An analytical framework for immunization programs in Canada

Documenting the Full Value of Vaccination: A Systematic Review of Value Frameworks

OBJECTIVES

Economic evaluations of vaccination may not fully account for nonhealth patient impacts on families, communities, and society (ie, broader value elements). Omission of broader value elements may reflect a lack of established measurement methodology, lack of agreement over which value elements to include in economic evaluations, and a lack of consensus on whether the value elements included should vary by vaccination type or condition. We conducted a systematic review of value frameworks to identify broader value elements and measurement guidance that may be useful for capturing the full value of vaccination.

METHODS

We searched Ovid MEDLINE, PubMed, Embase, and the gray literature to identify value frameworks for all health interventions, and we extracted information on each framework's context, value elements, and any available guidance on how these elements should be measured. We used descriptive statistics to analyze and compare the prevalence of broader value elements in vaccination value frameworks and other healthcare-related value frameworks.

RESULTS

Our search identified 62 value frameworks that met inclusion criteria, 9 of which were vaccination specific. Although vaccination frameworks included several broader value elements, such as reduced transmissibility and public health benefits, the elements were represented inconsistently across the frameworks. Vaccination frameworks omitted several value elements included in nonvaccination-specific frameworks, including dosing and administration complexity and affordability. In addition, guidance for measuring broader value elements was underdeveloped.

CONCLUSIONS

Future efforts should further evaluate inclusion of broader value elements in economic evaluations of vaccination and develop standards for their subsequent measurement.

Identifying factors that can be used to assess a country's readiness to deploy a new vaccine or improve uptake of an underutilised vaccine: a scoping review

OBJECTIVES

Identifying whether a country is ready to deploy a new vaccine or improve uptake of an existing vaccine requires knowledge of a diverse range of interdependent, context-specific factors. This scoping review aims to identify common themes that emerge across articles, which include tools or guidance that can be used to establish whether a country is ready to deploy a new vaccine or increase uptake of an underutilised vaccine.

DESIGN

Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines.

DATA SOURCES

Embase, CINAHL, Cochrane Library, Google Scholar, MEDLINE, PsycINFO and Web of Science were searched for articles published until 9 September 2023. Relevant articles were also identified through expert opinion.

ELIGIBILITY CRITERIA

Articles published in any year or language that included tools or guidance to identify factors that influence a country's readiness to deploy a new or underutilised vaccine.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened records and performed data extraction. Findings were synthesised by conducting a thematic analysis.

RESULTS

38 articles met our inclusion criteria; these documents were created using methodologies including expert review panels and Delphi surveys and varied in terms of content and context-of-use. 12 common themes were identified relevant to a country's readiness to deploy a new or underutilised vaccine. These themes were as follows: (1) legal, political and professional consensus; (2) sociocultural factors and communication; (3) policy, guidelines and regulations; (4) financing; (5) vaccine characteristics and supply logistics; (6) programme planning; (7) programme monitoring and evaluation; (8) sustainable and integrated healthcare provision; (9) safety surveillance and reporting; (10) disease burden and characteristics; (11) vaccination equity and (12) human resources and training of professionals.

CONCLUSIONS

This information has the potential to form the basis of a globally applicable evidence-based vaccine readiness assessment tool that can inform policy and immunisation programme decision-makers.

Perceptions of the seriousness of major public health problems during the COVID-19 pandemic in seven middle-income countries

INTRODUCTION

Public perception of the seriousness of the COVID-19 pandemic compared to six other major public health problems (alcoholism and drug use, HIV/AIDS, malaria, tuberculosis, lung cancer and respiratory diseases caused by air pollution and smoking, and water-borne diseases like diarrhea) is unclear. We designed a survey to examine this issue using YouGov's internet panels in seven middle-income countries in Africa, Asia, and Latin America in early 2022.

METHODS

Respondents rank ordered the seriousness of the seven health problems using a repeated best-worst question format. Rank-ordered logit models allow comparisons within and across countries and assessment of covariates.

RESULTS

In six of the seven countries, respondents perceived other respiratory illnesses to be a more serious problem than COVID-19. Only in Vietnam was COVID-19 ranked above other respiratory illnesses. Alcoholism and drug use was ranked the second most serious problem in the African countries. HIV/AIDS ranked relatively high in all countries. Covariates, particularly a COVID-19 knowledge scale, explained differences within countries; statistics about the pandemic were highly correlated with differences in COVID-19's perceived seriousness.

CONCLUSIONS

People in the seven middle-income countries perceived COVID-19 to be serious (on par with HIV/AIDS) but not as serious as other respiratory illnesses. In the African countries, respondents perceived alcoholism and drug use as more serious than COVID-19. Our survey-based approach can be used to quickly understand how the threat of a newly emergent disease, like COVID-19, fits into the larger context of public perceptions of the seriousness of health problems.

Canada's National Advisory Committee on immunization: Adaptations and challenges during the COVID-19 pandemic

The COVID-19 pandemic has challenged traditional vaccine guidance infrastructure and frameworks, and added urgency and complexity to the operation of National Immunization Technical Advisory Groups (NITAGs). Canada's National Advisory Committee on Immunization (NACI) provides immunization guidance to the Public Health Agency of Canada (PHAC) who publicly shares expert and evidence-informed guidance with Canadian provinces and territories. Throughout the pandemic, NACI and PHAC implemented many adaptations to meet urgent needs for pandemic vaccine guidance. In this paper, we describe: structural adaptations in response to the accelerated pace and amount of work required to issue recommendations that were timed around product authorizations and dynamic epidemiology; technical adaptations in response to rapidly evolving evidence of variable quality which required close monitoring, and which promoted reliance on basic vaccine principles due to incomplete direct evidence; the need to provide nimble advice (e.g., off-label recommendations, preferential recommendations); communications adaptations (e.g. identify sustainable spokespeople for the committee, receive stakeholder feedback, and ensure urgent nuanced advice was communicated to a diverse audience); and research adaptations focussing on solutions to constrained supply (e.g. prioritisation, extended intervals, and heterologous schedules). The early pandemic vaccine experience has created a roadmap of lessons and adaptations that should be leveraged in future pandemic vaccine programs, and has highlighted the essential role of NITAGs to complement regulatory structures during pandemics to ensure timely, impactful, and evidence-informed public health vaccine guidance.

How Does the Public Evaluate Vaccines for Low-Incidence, Severe-Outcome Diseases? A General-Population Choice Experiment

BACKGROUND

Because immunizing large numbers of healthy people could be required to reduce a relatively small number of infections, disease incidence has a large impact on cost effectiveness, even if the infection is associated with very serious health outcomes. In addition to cost effectiveness, the US Advisory Committee on Immunization Practices requires evidence of stakeholders' values and preferences to help inform vaccine recommendations. This study quantified general-population preferences for vaccine trade-offs among disease severity, disease incidence, and other vaccine features.

METHODS

We developed a best-practice discrete choice experiment survey and administered it to 1185 parents of children aged 12-23 years and 1203 young adults aged 18-25 years from a national opt-in consumer panel. The data were analyzed using exploded-logit latent-class analysis.

RESULTS

Latent-class analysis identified two classes with similar relative-importance weights in both samples. One of the two classes represented about half the samples and had preferences consistent with well-structured, logically ordered, and acceptably precise stated-preference utility. Preferences for the other half of the samples were poorly defined over the ranges of vaccine and disease attributes evaluated. Both parents and young adults in the first class evaluated protection from a disease with 1 in 100 incidence and full recovery at home as having statistically the same preference utility as a disease with 1 in 1 million incidence requiring hospitalization and resulting in permanent deafness.

