A cost comparison of introducing and delivering pneumococcal, rotavirus and human papillomavirus vaccines in Rwanda.

BACKGROUND: Detailed cost evaluations of delivery of new vaccines such as pneumococcal conjugate, human papillomavirus (HPV), and rotavirus vaccines in low and middle-income countries are scarce. This paper differs from others by comparing the costs of introducing multiple vaccines in a single country and then assessing the financial and economic impact at the time and implications for the future. The objective of the analysis was to understand the introduction and delivery cost per dose or per child of the three new vaccines in Rwanda to inform domestic and external financial resource mobilization. METHODS: Start-up, recurrent, and capital costs from a government perspective were collected in 2012. Since pneumococcal conjugate and HPV vaccines had already been introduced, cost data for those vaccines were collected retrospectively while prospective (projected) costing was done for rotavirus vaccine. RESULTS: The financial unit cost per fully immunized child (or girl for HPV vaccine) of delivering 3 doses of each vaccine (without costs related to vaccine procurement) was $0.37 for rotavirus (RotaTeq(®)) vaccine, $0.54 for pneumococcal (Prevnar(®)) vaccine in pre-filled syringes, and $10.23 for HPV (Gardasil (®)) vaccine. The financial delivery costs of Prevnar(®) and RotaTeq(®) were similar since both were delivered using existing health system infrastructure to deliver infant vaccines at health centers. The total financial cost of delivering Gardasil(®) was higher than those of the two infant vaccines due to greater resource requirements associated with creating a new vaccine delivery system in for a new target population of 12-year-old girls who have not previously been served by the existing routine infant immunization program. CONCLUSION: The analysis indicates that service delivery strategies have an important influence on costs of introducing new vaccines and costs per girl reached with HPV vaccine are higher than the other two vaccines because of its delivery strategy. Documented information on financial commitments for new vaccines, particularly from government sources, is a useful input into country policy dialogue on sustainable financing and co-financing of new vaccines, as well as for policy decisions by donors such as Gavi, the Vaccine Alliance.

Human Papillomavirus Vaccination Coverage Among School Girls in a Demonstration Project - Botswana, 2013.

What is already known on this topic? Human papillomavirus (HPV) infection is common and aggressive in persons infected with human immunodeficiency virus (HIV). With an HIV prevalence of 28% among females aged 15­49, cervical cancer is the leading cause of cancer death among women in Botswana. Before 2013, HPV vaccine had not been used in the public sector in Botswana.What is added by this report? Efforts to expand services for cervical cancer through the Pink Ribbon Red Ribbon initiative focused on HPV-related disease in Botswana. A demonstration project for HPV vaccination was developed by the Ministry of Health for school girls aged ≥9 years in primary schools in one community. A total of 1,967 (79%) of 2,488 eligible girls received 3 doses of vaccine in the immunization effort that was centered in schools.What are the implications for public health practice? Preventing HPV infection in girls is an important component of a national comprehensive cervical cancer control program. HPV vaccination programming is challenging, and demonstration projects can prepare countries for national introduction. The success of the initial HPV vaccination effort in Botswana led to an expanded project in 2014, with implementation of nationwide rollout of the HPV vaccine in 2015. It might be beneficial for future HPV vaccination campaigns to include strategies to reach out-of-school girls.

Preparing for human papillomavirus vaccine introduction in Kenya: implications from focus-group and interview discussions with caregivers and opinion leaders in Western Kenya.

