Last-mile delivery increases vaccine uptake in Sierra Leone.

Less than 30% of people in Africa received a dose of the COVID-19 vaccine even 18 months after vaccine development1. Here, motivated by the observation that residents of remote, rural areas of Sierra Leone faced severe access difficulties2, we conducted an intervention with last-mile delivery of doses and health professionals to the most inaccessible areas, along with community mobilization. A cluster randomized controlled trial in 150 communities showed that this intervention with mobile vaccination teams increased the immunization rate by about 26 percentage points within 48-72 h. Moreover, auxiliary populations visited our community vaccination points, which more than doubled the number of inoculations administered. The additional people vaccinated per intervention site translated to an implementation cost of US $33 per person vaccinated. Transportation to reach remote villages accounted for a large share of total intervention costs. Therefore, bundling multiple maternal and child health interventions in the same visit would further reduce costs per person treated. Current research on vaccine delivery maintains a large focus on individual behavioural issues such as hesitancy. Our study demonstrates that prioritizing mobile services to overcome access difficulties faced by remote populations in developing countries can generate increased returns in terms of uptake of health services3.

Public health and economic benefits of seasonal influenza vaccination in risk groups in France, Italy, Spain and the UK: state of play and perspectives.

BACKGROUND: Seasonal influenza epidemics have a substantial public health and economic burden, which can be alleviated through vaccination. The World Health Organization (WHO) recommends a 75% vaccination coverage rate (VCR) in: older adults (aged ≥ 65 years), individuals with chronic conditions, pregnant women, children aged 6-24 months and healthcare workers. However, no European country achieves this target in all risk groups. In this study, potential public health and economic benefits achieved by reaching 75% influenza VCR was estimated in risk groups across four European countries: France, Italy, Spain, and the UK. METHODS: A static epidemiological model was used to estimate the averted public health and economic burden of increasing the 2021/2022 season VCR to 75%, using the efficacy data of standard-dose quadrivalent influenza vaccine. For each country and risk group, the most recent data on population size, VCR, pre-pandemic influenza epidemiology, direct medical costs and absenteeism were identified through a systematic literature review, supplemented by manual searching. Outcomes were: averted influenza cases, general practitioner (GP) visits, hospitalisations, case fatalities, number of days of work lost, direct medical costs and absenteeism-related costs. RESULTS: As of the 2021/2022 season, the UK achieved the highest weighted VCR across risk groups (65%), followed by Spain (47%), France (44%) and Italy (44%). Based on modelling, the 2021/2022 VCR prevented an estimated 1.9 million influenza cases, avoiding 375,200 GP visits, 73,200 hospitalisations and 38,400 deaths. To achieve the WHO 75% VCR target, an additional 24 million at-risk individuals would need to be vaccinated, most of which being older adults and patients with chronic conditions. It was estimated that this could avoid a further 918,200 influenza cases, 332,000 GP visits, 16,300 hospitalisations and 6,300 deaths across the four countries, with older adults accounting for 52% of hospitalisations and 80% of deaths. An additional €84 million in direct medical costs and €79 million in absenteeism costs would be saved in total, with most economic benefits delivered in France. CONCLUSIONS: Older adults represent most vaccine-preventable influenza cases and deaths, followed by individuals with chronic conditions. Health authorities should prioritise vaccinating these populations for maximum public health and economic benefits.

Introduction of a hexavalent vaccine containing acellular pertussis into the national immunization program for infants in Peru: a cost-consequence analysis of vaccination coverage.

