Weighing Economic and Logistic Factors: Choosing Between Heplisav-B (2-Dose) and Traditional (3-Dose) HBV Vaccines

Introduction

In occupational health, ensuring the protection of employees against infectious diseases such as Hepatitis B is both critical and challenging. With advancements in vaccine technology, healthcare providers now have the option to choose between different vaccination regimens. The decision between the traditional 3-dose recombinant Hepatitis B vaccine and the novel 2-dose Heplisav-B vaccine has become a much-discussed topic. Understanding each option’s economic and logistical implications is essential for making informed vaccination decisions.

Background: The Evolution of Hepatitis B Vaccination

History of Hepatitis B

Hepatitis B is a long-standing public health concern, with the hepatitis B virus (HBV) responsible for substantial morbidity and mortality worldwide. First identified in the mid-20th century, HBV is primarily transmitted through percutaneous or mucosal exposure to infectious blood or body fluids, sexually, or perinatally from mother to child. Chronic infection can lead to serious conditions like cirrhosis or liver cancer, making it a significant burden not just for individuals but also for healthcare systems globally.

People and Economic Costs of Hepatitis B

The global burden of Hepatitis B is immense. According to the World Health Organization, over 296 million people were living with chronic HBV infection as of the early 2020s. The disease results in nearly 820,000 deaths annually due to HBV-related liver diseases. Economically, this translates to a burdensome cost on healthcare systems worldwide. The financial implications include direct medical costs for treatment and care, and indirect costs stemming from lost productivity due to illness and premature death. The economic strain is particularly pronounced in low- and middle-income countries, where chronic HBV infection is more prevalent and healthcare resources are limited.

Emergence of the Recombinant Hepatitis B Vaccines

The need for effective prevention led to the development of the first-generation plasma-derived HBV vaccines in the early 1980s. However, due to concerns about safety and limited supply, attention quickly shifted to recombinant DNA technology. In 1986, the first recombinant Hepatitis B vaccine was licensed. This innovation leveraged genetic engineering to produce viral antigens in yeast cells, ensuring safety and scalability.

Recombinant vaccines represented a pivotal advancement in public health:

• Wide Acceptance: Over the years, they became the standard for immunization against HBV due to their proven safety and efficacy.
• Public Health Impact: The introduction of universal infant vaccination programs significantly reduced incidences of acute and chronic hepatitis B, especially in regions with high vaccination coverage.
• Long-term Efficacy: These vaccines offered durable immunity, often lasting a lifetime without the need for booster doses.

Introduction of the Novel 2-Dose Heplisav-B Vaccine

While recombinant vaccines have been successful, there remained challenges related to vaccine adherence given the extended schedule. Enter Heplisav-B, a new entrant approved by the FDA in 2017. This 2-dose vaccine, developed by Dynavax Technologies, introduced a novel immunological adjuvant that enhanced immune response, allowing the vaccine to be delivered over one month instead of the six required by the three-dose traditional recombinant series.

Why Introduce Heplisav-B?

• Adherence Improvement: With adherence rates declining as the number of appointments increases, a two-dose regimen offered a practical solution, particularly in populations with low compliance.
• Quicker Immunity: The accelerated schedule ensures faster protection, crucial for individuals at immediate risk or entering high-exposure environments.
• Clinical Efficacy: Clinical trials demonstrated that Heplisav-B provided superior protection in certain populations (e.g., older adults, those with diabetes), traditionally less responsive to the standard vaccines.

Impact of Heplisav-B to Date

• Adoption in Specific Populations: Following its introduction, Heplisav-B has been embraced particularly where rapid immunization is prioritized, such as occupational settings, in emergency services, and for travel purposes.
• Healthcare Logistics: Its shorter schedule has eased logistical burdens on healthcare systems, reducing appointment-related resource allocation.
• Increased Completion Rates: Heplisav-B’s simplified regimen has resulted in higher series completion rates.
• Cost-Effectiveness: Despite its higher cost per dose, the reduction in administrative expenses and improved adherence offset the difference for many providers.

The development and introduction of the traditional recombinant vaccines followed by Heplisav-B signify a progressive enhancement in strategic efforts to combat hepatitis B. These innovations reflect continuous efforts to improve public health outcomes through scientific advancement and epidemiological insights. As healthcare landscapes evolve, the choice between these vaccines will remain a critical decision point, influencing the breadth and dynamics of hepatitis B prevention strategies globally.

