Thresholds for decision-making: informing the cost-effectiveness and affordability of rotavirus vaccines in Malaysia

Health economic evaluation of 2-dose and 3-dose rotavirus vaccines in children below 5 years of age in Morocco

Following the introduction of rotavirus vaccination into the Moroccan National Immunization Program, the prevalence of the disease has decreased by nearly 50%. However, evidence on the economic value of rotavirus vaccinations in Morocco is limited. This health economic analysis evaluated, from both country payer and societal perspectives, the costs and the cost-effectiveness of three rotavirus vaccines using a static, deterministic, population model in children aged < 5 years in Morocco. Included vaccines were HRV (2-dose schedule), HBRV (3-dose schedule) and BRV-PV 1-dose vial (3-dose schedule). One-way and probabilistic sensitivity analyses were conducted to assess the impact of uncertainty in model inputs. The model predicted that vaccination with HRV was estimated to result in fewer rotavirus gastroenteritis events (-194 homecare events, -57 medical visits, -8 hospitalizations) versus the 3-dose vaccines, translating into 7 discounted quality-adjusted life years gained over the model time horizon. HRV was associated with lower costs versus HBRV from both the country payer (-$1.8 M) and societal (-$4.1 M) perspectives, and versus BRV-PV 1-dose vial from the societal perspective (-$187,000), dominating those options in the cost-effectiveness analysis. However, costs of BRV-PV 1-dose vial were lower than HRV from the payer perspective, resulting in an ICER of approximately $328,376 per QALY, above the assumed cost effectiveness threshold of $3,500. Vaccination with a 2-dose schedule of HRV may be a cost-saving option and could lead to better health outcomes for children in Morocco versus 3-dose schedule rotavirus vaccines.

A Systematic Review of the Cost-Effectiveness of Cleft Care in Low- and Middle-Income Countries: What is Needed?

OBJECTIVE

The objective of this paper is to conduct a systematic review that summarizes the cost-effectiveness of cleft lip and/or palate (CL/P) care in low- and middle-income countries (LMICs) based on existing literature.

DESIGN

We searched eleven electronic databases for articles from January 1, 2000 to December 29, 2020. This study is registered in PROSPERO (CRD42020148402). Two reviewers independently conducted primary and secondary screening, and data extraction.

SETTING

All CL/P cost-effectiveness analyses in LMIC settings.

PATIENTS, PARTICIPANTS

In total, 2883 citations were screened. Eleven articles encompassing 1,001,675 patients from 86 LMICs were included.

MAIN OUTCOME MEASURES

We used cost-effectiveness thresholds of 1% to 51% of a country's gross domestic product per capita (GDP/capita), a conservative threshold recommended for LMICs. Quality appraisal was conducted using the Joanna Briggs Institute (JBI) checklist.

RESULTS

Primary CL/P repair was cost-effective at the threshold of 51% of a country's GDP/capita across all studies. However, only 1 study met at least 70% of the JBI criteria. There is a need for context-specific cost and health outcome data for primary CL/P repair, complications, and existing multidisciplinary management in LMICs.

CONCLUSIONS

Existing economic evaluations suggest primary CL/P repair is cost-effective, however context-specific local data will make future cost-effectiveness analyses more relevant to local decision-makers and lead to better-informed resource allocation decisions in LMICs.

Does a Standard Cost-Effectiveness Threshold Exist? The Case of Greece

OBJECTIVES

This study aimed to systematically review the use of cost-effectiveness (CE) threshold for evaluating pharmacological interventions in Greece.

METHODS

A systematic search of PubMed and ScienceDirect was conducted between January 2009 and June 2022. The data of selected studies were extracted using a relevant form and consequently were synthesized. Qualitative variables were presented with relative frequencies (%) and quantitative variables with median and interquartile range (IQR).

RESULTS

From the 302 identified studies, 83 satisfied the inclusion criteria. Studies were categorized to oncology (26.5%) and a nononcology related (73.5%) based on drug treatment. The most frequently reported outcome associated with CE threshold was the "per quality-adjusted life-year gained." A total of 32.5% of the studies with a reported threshold did not specify the origin of the threshold. From the rest of studies, the vast majority (92.8%) adopted thresholds equal to 1 to 3 times the gross domestic product (GDP) per capita, whereas the rest similar to National Institute for Health and Care Excellence guidelines. The median CE threshold was differentiated between oncology (€51 000 [IQR €50 000-€60 000]) and nononcology studies (€34 000 [IQR €30 000-€36 000]; P < .001). In both type of studies, the median CE thresholds were not statistically significantly different among GDP, National Institute for Health and Care Excellence, and not specified approaches.

