Cost-Effectiveness of Testing and Treatment for Hepatitis B Virus and Hepatitis C Virus Infections: An Analysis by Scenarios,Regions, and Income

ObjectivesTesting and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups.MethodsWe modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination).ResultsCompared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and –$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results.ConclusionsScaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices.     

Cost-effectiveness of the introduction of two-dose bi-valent (Cervarix) and quadrivalent (Gardasil) HPV vaccination for adolescent girls in Bangladesh

BackgroundCervical cancer is one of the most prevalent cancers in women caused by the human papillomavirus (HPV) that leads to a substantial disease burden for health systems. Prevention through vaccination can significantly reduce the prevalence of cervical cancer. The objective of this study is to evaluate the potential health and economic impacts of introducing two-dose bivalent (Cervarix) and quadrivalent (Gardasil) HPV vaccines in Bangladesh.MethodsThe study uses the Papillomavirus Rapid Interface for Modelling and Economics (PRIME) model to assess the cost-effectiveness of introducing HPV vaccination. The incremental cost-effectiveness ratios (ICERs) were estimated per disability-adjusted life years (DALYs) averted using the cost-effectiveness threshold (CET). The analyses were done from a health system perspective in terms of vaccine delivery routes.ResultsIntroduction of bi-valent HPV vaccination was found highly cost-effective (ICER = US$488/DALY) at Gavi (The Vaccine Alliance for Vaccines and Immunizations) negotiated prices. The value of ICERs were US$710, US$356 and US$397 per DALY averted for school-based, health facility-based, and outreach-based programs, respectively, which is consistent with the CET range (US$67 to US$854). However, bivalent and quadrivalent vaccines at listed prices were not found cost-effective, with ICERs of US$1405 and US$3250 per DALY averted, respectively, that exceeds the CETs values.ConclusionsIntroducing a two-dose bi-valent HPV vaccination program is cost-effective in Bangladesh at Gavi negotiated prices. Vaccine price is the dominating parameter for the cost-effectiveness of bivalent and quadrivalent vaccines. Both vaccines are not cost-effective at listed prices in Bangladesh. The evaluation highlights that introducing the two-dose bivalent HPV vaccine at Gavi negotiated prices into a national immunization program in Bangladesh is economically viable to reduce the burden of cervical cancer.     

Cost-effectiveness of dengue vaccination in ten endemic countries

Following publication of results from two phase-3 clinical trials in 10 countries or territories, endemic countries began licensing the first dengue vaccine in 2015. Using a published mathematical model, we evaluated the cost-effectiveness of dengue vaccination in populations similar to those at the trial sites in those same Latin American and Asian countries. Our main scenarios (30-year horizon, 80% coverage) entailed 3-dose routine vaccinations costing US$20/dose beginning at age 9, potentially supplemented by catch-up programs of 4- or 8-year cohorts. We obtained illness costs per case, dengue mortality, vaccine wastage, and vaccine administration costs from the literature. We estimated that routine vaccination would reduce yearly direct and indirect illness cost per capita by 22% (from US$10.51 to US$8.17) in the Latin American countries and by 23% (from US$5.78 to US$4.44) in the Asian countries. Using a health system perspective, the incremental cost-effectiveness ratio (ICER) averaged US$4,216/disability-adjusted life year (DALY) averted in the five Latin American countries (range: US$666/DALY in Puerto Rico to US$5,865/DALY in Mexico). In the five Asian countries, the ICER averaged US$3,751/DALY (range: US$1,935/DALY in Malaysia to US$5,101/DALY in the Philippines). From a health system perspective, the vaccine proved to be highly cost effective (ICER under one times the per capita GDP) in seven countries and cost effective (ICER 1–3 times the per capita GDP) in the remaining three countries. From a societal perspective, routine vaccination proved cost-saving in three countries. Including catch-up campaigns gave similar ICERs. Thus, this vaccine could have a favorable economic value in sites similar to those in the trials.     