BACKGROUND: Cervical cancer claims the lives of 275,000 women each year; most of these deaths occur in low-or middle-income countries. In Kenya, cervical cancer is the leading cause of cancer-related mortality among women of reproductive age. Kenya's Ministry of Public Health and Sanitation has developed a comprehensive strategy to prevent cervical cancer, which includes plans for vaccinating preteen girls against human papillomavirus (HPV) by 2015. To identify HPV vaccine communication and mobilization needs, this research sought to understand HPV vaccine-related perceptions and concerns of male and female caregivers and community leaders in four rural communities of western Kenya. METHODS: We conducted five focus groups with caregivers (n = 56) and 12 key-informant interviews with opinion leaders to explore cervical cancer-related knowledge, attitudes and beliefs, as well as acceptability of HPV vaccination for 9-12 year-old girls. Four researchers independently reviewed the data and developed codes based on questions in interview guides and topics that emerged organically, before comparing and reconciling results through a group consensus process. RESULTS: Cervical cancer was not commonly recognized, though it was understood generally in terms of its symptoms. By association with cancer and genital/reproductive organs, cervical cancer was feared and stigmatized. Overall acceptability of a vaccine that prevents cervical cancer was high, so long as it was endorsed by trusted agencies and communities were sensitized first. Some concerns emerged related to vaccine safety (e.g., impact on fertility), program intent, and health equity. CONCLUSION: For successful vaccine introduction in Kenya, there is a need for communication and mobilization efforts to raise cervical cancer awareness; prompt demand for vaccination; address health equity concerns and stigma; and minimize potential resistance. Visible endorsement by government leaders and community influencers can provide reassurance of the vaccine's safety, efficacy and benefits for girls and communities. Involvement of community leadership, parents and champions may also be critical for combatting stigma and making cervical cancer relevant to Kenyan communities. These findings underscore the need for adequate planning and resources for information, education and communication prior to vaccine introduction. Specific recommendations for communication and social-marketing strategies are made.

Costs of introducing and delivering HPV vaccines in low and lower middle income countries: inputs for GAVI policy on introduction grant support to countries.

BACKGROUND: In November 2011, the GAVI Alliance made the decision to add HPV vaccine as one of the new vaccines for which countries eligible for its funding (less than $1520 per capita income) could apply to receive support for national HPV vaccination, provided they could demonstrate the ability to deliver HPV vaccines. This paper describes the data and analysis shared with GAVI policymakers for this decision regarding GAVI HPV vaccine support. The paper reviews why strategies and costs for HPV vaccine delivery are different from other vaccines and what is known about the cost components from available data that originated primarily from HPV vaccine delivery costing studies in low and middle income-countries. METHODS: Financial costs of HPV vaccine delivery were compared across three sources of data: 1) vaccine delivery costing of pilot projects in five low and lower-middle income countries; 2) cost estimates of national HPV vaccination in two low income countries; and 3) actual expenditure data from national HPV vaccine introduction in a low income country. Both costs of resources required to introduce the vaccine (or initial one-time investment, such as cold chain equipment purchases) and recurrent (ongoing costs that repeat every year) costs, such as transport and health personnel time, were analyzed. The cost per dose, cost per fully immunized girl (FIG) and cost per eligible girl were compared across studies. RESULTS: Costs varied among pilot projects and estimates of national programs due to differences in scale and service delivery strategy. The average introduction costs per fully immunized girl ranged from $1.49 to $18.94 while recurrent costs per girl ranged from $1.00 to $15.69, with both types of costs varying by delivery strategy and country. Evaluating delivery costs along programme characteristics as well as country characteristics (population density, income/cost level, existing service delivery infrastructure) are likely the most informative and useful for anticipating costs for HPV vaccine delivery. CONCLUSIONS: This paper demonstrates the importance of country level cost data to inform global donor policies for vaccine introduction support. Such data are also valuable for informing national decisions on HPV vaccine introduction.

Factors associated with human immunodeficiency virus screening of women during pregnancy, labor and delivery, United States, 2005-2006.

