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Johns Hopkins Bloomberg School of Public Health


Keyword: economics

By Dr. Sachiko Ozawa

Evidence on the value of vaccines is essential for donors and government officials to see what their investment in vaccines buys. This value isn’t only about the health impacts we tend to think of – such as lives saved, illnesses prevented, and disability averted from vaccines. Vaccines also bring about broader economic benefits. Families avoid treatment costs and parents do not have to take off from work to care for sick children. Children may also have fewer missed school days, succeed better in school, and take on higher-paying jobs to support the country’s economy. In short, vaccines are likely to bring much value beyond direct health impacts.

Sachiko Ozawa

Sachiko Ozawa, PhD, MHS

Last week I participated on a value of vaccines panel at the GAVI Partners’ Forum that focused on just this idea. Raymond Hutubessy from the World Health Organization introduced the importance of valuing the full value of vaccines. I then presented the current evidence base including a recently published literature review from IVAC, which demonstrated that vaccines are cost-effective but highlighted the need to strengthen the economic data on vaccines. Till Barninghausen from the Harvard School of Public Health and Damian Walker from the Bill & Melinda Gates Foundation shared results from two case studies in South Africa and Bangladesh. These studies found that the measles vaccines can increase school attendance and improve school attainment (as measured by higher test scores), which may lead to a higher earning potential for these children.

We were pleased to have a truly engaged audience. The audience recognized that cost-benefit analyses that present the benefits of vaccines in dollar values are useful and needed, which is a contrast from the current norms to use cost-effectiveness data that assigns a dollar amount per DALY or disability-adjusted life year averted. An argument was made that just as interventions in other sectors could save lives, we need to present the benefits of health interventions in the same financial terms these sectors would use, in order to show the full return on investment. It was also noted that we are not done building the evidence base around the narrow benefits of vaccines. Therefore, a suggestion was made that we build economic evidence both at the narrow and broad levels concurrently. Another point made at the session was that many of these broad benefits may result not only because of vaccines, but because of a combination of health interventions that save lives and prevent illnesses. Audience members suggested looking into measuring the economic value of a package of interventions, or of a healthy child as a whole, in order to support efforts to advocate for investment in health vis-à-vis other sectors.

This successful panel and discussion led to an unexpected and truly exciting opportunity. Our panel was called upon by about 25 parliamentarians participating at the forum to give a separate presentation to this honorable group. This meant we could disseminate our work to the people who are actually advocating for vaccines in low- and middle-income countries. What an opportunity! We took to this occasion with enthusiasm and received feedback from the parliamentarians that confirmed they need evidence in dollar values to take to their ministers of finance. Many members of parliament in the room said they were glad to be armed with more evidence they can use to advocate for vaccines. We truly hope this type of engagement will continue with parliamentarians beyond this forum.

At IVAC we pride ourselves on being able to create, model and develop evidence that could be used in decision-making. Last week I witnessed that the evidence we develop indeed matters to audiences who use it to advocate for improvements in child health. Beyond the opportunity to share our evidence with parliamentarians and receive their feedback, I saw the economic evidence we developed put to use in advocacy materials such as an infographic created by the United Nations Foundation’s Shot@Life campaign.

One statement at the forum stuck with me: “Advocacy without evidence is just opinion.” I look forward to continuing to build the economic evidence that can be used by advocates – work that truly matters to saving children’s lives.

Sachiko Ozawa, PhD, MHS, is an Assistant Scientist with Johns Hopkins University Bloomberg School of Public Health and IVAC.

By Dr. Dagna Constenla

Few illnesses have as much power to cause panic among the population as meningococcal disease. And the facts are scary: meningococcal disease is one of the most severe and rapidly progressive community acquired infections. At any given time, 10 to 25 percent of the global population carry meningococcal bacteria in the back of their throats or in their noses, but this percentage may be much higher during an epidemic. Up to 20 percent of patients who come down with the disease die, typically within 24-48 hours of the onset of symptoms. The disease, which infects the membranes of the brain and spinal cord, is debilitating and potentially fatal for children, adolescents and people living in overcrowded conditions. And while meningococcal disease is considered a disease of mandatory notification in most countries, the exceedingly low rates of the disease reported by some countries and the high proportion of meningitis reported by others send conflicting messages about its real burden. Information about the true burden of this disease is usually neither published nor easily accessible.                  

What can we do about it?

Today, I write from Buenos Aires, where Latin American researchers, economists and global health leaders have gathered to focus on meningococcal disease in the region 181 experts attended the meeting, representing 21 countries. Latin America has high meningococcal-associated morbidity and mortality, even in the face of early therapeutic intervention. But we still need to have a greater understanding of the true burden of meningococcal disease in the region so that we can help promote programs and introduce vaccines to fight this killer.

Our work on this project, coordinated by the Sabin Vaccine Institute in partnership with the Pan American Health Organization, the International Vaccine Access Center at Johns Hopkins University and the Centers for Diseases Control and Prevention, set out to accomplish two primary goals: to estimate the burden of disease in the region by reviewing available epidemiological data on meningococcal disease in Latin America and the Caribbean (LAC); and to estimate the costs associated with management of meningococcal disease cases and outbreaks in selected countries of the LAC region.

Through this first-ever study, by estimating the burden and costs of meningococcal disease in Latin America, we can begin to determine what obstacles impede its prevention through vaccination.

What did we find?

