Potential impact of introducing the pneumococcal conjugate vaccine into national immunisation programmes: an economic-epidemiological analysis using data from India

Routine immunization against Streptococcus pneumoniae and Haemophilus influenzae type B and antibiotic consumption in India: a dynamic modeling analysis

Background

Childhood vaccinations can reduce disease burden and associated antibiotic use, in turn reducing the risk of antimicrobial resistance (AMR). We retrospectively estimated the population-level reductions in antibiotic use in India following the introduction of vaccines against Streptococcus pneumoniae and Haemophilius influenzae type B in the national immunization program for children in the mid-2010s and projected future gains to 2028 if vaccination coverage were to be increased.

Methods

Using IndiaSim, a dynamic agent-based microsimulation model (ABM) for India, we simulated the spread of Streptococcus pneumoniae and Haemophilius influenzae type B (Hib) among children to estimate reductions in antibiotic use under the scenarios of: (i) pneumococcal and Hib vaccine coverage levels equivalent to the national coverage of pentavalent diphtheria-pertussis-tetanus third dose (DPT3) compared to a baseline of no vaccination, and (ii) near-universal (90%) coverage of the vaccines compared to pre-COVID national DPT3-level coverage. Model parameters, including national DPT3 coverage rates, were based on data from the National Family Household Survey 2015-2016 and other published sources. We quantified reductions in antibiotic consumption nationally and by state and wealth quintiles.

Findings

We estimate that coverage of S. pneumoniae and Hib vaccines at the same level as DPT3 in India would translate to a 61.4% [95% UI: 43.8-69.5] reduction in attributable antibiotic use compared to a baseline of zero vaccination coverage. Increases in childhood vaccination coverage between 2004 and 2016 have likely reduced attributable antibiotic demand by as much as 93.4% among the poorest quintile. Increasing vaccination coverage by an additional 11 percentage points from 2016 levels results in mortality and antibiotic use across wealth quintiles becoming increasingly similar (p < 0.05), reducing in health inquities. We project that near-universal vaccine coverage would further reduce inequities in antibiotic demand and may eliminate of outbreak-associated antibiotic use from S. pneumoniae and Hib.

Interpretation

Though vaccination has a complex relationship with antibiotic use because both are modulated by socioeconomic factors, increasing vaccinations for S. pneumoniae and Hib may have a significant impact on reducing antibiotic use and improving health outcomes among the poorest individuals.

Funding

The Bill & Melinda Gates Foundation (grant numbers OPP1158136 and OPP1190803).

Do current economic evaluations fully capture vaccine value: a review of evidence from India

INTRODUCTION

Traditional economic evaluations typically focus on direct health effects and costs offset to the healthcare system. However, vaccines offer significant indirect benefits beyond direct health effects, such as herd immunity, reduced force of infection, reduction in antimicrobial resistance, and others. Failure to consider these benefits while evaluating vaccines may undervalue vaccines. Therefore, it is argued that the full value of vaccines should be estimated by incorporating these broader benefits.

AREAS COVERED

This review presents the broader value domains proposed in literature by various frameworks, and their definitions. The review of economic evidence of vaccine use in India to discuss to what extent these broader value domains have been considered in economic evaluations in India has been presented. We also discuss specific considerations that need to be taken care of while developing value frameworks or guidelines for the economic evaluation of vaccines.

EXPERT OPINION

To develop a comprehensive framework tailored to the country needs, prioritize relevant value domains and optimal methodologies based on the country's healthcare context, and data availability. These value domains must align with people's as well as decision-makers preferences to ensure economic assessments are relevant and actionable.

Pneumococcal Disease: Global Disease Prevention Strategies with a Focus on the Challenges in Iraq

Pneumococcal disease is a global public health concern that significantly contributes to clinical disease burden and economic burden. Patients frequently afflicted are young children and older adults, as well as the immunocompromised population. Immunization is the most effective public health strategy to combat pneumococcal disease and several vaccine formulations have been developed in this regard. Although vaccines have had a significant global impact in reducing pneumococcal disease, there are several barriers to its success in Iraq. The war and conflict situation, increasing economic crises and poverty, poor vaccine accessibility in the public sector, and high vaccine costs are a few of the major obstacles that impede a successful immunization program. The last reported third dose pneumococcal conjugate vaccine coverage for Iraq was 37% in 2019, which is expected to reduce even further owing to the COVID-19 pandemic. Thus, strategies and policies to improve pneumococcal vaccine availability and coverage need to be strengthened to achieve maximum benefits of immunization. In the current review, we provide an overview of the existing knowledge on pneumococcal disease-prevention strategies across the globe. The main aim of this manuscript is to discuss the current status and challenges of pneumococcal vaccination in Iraq as well as the strategies to prevent pneumococcal infections.

