The projected cost-effectiveness and budget impact of HPV vaccine introduction in Ghana

Systematic review of cost projections of new vaccine introduction

BACKGROUND

A recent review of guidance documents on vaccine delivery costing revealed current guidance on cost projections for new vaccine introduction has gaps on methods of sampling, data collection and analysis. In preparation for updating the respective guidance, this systematic review was undertaken to qualitatively assess methodologies used in new vaccine cost projection studies. This will inform researchers and stakeholders about the methods of new vaccine introduction cost projections for strategic directions in countries where cost data are not available.

METHODS

We systematically searched four search engines (PubMed, Cochrane Open Access, Mendeley and Google Scholar) for articles on cost projections for new vaccines published between 1999 and 15 June 2022. We developed inclusion and exclusion criteria for the selection of articles and analyzed the results using a PRISMA 2020 flow diagram.

RESULTS

Out of 1,108 articles identified, 171 met the criteria for inclusion in the study. Half of the articles were from high-income countries (50%), and most cost projections were part of cost-effectiveness analysis (84%). The most common source of cost data was secondary national information (43%), followed by author's assumptions (17%), secondary international information (14%), and primary data collection (7%). 19% of studies didn't include costs to deliver vaccines in their cost estimation. Among studies that included secondary vaccine delivery costs, approximately half only calculated vaccine administration costs (50%), while 35% included incremental system costs and 15% utilized ingredients data. Two thirds of the studies were conducted to inform policymakers of the cost-effectiveness or cost-benefit of introducing the vaccine.

CONCLUSIONS

Half of the economic evaluations on new vaccine introductions only included partial vaccine delivery costs. Thus, total costs of vaccine introduction were often being underestimated in economic evaluations. This suggests that guidelines on economic evaluations and journals should recommend that authors include more extensive vaccine delivery costs in their studies.

Cost-effectiveness of human papillomavirus (HPV) vaccination in Burkina Faso: a modelling study

BACKGROUND

Africa has some of the highest cervical cancer incidence and mortality rates globally. Burkina Faso launched a human papillomavirus (HPV) vaccination programme for 9-year-old girls in 2022 with support from Gavi, the Vaccine Alliance (Gavi). An economic evaluation of HPV vaccination is required to help sustain investment and inform decisions about optimal HPV vaccine choices.

METHODS

We used a proportionate outcomes static cohort model to evaluate the potential impact and cost-effectiveness of HPV vaccination for 9-year-old girls over a ten-year period (2022-2031) in Burkina Faso. The primary outcome measure was the cost (2022 US$) per disability-adjusted life year (DALY) averted from a limited societal perspective (including all vaccine costs borne by the government and Gavi, radiation therapy costs borne by the government, and all other direct medical costs borne by patients and their families). We evaluated four vaccines (CERVARIX®, CECOLIN®, GARDASIL-4®, GARDASIL-9®), comparing each to no vaccination (and no change in existing cervical cancer screening and treatment strategies) and to each other. We combined local estimates of HPV type distribution, healthcare costs, vaccine coverage and costs with GLOBOCAN 2020 disease burden data and clinical trial efficacy data. We ran deterministic and probabilistic uncertainty analyses.

RESULTS

HPV vaccination could prevent 37-72% of cervical cancer cases and deaths. CECOLIN® had the most favourable cost-effectiveness (cost per DALY averted < 0.27 times the national gross domestic product [GDP] per capita). When cross-protection was included, CECOLIN® remained the most cost-effective (cost per DALY averted < 0.20 times the national GDP per capita), but CERVARIX® provided greater health benefits (66% vs. 48% reduction in cervical cancer cases and deaths) with similar cost-effectiveness (cost per DALY averted < 0.28 times the national GDP per capita, with CECOLIN® as the comparator). We estimated the annual cost of the vaccination programme at US$ 2.9, 4.1, 4.4 and 19.8 million for CECOLIN®, GARDASIL-4®, CERVARIX® and GARDASIL-9®, respectively. A single dose strategy reduced costs and improved cost-effectiveness by more than half.

