Comparative cost effectiveness of varicella, hepatitis A, and pneumococcal conjugate vaccines

Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020

HEPATITIS A IS A VACCINE-PREVENTABLE, COMMUNICABLE DISEASE OF THE LIVER CAUSED BY THE HEPATITIS A VIRUS (HAV). THE INFECTION IS TRANSMITTED VIA THE FECAL-ORAL ROUTE, USUALLY FROM DIRECT PERSON-TO-PERSON CONTACT OR CONSUMPTION OF CONTAMINATED FOOD OR WATER. HEPATITIS A IS AN ACUTE, SELF-LIMITED DISEASE THAT DOES NOT RESULT IN CHRONIC INFECTION. HAV ANTIBODIES (IMMUNOGLOBULIN G [IGG] ANTI-HAV) PRODUCED IN RESPONSE TO HAV INFECTION PERSIST FOR LIFE AND PROTECT AGAINST REINFECTION; IGG ANTI-HAV PRODUCED AFTER VACCINATION CONFER LONG-TERM IMMUNITY. THIS REPORT SUPPLANTS AND SUMMARIZES PREVIOUSLY PUBLISHED RECOMMENDATIONS FROM THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) REGARDING THE PREVENTION OF HAV INFECTION IN THE UNITED STATES. ACIP RECOMMENDS ROUTINE VACCINATION OF CHILDREN AGED 12-23 MONTHS AND CATCH-UP VACCINATION FOR CHILDREN AND ADOLESCENTS AGED 2-18 YEARS WHO HAVE NOT PREVIOUSLY RECEIVED HEPATITIS A (HEPA) VACCINE AT ANY AGE. ACIP RECOMMENDS HEPA VACCINATION FOR ADULTS AT RISK FOR HAV INFECTION OR SEVERE DISEASE FROM HAV INFECTION AND FOR ADULTS REQUESTING PROTECTION AGAINST HAV WITHOUT ACKNOWLEDGMENT OF A RISK FACTOR. THESE RECOMMENDATIONS ALSO PROVIDE GUIDANCE FOR VACCINATION BEFORE TRAVEL, FOR POSTEXPOSURE PROPHYLAXIS, IN SETTINGS PROVIDING SERVICES TO ADULTS, AND DURING OUTBREAKS.

Model Comparisons of the Effectiveness and Cost-Effectiveness of Vaccination: A Systematic Review of the Literature

OBJECTIVES

To describe all published articles that have conducted comparisons of model-based effectiveness and cost-effectiveness results in the field of vaccination. Specific objectives were to 1) describe the methodologies used and 2) identify the strengths and limitations of the studies.

METHODS

We systematically searched MEDLINE and Embase databases for studies that compared predictions of effectiveness and cost-effectiveness of vaccination of two or more mathematical models. We categorized studies into two groups on the basis of their data source for comparison (previously published results or new simulation results) and performed a qualitative synthesis of study conclusions.

RESULTS

We identified 115 eligible articles (only 5% generated new simulations from the reviewed models) examining the effectiveness and cost-effectiveness of vaccination against 14 pathogens (69% of studies examined human papillomavirus, influenza, and/or pneumococcal vaccines). The goal of most of studies was to summarize evidence for vaccination policy decisions, and cost-effectiveness was the most frequent outcome examined. Only 33%, 25%, and 3% of studies followed a systematic approach to identify eligible studies, assessed the quality of studies, and performed a quantitative synthesis of results, respectively. A greater proportion of model comparisons using published studies followed a systematic approach to identify eligible studies and to assess their quality, whereas more studies using new simulations performed quantitative synthesis of results and identified drivers of model conclusions. Most comparative modeling studies concluded that vaccination was cost-effective.

CONCLUSIONS

Given the variability in methods used to conduct/report comparative modeling studies, guidelines are required to enhance their quality and transparency and to provide better tools for decision making.

Hepatitis A and considerations regarding the cost-effectiveness of vaccination programs

Hepatitis A vaccines have demonstrated a high degree of immunogenicity and an excellent safety profile. Immunization of certain populations and patient subgroups is recommended according to specific epidemiological and clinical factors, such as a greater likelihood of acquisition of infection or concerns regarding the risk of development of fulminant hepatitis and death. Therefore, the economic implications of routine and/or targeted vaccination programs in the general population and high-risk individuals have been examined. In this manuscript, the available data from the literature regarding the cost-effectiveness of hepatitis vaccination programs in healthy individuals and in those with chronic liver disease are reviewed.