Estimating the Public Health and Economic Impact of Introducing the 13-Valent Pneumococcal Conjugate Vaccine or 10-Valent Pneumococcal Conjugate Vaccines into State Immunization Programs in India

Introduction

Although the pneumococcal conjugate vaccine (PCV) has been introduced into select state immunization programs (SIPs) in India, many children remain unvaccinated. Recently, India’s Advisory Committee on Vaccines & Immunization Practices recommended PCV on the pediatric immunization schedule nationally. This study estimates the public health and economic impact of introducing either Pfizer’s 13-valent PCV (PCV13-PFE), GlaxoSmithKline’s 10-valent PCV (PCV10-GSK), or Serum Institute of India’s 10-valent PCV (PCV10-SII) into every pediatric SIP.

Methods

A model was developed to predict the disease cases, deaths, and costs associated with implementing PCV13-PFE, PCV10-GSK, or PCV10-SII in SIPs compared to no vaccination program across a 5-year period (2021–2025). State and national-level uptake rate and clinical and economic input parameters were collected from published literature. Disease outcomes included invasive pneumococcal disease, inpatient and outpatient pneumonia, and otitis media. Costs were estimated as vaccine-related costs and direct medical costs incurred to the healthcare system. Results were reported by individual state and aggregated nationally.

Results

Estimated over 5 years, implementing PCV13-PFE in SIPs could avert 12.1 million cases and save 626,512 lives among children under 5 years old compared to no vaccination. This corresponds to net national cost savings of over $1.0 billion. Both lower-valent PCVs are estimated to provide less economic savings than PCV13-PFE inclusive of vaccine-related costs. Compared with PCV13-PFE, implementing PCV10-GSK or PCV10-SII nationally is estimated to have a smaller public health impact, with PCV10-GSK averting 8.4 million cases (436,577 deaths) and PCV10-SII preventing 10.3 million cases (531,545 deaths) in India compared to no vaccination, respectively.

Conclusion

Implementation of PCV13-PFE throughout India is estimated to provide greater public health and economic benefits than PCV10-GSK or PCV10-SII SIPs. Our analysis highlights the substantial disease cases, deaths, and health system cost savings that may be realized from implementing PCV programs throughout India.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00498-4.

Improving vaccination coverage and timeliness through periodic intensification of routine immunization: evidence from Mission Indradhanush

Only an estimated 62% of Indian children under the age of 2 years are fully immunized. We examined the association between India's Mission Indradhanush (MI)-a periodic intensification of the routine immunization program-which was implemented in phases across districts between March 2015 and July 2017, and routine vaccination coverage and timeliness among children. We used data from a 2015 to 2016 national survey of children (n = 29,532) and employed difference-in-difference regressions to examine binary indicators of receipt of 11 vaccines and whether vaccines were received at recommended ages. The full immunization rate was 27% higher among children under 2 years old residing in MI phase 1 and 2 districts (intervention group) as compared with those residing elsewhere (control group). The rate of receiving all vaccines at recommended ages was 8% higher in the intervention group. Receiving doses of oral polio vaccine (OPV) birth dose, OPV dose 1 (OPV1), OPV2, OPV3, bacillus Calmette-Guérin, and hepatitis B birth dose vaccines were 9%, 9%, 11%, 16%, 5%, and 19% higher in the intervention group than the control group, respectively. More research is required on the cost-effectiveness of investing in MI-type programs as compared with routine immunization.

Control of Streptococcal Infections: Is a Common Vaccine Target Achievable Against Streptococcus agalactiae and Streptococcus pneumoniae

Both Streptococcus agalactiae [group B streptococcus (GBS)] and Streptococcus pneumoniae (pneumococcus) remain significant pathogens as they cause life threatening infections mostly in children and the elderly. The control of diseases caused by these pathogens is dependent on antibiotics use and appropriate vaccination. The introduction of the pneumococcal conjugate vaccines (PCVs) against some serotypes has led to reduction in pneumococcal infections, however, the subsequent serotype switching, and replacement has been a serious challenge. On the other hand, no vaccine is yet licensed for use in the control of GBS diseases. In this review, we provide an overview of the history and global disease burden, disease pathophysiology and management, vaccines update, and the biology of both pathogens. Furthermore, we address recent findings regarding structural similarities that could be explored for vaccine targets across both mucosal pathogens. Finally, we conclude by proposing future genomic sequence comparison using the wealth of available sequences from both species and the possibility of identifying more related structural components that could be exploited for pan-pathogen vaccine development.

A systematic literature review of economic evaluations of pneumococcal conjugate vaccines in east and southeast Asia (2006-2019)

INTRODUCTION

Pneumococcal infections can lead to serious invasive diseases such as meningitis, septicemia and pneumonia, as well as milder but more common illnesses such as sinusitis and otitis media. The World Health Organization (WHO) recommends the inclusion of pneumococcal conjugate vaccines (PCVs) in infant National Immunization Program (NIP) programs worldwide. Decision-makers in Asian countries planning to introduce PCVs in their respective NIP will need a comprehensive evidence of effectiveness of PCVs at the population level and economic evidence including cost-effectiveness.

AREAS COVERED

A systematic literature review (from 1/1/2016 to 10/11/2019) of PCVs in East and Southeast Asia to understand (1) the contributing factors to cost-effectiveness results of PCVs and (2) whether gaps in evidence exist suggesting why the region may have yet to implement full NIPs.