Comparison of Vaccine Efficacy

When evaluating the efficacy of hepatitis B vaccines, it is essential to consider the biological mechanisms, clinical outcomes, and demographic variances that might influence response rates and long-term protection. Both the traditional 3-dose traditional vaccine and the 2-dose Heplisav-B have demonstrated strong immunogenicity, but certain situations and populations may favor one over the other.

Efficacy of the 3-Dose Recombinant Vaccine

• Immune Response and Clinical Performance: The 3-dose traditional recombinant vaccine has a robust history of data supporting its efficacy. It achieves a seroprotection rate of around 95% in healthy adults who complete the series. This high rate of effectiveness has contributed significantly to lowering hepatitis B incidences in vaccinated populations worldwide.
• Long-term Immunity: One of the hallmarks of the traditional vaccine is its long-lasting immunity. Many studies have confirmed that individuals maintain protective immunity for 20 years or more after completing the series, potentially eliminating the need for booster doses in healthy adults.
• Impact on Special Populations:
  • Neonates and Infants: The traditional vaccine is particularly critical for infants born to HBV-positive mothers, reducing the risk of mother-to-child transmission. Administered within 24 hours of birth, often with HBIG, it significantly lowers the risk of chronic infection.
  • Immunocompromised Individuals: While generally effective, individuals with compromised immune systems may require additional doses or higher initial dosing schedules to achieve adequate immunity.
  • Non-Responders: Approximately 5-10% of the population may respond inadequately to the standard regimen, requiring additional doses or an alternative vaccination approach.

Efficacy of the 2-Dose Heplisav-B Vaccine

• Immune Response and Clinical Performance: Heplisav-B features a unique adjuvant (CpG 1018) that enhances immune response, leading to a high seroprotection rate, comparable to, and in some cases surpassing, that of the traditional vaccine. It’s particularly noted for its prompt protection, providing seroprotection after just one month.
• Special populations:
  • Older Adults: Studies indicate that Heplisav-B offers superior protection in older adults, a group that can exhibit a diminished immune response due to age-related changes. This makes it a compelling choice for protecting populations aged 60 and above.
  • Chronic Conditions: Individuals with chronic conditions like diabetes have shown a stronger immune response to Heplisav-B compared to the traditional vaccine.
  • Populations with Poor Adherence: The shorter two-dose schedule significantly boosts completion rates, making it ideal for populations that historically struggle with adhering to the full vaccination schedule, such as transient or highly mobile individuals.

Situational Efficacy Considerations

• Rapid Onset of Protection Needs: In cases where swift immunization is necessary—such as during an outbreak in a healthcare setting, for workers in high-risk occupations, or in regions with sudden increases in HBV cases—Heplisav-B’s quick schedule is advantageous.
• Occupational Hazards: For industries where employees may be at immediate risk of exposure, such as healthcare, hazmat, and public safety sectors, rapid protection is critical. Heplisav-B’s fast-acting nature can enable these sectors to maintain functional operations without significant interruptions.
• Geographic and Epidemiological Considerations: Regions with higher HBV prevalence might see a stronger need for vaccines that ensure higher series completion rates, such as Heplisav.-B Conversely, areas where HBV is less common may opt for traditional vaccines due to their low cost and well-documented long-term efficacy.

Overall, the decision between these vaccines should take into account not only the overall effectiveness but also how each vaccine’s unique characteristics best serve the specific needs of various populations and situations. By aligning vaccine strategies with the conditions under which they will be most beneficial, healthcare providers can optimize immunization outcomes and public health initiatives.

Economic Considerations

Choosing between the 2-dose Heplisav-B vaccine and the 3-dose traditional vaccine involves weighing several economic factors. These considerations are crucial for healthcare providers, occupational health professionals, and organizations tasked with managing costs while ensuring optimal protection against hepatitis B. Both direct and indirect costs play significant roles in shaping the economic landscape of vaccination programs.

