Health and economic impact of rotavirus vaccination in GAVI-eligible countries

Critical Analysis of Economic Evaluation of the Childhood Rotavirus Vaccination in Low- and Lower-Middle-Income Countries: A Systematic Review

OBJECTIVES

To identify, critically appraise, and summarize the use of different methods and results of economic evaluations to assess the efficiency of rotavirus vaccination programs in low- and lower-middle-income countries.

METHODS

A systematic literature search was performed in 3 bibliographic databases, including PubMed, ProQuest, Cochrane Library, and Science Direct (Elsevier) journal website, using key search terms. The study selection process was based on predefined inclusion criteria. The search results were presented using the research flow diagram based on guidelines of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The quality assessment of the selected studies was carried out using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) checklist.

RESULTS

A total of 21 studies were selected for review. All the studies, except 1, reported rotavirus vaccination to be a cost-effective intervention and a high-impact strategy to reduce substantial rotavirus disease burden. A decision analysis model was considered appropriate by all studies, although there were variabilities in the analytic horizon used. Lack of country-level data was highlighted by most studies. Multiples of gross domestic product of respective countries were used as a threshold to interpret cost-effectiveness.

CONCLUSIONS

Rotavirus vaccination was found to be cost-efficient in most settings, including complex humanitarian emergencies. The use of thresholds for interpreting incremental cost-effectiveness ratios and lack of local-level disease incidence and cost of illness data remains a point of contention. Lack of reporting probabilistic sensitivity analysis renders limited robustness to study results.

An Estimate Of The Return On Investment Of A Malaria Vaccine In 20 Sub-Saharan African Countries, 2021-30

Malaria is a leading global health problem that was responsible for an estimated 619,000 deaths worldwide in 2021. We modeled the return on investment (ROI) for the introduction and continuation of a four-dose malaria vaccine, RTS,S/AS01, from 2021 to 2030 in twenty sub-Saharan African countries supported by Gavi, the Vaccine Alliance. We used the Decade of Vaccine Economics benefits and costing outputs to calculate an ROI using health impact data modeled by the Swiss Tropical and Public Health Institute (hereafter "Swiss") and Imperial College London (hereafter "Imperial"). The Swiss estimates with a base vaccine price of US$7.00 resulted in an ROI of 0.42, and the Imperial impact estimates with the same base vaccine price resulted in an ROI of 2.30. Inclusion of the fifth seasonal dose for ten countries exhibiting high seasonal disease burden increased the Swiss ROI by 143 percent, to 1.02, and the Imperial ROI by 23.5 percent, to 2.84. To improve ROI, decision makers should continue to improve delivery platforms, decrease vaccine delivery costs, deliver the malaria vaccine in fewer doses, and provide access to vaccine resources.

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

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

Return on Investment of 10-Valent Pneumococcal Conjugate Vaccine in Ecuador From 2010 to 2030

OBJECTIVES

Ecuador introduced the pneumococcal conjugate vaccine in 2010. A recent time series analysis has demonstrated the impact of 10-valent pneumococcal conjugate vaccine (PCV10) on hospitalized pneumococcal disease in children. We leveraged these estimates to calculate the return on investment (ROI) of PCV10 in Ecuador from 2010 to 2030 at the national and regional levels.

METHODS

We used 2 approaches to estimate the economic benefits: (1) cost of illness, which includes treatment, transportation, and productivity loss averted, (2) and the value of statistical life, which reflects society's average willingness to pay to save one life. Costs of the immunization program include vaccine costs (doses, syringes, injection supplies) and immunization delivery costs (personnel, cold chain equipment and maintenance, transportation, distribution services, and other recurrent costs). We estimated the ROI by dividing the net benefits by costs.

RESULTS

The ROI using the cost-of-illness approach was slightly negative in the introduction year. From 2011 to 2020, we estimated the ROI to be 0.45 (0.15-0.73). For the future decade, the ROI is estimated at 0.37 (-0.03 to 1.03). Using the value-of-statistical-life approach, the ROI was 1.46 (0.82-2.17) in the introduction year. In the first decade, the ROI was 1.01 (0.49-1.60); in the second decade, the ROI fell to 0.83 (0.23-1.78).

CONCLUSIONS

The results of this study demonstrate the total economic benefits of PCV10 in Ecuador exceed immunization program costs after the introduction year. Estimates from this study will inform country policy makers and will contribute to efforts to mobilize resources for immunization.

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.

Economic Benefits of Immunization for 10 Pathogens in 94 Low- and Middle-Income Countries From 2011 to 2030 Using Cost-of-Illness and Value-of-Statistical-Life Approaches

OBJECTIVES

Vaccination has prevented millions of deaths and cases of disease in low- and middle-income countries (LMICs). During the Decade of Vaccines (2011-2020), international organizations, including the World Health Organization and Gavi, the Vaccine Alliance, focused on new vaccine introduction and expanded coverage of existing vaccines. As Gavi, other organizations, and country governments look to the future, we aimed to estimate the economic benefits of immunization programs made from 2011 to 2020 and potential gains in the future decade.

METHODS

We used estimates of cases and deaths averted by vaccines against 10 pathogens in 94 LMICs to estimate the economic value of immunization. We applied 3 approaches-cost of illness averted (COI), value of statistical life (VSL), and value of statistical life-year (VSLY)-to estimate observable and unobservable economic benefits between 2011 and 2030.

RESULTS

From 2011 to 2030, immunization would avert $1510.4 billion ($674.3-$2643.2 billion) (2018 USD) in costs of illness in the 94 modeled countries, compared with the counterfactual of no vaccination. Using the VSL approach, immunization would generate $3436.7 billion ($1615.8-$5657.2 billion) in benefits. Applying the VSLY approach, $5662.7 billion ($2547.2-$9719.4) in benefits would be generated.

CONCLUSION

Vaccination has generated significant economic benefits in LMICs in the past decade. To reach predicted levels of economic benefits, countries and international donor organizations need to meet coverage projections outlined in the Gavi Operational Forecast. Estimates generated using the COI, VSL, or VSLY approach may be strategically used by donor agencies, decision makers, and advocates to inform investment cases and advocacy campaigns.

Rotavirus infection in children in Southeast Asia 2008-2018: disease burden, genotype distribution, seasonality, and vaccination

Background

Rotaviruses (RVs) are recognized as a major cause of acute gastroenteritis (AGE) in infants and young children worldwide. Here we summarize the virology, disease burden, prevalence, distribution of genotypes and seasonality of RVs, and the current status of RV vaccination in Southeast Asia (Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam) from 2008 to 2018.

Methods

Rotavirus infection in Children in Southeast Asia countries was assessed using data from Pubmed and Google Scholars. Most countries in Southeast Asia have not yet introduced national RV vaccination programs. We exclude Brunei Darussalam, and Timor Leste because there were no eligible studies identified during that time.

Results

According to the 2008–2018 RV surveillance data for Southeast Asia, 40.78% of all diarrheal disease in children were caused by RV infection, which is still a major cause of morbidity and mortality in children under 5 years old in Southeast Asia. Mortality was inversely related to socioeconomic status. The most predominant genotype distribution of RV changed from G1P[8] and G2P[4] into the rare and unusual genotypes G3P[8], G8P[8], and G9P[8]. Although the predominat strain has changed, but the seasonality of RV infection remains unchanged. One of the best strategies for decreasing the global burden of the disease is the development and implementation of effective vaccines.

