The role of cost-effectiveness in U.S. vaccination policy

COVID-19 vaccines and blood glucose control: Friend or foe?

PURPOSE

To overview the recent literature regarding the relationship between COVID-19 vaccines and glycemic control.

METHODS

Data were extracted from text and tables of all available articles published up to September 2023 in PubMed Database describing glucose homeostasis data in subjects exposed to COVID-19 vaccines, focusing on patients with diabetes mellitus (DM).

RESULTS

It is debated if the immune system impairment observed in diabetic patients makes them susceptible to lower efficacy of vaccines, but evidence suggests a possible improvement in immune response in those with good glycemic control. Despite their proven protective role lowering infection rates and disease severity, COVID-19 vaccines can result in diabetic ketoacidosis, new-onset diabetes, or episodes of hyper- or hypoglycemia.

CONCLUSIONS

Evidence with COVID-19 vaccines highlights the strong relationship existing between DM and immune system function. Clinicians should strive to achieve optimal glucose control before vaccination and promptly manage possible glucose homeostasis derangement following vaccine exposure.

Extension of efficacy range for targeted malaria-elimination interventions due to spillover effects

Malaria-elimination interventions aim to extinguish hotspots and prevent transmission to nearby areas. Here, we re-analyzed a cluster-randomized trial of reactive, focal interventions (chemoprevention using artemether-lumefantrine and/or indoor residual spraying with pirimiphos-methyl) delivered within 500 m of confirmed malaria index cases in Namibia to measure direct effects (among intervention recipients within 500 m) and spillover effects (among non-intervention recipients within 3 km) on incidence, prevalence and seroprevalence. There was no or weak evidence of direct effects, but the sample size of intervention recipients was small, limiting statistical power. There was the strongest evidence of spillover effects of combined chemoprevention and indoor residual spraying. Among non-recipients within 1 km of index cases, the combined intervention reduced malaria incidence by 43% (95% confidence interval, 20-59%). In analyses among non-recipients within 3 km of interventions, the combined intervention reduced infection prevalence by 79% (6-95%) and seroprevalence, which captures recent infections and has higher statistical power, by 34% (20-45%). Accounting for spillover effects increased the cost-effectiveness of the combined intervention by 42%. Targeting hotspots with combined chemoprevention and vector-control interventions can indirectly benefit non-recipients up to 3 km away.

Monophosphoryl Lipid A-based Adjuvant to Promote the Immunogenicity of Multivalent Meningococcal Polysaccharide Conjugate Vaccines

Activation of the adaptive immune system requires the engagement of costimulatory pathways in addition to B and T cell Ag receptor signaling, and adjuvants play a central role in this process. Many Gram-negative bacterial polysaccharide vaccines, including the tetravalent meningococcal conjugate vaccines (MCV4) and typhoid Vi polysaccharide vaccines, do not incorporate adjuvants. The immunogenicity of typhoid vaccines is due to the presence of associated TLR4 ligands in these vaccines. Because the immunogenicity of MCV4 is poor and requires boosters, I hypothesized that TLR4 ligands are absent in MCV4 and that incorporation of a TLR4 ligand-based adjuvant would improve their immunogenicity. Consistent with this hypothesis, two Food and Drug Administration-approved MCV4 vaccines, MENVEO and MenQuadfi, lack TLR4 ligands. Admixing monophosphoryl lipid A, a TLR4 ligand-based adjuvant formulation named "Turbo" with MCV4 induced significantly improved IgM and IgG responses to all four meningococcal serogroup polysaccharides in adult and aged mice after a single immunization. Furthermore, in infant mice, a single booster was sufficient to promote a robust IgG response and 100% seroconversion when MCV4 was adjuvanted with Turbo. Turbo upregulated the expression of the costimulatory molecules CD40 and CD86 on B cells, and Turbo-driven adjuvanticity is lost in mice deficient in CD40 and CD86. These data suggest that Turbo induces the required costimulatory molecules for its adjuvant activity and that incorporation of Turbo could make bacterial polysaccharide vaccines more immunogenic, minimize booster requirements, and be cost-effective, particularly for those individuals in low- and middle-income and disease-endemic countries.

Cost of Medically Attended RSV Among Medicaid Beneficiaries ≤2 Years of Age by Underlying Risk Condition

We evaluated costs for respiratory syncytial virus (RSV) medical attention in children aged <24 months using MarketScan® Medicaid Multi-State claims database 2015-2019. Average cost was highest for RSV hospitalization with intensive care unit (ICU) admission ($23 514-24 835), followed by no ICU admission ($8039-8990), ED visits ($463-482), and outpatient visits ($145-151). Cost was higher for those with comorbidities.