Progress towards elimination of mother-to-child transmission of hepatitis B virus infection in China: a modelling analysis

ObjectiveTo determine the projected burden of hepatitis B virus (HBV) in China, the intervention strategies that can eliminate mother-to-child transmission (MTCT) by 2030 or earlier and the measurable parameters that can be used to monitor progress towards this target.MethodsWe developed a dynamic, sex- and age-stratified model of the HBV epidemic in China, calibrated using hepatitis B surface antigen (HBsAg) and e antigen (HBeAg) prevalence data from sequential national serosurveys (1979–2014) and the numbers of HBV-related cancer deaths (2012). We determined whether China can achieve elimination of MTCT of HBV by 2030 under current prevention interventions. We modelled various intervention scenarios to represent different coverage levels of birth-dose HBV vaccination, hepatitis B immunoglobulin to newborns of HBsAg-positive mothers and antiviral therapy (tenofovir) to HBeAg-positive pregnant women.FindingsWe project that, if current levels of prevention interventions are maintained, China will achieve the elimination target by 2029. By modelling various intervention scenarios, we found that this can be brought forward to 2025 by increasing coverage of birth-dose vaccination, or to 2024 by the administration of tenofovir to HBeAg-positive pregnant women. We found that achievement of the target by 2025 would be predicted by a measurement of less than 2% MTCT in 2020.ConclusionOur results highlight how high-quality national data can be combined with modelling in monitoring the elimination of MTCT of HBV. By demonstrating the impact of increased interventions on target achievement dates, we anticipate that other high-burden countries will be motivated to strengthen HBV prevention policies.     

Human health benefits from livestock vaccination for brucellosis: case study

OBJECTIVE: To estimate the economic benefit, cost-effectiveness, and distribution of benefit of improving human health in Mongolia through the control of brucellosis by mass vaccination of livestock. METHODS: Cost-effectiveness and economic benefit for human society and the agricultural sector of mass vaccination against brucellosis was modelled. The intervention consisted of a planned 10-year livestock mass vaccination campaign using Rev-1 livestock vaccine for small ruminants and S19 livestock vaccine for cattle. Cost-effectiveness, expressed as cost per disability-adjusted life year (DALY) averted, was the primary outcome. FINDINGS: In a scenario of 52% reduction of brucellosis transmission between animals achieved by mass vaccination, a total of 49,027 DALYs could be averted. Estimated intervention costs were US$ 8.3 million, and the overall benefit was US$ 26.6 million. This results in a net present value of US$ 18.3 million and an average benefit-cost ratio for society of 3.2 (2.27-4.37). If the costs of the intervention were shared between the sectors in proportion to the benefit to each, the public health sector would contribute 11%, which gives a cost-effectiveness of US$ 19.1 per DALY averted (95% confidence interval 5.3-486.8). If private economic gain because of improved human health was included, the health sector should contribute 42% to the intervention costs and the cost-effectiveness would decrease to US$ 71.4 per DALY averted. CONCLUSION: If the costs of vaccination of livestock against brucellosis were allocated to all sectors in proportion to the benefits, the intervention might be profitable and cost effective for the agricultural and health sectors.     

Economic evaluation of hepatitis B vaccination in low-income countries: using cost-effectiveness affordability curves

