Cost-effectiveness of a 3-dose pneumococcal conjugate vaccine program in the province of Quebec, Canada

Systematic Review of Cost-Utility Analyses That Have Included Carer and Family Member Health-Related Quality of Life

OBJECTIVES

Health interventions for patients can also affect the health of their informal carers and family members. These changes in carer or family member health could be reflected in cost-utility analyses (CUAs) through the inclusion of their quality-adjusted life-years (QALYs). We conducted a systematic review to identify and describe all CUAs that have included family member health-related QALYs.

METHODS

A total of 4 bibliographic databases were searched from inception to July 2021. A 2-stage sifting process for inclusion of studies was undertaken. We performed data extraction using a standardized data extraction form and performed a narrative synthesis of the evidence.

RESULTS

A total of 40 CUAs published between 1999 and 2021 were identified. CUAs were conducted in 15 different countries. CUAs examined 13 different conditions including 15 CUAs on vaccination, 5 on Alzheimer's disease, 2 on Parkinson's disease, 3 on dementia, and 2 on terminal illness. The EQ-5D was the most commonly used measure of family member health. Generally, including carer QALYs resulted in lower incremental cost-effectiveness ratios.

CONCLUSIONS

When considering the total number of economic evaluations published, few have included family member QALYs and the methods for doing so are often inconsistent and data sources often limited. Estimation of family member QALYs in patient CUAs was regularly uncertain and often substantial in magnitude. The findings highlight the variation among methods and call for greater consistency in methods for incorporating family member QALYs in patient CUAs.

Decrease of Pneumococcal Community-Acquired Pneumonia Hospitalization and Associated Complications in Children after the Implementation of the 13-Valent Pneumococcal Conjugate Vaccine (PCV13) in Taiwan

The impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on overall community-acquired pneumonia (CAP) and disease severity still needs thorough evaluation. In this study, we retrieve both pneumococcal CAP (P-CAP) and unspecific CAP (U-CAP) inpatient data from the Taiwan National Health Insurance Database (NHID) between 2005 and 2016. The interrupted time-series (ITS) analysis was performed to compare the incidence trend before and after the implementation of PCV13. After PCV13 implementation, there is a significant decreasing trend of P-CAP hospitalization, especially in children <1 year, 2-5 years, adults aged 19-65 years, 66 years, or older (all p value < 0.05). This corresponds to a 59% reduction in children <1 year, 47% in children aged 2-5 years, 39% in adult aged 19-65 years, and 41% in elderly aged 66 years or older. The intensive care rate (6.8% to 3.9%), severe pneumonia cases (21.7 to 14.5 episodes per 100,000 children-years), and the need for invasive procedures (4.3% to 2.0%) decreased in children aged 2-5 years (p value < 0.0001) with P-CAP. This PCV13 implementation program in Taiwan not only reduced the incidence of P-CAP, but also attenuated disease severity, especially in children aged 2-5 years.

Pneumococcal Disease: A Systematic Review of Health Utilities, Resource Use, Costs, and Economic Evaluations of Interventions

BACKGROUND

Pneumococcal diseases cause substantial mortality, morbidity, and economic burden. Evidence on data inputs for economic evaluations of interventions targeting pneumococcal disease is critical.

OBJECTIVES

To summarize evidence on resource use, costs, health utilities, and cost-effectiveness for pneumococcal disease and associated interventions to inform future economic analyses.

METHODS

We searched MEDLINE, Embase, Web of Science, CINAHL, PsycINFO, EconLit, and Cochrane databases for peer-reviewed studies in English on pneumococcal disease that reported health utilities using direct or indirect valuation methods, resource use, costs, or cost-effectiveness of intervention programs, and summarized the evidence descriptively.