Targeted malaria elimination interventions reduce Plasmodium falciparum infections up to 3 kilometers away

Malaria elimination interventions in low-transmission settings aim to extinguish hot spots and prevent transmission to nearby areas. In malaria elimination settings, the World Health Organization recommends reactive, focal interventions targeted to the area near malaria cases shortly after they are detected. A key question is whether these interventions reduce transmission to nearby uninfected or asymptomatic individuals who did not receive interventions. Here, we measured direct effects (among intervention recipients) and spillover effects (among non-recipients) of reactive, focal interventions delivered within 500m of confirmed malaria index cases in a cluster-randomized trial in Namibia. The trial delivered malaria chemoprevention (artemether lumefantrine) and vector control (indoor residual spraying with Actellic) separately and in combination using a factorial design. We compared incidence, infection prevalence, and seroprevalence between study arms among intervention recipients (direct effects) and non-recipients (spillover effects) up to 3 km away from index cases. We calculated incremental cost-effectiveness ratios accounting for spillover effects. The combined chemoprevention and vector control intervention produced direct effects and spillover effects. In the primary analysis among non-recipients within 1 km from index cases, the combined intervention reduced malaria incidence by 43% (95% CI 20%, 59%). In secondary analyses among non-recipients 500m-3 km from interventions, the combined intervention reduced infection by 79% (6%, 95%) and seroprevalence 34% (20%, 45%). Accounting for spillover effects increased the cost-effectiveness of the combined intervention by 37%. Our findings provide the first evidence that targeting hot spots with combined chemoprevention and vector control interventions can indirectly benefit non-recipients up to 3 km away.

Community pharmacists' knowledge, prospective and practice towards health related illness at Hajj and Umrah: A cross sectional study

Objectives

To assess the community pharmacists' (CPs) knowledge, attitude, and perception of health-related illness among pilgrims, and to investigate the common diseases and the pattern of medications dispensed by CPs during Hajj and Umrah seasons.

Method

A cross-sectional study was carried out in Riyadh, Saudi Arabia over two months in 2022, through electronic platform using prevalidated questionnaires adopted from the literature. The questionnaires were divided into 4 sections assessing the CP's knowledge, attitude, and perception about health-related illness, common dispensed agents, and required vaccination during Hajj and Umrah.

Results

A total of 544 CPs, mostly between the age of 31-40 (69.9%), participated in this research. About 87.9% of the CPs received a pilgrim after performing their rituals coming to the pharmacy complaining of infection or health problem. In this study, 99.8%(n = 544), 99.6%(n = 543), and 92.7% (n = 505) of the CPs identified influenza, food poisoning, and diarrhea/gastroenteritis as the most common issues during the Hajj & Umrah season respectively. As results, anti-diarrheal agents (96.3%), painkillers (87.3%), inhalers (89.4%), and sunscreens (88.3%) were the most requested pharmaceutical agents. Additionally, 96.7%(n = 527) of the CPs agreed that vaccination is safe to be given to Hajj and Umrah pilgrims particularly for those aged ≥ 65 years, and 89.4%(n = 487) of them reported awareness of vaccines that are required by Saudi Ministry of Health. Both Influenza and meningococcal meningitis vaccines were identified by 99.8% of the CPs, but polio vaccine was identified by 33.9%.

Conclusion

Community pharmacists provided pharmaceutical care services for Hajj and Umrah pilgrims. The majority of CPs had adequate knowledge about viral diseases during Hajj and Umrah and their requirement for vaccination.

Efficacy and Safety of Quadrivalent Conjugate Meningococcal Vaccines: A Systematic Review and Meta-Analysis

Over the last decades, different quadrivalent antimeningococcal vaccine formulations (diphteria toxoid conjugate, MenACWY-D; tetanus toxoid conjugate, MenACWY-TT; CRM₁₉₇ protein conjugate, MenACWY-CRM) have been developed. However, their availability varies, both in terms of authorized formulations and of inclusion in vaccination schedules. Furthermore, several countries include only the monovalent meningococcal C (MenC) vaccine in their immunization programmes. Finally, there is currently no updated systematic review that directly compares the MenACWY formulations. Thus, we summarized the evidence on efficacy and safety through four parallel, independent systematic literature reviews with meta-analysis which included randomized controlled trials comparing the abovementioned vaccines. A total of 16 studies have been included. In terms of efficacy, MenACWY-TT outperformed MenACWY-D and MenACWY-CRM for A, W-135, and Y serogroups, while no significant difference was found for serogroup C. Furthermore, we did not find significant differences in efficacy between MenC and MenACWY-TT. Regarding the safety, we were able to perform a quantitative analysis only between MenACWY-TT and MenC, finding no significant differences. Similarly, among the different MenACWY formulations no relevant differences were identified. These findings suggest that MenACWY-TT could be preferable to other formulations to improve current vaccination programs and to better develop future immunization policies.

