Programa nacional de inmunizacion en Chile: pasado, presente y futuro / National immunization program in Chile: past, present and future

El Programa Ampliado de Inmunizaciones (PAI) a nivel mundial nace en 1974 como iniciativa de la Organización Mundial de la Salud (OMS) y la Organización Panamericana de la Salud (OPS). En Chile, el actual Programa Nacional de Inmunizaciones (PNI) se origina en el Plan Ampliado de Inmunizaciones (PAI) establecido en el año 1978. En sus inicios, el PAI se basó en disposiciones legales definidas en 1975, que establecía las Enfermedades Trasmisibles de Vacunación Obligatoria. Desde el año 2010, el Decreto Exento N°6 promulgado el 29 de enero, se dispone la vacunación obligatoria contra enfermedades inmunoprevenibles de la población del país. Posteriormente se han realizado modificaciones al decreto exento N°6 reflejando la incorporación de nuevas vacunas al calendario, modificaciones en los grupos objetivo y/o cambios en las estrategias de vacunación, entre otros. En estas disposiciones también se establece que el Ministerio de Salud debe asegurar el acceso gratuito a vacunaciones seguras y efectivas para toda la población objetivo. El objetivo del artículo, es describir la evolución de las iniciativas de vacunación en nuestro país, desde antes de la creación del PAI, la sistematización de las estrategias de vacunación una vez que se establece el programa hasta las modificaciones realizadas en la última década.

The Expanded Program on Immunization (EPI) worldwide was created in 1974 as an initiative of the World Health Organization (WHO) and the Pan American Health Organization (PAHO). In Chile, the current National Immunization Program (PNI) originates from the Extended Inmunization Plan (EPI) established in 1978. In its beginnings, the EPI was based on legal provisions defined in 1975, which established the Communicable Diseases of Compulsory Vaccination. Since 2010, the Exempt Decree No. 6 promulgated on January 29, provides the Mandatory Vaccination against Immune preventable Diseases of the Population of the Country. Subsequently there have been modifications to the Exempt Decree No. 6 reflecting the incorporation of new vaccines to the calendar, modifications in the target groups and /or changes in vaccination strategies, among others. These provisions also state that the Ministry of Health must ensure free access to safe and effective vaccinations for the entire target population. The aim oh this article is to describe evolution of vaccination initiatives in our country, from before the creation of the EPI, the systematization of vaccination strategies once the program is established, until the modifications made in the last decade.

La vacuna contra el virus del papiloma humano: estado de la cuestión, principio de proporcionalidad y consentimiento informado / The vaccine against human papilloma virus: state of the question, proportionality principle and informed consent / A vacina contra o virus do papiloma humano: situação da questão, princípio de proporcionalidade e consentimento informado

Entre los debates actuales en torno a las prácticas de vacunación, la vacuna contra el Virus de Papiloma Humano (VPH) formula diversos desafíos desde la bioética: por una parte, existen controversias en cuanto al perfil de eficacia y seguridad de las vacunas comercializadas, así como respecto de su costo-efectividad. Es evidente en estudios empíricos que el proceso de consentimiento informado no ofrece los elementos necesarios para que las pacientes y sus representantes legales puedan participar de forma significativa en el proceso de toma de decisiones en torno a la vacunación. El presente artículo presenta una revisión sobre el estado de la cuestión, ofrece un análisis desde la bioética a partir del principio de proporcionalidad y el método deliberativo-sincrético y sugiere algunos aportes para optimizar el proceso de consentimiento informado para la vacuna contra el VPH.

Within the current discussions on immunization practices, Human Papillomavirus (HPV) made various challenges from bioethics: firstly, there are controversies regarding the efficacy and safety profile of marketed vaccines, and with respect to their cost-effectiveness. Around the discussion is evident in empirical studies that the informed consent process does not provide the necessary elements for the patients and their legal representatives can participate meaningfully in the process of making decisions about vaccination. This article presents an overview of the status of the issue, with an analysis from bioethics from the principle of proportionality and the deliberative syncretic method and suggests some input to optimize the process of informed consent for the HPV vaccine.

