Challenges to building capacity for evidence-based new vaccine policy in developing countries

HPV vaccine introduction in the Americas: a decade of progress and lessons learned

INTRODUCTION

Human papillomavirus (HPV) is an important public health concern due to its causative role in many cancers, especially cervical cancer, and other conditions that lead to serious health consequences in both men and women. In Latin America and the Caribbean, nearly 60,000 new cases of cervical cancer and another 7,000 HPV-associated cancers are diagnosed annually.

AREAS COVERED

HPV vaccination combined with comprehensive cervical cancer control programmingis paving the way for eliminating cervical cancer as a major public health problem and drastically reducing other HPV-associated diseases. To date, 44 countries and territories in the Americas have introduced HPV vaccines as part of their national immunization programs and cervical cancer control strategies. Early lessons from HPV vaccine introduction suggest that transparent and credible evidence-based decision-making, information, education and communication about HPV and cervical cancer, coordination with existing cervical cancer control initiatives, and precise planning for ensuring effective uptake of the vaccine in target groups are all critical elements of success.

EXPERT OPINION

There is an urgent need for strategies to increase HPV vaccine coverage, and as the integrated control programs evolve and other HPV-associated disease becomes important for public health, there will be a need for continued program and policy evaluation.

Optimized supply chain model reduces health system costs in DRC

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After implementing optimized model, we observed 34% reduction in supply chain costs.

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Costs increased for Provincial store but decreased for Zones and health facilities.

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Streamlined distribution practices supported cost reductions for transportation.

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After implementing optimized model, costs increased in control Zones and facilities.

Objective

In 2017, an optimized immunization supply chain (iSC) model was implemented in Equateur Province, Democratic Republic of the Congo. The optimized model aimed to address iSC challenges and featured direct deliveries to service delivery points (SDPs), longer replenishment intervals and increased cold chain capacity. This assessment examines iSC costs before and 5 months after implementing the optimized model.

Materials & Methods

We used a nonexperimental pre-post study design to compare iSC costs before and after implementation. We applied an activity-based costing approach with a comparison arm to assess procurement, management, storage and transportation costs for three iSC tiers: Province (n = 1); Zone (n = 4) and SDP (n = 15). We included data from 3 treatment Zones and 11 treatment SDPs; 1 control Zone and 4 control SDPs. We used sample and population data to estimate iSC costs for the entirety of Equateur Province.

Results

In the period immediately before implementing the optimized model, estimated annual iSC costs were $974,237. Following implementation, estimated annual iSC costs were $642,627—a 34% ($331,610) reduction. This change in costs was influenced by a 43% ($180,313) reduction in SDP costs, a 67% ($198,092) reduction in Zonal costs and an 18% ($46,795) increase in Provincial costs. After implementing the optimized model, average iSC costs for treatment Zones was $6,895 (SD: $6,072); for the control Zone was $21,738; for treatment SDPs was $989 (SD: $969); and for control SDPs was $1,356 (SD: $1,062).

Conclusions

We observed an absolute reduction in iSC costs in treatment Zones while control Zone post-implementation iSC costs remained the same or increased. The greatest cost reductions were for storage and transport at Zones and SDPs. Although cost implications of this model must continue to be evaluated over time, these findings are promising and will inform decisions around project expansion.

Evidence-based policymaking and the wicked problem of SDG 5 Gender Equality

Evidence-based policymaking (EBP) contends that policy decisions are successful when informed by evidence. However, where policy problems are “wicked” (systemic, ambiguous, complex, and conflictual), politics trumps evidence and solutions are never first best or permanent. Applying an EBP approach to solving wicked problems (WPs) therefore appears to be a daunting, impossible task. Despite the difficulties, we contend that blending insights from the EBP and WP literatures can provide actionable and practical policy advice to governments and MNEs for dealing with the WPs of the UN Sustainable Development Goals (SDGs). We support our thesis with a case study applying EBP to the WP of SDG 5 Gender Equality. We compare the statistical evidence from gender inequality indexes to SDG 5’s targets and indicators. We provide five insights from the EBP and WP literatures into why and how good evidence is necessary but not sufficient for progress on SDG 5. Building on these insights, we recommend that governments adopt an EBP approach employing public–private partnerships to address SDG 5. We also recommend that MNE executives use our new SDG Materiality Matrix, designed on EBP principles, to build SDG 5 into their global corporate social responsibility strategies.

