Giorgio Guzzetta

Perspectives on the Impact of Varicella Immunization on Herpes Zoster. A Model-Based Evaluation from Three European Countries

The introduction of mass vaccination against Varicella-Zoster-Virus (VZV) is being delayed in many European countries because of, among other factors, the possibility of a large increase in Herpes Zoster (HZ) incidence in the first decades after the initiation of vaccination, due to the expected decline of the boosting of Cell Mediated Immunity caused by the reduced varicella circulation. A multi-country model of VZV transmission and reactivation, is used to evaluate the possible impact of varicella vaccination on HZ epidemiology in Italy, Finland and the UK. Despite the large uncertainty surrounding HZ and vaccine-related parameters, surprisingly robust medium-term predictions are provided, indicating that an increase in HZ incidence is likely to occur in countries where the incidence rate is lower in absence of immunization, possibly due to a higher force of boosting (e.g. Finland), whereas increases in HZ incidence might be minor where the force of boosting is milder (e.g. the UK). Moreover, a convergence of HZ post vaccination incidence levels in the examined countries is predicted despite different initial degrees of success of immunization policies. Unlike previous model-based evaluations, our investigation shows that after varicella immunization an increase of HZ incidence is not a certain fact, rather depends on the presence or absence of factors promoting a strong boosting intensity and which might or not be heavily affected by changes in varicella circulation due to mass immunization. These findings might explain the opposed empirical evidences observed about the increases of HZ in sites where mass varicella vaccination is ongoing.

Population-level impact, herd immunity, and elimination after human papillomavirus vaccination: a systematic review and meta-analysis of predictions from transmission-dynamic models

Summary Background Modelling studies have been widely used to inform human papillomavirus (HPV) vaccination policy decisions; however, many models exist and it is not known whether they produce consistent predictions of population-level effectiveness and herd effects. We did a systematic review and meta-analysis of model predictions of the long-term population-level effectiveness of vaccination against HPV 16, 18, 6, and 11 infection in women and men, to examine the variability in predicted herd effects, incremental benefit of vaccinating boys, and potential for HPV-vaccine-type elimination. Methods We searched MEDLINE and Embase for transmission-dynamic modelling studies published between Jan 1, 2009, and April 28, 2015, that predicted the population-level impact of vaccination on HPV 6, 11, 16, and 18 infections in high-income countries. We contacted authors to determine whether they were willing to produce new predictions for standardised scenarios. Strategies investigated were girls-only vaccination and girls and boys vaccination at age 12 years. Base-case vaccine characteristics were 100% efficacy and lifetime protection. We did sensitivity analyses by varying vaccination coverage, vaccine efficacy, and duration of protection. For all scenarios we pooled model predictions of relative reductions in HPV prevalence (RRprev) over time after vaccination and summarised results using the median and 10th and 90th percentiles (80% uncertainty intervals [UI]). Findings 16 of 19 eligible models from ten high-income countries provided predictions. Under base-case assumptions, 40% vaccination coverage and girls-only vaccination, the RRprev of HPV 16 among women and men was 0·53 (80% UI 0·46–0·68) and 0·36 (0·28–0·61), respectively, after 70 years. With 80% girls-only vaccination coverage, the RRprev of HPV 16 among women and men was 0·93 (0·90–1·00) and 0·83 (0·75–1·00), respectively. Vaccinating boys in addition to girls increased the RRprev of HPV 16 among women and men by 0·18 (0·13–0·32) and 0·35 (0·27–0·39) for 40% coverage, and 0·07 (0·00–0·10) and 0·16 (0·01–0·25) for 80% coverage, respectively. The RRprev were greater for HPV 6, 11, and 18 than for HPV 16 for all scenarios investigated. Finally at 80% coverage, most models predicted that girls and boys vaccination would eliminate HPV 6, 11, 16, and 18, with a median RRprev of 1·00 for women and men for all four HPV types. Variability in pooled findings was low, but increased with lower vaccination coverage and shorter vaccine protection (from lifetime to 20 years). Interpretation Although HPV models differ in structure, data used for calibration, and settings, our population-level predictions were generally concordant and suggest that strong herd effects are expected from vaccinating girls only, even with coverage as low as 20%. Elimination of HPV 16, 18, 6, and 11 is possible if 80% coverage in girls and boys is reached and if high vaccine efficacy is maintained over time. Funding Canadian Institutes of Health Research.

Assessing the potential risk of Zika virus epidemics in temperate areas with established Aedes albopictus populations.

