COST-EFFECTIVENESS ANALYSIS OF ROUTINE IMMUNIZATION AND SUPPLEMENTARY IMMUNIZATION ACTIVITY FOR MEASLES IN A HEALTH DISTRICT OF BENIN

Sunday, 23rd of August 2015

"The benefit of SIA was 5601 measles cases averted and 6955 additional DALYs averted. Cost per vaccinated child for SIA (442 FCFA) was lower than for RI (1242 FCFA), in line with previous data from the literature. Cost per DALY averted was 2271 FCFA (4.73 USD) for SIA and 769 FCFA (1.60 USD) for RI. Analysis showed that low vaccine efficacy decreased the cost-effectiveness ratios for the two strategies. SIA was more cost-effective when the proportion of previously unvaccinated children was higher."

COST-EFFECTIVENESS ANALYSIS OF ROUTINE IMMUNIZATION AND SUPPLEMENTARY IMMUNIZATION ACTIVITY FOR MEASLES IN A HEALTH DISTRICT OF BENIN

Landry Kaucley^1* and Pierre Levy²

• * Corresponding author: Landry Kaucley tchaland@hotmail.com

¹ Health District of Natitingou, Ministry of Health, Natitingou, Benin

² Paris Dauphine University, LEDa-LEGOS, Place du Marechal de Lattre de Tassigny, Paris, 75016, France

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Cost Effectiveness and Resource Allocation 2015, 13:14  doi:10.1186/s12962-015-0039-7

The electronic version of this article is the complete one and can be found online at: http://www.resource-allocation.com/content/13/1/14

 

Received:	11 December 2014
Accepted:	10 August 2015
Published:	20 August 2015

© 2015 Kaucley and Levy.

Abstract

Background

This study was carried out at district level to describe the cost structure and measure the effectiveness of delivering supplementary immunization activity (SIA) and routine immunization (RI) for measles in Benin, a country heavily affected by this disease.

Methods

This cost-effectiveness study was cross sectional and considered 1-year time horizon. RI consists to vaccinate an annual cohort of children aged 0–1 year old and SIA consists to provide a second dose of measles vaccine to children aged 0–5 years old in order to reach both those who did not seroconvert and who were not vaccinated through RI. Ingredients approach to costing was used. Effectiveness indicators included measles vaccine doses used, vaccinated children, measles cases averted and disability adjusted life years averted. Data were collected from all the 18 health care centers of the health district of Natitingou for the year 2011. In the analysis, the coverage was 89 % for RI and 104 % for SIA.

Results

SIA total cost was higher than RI total cost (15,796,560 FCFA versus 9,851,938 FCFA). Personnel and vaccines were the most important cost components for the two strategies. Fuel for cold chain took a non-negligible part of RI total cost (4.03 %) because 83 % of refrigerators were working with kerosene. Cost structures were disproportionate as social mobilization and trainings were not financed during RI contrarily to SIA. In comparison with no intervention, the two strategies combined permitted to avoid 12,671 measles cases or 19,023 DALYs. The benefit of SIA was 5601 measles cases averted and 6955 additional DALYs averted. Cost per vaccinated child for SIA (442 FCFA) was lower than for RI (1242 FCFA), in line with previous data from the literature. Cost per DALY averted was 2271 FCFA (4.73 USD) for SIA and 769 FCFA (1.60 USD) for RI. Analysis showed that low vaccine efficacy decreased the cost-effectiveness ratios for the two strategies. SIA was more cost-effective when the proportion of previously unvaccinated children was higher. For the two strategies, costs per DALY were more likely to vary with measles case fatality ratio.

Conclusions

SIA is costlier than RI. Both SIA and RI for measles are cost-effective interventions to improve health in Benin compared to no vaccination. Policy makers could make RI more efficient if sufficient funds were allocated to communications activities and to staff motivation (trainings, salaries).

