Elsevier

Vaccine

Volume 31, Issue 1, 17 December 2012, Pages 96-108
Vaccine

Cost-effectiveness and economic benefits of vaccines in low- and middle-income countries: A systematic review

https://doi.org/10.1016/j.vaccine.2012.10.103Get rights and content

Abstract

Background

Public health interventions that prevent mortality and morbidity have greatly increased over the past decade. Immunization is one of these preventive interventions, with a potential to bring economic benefits beyond just health benefits. While vaccines are considered to be a cost-effective public health intervention, implementation has become increasingly challenging. As vaccine costs rise and competing priorities increase, economic evidence is likely to play an increasingly important role in vaccination decisions.

Methods

To assist policy decisions today and potential investments in the future, we provide a systematic review of the literature on the cost-effectiveness and economic benefits of vaccines in low- and middle-income countries from 2000 to 2010. The review identified 108 relevant articles from 51 countries spanning 23 vaccines from three major electronic databases (Pubmed, Embase and Econlit).

Results

Among the 44 articles that reported costs per disability-adjusted life year (DALY) averted, vaccines cost less than or equal to $100 per DALY averted in 23 articles (52%). Vaccines cost less than $500 per DALY averted in 34 articles (77%), and less than $1000 per DALY averted in 38 articles (86%) in one of the scenarios. 24 articles (22%) examined broad level economic benefits of vaccines such as greater future wage-earning capacity and cost savings from averting disease outbreaks. 60 articles (56%) gathered data from a primary source. There were little data on long-term and societal economic benefits such as morbidity-related productivity gains, averting catastrophic health expenditures, growth in gross domestic product (GDP), and economic implications of demographic changes resulting from vaccination.

Conclusions

This review documents the available evidence and shows that vaccination in low- and middle-income countries brings important economic benefits. The cost-effectiveness studies reviewed suggest to policy makers that vaccines are an efficient investment. This review further highlights key gaps in the available literature that would benefit from additional research, especially in the area of evaluating the broader economic benefits of vaccination in the developing world.

Highlights

► Reviews the economic benefits of adult and childhood vaccines in developing countries. ► Identified 108 articles from 51 countries covering 23 vaccines. ► 44 articles reported cost per disability-adjusted life years (DALY) averted. ► Vaccines cost less than $100 ($500) per DALY averted in 52% (77%) of articles. ► Few studies measure the long-term and societal economic benefits from vaccination.

Introduction

While vaccines are considered to be a cost-effective public health intervention, introduction and scale-up have become increasingly challenging. Governments in low- and middle-income countries and the international donor community face growing pressures on how to allocate their scarce resources and choose among many competing priorities. As the scope and costs of new vaccines continue to grow, economic evidence is likely to play an increasingly important role in decisions to introduce and sustain vaccination.

Vaccines may bring economic benefits beyond just health gains and there may be various pathways for these benefits to accrue. Unlike other health interventions, studies find that vaccines avert illness both directly through immunization and indirectly through herd immunity [1]. Both types of prevention can lead to a healthier, more productive population that can contribute more toward a country's economic development [2]. For example, by averting illness directly, households with vaccinated children can save medical costs and parents may take fewer days off of work to care for sick children [3]. By averting disabilities, some vaccines may prevent delays in cognitive development and may also improve school enrollment and attainment [4]. By averting deaths, vaccines may even alter fertility decisions due to greater child survival [3], [5]. While all such changes can have an immense impact on a country's economy, it is difficult to get a full picture of the economic impact resulting from immunization. Understanding the full economic benefits of vaccines is vital to policy makers whose decisions to introduce new vaccines not only impact the health of a society, but also its economy. Evidence on such economic benefits is therefore critical in assessing the full return on investment in vaccines.

For example, with the US$10 billion commitment and call to action by the Bill and Melinda Gates Foundation to increase access to life-saving vaccines during the “Decade of Vaccines” [6], there is greater need for evidence on vaccines’ return on investment, particularly at the country level. To assist both future investment and policy decisions today, we provide a review of the literature on the economic benefits of adult and childhood vaccines in low- and middle-income countries from 2000 to 2010. This systematic review addresses four research questions: How cost-effective are vaccines? How much are people willing to pay for vaccines? How frequently do economic benefit models use primary data? What narrow and broad economic benefits from vaccination have been reported?