Conclusions

The most predominant genotype distribution of RV was changed time by time. Rotavirus vaccine is highly cost effective in Southeast Asian countries because the ratio between cost per disability-adjusted life years (DALY) averted and gross domestic product (GDP) per capita is less than one. These data are important for healthcare practitioners and officials to make appropriate policies and recommendations about RV vaccination.

Japanese encephalitis vaccination in the Philippines: A cost-effectiveness analysis comparing alternative delivery strategies

INTRODUCTION

Japanese encephalitis (JE) is a mosquito-borne viral infection of the brain that can cause permanent brain damage and death. In the Philippines, efforts are underway to deliver a live attenuated JE vaccine (CD-JEV) to children under five years of age (YOA), who are disproportionately infected. Multiple vaccination strategies are being considered.

METHODS

We conducted a cost-effectiveness analysis comparing three vaccination strategies to the current state of no vaccination from the societal and government perspectives: (1) national routine vaccination only, (2) sub-national campaign followed by national routine, and (3) national campaign followed by national routine. We developed a Markov model to estimate impact of vaccination or no vaccination over the child's lifetime horizon, assuming an annual incidence of 10.6 cases per 100,000. Costs of illness ($859/case), vaccine ($0.50/dose), routine vaccination ($0.95/dose), and campaign vaccination ($0.98/dose) were based on hospital financial records, expert opinion and literature. The societal perspective included transportation and opportunity costs of caregiver time, in addition to costs incurred by the health system.

RESULTS

JE vaccination via national campaign followed by national routine delivery was the most cost-effective strategy modeled with a cost per disability adjusted life year (DALY) averted of $233 and $29 from the government and societal perspectives, respectively. Results were similar for other delivery strategies with cost/DALY ranging from $233 to $265 from the government perspective and $29-$57 from the societal perspective. JE vaccination was projected to prevent 27,856-37,277 cases, 5571-7455 deaths, and 173,233-230,704 DALYs among children under five over 20 consecutive birth cohorts. Total incremental costs of vaccination versus no vaccination over 20 birth cohorts were $6.6-$9.8 million from the societal perspective ($230 K-$440 K annually) and $45.9-$53.9 million ($2.2 M-$2.7 M annually) from the governmental perspective.

CONCLUSION

Vaccination with CD-JEV in the Philippines is projected to be cost-effective, reducing long-term costs associated with JE illness and improving health outcomes compared to no vaccination.

Modeling the Economic Impact of Substandard and Falsified Antimalarials in the Democratic Republic of the Congo

Substandard and falsified medicines pose significant risks to global health, including increased deaths, prolonged treatments, and growing drug resistance. Antimalarials are one of the most common medications to be of poor quality in low- and middle-income countries. We assessed the health and economic impact of substandard and falsified antimalarials for children less than 5 years of age in the Democratic Republic of the Congo, which has one of the world's highest malaria mortality rates. We developed an agent-based model to simulate patient care-seeking behavior and medicine supply chain processes to examine the impact of antimalarial quality in Kinshasa province and Katanga region. We simulated the impact of potential interventions to improve medicinal quality, reduce stockouts, or educate caregivers. We estimated that substandard and falsified antimalarials are responsible for $20.9 million (35% of $59.6 million; 95% CI: $20.7-$21.2 million) in malaria costs in Kinshasa province and $130 million (43% of $301 million; $129-$131 million) in malaria costs in the Katanga region annually. If drug resistance to artemisinin were to develop, total annual costs of malaria could increase by $17.9 million (30%; $17.7-$18.0 million) and $73 million (24%; $72.2-$72.8 million) in Kinshasa and Katanga, respectively. Replacing substandard and falsified antimalarials with good quality medicines had a larger impact than interventions that prevented stockouts or educated caregivers. The results highlight the importance of improving access to good quality antimalarials to reduce the burden of malaria and mitigate the development of antimalarial resistance.

Characterization of rotavirus possessing a DS-1-like VP3 gene from pigs in Brazil: Evidence for zooanthroponotic transmission

Porcine group A rotavirus (RVA) strains SUI15A and SUI24A are suggested to have VP3 genes of human origin possessing DS-1-like backbone. The aim of the present study was to analyse the genome of two strains (SUI15A and SUI24A) and understand the evolution of a rare human-like M2 genotype in pigs. On partial genomic analysis, strains SUI24A (G3-P[13]-I5-R1-C1-M2-A8-N1-T7-E1-H1) and SUI15A (G3-P[x]-Ix-R1-C1-M2-Ax-Nx-T7-E1-H1) were found to have VP3 gene RVA different from those of typical porcine RVA strains described in Brazil and worldwide. This genotypic constellation was a novel constellation that has not been reported previously in both humans and pigs. Furthermore, on phylogenetic analysis, VP3 gene of strains appeared to be of human origin. Therefore, suggested to have evidence for human-to-porcine zooanthroponotic transmission.

Re-evaluating the potential impact and cost-effectiveness of rotavirus vaccination in 73 Gavi countries: a modelling study

BACKGROUND

Previous studies have found rotavirus vaccination to be highly cost-effective in low-income countries. However, updated evidence is now available for several inputs (ie, rotavirus disease mortality rates, rotavirus age distributions, vaccine timeliness, and vaccine efficacy by duration of follow-up), new rotavirus vaccines have entered the market, vaccine prices have decreased, and cost-effectiveness thresholds have been re-examined. We aimed to provide updated cost-effectiveness estimates to inform national decisions about the new introduction and current use of rotavirus vaccines in Gavi countries.

METHODS

We calculated the potential costs and effects of rotavirus vaccination for ten successive birth cohorts in 73 countries previously and currently eligible for Gavi support, compared with no vaccination. We used a deterministic cohort model to calculate numbers of rotavirus gastroenteritis cases, outpatient visits, hospitalisations, and deaths between birth and 5 years, with and without rotavirus vaccination. We calculated treatment costs from the government and societal perspectives. The primary outcome measure was the incremental cost-effectiveness ratio (discounted US$ per disability-adjusted life-year averted). Country-specific model input parameters were based on the scientific literature, published meta-analyses, and international databases. We ran deterministic and probabilistic uncertainty analyses.

FINDINGS

Over the period 2018-27, rotavirus vaccination has the potential to prevent nearly 600 000 deaths in Gavi countries. Averted outpatient visits and hospitalisations could lead to treatment savings of approximately $484·1 million from the government perspective and $878·0 million from the societal perspective. The discounted dollars per disability-adjusted life-year averted has a very high probability (>90%) of being less than 0·5 times the gross domestic product per capita in 54 countries, and less than 1·0 times gross domestic product per capita in 63 countries.

INTERPRETATION

Rotavirus vaccination continues to represent good value for money across most Gavi countries despite lower rotavirus mortality estimates and more stringent willingness-to-pay thresholds.

FUNDING

Bill & Melinda Gates Foundation.

Economic benefit of neurosurgical intervention for infant hydrocephalus in Haiti

OBJECTIVE

Previous models have been utilized in other low- and middle-income countries (LMICs) to explore and assess the cost, sustainability, and effectiveness of infant hydrocephalus treatment. However, similar models have not been implemented in Haiti due to a paucity of data, epidemiology, and outcomes for hydrocephalus. Therefore, the authors utilized previously described economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at a neurosurgery referral center, Hospital Bernard Mevs (HBM), in Port-au-Prince, Haiti.

