Pneumonia prevention: Cost-effectiveness analyses of two vaccines among refugee children aged under two years, Haemophilus influenzae type b-containing and pneumococcal conjugate vaccines, during a humanitarian emergency, Yida camp, South Sudan

By September 2013, war between Sudan and South Sudan resulted in >70,000 Sudanese refugees and high pneumonia incidence among the 20,000 refugees in Yida camp, South Sudan. Using Médecins Sans Frontières (MSF)-provided data and modifying our decision-tree models, we estimated if administering Haemophilus influenzae type b (Hib)-containing (pentavalent vaccine, also with diphtheria pertussis and tetanus [DPT] and hepatitis B) and pneumococcal conjugate (PCV) vaccines were cost-effective against hospitalized pneumonia. Among children <2years old, compared with no vaccination, one- and two-doses of combined Hib-containing and PCV would avert an estimated 118 and 125 pneumonia cases, and 8.5 and 9.1 deaths, respectively. The cost per Disability-Adjusted-Life-Year averted for administering combined one- and two-doses was US$125 and US$209, respectively. MSF demonstrated that it was possible to administer these vaccines during an emergency and our analysis found it was highly cost-effective, even with just one-dose of either vaccine. Despite unknown etiology, there is strong field and now economic rationale for administering Hib and PCV during at least one humanitarian emergency.

Cost-effectiveness analysis of rotavirus vaccination in China: Projected possibility of scale-up from the current domestic option

Background

Rotavirus infection causes considerable disease burden of acute gastroenteritis (AGE) hospitalization and death among children less than 5 years in China. Although two rotavirus vaccines (Rotarix and RotaTeq) have been licensed in more than 100 countries in the world, the Lanzhou Lamb rotavirus vaccine (LLR) is the only vaccine licensed in China. This study aims to forecast the potential impacts of the two international vaccines compared to domestic LLR.

Methods

An economic evaluation was performed using a Markov simulation model. We compared costs at the societal aspect and health impacts with and without a vaccination program by LLR, Rotarix or RotaTeq. Parameters including demographic, epidemiological data, costs and efficacy of vaccines were obtained from literature review. The model incorporated the impact of vaccination on reduction of incidence of rotavirus infection and severity of AGE indicated by hospitalization, inpatient visits and deaths. Outcomes are presented in terms of quality-adjusted life years (QALYs) gained and incremental cost-effectiveness ratio (ICER) compared to status quo.

Results

In a hypothetical cohort of 100,000 infants, the two international vaccines showed very good cost-effectiveness, with ICER of Rotateq and Rotarix shifting from LLR of $1715.11/QALY and $2105.66/QALY, respectively. Rotateq and Rotarix had significantly decreased incidence compared to LLR, particularly among infants aged 6 months to 2 years.

Conclusions

RotaTeq is expected to introduce in the national routine immunization program to reduce disease burden of rotavirus infection with universal coverage.

Contribution of polio eradication initiative to strengthening routine immunization: Lessons learnt in the WHO African region

BACKGROUND

Important investments were made in countries for the polio eradication initiative. On 25 September 2015, a major milestone was achieved when Nigeria was removed from the list of polio-endemic countries. Routine Immunization, being a key pillar of polio eradication initiative needs to be strengthened to sustain the gains made in countries. For this, there is a huge potential on building on the use of polio infrastructure to contribute to RI strengthening.

METHODS

We reviewed estimates of immunization coverage as reported by the countries to WHO and UNICEF for three vaccines: BCG, DTP3 (third dose of diphtheria-tetanus toxoid- pertussis), and the first dose of measles-containing vaccine (MCV1).We conducted a systematic review of best practices documents from eight countries which had significant polio eradication activities.

RESULTS

Immunization programmes have improved significantly in the African Region. Regional coverage for DTP3 vaccine increased from 51% in 1996 to 77% in 2014. DTP3 coverage increased >3 folds in DRC (18-80%) and Nigeria from 21% to 66%; and >2 folds in Angola (41-87%), Chad (24-46%), and Togo (42-87%). Coverage for BCG and MCV1 increased in all countries. Of the 47 countries in the region, 18 (38%) achieved a national coverage for DTP3 ⩾90% for 2years meeting the Global Vaccine Action (GVAP) target. A decrease was noted in the Ebola-affected countries i.e., Guinea, Liberia and Sierra Leone.

CONCLUSIONS

PEI has been associated with increased spending on immunization and the related improvements, especially in the areas of micro planning, service delivery, program management and capacity building. Continued efforts are needed to mobilize international and domestic support to strengthen and sustain high-quality immunization services in African countries. Strengthening RI will in turn sustain the gains made to eradicate poliovirus in the region.

