Economics of vaccines revisited

Optimising the introduction of multiple childhood vaccines in Japan: A model proposing the introduction sequence achieving the highest health gains

BACKGROUND

Many countries struggle with the prioritisation of introducing new vaccines because of budget limitations and lack of focus on public health goals. A model has been developed that defines how specific health goals can be optimised through immunisation within vaccination budget constraints.

METHODS

Japan, as a country example, could introduce 4 new pediatric vaccines targeting influenza, rotavirus, pneumococcal disease and mumps with known burden of disease, vaccine efficacies and maximum achievable coverages. Operating under budget constraints, the Portfolio-model for the Management of Vaccines (PMV) identifies the optimal vaccine ranking and combination for achieving the maximum QALY gain over a period of 10 calendar years in children <5 years old. This vaccine strategy, of interest and helpful for a healthcare decision maker, is compared with an unranked vaccine selection process.

RESULTS

Results indicate that the maximum QALY gain with a fixed annual vaccination budget of 500 billion Japanese Yen over a 10-year period is 72,288 QALYs using the optimal sequence of vaccine introduction (mumps [1st], followed by influenza [2nd], rotavirus [3rd], and pneumococcal [4th]). With exactly the same budget but without vaccine ranking, the total QALY gain can be 20% lower.

CONCLUSION

The PMV model could be a helpful tool for decision makers in those environments with limited budget where vaccines have to be selected for trying to optimise specific health goals.

Towards a more comprehensive approach for a total economic assessment of vaccines?: 1. The building blocks for a health economic assessment of vaccination

​Since we were born, we all take preventative actions to avoid unpredictable adverse conditions. Some actions are done automatically. Others require a conscious choice , either for personal or social benefit. A distinction can therefore be drawn between non-active and active prevention, and between individual and social prevention. Active prevention requires making a choice in time, effort, and cost. We call it an economic choice. Vaccines belong to the group of active and social prevention. Because a vaccination program is an economic social choice, how should it be valued, and what cost should we pay for? To date, the economic evaluations developed for treatment have been applied to vaccines. However, over 25 different characteristics differentiate vaccines from treatment. For example, the benefit of vaccination is measured at the population level not at the individual level, the main effect of prevention is societal and not an individual-based gain only, and the biggest hurdle to implement a new vaccine is the initial budget investment and not so much its estimated 'value for money'. This makes the current application of incremental cost-utility analysis difficult for vaccines for a comprehensive evaluation. New approaches may be needed to capture the full economic benefit of vaccines.​.

A systematic review of health economic evaluations of vaccines in Brazil

BACKGROUND

In Brazil, since 2005, the Ministry of Health requires Health Economic Evaluation (HEE) of vaccines for introduction into the National Immunization Program.

OBJECTIVES

To describe and analyze the full HEE on vaccines conducted in Brazil from 1980 to 2013.

METHODS

Systematic review of the literature. We searched multiple databases. Two researchers independently selected the studies and extracted the data. The methodological quality of individual studies was evaluated using CHEERS items.

RESULTS

Twenty studies were reviewed. The most evaluated vaccines were pneumococcal (25%) and HPV (15%). The most used types of HEE were cost-effectiveness analysis (45%) and cost-utility analysis (20%). The research question and compared strategies were stated in all 20 studies and the target population was clear in 95%. Nevertheless, many studies did not inform the perspective of analysis or data sources.

CONCLUSIONS

HEE of vaccines in Brazil has increased since 2008. However, the studies still have methodological deficiencies.

2. How is the economic assessment of vaccines performed today?

This paper describes how the economic assessment of vaccines is performed today. It discusses why it may be incomplete and explores potential approaches to adjust the analysis to be more comprehensive. Besides helping protect against serious disease, vaccines also help avoid mild disease episodes that may not receive medical attention but which have important societal consequences. They also benefit unvaccinated individuals by reducing disease transmission. Wider societal benefits may extend beyond a decrease in disease incidence, as lower transmission rates reduce the risk of epidemics, which in turn reduces the pressure on healthcare providers, and may improve the quality of care for patients with unrelated diseases. Vaccines also lower the use of antibiotics leading to less pressure on anti-microbial resistance. Conventional ICUA focuses on individual health benefits, like increased survival. Therefore, this approach may not adequately capture the wider vaccination benefits. We discuss differences between treatment and vaccine prevention in the economic assessment, and how ICUA has been adapted to cope with the inconsistencies. Although such adaptations may fulfil the demand of one specific stakeholder, they may not meet the needs of other stakeholders who operate at the societal level, such as ministries other than healthcare, employers, caregivers, and insurers.