Entre os debates atuais em torno das práticas de vacinação, a vacina contra o vírus do Papiloma Humano (HPV) formula diversos desafios a partir da bioética: por uma parte, existem controvérsias quanto ao perfil de eficácia e segurança das vacinas comercializadas, assim como a respeito de seu custo-efetividade. É evidente em estudos empíricos que o processo de consentimento informado não oferece os elementos necessários para que as pacientes e seus representantes legais possam participar de forma significativa no processo de tomada de decisões em torno da vacinação. O presente artigo apresenta uma revisão sobre a situação da questão, oferece uma análise a partir da bioética, tendo como base o princípio da proporcionalidade e o método deliberativo-sincrético e sugere algumas contribuições para otimizar o processo de consentimento informado para a vacina contra o HPV.

Plan de acción sobre inmunización / Action plan on immunization

Un plan de acción sobre inmunización que busca proteger los logros históricos de la eliminación de la viruela, la poliomielitis y la rubéola ante un reciente aumento en las brechas de cobertura de vacunación y haciendo frente a nuevos objetivos.

A gripe sob diferentes perspectivas / Influenza from different perspectives

A gripe é uma importante causa de doença e óbito. Estima-se que, anualmente, cause grave comprometimento em 3-5 milhões de pessoas e 250 a 500 mil mortes. Tanto os custos médicos diretos como os indiretos, que dependem grandemente do absenteísmo e da perda de produtividade no trabalho, são substanciais. A gripe pode ser responsável por 10%-12% de todas as faltas ao trabalho por doenças, e o custo-efetividade da imunização na população trabalhadora geral ainda está em debate...

Influenza is an important cause of disease and death. Yearly, it is estimated that the influenza causes severe harm in 3-5 million people and 250 to 500 hundred thousand deaths. Both the indirect and direct medical costs which depends on absenteeism and loss of productivity at work are substantials. The influenza can be responsible for 10%- 12% of sickness absences and the cost-efectiveness immunization of general employment- population is still in discussion...

Contributions from the systematic review of economic evaluations: the case of childhood hepatitis A vaccination in Brazil / Contribuições da revisão sistemática de avaliações econômicas: o exemplo da vacinação infantil contra hepatite A no Brasil

The aim of this study was to present the contributions of the systematic review of economic evaluations to the development of a national study on childhood hepatitis A vaccination. A literature review was performed in EMBASE, MEDLINE, WOPEC, HealthSTAR, SciELO and LILACS from 1995 to 2010. Most of the studies (8 of 10) showed favorable cost-effectiveness results. Sensitivity analysis indicated that the most important parameters for the results were cost of the vaccine, hepatitis A incidence, and medical costs of the disease. Variability was observed in methodological characteristics and estimates of key variables among the 10 studies reviewed. It is not possible to generalize results or transfer epidemiological estimates of resource utilization and costs associated with hepatitis A to the local context. Systematic review of economic evaluation studies of hepatitis A vaccine demonstrated the need for a national analysis and provided input for the development of a new decision-making model for Brazil.

O objetivo deste estudo foi apresentar as contribuições da revisão sistemática de avaliações econômicas para o desenvolvimento de um estudo nacional, o caso da vacinação infantil contra hepatite A. Foi realizada revisão da literatura nas bases de dados EMBASE, MEDLINE, WOPEC, HealthSTAR, SciELO e LILACS, no período de 1995 a 2010. A maioria dos estudos (8 em 10) mostrou resultados favoráveis de custo-efetividade. As análises de sensibilidade indicaram como parâmetros mais importantes para os resultados os custos da vacina, incidência de hepatite A e custos médicos da doença. Foi observada variabilidade nas características metodológicas e estimativas de variáveis-chaves dos 10 estudos revisados. Não é possível generalização dos resultados e transferibilidade de estimativas epidemiológicas, de usos de recursos e custos associados à hepatite A para o contexto local. A revisão sistemática dos estudos de avaliação econômica da vacina contra hepatite A demonstrou a necessidade de uma análise nacional e forneceu elementos para o desenvolvimento de um novo modelo de decisão para o Brasil.

