The role of health economic analyses in vaccine decision making

The costs of introducing a vaccine in sub-Saharan Africa: a systematic review of the literature

Purpose

This study provides a systematic literature review and categorization of the costs reported in the literature for the introduction of new vaccines, focusing on sub-Saharan Africa within LMICs, where vaccines are highly needed, financial resources are scarce and data are lacking and scattered.

Design/methodology/approach

A systematic literature search of PubMed and Web of Science databases was conducted according to the PRISMA requirements. Searches also included the relevant grey literature. In total, 39 studies were selected and nine cost categories were investigated to build a comprehensive framework.

Findings

The paper considers nine cost categories that cover the whole life of the vaccine, from its initial study to its full implementation, including for each of them the relevant subcategories. The systematic review, besides providing specific quantitative data and allowing to assess their variability within each category, points out that delivery, program preparation, administration and procurement costs are the most frequently estimated categories, while the cost of the good sold, costs borne by households and costs associated to AEFI are usually overlooked. Data reported on R&D costs and investment in the production plant differ significantly among the selected contributions.

Originality/value

The literature contributions on cost estimation tend to focus on a precise vaccine, a specific geographic area, or to adopt a narrow approach that captures only a subset of the costs. This article presents a rich and inclusive set of the economic quantitative data on immunization costs in limited-resource countries.

Acceptance and application of a broad population health perspective when evaluating vaccine

The traditional health economic analysis is limited to estimating the impact on the treated patient. As vaccines are usually aimed at preventing infectious diseases, they may be associated with additional values for the non-treated wider population. Although there are valid reasons for treating vaccines differently, and a wide support for a broader perspective in the literature (i.e., beyond the net costs and health gain related to the outcome for the vaccinated individual), it remains unclear to what extent the Health Technology Assessment (HTA) agencies accept and apply a broader perspective.

The purpose of this study is to examine and discuss what type of consequences are relevant for a health economic analysis of vaccines and which consequences are considered by HTA agencies. The study includes a strategic review of literature and HTA decisions in Sweden and other countries, online round-table discussions with stakeholders in Sweden, and a basic estimation of the value of a COVID-19 vaccination in Sweden.

The study shows that, other than herd effect, broader economic consequences for the population are generally not included in the economic evaluation of vaccines. Also, all economic consequences for the treated patient (production loss) and caregiver (health loss) are not always considered. The perspective chosen can have a major impact on the outcome of the analysis. A vaccine for COVID-19 is estimated to provide a value of €744–€956 per dose when using a societal perspective including broader consequences for the population.

Providing a complete and appropriate picture of the value of vaccination is of importance to allocate resources efficiently, to provide incentives for vaccine development, and to show the cost of delaying decisions to implement a new vaccine.

A review of rotavirus vaccine use in Asia and the Pacific regions: challenges and future prospects