Keywords:

Measles; Efficiency; Supplementary immunization activity; Routine immunization; Benin

Background

Measles is one of the most serious infectious human diseases as it can cause severe illness, lifelong complications and death. WHO estimated 45 million measles cases and 1.1 million measles related deaths occurring each year in developing countries [1]. Benin is one of the 47 measles high burden countries in the world [2]. To meet measles mortality and morbidity reduction goals, WHO recommended four strategies: (1) strengthening routine immunization to achieve and sustain high coverage, (2) providing a second opportunity for measles immunization, (3) conducting epidemiologic surveillance with high laboratory confirmation of cases and outbreaks and (4) insuring that improved case management is implemented.

Benin is a small country of West Africa (112,622 Km ² ; 7,862,944 inhabitants) [3]. It is a low income country divided in 33 health districts. The health district of Natitingou is located in the north east region of Benin. It is a mountainous region. It covers an area of 3760 Km ² with 222,785 inhabitants estimated in 2011 (projection from 2002 national census); most of them are farmers [4]. There are 18 health facilities that provide immunization services.

The first dose of measles containing vaccine (MCV) is given in Benin to children at 9 months through Routine Immunization program (RI). The second opportunity for measles immunization is provided through Supplementary Immunization Activities (SIAs). These SIAs are follow-up campaigns conducted every 3 years since 2001 and targeting children aged 0–59 months. The second opportunity for measles vaccination aims at reaching children who were not vaccinated through RI and to protect children who did not seroconvert with the first dose. By doing so, the population could reach the 95 % population immunity threshold (herd immunity) necessary to stop measles virus circulation. By organizing SIAs campaigns, Benin saw a dramatic fall of measles reported cases with 334 measles cases reported in the first semester of the year 2011 while 5531 cases where annually reported on average during the decade 1991–2000 [5]. RI consists in providing all vaccinations listed in a country immunization program schedule. Services are delivered on an ongoing basis from permanent locations throughout the year. RI usually targets children under 1 year of age. In Benin, the following vaccines are administrated through RI to children under 1 year and to pregnant women: BCG, Pentavalent (DTP-Hep-Hib), OPV, MCV, PCV13, YFV and TT. SIAs are provided from multiple permanent and temporary locations. These campaigns usually have a short duration (1 week) and target children under 5 or 15. RI target population of children aged 0–12 months was estimated to 8911 children and SIA target population was estimated to 34,131 children aged 0–59 months, both for the year 2011. During this year, 7933 children under 1 year old were reached through RI corresponding to a coverage of 89 %. SIA permitted to vaccinate 35,564 children aged 0–59 months corresponding to a coverage of 104 %. A coverage rate of >100 % is commonly observed during SIAs in Benin, usually related to an inaccurate estimation of the target population because the number of eligible children came from not up-to-date national census data.

In a context of global economic crisis and resources scarcity, efficiency of measles immunization strategies needs to be taken into account in African health districts heavily affected by this disease. The operational level needs to know the economic value of their activities as this could help them to get more results at a lesser or equivalent costs. Ignorance of measles immunization costs, neglect of these costs, ignorance of the relative weight of cost components and lack of knowledge of the financial needs cause difficulties in planning, resources mobilization and resources allocation. Nothing is known about the efficiency of SIA and RI for measles in Benin. To fill this gap, this work was initiated by the health district of Natitingou using primary data from routine immunization and measles mass campaign for the year 2011.

The first objective of this paper was to describe cost structure of measles immunization strategies (RI and SIA) in a rural health district. Secondary, this study aimed at measuring the benefits of these strategies on population health. Finally, we assessed the efficiency of each strategy and we compared the cost-effectiveness ratios with a no vaccination strategy. Effectiveness indicators took into account not only the immediate results of immunization (vaccine doses used, vaccinated children) but also the impact on final health outcomes (measles cases averted, disability adjusted life years averted). This work will help immunization services providers at health facility level to streamline measles immunization practices for a greater efficiency. The results could also provide guidance to policy makers in Benin for resources allocation.