Strengthening national decision-making on immunization by building capacity for economic evaluation: Implementing ProVac in Europe

Operationalising Regional Cooperation for Infectious Disease Control: A Scoping Review of Regional Disease Control Bodies and Networks

BACKGROUND

The rapid spread of the coronavirus disease 2019 (COVID-19) pandemic demonstrates the value of regional cooperation in infectious disease prevention and control. We explored the literature on regional infectious disease control bodies, to identify lessons, barriers and enablers to inform operationalisation of a regional infectious disease control body or network in southeast Asia.

METHODS

We conducted a scoping review to examine existing literature on regional infectious disease control bodies and networks, and to identify lessons that can be learned that will be useful for operationalisation of a regional infectious disease control body such as the Association of Southeast Asian Nations (ASEAN) Center for Public Health Emergency and Emerging Diseases.

RESULTS

Of the 57 articles included, 53 (93%) were in English, with two (3%) in Spanish and one (2%) each in Dutch and French. Most were commentaries or review articles describing programme initiatives. Sixteen (28%) publications focused on organisations in the Asian continent, with 14 (25%) focused on Africa, and 14 (25%) primarily focused on the European region. Key lessons focused on organisational factors, diagnosis and detection, human resources, communication, accreditation, funding, and sustainability. Enablers and constraints were consistent across regions/ organisations. A clear understanding of the regional context, budgets, cultural or language issues, staffing capacity and governmental priorities, is pivotal. An initial workshop inclusive of the various bodies involved in the design, implementation, monitoring or evaluation of programmes is essential. Clear governance structure, with individual responsibilities clear from the beginning, will reduce friction. Secure, long-term funding is also a key aspect of the success of any programme.

CONCLUSION

Operationalisation of regional infectious disease bodies and networks is complicated, but with extensive groundwork, and focus on organisational factors, diagnosis and detection, human resources, communication, accreditation, funding, and sustainability, it is achievable. Ways to promote success are to include as many stakeholders as possible from the beginning, to ensure that context-specific factors are considered, and to encourage employees through capacity building and mentoring, to ensure they feel valued and reduce staff turnover.

SMART Vaccines 2.0 decision-support platform: a tool to facilitate and promote priority setting for sustainable vaccination in resource-limited settings

In resource-constrained environments, priority setting is critical to making sustainable decisions for introducing new and underused vaccines and choosing among vaccine products. Donor organisations and national governments in low-income and middle-income countries (LMICs) recognise the need to support prioritisation of vaccine decisions driven by local health system capacity, epidemiology and financial sustainability.

Successful efforts have supported the establishment of National Immunisation Technical Advisory Groups (NITAGs) to undertake evidence-informed decision making (EIDM) in LMICs. Now, attention is increasingly focused on supporting their function to leverage local expertise and priorities. EIDM and priority-setting functions are complex and dynamic processes. Here, we report a pilot of a web-based decision-support tool. Applying tenets of multicriteria decision analysis, SMART Vaccines 2.0 supported transparent, reproducible and evidence-informed priority setting with an easy-to-use interface and shareable outputs.

The pilot was run by the Uganda NITAG who were requested by the Ministry of Health (MOH) in 2016 to produce recommendations on the prioritised introduction of five new vaccines. The tool was acceptable to the NITAG and supported their recommendations to the MOH. The tool highlighted sensitivity in the prioritisation process to the inherent biases of different stakeholders. This feature also enabled examination of the implications of data uncertainty. Feedback from users identified areas where the tool could more explicitly support evidence-to-recommendation frameworks, ultimately informing the next generation of the platform, PriorityVax.

Country ownership and priority setting in vaccine decisions are central to sustainability. PriorityVax promotes auditable and rigorous deliberations; enables and captures the decision matrix of users; and generates shareable documentation of the process.

Cost-Effectiveness Comparison of Pneumococcal Conjugate Vaccines in Turkish Children

BACKGROUND

The 13-valent pneumococcal conjugate vaccine (PCV13) is used for universal infant vaccination in Turkey.