BACKGROUND: Infant vaccination coverage rates in Peru have declined in recent years, exacerbated by the COVID-19 pandemic. Introduction of the fully-liquid diphtheria, tetanus, and acellular pertussis (DTaP)-inactivated polio vaccine (IPV)-hepatitis B (HB)-Haemophilus influenzae type B (Hib) hexavalent vaccine (DTaP-IPV-HB-Hib) in Peru's infant National Immunization Program may help improve coverage. We evaluated costs and healthcare outcomes, including coverage, of switching from a pentavalent vaccine containing whole-cell pertussis component (DTwP-HB-Hib) plus IPV/oral polio vaccine (IPV/OPV) to the hexavalent vaccine for the primary vaccination scheme (2, 4 and 6 months). METHODS: The analysis was performed over a 5-year period on a cohort of children born in Peru in 2020 (N = 494,595). Four scenarios were considered: the pentavalent plus IPV/OPV scheme (S1); replacing the pentavalent plus IPV/OPV scheme with the hexavalent scheme (S2); expanded delivery of the pentavalent plus IPV/OPV scheme (S3); expanded delivery of the hexavalent scheme (S4). Vaccine coverage and incidence of adverse reactions (ARs) were estimated using Monte Carlo simulations and previous estimates from the literature. Cases of vaccine-preventable diseases were estimated using a Markov model. Logistical and healthcare costs associated with these outcomes were estimated. Impact of key variables (including coverage rates, incidence of ARs and vaccine prices) on costs was evaluated in sensitivity analyses. RESULTS: The overall cost from a public health payer perspective associated with the pentavalent plus IPV/OPV vaccine scheme (S1) was estimated at $56,719,350, increasing to $61,324,263 (+ 8.1%), $59,121,545 (+ 4.2%) and $64,872,734 (+ 14.4%) in scenarios S2, S3 and S4, respectively. Compared with the status quo (S1), coverage rates were estimated to increase by 3.1% points with expanded delivery alone, and by 9.4 and 14.3% points, if the hexavalent vaccine is deployed (S2 and S4, respectively). In both scenarios with the hexavalent vaccine (S2 and S4), pertussis cases would also be 5.7% and 8.7% lower, and AR rates would decrease by 32%. The cost per protected child would be reduced when the hexavalent vaccine scheme. Incidence of ARs was an important driver of cost variability in the sensitivity analysis. CONCLUSIONS: Implementation of the hexavalent vaccine in Peru's National Immunization Program has a positive public health cost consequence.

Health and economic impact of the pneumococcal conjugate vaccine in hindering antimicrobial resistance in China.

Antimicrobial resistance (AMR) poses a serious threat to global public health. However, vaccinations have been largely undervalued as a method to hinder AMR progression. This study examined the AMR impact of increasing pneumococcal conjugate vaccine (PCV) coverage in China. China has one of the world's highest rates of antibiotic use and low PCV coverage. We developed an agent-based DREAMR (Dynamic Representation of the Economics of AMR) model to examine the health and economic benefits of slowing AMR against commonly used antibiotics. We simulated PCV coverage, pneumococcal infections, antibiotic use, and AMR accumulation. Four antibiotics to treat pneumococcal diseases (penicillin, amoxicillin, third-generation cephalosporins, and meropenem) were modeled with antibiotic utilization, pharmacokinetics, and pharmacodynamics factored into predicting AMR accumulation. Three PCV coverage scenarios were simulated over 5 y: 1) status quo with no change in coverage, 2) scaled coverage increase to 99% in 5 y, and 3) accelerated coverage increase to 85% over 2 y followed by 3 y to reach 99% coverage. Compared to the status quo, we found that AMR against penicillin, amoxicillin, and third-generation cephalosporins was significantly reduced by 6.6%, 10.9%, and 9.8% in the scaled scenario and by 10.5%, 17.0%, and 15.4% in the accelerated scenario. Cumulative costs due to AMR, including direct and indirect costs to patients and caretakers, were reduced by $371 million in the scaled and $586 million in the accelerated scenarios compared to the status quo. AMR-reducing benefits of vaccines are essential to quantify in order to drive appropriate investment.

Distemper, extinction, and vaccination of the Amur tiger.

Canine distemper virus (CDV) has recently emerged as an extinction threat for the endangered Amur tiger (Panthera tigris altaica). CDV is vaccine-preventable, and control strategies could require vaccination of domestic dogs and/or wildlife populations. However, vaccination of endangered wildlife remains controversial, which has led to a focus on interventions in domestic dogs, often assumed to be the source of infection. Effective decision making requires an understanding of the true reservoir dynamics, which poses substantial challenges in remote areas with diverse host communities. We carried out serological, demographic, and phylogenetic studies of dog and wildlife populations in the Russian Far East to show that a number of wildlife species are more important than dogs, both in maintaining CDV and as sources of infection for tigers. Critically, therefore, because CDV circulates among multiple wildlife sources, dog vaccination alone would not be effective at protecting tigers. We show, however, that low-coverage vaccination of tigers themselves is feasible and would produce substantive reductions in extinction risks. Vaccination of endangered wildlife provides a valuable component of conservation strategies for endangered species.