Improved Global Capacity for Influenza Surveillance

CDC’s international capacity-building program shows evidence of progress.

During 2004–2009, the Centers for Disease Control and Prevention (CDC) partnered with 39 national governments to strengthen global influenza surveillance. Using World Health Organization data and program evaluation indicators collected by CDC in 2013, we retrospectively evaluated progress made 4–9 years after the start of influenza surveillance capacity strengthening in the countries. Our results showed substantial increases in laboratory and sentinel surveillance capacities, which are essential for knowing which influenza strains circulate globally, detecting emergence of novel influenza, identifying viruses for vaccine selection, and determining the epidemiology of respiratory illness. Twenty-eight of 35 countries responding to a 2013 questionnaire indicated that they have leveraged routine influenza surveillance platforms to detect other pathogens. This additional surveillance illustrates increased health-system strengthening. Furthermore, 34 countries reported an increased ability to use data in decision making; data-driven decisions are critical for improving local prevention and control of influenza around the world.

Improved Global Capacity for Influenza Surveillance

During 2004-2009, the Centers for Disease Control and Prevention (CDC) partnered with 39 national governments to strengthen global influenza surveillance. Using World Health Organization data and program evaluation indicators collected by CDC in 2013, we retrospectively evaluated progress made 4-9 years after the start of influenza surveillance capacity strengthening in the countries. Our results showed substantial increases in laboratory and sentinel surveillance capacities, which are essential for knowing which influenza strains circulate globally, detecting emergence of novel influenza, identifying viruses for vaccine selection, and determining the epidemiology of respiratory illness. Twenty-eight of 35 countries responding to a 2013 questionnaire indicated that they have leveraged routine influenza surveillance platforms to detect other pathogens. This additional surveillance illustrates increased health-system strengthening. Furthermore, 34 countries reported an increased ability to use data in decision making; data-driven decisions are critical for improving local prevention and control of influenza around the world.

Costing analysis and anthropological assessment of the vaccine supply chain system redesign in the Comé District (Benin)

OBJECTIVE

At the end of 2013, a pilot experiment was carried out in Comé health zone (HZ) in an attempt to optimize the vaccine supply chain. Four commune vaccine storage facilities were replaced by one central HZ facility. This study evaluated the incremental financial needs for the establishment of the new system; compared the economic cost of the supply chain in the Comé HZ before and after the system redesign; and analyzed the changes induced by the pilot project in immunization logistics management.

METHOD

The purposive sampling method was used to draw a sample from 37 health facilities in the zone for costing evaluation. Data on inputs and prices were collected retrospectively for 2013 and 2014. The analysis used an ingredient-based approach. In addition, 44 semi-structured interviews with health workers for anthropological analysis were completed in 2014.

RESULTS

The incremental financial costs amounted to US$55,148, including US$50,605 for upfront capital investment and US$4543 for ongoing recurrent costs. Annual economic cost per dose administered (including all vaccines distributed through the Expanded Program on Immunization (EPI)) in the Comé HZ increased from US$0.09 before system redesign to US$0.15 after implementation, mainly due to a high initial investment and the operational cost of HZ mobile warehouse. Interviews with health workers suggested that the redesigned system was associated with improvements in motivation and professional awareness due to training, supportive supervision, and improved work conditions.

CONCLUSIONS

The system redesign involved a considerable investment at HZ level. Benefits were found in the reduction of transportation costs to health posts (HP) and commune health center (CHC) levels, and the strengthening of health workers professional skills at all levels in Comé. The redesigned system contributed to a decrease in funding needs at HP and CHC levels. The benefits of the investment need to be examined after the introduction of new vaccines and after a longer period.

When cost-effective interventions are unaffordable: Integrating cost-effectiveness and budget impact in priority setting for global health programs

Potential cost-effective barriers in cost-effectiveness studies mean that budgetary impact analyses should also be included in post-2015 Sustainable Development Goal projects says Joshua Salomon and colleagues.

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.

Social inequality and children's health in Africa: a cross sectional study

BACKGROUND

This study examines socioeconomic inequality in children's health and factors that moderate this inequality. Socioeconomic measures include household wealth, maternal education and urban/rural area of residence. Moderating factors include reproductive behavior, access to health care, time, economic development, health expenditures and foreign aid.

