An Estimation of Private Household Costs to Receive Free Oral Cholera Vaccine in Odisha, India

Mogasale, Vittal,Kar, Shantanu K.,Kim, Jong-Hoon,Mogasale, Vijayalaxmi V.,Kerketta, Anna S.,Patnaik, Bikash,Rath, Shyam Bandhu,Puri, Mahesh K.,You, Young Ae,Khuntia, Hemant K.,Maskery, Brian,Wierzba, Public Library of Science 2015 PLoS neglected tropical diseases Vol.9 No.9

<▼1><P><B>Background</B></P><P>Service provider costs for vaccine delivery have been well documented; however, vaccine recipients’ costs have drawn less attention. This research explores the private household out-of-pocket and opportunity costs incurred to receive free oral cholera vaccine during a mass vaccination campaign in rural Odisha, India.</P><P><B>Methods</B></P><P>Following a government-driven oral cholera mass vaccination campaign targeting population over one year of age, a questionnaire-based cross-sectional survey was conducted to estimate private household costs among vaccine recipients. The questionnaire captured travel costs as well as time and wage loss for self and accompanying persons. The productivity loss was estimated using three methods: self-reported, government defined minimum daily wages and gross domestic product per capita in Odisha.</P><P><B>Findings</B></P><P>On average, families were located 282.7 (SD = 254.5) meters from the nearest vaccination booths. Most family members either walked or bicycled to the vaccination sites and spent on average 26.5 minutes on travel and 15.7 minutes on waiting. Depending upon the methodology, the estimated productivity loss due to potential foregone income ranged from $0.15 to $0.29 per dose of cholera vaccine received. The private household cost of receiving oral cholera vaccine constituted 24.6% to 38.0% of overall vaccine delivery costs.</P><P><B>Interpretation</B></P><P>The private household costs resulting from productivity loss for receiving a free oral cholera vaccine is a substantial proportion of overall vaccine delivery cost and may influence vaccine uptake. Policy makers and program managers need to recognize the importance of private costs and consider how to balance programmatic delivery costs with private household costs to receive vaccines.</P></▼1><▼2><P><B>Author Summary</B></P><P>The price of vaccine and the costs of its delivery are two important economic measures considered by governments and various international organizations in their decisions on the use of a new vaccine. However, the costs to the vaccine recipients resulting from their travel, time and wage loss are hardly considered and rarely documented. Even if the vaccine is provided for free, the costs borne by vaccine recipients could be sufficient enough to be a hurdle for taking vaccine. We elucidate this less explored angle of “vaccine recipient cost” in the context of oral cholera vaccine mass campaign in Odisha, India. Our research shows that the potential loss of income for individuals for receiving oral cholera vaccine ranged from 25% to 38% of overall vaccine delivery costs. We believe our findings have global implications on future decisions and policy making on vaccine introduction in balancing programmatic delivery costs with private household costs to receive vaccines.</P></▼2>

A forecast of typhoid conjugate vaccine introduction and demand in typhoid endemic low- and middle-income countries to support vaccine introduction policy and decisions

Mogasale, Vittal,Ramani, Enusa,Park, Il Yeon,Lee, Jung Seok TaylorFrancis 2017 Human Vaccines & Immunotherapeutics Vol.13 No.9

<P><B>ABSTRACT</B></P><P>A Typhoid Conjugate Vaccine (TCV) is expected to acquire WHO prequalification soon, which will pave the way for its use in many low- and middle-income countries where typhoid fever is endemic. Thus it is critical to forecast future vaccine demand to ensure supply meets demand, and to facilitate vaccine policy and introduction planning. We forecasted introduction dates for countries based on specific criteria and estimated vaccine demand by year for defined vaccination strategies in 2 scenarios: rapid vaccine introduction and slow vaccine introduction. In the rapid introduction scenario, we forecasted 17 countries and India introducing TCV in the first 5 y of the vaccine's availability while in the slow introduction scenario we forecasted 4 countries and India introducing TCV in the same time period. If the vaccine is targeting infants in high-risk populations as a routine single dose, the vaccine demand peaks around 40 million doses per year under the rapid introduction scenario. Similarly, if the vaccine is targeting infants in the general population as a routine single dose, the vaccine demand increases to 160 million doses per year under the rapid introduction scenario. The demand forecast projected here is an upper bound estimate of vaccine demand, where actual demand depends on various factors such as country priorities, actual vaccine introduction, vaccination strategies, Gavi financing, costs, and overall product profile. Considering the potential role of TCV in typhoid control globally; manufacturers, policymakers, donors and financing bodies should work together to ensure vaccine access through sufficient production capacity, early WHO prequalification of the vaccine, continued Gavi financing and supportive policy.</P>

