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Yemeke TT, Mitgang E, Wedlock PT, Higgins C, Chen HH, Pallas SW, Abimbola T, Wallace A, Bartsch SM, Lee BY, Ozawa S. Promoting, seeking, and reaching vaccination services: A systematic review of costs to immunization programs, beneficiaries, and caregivers. Vaccine 2021; 39:4437-4449. [PMID: 34218959 PMCID: PMC10711749 DOI: 10.1016/j.vaccine.2021.05.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Understanding the costs to increase vaccination demand among under-vaccinated populations, as well as costs incurred by beneficiaries and caregivers for reaching vaccination sites, is essential to improving vaccination coverage. However, there have not been systematic analyses documenting such costs for beneficiaries and caregivers seeking vaccination. METHODS We searched PubMed, Scopus, and the Immunization Delivery Cost Catalogue (IDCC) in 2019 for the costs for beneficiaries and caregivers to 1) seek and know how to access vaccination (i.e., costs to immunization programs for social mobilization and interventions to increase vaccination demand), 2) take time off from work, chores, or school for vaccination (i.e., productivity costs), and 3) travel to vaccination sites. We assessed if these costs were specific to populations that faced other non-cost barriers, based on a framework for defining hard-to-reach and hard-to-vaccinate populations for vaccination. RESULTS We found 57 studies describing information, education, and communication (IEC) costs, social mobilization costs, and the costs of interventions to increase vaccination demand, with mean costs per dose at $0.41 (standard deviation (SD) $0.83), $18.86 (SD $50.65) and $28.23 (SD $76.09) in low-, middle-, and high-income countries, respectively. Five studies described productivity losses incurred by beneficiaries and caregivers seeking vaccination ($38.33 per person; SD $14.72; n = 3). We identified six studies on travel costs incurred by beneficiaries and caregivers attending vaccination sites ($11.25 per person; SD $9.54; n = 4). Two studies reported social mobilization costs per dose specific to hard-to-reach populations, which were 2-3.5 times higher than costs for the general population. Eight studies described barriers to vaccination among hard-to-reach populations. CONCLUSION Social mobilization/IEC costs are well-characterized, but evidence is limited on costs incurred by beneficiaries and caregivers getting to vaccination sites. Understanding the potential incremental costs for populations facing barriers to reach vaccination sites is essential to improving vaccine program financing and planning.
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Affiliation(s)
- Tatenda T Yemeke
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Elizabeth Mitgang
- Public Health Informatics, Computational, and Operations Research (PHICOR), CUNY Graduate School of Public Health and Health Policy, New York City, NY 10027, USA
| | - Patrick T Wedlock
- Public Health Informatics, Computational, and Operations Research (PHICOR), CUNY Graduate School of Public Health and Health Policy, New York City, NY 10027, USA
| | - Colleen Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Hui-Han Chen
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Sarah W Pallas
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Taiwo Abimbola
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Aaron Wallace
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Sarah M Bartsch
- Public Health Informatics, Computational, and Operations Research (PHICOR), CUNY Graduate School of Public Health and Health Policy, New York City, NY 10027, USA
| | - Bruce Y Lee
- Public Health Informatics, Computational, and Operations Research (PHICOR), CUNY Graduate School of Public Health and Health Policy, New York City, NY 10027, USA
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA; Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
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Modeling the Cost-Effectiveness of Interventions to Prevent Plague in Madagascar. Trop Med Infect Dis 2021; 6:tropicalmed6020101. [PMID: 34208006 PMCID: PMC8293333 DOI: 10.3390/tropicalmed6020101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/24/2022] Open
Abstract
Plague (Yersinia pestis) remains endemic in certain parts of the world. We assessed the cost-effectiveness of plague control interventions recommended by the World Health Organization with particular consideration to intervention coverage and timing. We developed a dynamic model of the spread of plague between interacting populations of humans, rats, and fleas and performed a cost-effectiveness analysis calibrated to a 2017 Madagascar outbreak. We assessed three interventions alone and in combination: expanded access to antibiotic treatment with doxycycline, mass distribution of doxycycline prophylaxis, and mass distribution of malathion. We varied intervention timing and coverage levels. We calculated costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios from a healthcare perspective. The preferred intervention, using a cost-effectiveness threshold of $1350/QALY (GDP per capita in Madagascar), was expanded access to antibiotic treatment with doxycycline with 100% coverage starting immediately after the first reported case, gaining 543 QALYs at an incremental cost of $1023/QALY gained. Sensitivity analyses support expanded access to antibiotic treatment and leave open the possibility that mass distribution of doxycycline prophylaxis or mass distribution of malathion could be cost-effective. Our analysis highlights the potential for rapid expansion of access to doxycycline upon recognition of plague outbreaks to cost-effectively prevent future large-scale plague outbreaks and highlights the importance of intervention timing.