RESULTS

We included 383 studies: 9 reporting health utilities, 131 resource use, 160 economic costs of pneumococcal disease, 95 both resource use and costs, and 178 economic evaluations of pneumococcal intervention programs. Health state utility values ranged from 0 to 1 for both meningitis and otitis media and from 0.3 to 0.7 for both pneumonia and sepsis. Hospitalization was shortest for otitis media (range: 0.1-5 days) and longest for sepsis/septicemia (6-48). The main categories of costs reported were drugs, hospitalization, and household or employer costs. Resource use was reported in hospital length of stay and number of contacts with general practitioners. Costs and resource use significantly varied among population ages, disease conditions, and settings. Current vaccination programs for both adults and children, antibiotic use and outreach programs to promote vaccination, early disease detection, and educational programs are cost-effective in most countries.

CONCLUSION

This study has generated a comprehensive repository of health economic evidence on pneumococcal disease that can be used to inform future economic evaluations of pneumococcal disease intervention programs.

Kingdon's Multiple Streams Framework and the Analysis of Decision-Making Processes Regarding Publicly-Funded Immunization Programs

Introduction: The implementation of a publicly-funded immunization program results from a complex decision-making process. John Kingdon's 'Multiple Streams Framework' has been extensively used to analyze how and why governmental policies were adopted. Area covered: Ideas that will ultimately end up in a proposal for a new immunization program develop gradually along three main streams: (i) the problem stream, which focuses on a particular vaccine-preventable disease and its perception by stakeholders; (ii) the policy stream, which is centered on experts' views on the optimal use of available vaccines; and (iii) the politics stream, which consists of socio-political factors, including budgetary constraints. Ideas are progressively shaped by policy entrepreneurs into a proposal with concrete implementation strategies. The three streams then converge within a policy window, during which adoption is especially likely to occur. To survive, the proposed program should be operationally feasible, consistent with mainstream social values, and financially affordable. The timing of the policy window is usually unpredictable and of short duration. Expert opinion: Analytical frameworks traditionally used to assess immunization programs focus on the technical aspects of the disease, the vaccine, and the program. The 'Multiple Streams Framework' brings added analytical value by enlarging the scope of the analysis into the political arena.

Inclusion of the value of herd immunity in economic evaluations of vaccines. A systematic review of methods used

OBJECTIVE

The objectives of this review were to identify vaccine economic evaluations that include herd immunity and describe the methodological approaches used.

METHODS

We used Kim and Goldie's search strategy from a systematic review (1976-2007) of modelling approaches used in vaccine economic evaluations and additionally searched PubMed/MEDLINE and Embase for 2007-2015. Studies were classified according to modelling approach used. Methods for estimating herd immunity effects were described, in particular for the static models.

RESULTS

We identified 625 economic evaluations of vaccines against human-transmissible diseases from 1976 to 2015. Of these, 172 (28%) included herd immunity. While 4% of studies included herd immunity in 2001, 53% of those published in 2015 did this. Pneumococcal, human papilloma and rotavirus vaccines represented the majority of studies (63%) considering herd immunity. Ninety-five of the 172 studies utilised a static model, 59 applied a dynamic model, eight a hybrid model and ten did not clearly state which method was used. Relatively crude methods and assumptions were used in the majority of the static model studies.

CONCLUSION

The proportion of economic evaluations using a dynamic model has increased in recent years. However, 55% of the included studies used a static model for estimating herd immunity. Values from a static model can only be considered reliable if high quality surveillance data are incorporated into the analysis. Without this, the results are questionable and they should only be included in sensitivity analysis.

Hospitalisation for lower respiratory tract infection in children in the province of Quebec, Canada, before and during the pneumococcal conjugate vaccine era

Streptococcus pneumoniae is an important cause of community-acquired pneumonia and pneumococcal conjugate vaccines (PCVs) may reduce this burden. This study's goal was to analyse trends in lower respiratory tract infections (LRTI) hospitalisations before and during a routine vaccination programme targeting all newborns with PCV was started in the province of Quebec, Canada in December 2004. The study population included hospital admissions with a main diagnosis of LRTI among 6-59 month-old Quebec residents from April 2000 to December 2014. Trends in proportions and rates were analysed using Cochran-Armitage tests and Poisson regression models. We observed a general downward trend in all LTRI hospitalisations rate: from 11·55/1000 person-years in 2000-2001 to 9·59/1000 in 2013-2014, a 17·0% reduction, which started before the introduction of PCV vaccination. Downward trends in hospitalisation rates were more pronounced for all-cause of pneumonia (minus 17·8%) than for bronchiolitis (minus 15·4%). There was also a decrease in the mean duration of hospital stay. There was little evidence that all-cause pneumonia decreased over the study period due mainly to the introduction of PCVs. Trends may be related to changes in clinical practice. This study casts doubt on the interpretation of ecological analyses of the implementation of PCV vaccination programmes.

