Adolescent HPV vaccination: empowerment, equity and ethics.

Despite the great promise offered by human papillomavirus (HPV) vaccines to reduce disease burden and promote socioeconomic and gender equality, their implementation into national programmes has been slow. The vaccination of adolescents against a disease that may have serious consequences much later in life requires special consideration to the principles and processes of informed consent. Accumulating experiences from implementations in many countries indicate a need to examine ethical considerations related to adolescent vaccination. However, frameworks that integrate legal, development- and rights-based considerations in adolescent vaccination policies, while taking into account practical realities of HPV vaccination programmes, are currently lacking. We argue that principles of autonomy, social justice and gender equality have impacts on adolescent immunization that go beyond mere acceptance of vaccination and place greater demands on what constitutes meaningful informed consent, with implications for the provision of age- and context-appropriate information, vaccine financing and gender-based vaccination policies. Independent of cost-effectiveness considerations, we find a strong case to support universal HPV vaccination of girls that is free at the point of use and, where feasible, to extend vaccination to boys under the same financing schemes. ABBREVIATIONS: HPV: Human papillomavirus; STI: Sexually transmitted infections; WHO: World Health Organization.

Effect and cost-effectiveness of pneumococcal conjugate vaccination: a global modelling analysis.

BACKGROUND: Introduction of pneumococcal conjugate vaccines (PCVs) has substantially reduced disease burden due to Streptococcus pneumoniae, a leading cause of childhood morbidity and mortality globally. However, PCVs are among the most expensive vaccines, hindering their introduction in some settings and threatening sustainability in others. We aimed to assess the effect and cost-effectiveness of introduction of 13-valent PCV (PCV13) vaccination globally. METHODS: We assessed the incremental cost-effectiveness ratio of PCV13 introduction by integrating two models: an ecological model (a parsimonious, mechanistic model validated with data from post-seven-valent PCV introduction in 13 high-income settings) to predict the effect of PCV on childhood invasive pneumococcal disease, and a decision-tree model to predict a range of clinical presentations and economic outcomes under vaccination and no-vaccination strategies. The models followed 30 birth cohorts up to age 5 years in 180 countries from 2015 to 2045. One-way scenario and probabilistic sensitivity analyses were done to explore model uncertainties. FINDINGS: We estimate that global PCV13 use could prevent 0·399 million child deaths (95% credible interval 0·208 million to 0·711 million) and 54·6 million disease episodes (51·8 million to 58·1 million) annually. Global vaccine costs (in 2015 international dollars) of $15·5 billion could be partially offset by health-care savings of $3·19 billion (2·62 billion to 3·92 billion) and societal cost savings of $2·64 billion (2·13 billion to 3·28 billion). PCV13 use is probably cost-effective in all six UN regions. The 71 countries eligible for support from Gavi, the Vaccine Alliance, account for 83% of PCV13-preventable deaths but only 18% of global vaccination costs. The expected cost of PCV vaccination globally is around $16 billion per year. INTERPRETATION: Our findings highlight the value of Gavi's support for PCV introduction in low-income countries and of efforts to improve the affordability of PCVs in countries not eligible for, or transitioning from, Gavi support. FUNDING: World Health Organization; Gavi, the Vaccine Alliance; and the Bill & Melinda Gates Foundation.

Public Health Policy and Experience of the 2009 H1N1 Influenza Pandemic in Pune, India.

BACKGROUND: Prior experience and the persisting threat of influenza pandemic indicate the need for global and local preparedness and public health response capacity. The pandemic of 2009 highlighted the importance of such planning and the value of prior efforts at all levels. Our review of the public health response to this pandemic in Pune, India, considers the challenges of integrating global and national strategies in local programmes and lessons learned for influenza pandemic preparedness. METHODS: Global, national and local pandemic preparedness and response plans have been reviewed. In-depth interviews were undertaken with district health policy-makers and administrators who coordinated the pandemic response in Pune. RESULTS: In the absence of a comprehensive district-level pandemic preparedness plan, the response had to be improvised. Media reporting of the influenza pandemic and inaccurate information that was reported at times contributed to anxiety in the general public and to widespread fear and panic. Additional challenges included inadequate public health services and reluctance of private healthcare providers to treat people with flu-like symptoms. Policy-makers developed a response strategy that they referred to as the Pune plan, which relied on powers sanctioned by the Epidemic Act of 1897 and resources made available by the union health ministry, state health department and a government diagnostic laboratory in Pune. CONCLUSION: The World Health Organization's (WHO's) global strategy for pandemic control focuses on national planning, but state-level and local experience in a large nation like India shows how national planning may be adapted and implemented. The priority of local experience and requirements does not negate the need for higher level planning. It does, however, indicate the importance of local adaptability as an essential feature of the planning process. Experience and the implicit Pune plan that emerged are relevant for pandemic preparedness and other public health emergencies.

