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Taking vaccine effectiveness into public health decision making:
The ProVac Example
Cara Bess Janusz
Gabriela Felix
Jon Andrus
Immunization, PAHO Evaluating dengue effectiveness workshop June 12th, 2014 Washington, DC
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• ProVac’s Goal: strengthen national capacity to
make informed, evidence-based decisions
regarding vaccine introduction
• Current focus on 4 vaccines:
• Rotavirus
• Pneumococcal conjugate
• HPV
• Influenza
• (in the future: dengue, malaria, second generation & others)
Objectives of the ProVac Initiative
Objective 1 Strengthen infrastructure and processes for decision
making
Objective 4 Advocate for evidence based decisionmaking
Objective 2 Develop tools for EE and
provide training to multidisciplinary teams
Objective 3
Collect data, perform analysis and gather the framework of evidence
Objective 5 Support an effective &
sustainable NUVI
• NITAG strengthening • Legal frameworks • South-south academic network
• Cost-effectiveness models • Program costing model • Regional training workshops
• Direct country support • Methodological guidelines
• Results presented to authorities • Technical reports & policy briefs
• Costing exercises to inform new vaccine intro
2
Country CEA study (MoH-led team) WHO Regional Training Workshops
National Vaccine Committees ProVac Models, OLIVES (Data/Evidence)
Sustainable impact…
3
4
Countries have requested technical support from PAHO to help integrate
economic studies into the national decision-making process for
immunization - 2006 Directing Council resolution (CD47.R10)
National Advisory
Committee
ProVac at PAHO (Washington DC)
ProVac Centers of Excellence
Ministry of Health
National level Regional level
ProVac National
Team
EPI Manager Surveill.
Officers
Clinician
Health Economist
PAHO CountryOffice
Nat’l Consultant
ProVac’s technical cooperation
Considerations for new vaccine policymaking at country-level
Source: Andrus, JK., Toscano, CM., Lewis, M., Oliveira, L. , et al. 2007, “A model for enhancing evidence-based capacity to make informed policy decisions on the introduction of new vaccines in the Americas: PAHO’s ProVac Initiative”, Public Health Reports, 122(6): 811-816.
Technical
Social Operational & Programmatic
EVIDENCE PACKAGE
Considerations for new vaccine policymaking at country-level
Source: Andrus, JK., Toscano, CM., Lewis, M., Oliveira, L. , et al. 2007, “A model for enhancing evidence-based capacity to make informed policy decisions on the introduction of new vaccines in the Americas: PAHO’s ProVac Initiative”, Public Health Reports, 122(6): 811-816.
Social Operational & Programmatic
EVIDENCE PACKAGE
Disease burden Vaccine characteristics • Immunogenicity • Efficacy/effectiveness • Duration of protection • Type-specific protection • Dosage Safety and adverse events (harms) Cost-effectiveness
Technical
Considerations for new vaccine policymaking at country-level
Source: Andrus, JK., Toscano, CM., Lewis, M., Oliveira, L. , et al. 2007, “A model for enhancing evidence-based capacity to make informed policy decisions on the introduction of new vaccines in the Americas: PAHO’s ProVac Initiative”, Public Health Reports, 122(6): 811-816.
Social Operational & Programmatic
EVIDENCE PACKAGE
Vaccine supply Logistics & operational issues Financing strategies Partnerships
Technical
Considerations for new vaccine policymaking at country-level
Source: Andrus, JK., Toscano, CM., Lewis, M., Oliveira, L. , et al. 2007, “A model for enhancing evidence-based capacity to make informed policy decisions on the introduction of new vaccines in the Americas: PAHO’s ProVac Initiative”, Public Health Reports, 122(6): 811-816.
Technical
Social Operational & Programmatic
EVIDENCE PACKAGE
Acceptability Perception of risk
Political will Equity
Considerations for new vaccine policymaking at country-level
Source: Andrus, JK., Toscano, CM., Lewis, M., Oliveira, L. , et al. 2007, “A model for enhancing evidence-based capacity to make informed policy decisions on the introduction of new vaccines in the Americas: PAHO’s ProVac Initiative”, Public Health Reports, 122(6): 811-816.
