Applying a Constrained Optimization Portfolio Model to Aid Prioritization of Public Health Interventions in Malaysia.

OBJECTIVES: Countries have constrained healthcare budgets and must prioritize new interventions depending on health goals and time frame. This situation is relevant in the sphere of national immunization programs, for which many different vaccines are proposed, budgets are limited, and efficient choices must be made in the order of vaccine introduction. METHODS: A constrained optimization (CO) model for infectious diseases was developed in which different intervention types (prophylaxis and treatment) were combined for consideration in Malaysia. Local experts defined their priority public health issues: pneumococcal disease, dengue, hepatitis B and C, rotavirus, neonatal pertussis, and cholera. Epidemiological, cost, and effectiveness data were informed from local or regionally published literature. The model aimed to maximize quality-adjusted life-year (QALY) gain through the reduction of events in each of the different diseases, under budget and intervention coverage constraints. The QALY impact of the interventions was assessed over 2 periods: lifetime and 20 years. The period of investment was limited to 15 years. RESULTS: The assessment time horizon influenced the prioritization of interventions maximizing QALY gain. The incremental health gains compared with a uninformed prioritization were large for the first 8 years and declined thereafter. Rotaviral and pneumococcal vaccines were identified as key priorities irrespective of time horizon, hepatitis B immune prophylaxis and hepatitis C treatment were priorities with the lifetime horizon, and dengue vaccination replaced these with the 20-year horizon. CONCLUSIONS: CO modeling is a useful tool for making economically efficient decisions within public health programs for the control of infectious diseases by helping prioritize the selection of interventions to maximize health gain under annual budget constraints.

Improving the Hospital Quality of Care during Winter Periods by Optimizing Budget Allocation Between Rotavirus Vaccination and Bed Expansion.

BACKGROUND: During each winter the hospital quality of care (QoC) in pediatric wards decreases due to a surge in pediatric infectious diseases leading to overcrowded units. Bed occupancy rates often surpass the good hospital bed management threshold of 85%, which can result in poor conditions in the workplace. This study explores how QoC-scores could be improved by investing in additional beds and/or better vaccination programs against vaccine-preventable infectious diseases. METHODS: The Cobb-Douglas model was selected to define the improvement in QoC (%) as a function of two strategies (rotavirus vaccination coverage [%] and addition of extra hospital beds [% of existing beds]), allowing improvement-isocurves to be produced. Subsequently, budget minimization was applied to determine the combination of the two strategies needed to reach a given QoC improvement at the lowest cost. Data from Jessa Hospital (Hasselt, Belgium) were chosen as an example. The annual population in the catchment area to be vaccinated was 7000 children; the winter period was 90 days with 34 pediatric beds available. Rotavirus vaccination cost per course was €118.26 and the daily cost of a pediatric bed was €436.53. The target QoC increase was fixed at 50%. The model was first built with baseline parameter values. RESULTS: The model predicted that a combination of 64% vaccine coverage and 39% extra hospital beds (≈ 13 extra beds) in winter would improve QoC-scores by 50% for the minimum budget allocation. CONCLUSION: The model allows determination of the most efficient allocation of the healthcare budget between rotavirus vaccination and bed expansion for improving QoC-scores during the annual epidemic winter seasons.

Optimising the introduction of multiple childhood vaccines in Japan: A model proposing the introduction sequence achieving the highest health gains.

BACKGROUND: Many countries struggle with the prioritisation of introducing new vaccines because of budget limitations and lack of focus on public health goals. A model has been developed that defines how specific health goals can be optimised through immunisation within vaccination budget constraints. METHODS: Japan, as a country example, could introduce 4 new pediatric vaccines targeting influenza, rotavirus, pneumococcal disease and mumps with known burden of disease, vaccine efficacies and maximum achievable coverages. Operating under budget constraints, the Portfolio-model for the Management of Vaccines (PMV) identifies the optimal vaccine ranking and combination for achieving the maximum QALY gain over a period of 10 calendar years in children <5 years old. This vaccine strategy, of interest and helpful for a healthcare decision maker, is compared with an unranked vaccine selection process. RESULTS: Results indicate that the maximum QALY gain with a fixed annual vaccination budget of 500 billion Japanese Yen over a 10-year period is 72,288 QALYs using the optimal sequence of vaccine introduction (mumps [1st], followed by influenza [2nd], rotavirus [3rd], and pneumococcal [4th]). With exactly the same budget but without vaccine ranking, the total QALY gain can be 20% lower. CONCLUSION: The PMV model could be a helpful tool for decision makers in those environments with limited budget where vaccines have to be selected for trying to optimise specific health goals.

The Sustained Rotavirus Vaccination Impact on Nosocomial Infection, Duration of Hospital Stay, and Age: The RotaBIS Study (2005-2012).

INTRODUCTION: The benefits of rotavirus (RV) vaccination in developed countries have focused on reductions in mortality, hospitalization and medical visits, and herd protection. We investigated other aspects related to RV-induced nosocomial infection, duration of hospital stay, age shift, and sustained vaccine impact (VI) over time. METHOD: RotaBIS (Rotavirus Belgian Impact Study; ClinicalTrials.gov identifier, NCT01563146) annually collects retrospective data on hospitalization linked to RV testing in children up to 5 years old from 11 pediatric wards located all over Belgium. Data from 2005 to 2012 have been split in pre- (2005-2006) and post-vaccination (2007-2012) period. Information was collected on age, gender, RV test result, nosocomial infection caused by RV and duration of hospital stay. RESULTS: Over the 6-year period after the introduction of the RV vaccine, an 85% reduction in nosocomial infections was observed (221 in 2005 to 33 in 2012, p < 0.001). A significant reduction of almost 2 days in average duration of hospital stay per event was observed overall (7.62 days in 2005 to 5.77 days in 2012, p < 0.001). The difference is mainly explained by the higher reduction in number of nosocomial infections. A pronounced age shift (+24%, p < 0.01) of RV nosocomial infection to infants ≤2 months old was observed, increasing with length of post-vaccination period. VI was maintained over the follow-up (±79% VI per birth cohort). A decrease was seen depending on age, 85% (95% CI 76-91%) in the youngest to 63% (95% CI 22-92%) in the oldest age group. CONCLUSION: The higher reduction in nosocomial infection may affect the overall average duration of hospital stay for RV infection. No change in VI by birth cohort, but a reduction by age group was observed. These findings could be important for decision-makers considering the introduction of universal mass RV vaccination programs. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT01563146. FUNDING: GlaxoSmithKline Biologicals SA (Rixensart, Belgium).