Effects of baloxavir and oseltamivir antiviral therapy on the transmission of seasonal influenza in China: A mathematical modeling analysis

New antiviral influenza treatments can effectively alleviate illness while reducing viral shedding. However, how such effects can translate into lower population infections of seasonal influenza in China remains unknown. To shed light on the public health impacts of novel antiviral agents for influenza, we constructed a dynamic transmission model to simulate the seasonal influenza epidemics in China. Two antivirus treatments, baloxavir and oseltamivir, were evaluated by estimating their impacts on the incidences of influenza infection in a single flu season. In the base-case analysis of a 10% antiviral treatment uptake rate, 2760 and 3420 per 10 000 persons contracted influenza under the treatment of baloxavir and oseltamivir, respectively. These incidence rates amounted to an 18.90% relative risk reduction (RRR) of infection associated with baloxavir in relation to oseltamivir. The corresponding RRR was 82.16% when the antiviral treatment uptake rate was increased to 35%. In addition, the peak of the prevalence of infected individuals per 10 000 persons under the baloxavir treatment was 177 (range: 93-274) fewer than that of oseltamivir. Our analyses suggest that the baloxavir treatment strategy reduces the incidence of influenza in China compared with oseltamivir in the setting of a seasonal flu epidemic. Also, increasing the uptake rate of antiviral treatment can potentially prevent millions of infections during a single flu season.

Parental decision and intent towards COVID-19 vaccination in children with asthma: an econometric analysis

Objective

Vaccination will be instrumental in controlling the COVID-19 pandemic, and vaccination of children will be necessary to achieve herd immunity. Given that children with chronic health conditions may be at increased risk of COVID-19, it is crucial to understand factors influencing parental decisions about whether to have their child vaccinated. The study objectives were to measure parental intent to have their child with asthma vaccinated against COVID-19 and identify the determinants of their vaccination decision.

Study design

This study is based on a cross-sectional exploratory observational online survey assessing parents' risk perception in the context of COVID-19.

Methods

In this study conducted in August 2020, the primary outcome was parent’s answer to the question on their intention to get their child vaccinated if a vaccine against COVID-19 was available. Participants were also asked about their intention to get vaccinated themselves. Independent variables studied included sociodemographic, clinical data (e.g. presence of other chronic diseases), psychological, cognitive and risk perception related to COVID-19. Simultaneous equations models (3SLS) and seemingly unrelated regressions model (SUR) were carried out to identify factors associated with intention to have the child vaccinated and participants’ intention to get vaccinated themselves against COVID-19.

Results

A total of 305 participants completed the survey. Overall, 19.1% of participants reported being unlikely or very unlikely to vaccinate their child against COVID-19 if a vaccine was available. Similarly, 21.0% were unlikely or very unlikely to get vaccinated themselves. The following factors were significantly associated with parents’ decision to have their child vaccinated: parental level of education (p = 0.003), employment status (p < 0.001), sex of the child (p = 0.019), presence of other chronic diseases (p = 0.028), whether or not the child had been vaccinated against influenza in the past (p < 0.001), parental anxiety (p = 0.046), and consultation with a health professional since the beginning of the pandemic (p = 0.009). There was a strong relationship between likelihood of not intending to have one’s child vaccinated and personal intent not to get vaccinated.

Conclusion

These findings are essential in planning for the communication and dissemination of COVID-19 vaccination information to parents, especially for children with asthma or other chronic medical conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13933-z.

Estimation of the cost-effective threshold of a quality-adjusted life year in China based on the value of statistical life

Cost-effective threshold (CET) is essential for health technology assessment and decision-making based on health economic evaluations. Recently, it has been argued that the commonly used once and three times of gross domestic product (GDP) per capita CETs of a quality-adjusted life year (QALY) are not necessarily empirically supported in all countries. Therefore, we aimed to estimate the CET of a QALY as times of GDP per capita in China, of which the reimbursement coverage decisions are increasingly engaging economic evaluations. Estimates on the value of statistical life (VSL) in China were identified from several studies in the literature and converted to times of GDP per capita, the weighted average of which was used for subsequent calculation. By pooling data on population mortality, health utility, and age distribution, we estimated the value of a statistical QALY (VSQ) from VSL using an established mathematical process, which represented the theoretical upper bound of CET. The corresponding point estimate and theoretical lower bound were obtained using their numerical relationships with the upper bound. Scenarios analyses were also conducted. The estimated CET, its upper bound, and its lower bound were 1.45, 2.90, and 1.16 times of GDP per capita in China, respectively. In different scenarios, the estimated CET varied but was greater than once GDP per capita in most cases. As such, the CET of a QALY in China is close to 1.5 times of GDP per capita, which should be benchmarked for future ICER-based coverage decisions.

COVID-19 Vaccines Cost-Effectiveness Analysis: A Scenario for Iran

COVID-19 vaccines are supposed to be critical measure for ending the pandemic. Governments had to decide on the type of vaccine to provide for their population. In this decision-making process, cost-effectiveness analysis is considered a helpful tool. This study is a cost-effectiveness analysis utilized to calculate the incremental cost per averted disability-adjusted life year (DALY) by vaccination compared to no vaccination for different COVID-19 vaccines. The incremental cost-effectiveness ratio (ICER) for a vaccination with COVID-19 vaccines was estimated at 6.2 to 121.2 USD to avert one DALY and 566.8 to 10,957.7 USD per one death. The lowest and highest ICERs belong to Ad26.COV2.S and CoronaVac, respectively. Considering the scenario of Iran, vaccines that are recommended include ad26.cov2.s, chadox1-S, rAd26-S + rAd5-S, and BNT162b2 in the order of recommendation.