Direct Costs

• Cost per Dose:
  • traditional Recombinant Vaccine: traditional vaccines are generally less expensive per dose compared to Heplisav-B. However, the need for three doses offsets this price benefit, cumulatively increasing the total cost of completing the vaccination series.
  • Heplisav-B Vaccine: Although the per-dose cost of Heplisav-B is higher, only two doses are required, which can simplify budgeting for healthcare programs by reducing the overall number of doses needed.
• Vaccine Procurement and Storage:
  • Both vaccines require cold chain storage, but the reduced volume with Heplisav-B may lower refrigeration and logistical costs, particularly in organizations with limited storage capabilities or those administering vaccines in remote or low-resource settings.

Indirect Costs

• Administrative and Operational Costs:
  • Traditional Vaccine: Coordinating three clinic visits per patient entails increased administrative work, scheduling, patient reminders, and the potential need for further follow-up appointments, which add to operational expenses.
  • Heplisav-B Vaccine: Requiring only two visits, Heplisav-B reduces the logistical burden, minimizing labor costs related to scheduling and tracking appointments. This can be particularly beneficial for large workforce vaccination programs where time and resources are critical.
• Productivity Losses:
  • For both vaccines, employers must account for employee time away from work to receive each dose. With Heplisav-B, fewer doses mean less time lost, which translates into lesser productivity impacts and greater appeal to organizations needing to minimize disruption—particularly in high-demand sectors like healthcare and emergency services.

Cost-Effectiveness and Return on Investment (ROI)

• Adherence Impact:
  • Improved adherence through a shorter dosing schedule not only enhances health outcomes but also improves the overall cost-effectiveness of the vaccination program. Higher completion rates ensure full protection is achieved, reducing the risk of HBV transmission and potential treatment costs in the event of an infection.
• Healthcare Savings:
  • While Heplisav-B may represent a higher upfront cost, its ability to rapidly immunize at-risk populations can lead to significant savings by preventing outbreaks and subsequent healthcare expenditures. By mitigating the risk of chronic HBV infections, organizations can avert long-term costs associated with treating acute and chronic hepatitis B-related complications.
• Tailored Economic Decisions:
  • Choosing between these vaccines often involves context-specific economic analyses. For instance, in regions or industries with a high prevalence of hepatitis B, the enhanced immunity and adherence rates associated with Heplisav-B could justify its higher cost by securing a more reliable safety net against infection.
  • Conversely, in low-prevalence areas where budget constraints might be more pressing and adherence can be monitored effectively, the traditional recombinant vaccine might provide a more economical solution.

Weighing the economic considerations involves balancing immediate costs with long-term health outcomes and operational efficiencies. Organizations must assess their own unique circumstances, including workforce characteristics, industry demands, and regional health challenges, to determine which vaccine regimen offers the best value in securing occupational health and public safety. By making informed economic choices, healthcare providers can optimize resource allocation and strengthen their commitment to maintaining a healthy, productive workforce.

Prevalence and Risk Assessment

The choice between Heplisav-B’s 2-dose regimen and the traditional 3-dose traditional vaccine is significantly influenced by the prevalence of hepatitis B in a given region or population and the associated risk factors. A thorough risk assessment helps tailor vaccination strategies to local epidemiological conditions, ensuring optimal disease control while managing resources efficiently.

Understanding Hepatitis B Prevalence

Hepatitis B prevalence varies widely across different geographic regions, influenced by factors such as healthcare infrastructure, public health policies, socioeconomic conditions, and cultural practices. It’s critical to consider these elements when assessing the risks and benefits of selecting a vaccination type.

• High-Prevalence Areas:
  • In regions with high incidence rates of hepatitis B, there is a pressing need for effective vaccination programs to prevent widespread infections. Here, achieving high immunization coverage is necessary to reduce transmission rates and avoid significant health and economic impacts.
• Low-Prevalence Areas:
  • While the urgency may be less palpable in low-incidence regions, ensuring ongoing protection through vaccination remains vital to maintaining low transmission rates. Vaccines in these areas can serve more preventive and protective roles to contain the virus effectively.

