Toward economic evaluation of the value of vaccines and other health technologies in addressing AMR

Abstract

We discuss the need to make economic evaluations of vaccines antimicrobial resistance (AMR)-sensitive and ways to do so. Such AMR-sensitive evaluations can play a role in value-for-money comparisons of different vaccines within a national immunization program, or in comparisons of vaccine-centric and non-vaccine-centric technologies within an anti-AMR program. In general terms, incremental cost-effectiveness ratios and rates of return and their associated decision rules are unaltered by consideration of AMR-related value. The decision metrics need to have their various health, cost, and socioeconomic terms disaggregated into resistance-related subcategories, which in turn have to be measured carefully before they are reaggregated. The fundamental scientific challenges lie primarily in quantifying the causal impact of health technologies on resistance-related health outcomes, and secondarily in ascertaining the economic value of those outcomes. We emphasize the importance of evaluating vaccines in the context of other potentially complementary and substitutable nonvaccine technologies. Complementarity implies that optimal spending on each set of interventions is positive, and substitutability implies that the ratio of spending will depend on relative value for money. We exemplify this general point through a qualitative discussion of the complementarities and (especially the) substitutability between pneumococcal conjugate vaccines and antimicrobial stewardship and between research and development (R&D) of a gonorrhea vaccine versus R&D of a gonorrhea antibiotic. We propose a roadmap for future work, which includes quantifying the causal effects of vaccination and other health technologies on short-term and long-term resistance-related outcomes, measuring the health-sector costs and broader socioeconomic consequences of resistance-related mortality and morbidity, and evaluating vaccines in the context of nonvaccine complements and substitutes.

Estimating the proportion of bystander selection for antibiotic resistance among potentially pathogenic bacterial flora

“…We have described an approach for using estimates of bystander exposures to estimate how vaccines could reduce exposure across various nontarget pathogens. However, as noted by Sevilla et al (19) in PNAS, quantifying the impact of vaccines on antimicrobial resistance is a complex task, and many components of such calculations will depend on the population, vaccine, and timescale considered, among other variables.…”

Immunization: vital progress, unfinished agenda

“…There is also a need for innovation in trial design (for faster trials with smaller sample sizes, and including collection of valuable biosamples to inform correlates of protection) and in trial analysis, as well as in vaccine delivery. Escalating antimicrobial resistance is a powerful incentive to develop vaccines against bacterial infections, malaria, tuberculosis and HIV infection [108][109][110] . Innovation in the delivery of vaccination programmes is as important as product innovation.…”

Impact of vaccines on antimicrobial resistance

“…In practice, however, there are many barriers to implementing large-scale antibiotic stewardship, especially in countries with unregulated access to antibiotics. By contrast, vaccination has the potential to reduce both appropriate and inappropriate use of antibiotics, both of which lead to resistance, by reducing both susceptible and resistant disease (Sevilla et al, 2018). There is evidence showing a reduction in antibiotic-resistant infection and subsequent morbidity and mortality rates at the population level following vaccination programmes.…”