal)vaccine)outcome)improvements.$Hawaii$Medical$Journal,$2006.$65(10):$p.$288L9.$

88.$ Ansaldi,$F.,$et$al.,$Effectiveness)of)a)23Dvalent)polysaccharide)vaccine)in)preventing)pneumonia)and)nonDinvasive)pneumococcal)infection)in)elderly)people:)a)largeDscale)retrospective)cohort)study.$Journal$of$International$Medical$Research,$2005.$33(5):$p.$490L500.$

89.$ Ansaldi,$F.,$et$al.,$Decline)in)pneumonia)and)acute)otitis)media)after)the)introduction)of)childhood)pneumococcal)vaccination)in)Liguria,)Italy.$The$Journal$of$international$medical$research,$2008.$36(6):$p.$1255L1260.$

90.$ Poehling,$K.A.,$et$al.,$Reduction)of)frequent)otitis)media)and)pressureDequalizing)tube)insertions)in)children)after)introduction)of)pneumococcal)conjugate)vaccine.$Pediatrics,$2007.$119(4):$p.$707L715.$

91.$ Adamkiewicz,$T.V.,$et$al.,$Effectiveness)of)the)7Dvalent)pneumococcal)conjugate)vaccine)in)children)with)sickle)cell)disease)in)the)first)decade)of)life.$Pediatrics,$2008.$121(3):$p.$562L569.$

92.$ GortzakLUzan,$L.,$D.$Fraser,$and$R.$Dagan,$Epidemiology)of)invasive)Hemophilus)influenzae)B)infections)in)Bedouins)and)Jews;)conjugate)Hib)vaccines.)[Hebrew].$Harefuah,$1998.$135(5L6):$p.$175L180,$256.$

93.$ McIntyre,$P.B.,$T.$Chey,$and$W.T.$Smith,$THE)IMPACT)OF)VACCINATION)AGAINST)INVASIVE)HAEMOPHILUSDINFLUENZAE)TYPEDB)DISEASE)IN)THE)SYDNEY)REGION.$Medical$Journal$of$Australia,$1995.$162(5):$p.$245L248.$

94.$ Bower,$C.,$et$al.,$Measuring)the)impact)of)conjugate)vaccines)on)invasive)Haemophilus)influenzae)type)b)infection)in)Western)Australia.$Australian$&$New$Zealand$Journal$of$Public$Health,$1998.$22(1):$p.$67L72.$

95.$ Talbot,$T.R.,$et$al.,$Elimination)of)racial)differences)in)invasive)pneumococcal)disease)in)young)children)after)introduction)of)the)conjugate)pneumococcal)vaccine.$Pediatric$Infectious$Disease$Journal,$2004.$23(8):$p.$726L31.$


March$26,$2012$ 28$$

96.$ Scheifele,$D.W.,$et$al.,$Recent)trends)in)pediatric)Haemophilus)influenzae)type)b)infections)in)Canada.$Canadian$Medical$Association$Journal,$1996.$154(7):$p.$1041L1047.$

97.$ Ladhani,$S.,$et$al.,$Fall)in)Haemophilus)influenzae)serotype)b)(Hib))disease)following)implementation)of)a)booster)campaign.$Archives$of$Disease$in$Childhood,$2008.$93(8):$p.$665L669.$

98.$ DiezLDomingo,$J.,$et$al.,$Impact)of)nonDroutine)vaccination)on)the)incidence)of)invasive)Haemophilus)influenzae)type)b)(Hib))disease:)experience)in)the)autonomous)region)of)Valencia,)Spain.$Journal$of$Infection,$2001.$42(4):$p.$257L60.$

99.$ Dickinson,$F.O.,$et$al.,$[Impact)of)vaccination)against)Haemophilus)influenzae)type)b)in)Cuba].$Pan$American$Journal$of$Public$Health,$2001.$10(3):$p.$169L73.$

100.$ Cisse,$M.F.,$et$al.,$The)elimination)of)haemophilus)influenzae)type)b)meningitis)following)conjugate)vaccine)introduction)in)senegal.$Pediatric$Infectious$Disease$Journal,$2010.$29(6):$p.$499L503.$

101.$ Broadhurst,$L.E.,$R.L.$Erickson,$and$P.W.$Kelley,$Decreases)in)invasive)Haemophilus)influenzae)diseases)in)US)Army)children,)1984)through)1991.$JAMA,$1993.$269(2):$p.$227L31.$

102.$ Whitney,$C.G.,$et$al.,$Decline)in)invasive)pneumococcal)disease)after)the)introduction)of)proteinDpolysaccharide)conjugate)vaccine.$New$England$Journal$of$Medicine,$2003.$348(18):$p.$1737L46.$

103.$ van$der$Linden,$M.,$R.R.$Reinert,$and$M.$Imohl,$The)National)Immunization)Programme)for)pneumococcal)conjugate)vaccine)in)Germany)D)first)signs)of)a)herd)immunity)effect)in)adults.$International$Journal$of$Medical$Microbiology,$2009.$299:$p.$85L85.$

