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

Tiered Pricing and Alternative Mechanisms for Equitative Access to Vaccines in Latin America: A Narrative Review of the Literature

OBJECTIVES

To review and describe alternative strategies for the supply of vaccines in Latin America.

METHODS

We conducted a narrative review to explore and describe alternatives for equitable vaccine access in Latin America. We searched and considered the main access strategies reported in the literature through PubMed, Science Direct, and Google Scholar. Additionally, we reviewed the web sites of key stakeholders. The search was conducted using the following keywords: ("access" or "availability" or "acquisition" or "affordability" or "tiered pricing") and ("vaccine"). Subsequently, documents that met the inclusion criteria were selected. Finally, findings were grouped by means of a thematic analysis and an interpretative synthesis.

RESULTS

Twenty-four publications were included. We identified 5 main topics: current supply strategies, challenges for the acquisition of vaccines, vaccine prices equity, alternative supply strategies, and the advantages and impact of a tiered pricing strategy.

CONCLUSIONS

Our review suggests that tiered pricing can be an tool for accelerating the process of introducing vaccines in low-income countries at affordable prices and for countries that do not adhere to the current procurement mechanisms or are not eligible for Vaccine Alliance because giving countries prices for vaccines that reflect their ability to pay can result in better programmatic and financial planning for the purchase of these vaccines, and in return, vaccine manufacturers can gain access to wider markets However, this model has not been z improve access to vaccines that are aimed only at developing countries, mainly because the market in these countries is not profitable for producers.

Vaccine wastage in Ghana, Mozambique, and Pakistan: An assessment of wastage rates for four vaccines and the context, causes, drivers, and knowledge, attitudes and practices for vaccine wastage

Vaccine procurement costs comprise a significant share of immunization program costs in low- and middle-income countries, yet not all procured vaccines are administered. Vaccine wastage occurs due to vial breakage, excessive heat or freezing, expiration, or when not all doses in a multidose vial are used. Better estimates of vaccine wastage rates and their causes could support improved management of vaccine stocks and reduce procurement costs. This study examined aspects of wastage for four vaccines at service delivery points in Ghana (n = 48), Mozambique (n = 36), and Pakistan (n = 46). We used prospective data from daily and monthly vaccine usage data entry forms, along with cross-sectional surveys, and in-depth interviews. The analysis found that estimated monthly proportional open-vial wastage rates for vaccines in single-dose vials (SDV) or in multi-dose vials (MDV) that can be kept refrigerated up to four weeks after opening ranged from 0.08 % to 3 %. For MDV where remaining doses are discarded within six hours after opening, the mean wastage rates ranged from 5 % to 33 %, with rates being highest for measles containing vaccine. Despite national-level guidance to open a vaccine vial even when only one child is present, vaccines in MDV that are discarded within six hours of opening are sometimes offered less frequently than vaccines in SDV or in MDV where remaining doses can be used for up to 4 weeks. This practice can lead to missed opportunities for vaccination. While closed-vial wastage at service delivery points (SDPs) was relatively rare, individual instances can result in large losses, suggesting that monitoring closed-vial wastage should not be neglected. Health workers reported insufficient knowledge of vaccine wastage tracking and reporting methods. Improving reporting forms would facilitate more accurate reporting of all causes of wastage, as would additional training and supportive supervision. Globally, decreasing doses per vial could reduce open-vial wastage.

Gender neutral HPV vaccination programs: Reconsidering policies to expand cancer prevention globally

Human papillomavirus (HPV) infection is responsible for many cancers in both women and men. Cervical cancer, caused by HPV, is the fourth most common cancer among women worldwide, even though it is one of the most preventable cancers. Prevention efforts include HPV vaccination, however these programs remain nascent in many countries. In 2020 the World Health Assembly adopted the Global Strategy for cervical cancer elimination including a goal to fully vaccinate 90% of girls with the HPV vaccine by the age of 15. However, very few countries have reached even 70% coverage. Increased vaccine availability in the future may allow the opportunity to vaccinate more people. This could add to the feasibility of introducing gender-neutral HPV vaccination programs. Adopting a gender-neutral HPV vaccine approach will reduce HPV infections transmitted among the population, combat misinformation, minimize vaccine-related stigma, and promote gender equity. We propose approaching programmatic research through a gender-neutral lens to reduce HPV infections and cancers and promote gender equality. In order to design more effective policies and programs, a better understanding of the perspectives of clients, clinicians, community leaders, and policy-makers is needed. A clear, multi-level understanding of these stakeholders' views will facilitate the development of target policy and programs aimed at addressing common barriers and optimizing uptake. Given the benefit of developing gender-neutral HPV vaccination programs to eliminate cervical cancer and address other HPV associated cancers, we must build knowledge through implementation research around this topic to inform policy-makers and funders for future policy shifts.