CONCLUSIONS

The results suggest that vaccines that protect against low-incidence, severe-outcome diseases, provide 'peace of mind' benefits not captured by standard health-outcome metrics. The fact that half the respondents had poorly defined vaccine preferences is a reminder of the challenges of implementing patient-centric vaccine decision making.

Parents' and healthcare professionals' perception toward the introduction of a new fully liquid hexavalent vaccine in the Malaysian national immunization program: a cross-sectional study instrument development and its application

A newly developed fully liquid hexavalent vaccine that comprises six antigens for Diphtheria, Tetanus, acellular Pertussis, Inactivated Poliomyelitis, Haemophilus Influenza type b., and Hepatitis B, is proposed to be introduced in the Malaysian national immunization program, instead of the non-fully liquid pentavalent vaccine and monovalent Hepatitis B vaccine that is currently employed in the immunization schedule. Although the introduction of new vaccines is a necessary intervention, it still needs to be accepted by parents and healthcare professionals. Hence, this study aimed to develop three structured questionnaires and to investigate the participants' perception and acceptability toward the incorporation of the new fully liquid hexavalent vaccine. A cross-sectional study was conducted among a sample of 346 parents, 100 nurses, and 50 physicians attending twenty-two primary health care centers in the states of Selangor and the Federal Territory of Kuala Lumpur and Putrajaya during 2019-2020. The study found that Cronbach's alpha coefficients for the study instruments ranged from 0.825 to 0.918. Principal components analysis produced a good fit with KMO>0.6. For the parents' perception questionnaire, the only extracted factor explained 73.9 % of the total variance; for the nurses' perception toward a non-fully and fully liquid combined vaccine, there was a sole extracted factor that explained 65.2 % and 79.2% of the total variance, respectively. Whereas for the physicians' perception, there was one factor extracted that explains 71.8 % of the total variance. The median score for all the questionnaire items ranged from 4 to 5 (Q1 and Q3 vary between 3-5). Parents' ethnicity was significantly associated (P-value ≤ 0.05) with the perception that the new hexavalent vaccine would reduce their transportation expenses. Moreover, a significant association (P-value ≤ 0.05) was found between physicians' age and the perception of the hexavalent vaccine's ability to decrease patient overcrowding in primary healthcare centers. The instruments used in this study were valid and reliable. Parents of Malay ethnicity were the most concerned about transportation expenses since they have the lowest income and are more concentrated in rural areas compared to other races. Younger physicians were concerned about reducing patient crowding and hence reducing their workload and burnout.

Equity in vaccination policies to overcome social deprivation as a risk factor for invasive meningococcal disease

INTRODUCTION

Social deprivation is associated with poorer healthcare access. Vaccination is among the most effective public health interventions and achieving equity in vaccination access is vitally important. However, vaccines are often reimbursed by public funds only when recommended in national immunization programs (NIPs), which can increase inequity between high and low socioeconomic groups. Invasive meningococcal disease (IMD) is a serious vaccination-preventable disease. This review focuses on vaccination strategies against IMD designed to reduce inequity.

AREAS COVERED

We reviewed meningococcal epidemiology and current vaccination recommendations worldwide. We also reviewed studies demonstrating an association between social deprivation and risk of meningococcal disease, as well as studies demonstrating an impact of social deprivation on uptake of meningococcal vaccines. We discuss factors influencing inclusion of meningococcal vaccines in NIPs.

EXPERT OPINION

Incorporating meningococcal vaccines in NIPs is necessary to reduce inequity, but insufficient alone. Inclusion provides clear guidance to healthcare professionals and helps to ensure that vaccines are offered universally to all target groups. Beyond NIPs, cost of vaccination should be reimbursed especially for disadvantaged individuals. These approaches should help to achieve optimal protection against IMD, by increasing access and immunization rates, eventually reducing social inequities, and helping to protect those at greatest risk.

Evolving strategies for meningococcal vaccination in Europe: Overview and key determinants for current and future considerations

Invasive meningococcal disease (IMD) is a life-threatening, unpredictable condition. Vaccines are available against 5 of the 6 meningococcal serogroups (Men) accounting for nearly all IMD cases worldwide; conjugate monovalent MenC, quadrivalent MenACWY, and protein-based MenB vaccines are commonly used. We provide a comprehensive overview of the evolution of meningococcal vaccination strategies employed in national immunization programmes (NIPs) and their impact on IMD incidence in Europe. A more in-depth description is given for several countries: the United Kingdom (UK), the Netherlands, Greece, Italy, and Ireland. We searched European health authorities' websites and PubMed. Various vaccines and immunization schedules are used in 21 NIPs. Most countries implement MenC vaccination in infants, MenACWY in adolescents, and a growing number, MenB in infants. Only Malta has introduced MenACWY vaccination in infants, and several countries reimburse immunization of toddlers. The UK, Italy, Ireland, Malta, Andorra, and San Marino recommend MenB vaccination in infants and MenACWY vaccination in adolescents, targeting the most prevalent serogroups in the most impacted age groups. Main factors determining new vaccination strategies are fluctuating IMD epidemiology, ease of vaccine implementation, ability to induce herd protection, favorable benefit-risk balance, and acceptable cost-effectiveness. Since 1999, when the UK introduced MenC vaccination, the reduction in IMD incidence has been gradually enhanced as other countries adopted routine meningococcal vaccinations. Meningococcal vaccination strategies in each country are continually adapted to regional epidemiology and national healthcare priorities. Future strategies may include broader coverage vaccines when available (e.g., MenABCWY, MenACWY), depending on prevailing epidemiology.

Using an adaptive, codesign approach to strengthen clinic-level immunisation services in Khayelitsha, Western Cape Province, South Africa

INTRODUCTION

Optimal immunisation programme service delivery and childhood vaccine coverage remains an ongoing challenge in South Africa. Previous health systems approaches have made recommendations on how to address identified barriers but detailed local implementation studies are lacking. This study aimed to improve immunisation service delivery in children under 24 months in Khayelitsha, Western Cape Province using an adaptive, co-design approach to assess and improve childhood immunisation service delivery at the clinic level.

METHODS

A rapid, adaptive approach to identification of barriers and assessment of current childhood immunisation service delivery was developed with three clinics in Khayelitsha, Western Cape Province. This informed a short co-design process with key stakeholders and service providers to develop local interventions targeted at high priority barriers. Interventions were implemented for 4-6 months and evaluated using theory-based evaluation tools. Clinic service delivery, satisfaction and changes to clinic processes and parent engagement and knowledge were measured.

RESULTS

Interventions developed included weekly community immunisation education radio sessions, daily clinic health talks, immunisation education and promotion materials and service provider and parent quality checklists. Evaluation post-intervention showed improvement in parents'/guardians' knowledge about immunisation, parent engagement and service provider commitment to improvement in service quality. Radio sessions and immunisation education and communication materials were deemed most useful by parents and providers.

CONCLUSION

Immunisation service delivery can be strengthened using an adaptive, clinic-led assessment process which can effectively identify barriers, inform co-designed interventions and be evaluated over a short period. This approach provides a framework to guide future local participatory action research to more effectively improve childhood immunisation service delivery and other child health services in under-resourced settings.

Evaluating Vaccination Programs That Prevent Diseases With Potentially Catastrophic Health Outcomes: How Can We Capture the Value of Risk Reduction?

