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Health Economics of Vaccines: From Current Practice to Future Perspectives

  • Cornelis Boersma
    Affiliations
    Department of Health Sciences, University of Groningen, University Medical Center Groningen, The Netherlands

    Department of Management Sciences, Open University The Netherlands, Heerlen, The Netherlands

    Health-Ecore Ltd, Zeist, The Netherlands
    Search for articles by this author
  • Maarten J. Postma
    Correspondence
    Correspondence: Maarten Postma, Department of Health Sciencesen, University of Groningen, Illegaliteitslaan 29, Groningen 9727EB, The Netherlands.
    Affiliations
    Department of Health Sciences, University of Groningen, University Medical Center Groningen, The Netherlands

    Health-Ecore Ltd, Zeist, The Netherlands

    Department of Pharmacy, University of Groningen, Groningen, The Netherlands

    Department of Economics, Econometrics and Finance, University of Groningen, Groningen, The Netherlands

    Department of Pharmacology and Therapy, Universitas Airlangga, Surabaya, Indonesia

    Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
    Search for articles by this author
Open ArchivePublished:December 14, 2020DOI:https://doi.org/10.1016/j.jval.2020.11.006
      This special themed section of Value in Health with a focus on the health economics of vaccines seems timely with potentially various coronavirus disease 2019 (COVID-19) vaccines being close to market access. Although COVID-19 vaccines will likely not immediately be subject to health economics scrutiny, in the post–COVID-19 peak era there will soon be more emphasis on health economics when broader high-risk groups will be targeted and boosters and revaccinations are to be decided on.
      Health Technology Assessment international
      HTA’s critical role in the (early) assessment of (potential) vaccines to prevent the spread of COVID-19 globally.
      Considerations now eminent in controlling COVID-19 (eg, economic impacts, specific cost-effectiveness methodologies, basic reproduction rate estimates, real-world data calibrations, discounting of long-term effects, transmission modeling) have been present for other potentially vaccine-preventable infections for decades. The articles in this themed section address all those issues, with illustrations for meningococcal, varicella, human papilloma, and influenza vaccines. Finally, it is argued that a broader scope (as well as an adapted view) is needed that justifies the specifics that vaccines pose. This is in line with a recent statement of the World Health Organization.
      • Ultsch B.
      • Damm O.
      • Beutels P.
      • et al.
      Methods for health economic evaluation of vaccines and immunization decision frameworks: a consensus framework from a European vaccine economics community.
      Since the start of the COVID-19 pandemic, similarities with the influenza virus—both seasonal and potential pandemic nature—have been sketched. This theme includes 4 papers on influenza vaccination cost-effectiveness directed toward improving protection of older adults against the complications of influenza infections.
      • Zeevat F.
      • Crépey P.
      • Dolk C.F.
      • Postma A.J.
      • Breeveld-Dwarkasing V.N.A.
      • Postma M.J.
      Cost-effectiveness of quadrivalent versus trivalent influenza vaccination in the Dutch National Influenza Prevention Program.
      • Dolk F.C.K.
      • de Boer P.T.
      • Nagy L.
      • et al.
      Consultations for influenza-like illness in primary care in The Netherlands: a regression approach.
      • de Boer P.T.
      • Nagy L.
      • Dolk F.C.K.
      • Wilschut J.C.
      • Pitman R.
      • Postma M.J.
      Cost-effectiveness of pediatric influenza vaccination in The Netherlands.
      • Scholz S.M.
      • Weidemann F.
      • Damm O.
      • Ultsch B.
      • Greiner W.
      • Wichmann O.
      Cost-effectiveness of routine childhood vaccination against seasonal influenza in Germany.
       In particular, for influenza vaccines, such improvements target better-adjuvated, cell-based (rather than egg-based), higher-dosed, and quadrivalent vaccines.
      Joint Committee of Vaccination and Immunization
      Statement on influenza vaccines 2021-2022.
      Zeevat et al performed a cost-effectiveness analysis of the quadrivalent versus trivalent influenza vaccine for older adults and medical risk groups.
      • Zeevat F.
      • Crépey P.
      • Dolk C.F.
      • Postma A.J.
      • Breeveld-Dwarkasing V.N.A.
      • Postma M.J.
      Cost-effectiveness of quadrivalent versus trivalent influenza vaccination in the Dutch National Influenza Prevention Program.
      Three further articles analyze the potential of pediatric influenza vaccination for further indirect protection of older adults and medical risk groups, presenting detailed data analysis in one article
      • Dolk F.C.K.
      • de Boer P.T.
      • Nagy L.
      • et al.
