Viruses and Vaccines

Elmahdawy M., Elsisi G.H., Carapinha J., Lamorde M., Habib A., Agyie-Baffour P., Soualmi R., Ragab S., Udezi A.W., Usifoh C., Usifoh S. 
Value in Health Regional Issues. CEEWAA 2017;13

OBJECTIVES
The Ebola virus has spread across several Western Africa countries, adding a significant financial burden to their health systems and economies. In this article the experience with Ebola is reviewed, and economic challenges and policy recommendations are discussed to help curb the impact of other diseases in the future. The West African Ebola virus disease epidemic started in resource-constrained settings and caused thousands of fatalities during the last epidemic. Nevertheless, given population mobility, international travel, and an increasingly globalized economy, it has the potential to re-occur and evolve into a global pandemic. Struggling health systems in West African countries hinder the ability to reduce the causes and effects of the Ebola epidemic. The lessons learned include the need for strengthening health systems, mainly primary care systems, expedited access to treatments and vaccines to treat the Ebola virus disease, guidance on safety, efficacy, and regulatory standards for such treatments, and ensuring that research and development efforts are directed toward existing needs. Other lessons include adopting policies that allow for better flow of relief, averting the adverse impact of strong quarantine policy that includes exaggerating the aversion behavior by alarming trade and business partners providing financial support to strengthen growth in the affected fragile economies by the Ebola outbreak. Curbing the impact of future Ebola epidemics, or comparable diseases, requires increased long-term investments in health system strengthening, better collaboration between different international organizations, more funding for research and development efforts aimed at developing vaccines and treatments, and tools to detect, treat, and prevent future epidemics.

Alvis-Zakzuk N.J., Díaz-Jiménez D., Castillo-Rodríguez L., Castañeda-Orjuela C., Paternina-Caicedo Á., Pinzón-Redondo H., Carrasquilla-Sotomayor M., Alvis-Guzmán N., De La Hoz-Restrepo F.
Value in Health Regional Issues. Latin America 2018;17

OBJECTIVE
The aim of the present study was to estimate the economic impact of chikungunya virus (CHIKV) infection in Colombia from a societal perspective.

METHODS
We conducted a retrospective, bottom-up cost-of-illness study in clinically confirmed cases during the first chikungunya (CHIK) outbreak in Colombia in 2014. Direct and indirect costs were estimated per patient. Economic costs were calculated by the addition of direct costs (direct medical costs and out-of-pocket heath expenditures) and indirect cost as a result of loss of productivity.

RESULTS 
A total of 126 patients (67 children and 59 adults) with CHIK were included. The median of the direct medical cost in children was US$257.9 (interquartile range [IQR] 121.7–563.8), and US$66.6 (IQR 26.5–317.3) for adults. The productivity loss median expenditures reached US$81.3 (IQR 72.2–203.2) per adult patient. The median economic cost in adults as a result of CHIK was US$152.9 (IQR 101.0–539.6), of which 53.2% was a result of indirect costs. Out-of-pocket expenditures comprised 3.3% of all economic costs.

CONCLUSIONS 
Our study can help health decision makers to properly assess the burden of disease caused by CHIK in Colombia, an endemic tropical country. We recommend to strength the health information systems and to continue investing in public health measures to prevent CHIK.

Hiebert L., Hecht R., Soe-Lin S., Mohamed R., Shabaruddin F.H., Syed Mansor S.M., Dahlui M., Azzeri A., McDonald S.A.
Value in Health Regional Issues. Asia Pacific 2019;18.

BACKGROUND
In Malaysia, more than 330 000 individuals are estimated to be chronically infected with hepatitis C virus (HCV), but less than 2% have been treated to date.

OBJECTIVES
To estimate the required coverage and costs of a national screening strategy to inform the launch of an HCV elimination program.

METHODS
We designed an HCV screening strategy based on a “stepwise” approach. This approach relied on targeting of people who inject drugs in the early years, with delayed onset of widespread general population screening. Annual coverage requirements and associated costs were estimated to ensure that the World Health Organization elimination treatment targets were met.