In the last 5 years, guidelines have been developed for performing cost-effectiveness analyses (CEAs) for the economic evaluation of vaccination programs against infectious diseases. However, these cost-effectiveness guidelines do not provide specific guidance for including the value of reducing the risk of rare but potentially catastrophic health outcomes, such as mortality or long-term sequelae. Alternative economic evaluation methods, including extended CEA, the impact inventory, cost-benefit analyses, willingness to pay or the value of a statistical life, to capture the value of this risk reduction could provide more complete estimates of the value of vaccination programs for diseases with potentially catastrophic health and nonhealth outcomes. In this commentary, using invasive meningococcal disease as an example, we describe these alternative approaches along with examples to illustrate how the benefits of vaccination in reducing risk of catastrophic health outcomes can be valued. These benefits are not usually captured in CEAs that only include population benefits estimated as the quality-adjusted life-years gained and reduced costs from avoided cases.

A systematic review of factors that influence the acceptability of vaccines among Canadians

BACKGROUND

Canada's National Advisory Committee on Immunization (NACI) provides guidance on the use of vaccines in Canada. To support the expansion of its mandate to include considerations for vaccine acceptability when making recommendations, the NACI Secretariat developed a matrix of factors that influence acceptability. To inform and validate the matrix, we systematically reviewed evidence for factors that influence vaccine acceptability, and for interventions aimed at improving acceptability.

METHODS

On 10-11 October 2018 we searched four bibliographic databases, the Theses Canada Portal, and ClinicalTrials.gov. Two reviewers agreed on the included studies. From each study, we extracted information about the participants, intervention or exposure, comparator, and relevant outcomes. Due to heterogeneity in the reported factors and acceptability indicators we synthesized the findings narratively. We appraised the certainty of evidence using GRADE. For each vaccine-preventable disease we populated a matrix of factors for which there was evidence of an influence on acceptability.

RESULTS

One hundred studies (>1 million participants) contributed data relevant to the public, 16 (6191 participants) to healthcare providers, and three (84 participants) to policymakers. There were 43 intervention studies (~2 million participants). Across vaccines, we identified low certainty evidence for 70 factors relevant to the general population, 56 to high-risk groups, and 30 to healthcare providers. The perceived safety and importance of the vaccine, vaccination history, and receiving a recommendation from a healthcare provider were common influential factors. We found low certainty evidence that reminders for childhood vaccines and policies or delivery models for rotavirus vaccines could improve uptake and coverage. Evidence for other interventions was of very low certainty.

CONCLUSIONS

The NACI vaccine acceptability matrix is useful for categorizing acceptability factors for the general public. Reminder systems may improve the uptake of childhood vaccines. Policies that make the rotavirus vaccine universally available and easily accessible may improve coverage.

FUNDING

This systematic review was completed under contract to the Public Health Agency of Canada, Contract #4600001536.

Influenza vaccination and the evolution of evidence-based recommendations for older adults: A Canadian perspective

Older adults are at high risk from influenza and its complications, and are therefore an important population for prevention efforts. In Canada, public health efforts targeting influenza are multi-pronged and include vaccination programs as well as surveillance which informs the national surveillance reporting platform FluWatch run by the Public Health Agency of Canada. Recommendations regarding use of vaccines are made nationally by the National Advisory Committee on Immunization (NACI) and by the Comité sur l'immunisation du Québec in Quebec, while vaccination programs are planned and delivered at the provincial/territorial level as opposed to as a harmonized national immunization program. NACI performs rigorous targeted literature reviews to inform their statements, and recommendations also vary by whether they apply on Individual (pertaining to decisions for individual patients) vs. Programmatic (informing policy decisions for implementation of publicly funded vaccination programs) levels. This unique context results in inter-provincial variation in vaccine schedules and funded vaccine products. In this paper, the importance of influenza vaccination for older adults is discussed; to provide insights from the Canadian context, the evolution of NACI evidence reviews and recommendations on influenza vaccination is presented.

A framework for the systematic consideration of ethics, equity, feasibility, and acceptability in vaccine program recommendations

For the successful implementation of population-level recommendations, it is critical to consider the full spectrum of public health science, including clinical and programmatic factors. Current frameworks may identify various factors that should be examined when making evidence-informed vaccine-related recommendations. However, while most immunization guidelines systematically assess clinical factors, such as efficacy and safety of vaccines, there is no published framework outlining how to systematically assess programmatic factors, such as the ethics, equity, feasibility, and acceptability of recommendations. We have addressed this gap with the development of the EEFA (Ethics, Equity Feasibility, Acceptability) Framework, supported by evidence-informed tools, including Ethics Integrated Filters, Equity Matrix, Feasibility Matrix, and an Acceptability Matrix. The Framework and tools are based on five years of environmental scans, systematic reviews and surveys, and refined by expert and stakeholder consultations and feedback. For each programmatic factor, the EEFA Framework summarizes the minimum threshold for consideration and when further in-depth analysis may be required, which aspects of the factor should be considered, how to assess the factor using the supporting evidence-informed tools, and who should be consulted to complete the assessment. Research, particularly in the fields of vaccine acceptability and equity, has validated the utility and comprehensiveness of the tools. The Framework has been successfully used in Canada for clear, timely, transparent vaccine guidance with positive stakeholder feedback on its comprehensiveness, relevance and appropriateness. Applying the EEFA Framework allows for the systematic consideration of the spectrum of public health science without a delay in recommendations, complementing existing decision-making frameworks. This Framework will therefore be useful for advisory groups worldwide to integrate critical factors that could impact the successful and timely implementation of comprehensive, transparent recommendations, and will further the global objective of developing practical and evidence-informed immunization policies.

Gap analyses to assess Canadian readiness for respiratory syncytial virus vaccines: Report from an expert retreat

Respiratory syncytial virus (RSV) can cause severe disease in infants and older adults. Various vaccine candidates are in development and may become authorized for use in Canada within the next 2-5 years. The Public Health Agency of Canada sought to enhance preparedness for RSV vaccine and passive immunization candidates by organizing an expert retreat to identify knowledge gaps in surveillance and research and development in the context of provincial and territorial RSV public health priorities. We determined that RSV candidate vaccines in development directly address four out of five identified public health priorities, and identified remaining data gaps around vaccine efficacy and effectiveness. We determined that limited or sufficient surveillance data is available to support decision-making for four out of five RSV public health priorities and identified data gaps for several key populations: (i) for RSV cases under 17 years of age, gaps remain for denominator data to calculate incidence and data on medically attended outpatient visits; (ii) for RSV cases in Indigenous and remote communities, gaps remain for data on incidence, prevalence, specific risk factors, feasibility and acceptability; and (iii) for RSV cases in older adults, gaps remain for data on incidence. This process demonstrated the feasibility of, and stakeholder support for, gap analyses in surveillance data to support decisions about prospective vaccines and immune products.

Epidemiology and Control of Meningococcal Disease in Canada: A Long, Complex, and Unfinished Story

The epidemiology of meningococcal disease in Canada has been punctuated by outbreaks caused by serogroup A strains in the 1940s, virulent serogroup C clones from 1985 to 2001, a serogroup B clone in Quebec from 2003 to 2014, and more recently a W clone in British Columbia. Region- and province-wide immunization campaigns have been implemented to control these outbreaks using meningococcal C polysaccharide and conjugate vaccines, a quadrivalent ACWY conjugate vaccine, and a serogroup B protein-based vaccine. Meningococcal C conjugate vaccines have been included in routine immunization programs for children, and ACWY conjugate vaccines have been included in school-based programs for adolescents in most jurisdictions. In contrast, serogroup B protein-based vaccines were only recommended and used for high-risk individuals and to control outbreaks. Currently, the immunization schedules adopted in provinces and territories are not uniform. This is not explained by notable epidemiologic differences. Publicly funded immunization programs are the result of a complex decision-making process. Political factors including public opinion, media attention, interest groups' advocacy campaigns, decision-makers' priorities and budgetary constraints have played important roles in shaping meningococcal programs in Canada, and this should be recognized. As the recent occurrence of outbreaks caused by virulent W clones shows, continued investments in epidemiological surveillance at both the provincial and national levels are necessary, so there can be early warning and informed decisions can be made.