METHODS

The authors conducted a retrospective review of data obtained in all children treated for hydrocephalus at the HBM from 2008 to 2015. The raw data were pooled with previously described surgical outcomes for hydrocephalus in other LMICs. Modeling was performed to determine outcomes, neurosurgical costs, disability-adjusted life years (DALYs), and economic benefits of Haitian hydrocephalus treatment during this time frame. Standard account methodology was employed to calculate cost per procedure. Using these formulas, the net economic benefit and cost/DALY were determined for hydrocephalus treatment at HBM from 2008 to 2015.

RESULTS

Of the 401 patients treated during the study period, 158 (39.4%) met criteria for postinfectious hydrocephalus, 54 (13.5%) had congenital hydrocephalus, 38 (9.5%) had myelomeningocele, 19 (4.7%) had aqueductal stenosis, and 132 (33%) were not placed into a category. Overall, 317 individuals underwent surgical treatment of their hydrocephalus, averting 3077 DALYs. The total cost of the procedures was $754,000, and the cost per DALY ranged between $86 and $245. The resulting net economic benefit for neurosurgical intervention ranged from $2.5 to $5.5 million.

CONCLUSIONS

This work demonstrates the substantial economic benefit of neurosurgical intervention for the treatment of pediatric hydrocephalus at a single hospital in Haiti. Based on DALYs averted, the need for additional centers offering basic neurosurgical services is apparent. A single center offering these services for several days each month was able to generate between $2.5 to $5.5 million in economic benefits, suggesting the need to develop neurosurgical capacity building in Haiti. Ultimately, prevention, screening, and early surgical treatment of these infants represent a public health and socioeconomic requisite for Haiti.

Economic value of vaccinating geographically hard-to-reach populations with measles vaccine: A modeling application in Kenya

BACKGROUND

Since special efforts are necessary to vaccinate people living far from fixed vaccination posts, decision makers are interested in knowing the economic value of such efforts.

METHODS

Using our immunization geospatial information system platform and a measles compartment model, we quantified the health and economic value of a 2-dose measles immunization outreach strategy for children <24 months of age in Kenya who are geographically hard-to-reach (i.e., those living outside a specified catchment radius from fixed vaccination posts, which served as a proxy for access to services).

FINDINGS

When geographically hard-to-reach children were not vaccinated, there were 1427 total measles cases from 2016 to 2020, resulting in $9.5 million ($3.1-$18.1 million) in direct medical costs and productivity losses and 7504 (3338-12,903) disability-adjusted life years (DALYs). The outreach strategy cost $76 ($23-$142)/DALY averted (compared to no outreach) when 25% of geographically hard-to-reach children received MCV1, $122 ($40-$226)/DALY averted when 50% received MCV1, and $274 ($123-$478)/DALY averted when 100% received MCV1.

CONCLUSION

Outreach vaccination among geographically hard-to-reach populations was highly cost-effective in a wide variety of scenarios, offering support for investment in an effective outreach vaccination strategy.

Poverty reduction and equity benefits of introducing or scaling up measles, rotavirus and pneumococcal vaccines in low-income and middle-income countries: a modelling study

Introduction

Beyond their impact on health, vaccines can lead to large economic benefits. While most economic evaluations of vaccines have focused on the health impact of vaccines at a national scale, it is critical to understand how their impact is distributed along population subgroups.

Methods

We build a financial risk protection model to evaluate the impact of immunisation against measles, severe pneumococcal disease and severe rotavirus for birth cohorts vaccinated over 2016-2030 for three scenarios in 41 Gavi-eligible countries: no immunisation, current immunisation coverage forecasts and the current immunisation coverage enhanced with funding support. We distribute modelled disease cases per socioeconomic group and derive the number of cases of: (1) catastrophic health costs (CHCs) and (2) medical impoverishment.

Results

In the absence of any vaccine coverage, the number of CHC cases attributable to measles, severe pneumococcal disease and severe rotavirus would be approximately 18.9 million, 6.6 million and 2.2 million, respectively. Expanding vaccine coverage would reduce this number by up to 90%, 30% and 40% in each case. More importantly, we find a higher share of CHC incidence among the poorest quintiles who consequently benefit more from vaccine expansion.

Conclusion

Our findings contribute to the understanding of how vaccines can have a broad economic impact. In particular, we find that immunisation programmes can reduce the proportion of households facing catastrophic payments from out-of-pocket health expenses, mainly in lower socioeconomic groups. Thus, vaccines could have an important role in poverty reduction.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

When cost-effective interventions are unaffordable: Integrating cost-effectiveness and budget impact in priority setting for global health programs

Potential cost-effective barriers in cost-effectiveness studies mean that budgetary impact analyses should also be included in post-2015 Sustainable Development Goal projects says Joshua Salomon and colleagues.

Estimated economic impact of vaccinations in 73 low- and middle-income countries, 2001-2020

Objective

To estimate the economic impact likely to be achieved by efforts to vaccinate against 10 vaccine-preventable diseases between 2001 and 2020 in 73 low- and middle-income countries largely supported by Gavi, the Vaccine Alliance.

Methods

We used health impact models to estimate the economic impact of achieving forecasted coverages for vaccination against Haemophilus influenzae type b, hepatitis B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, rotavirus, rubella, Streptococcus pneumoniae and yellow fever. In comparison with no vaccination, we modelled the costs – expressed in 2010 United States dollars (US$) – of averted treatment, transportation costs, productivity losses of caregivers and productivity losses due to disability and death. We used the value-of-a-life-year method to estimate the broader economic and social value of living longer, in better health, as a result of immunization.

Findings

We estimated that, in the 73 countries, vaccinations given between 2001 and 2020 will avert over 20 million deaths and save US$ 350 billion in cost of illness. The deaths and disability prevented by vaccinations given during the two decades will result in estimated lifelong productivity gains totalling US$ 330 billion and US$ 9 billion, respectively. Over the lifetimes of the vaccinated cohorts, the same vaccinations will save an estimated US$ 5 billion in treatment costs. The broader economic and social value of these vaccinations is estimated at US$ 820 billion.

Conclusion

By preventing significant costs and potentially increasing economic productivity among some of the world’s poorest countries, the impact of immunization goes well beyond health.

Return On Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011-20

An analysis of return on investment can help policy makers support, optimize, and advocate for the expansion of immunization programs in the world's poorest countries. We assessed the return on investment associated with achieving projected coverage levels for vaccinations to prevent diseases related to ten antigens in ninety-four low- and middle-income countries during 2011-20, the Decade of Vaccines. We derived these estimates by using costs of vaccines, supply chains, and service delivery and their associated economic benefits. Based on the costs of illnesses averted, we estimated that projected immunizations will yield a net return about 16 times greater than costs over the decade (uncertainty range: 10-25). Using a full-income approach, which quantifies the value that people place on living longer and healthier lives, we found that net returns amounted to 44 times the costs (uncertainty range: 27-67). Across all antigens, net returns were greater than costs. But to realize the substantial positive return on investment from immunization programs, it is essential that governments and donors provide the requisite investments.