OBJECTIVE: We sought to describe a method that explicitly considers both a health-care programmes cost-effectiveness and its affordability. For illustration, we apply the method to the programme to vaccinate infants against hepatitis B in the Gambia. METHODS: We synthesized selected data and developed a computer-based model from the societal and payer perspectives to evaluate the cost-effectiveness of routine infant vaccination against hepatitis B in the Gambia compared with no vaccination. The primary outcome measure was cost per averted disability-adjusted life year (DALY), which was expressed in 2002 US dollars. We used Monte Carlo methods for uncertainty analysis to examine the affordability of the programme from the payers perspective, and we derived an affordability curve and cost-effectiveness affordability curves for the programme. FINDINGS: In the Gambia, vaccinating infants against hepatitis B is highly cost-effective. Compared with offering no intervention, the vaccination programme would cost US$ 28 per DALY averted from the societal perspective or US$ 47 per DALY averted from the payers perspective. The programme also has the potential to be affordable, starting at a relatively low budget of US$ 160,000 per year. Combining the two dimensions of the outcome measure, the probability that vaccinating infants would be both cost-effective and affordable is 40% at an annual programme budget of US$ 182,000 (the estimated total programme cost from the payers perspective), given a threshold cost-effectiveness value of US$ 47 per DALY averted. CONCLUSION: In the face of uncertainties about both the health and economic consequences of a vaccine programme, as well as the availability and magnitude of resources needed to fund the programme, cost-effectiveness affordability curves can provide information to decision-makers about the probability that a programme will be both cost-effective and affordable: these are distinct but equally relevant considerations in resource-poor settings.     

Cost-effectiveness of rotavirus vaccination in children under five years of age in 195 countries: A meta-regression analysis

BackgroundRotavirus caused an estimated 151,714 deaths from diarrhea among children under 5 in 2019. To reduce mortality, countries are considering adding rotavirus vaccination to their routine immunization program. Cost-effectiveness analyses (CEAs) to inform these decisions are not available in every setting, and where they are, results are sensitive to modeling assumptions, especially about vaccine efficacy. We used advances in meta-regression methods and estimates of vaccine efficacy by location to estimate incremental cost-effectiveness ratios (ICERs) for rotavirus vaccination in 195 countries.MethodsBeginning with Tufts University CEA and Global Health CEA registries we used 515 ICERs from 68 articles published through 2017, extracted 938 additional one-way sensitivity analyses, and excluded 33 ICERs for a sample of 1,418. We used a five-stage, mixed-effects, Bayesian metaregression framework to predict ICERs, and logistic regression model to predict the probability that the vaccine was cost-saving. For both models, covariates were vaccine characteristics including efficacy, study methods, and country-specific rotavirus disability-adjusted life-years (DALYs) and gross domestic product (GDP) per capita. All results are reported in 2017 United States dollars.ResultsVaccine efficacy, vaccine cost, GDP per capita and rotavirus DALYs were important drivers of variability in ICERs. Globally, the median ICER was $2,289 (95% uncertainty interval (UI): $147–$38,993) and ranged from $85 per DALY averted (95% UI: $13–$302) in Central African Republic to $70,599 per DALY averted (95% UI: $11,030–$263,858) in the United States. Among countries eligible for support from Gavi, The Vaccine Alliance, the mean ICER was $255 per DALY averted (95% UI: $39–$918), and among countries eligible for the PAHO revolving fund, the mean ICER was $2,464 per DALY averted (95% UI: $382–$3,118).ConclusionOur findings incorporate recent evidence that vaccine efficacy differs across locations, and support expansion of rotavirus vaccination programs, particularly in countries eligible for support from Gavi, The Vaccine Alliance.     

The cost-effectiveness of introducing hepatitis B vaccine into infant immunization services in Mozambique

OBJECTIVE: To estimate the cost-effectiveness of introducing hepatitis B vaccine into routine infant immunization services in Mozambique, which took place in the year 2001. METHODS: A decision analytic model was used to estimate the impact of hepatitis B vaccination. This model was developed for the WHO to estimate the global burden of disease from hepatitis B. Cost data of vaccine delivery and medical treatment related to hepatitis B infection were collected for the analysis. FINDINGS: The introduction of hepatitis B vaccine has increased the annual budget for immunization services by approximately 56%. It is predicted that more than 4000 future deaths are averted annually by the intervention. In the base case scenario, the incremental costs per undiscounted deaths averted amount to US$436, and the costs per undiscounted DALY averted amount to US$36. Since the major impact of hepatitis B vaccination will not start to be evident for at least another 40 years (deaths from hepatitis B mainly occur between 40-60 years of age), the cost per DALY averted rises to US$47, when using a discount rate of 3% on health effects. We found that the monovalent hepatitis B vaccine was considerably more cost-effective than the hepatitis B vaccine in combination with DTP. INTERPRETATION: If policy makers value future health benefits equal to current benefits, the cost-effectiveness of infant hepatitis B vaccination is in the range of other primary health care interventions for which similar analysis has been undertaken.     

