Cost-effectiveness of providing measles vaccination to all children in Guinea-Bissau

Abstract

Background: Measles vaccination is associated with major reductions in child mortality and morbidity. In Guinea-Bissau, to limit vaccine wastage, children are only measles-vaccinated if at least six children aged 9–11 months are present at a vaccination session.Objective: To estimate the incremental cost-effectiveness of providing measles vaccine (MV) to all children regardless of age and number of children present.Methods: We estimated MV coverage among children living in villages cluster-randomized to MV for all children and among children cluster-randomized to the current restrictive MV policy (status quo). Prices of MV and injection equipment were obtained from the United Nations Children’s Fund (UNICEF). Cost savings of hospital admissions averted were collected from a sample of health facilities. The non-specific mortality effects of MV were estimated and presented as deaths averted and life years gained (LYG) from providing MV-for-all.Results: MV coverage at 36 months was 97% in MV-for-all clusters and 84% in restrictive MV policy clusters. Conservatively assuming 90% wastage of MV under the MV-for-all policy and 40% under the restrictive MV policy, cost per child vaccinated was USD 3.08 and USD 1.19, respectively. The incremental costs per LYG and death averted of the MV-for-all policy were USD 5.61 and USD 148, respectively. The MV-for-all policy became cost-saving at 88% wastage.Conclusions: Taking the low cost of MV and the beneficial non-specific effects of MV into consideration, a 10-dose MV vial should be reclassified as a ‘1+ dose vial’. The vial should be opened for a single child, irrespective of age, but can vaccinate up to 10 children.

Modeling the economic impact of different vial-opening thresholds for measles-containing vaccines

“…In each country, we modeled three vial-opening threshold policies to capture a range of existing policies and practices across different immunization programs. Instituting no vial-opening threshold policy allowed MCVs to be opened for one or more children. This practice has high potential for MCV wastage, but is advocated for in literature and guidelines as a potential solution to improving MCV coverage and reducing missed opportunities to vaccinate [2], [5]. Instituting a 30% vial-opening threshold policy meant that MCVs would be opened only if the demand in a given session would use 30% of MCV doses, i.e. a 10-dose MCV would be opened if at least three children were present and a 5-dose MCV would be opened if at least two children were present.…”

“…The lack of specific policies on how many children must be present at a vaccinating location before a healthcare worker can open a measles-containing vaccine (MCV) – referred to as the vial-opening threshold – has led to variable and inconsistent practices within and between countries [1], [2]. Due to the complexity of vaccine supply chains [3], vial-opening threshold decisions for MCV, which must be discarded within six hours of opening, may have reverberating effects on the entire system.…”

“…While various MCV vial-opening threshold policies have been advocated [1], [2], [4], [5], the direct effects of these policies are not well documented and their effects on the entire vaccine supply chain system are unknown. Advocates for no vial-opening threshold (i.e.…”

“…Advocates for no vial-opening threshold (i.e. opening an MCV vial for any number of children) want to reduce missed opportunities to vaccinate at the expense of higher MCV open-vial wastage [2], [5]. Conversely, advocates for strict vial-opening thresholds (requiring six or more children to be present before a 10-dose MCV vial is opened) want to preserve MCV vials for larger vaccination sessions and reduce the costs associated with wastage and procurement of additional vaccines [1], [4].…”

“…Conversely, advocates for strict vial-opening thresholds (requiring six or more children to be present before a 10-dose MCV vial is opened) want to preserve MCV vials for larger vaccination sessions and reduce the costs associated with wastage and procurement of additional vaccines [1], [4]. Such existing policies for strict vial-opening measures are often a response to specific wastage targets established for immunization programs of Gavi-eligible countries [1], [2]. While few studies have pointed to the effects of these policies on MCV availability, wastage, and costs for specific supply chains, there is no evidence for how these or any other vial-opening threshold policies may affect the entire supply chain system – particularly the availability of other routine immunizations – or apply across multiple heterogenous supply chains.…”