WHO-led consensus statement on vaccine delivery costing: process, methods, and findings

Costs of human papillomavirus vaccine delivery in low- and middle-income countries: A systematic review

Vaccines to protect against human papillomavirus (HPV) infection are recommended for all adolescents by the World Health Organization (WHO) and are primarily delivered in school-based settings. This systematic review aims to summarize the available evidence on the cost of HPV vaccine delivery in low- and middle-income countries (LMICs). This updated evidence is eminent given recent global efforts to revitalize HPV vaccine delivery following the COVID-19 pandemic and can be used to inform planning for program sustainability. We carried out a systematic review of published literature reporting the costs of HPV vaccine delivery in LMICs published between 2005 and 2023. Eligibility criteria were developed using the Population, Intervention, Comparator, Outcome (PICO) framework, and studies that reported primary costing data and unit costs of HPV vaccine delivery were included. From the included studies, we extracted data such as phase of HPV vaccine implementation when costing was done, delivery strategy, and unit costs. Unit costs were converted into 2022 US$ for comparability. All included studies underwent critical appraisal using an adapted framework including Consolidated Health Economics Evaluation Reporting Standards criteria, the WHO-led consensus statement on vaccine delivery costing, and other frameworks. Our research identified 226 records, of which 15 met our inclusion criteria. Most studies (64 %) were carried out in African countries and during HPV vaccine pilots or demonstrations (60 %). Vaccine delivery cost ranged from $0.31 to $24.07 per dose for financial costs and $1.48 to $48.70 per dose for economic costs. The critical appraisal showed that most studies did not describe the uncertainty of reported delivery cost. Our systematic review evidence suggests that HPV vaccine delivery costs vary widely depending on country and stage of implementation when costing was done. Areas for further research include costing when programs are beyond the introduction phase and in LMICs outside of Africa.

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.

Costs and cost-effectiveness of influenza illness and vaccination in low- and middle-income countries: A systematic review from 2012 to 2022

BACKGROUND

Historically, lack of data on cost-effectiveness of influenza vaccination has been identified as a barrier to vaccine use in low- and middle-income countries. We conducted a systematic review of economic evaluations describing (1) costs of influenza illness; (2) costs of influenza vaccination programs; and (3) vaccination cost-effectiveness from low- and middle-income countries to assess if gaps persist that could hinder global implementation of influenza vaccination programs.

METHODS AND FINDINGS

We performed a systematic search in Medline, Embase, Cochrane Library, CINAHL, and Scopus in January 2022 and October 2023 using a combination of the following key words: "influenza" AND "cost" OR "economic." The search included studies with publication years 2012 through 2022. Studies were eligible if they (1) presented original, peer-reviewed findings on cost of illness, cost of vaccination program, or cost-effectiveness of vaccination for seasonal influenza; and (2) included data for at least 1 low- or middle-income country. We abstracted general study characteristics and data specific to each of the 3 study types. Of 54 included studies, 26 presented data on cost-effectiveness, 24 on cost-of-illness, and 5 on program costs. Represented countries were classified as upper-middle income (UMIC; n = 12), lower-middle income (LMIC; n = 7), and low-income (LIC; n = 3). The most evaluated target groups were children (n = 26 studies), older adults (n = 17), and persons with chronic medical conditions (n = 12); fewer studies evaluated pregnant persons (n = 9), healthcare workers (n = 5), and persons in congregate living settings (n = 1). Costs-of-illness were generally higher in UMICs than in LMICs/LICs; however, the highest national economic burden, as a percent of gross domestic product and national health expenditure, was reported from an LIC. Among studies that evaluated the cost-effectiveness of influenza vaccine introduction, most (88%) interpreted at least 1 scenario per target group as either cost-effective or cost-saving, based on thresholds designated in the study. Key limitations of this work included (1) heterogeneity across included studies; (2) restrictiveness of the inclusion criteria used; and (3) potential for missed influenza burden from use of sentinel surveillance systems.

CONCLUSIONS

The 54 studies identified in this review suggest an increased momentum to generate economic evidence about influenza illness and vaccination from low- and middle-income countries during 2012 to 2022. However, given that we observed substantial heterogeneity, continued evaluation of the economic burden of influenza illness and costs/cost-effectiveness of influenza vaccination, particularly in LICs and among underrepresented target groups (e.g., healthcare workers and pregnant persons), is needed. Use of standardized methodology could facilitate pooling across settings and knowledge sharing to strengthen global influenza vaccination programs.

Costs of seasonal influenza vaccine delivery in a pediatric demonstration project for children aged 6-23 months - Nakuru and Mombasa Counties, Kenya, 2019-2021

BACKGROUND

During November 2019-October 2021, a pediatric influenza vaccination demonstration project was conducted in four sub-counties in Kenya. The demonstration piloted two different delivery strategies: year-round vaccination and a four-month vaccination campaign. Our objective was to compare the costs of both delivery strategies.

