The potential cost-effectiveness of HPV vaccination among girls in Mongolia.

Introduction: Cervical cancer is a leading cause of cancer among women in Mongolia with an age-standardized incidence rate of 23.5 per 100,000. HPV vaccination has not been introduced nationally and Gavi co-financing support is not available in Mongolia. Extended Gavi pricing for HPV vaccine may be available from vaccine manufacturers for a number of years. To inform introduction decision-making, we evaluated the potential cost-effectiveness of HPV vaccination among girls and young women in Mongolia. Methods: We used UNIVAC (version 1.4), a static decision model, to evaluate the health and economic outcomes of single-cohort vaccination among females from the government perspective compared to no vaccination. We modeled vaccine introduction over 10 birth cohorts starting in 2022 comparing quadrivalent or bivalent vaccine selection and vaccine pricing variations. We used locally-specific data for cancer incidence, mortality, treatment and costs. Model outcomes included cancer cases, hospitalizations, deaths, disability-adjusted life years (DALY), and costs presented in 2018 USD. Incremental costs and health outcomes were discounted at 3% and aggregated into an Incremental Cost-Effectiveness Ratio (ICER). Results: The base-case scenario of HPV vaccination among 9 year-old girls was projected to avert 5,692 cervical cancer cases, 3,240 deaths, and 11,886 DALYs and incur $2.4-3.1M more costs compared to no vaccination. At prices of ($4.50-$4.60/dose), we estimated an ICER of $166-$265/DALY averted among 9-year-olds. When price per dose was increased to reported mean vaccine purchase price for non-Gavi LMICs ($14.17/dose), the ICER ranged from $556-820/DALY averted. Conclusion: HPV vaccination among girls is highly likely to be a cost-effective investment in Mongolia compared to no vaccination with projected ICERs less than 20% of the 2018 GDP per capita of $3,735.

Cost-effectiveness of 13-valent pneumococcal conjugate vaccination in Mongolia.

OBJECTIVE: The Ministry of Health (MOH), Mongolia, is considering introducing 13-valent pneumococcal conjugate vaccine (PCV13) in its national immunization programme to prevent the burden of disease caused by Streptococcus pneumoniae. This study evaluates the cost-effectiveness and budget impact of introducing PCV13 compared to no PCV vaccination in Mongolia. METHODS: The incremental cost-effectiveness ratio (ICER) of introducing PCV13 compared to no PCV vaccination was assessed using an age-stratified static multiple cohort model. The risk of various clinical presentations of pneumococcal disease (meningitis, pneumonia, non-meningitis non-pneumonia invasive pneumococcal disease and acute otitis media) at all ages for thirty birth cohorts was assessed. The analysis considered both health system and societal perspectives. A 3+0 vaccine schedule and price of US$3.30 per dose was assumed for the baseline scenario based on Gavi, the Vaccine Alliance's advance market commitment tail price. RESULTS: The ICER of PCV13 introduction is estimated at US$52 per disability-adjusted life year (DALY) averted (health system perspective), and cost-saving (societal perspective). Although indirect effects of PCV have been well-documented, a conservative scenario that does not consider indirect effects estimated PCV13 introduction to cost US$79 per DALY averted (health system perspective), and US$19 per DALY averted (societal perspective). Vaccination with PCV13 is expected to cost around US$920,000 in 2016, and thereafter US$820,000 every year. The programme is likely to reduce direct disease-related costs to MOH by US$440,000 in the first year, increasing to US$510,000 by 2025. CONCLUSION: Introducing PCV13 as part of Mongolia's national programme appears to be highly cost-effective when compared to no vaccination and cost-saving from a societal perspective at vaccine purchase prices offered through Gavi. Notwithstanding uncertainties around some parameters, cost-effectiveness of PCV introduction for Mongolia remains robust over a range of conservative scenarios. Availability of high-quality national data would improve future economic analyses for vaccine introduction.

The influence of season and living environment on children's urinary 1-hydroxypyrene levels in Ulaanbaatar, Mongolia.