Comparative cost-effectiveness of a 2-dose versus 3-dose vaccine for hepatitis B prevention in selected adult populations

The hepatitis B virus is highly infectious and can cause incurable liver disease, leading to high morbidity rates, increased healthcare utilization, and high mortality. Multiple preventative hepatitis B vaccine options have been available for decades, but adherence to the traditional 6-month vaccine schedule for the approved 3-dose series remains low in adult populations at risk of hepatitis B exposure. A 2-dose hepatitis B vaccine (HEPLISAV-B) approved by the US Food and Drug Administration in 2017 induces rapid seroprotection within 1 month and has a safety profile comparable to a commonly used 3-dose vaccine. In a previous cost-effectiveness study, HEPLISAV-B had a favorable cost-effectiveness profile for multiple at-risk populations. The goal of the current analysis was to update and extend previous findings by evaluating cost-effectiveness of HEPLISAV-B compared with a 3-dose vaccine (Engerix-B) in selected adult populations, including patients with diabetes, chronic liver or kidney disease, end-stage renal disease, healthcare personnel, travelers to countries with endemic hepatitis B, and a public health population. Cost-effectiveness was measured as incremental cost-effectiveness ratios using a health economics Markov model that accounts for adherence rates, seroprotection rates, healthcare costs, and current pricing considerations. Patients progressed between a series of health states, and the difference in lifetime spending and survival for individuals receiving either HEPLISAV-B or Engerix-B was estimated from the perspective of a US managed care payer, HEPLISAV-B had favorable cost-effectiveness profiles for patients with diabetes, healthcare personnel, travelers, and patients with chronic liver disease and dominant incremental cost-effectiveness ratios for patients with chronic kidney disease and end-stage renal disease. A probabilistic sensitivity analysis supported the robustness of the cost-effectiveness profiles, and an additional analysis indicated that HEPLISAV-B was cost-effective in the general adult population. Overall, HEPLISAV-B was cost-effective in multiple adult populations recommended for HBV vaccination in the United States.

Do penalty-based pay-for-performance programs improve surgical care more effectively than other payment strategies? A systematic review

Background

The aim of this systematic review is to assess if penalty-based pay-for-performance (P4P) programs are more effective in improving quality and cost outcomes compared to two other payment strategies (i.e., rewards and a combination of rewards and penalties) for surgical care in the United States. Penalty-based programs have gained in popularity because of their potential to motivate behavioral change more effectively than reward-based programs to improve quality of care. However, little is known about whether penalties are more effective than other strategies.

Materials and methods

A systematic literature review was conducted according to the PRISMA guideline to identify studies that evaluated the effects of P4P programs on quality and cost outcomes for surgical care. Five databases were used to search studies published from 2003 to March 1, 2020. Studies were selected based on the PRISMA guidelines. Methodological quality of individual studies was assessed based on ROBINS-I with GRADE approach.

Results

This review included 22 studies. Fifteen cross-sectional, 1 prospective cohort, 4 retrospective cohort, and 2 case-control studies were found. We identified 11 unique P4P programs: 5 used rewards, 3 used penalties, and 3 used a combination of rewards and penalties as a payment strategy. Five out of 10 studies reported positive effects of penalty-based programs, whereas evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null.

Conclusions

This review highlights that P4P programs with a penalty design could be more effective than programs using rewards or a combination of rewards and penalties to improve quality of surgical care.

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Evidence on the effectiveness of pay-for-performance programs in quality improvement is mixed.

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Five out of 10 studies reported positive effects of penalty-based programs.

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Evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null.

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The increasing use of penalty-based pay-for-performance programs has the potential to improve surgical care quality.

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Penalties may induce stronger provider and hospital behavioral change than other payment strategies.

Pediatric Vaccines and Cost-Effectiveness Thresholds: How Much is Too Much to Pay for Prevention?

Cost-effectiveness evaluations play an important role in recommendations for use of pediatric vaccines that are set forth by the US Advisory Committee on Immunization Practices (ACIP). The fact that these evaluations are undertaken and accorded weight suggests that a critical value for designating pediatric vaccines as cost-effective (or not) must exist. For recommended pediatric vaccines, however, reported incremental cost-effectiveness ratios (ICERs) have varied greatly, and there does not appear to be an explicit threshold used by the ACIP to define how much is too much to pay for the prevention of communicable diseases in children. Further complicating this issue is the fact that conventional ICER thresholds—expressed in terms of cost per quality-adjusted life-year (QALY) gained—accord value only to length and quality of life and may not reflect our preferences as individuals or a society. For example, risk, an important attribute of many healthcare decisions, is ignored by the QALY model, as is the distribution of health benefits across different members of society. Are we indeed indifferent about risk and do we really believe that the value of disease prevention in children should be measured by the same “yardstick” as that for older adults? Accordingly, do we really believe that “a QALY is a QALY”? These issues, which are reviewed and discussed in this article, are more than just of theoretical interest; the answers impact how public health policy is determined, which impacts the lives and well-being of entire populations as well as the budgets of payers.

