Modeling the Cost of Vaccinating a Measles Zero-Dose Child in Zambia Using Three Vaccination Strategies.

Countries with moderate to high measles-containing vaccine coverage face challenges in reaching the remaining measles zero-dose children. There is growing interest in targeted vaccination activities to reach these children. We developed a framework for prioritizing districts for targeted measles and rubella supplementary immunization activities (SIAs) for Zambia in 2020, incorporating the use of the WHO's Measles Risk Assessment Tool (MRAT) and serosurveys. This framework was used to build a model comparing the cost of vaccinating one zero-dose child under three vaccination scenarios: standard nationwide SIA, targeted subnational SIA informed by MRAT, and targeted subnational SIA informed by both MRAT and measles seroprevalence data. In the last scenario, measles seroprevalence data are acquired via either a community-based serosurvey, residual blood samples from health facilities, or community-based IgG point-of-contact rapid diagnostic testing. The deterministic model found that the standard nationwide SIA is the least cost-efficient strategy at 13.75 USD per zero-dose child vaccinated. Targeted SIA informed by MRAT was the most cost-efficient at 7.63 USD per zero-dose child, assuming that routine immunization is just as effective as subnational SIA in reaching zero-dose children. Under similar conditions, a targeted subnational SIA informed by both MRAT and seroprevalence data resulted in 8.17-8.35 USD per zero-dose child vaccinated, suggesting that use of seroprevalence to inform SIA planning may not be as cost prohibitive as previously thought. Further refinement to the decision framework incorporating additional data may yield strategies to better target the zero-dose population in a financially feasible manner.

Equity in vaccine coverage in Uganda from 2000 to 2016: revealing the multifaceted nature of inequity.

BACKGROUND: This study analyses vaccine coverage and equity among children under five years of age in Uganda based on the 2016 Uganda Demographic and Health Survey (UDHS) dataset. Understanding equity in vaccine access and the determinants is crucial for the redress of emerging as well as persistent inequities. METHODS: Applied to the UDHS for 2000, 2006, 2011, and 2016, the Vaccine Economics Research for Sustainability and Equity (VERSE) Equity Toolkit provides a multivariate assessment of immunization coverage and equity by (1) ranking the sample population with a composite direct unfairness index, (2) generating quantitative measure of efficiency (coverage) and equity, and (3) decomposing inequity into its contributing factors. The direct unfairness ranking variable is the predicted vaccination coverage from a logistic model based upon fair and unfair sources of variation in vaccination coverage. Our fair source of variation is defined as the child's age - children too young to receive routine immunization are not expected to be vaccinated. Unfair sources of variation are the child's region of residence, and whether they live in an urban or rural area, the mother's education level, the household's socioeconomic status, the child's sex, and their insurance coverage status. For each unfair source of variation, we identify a "more privileged" situation. RESULTS: The coverage and equity of the Diphtheria-Pertussis-Tetanus vaccine, 3rd dose (DPT3) and the Measles-Containing Vaccine, 1st dose (MCV1) - two vaccines indicative of the health system's performance - improved significantly since 2000, from 49.7% to 76.8% and 67.8% to 82.7%, respectively, and there are fewer zero-dose children: from 8.4% to 2.2%. Improvements in retaining children in the program so that they complete the immunization schedule are more modest (from 38.1% to 40.8%). Progress in coverage was pro-poor, with concentration indices (wealth only) moving from 0.127 (DPT3) and 0.123 (MCV1) in 2000 to -0.042 and -0.029 in 2016. Gains in overall equity (composite) were more modest, albeit significant for most vaccines except for MCV1: concentration indices of 0.150 (DPT3) and 0.087 (MCV1) in 2000 and 0.054 and 0.055 in 2016. The influence of the region and settings (urban/rural) of residence significantly decreased since 2000. CONCLUSION: The past two decades have seen significant improvements in vaccine coverage and equity, thanks to the efforts to strengthen routine immunization and ongoing supplemental immunization activities such as the Family Health Days. While maintaining the regular provision of vaccines to all regions, efforts should be made to alleviate the impact of low maternal education and literacy on vaccination uptake.

An Estimate Of The Return On Investment Of A Malaria Vaccine In 20 Sub-Saharan African Countries, 2021-30.