Introduction: Rotavirus infection causes a significant proportion of diarrhea disease burden in children <5 years of age in Asia and the Pacific regions. The World Health Organization recommends that rotavirus vaccination should be included in national immunization programs to prevent rotavirus gastroenteritis (RVGE).Areas covered: A literature review was performed to identify and summarize published evidence on RVGE epidemiology and status of rotavirus vaccine use, including the impact and cost-effectiveness of rotavirus vaccination programs in Asia and the Pacific regions (49 countries) during the period 2000-2018.Expert opinion: Rotavirus vaccination programs have successfully reduced the burden of RVGE in many countries. However, such programs still do not exist in most Asia-Pacific countries, and therefore the burden of RVGE remains high in children <5 years of age. Challenges to vaccine implementation include a lack of surveillance data; safety concerns around intussusception; a general lack of awareness about RVGE disease epidemiology and vaccines among physicians, policy-makers, and parents; insufficient cost-effectiveness analyses; and potential issues with vaccine affordability including vaccination costs and lack of political will. Recommendations to overcome these challenges include developing cost-effectiveness analyses for more diverse national and regional settings, providing non-governmental support for low-income countries, and improving advocacy efforts.Plain language summaryWhat is the context?• Rotavirus (RV) infection causes acute gastroenteritis (GE) in children under 5 years of age.• Rotavirus vaccination (RVV) implementation has been slow in Asia and the Pacific (AP) regions, which could be responsible for the region falling behind in their fight against RVGE.What is new?• RVV via national immunization programs (NIPs) is available in 8/49 countries and through the private market or non-governmental support in other countries. Coverage rates vary between countries, possibly driven by the mechanism through which RVV is available.• A substantial positive impact of RVV on RVGE disease burden with a very low risk of intestinal intussusception for up to 7 days after RVV has been documented in the AP regions.• Economic evaluation studies, mainly cost-effectiveness analyses, predict a significant reduction in treatment costs related to RVGE and its complications showing that RVV is good value for money.What is the impact?• The prospect of continued safe and effective use of RVV in the AP regions is promising.• Challenges to RVV implementation include establishing evidence of burden of disease, poor awareness of rotavirus vaccines, limited evidence from cost-effectiveness analyses from several countries, issues of affordability of the vaccine and a lack of political will.• Recommendations for RVV implementation into the NIPs include conducting clinical and cost-effectiveness studies in countries where these are not available, establishing reliable surveillance mechanisms, providing non-governmental support for low-income countries and improving advocacy efforts.• Maintenance of high vaccination coverage is needed in countries that have implemented national RVV programs.Graphical abstract[Formula: see text].

National decision-making for the introduction of new vaccines: A systematic review, 2010-2020

BACKGROUND

Competing priorities make using a transparent and evidence-based approach important when deciding to recommend new vaccines. We conducted a literature review to document the processes and frameworks for national decision-making on new vaccine introductions and explored which key features have evolved since 2010.

METHODS

We searched literature published on policymaking related to vaccine introduction from March 2010 to August 2020 in six databases. We screened articles for eligibility with the following exclusion criteria: non-human or hypothetical vaccines, the sole focus on economic evaluation or decision to adopt rather than policy decision-making. We employed nine broad categories of criteria from the 2012 review for categorization and abstracted data on the country, income level, vaccine, and other relevant criteria.

RESULTS

Of the 3808 unique references screened, 116 met eligibility criteria and were classified as: a) framework of vaccine adoption decision-making (27), b) studies that analyse empirical data on or examples of vaccine adoption decision-making (45), c) theoretical and empirical articles that provide insights into the vaccine policymaking process (44 + 17 already included in the previous categories). Commonly reported criteria for decision-making were the burden of disease; vaccine efficacy/effectiveness, safety; impact on health and non-health outcomes; economic evaluation and cost-effectiveness of alternative interventions. Programmatic and acceptability aspects were not as often considered. Most (50; 82%) of the 61 articles describing the process of vaccine introduction policymaking highlighted the role of country, regional, or global evidence-informed recommendations and a robust national governance as enabling factors for vaccine adoption.

CONCLUSIONS

The literature on vaccine adoption decision-making has expanded since 2010. We found that policymakers and expert advisory committee members (e.g., National Immunization Technical Advisory Group [NITAG]) increasingly value the interventions based on economic evaluations. The results of this review could guide discussions on evidence-informed immunization decision-making among country, sub-regional, and regional stakeholders.

Use of Cost-Effectiveness Analyses for Decisions About Vaccination Programs for Meningococcal Disease in the United States, United Kingdom, The Netherlands, and Canada

INTRODUCTION

Meningococcal vaccines to protect against invasive meningococcal disease (IMD) vary in terms of vaccine technology and serogroup coverage (Polysaccharide MnACWY, conjugated C and ACWY, outer membrane vesicle-based or protein-based B vaccines), and the national recommendations for each of them vary in terms of target population and number of doses. We sought to understand factors associated with the evolution of meningococcal vaccination program recommendations in four countries with formal evaluation processes: the UK, US, the Netherlands, and Canada.