Pneumococcal Vaccination for Children in Asian Countries: A Systematic Review of Economic Evaluation Studies

Background: Evidence on costs and health benefits of pneumococcal conjugate vaccine (PCV) for children in Asian countries is limited but growing. As a region with a considerably high burden of pneumococcal disease, it is prominent to have a comprehensive overview on the cost-effectiveness of implementing and adopting a PCV vaccination program. Methods: We conducted a systematic review from Pubmed and Embase to identify economic evaluation studies of PCV for children in Asian countries up to May 2020. Data extraction included specific characteristics of the study, input parameters, cost elements, cost-effectiveness results, and key drivers of uncertainty. The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement was followed for this systematic review. The reporting quality of the included studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Results: After the screening process on both the title and abstract and full text of 518 records, a total of 25 studies fulfilled the inclusion criteria, and were included in the review. The majority of included studies demonstrates that PCV for children is cost-effective in most of the Asian region, and even cost-saving in some countries. Most of the included studies implemented cost utility analysis (CUA) using either quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs). Overall, the main drivers affecting the cost effectiveness were vaccine price, burden regarding pneumonia-related parameters, and the inclusion of herd effects. Conclusion: The children pneumococcal vaccination program appears to be a cost-effective intervention in Asia, and even cost-saving in certain conditions. Vaccine price, pneumonia-related disease burden, and the inclusion of the herd effect are observed as important key drivers in estimating cost-effectiveness in this region. Incorporating PCV in vaccination programs in this region was found to be highly favorable.

[Recommendations in Male HPV from the Portuguese Society of Andrology, Sexual Medicine and Reproduction: Prevention]

The prevention of HPV-related diseases is an important healthcare issue due to its increasing incidence. Primary prevention is most important in males as it avoids initial infection and includes the use of condom, circumcision and vaccination. Primary prevention with vaccination is effective in decreasing HPV-related lesions in women up to 45 years old and the existing data for men comes from the experience from vaccinating women. Although it is the only vaccine that prevents cancer, the worldwide rates of vaccination in males is very low due to lack of information related to efficacy and side effects, lack of recommendation from the treating doctor, price and concern about encouragement of sexual promiscuity.

A conceptual value-based incentivization model of adult immunization for community pharmacists

OBJECTIVE

To design a value-based payment model to incentivize pharmacists for increased administration of influenza, herpes zoster, pertussis-containing, and pneumococcal vaccines to adults at community pharmacies.

DESIGN

A modified delphi technique was used to create a concept for a value-based payment model through consensus of expert opinion.

SETTING

and participants: Experts were recruited from a regional supermarket pharmacy, a self-insured employer, a managed care organization, and an academic institution to participate in 4 electronic surveys and 1 in-person meeting.

OUTCOME MEASURES

Consensus on model design by means of a modified delphi technique.

RESULTS

A panel of 11 experts participated in a series of electronic surveys and 1 in-person meeting. The final value-based payment model addressed how and when pharmacists would receive an incentive for meeting specific vaccination goals. The final value-based payment model also addressed the following concepts: estimated cost avoidance, vaccine effectiveness, and community protection. A 3-tiered incentive model was agreed on by the participants to tie increased vaccination rates with increased payment. Vaccination goals for each tier were defined as the percent increase in vaccination rates from the year immediately preceding. Incentives were defined as a percentage of estimated direct medical costs avoided to be shared between the payer and pharmacy.

CONCLUSION

A conceptual value-based payment model to incentivize pharmacists for increased delivery of adult vaccinations at community pharmacies was designed and agreed on by experts representing a regional supermarket pharmacy, a self-insured employer, a managed care organization, and an academic institution. Consensus was achieved by aligning the interests of both payers and pharmacies. The final model included 3 tiers of bundled incentives to reward percent increases in adult vaccination from historical baselines. This model may be used as an example for community pharmacies and health care payers to design future value-based immunization programs.

Incorporation of health economic evaluation into immunization policy-making in Canada: Barriers and facilitators

INTRODUCTION

Despite the WHO recommendation that economic evidence be considered in national vaccine recommendations, this element of decision-making has been lacking or not done routinely in Canada. This study aimed to investigate barriers and facilitators to using economic evaluations in public health immunization programs decision-making across Canadian jurisdictions.

METHODS

This mixed methods study consisted of a cross-sectional survey and semi-structured interviews of national, provincial and territorial public health level key informants, and of members of the national immunization research network in Canada. Barriers were categorized according to accessibility (e.g. access to human resources to conduct the evaluation) and acceptability (e.g. political resistance to using the evaluation).

RESULTS

Of 63 survey participants, 12 were federal, provincial or territorial key informants (response rate 12/31, 39%) and 51 were members from the research network (response rate 51/214, 24%). Eleven stakeholders gave semi-structured interviews. All respondents support increased use of economic evaluation and of it becoming a routine part of immunization policy-making. However, 70% of the survey respondents identified limited resources (human and financial) to perform economic evaluations, and 39% reported lack of expertise to interpret economic evidence. Vaccine effectiveness and the burden of disease were seen as more important than cost-effectiveness by survey respondents and interviewees. Potential facilitators were for economic evaluations to either be conducted at the national level, or through a collaboration between provinces and territories with capacity to address shared needs so that evaluations occurred in a co-ordinated but distributed way.