OBJECTIVES

To assess the cost effectiveness of replacing PCV13 with pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV).

METHODS

A Markov cohort model with monthly cycles following 1 cohort of infants over a 10-year time horizon was used. Local input parameters were obtained from published sources and expert consultation whenever possible. The model was adapted to estimate the health benefits and economic impact of each vaccine on invasive pneumococcal disease, pneumonia, and acute otitis media (AOM). An annual discount rate of 3% was used for benefits and costs (2016 euros).

RESULTS

Under base-case assumptions, vaccinating 1 birth cohort of 1 325 783 infants with PHiD-CV instead of PCV13 was predicted to have the same impact on meningitis and pneumonia, a similar impact on bacteremia (+30 cases), but greater reductions in AOM-related general practitioner visits (-34 955) and hospitalizations (-624). Assuming equal vaccine prices, PHiD-CV was predicted to be dominant over PCV13 (176 additional quality-adjusted life-years while saving €635 330 [discounted]). One-way sensitivity analysis indicated that varying the vaccine price differential had the largest effect on the incremental cost-effectiveness ratio, and then AOM parameters. Probabilistic sensitivity analysis predicted PHiD-CV to be dominant over PCV13 in 92.4% of simulations.

CONCLUSIONS

Any difference in price between PHiD-CV and PCV13 is expected to be the key driver of vaccine choice for preventing childhood pneumococcal disease in Turkey. At price parity, PHiD-CV use is likely to be a dominant strategy over the use of PCV13.

Pneumococcal conjugate vaccine implementation in middle-income countries

BACKGROUND

Since 2000, the widespread adoption of pneumococcal conjugate vaccines (PCVs) has had a major impact in the prevention of pneumonia. Limited access to international financial support means some middle-income countries (MICs) are trailing in the widespread use of PCVs. We review the status of PCV implementation, and discuss any needs and gaps related to low levels of PCV implementation in MICs, with analysis of possible solutions to strengthen the PCV implementation process in MICs.

MAIN BODY

We searched PubMed, PubMed Central, Ovid MEDLINE, and SCOPUS databases using search terms related to pneumococcal immunization, governmental health policy or programmes, and MICs. Two authors independently reviewed the full text of the references, which were assessed for eligibility using pre-defined inclusion and exclusion criteria. The search terms identified 1,165 articles and the full texts of 21 were assessed for suitability, with eight articles included in the systematic review. MICs are implementing PCVs at a slower rate than donor-funded low-income countries and wealthier developed countries. A significant difference in the uptake of PCV in lower middle-income countries (LMICs) (71%) and upper middle-income countries (UMICs) (48%) is largely due to an unsuccessful process of "graduation" of MICs from GAVI assistance, an issue that arises as countries cross the income eligibility threshold and are no longer eligible to receive the same levels of financial assistance. A lack of country-specific data on disease burden, a lack of local expertise in economic evaluation, and the cost of PCV were identified as the leading causes of the slow uptake of PCVs in MICs. Potential solutions mentioned in the reviewed papers include the use of vaccine cost-effectiveness analysis and the provision of economic evidence to strengthen decision-making, the evaluation of the burden of disease, and post-introduction surveillance to monitor vaccine impact.

CONCLUSION

The global community needs to recognise the impediments to vaccine introduction into MICs. Improving PCV access could help decrease the incidence of pneumonia and reduce the selection pressure for pneumococcal antimicrobial resistance.

Theory and strategy for Pneumococcal vaccines in the elderly

Pneumonia is the fourth-leading cause of death globally, and Streptococcus pneumoniae is the most important causative pathogen. Because the incidence of pneumococcal diseases is likely to increase with the aging society, we should determine an optimal strategy for pneumococcal vaccination. While consensus indicates that 23-valent pneumococcal polysaccharide vaccine prevents invasive pneumococcal diseases (IPD), its effects on community-acquired pneumonia (CAP) remain controversial. Recently, a 13-valent pneumococcal conjugate vaccine (PCV13) was released. The latest clinical study (CAPiTA study) showed that PCV13 reduced vaccine-type CAP and IPD. Based on these results, the Advisory Committee on Immunization Practices recommended initial vaccination with PCV13 for the elderly. Scientific evidence regarding immunosenescence is needed to determine a more ideal vaccination strategy for the elderly with impaired innate and adaptive immunity. Continuing research on the cost effectiveness of new vaccine strategies considering constantly changing epidemiology is also warranted.

