Do current cost-effectiveness analyses reflect the full value of childhood vaccination in Europe? A rotavirus case study

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

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

The economic impact of the introduction of universal rotavirus vaccination on rotavirus gastroenteritis related hospitalisations in children in Ireland

BACKGROUND

Rotavirus gastroenteritis (RVGE), a vaccine preventable disease, remains a common cause of severe gastroenteritis in children globally. Ireland introduced the universal rotavirus vaccination to the national immunisation programme in 2016. In this paper the economic impact on RVGE related hospitalisations amongst children under 5 years is examined.

METHODS

Using national data from all Irish public hospitals, an Interrupted Times Series Analysis (ITSA) compares RVGE hospitalisations amongst children under 5 years, pre- and post-vaccine introduction. Costs are estimated and ITSA results are compared to the counterfactual to estimate the economic impact of the vaccine. A probit model examines patient characteristics pre- and post-vaccine introduction.

RESULTS

Vaccine introduction coincided with lowered RVGE related hospitalisations. While this effect was delayed (1 year) there is evidence of a sustained impact. RVGE patients' post-vaccine introduction were likely to be over 2 years (p = 0.001) and length of stay was lower on average (p = 0.095). The counterfactual analysis revealed 492 RVGE hospitalisations were avoided on average annually since the introduction of the vaccine. This has an estimated economic value of €0.92 million per annum.

CONCLUSIONS

Following the introduction of the rotavirus vaccine in Ireland, hospitalisations for RVGE decreased significantly and those hospitalised were older and with a reduced length of stay on average. This has the potential for significant cost savings for the Irish healthcare system.

Explaining the formation of a plateau in rotavirus vaccine impact on rotavirus hospitalisations in Belgium

BACKGROUND

Observational data on the reduction in hospitalisations after rotavirus vaccine introduction in Belgium suggest that vaccine impact plateaued at an unexpectedly high residual hospitalisation rate. The objective of this analysis was to identify factors that influence real-world vaccine impact.

METHODS

Data were collected on hospitalisations in children aged ≤ 5 years with rotavirus disease from 11 hospitals since 2005 (the RotaBIS study). The universal rotavirus vaccination campaign started late in 2006. A mathematical model simulated rotavirus hospitalisations in different age groups using vaccine efficacy and herd effect, influenced by vaccine coverage, vaccine waning, and secondary infection sources. The model used optimisation analysis to fit the simulated curve to the observed data, applying Solver add-in software. It also simulated an 'ideal' vaccine introduction maximising hospitalisation reduction (maximum coverage, maximum herd effect, no waning), and compared this with the best-fit simulated curve. Modifying model input values identified factors with the largest impact on hospitalisations.

RESULTS

Compared with the 'ideal' simulation, observed data showed a slower decline in hospitalisations and levelled off after three years at a higher residual hospitalisation rate. The slower initial decline was explained by the herd effect in unvaccinated children. The higher residual hospitalisation rate was explained by starting the vaccine programme in November, near the rotavirus seasonal peak. This resulted in low accumulated vaccine coverage during the first rotavirus disease peak season, with the consequential appearance of secondary infection sources. This in turn reduced the herd effect, resulting in a diminished net impact.

CONCLUSIONS

Our results indicate that countries wishing to maximise the impact of rotavirus vaccination should start vaccinating well ahead of the rotavirus seasonal disease peak. This maximises herd effect during the first year leading to rapid and high reduction in hospitalisations. Secondary infection sources explain the observed data in Belgium better than vaccine waning.

Selection and Interpretation of Scientific Evidence in Preparation for Policy Decisions: A Case Study Regarding Introduction of Rotavirus Vaccine Into National Immunization Programs in Sweden, Norway, Finland, and Denmark

The World Health Organization recommends inclusion of rotavirus vaccines in national immunization programs (NIPs) worldwide. Nordic countries are usually considered comparable in terms of demographics and health-care services and have comparable rotavirus disease burden. Nevertheless, the countries have reached different decisions regarding rotavirus vaccine: Norway and Finland have already introduced rotavirus vaccines into their NIPs and Sweden is currently changing its recommendation and vaccines will now be introduced on a national scale while Denmark has decided against it. This study focuses on the selection and interpretation of medical and epidemiological evidence used during the decision-making processes in Sweden, Norway, Finland, and Denmark. The so-called "severity criteria" is identified as one of the main reasons for the different policy decisions reached across the Nordic countries.

A review of recommendations for rotavirus vaccination in Europe: Arguments for change

BACKGROUND

More than 10 years after the authorisation of two rotavirus vaccines of demonstrated efficacy and with a strongly positive benefit-risk profile, uptake in Europe remains low. Only 13 countries in Europe provide a fully-funded rotavirus universal mass vaccination (UMV) programme, three provide a partially-funded programme, and one provides full funding for a reduced programme targeting at-risk infants. Around 40% of countries in Europe currently have no existing recommendations for rotavirus vaccine use in children from the national government.