Cost-effectiveness studies of pneumococcal conjugate vaccines

The 7-valent pneumococcal conjugate vaccine is licensed in many countries for the prevention of pediatric pneumococcal disease. The vaccine is known to be highly immunogenic in infants and young children, and has been shown to be efficacious not only in decreasing disease in pediatric age groups but also in adults through herd immunity. Cost-effectiveness analyses of this vaccine have been performed in a number of countries. The present review compiles, summarizes and critiques these analyses. The range of values for cost-effectiveness, as measured in cost per life-years gained, in the studies reviewed, ranges from 14,000 US dollars to 147,000 US dollars with one outlier at 504,000 US dollars. For cost per quality-adjusted life years the range is 26,000 US dollars to 66,000 US dollars. Recommendations for the use of the vaccine will take account not only of these ratios but also of the absolute burden of disease. Performing cost-effectiveness analyses for healthcare interventions in infants and children is one means of redressing inequalities.

Economic evaluations of hepatitis A vaccination in middle-income countries

Economic evaluations of hepatitis A vaccination are important to assist national and international policy makers in different jurisdictions on making effective decisions. Up to now, a comprehensive review of the potential health and economic benefits on hepatitis A vaccination in middle-income countries (MICs) has not been performed yet. In this study, we reviewed the literature on the cost-effectiveness of hepatitis A vaccination in MICs. Most of the studies confirmed that hepatitis A vaccination was cost effective or even cost saving under certain conditions. We found that vaccine price, medical costs, incidence and discount rate were the most influential parameters on the sensitivity analyses. Vaccine price has been shown as a barrier for MICs in implementing universal vaccination of hepatitis A. Given their relatively limited financial resources, implementation of single-dose vaccination could be considered. Despite our findings, we argue that further economic evaluations in MICs are still required in the near future.

Universal hepatitis A vaccination in the United States: a call for action

Previous hepatitis A recommendations for the United States targeted vaccination of at-risk individuals and children living in states and communities with consistently elevated rates of hepatitis A. Recommendations now call for routine hepatitis A vaccination of all children in the United States beginning at age 1 year (12-23 months). Currently, vaccination coverage rates for hepatitis A remain below rates of other routine childhood vaccines. Achieving a national immunization rate greater than 90% for the recommended 2 doses of hepatitis A vaccine would lessen disease impact throughout society. Routine childhood immunization against hepatitis A can be a highly effective strategy to reduce infection in children and community transmission of the virus, and the elimination of indigenous transmission of hepatitis A is an attainable goal.

Medicaid-based child restraint system disbursement and education and the vaccines for children program: comparative cost-effectiveness

OBJECTIVE

Low-income children are disproportionately at risk for preventable motor-vehicle injury. Many of these children are covered by Medicaid programs placing substantial economic burden on states. Child restraint systems (CRSs) have demonstrated efficacy in preventing death and injury among children in crashes but remain underutilized because of poor access and education. The objective of this study was to evaluate the cost-effectiveness of Medicaid-based reimbursement for CRS disbursement and education for low-income children and compare it with vaccinations covered under the Vaccines For Children (VFC) program.

METHODS

A cost-effectiveness analysis was performed of Medicaid reimbursement for CRS disbursement/education for low-income children based on data from public and private databases. Primary outcomes measured include cost per life-year saved, death, serious injury, and minor injury averted, as well as medical, parental work loss, and future productivity loss costs averted. Cost-effectiveness calculations were compared with published cost-effectiveness data for vaccinations covered under the VFC program.

RESULTS

The adoption of a CRS disbursement/education program could prevent up to 2 deaths, 12 serious injuries, and 51 minor injuries per 100,000 low-income children annually. When fully implemented, the program could save Medicaid over $1 million per 100,000 children in direct medical costs while costing $13 per child per year after all 8 years of benefit. From the perspective of Medicaid, the program would cost $17,000 per life-year saved, $60,000 per serious injury prevented, and $560,000 per death averted. The program would be cost saving from a societal perspective. These data are similar to published vaccination cost-effectiveness data.

CONCLUSION

Implementation of a Medicaid-funded CRS disbursement/education program was comparable in cost-effectiveness with federal vaccination programs targeted toward similar populations and represents an important potential strategy for addressing injury disparities among low-income children.