CONCLUSION

HPV vaccination is cost-effective in Burkina Faso from a limited societal perspective. A single dose strategy and/or alternative Gavi-supported HPV vaccines could further improve cost-effectiveness.

Imagine beyond: recent breakthroughs and next challenges in mammary gland biology and breast cancer research

On 8 December 2022 the organizing committee of the European Network for Breast Development and Cancer labs (ENBDC) held its fifth annual Think Tank meeting in Amsterdam, the Netherlands. Here, we embraced the opportunity to look back to identify the most prominent breakthroughs of the past ten years and to reflect on the main challenges that lie ahead for our field in the years to come. The outcomes of these discussions are presented in this position paper, in the hope that it will serve as a summary of the current state of affairs in mammary gland biology and breast cancer research for early career researchers and other newcomers in the field, and as inspiration for scientists and clinicians to move the field forward.

Impact, cost-effectiveness, and budget implications of HPV vaccination in Kenya: A modelling study

BACKGROUND

Sub-Saharan Africa has the highest rate of cervical cancer cases and deaths worldwide. Kenya introduced a quadrivalent HPV vaccine (GARDASIL, hereafter referred to as GARDASIL-4) for ten-year-old girls in late 2019 with donor support from Gavi, the Vaccine Alliance. As Kenya may soon graduate from Gavi support, it is important to evaluate the potential cost-effectiveness and budget impact of the current HPV vaccine, and potential alternatives.

METHODS

We used a proportionate outcomes static cohort model to evaluate the annual budget impact and lifetime cost-effectiveness of vaccinating ten-year-old girls over the period 2020-2029. We included a catch-up campaign for girls aged 11-14 years in 2020. We estimated cervical cancer cases, deaths, disability adjusted life years (DALYs), and healthcare costs (government and societal perspective) expected to occur with and without vaccination over the lifetimes of each cohort of vaccinated girls. For each of the four products available globally (CECOLIN©, CERVARIX©, GARDASIL-4©, and GARDASIL-9 ©), we estimated the cost (2021 US$) per DALY averted compared to no vaccine and to each other. Model inputs were obtained from published sources, as well as local stakeholders.

RESULTS

We estimated 320,000 cases and 225,000 deaths attributed to cervical cancer over the lifetimes of the 14 evaluated birth cohorts. HPV vaccination could reduce this burden by 42-60 %. Without cross-protection, CECOLIN had the lowest net cost and most attractive cost-effectiveness. With cross-protection, CERVARIX was the most cost-effective. Under either scenario the most cost-effective vaccine had a 100 % probability of being cost-effective at a willingness-to-pay threshold of US$ 100 (5 % of Kenya's national gross domestic product per capita) compared to no vaccination. Should Kenya reach its target of 90 % coverage and graduate from Gavi support, the undiscounted annual vaccine program cost could exceed US$ 10 million per year. For all three vaccines currently supported by Gavi, a single-dose strategy would be cost-saving compared to no vaccination.

CONCLUSION

HPV vaccination for girls is highly cost-effective in Kenya. Compared to GARDASIL-4, alternative products could provide similar or greater health benefits at lower net costs. Substantial government funding will be required to reach and sustain coverage targets as Kenya graduates from Gavi support. A single dose strategy is likely to have similar benefits for less cost.

Impact and Cost-Effectiveness of Alternative Human Papillomavirus Vaccines for Preadolescent Girls in Mozambique: A Modelling Study

