{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T01:42:43Z","timestamp":1782783763133,"version":"3.54.5"},"reference-count":45,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2021,7,8]],"date-time":"2021-07-08T00:00:00Z","timestamp":1625702400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004334","name":"Merck","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004334","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100009947","name":"Merck Sharp and Dohme","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100009947","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\"><jats:title>Background<\/jats:title><jats:p>Norway has not implemented universal varicella vaccination, despite the considerable clinical and economic burden of varicella disease.<\/jats:p><\/jats:sec><jats:sec id=\"sec002\"><jats:title>Methods<\/jats:title><jats:p>An existing dynamic transmission model of varicella infection was calibrated to age-specific seroprevalence rates in Norway. Six two-dose vaccination strategies were considered, consisting of combinations of two formulations each of a monovalent varicella vaccine (Varivax<jats:sup>\u00ae<\/jats:sup>or Varilrix<jats:sup>\u00ae<\/jats:sup>) and a quadrivalent vaccine against measles-mumps-rubella-varicella (ProQuad<jats:sup>\u00ae<\/jats:sup>or PriorixTetra<jats:sup>\u00ae<\/jats:sup>), with the first dose given with a monovalent vaccine at age 15 months, and the second dose with either a monovalent or quadrivalent vaccine at either 18 months, 7 or 11 years. Costs were considered from the perspectives of both the health care system and society. Quality-adjusted life-years saved and incremental cost-effectiveness ratios relative to no vaccination were calculated. A one-way sensitivity analysis was conducted to assess the impact of vaccine efficacy, price, the costs of a lost workday and of inpatient and outpatient care, vaccination coverage, and discount rate.<\/jats:p><\/jats:sec><jats:sec id=\"sec003\"><jats:title>Results<\/jats:title><jats:p>In the absence of varicella vaccination, the annual incidence of natural varicella is estimated to be 1,359 per 100,000 population, and the cumulative numbers of varicella outpatient cases, hospitalizations, and deaths over 50 years are projected to be 1.81 million, 10,161, and 61, respectively. Universal varicella vaccination is projected to reduce the natural varicella incidence rate to 48\u201359 per 100,000 population, depending on the vaccination strategy, and to reduce varicella outpatient cases, hospitalizations, and deaths by 75\u201385%, 67\u201379%, and 75\u201379%, respectively. All strategies were cost-saving, with the most cost-saving as two doses of Varivax<jats:sup>\u00ae<\/jats:sup>at 15 months and 7 years (payer perspective) and two doses of Varivax<jats:sup>\u00ae<\/jats:sup>at 15 months and 18 months (societal perspective).<\/jats:p><\/jats:sec><jats:sec id=\"sec004\"><jats:title>Conclusions<\/jats:title><jats:p>All modeled two-dose varicella vaccination strategies are projected to lead to substantial reductions in varicella disease and to be cost saving compared to no vaccination in Norway.<\/jats:p><\/jats:sec>","DOI":"10.1371\/journal.pone.0254080","type":"journal-article","created":{"date-parts":[[2021,7,8]],"date-time":"2021-07-08T17:34:26Z","timestamp":1625765666000},"page":"e0254080","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":19,"title":["Clinical and economic impact of universal varicella vaccination in Norway: A modeling 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Economic Burden of Varicella in Europe in Absence of Universal Varicella Vaccination. 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[Available from: https:\/\/www.ssb.no\/."},{"key":"pone.0254080.ref029","unstructured":"Centers for Disease Control and Prevention. Chickenpox [updated December 31, 2018. Available from: https:\/\/www.cdc.gov\/chickenpox\/about\/complications.html."},{"issue":"4","key":"pone.0254080.ref030","doi-asserted-by":"crossref","first-page":"830","DOI":"10.1016\/j.clinthera.2015.01.006","article-title":"Cost-effectiveness of routine varicella vaccination using the measles, mumps, rubella and varicella vaccine in France: an economic analysis based on a dynamic transmission model for varicella and herpes zoster","volume":"37","author":"KJ Littlewood","year":"2015","journal-title":"Clinical therapeutics"},{"issue":"2","key":"pone.0254080.ref031","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1097\/01.inf.0000109287.97518.67","article-title":"Ten year follow-up of healthy children who received one or two injections of varicella vaccine","volume":"23","author":"B Kuter","year":"2004","journal-title":"The Pediatric infectious disease journal"},{"issue":"9925","key":"pone.0254080.ref032","doi-asserted-by":"crossref","first-page":"1313","DOI":"10.1016\/S0140-6736(12)61461-5","article-title":"Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine versus one dose of monovalent varicella vaccine: a multicentre, observer-blind, randomised, controlled trial","volume":"383","author":"R Prymula","year":"2014","journal-title":"Lancet (London, England)"},{"issue":"4","key":"pone.0254080.ref033","doi-asserted-by":"crossref","first-page":"816","DOI":"10.1016\/j.clinthera.2014.12.017","article-title":"The impact of 2-dose routine measles, mumps, rubella, and varicella vaccination in France on the epidemiology of varicella and zoster using a dynamic model with an empirical contact matrix","volume":"37","author":"MJ Ouwens","year":"2015","journal-title":"Clinical therapeutics"},{"issue":"1","key":"pone.0254080.ref034","doi-asserted-by":"crossref","first-page":"1103","DOI":"10.1186\/s12889-016-3738-x","article-title":"Coverage, efficacy or dosing interval: which factor predominantly influences the impact of routine childhood vaccination for the prevention of varicella? 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