Based on 2015 abundance of Aedes albopictus in nine northern Italian municipalities with temperate continental/oceanic climate, we estimated the basic reproductive number R0 for Zika virus (ZIKV) to be systematically below the epidemic threshold in most scenarios. Results were sensitive to the value of the probability of mosquito infection after biting a viraemic host. Therefore, further studies are required to improve models and predictions, namely evaluating vector competence and potential non-vector transmissions.

Modeling socio-demography to capture tuberculosis transmission dynamics in a low burden setting.

Evidence of preferential mixing through selected social routes has been suggested for the transmission of tuberculosis (TB) infection in low burden settings. A realistic modelization of these contact routes is needed to appropriately assess the impact of individually targeted control strategies, such as contact network investigation of index cases and treatment of latent TB infection (LTBI). We propose an age-structured, socio-demographic individual based model (IBM) with a realistic, time-evolving structure of preferential contacts in a population. In particular, transmission within households, schools and workplaces, together with a component of casual, distance-dependent contacts are considered. We also compared the model against two other formulations having no social structure of contacts (homogeneous mixing transmission): a baseline deterministic model without age structure and an age-structured IBM. The socio-demographic IBM better fitted recent longitudinal data on TB epidemiology in Arkansas, USA, which serves as an example of a low burden setting. Inclusion of age structure in the model proved fundamental to capturing actual proportions of reactivated TB cases (as opposed to recently transmitted) as well as profiling age-group specific incidence. The socio-demographic structure additionally provides a prediction of TB transmission rates (the rate of infection in household contacts and the rate of secondary cases in household and workplace contacts). These results suggest that the socio-demographic IBM is an optimal choice for evaluating current control strategies, including contact network investigation of index cases, and the simulation of alternative scenarios, particularly for TB eradication targets.

The impact of demographic changes on the epidemiology of herpes zoster: Spain as a case study

Varicella zoster virus (VZV) causes varicella upon first exposure and may reactivate later in life into herpes zoster (HZ), with a risk that is thought to be reduced by re-exposures to VZV. Given the decades-long time scales of reactivation and its dependence on the accumulation of re-exposure episodes, adopting a long-term perspective may be useful to correctly interpret current epidemiological trends of VZV. In this study, we investigate the possible impact of demographic changes on varicella and HZ in Spain, using an age-structured mathematical model informed with historical demographic data and calibrated against age-specific profiles of varicella seroprevalence and HZ incidence data. The model qualitatively reproduces the remarkable growth of HZ incidence observed in Spain between 1997 and 2004, before the introduction of varicella vaccination programmes. We demonstrate that this growth may be partially ascribed to the reduction of varicella circulation that followed the overall decline of the birth rate in the twentieth century. Model predictions further suggest that, even under the most optimistic projections, HZ incidence will continue its rise until at least 2040. Considering the effect of demographic changes can help interpreting variations in epidemiological trends of HZ, contributing to a more accurate evaluation of vaccination programmes against VZV.

The Roles of Immune Memory and Aging in Protective Immunity and Endogenous Reactivation of Tuberculosis

Finding more effective vaccines against tuberculosis (TB) and improved preventive treatments against endogenous reactivation of latent TB is strategic to block transmission and reach the WHO goal of eliminating TB by 2050. Key related open questions in TB research include: i) what are the determinants of a strong memory response upon primary infection? ii) what is the role of cytokines towards protective memory response against a secondary infection? iii) what are the mechanisms responsible for the increased risk of reactivation in elderly individuals? To address these questions, we explored a computational model of the immune response to Mycobacterium tuberculosis including a mathematical description of immunosenescence and the generation and maintenance of immune memory. Sensitivity analysis techniques, together with extensive model characterization and in silico experiments, were applied to identify key mechanisms controlling TB reactivation and immunological memory. Key findings of this study are summarized by the following model predictions: i) increased strength and duration of memory protection is associated with higher levels of Tumor Necrosis Factor- (TNF) during primary infection; ii) production of TNF, but not of interferon-, by memory T cells during secondary infection is a major determinant of effective protection; iii) impaired recruitment of CD4+ T cells may promote reactivation of latent TB infections in aging hosts. This study is a first attempt to consider the immune dynamics of a persistent infection throughout the lifetime of the host, taking into account immunosenescence and memory. While the model is TB specific, the results are applicable to other persistent bacterial infections and can aid in the development, evaluation and refinement of TB treatment and/or vaccine protocols.

Potential Risk of Dengue and Chikungunya Outbreaks in Northern Italy Based on a Population Model of Aedes albopictus (Diptera: Culicidae).