CONCLUSIONS

Aligned with other countries where there is no standard CE threshold to promote efficient use of healthcare resources, the most prominent practice in Greece was found to be that of 1 to 3 times the GDP per capita irrespective of type of treatment or outcome studied.

Potential health and economic impact of paediatric vaccination using next-generation influenza vaccines in Kenya: a modelling study

BACKGROUND

Influenza is a major year-round cause of respiratory illness in Kenya, particularly in children under 5. Current influenza vaccines result in short-term, strain-specific immunity and were found in a previous study not to be cost-effective in Kenya. However, next-generation vaccines are in development that may have a greater impact and cost-effectiveness profile.

METHODS

We expanded a model previously used to evaluate the cost-effectiveness of seasonal influenza vaccines in Kenya to include next-generation vaccines by allowing for enhanced vaccine characteristics and multi-annual immunity. We specifically examined vaccinating children under 5 years of age with improved vaccines, evaluating vaccines with combinations of increased vaccine effectiveness, cross-protection between strains (breadth) and duration of immunity. We evaluated cost-effectiveness using incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits (INMBs) for a range of values for the willingness-to-pay (WTP) per DALY averted. Finally, we estimated threshold per-dose vaccine prices at which vaccination becomes cost-effective.

RESULTS

Next-generation vaccines can be cost-effective, dependent on the vaccine characteristics and assumed WTP thresholds. Universal vaccines (assumed to provide long-term and broad immunity) are most cost-effective in Kenya across three of four WTP thresholds evaluated, with the lowest median value of ICER per DALY averted ($263, 95% Credible Interval (CrI): $ - 1698, $1061) and the highest median INMBs. At a WTP of $623, universal vaccines are cost-effective at or below a median price of $5.16 per dose (95% CrI: $0.94, $18.57). We also show that the assumed mechanism underlying infection-derived immunity strongly impacts vaccine outcomes.

CONCLUSIONS

This evaluation provides evidence for country-level decision makers about future next-generation vaccine introduction, as well as global research funders about the potential market for these vaccines. Next-generation vaccines may offer a cost-effective intervention to reduce influenza burden in low-income countries with year-round seasonality like Kenya.

The cost and cost-effectiveness of novel tuberculosis vaccines in low- and middle-income countries: A modeling study

BACKGROUND

Tuberculosis (TB) is preventable and curable but eliminating it has proven challenging. Safe and effective TB vaccines that can rapidly reduce disease burden are essential for achieving TB elimination. We assessed future costs, cost-savings, and cost-effectiveness of introducing novel TB vaccines in low- and middle-income countries (LMICs) for a range of product characteristics and delivery strategies.

METHODS AND FINDINGS

We developed a system of epidemiological and economic models, calibrated to demographic, epidemiological, and health service data in 105 LMICs. For each country, we assessed the likely future course of TB-related outcomes under several vaccine introduction scenarios, compared to a "no-new-vaccine" counterfactual. Vaccine scenarios considered 2 vaccine product profiles (1 targeted at infants, 1 at adolescents/adults), both assumed to prevent progression to active TB. Key economic inputs were derived from the Global Health Cost Consortium, World Health Organization (WHO) patient cost surveys, and the published literature. We estimated the incremental impact of vaccine introduction for a range of health and economic outcomes. In the base-case, we assumed a vaccine price of $4.60 and used a 1× per-capita gross domestic product (GDP) cost-effectiveness threshold (both varied in sensitivity analyses). Vaccine introduction was estimated to require substantial near-term resources, offset by future cost-savings from averted TB burden. From a health system perspective, adolescent/adult vaccination was cost-effective in 64 of 105 LMICs. From a societal perspective (including productivity gains and averted patient costs), adolescent/adult vaccination was projected to be cost-effective in 73 of 105 LMICs and cost-saving in 58 of 105 LMICs, including 96% of countries with higher TB burden. When considering the monetized value of health gains, we estimated that introduction of an adolescent/adult vaccine could produce $283 to 474 billion in economic benefits by 2050. Limited data availability required assumptions and extrapolations that may omit important country-level heterogeneity in epidemiology and costs.

CONCLUSIONS

TB vaccination would be highly impactful and cost-effective in most LMICs. Further efforts are needed for future development, adoption, and implementation of novel TB vaccines.