Mozambique has one of the highest rates of cervical cancer in the world. Human papillomavirus (HPV) vaccination was introduced in 2021. This study evaluated the health and economic impact of the current HPV vaccine (GARDASIL^® hereafter referred to as GARDASIL-4) and two other vaccines (CECOLIN^® and CERVARIX^®) that could be used in the future. A static cohort model was used to estimate the costs and benefits of vaccinating girls in Mozambique over the period 2022-2031. The primary outcome measure was the incremental cost per disability-adjusted life-year averted from a government perspective. We conducted deterministic and probabilistic sensitivity analyses. Without cross-protection, all three vaccines averted approximately 54% cervical cancer cases and deaths. With cross-protection, CERVARIX averted 70% of cases and deaths. Without Gavi support, the discounted vaccine program costs ranged from 60 million to 81 million USD. Vaccine program costs were approximately 37 million USD for all vaccines with Gavi support. Without cross-protection, CECOLIN was dominant, being cost-effective with or without Gavi support. With cross-protection and Gavi support, CERVARIX was dominant and cost-saving. With cross-protection and no Gavi support, CECOLIN had the most favorable cost-effectiveness ratio. Conclusions: At a willingness-to-pay (WTP) threshold set at 35% of Gross Domestic Product (GDP) per capita, HPV vaccination is cost-effective in Mozambique. The optimal vaccine choice depends on cross-protection assumptions.

Public relations strategies employed by the Ghana Health Service to address COVID-19 vaccine hesitancy: a qualitative inquiry

BACKGROUND

Strategies for developing and advancing good public relations can be recognized in nearly all fields of life without making an exception for the healthcare industry. In the wake of the COVID-19 pandemic, matters of public health have gathered more force. The importance of effective public relations for improving healthcare is highlighted by the position that immediate access to reliable health information should be the hallmark of a just society. However, the strategies available for addressing major threats to the uptake of public health services such as mass vaccination campaigns are not properly studied and documented in the Ghanaian context. This organizational case study explored strategies used by healthcare professionals working with the Ghana Health Service (GHS) to address COVID-19-related vaccine hesitancy in the country.

METHODS

We performed a qualitative inquiry with semi-structured in-depth interviews conducted with 25 public health officials of the GHS. The interviews were timed to coincide with the mass deployment of COVID-19 vaccines in four Regions. Participants were recruited through purposive sampling. Data collected included demographic characteristics, perspectives on public relations strategies used in the past year to improve COVID-19 vaccine uptake as well as successes and pitfalls. Thematic analysis was performed with NVIVO software to generate themes from interview transcripts.

RESULTS

Four main themes emerged from the data analysis and these are presented. Healthcare workers perceived vaccine hesitancy to be a threat with the potential to undermine an important strategic organizational goal related to COVID-19 illness. In terms of PR strategies, we determined that a combination of informative, motivational, persuasive and coercive public relations strategies was employed by the Ghana Health Service to address the challenge of vaccine hesitancy. We further found that PR strategies were deployed across both traditional (print, radio, TV) and emerging/social media networks. Officials were optimistic that the strategies would produce results, but were uncertain whether they could attribute current successes or failures to the PR strategies used.

CONCLUSION

Since the onset of the COVID-19 pandemic, public relations strategies which have been employed by the Ghana Health Service to address vaccine hesitancy are characterized and catalogued. The nature of the audience and PR strategies employed suggests that the effect of these strategies may be short-lived unless they are constantly reinforced by the GHS. These findings show that effective PR strategies exist for addressing vaccine hesitancy in public health practice.

Assessing the Efficacy of the 3R (Reframe, Reprioritize, and Reform) Communication Model to Increase HPV Vaccinations Acceptance in Ghana: Community-Based Intervention

The study examined whether the 3R (reframe, prioritize, and reform) communication model intervention can impact parents' and adolescents' HPV vaccination acceptability. We used face-to-face methods to recruit participants from three local churches in the Ashanti Region of Ghana. Participants completed pre- and post-intervention assessments based on the validated Theory of Planned Behavior survey. We organized two face-to-face presentations for parents and adolescents separately for parents (n = 85) and adolescents (n = 85). Participants' post-intervention vs. pre-intervention scores for attitude (mean = 35.46 ± SD = 5.46 vs. mean = 23.42 ± SD = 8.63), knowledge (M = 28.48 ± SD = 5.14 vs. M = 16.56 ± SD = 7.19), confidence (M = 8.96 ± SD = 3.43 vs. M = 6.17 ± SD = 2.84), and intention for vaccine acceptance (M = 4.73 ± SD = 1.78 vs. M = 3.29 ± SD = 1.87) increased significantly (p < 0.001). The intervention showed that for every one-unit increase in the participants' self-confidence and attitude scores, the odds of the HPV vaccination acceptability increased by 22% (95% CI: 10-36) and 6% (95% CI: 0.1-12), respectively. Intention for vaccine acceptance, F (1167) = 6.89, and attitude toward vaccination, F (1167) = 19.87, were significantly higher among parents than adolescents (p < 0.001), after controlling for the baseline scores. These findings suggest that the intervention targeting parents' and adolescents' attitudes and knowledge has the potential to increase HPV vaccination acceptance in Ghana.