Cost-effectiveness of sub-national geographically targeted vaccination programs: A systematic review

Immunization is an essential component of national health plans. However, the growing number of new vaccine introductions, vaccination campaigns and increasing administrative costs create logistic and financial challenges, especially in resource-limited settings. Sub-national geographic targeting of vaccination programs is a potential strategy for governments to reduce the impact of infectious disease outbreaks while optimizing resource allocation and reducing costs, promoting sustainability of critically important national immunization plans. We conducted a systematic review of peer-reviewed literature to identify studies that investigated the cost-effectiveness of geographically targeted sub-national vaccination programs, either through routine immunization or supplementary immunization activities. A total of 16 studies were included in our review, covering nine diseases of interest: cholera, dengue, enterotoxigenic Escherichia coli (ETEC), hepatitis A, Japanese encephalitis, measles, rotavirus, Shigella and typhoid fever. All studies modelled cost-effectiveness of geographically targeted vaccination. Despite the variation in study design, disease focus and country context, studies generally found that in countries where a heterogenous burden of disease exists, sub-national geographic targeting of vaccination programs in areas of high disease burden was more cost-effective than a non-targeted strategy. Sensitivity analysis revealed that cost-effectiveness was most sensitive to variations in vaccine price, vaccine efficacy, mortality rate, administrative and operational costs, discount rate, and treatment costs. This systematic review identified several key characteristics related to geographic targeting of vaccination, including the vaccination strategy used, variations in modelling parameters and their impact on cost-effectiveness. Additional research and guidance is needed to support the appropriateness and feasibility of geographically targeted vaccination and to determine what country context would make this a viable complement to routine immunization programs.

Advancing sustainable development goals through immunization: a literature review

BACKGROUND

Immunization directly impacts health (SDG3) and brings a contribution to 14 out of the 17 Sustainable Development Goals (SDGs), such as ending poverty, reducing hunger, and reducing inequalities. Therefore, immunization is recognized to play a central role in reaching the SDGs, especially in low- and middle-income countries (LMICs). Despite continuous interventions to strengthen immunization systems and to adequately respond to emergency immunization during epidemics, the immunization-related indicators for SDG3 lag behind in sub-Saharan Africa. Especially taking into account the current Covid19 pandemic, the current performance on the connected SDGs is both a cause and a result of this.

METHODS

We conduct a literature review through a keyword search strategy complemented with handpicking and snowballing from earlier reviews. After title and abstract screening, we conducted a qualitative analysis of key insights and categorized them according to showing the impact of immunization on SDGs, sustainability challenges, and model-based solutions to these challenges.

RESULTS

We reveal the leveraging mechanisms triggered by immunization and position them vis-à-vis the SDGs, within the framework of Public Health and Planetary Health. Several challenges for sustainable control of vaccine-preventable diseases are identified: access to immunization services, global vaccine availability to LMICs, context-dependent vaccine effectiveness, safe and affordable vaccines, local/regional vaccine production, public-private partnerships, and immunization capacity/capability building. Model-based approaches that support SDG-promoting interventions concerning immunization systems are analyzed in light of the strategic priorities of the Immunization Agenda 2030.

CONCLUSIONS

In general terms, it can be concluded that relevant future research requires (i) design for system resilience, (ii) transdisciplinary modeling, (iii) connecting interventions in immunization with SDG outcomes, (iv) designing interventions and their implementation simultaneously, (v) offering tailored solutions, and (vi) model coordination and integration of services and partnerships. The research and health community is called upon to join forces to activate existing knowledge, generate new insights and develop decision-supporting tools for Low-and Middle-Income Countries' health authorities and communities to leverage immunization in its transformational role toward successfully meeting the SDGs in 2030.

Human papillomavirus vaccination uptake in low-and middle-income countries: a meta-analysis

BACKGROUND

The proportion of incident cases of HPV-attributable cancers is highest in the low- and middle-income countries (LMICs) but many are yet to initiate HPV vaccination programs. This meta-analysis was performed to assess the uptake of HPV vaccination in LMICs at the beginning of the global strategy to eliminate cervical cancer and describes the gaps and challenges.

METHODS

A systematic search was conducted in PubMed, EMBASE, Scopus, Web of Science, and CENTRAL databases for observational studies that reported the uptake of HPV vaccination until October 2020. The meta-analysis was done using a random-effects model to assess the pooled estimate of HPV uptake. CRD42021218429.

FINDINGS

During 2008-2020, an estimated 3.3 million females received at least one dose of HPV vaccine with 61.69% of the target population vaccinated. In countries with high uptake, the pooled estimate of uptake was higher in females than males (45.48% vs 8.45%) and showed significant decline in 2015-2020 compared to 2006-2014 (89.03% vs 41.48%). In countries with low uptake, the estimate of uptake was low in both males and females (5.31% vs 2.93%) and showed increase in uptake in 2015-2020 compared to 2006-2014 (0.76% vs 5.22%). In countries with high uptake, compared to routine programs, the estimate was higher when delivered through demonstration programs (89.94% vs 59.74%).