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Cutts FT, Dansereau E, Ferrari MJ, Hanson M, McCarthy KA, Metcalf CJE, Takahashi S, Tatem AJ, Thakkar N, Truelove S, Utazi E, Wesolowski A, Winter AK. Using models to shape measles control and elimination strategies in low- and middle-income countries: A review of recent applications. Vaccine 2020; 38:979-992. [PMID: 31787412 PMCID: PMC6996156 DOI: 10.1016/j.vaccine.2019.11.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 01/30/2023]
Abstract
After many decades of vaccination, measles epidemiology varies greatly between and within countries. National immunization programs are therefore encouraged to conduct regular situation analyses and to leverage models to adapt interventions to local needs. Here, we review applications of models to develop locally tailored interventions to support control and elimination efforts. In general, statistical and semi-mechanistic transmission models can be used to synthesize information from vaccination coverage, measles incidence, demographic, and/or serological data, offering a means to estimate the spatial and age-specific distribution of measles susceptibility. These estimates complete the picture provided by vaccination coverage alone, by accounting for natural immunity. Dynamic transmission models can then be used to evaluate the relative impact of candidate interventions for measles control and elimination and the expected future epidemiology. In most countries, models predict substantial numbers of susceptible individuals outside the age range of routine vaccination, which affects outbreak risk and necessitates additional intervention to achieve elimination. More effective use of models to inform both vaccination program planning and evaluation requires the development of training to enhance broader understanding of models and where feasible, building capacity for modelling in-country, pipelines for rapid evaluation of model predictions using surveillance data, and clear protocols for incorporating model results into decision-making.
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Affiliation(s)
- F T Cutts
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - E Dansereau
- Vaccine Delivery, Global Development, The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - M J Ferrari
- Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, USA
| | - M Hanson
- Vaccine Delivery, Global Development, The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - K A McCarthy
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005, USA
| | - C J E Metcalf
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA
| | - S Takahashi
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA; Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - A J Tatem
- WorldPop, Department of Geography and Environmental Science, University of Southampton, Highfield, Southampton SO17 1BJ, UK
| | - N Thakkar
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005, USA
| | - S Truelove
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - E Utazi
- WorldPop, Department of Geography and Environmental Science, University of Southampton, Highfield, Southampton SO17 1BJ, UK
| | - A Wesolowski
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - A K Winter
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Ozawa S, Yemeke TT, Evans DR, Pallas SE, Wallace AS, Lee BY. Defining hard-to-reach populations for vaccination. Vaccine 2019; 37:5525-5534. [PMID: 31400910 PMCID: PMC10414189 DOI: 10.1016/j.vaccine.2019.06.081] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/29/2022]
Abstract
Extending the benefits of vaccination to everyone who is eligible requires an understanding of which populations current vaccination efforts have struggled to reach. A clear definition of "hard-to-reach" populations - also known as high-risk or marginalized populations, or reaching the last mile - is essential for estimating the size of target groups, sharing lessons learned based on consistent definitions, and allocating resources appropriately. A literature review was conducted to determine what formal definitions of hard-to-reach populations exist and how they are being used, and to propose definitions to consider for future use. Overall, we found that (1) there is a need to distinguish populations that are hard to reach versus hard to vaccinate, and (2) the existing literature poorly defined these populations and clear criteria or thresholds for classifying them were missing. Based on this review, we propose that hard-to-reach populations be defined as those facing supply-side barriers to vaccination due to geography by distance or terrain, transient or nomadic movement, healthcare provider discrimination, lack of healthcare provider recommendations, inadequate vaccination systems, war and conflict, home births or other home-bound mobility limitations, or legal restrictions. Although multiple mechanisms may apply to the same population, supply-side barriers should be distinguished from demand-side barriers. Hard-to-vaccinate populations are defined as those who are reachable but difficult to vaccinate due to distrust, religious beliefs, lack of awareness of vaccine benefits and recommendations, poverty or low socioeconomic status, lack of time to access available vaccination services, or gender-based discrimination. Further work is needed to better define hard-to-reach populations and delineate them from populations that may be hard to vaccinate due to complex refusal reasons, improve measurement of the size and importance of their impact, and examine interventions related to overcoming barriers for each mechanism. This will enable policy makers, governments, donors, and the vaccine community to better plan interventions and allocate necessary resources to remove existing barriers to vaccination.
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Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA; Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Tatenda T Yemeke
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | | | - Sarah E Pallas
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Aaron S Wallace
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Bruce Y Lee
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, MD, USA
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