Comparing cost-effectiveness results for a vaccine across different countries worldwide: what can we learn?

INTRODUCTION

Cost-effectiveness analysis (CEA) using country-specific thresholds tied to gross domestic product (GDP) might not be appropriate in countries with low healthcare investment and a high disease burden as a consequence.

METHODS

Using data from previously published CEA of rotavirus vaccination across nine countries worldwide, we calculated the cost neutral price (Pn) for the new intervention that reflects the price resulting in no net increase in health care costs compared with the current situation, and the maximum price (Pm) obtained with an incremental cost-effectiveness ratio (ICER) at the threshold value of 1×GDP/capita.

RESULTS

In countries with low GDP/capita, the paradoxical finding for rotavirus vaccination is that the Pm is much higher than in countries with a high GDP/capita. On the other hand, the Pn for the low GDP/capita countries is much lower than for high GDP/capita countries because of the low investment in health care.

CONCLUSION

In countries with low healthcare investment and a high disease burden, the difference between the Pn and Pm for rotavirus vaccine which is the price range within which the ICER is below the World Health Organization (WHO) threshold value, is large. One reason could be that the WHO threshold value may not properly account for the local opportunity cost of health care expenditures. Therefore, either alternative threshold values should be selected or alternative economic assessment tools should be considered, such as budget optimisation or return on investment, if we want to communicate about real economic value of new vaccines in those countries.

Do current cost-effectiveness analyses reflect the full value of childhood vaccination in Europe? A rotavirus case study

Economic evaluation of vaccination programs can be challenging and does not always fully capture the benefits provided. Reasons for this include the difficulties incurred in accurately capturing the health and economic impact of infectious diseases and how different diseases may interact with each other. Rotavirus infection, for example, peaks at a similar time than other infectious diseases, such as RSV and influenza, which can cause hospital overcrowding and disruption, and may pose a risk to more vulnerable children due to limited availability of isolation facilities. Another challenge, specific to evaluating childhood vaccination, is that QoL cannot be accurately measured in children due to a lack of validated instruments. Childhood diseases also incur a care giver burden, due to the need for parents to take time off work, and this is important to consider. Finally, for diseases such as RVGE, cost-effectiveness analyses in which longer time horizons are considered may not reflect the short-term benefits of vaccination. Further quantification of the economic impact of childhood diseases is thus required to fully highlight the true benefits of childhood vaccination that may be realized. Herein we explore the limitations of existing economic evaluations for childhood vaccination, and how economic analyses could be better adapted in future.

Is the gap between micro- and macroeconomic assessments in health care well understood? The case of vaccination and potential remedies

Vaccination is an established intervention that reduces the burden and prevents the spread of infectious diseases. Investing in vaccination is known to offer a wide range of economic and intangible benefits that can potentiate gains for the individual and for society. The discipline of economics provides us with microeconomic and macroeconomic methods for evaluating the economic gains attributed to health status changes. However, the observed gap between micro and macro estimates attributed to health presents challenges to our understanding of health-related productivity changes and, consequently, economic benefits. The gap suggests that the manner in which health-related productive output is quantified in microeconomic models might not adequately reflect the broader economic benefit. We propose that there is a transitional domain that links the micro- and macroeconomic improvement attributed to health status changes. Currently available economic evaluation methods typically omit these consequences, however; they may be adjusted to integrate these transitional consequences. In practical terms, this may give rise to multipliers to apply toward indirect costs to account for the broader macroeconomic benefits linked to changes in health status. In addition, it is possible to consider that different medical conditions and health care interventions may pose different multiplying effects, suggesting that the manner in which resources are allocated within health services gives rise to variation in the amount of the micro-macro gap. An interesting way to move forward in integrating the micro- and macro-level assessment might be by integrating computable general equilibrium (CGE) models as part of the evaluation framework, as was recently performed for pandemic flu and malaria vaccination.

Economic evaluation of vaccines: specificities and future challenges illustrated by recent European examples

This study reviews the current challenges in the economic evaluation of vaccines with a focus on European countries. In particular, the type of clinical evidence generally available, the impact of discounting for time preference and the use of modeling to derive valid cost-effectiveness assessments are considered. First, the characteristics of evidence for vaccines are discussed, as well as potential difficulties faced when using evidence-based medicine applied to curative drugs to interpret vaccine evidence. Then, discounting is considered and specific examples illustrating issues with different types of discounting are described, taking HPV as the example. Finally, the need for sometimes complex dynamic models for vaccines is explored, and specific types of models are reviewed, keeping into consideration the adage "complex when needed, straightforward if allowed."