INTERPRETATION

The major concern was a significant drop in the uptake in countries that started with high uptake, challenges in the maintenance of vaccine uptake, sustainability of funding and the lack of standard monitoring and reporting.

Reasons why children miss vaccinations in Western Kenya; A step in a five-point plan to improve routine immunization

Global childhood vaccination coverage has stagnated over the past decade and raising coverage will require a collection of approaches since no single approach has been suitable for all countries or situations. The American Red Cross has developed a 5-Point Plan^a to geolocate under-vaccinated children and determine the reasons why they miss vaccination by capitalizing on the Red Cross Movement's large cadres of trusted community volunteers. The Plan was piloted in Bobasi sub-county in Western Kenya, with volunteers seeking to conduct a face-to-face interview in all households, visiting over 60,000 over 7 days. Six pockets of 233 children without a home-based vaccination record or missing an age-appropriate dose of Penta1, Penta3 or measles-containing vaccine were identified. Three activities were carried out to learn why these children were not vaccinated: 1) one-on-one interviews and 2) focus group discussions with the caregivers of the under-vaccinated children and 3) interviews with healthcare workers who vaccinate in Bobasi. Complacency was commonly reported by caregivers during one-on-one interviews while bad staff attitude or practice was most frequently reported in focus group discussions; health staff reported caregiver hesitency, not knowing vaccination due date and vaccine stock-outs as the most common reasons for caregivers to not have their child vaccinated. As reasons varied across the three different activities, the different perspectives and approaches helped characterize vaccination barriers. Civil society organizations working together with the Ministry of Health can provide valuable information for immunization managers to act on.

What We Do Not Know About the Costs of Immunization Programs in Low- and Middle-Income Countries

• For many countries, there are limited data on the costs of running immunization services, and even less on the costs of increasing immunization coverage. • When considering different approaches for scaling up coverage, countries and funders need to understand the marginal change in coverage produced, costs of introduction, and how cost and coverage effects change depending on programmatic context. • Costing studies would benefit from improved, systematic reporting and leveraging ongoing program evaluation efforts to collect costing data. Long-term investments in the health system may allow for routine data collection and improved efficiency for budgeting and planning.

Vaccine storage and distribution between expanded program on immunization and medical store department in Tanzania: a cost-minimization analysis

BACKGROUND

In 2016, the Tanzanian government shifted the vaccine supply chain responsibilities from the Medical Store Department (MSD) to the Expanded Program on Immunization (EPI) to reduce costs. However, cost estimates that informed the decision were based on invoice value of vaccines and related supplies, rather than a proper economic evaluation study. Therefore, this study aims to compare the actual storage and distribution costs of vaccines and related supplies between MSD to EPI.

METHOD

Micro-costing approach was used to estimate resource use at MSD and EPI for the year 2018. Data were collected through a review of documents, warehouse databases, and interviews with key staff at MSD and EPI. We included both capital and recurrent costs. Microsoft Excel® was used for analysis with input data from the UNICEF forecasting tool, WHOs vaccine volume and capacity estimation tool, diesel generator calculator, and supply chain service fee estimator version 1.02.

RESULTS

The total vaccine storage and distribution costs were estimated to be USD 1,996,286 at MSD and USD 543,648 at EPI. Distribution and program management costs represented 41% (USD 819,288) and 38% (USD 762,968) of the total costs at MSD, while storage and distribution costs represented 43% (USD 234,423) and 34% (USD 184,620) of the total costs at EPI, respectively. The cost drivers at MSD were fuel and transport (21%), receiving and dispatch (19%) and, program management personnel cost (14%), while at EPI were storage space (20%), program management personnel cost (18%) and fuel and transport (15%).

CONCLUSION

The storage and distribution of vaccines in Tanzania via the EPI reduced the vaccine supply chain cost to about 27% of the program costs at MSD.

Producing Standardized Country-Level Immunization Delivery Unit Cost Estimates

BACKGROUND

To plan for the financial sustainability of immunization programs and make informed decisions to improve immunization coverage and equity, decision-makers need to know how much these programs cost beyond the cost of the vaccine. Non-vaccine delivery cost estimates can significantly influence the cost-effectiveness estimates used to allocate resources at the country level. However, many low- and middle-income countries (LMICs) do not have immunization delivery unit cost estimates available, or have estimates that are uncertain, unreliable, or old. We undertook a Bayesian evidence synthesis to generate country-level estimates of immunization delivery unit costs for LMICs.

METHODS

From a database of empirical immunization costing studies, we extracted estimates of the delivery cost per dose for routine childhood immunization services, excluding vaccine costs. A Bayesian meta-regression model was used to regress delivery cost per dose estimates, stratified by cost category, against a set of predictor variables including country-level [gross domestic product per capita, reported diphtheria-tetanus-pertussis third dose coverage (DTP3), population, and number of doses in the routine vaccination schedule] and study-level (study year, single antigen or programmatic cost per dose, and financial or economic cost) predictors. The fitted prediction model was used to generate standardized estimates of the routine immunization delivery cost per dose for each LMIC for 2009-2018. Alternative regression models were specified in sensitivity analyses.