Economic evaluations of vaccines in Canada: a scoping review

Background

This study aims to summarise and describe the evolution of published economic evaluations of vaccines in Canada, thereby outlining the current state of this expanding and meaningful research.

Methods

Using Arksey and O’Malley’s scoping review framework we assembled relevant research from both academic and grey literature. Following abstract and full-text review we identified 60 articles to be included in the final analysis.

Results

We found that since 1988 there has been a steady increase in the number of economic evaluations on vaccines in Canada. Many of these studies focus on the more recently licensed vaccines, such as influenza (16.7%), human papillomavirus (15.0%) and pneumococcal disease (15.0%). Since 2010 economic evaluations of vaccines have shown increased adherence to economic evaluation guidelines (OR = 4.6, CI 1.33, 18.7), suggesting there has been improvement in the consistency and transparency of these studies. However, there remains room for improvement, for instance, we found evidence that studies who stated a conflict of interest are more likely to assert the vaccine of interest was cost-effective (OR = 7.4; CI 1.04, 17.8). Furthermore, most reports use static models that do not consider herd immunity, and only a few evaluate vaccines post-implementation (ex-post) and traveller’s vaccinations.

Conclusion

Researchers should examine identified research gaps and continue to improve standardization and transparency when reporting to ensure economic evaluations of vaccines best meet the needs of policy-makers, other researchers and the public.

Electronic supplementary material

The online version of this article (doi:10.1186/s12962-017-0069-4) contains supplementary material, which is available to authorized users.

Increasing Coverage of Appropriate Vaccinations: A Community Guide Systematic Economic Review

CONTEXT

Population-level coverage for immunization against many vaccine-preventable diseases remains below optimal rates in the U.S. The Community Preventive Services Task Force recently recommended several interventions to increase vaccination coverage based on systematic reviews of the evaluation literature. The present study provides the economic results from those reviews.

EVIDENCE ACQUISITION

A systematic review was conducted (search period, January 1980 through February 2012) to identify economic evaluations of 12 interventions recommended by the Task Force. Evidence was drawn from included studies; estimates were constructed for the population reach of each strategy, cost of implementation, and cost per additional vaccinated person because of the intervention. Analyses were conducted in 2014.

EVIDENCE SYNTHESIS

Reminder systems, whether for clients or providers, were among the lowest-cost strategies to implement and the most cost effective in terms of additional people vaccinated. Strategies involving home visits and combination strategies in community settings were both costly and less cost effective. Strategies based in settings such as schools and MCOs that reached the target population achieved additional vaccinations in the middle range of cost effectiveness.

CONCLUSIONS

The interventions recommended by the Task Force differed in reach, cost, and cost effectiveness. This systematic review presents the economic information for 12 effective strategies to increase vaccination coverage that can guide implementers in their choice of interventions to fit their local needs, available resources, and budget.

Economic evaluation of vaccines in Canada: A systematic review

BACKGROUND

Economic evaluations should form part of the basis for public health decision making on new vaccine programs. While Canada's national immunization advisory committee does not systematically include economic evaluations in immunization decision making, there is increasing interest in adopting them. We therefore sought to examine the extent and quality of economic evaluations of vaccines in Canada.

OBJECTIVE

We conducted a systematic review of economic evaluations of vaccines in Canada to determine and summarize: comprehensiveness across jurisdictions, studied vaccines, funding sources, study designs, research quality, and changes over time.