Risk Factors Influencing Vaccination Strategy

Several factors must be considered in assessing the risk of hepatitis B transmission within specific populations or sectors:

• Occupational Risks:
  • Workers in healthcare, sanitation, and emergency services are at elevated risk due to potential exposure to bloodborne pathogens. A robust vaccination strategy is essential to protect these individuals and prevent workplace transmission.
  • In high-risk occupations, Heplisav-B’s rapid protection may offer substantial benefits in ensuring that employees receive full immunization without delay, which is crucial in dynamic work environments.
• Population Demographics:
  • Age, health status, and behavioral factors can affect hepatitis B risk levels. For example, younger, healthier populations may have lower immediate risk but might still benefit from long-term protective measures, guiding them towards traditional vaccine protocols.
  • Conversely, older adults or those with pre-existing conditions might benefit from Heplisav-b’s strong efficacy in populations that typically display a weaker immune response to vaccines.
• Community and Environmental Factors:
  • Areas with high migration rates or communities living in close quarters may see faster virus spread and thus require rapid immunization strategies, which can be facilitated by Heplisav’-Bs shorter dosing schedule.
  • Additionally, tailored outreach and education may be necessary in such communities to ensure high vaccination uptake, regardless of the chosen regimen.

Strategic Implications of Risk Assessment

• Balancing Efficacy with Contextual Needs:
  • While both vaccines demonstrate strong efficacy, situational factors like regional prevalence and specific population risks might tilt the decision in favor of one approach over the other. Organizations might leverage Heplisav-B’s quick schedule in outbreak-prone areas to rapidly curb transmission.
• Resource Allocation:
  • In resource-constrained environments, especially those recovering from economic or natural disruptions, the simplified logistics and reduced appointments required by Heplisav-B can conserve healthcare resources while delivering effective protection.
• Public Health Policy:
  • Policymakers might adopt Heplisav-B as part of a targeted approach in areas with sudden spikes in hepatitis B cases or where improving vaccination adherence is a public health priority. Conversely, broader use of traditional vaccines might continue when gradual, long-term protection suffices.

By understanding and anticipating these varied factors, healthcare decision-makers can more effectively design and implement vaccination strategies that align with the specific needs and challenges of their communities, thereby maximizing health outcomes while accommodating logistical and economic constraints. Adjusting these strategies in line with evolving epidemiological data and risk assessments ensures ongoing relevance and efficacy in hepatitis B prevention efforts.

Industry-Specific Considerations

When determining the most appropriate hepatitis B vaccination strategy, industry-specific factors play a crucial role. Occupational environments, inherent risks, workforce demographics, and operational demands all influence whether the 2-dose Heplisav-B or the 3-dose traditional vaccine regimen is more suitable. Different industries require unique strategies to ensure both effective immunization and efficient resource management.

Healthcare Industry

• High Exposure Risk:
  • Healthcare workers are frequently exposed to bloodborne pathogens, including HBV, making them a high-priority group for vaccination programs. The risk is particularly significant in settings such as emergency rooms, surgical departments, and infection control units.
• Vaccination Strategy:
  • The rapid immunization provided by Heplisav-B can be advantageous in quickly establishing immunity among incoming staff, especially those working in high-turnover environments or dealing with immediate risks, such as a sudden increase in exposure incidents.
  • Alternatively, for stable and long-term facilities, the traditional vaccine’s proven track record and its comprehensive immunization over time can suffice, ensuring long-term safety with a focus on adherence support mechanisms.

Public Safety and Emergency Services

• Operational Demands:
  • Personnel in emergency services, such as police officers, firefighters, and paramedics, work in high-pressure environments where time and immediate readiness are critical. They may encounter situations where fast immunization is essential to mitigate risk.
• Vaccination Strategy:
  • Heplisav-B-B’s two-dose schedule minimizes disruptions and allows for rapid protection, making it particularly well-suited to the exigencies of public safety roles. Improved adherence and minimal downtime align well with the operational constraints faced.
  • Conversely, for administrative staff or roles with predictable schedules, traditional vaccines might be administered alongside regular health checks to ensure long-term protection without interfering with day-to-day operations.

Hazardous Materials and Industrial Occupations

• Exposure Risks:
  • These workers often operate in environments where they may come into contact with biohazards, making them susceptible to potential HBV exposure. Ensuring that a fully immunized status is maintained is paramount for occupational safety.
• Vaccination Strategy:
  • Heplisav-B can provide a rapid immunization solution, fitting seamlessly into the ongoing safety training and certification cycles often required in these roles, ensuring workers are quickly protected without prolonged absence from critical tasks.
  • When workforce stability is assured and schedules allow for multiple visits, traditional vaccines can also be a methodically integrated part of comprehensive occupational health programs that include other preventive measures.