The Use of Cost-Effectiveness Thresholds for Evaluating Health Interventions in Low- and Middle-Income Countries From 2015 to 2020: A Review

OBJECTIVES

Evidence-informed priority setting, in particular cost-effectiveness analysis (CEA), can help target resources better to achieve universal health coverage. Central to the application of CEA is the use of a cost-effectiveness threshold. We add to the literature by looking at what thresholds have been used in published CEA and the proportion of interventions found to be cost-effective, by type of threshold.

METHODS

We identified CEA studies in low- and middle-income countries from the Global Health Cost-Effectiveness Analysis Registry that were published between January 1, 2015, and January 6, 2020. We extracted data on the country of focus, type of interventions under consideration, funder, threshold used, and recommendations.

RESULTS

A total of 230 studies with a total 713 interventions were included in this review; 1 to 3× gross domestic product (GDP) per capita was the most common type of threshold used in judging cost-effectiveness (84.3%). Approximately a third of studies (34.2%) using 1 to 3× GDP per capita applied a threshold at 3× GDP per capita. We have found that no study used locally developed thresholds. We found that 79.3% of interventions received a recommendation as "cost-effective" and that 85.9% of studies had at least 1 intervention that was considered cost-effective. The use of 1 to 3× GDP per capita led to a higher proportion of study interventions being judged as cost-effective compared with other types of thresholds.

CONCLUSIONS

Despite the wide concerns about the use of 1 to 3× GDP per capita, this threshold is still widely used in the literature. Using this threshold leads to more interventions being recommended as "cost-effective." This study further explore alternatives to the 1 to 3× GDP as a decision rule.

Inclusion of Additional Unintended Consequences in Economic Evaluation: A Systematic Review of Immunization and Tuberculosis Cost-Effectiveness Analyses

OBJECTIVE

Our objective was to review economic evaluations of immunization and tuberculosis to determine the extent to which additional unintended consequences were taken into account in the analysis and to describe the methodological approaches used to estimate these, where possible.

METHODS

We sourced the vaccine economic evaluations from a previous systematic review by Nymark et al. (2009-2015) and searched PubMed/MEDLINE and Embase from 2015 to 2019 using the same search strategy. For tuberculosis economic evaluations, we extracted studies from 2009 to 2019 that were published in a previous review by Siapka et al. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Studies were classified according to the categories and subcategories (e.g., herd immunity, non-specific effects, and labor productivity) defined in a framework identifying additional unintended consequences by Nymark and Vassall. Where possible, methods for estimating the additional unintended consequences categories and subcategories were described. We evaluated the reporting quality of included studies according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) extraction guideline.

RESULTS

We identified 177 vaccine cost-effectiveness analyses (CEAs) between 2009 and 2019 that met the inclusion criteria. Of these, 98 included unintended consequences. Of the total 98 CEAs, overall health consequence categories were included 73 times; biological categories: herd immunity 43 times; pathogen response: resistance 15 times; and cross-protection 15 times. For health consequences pertaining to the supply-side (health systems) categories, side effects were included five times. On the nonhealth demand side (intrahousehold), labor productivity was included 60 times. We identified 29 tuberculosis CEAs from 2009 to 2019 that met the inclusion criteria. Of these, six articles included labor productivity, four included indirect transmission effects, and one included resistance. Between 2009 and 2019, only 34% of tuberculosis CEAs included additional unintended consequences, compared with 55% of vaccine CEAs.

CONCLUSIONS

The inclusion of additional unintended consequences in economic evaluations of immunization and tuberculosis continues to be limited. Additional unintended consequences of economic benefits, such as those examined in this review and especially those that occur outside the health system, offer valuable information to analysts. Further work on appropriate ways to value these additional unintended consequences is still warranted.

The road to cervical cancer elimination in Malaysia: Evaluation of the impact and cost-effectiveness of human papillomavirus screening with self-collection and digital registry support

