Transcript EEN ECONOMISCHE EVALUATIE VAN ROUTINE

ECONOMIC ASPECTS
OF COMBINED VACCINES
Malta, 22-23 October 2001
Philippe Beutels
Centre for the Evaluation of Vaccination
WHO collaborating centre for the prevention and control of viral hepatitis
Epidemiology and Community Medicine
University of Antwerp
Belgium
Pin cushion syndrome

USA & W-Europe:
» 1989: ca. 8 injections < 16 y
» 2000: USA: 16 injections < 16 y, (EUR: ca. 8-16)

Pipeline / Future:
» pneumococcal conjugate, meningococcal C,
varicella, hepatitis A, rotavirus
Demand for combined vaccines from parents,
health care providers and decision makers
Supply of combined vaccines
Complex R&D and clinical trials
 Major competitive advantage / improved product

-Clear incentives for some manufacturers
to supply such vaccines
-Increases barriers of entrance
onto the vaccine market
-Increased monopolistic behaviour
(consequences in supply, choice and price?)
Complete economic evaluation

Comparing different alternatives:
 E.g., “combined vaccine” versus “same separate vaccines”
versus “same separate vaccines minus one or more”

Analysing both economic costs and medical effects:
 If not: cost analysis or effectiveness analysis
Effectiveness

Free rider effect
» for important vaccines with an image problem (HBV)
» for not so important vaccines (HAV, VZV, mumps)
greater coverage and improved compliance
against more agents

Danger: new vaccine scare stories: important vaccines could be
dragged down by less important vaccines (e.g., measles)
Change in coverage of at least
one antigen

Affects both costs and effects

Above the herd immunity threshold:
» nonlinear influence on effects

Below herd immunity threshold:
» linear influence on effects
Unit vaccination costs
= Administration + Adverse events + Price
Administration Costs

Fewer injections & fewer visits
» Lower administration costs
– time vaccinators
– storage, transportation, material and equipment (?)
» Reduced time, money and pain losses of children and
parents (direct personal and indirect costs)
» Fewer side effects and related treatment
» Safety improves
Safety of injection,
developing countries


In some countries, up to 80% of disposable needles are reused
Safety of injection is more related to adapting the needle
(auto-disable syringes in immunisation programmes) than
to providing combined vaccines
The role of combined vaccination in
reducing unsafe injection is limited
Administration costs,
developing countries

EPI with HBV versus EPI without HBV:
» Addis Ababa, 1996: (Edmunds et al, 2000)
– Increase in programme costs by 43%
– 79% for buying vaccines (28% in current EPI)
» The Gambia, 1989: (Hall et al, 1993)
– Increase in programme costs by 63%
– 82% for buying vaccines (16% in current EPI)
Administration costs are an important,
not THE most important marginal cost factor
Multiple injections & visits and
Willingness To Pay
Study in N-California, parents of 1-8 m infants
(Lieu et al, Vaccine 2000):

median WTP:
– $25 for reduction from 4 to 3 injections
– $25 for reduction from 3 to 2 injections
– $50 for reduction from 2 to 1 injections

greater value of avoiding adverse events ($50) than
of avoiding third or fourth injection
Unit vaccination costs
= Administration + Adverse events + Price
=++?
Trade off:
value of fewer injections and side effects
versus
price
How much higher can the price of the combination be
before it is less interesting than the combination of prices?
Vaccination costs Addis Ababa, 1996 (Edmunds et al, 2000)
Average costs per dose given
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
1
0.5
0.25
0.1
Unit vaccine price
DTP-HB preferable if price <$0.77/dose (+54%)
Economic evaluation of combined vaccines
Most EE: incremental analysis of one
component (eg, MMRV versus MMR; DTPa
versus DTPw; HB-Hib versus Hib)
 Some EE: summation of two programmes (eg,
HA & HB) versus doing nothing
 Few/missing EE: Complete joint analysis of a
combined vaccine versus the same components,
separately

Cost-effectiveness of combined vaccines
versus same components, separately

Very likely: Effectiveness

Very likely: Costs upfront

Very likely: Downstream costs

Condition: no bad publicity or excess price
Cost-effectiveness
Examples: combinations of DTP-IPV-Hib-HBV
Incremental cost-effectiveness of a new
addition to an existing (combined) vaccine

Very likely: Effectiveness

Very likely: Costs upfront

Very likely: Downstream costs
Cost-effectiveness
?
Examples: MMRV, HB-Hib, HA-HB
CONCLUSION

Very likely that combined vaccines versus separate
components is cost-saving, conditional on
» price setting
» avoiding bad publicity



Cost-effectiveness of new additions to an existing vaccine
depends
Not generalisable, dependent on vaccine and starter
situation
Till now rarely investigated