Malaria is a leading global health problem that was responsible for an estimated 619,000 deaths worldwide in 2021. We modeled the return on investment (ROI) for the introduction and continuation of a four-dose malaria vaccine, RTS,S/AS01, from 2021 to 2030 in twenty sub-Saharan African countries supported by Gavi, the Vaccine Alliance. We used the Decade of Vaccine Economics benefits and costing outputs to calculate an ROI using health impact data modeled by the Swiss Tropical and Public Health Institute (hereafter "Swiss") and Imperial College London (hereafter "Imperial"). The Swiss estimates with a base vaccine price of US$7.00 resulted in an ROI of 0.42, and the Imperial impact estimates with the same base vaccine price resulted in an ROI of 2.30. Inclusion of the fifth seasonal dose for ten countries exhibiting high seasonal disease burden increased the Swiss ROI by 143 percent, to 1.02, and the Imperial ROI by 23.5 percent, to 2.84. To improve ROI, decision makers should continue to improve delivery platforms, decrease vaccine delivery costs, deliver the malaria vaccine in fewer doses, and provide access to vaccine resources.

Multivariate Assessment of Vaccine Equity in Cambodia: A Longitudinal VERSE Tool Case Study Using Demographic and Health Survey 2004, 2010, and 2014.

Cambodia has exhibited great progress in achieving high coverage in nationally recommended immunizations. As vaccination program managers plan interventions to reach last-mile children, it is important to consider issues of equity immunization priority setting. In this analysis, we apply the VERSE Equity Tool to Cambodia's Demographic and Health Survey for the years 2004, 2010, and 2014 to evaluate multivariate equity in vaccine coverage for 11 vaccination statuses, emphasizing the results of the 2014 survey for MCV1, DTP3, fully immunized for age (FULL), and zero dose (ZERO). The largest drivers of vaccination inequity are socioeconomic status and the educational attainment of the child's mother. MCV1, DTP3, and FULL exhibit increasing levels of both coverage and equity with increasing survey years. The national composite Wagstaff concentration index values from the 2014 survey for DTP3, MCV1, ZERO, and FULL are 0.089, 0.068, 0.573, and 0.087, respectively. The difference in vaccination status coverage between the most and least advantaged quintiles of Cambodia's population, using multivariate ranking criteria, is 23.5% for DTP3, 19.5% for MCV1, 9.1% for ZERO, and 30.3% for FULL. By utilizing these VERSE Equity Tool outputs, immunization program leaders in Cambodia can identify subnational regions in need of targeted interventions.

Multivariate assessment of vaccine equity in Nigeria: A VERSE tool case study using demographic and health survey 2018.

Nigeria experiences wide heterogeneity in vaccination rates by vaccine and region. However, inequities in vaccination status extend beyond just geographic covariates. Traditionally, inequity is represented by a single metric pertaining to socioeconomic status. A growing body of literature suggests that this view is limiting, and a multi-factor approach is necessary to comprehensively evaluate relative disadvantage between individuals. The Vaccine Economics Research for Sustainability and Equity (VERSE) tool produces a composite equity metric, which accounts for multiple factors influencing inequity in vaccination coverage. We apply the VERSE tool to Nigeria's 2018 Demographic and Health Survey (DHS) to cross-sectionally evaluate equity in vaccination status for national immunization program (NIP) vaccines over the following contributing covariates: age of child, sex of child, maternal education level, socioeconomic status, health insurance status, state of residence, and urban or rural designation. We also assess equity for zero-dose, fully immunized for age, and completion of NIP. Results show that socioeconomic status contributes substantially to variation vaccination coverage, but it is not the most substantial factor. For all vaccination statuses, except for NIP completion, maternal education level is the greatest contributor towards a child's immunization status among model variables. We highlight the outputs for zero-dose, fully immunized at infancy, MCV1 and PENTA1. The percentage point gap in vaccination status between the top and bottom quintiles of disadvantage, as ranked by the composite indicator is 31.1 (29.5-32.7) for zero-dose status, 53.1 (51.3-54.9) for full immunization status, 48.9 (46.9-50.9) for MCV1, and 67.6 (66.0-69.2) for PENTA1. Though concentration indices indicate inequity for all statuses, full immunization coverage is very low at 31.5% suggesting significant gaps in reaching children after initial doses for routine immunizations. Applying the VERSE tool to future Nigeria DHS surveys can allow decisionmakers to track changes in vaccination coverage equity, in a standardized manner, over time.