AREAS COVERED

A targeted review of published literature and internet sources for the four countries relating to meningococcal vaccination decision-making was conducted. The review focused on the impact of cost-effectiveness analyses on vaccine policy decisions and the extent to which variation in incidence of IMD and its potential catastrophic consequences influenced policy decisions.The evolution of meningococcal vaccine recommendations in the four countries was mainly driven by changes in vaccine availability and changes in serogroup incidence. Public pressure due to the catastrophic nature of IMD influenced recommendations. The role of cost-effectiveness analyses varied across the 4 countries.

EXPERT OPINION

The value of implementing meningococcal vaccination programs should be assessed using factors beyond those included in traditional cost-effectiveness analyses.

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.

Where and when to vaccinate? Interdisciplinary design and evaluation of the 2018 Tanzanian anti-rabies campaign

OBJECTIVES

Hoping to improve health-related effectiveness, a two-phase vaccination against rabies was designed and executed in northern Tanzania in 2018, which included geo-epidemiological and economic perspectives.

METHODS

Considering the local bio-geography and attempting to rapidly establish a protective ring around a city at risk, the first phase intervened on sites surrounding that city, where the population density was lower than in the city at risk. The second phase vaccinated a rural area.

RESULTS

No rabies-related case has been reported in the vaccinated areas for over a year post-immunisation; hence, the campaign is viewed as highly cost-effective. Other metrics included: rapid implementation (concluded in half the time spent on other campaigns) and the estimated cost per protected life, which was 3.28 times lower than in similar vaccinations.

CONCLUSIONS

The adopted design emphasised local bio-geographical dynamics: it prevented the occurrence of an epidemic in a city with a higher demographic density than its surrounding area and it also achieved greater effectiveness than average interventions. These interdisciplinary, policy-oriented experiences have broad and immediate applications in settings of limited and/or time-sensitive (expertise, personnel, and time available to intervene) resources and conditions.

Cost-effectiveness of alternative strategies for vaccination of adolescents against serogroup B IMD with the MenB-FHbp vaccine in Canada

OBJECTIVE

Serogroup B meningococci (MnB) are now the largest cause of invasive meningococcal disease (IMD) in Canada. We assessed the clinical and economic impact of 3 adolescent MenB-FHbp immunization strategies.

METHODS

A population-based dynamic transmission model was developed to simulate the transmission of MnB among the entire Canadian population over a 30-year time horizon. Age group-based IMD incidence, bacterial carriage and transmission, disease outcomes, costs, and impact on quality of life were obtained from Canadian surveillance data and published literature. The vaccine was assumed to provide 85% protection against IMD and 26.6% against carriage acquisition. The model estimated the impact of routine vaccination with MenB-FHbp in 3 strategies: (1) age 14, along with existing school-based programs, with 75% uptake; (2) age 17 with 75% uptake, assuming school vaccination; and (3) age 17 with 30% uptake, assuming vaccination outside of school. Costs were calculated from the Canadian societal perspective.

RESULTS

With no vaccination, an estimated 3974 MnB cases would be expected over 30 years. Vaccination with strategies 1-3 were estimated to avert 688, 1033, and 575 cases, respectively. These outcomes were associated with incremental costs per quality-adjusted life-year of $976,000, $685,000, and $490,000.

CONCLUSIONS

Our model indicated that if the vaccine reduces risk of carriage acquisition, vaccination of older adolescents, even at lower uptake, could have a significant public health impact. Due to low disease incidence, MnB vaccination is unlikely to meet widely accepted cost-effectiveness thresholds, but evaluations of new programs should consider the overall benefits of the vaccination.