Epidemiology of Clostridioides difficile infection in Canada: A six-year review to support vaccine decision-making

BACKGROUND

Two vaccines against Clostridioides difficile infections (CDI) are currently in phase III trials. To enable decision-making on their use in public health programs, national disease epidemiology is necessary.

OBJECTIVES

To determine the epidemiology of hospital-acquired CDI (HA-CDI) and community-associated CDI (CA-CDI) in Canada using provincial surveillance data and document discrepancies in CDI-related definitions among provincial surveillance programs.

METHODS

Publicly-available CDI provincial surveillance data from 2011 to 2016 that distinguished between HA-CDI and CA-CDI were included and the most common surveillance definitions for each province were used. The HA-, CA-CDI incidence rates and CA-CDI proportions (%) were calculated for each province. Both HA- and CA-CDI incidence rates were examined for trends. Types of disparities were summarized and detailed discrepancies were documented.

RESULTS

Canadian data were analyzed from nine provinces. The HA-CDI rates ranged from 2.1/10,000 to 6.5/10,000 inpatient-days, with a decreasing trend over time. Available data on CA-CDI showed that both rates and proportions have been increasing over time. Discrepancies among provincial surveillance definitions were documented in CDI case classifications, surveillance populations and rate calculations.

CONCLUSION

In Canada overall, the rate of HA-CDI has been decreasing and the rate of CA-CDI has been increasing, although this calculation was impeded by discrepancies in CDI-related definitions among provincial surveillance programs. Nationally-adopted common definitions for CDI would enable better comparisons of CDI rates between provinces and a calculation of the pan-Canadian burden of illness to support vaccine decision-making.

Kingdon's Multiple Streams Framework and the Analysis of Decision-Making Processes Regarding Publicly-Funded Immunization Programs

Introduction: The implementation of a publicly-funded immunization program results from a complex decision-making process. John Kingdon's 'Multiple Streams Framework' has been extensively used to analyze how and why governmental policies were adopted. Area covered: Ideas that will ultimately end up in a proposal for a new immunization program develop gradually along three main streams: (i) the problem stream, which focuses on a particular vaccine-preventable disease and its perception by stakeholders; (ii) the policy stream, which is centered on experts' views on the optimal use of available vaccines; and (iii) the politics stream, which consists of socio-political factors, including budgetary constraints. Ideas are progressively shaped by policy entrepreneurs into a proposal with concrete implementation strategies. The three streams then converge within a policy window, during which adoption is especially likely to occur. To survive, the proposed program should be operationally feasible, consistent with mainstream social values, and financially affordable. The timing of the policy window is usually unpredictable and of short duration. Expert opinion: Analytical frameworks traditionally used to assess immunization programs focus on the technical aspects of the disease, the vaccine, and the program. The 'Multiple Streams Framework' brings added analytical value by enlarging the scope of the analysis into the political arena.

Costs of Invasive Meningococcal Disease: A Global Systematic Review

BACKGROUND

Invasive meningococcal disease remains a public health concern because of its rapid onset and significant risk of death and long-term disability. New meningococcal serogroup B and combination serogroup ACWY vaccines are being considered for publicly funded immunization programs in many countries. Contemporary costing data associated with invasive meningococcal disease are required to inform cost-effectiveness analyses.

OBJECTIVE

The objective of this study was to estimate costs and resource utilization associated with acute infection and the long-term care of invasive meningococcal disease.

DATA SOURCES AND METHODS

PubMed, EMBASE, The Cochrane Library, health economic databases, and electronically available conference abstracts were searched. Studies reporting any costs associated with acute infection and long-term sequelae of invasive meningococcal disease in English were included. All costs were converted into purchasing power parity-adjusted estimates [international dollars (I$)] using the Campbell and Cochrane Economics Methods Group and the Evidence for Policy and Practice Information and Coordinating Centre cost converter.

RESULTS

Fourteen studies met our eligibility criteria and were included. The mean costs of acute admission ranged from I$1629 to I$50,796, with an incremental cost of I$16,378. The mean length of hospital stay was reported to be 6-18 days in multiple studies. The average costs reported for readmissions ranged from I$7905 to I$15,908. Key variables such as the presence of sequelae were associated with higher hospitalization costs and longer inpatient stay. No studies estimated direct non-healthcare costs and productivity loss. Ten studies reported only unadjusted mean values without using appropriate statistical methods for adjustment.

CONCLUSIONS

Invasive meningococcal disease can result in substantial costs to healthcare systems. However, costing data on long-term follow-up and indirect costs used to populate health economic models are lacking.

Adoption costs of new vaccines - A Stackelberg dynamic game with risk-perception transition states

Vaccination has become an integral part of public health, since an increase in overall vaccination in a given population contributes to a decline in infectious diseases and mortality. Vaccination also contributes to a lower rate of infection even for nonvaccinators due to herd immunity ((Brisson and Edmunds, 2002)). In this work we model human decision-making (with respect to a vaccination program in a single-payer health care provider country) using a leader-follower game framework. We then extend our model to a discrete dynamic game, where time passing is modelled by risk perception changes among population groups considering whether or not to vaccinate. The risk perception changes are encapsulated by probability transition matrices. We assume that the single-payer provider has a given fixed budget which would not be sufficient to cover 100% of a new vaccine for the entire population. To increase the potential coverage, we propose the introduction of a partial vaccine adoption policy, whereby an individual would pay a portion of the vaccine price and the single payer would support the rest for the entire population. We show how this policy, together with changes in risk perceptions regarding vaccination, impact the strategic decisions of individuals in each group, the policy cost under budgetary constraints and, ultimately, how it impacts the overall uptake of the vaccine in the entire population.

Early use of the HPV 2-dose vaccination schedule: Leveraging evidence to support policy for accelerated impact

Although human papillomavirus (HPV) vaccines were initially licensed based on efficacy after three-dose regimens in women aged 15-26 years, it was recognized early in clinical development that comparable immunogenicity could be obtained after just two doses when administered to younger girls. In both Canada and Mexico, public health authorities made the decision to administer two doses 6 months apart with a planned additional dose at 60 months, while simultaneously doing further study to determine if the third dose would confer meaningful additional benefit. This delayed third dose approach permitted a more cost-effective program with opportunities for improved compliance while minimizing injections and leaving open the opportunity to provide a full three-dose vaccination series. It required close cooperation across many governmental and civil society leadership bodies and real-time access to emerging data on HPV vaccine effectiveness. Although still limited, there is increasing evidence that even one-dose vaccination is sufficient to provide prolonged protection against HPV infection and associated diseases. Ongoing clinical trials and ecological studies are expected to consolidate existing data regarding one dose schedule use. However, to accelerate the preventive effect of HPV vaccination some jurisdictions, in particular those with limited resources may already consider the initiation of a one dose vaccination with the possibility of giving the second dose later in life if judged necessary. Such an approach would facilitate vaccination implementation and might permit larger catch-up vaccination programs in older girls (or as appropriate, girls and boys), thereby accelerating the impact on cervical cancer and other HPV-associated diseases.