HPV vaccination: Intention to participate among female senior high school students in Ghana

INTRODUCTION

Cervical cancer is the second most common cancer and the second leading cause of cancer death among women in Ghana. HPV vaccination is expected to be added to the national vaccination schedule in 2023. This study aimed to: i) describe intentions to participate in HPV vaccination and ii) explore factors associated with vaccination intentions among female senior high school students in Ghana.

METHODS

Female students (aged 16-24) were recruited from 17 senior high schools in Ashanti Region. A cross-sectional anonymous self-report paper-and-pen survey assessed students' HPV vaccination intentions using three items, and a range of correlates (individual, parent/family, social networks, service provision). Descriptive statistics were calculated for vaccination intentions, and correlates of intention scores (where higher scores indicate stronger intentions) were explored with a linear mixed-effect model.

RESULTS

Of 2400 participants, 64% (95%CI: 62%, 67%) agreed with at least one vaccination intention item. Uncertainty and disagreement with at least one item were endorsed by 51% (95%CI: 49%, 53%) and 44% (95%CI: 42%, 46%) of students, respectively. One-quarter of the students (25%, 95%CI: 23%, 26%) agreed, 12% (95% 11%, 13%) disagreed, and 11% (95%CI: 10%,13%) indicated uncertainty, on all three vaccination intention items. Vaccination uptake was 4.5%. Students were likely to have higher vaccination intention scores if: they had stronger beliefs about vaccine effectiveness; vaccination was recommended by parents, religious leaders and service providers, and vaccinated peers; and it was free. Students were likely to have lower vaccination intention scores if they perceived barriers to vaccination (e.g., side effects).

CONCLUSIONS

While two-thirds of students had some intention to participate in HPV vaccination, vaccine hesitancy (i.e., uncertainty or disagreement) was apparent. Alongside the rollout of a free national vaccination programme, messaging about vaccination benefits and effectiveness targeting students, as well as parents, religious leaders, service providers and peers would be beneficial given their influential role in students' vaccination intentions.

Human papillomavirus genotype distribution among women with and without cervical cancer: Implication for vaccination and screening in Ghana

INTRODUCTION

Determining the high-risk human papillomavirus (HR-HPV) genotypes burden in women with and without cervical cancer afford a direct comparison of their relative distributions. This quest is fundamental to implementing a future population-based cervical cancer prevention strategy in Ghana. We estimated the cervical cancer risk by HPV genotypes, and the HPV vaccine-preventable proportion of cervical cancer diagnosed in Ghana.

MATERIALS AND METHODS

An unmatched case-control study was conducted at the two largest cervical cancer treatment centres in Ghana from 1st October 2014 to 31st May 2015. Cases were women diagnosed with cervical cancer and controls were women without cervical cancer who were seeking care at the two hospitals. Nested multiplex polymerase chain reaction (NM-PCR) was used to detect HPV infection in cervical samples. Logistic regression was used to determine the association between the risk of cervical cancer and identified HPV infection. P ≤0.05 was considered statistically significant.

