title: The projected effectiveness of Clostridium difficile vaccination as part of an integrated infection control strategy.
abstract: Early clinical trials of a Clostridium difficile toxoid vaccine show efficacy in preventing C. difficile infection (CDI). The optimal patient group to target for vaccination programmes remains unexplored. This study performed a model-based evaluation of the effectiveness of different CDI vaccination strategies, within the context of existing infection prevention and control strategies such as antimicrobial stewardship.
  
  
  
  An individual-based transmission model of CDI in a high-risk hospital setting was developed. The model incorporated data on patient movements between the hospital, and catchment populations from the community and long-term care facilities (LTCF), using English national and local level data for model-parameterisation. We evaluated vaccination of: (1) discharged patients who had an CDI-occurrence in the ward; (2) LTCF-residents; (3) Planned elective surgical admissions and (4) All three strategies combined.
  
  
  
  Without vaccination, 10.9 [Interquartile range: 10.0-11.8] patients per 1000 ward admissions developed CDI, of which 31% were ward-acquired. Immunising all three patient groups resulted in a 43% [42-44], reduction of ward-onset CDI on average. Among the strategies restricting vaccination to one target group, vaccinating elective surgical patients proved most effective (35% [34-36] reduction), but least efficient, requiring 146 [133-162] courses to prevent one ICU-onset case. Immunising LTCF residents was most efficient, requiring just 13 [11-16] courses to prevent one case, but considering this only comprised a small group of our hospital population, it only reduced ICU-onset CDI by 9% [8-11]. Vaccination proved most efficient when ward-based transmission rates and antimicrobial consumption were high.
  
  
  
  Strategy success depends on the interaction between hospital and catchment populations, and importantly, consideration of importations of CDI from outside the hospital which we found to substantially impact hospital dynamics. Vaccination may be most desirable in settings or patient groups where levels of broad-spectrum antimicrobial use are high and difficult to reduce.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom; Modelling and Economics Unit, Public Health England, London, United Kingdom. Electronic address: esther.vankleef@phe.gov.uk.
authors.forename: Esther
authors.initials: E
authors.lastname: van Kleef
authors.affiliation: Modelling and Economics Unit, Public Health England, London, United Kingdom; Health Protection Research Unit in Modelling Methodology, Public Health England, London, United Kingdom.
authors.forename: Sarah R
authors.initials: SR
authors.lastname: Deeny
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom; Modelling and Economics Unit, Public Health England, London, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Jit
authors.affiliation: University College London, London, United Kingdom.
authors.forename: Barry
authors.initials: B
authors.lastname: Cookson
authors.affiliation: Guy's & St Thomas' NHS Foundation Trust and King's College, London, United Kingdom.
authors.forename: Simon D
authors.initials: SD
authors.lastname: Goldenberg
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: W John
authors.initials: WJ
authors.lastname: Edmunds
authors.affiliation: Modelling and Economics Unit, Public Health England, London, United Kingdom.
authors.forename: Julie V
authors.initials: JV
authors.lastname: Robotham
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000073602:Antimicrobial Stewardship; D001428:Bacterial Vaccines / Q000008:administration & dosage*; D002986:Clinical Trials as Topic; D016360:Clostridioides difficile / Q000502:physiology; D003015:Clostridium Infections / Q000382:microbiology / Q000517:prevention & control* / Q000635:transmission; D003428:Cross Infection / Q000517:prevention & control*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D017053:Infection Control / Q000379:methods*; D008134:Long-Term Care / Q000706:statistics & numerical data; D008297:Male; D008962:Models, Theoretical; D014611:Vaccination
chemical_list: D000900:Anti-Bacterial Agents; D001428:Bacterial Vaccines
keywords: Clostridium difficile; Mathematical modelling; Vaccination