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Background The Indian Armed Forces, on entry, vaccinates all cadets and recruits with varicella vaccine for the prevention of varicella. This health technology assessment (HTA) report puts forth evidence for HTA of varicella vaccination in the Armed Forces in various domains namely clinical, societal, ethical, economic, and legal. Methods The policy question under each domain has been developed according to best-practice methods for HTA. The costs included were hospitalization cost due to varicella infection; training lost cost; the varicella vaccine cost; cost of the side effects of vaccine; and the outbreak investigation cost. The incremental cost-effectiveness ratio (ICER) for varicella cases averted and man-days saved, and quality-adjusted life years (QALYs) gained due to varicella vaccination strategy were calculated. Results Evidence suggests a reduction of 81% in hospitalization rates with 19392 man-days saved per 1 lakh population due to varicella vaccination strategy. The ICER for varicella cases averted is estimated to be Rs 56732/- per case averted and Rs 5687/- per man-day saved. QALYs gained due to two-dose varicella vaccination strategy is estimated to be 1152 per 1 lakh population with cost per QALY gained Rs 95735/-. Conclusion The study showed a large reduction in hospitalizations and consequently man-days lost after the introduction of the vaccination strategy. The QALYs was another aspect of importance brought out by this study. Thus, a two-dose vaccination strategy for varicella-zoster virus (VZV) for the Armed Forces trainees is a cost-effective policy.

Previous studies reported a dramatic decline in the incidence of varicella and varicella-related deaths after implementing universal varicella vaccination (VarV). Although previous studies reported the effectiveness and economic impact of VarV, they were unknown in the emergency department (ED) setting.To determine the effectiveness and economic impact of VarV in the ED, Kobe, Japan, we retrospectively reviewed the clinical database of consecutive patients younger than 16 years presenting to our primary ED from 2011 to 2019.Of the 265,191 children presenting to our ED, 3,092 patients were clinically diagnosed with varicella. The number of patients with varicella was approximately 500 annually, before introducing the universal two-dose VarV for children aged 1 to3 years in October 2014, in the Japanese national immunization program, and decreased to approximately 200 in 2019. The number of patients with varicella younger than 1 year (ineligible for the vaccination) also decreased. Regarding the economic impact, the medical cost in our ED reduced after the introduction of VarV was JPY 4.1 million (US$ 40,049) annually. From the central data, approximately 95% of children were vaccinated after October 2014; however, a relatively large percentage of infected unvaccinated children (59.0%) presented to ED in this study. After the implementation of the universal VarV, infection was mainly observed in older children (i.e., the unvaccinated generation).Our data showed the effectiveness and economic impact of VarV in the ED setting. Additionally, our data suggested that the public vaccination program should include older unvaccinated children and other unvaccinated individuals.

OBJECTIVE To elucidate the trend and clinical spectrum of virologically diagnosed varicella patients after implementation of universal vaccination as a national immunization program in Japan. PATIENTS AND METHODS Study subjects were patients suspected of varicella, less than 15 years of age, who visited 14 pediatric clinics in the Nagoya VZV Study Group from September 2015 to August 2019. Practitioners collected patient samples and information such as backgrounds, clinical symptoms, and previous immunization status. All patients were confirmed as having varicella based on molecular diagnostic assays. RESULTS Varicella zoster virus (VZV) DNA was detected in swab samples from 506 (83.1%) of the 609 suspected patients. The 455 varicella patients for whom vaccination status was available were divided into two groups: 180 universal vaccination targets and 275 non-targets. Numbers of monthly varicella patients decreased gradually during the observation period. In the 2016/17 season, the seasonal epidemic of varicella became undetectable in the universal vaccination target group, and starting in the 2017/18 season, it was obscured even in the non-target group. The median age of patients was significantly lower in the universal vaccination target group (3 years) than the non-target group (7 years) (P