RECOMMENDATIONS

Barriers to incorporation of economic evaluation in immunization policy-making in Canada include lacking human and financial resources to conduct them and understanding of economic evidence. National, provincial and territorial public health actors reported that facilitators to incorporating economic evidence include developing increased capacity to conduct and use economic evaluations and establishing inter-jurisdictional systems to share the work of conducting economic evaluation and/or by national leadership.

Natural history of human papillomavirus and vaccinations in men: A literature review

BACKGROUND AND AIMS

Infection with high-risk (HR) genotypes of the human papillomavirus (HPV) is necessary for and causative of almost all cervical cancers and their precursor condition, cervical intraepithelial neoplasia. These conditions have been sharply reduced by cervical cytology screening, and a further decrease is expected because of the recent introduction of prophylactic HPV vaccinations. While significant attention has been given to gynecologic HPV disease, men can be affected by HPV-related cancers of the anus, penis, and oropharynx. This literature review aims to address disparities in HPV-related disease in men, and certain HR male subpopulations, compared with women.

DISCUSSION

Overall, immunocompetent men are far less likely than women to develop anogenital HPV-related cancers, despite harboring HR HPV infections at anogenital sites. On the other hand, men who have sex with men and men living with human immunodeficiency virus infection are at considerably higher risk of HPV-related disease. Historic rates of prophylactic HPV vaccination in males have trailed those of females due to numerous multilevel factors, although, in recent years, this sex gap in vaccination coverage has been closing. In the absence of routine HPV screening in males, therapeutic vaccinations have emerged as a potential treatment modality for preinvasive neoplasia and are in various phases of clinical testing.

CONCLUSION

Successful reductions in HPV disease morbidity at the population level must acknowledge and target HPV infections in men.

Understanding FDA-Approved Labeling and CDC Recommendations for Use of Vaccines

Adherence to recommendations for the use of licensed vaccines ensures maximum individual and societal benefits from the national immunization program. The US Food and Drug Administration (FDA) licenses a vaccine once it determines that data submitted by the manufacturer reveal that the vaccine is safe and effective for its intended use. For each US-licensed vaccine, the FDA-approved prescribing information contains detailed information for health care providers to ensure safe and effective use. Centers for Disease Control and Prevention recommendations for the use of a licensed vaccine often are based on additional considerations, such as disease epidemiology, public acceptance, vaccine supply, and cost. Our objective in this article is to explain the reasons for the differences between FDA-approved prescribing information and Centers for Disease Control and Prevention recommendations for vaccine use.

Maurice Hilleman: Creator of Vaccines That Changed the World

Maurice Ralph Hilleman (1919–2005) was one of the greatest microbiologists/vaccinologists of all time. He played a key role in developing vaccines for Asian flu in 1957 and Hong Kong flu in 1968. Over six decades, most of which were spent at Merck & Company, his leadership and innovations blazed new trails in virology, epidemiology, immunology, cancer research, and vaccine development that were unmatched. His work resulted in current vaccines used for the prevention of measles, mumps, hepatitis A and B, chickenpox, meningitis, and pneumonia, which have saved millions of lives across the globe. The need for close cooperation between public and private agencies, including donors, to promote research in vaccinology is reemphasized by recent global health crises such as the Ebola and Zika viruses, as well as the annual influenza virus threats. Eradication of many diseases is feasible, but requires political support for resources, vaccine development and harmonization of vaccination policies, to be achievable. Hilleman worked with many collaborators in academic centers, in industrial management, with which he led his research and development team to produce world-changing achievements.

Impact of vaccine herd-protection effects in cost-effectiveness analyses of childhood vaccinations. A quantitative comparative analysis

BACKGROUND

Inclusion of vaccine herd-protection effects in cost-effectiveness analyses (CEAs) can impact the CEAs-conclusions. However, empirical epidemiologic data on the size of herd-protection effects from original studies are limited.

METHODS

We performed a quantitative comparative analysis of the impact of herd-protection effects in CEAs for four childhood vaccinations (pneumococcal, meningococcal, rotavirus and influenza). We considered CEAs reporting incremental-cost-effectiveness-ratios (ICERs) (per quality-adjusted-life-years [QALY] gained; per life-years [LY] gained or per disability-adjusted-life-years [DALY] avoided), both with and without herd protection, while keeping all other model parameters stable. We calculated the size of the ICER-differences without vs with-herd-protection and estimated how often inclusion of herd-protection led to crossing of the cost-effectiveness threshold (of an assumed societal-willingness-to-pay) of $50,000 for more-developed countries or X3GDP/capita (WHO-threshold) for less-developed countries.