The Direct Medical Costs of Diseases Associated with Human Papillomavirus Infection in Manitoba, Canada

BACKGROUND

The total direct cost of screening and treating all human papillomavirus-related diseases (HPV-RD) has not been measured in a single study. Accurate cost estimates are needed to inform decisions on intervention priorities and evaluate the cost-effectiveness of existing programs. We used province-wide clinical, administrative, and accounting databases to measure direct medical costs of HPV infection in Manitoba (Canada).

METHODS

All persons 9 years or older with health insurance coverage in Manitoba between April 2000 and March 2015 were eligible. We identified all persons with an incident HPV-RD and aggregated all medical costs (in 2014 Canadian dollars) related to that condition, including prescription drugs, diagnostic procedures, in-hospital and outpatient treatment, and physician visits.

RESULTS

We found that the median cost of treating a case of anogenital warts was $130. An episode of cervical dysplasia had a median cost of $220, compared to $1300 for an episode of cervical carcinoma in situ. The cost of treating HPV-related invasive cancer varied from $15,000 for cervical cancer to $33,000 for oral cavity cancer. Overall, 80% ($145 million) of the total cost was attributable to HPV infection. Cervical screening and follow-up accounted for $96 million (66%) of all costs and this cost component has declined following the introduction of new screening guidelines.

CONCLUSIONS

Overall, the average direct medical cost of HPV infection was $720 per newborn. The economic burden of HPV remains significant, although changes in cervical screening guidelines, prompted by the introduction of a public HPV vaccine program, appear to have promoted a promising trend towards lower costs.

Unknown Unknowns: We Need to Know How Many People Experience Imprisonment in Canada

Background:

Understanding the size of a population is necessary to define the burden of disease, evaluate opportunities to improve health, inform service planning and assess demographic trends over time.

Methods:

In this article, we described available data on the number of admissions and number of people admitted to custody in Canada. We identified gaps in data, and described the potential value of these data for public health and health care purposes.

Conclusion:

We recommend the systematic collection and dissemination of relevant data on this population in Canada.

Cost-effectiveness Comparison of Monovalent C Versus Quadrivalent ACWY Meningococcal Conjugate Vaccination in Canada

BACKGROUND

In Quebec, 1 dose of monovalent C meningococcal conjugate vaccine (Men-C-Con) is offered at 12 months of age and a booster dose in grade 9 (14-15 years of age). In other Canadian provinces, a quadrivalent vaccine against serogroups ACWY (Men-4-Con) is increasingly used for adolescents. An economic analysis was performed to assess the value of a switch from Men-C-Con to Men-4-Con.

METHODS

A compartmental static simulation model was developed to assess the burden of invasive meningococcal disease due to serogroups AWY (AWY-IMD) in a cohort of 100,000 persons with different vaccination programs. Univariate and multivariate sensitivity analyses were performed, including variation in vaccine price difference ($12; range: $0-$20), AWY-IMD rate (0.08/100,000 to 0.28/100,000 person-years), level of herd immunity generated by adolescent vaccination (from zero to disease elimination) and discounting rate (0%, 3% or 6%).

RESULTS

In the low AWY-IMD rate base scenario, replacing Men-C-Con by Men-4-Con for adolescents would reduce disease burden by 16% (no herd effect) to 58% (moderate herd effect), with an incremental cost-effectiveness ratios between $445,000 per quality-adjusted life-year (QALY) and $167,000/QALY in a societal perspective. In the high AWY-IMD rate scenario, incremental cost-effectiveness ratio would be in the range of $97,000/QALY to $19,000/QALY.

CONCLUSION

Based on the epidemiologic conditions in Quebec and in most other Canadian provinces, the benefits of Men-4-Con in reducing the burden of disease would be low for a high cost. The switch would, however, be more economically attractive with a much higher incidence rate (as in a few provinces) or with a reduced vaccine price in conditions assuming a moderate to high herd effect.

Exploring the acceptability of the available pneumococcal conjugate vaccines in Canadian health care professionals and immunization experts

BACKGROUND

In children, the 13 and 10-valent pneumoccocal conjugate vaccines (PCV13/10) are currently approved for the prevention of invasive pneumococcal disease (IPD). Acceptability is a key consideration in the implementation of a vaccine program and it is recognized that health professional's attitudes and opinions towards vaccines are independent predictors of the success of an immunization program. We aimed to survey the beliefs and attitudes for the two available PCVs in health care professionals and immunization experts.

FINDINGS

We interviewed 21 members of Canadian immunization committees and/or participants working in frontline healthcare delivery. Overall, participants predominantly preferred PCV-13 over PCV10. For most, AOM should not be taken into considerations in decisions for pneumococcal vaccination programs implementation. AOM was considered an important endpoint of the program but an ineffective measure of program success due to the lack of surveillance for the condition. Recent evidence pertaining to PCV10 cross-protection against 19A did not affect preference but had an impact on perceptions regarding pricing.

CONCLUSION

To consider implementing any changes to the current program, most participants would require more evidence regarding PCV10 cross-protection and effectiveness against OM. Decreasing vaccine price was cited as a positive outcome of funding both vaccines.

Canadian Institutes of Health Research funding of prison health research: a descriptive study

BACKGROUND

Health research provides a means to define health status and to identify ways to improve health. Our objective was to define the proportion of grants and funding from the Government of Canada's health research investment agency, the Canadian Institutes of Health Research (CIHR), that was awarded for prison health research, and to describe the characteristics of funded grants.

METHODS

In this descriptive study, we defined prison health research as research on the health and health care of people in prisons and at the time of their release. We searched the CIHR Funding Decisions Database by subject and by investigator name for funded grants for prison health research in Canada in all competitions between 2010 and 2014. We calculated the proportion of grants and funding awarded for prison health research, and described the characteristics of funded grants.

RESULTS

During the 5-year study period, 21 grants were awarded that included a focus on prison health research, for a total of $2 289 948. Six of these grants were operating grants and 6 supported graduate or fellowship training. In total, 0.13% of all grants and 0.05% of all funding was for prison health research.

INTERPRETATION

A relatively small proportion of CIHR grants and funding were awarded for prison health research between 2010 and 2014. If prison health is a priority for Canada, strategic initiatives that include funding opportunities could be developed to support prison health research in Canada.

What criteria do decision makers in Thailand use to set priorities for vaccine introduction?

Background

There is a need to identify rational criteria and set priorities for vaccines. In Thailand, many licensed vaccines are being considering for introduction into the Expanded Program on Immunization; thus, the government has to make decisions about which vaccines should be adopted. This study aimed to set priorities for new vaccines and to facilitate decision analysis.

Methods

We used a best-worst scaling study for rank-ordering of vaccines. The candidate vaccines were determined by a set of criteria, including burden of disease, target age group, budget impact, side effect, effectiveness, severity of disease, and cost of vaccine. The criteria were identified from a literature review and by in-depth, open-ended interviews with experts. The priority-setting model was conducted among three groups of stakeholders, including policy makers, healthcare professionals and healthcare administrators. The vaccine data were mapped and then calculated for the probability of selection.

Results

From the candidate vaccines, the probability of hepatitis B vaccine being selected by all respondents (96.67 %) was ranked first. This was followed, respectively, by pneumococcal conjugate vaccine-13 (95.09 %) and Haemophilus influenzae type b vaccine (90.87 %). The three groups of stakeholders (policy makers, healthcare professionals and healthcare administrators) showed the same ranking trends. Most severe disease, high fever rate and high disease burden showed the highest coefficients for criterion levels being selected by all respondents. This result can be implied that a vaccine which can prevent most severe disease with high disease burden and has low safety has a greater chance of being selected by respondents in this study.

