The impact of alternative delivery strategies for novel tuberculosis vaccines in low-income and middle-income countries: a modelling study

BackgroundTuberculosis is a leading infectious cause of death worldwide. Novel vaccines will be required to reach global targets and reverse setbacks resulting from the COVID-19 pandemic. We estimated the impact of novel tuberculosis vaccines in low-income and middle-income countries (LMICs) in several delivery scenarios.MethodsWe calibrated a tuberculosis model to 105 LMICs (accounting for 93% of global incidence). Vaccine scenarios were implemented as the base-case (routine vaccination of those aged 9 years and one-off vaccination for those aged 10 years and older, with country-specific introduction between 2028 and 2047, and 5-year scale-up to target coverage); accelerated scale-up similar to the base-case, but with all countries introducing vaccines in 2025, with instant scale-up; and routine-only (similar to the base-case, but including routine vaccination only). Vaccines were assumed to protect against disease for 10 years, with 50% efficacy.FindingsThe base-case scenario would prevent 44·0 million (95% uncertainty range 37·2–51·6) tuberculosis cases and 5·0 million (4·6–5·4) tuberculosis deaths before 2050, compared with equivalent estimates of cases and deaths that would be predicted to occur before 2050 with no new vaccine introduction (the baseline scenario). The accelerated scale-up scenario would prevent 65·5 million (55·6–76·0) cases and 7·9 million (7·3–8·5) deaths before 2050, relative to baseline. The routine-only scenario would prevent 8·8 million (95% uncertainty range 7·6–10·1) cases and 1·1 million (0·9–1·2) deaths before 2050, relative to baseline.InterpretationOur results suggest novel tuberculosis vaccines could have substantial impact, which will vary depending on delivery strategy. Including a one-off vaccination campaign will be crucial for rapid impact. Accelerated introduction—at a pace similar to that seen for COVID-19 vaccines—would increase the number of lives saved before 2050 by around 60%. Investment is required to support vaccine development, manufacturing, prompt introduction, and scale-up

Cost effectiveness of pediatric pneumococcal conjugate vaccines: a comparative assessment of decision-making tools

BACKGROUND: Several decision support tools have been developed to aid policymaking regarding the adoption of pneumococcal conjugate vaccine (PCV) into national pediatric immunization programs. The lack of critical appraisal of these tools makes it difficult for decision makers to understand and choose between them. With the aim to guide policymakers on their optimal use, we compared publicly available decision-making tools in relation to their methods, influential parameters and results. METHODS: The World Health Organization (WHO) requested access to several publicly available cost-effectiveness (CE) tools for PCV from both public and private provenance. All tools were critically assessed according to the WHO's guide for economic evaluations of immunization programs. Key attributes and characteristics were compared and a series of sensitivity analyses was performed to determine the main drivers of the results. The results were compared based on a standardized set of input parameters and assumptions. RESULTS: Three cost-effectiveness modeling tools were provided, including two cohort-based (Pan-American Health Organization (PAHO) ProVac Initiative TriVac, and PneumoADIP) and one population-based model (GlaxoSmithKline's SUPREMES). They all compared the introduction of PCV into national pediatric immunization program with no PCV use. The models were different in terms of model attributes, structure, and data requirement, but captured a similar range of diseases. Herd effects were estimated using different approaches in each model. The main driving parameters were vaccine efficacy against pneumococcal pneumonia, vaccine price, vaccine coverage, serotype coverage and disease burden. With a standardized set of input parameters developed for cohort modeling, TriVac and PneumoADIP produced similar incremental costs and health outcomes, and incremental cost-effectiveness ratios. CONCLUSIONS: Vaccine cost (dose price and number of doses), vaccine efficacy and epidemiology of critical endpoint (for example, incidence of pneumonia, distribution of serotypes causing pneumonia) were influential parameters in the models we compared. Understanding the differences and similarities of such CE tools through regular comparisons could render decision-making processes in different countries more efficient, as well as providing guiding information for further clinical and epidemiological research. A tool comparison exercise using standardized data sets can help model developers to be more transparent about their model structure and assumptions and provide analysts and decision makers with a more in-depth view behind the disease dynamics. Adherence to the WHO guide of economic evaluations of immunization programs may also facilitate this process. Please see related article: http://www.biomedcentral.com/1741-7007/9/55

Global economic evaluation of oral cholera vaccine: A systematic review

World Health Organization recommends oral cholera vaccine (OCV) to prevent and control cholera, but requires cost-effectiveness evidence. This review aimed to provide a critical appraisal and summary of global economic evaluation (EE) studies involving OCV to guide future EE study. Full EE studies, published from inception to December 2015, evaluating OCV against cholera disease were included. The included studies were appraised using WHO guide for standardization of EE of immunization programs. Out of 14 included studies, almost all (13/14) were in low- and middle-income countries. Most studies (11/14) evaluated mass vaccination program. Most of the studies (9/14) incorporated herd protective effect. The most common influential parameters were cholera incidence, OCV coverage, herd protection and OCV price. OCV vaccination is likely to be cost-effective when targeted at the population with high-risk of cholera and poor access to health care facilities when herd protection effect is incorporated and OCV price is low

Fiscal consequences of changes in morbidity and mortality attributed to rotavirus immunisation

<p>Changes in population health status are known to influence government fiscal transfers both in terms of lost tax revenue and increased expenditure for health and social services. To estimate the fiscal impact of changes in morbidity and mortality attributed to rotavirus immunisation, we developed a government perspective model to estimate discounted net tax revenue for Ghana and Vietnam. The model derived the impact of rotavirus morbidity and mortality on lifetime productive capacity and related tax transfers, and demand for government transfers in relation to education and healthcare in immunised and non-immunised cohorts. The discounted age-specific net tax revenue was derived by deducting transfers from gross taxes and discounting for time preference. In Ghana, taking into account immunisation costs, tax and transfers, the estimated net discounted tax for the immunised cohort was estimated to generate $2.6 billion in net taxes up to age 65. In Vietnam, the net revenue attributed to the immunised cohort reached$55.17 billion suggesting an incremental benefit of approximately $29 million. We posit that the government perspective fiscal framework described here is a valid approach for estimating how governments benefit from investments in immunisation that can be considered supplementary to conventional cost-effectiveness approaches for defining value. (C) 2013 Elsevier Ltd. All rights reserved.</p>

Experiences of operational costs of HPV vaccine delivery strategies in Gavi-supported demonstration projects.