Routine childhood immunization using two doses of the varicella vaccine was introduced in Japan in October 2014. In this study, we analyzed the data extracted from national varicella surveillance, including pediatric sentinel surveillance from 2000 to 2017 and hospitalized varicella surveillance from the 38th week of 2014 to the 37th week of 2017. Compared with the 2000-2011 baseline data, the number of varicella cases per sentinel decreased substantially by 76.6% overall and by 88.2% among children aged 1-4 years in 2017. Of 997 hospitalized patients, we found a decreasing trend in the number of cases among children aged5 years. We also found a decreasing trend in the number of cases with complications among children aged 1-4 years. Data on the self-reported transmission sites in 35.5% (354/997) of the hospitalized varicella patients showed that transmission of varicella zoster virus (VZV) occurred frequently in household, at school for young children, in the workplace for adults, and at hospital for all age groups. Data from 29.0% (289/997) of the hospitalized patients with a self-reported source of infection showed that transmission of VZV occurred from a patient with herpes zoster (HZ) in 30.4% (88/289) of cases. Our data demonstrate a substantial decrease in the number of varicella cases in young children following introduction of routine childhood vaccination program with two-dose varicella vaccination in Japan. These data highlight the unique aspects of transmission sites across age groups and the important role of HZ cases in disease circulation.

1-Dose varicella vaccination was recommended for children in Beijing before November 2012. To further control school-based outbreaks and decrease incidence, a 2-dose vaccination was implemented in 2013. We described the varicella epidemiology and assessed impact of the 2-dose vaccination in Haidian district, Beijing, 2007-2015.We examined the estimated incidence and disease characteristics of varicella during 2007-2015 and obtained the 1-dose vaccination coverage for children born during 2005-2013. Number of vaccine doses given was used to indirectly reflect the second-dose vaccination coverage. Overall and age-specific estimated incidences were compared between 2007-2012 and 2013-2015.A total of 23,497 cases were reported during 2007-2015. Of the 23,497 cases, 13,440 (57.20%) were male, and 68.40% were20years of age and 70.02% were students and children in kindergarten. The estimated incidence increased from 82 cases per 100,000 population in 2007 to 104 in 2011, before substantially decreasing from 86 in 2012 to 56 in 2015. The median age increased from 14years in 2007 to 18years in 2015. The 1-dose varicella coverage for children at ≥2years of age gradually increased from 74.21% in 2007 to 90.06% in 2015. Compared with 2007-2012, two-fold average vaccine doses were given during 2013-2015, and the overall estimated incidence declined by 34.4%, particularly in children aged 5-9years, with a significantly declined trend in children aged 1-9years and older adolescents aged 15-19years and non-significantly declined trend in adults aged ≥20years, but a significant increasing trend in infants.The overall incidence of varicella has decreased substantially in Haidian district since 2013, with largest decline in children aged 5-9years. The 2-dose varicella vaccination might not lead to increase in incidence in adults. Long-term surveillance is needed to fully evaluate the long-term impact of the 2-dose varicella vaccination.

Objective To evaluate the long-term safety and efficacy of varicella vaccination in children with juvenile idiopathic arthritis (JIA) treated with biologics. Methods We performed a prospective study with long term follow up. Six patients with JIA treated with biologics, received 2 doses of varicella vaccine. Before vaccination, JIA was stable on therapy and peripheral blood lymphocyte populations were within normal limits. After vaccination, children were followed for disease activity, infections and production of protective antibodies. Results There were no serious side effects after vaccination and no varicella infection. Disease activity remained stable. Five patients (83%) produced protective antibodies against varicella virus 6 weeks after the second vaccination. One patient with low level of protective antibodies got mild varicella infection 4 months after the second vaccination. Conclusion Varicella vaccination appears to be safe in our group of six JIA patients treated with biologics. Vaccination does not always protect against varicella infection.

Varicella vaccines available in Spain were marketed in 1998 and 2003 for non-routine use. Since 2006 some regions included universal varicella vaccination in their regional routine vaccination programs at 15-18 months of age. Regions without universal vaccination in toddlers, but instead with the strategy of vaccinating susceptible adolescents, reached different varicella vaccination coverage through private market. This study shows the correlation between severe varicella zoster virus infections requiring hospitalization and the varicella vaccination coverage by region. A total of 3009 hospital discharges related to varicella were reported in 2009-2010. The overall annual rate of hospitalization was 3.27 cases per 100,000. In children younger than 5 years old varicella hospitalization rate was 30.73 cases per 100,000. Varicella related hospitalizations were significantly lower in the regions with universal vaccination. In those regions without universal vaccination at 15-18 months of age, those with higher coverage in private market showed lower hospitalization rates.