Cost-effectiveness of 13-valent pneumococcal conjugate vaccination in Mongolia

Objective

The Ministry of Health (MOH), Mongolia, is considering introducing 13-valent pneumococcal conjugate vaccine (PCV13) in its national immunization programme to prevent the burden of disease caused by Streptococcus pneumoniae. This study evaluates the cost-effectiveness and budget impact of introducing PCV13 compared to no PCV vaccination in Mongolia.

Methods

The incremental cost-effectiveness ratio (ICER) of introducing PCV13 compared to no PCV vaccination was assessed using an age-stratified static multiple cohort model. The risk of various clinical presentations of pneumococcal disease (meningitis, pneumonia, non-meningitis non-pneumonia invasive pneumococcal disease and acute otitis media) at all ages for thirty birth cohorts was assessed. The analysis considered both health system and societal perspectives. A 3 + 0 vaccine schedule and price of US$3.30 per dose was assumed for the baseline scenario based on Gavi, the Vaccine Alliance’s advance market commitment tail price.

Results

The ICER of PCV13 introduction is estimated at US$52 per disability-adjusted life year (DALY) averted (health system perspective), and cost-saving (societal perspective). Although indirect effects of PCV have been well-documented, a conservative scenario that does not consider indirect effects estimated PCV13 introduction to cost US$79 per DALY averted (health system perspective), and US$19 per DALY averted (societal perspective). Vaccination with PCV13 is expected to cost around US$920,000 in 2016, and thereafter US$820,000 every year. The programme is likely to reduce direct disease-related costs to MOH by US$440,000 in the first year, increasing to US$510,000 by 2025.

Conclusion

Introducing PCV13 as part of Mongolia’s national programme appears to be highly cost-effective when compared to no vaccination and cost-saving from a societal perspective at vaccine purchase prices offered through Gavi. Notwithstanding uncertainties around some parameters, cost-effectiveness of PCV introduction for Mongolia remains robust over a range of conservative scenarios. Availability of high-quality national data would improve future economic analyses for vaccine introduction.

Rotavirus vaccines contribute towards universal health coverage in a mixed public-private healthcare system

OBJECTIVES

To evaluate rotavirus vaccination in Malaysia from the household's perspective. The extended cost-effectiveness analysis (ECEA) framework quantifies the broader value of universal vaccination starting with non-health benefits such as financial risk protection and equity. These dimensions better enable decision-makers to evaluate policy on the public finance of health programmes.

METHODS

The incidence, health service utilisation and household expenditure related to rotavirus gastroenteritis according to national income quintiles were obtained from local data sources. Multiple birth cohorts were distributed into income quintiles and followed from birth over the first five years of life in a multicohort, static model.

RESULTS

We found that the rich pay more out of pocket (OOP) than the poor, as the rich use more expensive private care. OOP payments among the poorest although small are high as a proportion of household income. Rotavirus vaccination results in substantial reduction in rotavirus episodes and expenditure and provides financial risk protection to all income groups. Poverty reduction benefits are concentrated amongst the poorest two income quintiles.

CONCLUSION

We propose that universal vaccination complements health financing reforms in strengthening Universal Health Coverage (UHC). ECEA provides an important tool to understand the implications of vaccination for UHC, beyond traditional considerations of economic efficiency.

Methodological Challenges to Economic Evaluations of Vaccines: Is a Common Approach Still Possible?

Economic evaluation of vaccination is a key tool to inform effective spending on vaccines. However, many evaluations have been criticised for failing to capture features of vaccines which are relevant to decision makers. These include broader societal benefits (such as improved educational achievement, economic growth and political stability), reduced health disparities, medical innovation, reduced hospital beds pressures, greater peace of mind and synergies in economic benefits with non-vaccine interventions. Also, the fiscal implications of vaccination programmes are not always made explicit. Alternative methodological frameworks have been proposed to better capture these benefits. However, any broadening of the methodology for economic evaluation must also involve evaluations of non-vaccine interventions, and hence may not always benefit vaccines given a fixed health-care budget. The scope of an economic evaluation must consider the budget from which vaccines are funded, and the decision-maker's stated aims for that spending to achieve.

Cost-effectiveness of rotavirus vaccination in Kenya and Uganda

INTRODUCTION

Rotavirus vaccines have the potential to prevent a substantial amount of life-threatening gastroenteritis in young African children. This paper presents the results of prospective cost-effectiveness analyses for rotavirus vaccine introduction for Kenya and Uganda.

METHODOLOGY

In each country, a national consultant worked with a national technical working group to identify appropriate data and validate study results. Secondary data on demographics, disease burden, health utilization, and costs were used to populate the TRIVAC cost-effectiveness model. The baseline analysis assumed an initial vaccine price of $0.20 per dose, corresponding to Gavi, the Vaccine Alliance stipulated copay for low-income countries. The incremental cost-effectiveness of a 2-dose rotavirus vaccination schedule was evaluated for 20 successive birth cohorts from the government perspective in both countries, and from the societal perspective in Uganda.

RESULTS

Between 2014 and 2033, rotavirus vaccination can avert approximately 60,935 and 216,454 undiscounted deaths and hospital admissions respectively in children under 5 years in Kenya. In Uganda, the respective number of undiscounted deaths and hospital admission averted is 70,236 and 329,779 between 2016 and 2035. Over the 20-year period, the discounted vaccine program costs are around US$ 80 million in Kenya and US$ 60 million in Uganda. Discounted government health service costs avoided are US$ 30 million in Kenya and US$ 10 million in Uganda (or US$ 18 million including household costs). The cost per disability-adjusted life-year (DALY) averted from a government perspective is US$ 38 in Kenya and US$ 34 in Uganda (US$ 29 from a societal perspective).

CONCLUSIONS

Rotavirus vaccine introduction is highly cost-effective in both countries in a range of plausible 'what-if' scenarios. The involvement of national experts improves the quality of data used, is likely to increase acceptability of the results in decision-making, and can contribute to strengthened national capacity to undertake economic evaluations.

Epidemiological and Economic Impact of Monovalent and Pentavalent Rotavirus Vaccines in Low and Middle Income Countries: A Cost-effectiveness Modeling Analysis

BACKGROUND

The competing choices of vaccination with either RV1 or RV5, the potential budget impact of vaccines on the EPI with different prices and new evidence make important an updated analysis for health decision makers in each country. The objective of this study is to assess cost-effectiveness of the monovalent and pentavalent rotavirus vaccines and impact on children deaths, inpatient and outpatient visits in 116 low and middle income countries that represent approximately 99% of rotavirus mortality.

METHODS

A decision tree model followed hypothetical cohorts of children from birth up to 5 years of age for each country in 2010. Inputs were gathered from international databases and previous research on incidence and effectiveness of monovalent and pentavalent vaccines. Costs were expressed in 2010 international dollars. Outcomes were reported in terms of cost per disability-adjusted life-year averted, comparing no vaccination with either monovalent or pentavalent mass introduction. Vaccine price was assumed fixed for all world low-income and middle-income countries.

RESULTS

Around 292,000 deaths, 3.34 million inpatient cases and 23.09 million outpatient cases would occur with no vaccination. In the base-case scenario, monovalent vaccination would prevent 54.7% of inpatient cases and 45.4% of deaths. Pentavalent vaccination would prevent 51.4% of inpatient cases and 41.1% of deaths. The vaccine was cost-effective in all world countries in the base-case scenario for both vaccines. Cost per disability-adjusted life-year averted in all selected countries was I$372 for monovalent, and I$453 for pentavalent vaccination.