Inmunizaciones y equidad en el Plan Regional del Sistema Mesoamericano de Salud Pública / Immunization and equity in the Regional Initiative of the Mesoamerican Health Initiative

Las cifras nacionales de inmunización indican altas coberturas de vacunación en Mesoamérica, sin embargo, hay evidencia creciente de que los grupos más vulnerables no son alcanzados por los programas de vacunación. La planeación de este proyecto se llevó a cabo entre junio y diciembre de 2009. La ejecución del proyecto se llevará a cabo en la población objetivo seleccionada a partir de junio de 2011. Está integrada por niños menores de cinco años y mujeres en edad fértil de las poblaciones más vulnerables en los países de Mesoamérica, identificadas geográficamente por un bajo índice de desarrollo humano o por la alta prevalencia de pobreza en el ámbito municipal, o a través del uso de métodos participativos para definir pobreza y vulnerabilidad en contextos locales. El Grupo de Trabajo ha definido tres líneas de acción para las intervenciones de enfermedades prevenibles por vacunación, para lograr una mejor cobertura efectiva en poblaciones vulnerables: 1) estudios piloto de coberturas para vacíos de conocimiento, 2) fortalecimiento de las políticas de vacunación, 3) ejecución de prácticas basadas en evidencia. El fortalecimiento de los sistemas de salud bajo la óptica de equidad en salud es el objetivo regional central del Grupo de Trabajo en inmunizaciones enfocado en un aumento de la cobertura efectiva.

National immunization rates indicate high vaccine coverage in Mesoamerica, but there is growing evidence that the most vulnerable groups are not being reached by immunization programs. Therefore, there is likely low effective vaccine coverage in the region, leading to persistent and growing health inequity. The planning phase of this project was from June to December 2009. The project will be conducted in the target populations which includes children under five, pregnant women, and women of child-bearing age from the most vulnerable populations within countries of the Mesoamerican region, as indicated geographically by a low human development index (HDI) and/or high prevalence of poverty at the municipal level and through the use of participatory methods to define poverty and vulnerability in local contexts. We defined three lines of action for vaccine-preventable disease interventions: 1) pilot projects to fill gaps in knowledge; 2) strengthening immunization policy; and 3) implementation of evidence-based practices. Health system strengthening through health equity is the central regional objective of the immunization workgroup. We hope to have a transformational impact on health systems so as to improve effective coverage, including vaccine and other integrated primary healthcare services.

Costo-efectividad de prácticas en salud pública: revisión bibliográfica de las intervenciones de la Iniciativa Mesoamericana de Salud / Cost-effectiveness of public health practices: A literature review of public health interventions from the Mesoamerican Health Initiative

OBJETIVO: Presentar y analizar información de costo-efectividad de intervenciones propuestas por la Iniciativa Mesoamericana de Salud (IMS) en las áreas de nutrición infantil, inmunizaciones, paludismo, dengue y salud materno-infantil y reproductiva. MATERIAL Y MÉTODOS: Se llevó a cabo una revisión sistemática de la literatura de evaluaciones económicas publicadas entre el año 2000 y agosto 2009 sobre intervenciones en las áreas de la salud mencionadas, en los idiomas inglés y español. RESULTADOS: Las intervenciones en nutrición y de salud materno-infantil mostraron ser altamente costo-efectivas (con rangos menores a US$200 por año de vida ajustado por discapacidad [AVAD] evitado para nutrición y US$100 para materno-infantil). En dengue sólo se encontró información sobre la aplicación de larvicidas, cuya razón de costo efectividad estimada fue de US$40.79 a US$345.06 por AVAD evitado. Respecto al paludismo, las intervenciones estudiadas resultaron costo-efectivas (

OBJECTIVE: Present and analyze cost-effectiveness information of public health interventions proposed by the Mesoamerican Health Initiative in child nutrition, vaccination, malaria, dengue, and maternal, neonatal, and reproductive health. MATERIAL AND METHODS: A systematic literature review was conducted on cost-effectiveness studies published between January 2000 and August 2009 on interventions related to the health areas previously mentioned. Studies were included if they measured effectiveness in terms of Disability-Adjusted Life Year (DALY) or death averted. RESULTS: Child nutrition and maternal and neonatal health interventions were found to be highly cost-effective (most of them below US$200 per DALY averted for nutritional interventions and US$100 for maternal and neonatal health). For dengue, information on cost-effectiveness was found just for application of larvicides, which resulted in a cost per DALY averted ranking from US$40.79 to US$345.06. Malarial interventions were found to be cost-effective (below US$150 per DALY averted or US$4,000 per death averted within Africa). In the case of pneumococcus and rotavirus vaccination, cost-effectiveness estimates were always above one GDP per capita per DALY averted. CONCLUSIONS: In Mesoamerica there are still important challenges in child nutrition, vaccination, malaria, dengue and maternal, neonatal, and reproductive health, challenges that could be addressed by scaling-up technically feasible and cost-effective interventions.