EXPERT OPINION

In East and Southeast Asia, vaccination with PCVs was found to significantly reduce the mortality and morbidity of pneumococcal diseases and was cost-effective compared to no vaccination. Study assumptions, specifically vaccine local acquisition, the inclusion or exclusion of indirect effects (serotype replacement and herd effect), cross-protection, and protection against nontypeable haemophilus influenzae and serotype 3, were the main drivers of cost-effectiveness.

Trading off health and financial protection benefits with multiobjective optimization

Countries which are introducing a system of Universal health coverage have to make a number of key tradeoffs, of which one is the tradeoff between the level of coverage and the degree to which patients are exposed to potentially catastrophic financial risk. In this study, we first present a way in which decision makers might be supported to focus on in a particular part of the tradeoff curve and ultimately choose an efficient solution. We then introduce some multiobjective optimization models for generating the tradeoff curves given data about potential treatment numbers, costs, and benefits. Using a dataset from Malawi, we demonstrate the approach and suggest a core index metric to make specific observations on the individual treatments. Moreover, as there has been some debate about the best way to measure financial exposure, we also investigate the extent to sensitivity of our results to the precise technical choice of financial exposure metric. Specifically, we consider two metrics, which are the total number of cases protected from catastrophic expenditure and a convex penalty function that penalizes out-of-pocket expenditures in an increasingly growing way, respectively.

Why vaccines matter: understanding the broader health, economic, and child development benefits of routine vaccination

The direct benefits of childhood vaccination in reducing the burden of disease morbidity and mortality in a cost-effective manner are well-established. By preventing episodes of vaccine-preventable diseases, vaccination can also help avert associated out-of-pocket medical expenses, healthcare provider costs, and losses in wages of patients and caregivers. Studies have associated vaccines positively with cognition and school attainment, suggesting benefits of long-term improved economic productivity. New evidence suggests that the measles vaccine may improve immunological memory and prevent co-infections, thereby forming a protective shield against other infections, and consequently improving health, cognition, schooling and productivity outcomes well into the adolescence and adulthood in low-income settings. Systematically documenting these broader health, economic, and child development benefits of vaccines is important from a policy perspective, not only in low and middle-income countries where the burden of vaccine-preventable diseases is high and public resources are constrained, but also in high-income settings where the emergence of vaccine hesitancy poses a threat to benefits gained from reducing vaccine-preventable diseases. In this paper, we provide a brief summary of the recent evidence on the benefits of vaccines, and discuss the policy implications of these findings.

National Immunization Programme - Mission Indradhanush Programme: Newer Approaches and Interventions

Vaccines are globally accepted as instrumental in drastically bringing down vaccine preventable diseases (VPDs) related mortality and morbidity. Despite global relentless efforts, about 19.3 million children still go missing for full immunization and are at risk for VPDs. Government of India has tried to rejuvenate its four decades old Universal Immunization Programme (UIP) by recently launching Mission Indradhanush in 2014, followed by Intensified Mission Indradhanush in 2017 to boost up immunization coverage. UIP have also brought in newer vaccines, changed dose schedules, open vial policy and a robust surveillance system. Even then, country's average immunization coverage is much below par. Thus, there is a pressing need for transforming immunization program from simple vaccine delivery platform to a comprehensive disease control programme. Country should introduce newer vaccines through evidence-based policies and increase access to immunization services through system strengthening.

Impact and cost effectiveness of pneumococcal conjugate vaccine in India

BACKGROUND

World Health Organization has recommended the introduction of pneumococcal conjugate vaccine (PCV) in the childhood immunisation programme of all the countries in the world. In lieu of its introduction in India, there is a need to generate evidence on cost-effectiveness of this vaccine. The current study looks into the impact and cost-effectiveness of PCV vaccine in India.

METHODS

We evaluated the cost effectiveness of implementation of PCV 13 vaccination program at national level by comparing with no vaccination program for a period of 10 birth cohorts from 2018 to 2027. UNIVAC, a deterministic static cohort model is developed by giving the conservative estimates of vaccine program related to mortality, disease event rates, vaccine efficacy and coverage projections, system and health care costs for the first five years of life. Cost effectiveness is reported as Incremental Cost Effectiveness Ratio (ICER). Further scenario and sensitivity analysis were done. Probability of PCV intervention to be cost effective at a willingness to pay (WTP) threshold equal to per capita gross domestic product (GDP) is calculated using the government perspective.

RESULTS

We found that the introduction of PCV vaccination program can cost an additional $467 (INR 31,666) for averting per DALY which is less than one time GDP per capita of India. Even with the most unfavourable scenario for PCV vaccine, cost per DALY averted is found to be $2323 (INR 1,57,520) which is still a cost effective intervention in India. Probabilistic sensitivity analysis found the ICER for PCV to be $649 (INR 44,008) with 95% CI: $374-$1161.

CONCLUSION

This study shows that the PCV program is a highly cost effective intervention and justifies the introduction of PCV into routine immunisation schedule in some of the states and recommends introducing it throughout the country to reduce morbidity and mortality among the under-five children.