Cost of varicella-related hospitalisations in an Italian paediatric hospital: comparison with possible vaccination expenses

OBJECTIVE

The aims of the study were to evaluate the economic burden of hospitalisations due to varicella in an Italian paediatric hospital during a 1-year period and to compare the data with potential expenses projected for a varicella mass vaccination programme.

RESEARCH DESIGN AND METHODS

An observational, retrospective, cohort study was designed to measure hospital admission costs in a cohort of paediatric patients with varicella in a 12-month period. A cost comparison with a vaccination programme planned to prevent varicella in a whole birth cohort was performed. All children 0-16 years referred to the Anna Meyer Children's Hospital (AMCH) were considered. Since AMCH is a tertiary-level hospital and accept patients from other Italian regions, in order to avoid overestimation of hospitalisation expenses, all analyses pertaining to both vaccination and hospitalisation costs were uniquely calculated on the basis of the cohort of residents in the district of Florence.

RESULTS

A total of 279 children were examined in the emergency department for varicella; 47/279 (16.8%) were sent to the inpatient clinic. The highest rate of hospitalisation (85.1%) was found in children < 4 years of age, and the largest number of complications (87.2%) occurred in previously healthy children. Mean length of hospitalisation (5.7 +/- 0.6 days) was similar to that reported in other western countries.

CONCLUSION

Excluding any indirect cost, permanent sequelae and serious outcomes such as death, hospital expenses (corresponding to euro239 654 in a 1-year period), would account for around 80% of total expenses for vaccinating an entire birth cohort (euro310353).

Cost-effectiveness analysis of a practice-based immunization education intervention

OBJECTIVE

To evaluate the cost-effectiveness of academic detailing programs to improve immunization coverage in communities through implementation and evaluation of the Raising Immunizations Thru Education (RITE) program in the Greater Houston area.

METHODS

RITE was a preintervention and postintervention pilot study with randomized intervention and control sites implemented in private practices in pediatrics and family medicine. Changes in self-reported provider behaviors (n = 186) and comparisons of immunization coverage levels between intervention (n = 61) and control (n = 62) practices were evaluated. Intervention costs, computed from the perspective of an agency wanting to replicate the intervention, included direct expenses and time costs, based on time logs and compensation. Sensitivity analysis describes variations in costs. The cost-effectiveness ratio was computed as dollars per additional outcome unit.

RESULTS

The RITE intervention improved self-reported provider behavior. The immunization rates in the intervention group increased by 1 per cent, whereas immunization rates in the control group decreased by 2 per cent -3 per cent, but the 3 per cent - 4 per cent difference was not significant. A 1 per cent increase in practice immunization rates costs $424-$550, depending on the up-to-date criteria used and the targeted age group.

CONCLUSIONS

The costs for 1 additional child with up-to-date immunization status are higher than potential societal savings, as reported in the literature. This intervention does not have a favorable cost-benefit ratio.

Do we fully understand the economic value of vaccines?

Although many vaccination strategies are cost-effective, some of the newer vaccines are more expensive and may raise concerns about value for money. However, standard methods of economic evaluation may not adequately assess the true cost-effectiveness of vaccines, with the consequent under-application of vaccine strategies. Therefore, this paper reviews the evidence on cost-effectiveness of vaccines and vaccination strategies for pneumococcal disease, meningococcal disease, Hepatitis A and influenza. In each case the evidence is considered alongside existing vaccination policies in the major developed countries. The paper also highlights areas where traditional economic evaluations may not adequately reflect the value of vaccines.

The cost-effectiveness of universal vaccination of children against hepatitis A in Argentina: results of a dynamic health-economic analysis

BACKGROUND

Socioeconomic improvements can reduce levels of endemic hepatitis A, but conversely increase the burden of disease. Routine childhood vaccination can rapidly control hepatitis A infection rates through the induction of herd immunity, although such programs can be costly.

METHODS

We evaluated the healthcare benefits and cost-effectiveness of a routine childhood vaccination program against hepatitis A in Argentina, using a dynamic model that incorporated the changing epidemiology of infection and the impact of vaccine-induced herd immunity. Demographic, disease, and economic data from Argentina were used where available.