Diseño mixto de evaluación de la iniciativa Salud Mesoamérica 2015 / Mixed design for the evaluation of the Mesoamerica Health 2015 initiative

El propósito de la iniciativa Salud Mesoamérica 2015 (SM-2015) es mejorar el estado de salud y nutrición de la población con mayor grado de vulnerabilidad en Mesoamérica. El objetivo de la evaluación es generar evidencia sobre la efectividad conjunta de un paquete de intervenciones diseñadas para mejorar las condiciones de salud en la región. Se propone una evaluación de impacto con métodos mixtos, para conocer la magnitud de los cambios atribuibles a la SM-2015, e identificar los significados de estos cambios para la población objetivo, en el contexto de cada país. El eje conductor es un panel de localidades con el que se colectará información de individuos, hogares y unidades de salud de primero y segundo nivel de atención. El diseño que se describe en este documento fue desarrollado entre junio y diciembre de 2009, y su articulación se llevó a cabo en talleres realizados en Cuernavaca (México), Managua (Nicaragua), y San José (Costa Rica). El diseño propuesto permitirá generar evidencia sobre la efectividad conjunta del paquete de intervenciones propuesto en los planes maestros mesoamericanos. El éxito de este diseño radica en la voluntad y en el compromiso político de los países y los donantes.

Since the Salud Mesoamerica 2015 initiative (SM-2015) aim is to improve health and nutrition conditions of those most vulnerable in Mesoamerica, the goal of the evaluation is to generate evidence of the joint effectiveness of a package of interventions designed to improve the health conditions. We propose a mix design for the evaluation, which will allow to know the magnitude of changes attributable to the interventions, as well as the meanings of these changes for the target population, taking into account the specificities of each country. The main axis of this design is a locality panel where information about individuals, households, and health facilities (first and second level) will also be collected. The evaluation design described in this paper was developed between June and December, 2009, and it was integrated during workshops in Cuernavaca (Mexico), Managua (Nicaragua), and San Jose (Costa Rica). The proposed design will allow to generate evidence about the joint effectiveness of the package of interventions proposed for the SM-2015. The success of this design rests on the political commitment of countries and donors.

Impacto económico de la introducción de la vacuna inactivada inyectable contra la poliomielitis en Colombia / Economic impact of introducing the injectable inactivated polio vaccine in Colombia

OBJETIVOS: Evaluar la relación costo-efectividad de la introducción de la vacuna inyectable contra la poliomielitis (VIP) en Colombia con respecto al sistema actual basado en el empleo de la vacuna oral (VOP). MÉTODOS: Se diseñó un modelo de Markov basado en una cohorte hipotética de recién nacidos que recibiría la VIP o la VOP con un seguimiento de dos años y estimaciones mensuales del número de casos de poliomielitis paralítica asociada con la vacuna (PPAV). El análisis del costo se realizó desde la perspectiva del asegurador (costos a lo largo de la vida) y la sociedad (casos de PPAV evitados y años de vida ajustados por discapacidad [AVAD] evitados). RESULTADOS: Entre 1988 y 1998 se aplicaron en Colombia 22,5 millones de dosis de la VOP y se detectaron nueve casos de PPAV, para una tasa de 4,0 ¥ 10-7 por dosis. Según el modelo, se podrían esperar entre 2 y 4 casos de PPAV en los dos años de seguimiento. El costo de tratar los casos de PPAV sería de US$ 302 008, con costos de vacunación con la VOP de US$ 737 037 y de US$ 5 527 777 con la VIP. La vacunación con la VIP permitiría evitar 64 AVAD con un costo de US$ 71 062 por AVAD evitado; evitar un caso de PPAV mediante la sustitución de la VOP por la VIP costaría entre US$ 1,8 millones y US$ 2,2 millones. CONCLUSIONES: La sustitución de la VOP por la VIP no es una medida efectiva en función del costo en Colombia, incluso si se sustituyera la vacuna celular contra la tos ferina, actualmente en uso, por una vacuna acelular combinada con una VIP.