Section snippets

Materials and methods

We conducted a systematic search in three major electronic databases [Pubmed (MEDLINE), Embase and Econlit (EBSCOhost)] to locate peer-reviewed articles on the economic benefit of vaccines in low- and middle-income countries. Specifically, we searched for articles that tried to quantify this benefit. The search, performed in February 2011, used variations of the following three keywords: “economic benefit” AND “vaccine” AND “low- and middle-income country”. Relevant MESH terms were selected and

Results

Pubmed search yielded 1225 articles. The search in Econlit yielded 44 articles where two unique articles were included. The Embase search produced 537 articles with nine unique studies. 14 additional articles were identified through reference list review and expert consultation. The initial screening resulted in 205 articles, of which 39 were duplicates. We read full-length versions of the 166 articles of which 58 articles were further excluded based on our criteria. This resulted in 108

Discussion

This review documents the available evidence showing that vaccination in low- and middle-income countries brings economic benefits beyond just health gains. The majority of studies illustrate that vaccines are cost-effective at less than $1000 per DALY averted, and many less than $100 per DALY averted. This suggests to policy makers that vaccines tend to be an efficient investment. Just as importantly, this review highlights key gaps in the available literature that need additional research,

Conclusions

This review identified more than 100 papers that illustrate the cost-effectiveness and economic benefits of vaccination in low- and middle-income countries. However, it also shows that most studies take a narrow perspective of the economic benefits of vaccination, and that a number of key gaps in evidence remain unfilled. To better represent the full economic benefits of vaccines in low- and middle-income country settings, the published literature would greatly benefit from approaches that

Acknowledgements

We thank Rohan Deogaonkar, Raymond Hutubessy and Mark Jit for their valuable comments. This study was performed with financial support from the Bill & Melinda Gates Foundation. The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation.

References (119)

  • M. Cropper et al.

    The demand for a malaria vaccine: evidence from Ethiopia

    J Dev Econ

    (2004)
  • G.H. Dayan et al.

    Cost-effectiveness of three different vaccination strategies against measles in Zambian children

    Vaccine

    (2004)
  • F. De la Hoz et al.

    Potential epidemiological and economical impact of two rotavirus vaccines in Colombia

    Vaccine

    (2010)
  • N.D. Giglio et al.

    Cost-effectiveness of the CRM-based 7-valent pneumococcal conjugated vaccine (PCV7) in Argentina

    Vaccine

    (2010)
  • S.J. Goldie et al.

    Cost-effectiveness of HPV 16,18 vaccination in Brazil

    Vaccine

    (2007)
  • S.J. Goldie et al.

    Health and economic outcomes of HPV 16,18 vaccination in 72 GAVI-eligible countries

    Vaccine

    (2008)
  • S.J. Goldie et al.

    Benefits, cost requirements and cost-effectiveness of the HPV16,18 vaccine for cervical cancer prevention in developing countries: policy implications

    Reprod Health Matters

    (2008)
  • U.K. Griffiths et al.

    The cost-effectiveness of alternative polio immunization policies in South Africa

    Vaccine

    (2006)
  • R.P. Insinga et al.

    Cost-effectiveness of quadrivalent human papillomavirus (HPV) vaccination in Mexico: a transmission dynamic model-based evaluation

    Vaccine

    (2007)
  • E.T. Isakbaeva et al.

    Rotavirus disease in Uzbekistan: cost-effectiveness of a new vaccine

    Vaccine

    (2007)
  • Z. Islam et al.

    Private demand for cholera vaccines in rural Matlab, Bangladesh

    Health Policy

    (2008)
  • M. Jeuland et al.

    Cost-effectiveness of new-generation oral cholera vaccines: a multisite analysis

    Value Health

    (2009)
  • M. Jeuland et al.

    Cost–benefit comparisons of investments in improved water supply and cholera vaccination programs

    Vaccine

    (2009)
  • M. Jeuland et al.