METHODS

Cost data were collected using standardized questionnaires and extracted from government and project accounting records. We reported total costs and costs per vaccine dose administered by delivery strategy from the Kenyan government perspective in 2021 US$. Costs were separated into financial costs (monetary expenditures) and economic costs (financial costs plus the value of existing resources). We also separated costs by administrative level (national, regional, county, sub-county, and health facility) and program activity (advocacy and social mobilization; training; distribution, storage, and waste management; service delivery; monitoring; and supervision).

RESULTS

The total estimated cost of the pediatric influenza demonstration project was US$ 225,269 (financial) and US$ 326,691 (economic) for the year-round delivery strategy (30,397 vaccine doses administered), compared with US$ 214,753 (financial) and US$ 242,385 (economic) for the campaign strategy (25,404 doses administered). Vaccine purchase represented the largest proportion of costs for both strategies. Excluding vaccine purchase, the cost per dose administered was US$ 1.58 (financial) and US$ 5.84 (economic) for the year-round strategy and US$ 2.89 (financial) and US$ 4.56 (economic) for the campaign strategy.

CONCLUSIONS

The financial cost per dose was 83% higher for the campaign strategy than the year-round strategy due to larger expenditures for advocacy and social mobilization, training, and hiring of surge staff for service delivery. However, the economic cost per dose was more comparable for both strategies (year-round 22% higher than campaign), balanced by higher costs of operating equipment and monitoring activities for the year-round strategy. These delivery cost data provide real-world evidence to inform pediatric influenza vaccine introduction in Kenya.

Estimating the delivery costs of COVID-19 vaccination using the COVID-19 Vaccine Introduction and deployment Costing (CVIC) tool: the Lao People's Democratic Republic experience

BACKGROUND

The COVID-19 Vaccine Introduction and deployment Costing (CVIC) tool was developed to assist countries to estimate incremental financial costs to roll out COVID-19 vaccines. This article describes the purposes, assumptions and methods used in the CVIC tool and presents the estimated financial costs of delivering COVID-19 vaccines in the Lao People's Democratic Republic (Lao PDR).

METHODS

From March to September 2021, a multidisciplinary team in Lao PDR was involved in the costing exercise of the National Deployment and Vaccination Plan for COVID-19 vaccines to develop potential scenarios and gather inputs using the CVIC tool. Financial costs of introducing COVID-19 vaccines for 3 years from 2021 to 2023 were projected from the government perspective. All costs were collected in 2021 Lao Kip and presented in United States dollar.

RESULTS

From 2021 to 2023, the financial cost required to vaccinate all adults in Lao PDR with primary series of COVID-19 vaccines (1 dose for Ad26.COV2.S (recombinant) vaccine and 2 doses for the other vaccine products) is estimated to be US$6.44 million (excluding vaccine costs) and additionally US$1.44 million and US$1.62 million to include teenagers and children, respectively. These translate to financial costs of US$0.79-0.81 per dose, which decrease to US$0.6 when two boosters are introduced to the population. Capital and operational cold-chain costs contributed 15-34% and 15-24% of the total costs in all scenarios, respectively. 17-26% went to data management, monitoring and evaluation, and oversight, and 13-22% to vaccine delivery.

CONCLUSIONS

With the CVIC tool, costs of five scenarios were estimated with different target population and booster dose use. These facilitated Lao PDR to refine their strategic planning for COVID-19 vaccine rollout and to decide on the level of external resources needed to mobilize and support outreach services. The results may further inform inputs in cost-effectiveness or cost-benefit analyses and potentially be applied and adjusted in similar low- and middle-income settings.

The Full Value of Vaccine Assessments (FVVA): a framework for assessing and communicating the value of vaccines for investment and introduction decision-making

BACKGROUND

Several economic obstacles can deter the development and use of vaccines. This can lead to limited product options for some diseases, delays in new product development, and inequitable access to vaccines. Although seemingly distinct, these obstacles are actually interrelated and therefore need to be addressed through a single over-arching strategy encompassing all stakeholders.

METHODS

To help overcome these obstacles, we propose a new approach, the Full Value of Vaccines Assessments (FVVA) framework, to guide the assessment and communication of the value of a vaccine. The FVVA framework is designed to facilitate alignment across key stakeholders and to enhance decision-making around investment in vaccine development, policy-making, procurement, and introduction, particularly for vaccines intended for use in low- and middle-income countries.

RESULTS

The FVVA framework has three key elements. First, to enhance assessment, existing value-assessment methods and tools are adapted to include broader benefits of vaccines as well as opportunity costs borne by stakeholders. Second, to improve decision-making, a deliberative process is required to recognize the agency of stakeholders and to ensure country ownership of decision-making and priority setting. Third, the FVVA framework provides a consistent and evidence-based approach that facilitates communication about the full value of vaccines, helping to enhance alignment and coordination across diverse stakeholders.