The WHO has launched a global strategy to eliminate cervical cancer through the scale‐up of human papillomavirus (HPV) vaccination, cervical screening, and cervical cancer treatment. Malaysia has achieved high‐coverage HPV vaccination since 2010, but coverage of the existing cytology‐based program remains low. Pilot studies found HPV self‐sampling was acceptable and effective, with high follow‐up rates when a digital registry was used, and recently the Malaysian Government announced plans for a national HPV‐based screening program. We therefore evaluated the impact of primary HPV screening with self‐collection in Malaysia in the context of Malaysia's existing vaccination program. We used the “Policy1‐Cervix” modeling platform to assess health outcomes, cost‐effectiveness, resource use and cervical cancer elimination timing (the year when cervical cancer rates reach four cases per 100 000 women) of implementing primary HPV testing with self‐collection, assuming 70% routine‐screening coverage could be achieved. Based on available data, we assumed that compliance with follow‐up was 90% when a digital registry was used, but that compliance with follow‐up would be 50‐75% without the use of a digital registry. We found that the current vaccination program would prevent 27 000 to 32 200 cervical cancer cases and 11 700 to 14 000 deaths by 2070. HPV testing with a digital registry was cost‐effective (CER = $US 6953‐7549 < $US 11 373[<1×GDP per capita]) and could prevent an additional 15 900 to 17 800 cases and 9700 to 10 600 deaths by 2070, expediting national elimination by 11 to 20 years, to 2055 to 2059. If HPV screening were implemented without a digital registry, there would be 1800 to 4900 fewer deaths averted by 2070 and the program would be less cost‐effective. These results underline the importance of HPV testing as a key elimination pillar in Malaysia.

Cost-effectiveness and budget impact analyses of dengue vaccination in Indonesia

Despite the fact that the incidence and mortality rates due to dengue virus (DENV) infection in Indonesia are relatively high, dengue vaccination has not yet been introduced. This study aimed to analyse the cost-effectiveness and the budget impact of dengue vaccination in Indonesia by taking the potential of pre-vaccination screening into account. An age-structured decision tree model was developed to assess the cost-effectiveness value by applying a single cohort of 4,710,100 children that was followed-up in a 10-year time horizon within a 1-year analytical cycle. The budget impact was analysed in a 5-year period (2020-2024) by considering provinces' readiness to introduce dengue vaccine and their incidence rate of DENV infection in the last 10 years. Vaccination that was coupled with pre-vaccination screening would reduce dengue fever (DF), dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) by 188,142, 148,089 and 426 cases, respectively. It would save treatment cost at $23,433,695 and $14,091,642 from the healthcare and payer perspective, respectively. The incremental cost-effectiveness ratios (ICERs) would be $5,733 and $5,791 per quality-adjusted-life-year (QALY) gained from both perspectives. The most influential parameters affecting the ICERs were probability of DENV infection, vaccine efficacy, under-reporting factor, vaccine price, case fatality rate and screening cost. It can be concluded that dengue vaccination and pre-vaccination screening would be cost-effective to be implemented in Indonesia. Nevertheless, it seems unaffordable to be implemented since the total required cost for the nationwide vaccination would be 94.44% of routine immunization budget.

Economic evaluation of rotavirus vaccination: an important step of the introduction to the national immunization program in Thailand

INTRODUCTION

World Health Organization recommends rotavirus vaccine for all national immunization programs (NIPs). To provide country-specific evidence, we conducted economic evaluation of a monovalent rotavirus vaccination using specific data of the pilot phase in Thailand.

METHOD

A Markov model was adopted to compare the 2020 birth cohort once receiving rotavirus vaccination versus no vaccination from healthcare and societal perspective over five years. Data on disease burden, vaccine effectiveness, costs, and utilities were taken from a cohort study in two provinces of Thailand.  Sensitivity analyses were performed to test the robustness of the results.

RESULTS

Rotavirus vaccination would reduce rotavirus diarrhea and costs of illness by 48% and 71%, respectively, over the first five years of life. At USD 13 per dose, vaccine was cost-effective with the ICERs of USD 4,114 and USD 1,571per QALY gained from healthcare and societal perspective, respectively. Results were sensitive to incidence and vaccine cost.  The budget for vaccine purchasing was estimated at USD13 million per year.

CONCLUSION

Incorporating rotavirus vaccination into the NIP substantially reduced health and cost outcomes and was cost-effective for both perspectives. However, the government needs to negotiate vaccine price prior to program implementation to achieve favorable budget impact.