Purpose: A universal publicly funded chickenpox vaccination program was implemented in Alberta in 2002. We examine the epidemiology of medically attended shingles in Alberta from 1994 to 2010. Methods: Incident shingles cases (earliest health service utilizations for ICD-9 053 or ICD-10-CA B02) and their co-morbid conditions for the 12 months prior to shingles diagnosis were identified from the records of Alberta's universal, publicly funded health-care insurance system for 1994–2010. Shingles diagnostic codes at least 180 days after the first were classified as recurrent episodes. Denominators for rates were estimated using mid-year population estimates from the Alberta Health Care Insurance Plan Registry. Annual age- and sex-specific rates were estimated. We estimated the proportion of all cases that were hospitalized. We explored the pattern of rates for sex, age-group co-morbidity and year effects and their interactions. Results: Crude rates of shingles increased over the interval 1994–2010. Most persons had only a single episode of shingles; 4% of cases were hospitalized. Shingles rates were higher among females than males. While only 2% of shingles cases had one or more co-morbidities, this proportion was also higher for females than males. Prior to 2002, all age groups of both sexes experienced increasing annual rates of shingles. However, there was a sharp decline in the rate of shingles for both females and males under the age of 10 years for 2002–2010, the period in which there was publicly funded chickenpox vaccination. Conclusion: The declining rates of shingles among persons under the age of 10 years are consistent with an impact of the chickenpox vaccination program. The trend of increasing rates of shingles among older persons began prior to implementation of vaccination.

Characteristics of varicella-related hospitalizations in the mature varicella vaccination era, including the proportion vaccinated and the severity of disease, are not well described. We present the vaccination status, severity and reasons for hospitalization of the hospitalized varicella cases reported to the Los Angeles County Health Department from 2003 to 2011, the period which includes the last 4 years of the mature one-dose program and the first 5 years after introduction of the routine two-dose program. A total of 158 hospitalized varicella cases were reported overall, of which 52.5% were potentially preventable and eligible for vaccination, 41.8% were not eligible for vaccination, and 5.7% were vaccinated. Most hospitalizations (72.2%) occurred among healthy persons, 54.4% occurred among persons ≥20 years of age, and 3.8% of hospitalizations resulted in death. Our data suggest that as many as half of the hospitalized varicella cases, including half of the deaths, may have been preventable given that they occurred in persons who were eligible for vaccination. More complete implementation of the routine varicella vaccination program could further reduce the disease burden of severe varicella.

Highlights • Chickenpox history may enable cost-effective vaccination of susceptible individuals. • We tested the validity of reported chickenpox history in adolescents. • Vaccine would be wasted in most adolescents with a negative or uncertain history. • 6–9% of those with a positive chickenpox history would remain susceptible. • These data are needed to inform cost-effectiveness of proposed vaccine programmes., Introduction In the UK, primary varicella is usually a mild infection in children, but can cause serious illness in susceptible pregnant women and adults. The UK Joint Committee on Vaccination and Immunisation is considering an adolescent varicella vaccination programme. Cost-effectiveness depends upon identifying susceptibles and minimising vaccine wastage, and chickenpox history is one method to screen for eligibility. To inform this approach, we estimated the proportion of adolescents with varicella antibodies by reported chickenpox history. Methods Recruitment occurred through secondary schools in England from February to September 2012. Parents were asked about their child's history of chickenpox, explicitly setting the context in terms of the implications for vaccination. 247 adolescents, whose parents reported positive (120), negative (77) or uncertain (50) chickenpox history provided oral fluid for varicella zoster virus-specific immunoglobulin-G (VZV-IgG) testing. Results 109 (90.8% [85.6–96.0%]) adolescents with a positive chickenpox history, 52 (67.5% [57.0–78.1%]) with a negative history and 42 (84.0% [73.7–94.3%]) with an uncertain history had VZV-IgG suggesting prior infection. Combining negative and uncertain histories, 74% had VZV-IgG (best-case). When discounting low total-IgG samples and counting equivocals as positive (worst-case), 84% had VZV-IgG. We also modelled outcomes by varying the negative predictive value (NPV) for the antibody assay, and found 74–87% under the best-case and 84–92% under the worst-case scenario would receive vaccine unnecessarily as NPV falls to 50%. Conclusion Reported chickenpox history discriminates between varicella immunity and susceptibility in adolescents, but significant vaccine wastage would occur if this approach alone were used to determine vaccine eligibility. A small but important proportion of those with positive chickenpox history would remain susceptible. These data are needed to determine whether reported history, with or without oral fluid testing in those with negative and uncertain history, is sufficiently discriminatory to underpin a cost-effective adolescent varicella vaccination programme.