RESULTS

We estimated the prediction model using the results from 29 individual studies, covering 24 countries. The predicted economic cost per dose for routine delivery of childhood vaccines (2018 US dollars), not including the price of the vaccine, was $1.87 (95% uncertainty interval $0.64-4.38) across all LMICs. By individual cost category, the programmatic economic cost per dose for routine delivery of childhood vaccines was $0.74 ($0.26-1.70) for labor, $0.26 ($0.08-0.67) for supply chain, $0.22 ($0.06-0.57) for capital, and $0.65 ($0.20-1.66) for other service delivery costs.

CONCLUSIONS

Accurate immunization delivery costs are necessary for assessing the cost-effectiveness and strategic planning needs of immunization programs. The cost estimates from this analysis provide a broad indication of immunization delivery costs that may be useful when accurate local data are unavailable.

Two media-reported vaccine events in China from 2013 to 2016: Impact on confidence and vaccine utilization

BACKGROUND

China media reported infant deaths following hepatitis B vaccination in late 2013, leading to temporary suspension of hepatitis B vaccine (HepB Event) until the deaths were shown to be coincidental and the vaccine was of standard, good quality. In 2016, a criminal ring in Shandong province that had been purchasing, improperly storing, and reselling Category 2 vaccines (private-sector) to 60 (of 200,000) clinics for 5 years, was exposed, publicized, and prosecuted, and the potential health and epidemiological impacts were investigated to determine whether revaccination was necessary (Shandong Vaccine Event).

METHODS

We assessed parental confidence in vaccines through 9 telephone surveys in 6 and 11 provinces before, during, and after the two events. Provider confidence was assessed through in-person interviews following each event. Vaccine utilization was assessed using Immunization Information Management System data from township clinics.

RESULTS

In the early stages of each event, approximately 30% of parents indicated vaccine hesitancy and 18% said they would refuse routine immunization. Five and nine months after each event, hesitancy and refusal decreased, but not to pre-event levels. During the Shandong Vaccine Event, 49·1% of parents indicated refusal to use Category 2 vaccines; six months later, the rate was 32·8%. Use of HepB decreased by 21% during the first 2 weeks of the HepB Event and by 12·6% during the first 4 weeks of Shandong Vaccine Event, but returned to baseline in less than 3 months. Use of Category 2 vaccine decreased by 49·5% in the first 3 weeks of the Shandong Vaccine Event and by 28·7% 6 months later. After the Shandong Vaccine Event, 64% of clinicians held high confidence in routine immunization, lower than at baseline.

CONCLUSIONS

The two events caused mistrust, loss of confidence, and decreases in use of vaccines by parents and providers. In addition to ensuring immunization program integrity, effective communications and ongoing monitoring of vaccine use and confidence should be included to restore confidence and trust in vaccines.

Immunization: vital progress, unfinished agenda

Vaccination against infectious diseases has changed the future of the human species, saving millions of lives every year, both children and adults, and providing major benefits to society as a whole. Here we show, however, that national and sub-national coverage of vaccination varies greatly and major unmet needs persist. Although scientific progress opens exciting perspectives in terms of new vaccines, the pathway from discovery to sustainable implementation can be long and difficult, from the financing, development and licensing to programme implementation and public acceptance. Immunization is one of the best investments in health and should remain a priority for research, industry, public health and society.

Implementation strategy and cost of Mozambique's HPV vaccine demonstration project

BACKGROUND

Cost is an important determinant of health program implementation. In this study, we conducted a comprehensive evaluation of the implementation strategy of Mozambique's school-based HPV vaccine demonstration project. We sought to estimate the total costs for the program, cost per fully immunized girl (FIG), and compute projections for the total cost of implementing a similar national level vaccination program.

METHODS

We collected primary data through document review, participatory observation, and key informant interviews at all levels of the national health system and Ministry of Education. We used a combination of micro-costing methods-identification and measurement of resource quantities and valuation by application of unit costs, and gross costing-for consideration of resource bundles as they apply to the number of vaccinated girls. We extrapolated the cost per FIG to the HPV-vaccine-eligible population of Mozambique, to demonstrate the projected total annual cost for two scenarios of a similarly executed HPV vaccine program.

RESULTS

The total cost of the Mozambique HPV vaccine demonstration project was $523,602. The mean cost per FIG was $72 (Credibility Intervals (CI): $62 - $83) in year one, $38 (CI: $37 - $40) in year two, and $54 CI: $49 - $61) for years one and two. The mean cost per FIG with the third HPV vaccine dose excluded from consideration was $60 (CI: $50 - $72) in year one, $38 (CI: $31 - $46) in year two, and $48 (CI: $42 - $55) for years one and two. The mean cost per FIG when only one HPV vaccine dose is considered was $30 (CI: $27 - $33)) in year one, $19 (CI: $15-$23) in year two, and $24 (CI: $22-$27) for both years. The projected annual cost of a two-and one-dose vaccine program targeting all 10-year-old girls in the country was $18.2 m (CI: $15.9 m - $20.7 m) and $9 m (CI: $8 m - $10 m) respectively.