CONCLUSION

Rotavirus vaccine is cost-effective in most analyzed countries. Despite cost-effectiveness analysis is a useful tool for decision making in middle-income countries, for low-income countries health decision makers should also assess the impact of introducing either vaccine on local resources and budget impact analysis of vaccination.

Methodological variation in economic evaluations conducted in low- and middle-income countries: information for reference case development

Information generated from economic evaluation is increasingly being used to inform health resource allocation decisions globally, including in low- and middle- income countries. However, a crucial consideration for users of the information at a policy level, e.g. funding agencies, is whether the studies are comparable, provide sufficient detail to inform policy decision making, and incorporate inputs from data sources that are reliable and relevant to the context. This review was conducted to inform a methodological standardisation workstream at the Bill and Melinda Gates Foundation (BMGF) and assesses BMGF-funded cost-per-DALY economic evaluations in four programme areas (malaria, tuberculosis, HIV/AIDS and vaccines) in terms of variation in methodology, use of evidence, and quality of reporting. The findings suggest that there is room for improvement in the three areas of assessment, and support the case for the introduction of a standardised methodology or reference case by the BMGF. The findings are also instructive for all institutions that fund economic evaluations in LMICs and who have a desire to improve the ability of economic evaluations to inform resource allocation decisions.

Comparison of impact and cost-effectiveness of rotavirus supplementary and routine immunization in a complex humanitarian emergency, Somali case study

Background

A humanitarian emergency involves a complete breakdown of authority that often disrupts routine health care delivery, including immunization. Diarrheal diseases are a principal cause of morbidity and mortality among children during humanitarian emergencies. The objective of this study was to assess if vaccination against rotavirus, the most common cause of severe diarrhea among children, either as an addition to routine immunization program (RI) or supplemental immunization activity (SIA) would be cost-effective during a humanitarian emergency to decrease diarrhea morbidity and mortality, using Somalia as a case study.

Methods

An impact and cost-effectiveness analysis was performed comparing no vaccine; two-dose rotavirus SIA and two-dose of RI for the 424,592 births in the 2012 Somali cohort. The main summary measure was the incremental cost per disability-adjusted life-year (DALY) averted. Univariate sensitivity analysis examined the extent to which the uncertainty in the variables affected estimates.

Results

If introduced in Somalia, a full-series rotavirus RI and SIA would save 908 and 359 lives, respectively, and save US$63,793 and US$25,246 in direct medical costs, respectively. The cost of a RI strategy would be US$309,458. Because of the high operational costs, a SIA strategy would cost US$715,713. US$5.30 per DALY would be averted for RI and US$37.62 per DALY averted for SIA. Variables that most substantially influenced the cost-effectiveness for both RI and SIA were vaccine program costs, mortality rate, and vaccine effectiveness against death.

Conclusions

Based on our model, rotavirus vaccination appears to be a cost-effective intervention as either RI or SIA, as defined by the World Health Organization as one to three times the per capita Gross Domestic Product (Somalia $112 in 2011). RI would have greater health impact and is more cost effective than SIA, assuming feasibility of reaching the target population. However, given the lack of infrastructure, whether RI is realistic in this setting remains unanswered, and alternative approaches like SIA should be further examined.

Rota Viral Infection: A Significant Disease Burden to Libya

BACKGROUND

Rotavirus is a common infection causing 450,000 deaths annually primarily in children 5 years and below. Despite the high burden of disease, little is known about the epidemiology of rotavirus in Libya. The aim of this study was to estimate the rotavirus disease burden among Libyan children.

METHODS

A cross-sectional study was carried out prospectively among children 5 years old and below between August 2012 and April 2013. Stool samples of children with diarrhea attending the outpatient department or admitted to the pediatric wards, at three public hospitals within the northwestern region of Libya were tested for rotavirus. The seasonality, symptomology demographics and outcomes of rotavirus cases were determined and compared to other diarrhea illnesses. An estimated incidence rate per 100,000 children aged 5 years and below was determined.

RESULTS

A total of 545 children with diarrhea were identified for participation. Results of rotavirus immunoassays determined 57% of cases were caused by rotavirus. Inpatients were more likely to be rotavirus positive than outpatients (58% vs. 53%, P<0.05), Most rotavirus positive cases (86%) were found among children below 2 years of age. Rotaviral cases peaked in the winter, constituting 76% of diarrheal illness in February and very few rotavirus cases in the summer months. The incidence rate of rotavirus diarrhea was estimated at 640/100,000 children aged 5 years and below.

CONCLUSION

Rotavirus infection poses a significant disease burden in Libya. Preventive measures such as proper hygiene should be emphasized. Introduction of vaccination against rotavirus into the national immunization program should be examined, as it would likely be a cost-effective investment.

Systematic review of the economic value of diarrheal vaccines

Diarrheal disease is a leading cause of child mortality in low-income settings and morbidity across a range of settings. A growing number of studies have addressed the economic value of new and emerging vaccines to reduce this threat. We conducted a systematic review to assess the economic value of diarrheal vaccines targeting a range of pathogens in different settings. The majority of studies focused on the economic value of rotavirus vaccines in different settings, with most of these concluding that vaccination would provide significant economic benefits across a range of vaccine prices. There is also evidence of the economic benefits of cholera vaccines in specific contexts. For other potential diarrheal vaccines data are limited and often hypothetical. Across all target pathogens and contexts, the evidence of economic value focuses the short-term health and economic gains. Additional information is needed on the broader social and long-term economic value of diarrhea vaccines.

Systematic review of studies on rotavirus disease cost-of-illness and productivity loss in Latin America and the Caribbean

BACKGROUND

Rotavirus is the most common cause of severe acute diarrhea among children in both developed and developing countries. Vaccination can reduce the disease burden and its incorporation into health care systems should consider future costs and benefits.

OBJECTIVES

To systematically review studies on costs due to rotavirus infection in Latin America and Caribbean (LAC) region, considering their methods and results.

METHODS

A search of relevant databases including the Cochrane Central Register of Controlled Trials, Embase, MEDLINE via PubMed, the Latin American and Caribbean Health Sciences Literature database (LILACS), and the Brazilian Thesis Databank was performed. Inclusion criteria for studies were: (a) economic evaluation or cost-of-illness studies; (b) conducted in the LAC region; (c) assess economic burden of rotavirus disease or the economic impact of rotavirus vaccination programs. Two authors independently screened the studies for eligibility.

RESULTS

Of 444 studies initially retrieved, 21 met the eligibility criteria and were included (14 cost-effectiveness analyses of vaccination programs and 7 cost-of-illness studies). Direct medical costs were assessed in all 21 studies, but only 10 also investigated indirect and non-medical direct costs. The most commonly observed methods for cost estimation were retrospective database analysis and hospital-based surveillance study. Only one study was a household-based survey.A wide cost range was identified (e.g., inpatient care US$79.91 to US$858.40 and outpatient care US$13.06 to US$64.10), depending on the methods, study perspective, and type of costs included.

CONCLUSION

Rotavirus-associated costs were assessed in 21 studies across the Latin America and Caribbean region. The majority of studies were made alongside economic evaluations of vaccination programs. Methods are broadly different among studies but administrative databases seem to be the most employed source of data.