    Estimating the private benefits of vaccination against cholera in Beira, Mozambique: a travel cost approach

    J Dev Econ

    (2010)
  • M.M. Khan

    Economics of polio vaccination in the post-eradication era: should OPV-using countries adopt IPV?

    Vaccine

    (2008)
  • J.J. Kim et al.

    Exploring the cost-effectiveness of HPV vaccination in Vietnam: insights for evidence-based cervical cancer prevention policy

    Vaccine

    (2008)
  • M.E. Lucas et al.

    Private demand for cholera vaccines in Beira, Mozambique

    Vaccine

    (2007)
  • J.J. Meij et al.

    Low-cost interventions accelerate epidemiological transition in Upper East Ghana

    Trans R Soc Trop Med Hyg

    (2009)
  • R. Palanca-Tan

    The demand for a dengue vaccine: a contingent valuation survey in Metro Manila

    Vaccine

    (2008)
  • I. Parent du Châtelet et al.

    Comparison of cost-effectiveness of preventive and reactive mass immunization campaigns against meningococcal meningitis in West Africa: a theoretical modeling analysis

    Vaccine

    (2001)
  • A.E. Platonov et al.

    Economic evaluation of Haemophilus influenzae type b vaccination in Moscow, Russian Federation

    Vaccine

    (2006)
  • L.M. Reynales-Shigematsu et al.

    Cost-effectiveness analysis of a quadrivalent human papilloma virus vaccine in Mexico

    Arch Med Res

    (2009)
  • J.M. Simmerman et al.

    The cost of influenza in Thailand

    Vaccine

    (2006)
  • E. Sinanovic et al.

    The potential cost-effectiveness of adding a human papillomavirus vaccine to the cervical cancer screening programme in South Africa

    Vaccine

    (2009)
  • A. Sinha et al.

    Cost-effectiveness of pneumococcal conjugate vaccination in the prevention of child mortality: an international economic analysis

    Lancet

    (2007)
  • T.J. John et al.

    Herd immunity and herd effect: new insights and definitions

    Eur J Epidemiol

    (2000)
  • D. Evans et al.

    WHO guide to identifying the economic consequences of disease and injury

    (2009)
  • D. Bloom et al.

    Health, wealth and welfare

    Finance Dev

    (2004)
  • C. Elias

    The Decade of Vaccines Collaboration: developing a global roadmap for saving lives

    Expert Rev Vaccines

    (2011)
  • T. Barnighausen et al.

    Accounting for the full benefits of childhood vaccination in South Africa

    S Afr Med J

    (2008)
  • D. Moher et al.

    Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

    PLoS Med

    (2009)
  • A.O. Akumu et al.

    Economic evaluation of delivering Haemophilus influenzae type b vaccine in routine immunization services in Kenya

    Bull World Health Organ

    (2007)
  • S. Amirfar et al.

    Modeling the impact of a partially effective HIV vaccine on HIV infection and death among women and infants in South Africa

    J Acquir Immune Defic Syndr

    (2006)
  • A. Apisarnthanarak et al.

    Outbreaks of Influenza A among nonvaccinated healthcare workers: implications for resource-limited settings

    Infect Control Hosp Epidemiol

    (2008)
  • D. Atherly et al.

    Rotavirus vaccination: cost effectiveness and impact on child mortality in developing countries

    J Infect Dis

    (2009)
  • R. Bahl et al.

    Costs of illness due to typhoid fever in an Indian urban slum community: implications for vaccination policy

    J Health Popul Nutr

    (2004)
  • A.A. Bawah et al.

    The impact of immunization on the association between poverty and child survival: evidence from Kassena-Nankana District of northern Ghana

    Scand J Public Health

    (2010)
  • E.R. Berndt et al.

    Advance market commitments for vaccines against neglected diseases: estimating costs and effectiveness

    Health Econ

    (2007)
  • S.A. Berry et al.

    The cost-effectiveness of rotavirus vaccination in Malawi

    J Infect Dis

    (2010)
  • D. Bishai et al.

    Cost effectiveness of measles eradication

    (2010)
  • Cited by (181)

    View all citing articles on Scopus
    View full text