OBJECTIVE: Evaluate the cost-effectiveness of introducing the injectable inactivated polio vaccine (IPV) in Colombia versus the current system based on the use of the oral vaccine (OPV). METHODS: A Markov model was designed, based on a hypothetical cohort of newborns that would receive the IPV or the OPV vaccine, with a two-year follow-up and monthly estimates of the number of cases of vaccine-associated paralytic poliomyelitis (VAPP) that would emerge. The cost was analyzed from the perspective of the insurer (costs throughout life) and society (cases of VAPP and disability-adjusted life years [DALYs] prevented). RESULTS: From 1988 to 1998, some 22.5 million doses of OVP were administered in Colombia and nine cases of VAPP were detected, for a rate of 4.0 ¥ 10-7 dose. According to the model, 2 to 4 cases of VAPP could be anticipated in the following two years. The cost of treating the VAPP cases would total US$302 008, with the cost of vaccination with OPV coming to US$737 037 and with IPV, US$5 527 777. Vaccination with IPV would prevent 64 DALYs, at a cost of US$71 062 per DALY prevented; preventing one case of VAPP by substituting OPV with IPV would cost between US$1.8 and US$2.2 million. CONCLUSIONS: Substituting OPV with IPV is not a cost-effective measure in Colombia, even if the cellular vaccine against whooping cough currently in use were replaced with an acellular vaccine combined with an IPV.

Intensified pulse polio immunization: Time spent and cost incurred at a primary healthcare centre.

Background. Despite launching the polio eradication initiative in 1995, India is among the world’s largest reservoir of wild poliovirus with 559 cases of poliomyelitis reported in 2008. This continued failure has been criticised for its negative impact on routine healthcare delivery. We assessed the impact of the pulse polio immunization programme at the primary health level in terms of services, time and cost. Methods. All activities during a single round of intensified pulse polio immunization were modelled on actual requirements at the primary health centre at Dayalpur in Haryana. Total person-hours and cost per child vaccinated at the primary health centre were computed. Results. Almost all routine healthcare services at the primary health centre were suspended during the round. Total person-hours consumed were 4446 and the total direct cost was Rs 24.2 per child vaccinated during a single round of the intensified pulse polio immunization programme. Conclusion. A single round of intensified pulse polio immunization consumes a substantial number of person-hours and leads to a temporary suspension of routine services provided at the primary health centre. This should be factored in while planning any future strategy of polio eradication or control and suggests the need to re-think the ‘intensified pulse polio strategy’.

Impact of methodology on the results of economic evaluations of varicella vaccination programs: is it important for decision-making? / Impacto da metodologia nos resultados de avaliações econômicas de programas de vacinação da varicela: é importante para o processo de tomada de decisão?

This study aims to review the literature on economic evaluation of childhood varicella vaccination programs and to discuss how heterogeneity in methodological aspects and estimation of parameters can affect the studies' results. After applying the inclusion criteria, 27 studies published from 1980 to 2008 were analyzed in relation to methodological differences. There was great heterogeneity in the perspective adopted, evaluation of indirect costs, type of model used, modeling of the effect on herpes zoster, and estimation of vaccine price and efficacy parameters. The factor with the greatest impact on results was the inclusion of indirect costs, followed by the perspective adopted and vaccine price. The choice of a particular methodological aspect or parameter affected the studies' results and conclusions. It is essential that authors present these choices transparently so that users of economic evaluations understand the implications of such choices and the direction in which the results of the analysis were conducted.

O presente trabalho tem por objetivo rever a literatura sobre avaliação econômica de programas de vacinação infantil contra varicela, e discutir como a heterogeneidade em aspectos metodológicos e na estimativa dos parâmetros pode afetar os resultados dos estudos. Após aplicação dos critérios de inclusão, 27 estudos do período de 1980 a 2008 foram analisados com relação às diferenças metodológicas. Observou-se grande heterogeneidade na perspectiva adotada, valoração dos custos indiretos, tipo de modelo empregado, modelagem do efeito no herpes zoster, e na estimativa dos parâmetros de preço e eficácia da vacina. O fator que mais impactou os resultados foi a inclusão dos custos indiretos seguido da perspectiva e preço de vacina adotados. A escolha de um determinado aspecto metodológico ou parâmetro afetou os resultados e conclusões dos estudos. É de fundamental importância que os autores apresentem essas escolhas com transparência para que os usuários das avaliações econômicas compreendam as repercussões dessas escolhas, e em qual direção os resultados das análises foram conduzidos.