Comparing Multivariate with Wealth-Based Inequity in Vaccination Coverage in 56 Countries: Toward a Better Measure of Equity in Vaccination Coverage.

INTRODUCTION: Following a call from the World Health Organization in 2017 for a methodology to monitor immunization coverage equity in line with the 2030 Agenda for Sustainable Development, this study applies the Vaccine Economics Research for Sustainability and Equity (VERSE) vaccination equity toolkit to measure national-level inequity in immunization coverage using a multidimensional ranking procedure and compares this with traditional wealth-quintile based ranking methods for assessing inequity. The analysis covers 56 countries with a most recent Demographic & Health Survey (DHS) between 2010 and 2022. The vaccines examined include Bacillus Calmette-Guerin (BCG), Diphtheria-Tetanus-Pertussis-containing vaccine doses 1 through 3 (DTP1-3), polio vaccine doses 1-3 (Polio1-3), the measles-containing vaccine first dose (MCV1), and an indicator for being fully immunized for age with each of these vaccines. MATERIALS & METHODS: The VERSE equity toolkit is applied to 56 DHS surveys to rank individuals by multiple disadvantages in vaccination coverage, incorporating place of residence (urban/rural), geographic region, maternal education, household wealth, sex of the child, and health insurance coverage. This rank is used to estimate a concentration index and absolute equity coverage gap (AEG) between the top and bottom quintiles, ranked by multiple disadvantages. The multivariate concentration index and AEG are then compared with traditional concentration index and AEG measures, which use household wealth as the sole criterion for ranking individuals and determining quintiles. RESULTS: We find significant differences between the two sets of measures in almost all settings. For fully-immunized for age status, the inequities captured using the multivariate metric are between 32% and 324% larger than what would be captured examining inequities using traditional metrics. This results in a missed coverage gap of between 1.1 and 46.4 percentage points between the most and least advantaged. CONCLUSIONS: The VERSE equity toolkit demonstrated that wealth-based inequity measures systematically underestimate the gap between the most and least advantaged in fully-immunized for age coverage, correlated with maternal education, geography, and sex by 1.1-46.4 percentage points, globally. Closing the coverage gap between the bottom and top wealth quintiles is unlikely to eliminate persistent socio-demographic inequities in either coverage or access to vaccines. The results suggest that pro-poor interventions and programs utilizing needs-based targeting, which reflects poverty only, should expand their targeting criteria to include other dimensions to reduce systemic inequalities, holistically. Additionally, a multivariate metric should be considered when setting targets and measuring progress toward reducing inequities in healthcare coverage.

Financing And Funding Gap For 16 Vaccines Across 94 Low- And Middle-Income Countries, 2011-30.

We estimated immunization program costs, financing, and funding gaps for sixteen vaccines among ninety-four low- and middle-income countries during the period 2011-30. Inputs were obtained from the Institute for Health Metrics and Evaluation, the 2020 Decade of Vaccine Economics costing analysis, the World Health Organization, Gavi, and the United Nations Children's Fund. We found a total funding gap of $38.4 billion between 2011 and 2030, with the cost of immunization delivery being the main driver (86 percent) of the funding gap. On average, government financing of vaccination programs steadily rises throughout the period. However, the decline in both Gavi and development assistance for health (DAH) financing anticipated between 2011 and 2030 outpaces the forecasted increases in domestic government immunization spending. Probabilistic sensitivity analysis was applied to both the costing and the scenario analyses to address uncertainty in the financing of vaccines and vaccine delivery. The results highlight a narrowing gap for vaccine acquisition but a growing gap for vaccine delivery, which emphasizes the critical need for resource mobilization and sustainable financial strategies for immunization programs at national and global levels, as well as a need to address the COVID-19 pandemic's potential effects on government financing for vaccines between 2021 and 2030.

Coverage and Equity of Childhood Vaccines in China.