Trends in governmental expenditure on vaccination programmes in the Netherlands, a historical analysis

BACKGROUND

Health economic evaluations are often required before implementing a vaccination programme. Such evaluations rarely consider the historical context of a vaccination programme. We review the financial history of vaccination programmes in the Netherlands, and compare these to demographic and macroeconomic developments as well as avoided mortality burden.

METHODS

Previously uncatalogued historical expenditures on the Dutch National Immunisation Programme (NIP) and influenza vaccination were obtained from official reports. Costs were adjusted for inflation using Consumer Price Indices and expressed in Euro of 2016. Estimates on mortality burden averted were obtained from previous research and used to calculate the ratio of expenses to averted mortality burden for vaccinations against diphtheria, tetanus, pertussis, polio, measles, mumps and rubella for birth cohorts 1953-1992.

RESULTS

Developments towards a uniform government funded NIP started early 1950s with vaccinations against diphtheria, pertussis and tetanus, culminating in its official launch in 1957 together with polio vaccinations. Since the 1980s, expenditure increased nearly five-fold mostly due to the addition of new vaccines, while spending on already implemented vaccinations tended to decline. Overall, expenditure increased from € 5 million in 1957 to € 93 million in 2014. Relative to total healthcare expenditure, the NIP contributed little, ranging between 0.05% and 0.14%. Spending on influenza vaccination increased from € 37 million in 1996 to € 52 million in 2014, while relative to total healthcare expenditure it decreased from 0.069% to 0.055%. In 2014, 0.15% of healthcare expenditure and € 533 per birth was spent on vaccination programmes. Overall, for birth cohorts 1953-1992, € 5.4 thousand (95% confidence interval: 4.0-7.3) was expended per year-of-life-lost averted.

CONCLUSION

The actual costs per year-of-life gained are more favorable than estimated here since averted medical costs were not included. Although expenditure on vaccination programmes increased substantially, the contribution to overall healthcare expenditure remained small.

Systematic review of the incremental costs of interventions that increase immunization coverage

Achieving and maintaining high vaccination coverage requires investments, but the costs and effectiveness of interventions to increase coverage remain poorly characterized. We conducted a systematic review of the literature to identify peer-reviewed studies published in English that reported interventions aimed at increasing immunization coverage and the associated costs and effectiveness of the interventions. We found limited information in the literature, with many studies reporting effectiveness estimates, but not providing cost information. Using the available data, we developed a cost function to support future programmatic decisions about investments in interventions to increase immunization coverage for relatively low and high-income countries. The cost function estimates the non-vaccine cost per dose of interventions to increase absolute immunization coverage by one percent, through either campaigns or routine immunization. The cost per dose per percent increase in absolute coverage increased with higher baseline coverage, demonstrating increasing incremental costs required to reach higher coverage levels. Future studies should evaluate the performance of the cost function and add to the database of available evidence to better characterize heterogeneity in costs and generalizability of the cost function.

Estimating the cost-effectiveness of a sequential pneumococcal vaccination program for adults in Germany

Introduction

In Germany, a 23-valent polysaccharide pneumococcal vaccine (PPSV23) is recommended for elderly (60+) and patients 16+ with chronic diseases not associated with immune suppression. For all other patients at risk, sequential immunization with a 13-valent pneumococcal conjugate vaccine (PCV13) first, followed by PPSV23 is recommended. Repeated vaccination with PPSV23 is recommended every 6 years after individual assessment by the physician. This was adopted into the vaccination directive with binding reimbursement and funding. However, additional voluntary services allow statutory health insurances to differentiate from each other. Aim of this study is to estimate the cost-effectiveness of voluntary service scenarios compared to the strategy in place to support informed decision making.

Methods

A microsimulation framework with Markov-type process of a population susceptible to pneumococcal disease over a lifetime horizon was developed to compare effectiveness and cost-effectiveness of different vaccination strategies. We simulated 1,000 iterations for seven scenarios. Assumptions were derived from published literature and probabilistic sensitivity analysis was run to show the robustness of the model.

