Cost-Effectiveness of Canine Vaccination to Prevent Human Rabies in Rural Tanzania

Annals of Internal Medicine
21 January 2014, Vol. 160. No. 2

Original Research | 21 January 2014
Cost-Effectiveness of Canine Vaccination to Prevent Human Rabies in Rural Tanzania
Meagan C. Fitzpatrick, MPhil; Katie Hampson, PhD; Sarah Cleaveland, PhD, VetMB; Imam Mzimbiri, BVM; Felix Lankester, DVM; Tiziana Lembo, PhD; Lauren A. Meyers, PhD; A. David Paltiel, PhD; and Alison P. Galvani, PhD

Background: The annual mortality rate of human rabies in rural Africa is 3.6 deaths per 100 000 persons. Rabies can be prevented with prompt postexposure prophylaxis, but this is costly and often inaccessible in rural Africa. Because 99% of human exposures occur through rabid dogs, canine vaccination also prevents transmission of rabies to humans.

Objective: To evaluate the cost-effectiveness of rabies control through annual canine vaccination campaigns in rural sub-Saharan Africa.

Design: We model transmission dynamics in dogs and wildlife and assess empirical uncertainty in the biological variables to make probability-based evaluations of cost-effectiveness.

Data Sources: Epidemiologic variables from a contact-tracing study and literature and cost data from ongoing vaccination campaigns.

Target Population: Two districts of rural Tanzania: Ngorongoro and Serengeti.

Time Horizon: 10 years.

Perspective: Health policymaker.

Intervention: Vaccination coverage ranging from 0% to 95% in increments of 5%.

Outcome Measures: Life-years for health outcomes and 2010 U.S. dollars for economic outcomes.

Results of Base-Case Analysis: Annual canine vaccination campaigns were very cost-effective in both districts compared with no canine vaccination. In Serengeti, annual campaigns with as much as 70% coverage were cost-saving.

Results of Sensitivity Analysis: Across a wide range of variable assumptions and levels of societal willingness to pay for life-years, the optimal vaccination coverage for Serengeti was 70%. In Ngorongoro, although optimal coverage depended on willingness to pay, vaccination campaigns were always cost-effective and life-saving and therefore preferred.

Limitation: Canine vaccination was very cost-effective in both districts, but there was greater uncertainty about the optimal coverage in Ngorongoro.

Conclusion: Annual canine rabies vaccination campaigns conferred extraordinary value and dramatically reduced the health burden of rabies.

Primary Funding Source: National Institutes of Health.

Updating the evidence base on the operational costs of supplementary immunization activities for current and future accelerated disease control, elimination and eradication efforts

BMC Public Health
(Accessed 25 January 2014)

Research article
Updating the evidence base on the operational costs of supplementary immunization activities for current and future accelerated disease control, elimination and eradication efforts
Gian Gandhi and Patrick Lydon

Abstract (provisional)
To achieve globally or regionally defined accelerated disease control, elimination and eradication (ADC/E/E) goals against vaccine-preventable diseases requires complementing national routine immunization programs with intensive, time-limited, and targeted Supplementary Immunization Activities (SIAs). Many global and country-level SIA costing efforts have historically relied on what are now outdated benchmark figures. Mobilizing adequate resources for successful implementation of SIAs requires updated estimates of non-vaccine costs per target population.

This assessment updates the evidence base on the SIA operational costs through a review of literature between 1992 and 2012, and an analysis of actual expenditures from 142 SIAs conducted between 2004 and 2011 and documented in country immunization plans. These are complemented with an analysis of budgets from 31 SIAs conducted between 2006 and 2011 in order to assess the proportion of total SIA costs per person associated with various cost components. All results are presented in 2010 US dollars.