Importance: Measuring vaccination coverage rates and equity is crucial for informing immunization policies in China. Objectives: To estimate coverage rates and multidimensional equity for childhood vaccination in China. Design, Setting, and Participants: This cross-sectional study was conducted via a survey in 10 Chinese provinces between August 5 and October 16, 2019, among children ages 6 months to 5 years and their primary caregivers. Children's vaccination records and their primary caregivers' demographics and socioeconomic status were collected. Data were analyzed from November 2019 to March 2022. Main Outcomes and Measures: Vaccine coverage rates were measured as a percentage of National Immunization Program (NIP) and non-NIP vaccines administered before the day on which the child was surveyed. A multidimensional equity model applied a standardized approach to ranking individuals from least to most unfairly disadvantaged by estimating differences between observed vaccination status and estimated vaccination status as function of fair and unfair variation. Fair sources of variation in coverage included whether the child was of age to receive the vaccine, and unfair sources of variation included sex of the child and sociodemographic characteristics of caregivers. Absolute equity gaps (AEGs), concentration index values, and decompositions of factors associated with vaccine equity were estimated in the model. Results: Vaccine records and sociodemographic information of 5294 children (2976 [52.8%] boys and 2498 [47.2%] girls; age range, 6-59 months; 1547 children aged 12-23 months) and their primary caregivers were collected from 10 provinces. Fully immunized coverage under the NIP was 83.1% (95% CI, 82.0%-84.1%) at the national level and more than 80% in 7 provinces (province coverage ranged from 77.8% [95% CI, 74.3% to 81.3%] in Jiangxi to 88.4% [95% CI, 85.7%-91.1%] in Beijing). For most non-NIP vaccines, however, coverage rates were less than 50%, ranging from 1.8% (95% CI, 1.3%-2.2%) for the third dose of rotavirus vaccine to 67.1% (65.4% to 68.8%) for the first dose of the varicella vaccine. The first dose of Haemophilus influenzae type b vaccine had the largest AEG, at 0.603 (95% CI, 0.570-0.636), and rotavirus vaccine dose 3 had the largest concentration index value, at 0.769 (95% CI, 0.709-0.829). The largest share of non-NIP vaccine inequity was contributed by monthly family income per capita, followed by education level, place of residence, and province for caregivers. For example, the proportion of explained inequity for pneumococcal conjugate vaccine dose 3 was 40.94% (95% CI, 39.49%-42.39%), 22.67% (95% CI, 21.43%-23.9%), 27.15% (95% CI, 25.84%-28.46%), and 0.68% (95% CI, 0.44%-0.92%) for these factors, respectively. Conclusions and Relevance: This cross-sectional study found that NIP vaccination coverage in China was high but there was inequity for non-NIP vaccines. These findings suggest that improvements in equitable coverage of non-NIP vaccination may be urgently needed to meet national immunization goals.

COVAX and equitable access to COVID-19 vaccines.

Objective: To evaluate equity in the allocation and distribution of vaccines for coronavirus disease 2019 (COVID-19) to countries and territories participating in the COVID-19 Vaccines Global Access (COVAX) Facility. Methods: We used publicly available data on the numbers of COVAX vaccine doses allocated and distributed to 88 countries and territories qualifying for COVAX-sponsored vaccine doses and 60 countries self-financing their vaccine doses facilitated by COVAX. We conducted a benefit-incident analysis to examine the allocation and distribution of vaccines based on countries' gross domestic product (GDP) per capita. We plotted cumulative country-level per capita allocation and distribution of COVID-19 vaccines from COVAX against the ranked per capita GDP of the countries and territories to generate a measure of the equity of COVAX benefits. Findings: By 23 January 2022 the COVAX Facility had allocated a total of 1 678 517 990 COVID-19 vaccine doses, of which 1 028 291 430 (61%) doses were distributed to 148 countries and territories. Taking account of COVAX subsidies, we found that countries and territories with low per capita GDP benefited more than higher-income countries in the numbers of vaccines. The benefits increased further when the analysis was adjusted by population age group (aged 65 years and older). Conclusion: The COVAX Facility is helping to balance global inequities in the allocation and distribution of COVID-19 vaccines. However, COVAX alone has not been enough to reverse the inequality of total COVID-19 vaccine distribution. Future studies could examine the equity of all COVID-19 vaccine allocation and distribution beyond the COVAX-facilitated vaccines.

A standardized approach for measuring multivariate equity in vaccination coverage, cost-of-illness, and health outcomes: Evidence from the Vaccine Economics Research for Sustainability & Equity (VERSE) project.