Correction: A Multi-country Study of the Household Willingness-to-Pay for Dengue Vaccines: Household Surveys in Vietnam, Thailand, and Colombia

Lee, Jung-Seok,Mogasale, Vittal,Lim, Jacqueline K.,Carabali, Mabel,Sirivichayakul, Chukiat,Anh, Dang Duc,Lee, Kang-Sung,Thiem, Vu Dinh,Limkittikul, Kriengsak,Tho, Le Huu,Velez, Ivan D.,Osorio, Jorge E Public Library of Science 2015 PLoS neglected tropical diseases Vol.9 No.6

A multi-country study of the economic burden of dengue fever: Vietnam, Thailand, and Colombia

Lee, Jung-Seok,Mogasale, Vittal,Lim, Jacqueline K.,Carabali, Mabel,Lee, Kang-Sung,Sirivichayakul, Chukiat,Dang, Duc Anh,Palencia-Florez, Diana Cristina,Nguyen, Thi Hien Anh,Riewpaiboon, Arthorn,Chanth Public Library of Science 2017 PLoS neglected tropical diseases Vol.11 No.10

<▼1><P><B>Background</B></P><P>Dengue fever is a major public health concern in many parts of the tropics and subtropics. The first dengue vaccine has already been licensed in six countries. Given the growing interests in the effective use of the vaccine, it is critical to understand the economic burden of dengue fever to guide decision-makers in setting health policy priorities.</P><P><B>Methods/Principal findings</B></P><P>A standardized cost-of-illness study was conducted in three dengue endemic countries: Vietnam, Thailand, and Colombia. In order to capture all costs during the entire period of illness, patients were tested with rapid diagnostic tests on the first day of their clinical visits, and multiple interviews were scheduled until the patients recovered from the current illness. Various cost items were collected such as direct medical and non-medical costs, indirect costs, and non-out-of-pocket costs. In addition, socio-economic factors affecting disease severity were also identified by adopting a logit model. We found that total cost per episode ranges from $141 to $385 for inpatient and from $40 to $158 outpatient, with Colombia having the highest and Thailand having the lowest. The percentage of the private economic burden of dengue fever was highest in the low-income group and lowest in the high-income group. The logit analyses showed that early treatment, higher education, and better knowledge of dengue disease would reduce the probability of developing more severe illness.</P><P><B>Conclusions/Significance</B></P><P>The cost of dengue fever is substantial in the three dengue endemic countries. Our study findings can be used to consider accelerated introduction of vaccines into the public and private sector programs and prioritize alternative health interventions among competing health problems. In addition, a community would be better off by propagating the socio-economic factors identified in this study, which may prevent its members from developing severe illness in the long run.</P></▼1><▼2><P><B>Author summary</B></P><P>Dengue fever has been prevalent in South-East Asia and South America. Despite the increase of dengue fever cases, there continues to be a lack of economic assessment partly due to the absence of vaccines until recent times. Many of the previous economic burden studies for dengue fever were not standardized, making them difficult to compare. We implemented the standardized economic burden survey for dengue fever in a multi-country setting: Vietnam, Thailand, and Colombia. We found that the economic burden of dengue fever is substantial in all three dengue endemic countries. Our study also identified socio-economic factors which are related to the probability of experiencing severe illness. The first live attenuated, tetravalent dengue vaccine (CYD-TDV) has been already licensed in some dengue-endemic countries. As three countries will soon face decisions on whether and how to incorporate current and future vaccine candidates within their budget constraints, the updated economic burden estimates can be used to develop sustainable financing plans.</P></▼2>

A multi-country study of the economic burden of dengue fever based on patient-specific field surveys in Burkina Faso, Kenya, and Cambodia