Results

Our study indicates that all voluntary service strategies could prevent further clinical cases compared to the existing policy. Depending on the scenario, 48–142 invasive pneumococcal disease (IPD), 24,000–45,000 hospitalized all-cause nonbacteremic pneumonia (NBP), 15,000–45,000 outpatient NBP cases, and 4,000–8,000 deaths could be avoided on average. This refers to potential savings of €115 Mio. - €187 Mio. for medical and non-medical costs. Additional costs per patient for the payer are €2.48 to €7.13 and for the society €2.20 to €6.85. The ICER per LYG ranged from €3,662 to €23,061 (payer) and €3,258 to €29,617 (societal). All but one scenario was cost-effective in ≥60% of the generated 1,000 simulations.

Conclusion

Compared to the vaccination strategy in place, the different hypothetical scenarios can be considered cost-effective and suitable as additional voluntary services.

Using campaigns to improve perceptions of the value of adult vaccination in the United States: Health communication considerations and insights

Vaccines have much relevance and promise for improving adult health in the United States, but to date, overall use and uptake remain far below desired levels. Many adults have not received recommended vaccinations and many healthcare providers do not strongly and actively encourage their use with patients. This has led some public health and medical experts to conclude that adult vaccines are severely undervalued by the U.S. public and healthcare providers and to call for campaigns and communication-based efforts to foster increased appreciation, and in turn, higher adult immunization rates. A narrative integrative review that draws upon the vaccine valuation and health communication literatures is used to develop a framework to guide campaign and communication-based efforts to improve public, provider, and policymakers' assessment of the value of adult vaccination. The review does this by: (1) distinguishing social psychological value from economic value; (2) identifying the implications of social psychological value considerations for adult vaccination-related communication campaigns; and (3) using five core health communication considerations to illustrate how social psychological notions of value can be integrated into campaigns or communication that are intended to improve adult vaccination value perceptions and assessments, and in turn, motivate greater support for and uptake of recommended adult vaccines.

Burden of paediatric respiratory syncytial virus disease and potential effect of different immunisation strategies: a modelling and cost-effectiveness analysis for England

BACKGROUND

Vaccines and prophylactic antibodies against respiratory syncytial virus (RSV) are in development and likely to be available in the next 5-10 years. The most efficient way to use these products when they become available is an important consideration for public health decision makers.

METHODS

We performed a multivariate regression analysis to estimate the burden of RSV in children younger than 5 years in England (UK), a representative high-income temperate country, and used these results to assess the potential effect of different RSV immunisation strategies (targeting vaccination for infants, or pregnant women, or prophylactic antibodies for neonates). We did a cost-effectiveness analysis for these strategies, implemented either separately or concurrently, and assessed the effect of restricting vaccination to certain months of the year.

FINDINGS

We estimated that RSV is responsible for 12 primary care consultations (95% CI 11·9-12·1) and 0·9 admissions to hospital annually per 100 children younger than 5 years (95% CI 0·89-0·90), with the major burden occurring in infants younger than 6 months. The most cost-effective strategy was to selectively immunise all children born before the start of the RSV season (maximum price of £220 [95% uncertainty interval (UI) 208-232] per vaccine, for an incremental cost-effectiveness ratio of £20 000 per quality-adjusted life-year). The maximum price per fully protected person that should be paid for the infant, newborn, and maternal strategies without seasonal restrictions was £192 (95% UI 168-219), £81 (76-86), and £54 (51-57), respectively.

INTERPRETATION

Nearly double the number of primary care consultations, and nearly five times the number of admissions to hospital occurred with RSV compared with influenza. RSV vaccine and antibody strategies are likely to be cost-effective if they can be priced below around £200 per fully protected person. A seasonal vaccination strategy is likely to provide the most direct benefits. Herd effects might render a year-round infant vaccination strategy more appealing, although it is currently unclear whether such a programme would induce herd effects.

