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.

Post introduction evaluation of the malaria vaccine implementation programme in Ghana, 2021

BACKGROUND

Malaria remains a public health challenge in Sub-Saharan Africa with the region contributing to more than 90% of global cases in 2020. In Ghana, the malaria vaccine was piloted to assess the feasibility, safety, and its impact in the context of routine use alongside the existing recommended malaria control measures. To obtain context-specific evidence that could inform future strategies of introducing new vaccines, a standardized post-introduction evaluation (PIE) of the successes and challenges of the malaria vaccine implementation programme (MVIP) was conducted.

METHODS

From September to December 2021, the WHO Post-Introduction Evaluation (PIE) tool was used to conduct a mixed methods evaluation of the MVIP in Ghana. To ensure representativeness, study sites and participants from the national level, 18 vaccinating districts, and 54 facilities from six of the seven pilot regions were purposively selected. Quantitative and qualitative data were collected using data collection tools that were adapted based on the WHO PIE protocol. We performed summary descriptive statistics on quantitative data, thematic analysis on qualitative data, and triangulation of the results from both sets of analyses.

RESULTS

About 90.7% (49/54) of health workers stated that the vaccine introduction process was smooth and contributed to an overall improvement of routine immunisation services. About 87.5% (47/54) of healthcare workers, and 95.8% (90/94) of caregivers accepted RTS,S malaria vaccine. Less than half [46.3%; (25/54)] of the healthcare workers participated in the pre-vaccine introduction training but almost all [94.4%; (51/54)] were able to constitute and administer the vaccine appropriately. About 92.5% (87/94) of caregivers were aware of the RTS,S introduction but only 44.0% (44/94) knew the number of doses needed for maximum protection. Health workers believed that the MVIP has had a positive impact on under five malaria morbidity.

CONCLUSIONS

The malaria vaccine has been piloted successfully in Ghana. Intensive advocacy; community engagement, and social mobilization; and regular onsite supportive supervision are critical enablers for successful introduction of new vaccines. Stakeholders are convinced of the feasibility of a nationwide scale up using a phased subnational approach taking into consideration malaria epidemiology and global availability of vaccines.

Cost of introducing and delivering RTS,S/AS01 malaria vaccine within the malaria vaccine implementation program

BACKGROUND

The World Health Organization (WHO) recommended widespread use of the RTS,S/AS01 (RTS,S) malaria vaccine among children residing in regions of moderate to high malaria transmission. This recommendation is informed by RTS,S evidence, including findings from the pilot rollout of the vaccine in Ghana, Kenya, and Malawi. This study estimates the incremental costs of introducing and delivering the malaria vaccine within routine immunization programs in the context of malaria vaccine pilot introduction, to help inform decision-making.

METHODS

An activity-based, retrospective costing was conducted from the governments' perspective. Vaccine introduction and delivery costs supported by the donors during the pilot introduction were attributed as costs to the governments under routine implementation. Detailed resource use data were extracted from the pilot program expenditure and activity reports for 2019-2021. Primary data from representative health facilities were collected to inform recurrent operational and service delivery costs.Costs were categorized as introduction or recurrent costs. Both financial and economic costs were estimated and reported in 2020 USD. The cost of donated vaccine doses was evaluated at $2, $5 and $10 per dose and included in the economic cost estimates. Financial costs include the procurement add on costs for the donated vaccines and immunization supplies, along with other direct expenses.

FINDINGS

At a vaccine price of $5 per dose, the incremental cost per dose administered across countries ranges from $2.30 to $3.01 (financial), and $8.28 to $10.29 (economic). The non-vaccine cost of delivery ranges between $1.04 and $2.46 (financial) and $1.52 and $4.62 (economic), by country. Considering only recurrent costs, the non-vaccine cost of delivery per dose ranges between $0.29 and $0.89 (financial) and $0.59 and $2.29 (economic), by country. Introduction costs constitute between 33% and 71% of total financial costs. Commodity and procurement add-on costs are the main cost drivers of total cost across countries. Incremental resource needs for implementation are dependent on country's baseline immunization program capacity constraints.