Educational Institutions

• Diverse Demographics:
  • Educators and staff in schools and universities encounter diverse populations, including international students who might come from regions with varying HBV prevalence rates.
• Vaccination Strategy:
  • The simpler Heplisav-B regimen may better serve transient populations such as visiting faculty or international students, ensuring they receive full vaccination before the start of academic terms.
  • For permanent staff and long-term faculty, the traditional vaccine can be incorporated into routine health initiatives, providing ongoing immunization and aligning with potential teachable moments in health education programs.

Travel and Tourism Sectors

• Traveler Interaction:
  • Employees in this sector frequently interact with individuals from various regions, some with high HBV incidences, posing specific occupational health risks.
• Vaccination Strategy:
  • Quick immunization offered by Heplisav-B can be crucial for staff embarking on frequent overseas assignments or those experiencing constant traveler turnover, as it minimizes vaccination-related time off.
  • In contrast, in local settings with fewer interactions, the traditional vaccine may be integrated into broader health initiatives, providing structured long-term protection.

Each industry presents unique factors influencing the decision between Heplisav-B and traditional vaccines. Factors such as immediacy of risk, workforce fluidity, operational demands, and demographic diversity dictate the most effective immunization approach. By aligning vaccination strategies with industry-specific needs, occupational health professionals can ensure maximum protection against hepatitis B, coupled with efficient use of resources and minimal disruption to critical operational workflows. In the end, tailored vaccination protocols provide the dual benefit of safeguarding health while supporting seamless industry operations.

Logistical Considerations

Logistical aspects of vaccine administration include the planning, coordination, and implementation required to achieve high vaccination coverage efficiently and effectively. For occupational health professionals, logistical considerations may greatly influence the choice between the Heplisav-B 2-dose regimen and the traditional 3-dose traditional vaccine. Each approach presents its own set of logistical challenges and advantages, which must be managed to ensure successful immunization outcomes.

Scheduling and Appointment Management

• Number of Appointments:
  • Traditional Recombinant Vaccine: Administering three doses over six months necessitates significant effort in scheduling and ensuring compliance. This can result in more complex follow-up protocols to guarantee that each dose is given at the correct interval.
  • Heplisav-B Vaccine: The streamlined two-dose schedule simplifies appointment scheduling, reducing the number of visits by a third. This makes it easier for both employees and administrators to handle logistics, ensuring higher adherence rates with less burden on operational resources.
• Missed Appointments and Rescheduling:
  • The longer duration and higher number of appointments needed for the traditional vaccine increase the probability of missed doses, necessitating extensive reminder systems and rescheduling efforts. Conversely, Heplisav-B’s shorter schedule allows for a more straightforward, less resource-intensive approach to follow-up.

Compliance and Adherence

• Complexity of Regimen:
  • The more complex the regimen, the higher the likelihood of incomplete vaccination. With Heplisav-B, the simpler regimen significantly enhances adherence rates, crucially ensuring that individuals complete the series and are fully protected.
  • High adherence is critical not only for individual protection but also for public health efforts aiming to reduce HBV transmission at a community level.
• Tools and Technologies for Tracking:
  • Effective use of digital tools, such as electronic health records and automated reminder systems, can support both regimens. However, fewer doses require fewer reminders and less monitoring, reducing administrative workload considerably for Heplisav-B.

Resource Allocation and Staffing

• Staff Requirements:
  • The administration of a three-dose regimen requires more healthcare personnel involvement for both administration and patient management over an extended period. Staffing needs are reduced when opting for Heplisav-B, freeing up healthcare professionals to focus on other patient care tasks.
• Training and Preparedness:
  • Both vaccines require proper storage and handling training, but reduced dosing intervals with Heplisav-B streamline processes, reduce training time for complex appointment scheduling, and improve workforce readiness.

Storage and Supply Chain Management

• Supply Demand and Management:
  • Heplisav-B’s reduced dosage requirement decreases the overall volume of vaccines needed, easing supply chain pressures and minimizing the chance of shortages. It makes it a particularly attractive option in settings where storage capacity is limited or where logistical constraints are significant.
• Cold Chain Considerations:
  • Both vaccines necessitate cold chain maintenance to ensure their viability. However, fewer doses reduce the frequency of handling and distributing vaccines, mitigating risks of improper storage and temperature excursions that could compromise vaccine integrity.