Germany introduced routine varicella (V) vaccination in 2004. Due to a slightly increased risk of febrile convulsions after first-dose application of combined measles-mumps-rubella-varicella (MMRV) vaccine separate first-dose vaccinations with MMR and monovalent V vaccine were recommended in September 2011.We compared V and MMR vaccinations in paediatric practices from two surveillance regions (Munich and Würzburg) one year before and after the change in the recommendation.A total of 1405/326 monthly reports were provided by a monthly average of 79/14 practices participating in Munich/Würzburg. V first-dose vaccinations (monovalent V or MMRV vaccine) declined by 12% in Munich (from 10.1 to 8.9 vaccinations per month and practice; p0.005) and by 4% in Würzburg (from 9.9 to 9.5; p=0.620), respectively. First-dose vaccinations for MMR (MMR or MMRV vaccine) did not change significantly in both regions.Acceptance of V vaccination depends in part on the use of combination vaccine.

Varicella vaccines available in Spain were marketed in 1998 and 2003 for non-routine use. Since 2006 some regions decided to include varicella vaccination in their regional routine vaccination programmes at 15-18 months of age. Other regions chose the strategy of vaccinating susceptible adolescents. This study shows the trends in severe varicella zoster virus infections through the analysis of the hospital discharges related to varicella and herpes zoster in the general population from 2005 to 2010 in Spain. A total of 11,125 hospital discharges related to varicella and 27,736 related to herpes zoster were reported during the study period. The overall annual rate of hospitalization was 4.14 cases per 100,000 for varicella and 10.33 cases per 100,000 for herpes zoster. In children younger than 5 years old varicella hospitalization rate significantly decreased from 46.77 in 2005 to 26.55 per 100,000 in 2010. The hospitalization rate related to herpes zoster slightly increased from 9.71 in 2005 to 10.90 per 100,000 in 2010. This increase was mainly due to the significant increase occurring in the >84 age group, from 69.55 to 97.68 per 100,000. When gathering for regions taking into account varicella vaccine strategy, varicella related hospitalizations decreased significantly more in those regions which included the vaccine at 15-18 months of age as a routine vaccine comparing with those vaccinating at 10-14 years old. No significant differences were found in herpes zoster hospitalization rates regarding the varicella vaccination strategy among regions. Severe varicella infections decreased after implementation of varicella vaccination in Spain. This decrease was significantly higher in regions including the vaccine at 15-18 months of age compared with those vaccinating susceptible adolescents.

Objectives The authors assessed the knowledge and practices of French family physicians concerning the application of the new 2007 varicella vaccination guidelines for non-immune teenagers, 12 to 18 years of age. They also estimated the vaccination coverage in this population. Method A questionnaire link was sent by to 1008 family physicians of the French Inserm Sentinel network. Each family physician had to include the last teenager aged 12 to 18 years seen in consultation, with no or uncertain history of clinical varicella. Results One hundred and forty-one family physicians agreed to participate and included one patient (participation rate = 14%) between 4th November 2010 and 4th January 2011. One hundred and thirty-three questionnaires out of 141 (94%) were analyzed. Three patients were vaccinated and 127 were not, giving a weak vaccination coverage in the investigated population at 2%. Eighty-nine family physicians (70%) did not know about the recommendation, and 90 (71%) declared that they had no intention to vaccinate their patient against varicella. Conclusion Guidelines on varicella vaccination of non-immune teenagers are poorly followed and accepted by family physicians. Vaccination coverage is very low, and efforts should be made to improve application of recommendations.

Varicella vaccines have been available for private purchase in Canada since 1998. Ontario introduced publicly funded varicella vaccination in 2004. We assessed the effects of private availability of varicella vaccines and subsequent implementation of a publicly funded vaccination program on varicella-related hospitalizations, emergency department (ED) use, and visits to physicians' offices in Ontario. Rates of hospitalizations, ED use, and office visits decreased 53% (95% CI, 48-58%), 43% (95% CI, 41-44%), and 45% (95% CI, 44-45%) after publicly funded vaccination, compared to only 9% (95% CI, 4-14%), 23% (95% CI, 22-24%), and 29% (95% CI, 28-29%) after private availability. Varicella vaccination is effective at reducing varicella-related health care use, with benefits extending beyond those who receive the vaccine. Publicly funded vaccination programs may be more effective than private vaccine availability.