The road to cervical cancer elimination in Malaysia: Evaluation of the impact and cost-effectiveness of human papillomavirus screening with self-collection and digital registry support.

The WHO has launched a global strategy to eliminate cervical cancer through the scale-up of human papillomavirus (HPV) vaccination, cervical screening, and cervical cancer treatment. Malaysia has achieved high-coverage HPV vaccination since 2010, but coverage of the existing cytology-based program remains low. Pilot studies found HPV self-sampling was acceptable and effective, with high follow-up rates when a digital registry was used, and recently the Malaysian Government announced plans for a national HPV-based screening program. We therefore evaluated the impact of primary HPV screening with self-collection in Malaysia in the context of Malaysia's existing vaccination program. We used the "Policy1-Cervix" modeling platform to assess health outcomes, cost-effectiveness, resource use and cervical cancer elimination timing (the year when cervical cancer rates reach four cases per 100 000 women) of implementing primary HPV testing with self-collection, assuming 70% routine-screening coverage could be achieved. Based on available data, we assumed that compliance with follow-up was 90% when a digital registry was used, but that compliance with follow-up would be 50-75% without the use of a digital registry. We found that the current vaccination program would prevent 27 000 to 32 200 cervical cancer cases and 11 700 to 14 000 deaths by 2070. HPV testing with a digital registry was cost-effective (CER = $US 6953-7549 < $US 11 373[<1×GDP per capita]) and could prevent an additional 15 900 to 17 800 cases and 9700 to 10 600 deaths by 2070, expediting national elimination by 11 to 20 years, to 2055 to 2059. If HPV screening were implemented without a digital registry, there would be 1800 to 4900 fewer deaths averted by 2070 and the program would be less cost-effective. These results underline the importance of HPV testing as a key elimination pillar in Malaysia.

Costs of Immunization Programs for 10 Vaccines in 94 Low- and Middle-Income Countries From 2011 to 2030.

OBJECTIVES: Understanding the level of investment needed for the 2021-2030 decade is important as the global community faces the next strategic period for vaccines and immunization programs. To assist with this goal, we estimated the aggregate costs of immunization programs for ten vaccines in 94 low- and middle-income countries from 2011 to 2030. METHOD: We calculated vaccine, immunization delivery and stockpile costs for 94 low- and middle-income countries leveraging the latest available data sources. We conducted scenario analyses to vary assumptions about the relationship between delivery cost and coverage as well as vaccine prices for fully self-financing countries. RESULTS: The total aggregate cost of immunization programs in 94 countries for 10 vaccines from 2011 to 2030 is $70.8 billion (confidence interval: $56.6-$93.3) under the base case scenario and $84.1 billion ($72.8-$102.7) under an incremental delivery cost scenario, with an increasing trend over two decades. The relative proportion of vaccine and delivery costs for pneumococcal conjugate, human papillomavirus, and rotavirus vaccines increase as more countries introduce these vaccines. Nine countries in accelerated transition phase bear the highest burden of the costs in the next decade, and uncertainty with vaccine prices for the 17 fully self-financing countries could lead to total costs that are 1.3-13.1 times higher than the base case scenario. CONCLUSION: Resource mobilization efforts at the global and country levels will be needed to reach the level of investment needed for the coming decade. Global-level initiatives and targeted strategies for transitioning countries will help ensure the sustainability of immunization programs.

Economic Benefits of Immunization for 10 Pathogens in 94 Low- and Middle-Income Countries From 2011 to 2030 Using Cost-of-Illness and Value-of-Statistical-Life Approaches.