METHODS

Searches in multiple databases were conducted using the terms "vaccine," "economics" and "Canada." Descriptive data from eligible manuscripts was abstracted and three authors independently evaluated manuscript quality using a 7-point Likert-type scale scoring tool based on criteria from the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

RESULTS

42/175 articles met the search criteria. Of these, Canada-wide studies were most common (25/42), while provincial studies largely focused on the three populous provinces of Ontario, Quebec and British Columbia. The most common funding source was industry (17/42), followed by government (7/42). 38 studies used mathematical models estimating expected economic benefit while 4 studies examined post-hoc data on established programs. Studies covered 10 diseases, with 28/42 addressing pediatric vaccines. Many studies considered cost-utility (22/42) and the majority of these studies reported favorable economic results (16/22). The mean quality score was 5.9/7 and was consistent over publication date, funding sources, and disease areas.

CONCLUSIONS

We observed diverse approaches to evaluate vaccine economics in Canada. Given the increased complexity of economic studies evaluating vaccines and the impact of results on public health practice, Canada needs improved, transparent and consistent processes to review and assess the findings of the economic evaluations of vaccines.

Sources and Characteristics of Utility Weights for Economic Evaluation of Pediatric Vaccines: A Systematic Review

BACKGROUND

Cost-effectiveness analysis of pediatric vaccines for infectious diseases often requires quality-of-life (utility) weights.

OBJECTIVE

To investigate how utility weights have been elicited and used in this context.

METHODS

A systematic review was conducted of studies published between January 1990 and July 2013 that elicited or used utility weights in cost-effectiveness analyses of vaccines for pediatric populations. The review focused on vaccines for 17 infectious diseases and is presented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology.

RESULTS

A total of 6410 titles and abstracts and 225 full-text articles were reviewed. Of those selected for inclusion (n = 101), 15 articles described the elicitation of utility weights and 86 described economic modeling studies using utilities. Various methods were used to generate utilities, including time trade-off, contingent valuation, and willingness to pay, as well as a preference-based measure with associated value sets, such as the EuroQol five-dimensional questionnaire or the Health Utilities Index. In modeling studies, the source of utilities used was often unclear, poorly reported, or based on weak underlying evidence. We found no articles that reported on the elicitation or use of utilities in diphtheria, polio, or tetanus.

CONCLUSIONS

The scarcity of appropriate utility weights for vaccine-preventable infectious diseases in children and a lack of standardization in their use in economic assessments limit the ability to accurately assess the benefits associated with interventions to prevent infectious diseases. This is an issue that should be of concern to those making decisions regarding the prevention and treatment of infectious childhood illnesses.

Choosing between 7-, 10- and 13-valent pneumococcal conjugate vaccines in childhood: a review of economic evaluations (2006-2014)

BACKGROUND

Seven-valent pneumococcal conjugate vaccines (PCV7) have been used in children for more than a decade. Given the observed increase in disease caused by pneumococcal serotypes not covered by PCV7, an increasing number of countries are switching from 7-valent to 10- and 13-valent PCVs ("PCV10" and "PCV13"). Economic evaluations are important tools to inform decisions and price negotiations to make such a switch.

OBJECTIVE

This review aims to provide a critical assessment of economic evaluations involving PCV10 or PCV13, published since 2006.

METHODS

We searched Scopus, ISI Web of Science (SCI and SSCI) and Pubmed to retrieve, select and review relevant studies, which were archived between 1st January 2006 and 31st January 2014. The review protocol involved standard extraction of assumptions, methods, results and sponsorships from the original studies.

RESULTS

Sixty-three economic evaluations on PCVs published since January 2006 were identified. About half of these evaluated PCV10 and/or PCV13, the subject of this review. At current prices, both PCV13 and PCV10 were likely judged preferable to PCV7. However, the combined uncertainty related to price differences, burden of disease, vaccine effectiveness, herd and serotype replacement effects determine the preference base for either PCV10 or PCV13. The pivotal assumptions and results of these analyses also depended on which manufacturer sponsored the study.

