Rotavirus vaccine product switch in Ghana: An assessment of service delivery costs, switching costs, and cost-effectiveness

Ghana introduced rotavirus vaccine (ROTARIX 1-dose presentation) into the routine national immunization program in 2012 and switched to a different product (ROTAVAC 5-dose presentation) in 2020. ROTAVAC has a lower price per dose (US$0.85 versus US$2.15 for ROTARIX) and smaller cold chain footprint but requires more doses per regimen (three versus two). This study estimates the supply chain and service delivery costs associated with each product, the costs involved in switching products, and compares the cost-effectiveness of both products over the next ten years. We estimated the supply chain and service delivery costs associated with ROTARIX and ROTAVAC (evaluating both the 5-dose and 10-dose presentations) using primary data collected from health facilities in six of the 14 regions in the country. We estimated the costs of switching from ROTARIX to ROTAVAC using information collected from key informant interviews and financial records provided by the government. All costs were reported in 2020 US$. We used the UNIVAC decision-support model to evaluate the cost-effectiveness (US$ per disability-adjusted life-year (DALY) averted from government and societal perspectives) of ROTARIX and ROTAVAC (5-dose or 10-dose presentations) compared to no vaccination, and to each other, over a ten-year period (2020 to 2029). We ran probabilistic sensitivity analyses and other threshold analyses. The supply chain and service delivery economic cost per dose was $2.40 for ROTARIX, $1.81 for ROTAVAC 5-dose, and $1.76 for ROTAVAC 10-dose. The financial and economic cost of switching from ROTARIX to ROTAVAC 5-dose was $453,070 and $883,626, respectively. Compared to no vaccination, the cost per DALY averted was $360 for ROTARIX, $298 for ROTAVAC 5-dose, and $273 for ROTAVAC 10-dose. ROTAVAC 10-dose was the most cost-effective option and would be cost-effective at willingness-to-pay thresholds exceeding 0.12 times the national GDP per capita ($2,206 in the year 2020). The switch from ROTARIX to ROTAVAC 5-dose in 2020 was cost-saving. Rotavirus vaccination is highly cost-effective in Ghana. A switch from ROTAVAC 5-dose to ROTAVAC 10-dose would be cost-saving and should be considered.

Vaccine wastage in Ghana, Mozambique, and Pakistan: An assessment of wastage rates for four vaccines and the context, causes, drivers, and knowledge, attitudes and practices for vaccine wastage

Vaccine procurement costs comprise a significant share of immunization program costs in low- and middle-income countries, yet not all procured vaccines are administered. Vaccine wastage occurs due to vial breakage, excessive heat or freezing, expiration, or when not all doses in a multidose vial are used. Better estimates of vaccine wastage rates and their causes could support improved management of vaccine stocks and reduce procurement costs. This study examined aspects of wastage for four vaccines at service delivery points in Ghana (n = 48), Mozambique (n = 36), and Pakistan (n = 46). We used prospective data from daily and monthly vaccine usage data entry forms, along with cross-sectional surveys, and in-depth interviews. The analysis found that estimated monthly proportional open-vial wastage rates for vaccines in single-dose vials (SDV) or in multi-dose vials (MDV) that can be kept refrigerated up to four weeks after opening ranged from 0.08 % to 3 %. For MDV where remaining doses are discarded within six hours after opening, the mean wastage rates ranged from 5 % to 33 %, with rates being highest for measles containing vaccine. Despite national-level guidance to open a vaccine vial even when only one child is present, vaccines in MDV that are discarded within six hours of opening are sometimes offered less frequently than vaccines in SDV or in MDV where remaining doses can be used for up to 4 weeks. This practice can lead to missed opportunities for vaccination. While closed-vial wastage at service delivery points (SDPs) was relatively rare, individual instances can result in large losses, suggesting that monitoring closed-vial wastage should not be neglected. Health workers reported insufficient knowledge of vaccine wastage tracking and reporting methods. Improving reporting forms would facilitate more accurate reporting of all causes of wastage, as would additional training and supportive supervision. Globally, decreasing doses per vial could reduce open-vial wastage.

The projected cost-effectiveness and budget impact of HPV vaccine introduction in Ghana

BACKGROUND

Cervical cancer is responsible for around one-quarter of all cancer deaths among Ghanaian women. Between 2013 and 2015, Ghana conducted a pilot of HPV vaccination among 10-14-year-old girls in four regions; however, the country has yet to introduce the vaccine nationally. This study projected the cost-effectiveness and budget impact of adding HPV vaccination into Ghana's national immunization program.