Conclusions

The priority setting of vaccines through a multiple-criteria approach could contribute to transparency and accountability in the decision-making process. This is a step forward in the development of an evidence-based approach that meets the need of developing country. The methodology is generalizable but its application to another country would require the criteria as relevant to that country.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3382-5) contains supplementary material, which is available to authorized users.

Introduction of pentavalent vaccine in Indonesia: a policy analysis

The introduction of pentavalent vaccine containing Haemophilus influenzae type b antigen in Indonesia's National Immunization Program occurred nearly three decades after the vaccine was first available in the United States and 16 years after Indonesia added hepatitis B vaccine into the program. In this study, we analyzed the process that led to the decision to introduce pentavalent vaccine in Indonesia. Using process tracing and case comparison, we used qualitative data gathered through interviews with key informants and data extracted from written sources to identify four distinct but interrelated processes that were involved in the decision making: (a) pentavalent vaccine use policy process, (b) financing process, (c) domestic vaccine development process and (d) political process. We hypothesized that each process is associated with four necessary conditions that are jointly sufficient for the successful introduction of pentavalent vaccine in Indonesia, namely (a) an evidence-based vaccine use recommendation, (b) sufficient domestic financing capacity, (c) sufficient domestic vaccine manufacturing capacity and (d) political support for introduction. This analysis of four processes that led to the decision to introduce a new vaccine in Indonesia may help policy makers and other stakeholders understand and manage activities that can accelerate vaccine introduction in the future.

Methods for Health Economic Evaluation of Vaccines and Immunization Decision Frameworks: A Consensus Framework from a European Vaccine Economics Community

BACKGROUND

Incremental cost-effectiveness and cost-utility analyses [health economic evaluations (HEEs)] of vaccines are routinely considered in decision making on immunization in various industrialized countries. While guidelines advocating more standardization of such HEEs (mainly for curative drugs) exist, several immunization-specific aspects (e.g. indirect effects or discounting approach) are still a subject of debate within the scientific community.

OBJECTIVE

The objective of this study was to develop a consensus framework for HEEs of vaccines to support the development of national guidelines in Europe.

METHODS

A systematic literature review was conducted to identify prevailing issues related to HEEs of vaccines. Furthermore, European experts in the field of health economics and immunization decision making were nominated and asked to select relevant aspects for discussion. Based on this, a workshop was held with these experts. Aspects on 'mathematical modelling', 'health economics' and 'decision making' were debated in group-work sessions (GWS) to formulate recommendations and/or--if applicable--to state 'pros' and 'contras'.

RESULTS

A total of 13 different aspects were identified for modelling and HEE: model selection, time horizon of models, natural disease history, measures of vaccine-induced protection, duration of vaccine-induced protection, indirect effects apart from herd protection, target population, model calibration and validation, handling uncertainty, discounting, health-related quality of life, cost components, and perspectives. For decision making, there were four aspects regarding the purpose and the integration of HEEs of vaccines in decision making as well as the variation of parameters within uncertainty analyses and the reporting of results from HEEs. For each aspect, background information and an expert consensus were formulated.

CONCLUSIONS

There was consensus that when HEEs are used to prioritize healthcare funding, this should be done in a consistent way across all interventions, including vaccines. However, proper evaluation of vaccines implies using tools that are not commonly used for therapeutic drugs. Due to the complexity of and uncertainties around vaccination, transparency in the documentation of HEEs and during subsequent decision making is essential.

HPV vaccination for MSM: Synthesis of the evidence and recommendations from the Québec Immunization Committee

Diseases associated with the human papilloma virus (HPV) are particularly common among men who have sex with men (MSM). Unlike heterosexual men, MSM do not benefit from the herd protection provided by the vaccination of girls. In this review, we synthesize the available evidence on HPV vaccination for MSM. We also present the recommendations of the Québec Immunization Committee (CIQ) in this regard, which are: to provide targeted vaccination for MSM up to 26 years of age and in-school vaccination of preadolescent boys since this is the best approach to take to have a real impact on the burden related to HPV in the MSM population and to provide direct protection for all men.

The role of pediatricians as key stakeholders in influencing immunization policy decisions for the introduction of meningitis B vaccine in Canada: The Ontario perspective

As key stakeholders in immunization policy decisions, the Pediatricians of Ontario held an accredited conference on January 18, 2014, to discuss prevention of invasive meningococcal disease. Five key recommendations were put forth regarding immunization strategies to protect children from meningococcal serogroup B disease. The recently approved four-component meningococcal B (4CMenB) vaccine should be recommended and funded as part of Ontario's routine immunization schedule and should also be mandated for school attendance. Public funding for 4CMenB immunization is justified based on current MenB epidemiology, vaccine coverage, cost effectiveness and acceptability, as well as legal, political and ethical considerations related to 4CMenB immunization, particularly because routine recommendations and funding are currently in place for vaccination against meningococcal serogroups that cause significantly less disease in Canada than MenB. Broadly, the goals are to assist individual practitioners in advocating the benefits of 4CMenB vaccination to parents, and to counterbalance recommendations from the National Advisory Committee on Immunization and the Canadian Paediatric Society.

How do economic evaluations inform health policy decisions for treatment and prevention in Canada and the United States?

Canadian and US health systems have often been characterized as having vastly different approaches to the financing and delivery of healthcare, with Canada portrayed as more reliant on rationing based on costs. In this article, we examine the similarities and differences between the two countries, the evolution and current role of health economic evaluation, and the roles played by health economists. We suggest both countries have similarly used economic evaluation to a limited extent for drug and immunization decisions, with variability in use more of a reflection of the incompleteness of both systems and their inherent institutional barriers rather than political ideology.

Stakeholders' perception on including broader economic impact of vaccines in economic evaluations in low and middle income countries: a mixed methods study

Background

Current health economic evaluation guidelines mainly concentrate on immediate health gains and cost savings for the individual involved in the intervention. However, it has been argued that these guidelines are too narrow to capture the full impact of vaccination in low and middle income countries. The inclusion of broader economic impact of vaccines (BEIV) has therefore been proposed. Some examples of these are productivity-related gains, macro-economic impact, and different externalities. Despite their potency, the extent to which such benefits can and should be incorporated into economic evaluations of vaccination is still unclear. This mixed methods study aims to assess the relevance of BEIV to different stakeholders involved in the vaccine introduction decision making process.

Methods

In this mixed method study an internet based survey was sent to attendees of the New and Underutilized Vaccines Initiative meeting in Montreux, Switzerland in 2011. Additionally, semi-structured interviews of 15 minutes each were conducted during the meeting. Study participants included decision makers, experts and funders of vaccines and immunization programs in low and middle income countries. Descriptive analysis of the survey, along with identification of common themes and factors extracted from the interviews and open survey questions was undertaken.

Results

Evidence on macro-economic impact, burden of disease and ecological effects were perceived as being most valuable towards aiding decision making for vaccine introduction by the 26 survey respondents. The 14 interviewees highlighted the importance of burden of disease and different types of indirect effects. Furthermore, some new interpretations of BEIVs were discussed, such as the potential negative impact of wastage during immunization programs and the idea of using vaccines as a platform for delivering other types of health interventions. Interviewees also highlighted the importance of using a broader perspective in connection to measuring economic impacts, particularly when attempting to derive the value of newer, more expensive vaccines.

Conclusion

According to participants, BEIVs were seen as being equally important as traditional outcome measures used in cost-effectiveness analyses. Such insight can be used to shape research agendas within this field and to eventually create broader, more inclusive practical guidelines for economic evaluations of vaccines.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1638-0) contains supplementary material, which is available to authorized users.