METHODS

We provide an overview of the status of rotavirus vaccine recommendations across Europe and the factors impeding uptake. We consider the evidence for the benefits and risks of vaccination, and argue that cost-effectiveness and cost-saving benefits justify greater access to rotavirus vaccines for infants living in Europe.

RESULTS

Lack of awareness of the direct and indirect burden caused by rotavirus disease, potential cost-saving from rotavirus vaccination including considerable benefits to children, families and society, and government/insurer cost constraints all contribute to complacency at different levels of health policy in individual countries.

CONCLUSIONS

More than 10 years after their introduction, available data confirm the benefits and acceptable safety profile of infant rotavirus UMV programmes. Europe serves to gain considerably from rotavirus UMV in terms of reductions in healthcare resource utilization and related costs in both vaccinated subjects and their unvaccinated siblings through herd protection.

Cost-Effectiveness of Rotavirus Vaccination in France-Accounting for Indirect Protection

BACKGROUND

Vaccination against rotavirus has shown great potential for reducing the primary cause of severe childhood gastroenteritis. Previous economic evaluations of rotavirus vaccination in France have not modeled the potential impact of vaccines on disease burden via reduced transmission.

OBJECTIVE

To determine the cost-effectiveness of the introduction of pentavalent rotavirus vaccination into the French infant vaccination schedule.

METHODS

We developed an age-structured model of rotavirus transmission calibrated to 6 years of French gastroenteritis incidence and vaccine clinical trial data. We evaluated the cost-effectiveness of pentavalent rotavirus vaccination considering that 75% of infants would receive the three-dose vaccine course.

RESULTS

Our model predicts that rotavirus vaccination will decrease rotavirus gastroenteritis incidence and associated clinical outcomes in vaccinated and unvaccinated individuals, delay the seasonal peak of infection, and increase the age of infection. From the societal perspective, our base-case scenario predicts that vaccination coverage would be cost-effective at €115 or €135 per vaccine course at €28,500 and €39,500/quality-adjusted life-year (QALY) gained, respectively, and suggests that almost 95% of the financial benefits will be recouped within the first 5 years following vaccination implementation. From the third-party payer perspective, incremental cost-effectiveness ratios ranged from €12,500 to €20,000/QALY, respectively. Our uncertainty analysis suggests that findings were sensitive to various assumptions including the number of hospitalizations, outpatient visits, and the extent of QALY losses per rotavirus episode.

CONCLUSIONS

Introducing pentavalent rotavirus vaccination into the French infant vaccination schedule would significantly reduce the burden of rotavirus disease in children, and could be cost-effective under plausible conditions.

The cost of vaccination throughout life: A western European overview

Despite the interest of policy makers, the actual investment in vaccination is poorly documented. Our study assessed the costs of vaccination throughout life for a fully immunized Western European citizen. National vaccination calendars for England, France, Germany, Italy, Portugal, Spain and Sweden were retrieved. We differentiated men from women and healthy individuals from those suffering from underlying conditions who require specific additional vaccinations. Vaccine costs and administration fees were retrieved from official national source and calculated from the national healthcare perspective. Vaccinating an individual against up to 17 diseases throughout his entire life and in full compliance with national vaccination calendars cost between €328 and €2,352 (vaccines costs only) and between €443 and €3,395 (administration costs included), the lowest range corresponds to a healthy man in Sweden and the highest to a woman with underlying conditions in England. Vaccination costs varied among countries due to heterogeneous national vaccination calendars and organization. In all countries, adults (18-64 y) and elderly (≥65 y) accounted for the lowest vaccines costs compared with infants (0-24 m) and children/adolescents (2-17 y). In comparison, other mass secondary preventive therapies may be at least 3 times more costly. Vaccination requires a relatively low level of investment per individual. Our estimates should be considered to be the maximum potential costs due to our 100% compliance assumption. Increasing coverage rates would bring additional public health benefits for a relatively low incremental cost. A life-course approach of vaccination should also be encouraged because some missed opportunities remain in senior vaccinations.

Protection of young children from influenza through universal vaccination

Influenza is a very common disease among infants and young children, with a considerable clinical and socioeconomic impact. A significant number of health authorities presently recommend universal influenza vaccination for the pediatric population, but a large number of European health authorities is still reluctant to include influenza vaccination in their national vaccination programs. The reasons for this reluctance include the fact that the protection offered by the currently available vaccines is considered poor. This review shows that although future research could lead to an increase in the immunogenicity and potential efficacy of influenza vaccines, the available vaccines, even with their limits, assure sufficient protection in most subjects aged ≥ 6 months, thus reducing the total burden of influenza in young children and justifying the recommendation for the universal vaccination of the whole pediatric population. For younger subjects, the vaccination of their mother during pregnancy represents an efficacious strategy.