METHODS

We used a proportional outcomes model (UNIVAC, version 1.4) to evaluate the cost-effectiveness of introduction with bivalent (Cervarix™) and quadrivalent (Gardasil®) vaccines from government and societal perspectives. Vaccine introduction was modeled to start in 2022 and continue over ten birth cohorts using a combined delivery strategy of school (80%) and community outreach (20%). We modeled vaccination in a single age cohort of 9-year-old girls vs. a multi-age cohort of 9-year-old girls (routine) and 10-14-year-old girls (one-time campaign) compared to no vaccination. Health outcomes included cervical cancer cases, hospitalizations, deaths, and disability-adjusted life years (DALYs). We applied a discount rate of 3% to costs and outcomes. All monetary units are reported in USD 2018.

RESULTS

National HPV vaccination in Ghana was projected to be cost-effective compared to no vaccination in all scenarios evaluated. The most cost-effective and dominant strategy was vaccination among 9-year-old girls, plus a one-time campaign among 10-14-year-old with the bivalent vaccine ($158/DALY averted from the government perspective; 95% credible range: $19-$280/DALY averted). Projected average annual costs of the vaccine program ranged from $11.2 to $15.4 M, depending on strategy. This represents 11-15% of the estimated total immunization costs for 2022 ($100,857,875 based on Ghana's comprehensive Multi-Year Plan for Immunization, 2020-2024).

DISCUSSION

Our model suggests that introducing HPV vaccination would be cost-effective in Ghana under any strategy when willingness-to-pay is at least 40% GDP per capita ($881). Inclusion of a one-time catch-up campaign is shown to create greater value for money than routine immunization alone but would incur greater program costs.

"Top-down bottom-up" estimation of per capita cost of new-born care interventions in four regions of Ghana: beyond implementation to scalability and sustainability

BACKGROUND

Limited financial, human and material health resources coupled with increasing demand for new-born care services require efficiency in health systems to maximize the available sources for improved health outcomes. Making Every Baby Count Initiative (MEBCI) implemented by local and international partners in 2013 in Ghana aimed at attaining neonatal mortality of 21 per 1000 livebirths by 2018 in four administrative regions in Ghana. MEBCI interventions benefited 4027 health providers, out of which 3453 (86%) were clinical healthcare staff.

OBJECTIVE

Determine the per capita cost of the MEBCI interventions towards enhancing new-born care best practices through capacity trainings for frontline clinical and non-clinical staff.

METHODS

Parameters for determining per capita cost of the new-born care interventions were estimated using expenditure on trainings, supervisions, monitoring and evaluation, advocacy, administrative/services and medical logistics. Data collection started in October 2017 and ended in September 2018. Data sources for the per capita cost estimations were invoices, expense reports and ledger books at the national, regional and district levels of the health system.

RESULTS

Total of 4027 healthcare providers benefited from the MEBCI training activities comprising of 3453 clinical staff and 574 non-clinical personnel. Cumulative cost of implementing the MEBCI interventions did not necessarily match the cost per capita in staff capacity building; average cost per capita for all staff (clinical and non-clinical staff) was approximately US$ 982 compared to a per capita cost of US$ 799 for training only core clinical staff. Average cost per capita for all regions was approximately US$ 965 for all staff compared to US$ 777 per capita cost for only clinical staff. Per capita cost of training was relatively lower in regions with more staff than regions with lower numbers, perhaps due to economies of scale.

CONCLUSION

The MEBCI intervention had a wide coverage in terms of training for frontline healthcare providers albeit the associated cost may be potentially unsustainable for Ghana's health system. Emerging digital training platforms could be leveraged to reduce per capita cost of training. Large-scale on-site batch-training approach could also be replaced with facility-based workshops using training of trainers (TOTs) approach to promote efficiency.

Costs of continuing RTS,S/ASO1E malaria vaccination in the three malaria vaccine pilot implementation countries

Background

The RTS,S/ASO1_E malaria vaccine is being piloted in three countries—Ghana, Kenya, and Malawi—as part of a coordinated evaluation led by the World Health Organization, with support from global partners. This study estimates the costs of continuing malaria vaccination upon completion of the pilot evaluation to inform decision-making and planning around potential further use of the vaccine in pilot areas.

Methods

We used an activity-based costing approach to estimate the incremental costs of continuing to deliver four doses of RTS,S/ASO1_E through the existing Expanded Program on Immunization platform, from each government’s perspective. The RTS,S/ASO1_E pilot introduction plans were reviewed and adapted to identify activities for costing. Key informant interviews with representatives from Ministries of Health (MOH) were conducted to inform the activities, resource requirements, and assumptions that, in turn, inform the analysis. Both financial and economic costs per dose, cost of delivery per dose, and cost per fully vaccinated child (FVC) are estimated and reported in 2017 USD units.

