Vaccines are more expensive, budgets are stretched, and we’ve moved beyond your standard efficiency evaluation.
Budgets are tighter, R&D costs are higher and the schedule is crowded, but new vaccines are a net good in ways we haven’t counted before.
The “old” vaccines were “a no-brainer”, says Professor Mark Jit, the inaugural chair in the Department of Global and Environmental Health at NYU School of Global and Public Health. But determining the value of new vaccines requires “new narratives”.
“New vaccines will save even more lives, but they face hurdles, ecological complexities, tight budgets, crowded schedules, and so we need some fresh methods. We need some fresh analyses so that we properly understand their value and make sure that we’re using them … to the best of our ability,” he said.
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Professor Jit was speaking at the Public Health Association of Australia’s summit in Adelaide today on communicable diseases and immunisation.
Measles vaccines, for instance, cost under a dollar a dose, they address a very common infection, and they are delivered at low cost to a large population of children.
In the UK, for instance, measles cases went from 400,000 in number per year from 1950-1968 to 3000 in 2000-2010. The cost of treating measles went from $400 million in the first period to $3 million in the second. And the cost of vaccinating 700,000 children in the intervening time was just $0.7 million overall.
But vaccines developed since then, such as for PCV, RSV, HPV, dengue and covid, are different, Professor Jit told delegates.
They are more expensive, the technology is more complicated, and manufacturers need to make back their money on research and development.
They also target less common infections, like meningitis B; efficacy can be partial or can wane, as in the case of malaria, RSV and dengue vaccines. And they are delivered to groups of people that pose different challenges to traditional at-risk groups.
Professor Jit said there were three main challenges to establishing value propositions for vaccines at this point in time:
1. The new vaccines have complicated ecological externalities beyond the impact on the vaccinated person, and this complicates the calculation of cost and benefit.
For instance, herd immunity has benefits beyond those to the vaccinated individual. Some infections, like smallpox, are eradicated altogether, which means the benefits extend far beyond the initial cost.
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“We are continuing to get the benefits from smallpox vaccination today, but we pay no cost for it. So the benefits continue forever. Our grandchildren will get the benefits of smallpox eradication, but the costs end,” said Professor Jit.
In addition, vaccination could result in strain replacements which might not be susceptible to vaccines. It could change the profile of the people affected, which has various impacts.
And less disease could see less antibiotic prescription and less antimicrobial resistance.
Professor Jit used the example of modelling done for the PCV7 pneumoccoal disease vaccine in England and Wales, which was introduced into the schedule in 2006.
Analyses showed the cost of this vaccine was 60,000 GBP per year of life lived in good health (QALY) when only the (substantial) drop in disease among children, the group to be vaccinated, was considered.
There was a similar decrease in disease among other age groups, however.
When that was considered the QALY cost fell to less than 1000 GBP. And when the model included the cost due to non-vaccine susceptible strain replacement, the cost went up to just below 20,000 GBP per QALY – “just cost-effective enough”, said Professor Jit.
“If you had gone to [the first] analysis, you’d have got a result which wouldn’t have been realistic. You need the full model with all these effects at the same time to see what’s really going on.”
2. The new vaccines are expensive and health budgets are tight.
Traditionally, economic evaluation meant comparing the incremental costs and benefits between one scenario – the one with the vaccine – and another scenario – the one without the vaccine.
“However, I think we live now in a more complicated world,” said Professor Jit.
“There are challenges to healthcare budgets, but there are also different narratives going on about the value or otherwise of health.
“And I would say that, actually, we need to come up with new narratives and new analyses to frame the value of vaccines in a world of diminishing healthcare resources.”
The traditional narrative is all about economic efficiency, the best use of health budgets.
In addition, there is the justice narrative which explores how the vaccines are valuable because they protect the most vulnerable communities with the greatest burden of disease.
There is the growth narrative, which looks at how vaccines can promote human capital development, which is possible when disease burden is lessened.
And there is the security narrative, which considers the protection that vaccines provide against threats to security, such as pandemics, antimicrobial resistance, climate change risk and political unrest.
“In the last 10 or 15 years, working with WHO and other colleagues, there’s been an emerging narrative about the broader impacts of vaccines,” said Professor Jit.
“[It’s] not just what are called the traditional impacts, the immediate health impacts or the immediate impact on healthcare systems, but wider effects on public sector budgets, the macroeconomic impact on households protected from getting impoverished – parents are encouraged to invest more in the human capital development of their children as a result of knowing their children will grow up healthier, equity is promoted.”
One obvious example was the covid vaccine, he said, with analysis showing the impact vaccines had on allowing lockdowns to be relaxed and averting economic losses.
“The economic damage of lockdowns could be measured in hundreds of billions of pounds. This probably was one of the most valuable vaccines ever introduced in the UK,” said Professor Jit.
The consideration of this wider value of vaccines was useful even before their availability, in their development stage, he said.
The WHO’s investigation into the “full value” of the TB vaccine’s continuum included, but went beyond, the traditional analyses showing the vaccine would save lives and be cost effective, also looking at how they fought antimicrobial resistance, improved healthcare budgets, advanced health equity and promoted economic growth, he said.
3. The vaccine schedule is crowded.
There might be up to 30 diseases prevented by vaccines, up from six in the 1980s.
“This is a good thing. This is the success of vaccine science, but it also presents a challenge,” Professor Jit said.
He pointed out a couple of very practical considerations.
“We have a very limited number of limbs that we can poke the infant in, right? And the parents have a limit in the number of pokes they want the infant to have on a single visit!
“Vaccines slots are a bit like property. There are valuable locations and less valuable locations.
“A parking space in Hong Kong central costs about the same as a castle in the north of England. The difference all goes down to location, and it’s the same with slots in the vaccine schedule,” he said.
The four-month time slot was “a very prime location” but a slot after the age of two was more like the northern English castle, he said, because it was harder to get the child in at that time.
Work is being undertaken in this area, looking at the value of combination vaccines and reducing the pressure on those valuable four-month and six-month time slots.
“The economists would call that the opportunity costs. What are the benefits we get in terms of simplified delivery, or greater willingness by parents to bring their child in for vaccines because they know one vaccine can protect against many things, instead of having to come back very often? Can we get better coverage, better timeliness?”
Seeing the value could bring forth the development of new combination vaccines, he said.
“We need to make the case that the right vaccines are not a cost; ultimately, they are an investment because they bring better health, they build human capital, they actually improve economies across the world, protect us from some of the threats that we’re seeing, including security threats.
“We need to be able to explain how we use our health dollar.
“But we also need to be able to speak to other sectors besides the health sector and say we are advocates for these vaccines because they have all these other benefits.
“They ultimately build not just a healthier, but a wealthier and more secure society. Those are important narratives and analyses that we need to do.”