The purpose of this study was to estimate prenatal human immunodeficiency virus (HIV) screening rates prior to and on admission to labor and delivery (L&D) and to examine factors associated with HIV screening, including hospital policies, with a comparison of HIV and hepatitis B prenatal screening practices and hospital policies. In March 2006, a survey of hospitals (n = 190) and review of paired maternal and infant medical records (n = 4,762) were conducted in 50 US states, DC, and Puerto Rico. Data from the survey and medical record review were analyzed using SAS software v9.2 (SAS Institute, Cary, NC). HIV testing before delivery occurred among 3,438 women (73.9%); African American and Hispanic women were more likely to be tested than white women [aOR 2.22, 95% CI (1.6-3.1) and aOR 1.55, 95% CI (1.1-2.2), respectively]. Among women without previous HIV testing, 138 (16.6%) were tested after admission to labor and delivery. Policies to test women with undocumented HIV status in at delivery were present in 65 (36.3%) hospitals. HIV testing after admission to L&D was more likely in hospitals with policies to test women with undocumented HIV status [aOR 5.91, 95% CI (2.0-17.8)]. Overall, policies and screening practices for HIV were consistently less prevalent than those for hepatitis B. Many women are not being routinely screened for HIV before or at delivery. Women with unknown HIV status were more likely to be tested in L&D in hospitals with testing policies.

Human papillomavirus vaccine introduction--the first five years.

The availability of prophylactic human papillomavirus (HPV) vaccines has provided powerful tools for primary prevention of cervical cancer and other HPV-associated diseases. Since 2006, the quadrivalent and bivalent vaccines have each been licensed in over 100 countries. By the beginning of 2012, HPV vaccine had been introduced into national immunization programs in at least 40 countries. Australia, the United Kingdom, the United States, and Canada were among the first countries to introduce HPV vaccination. In Europe, the number of countries having introduced vaccine increased from 3 in 2007 to 22 at the beginning of 2012. While all country programs target young adolescent girls, specific target age groups vary as do catch-up recommendations. Different health care systems and infrastructure have resulted in varied implementation strategies, with some countries delivering vaccine in schools and others through health centers or primary care providers. Within the first 5 years after vaccines became available, few low- or middle-income countries had introduced HPV vaccine. The main reason was budgetary constraints due to the high vaccine cost. Bhutan and Rwanda implemented national immunization after receiving vaccine through donation programs in 2010 and 2011, respectively. The GAVI Alliance decision in 2011 to support HPV vaccination should increase implementation in low-income countries. Evaluation of vaccination programs includes monitoring of coverage, safety, and impact. Vaccine safety monitoring is part of routine activities in many countries. Safety evaluations are important and communication about vaccine safety is critical, as events temporally associated with vaccination can be falsely attributed to vaccination. Anti-vaccination efforts, in part related to concerns about safety, have been mounted in several countries. In the 5 years since HPV vaccines were licensed, there have been successes as well as challenges with vaccine introduction and implementation. Further progress is anticipated in the coming years, especially in low- and middle-income countries where the need for vaccine is greatest. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Recommendations for identification and public health management of persons with chronic hepatitis B virus infection.

Serologic testing for hepatitis B surface antigen (HBsAg) is the primary way to identify persons with chronic hepatitis B virus (HBV) infection. Testing has been recommended previously for pregnant women, infants born to HBsAg-positive mothers, household contacts and sex partners of HBV-infected persons, persons born in countries with HBsAg prevalence of >/=8%, persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (e.g., needlestick injury to a health-care worker or sexual assault), and persons infected with human immunodeficiency virus. This report updates and expands previous CDC guidelines for HBsAg testing and includes new recommendations for public health evaluation and management for chronically infected persons and their contacts. Routine testing for HBsAg now is recommended for additional populations with HBsAg prevalence of >/=2%: persons born in geographic regions with HBsAg prevalence of >/=2%, men who have sex with men, and injection-drug users. Implementation of these recommendations will require expertise and resources to integrate HBsAg screening in prevention and care settings serving populations recommended for HBsAg testing. This report is intended to serve as a resource for public health officials, organizations, and health-care professionals involved in the development, delivery, and evaluation of prevention and clinical services.