METHODS

Data are taken from Demographic and Health Surveys conducted between 2003 and 2012 in 26 African countries.

RESULTS

Birth spacing, skilled birth attendants, economic development and greater per capita health expenditures benefit the children of disadvantaged mothers, but the wealthy benefit more from the services of a skilled birth attendant and from higher per capita expenditure on health.

CONCLUSION

Some health behavior and policy changes would reduce social inequality, but the wealthy benefit more than the poor from provision of health services.

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.

The composition of demand for newly launched vaccines: results from the pneumococcal and rotavirus vaccine introductions in Ethiopia and Malawi

Understanding post-launch demand for new vaccines can help countries maximize the benefits of immunization programmes. In particular, low- and middle-income countries (LMICs) should ensure adequate resource planning with regards to stock consumption and service delivery for new vaccines, whereas global suppliers must produce enough vaccines to meet demand. If a country underestimates the number of children seeking vaccination, a stock-out of commodities will create missed opportunities for saving lives. We describe the post-launch demand for the first dose of pneumococcal conjugate vaccine (PCV1) in Ethiopia and Malawi and the first dose of rotavirus vaccine (Rota1) in Malawi, with focus on the new birth cohort and the ‘backlog cohort’, comprised of older children who are still eligible for vaccination at the time of launch. PCV1 and Rota1 uptake were compared with the demand for the first dose of pentavalent vaccine (Penta1), a routine immunization that targets the same age group and immunization schedule. In the first year, the total demand for PCV1 was 37% greater than that of Penta1 in Ethiopia and 59% greater in Malawi. In the first 6 months, the demand of Rota1 was only 5.9% greater than Penta1 demand in Malawi. Over the first three post-introduction months, 70.7% of PCV1 demand in Ethiopia and 71.5% of demand in Malawi came from children in the backlog cohort, whereas only 28.0% of Rota1 demand in Malawi was from the backlog cohort. The composition of demand was impacted by time elapsed since vaccine introduction and age restrictions. Evidence suggests that countries’ plans should account for the impact of backlog demand, especially in the first 3 months post-introduction. LMICs should request for higher stock volumes when compared with routine needs, plan social mobilization activities to reach the backlog cohort and allocate human resources and cold chain capacity to accommodate high demand following vaccine introduction.

Current issues in the economics of vaccination against dengue

Dengue is a major public health concern in tropical and subtropical areas of the world. The prospects for dengue prevention have recently improved with the results of efficacy trials of a tetravalent dengue vaccine. Although partially effective, once licensed, its introduction can be a public health priority in heavily affected countries because of the perceived public health importance of dengue. This review explores the most immediate economic considerations of introducing a new dengue vaccine and evaluates the published economic analyses of dengue vaccination. Findings indicate that the current economic evidence base is of limited utility to support country-level decisions on dengue vaccine introduction. There are a handful of published cost-effectiveness studies and no country-specific costing studies to project the full resource requirements of dengue vaccine introduction. Country-level analytical expertise in economic analyses, another gap identified, needs to be strengthened to facilitate evidence-based decision-making on dengue vaccine introduction in endemic countries.

Role of vaccine manufacturers in developing countries towards global healthcare by providing quality vaccines at affordable prices

Vaccines represent one of the greatest achievements of science and medicine in the fight against infectious diseases. Vaccination is one of the most cost-effective public health tools to prevent infectious diseases. Significant progress has been made in expanding the coverage of vaccines globally, resulting in the prevention of more than two million deaths annually. In 2010, nearly 200 countries endorsed a shared vision to extend the benefits of vaccines to every person by 2020, known as the Decade of Vaccine Initiative (DoV). Vaccine manufacturers in developing countries, as represented by the Developing Countries Vaccine Manufacturers Network (DCVMN), make a significant contribution to DoV by supplying quality vaccines at affordable prices to the people who need them most. About 70% of the global Expanded Program on Immunization (EPI) vaccine supplies are met by DCVMN. Besides EPI vaccine supplies, DCVMN is also targeting vaccines against rotavirus, Japanese encephalitis, pneumonia, human papillomavirus, meningitis and neglected tropical diseases. This article reviews the roles and contributions of DCVMN in making the vaccines accessible and affordable to all.

New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries

As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions. Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries. The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics. Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished. This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.