BACKGROUND: Heating indoor living environments elevates air pollution in Ulaanbaatar, Mongolia. OBJECTIVE: This study was conducted to investigate the influence of season and living environment on children's urinary 1-hydroxypyrene (1-OHP) levels in Ulaanbaatar, Mongolia. METHODS: Our study subjects were 320 children aged 11-15 years living in gers, brick houses and apartments, in ger and non-ger areas of Ulaanbaatar. Spot urine samples and questionnaires were collected three times from each subject in three seasons, September (warm) and December (cold) in 2011 and March (moderate) in 2012. Urinary 1-OHP was analyzed by high-performance liquid chromatography with fluorescent detection (HPLC/FLD). Generalized estimating equation (GEE) models were applied to estimate the seasonal and residential effects on 1-OHP levels, adjusting for demographic and environmental factors. RESULTS: Children's urinary 1-OHP levels showed significant seasonal differences with 0.30 ± 0.57 µmol/mol creatinine in cold season, 0.14 ± 0.12 µmol/mol creatinine in moderate season, and 0.14 ± 0.21 µmol/mol creatinine in warm season. After controlling confounding factors, the GEE model showed that season, living area, and housing type had significant influence on children's urinary 1-OHP levels. Urinary 1-OHP levels in the cold and moderate seasons were, respectively 2.13 and 1.37 times higher than the warm season. Urinary 1-OHP levels for children living in ger areas were 1.27 times higher than those living in non-ger areas. Children who lived in gers or brick houses had 1.58 and 1.34 times higher 1-OHP levels, respectively, compared with those living in apartments. Children's urinary 1-OHP levels were associated with either estimated NO2 or SO2 concentrations at their home addresses in Ulaanbaatar. CONCLUSION: Mongolian children's urinary 1-OHP levels were significantly elevated during the cold season, and for those living in ger areas, gers, or brick houses in Ulaanbaatar. Children's urinary 1-OHP levels were associated PAH co-pollutants SO2 and NO2, suggesting elevated 1-OHP levels may be attributable to PAH emissions from coal burning and traffic respectively, with indoor emissions from stoves further contributing to elevated 1-OHP in some children.

Land use patterns and SO2 and NO2 pollution in Ulaanbaatar, Mongolia.

We proposed to study spatial distribution and source contribution of SO2 and NO2 pollution in Ulaanbaatar, Mongolia. We collected 2-week ambient SO2 and NO2 concentration samples at 38 sites, which were classified by major sources of air pollution such as ger areas and/or major roads, in three seasons as warm (September, 2011), cold (November-December, 2011), and moderate (March, 2012) in Ulaanbaatar. The SO2 and NO2 concentrations were collected by Ogawa ambient air passive samplers and analyzed by ion chromatography and spectrophotometry methods, respectively. Stepwise regression models were used to estimate the contribution of emission proxies, such as the distance to major roads, ger areas, power plants, and city center, to the ambient concentrations of SO2 and NO2. We found that the SO2 and NO2 concentrations were significantly higher in the cold season than in the warm and moderate seasons at all 38 ambient sampling sites. The SO2 concentrations in 20 ger sites (46.60 ppb in the cold season and 17.82 ppb in the moderate season) were significantly higher than in 18 non-ger sites (23.35 ppb in the cold season and 12.53 ppb in the moderate season). The NO2 concentrations at 19 traffic/road sites (12.85 ppb in the warm season and 20.48 ppb in the moderate season) were significantly higher than those at 19 urban sites (7.60 ppb and 14.39 ppb in the moderate season). Multiple regression models show that SO2 concentrations decreased by 23% in the cold and 17% in the moderate seasons at 0.70 km from the ger areas, an average of all sampling sites, and by 29% in the moderate season at 4.83 km from the city center, an average of all sampling sites. Multiple regression models show that the NO2 concentrations at 4.83 km from the city center decreased by 38% in the warm and 29% in the moderate seasons. Our models also report that NO2 concentrations at 0.16 km from the main roads decreased by 15% and 9% in the warm and the moderate seasons, respectively, and by 16% in the cold season decreased at the location 0.70 km from the ger area. The NO2 concentration at the location 4.83 km from the city center was decreased by 18% and at the location 4.79 km from the power plants by 21%. Our study concludes that SO2 and NO2 concentrations are very high in Ulaanbaatar, especially in the winter, and can be explained by several land use variables, including the distance to the ger areas, the city center, the main roads, and the power plants.