RESULTS

We identified 35 CEA studies (20 pneumococcal, 4 meningococcal, 8 rotavirus and 3 influenza vaccines) with 99 ICER-analyses (55 per-QALY, 27 per-LY and 17 per-DALY). The median ICER-absolute differences per QALY, LY and DALY (without minus with herd-protection) were $15,620 (IQR: $877 to $48,376); $54,871 (IQR: $787 to $115,026) and $49 (IQR: $15 to $1,636) respectively. When the target-vaccination strategy was not cost-saving without herd-protection, inclusion of herd-protection always resulted in more favorable results. In CEAs that had ICERs above the cost-effectiveness threshold without herd-protection, inclusion of herd-protection led to crossing of that threshold in 45% of the cases. This impacted only CEAs for more developed countries, as all but one CEAs for less developed countries had ICERs below the WHO-cost-effectiveness threshold even without herd-protection. In several analyses, recommendation for the adoption of the target vaccination strategy depended on the inclusion of the herd protection effect.

CONCLUSIONS

Inclusion of herd-protection effects in CEAs had a substantial impact in the estimated ICERs and made target-vaccination strategies more attractive options in almost half of the cases where ICERs were above the societal-willingness to pay threshold without herd-protection. More empirical epidemiologic data are needed to determine the size of herd-protection effects across diverse settings and also the size of negative vaccine effects, e.g. from serotype substitution.

Economic evaluation of vaccines in Canada: A systematic review

BACKGROUND

Economic evaluations should form part of the basis for public health decision making on new vaccine programs. While Canada's national immunization advisory committee does not systematically include economic evaluations in immunization decision making, there is increasing interest in adopting them. We therefore sought to examine the extent and quality of economic evaluations of vaccines in Canada.

OBJECTIVE

We conducted a systematic review of economic evaluations of vaccines in Canada to determine and summarize: comprehensiveness across jurisdictions, studied vaccines, funding sources, study designs, research quality, and changes over time.

METHODS

Searches in multiple databases were conducted using the terms "vaccine," "economics" and "Canada." Descriptive data from eligible manuscripts was abstracted and three authors independently evaluated manuscript quality using a 7-point Likert-type scale scoring tool based on criteria from the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

RESULTS

42/175 articles met the search criteria. Of these, Canada-wide studies were most common (25/42), while provincial studies largely focused on the three populous provinces of Ontario, Quebec and British Columbia. The most common funding source was industry (17/42), followed by government (7/42). 38 studies used mathematical models estimating expected economic benefit while 4 studies examined post-hoc data on established programs. Studies covered 10 diseases, with 28/42 addressing pediatric vaccines. Many studies considered cost-utility (22/42) and the majority of these studies reported favorable economic results (16/22). The mean quality score was 5.9/7 and was consistent over publication date, funding sources, and disease areas.

CONCLUSIONS

We observed diverse approaches to evaluate vaccine economics in Canada. Given the increased complexity of economic studies evaluating vaccines and the impact of results on public health practice, Canada needs improved, transparent and consistent processes to review and assess the findings of the economic evaluations of vaccines.

Global incidence of serogroup B invasive meningococcal disease: a systematic review

Use of recently licensed vaccines against Neisseria meningitidis serogroup B (NmB) will depend partly on disease burden estimates. We systematically reviewed NmB incidence and mortality worldwide between January, 2000, and March, 2015, incorporating data from 37 articles and 12 websites. Most countries had a yearly invasive NmB incidence of less than 2 per 100,000 people. Within these relatively low incidence rates (compared with common causes of invasive bacterial diseases), substantial variation was detected between countries, with a notably higher incidence in Australia, Europe, North America, and South America. China and India had reports only of sporadic cases, and except for South Africa, sub-Saharan Africa showed a near absence of disease. In countries with consistently collected data, NmB incidence has tended to decrease, even as the proportion of invasive meningococcal disease cases caused by serogroup B has increased. With few exceptions, case-fatality ratios were fairly consistent, ranging between 3% and 10%. In high-income countries, incidence rates of NmB were relatively low compared with other vaccine-preventable diseases and might be decreasing. High case-fatality ratios, substantial disease-related morbidity, and the threat of outbreaks could nevertheless make NmB an attractive target for preventive and reactive immunisation programmes. The low availability of data from low-income and middle-income countries suggests the need for improved surveillance before vaccination strategies are designed.

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

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

Making the case for the development of a vaccination against hepatitis E virus

Hepatitis E virus (HEV) infection is a global problem that affects 20 million individuals, and cause acute hepatitis in 3.5 million, with approximately 70,000 deaths worldwide per year. While the acute disease is generally self-limited, however, it may progress to fatal fulminant liver failure in certain individuals. Contaminated water supplies disseminate this virus through the faecal-oral route, and swine is thought to be its zoonotic reservoir. Attempts have been made to develop effective HEV vaccines, and two candidates have undergone successful clinical trials. In this review, we discuss HEV epidemiology, genotypes, microbiological structure, as well as the most recent advances in vaccination developments.