OBJECTIVES: Vaccination has prevented millions of deaths and cases of disease in low- and middle-income countries (LMICs). During the Decade of Vaccines (2011-2020), international organizations, including the World Health Organization and Gavi, the Vaccine Alliance, focused on new vaccine introduction and expanded coverage of existing vaccines. As Gavi, other organizations, and country governments look to the future, we aimed to estimate the economic benefits of immunization programs made from 2011 to 2020 and potential gains in the future decade. METHODS: We used estimates of cases and deaths averted by vaccines against 10 pathogens in 94 LMICs to estimate the economic value of immunization. We applied 3 approaches-cost of illness averted (COI), value of statistical life (VSL), and value of statistical life-year (VSLY)-to estimate observable and unobservable economic benefits between 2011 and 2030. RESULTS: From 2011 to 2030, immunization would avert $1510.4 billion ($674.3-$2643.2 billion) (2018 USD) in costs of illness in the 94 modeled countries, compared with the counterfactual of no vaccination. Using the VSL approach, immunization would generate $3436.7 billion ($1615.8-$5657.2 billion) in benefits. Applying the VSLY approach, $5662.7 billion ($2547.2-$9719.4) in benefits would be generated. CONCLUSION: Vaccination has generated significant economic benefits in LMICs in the past decade. To reach predicted levels of economic benefits, countries and international donor organizations need to meet coverage projections outlined in the Gavi Operational Forecast. Estimates generated using the COI, VSL, or VSLY approach may be strategically used by donor agencies, decision makers, and advocates to inform investment cases and advocacy campaigns.

Significant decline of HPV 6 infection and genital warts despite low HPV vaccination coverage in young women in Germany: a long-term prospective, cohort data analysis.

BACKGROUND: The introduction of human papillomavirus (HPV) vaccination has resulted in a remarkable decline of genital warts in women and men, but in Germany historical rates of vaccination are relatively low. We report long-term surveillance data on changes in HPV 6 and HPV 11 infection and the prevalence of genital warts in young women in the Wolfsburg HPV epidemiological study (WOLVES). METHODS: Women born in 1983/84, 1988/89, and 1993/94 participated in four cohorts between 2009/10 and 2014/15. Quadrivalent vaccination coverage and prevalence of HPV 6/11 infection and genital warts are reported for participants aged 19-22 years and 24-27 years at the time of sample collection. Statistical analyses were done to compare similarly aged participants using 2 × 2 contingency tables (Röhmel-Mansmann unconditional exact test; two-side alpha of 0.05). RESULTS: A total of 2456 women were recruited. Between 2010 and 2015, there was a statistically significant decrease in the prevalence of HPV 6 infection among women aged 24-27 years (2.1% versus 0.0%; P < 0.0001) and women aged 19-22 years (2.0% versus 0.0%; P = 0.0056). There was no significant decline in HPV 11 infection. In total, 52 of 2341 participants were diagnosed with genital warts. There was a statistically significant drop in the risk of developing genital warts in women aged 24-27 years between 2010 and 2015 (4.7% versus 1.7%, respectively; P = 0.0018). The overall risk of developing genital warts in women aged 19-27 years decreased from 3.1% in 2010 to 1.2% in 2015 (P = 0.0022). CONCLUSIONS: An increase in vaccination coverage was associated with a decreased prevalence of genital warts in young women. A protective effect greater than herd immunity alone was seen despite low vaccination rates. Quadrivalent vaccine had a protective effect on genital HPV 6 infection and an almost fully protective effect on the development of genital warts in the youngest population.

An evaluation of strategies to achieve greater than 90% coverage of maternal influenza and pertussis vaccines including an economic evaluation.