RESULTS
In total, 6 million individuals would have to be screened between 2018 and 2030. Targeting of people who inject drugs in the early years would limit annual screening coverage to less than 1 million individuals from 2018 to 2026. General population screening would have to be launched by 2026. Total costs were estimated at MYR 222 million ($58 million). Proportional to coverage targets, 60% of program costs would fall from 2026 to 2030.

CONCLUSION
This exercise was one of the first attempts to conduct a detailed analysis of the required screening coverage and costs of a national HCV elimination strategy. These findings suggest that the stepwise approach could delay the onset of general population screening by more than 5 years after the program's launch. This delay would allow additional time to mobilize investments required for a successful general population screening program and also minimize program costs. This strategy prototype could inform the design of effective screening strategies in other countries.

Supadmi W., Suwantika A.A., Perwitasari D.A., Abdulah R.
Value in Health Regional Issue. Asia Pacific 2019;18.

Lara C., De Graeve D., Franco F.
Value in Health Regional Issue. Latin America 2018;17.

BACKGROUND
The Colombian health authorities introduced the pneumococcal conjugated vaccine and the seasonal influenza vaccine into the national immunization schedule for children in 2009 and 2007, respectively. Despite this, the health authorities continue to be concerned about the high economic and disease burden among children from low-income households caused by these vaccine-preventable diseases.

OBJECTIVES
1) To evaluate the potential health outcomes of four vaccination strategies for subsidized children younger than 5 years in a low-income district in Colombia from a public, direct medical health care perspective. 2) To perform univariate, multivariate, and probabilistic sensitivity analysis to evaluate the robustness of these results.

METHODS
We built a Markov deterministic cohort model to evaluate five consecutive cohorts across four alternative situations: 1) no vaccination; 2) vaccination with the 10-valent pneumococcal conjugate vaccine (PCV10 vaccine); 3) vaccination with the trivalent inactivated vaccine (TIV) annually; and 4) combined vaccination with PCV10 vaccine and TIV.

RESULTS
The introduction of PCV10 vaccine and TIV and their combined use in particular would be highly cost-effective in comparison to no vaccination. For the combined vaccination with PCV10 vaccine and TIV, the incremental cost-effectiveness ratio would be $1,280 per disability-adjusted life-year (DALY) averted, the total incremental cost of the vaccination program would be $776,800, and it would avert four deaths and 332 DALYs for the five cohorts.

CONCLUSIONS
The introduction of PCV10 vaccine and TIV would be highly cost-effective from a public, direct medical health care perspective. Despite these results, we have not observed decreases in severity or hospitalizations. Our findings highlight the need for further studies of the immunization campaign indicators and socioeconomic indicators for this low-income community.

Prasolov A.V., Kolbin A.S., Balykina Y.E.
Value in Health Regional Issue. CEEWAA 2018;16.

OBJECTIVES
To propose an algorithm that relates the effectiveness of drugs for a wide range of diseases with the financial capabilities of patients.

METHODS
Estimates of the volume of pharmaceuticals that are consumed in the Russian Federation by all segments of the population regardless of household income were considered. These were calculated using statistically valid probabilities of the appearance of various diseases, official state data on the structure of expenditures of various strata of the population, and the optimal choice of the most effective medicines with income restrictions taken into account. The main idea was to introduce the utility function of the drug and the cost of treatment. For each disease, its own set of drugs was selected.

RESULTS
On the basis of the real-world data for several diseases, optimal estimates were calculated using the proposed algorithm. In the process of approbation, some weak points of the algorithm were found, such as the methods of packaging pharmaceuticals and associated cost of a packaging unit. These characteristics should be discussed separately, introducing conventional units of drug volumes. A unit of quantity corresponding to the maximum effect of the drug in question is proposed in the work.