A strong TB programme embedded in a developing primary healthcare system is a lose-lose situation: insights from patient and community perspectives in Cambodia.

As exemplified by the situation in Cambodia, disease specific (vertical) health programmes are often favoured when the health system is fragile. The potential of such an approach to impede strengthening of primary healthcare services has been studied from a health systems perspective in terms of access and quality of care. In this bottom-up, qualitative study we investigate patient and community member experiences of health services when a strong tuberculosis (TB) programme is embedded into a relatively underutilized primary healthcare system. We conducted six gender-stratified community focus group discussions (n = 49) and seven mixed-gender focus group discussions with TB patients (n = 45) in three provinces located in urban, peri-urban and rural areas of Cambodia. Our analysis of health-seeking behaviour and experiences for TB and TB-like illness indicates that building a strong vertical TB control programme has had numerous benefits, including awareness of typical symptoms and need to seek care early; confidence in free TB services at public facilities; and willingness to complete treatment. However, there was a clear dichotomy in experiences and behaviour with respect to care-seeking for less severe illness at primary health services, which were generally avoided owing to access barriers and perceived poor quality. The tendency to delay seeking health care until the development of severe symptoms clearly indicative of TB is a major barrier to early diagnosis and treatment of TB. Our study indicates that an imbalance in the strength of vertical and primary health services could be a lose-lose situation as this impedes improvements in health system functioning and constrains progress of vertical disease control programmes.

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.

Less research on tuberculosis than HIV and malaria when research agendas are poorly coordinated: a systematic review of research outputs from Cambodia.

OBJECTIVE: Coordination of health interventions and research is often weak during periods of political transition and unprecedented aid inflows, which Cambodia has recently experienced. Although HIV, tuberculosis (TB), and malaria have been a focus of international funding, TB has received much less. This study compares the numbers and methodologies of studies conducted on TB, malaria, and HIV in Cambodia, identifying evidence gaps and future research needs. METHODS: Three electronic databases and the grey literature were searched for studies on HIV, TB, and malaria published between January 2000 and October 2015. Information about the disease focus and methodology was extracted from the studies included. RESULTS: A total of 2581 unique studies were screened and 712 were included in the analysis. The results of this review demonstrated that despite increasing numbers of publications, there have been fewer studies on TB (16%) than HIV (43%) and malaria (41%). Observational epidemiological studies outnumbered other methodologies (44%) for all three diseases. CONCLUSIONS: Despite substantial investments, important research areas appear to have been neglected in Cambodia; specifically, studies on TB and studies involving economic, qualitative, interventional, and genomics methods. The inter-disease disparity in published research in Cambodia identified, considered alongside disease burden, suggests that an increase in TB research may be needed to inform control strategies.

The broader economic impact of vaccination: reviewing and appraising the strength of evidence.

BACKGROUND: Microeconomic evaluations of public health programmes such as immunisation typically only consider direct health benefits and medical cost savings. Broader economic benefits around childhood development, household behaviour, and macro-economic indicators are increasingly important, but the evidence linking immunization to such benefits is unclear. METHODS: A conceptual framework of pathways between immunisation and its proposed broader economic benefits was developed through expert consultation. Relevant articles were obtained from previous reviews, snowballing, and expert consultation. Articles were associated with one of the pathways and quality assessed using modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. RESULTS: We found 20 studies directly relevant to one or more pathways. Evidence of moderate quality from experimental and observational studies was found for benefits due to immunisation in improved childhood physical development, educational outcomes, and equity in distribution of health gains. Only modelling evidence or evidence outside the immunization field supports extrapolating these benefits to household economic behaviour and macro-economic indicators. CONCLUSION: Innovative use of experimental and observational study designs is needed to fill evidence gaps around key pathways between immunisation and many of its proposed economic benefits.