A model to estimate the probability of hepatitis B- and Haemophilus influenzae type b-vaccine uptake into national vaccination programs

Closing the pneumococcal conjugate vaccine (PCV) introduction gap: an archetype analysis of last-mile countries

BACKGROUND

Pneumonia remains the leading infectious cause of global childhood deaths, despite the availability of pneumococcal conjugate vaccine (PCV) products and widespread evidence of their safety and efficacy.

OBJECTIVE

To map the landscape of countries that are yet to fully include PCV in their National Immunization Programs, we conducted an archetype analysis of country indicators related to barriers and facilitators for PCV decision-making.

METHODS

We created a country matrix focused on three key domains - health characteristics, immunisation factors, and policy framework, and identified ten related indicators. We scored countries based on indicator performance and subsequently ranked and grouped them into three archetypes of low-, moderate-, and high-barrier countries with regard to PCV introduction.

RESULTS

Our results indicated 39 countries (33 low- and middle-income countries [LMICs] and 6 high-income countries) that are yet to introduce PCV. Among LMICs, 15 countries were classified as 'low-barrier,' indicating factors favourable for PCV introduction such as high immunisation coverage of common childhood vaccines, supportive governments, and substantial disease burden and eligibility for Gavi support. Countries classified in the 'moderate-barrier' (12) and 'high-barrier' (6) archetypes demonstrated adequate capacity in immunisation systems but had competing national priorities and cost barriers that impeded policy decision-making on PCV introduction.

CONCLUSIONS

The current health and policy indicator-based categorisation provides an actionable framework to design tailored PCV advocacy within these last-mile countries. Policy approaches emerging from this framework can lead to strengthened decision-making on vaccine introduction and sustained vaccine access that can enhance child survival worldwide.

Introduction of pentavalent vaccine in Indonesia: a policy analysis

The introduction of pentavalent vaccine containing Haemophilus influenzae type b antigen in Indonesia's National Immunization Program occurred nearly three decades after the vaccine was first available in the United States and 16 years after Indonesia added hepatitis B vaccine into the program. In this study, we analyzed the process that led to the decision to introduce pentavalent vaccine in Indonesia. Using process tracing and case comparison, we used qualitative data gathered through interviews with key informants and data extracted from written sources to identify four distinct but interrelated processes that were involved in the decision making: (a) pentavalent vaccine use policy process, (b) financing process, (c) domestic vaccine development process and (d) political process. We hypothesized that each process is associated with four necessary conditions that are jointly sufficient for the successful introduction of pentavalent vaccine in Indonesia, namely (a) an evidence-based vaccine use recommendation, (b) sufficient domestic financing capacity, (c) sufficient domestic vaccine manufacturing capacity and (d) political support for introduction. This analysis of four processes that led to the decision to introduce a new vaccine in Indonesia may help policy makers and other stakeholders understand and manage activities that can accelerate vaccine introduction in the future.

Forecasting dengue vaccine demand in disease endemic and non-endemic countries

BACKGROUND

A dengue vaccine in large-scale clinical trials could be licensed in several years. We estimated the potential vaccine demand for different introduction strategies in 54 dengue-endemic countries and for travelers from non-endemic countries to enable vaccine producers and public health agencies to better prepare for timely utilization of the vaccine.

RESULTS

Under our assumptions, 2.4-3.5 billion dengue vaccine doses would be needed in the first five years after introduction with >75% delivered in the public sector. Among 20 potential 'early-adopter' countries, an estimated 0.9-1.4 billion doses would be needed for the same introduction approach. For the private sector, covering 10% of children and 30% of adults an estimated 443-664 million doses would be required. In non-endemic countries, travelers could use an estimated 59-89 million vaccine doses, although the present product profile would make it unlikely to be able to administer vaccine in a timely manner.

METHODS

Calculations were based on 2015-2020 population projections for endemic countries in Asia and the Americas with populations >100,000. For dengue-endemic countries we assumed country-wide routine 12-23 month-old vaccination and catch-up vaccination among 2-14 year-old children employing a 2 or 3-dose schedule. Assumptions on expected vaccination coverage were based on country-specific public, private and travelers' sectors immunization performance.

CONCLUSIONS

Our results project an upper-limit estimate of vaccine demand, with actual demand depending on country priorities, cost and product profile. Given the potential for a dengue vaccine, policymakers in endemic and nonendemic countries should consider appropriate implementation strategies in advance of licensure.