Analytics for vaccine economics and pricing: insights and observations

Pediatric immunization programs in the USA are a successful and cost-effective public health endeavor, profoundly reducing mortalities caused by infectious diseases. Two important issues relate to the success of the immunization programs, the selection of cost-effective vaccines and the appropriate pricing of vaccines. The recommended childhood immunization schedule, published annually by the CDC, continues to expand with respect to the number of injections required and the number of vaccines available for selection. The advent of new vaccines to meet the growing requirements of the schedule results: in a large, combinatorial number of possible vaccine formularies. The expansion of the schedule and the increase in the number of available vaccines constitutes a challenge for state health departments, large city immunization programs, private practices and other vaccine purchasers, as a cost-effective vaccine formulary must be selected from an increasingly large set of possible vaccine combinations to satisfy the schedule. The pediatric vaccine industry consists of a relatively small number of pharmaceutical firms engaged in the research, development, manufacture and distribution of pediatric vaccines. The number of vaccine manufacturers has dramatically decreased in the past few decades for a myriad of reasons, most notably due to low profitability. The contraction of the industry negatively impacts the reliable provision of pediatric vaccines. The determination of appropriate vaccine prices is an important issue and influences a vaccine manufacturer's decision to remain in the market. Operations research is a discipline that applies advanced analytical methods to improve decision making; analytics is the application of operations research to a particular problem using pertinent data to provide a practical result. Analytics provides a mechanism to resolve the challenges facing stakeholders in the vaccine development and delivery system, in particular, the selection of cost-effective vaccines and the appropriate pricing of vaccines. A review of applicable analytics papers is provided.

The use of expensive technologies instead of simple, sound and effective lifestyle interventions: a perpetual delusion

A dangerous distortion of priorities seems to be currently apparent in the dominant approaches to major public health problems, including cardiovascular disease, diabetes, obesity, cancer and some infectious diseases. Relevant examples suggest an apparently inappropriate tendency to prioritise technocratic, partial solutions rather than confronting their true behavioural and structural determinants. Technically oriented preventive medicine often takes excessive precedence over simpler, more sensible approaches to modify lifestyles, the environment and the social structure. Structural factors (social, cultural, financial, familiar, educational, political or ideological factors) that act as determinants of individual behaviours should be effectively addressed to confront the essential causes of the most prevalent and important health problems. Some consumer-directed commercial forces seem to be increasingly driving many aspects of the current sociocultural environment, and may eventually compromise the main pursuits of public health. Population-wide strategies are needed to create a healthy sociocultural environment and to empower individuals and make themselves resistant to these adverse environmental and structural pressures. Otherwise most public health interventions will most likely end in failures.

Human papillomavirus and cervical cancer

Cervical cancer is caused by human papillomavirus infection. Most human papillomavirus infection is harmless and clears spontaneously but persistent infection with high-risk human papillomavirus (especially type 16) can cause cancer of the cervix, vulva, vagina, anus, penis, and oropharynx. The virus exclusively infects epithelium and produces new viral particles only in fully mature epithelial cells. Human papillomavirus disrupts normal cell-cycle control, promoting uncontrolled cell division and the accumulation of genetic damage. Two effective prophylactic vaccines composed of human papillomavirus type 16 and 18, and human papillomavirus type 16, 18, 6, and 11 virus-like particles have been introduced in many developed countries as a primary prevention strategy. Human papillomavirus testing is clinically valuable for secondary prevention in triaging low-grade cytology and as a test of cure after treatment. More sensitive than cytology, primary screening by human papillomavirus testing could enable screening intervals to be extended. If these prevention strategies can be implemented in developing countries, many thousands of lives could be saved.

Size of clinical trials and Introductory prices of prophylactic vaccine series

Costs of completing the recommended immunization schedule have increased over the last decade. Access to prophylactic vaccines may become limited due to financing obstacles within current delivery systems. Vaccine prices reflect research and development expenses incurred by vaccine manufacturers, including costs associated with evaluating candidate vaccines in human subjects. If the number of subjects in clinical trials is increasing over time and associated with vaccine price, this may help explain increases in prices of vaccine series. We examined whether: (A) the initial public- and private-sector prices for recommended prophylactic vaccine series licensed and recommended in the US increased from 2000–2011, (B) the number of human subjects per licensed vaccine increased during the time period, and (C) the number of human subjects was associated with the initial public–and private–sector prices of the vaccine series. In regression analyses of 13 vaccines, approval year was not significantly associated with the number of human subjects, initial public-sector prices, or initial private-sector prices. While the number of phase II subjects was not significantly associated with prices, the numbers of phase III and combined late phase (phases II + III) subjects were significantly associated with initial public- and private-sector series prices (p < 0.05). The association between number of subjects and initial prices demonstrated diminishing marginal increases in price with increasing numbers of subjects. These findings may help guide the number of subjects required by the FDA in clinical trials, in order to reduce expenses for manufacturers and thereby help mitigate increases in initial vaccine series prices.

Economic impact of human papillomavirus-associated head and neck cancers in the United States

Cases of human papillomavirus (HPV)-associated head and neck cancers are rapidly increasing in the United States. Little is known about the economic burden of these cancers. A literature review identified 7 studies that characterized aspects of the overall economic burden of HPV-associated head and neck cancers in the United States. Other cost studies are detailed to highlight the clinical reality in treating these patients. As the clinical awareness of the role of HPV in head and neck cancers continues, the economic impact of cancers caused by this virus will have implications for the role of various preventive measures.