Economic evaluation of typhoid vaccination in a prolonged typhoid outbreak setting: The case of Kasese district in Uganda

BackgroundVaccination has been increasingly promoted to help control epidemic and endemic typhoid fever in high-incidence areas. Despite growing recognition that typhoid incidence in some areas of sub-Saharan Africa is similar to high-incidence areas of Asia, no large-scale typhoid vaccination campaigns have been conducted there. We performed an economic evaluation of a hypothetical one-time, fixed-post typhoid vaccination campaign in Kasese, a rural district in Uganda where a large, multi-year outbreak of typhoid fever has been reported.MethodsWe used medical cost and epidemiological data retrieved on-site and campaign costs from previous fixed-post vaccination campaigns in Kasese to account for costs from a public sector health care delivery perspective. We calculated program costs and averted disability-adjusted life years (DALYs) and medical costs as a result of vaccination, to calculate the cost of the intervention per DALY and case averted.ResultsOver the 3 years of projected vaccine efficacy, a one-time vaccination campaign was estimated to avert 1768 (90%CI: 684–4431) typhoid fever cases per year and a total of 3868 (90%CI: 1353–9807) DALYs over the duration of the immunity conferred by the vaccine. The cost of the intervention per DALY averted was US$ 484 (90%CI: 18–1292) and per case averted US$ 341 (90%CI: 13–883).ConclusionWe estimated the vaccination campaign in this setting to be highly cost-effective, according to WHO's cost-effective guidelines. Results may be applicable to other African settings with similar high disease incidence estimates.     

Cost-effectiveness of rotavirus vaccination in Mozambique

IntroductionRotavirus is one of the most common cause of severe gastroenteritis in children, with the largest mortality burden in low- and middle-income countries. To prevent rotavirus gastroenteritis, Mozambique introduced ROTARIX® vaccine in 2015, however, its cost-effectiveness has never been established in the country. In 2018, additional vaccines became available globally. This study estimates the cost-effectiveness of the recently introduced ROTARIX in Mozambique and compares the cost-effectiveness of ROTARIX®, ROTAVAC®, and ROTASIIL® to inform future use.MethodsWe used a decision-support model to calculate the potential cost-effectiveness of vaccination with ROTARIX compared to no vaccination over a five-year period (2016–2020) and to compare the cost-effectiveness of ROTARIX, ROTAVAC, and ROTASIIL to no vaccination and to each other over a ten-year period (2021–2030). The primary outcome was the incremental cost per disability-adjusted life-year (DALY) averted from a government perspective. We assessed uncertainty through sensitivity analyses.ResultsFrom 2016 to 2020, we estimate the vaccine program with ROTARIX cost US$12.3 million, prevented 4,628 deaths, and averted US$3.1 million in healthcare costs. The cost per DALY averted was US$70. From 2021 to 2030, we estimate all three vaccines could prevent 9,000 deaths and avert US$7.8 million in healthcare costs. With Global Alliance for Vaccines and Immunization (Gavi) support, ROTARIX would have the lowest vaccine program cost (US$31 million) and 98 % probability of being cost-effective at a willingness-to-pay threshold of 0.5x GDP per capita. Without Gavi support, ROTASIIL would have the lowest vaccine program cost (US$75.8 million) and 30 % probability of being cost-effective at the same threshold.ConclusionROTARIX vaccination had a substantial public health impact in Mozambique between 2016 and 2020. ROTARIX is currently estimated to be the most cost-effective product, but the choice of vaccine should be re-evaluated as more evidence emerges on the price, incremental delivery cost, wastage, and impact associated with each of the different rotavirus vaccines.     