The rapid invasion and spread of Aedes albopictus (Skuse, 1894) within new continents and climatic ranges has created favorable conditions for the emergence of tropical arboviral diseases in the invaded areas. We used mosquito abundance data from 2014 collected across ten sites in northern Italy to calibrate a population model for Aedes albopictus and estimate the potential of imported human cases of chikungunya or dengue to generate the condition for their autochthonous transmission in the absence of control interventions. The model captured intra-year seasonality and heterogeneity across sites in mosquito abundance, based on local temperature patterns and the estimated site-specific mosquito habitat suitability. A robust negative correlation was found between the latter and local late spring precipitations, indicating a possible washout effect on larval breeding sites. The model predicts a significant risk of chikungunya outbreaks in most sites if a case is imported between the beginning of summer and up to mid-November, with an average outbreak probability between 4.9% and 25%, depending on the site. A lower risk is predicted for dengue, with an average probability between 4.2% and 10.8% for cases imported between mid-July and mid-September. This study shows the importance of an integrated entomological and medical surveillance for the evaluation of arboviral disease risk, which is a precondition for designing cost-effective vector control programs.

The Epidemiology of Herpes Zoster After Varicella Immunization Under Different Biological Hypotheses: Perspectives From Mathematical Modeling

The impact of varicella vaccination on the epidemiology of herpes zoster (HZ) critically depends on the mechanism of immunological boosting, through which reexposures to varicella-zoster virus are thought to reduce the individual risk of HZ development. However, the qualitative and quantitative dynamics of this process are largely unknown. Consequently, mathematical models evaluating immunization strategies need to rely on theoretical assumptions. Available varicella-zoster virus models can be classified in 3 main families according to the postulated effect of exogenous boosting: 1) progressive accumulation of immunity following repeated reexposures; 2) partial protection that wanes over time; or 3) full but temporary immunity against HZ. In this work, we review and compare quantitative predictions from the 3 modeling approaches regarding the effect of varicella immunization on HZ. All models predict a qualitatively similar, but quantitatively heterogeneous, transient increase of HZ incidence. In particular, novel estimates from the progressive immunity model predict the largest increase in natural HZ and the largest incidence of HZ cases from reactivation of the vaccine strain, which in the long term will likely outnumber prevaccination numbers. Our results reinforce the idea that a better understanding of HZ pathogenesis is required before further mass varicella immunization programs are set out.

Transmission dynamics of the ongoing chikungunya outbreak in Central Italy: from coastal areas to the metropolitan city of Rome, summer 2017

A large chikungunya outbreak is ongoing in Italy, with a main cluster in the Anzio coastal municipality. With preliminary epidemiological data, and a transmission model using mosquito abundance and biting rates, we estimated the basic reproduction number R0 at 2.07 (95% credible interval: 1.47–2.59) and the first case importation between 21 May and 18 June 2017. Outbreak risk was higher in coastal/rural sites than urban ones. Novel transmission foci could occur up to mid-November.

The effect of interspecific competition on the temporal dynamics of Aedes albopictus and Culex pipiens

BackgroundAedes albopictus and Culex pipiens larvae reared in the same breeding site compete for resources, with an asymmetrical outcome that disadvantages only the latter species. The impact of these interactions on the overall ecology of these two species has not yet been assessed in the natural environment. In the present study, the temporal patterns of adult female mosquitoes from both species were analysed in north-eastern Italy, and substantial temporal shifts between abundance curves of Cx. pipiens and Ae. albopictus were observed in several sites. To understand which factors can drive the observed temporal shifts, we developed a mechanistic model that takes explicitly into account the effect of temperature on the development and survival of all mosquito stages. We also included into the model the effect of asymmetric interspecific competition, by adding a mortality term for Cx. pipiens larvae proportional to the larval abundance of Ae. albopictus within the same breeding site. Model calibration was performed through a Markov Chain Monte Carlo approach using weekly capture data collected in our study sites during 2014 and 2015.ResultsIn almost half of observation sites, temporal shifts were due to competition, with an early decline of Cx. pipiens caused by the concurrent rise in abundance of its competitor, and this effect was enhanced by higher abundance of both species. We estimate that competition may reduce Cx. pipiens abundance in some sites by up to about 70%. However, in some cases temporal shifts can also be explained in the absence of competition between species resulting from a “temporal niche” effect, when the optimal fitness to environmental conditions for the two species are reached at different times of the year.ConclusionsOur findings demonstrate the importance of considering ecological interactions and, in particular, competition between mosquito species in temperate climates, with important implications for risk assessment of mosquito transmitted pathogens, as well as the implementation of effective control measures.