The effect of mass vaccination campaigns against polio on the utilization of routine immunization services: A regression discontinuity design

BACKGROUND

In most low and middle-income countries (LMIC), vaccines are primarily distributed by routine immunization services (RI) at health facilities. Additional opportunities for vaccination are also provided through mass vaccination campaigns, conducted periodically as part of disease-specific initiatives. It is unclear whether these campaigns are detrimental to RI services, or wether they may stimulate the utilization of RI.

METHODS

Unobserved confounders and reverse causality have limited existing evaluations of the effects of mass vaccination campaigns on RI services. We explored the use of a regression discontinuity design (RDD) to measure these effects more precisely. This is a quasi-experimental method, which exploits random variations in birth dates to identify the causal effects of vaccination campaigns. We applied RDD to survey data on a nationwide vaccination campaign against Polio conducted in Bangladesh.

RESULTS

We compared systematically the children born immediately before vs. after the vaccination campaign. These two groups had similar background characteristics, but differed by their exposure to the vaccination campaign. Contrary to previous studies, exposure to the campaign had positive effects on RI utilization. Children exposed to the campaign received between 0.296 and 0.469 additional doses of DPT vaccine by age 4months than unexposed children.

CONCLUSIONS

RDD constitutes a promising tool to assess the effects of mass vaccination campaigns on RI services. It could be tested in additional settings, using larger and more precise datasets. It could also be extended to measure the effects of other disease-specific interventions on the functioning of health systems, in particular those that occur at a discrete point in time and/or include age-related eligibility criteria.

What have we learned on costs and financing of routine immunization from the comprehensive multi-year plans in GAVI eligible countries?

BACKGROUND

Immunization is one of the most cost-effective health interventions, but as countries introduce new vaccines and scale-up immunization coverage, costs will likely increase. This paper updates estimates of immunization costs and financing based on information from comprehensive multi-year plans (cMYPs) from GAVI-eligible countries during a period when countries planned to introduce a range of new vaccines (2008-2016).

METHODS

The analysis database included information from baseline and 5-year projection years for each country cMYP, resulting in a total sample size of 243 observations. Two-thirds were from African countries. Cost data included personnel, vaccine, injection, transport, training, maintenance, cold chain and other capital investments. Financing from government and external sources was evaluated. All estimates were converted to 2010 US Dollars. Statistical analysis was performed using STATA, and results were population-weighted.

RESULTS

Results pertain to country planning estimates. Average annual routine immunization cost was $62 million. Vaccines continued to be the major cost driver (51%) followed by immunization-specific personnel costs (22%). Non-vaccine delivery costs accounted for almost half of routine program costs (44%). Routine delivery cost per dose averaged $0.61 and the delivery cost per infant was $10. The cost per DTP3 vaccinated child was $27. Routine program costs increased with each new vaccine introduced. Costs accounted for 5% of government health expenditures. Governments accounted for 67% of financing.

CONCLUSION

Total and average costs of routine immunization programs are rising as coverage rates increase and new vaccines are introduced. The cost of delivering vaccines is nearly equivalent to the cost of vaccines. Governments are financing greater proportions of the immunization program but there may be limits in resource scarce countries. Price reductions for new vaccines will help reduce costs and the burden of financing. Strategies to improve efficiency in service delivery should be pursued.

Costs of vaccine programs across 94 low- and middle-income countries

While new mechanisms such as advance market commitments and co-financing policies of the GAVI Alliance are allowing low- and middle-income countries to gain access to vaccines faster than ever, understanding the full scope of vaccine program costs is essential to ensure adequate resource mobilization. This costing analysis examines the vaccine costs, supply chain costs, and service delivery costs of immunization programs for routine immunization and for supplemental immunization activities (SIAs) for vaccines related to 18 antigens in 94 countries across the decade, 2011-2020. Vaccine costs were calculated using GAVI price forecasts for GAVI-eligible countries, and assumptions from the PAHO Revolving Fund and UNICEF for middle-income countries not supported by the GAVI Alliance. Vaccine introductions and coverage levels were projected primarily based on GAVI's Adjusted Demand Forecast. Supply chain costs including costs of transportation, storage, and labor were estimated by developing a mechanistic model using data generated by the HERMES discrete event simulation models. Service delivery costs were abstracted from comprehensive multi-year plans for the majority of GAVI-eligible countries and regression analysis was conducted to extrapolate costs to additional countries. The analysis shows that the delivery of the full vaccination program across 94 countries would cost a total of $62 billion (95% uncertainty range: $43-$87 billion) over the decade, including $51 billion ($34-$73 billion) for routine immunization and $11 billion ($7-$17 billion) for SIAs. More than half of these costs stem from service delivery at $34 billion ($21-$51 billion)-with an additional $24 billion ($13-$41 billion) in vaccine costs and $4 billion ($3-$5 billion) in supply chain costs. The findings present the global costs to attain the goals envisioned during the Decade of Vaccines to prevent millions of deaths by 2020 through more equitable access to existing vaccines for people in all communities. By projecting the full costs of immunization programs, our findings may aid to garner greater country and donor commitments toward adequate resource mobilization and efficient allocation. As service delivery costs have increasingly become the main driver of vaccination program costs, it is essential to pay additional consideration to health systems strengthening.