CONCLUSION

A more thorough exploration of uncertainty should be made in future analyses on this subject, as we lack understanding to adequately model herd and serotype replacement effects to reliably predict the population impact of PCVs. The introduction of further improved PCVs in an environment of evolving antibiotic resistance and under the continuing influence of previous PCVs implies that the complexity and data requirements for relevant analyses will further increase. Decision makers using these analyses should not just rely on an analysis from a single manufacturer.

Systematic review of incremental non-vaccine cost estimates used in cost-effectiveness analysis on the introduction of rotavirus and pneumococcal vaccines

OBJECTIVE

To review the approaches used in the cost-effectiveness analysis (CEAs) literature to estimate the cost of expanded program on immunization (EPI) activities, other than vaccine purchase, for rotavirus and pneumococcal vaccines.

METHODS

A systematic review in PubMed and NHS EED databases of rotavirus and pneumococcal vaccines CEAs was done. Selected articles were read and information on how EPI costs were calculated was extracted. EPI costing approaches were classified according to the method or assumption used for estimation.

RESULTS

Seventy-nine studies that evaluated cost effectiveness of rotavirus (n=43) or pneumococcal (n=36) vaccines were identified. In general, there are few details on how EPI costs other than vaccine procurement were estimated. While 30 studies used some measurement of that cost, only one study on pneumococcal vaccine used a primary cost evaluation (bottom-up costing analysis) and one study used a costing tool. Twenty-seven studies (17 on rotavirus and 10 on pneumococcal vaccine) assumed the non-vaccine costs. Five studies made no reference to additional costs. Fourteen studies (9 rotavirus and 5 pneumococcal) did not consider any additional EPI cost beyond vaccine procurement. For rotavirus studies, the median for non-vaccine cost per dose was US$0.74 in developing countries and US$6.39 in developed countries. For pneumococcal vaccines, the median for non-vaccine cost per dose was US$1.27 in developing countries and US$8.71 in developed countries.

CONCLUSIONS

Many pneumococcal (52.8%) and rotavirus (60.4%) cost-effectiveness analyses did not consider additional EPI costs or used poorly supported assumptions. Ignoring EPI costs in addition to those for vaccine procurement in CEA analysis of new vaccines may lead to significant errors in the estimations of ICERs since several factors like personnel, cold chain, or social mobilization can be substantially affected by the introduction of new vaccines.

Cost-effectiveness of using 2 vs 3 primary doses of 13-valent pneumococcal conjugate vaccine

BACKGROUND AND OBJECTIVE

Although effective in preventing pneumococcal disease, 13-valent pneumococcal conjugate vaccine (PCV13) is the most expensive vaccine on the routinely recommended pediatric schedule in the United States. We examined the cost-effectiveness of switching from 4 total doses to 3 total doses by removing the third dose in the primary series in the United States.

METHODS

We used a probabilistic model following a single birth cohort of 4.3 million to calculate societal cost savings and increased disease burden from removing the 6-month dose of PCV13. Based on modified estimates of 7-valent pneumococcal conjugate vaccine from randomized trials and observational studies, we assumed that vaccine effectiveness under the 2 schedules is identical for the first 6 months of life and largely similar after administration of the 12- to 15-month booster dose.

RESULTS

Removing the third dose of PCV13 would annually save $500 million (in 2011$) but would also result in an estimated 2.5 additional deaths among inpatients with pneumonia or invasive pneumococcal disease. Such dose removal would also result in 261,000 estimated otitis media and 12,000 estimated pneumonia cases annually. These additional illnesses could be prevented through modest increases in coverage. Overall, societal savings per additional life-year lost would be ∼$6 million. When nonfatal outcomes are also considered, savings would range from $143,000 to $4 million per additional quality adjusted life-year lost, depending on the assumptions used for otitis media.

CONCLUSIONS

Sizable societal cost savings and a moderate pneumococcal disease increase could be expected from removing the PCV13 primary series' third dose.