BACKGROUND: Maternal immunisation is an essential public health intervention aimed at improving the health outcomes for pregnant women and providing protection to the newborn. Despite international recommendations, safety and efficacy data for the intervention, and often a fully funded program, uptake of vaccines in pregnancy remain suboptimal. One possible explanation for this includes limited access to vaccination services at the point of antenatal care. The aim of this study is to evaluate the change in vaccine coverage among pregnant women following implementation of a modified model of delivery aimed at improving access at the point of antenatal care, including an economic evaluation. METHODS: This prospective multi-centre study, using action research design, across six maternity services in Victoria, Australia, evaluated the implementation of a co-designed vaccine delivery model (either a pharmacy led model, midwife led model or primary care led model) supported by provider education. The main outcome measure was influenza and pertussis vaccine uptake during pregnancy and the incremental cost of the new model (compared to existing models) and the cost-effectiveness of the new model at each participating health service. RESULTS: Influenza vaccine coverage in 2019 increased between 50 and 196% from baseline. All services reduced their average cost per immunisation under the new platforms due to efficiencies achieved in the delivery of maternal immunisations. This cost saving ranged from $9 to $71. CONCLUSION: Our study demonstrated that there is no 'one size fits all' model of vaccine delivery. Future successful strategies to improve maternal vaccine coverage at other maternity services should be site specific, multifaceted, targeted at the existing barriers to maternal vaccine uptake, and heavily involve local stakeholders in the design and implementation of these strategies. The cost-effectiveness analysis indicates that an increase in maternal influenza immunisation uptake can be achieved at a relatively modest cost through amendment of maternal immunisation platforms.

Comparative Distributional Impact of Routine Immunization and Supplementary Immunization Activities in Delivery of Measles Vaccine in Low- and Middle-Income Countries.

OBJECTIVES: In many countries, measles disproportionately affects poorer households. To achieve equitable delivery, national immunization programs can use 2 main delivery platforms: routine immunization and supplementary immunization activities (SIAs). The objective of this article is to use data concerning measles vaccination coverage delivered via routine and SIA strategies to make inferences about the associated equity impact. METHODS: We relied on Demographic and Health Survey and Multiple Indicator Cluster Surveys multi-country survey data to conduct a comparative analysis of routine and SIA measles vaccination status of children by wealth quintile. We estimated the value of the angle, θ, for the ratio of the difference between coverage levels of adjacent wealth quintiles by using the arc-tangent formula. For each country/year observation, we averaged the θ estimates into one summary measurement, defined as the "equity impact number." RESULTS: Across 20 countries, the equity impact number summarized across wealth quintiles was greater (and hence less equitable) for routine delivery than for SIAs in the survey rounds (years) during, before, and after an SIA about 65% of the time. The equity impact numbers for routine measles vaccination averaged across wealth quintiles were usually greater than for SIA measles vaccination across country-year observations. CONCLUSIONS: This analysis examined how different measles vaccine delivery platforms can affect equity. It can serve to elucidate the impact of immunization and public health programs in terms of comparing horizontal to vertical delivery efforts and in reducing health inequalities in global and country-level decision-making.

Inequalities in measles immunization coverage in Ethiopia: a cross-sectional analysis of demographic and health surveys 2000-2016.

BACKGROUND: Ethiopia has low measles immunization coverage and little is known about the disparities surrounding what coverage is provided. This study assessed disparities in measles immunization and its change over time using the four Ethiopia Demographic and Health Surveys conducted between 2000 and 2016. METHODS: This is a cross-sectional analysis of data using Ethiopia Demographic and Health Surveys (EDHS) conducted between 2000 and 2016. We used the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) to present the inequalities. Four measures of inequality were calculated: Difference (D), Ratio (R), Population Attributable Fraction (PAF) and Population Attributable Risk (PAR). The results were disaggregated by wealth, education, residence, sex and sub-national regions and 95% Uncertainty Intervals (UIs) were computed for each point estimate to boost confidence of the findings. RESULTS: Measles immunization coverage was higher among the richest and secondary and above schools' subgroup by nearly 30 to 31 percentage points based on point estimates (D = 31%; 95% CI; 19.48, 42.66) and 29.8 percentage points (D = 29.8%; 95% CI; 16.57, 43.06) as compared to the poorest and no education subgroup respectively in the 2016 survey. Still, in the 2016 survey, substantial economic status (PAF = 36.73; 95%CI: 29.78, 43.68), (R = 1.71; 95%CI: 1.35, 2.08), education status (PAF = 45.07; 95% CI: 41.95, 48.18), (R = 1.60; 95% CI: 1.30, 1.90), place of residence (PAF = 39.84, 95% CI: 38.40, 41.27), (R = 1.47, 95% CI: 1.20, 1. 74) and regional (PAF = 71.35, 95% CI: 31.76, 110.95), (R = 3.09, 95%CI: 2.01, 4.17) inequality were observed with both simple and complex measures. There was no statistically significant difference in the prevalence of measles immunization between male and female children in all the studied years, as indicated, for instance, by measures of PAF in 2000 (PAF = 0; 95%CI: - 6.79, 6.79), 2005 (PAF = 0; 95%CI: - 6.04, 6.04), 2011(PAF = 0; 95%CI: - 3.79, 3.79) and 2016 (PAF = 2.66; - 1.67; 6.99). Overall, the inequality of measles immunization narrowed significantly by at least some of the measures between the first and the last survey periods across all the studied subgroups. CONCLUSIONS: National, regional and district levels of government should make a pledge to reduce inequalities in coverage of measles immunization. Equity-sensitive strategies, sufficient human and financial resources as well as continued research and monitoring of immunization coverage inequalities are necessary to achieve related sustainable development goals.