Comparison of model predictions of typhoid conjugate vaccine public health impact and cost-effectiveness

Models are useful to inform policy decisions on typhoid conjugate vaccine (TCV) deployment in endemic settings. However, methodological choices can influence model-predicted outcomes. To provide robust estimates for the potential public health impact of TCVs that account for structural model differences, we compared four dynamic and one static mathematical model of typhoid transmission and vaccine impact. All models were fitted to a common dataset of age-specific typhoid fever cases in Kolkata, India. We evaluated three TCV strategies: no vaccination, routine vaccination at 9 months of age, and routine vaccination at 9 months with a one-time catch-up campaign (ages 9 months to 15 years). The primary outcome was the predicted percent reduction in symptomatic typhoid cases over 10 years after vaccine introduction. For three models with economic analyses (Models A-C), we also compared the incremental cost-effectiveness ratios (ICERs), calculated as the incremental cost (US$) per disability-adjusted life-year (DALY) averted. Routine vaccination was predicted to reduce symptomatic cases by 10–46 % over a 10-year time horizon under an optimistic scenario (95 % initial vaccine efficacy and 19-year mean duration of protection), and by 2–16 % under a pessimistic scenario (82 % initial efficacy and 6-year mean protection). Adding a catch-up campaign predicted a reduction in incidence of 36–90 % and 6–35 % in the optimistic and pessimistic scenarios, respectively. Vaccine impact was predicted to decrease as the relative contribution of chronic carriers to transmission increased. Models A-C all predicted routine vaccination with or without a catch-up campaign to be cost-effective compared to no vaccination, with ICERs varying from $95–789 per DALY averted; two models predicted the ICER of routine vaccination alone to be greater than with the addition of catch-up campaign. Despite differences in model-predicted vaccine impact and cost-effectiveness, routine vaccination plus a catch-up campaign is likely to be impactful and cost-effective in high incidence settings such as Kolkata.     

Potential health impact and cost-effectiveness of bivalent human papillomavirus (HPV) vaccination in Afghanistan

IntroductionHuman papillomavirus (HPV) vaccination has not been introduced in many countries in South-Central Asia, including Afghanistan, despite the sub-region having the highest incidence rate of cervical cancer in Asia. This study estimates the potential health impact and cost-effectiveness of HPV vaccination in Afghanistan to inform national decision-making.MethodAn Excel-based static cohort model was used to estimate the lifetime costs and health outcomes of vaccinating a single cohort of 9-year-old girls in the year 2018 with the bivalent HPV vaccine, compared to no vaccination. We also explored a scenario with a catch-up campaign for girls aged 10–14 years. Input parameters were based on local sources, published literature, or assumptions when no data was available. The primary outcome measure was the discounted cost per disability-adjusted life-year (DALY) averted, evaluated from both government and societal perspectives.ResultsVaccinating a single cohort of 9-year-old girls against HPV in Afghanistan could avert 1718 cervical cancer cases, 125 hospitalizations, and 1612 deaths over the lifetime of the cohort. The incremental cost-effectiveness ratio was US$426 per DALY averted from the government perspective and US$400 per DALY averted from the societal perspective. The estimated annual cost of the HPV vaccination program (US$3,343,311) represents approximately 3.53% of the country′s total immunization budget for 2018 or 0.13% of total health expenditures.ConclusionIn Afghanistan, HPV vaccine introduction targeting a single cohort is potentially cost-effective (0.7 times the GDP per capita of $586) from both the government and societal perspective with additional health benefits generated by a catch-up campaign, depending on the government′s willingness to pay for the projected health outcomes.     