Systematic review of incremental non-vaccine cost estimates used in cost-effectiveness analysis on the introduction of rotavirus and pneumococcal vaccines

OBJECTIVE

To review the approaches used in the cost-effectiveness analysis (CEAs) literature to estimate the cost of expanded program on immunization (EPI) activities, other than vaccine purchase, for rotavirus and pneumococcal vaccines.

METHODS

A systematic review in PubMed and NHS EED databases of rotavirus and pneumococcal vaccines CEAs was done. Selected articles were read and information on how EPI costs were calculated was extracted. EPI costing approaches were classified according to the method or assumption used for estimation.

RESULTS

Seventy-nine studies that evaluated cost effectiveness of rotavirus (n=43) or pneumococcal (n=36) vaccines were identified. In general, there are few details on how EPI costs other than vaccine procurement were estimated. While 30 studies used some measurement of that cost, only one study on pneumococcal vaccine used a primary cost evaluation (bottom-up costing analysis) and one study used a costing tool. Twenty-seven studies (17 on rotavirus and 10 on pneumococcal vaccine) assumed the non-vaccine costs. Five studies made no reference to additional costs. Fourteen studies (9 rotavirus and 5 pneumococcal) did not consider any additional EPI cost beyond vaccine procurement. For rotavirus studies, the median for non-vaccine cost per dose was US$0.74 in developing countries and US$6.39 in developed countries. For pneumococcal vaccines, the median for non-vaccine cost per dose was US$1.27 in developing countries and US$8.71 in developed countries.

CONCLUSIONS

Many pneumococcal (52.8%) and rotavirus (60.4%) cost-effectiveness analyses did not consider additional EPI costs or used poorly supported assumptions. Ignoring EPI costs in addition to those for vaccine procurement in CEA analysis of new vaccines may lead to significant errors in the estimations of ICERs since several factors like personnel, cold chain, or social mobilization can be substantially affected by the introduction of new vaccines.

Cost-effectiveness of a new rotavirus vaccination program in Pakistan: a decision tree model

BACKGROUND

Rotavirus gastroenteritis places a significant health and economic burden on Pakistan. To determine the public health impact of a national rotavirus vaccination program, we performed a cost-effectiveness study from the perspective of the health care system.

METHODS

A decision tree model was developed to assess the cost-effectiveness of a national vaccination program in Pakistan. Disease and cost burden with the program were compared to the current state. Disease parameters, vaccine-related costs, and medical treatment costs were based on published epidemiological and economic data, which were specific to Pakistan when possible. An annual birth cohort of children was followed for 5 years to model the public health impact of vaccination on health-related events and costs. The cost-effectiveness was assessed and quantified in cost (2012 US$) per disability-adjusted life-year (DALY) averted and cost per death averted. Sensitivity analyses were performed to assess the robustness of the incremental cost-effectiveness ratios (ICERs).

RESULTS

The base case results showed vaccination prevented 1.2 million cases of rotavirus gastroenteritis, 93,000 outpatient visits, 43,000 hospitalizations, and 6700 deaths by 5 years of age for an annual birth cohort scaled from 6% current coverage to DPT3 levels (85%). The medical cost savings would be US$1.4 million from hospitalizations and US$200,000 from outpatient visit costs. The vaccination program would cost US$35 million at a vaccine price of US$5.00. The ICER was US$149.50 per DALY averted or US$4972 per death averted. Sensitivity analyses showed changes in case-fatality ratio, vaccine efficacy, and vaccine cost exerted the greatest influence on the ICER.

CONCLUSIONS

Across a range of sensitivity analyses, a national rotavirus vaccination program was predicted to decrease health and economic burden due to rotavirus gastroenteritis in Pakistan by ~40%. Vaccination was highly cost-effective in this context. As discussions of implementing the intervention intensify, future studies should address affordability, efficiency, and equity of vaccination introduction.

Public finance of rotavirus vaccination in India and Ethiopia: an extended cost-effectiveness analysis

BACKGROUND

An estimated 4% of global child deaths (approximately 300,000 deaths) were attributed to rotavirus in 2010. About a third of these deaths occurred in India and Ethiopia. Public finance of rotavirus vaccination in these two countries could substantially decrease child mortality and also reduce rotavirus-related hospitalizations, prevent health-related impoverishment and bring significant cost savings to households.

METHODS

We use a methodology of 'extended cost-effectiveness analysis' (ECEA) to evaluate a hypothetical publicly financed program for rotavirus vaccination in India and Ethiopia. We measure program impact along four dimensions: 1) rotavirus deaths averted; 2) household expenditures averted; 3) financial risk protection afforded; 4) distributional consequences across the wealth strata of the country populations.

RESULTS

In India and Ethiopia, the program would lead to a substantial decrease in rotavirus deaths, mainly among the poorer; it would reduce household expenditures across all income groups and it would effectively provide financial risk protection, mostly concentrated among the poorest. Potential indirect benefits of vaccination (herd immunity) would increase program benefits among all income groups, whereas potentially decreased vaccine efficacy among poorer households would reduce the equity benefits of the program.

CONCLUSIONS

Our approach incorporates financial risk protection and distributional consequences into the systematic economic evaluation of vaccine policy, illustrated here with the case study of public finance for rotavirus vaccination. This enables selection of vaccine packages based on the quantitative inclusion of information on equity and on how much financial risk protection is being bought per dollar expenditure on vaccine policy, in addition to how much health is being bought.

Cost-effectiveness of Haemophilus influenzae type b conjugate vaccine in low- and middle-income countries: regional analysis and assessment of major determinants

OBJECTIVES

To estimate the cost-effectiveness of Haemophilus influenzae type b (Hib) conjugate vaccine in low- and middle-income countries and identify the model variables, which are most important for the result.

STUDY DESIGN

A static decision tree model was developed to predict incremental costs and health impacts. Estimates were generated for 4 country groups: countries eligible for funding by the GAVI Alliance in Africa and Asia, lower middle-income countries, and upper middle-income countries. Values, including disease incidence, case fatality rates, and treatment costs, were based on international country estimates and the scientific literature.

RESULTS

From the societal perspective, it is estimated that the probability of Hib conjugate vaccine cost saving is 34%-53% in Global Alliance for Vaccines and Immunization eligible African and Asian countries, respectively. In middle-income countries, costs per discounted disability adjusted life year averted are between US$37 and US$733. Variation in vaccine prices and risks of meningitis sequelae and mortality explain most of the difference in results. For all country groups, disease incidence cause the largest part of the uncertainty in the result.

CONCLUSIONS

Hib conjugate vaccine is cost saving or highly cost-effective in low- and middle-income settings. This conclusion is especially influenced by the recent decline in Hib conjugate vaccine prices and new data revealing the high costs of lost productivity associated with meningitis sequelae.

Putting health metrics into practice: using the disability-adjusted life year for strategic decision making

BACKGROUND

Implementing organizations are pressured to be accountable for performance. Many health impact metrics present limitations for priority setting; they do not permit comparisons across different interventions or health areas. In response, Population Services International (PSI) adopted the disability-adjusted life year (DALY) averted as its bottom-line performance metric. While international standards exist for calculating DALYs to determine burden of disease (BOD), PSI's use of DALYs averted is novel. It uses DALYs averted to assess and compare the health impact of its country programs, and to understand the effectiveness of a portfolio of interventions. This paper describes how the adoption of DALYs averted influenced organizational strategy and presents the advantages and constraints of using the metric.