Accelerating policy decisions to adopt haemophilus influenzae type B vaccine: a global, multivariable analysis

BACKGROUND

Adoption of new and underutilized vaccines by national immunization programs is an essential step towards reducing child mortality. Policy decisions to adopt new vaccines in high mortality countries often lag behind decisions in high-income countries. Using the case of Haemophilus influenzae type b (Hib) vaccine, this paper endeavors to explain these delays through the analysis of country-level economic, epidemiological, programmatic and policy-related factors, as well as the role of the Global Alliance for Vaccines and Immunisation (GAVI Alliance).

METHODS AND FINDINGS

Data for 147 countries from 1990 to 2007 were analyzed in accelerated failure time models to identify factors that are associated with the time to decision to adopt Hib vaccine. In multivariable models that control for Gross National Income, region, and burden of Hib disease, the receipt of GAVI support speeded the time to decision by a factor of 0.37 (95% CI 0.18-0.76), or 63%. The presence of two or more neighboring country adopters accelerated decisions to adopt by a factor of 0.50 (95% CI 0.33-0.75). For each 1% increase in vaccine price, decisions to adopt are delayed by a factor of 1.02 (95% CI 1.00-1.04). Global recommendations and local studies were not associated with time to decision.

CONCLUSIONS

This study substantiates previous findings related to vaccine price and presents new evidence to suggest that GAVI eligibility is associated with accelerated decisions to adopt Hib vaccine. The influence of neighboring country decisions was also highly significant, suggesting that approaches to support the adoption of new vaccines should consider supply- and demand-side factors.

Forecasting demand for Hib-containing vaccine in the world's poorest countries: a 4-year prospective experience

This article analyzes the performance of a Hib vaccine demand forecast developed in 2003 for 68 GAVI-supported countries between 2004 and 2007. During that period of time, corresponding to an acceleration of Hib vaccine uptake, several groups of countries were identified based on the stage of their decision-making process, perception of Hib disease burden and programme performance. Better forecast accuracy was obtained for countries having already introduced the vaccine or that were about to do so. The ability to anticipate global needs in terms of vaccine volumes was highly dependant on the actual year of introduction of a small number of very large countries.

Estimating the demand for a preventive HIV vaccine: why we need to do better. Reliable estimates would help in achieving several policy and advocacy objectives

Additional research on public and private demand for HIV vaccines is needed to strengthen ongoing advocacy and planning for eventual vaccine introduction, say Hecht and Suraratdecha.

Chapter 26: Innovative financing mechanisms to accelerate the introduction of HPV vaccines in developing countries

The costs of developing and producing new-generation vaccines have increased compared to many of the older, "traditional" vaccines because of new technologies and regulatory requirements. While the public sector often supports basic research costs, private manufacturers are usually responsible for the investments in product development and production scale-up. When considering investments, firms evaluate the probability of a market. Unfortunately, the developing country vaccine market is small (in revenue terms) and often unpredictable, particularly given inaccurate forecasting in the past. Low-income developing countries expect low prices. Demand (actual decisions to pay for and introduce the vaccine) is almost always lower than need (estimates of requirements to achieve optimal public health outcomes), a distinction that may be even more significant for HPV vaccines given the number of new vaccines against priority diseases that will become available over the coming 5 years. One new mechanism under consideration to address some of these challenges is Advanced Market Commitments (AMCs). By providing an assured price subsidy for developing country purchase of a future vaccine meeting predefined standards, an AMC would provide industry with greater assurances of earning a reasonable return on their investment to serve the poorest developing countries. The AMC mechanism could provide critical motivation for increased industry (private) investment that would otherwise not occur. HPV vaccines are one of six vaccines being considered for a possible AMC pilot.

Vaccines for children: policies, politics and poverty

The dawn of the 21st century ushered in spectacular advances in vaccine production technology. However, the benefits of these developments have been largely confined to the world's most affluent and least afflicted. Of the 14 million deaths that occur world-wide in children aged less than 5 years, over 95% of these occur in developing countries and at least 70% are caused by infections for which vaccines are already available in other countries. While impoverished countries do not have a right to be assisted with the provision of funds or vaccines by affluent developed countries, an initiative for the global eradication of a vaccine preventable disease, requires a global effort. Assisting developing countries to achieve such goals should be a high priority for wealthy nations, even if only to protect their own populations. With improved international travel, not only can newly emerging diseases spread across the globe, but pathogens eliminated from one population can be re-imported by travellers or immigrants. In contrast, the recent decline in acceptance of immunisation programmes in developed countries are secondary to strong anti-vaccine movements attributing unproven adverse reactions to vaccines, placing these life-saving vaccines into disrepute. A fertile ground for propagation of these ideologies is created by parents who in their lifetime may not have seen a child killed or maimed from bacterial meningitis or measles and therefore have little understanding of the risk-benefit of vaccination. The development and deployment of vaccines must be a global effort as are the treaties for global disarmament for weapons of mass destruction.