Desafíos del plan ampliado de inmunizaciones: Chile 2006 / Challenges of the immunizations extended program (PAI): Chile 2006

The support given to infant immunization programs wishes to improve life quality and strengthen the public image of the government and its health ministry. At an international level, Chile has always been an example on public immunization, so it is necessary to examine our PAI, in terms of valency number administered in the public system versus private resources. In this document, a proposal by stages is made, according to costs, availability and most relevant epidemiologic data for new schemes. First Stage: Hepatitis B in newborns, Haemophilus influenzae b 4° doses and Hepatitis A in toddlers. Second Stage: combined vaccines with acellular Pertussis and injectable Polio vaccine. Third Stage: Chickenpox 1 dose and Rotavirus vaccines. Fourth Stage: conjugated anti pneumococcal vaccines and Human Papiloma Virus vaccine. In conclusion, the important progress on immunizations and the huge amount of resources invested worldwide show us the tendency that should be followed by our Health Ministry.

El impulso a los programas de vacunación infantil apunta a mejorar la calidad de vida de la población y a fortalecer la imagen pública del Estado y sus ministerios de salud. A nivel internacional, Chile siempre ha sido referente en vacunación pública por lo cual parece necesario revisar nuestro PAI, específicamente en la vacunación del niño, en términos del número de valencias administradas en el sistema público, versus aquellas que puede recibir un menor cuya familia cuenta con más recursos económicos. En este documento se hace una propuesta por etapas, según costos, factibilidad y datos epidemiológicos más relevantes, para nuevas valencias o nuevos esquemas. Primera Etapa: Hepatitis B en el Recién Nacido, Haemophillus influenzae b cuarta dosis y Hepatitis A en el lactante. Segunda Etapa: Incorporación de Vacunas combinadas con Pertussis acelular e incorporación de vacuna con Polio Inyectable. El costo necesario para estas modificaciones sería comparable al gasto público per capita en vacunas en el niño en países vecinos. Tercera Etapa: Varicela en una dosis y vacunas anti Rotavirus. Cuarta Etapa: Vacunas anti neumocócicas conjugadas y vacunas anti Virus Papiloma Humano. En conclusión, el avance en vacunas experimentado a nivel mundial y el enérgico traspaso de recursos que los países desarrollados y otros en vías de desarrollo hacen a su población mediante la incorporación de nuevas vacunas en sus programas preventivos, nos indica la tendencia que debería seguir nuestro Ministerio de Salud.

Introducing hepatitis B virus vaccine into the Expanded Programme on Immunization in Bangladesh: a proposed method to evaluate whether the existing infrastructure has the capacity.

To determine whether the existing Expanded Programme on Immunization (EPI) in Bangladesh has the capacity to introduce the hepatitis B virus (HBV) vaccine, this study was carried out in all the nine health facilities, which maintain a cold-chain, in Chandpur district of Bangladesh. The research, focusing specifically on cold-chain equipment, aimed at developing and applying an indicator of the use of cold-chain equipment. A structured questionnaire, developed and field-tested, was used for collecting information on cold-chain equipment and their use-rate. Data were used for estimating the resources needed to introduce the HBV vaccine and for increasing the coverage of measles and DPT vaccines. The findings of the study showed that the use-rate of cold-chain equipment in this district was low, suggesting that the district has sufficient spare capacity to introduce and sustain the storage of an increased quantity of vaccines. This paper suggests an approach to study capacity in relation to infrastructural facilities. By measuring the capacity of capital equipment, the study has illustrated that the measurement of resource-use rates provides useful information about the burden that a new vaccine places on the EPI.

Cost of delivering child immunization services in urban Bangladesh: a study based on facility-level surveys.