104.$ Shafinoori,$S.,$et$al.,$Impact)of)pneumococcal)conjugate)vaccine)and)the)severity)of)winter)influenzaDlike)illnesses)on)invasive)pneumococcal)infections)in)children)and)adults.$Pediatric$Infectious$Disease$Journal,$2005.$24(1):$p.$10L6.$

105.$ Poehling,$K.A.,$et$al.,$Invasive)pneumococcal)disease)among)infants)before)and)after)introduction)of)pneumococcal)conjugate)vaccine.$JAMA,$2006.$295(14):$p.$1668L74.$

106.$ McBean,$A.M.,$et$al.,$Declining)invasive)pneumococcal)disease)in)the)U.S.)elderly.$Vaccine,$2005.$23(48L49):$p.$5641L5.$

107.$ Jardine,$A.,$R.I.$Menzies,$and$P.B.$McIntyre,$Reduction)in)hospitalizations)for)pneumonia)associated)with)the)introduction)of)a)pneumococcal)conjugate)vaccination)schedule)without)a)booster)dose)in)Australia.$Pediatric$Infectious$Disease$Journal,$2010.$29(7):$p.$607L612.$

108.$ Flannery,$B.,$et$al.,$Impact)of)childhood)vaccination)on)racial)disparities)in)invasive)Streptococcus)pneumoniae)infections.$JAMA,$2004.$291(18):$p.$2197L203.$

109.$ Salleras,$L.,$et$al.,$Dramatic)decline)of)serogroup)C)meningococcal)disease)incidence)in)Catalonia)(Spain))24)months)after)a)mass)vaccination)programme)of)children)and)young)people.$Journal$of$Epidemiology$&$Community$Health,$2001.$55(4):$p.$283L287.$

110.$ Ramsay,$M.E.,$et$al.,$Herd)immunity)from)meningococcal)serogroup)C)conjugate)vaccination)in)England:)database)analysis.$BMJ,$2003.$326(7385):$p.$365L6.$

111.$ Kinlin,$L.M.,$et$al.,$Rapid)identification)of)herd)effects)with)the)introduction)of)serogroup)C)meningococcal)conjugate)vaccine)in)Ontario,)Canada,)2000D2006.$Vaccine,$2009.$27(11):$p.$1735L1740.$

112.$ De$Wals,$P.$and$L.$Erickson,$Economic)analysis)of)the)1992D1993)mass)immunization)campaign)against)serogroup)C)meningococcal)disease)in)Quebec.$Vaccine,$2002.$20(21L22):$p.$2840L4.$

113.$ De$Wals,$P.,$Meningococcal)C)vaccines:)the)Canadian)experience.$Pediatric$Infectious$Disease$Journal,$2004.$23(12$Suppl):$p.$S280L4.$

114.$ Bergman,$B.P.,$J.C.$Hayton,$and$A.D.$Green,$Effectiveness)of)the)meningococcal)vaccination)programme)for)British)Armed)Forces)recruits.$Communicable$Disease$&$Public$Health,$2000.$3(4):$p.$298L9.$


March$26,$2012$ 29$$

115.$ Balmer,$P.,$R.$Borrow,$and$E.$Miller,$Impact)of)meningococcal)C)conjugate)vaccine)in)the)UK.$Journal$of$Medical$Microbiology,$2002.$51(9):$p.$717L722.$

116.$ Chan,$C.Y.,$S.D.$Lee,$and$K.J.$Lo,$Legend)of)hepatitis)B)vaccination:)The)Taiwan)experience.$Journal$of$Gastroenterology$and$Hepatology,$2004.$19(2):$p.$121L126.$

117.$ Richardson,$V.,$et$al.,$Effect)of)rotavirus)vaccination)on)death)from)childhood)diarrhea)in)Mexico.$New$England$Journal$of$Medicine,$2010.$362(4):$p.$299L305.$

118.$ PaulkeLKorinek,$M.,$et$al.,$Universal)mass)vaccination)against)rotavirus)gastroenteritis:)impact)on)hospitalization)rates)in)austrian)children.$Pediatric$Infectious$Disease$Journal,$2010.$29(4):$p.$319L23.$

119.$ de$Palma,$O.,$et$al.,$Effectiveness)of)rotavirus)vaccination)against)childhood)diarrhoea)in)El)Salvador:)caseDcontrol)study.$BMJ,$2010.$340:$p.$c2825.$

120.$ Cortese,$M.M.,$et$al.,$Reduction)in)Gastroenteritis)in)United)States)Children)and)Correlation)With)Early)Rotavirus)Vaccine)Uptake)From)National)Medical)Claims)Databases.$Pediatric$Infectious$Disease$Journal,$2010.$29(6):$p.$489L494.$

121.$ Clark,$H.F.,$et$al.,$Decline)in)Cases)of)Rotavirus)Gastroenteritis)Presenting)to)The)Children's)Hospital)of)Philadelphia)after)Introduction)of)a)Pentavalent)Rotavirus)Vaccine.$Clinical$and$Vaccine$Immunology,$2009.$16(3):$p.$382L386.$