Implementation in Mass Vaccination Campaigns

• Population Size and Volume:
  • In mass vaccination campaigns, such as for large organizations or community-wide initiatives, logistical simplicity becomes even more crucial. Heplisav-B’s reduced number of doses can significantly streamline such campaigns, simplifying logistics and reducing barriers to high coverage.
• Economic Implications:
  • From an economic standpoint, lower administration and operational costs stemming from fewer doses translate into substantial savings, particularly when considering additional logistical factors such as transportation, storage, staffing, and follow-ups.

Logistical considerations are integral to designing effective vaccination programs, especially in occupational and population health initiatives. Simplifying logistics through a 2-dose Heplisav-B regimen can result in higher adherence, reduced administrative burden, and cost-efficiency, making it particularly appealing in resource-constrained environments or when rapid immunization is necessary. Conversely, where longer-term structure and well-established programs exist, and logistical capacity is robust, the traditional vaccine continues to be a viable, cost-effective option. By aligning vaccination strategies with logistical capabilities, healthcare providers ensure both efficacy and operational harmony in their immunization efforts.

Conclusion

When selecting between the 2-dose Heplisav-B and the 3-dose traditional hepatitis B vaccines, occupational health professionals must navigate a complex interplay of efficacy, economic considerations, logistical challenges, and specific industry needs. Each vaccine offers distinct advantages that align differently with these factors, underscoring the importance of context-driven decision-making.

Vaccine Efficacy: Both vaccines demonstrate high efficacy, yet certain populations—such as older adults and those with chronic conditions—may benefit more from Heplisav-B’s enhanced protection, while others may find sufficient long-term immunity with the traditional options.

Economic Considerations: Direct and indirect costs play a pivotal role, with Heplisav-B offering potential savings in administrative and operational expenses, despite its higher per-dose cost. This, combined with improved adherence rates, may yield greater overall cost-effectiveness, especially in high-turnover or high-risk areas.

Prevalence and Risk Assessment: Understanding regional HBV prevalence and workplace risk factors is critical. High-prevalence regions and occupations with immediate exposure risks might prioritize Heplisav-B’s rapid immunization, while areas with stable HBV rates might benefit from the economically advantageous traditional vaccines.

Industry-Specific Strategies: Different sectors require tailored vaccination strategies. Healthcare, public safety, and hazmat industries might favor Heplisav-B for its rapid protection and minimal downtime. In contrast, educational and travel sectors might balance both vaccines based on demographic needs and exposure risks.

Logistical Considerations: The logistical simplicity of the Heplisav-B regimen can significantly enhance adherence and reduce resource burdens, making it ideal for environments with capacity constraints or mass vaccination initiatives. Meanwhile, established settings with robust support systems might find the structured scheduling of traditional vaccines suits long-term planning.

Ultimately, aligning the choice of vaccine with the specific needs and constraints of the population or industry ensures optimized health outcomes. By carefully assessing and integrating these expanded considerations into their vaccination strategies, healthcare decision-makers can effectively safeguard their communities, balancing disease prevention with economic and operational efficiency.

References

1. World Health Organization. (2022). Hepatitis B. Retrieved from WHO website
2. Centers for Disease Control and Prevention. (2021). Hepatitis B FAQs for the Public. Retrieved from CDC website
3. Recent Advances in Protective Vaccines against Hepatitis Viruses: A Narrative Review
4. Mast, E.E., et al. (2005). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part II: immunization of adults.
5. Cost-effectiveness of hepatitis B vaccination using HEPLISAV™ in selected adult populations compared to Engerix-B® vaccine
6. Dynavax Technologies. (2017). Heplisav-B [Package Insert]. Berkeley, CA: Dynavax Technologies Corporation.
7. Hepatitis vaccination adherence and completion rates and factors associated with low compliance: A claims-based analysis of U.S. adults
8. Schillie, S., et al. (2018). CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management.
9. Formulary Submission Dossier HEPLISAV-B® Hepatitis B Vaccine (Recombinant), Adjuvanted July 12, 2024 Prepared by: Dynavax Technologies Corporation

**A special thank you to Dr. Laura Radke, medical director and adjuvant professor Froedtert/MCW, Occmed and Infectious Disease for reviewing this article for accuracy and bias.**