Lee, Jung-Seok,Mogasale, Vittal,Lim, Jacqueline K.,Ly, Sowath,Lee, Kang Sung,Sorn, Sopheak,Andia, Esther,Carabali, Mabel,Namkung, Suk,Lim, Sl-Ki,Ridde, Valé,ry,Njenga, Sammy M.,Yaro, Seydou,Yoon Public Library of Science 2019 PLoS neglected tropical diseases Vol.13 No.2

<▼1><P><B>Background</B></P><P>Dengue fever is a rapidly growing public health problem in many parts of the tropics and sub-tropics in the world. While there are existing studies on the economic burden of dengue fever in some of dengue-endemic countries, cost components are often not standardized, making cross-country comparisons challenging. Furthermore, no such studies have been available in Africa.</P><P><B>Methods/Principal findings</B></P><P>A patient-specific survey questionnaire was developed and applied in Burkina Faso, Kenya, and Cambodia in a standardized format. Multiple interviews were carried out in order to capture the entire cost incurred during the period of dengue illness. Both private (patient’s out-of-pocket) and public (non-private) expenditure were accessed to understand how the economic burden of dengue is distributed between private and non-private payers.</P><P>A substantial number of dengue-confirmed patients were identified in all three countries: 414 in Burkina Faso, 149 in Kenya, and 254 in Cambodia. The average cost of illness for dengue fever was $26 (95% CI $23-$29) and $134 (95% CI $119-$152) per inpatient in Burkina Faso and Cambodia, respectively. In the case of outpatients, the average economic burden per episode was $13 (95% CI $23-$29) in Burkina Faso and $23 (95% CI $19-$28) in Kenya. Compared to Cambodia, public contributions were trivial in Burkina Faso and Kenya, reflecting that a majority of medical costs had to be directly borne by patients in the two countries.</P><P><B>Conclusions/Significance</B></P><P>The cost of illness for dengue fever is significant in the three countries. In particular, the current study sheds light on the potential economic burden of the disease in Burkina Faso and Kenya where existing evidence is sparse in the context of dengue fever, and underscores the need to achieve Universal Health Coverage. Given the availability of the current (CYD-TDV) and second-generation dengue vaccines in the near future, our study outcomes can be used to guide decision makers in setting health policy priorities.</P></▼1><▼2><P><B>Author summary</B></P><P>Dengue fever is a major public health concern in many parts of South-East Asia and South America. In addition to countries where dengue has been highly prevalent for many years, there is a growing concern on the undocumented burden of dengue in Africa. Following the successful execution of the first-round economic burden study in Vietnam, Thailand, and Colombia by the Dengue Vaccine Initiative, the second-round economic burden study was implemented in Burkina Faso, Kenya and Cambodia using the same standardized methodology. In particular, the second-round study targeted GAVI eligible countries for future vaccine introductions and included two African countries where the burden of dengue was relatively unknown. Our study outcomes show that the economic burden of dengue fever is significant in all three countries. The dengue vaccination era began in 2016 with the first dengue vaccine (CYD-TDV) although its public use should be carefully determined due to the safety concerns related to the vaccine. Considering that there are other second-generation dengue vaccines in development, the current study outcomes provide an important step to estimate the economic benefits of vaccination in the three countries.</P></▼2>

The health economics of cholera: A systematic review

Hsiao, Amber,Hall, Angela H.,Mogasale, Vittal,Quentin, Wilm Elsevier 2018 Vaccine Vol.36 No.30

<P><B>Abstract</B></P> <P><B>Background</B></P> <P> <I>Vibrio cholera</I> is a major contributor of diarrheal illness that causes significant morbidity and mortality globally. While there is literature on the health economics of diarrheal illnesses more generally, few studies have quantified the cost-of-illness and cost-effectiveness of cholera-specific prevention and control interventions. The present systematic review provides a comprehensive overview of the literature specific to cholera as it pertains to key health economic measures.</P> <P><B>Methods</B></P> <P>A systematic review was performed with no date restrictions up through February 2017 in PubMed, Econlit, Embase, Web of Science, and Cochrane Review to identify relevant health economics of cholera literature. After removing duplicates, a total of 1993 studies were screened and coded independently by two reviewers, resulting in 22 relevant studies. Data on population, methods, and results (cost-of-illness and cost-effectiveness of vaccination) were compared by country/region. All costs were adjusted to 2017 USD for comparability.</P> <P><B>Results</B></P> <P>Costs per cholera case were found to be rather low: <$100 per case in most settings, even when costs incurred by patients/families and lost productivity are considered. When wider socioeconomic costs are included, estimated costs are >$1000/case. There is adequate evidence to support the economic value of vaccination for the prevention and control of cholera when vaccination is targeted at high-incidence populations and/or areas with high case fatality rates due to cholera. When herd immunity is considered, vaccination also becomes a cost-effective option for the general population and is comparable in cost-effectiveness to other routine immunizations.</P> <P><B>Conclusions</B></P> <P>Cholera vaccination is a viable short-to-medium term option, especially as the upfront costs of building water, sanitation, and hygiene (WASH) infrastructure are considerably higher for countries that face a significant burden of cholera. While WASH may be the more cost-effective solution in the long-term when implemented properly, cholera vaccination can still be a feasible, cost-effective strategy.</P>