This facility-based study estimated the costs of providing child immunization services in Dhaka, Bangladesh, from the perspective of healthcare providers. About a quarter of all immunization (EPI) delivery sites in Dhaka city were surveyed during 1999. The EPI services in urban Dhaka are delivered through a partnership of the Government of Bangladesh (GoB) and non-governmental organizations (NGOs). About 77% of the EPI delivery sites in Dhaka were under the management of NGOs, and 62% of all vaccinations were provided through these sites. The outreach facilities (both GoB and NGO) provided immunization services at a much lower cost than the permanent static facilities. The average cost per measles-vaccinated child (MVC), an indirect measure of number of children fully immunized (FIC-the number of children immunized by first year of life), was 11.61 U.S. dollars. If all the immunization doses delivered by the facilities were administered to children who were supposed to be immunized (FVC), the cost per child would have been 6.91 U.S. dollars. The wide gap between the cost per MVC and the cost per FVC implies that the cost of immunizing children can be reduced significantly through better targeting of children. The incremental cost of adding new services or interventions with current EPI was quite low, not significantly higher than the actual cost of new vaccines or drugs to be added. NGOs in Dhaka mobilized about 15,000 U.S. dollars from the local community to support the immunization activities. Involving local community with EPI activities not only will improve the sustainability of the programme but will also increase the immunization coverage.

A cost-benefit analysis of typhoid fever immunization programmes in an Indian urban slum community.

Many economic analyses of immunization programmes focus on the benefits in terms of public-sector cost savings, but do not incorporate estimates of the private cost savings that individuals receive from vaccination. This paper considers the implications of Bahl et al.'s cost-of-illness estimates for typhoid immunization policy by examining how community-level incidence estimates and information on distribution of costs of illness among patients and the public-health sector can be used in the economic analysis of vaccination-programme options. The findings illustrate why typhoid vaccination programmes may often appear to be unattractive to public-health officials who adopt a public budgetary perspective. Under many plausible sets of assumptions, public-sector expenditure on typhoid vaccination does not yield comparable public-sector cost savings. If public-health officials adopt a societal perspective on the economic benefits of vaccination, there are many situations in which different vaccination programmes will make economic sense. The findings show that this is especially true when public decision-makers recognize that (a) the incidence of typhoid fever is underestimated by blood culture-positive cases and (b) avoided costs of illness represent a significant underestimate of the actual economic benefits to individuals of vaccination.

Economic burden of varicella in Singapore--a cost benefit estimate of implementation of a routine varicella vaccination.

Varicella is a common childhood illness that can result in significant morbidity and mortality. As early as 1995, recommendations for routine varicella vaccination have been published, but have not been universally implemented, with cost of vaccination as a major reason. Though available from 1996, the vaccine has yet to be routinely implemented in Singapore. We set out to assess the economic burden of varicella and the cost-benefit of adding a varicella vaccine to the existing immunization schedule in Singapore. In this study, using data from 1994--1995 the direct cost estimates were based on all levels of medical care; inpatient care, emergency room visits, primary health care and medication. Indirect costs were estimated from the cost of time lost by patients and their families attending to medical needs, as well as loss of productivity due to absenteeism. The cost of a vaccination program targeted at 15-month old infants receiving concomitant measles-mumps-rubella immunization was also assessed. The cost-benefit ratio was then estimated. The total cost of varicella in Singapore was estimated to be US$11.8 million per annum. The loss of productivity accounted for a large proportion of the total cost as a lot of parents took leave when their children were ill. The estimates of total cost represent approximately US$188 per varicella case per year. In comparison, the cost of a vaccination program was found to be US$3.3 million per annum. The cost per case averted was US$104. From a societal point of view, for every dollar invested in a vaccination program, we would save about US$2 dollars.

GAVI and the Vaccine Fund--a boon for immunization in the developing world.

The Global Alliance for Vaccines and Immunization (GAVI) and The Vaccine Fund are two major global initiatives adopted with the objectives of improving access to immunization services particularly in the underdeveloped and developing countries and introduction of new but under-used vaccines in the developing countries in particular where these diseases are highly prevalent. GAVI is a collaborative mission that brings together governments in developing and industrialized countries, UNICEF, WHO, the World Bank, the Bill & Melinda Gates Foundation, vaccine manufacturers and all other stake holders to harness the strengths and experiences of multiple partners in immunization. The Vaccine Fund is a financing mechanism established to mobilize resources to serve the mission of GAVI. This article reviews the objectives, strategies, organization and the funding issues of this global initiative. In the Indian perspective, GAVI is presently playing a major role in introduction of Hepatitis-B vaccine for infants in India. The article outlined the pilot project currently being implemented by GoI and the future prospects of integrating Hepatitis-B vaccine and auto disable syringes into the routine immunization program as well as strengthening the routine immunization services when the government decides to expand the project.