RESULTS

At 95% coverage, the program would reduce the number of hepatitis A infections by 352,405 annually, avoiding 121,587 symptomatic cases and 428 deaths. Substantial healthcare benefits were also observed with vaccination coverage as low as 70%, which would prevent 295,826 infections. Economically, the program would save 23,989,963 US$ annually at 95% coverage, equivalent to 3,429 US$ per life-year gained. The program remained cost-saving in response to variation in factors, including disease-related costs, discount rate, herd immunity level, and rate of decrease of force of infection. The break-even cost per vaccine dose for the society was 25 US$ in the base-case, more than three times the current public cost of 7 US$ per dose.

CONCLUSIONS

Routine childhood vaccination against hepatitis A showed both health benefits and robust economic benefits in this analysis, supporting the recent decision of the Argentine government to implement such a program.

Preventing pneumonia: the role for pneumococcal and influenza vaccines

Streptococcus pneumoniae and influenza cause a wide spectrum of illness and result in substantial morbidity and mortality. They are significant public health concerns, and vaccines against both organisms exist. The pneumococcal polysaccharide vaccine has been available in its current form for over 20 years. Nonetheless, definitive evidence from prospective trials of its efficacy is lacking. Experts recommend that patients at high risk for pneumococcal infection and complications from this process be vaccinated. The role for revaccination remains controversial. Traditional influenza vaccine is composed of three virus types and decreases rates of serologically confirmed cases of influenza, hospital admissions for respiratory infection, and mortality. The pneumococcal and influenza vaccines are considered cost-effective options for pneumonia prevention.

The societal value of universal childhood vaccination

Availability of new vaccines preventing infectious diseases in healthy children populations is increasing worldwide. In Canada, despite the current recommendation of the National Advisory Committee on Immunization to include recent vaccines in routine schedule, only a few provinces have incorporated some of the newer vaccines in routine vaccination programs. A review was undertaken of economic evaluations of childhood vaccination strategies performed from the societal point of view in industrialized countries, to gain perspective on their global benefits. The general trend supports most universal vaccination programs as cost-saving or cost-effective for society. Comparison of vaccination programs with other health care interventions indicates that vaccines are often one of society's best healthcare investments. Current data suggest that the Canadian society would benefit from a more complete immunization program.

The cost-effectiveness of pneumococcal conjugate vaccination in Australia

BACKGROUND

Pneumococcal conjugate vaccine, 7 valent (PCV7) is the most costly vaccine yet considered for publicly funded programs. In mid 2001, Australia funded PCV7 for high-risk groups only (indigenous children and children with certain underlying medical conditions). World wide, non-industry-funded studies and studies using cost-utility measures are sparse. We undertook an independent economic analysis of PCV7 compared with no vaccination in the non high-risk Australian childhood population using cost-utility and cost-effectiveness measures.

METHODS

The incidence of invasive pneumococcal disease (IPD), non-bacteraemic pneumonia and otitis media was estimated using representative urban Australian data, or by extrapolation from comparable industrialised countries. A decision-analytic model was developed for a hypothetical birth cohort using the age-specific vaccine coverage from the Californian randomised controlled trial of PCV7. Health outcomes were measured by life-years saved and deaths and disability-adjusted life-years (DALYs) averted. In line with government guidelines, only direct costs were considered in 1997-1998 Australian dollars.

RESULTS

For a birth cohort of 250,000, the gross cost of vaccination is $ 78.6 million. Subtracting treatment cost savings, the net cost (discounted) is $ 61.7 million. In undiscounted terms, vaccination prevents 13.7 deaths, 11.2 (82%) from IPD and the remainder from non-bacteraemic pneumonia. The discounted cost per death avoided is $ 5.0 million, per life-year saved $ 230,130 and per DALY averted $ 121,100, giving a break-even vaccine price of $ 15.40 per dose. These estimates are most sensitive to the unit cost per dose of vaccine, estimates of incidence and vaccine efficacy against non-bacteraemic pneumonia and the discount rate. The cost per DALY reduced to $ 81,000 with a discount rate of 3% rather than 5% and to $ 90,000 with the most favourable assumptions concerning pneumonia reduction.

DISCUSSION

With a vaccine price of $ 90 per dose, mid-range estimates of impact against non-bacteraemic pneumonia, and discount rate of 5%, a PCV7 program for infants not at high risk of IPD is at the upper limit of cost per DALY previously approved under Australian pharmaceutical funding guidelines. The impact of PCV7 against non-bacteraemic pneumonia is poorly defined, but its importance to cost-effectiveness in resource rich and resource poor settings warrants further studies or analysis to give greater precision to this outcome.