INTERPRETATION

The financial costs of introducing RTS,S are comparable with costs of introducing other new vaccines. Country resource requirements for malaria vaccine introduction are most influenced by vaccine price and potential donor funding for vaccine purchases and introduction support.

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.

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.

Evaluation of the tuberculosis surveillance system in the Ashaiman municipality, in Ghana

Introduction

Tuberculosis (TB) was the leading cause of death from an infectious illness globally with an estimated 10.4 million new cases and 1.4 million deaths in 2015. In Ghana, from the 2013 TB prevalence survey conducted by the National Tuberculosis Control Programme, the incidence is estimated as 165 per 100,000 population and a mortality rate of 7.5 per 1,000 infected people. The Tuberculosis surveillance system is part of the general framework of the Integrated Disease Surveillance and Response. This evaluation was to assess whether the system is meeting its set objectives, assess its usefulness and describe its attributes.

Methods

The TB surveillance system of the Ashaiman municipality was evaluated using Centre for Disease Control and Prevention updated guidelines for evaluating public health surveillance systems 2006. Records review from 2014 to 2016 was done to assess objectives of the system and surveillance data source of 2016 was used to assess attributes. Interviews were conducted at the various levels using semi-structured questionnaire and data analysis done with Epi info 7 and Microsoft Excel to run frequencies and percentages.

Results

The surveillance system is well structured with standardized data collection tools. The system was found to be useful, though it just partially met its objectives. It was also found to be simple, flexible and fairly stable with average timeliness. It had low acceptability and is not geographically representative. It had low sensitivity of 45/100,000 and a low predictive value positive of 6.6%.

Conclusion

The surveillance system was found to be useful but partially met its objectives. There is the need to improve the sensitivity, predictive value positive timeliness and acceptability.

Use of hub cutters and the volume of sharp waste and occurrence of needle-stick injuries during 2011 mass immunization campaigns against yellow fever in Ghana: a cohort study

BACKGROUND

Current WHO best infection control practices for injections do not address the use of hub cutters due to insufficient evidence on safety and efficacy.

OBJECTIVE

To assess the impact of the use of hub cutters on 1) the frequency of needle-stick injuries (NSIs) and other blood exposures among workers and 2) the volume of sharps waste in a mass vaccination campaign setting.

METHODS

During yellow fever vaccination in Ghana, we conducted a cohort study on the use of hub cutters. We compared two groups---one group using hub cutters and a control group---for the occurrences of NSIs and the volume of sharp waste produced.

RESULTS

In the control arm, vaccinators used 284 482 syringes in 825 vaccination sessions. In the group using hub cutter, vaccinators used 397 079 syringes in 1599 sessions. Among vaccinators, the rate of NSI was not significantly (p=0.14) different between the hub cutter users (0.15/10 000 syringes) and the control group (0.04/10 000). Factors such as workload, lack of organization and pressure seemed to have influence the occurrence of NSIs. With all the limitations of the work, the volume of sharp waste per 10 000 syringes was 0.24 m(3) in the hub cutter users and 0.41 m(3) in the control group---a reduction of 41.2%. Vaccinators found hub cutters easy to use and safe. Use of hub cutter was not associated with increased duration of work.

CONCLUSION

The use of hub cutters did not increase the risk of NSIs. More training is needed to facilitate its implementation in mass campaign setting.

Introduction of Haemophilus influenzae type B conjugate vaccine into routine immunization in Ghana and its impact on bacterial meningitis in children younger than five years

This report shows the impact of a pentavalent vaccine that includes Haemophilus influenzae type b (Hib) conjugate vaccine on bacterial meningitis in children younger than 5 years in Ghana. A review of the first 3 years of a pediatric bacterial meningitis surveillance program, started in August 2001 in Accra, Ghana, was undertaken. There was a significant reduction, P = 0.042 and 0.017, in percentage of purulent meningitis in children younger than 1 year, comparing the first year when the vaccine was introduced, to the second and third years, respectively.