Existing evidence indicate that average SIA operational costs were usually less than US$0.50 per person in 2010 dollars. However, the evidence is sparse, non-standardized, and largely out of date. Average operational costs per person generated from our analysis of country immunization plans are consistently higher than published estimates, approaching US$1.00 for injectable vaccines. The results illustrate that the benchmarks often used to project needs underestimate the true costs of SIAs and the analysis suggests that SIA operational costs have been increasing over time in real terms. Our assessment also illustrates that operational costs vary across several dimensions. Variations in the actual costs of SIAs likely to reflect the extents to which economies of scale associated with campaign-based delivery can be attained, the underlying strength of the immunization program, sensitivities to the relative ease of vaccine administration (i.e. orally, or by injection), and differences in disease-specific programmatic approaches. The assessment of SIA budgets by cost component illustrates that four cost drivers make up the largest proportion of costs across all vaccines: human resources, program management, social mobilization, and vehicles and transportation. These findings suggest that SIAs leverage existing health system infrastructure, reinforcing the fact that strong routine immunization programs are an important pre-requisite for achieving ADC/E/E goals.

The results presented here will be useful for national and global-level actors involved in planning, budgeting, resource mobilization, and financing of SIAs in order to create more realistic assessments of resource requirements for both existing ADC/E/E efforts as well as for new vaccines that may deploy a catch-up campaign-based delivery component. However, limitations of our analysis suggest a need to conduct further research into operational costs of SIAs. Understanding the changing face of delivery costs and cost structures for SIAs will continue to be critical to avoid funding gaps and in order to improve vaccination coverage, reduce health inequities, and achieve the ADC/E/E goals many of which have been endorsed by the World Health Assembly and are included in the Decade of Vaccines Global Vaccine Action Plan.

Upscaling human papillomavirus vaccination in high-income countries: impact assessment based on transmission model

Infectious Diseases of Poverty
[Accessed 25 January 2014]

Research article
Upscaling human papillomavirus vaccination in high-income countries: impact assessment based on transmission model
Iacopo Baussano1*, Joakim Dillner2, Fulvio Lazzarato3, Guglielmo Ronco4 and Silvia Franceschi1

The decrease in human papillomavirus (HPV) vaccine prices may allow upscale already started vaccination programmes but the advantages of different options are unclear.

Using a mathematical model of HPV16 and 18 transmission and data on vaccination coverage from Italy, we compared 3 options to upscale an already started programme targeting 11-year old girls (coverage 65%): a) coverage improvement (from 65% to 90%); b) addition of 11-year-old boys (coverage 65%); or c) 1-year catch-up of older girls (coverage 50%).

The reduction of cervical HPV16/18 infection as compared to no vaccination (i.e. effectiveness against HPV16/18) increased from 76% to 98% with coverage improvement in girls and to 90% with the addition of boys. With higher coverage in girls, HPV16/18 infection cumulative probability by age 35 decreased from 25% to 8% with a 38% increase in vaccine number. The addition of boys decreased the cumulative probability to 18% with a 100% increase in the number of vaccinees. For any coverage in girls, the number of vaccinees to prevent 1 woman from being infected by HPV16/18 by age 35 was 1.5, whereas it was 2.7 for the addition of boys. Catch-up of older girls only moved forward the vaccination effectiveness by 2–5 years.

Increasing vaccination coverage among girls is the most effective option for decreasing HPV16/18. If not achievable, vaccinating boys is justifiable if vaccine cost has at least halved, because this option would almost double the number of vaccinees.

Poliomyelitis in Nigeria

The Lancet Global Health
Feb 2014  Volume 2  Number 2  e58 – 116

Persistence of poliomyelitis in Nigeria
Festus D Adu, Itam Hogan Itam
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The World Health Assembly launched the Global Polio Eradication Initiative in 1988 and declared the year 2000 as the target by which to achieve poliomyelitis eradication.1 After aggressive mass immunisation, backed up by effective routine immunisation, cases of poliomyelitis reduced from 350 000 in 165 countries in 1988 to 355 occurring mainly in three countries—Nigeria, Afghanistan, and Pakistan—by 2013.2 Nigeria is the only country in the world where the three poliovirus types are still circulating; as of December, 2013, it had contributed 14·1% of all poliomyelitis cases worldwide.