CONCLUSIONS

The FVVA framework provides guidance for stakeholders organizing global-level efforts to promote investment in vaccines that are priorities for LMICs. By providing a more holistic view of the benefits of vaccines, its application also has the potential to encourage greater take-up by countries, thereby leading to more sustainable and equitable impacts of vaccines and immunization programmes.

Cost of introducing and delivering malaria vaccine (RTS,S/AS01E) in areas of seasonal malaria transmission, Mali and Burkina Faso

BACKGROUND

The WHO recommends use of the RTS,S/AS01_E (RTS,S) malaria vaccine for young children living in areas of moderate to high Plasmodium falciparum malaria transmission and suggests countries consider seasonal vaccination in areas with highly seasonal malaria. Seasonal vaccination is uncommon and may require adaptations with potential cost consequences. This study prospectively estimates cost of seasonal malaria vaccine delivery in Mali and Burkina Faso.

METHODS

Three scenarios for seasonal vaccine delivery are costed (1) mass campaign only, (2) routine Expanded Programme on Immunisation (EPI) and (3) mixed delivery (mass campaign and routine EPI)), from the government's perspective. Resource use data are informed by previous new vaccine introductions, supplemented with primary data from a sample of health facilities and administrative units.

FINDINGS

At an assumed vaccine price of US $5 per dose, the economic cost per dose administered ranges between $7.73 and $8.68 (mass campaign), $7.04 and $7.38 (routine EPI) and $7.26 and $7.93 (mixed delivery). Excluding commodities, the cost ranges between $1.17 and $2.12 (mass campaign), $0.48 and $0.82 (routine EPI) and $0.70 and $1.37 (mixed delivery). The financial non-commodity cost per dose administered ranges between $0.99 and $1.99 (mass campaign), $0.39 and $0.76 (routine EPI) and $0.58 and $1.28 (mixed delivery). Excluding commodity costs, service delivery is the main cost driver under the mass campaign scenario, accounting for 36% to 55% of the financial cost. Service delivery accounts for 2%-8% and 12%-23% of the total financial cost under routine EPI and mixed delivery scenarios, respectively.

CONCLUSION

Vaccine delivery using the mass campaign approach is most costly followed by mixed delivery and routine EPI delivery approaches, in both countries. Our cost estimates provide useful insights for decisions regarding delivery approaches, as countries plan the malaria vaccine rollout.

Voluntary Medical Male Circumcision to Reduce HIV Acquisition and Transmission

PURPOSE OF REVIEW

This commentary introduces the special Global Health Section on the state of voluntary medical male circumcision (VMMC) programs and current knowledge as to role of VMMC prevention of HIV infection acquisition in men and, indirectly, women.

RECENT FINDINGS

Since the first clinical trial of VMMC in Africa was published in 2005, implementation of programs has depended on illuminating best practices and key obstacles in the effort to expand VMMC in areas of high HIV prevalence to reduce HIV acquisition among men, with consequent benefits that uninfected men will not infect others. Global efforts are focused on sub-Saharan Africa, given the favorable expected impact of VMMC deployment where HIV incidence is high and circumcision rates are low. With estimated field effectiveness estimated to exceed 60%, reduced HIV risk for circumcised men in sub-Saharan Africa based on a once-only minor surgical intervention provides extraordinary preventive benefits. Where high VMMC rates have been achieved, declining HIV incidence rates may be partially or substantially attributed to VMMC, but this remains to be investigated. Articles in this special section address achievements, obstacles and risks, and plans for future progress in partnership with affected communities.

Costs of seasonal influenza vaccination in South Africa

Background

Influenza accounts for a substantial number of deaths and hospitalisations annually in South Africa. To address this disease burden, the South African National Department of Health introduced a trivalent inactivated influenza vaccination programme in 2010.

Methods

We adapted and populated the WHO Seasonal Influenza Immunization Costing Tool (WHO SIICT) with country‐specific data to estimate the cost of the influenza vaccination programme in South Africa. Data were obtained through key‐informant interviews at different levels of the health system and through a review of existing secondary data sources. Costs were estimated from a public provider perspective and expressed in 2018 prices. We conducted scenario analyses to assess the impact of different levels of programme expansion and the use of quadrivalent vaccines on total programme costs.

Results

Total financial and economic costs were estimated at approximately USD 2.93 million and USD 7.91 million, respectively, while financial and economic cost per person immunised was estimated at USD 3.29 and USD 8.88, respectively. Expanding the programme by 5% and 10% increased economic cost per person immunised to USD 9.36 and USD 9.52 in the two scenarios, respectively. Finally, replacing trivalent inactivated influenza vaccine (TIV) with quadrivalent vaccine increased financial and economic costs to USD 4.89 and USD 10.48 per person immunised, respectively.

Conclusion

We adapted the WHO SIICT and provide estimates of the total costs of the seasonal influenza vaccination programme in South Africa. These estimates provide a basis for planning future programme expansion and may serve as inputs for cost‐effectiveness analyses of seasonal influenza vaccination programmes.