From 2012 to 2016, Gavi, the Vaccine Alliance, provided support for countries to conduct small-scale demonstration projects for the introduction of the human papillomavirus vaccine, with the aim of determining which human papillomavirus vaccine delivery strategies might be effective and sustainable upon national scale-up. This study reports on the operational costs and cost determinants of different vaccination delivery strategies within these projects across twelve countries using a standardized micro-costing tool. The World Health Organization Cervical Cancer Prevention and Control Costing Tool was used to collect costing data, which were then aggregated and analyzed to assess the costs and cost determinants of vaccination. Across the one-year demonstration projects, the average economic and financial costs per dose amounted to US$19.98 (standard deviation ±12.5) and US$8.74 (standard deviation ±5.8), respectively. The greatest activities representing the greatest share of financial costs were social mobilization at approximately 30% (range, 6-67%) and service delivery at about 25% (range, 3-46%). Districts implemented varying combinations of school-based, facility-based, or outreach delivery strategies and experienced wide variation in vaccine coverage, drop-out rates, and service delivery costs, including transportation costs and per diems. Size of target population, number of students per school, and average length of time to reach an outreach post influenced cost per dose. Although the operational costs from demonstration projects are much higher than those of other routine vaccine immunization programs, findings from our analysis suggest that HPV vaccination operational costs will decrease substantially for national introduction. Vaccination costs may be decreased further by annual vaccination, high initial investment in social mobilization, or introducing/strengthening school health programs. Our analysis shows that drivers of cost are dependent on country and district characteristics. We therefore recommend that countries carry out detailed planning at the national and district levels to define a sustainable strategy for national HPV vaccine roll-out, in order to achieve the optimal balance between coverage and cost

Identification and Prioritization of the Economic Impacts of Vaccines

Understanding the most important economic impacts of vaccines can provide relevant information to stakeholders when selecting vaccine immunization strategies from a broader perspective. This study was therefore designed to first identify economic impacts to vaccinated individuals and, second, assess the relative importance of these economic impacts. A four-step approach was used, including a review of the literature, a pilot study, and expert consultation. As a fourth step, a survey utilizing a best-worst scaling was conducted among 26 different stakeholders to assess the relative importance of the identified economic impacts. In each of the 15 choice tasks, participants were asked to choose the most important and the least important economic impact from a set of four from the master list. We identified 23 economic impacts relevant for vaccine introduction. Four domains were identified, namely, health related benefits to vaccinated individuals, short- and long-term productivity gains, community or health systems externalities, and broader economic indicators. The first domain was seen as especially important with mortality, health care expenditure, and morbidity ranking in the top three overall. In conclusion, our study suggests that domain A “health related benefits to vaccinated individuals” are valued as more important than the other economic impacts

Identification and Prioritization of the Economic Impacts of Vaccines

Understanding the most important economic impacts of vaccines can provide relevant information to stakeholders when selecting vaccine immunization strategies from a broader perspective. This study was therefore designed to first identify economic impacts to vaccinated individuals and, second, assess the relative importance of these economic impacts. A four-step approach was used, including a review of the literature, a pilot study, and expert consultation. As a fourth step, a survey utilizing a best-worst scaling was conducted among 26 different stakeholders to assess the relative importance of the identified economic impacts. In each of the 15 choice tasks, participants were asked to choose the most important and the least important economic impact from a set of four from the master list. We identified 23 economic impacts relevant for vaccine introduction. Four domains were identified, namely, health related benefits to vaccinated individuals, short-and long-term productivity gains, community or health systems externalities, and broader economic indicators. The first domain was seen as especially important with mortality, health care expenditure, and morbidity ranking in the top three overall. In conclusion, our study suggests that domain A &quot;health related benefits to vaccinated individuals&quot; are valued as more important than the other economic impacts

Evidence-informed vaccine decision making: The introduction of Human Papilloma Virus (HPV) vaccination in the Netherlands

Little is known about the role of (economic) information or evidence in the different stages of the decision-making process on vaccine introduction. By conducting a document analysis on the public decision-making process of introducing human Papilloma virus (HPV) vaccine into the national vaccination program (NVP) in the Netherlands, we aim to gain insight into which information plays a role during the introduction of a vaccination programme.A document analysis was performed on the public decision-making process regarding the introduction of HPV vaccine into the NVP in the Netherlands. Information used or asked for by various stakeholders during different stages of the policymaking process was identified. In total, 42 documents were found, analyzed and synthesized, for the period between August 2006 and September 2009. Documents were analyzed using directed content analysis based on eight broad categories of criteria used in decision-making frameworks for introducing a vaccine.Our analysis demonstrates that a wide variety of stakeholders is involved in the process. Financial or economic issues were stipulated in 64.3% of the documents and information on vaccine characteristics were discussed in 59.5%. Economic information from economic evaluations was discussed most (47.6%). Based on our analysis, it can be concluded that economic information, in particular information from economic evaluations, played an important role in the decision-making process regarding the introduction of HPV-vaccination. (C) 2018 Elsevier B.V. All rights reserved.</p