Cost-effectiveness analysis of routine immunization and supplementary immunization activity for measles in a health district of Benin

Background

This study was carried out at district level to describe the cost structure and measure the effectiveness of delivering supplementary immunization activity (SIA) and routine immunization (RI) for measles in Benin, a country heavily affected by this disease.

Methods

This cost-effectiveness study was cross sectional and considered 1-year time horizon. RI consists to vaccinate an annual cohort of children aged 0–1 year old and SIA consists to provide a second dose of measles vaccine to children aged 0–5 years old in order to reach both those who did not seroconvert and who were not vaccinated through RI. Ingredients approach to costing was used. Effectiveness indicators included measles vaccine doses used, vaccinated children, measles cases averted and disability adjusted life years averted. Data were collected from all the 18 health care centers of the health district of Natitingou for the year 2011. In the analysis, the coverage was 89 % for RI and 104 % for SIA.

Results

SIA total cost was higher than RI total cost (15,796,560 FCFA versus 9,851,938 FCFA). Personnel and vaccines were the most important cost components for the two strategies. Fuel for cold chain took a non-negligible part of RI total cost (4.03 %) because 83 % of refrigerators were working with kerosene. Cost structures were disproportionate as social mobilization and trainings were not financed during RI contrarily to SIA. In comparison with no intervention, the two strategies combined permitted to avoid 12,671 measles cases or 19,023 DALYs. The benefit of SIA was 5601 measles cases averted and 6955 additional DALYs averted. Cost per vaccinated child for SIA (442 FCFA) was lower than for RI (1242 FCFA), in line with previous data from the literature. Cost per DALY averted was 2271 FCFA (4.73 USD) for SIA and 769 FCFA (1.60 USD) for RI. Analysis showed that low vaccine efficacy decreased the cost-effectiveness ratios for the two strategies. SIA was more cost-effective when the proportion of previously unvaccinated children was higher. For the two strategies, costs per DALY were more likely to vary with measles case fatality ratio.

Conclusions

SIA is costlier than RI. Both SIA and RI for measles are cost-effective interventions to improve health in Benin compared to no vaccination. Policy makers could make RI more efficient if sufficient funds were allocated to communications activities and to staff motivation (trainings, salaries).

Electronic supplementary material

The online version of this article (doi:10.1186/s12962-015-0039-7) contains supplementary material, which is available to authorized users.

Comparison of impact and cost-effectiveness of rotavirus supplementary and routine immunization in a complex humanitarian emergency, Somali case study

Background

A humanitarian emergency involves a complete breakdown of authority that often disrupts routine health care delivery, including immunization. Diarrheal diseases are a principal cause of morbidity and mortality among children during humanitarian emergencies. The objective of this study was to assess if vaccination against rotavirus, the most common cause of severe diarrhea among children, either as an addition to routine immunization program (RI) or supplemental immunization activity (SIA) would be cost-effective during a humanitarian emergency to decrease diarrhea morbidity and mortality, using Somalia as a case study.

Methods

An impact and cost-effectiveness analysis was performed comparing no vaccine; two-dose rotavirus SIA and two-dose of RI for the 424,592 births in the 2012 Somali cohort. The main summary measure was the incremental cost per disability-adjusted life-year (DALY) averted. Univariate sensitivity analysis examined the extent to which the uncertainty in the variables affected estimates.

Results

If introduced in Somalia, a full-series rotavirus RI and SIA would save 908 and 359 lives, respectively, and save US$63,793 and US$25,246 in direct medical costs, respectively. The cost of a RI strategy would be US$309,458. Because of the high operational costs, a SIA strategy would cost US$715,713. US$5.30 per DALY would be averted for RI and US$37.62 per DALY averted for SIA. Variables that most substantially influenced the cost-effectiveness for both RI and SIA were vaccine program costs, mortality rate, and vaccine effectiveness against death.

Conclusions

Based on our model, rotavirus vaccination appears to be a cost-effective intervention as either RI or SIA, as defined by the World Health Organization as one to three times the per capita Gross Domestic Product (Somalia $112 in 2011). RI would have greater health impact and is more cost effective than SIA, assuming feasibility of reaching the target population. However, given the lack of infrastructure, whether RI is realistic in this setting remains unanswered, and alternative approaches like SIA should be further examined.