Health and economic impact of PHiD-CV in Canada and the UK: a Markov modelling exercise

OBJECTIVE

The spectrum of diseases caused by Streptococcus pneumoniae and non-typeable Haemophilus influenzae (NTHi) represents a large burden on healthcare systems around the world. Meningitis, bacteraemia, community-acquired pneumonia (CAP), and acute otitis media (AOM) are vaccine-preventable infectious diseases that can have severe consequences. The health economic model presented here is intended to estimate the clinical and economic impact of vaccinating birth cohorts in Canada and the UK with the 10-valent, pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) compared with the newly licensed 13-valent pneumococcal conjugate vaccine (PCV-13).

METHODS

The model described herein is a Markov cohort model built to simulate the epidemiological burden of pneumococcal- and NTHi-related diseases within birth cohorts in the UK and Canada. Base-case assumptions include estimates of vaccine efficacy and NTHi infection rates that are based on published literature.

RESULTS

The model predicts that the two vaccines will provide a broadly similar impact on all-cause invasive disease and CAP under base-case assumptions. However, PHiD-CV is expected to provide a substantially greater reduction in AOM compared with PCV-13, offering additional savings of Canadian $9.0 million and £4.9 million in discounted direct medical costs in Canada and the UK, respectively.

LIMITATIONS

The main limitations of the study are the difficulties in modelling indirect vaccine effects (herd effect and serotype replacement), the absence of PHiD-CV- and PCV-13-specific efficacy data and a lack of comprehensive NTHi surveillance data. Additional limitations relate to the fact that the transmission dynamics of pneumococcal serotypes have not been modelled, nor has antibiotic resistance been accounted for in this paper.

CONCLUSION

This cost-effectiveness analysis suggests that, in Canada and the UK, PHiD-CV's potential to protect against NTHi infections could provide a greater impact on overall disease burden than the additional serotypes contained in PCV-13.

Optimizing the acceptability, effectiveness and costs of immunization programs: the Quebec experience

In Canada, publicly funded immunization programs are a provincial/territorial responsibility. In the province of Quebec, much effort has been devoted to optimize the acceptability, effectiveness and cost-effectiveness of publicly funded immunization programs for children during the last 20 years. The aim of this article is to describe how programs are planned, implemented and evaluated and to identify key factors that contribute to the success of this enterprise. A comprehensive framework was developed for the evaluation of new vaccines and new programs in a societal perspective. It is used by the Quebec Immunization Committee to prepare reports proposing options with their costs and consequences for the public health authority. When a decision is made, the implementation of the new program is carefully planned. Surveys and consultations with stakeholders are systematically conducted to identify potential obstacles. A fraction of the budget is always reserved for program evaluation and monitoring. At the present time, the recommended immunization schedule targets 15 different diseases and only 20 injections are offered up to 15 years of age. Vaccine uptake rate is high and, although a reduced number of doses are recommended for several vaccines, program effectiveness is highly satisfactory, as shown for hepatitis B, meningococcal and pneumococcal diseases.

Quality of life of children and their caregivers during an AOM episode: development and use of a telephone questionnaire

BACKGROUND

The negative consequences of acute otitis media (AOM) on the quality of life (QOL) of children and their families need to be measured to assess benefits of preventive interventions.

METHODS

A new questionnaire was specifically designed for use in telephone surveys. A random sample of Canadian families was selected using random-digit dialling. Caregivers of children 6-59 months of age who experienced at least one AOM episode during the last 12 months were interviewed. Multidimensional severity and global QOL scores were measured both for affected children and their caregivers. Internal consistency of scores was assessed using standard tests.

RESULTS

Of the 502 eligible caregivers who completed the survey, 161 (32%) reported at least one AOM episode during the last 12 months and these cases were included in the analysis. Average severity was 2.6 for children and 2.4 for caregivers on a 1 to 4 scale (maximum severity). Cronbach alpha values were 0.78 and 0.81 for the severity score of children and caregivers respectively. Average QOL was 3.4 for children and 3.5 for caregivers on a 1 to 5 scale (best QOL). There was moderate to high correlation between severity and QOL scores, and between these scores and duration of AOM episodes.

CONCLUSIONS

The questionnaire was easy to use during telephone interviews and results suggest good reliability and validity of the different scores to measure AOM severity and QOL of children and their caregivers during an AOM episode.