METHODS

Health impact data from 2001-2011 were analyzed by program area and geographic region to measure PSI's performance against its goal of doubling health impact between 2007-2011. Analyzing 10 years of data permitted comparison with previous years' performance. A case study of PSI's Asia and Eastern European (A/EE) region, and PSI/Laos, is presented to illustrate how the adoption of DALYs averted affected strategic decision making.

RESULTS

Between 2007-2011, PSI's programs doubled the total number of DALYs averted from 2002-2006. Most DALYs averted were within malaria, followed by HIV/AIDS and family planning (FP). The performance of PSI's A/EE region relative to other regions declined with the switch to DALYs averted. As a result, the region made a strategic shift to align its work with countries' BOD. In PSI/Laos, this redirection led to better-targeted programs and an approximate 50% gain in DALYs averted from 2009-2011.

CONCLUSIONS

PSI's adoption of DALYs averted shifted the organization's strategic direction away from product sales and toward BOD. Now, many strategic decisions are based on "BOD-relevance," the share of the BOD that interventions can potentially address. This switch resulted in more targeted strategies and greater program diversification. Challenges remain in convincing donors to support interventions in disease areas that are relevant to a country's BOD, and in developing modeling methodologies. The global health community will benefit from the use of standard health impact metrics to improve strategic decision making and more effectively respond to the changing global burden of disease.

The use of cost-effectiveness analysis for pediatric immunization in developing countries

CONTEXT

Developing countries face critical choices for introducing needed, effective, but expensive new vaccines, especially given the accelerated need to decrease the mortality of children under age five and the increased immunization resources available from international donors. Cost-effectiveness analysis (CEA) is a tool that decision makers can use for efficiently allocating expanding resources. Its use in developing countries, however, lags behind that in industrialized countries.

METHODS

We explored how CEA could be made more relevant to immunization policymaking in developing countries by identifying the limitations for using CEA in developing countries and the impact of donor funding on the CEA estimation. We conducted a comprehensive literature search using formal search protocols and hand searching indexed and gray literature sources. We then systematically summarized the application of CEA in industrialized and developing countries through thematic analysis, focusing on pediatric immunization and methodological and contextual issues relevant to developing countries.

FINDINGS

Industrialized and developing countries use CEA differently. The use of the Disability-Adjusted Life Year (DALY) outcome measure and an alternative generalized cost-effectiveness analysis approach is restricted to developing countries. In pediatric CEAs, the paucity of evaluations and the lack of attention to overcoming the methodological limitations pertinent to children's cognitive and development distinctiveness, such as discounting and preference characterization, means that pediatric interventions may be systematically understudied and undervalued. The ability to generate high-quality CEA evidence in child health is further threatened by an inadequate consideration of the impact of donor funding (such as GAVI immunization funding) on measurement uncertainty and the determination of opportunity cost.

CONCLUSIONS

Greater attention to pediatric interventions and donor funding in the conduct of CEA could lead to better policies and thus more worthwhile and good-value programs to benefit children's health in developing countries.

Pharmacoeconomic spotlight on rotavirus vaccine RIX4414 (Rotarix™) in the prevention of rotavirus gastroenteritis in developing countries

This article provides an overview of the clinical profile of rotavirus vaccine RIX4414 (Rotarix™) in the prevention of rotavirus gastroenteritis (RVGE) in developing countries, followed by a review of pharmacoeconomic analyses with the vaccine in low- and middle-income countries. RVGE is associated with significant morbidity and mortality among children <5 years of age in developing countries. The protective efficacy of a two-dose oral series of rotavirus vaccine RIX4414 has been demonstrated in several well designed clinical trials conducted in developing countries, and the 'real-world' effectiveness of the vaccine has also been shown in naturalistic and case-control trials after the introduction of universal vaccination programs with RIX4414 in Latin American countries. The WHO recommends universal rotavirus vaccination programs for all countries. Numerous modelled cost-effectiveness analyses have been conducted with rotavirus vaccine RIX4414 across a wide range of low- and middle-income countries. Although data sources and assumptions varied across studies, results of the analyses consistently showed that the introduction of the vaccine as part of a national vaccination program would be very cost effective compared with no rotavirus vaccination program, according to widely used cost-effectiveness thresholds for developing countries. Vaccine price was not known at the time the analyses were conducted and had to be estimated. In sensitivity analyses, rotavirus vaccine RIX4414 generally remained cost effective at the highest of a range of possible vaccine prices considered. Despite these favorable results, decisions regarding the implementation of universal vaccination programs with RIX4414 may also be contingent on budgetary and other factors, underscoring the importance of subsidized vaccination programs for poor countries through the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization).

Cost-effectiveness and economic benefits of vaccines in low- and middle-income countries: a systematic review

BACKGROUND

Public health interventions that prevent mortality and morbidity have greatly increased over the past decade. Immunization is one of these preventive interventions, with a potential to bring economic benefits beyond just health benefits. While vaccines are considered to be a cost-effective public health intervention, implementation has become increasingly challenging. As vaccine costs rise and competing priorities increase, economic evidence is likely to play an increasingly important role in vaccination decisions.

METHODS

To assist policy decisions today and potential investments in the future, we provide a systematic review of the literature on the cost-effectiveness and economic benefits of vaccines in low- and middle-income countries from 2000 to 2010. The review identified 108 relevant articles from 51 countries spanning 23 vaccines from three major electronic databases (Pubmed, Embase and Econlit).

RESULTS

Among the 44 articles that reported costs per disability-adjusted life year (DALY) averted, vaccines cost less than or equal to $100 per DALY averted in 23 articles (52%). Vaccines cost less than $500 per DALY averted in 34 articles (77%), and less than $1000 per DALY averted in 38 articles (86%) in one of the scenarios. 24 articles (22%) examined broad level economic benefits of vaccines such as greater future wage-earning capacity and cost savings from averting disease outbreaks. 60 articles (56%) gathered data from a primary source. There were little data on long-term and societal economic benefits such as morbidity-related productivity gains, averting catastrophic health expenditures, growth in gross domestic product (GDP), and economic implications of demographic changes resulting from vaccination.

CONCLUSIONS

This review documents the available evidence and shows that vaccination in low- and middle-income countries brings important economic benefits. The cost-effectiveness studies reviewed suggest to policy makers that vaccines are an efficient investment. This review further highlights key gaps in the available literature that would benefit from additional research, especially in the area of evaluating the broader economic benefits of vaccination in the developing world.

Country planning for health interventions under development: lessons from the malaria vaccine decision-making framework and implications for other new interventions

Traditionally it has taken years or decades for new public health interventions targeting diseases found in developing countries to be accessible to those most in need. One reason for the delay has been insufficient anticipation of the eventual processes and evidence required for decision making by countries. This paper describes research into the anticipated processes and data needed to inform decision making on malaria vaccines, the most advanced of which is still in phase 3 trials. From 2006 to 2008, a series of country consultations in Africa led to the development of a guide to assist countries in preparing their malaria vaccine decision-making frameworks. The guide builds upon the World Health Organization's Vaccine Introduction Guidelines. It identifies the processes and data for decisions, when they would be needed relative to the development timelines of the intervention, and where they will come from. Policy development will be supported by data (e.g. malaria disease burden; roles of other malaria interventions; malaria vaccine impact; economic and financial issues; malaria vaccine efficacy, quality and safety) as will implementation decisions (e.g. programmatic issues and socio-cultural environment). This generic guide can now be applied to any future malaria vaccine. The paper discusses the opportunities and challenges to early planning for country decision-making-from the potential for timely, evidence-informed decisions to the risks of over-promising around an intervention still under development. Careful and well-structured planning by countries is an important way to ensure that new interventions do not remain unused for years or decades after they become available.