Estimating a cost-effectiveness threshold for health care decision-making in South Africa

Cost-effectiveness thresholds are important decision rules that determine whether health interventions represent good value for money. In low- and middle-income countries, the World Health Organization (WHO) one to three times per capita gross domestic product (GDP) per disability-adjusted life years (DALYs) averted has been the most widely used threshold for informing resource allocation decisions. However, in 2016, the WHO withdrew recommendations for using this threshold, creating a significant vacuum in South Africa and many countries that rely on results of cost-effectiveness analyses for making resource allocation decisions. This study estimates a cost-effectiveness threshold that reflects the health opportunity cost of health spending in South Africa using a three-step approach. First, marginal returns to health spending was estimated as health spending elasticity for crude death rates using a fixed effect estimation approach. Second, the opportunity cost of health spending was estimated as DALYs averted. Finally, a cost per DALY averted threshold was estimated as the inverse of the marginal product of health spending. We show that 1% of total health spending in 2015 (equivalent to approximately ZAR 1.54 billion/USD 120.7 million) averted 1050 deaths, 34 180 years of life lost, 5880 years lived with disability and 40 055 DALYs. The cost-effectiveness threshold was estimated at approximately ZAR 38 500 (USD 3015) per DALY averted, ∼53% of South Africa's per capita GDP in 2015 (ZAR 72 700/USD 5700) and lower than the previously recommended one to three times per capita GDP. As South Africa moves towards implementing universal health coverage reforms through National Health Insurance by 2025, the adoption of a threshold that reflects health opportunity costs will be crucial for ensuring efficiency in the allocation of scarce resources. This study provides useful insight into the magnitude of the health opportunity cost of health spending in South Africa and highlights the need for further research.

Choosing the optimal HPV vaccine: The health impact and economic value of the nonavalent and bivalent HPV vaccines in 48 Gavi-eligible countries

The human papillomavirus (HPV) vaccines may provide some level of cross-protection against high-risk HPV genotypes not directly targeted by the vaccines. We evaluated the long-term health and economic impacts of routine HPV vaccination using either the nonavalent HPV vaccine or the bivalent HPV vaccine in the context of 48 Gavi-eligible countries. We used a multi-modeling approach to compare the bivalent with or without cross-protection and the nonavalent HPV vaccine. The optimal, that is, most cost-effective, vaccine was the vaccine with an incremental cost-effectiveness ratio below the per-capita gross domestic product (GDP) for each country. By 2100 and assuming 70% HPV vaccination coverage, a bivalent vaccine without cross-protection, a bivalent vaccine with favorable cross-protection and the nonavalent vaccine were projected to avert 14.9, 17.2 and 18.5 million cumulative cases of cervical cancer across all 48 Gavi-eligible countries, respectively. The relative value of the bivalent vaccine compared to the nonavalent vaccine increased assuming a bivalent vaccine conferred high cross-protection. For example, assuming a cost-effectiveness threshold of per-capita GDP, the nonavalent vaccine was optimal in 83% (n = 40) of countries if the bivalent vaccine did not confer cross-protection; however, the proportion of countries decreased to 63% (n = 30) if the bivalent vaccine conferred high cross-protection. For lower cost-effectiveness thresholds, the bivalent vaccine was optimal in a greater proportion of countries, under both cross-protection assumptions. Although the nonavalent vaccine is projected to avert more cases of cervical cancer, the bivalent vaccine with favorable cross-protection can prevent a considerable number of cases and would be considered a high-value vaccine for many Gavi-eligible countries.

From Evidence to Policy: Economic Evaluations of Healthcare in Malaysia: A Systematic Review

OBJECTIVE

To identify and describe the various economic evaluation studies in Malaysia and to determine the range of incremental cost-effectiveness ratios (ICERs) as reported in these studies.

METHODS

A comprehensive search of the scientific electronic databases was conducted (Medline, EBM Reviews, Embase, and hand search) to identify all published economic evaluation studies related to Malaysian healthcare. Two researchers assessed the quality of selected studies using the Critical Appraisal Skills Programme (CASP) checklist and Quality of Health Economic Studies instrument. The assessment was also reviewed by expert members of the Technical Advisory Committee of Health Technology Economic Evaluations (TACHTEE).

RESULTS

A total of 64 full-text articles were assessed for eligibility and included in this systematic review. Thirty studies were partial economic evaluations; the full economic evaluations included 17 cost-effectiveness analyses and 17 cost-utility analyses. From all the reported ICERs, the majority (68%) were categorized as highly cost-effective (ICER of less than 1 gross domestic product (GDP) per capita per quality-adjusted life-years or disability-adjusted life-years gained).

CONCLUSION

This review identifies information gaps and loopholes in health economics research in Malaysia. Additionally, this study provides the information that the majority of published interventions in Malaysia fell within the cost-effectiveness threshold of 1 GDP per capita per quality-adjusted life-years or disability-adjusted life-years gained.