RESULTS

HPV deoxyribonucleic acid (DNA) data were analysed for 177 women with cervical cancer (cases) and 201 without cancer (controls). Cervical cancer was diagnosed at older ages compared to the age at which controls were recruited (median ages, 57 years vs 34 years; p < 0.001). Most women with cervical cancer were more likely to be single with no formal education, unemployed and less likely to live in metropolitan areas compared to women without cervical cancer (all p-value <0.001). HPV DNA was detected in more women with cervical cancer compared to those without cervical cancer (84.8% vs 45.8%). HR-HPV genotypes 16, 18, 45, 35 and 52 were the most common among women with cervical cancer, while 66, 52, 35, 43 and 31 were frequently detected in those without cancer. HPV 66 and 35 were the most dominant non-vaccine genotypes; HPV 66 was more prevalent among women with cervical cancer and HPV 35 in those without cervical cancer. Cervical cancer risk was associated with a positive HPV test (Adjusted OR (AOR): 5.78; 95% CI: 2.92-11.42), infection with any of the HR-HPV genotypes (AOR: 5.56; 95% CI: 3.27-13.16) or multiple HPV infections (AOR: 9.57 95% CI 4.06-22.56).

CONCLUSION

Women with cervical cancer in Ghana have HPV infection with multiple genotypes, including some non-vaccine genotypes, with an estimated cervical cancer risk of about six- to ten-fold in the presence of a positive HPV test. HPV DNA tests and multivalent vaccine targeted at HPV 16, 18, 45 and 35 genotypes will be essential in Ghana's cervical cancer control programme. Large population-based studies are required in countries where cervical cancer is most prevalent to determine non-vaccine HPV genotypes which should be considered for the next-generation HPV vaccines.

Estimating the cost of COVID-19 vaccine deployment and introduction in Ghana using the CVIC Tool

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Current COVID-19 vaccine supply market means LMICs will have to rely on a combination of different sources/types of vaccines to meet their demand.

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Deployment of COVID-19 vaccine plans in Ghana will cost $348.7–$436.1 million for coverage of 17.5 million of eligible Ghanaians.

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Vaccine cost constitute 78–83% of total cost whereas the total vaccination cost is 0.48–0.60% of the country’s 2020 GDP.

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The WHO-UNICEF CVIC tool is useful for comprehensive COVID-19 vaccine deployment costing and resource planning.

Background

This study estimated cost of COVID-19 vaccine introduction and deployment in Ghana.

Methods

Using the WHO-UNICEF COVID-19 Vaccine Introduction and deployment Costing (CVIC) tool Ghana’s Ministry of Health Technical Working Group for Health Technology Assessment (TWG-HTA) in collaboration with School of Public Health, University of Ghana, organized an initial two-day workshop that brought together partners to deliberate and agree on input parameters to populate the CVIC tool. A further 2–3 days validation with the Expanded Program of Immunization (EPI) and other partners to finalize the analysis was done. Three scenarios, with different combinations of vaccine products and delivery modalities, as well as time period were analyzed. The scenarios included AstraZeneca (40%), Johnson & Johnson (J&J) (30%), Moderna, Pfizer, and Sputnik V at 10% each; with primary schedule completed by second half of 2021 (Scenario 1); AstraZeneca (30%), J&J (40%), Moderna, Pfizer, and Sputnik V at 10% each with primary schedule completed by first half of 2022 (Scenario 2); and equal distribution (20%) among AstraZeneca, J&J, Moderna, Pfizer, and Sputnik V with primary schedule completed by second half of 2022 (Scenario 3).

Results

The estimated total cost of COVID-19 vaccination ranges between $348.7 and $436.1 million for the target population of 17.5 million. These translate into per person completed primary schedule cost of $20.9–$26.2 and per dose (including vaccine cost) of $10.5–$13.1. Again, per person completed primary schedule excluding vaccine cost was $4.5 and $4.6, thus per dose excluding vaccine also ranged from $2.2 – $2.3. The main cost driver was vaccine doses, including shipping, which accounts for between 78% and 83% of total cost. Further, an estimated 8,437–10,247 vaccinators (non-FTEs) would be required during 2021–2022 to vaccinate using a mix of delivery strategies, accounting for 8–10% of total cost.

Conclusion

These findings provide the estimates to inform resource mobilization efforts by government and other partners.