Targeted hepatitis E vaccination for women of childbearing age is cost-effective in China

BackgroundHepatitis E virus (HEV) infection is hyper-endemic in China, it is characterized with a high morbidity of fulminant hepatitis and mortality in pregnant women. The first hepatitis E vaccine, HEV 239, was licensed in China in 2011 which provides an effective preventive measure.ObjectiveTo evaluate the cost-effectiveness of vaccination with HEV 239 in women of childbearing age in China and whether HEV antibody screening should be considered before vaccination.MethodsA decision tree-Markov model was constructed to simulate HEV infection in a closed female cohort with an average first-marriage age of 25 years and evaluate health and economic outcomes of two potential vaccination strategies, direct vaccination and combined screening and vaccination, from a societal perspective. An incremental cost-effectiveness ratio (ICER, additional costs per disability-adjusted life-year (DALY) averted) was calculated for each vaccination strategy versus no vaccination and between two vaccination strategies. Univariate and probabilistic sensitivity analyses were conducted to assess the robustness of the model findings.ResultsICERs of direct vaccination and combined screening and vaccination versus no vaccination were $4040 and $3114 per DALY averted, respectively, much lower than 1-time Chinese per-capita GDP ($8127). Direct vaccination would need additional $45,455 for each DALY averted compared with combined screening and vaccination, far more than the 3-time per-capita GDP. Probabilistic sensitivity analyses confirmed our findings that two vaccination strategies would be cost-effective if the willingness-to-pay reached the 1-time per-capita GDP, and that combined screening and vaccination would be more cost-effective than direct vaccination strategy.ConclusionVaccinating women of childbearing age with HEV 239 would cost less than the 1-time per-capita GDP for each DALY averted in China, and the vaccination with a prior screening would be the optimal option.     

Cost-effectiveness of rotavirus vaccination in Ghana: Examining impacts from 2012 to 2031

BackgroundDiarrhea causes about 10% of all deaths in children under five years globally, with rotavirus causing about 40% of all diarrhea deaths. Ghana introduced rotavirus vaccination as part of routine immunization in 2012 and it has been shown to be effective in reducing disease burden in children under five years. Ghana’s transition from low to lower-middle income status in 2010 implies fewer resources from Gavi as well as other major global financing mechanisms. Ghana will soon bear the full cost of vaccines. The aim of this study was to estimate the health impact, costs and cost-effectiveness of rotavirus vaccination in Ghana from introduction and beyond the Gavi transition.MethodsThe TRIVAC model is used to estimate costs and effects of rotavirus vaccination from 2012 through 2031. Model inputs include demographics, disease burden, health system structure, health care utilization and costs as well as vaccine cost, coverage, and efficacy. Model inputs came from local data, the international literature and expert consultation. Costs were examined from the health system and societal perspectives.ResultsThe results show that continued rotavirus vaccination could avert more than 2.2 million cases and 8900 deaths while saving US$6 to US$9 million in costs over a 20-year period. The net cost of vaccination program is approximately US$60 million over the same period. The societal cost per DALY averted is US$238 to US$332 with cost per case averted ranging from US$27 to US$38. The cost per death averted is approximately US$7000.ConclusionThe analysis shows that continued rotavirus vaccination will be highly cost-effective, even for the period during which Ghana will assume responsibility for purchasing vaccines after transition from Gavi support.     

Cost-effectiveness of 13-valent pneumococcal conjugate vaccination in Mongolia

ObjectiveThe Ministry of Health (MOH), Mongolia, is considering introducing 13-valent pneumococcal conjugate vaccine (PCV13) in its national immunization programme to prevent the burden of disease caused by Streptococcus pneumoniae. This study evaluates the cost-effectiveness and budget impact of introducing PCV13 compared to no PCV vaccination in Mongolia.MethodsThe incremental cost-effectiveness ratio (ICER) of introducing PCV13 compared to no PCV vaccination was assessed using an age-stratified static multiple cohort model. The risk of various clinical presentations of pneumococcal disease (meningitis, pneumonia, non-meningitis non-pneumonia invasive pneumococcal disease and acute otitis media) at all ages for thirty birth cohorts was assessed. The analysis considered both health system and societal perspectives. A 3 + 0 vaccine schedule and price of US$3.30 per dose was assumed for the baseline scenario based on Gavi, the Vaccine Alliance’s advance market commitment tail price.ResultsThe ICER of PCV13 introduction is estimated at US$52 per disability-adjusted life year (DALY) averted (health system perspective), and cost-saving (societal perspective). Although indirect effects of PCV have been well-documented, a conservative scenario that does not consider indirect effects estimated PCV13 introduction to cost US$79 per DALY averted (health system perspective), and US$19 per DALY averted (societal perspective). Vaccination with PCV13 is expected to cost around US$920,000 in 2016, and thereafter US$820,000 every year. The programme is likely to reduce direct disease-related costs to MOH by US$440,000 in the first year, increasing to US$510,000 by 2025.ConclusionIntroducing PCV13 as part of Mongolia’s national programme appears to be highly cost-effective when compared to no vaccination and cost-saving from a societal perspective at vaccine purchase prices offered through Gavi. Notwithstanding uncertainties around some parameters, cost-effectiveness of PCV introduction for Mongolia remains robust over a range of conservative scenarios. Availability of high-quality national data would improve future economic analyses for vaccine introduction.     