FUNDING

UK National Institute for Health Research.

Core values for vaccine evaluation

Currently, most health economic modelling approaches tend to inadequately incorporate crucial disease-specific criteria and other attributes of benefit resulting from vaccination, which limits their utility for evaluating vaccines and, in consequence, for optimally guiding vaccine decision-making. Additionally, vaccine evaluation methods are frequently poorly standardised and non-transparent, leading to a potentially low level of accountability that can hinder acceptance of resulting decisions. To address these issues, we have considered whether it is possible to identify a set of universal vaccine-disease considerations, which we have called Core Values. To begin to identify such a set of criteria, and to establish whether strong agreement around such core values exists, we conducted two studies based on the Delphi technique. Both studies surveyed a cohort consisting of expert members of the global vaccine community with diverse professional backgrounds. Formal statistical analysis of both studies identified four attributes with strong agreement: 1. Incidence disease cases prevented per year, 2. Cost-effectiveness (including cost-benefit and cost-utility analysis), 3. High mortality disease (case-fatality-rate), and 4. Severity of target disease (risk of morbidity and mortality). These results suggest the feasibility of identifying a clear consensus on a specific set of Core Values for Vaccine Evaluation.

Theory and strategy for Pneumococcal vaccines in the elderly

Pneumonia is the fourth-leading cause of death globally, and Streptococcus pneumoniae is the most important causative pathogen. Because the incidence of pneumococcal diseases is likely to increase with the aging society, we should determine an optimal strategy for pneumococcal vaccination. While consensus indicates that 23-valent pneumococcal polysaccharide vaccine prevents invasive pneumococcal diseases (IPD), its effects on community-acquired pneumonia (CAP) remain controversial. Recently, a 13-valent pneumococcal conjugate vaccine (PCV13) was released. The latest clinical study (CAPiTA study) showed that PCV13 reduced vaccine-type CAP and IPD. Based on these results, the Advisory Committee on Immunization Practices recommended initial vaccination with PCV13 for the elderly. Scientific evidence regarding immunosenescence is needed to determine a more ideal vaccination strategy for the elderly with impaired innate and adaptive immunity. Continuing research on the cost effectiveness of new vaccine strategies considering constantly changing epidemiology is also warranted.

Questions regarding the safety and duration of immunity following live yellow fever vaccination

INTRODUCTION

The World Health Organization (WHO) and other health agencies have concluded that yellow fever booster vaccination is unnecessary since a single dose of vaccine confers lifelong immunity. Areas covered: We reviewed the clinical studies cited by health authorities in their investigation of both the safety profile and duration of immunity for the YFV-17D vaccine and examined the position that booster vaccination is no longer needed. We found that antiviral immunity may be lost in 1-in-3 to 1-in-5 individuals within 5 to 10 years after a single vaccination and that children may be at greater risk for primary vaccine failure. The safety profile of YFV-17D was compared to other licensed vaccines including oral polio vaccine (OPV) and the rotavirus vaccine, RotaShield, which have subsequently been withdrawn from the US and world market, respectively. Expert commentary: Based on these results and recent epidemiological data on vaccine failures (particularly evident at >10 years after vaccination), we believe that current recommendations to no longer administer YFV-17D booster vaccination be carefully re-evaluated, and that further development of safer vaccine approaches should be considered.

"Saving lives": Adapting and adopting Human Papilloma Virus (HPV) vaccination in Austria

Vaccination against the sexually transmitted Human Papilloma Virus (HPV), a necessary agent for the development of cervical cancer, has triggered much debate. In Austria, HPV policy turned from "lagging behind" in 2008 into "Europe's frontrunner" by 2013. Drawing on qualitative research, the article shows how the vaccine was transformed and made "good enough" over the course of five years. By means of tinkering and shifting storylines, policy officials and experts disassociated the vaccine from gender, vaccine manufacturers, and youth sexuality. Ultimately, the HPV vaccine functioned to strengthen the national immunization program. To this end, preventing an effective problematization of the extant screening program was essential.