Regional variation in the cost effectiveness of childhood hepatitis A immunization

BACKGROUND

Routine childhood hepatitis A immunization is recommended in regions with incidence rates twice the national average, but it may be cost-effective in a wider geographic area.

OBJECTIVE

To evaluate the costs and benefits of potential hepatitis A immunization of healthy US children in regions with varying hepatitis A incidences.

METHODS

We considered vaccination of the 2000 US birth cohort in states defined by historic hepatitis A incidence rates. Infections among potential vaccinees and their personal contacts were predicted from age 2 through 85 years. Net vaccination costs were estimated from health system and societal perspectives and were compared with life-years saved and quality-adjusted life years (QALYs) gained using a 3% discount rate. RESULTS Nationally vaccination would prevent >75 000 cases of overt hepatitis A disease. Approximately two-thirds of health benefits would accrue to personal contacts rather than to vaccinees themselves. In states with incidence rates of > or =200%, 100 to 199%, 50 to 99% and <50% the national average, societal costs per QALY gained would be <0, <0, 13,800 and 63,000 US dollars, respectively. Nationally vaccination would cost 9100 US dollars per QALY gained from the perspective of the health system and 1400 US dollars per QALY gained from society's perspective. Results are most sensitive to vaccination costs and rates of disease transmission through personal contact.

CONCLUSION

Childhood hepatitis A vaccination is most cost-effective in areas with the highest incidence rates but would also meet accepted standards of economic efficiency in most of the US. A national immunization policy would prevent substantial morbidity and mortality, with cost effectiveness similar to that of other childhood immunizations.

The cost effectiveness of hepatitis immunization for US college students

Hepatitis B immunization is recommended for all American children, and hepatitis A immunization is recommended for children who live in areas with elevated disease rates. Because hepatitis A and B occur most commonly in young adults, the authors examined the cost effectiveness of college-based vaccination. They developed epidemiologic models to consider infection risks and disease progression and then compared the cost of vaccination with economic, longevity, and quality of life benefits. Immunization of 100,000 students would prevent 1,403 acute cases of hepatitis A, 929 cases of hepatitis B, and 144 cases of chronic hepatitis B. Hepatitis B vaccination would cost the health system $7,600 per quality-adjusted life year (QALY) gained but would reduce societal costs by 6%. Hepatitis A/B vaccination would cost the health system dollar 8,500 per QALY but would reduce societal costs by 12%. Until childhood and adolescent vaccination can produce immune cohorts of young adults, college-based hepatitis immunization can reduce disease transmission in a cost-effective manner.

[Hepatitis A]

Hepatitis A infection is known since the ancient Chinese, Greek and Roman civilizations but the first documented report was published in the eighteenth century. The hepatovirus belongs to the Picornaviridae family, and carries a single strand RNA. There are 7 genotypes. Antibodies of the IgM and IgA classes, during natural infections, appear early in the serum, together with the first clinical manifestations of the disease, but they may also appear at the end of the first week of infection. There is a spectrum of clinical presentation: asymptomatic infection, symptomatic without jaundice and symptomatic jaundiced. A rare fatal form of hepatitis has been described. Diagnosis of the hepatitis A infection is confirmed by the finding of IgM anti-HAV antibodies, routinely performed using an ELISA test. Treatment is supportive. Intramuscular anti-A gamma globulin is used for passive immune prophylaxis, and there is an efficient vaccine for active immune prophylaxis.

Hepatitis A vaccination options for Australia

The epidemiology of hepatitis A is changing, with an increasing proportion of the population becoming susceptible to infection. The burden of hepatitis A is comparable to that of other vaccine-preventable diseases for which new vaccines are available. Options for vaccination include selective programmes for high-risk groups, which could involve screening prior to vaccination, or universal programmes for infants and/or adolescents. Selective programmes have been shown to be highly cost-effective if well implemented, but there is evidence that they might be poorly implemented. If a universal vaccination programme were considered for Australia, an infant programme, with doses at 18 months and 2 years, possibly with an additional adolescent programme, would be the recommended option. Universal hepatitis A vaccination for infants and/or adolescents is of comparable cost-effectiveness compared with other preventive strategies, but needs to be considered in the context of competing vaccination options.