Key issues in the persistence of poliomyelitis in Nigeria: a case-control study
Dr Tara D Mangal PhD a, R Bruce Aylward MD b, Michael Mwanza BComm c, Alex Gasasira MBChB d, Emmanuel Abanida MBChB e, Prof Muhammed A Pate MD f, Prof Nicholas C Grassly PhD a

The completion of poliomyelitis eradication is a global emergency for public health. In 2012, more than 50% of the world’s cases occurred in Nigeria following an unanticipated surge in incidence. We aimed to quantitatively analyse the key factors sustaining transmission of poliomyelitis in Nigeria and to calculate clinical efficacy estimates for the oral poliovirus vaccines (OPV) currently in use.

We used acute flaccid paralysis (AFP) surveillance data from Nigeria collected between January, 2001, and December, 2012, to estimate the clinical efficacies of all four OPVs in use and combined this with vaccination coverage to estimate the effect of the introduction of monovalent and bivalent OPV on vaccine-induced serotype-specific population immunity. Vaccine efficacy was determined using a case-control study with CIs based on bootstrap resampling. Vaccine efficacy was also estimated separately for north and south Nigeria, by age of the children, and by year. Detailed 60-day follow-up data were collected from children with confirmed poliomyelitis and were used to assess correlates of vaccine status. We also quantitatively assessed the epidemiology of poliomyelitis and programme performance and considered the reasons for the high vaccine refusal rate along with risk factors for a given local government area reporting a case.

Against serotype 1, both monovalent OPV (median 32·1%, 95% CI 26·1—38·1) and bivalent OPV (29·5%, 20·1—38·4) had higher clinical efficacy than trivalent OPV (19·4%, 16·1—22·8). Corresponding data for serotype 3 were 43·2% (23·1—61·1) and 23·8% (5·3—44·9) compared with 18·0% (14·1—22·1). Combined with increases in coverage, this factor has boosted population immunity in children younger than age 36 months to a record high (64—69% against serotypes 1 and 3). Vaccine efficacy in northern states was estimated to be significantly lower than in southern states (p≤0·05). The proportion of cases refusing vaccination decreased from 37—72% in 2008 to 21—51% in 2012 for routine and supplementary immunisation, and most caregivers cited ignorance of either vaccine importance or availability as the main reason for missing routine vaccinations (32·1% and 29·6% of cases, respectively). Multiple regression analyses highlighted associations between the age of the mother, availability of OPV at health facilities, and the primary source of health information and the probability of receiving OPV (all p<0·05).

Although high refusal rates, low OPV campaign awareness, and heterogeneous population immunity continued to support poliomyelitis transmission in Nigeria at the end of 2012, overall population immunity had improved due to new OPV formulations and improvements in programme delivery.

Bill & Melinda Gates Foundation Vaccine Modeling Initiative, Royal Society.

Comment: Rebalancing the global battle against tuberculosis

The Lancet Global Health
Feb 2014  Volume 2  Number 2  e58 – 116

Rebalancing the global battle against tuberculosis
Mario Raviglione, Mukund Uplekar, Cheri Vincent, Ariel Pablos-Méndez
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Meetings of health ministers from the five BRICS countries (Brazil, Russia, India, China, and South Africa) have produced two joint statements in less than a year: the Delhi Communiqué1 (Jan 12, 2013) and the Cape Town Communiqué2 (Nov 7, 2013). Both statements bode well for global tuberculosis control. The Delhi Communiqué underscores the principle of equity and focuses on populations who are most affected by the disease. The Cape Town Communiqué emphasises promotion of consortia of researchers to collaborate for clinical trials of drugs and vaccines, strengthening of access to affordable, high-quality, effective, and safe medicines, and delivery of high-quality health care.

Malaria burden and control in Bangladesh and prospects for elimination: an epidemiological and economic assessment

The Lancet Global Health
Feb 2014  Volume 2  Number 2  e58 – 116

Malaria burden and control in Bangladesh and prospects for elimination: an epidemiological and economic assessment
Ubydul Haque, Hans J Overgaard, Archie C A Clements, Douglas E Norris, Nazrul Islam, Jahirul Karim, Shyamal Roy, Waziul Haque, Moktadir Kabir, David L Smith, Gregory E Glass
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Malaria elimination is an achievable prospect in Bangladesh and failure to push for elimination nearly ensures a resurgence of disease. Consistent financing is needed to avoid resurgence and maintain elimination goals.