Stopping the HPV vaccine crisis in Japan: Quantifying the benefits and risks of HPV vaccination in quality-adjusted life-years for appropriate decision-making.

BACKGROUND: The human papilloma virus (HPV) vaccination coverage rate in Japan has dropped dramatically from more than 70% to less than 1% since 2013. With conflicting information and a lack of quantification of the benefits and risks of the HPV vaccine, parents have been hindered in making their decision. We quantified the benefits and risks of the HPV vaccine in terms of quality-adjusted life-years (QALYs), to help their informed decision. METHOD: A literature search was performed to determine the incidence and burden of each outcome in a decision tree model. The benefits and the risks of the HPV vaccination were determined in QALY change with a sensitivity analysis. RESULT: The benefits of the HPV vaccine in terms of QALYs gained were 703.72, 14.45, and 30.83/100,000 persons for cervical cancer, cervical intraepithelial neoplasm 3 (CIN 3), and genital warts, respectively. The QALY loss due to acute adverse reactions, chronic adverse reactions without assistance needs, and chronic adverse reactions with assistance needs were 0.07, 5.83, and 5.82/100,000 persons, respectively. The risk/benefit ratio in QALY change in the base case was 0.0156. In all scenarios, the benefit of the HPV vaccine was significantly greater than the risk. CONCLUSION: The benefits are much greater than the risks, even if it is assumed that all reported adverse events were due to the vaccination. The Japanese government and health care providers should immediately recommend the HPV vaccine to all adolescent girls irrespective of any causal links between the vaccine and reported adverse events.

The case for a universal hepatitis C vaccine to achieve hepatitis C elimination.

BACKGROUND: The introduction of highly effective direct-acting antiviral (DAA) therapy for hepatitis C has led to calls to eliminate it as a public health threat through treatment-as-prevention. Recent studies suggest it is possible to develop a vaccine to prevent hepatitis C. Using a mathematical model, we examined the potential impact of a hepatitis C vaccine on the feasibility and cost of achieving the global WHO elimination target of an 80% reduction in incidence by 2030 in the era of DAA treatment. METHODS: The model was calibrated to 167 countries and included two population groups (people who inject drugs (PWID) and the general community), features of the care cascade, and the coverage of health systems to deliver services. Projections were made for 2018-2030. RESULTS: The optimal incidence reduction strategy was to implement test and treat programmes among PWID, and in settings with high levels of community transmission undertake screening and treatment of the general population. With a vaccine available, the optimal strategy was to include vaccination within test and treat programmes, in addition to vaccinating adolescents in settings with high levels of community transmission. Of the 167 countries modelled, between 0 and 48 could achieve an 80% reduction in incidence without a vaccine. This increased to 15-113 countries if a 75% efficacious vaccine with a 10-year duration of protection were available. If a vaccination course cost US$200, vaccine use reduced the cost of elimination for 66 countries (40%) by an aggregate of US$7.4 (US$6.6-8.2) billion. For a US$50 per course vaccine, this increased to a US$9.8 (US$8.7-10.8) billion cost reduction across 78 countries (47%). CONCLUSIONS: These findings strongly support the case for hepatitis C vaccine development as an urgent public health need, to ensure hepatitis C elimination is achievable and at substantially reduced costs for a majority of countries.