CONCLUSION

National adaptation and scale-up of Mozambique's school-based HPV vaccine strategy may result in substantial costs depending on dosing. For sustainability, stakeholders will need to negotiate vaccine price and achieve higher efficiency in startup activities and demand creation.

The costs of delivering vaccines in low- and middle-income countries: Findings from a systematic review

Introduction

Information on immunization delivery costs (IDCs) is essential for better planning and budgeting for the sustainability and performance of national programs. However, delivery cost evidence is fragmented and of variable quality, making it difficult for policymakers, planners, and other stakeholders to understand and use. This study aimed to consolidate and summarize the evidence on delivery costs, answering the question: What are the unit costs of vaccine delivery across low- and middle-income countries (LMICs) and through a variety of delivery strategies?

Methods

We conducted a systematic review of over 15,000 published and unpublished resources from 2005 to 2018 that included IDCs in LMICs. We quality-rated and extracted data from 61 resources that contained 410 immunization delivery unit costs (e.g., cost per dose, cost per fully immunized child). We converted cost findings to a common year (2016) and currency (U.S. dollars) to ensure comparability across studies and settings. We performed a descriptive and gap analysis and developed immunization delivery cost ranges using comparable unit costs for single vaccines and schedules of vaccines.

Results

The majority of IDC evidence comes from low-income countries and Sub-Saharan Africa. Most unit costs are presented as cost per dose and represent health facility-based delivery.

Discussion

The cost ranges may be higher than current estimates used in many LMICs for budgeting: $0.16-$2.54 incremental cost per dose (including economic, financial, and fiscal costs) for single, newly introduced vaccines, and $0.75-$9.45 full cost per dose (economic costs) for schedules of four to eight vaccines delivered to children under one.

Conclusions

Despite increased attention on improving coverage and strengthening immunization delivery, evidence on the cost of delivery is nascent but growing. The cost ranges can inform planning and policymaking, but should be used with caution given their width and the few unit costs used in their development.

A Systematic Review of the Incremental Costs of Implementing a New Vaccine in the Expanded Program of Immunization in Sub-Saharan Africa

Background. The World Health Organization is planning a pilot introduction of a new malaria vaccine in three sub-Saharan African countries. To inform considerations about including a new vaccine in the vaccination program of those and other countries, estimates from the scientific literature of the incremental costs of doing so are important. Methods. A systematic review of scientific studies reporting the costs of recent vaccine programs in sub-Saharan countries was performed. The focus was to obtain from each study an estimate of the cost per dose of vaccine administered excluding the acquisition cost of the vaccine and wastage. Studies published between 2000 and 2018 and indexed on PubMed could be included and results were standardized to 2015 US dollars (US$). Results. After successive screening of 2119 titles, and 941 abstracts, 58 studies with 80 data points (combinations of country, vaccine type, and vaccination approach-routine v. campaign) were retained. Most studies used the so-called ingredients approach as costing method combining field data collection with documented unit prices per cost item. The categorization of cost items and the extent of detailed reporting varied widely. Across the studies, the mean and median cost per dose administered was US$1.68 and US$0.88 with an interquartile range of US$0.54 to US$2.31. Routine vaccination was more costly than campaigns, with mean cost per dose of US$1.99 and US$0.88, respectively. Conclusion. Across the studies, there was huge variation in the cost per dose delivered, between and within countries, even in studies using consistent data collection tools and analysis methods, and including many health facilities. For planning purposes, the interquartile range of US$0.54 to US$2.31 may be a sufficiently precise estimate.

Assessing the operational costs of routine immunization activities at the sub-center level in Myanmar: What matters for increasing national immunization coverage?

BACKGROUND

Myanmar's national immunization program was launched in 1978. Routine immunization is mainly provided at sub-center level with midwives assigned as main vaccinators. The vaccinators at the sub-centers have to obtain vaccines from their designated township health department's cold room for immunization services. This study aimed to calculate the operational costs of routine immunization at sub-centers in Myanmar.

METHODS

A cross-sectional study was conducted among 160 sub-centers throughout the country. Face-to-face interviews were conducted with the main vaccinator at each sub-center using a pre-tested questionnaire. The study analyzed the operational costs per facility and the associations between sub-center characteristics and operational costs.

RESULTS

In Myanmar, the average operational costs of routine immunization per sub-center ranged from 434,700-990,125 MMK for rural areas and 235,875-674,250 MMK for urban areas. The operational costs increased by 8,749.50 MMK (95% CI: 6,805.79-10,693.21; p < 0.001) per mile and 5,752.50 MMK (95% CI: 914.22-10,590.79; p < 0.05) per working day.

