The ProVac Example - Sabin

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




EVIDENCE PACKAGE

Disease burden Vaccine characteristics • Immunogenicity • Efficacy/effectiveness • Duration of protection • Type-specific protection • Dosage Safety and adverse events (harms) Cost-effectiveness

Technical




EVIDENCE PACKAGE

Vaccine supply Logistics & operational issues Financing strategies Partnerships

Technical



Technical


EVIDENCE PACKAGE

Acceptability Perception of risk

Political will Equity



Technical


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


HPV (CERVIVAC)

Training workshop


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:

[email protected]

How can I learn more about ProVac?

http://www.paho.org/provac

mailto:[email protected]



Documents

The ProVac Example - Sabin