122.$ Centers$for$Disease,$C.$and$Prevention,$Reduction)in)rotavirus)after)vaccine)introductionDDUnited)States,)2000D2009.$MMWR$L$Morbidity$&$Mortality$Weekly$Report,$2009.$58(41):$p.$1146L9.$

123.$ Centers$for$Disease,$C.$and$Prevention,$Delayed)onset)and)diminished)magnitude)of)rotavirus)activityDDUnited)States,)November)2007DMay)2008.$MMWR$L$Morbidity$&$Mortality$Weekly$Report,$2008.$57(25):$p.$697L700.$

124.$ Belshaw,$D.A.,$et$al.,$Rotavirus)vaccination)one)year)on.$Communicable$diseases$intelligence,$2009.$33(3):$p.$337L340.$

125.$ Fairley,$C.K.,$et$al.,$Rapid)decline)in)presentations)of)genital)warts)after)the)implementation)of)a)national)quadrivalent)human)papillomavirus)vaccination)programme)for)young)women.$Sexually$Transmitted$Infections,$2009.$85(7):$p.$499L502.$

126.$ Barr,$E.,$et$al.,$Impact)of)a)prophylactic)quadrivalent)human)papillomavirus)(types)6,)11,)16,)18))L1)virusDlike)particle)vaccine)in)a)sexually)active)population)of)North)American)women.$American$Journal$of$Obstetrics$and$Gynecology,$2008.$198(3):$p.$11.$

127.$ Lydon,$P.,$et$al.,$Introducing)new)vaccines)in)the)poorest)countries:)what)did)we)learn)from)the)GAVI)experience)with)financial)sustainability?$Vaccine,$2008.$26(51):$p.$6706L16.$

128.$ Brugha,$R.,$M.$Starling,$and$G.$Walt,$GAVI,)the)first)steps:)lessons)for)the)Global)Fund.$Lancet,$2002.$359(9304):$p.$435L8.$

129.$ Simoens,$C.,$et$al.,$Introduction)of)human)papillomavirus)(HPV))vaccination)in)Belgium,)2007D2008.$Euro$Surveillance:$Bulletin$Europeen$sur$les$Maladies$Transmissibles$=$European$Communicable$Disease$Bulletin,$2009.$14(46).$

130.$ Papaevangelou,$G.,$Hepatitis)B)immunization)programme:)Lessons)learnt)in)Greece.$Vaccine,$1998.$16(SUPPL.):$p.$S45LS47.$

131.$ Bonanni,$P.$and$P.$Crovari,$Success)stories)in)the)implementation)of)universal)hepatitis)B)vaccination:)an)update)on)Italy.$Vaccine,$1998.$16*Suppl:$p.$S38L42.$

132.$ Bonanni,$P.,$et$al.,$Impact)of)routine)infant)and)adolescent)hepatitis)B)vaccination)in)Tuscany,)Central)Italy.$Pediatric$Infectious$Disease$Journal,$1999.$18(8):$p.$677L82.$

133.$ Favin,$M.,$R.$Macabasco,$and$R.$Steinglass,$Impact)of)New)Vaccine)Introduction)on)Developing)Country)Immunization)Programs)and)Broader)Health)Systems:)A)Review)of)the)Grey)Literature)2012,$USAIDLfunded$Maternal$and$Child$Health$Integrated$Program$(MCHIP).$


March$26,$2012$ 30$$

134.$ World$Health$Organization,$Introduction)of)rotavirus)vaccines)into)national)immunization)programmes)Management)manual,)including)operational)information)for)health)workers,$V.a.B.$Department$of$Immunization,$Editor$2009,$WHO$Press:$Geneva.$

135.$ World$Health$Organization.$Effective)Vaccine)Management)Initiative.$2010$$March$6,$2012];$Available$from:$http://www.who.int/immunization_delivery/systems_policy/logistics/en/index6.html.$

136.$ UNICEF.$Vaccine)Independence)Initiative)(VII).$$[cited$2012$March$26];$Available$from:$http://www.unicef.org/pacificislands/immunization_2881.html.$

137.$ Snyder,$C.M.,$W.$Begor,$and$E.R.$Berndt,$Economic)perspectives)on)the)advance)market)commitment)for)pneumococcal)vaccines.$Health$Affairs,$2011.$30(8):$p.$1508L17.$

138.$ International$Finance$Facility$for$Immunisation.$International)Finance)Facility)for)Immunisation.$2012$$[cited$2012$March$6];$Available$from:$http://www.iffim.org/about/.$

139.$ Kamara,$L.,$et$al.,$Strategies)for)financial)sustainability)of)immunization)programs:)a)review)of)the)strategies)from)50)national)immunization)program)financial)sustainability)plans.$Vaccine,$2008.$26(51):$p.$6717L26.$

140.$ Wals,$P.D.,$et$al.$$ $ ,$Reduced)Physician)Claims)for)Otitis)Media)after)Implementation)of)Pneumococcal)Conjugate)Vaccine)Program)in)the)Province)of)Quebec,)Canada.$Pediatric$Infectious$Disease$Journal,$2009.$28(9):$p.$e271L5.$

$

title: impact of new vaccine introduction on the ......the introduction of a new vaccine can have...

Documents