CONCLUSIONS
The proposed algorithm for estimating the amount of medicines can be successfully used by both pharmaceutical (or dealer) companies and government agencies for objective population provision. The usual sources of such estimates are based either on market surveys or on pharmacy network data. Both ways are very expensive and do not allow predicting mass demand in the future, for example, with an unexpected epidemic or the emergence of new medicines. In addition, the proposed algorithm can be successfully applied to the pricing problem: a variation in price may show a change in the volume of use.

Salcedo-Mejía F., Alvis-Zakzuk N.J., Carrasquilla-Sotomayor M., Redondo H.P., Castañeda-Orjuela C., De la Hoz-Restrepo F., Alvis-Guzmán N.
Value in Health Regional Issue. Latin America 2019;20.

BACKGROUND
Influenza is considered a leading public health problem because its large economic burden of disease worldwide, especially in low-and middle-income countries, such as Colombia.

OBJECTIVES
We aimed to estimate the economic costs of influenza-confirmed patients in a pediatric hospital in Cartagena, Colombia.

METHODS
We conducted a retrospective costing analysis. We estimated the direct (direct medical and out-of-pocket expenditures) and indirect costs for influenza-confirmed severe acute respiratory infection cases from a societal perspective. Total economic costs were calculated adding direct medical costs, out-of-pocket expenditures, and indirect costs owing to loss of productivity of caregivers. Mean, median, 95% confidence interval (95% CI) and interquartile range (IQR) of costs were measured. All costs are reported in USD ($1.00 = COP$2000.7)

RESULTS
Forty-four cases were included in the analysis: 30 had influenza B, 10 influenza A and B, and 4 influenza AH1N1. Thirty patients were hospitalized in the general ward, 14 went to the intensive care unit. The average duration of stay was ∼9 days (95% CI, 6.3-11.5). The median direct medical cost for hospitalized case in general ward was $743.50 (IQR $590.20-$1404.60) and in intensive care unit $4669.80 (IQR $1614.60-$7801.50). The economic cost per hospitalized case was $1826.10 (IQR $1343.30-$2376.50); direct medical costs represented 93.8% of this cost. The median indirect cost was $82.10 (IQR $41.10-$133.40) and the median out-of-pocket expenditure per case was $45.70 (IQR $29.50-$64.90).

CONCLUSIONS
Severe acute respiratory infection is an important source of economic burden for the health system, families, and society in Colombia. Seasonal influenza vaccination should be strengthened to prevent more cases and save economic resources.

Kieffer A., Hoestlandt C., Gil-Rojas Y., Broban A., Castañeda-Cardona C., Rosselli D.
Value in Health Regional Issue. Latin America 2019;20.

OBJECTIVES
To evaluate the public health benefits and economic value of live-attenuated yellow fever (YF) 17D vaccine in Colombia.

METHODS
A decision tree model was used to assess the theoretical impact of routine YF vaccination of 1-year-olds (no “catch-up”) during the interepidemic period from 1980 to 2002, avoiding capturing the impact of YF vaccine introduction in 2003. The vaccine was assumed to be 99% effective, to provide lifetime protection, and to cover 85% of the target population. Costs per disability-adjusted life-year (DALY) averted were computed from payer and societal perspectives. Univariate sensitivity analyses were performed.

RESULTS
During the interepidemic period, routine YF vaccination would have averted 2223 nonfatal cases of YF and 65 deaths, leading to an overall reduction of 1365 DALYs. The net cost of this vaccination would have been $25 964 813 (payer’s perspective) and $16 535 465 (societal perspective). Cost per DALY averted was $19 022 and $12 114 from payer and societal perspectives, respectively (all costs in 2015 US dollars). Vaccination was considered cost-effective from both perspectives (ie, between 1- and 3-fold the gross domestic product per capita, $7158) and remains so if price per dose was $2.75 or less and $4.66 from payer and societal perspectives, respectively. Underreporting had the largest impact on the results.

CONCLUSIONS
Routine toddler YF vaccination in Colombia would have been considered cost-effective in the prevaccination era. This study provides insights on the value of vaccination in an upper middle-income country.