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.

Developing vaccines for an aging population

The demographics of the world's population are changing, with many adults now surviving into their 80s. With this change comes the need to protect the aging and other underserved populations not only against infectious diseases but also against cancer and other chronic conditions. New technologies derived from recent advances in the fields of immunology, structural biology, synthetic biology, and genomics have brought a revolution in the vaccine field. Among them, vaccine adjuvants have the potential to harness the immune system to provide protection against new types of diseases, improve protection in young children, and expand this protection to adults and the elderly. However, in order to do so we need also to overcome the nontechnical challenges that could limit the implementation of innovative vaccines, including controversies regarding the safety of adjuvants, increasing regulatory complexity, the inadequate methods used to assess the value of novel vaccines, and the resulting industry alienation from future investment. This Perspective summarizes the outcome of a recent multidisciplinary symposium entitled "Enhancing Vaccine Immunity and Value," held in Siena, Italy, in July 2014, that addressed two related questions: how to improve vaccine efficacy by using breakthrough technologies and how to capture the full potential of novel vaccines.

Delivering vaccines to the people who need them most

Thanks to the Global Alliance for Vaccines and Immunization (GAVI), the Vaccine Fund and the Bill & Melinda Gates Foundation, the global health community has made enormous progress in providing already existing vaccines to developing countries. However, there still exists a gap to develop vaccines for which there is no market in the Western world, owing to low economic incentives for the private sector to justify the investments necessary for vaccine development. In many cases, industry has the technologies, but lacks the impetus to direct resources to develop these vaccine products. The present emergency with the Ebola vaccine provides us an excellent example where a vaccine was feasible several years ago, but the global health community waited for a humanitarian disaster to direct efforts and resources to develop this vaccine. In the beginning of 2015, the first large-scale trials of two experimental vaccines against Ebola virus disease have begun in West Africa. During the past few years, several institutions have dedicated efforts to the development of vaccines against diseases present only in low-income countries. These include the International Vaccine Institute, the Novartis Vaccines Institute for Global Health, the Hilleman Institute, the Sabin Vaccine Institute and the Infectious Disease Research Institute. Nevertheless, solving this problem requires a more significant global effort than that currently invested. These efforts include a clear policy, global coordination of funds dedicated to the development of neglected disease and an agreement on regulatory strategies and incentives for the private sector.

Vaccination in elite athletes

Public health vaccination guidelines cannot be easily transferred to elite athletes. An enhanced benefit from preventing even mild diseases is obvious but stronger interference from otherwise minor side effects has to be considered as well. Thus, special vaccination guidelines for adult elite athletes are required. In most of them, protection should be strived for against tetanus, diphtheria, pertussis, influenza, hepatitis A, hepatitis B, measles, mumps and varicella. When living or traveling to endemic areas, the athletes should be immune against tick-borne encephalitis, yellow fever, Japanese encephalitis, poliomyelitis, typhoid fever, and meningococcal disease. Vaccination against pneumococci and Haemophilus influenzae type b is only relevant in athletes with certain underlying disorders. Rubella and papillomavirus vaccination might be considered after an individual risk–benefit analysis. Other vaccinations such as cholera, rabies, herpes zoster, and Bacille Calmette–Guérin (BCG) cannot be universally recommended for athletes at present. Only for a very few diseases, a determination of antibody titers is reasonable to avoid unnecessary vaccinations or to control efficacy of an individual’s vaccination (especially for measles, mumps, rubella, varicella, hepatitis B and, partly, hepatitis A). Vaccinations should be scheduled in a way that possible side effects are least likely to occur in periods of competition. Typically, vaccinations are well tolerated by elite athletes, and resulting antibody titers are not different from the general population. Side effects might be reduced by an optimal selection of vaccines and an appropriate technique of administration. Very few discipline-specific considerations apply to an athlete’s vaccination schedule mainly from the competition and training pattern as well as from the typical geographical distribution of competitive sites.