This is the first study in the region to estimate the cost of meningococcal disease, and the numbers are striking, giving us new urgency for our work: Meningococcal disease incurs a considerable societal economic burden in countries of the region, generating up to $6,228 (USD) in costs per patient. This burden represents the cost of treating an endemic case, not a case during an outbreak.

A detailed socioeconomic study during the 2007 epidemic in Burkina Faso showed that each case of meningitis in a family results in a sudden expenditure of about US$90—what amounts to three or four months of the family's disposable income. Families with few resources cycle inexorably downward to the next level of poverty. In addition, about 25 percent of survivors have permanent after-effects such as deafness, leaving them less likely to be economically productive citizens, and they often become wards of an already financially stretched extended family. Furthermore, what is not captured in the above analysis is the chaos to health systems engendered by a meningitis epidemic.

Closer to home, in Brazil, one community had a meningitis outbreak causing nine cases and spent $143,000 (USD) on investigation and outbreak management alone. This study did not consider the cost of treating the outbreak cases, which would bring the costs of the outbreak even higher. The new study concluded that more and better information is needed to help control outbreaks.

What’s next?

Given the availability of new highly effective vaccines, better epidemiological information, carriage studies and characterization of N. meningitidis isolates are critical to understand the epidemiology of meningococcal disease in Latin American countries.

Along with understanding the biology of disease itself, we must also examine the economic impact, which can vary widely across countries in the LAC region. An economic study is one way of providing such information. Yet what is clear from our research is that coordinated vaccination programs would not only significantly reduce outbreaks, but would also reduce the overall financial burden the disease can have on local health systems.

Our work concludes that through improved surveillance and better understanding of meningococcal epidemiology and costs, we can help devise meningitis vaccination programs that can not only save lives but also prevent these extraordinary economic impacts.

We can eliminate meningitis as a public health problem in the LAC region by increasing awareness of the disease and economic burden, and through the development, testing, introduction, and widespread use of meningococcal vaccines.


The meeting has received plenty of great attention! Here are just some of the many links that have appeared in Latin American media:

Dr. Dagna Constenla is the Director of Economics & Finance at IVAC.

By Dr. Dagna Constenla

Dengue, also known as breakbone fever, is a painful and sometimes fatal disease spread by the bite of a mosquito. Patients that get dengue fever often have painful headache, skin rash and debilitating muscle and joint pains. In some cases, it can lead to circulatory failure, shock, coma and death. Though early and effective treatment can ease symptoms, there is no specific cure available for dengue. Because the mosquito bites all day and can breed even in small bits of stagnant water, efforts to control dengue by preventing bites and breeding are often expensive and provide limited relief.

A vaccine is coming though. After more than 60 years, the development of dengue vaccines has accelerated dramatically. Today, several vaccines are in various stages of advanced development, with clinical trials currently underway on five candidate vaccines. Trials in the most advanced stages are showing encouraging preliminary data, and the leading candidate could be licensed as early as 2015.

Controling dengue by preventing bites and breeding is often expensive and only provides limited relief. A dengue vaccine could prevent illness and change the disease landscape in Latin America and beyond. Photo: CDC/James Gathany

But unlike a new iteration of an existing vaccine, this is uncharted territory. How do we predict its use? Its cost? Cost-effectiveness? Its affordability? How will countries introduce it? To lay the groundwork for the vaccine's eventual introduction, experts from the Latin America and Caribbean region are gathering in Baltimore on March 6-8, 2012 not only to ask questions, but to develop guidelines and standards for costing dengue so that over the next decade, local, and regional decision-makers will have access to robust information on the true cost of dengue in endemic countries of the region.

As a core partner in the Dengue Vaccine Initiative, the International Vaccine Access Center (IVAC) at Johns Hopkins University is pleased to be hosting this workshop in partnership with the Pan-American Health and Education Foundation (PAHEF). For 3 days, more than 15 experts in health economics and epidemiology will work to assess the current evidence of dengue economics research, identify methodological strengths and weaknesses of this evidence, and foster consensus, where possible, on the best way to conduct dengue economics research.

In order to make this work valuable to the entire Latin American region, the guidelines and outputs from this workshop will be made available in Spanish, Portuguese and English on the internet in the months ahead. And then the real work begins. Putting these guidelines to use so that we can improve the evidence-base for decisions in Latin America on how to use dengue vaccines. 

Dr. Dagna Constenla is the Director of Economics & Finance at IVAC.

Research and experience show that when a decision-maker is considering a new vaccine for their national immunization program their first consideration is the impact that the disease has on their population. Even before they consider how much the vaccine costs or its safety or effectiveness.

This makes perfect sense. The USA could afford a Japanese Encephalitis vaccine but we don’t use it because we don’t have the disease.

Increasingly, the “impact” of vaccines will be measured as much or more by the economic consequences of the disease as by the number of cases or deaths that it prevents. Treatment costs that averted by preventing an illness with vaccines are just the most limited and basic measure of the economic effects of vaccination. A fuller, more comprehensive assessment would include other economic costs like the productivity lost when a child is disabled for life and unable to contribute to a growing economy and benefits like the macroeconomic impact from accelerating the demographic transition and encouraging economic growth in poor countries.

IVAC is actively working to develop a rigorous evidence-base on the economics of vaccines. One small example of our team’s work is included in this this cool new video from the Gates Foundation.

Have a look and see what you think.  And help us start the conversation on the importance of economic evaluation of vaccines.