Characteristics and practices of National Immunisation Technical Advisory Groups in Europe and potential for collaboration, April 2014

Binary file ES_Abstracts_Final_ECDC.txt matches

Comparison of NITAG policies and working processes in selected developed countries

BACKGROUND

Vaccines are specific medicines characterized by two country-specific market access processes: (1) a recommendation by National Immunization Technical Advisory Group (NITAG), and (2) a funding policy decision.

OBJECTIVES

The objective of this study was to compare and analyze NITAGs of 13 developed countries by describing vaccination committees' bodies and working processes.

METHODS

Information about NITAGs bodies and working processes was searched from official sources from June 2011 to November 2012. Retrieved information was completed from relevant articles identified through a systematic literature review and by information provided by direct contact with NITAGs or parent organizations. An expert panel was also conducted to discuss, validate, and provide additional input on obtained results.

RESULTS

While complete information, defined as 100%, was retrieved only for the UK, at least 80% of data was retrieved for 9 countries out of the 13 selected countries. Terms of references were identified in 7 countries, and the main mission for all NITAGs was to provide advice for National immunization programs. However, these terms of references did not fully encompass all the actual missions of the NITAGs. Decision analysis frameworks were identified for 10 out of the 13, and all NITAGs considered at least four criteria for decision-making: disease burden, efficacy/effectiveness, safety and cost-effectiveness. Advices were published by most NITAGs, but few NITAGs published meeting agendas and minutes. Only the United States had open meetings.

CONCLUSIONS

This study supports previous findings about the disparities in NITAGs processes which could potentially explain the disparity in access to vaccinations and immunization programs across Europe. With NITAGs recommendations being used by policy decision makers for implementation and funding of vaccine programs, guidances should be well-informed and transparent to ensure National Immunization Programs' (NIP) credibility among the public and health care professionals.

Implementation of a universal rotavirus vaccination program: comparison of two delivery systems

Background

Rotavirus vaccine is recommended for all infants in Canada. To evaluate the logistics of implementing a universal rotavirus vaccination program, we compared the effectiveness of program implementation in jurisdictions with either a physician-administered or public health nurse-administered program.

Methods

All infants born between October 1, 2010 and September 30, 2012 in Prince Edward Island and Nova Scotia’s Capital District Health Authority were eligible for the vaccination program. A universal rotavirus vaccination program was implemented and delivered in public health clinics in Prince Edward Island and in physicians’ offices in Nova Scotia.

Results

Engagement of vaccinators in delivery of the universal vaccination program was more successful in Prince Edward Island than in Nova Scotia. Vaccine coverage rates rose rapidly in Prince Edward Island, exceeding 90% for both doses within 3 months and remaining at those levels over the two-year program. In contrast, coverage rates in Nova Scotia rose more slowly and never exceeded 40% during the two years. Access to coverage data was more timely and accurate in Prince Edward Island than Nova Scotia.

Conclusion

A universal rotavirus vaccination program delivered through public health clinics achieved more rapid and higher levels of coverage than a program administered through physicians’ offices.

Trial registration

NCT01273077.

Approved but non-funded vaccines: accessing individual protection

Funded immunization programs are best able to achieve high participation rates, optimal protection of the target population, and indirect protection of others. However, in many countries public funding of approved vaccines can be substantially delayed, limited to a portion of the at-risk population or denied altogether. In these situations, unfunded vaccines are often inaccessible to individuals at risk, allowing potentially avoidable morbidity and mortality to continue to occur. We contend that private access to approved but unfunded vaccines should be reconsidered and encouraged, with recognition that individuals have a prerogative to take advantage of a vaccine of potential benefit to them whether it is publicly funded or not. Moreover, numbers of "approved but unfunded" vaccines are likely to grow because governments will not be able to fund all future vaccines of potential benefit to some citizens. New strategies are needed to better use unfunded vaccines even though the net benefits will fall short of those of funded programs. Canada, after recent delays funding several new vaccine programs, has developed means to encourage private vaccine use. Physicians are required to inform relevant patients about risks and benefits of all recommended vaccines, publicly funded or not. Likewise, some provincial public health departments now recommend and promote both funded and unfunded vaccines. Pharmacists are key players in making unfunded vaccines locally available. Professional organizations are contributing to public and provider education about unfunded vaccines (e.g. herpes zoster, not funded in any province). Vaccine companies are gaining expertise with direct-to-consumer advertising. However, major challenges remain, such as making unfunded vaccines more available to low-income families and overcoming public expectations that all vaccines will be provided cost-free, when many other recommended personal preventive measures are user-pay. The greatest need is to change the widespread perception that approved vaccines should be publicly funded or ignored.

Controlling serogroup B invasive meningococcal disease: the Canadian perspective

With publically funded meningococcal immunization programs established in infants, children and adolescents, Canada is at the forefront of invasive meningococcal disease prevention. The advent of two new serogroup B vaccines that may protect against multiple disease-causing strains offers the potential to reduce endemic disease to very low levels in Canada. Canada likely will be one of the first countries with approval to use recombinant serogroup B vaccine. However, inclusion of these new vaccines into public immunization programs will be decided at the provincial/territorial level, rather than nationally, and may result initially in different immunization schedules throughout the country as we have seen with conjugate meningococcal vaccines. Such heterogeneous use and adoption of new vaccines complicates disease control, but may assist in evaluation of effectiveness. Minimally, it requires regionally specific information. In this article, the authors provide an overview of the Canadian epidemiology, serogroup B vaccine characteristics, potential strain coverage, immunization strategies and remaining postmarketing research questions.

Evaluation of serogroup C and ACWY meningococcal vaccine programs: projected impact on disease burden according to a stochastic two-strain dynamic model

OBJECTIVE

Advisory committees in Canada and the United States have updated recommendations for quadrivalent meningococcal conjugate vaccines against serogroups A, C, W135, and Y. Our objective was to evaluate optimally effective meningococcal vaccination policies using a stochastic dynamic model. Canada was used as an example.

METHODS

Our stochastic dynamic model of Neisseria meningitidis (Nm) transmission in an age-structured population assumed partial cross-immunity among two aggregated serogroup categories: 'AWY' containing A, W135, and Y; and 'Other' containing B, C, and ungroupable types. We compared the impact of monovalent C versus quadrivalent ACWY vaccination on Nm carriage and invasive meningococcal disease (IMD). Our model was parameterized with Canadian epidemiological and demographic data and employed probabilistic sensitivity analysis.

RESULTS

Routine infant immunization at 12 months and boosting at 15 years with a quadrivalent vaccine is projected to have the largest impact on total IMD incidence: a 74% reduction over 40 years. Routine infant immunization with a monovalent vaccine at 12 months only has much less impact and also generates strain replacement appearing after approximately ten years of continuous use.

CONCLUSIONS

Immunizing infants at 12 months and boosting adolescents at 15 years with an ACWY vaccine is predicted to be most effective at reducing IMD incidence.

National Advisory Groups and their role in immunization policy-making processes in European countries

During the twenty-first century, the development of national immunization programmes (NIP) has matured into robust processes where evidence-based methodologies and frameworks have increasingly been adopted. A key role in the decision-making and recommending processes is played by National Immunization Technical Advisory Groups (NITAGs). In a survey performed among European Union member states, Norway and Iceland, in February 2013, 85% of the 27 responding countries reported having established a NITAG, and of these, 45% have formal frameworks in place for the systematic development of vaccination recommendations. Independent of whether a formal framework is in place, common key factors are addressed by all NITAGs and also in countries without NITAGs. The four main factors addressed by all were: disease burden in the country, severity of the disease, vaccine effectiveness or efficacy, and vaccine safety at population level. Mathematical modelling and cost-effectiveness analyses are still not common tools. Differences in the relative weighting of these key factors, differences in data or assumptions on country-specific key factors, and differences in existing vaccination systems and financing, are likely to be reasons for differences in NITAG recommendations, and eventually NIPs, across Europe. Even if harmonization of NIPs is presently not a reasonable aim, systematic reviews and the development of mathematical/economic models could be performed at supranational level, thus sharing resources and easing the present work-load of NITAGs. Nevertheless, it has been argued that harmonization would ease central purchase of vaccines, thus reducing the price and increasing access to new vaccines.