Vaccines have features that require special consideration when assessing their cost-effectiveness. These features are related to herd immunity, quality-of-life losses in young children, parental care and work loss, time preference, uncertainty, eradication, macroeconomics, and tiered pricing. Advisory committees on public funding for vaccines, or for pharmaceuticals in general, should be knowledgable about these special features. We discuss key issues and difficulties in decision making for vaccines against rotavirus, human papillomavirus, varicella-zoster virus, influenza virus, and Streptococcus pneumoniae. We argue that guidelines for economic evaluation should be reconsidered generally to recommend (1) modelling options for the assessment of interventions against infectious diseases; (2) a wider perspective to account for impacts on third parties, if relevant; (3) a wider scope of costs than health-care system costs alone, if appropriate; and (4) alternative discounting techniques to explore social time preference over long periods.

The addition of varicella vaccine to the universal childhood immunization schedule in the United States in 1995 can be seen as a bold step. Shown to be safe and efficacious against varicella in extensive prelicensure studies, it is nonetheless the first vaccine against a herpesvirus and, furthermore, it is a live, attenuated vaccine. Both wild-type and vaccine strain varicella zoster virus (VZV) are noteworthy for their ability to establish latent infection within the host, with the subsequent possibility of reactivation. Therefore, at the population level, a successful vaccination program could result in the eventual displacement of wild-type VZV by the attenuated vaccine virus. The immediate objective of universal vaccination, however, was to reduce the significant morbidity and mortality associated with primary VZV infection. Data now accumulating suggest that the varicella vaccine as used in the United States has so far been highly effective. The challenge for the future is to predict how the resulting substantial reduction in circulation of VZV will affect immunity among both vaccinees and the unvaccinated. Vaccination strategies likely will need to be adjusted as the epidemiology of VZV in the United States continues to evolve.

Although frequently reported in the literature, a staff varicella policy is not standard in many hospitals even in developed countries. In the present study, we assessed varicella zoster immunity in staff from two neonatal units from hospitals in São Paulo, Brazil. Ninety-seven percent of all staff working in both units agreed to participate. A simple and cost-effective varicella policy was subsequently set up, based on costs and data from serology and a history of previous varicella infection. Our results confirm that a varicella vaccination programme can be implemented in a healthcare facility, even in developing countries.

The impact of a varicella vaccination program on disease in a large HMO population during 1996-1999 was assessed by multiple cross-sectional analyses of automated database records of vaccinations and varicella diagnoses for children (0-18 years). The cumulative proportion of the population vaccinated reached 73% among 2-year-olds, and 22% overall. An overall 49.7% reduction in varicella incidence was estimated to be attributable to an 18.5% point increase in the proportion of the population vaccinated.

Active surveillance for herpes zoster (HZ) was conducted for 2 years (2000–2001) in the Antelope Valley community of 312,000 residents among 290 public and private schools, daycares, and healthcare providers. The true ascertainment-adjusted HZ incidence rate is 307 per 100,000 person-years and 138 per 100,000 person-years among children

Varicella vaccine has been extensively studied in Japan, the United States and Canada since 1974. Its efficacy in healthy children is good, on the order of 94%. It also has a good efficacy in immunocompromised children, such as children treated for acute leukemia or malignant tumors. However, the vaccine has to be administrated during a 2-3 week transient suppression of chemotherapy. In the USA, varicella vaccination is recommended for receptive adults who are particularly exposed to varicella, such as health professionals working with immunocompromised patients. Benefits and cost analysis of a generalized varicella vaccination in children has shown that it would be beneficial due to the cost of parents' work leave during the children's illness.

– Wide range in the cost per day lost (12.70-326.40 in 2008 purchasing power parity adjusted dollars) using the human capital method. • This finding was aligned with the findings from Soarez and colleagues3 that the value of a work day ranged widely even when adjusting country-specific wages to a common currency (purchasing power parity), highlighting the wide variation in wage scales between countries.