      Consultations for influenza-like illness in primary care in The Netherlands: a regression approach.
      and cost-effectiveness analyses in the next.
      • de Boer P.T.
      • Nagy L.
      • Dolk F.C.K.
      • Wilschut J.C.
      • Pitman R.
      • Postma M.J.
      Cost-effectiveness of pediatric influenza vaccination in The Netherlands.
      ,
      • Scholz S.M.
      • Weidemann F.
      • Damm O.
      • Ultsch B.
      • Greiner W.
      • Wichmann O.
      Cost-effectiveness of routine childhood vaccination against seasonal influenza in Germany.
      Currently, the United Kingdom is one of few European countries that implemented pediatric influenza vaccination based on favorable cost-effectiveness outcomes,
      • Baguelin M.
      • Camacho A.
      • Flasche S.
      • Edmunds W.J.
      Extending the elderly- and risk-group programme of vaccination against seasonal influenza in England and Wales: a cost-effectiveness study.
      and such information for other countries as presented here is urgently needed. With current health economic influenza vaccination programs being investigated in isolation, this collection of articles also expresses the need to develop integrated health economic models for multiple infections. After all, control strategies for one (eg, COVID-19) influence the others (influenza, respiratory syncytial virus, pneumococcal infections), and infections augment or mitigate each other in seriousness of manifestations, as currently analyzed in the EU project, Vaccine and Infectious Diseases in the Aging Population (VITAL; EU project #806776).
      Additionally, new vaccination strategies are continuously considered. Typically, chickenpox reflects an area where many countries are still reluctant to implement protective infant vaccination strategies, largely informed by worries on decremental long-term effects on herpes zoster caused by the same virus.
      • de Boer P.T.
      • Wilschut J.C.
      • Postma M.J.
      The “dynamic” marriage between varicella and zoster.
      Also, it has often been argued that infant varicella vaccination is not cost-effective, except when a broader societal (instead of a narrower healthcare perspective) is applied.
      • Rozenbaum M.H.
      • van Hoek A.J.
      • Vegter S.
      • Postma M.J.
      Cost-effectiveness of varicella vaccination programs: an update of the literature.
      However, Luyten et al argue that favorable cost-effectiveness can already be achieved within the healthcare perspective if alternative social/public preferences for quality-adjusted life-years (QALYs) gained for children versus those for older adults and for side effects are used.
      • Luyten J.
      • van Hoek A.J.
      Integrating alternative social value judgments into cost-effectiveness analysis of vaccines: an application to varicella-zoster virus vaccination.
      Additionally, Rafferty et al analyzed infant varicella vaccination using an innovative approach with an agent-based model and alternative vaccination schedules being investigated and show potential favorable cost-effectiveness already from the healthcare perspective in Canada, notably one of the few countries that often even apply the societal perspective.
      • Rafferty E.R.S.
      • McDonald W.
      • Osgood N.D.
      • Doroshenko A.
      • Farag M.
      What we know now: an economic evaluation of chickenpox vaccination and dose timing using an agent-based model.
      Whereas articles in this themed section mostly address the European situation or Canada, 4 other articles explicitly take a global view. Specifically, new analyses with the PRIME model (Papillomavirus Rapid Interface for Modeling and Economics
      • Jit M.
      • Brisson M.
      • Portnoy A.
      • Hutubessy R.
      Cost-effectiveness of female human papillomavirus vaccination in 179 countries: a PRIME modelling study.
      ) explicitly relate the implementation of human papilloma virus (HPV) vaccination programs in 179 countries to its cost-effectiveness and country-specific gross domestic product per capita.
      • Jit M.
      Informing global cost-effectiveness thresholds using country investment decisions: human papillomavirus vaccine introductions in 2006-2018.
      Obviously, costs of immunization services reflect a core piece of real-world data to populate health economic models. In a targeted literature review, it is found that such data are still lacking for most low- and middle-income countries—specifically, if additionally considering the need to understand costing effects of scaling-up vaccine coverages in such settings.
      • Portnoy A.
      • Resch S.C.
      • Suharlim C.
      • Brenzel L.
      • Menzies N.A.
      What we don not know about the costs of immunization programs in low- and middle-income countries.
      The authors express a call for intensified research into these costs. Responding to this call to the global health community, Sim et al estimate the costs/investment required for keeping up adequate immunization services in 94 countries for 10 vaccines, including rotavirus, HPV, and pneumococcal vaccines.