Rotavirus vaccine RIX4414 (Rotarix™): a pharmacoeconomic review of its use in the prevention of rotavirus gastroenteritis in developing countries

This article provides an overview of the clinical profile of rotavirus vaccine RIX4414 (Rotarix™) in the prevention of rotavirus gastroenteritis (RVGE) in developing countries, followed by a comprehensive review of pharmacoeconomic analyses with the vaccine in low- and middle-income countries. RVGE is associated with significant morbidity and mortality among children <5 years of age in developing countries. The protective efficacy of a two-dose oral series of rotavirus vaccine RIX4414 has been demonstrated in several well designed clinical trials conducted in developing countries, and the 'real-world' effectiveness of the vaccine has also been shown in naturalistic and case-control trials after the introduction of universal vaccination programmes with RIX4414 in Latin American countries. The WHO recommends universal rotavirus vaccination programmes for all countries. Numerous modelled cost-effectiveness analyses have been conducted with rotavirus vaccine RIX4414 across a wide range of low- and middle-income countries. Although data sources and assumptions varied across studies, results of the analyses consistently showed that the introduction of the vaccine as part of a national vaccination programme would be very (or highly) cost effective compared with no rotavirus vaccination programme, according to widely used cost-effectiveness thresholds for developing countries. Vaccine price was not known at the time the analyses were conducted and had to be estimated. In sensitivity analyses, rotavirus vaccine RIX4414 generally remained cost effective at the highest of a range of possible vaccine prices considered. Despite these favourable results, decisions regarding the implementation of universal vaccination programmes with RIX4414 may also be contingent on budgetary and other factors, underscoring the importance of subsidized vaccination programmes for poor countries through the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization).

Comparative evaluation of the potential impact of rotavirus versus HPV vaccination in GAVI-eligible countries: a preliminary analysis focused on the relative disease burden

BACKGROUND

Immunization policymakers at global and local levels need to establish priorities among new vaccines competing for limited resources. However, comparison of the potential impact of single vaccination programs is challenging, primarily due to the limited number of vaccine analyses as well as their differing analytic approaches and reporting formats. The purpose of this study is to provide early insight into how the comparative impact of different new vaccines could be assessed in resource-poor settings with respect to affordability, cost-effectiveness, and distributional equity.

METHODS

We compared the health, economic, and financial consequences of introducing the two vaccines in 72 GAVI-eligible countries using a number of different outcome measures to evaluate affordability, cost-effectiveness, and distributional equity. We use simple static models to standardize the analytic framework and improve comparability between the two new vaccines. These simple models were validated by leveraging previously developed, more complex models for rotavirus and human papillomavirus (HPV).

RESULTS

With 70% coverage of a single-age cohort of infants and pre-adolescent girls, the lives saved with rotavirus (~274,000) and HPV vaccines (~286,000) are similar, although the timing of averted mortality differs; rotavirus-attributable deaths occur in close proximity to infection, while HPV-related cancer deaths occur largely after age 30. Deaths averted per 1000 vaccinated are 5.2 (rotavirus) and 12.6 (HPV). Disability-adjusted life years (DALYs) averted were ~7.15 million (rotavirus) and ~1.30 million (HPV), reflecting the greater influence of discounting on the latter, given the lagtime between vaccination and averted cancer. In most countries (68 for rotavirus and 66 for HPV, at the cost of I$25 per vaccinated individual) the incremental cost per DALY averted was lower than each country's GDP per capita. Financial resources required for vaccination with rotavirus are higher than with HPV since both genders are vaccinated.

CONCLUSIONS

While lifesaving benefits of rotavirus and HPV vaccines will be realized at different times, the number of lives saved over each target populations' lifetimes will be similar. Model-based analyses that use a standardized analytic approach and generate comparable outputs can enrich the priority-setting dialogue. Although new vaccines may be deemed cost-effective, other factors including affordability and distributional equity need to be considered in different settings. We caution that for priority setting in an individual country, more rigorous comparisons should be performed, using more comprehensive models and considering all relevant vaccines and delivery strategies.

Health care seeking behavior for diarrhea in children under 5 in rural Niger: results of a cross-sectional survey

BACKGROUND

Diarrhea remains the second leading cause of death in children under 5 years of age in sub-Saharan Africa. Health care seeking behavior for diarrhea varies by context and has important implications for developing appropriate care strategies and estimating burden of disease. The objective of this study was to determine the proportion of children under five with diarrhea who consulted at a health structure in order to identify the appropriate health care levels to set up surveillance of severe diarrheal diseases.

METHODS

A cluster survey was done on 35 clusters of 21 children under 5 years of age in each of four districts of the Maradi Region, Niger. Caretakers were asked about diarrhea of the child during the recall period and their health seeking behavior in case of diarrhea. A weighted cluster analysis was conducted to determine the prevalence of diarrhea, as well as the proportion of consultations and types of health structures consulted.

RESULTS

In total, the period prevalence of diarrhea and severe diarrhea between April 24th and May 21st 2009 were 36.8% (95% CI: 33.7 - 40.0) and 3.4% (95% CI: 2.2-4.6), respectively. Of those reporting an episode of diarrhea during the recall period, 70.4% (95% CI: 66.6-74.1) reported seeking care at a health structure. The main health structures visited were health centers, followed by health posts both for simple or severe diarrhea. Less than 10% of the children were brought to the hospital. The proportion of consultations was not associated with the level of education of the caretaker, but increased with the number of children in the household.

CONCLUSIONS

The proportion of consultations for diarrhea cases in children under 5 years old was higher than those reported in previous surveys in Niger and elsewhere. Free health care for under 5 years old might have participated in this improvement. In this type of decentralized health systems, the WHO recommended hospital-based surveillance of severe diarrheal diseases would capture only a fraction of severe diarrhea. Lower levels of health structures should be considered to obtain informative data to ensure appropriate care and burden estimates.

Economic impact of dengue illness in the Americas

The growing burden of dengue in endemic countries and outbreaks in previously unaffected countries stress the need to assess the economic impact of this disease. This paper synthesizes existing studies to calculate the economic burden of dengue illness in the Americas from a societal perspective. Major data sources include national case reporting data from 2000 to 2007, prospective cost of illness studies, and analyses quantifying underreporting in national routine surveillance systems. Dengue illness in the Americas was estimated to cost $2.1 billion per year on average (in 2010 US dollars), with a range of $1-4 billion in sensitivity analyses and substantial year to year variation. The results highlight the substantial economic burden from dengue in the Americas. The burden for dengue exceeds that from other viral illnesses, such as human papillomavirus (HPV) or rotavirus. Because this study does not include some components (e.g., vector control), it may still underestimate total economic consequences of dengue.