Cost-effectiveness of community-based management of acute malnutrition in Malawi

This study assessed the cost-effectiveness of community-based management of acute malnutrition (CMAM) to prevent deaths due to severe acute malnutrition among children under-five. The analysis used a decision tree model to compare the costs and effects of two options to treat severe acute malnutrition: existing health services with CMAM vs existing health services without CMAM. The model used outcome and cost data from a CMAM programme in Dowa district, Malawi and a set of key assumptions regarding treatment-seeking behaviour and mortality outcomes. Under our 'base case' scenario, we found that CMAM cost US$42 per disability-adjusted life year (DALY) averted (2007 US$) and US$493 per DALY averted under an assumed 'worst case' scenario for each variable. The results suggest that CMAM was highly cost-effective in the 'base case' as defined by the World Health Organization, as the cost per DALY falls well below Malawi's 2007 gross national income (GNI) per capita of US$250, and is within the range of DALYs reported for other child health interventions. Under a hypothetical 'worst case' for all variables, the model indicates CMAM is still cost-effective. The results indicate the decision to scale-up CMAM within essential health services in Dowa was a cost-effective one and that scaling up CMAM in similar contexts is also likely to be cost-effective. However, several contextual and programmatic factors should be considered when generalizing to diverse contexts.     

Cost-utility analysis of dengue vaccination in a country with heterogeneous risk of dengue transmission

BackgroundDengue is one of the most important vector-borne diseases worldwide, and annually, nearly 390 million people are infected and 500,000 patients are hospitalized for severe dengue. Argentina has great variability in the risk of dengue transmission due to eco-climatic reasons. Currently no vaccines are available for dengue even though several vaccines are under development.ObjectiveThe aim of this study was to estimate the cost-effectiveness of a dengue vaccine in a country with heterogeneous risk of dengue transmission like Argentina.MethodsThe analysis was carried out from a societal perspective using a Markov model that included both vaccine and disease parameters. Utility was measured as disability adjusted life years (DALYs) averted, and the incremental cost-effectiveness ratio (ICER) of the vaccination was expressed in 2014 American dollars (US$) per DALY averted. One-way and probabilistic sensitivity analyses were performed to evaluate uncertainty in model outcomes, and a threshold analysis was conducted to estimate the highest possible price of the vaccine.ResultsThe ICER of the vaccination program was found to be US$ 5714 per DALY averted. This value is lower than 3 times the per capita GDP of Argentina (US$ 38,619 in 2014); 54.9% of the simulations were below this value. If a vaccination program would be implemented the maximum vaccine price per dose has to be US$1.49 for a vaccination at national level or US$28.72 for a targeted vaccination in high transmission areas.ConclusionsThese results demonstrate that vaccination against dengue would be cost-effective in Argentina, especially if carried out in predetermined regions at high risk of dengue transmission. However, these results should be interpreted with caution because the probabilistic sensitivity analysis showed that there was considerable uncertainty around the ICER value. The influence of variations in vaccine efficacy, cost and other important parameters are discussed in the text.     