CONCLUSION

This study indicated that the operational costs at sub-centers were high and varied significantly among the different geographical areas. The operational costs could be reduced by additional support for the resources, for example, installing cold chain facilities at sub-centers and opening new sub-centers throughout the country.

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.

Routine immunization services costs and financing in China, 2015

OBJECTIVE

To estimate the costs of routine immunization (RI) services in China in 2015, to provide objective data relevant to investment in the Expanded Program on Immunization, and to contribute to global data on costing and financing of RI.

METHODS

The study was conducted between January and March 2016. We selected 276 villages, 138 townships, 46 counties, and 40 prefectures from 15 provinces as investigation sites at random, stratified by eastern, middle, and western regions. Direct cost items included vaccines, personnel, cold chain, surveillance, communication, training, and supervision at the national, provincial, prefecture, county, township, and village levels. We obtained financial data from governmental and external sources. Indirect costs of RI included parents' transportation costs and productivity lost due to taking their children for vaccination.

RESULTS

Total direct costs were $92.42 for each child fully immunized ($4.20/dose), which equates to $1529.55 million per birth cohort. RI costs were higher in the eastern region than in the western region, and higher than that of the central region. Vaccination coverage was positively associated with direct routine immunization costs. The cost of the recommended vaccines was $19.08/child and vaccine only accounted for 20.64% of total costs. Operational cost, including surveillance, communication, training and supervision, was $217.31/child, accounting for 14.21% of total cost. The indirect cost per child was $72.86; the total indirect cost was $1205.83 million for the birth cohort. Government investment in RI accounted for about 70% of total costs. Revenue from sales of private-sector vaccine supported the remaining 30% of RI costs.

CONCLUSIONS

While government financing has increased, some operating costs continue to be provided from revenue generated by sales of Category 2 (private-sector) vaccines to families. China could benefit from bringing new and underutilized vaccines into the EPI system based on evidence that includes routine immunization vaccine and operations costs.

Capturing Budget Impact Considerations Within Economic Evaluations: A Systematic Review of Economic Evaluations of Rotavirus Vaccine in Low- and Middle-Income Countries and a Proposed Assessment Framework

BACKGROUND

In low- and middle-income countries, budget impact is an important criterion for funding new interventions, particularly for large public health investments such as new vaccines. However, budget impact analyses remain less frequently conducted and less well researched than cost-effectiveness analyses.

OBJECTIVE

The objective of this study was to fill the gap in research on budget impact analyses by assessing (1) the quality of stand-alone budget impact analyses, and (2) the feasibility of extending cost-effectiveness analyses to capture budget impact.

METHODS

We developed a budget impact analysis checklist and scoring system for budget impact analyses, which we then adapted for cost-effectiveness analyses, based on current International Society for Pharmacoeconomics and Outcomes Research Task Force recommendations. We applied both budget impact analysis and cost-effectiveness analysis checklists and scoring systems to examine the extent to which existing economic evaluations provide sufficient evidence about budget impact to enable decision making. We used rotavirus vaccination as an illustrative case in which low- and middle-income countries uptake has been limited despite demonstrated cost effectiveness. A systematic literature review was conducted to identify economic evaluations of rotavirus vaccine in low- and middle-income countries published between January 2000 and February 2017. We critically appraised the quality of budget impact analyses, and assessed the extension of cost-effectiveness analyses to provide useful budget impact information.

RESULTS

Six budget impact analyses and 60 cost-effectiveness analyses were identified. Budget impact analyses adhered to most International Society for Pharmacoeconomics and Outcomes Research recommendations, with key exceptions being provision of undiscounted financial streams for each budget period and model validation. Most cost-effectiveness analyses could not be extended to provide useful budget impact information; cost-effectiveness analyses also rarely presented undiscounted annual costs, or estimated financial streams during the first years of programme scale-up.

CONCLUSIONS

Cost-effectiveness analyses vastly outnumber budget impact analyses of rotavirus vaccination, despite both being critical for policy decision making. Straightforward changes to the presentation of cost-effectiveness analyses results could facilitate their adaptation into budget impact analyses.

Maternal influenza immunization in Malawi: Piloting a maternal influenza immunization program costing tool by examining a prospective program

BACKGROUND

This costing study in Malawi is a first evaluation of a Maternal Influenza Immunization Program Costing Tool (Costing Tool) for maternal immunization. The tool was designed to help low- and middle-income countries plan for maternal influenza immunization programs that differ from infant vaccination programs because of differences in the target population and potential differences in delivery strategy or venue.

METHODS

This analysis examines the incremental costs of a prospective seasonal maternal influenza immunization program that is added to a successful routine childhood immunization and antenatal care program. The Costing Tool estimates financial and economic costs for different vaccine delivery scenarios for each of the major components of the expanded immunization program.