      • Sim S.Y.
      • Watts E.
      • Constenla D.
      • Huang S.
      • Brenzel L.
      • Patenaude B.N.
      Costs of immunization programs for 10 vaccines in 94 low-and middle-income countries from 2011 to 2030.
      In their next article,
      • Watts E.
      • Sim S.Y.
      • Constenla D.
      • Sriudomporn S.
      • Brenzel L.
      • Patenaude B.
      Economic benefits of immunization for 10 pathogens in 94 low- and middle-income countries from 2011 to 2030 using cost-of-illness and value-of-statistical-life approaches.
      those investments are confronted with the potential benefits to be achieved on the costs of the corresponding 10 pathogens, including a value-of-a-statistical-life approach.
      Mauskopf et al argue that conventional cost-effectiveness may not incorporate all values of vaccination, for example the capability of vaccines to reduce risks for catastrophic outcomes to justify taking the value of a statistical life into the analysis.
      • Mauskopf J.
      • Masaquel C.
      • Huang L.
      Evaluating vaccination programs that prevent diseases with potentially catastrophic health outcomes: how can we capture the value of risk reduction?.
      An illustration further broader impacts—possible not fully covered in the QALY—is presented by Beck et al for meningococcal disease, considered a disease of relatively high severity.
      • Beck E.
      • Klint J.
      • Neine M.
      • Garcia S.
      • Meszaros K.
      Cost-effectiveness of 4CMenB infant vaccination in England: a comprehensive valuation considering the broad impact of serogroup B invasive meningococcal disease.
      As in some other disease areas (such as rare diseases
      • Schlander M.
      • Garattini S.
      • Kolominsky-Rabas P.
      • et al.
      Determining the value of medical technologies to treat ultra-rare disorders: a consensus statement.
      ), it is consistently argued that relevant value drivers for vaccines are not in the cost-effectiveness per QALY, and, therefore, a broader perspective than conventionally taken is required.
      • Christensen H.
      • Al-Janabi H.
      • Levy P.
      • et al.
      Economic evaluation of meningococcal vaccines: considerations for the future.
      For example, in this respect health and productivity effects for caregivers, effects on antimicrobial resistance, and distributive effects have been specifically mentioned.
      • Bärnighausen T.
      • Berkley S.
      • Bhutta Z.A.
      • et al.
      Reassessing the value of vaccines.
      • Atkins K.E.
      • Lafferty E.
      • Deeny S.R.
      • Davies N.G.
      • Robotham J.V.
      • Jit M.
      Use of mathematical modelling to access the impact of vaccines on antibiotic resistance.
      • Verguet S.
      • Kim J.
      • Jamison D.T.
      Extended cost-effectiveness analysis for health policy assessment: a tutorial.
      These specific issues are addressed in the final article.
      • Annemans L.
      • Beutels P.
      • Bloom D.E.
      • et al.
      Economic evaluation of vaccines: Belgian reflections on the need for a broader perspective.
      This article by Annemans et al is a timely and illustrative example of what societies are currently facing with COVID-19, namely its immense macroeconomic impact and enormous drive to implement effective and safe vaccination strategies. In this respect, potential enormous impacts of infectious diseases, heterogeneity of populations with corresponding interdependencies between infectious diseases, and the (cost-)effectiveness of preventive interventions will increasingly be important for future public health investments and allocative efficiency considerations.
      Author Contributions: Concept and design: Postma, Boersma
      Acquisition of data: Postma
      Analysis and interpretation of data: Postma
      Drafting of the manuscript: Postma, Boersma
      Critical revision of the paper for important intellectual content: Postma, Boersma
      Provision of study materials or patients: Postma
      Administrative, technical, or logistic support: Postma
      Supervision: Postma
      Conflict of Interest Disclosures: Dr Postma reported receiving grants and personal fees from Merck Sharp & Dohme, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Novavax, Bristol Myers Squibb, Astra Zeneca, Sanofi, IQVIA, and Seqirus outside the submitted work; personal fees from Quintiles, Novartis, and Pharmerit outside the submitted work; grants from Bayer, BioMerieux, the World Health Organization, EU, FIND, Antilope, DIKTI, LPDP, and Budi outside the submitted work. In addition, Dr Postma is a stockholder of Health-Ecore and PAG Ltd, and an advisor to Asc Academics. Dr Postma is an editor for Value in Health and had no role in the peer review process of this article. No other disclosures were reported.
      Funding/Support: The authors received no financial support for this research.

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