Technical
Social Operational & Programmatic
EVIDENCE PACKAGE
Disease burden Vaccine characteristics • Immunogenicity • Efficacy/effectiveness • Duration of protection • Type-specific protection • Dosage Safety and adverse events (harms) Cost-effectiveness
Vaccine supply Logistics & operational issues Financing strategies Partnerships
Acceptability Perception of risk
Political will Equity
MoH-led CEA/impact
(ProVac)
(PCV in Argentina)
Agency-led
CEA/impact
(Hib vaccine in India)
– TRIVAC model used
– Outside agency
presented to NITAG
– Outside agency led
publication of results
– No MoH training
– GAVI finance
available but
significant delays in
adoption
10
CEA/impact not
considered
(political decision)
Scenario 1 Scenario 2 Scenario 3
– TRIVAC model used
– MoH presented to
NITAG
– MoH-led publication of
results
– MoH trained and led
subsequent CEA of
RV/HPV
– PCV quickly
financed/adopted
Slide courtesy of Andrew Clark, ProVac Modeller
TRIVAC:
Impact/CEA of
Hib, RV and PCV
CERVIVAC:
impact/CEA of
HPV vaccine
and/or screening
Effectiveness important driver of cost-effectiveness analysis results…
Numerator = total costs to implement new vaccine program – health
services cost savings associated with disease prevention
Denominator = life years lost due to premature mortality + life years lost
due to disability (in presence of vaccination)
Incremental cost-effectiveness ratios (Cost per DALY averted) are
compared to cost-effectiveness threshold, generally GNI per capita
Other outcomes: Lives saved, cases prevented, sequaela prevented,
hospitalizations averted
Step-wise calculations to estimate vaccine impact (effectiveness): Example childhood vaccine
Number of life-years 1-59 months per cohort
x Incidence of cases 1-59 months per 100,000 per year
x % of cases by age (<3m, 3-5m, 6-8m, 9-11m, 12-23m, 24-35m, 36-47m, 48-59m)
x Efficacy by dose (1, 2, 3, booster)
x Vaccine Type Coverage (SP and Rota) & replacement effects
x Coverage by dose (1, 2, 3, booster)
x Timeliness by dose (1, 2, 3, booster)
x Relative coverage (% of coverage reaching high risk children)
x Decrease in protection due to Waning
x Herd Effect multiplier
….includes options for one-way sensitivity analysis, scenario analysis and PSA
Methods published
15
Country Study Request Status Publication Decision
Argentina CEA pneumo 2010 Finished Published Introduced
Argentina CEA rota 2011 Finished Drafting Pending…
Bolivia CEA pneumo 2011 Finished Drafting Introduced
Costa Rica CEA pneumo 2012 Finished - Introduced
Ecuador CEA pneumo 2011 Finished Drafting Introduced
El Salvador CEA pneumo 2011 Finished Drafting Introduced
Guatemala CEA pneumo 2011 Finished Drafting Introduced
Guatemala CEA rota 2011 Finished Drafting Introduced
Nicaragua CEA pneumo 2010 Finished - Introduced
Paraguay CEA pneumo 2010 Finished For submission Introduced
Peru CEA pneumo 2012 Finished Drafting Introduced
Venezuela CEA pneumo 2013 Request received - Pending…
Country Study Request Status Publication Decision
Argentina CEA HPV 2011 In progress - Introduced
Belize CEA HPV 2013 Request received - Pending…
Bolivia CEA HPV 2011 Finished Drafting Pending…
Costa Rica CEA HPV 2013 Request received - Pending…
Ecuador CEA HPV 2012 Finished Drafting Pending…
Guatemala CEA HPV 2012 In progress - Pending…
Honduras CEA HPV 2012 In progress - Pending…
Jamaica CEA HPV 2011 Finished Drafting Pending…
Paraguay CEA HPV 2011 In progress - Pending…
Peru CEA HPV 2013 Request received - Pending…
Uruguay CEA HPV 2012 In progress - Pending…
TRIVAC Model
CERVIVAC Model
ProVac direct technical support to countries to
conduct a cost-effectiveness analysis
2009 2010 2011 2012 2013 2014
Models (Impact and cost-effectiveness)
PCV (TRIVAC)
Training workshop
Ongoing country studies….
RV (TRIVAC)
Training workshop
Ongoing country studies….
HPV (CERVIVAC)
Training workshop
Ongoing country studies….
UNIVAC
Model (EPI Costing)
COSTVAC Pilot and develop
Training workshop
Country studies…
Model (Disease Cost)
COSTCARE
Data/Evidence OLIVES Maintenance of database of evidence used in models On-line Launch
Methods WHO GUIDELINES
Development of Guides
On-line Launch
Dissemination Templates
REPORTING TEMPLATES
Development of Templates
On-line Launch
ProVac Initiative: models, data and guides
17
Future direction
• Model development: UNIVAC o Integrate Hib, Rotavirus, Pneumococcal and HPV modules
o Expand to include Hepatitis A
o Other vaccines – different transmission mechanisms and dynamics…
malaria, dengue
• Share framework and lessons learnt with other WHO
Regions
• Further strengthening of country capacity to
incorporate equity metrics and financing
implications, i.e. long term vision
For general information, technical documents and articles go to:
www.paho.org/provac
To request for direct technical support contact: Cara Janusz ([email protected]), ProVac Technical Officer
Gabriela Felix ([email protected]), ProVac IWG Coordinator
Or this e-mail address:
How can I learn more about ProVac?