ECONOMIC ASPECTS OF COMBINED VACCINES

1
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

2
Pin cushion syndrome

• USA W-Europe
• 1989 ca. 8 injections
• 2000 USA 16 injections
• Pipeline / Future
• pneumococcal conjugate, meningococcal C,
  varicella, hepatitis A, rotavirus

Demand for combined vaccines from parents,
health care providers and decision makers
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Supply of combined vaccines

• Complex RD 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?)
4
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

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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)

6
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

7
Unit vaccination costs
Administration Adverse events Price
8
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

9
Safety of injection, developing countries

• In some countries, up to 80 of disposable
  needles are re-used
• 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
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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
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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

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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?
13
Vaccination costs Addis Ababa, 1996 (Edmunds et
al, 2000)
DTP-HB preferable if price 14
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

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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
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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
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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