Re-evaluating cost effectiveness of universal meningitis vaccination (Bexsero) in England: modelling study

OBJECTIVE

To use mathematical and economic models to predict the epidemiological and economic impact of vaccination with Bexsero, designed to protect against group B meningococcal disease, to help inform vaccine policy in the United Kingdom.

DESIGN

Modelling study.

SETTING

England.

POPULATION

People aged 0-99.

INTERVENTIONS

Incremental impact of introductory vaccine strategies simulated with a transmission dynamic model of meningococcal infection and vaccination including potential herd effects. Model parameters included recent evidence on the vaccine characteristics, disease burden, costs of care, litigation costs, and loss of quality of life from disease, including impacts on family and network members. The health impact of vaccination was assessed through cases averted and quality adjusted life years (QALYs) gained.

MAIN OUTCOME MEASURES

Cases averted and cost per QALY gained through vaccination; programmes were deemed cost effective against a willingness to pay of £20,000 (€25,420, $32,677) per QALY gained from an NHS and personal and social services perspective.

RESULTS

In the short term, case reduction is greatest with routine infant immunisation (26.3% of cases averted in the first five years). This strategy could be cost effective at £3 (€3.8, $4.9) a vaccine dose, given several favourable assumptions and the use of a quality of life adjustment factor. If the vaccine can disrupt meningococcal transmission more cases are prevented in the long term with an infant and adolescent combined programme (51.8% after 30 years), which could be cost effective at £4 a vaccine dose. Assuming the vaccine reduces acquisition by 30%, adolescent vaccination alone is the most favourable strategy economically, but takes more than 20 years to substantially reduce the number of cases.

CONCLUSIONS

Routine infant vaccination is the most effective short term strategy and could be cost effective with a low vaccine price. Critically, if the vaccine reduces carriage acquisition in teenagers, the combination of infant and adolescent vaccination could result in substantial long term reductions in cases and be cost effective with competitive vaccine pricing.

Vaccines, new opportunities for a new society

Vaccination is the most effective medical intervention ever introduced and, together with clean water and sanitation, it has eliminated a large part of the infectious diseases that once killed millions of people. A recent study concluded that since 1924 in the United States alone, vaccines have prevented 40 million cases of diphtheria, 35 million cases of measles, and a total of 103 million cases of childhood diseases. A report from the World Health Organization states that today vaccines prevent 2.5 million deaths per year: Every minute five lives are saved by vaccines worldwide. Overall, vaccines have done and continue to do an excellent job in eliminating or reducing the impact of childhood diseases. Furthermore, thanks to new technologies, vaccines now have the potential to make an enormous contribution to the health of modern society by preventing and treating not only communicable diseases in all ages, but also noncommunicable diseases such as cancer and neurodegenerative disorders. The achievement of these results requires the development of novel technologies and health economic models able to capture not only the mere cost-benefit of vaccination, but also the value of health per se.

Systematic review of the economic value of diarrheal vaccines

Diarrheal disease is a leading cause of child mortality in low-income settings and morbidity across a range of settings. A growing number of studies have addressed the economic value of new and emerging vaccines to reduce this threat. We conducted a systematic review to assess the economic value of diarrheal vaccines targeting a range of pathogens in different settings. The majority of studies focused on the economic value of rotavirus vaccines in different settings, with most of these concluding that vaccination would provide significant economic benefits across a range of vaccine prices. There is also evidence of the economic benefits of cholera vaccines in specific contexts. For other potential diarrheal vaccines data are limited and often hypothetical. Across all target pathogens and contexts, the evidence of economic value focuses the short-term health and economic gains. Additional information is needed on the broader social and long-term economic value of diarrhea vaccines.

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.