Comparative cost-effectiveness of the quadrivalent and bivalent human papillomavirus vaccines: a transmission-dynamic modeling study

BACKGROUND

The quadrivalent and bivalent human papillomavirus (HPV) vaccines are now licensed in several countries. We compared the cost-effectiveness of the HPV vaccines to provide evidence for policy decisions.

METHODS

We developed HPV-ADVISE, a multi-type individual-based transmission-dynamic model of HPV infection and disease (anogenital warts, and cervical, anogenital and oropharyngeal cancers). We calibrated the model to sexual behavior and epidemiologic data from Canada, and estimated quality-adjusted life-years (QALYs) lost and costs ($CAN 2010) from the literature. Vaccine-type efficacy was based on a systematic literature review. The analysis was performed from the healthcare provider perspective, and costs and benefits were discounted at 3%. Predictions are presented using the median [10th;90th percentiles] of simulations.

RESULTS

Under base-case assumptions (vaccinating 10-year-old girls, 80% coverage, $95/dose), using the quadrivalent and bivalent vaccines is estimated to cost $15,528 [12,056;19,140] and $20,182 [15,531;25,240] per QALY-gained, respectively. At equal price, the quadrivalent vaccine is more cost-effective than bivalent under all scenarios investigated, except when assuming longer duration of protection for the bivalent and minimal anogenital warts burden. Under base-case assumptions, the maximum additional cost per dose for the quadrivalent vaccine to remain more cost-effective than the bivalent is $32 [17;46] (using a $40,000/QALY-gained threshold). Results were most sensitive to discounting, time-horizon, differences in durations of protection and anogenital warts burden.

CONCLUSIONS

Vaccinating pre-adolescent girls against HPV is predicted to be highly cost-effective. If equally priced, the quadrivalent is the most economically desirable vaccine. However, ultimately, the most cost-effective HPV vaccine will be determined by their relative price.

Cost effectiveness of infant vaccination for rotavirus in Canada

INTRODUCTION

Rotavirus is the main cause of gastroenteritis in Canadian children younger than five years of age, resulting in significant morbidity and cost. The present study provides evidence on the cost effectiveness of two alternative rotavirus vaccinations (RotaTeq [Merck Frosst Canada Ltd, Canada] and Rotarix [GlaxoSmithKline, Canada]) available in Canada.

METHODS

Analysis was conducted through a Markov model that followed a cohort of children from birth to five years of age. Analysis used pertinent data on the natural history of rotavirus and the effects of vaccination. Estimates of heath care costs for children requiring hospitalizations and emergency department visits were derived from the Canadian Immunization Monitoring Program, Active (IMPACT) surveillance, emergency department studies, as well as other Canadian studies. The model estimated the effect of vaccination on costs and quality-adjusted life years (QALYs).

RESULTS

The incremental cost per QALY gained from the health care system perspective was $122,000 for RotaTeq and $108,000 for Rotarix. From the societal perspective, both vaccination strategies were dominant - both cost saving and more effective. The cost-effectiveness of vaccination is dependent on the mode of administration, the perspective adopted and the cost of the vaccine.

CONCLUSIONS

From a societal perspective, a universal vaccination program against rotavirus will be both cost saving and more effective than no vaccination. Becasue the majority of rotavirus infections do not require emergency department visits or hospital admission, from a health care system perspective, a program would not be considered cost effective.

Awareness, knowledge and beliefs about HPV, cervical cancer and HPV vaccines among nurses in Cameroon: an exploratory study

BACKGROUND

While it is known that sub-Saharan African countries face multiple obstacles such as cost in adopting vaccination against human papillomavirus (HPV), the crucial role nurses can play in implementing such programs has not been adequately examined.

OBJECTIVES

To investigate the knowledge and awareness of HPV, primary cause of cervical cancer and HPV vaccine among nurses working at four Cameroon Baptist Convention Health Services facilities, and to explore what factors influence nurses' willingness to inform and recommend HPV vaccine to adolescents and parents attending clinics.

DESIGN AND SETTING

A structured questionnaire survey was administered to a convenience sample of nursing staff working at the four health facilities.

RESULTS

Of 192 eligible nurses 76 (39.6%) participated in the study. There were moderately low levels of knowledge about HPV infection and prevention of cervical cancer, but a moderately high level of knowledge about HPV vaccine. Although 90.8% acknowledged that cervical cancer is directly linked to HPV infection, nearly 32% failed to identify it as a sexually transmitted infection (STI), while 43.4% believed it is an uncommon infection. Willingness to recommend the HPV vaccine was moderate, with 69.7% intentionally initiating discussions with patients about the subject. The most important factors considered when deciding to recommend the vaccine included effectiveness (56.6%) and side effects/safety (11.8%). Cost was less of a concern (6.6%), likely due to the availability of donated vaccine.

CONCLUSION

Despite high awareness about HPV, more education about the virus, cervical cancer and the vaccine are required to further increase nurses' willingness to recommend the vaccine and strengthen strategies for reaching adolescents through nurses in Cameroon.

Population-level impact of the bivalent, quadrivalent, and nonavalent human papillomavirus vaccines: a model-based analysis

BACKGROUND

Bivalent and quadrivalent human papillomavirus (HPV) vaccines are now licensed in several countries. Furthermore, clinical trials examining the efficacy of a nonavalent vaccine are underway. We aimed to compare the potential population-level effectiveness of the bivalent, quadrivalent, and candidate nonavalent HPV vaccines.

METHODS

We developed an individual-based, transmission-dynamic model of HPV infection and disease in a population stratified by age, gender, sexual activity, and screening behavior. The model was calibrated to highly stratified sexual behavior, HPV epidemiology, and cervical screening data from Canada.

RESULTS

Under base case assumptions, vaccinating 12-year-old girls (70% coverage) with the bivalent (quadrivalent) vaccine is predicted to reduce the cumulative incidence of anogenital warts (AGWs) by 0.0% (72.1%), diagnosed cervical intraepithelial neoplasia lesions 2 and 3 (CIN2 and -3) by 51.0% (46.1%), and cervical squamous cell carcinoma (SCC) by 31.9% (30.5%), over 70 years. Changing from a bivalent (quadrivalent) to a nonavalent vaccine is predicted to reduce the cumulative number of AGW episodes by an additional 66.7% (0.0%), CIN2 and -3 episodes by an additional 9.3% (12.5%), and SCC cases by an additional 4.8% (6.6%) over 70 years. Differences in predicted population-level effectiveness between the vaccines were most sensitive to duration of protection and the time horizon of analysis. The vaccines produced similar effectiveness at preventing noncervical HPV-related cancers.

CONCLUSIONS

The bivalent vaccine is expected to be slightly more effective at preventing CIN2 and -3 and SCC in the longer term, whereas the quadrivalent vaccine is expected to substantially reduce AGW cases shortly after the start of vaccination programs. Switching to a nonavalent vaccine has the potential to further reduce precancerous lesions and cervical cancer.