Following a call from the World Health Organization in 2017 for a methodology to monitor immunization coverage equity in line with the 2030 Agenda for Sustainable Development, this study outlines a standardized approach for measuring multivariate equity in vaccine coverage, economic impact, and health outcomes. The Vaccine Economics Research for Sustainability & Equity (VERSE) composite vaccination equity measurement approach is derived from literature on the measurement of socioeconomic inequality combined with measures of direct unfairness in healthcare access. The final metrics take the form of a concentration index for vaccination coverage where individuals are ranked by multivariate unfairness in access and an absolute equity gap representing the difference in coverage between the top and bottom quintiles of individuals ranked by multivariate unfairness in access. Regression decomposition is applied to the concentration index to determine each factor's relative influence on observed inequity. These methods are applied to India's National Family Health Survey (NFHS) from 2015 to 2016 to assess the equity in being fully-immunized for age vaccination coverage and zero-dose status. The multivariate absolute equity gap is 0.120 (SE: 003) and 0.371 (SE: 0.008) for zero-dose status and fully-immunized for age, respectively. Therefore, the most disadvantaged quintile is 12 percentage points more likely to be zero-dose than the most advantaged quintile and 37.1 percentage points less likely to be fully immunized. The primary correlate of unfair disadvantage for both outcomes is maternal education accounting for 27.4% and 19.1% of observed inequality. The VERSE model provides a standardized approach for measuring multivariate vaccine coverage equity. It also allows policymakers to determine the relative magnitude of factors influencing multivariate equity rather than only the correlates of socioeconomic or bivariate equity. This framework could be adapted to track equitable progress toward Universal Health Coverage (UHC) or outcomes beyond the vaccine space.

Acupuncture for Poststroke Dysphagia: A Pilot, Nonrandomized, Self-Controlled Trial.

OBJECTIVE: To evaluate the effectiveness and safety of acupuncture treatment for dysphagia as a complication of stroke. Methods and Design. This is a multicenter, pragmatic, nonrandomized, self-controlled clinical trial. A total of 39 patients were recruited from several Chinese medicine outpatient clinics and hospital-affiliated speech therapy outpatient clinics in Hong Kong. 26 patients completed all the 24 sessions of acupuncture treatment within two months, and only 12 of them were used as self-control. For the self-control group, the retrospective clinical data was taken from the electronic patient records with patient consent. The descriptive swallowing function data were converted into the quantitative Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS) scores by two registered speech therapists through a validation process. And the data were validated by reaching consensus between the two speech therapists. All subjects underwent a baseline assessment before commencement of treatment, and outcome assessments were conducted upon the completion of treatment. The primary outcome measure is the RBHOMS score, which is a swallowing disability rating scale for monitoring difficulties in daily swallowing function. Secondary outcome measures include the Chinese version of the Swallow Quality-of-Life Questionnaire and adverse events. All the primary and secondary outcomes were assessed at baseline as well as at the end of acupuncture treatment (month 2). RESULTS: A total of 39 participants aged 46 to 89 years were enrolled in the study, and the male-to-female ratio was 15 : 11. The mean baseline RBHOMS score of all 39 participants was 5.92 ± 2.23. The mean retrospective RBHOMS score of the 12 subjects who were used as self-control was 5.67 ± 1.72 before enrollment, while the mean RBHOMS score of the 26 participants who completed all the 24 sessions of treatment was 6.92 ± 2.07. There were statistically significant differences between the RBHOMS score at the completion of treatment and baseline (p=0.006), and retrospective data (p=0.042). Moreover, a significant difference was also found in terms of swallow quality-of-life score before and after acupuncture treatment (p < 0.01). CONCLUSIONS: This pilot study provides preliminary evidence for the effectiveness of acupuncture for poststroke dysphagia. The findings from this trial can be used as a foundation for future full-scale randomized controlled clinical trials to assess the efficacy and safety of acupuncture for poststroke dysphagia. Ethics and Dissemination. The ethical approval of the clinical research study was granted by the Research Ethics Committee of both New Territories East and West Cluster of Hong Kong. Written informed consent was obtained from all participants, and the study was undertaken according to the ICH-GCP Guidelines. Trial Registration. This trial is registered with ChiCTR-TRC-12002621 and the registration date is 2012-10-26.