RESULTS

In our base scenario, which specifies a donated single dose pre-filled vaccine formulation, the total financial cost of a program that would reach 2.3 million women is approximately $1.2 million over five years. The economic cost of the program, including the donated vaccine, is $10.4 million over the same period. The financial and economic costs per immunized pregnancy are $0.52 and $4.58, respectively. Other scenarios examine lower vaccine uptake, reaching 1.2 million women, and a vaccine purchased at $2.80 per dose with an alternative presentation.

CONCLUSION

This study estimates the financial and economic costs associated with a prospective maternal influenza immunization program in a low-income country. In some scenarios, the incremental delivery cost of a maternal influenza immunization program may be as low as some estimates of childhood vaccination programs, assuming the routine childhood immunization and antenatal care systems are capable of serving as the platform for an additional vaccination program. However, purchasing influenza vaccines at the prices assumed in this analysis, instead of having them donated, is likely to be challenging for lower-income countries. This result should be considered as a starting point to understanding the costs of maternal immunization programs in low- and middle-income countries.

Experiences of operational costs of HPV vaccine delivery strategies in Gavi-supported demonstration projects

From 2012 to 2016, Gavi, the Vaccine Alliance, provided support for countries to conduct small-scale demonstration projects for the introduction of the human papillomavirus vaccine, with the aim of determining which human papillomavirus vaccine delivery strategies might be effective and sustainable upon national scale-up. This study reports on the operational costs and cost determinants of different vaccination delivery strategies within these projects across twelve countries using a standardized micro-costing tool. The World Health Organization Cervical Cancer Prevention and Control Costing Tool was used to collect costing data, which were then aggregated and analyzed to assess the costs and cost determinants of vaccination. Across the one-year demonstration projects, the average economic and financial costs per dose amounted to US$19.98 (standard deviation ±12.5) and US$8.74 (standard deviation ±5.8), respectively. The greatest activities representing the greatest share of financial costs were social mobilization at approximately 30% (range, 6–67%) and service delivery at about 25% (range, 3–46%). Districts implemented varying combinations of school-based, facility-based, or outreach delivery strategies and experienced wide variation in vaccine coverage, drop-out rates, and service delivery costs, including transportation costs and per diems. Size of target population, number of students per school, and average length of time to reach an outreach post influenced cost per dose. Although the operational costs from demonstration projects are much higher than those of other routine vaccine immunization programs, findings from our analysis suggest that HPV vaccination operational costs will decrease substantially for national introduction. Vaccination costs may be decreased further by annual vaccination, high initial investment in social mobilization, or introducing/strengthening school health programs. Our analysis shows that drivers of cost are dependent on country and district characteristics. We therefore recommend that countries carry out detailed planning at the national and district levels to define a sustainable strategy for national HPV vaccine roll-out, in order to achieve the optimal balance between coverage and cost.

The cost determinants of routine infant immunization services: a meta-regression analysis of six country studies

BACKGROUND

Evidence on immunization costs is a critical input for cost-effectiveness analysis and budgeting, and can describe variation in site-level efficiency. The Expanded Program on Immunization Costing and Financing (EPIC) Project represents the largest investigation of immunization delivery costs, collecting empirical data on routine infant immunization in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia.

METHODS

We developed a pooled dataset from individual EPIC country studies (316 sites). We regressed log total costs against explanatory variables describing service volume, quality, access, other site characteristics, and income level. We used Bayesian hierarchical regression models to combine data from different countries and account for the multi-stage sample design. We calculated output elasticity as the percentage increase in outputs (service volume) for a 1% increase in inputs (total costs), averaged across the sample in each country, and reported first differences to describe the impact of other predictors. We estimated average and total cost curves for each country as a function of service volume.

RESULTS

Across countries, average costs per dose ranged from $2.75 to $13.63. Average costs per child receiving diphtheria, tetanus, and pertussis ranged from $27 to $139. Within countries costs per dose varied widely-on average, sites in the highest quintile were 440% more expensive than those in the lowest quintile. In each country, higher service volume was strongly associated with lower average costs. A doubling of service volume was associated with a 19% (95% interval, 4.0-32) reduction in costs per dose delivered, (range 13% to 32% across countries), and the largest 20% of sites in each country realized costs per dose that were on average 61% lower than those for the smallest 20% of sites, controlling for other factors. Other factors associated with higher costs included hospital status, provision of outreach services, share of effort to management, level of staff training/seniority, distance to vaccine collection, additional days open per week, greater vaccination schedule completion, and per capita gross domestic product.

CONCLUSIONS

We identified multiple features of sites and their operating environment that were associated with differences in average unit costs, with service volume being the most influential. These findings can inform efforts to improve the efficiency of service delivery and better understand resource needs.

First-in-human safety and immunogenicity investigations of three adjuvanted reduced dose inactivated poliovirus vaccines (IPV-Al SSI) compared to full dose IPV Vaccine SSI when given as a booster vaccination to adolescents with a history of IPV vaccination at 3, 5, 12months and 5years of age

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Three adjuvanted reduced dose IPV-Al SSI were safe and immunogenic in adolescents.

