The Case Against Universal Varicella Immunization

1
The Case Against Universal Varicella Immunization

• Leonardo Emberti Gialloreti, MD, PhD
• University of Rome Tor Vergata

12th Annual Meeting of the IHMF Lisbon, 29
October 2005
2
This House Believes that Universal Immunization
Against Varicella is Warranted

• The implementation of strategies should take into
  account the context of other, more serious,
  diseases preventable by vaccination
• In which countries?

3
This House Believes that Universal Immunization
Against Varicella is Warranted

• Most developing countries have other
  vaccine-preventable diseases, which cause
  significantly greater morbidity and mortality,
  and varicella vaccine is not a high priority for
  routine introduction into their national
  immunization programmes.
• WHO position paper on varicella vaccines

4

• In most developing countries other new
  vaccines, including hepatitis B, rotavirus, as
  well as conjugated Haemophilus influenzae b and
  pneumococcal vaccine, have the potential for a
  much greater public health impact, and WHO does
  not recommend the inclusion of varicella
  vaccination into the routine immunization
  programmes of developing countries.
• WHO position paper on varicella vaccines

5
This house believes that in low- and
middle-income economies (i.e. about 80 of the
world) universal immunization against varicella
is not warranted
6

• Routine childhood immunization against
  varicella may be considered in countries where
  this disease is a relatively important public
  health and socio-economic problem, where the
  vaccine is affordable, and where high and
  sustained vaccine coverage can be achieved.
• WHO position paper on varicella vaccines

7
This house believes that universal immunization
against varicella in high-income economies is
warranted

• Is it the most optimal option in terms of averted
  cases and complications?

8
Open Issues

• Which is the influence on the occurrence of
  herpes zoster?
• Breakthrough cases?

9
Is universal vaccination the most cost-effective
option?

• Indirect costs?
• Direct costs?
• Breakthrough cases?
• Effect on herpes zoster disease?

In some countries, universal immunization will
probably generate some overall savings, but it
will also require an increase in healthcare
expenditures
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Are there alternative strategies to universal
immunization?

• The catch-up adolescent strategy results in net
  direct cost savings, prevents a significant
  number of severe chickenpox, and has little or no
  effect on the incidence of herpes zoster

But it has a lower overall impact on varicella
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Can high coverage be achieved in all high income
countries?

• Routine childhood varicella immunization
  programmes Germany, Sicily (Italy)
• Varicella vaccination recommended for children
  Cyprus, Lithuania, Italy
• Targeted varicella vaccination of specific
  groups Belgium, England and Wales, Finland,
  Ireland, Luxemburg, Malta, Slovenia, Spain
• No licensed varicella vaccine Bulgaria, Greece,
  the Netherlands, Romania, Slovakia, Slovenia
• Jan 2005

12
European vaccination schedules and systems differ
widely to meet local epidemiological, structural
and cultural needs
There is no single optimal vaccination schedule
for European children
For further information, see Schmitt H-J et al.
Child vaccination policies in Europe a report
from the Summits of Independent European
Vaccination Experts. The Lancet Infectious
Diseases 20033
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Can high coverage be achieved in all high income
countries?

• Centralised vs. decentralised health systems
• Mandatory vs. recommended vaccinations

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Is universal immunization a priority?

• Varicella is treatable
• Common vaccination goals need to be defined,
  including specific and realistic time frames for
  each country
• Priorities (e.g.)
• Elimination of measles and diptheria
• Reduction in the number of cases of invasive H
  influenzae type B infections