Estimating the effectiveness of vaccine programs in dog populations.

Dogs harbor numerous zoonotic pathogens, many of which are controlled through vaccination programs. The delivery of these programs can be difficult where resources are limited. We developed a dynamic model to estimate vaccination coverage and cost-per-dog vaccinated. The model considers the main factors that affect vaccination programs: dog demographics, effectiveness of strategies, efficacy of interventions and cost. The model was evaluated on data from 18 vaccination programs representing eight countries. Sensitivity analysis was performed for dog confinement and vaccination strategies. The average difference between modelled vaccination coverage and field data was 3.8% (2.3%-5.3%). Central point vaccination was the most cost-effective vaccination strategy when >88% of the dog population was confined. More active methods of vaccination, such as door-to-door or capture-vaccinate-release, achieved higher vaccination coverage in free-roaming dog populations but were more costly. This open-access tool can aid in planning more efficient vaccination campaigns in countries with limited resources.

Health policy analysis of the non-implementation of HPV vaccination coverage in the pay for performance scheme in France.

Background: The French National Cancer Control Plan (NCCP) launched in 2014 set the objective to improve human papillomavirus (HPV) vaccination coverage (VC). The NCCP included a measure to integrate a VC indicator in the pay for performance (P4P) scheme for general practitioners (GPs), which was not implemented. The objective of the study was to analyse the reasons for non-implementation of this measure, using the health policy analysis framework. Methods: The policy from proposal to non-implementation of the HPV VC indicator into the P4P scheme was analysed through the actors involved, the content of the measure, the contextual factors and the processes of policy-making. Results: The actors were the Ministry of Health (MOH) and National Cancer Institute as policy-makers, the public health insurance as an indirect target, and GPs as direct targets. The content of the policy was not evidence-informed and was not included into the NCCP preparation report. The context included vaccine hesitancy and ethical concerns from GPs in opposition with MOH. The process involved a diversity of stakeholders with a complex governance and no strict monitoring of the measure. Conclusions: Complex vaccination policy governance associated with a non-evidence-informed policy content and an unfavourable context may have been the reasons for the policy failure.

Systematic review of the costs and effectiveness of interventions to increase infant vaccination coverage in low- and middle-income countries.

BACKGROUND: In recent years, several large studies have assessed the costs of national infant immunization programs, and the results of these studies are used to support planning and budgeting in low- and middle-income countries. However, few studies have addressed the costs and cost-effectiveness of interventions to improve immunization coverage, despite this being a major focus of policy attention. Without this information, countries and international stakeholders have little objective evidence on the efficiency of competing interventions for improving coverage. METHODS: We conducted a systematic literature review on the costs and cost-effectiveness of interventions to improve immunization coverage in low- and middle-income countries, including both published and unpublished reports. We evaluated the quality of included studies and extracted data on costs and incremental coverage. Where possible, we calculated incremental cost-effectiveness ratios (ICERs) to describe the efficiency of each intervention in increasing coverage. RESULTS: A total of 14 out of 41 full text articles reviewed met criteria for inclusion in the final review. Interventions for increasing immunization coverage included demand generation, modified delivery approaches, cash transfer programs, health systems strengthening, and novel technology usage. We observed substantial heterogeneity in costing methods and incompleteness of cost and coverage reporting. Most studies reported increases in coverage following the interventions, with coverage increasing by an average of 23 percentage points post-intervention across studies. ICERs ranged from $0.66 to $161.95 per child vaccinated in 2017 USD. We did not conduct a meta-analysis given the small number of estimates and variety of interventions included. CONCLUSIONS: There is little quantitative evidence on the costs and cost-effectiveness of interventions for improving immunization coverage, despite this being a major objective for national immunization programs. Efforts to improve the level of costing evidence-such as by integrating cost analysis within implementation studies and trials of immunization scale up-could allow programs to better allocate resources for coverage improvement. Greater adoption of standardized cost reporting methods would also enable the synthesis and use of cost data.