How much money is spent on vaccines across Western European countries?

Prevention programs, particularly vaccinations, remain highly vulnerable to budget cuts because their benefits may not be immediately identifiable. Seven Western European countries were selected (Germany, England, France, Italy, Spain, Sweden and Portugal) constituting a good mix of vaccine procurement modalities, with the objective to document the proportion of healthcare spending devoted to vaccines and its evolution. A data search was performed using the OECD online databases and official national sources from 2008 (2006 for England). No country spent more than 0.5% of its healthcare budget on vaccines. The proportion ranged from 0.25% in Spain (2012) and France (2013) to 0.47% in Germany (2014). Whereas healthcare spending increased in all countries but Spain (with increases ranging from +2.6% per year in France between 2008 and 2013 to +8.1% per year in England between 2006/07 and 2009/10), vaccine spending diminished markedly in Germany (-6.2% per year from 2008 to 2014), Spain (-6.7% per year from 2008 to 2012) and France (-4.2% per year from 2008 to 2013). Only Sweden (+5.9% per year from 2011 to 2013) and England (+18.9% per year from 2006/07 to 2009/10) increased their spending on vaccines. Vaccination involves relatively low levels of healthcare investment in Western Europe relative to the far-reaching public health benefits that it provides. We found a net trend toward a decrease in such spending in recent years, with the exception of Sweden and England. Vaccination budgets should be preserved or even increased to sustain a life-course approach to immunization with sufficient coverage rates.

Sources and Characteristics of Utility Weights for Economic Evaluation of Pediatric Vaccines: A Systematic Review

BACKGROUND

Cost-effectiveness analysis of pediatric vaccines for infectious diseases often requires quality-of-life (utility) weights.

OBJECTIVE

To investigate how utility weights have been elicited and used in this context.

METHODS

A systematic review was conducted of studies published between January 1990 and July 2013 that elicited or used utility weights in cost-effectiveness analyses of vaccines for pediatric populations. The review focused on vaccines for 17 infectious diseases and is presented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology.

RESULTS

A total of 6410 titles and abstracts and 225 full-text articles were reviewed. Of those selected for inclusion (n = 101), 15 articles described the elicitation of utility weights and 86 described economic modeling studies using utilities. Various methods were used to generate utilities, including time trade-off, contingent valuation, and willingness to pay, as well as a preference-based measure with associated value sets, such as the EuroQol five-dimensional questionnaire or the Health Utilities Index. In modeling studies, the source of utilities used was often unclear, poorly reported, or based on weak underlying evidence. We found no articles that reported on the elicitation or use of utilities in diphtheria, polio, or tetanus.

CONCLUSIONS

The scarcity of appropriate utility weights for vaccine-preventable infectious diseases in children and a lack of standardization in their use in economic assessments limit the ability to accurately assess the benefits associated with interventions to prevent infectious diseases. This is an issue that should be of concern to those making decisions regarding the prevention and treatment of infectious childhood illnesses.

Assessing the Costs and Cost-Effectiveness of Genomic Sequencing

Despite dramatic drops in DNA sequencing costs, concerns are great that the integration of genomic sequencing into clinical settings will drastically increase health care expenditures. This commentary presents an overview of what is known about the costs and cost-effectiveness of genomic sequencing. We discuss the cost of germline genomic sequencing, addressing factors that have facilitated the decrease in sequencing costs to date and anticipating the factors that will drive sequencing costs in the future. We then address the cost-effectiveness of diagnostic and pharmacogenomic applications of genomic sequencing, with an emphasis on the implications for secondary findings disclosure and the integration of genomic sequencing into general patient care. Throughout, we ground the discussion by describing efforts in the MedSeq Project, an ongoing randomized controlled clinical trial, to understand the costs and cost-effectiveness of integrating whole genome sequencing into cardiology and primary care settings.

The intangible benefits of vaccination - what is the true economic value of vaccination?

Previous economic evaluations of new vaccines largely focussed on a narrow set of benefit categories, including primarily health gains and disease-related medical cost-savings, which probably resulted in underestimates of the true value of these vaccines. Other economic benefits of vaccines could be considered to assess the full economic value of vaccination, such as, for example, impact of the human papillomavirus vaccine on women's fertility through the decrease in precancerous lesions and, therefore, in the number of diagnostic and treatment interventions, which can be associated with an increased risk of subsequent pregnancy complications. Vaccines' impact on resource allocation at hospital level or on antimicrobial resistance, such as pneumococcal conjugate vaccines that have substantially reduced infections due to antimicrobial non-susceptible strains, thereby rendering the residual disease easier to treat, are other examples of intangible benefits of vaccination. These benefits are generally not considered in economic evaluations because they may not be immediately visible and are difficult to quantify. However, they should be taken into consideration in health technology assessments to enable those responsible for healthcare policies to make well-informed decisions on vaccination.