Results

At a vaccine price of $5 per dose and assuming the vaccine is donor-funded, our estimated incremental financial costs range from $1.70 (Kenya) to $2.44 (Malawi) per dose, $0.23 (Malawi) to $0.71 (Kenya) per dose delivered (excluding procurement add-on costs), and $11.50 (Ghana) to $13.69 (Malawi) per FVC. Estimates of economic costs per dose are between three and five times higher than financial costs. Variations in activities used for costing, procurement add-on costs, unit costs of per diems, and allowances contributed to differences in cost estimates across countries.

Conclusion

Cost estimates in this analysis are meant to inform country decision-makers as they face the question of whether to continue malaria vaccination, should the intervention receive a positive recommendation for broader use. Additionally, important cost drivers for vaccine delivery are highlighted, some of which might be influenced by global and country-specific financing and existing procurement mechanisms. This analysis also adds to the evidence available on vaccine delivery costs for products delivered outside the standard immunization schedule.

A phase 3 trial of RTS,S/AS01 malaria vaccine in African infants

BACKGROUND

The candidate malaria vaccine RTS,S/AS01 reduced episodes of both clinical and severe malaria in children 5 to 17 months of age by approximately 50% in an ongoing phase 3 trial. We studied infants 6 to 12 weeks of age recruited for the same trial.

METHODS

We administered RTS,S/AS01 or a comparator vaccine to 6537 infants who were 6 to 12 weeks of age at the time of the first vaccination in conjunction with Expanded Program on Immunization (EPI) vaccines in a three-dose monthly schedule. Vaccine efficacy against the first or only episode of clinical malaria during the 12 months after vaccination, a coprimary end point, was analyzed with the use of Cox regression. Vaccine efficacy against all malaria episodes, vaccine efficacy against severe malaria, safety, and immunogenicity were also assessed.

RESULTS

The incidence of the first or only episode of clinical malaria in the intention-to-treat population during the 14 months after the first dose of vaccine was 0.31 per person-year in the RTS,S/AS01 group and 0.40 per person-year in the control group, for a vaccine efficacy of 30.1% (95% confidence interval [CI], 23.6 to 36.1). Vaccine efficacy in the per-protocol population was 31.3% (97.5% CI, 23.6 to 38.3). Vaccine efficacy against severe malaria was 26.0% (95% CI, -7.4 to 48.6) in the intention-to-treat population and 36.6% (95% CI, 4.6 to 57.7) in the per-protocol population. Serious adverse events occurred with a similar frequency in the two study groups. One month after administration of the third dose of RTS,S/AS01, 99.7% of children were positive for anti-circumsporozoite antibodies, with a geometric mean titer of 209 EU per milliliter (95% CI, 197 to 222).

CONCLUSIONS

The RTS,S/AS01 vaccine coadministered with EPI vaccines provided modest protection against both clinical and severe malaria in young infants. (Funded by GlaxoSmithKline Biologicals and the PATH Malaria Vaccine Initiative; RTS,S ClinicalTrials.gov number, NCT00866619.).

First results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children

BACKGROUND

An ongoing phase 3 study of the efficacy, safety, and immunogenicity of candidate malaria vaccine RTS,S/AS01 is being conducted in seven African countries.

METHODS

From March 2009 through January 2011, we enrolled 15,460 children in two age categories--6 to 12 weeks of age and 5 to 17 months of age--for vaccination with either RTS,S/AS01 or a non-malaria comparator vaccine. The primary end point of the analysis was vaccine efficacy against clinical malaria during the 12 months after vaccination in the first 6000 children 5 to 17 months of age at enrollment who received all three doses of vaccine according to protocol. After 250 children had an episode of severe malaria, we evaluated vaccine efficacy against severe malaria in both age categories.

RESULTS

In the 14 months after the first dose of vaccine, the incidence of first episodes of clinical malaria in the first 6000 children in the older age category was 0.32 episodes per person-year in the RTS,S/AS01 group and 0.55 episodes per person-year in the control group, for an efficacy of 50.4% (95% confidence interval [CI], 45.8 to 54.6) in the intention-to-treat population and 55.8% (97.5% CI, 50.6 to 60.4) in the per-protocol population. Vaccine efficacy against severe malaria was 45.1% (95% CI, 23.8 to 60.5) in the intention-to-treat population and 47.3% (95% CI, 22.4 to 64.2) in the per-protocol population. Vaccine efficacy against severe malaria in the combined age categories was 34.8% (95% CI, 16.2 to 49.2) in the per-protocol population during an average follow-up of 11 months. Serious adverse events occurred with a similar frequency in the two study groups. Among children in the older age category, the rate of generalized convulsive seizures after RTS,S/AS01 vaccination was 1.04 per 1000 doses (95% CI, 0.62 to 1.64).

CONCLUSIONS

The RTS,S/AS01 vaccine provided protection against both clinical and severe malaria in African children. (Funded by GlaxoSmithKline Biologicals and the PATH Malaria Vaccine Initiative; RTS,S ClinicalTrials.gov number, NCT00866619 .).