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The three IPV-Al SSI were highly immunogenic, but inferior to IPV Vaccine SSI as a booster.

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Reduced dose IPV-Al SSI is intended for markets in need of affordable IPV.

Background

There is a demand of affordable IPV in the World. Statens Serum Institut (SSI) has developed three reduced dose IPV formulations adsorbed to aluminium hydroxide; 1/3 IPV-Al, 1/5 IPV-Al and 1/10 IPV-Al SSI, and now report the results of the first investigations in humans.

Methods

240 Danish adolescents, aged 10–15 years, and childhood vaccinated with IPV were booster vaccinated with 1/3 IPV-Al, 1/5 IPV-Al, 1/10 IPV-Al or IPV Vaccine SSI. The booster effects (GMTRs) of the three IPV-Al SSI were compared to IPV Vaccine SSI, and evaluated for non-inferiority.

Immunogenicity results

The pre-vaccination GMTs were similar across the groups; 926 (type 1), 969 (type 2) and 846 (type 3) in the total trial population.

The GMTRs by poliovirus type and IPV formulation were:

Type 1: 17.0 (1/3 IPV-Al), 13.0 (1/5 IPV-Al), 7.1 (1/10 IPV-Al) and 42.2 (IPV Vaccine SSI).

Type 2: 12.5 (1/3 IPV-Al), 13.1 (1/5 IPV-Al), 7.6 (1/10 IPV-Al) and 47.8 (IPV Vaccine SSI).

Type 3: 14.5 (1/3 IPV-Al), 16.2 (1/5 IPV-Al), 8.9 (1/10 IPV-Al) and 62.4 (IPV Vaccine SSI)

Thus, the three IPV-Al formulations were highly immunogenic, but inferior to IPV Vaccine SSI, in this booster vaccination trial.

Safety results

No SAE and no AE of severe intensity occurred. 59.2% of the subjects reported at least one AE. Injection site pain was the most frequent AE in all groups; from 24.6% to 43.3%. Injection site redness and swelling frequencies were < 5% in most and < 10% in all groups. The most frequent systemic AEs were fatigue (from 8.2% to 15.0%) and headache (from 15.0% to 28.3%). Most AEs were of mild intensity. In conclusion, the three IPV-Al SSI were safe in adolescents and the booster effects were satisfactory.

ClinicalTrials.gov registration number: NCT02280447.

Funding gap for immunization across 94 low- and middle-income countries

Novel vaccine development and production has given rise to a growing number of vaccines that can prevent disease and save lives. In order to realize these health benefits, it is essential to ensure adequate immunization financing to enable equitable access to vaccines for people in all communities. This analysis estimates the full immunization program costs, projected available financing, and resulting funding gap for 94 low- and middle-income countries over five years (2016-2020). Vaccine program financing by country governments, Gavi, and other development partners was forecasted for vaccine, supply chain, and service delivery, based on an analysis of comprehensive multi-year plans together with a series of scenario and sensitivity analyses. Findings indicate that delivery of full vaccination programs across 94 countries would result in a total funding gap of $7.6 billion (95% uncertainty range: $4.6-$11.8 billion) over 2016-2020, with the bulk (98%) of the resources required for routine immunization programs. More than half (65%) of the resources to meet this funding gap are required for service delivery at $5.0 billion ($2.7-$8.4 billion) with an additional $1.1 billion ($0.9-$2.7 billion) needed for vaccines and $1.5 billion ($1.1-$2.0 billion) for supply chain. When viewed as a percentage of total projected costs, the funding gap represents 66% of projected supply chain costs, 30% of service delivery costs, and 9% of vaccine costs. On average, this funding gap corresponds to 0.2% of general government expenditures and 2.3% of government health expenditures. These results suggest greater need for country and donor resource mobilization and funding allocation for immunizations. Both service delivery and supply chain are important areas for further resource mobilization. Further research on the impact of advances in service delivery technology and reductions in vaccine prices beyond this decade would be important for efficient investment decisions for immunization.

EPIC Studies: Governments Finance, On Average, More Than 50 Percent Of Immunization Expenses, 2010-11

Governments in resource-poor settings have traditionally relied on external donor support for immunization. Under the Global Vaccine Action Plan, adopted in 2014, countries have committed to mobilizing additional domestic resources for immunization. Data gaps make it difficult to map how well countries have done in spending government resources on immunization to demonstrate greater ownership of programs. This article presents findings of an innovative approach for financial mapping of routine immunization applied in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia. This approach uses modified System of Health Accounts coding to evaluate data collected from national and subnational levels and from donor agencies. We found that government sources accounted for 27-95 percent of routine immunization financing in 2011, with countries that have higher gross national product per capita better able to finance requirements. Most financing is channeled through government agencies and used at the primary care level. Sustainable immunization programs will depend upon whether governments have the fiscal space to allocate additional resources. Ongoing robust analysis of routine immunization should be instituted within the context of total health expenditure tracking.