Risk factors associated with immunoprophylaxis failure against mother to child transmission of hepatitis B virus and hepatitis B vaccination status in Yunnan province,China

ObjectiveTo explore the risk factors associated with immunoprophylaxis failure against mother to child transmission of hepatitis B virus (HBV) and hepatitis B vaccination status in Yunnan province, China.MethodsMulticenter cluster sampling was used to select pregnant women who were positive for hepatitis B surface antigen (HBsAg). HBV immunoprophylaxis was carried out for the newborns. Blood samples were collected and tested for HBV markers from 7 to 10 month old infants. The factors were analyzed by univariate and logistic regression.ResultsA total of 2765 mothers and their infants were enrolled. The failure rate of prevention of mother to child transmission (PMTCT) was 4.12%. The rate of timely HepB1 vaccination within 24 h was 98.04%, the rate of three-dose vaccination was 92.30% and the rate of hepatitis B immune globulin (HBIG) administration was 68.97%. Place of residence, maternal education, gestational age and birth weight were related to administration of HBV immunoprophylaxis. It was remarkable that the rate of HBIG administration of infants was only 63.89% with whose mothers were both HBsAg and hepatitis B e antigen (HBeAg)-positive. Further analysis showed that there were three risk factors associated with HBV immunoprophylaxis failure: mothers who were positive for HBsAg and HBeAg, maternal HBVDNA level, and HBIG administration or not.ConclusionsPMTCT of HBV was well implemented in Yunnan. However, in order to achieve optimal prevention of vertical HBV transmission, it is mandatory to make additional efforts to improve the implementation of regulatory HBV immunoprophylaxis, especially for HBsAg-positive pregnant women.     

Economic evaluation and budget impact analysis of dengue vaccination following pre-vaccination serological screening in India

ObjectivesTo evaluate the budget impact and cost-effectiveness of dengue vaccination following pre-vaccination serological screening in India.MethodsWe used a static cohort model (combination of decision tree and Markov model) to compare dengue disease and cost burden with and without dengue vaccination program with serological screening for a hypothetical cohort of 10-year-old adolescents. Budget impact was expressed in terms of total budget required for implementation of vaccination programme. Program impact was expressed in terms of disability-adjusted life-years (DALYs) averted. Cost effectiveness was expressed as costs per DALY averted. All costs are expressed in 2018 US dollars. Sensitivity analysis was performed for ICERs in different vaccination scenarios.ResultsThe total budget for implementation of dengue vaccination programme is approximately around US$ 530 million (INR 3620 crores). Our model results suggest dengue vaccination result in a net gain of almost 86,000 DALYS. We found the Dengue vaccine to be a cost-effective intervention with an ICER of $3364 (INR 2,30,098) which is less than three-times GDP per capita of India ($6047; INR 413,601). One-way sensitivity analysis shows that the ICER is most affected by the overall incidence of dengue infections followed by vaccine price. Probabilistic sensitivity analysis shows that ICER for dengue vaccination varied from $1182 (INR 80,837) to $6367 (INR 435,439).ConclusionOur study shows that dengue vaccine with pre-vaccination serological screening programme is a cost-effective intervention with the conservative estimates.     

Estimating the costs and health benefits of water and sanitation improvements at global level

The aim of this study was to estimate the costs and the health benefits of the following interventions: increasing access to improved water supply and sanitation facilities, increasing access to in house piped water and sewerage connection, and providing household water treatment, in ten WHO sub-regions. The cost-effectiveness of each intervention was assessed in terms of US dollars per disability adjusted life year (DALY) averted. This analysis found that almost all interventions were cost-effective, especially in developing countries with high mortality rates. The estimated cost-effectiveness ratio (CER) varied between US$20 per DALY averted for disinfection at point of use to US$13,000 per DALY averted for improved water and sanitation facilities. While increasing access to piped water supply and sewage connections on plot was the intervention that had the largest health impact across all sub-regions, household water treatment was found to be the most cost-effective intervention. A policy shift to include better household water quality management to complement the continuing expansion of coverage and upgrading of services would appear to be a cost-effective health intervention in many developing countries.