A Systematic Review of Economic Evaluation Methodologies Between Resource-Limited and Resource-Rich Countries: A Case of Rotavirus Vaccines

BACKGROUND

For more than three decades, the number and influence of economic evaluations of healthcare interventions have been increasing and gaining attention from a policy level. However, concerns about the credibility of these studies exist, particularly in studies from low- and middle- income countries (LMICs). This analysis was performed to explore economic evaluations conducted in LMICs in terms of methodological variations, quality of reporting and evidence used for the analyses. These results were compared with those studies conducted in high-income countries (HICs).

METHODS

Rotavirus vaccine was selected as a case study, as it is one of the interventions that many studies in both settings have explored. The search to identify individual studies on rotavirus vaccines was performed in March 2014 using MEDLINE and the National Health Service Economic Evaluation Database. Only full economic evaluations, comparing cost and outcomes of at least two alternatives, were included for review. Selected criteria were applied to assess methodological variation, quality of reporting and quality of evidence used.

RESULTS

Eighty-five studies were included, consisting of 45 studies in HICs and 40 studies in LMICs. Seventy-five percent of the studies in LMICs were published by researchers from HICs. Compared with studies in HICs, the LMIC studies showed less methodological variety. In terms of the quality of reporting, LMICs had a high adherence to technical criteria, but HICs ultimately proved to be better. The same trend applied for the quality of evidence used.

CONCLUSION

Although the quality of economic evaluations in LMICs was not as high as those from HICs, it is of an acceptable level given several limitations that exist in these settings. However, the results of this study may not reflect the fact that LMICs have developed a better research capacity in the domain of health economics, given that most of the studies were in theory led by researchers from HICs. Putting more effort into fostering the development of both research infrastructure and capacity building as well as encouraging local engagement in LMICs is thus necessary.

Evidence-based decision-making for vaccine introductions: Overview of the ProVac International Working Group's experience

INTRODUCTION

Pan American Health Organization's (PAHO) ProVac Initiative aims to strengthen countries' technical capacity to make evidence-based immunization policy. With financial support from the Bill and Melinda Gates Foundation, PAHO established the ProVac International Working Group (IWG), a platform created for two years to transfer the ProVac Initiative's tools and methods to support decisions in non-PAHO regions.

METHODS

In 2011, WHO Regional Offices and partner agencies established the IWG to transfer the ProVac framework for new vaccine decision support, including tools and trainings to other regions of the world. During the two year period, PAHO served as the coordinating secretariat and partner agencies played implementing or advisory roles.

RESULTS

Fifty nine national professionals from 17 countries received training on the use of economic evaluations to aid vaccine policy making through regional workshops. The IWG provided direct technical support to nine countries to develop cost-effectiveness analyses to inform decisions. All nine countries introduced the new vaccine evaluated or their NITAGs have made a recommendation to the Ministry of Health to introduce the new vaccine.

DISCUSSION

Developing countries around the world are increasingly interested in weighing the potential health impact due to new vaccine introduction against the investments required. During the two years, the ProVac approach proved valuable and timely to aid the national decision making processes, even despite the different challenges and idiosyncrasies encountered in each region. The results of this work suggest that: (1) there is great need and demand for technical support and for capacity building around economic evaluations; and (2) the ProVac method of supporting country-owned analyses is as effective in other regions as it has been in the PAHO region.

CONCLUSION

Decision support for new vaccine introduction in low- and middle-income countries is critical to guiding the efficient use of resources and prioritizing high impact vaccination programs.