The Euvichol story – Development and licensure of a safe, effective and affordable oral cholera vaccine through global public private partnerships

Odevall, Lina,Hong, Deborah,Digilio, Laura,Sahastrabuddhe, Sushant,Mogasale, Vittal,Baik, Yeongok,Choi, Seukkeun,Kim, Jerome H.,Lynch, Julia Elsevier Science 2018 Vaccine Vol.36 No.45

<P>Cholera, a diarrheal disease primarily affecting vulnerable populations in developing countries, is estimated to cause disease in more than 2.5 million people and kill almost 100,000 annually. An oral cholera vaccine (OCV) has been available globally since 2001; the demand for this vaccine from affected countries has however been very low, due to various factors including vaccine price and mode of administration. The low demand for the vaccine and limited commercial incentives to invest in research and development of vaccines for developing country markets has kept the global supply of OCVs down. Since 1999, the International Vaccine Institute has been committed to make safe, effective and affordable OCVs accessible. Through a variety of partnerships with collaborators in Sweden, Vietnam, India and South Korea, and with public and private funding, IVI facilitated development and production of two affordable and WHO-prequalified OCVs and together with other stakeholders accelerated the introduction of these vaccines for the global public-sector market.</P>

Uptake during an oral cholera vaccine pilot demonstration program, Odisha, India.

Kar, Shantanu K,Pach, Alfred,Sah, Binod,Kerketta, Anna S,Patnaik, Bikash,Mogasale, VijayaLaxmi,Kim, Yang Hee,Rath, Shyam Bandhu,Shin, Sunheang,Khuntia, Hemant K,Bhattachan, Anuj,Puri, Mahesh K,Wierzba Landes Bioscience 2014 Human Vaccines & Immunotherapeutics Vol.10 No.10

<P>Approximately 30% of reported global cholera cases occur in India. In 2011, a household survey was conducted 4 months after an oral cholera vaccine pilot demonstration project in Odisha India to assess factors associated with vaccine up-take and exposure to a communication and social mobilization campaign. Nine villages were purposefully selected based on socio-demographics and demonstration participation rates. Households were stratified by level of participation and randomly selected. Bivariate and ordered logistic regression analyses were conducted. 517/600 (86%) selected households were surveyed. At the household level, participant compared to non-participant households were more likely to use the local primary health centers for general healthcare (P < 0.001). Similarly, at the village level, higher participation was associated with use of the primary health centers (P < 0.001) and private clinics (p = 0.032). Also at the village level, lower participation was associated with greater perceived availability of effective treatment for cholera (p = 0.013) and higher participation was associated with respondents reporting spouse as the sole decision-maker for household participation in the study. In terms of pre-vaccination communication, at the household level verbal communication was reported to be more useful than written communication. However written communication was perceived to be more useful by respondents in low-participating villages compared to average-participating villages (p = 0.007) These data on participation in an oral cholera vaccine demonstration program are important in light of the World Health Organization's (WHO) recommendations for pre-emptive use of cholera vaccine among vulnerable populations in endemic settings. Continued research is needed to further delineate barriers to vaccine up-take within and across targeted communities in low- and middle-income countries.</P>

Impact of Renewable Energy on Extension of Vaccine Cold-chain: a case study in Nepal

김민수,문정욱,류종하,김민식,비나약 반다리,박정은,Anuj Bhattachan,Vittal Mogasale,추원식,이선영,송철기,안성훈 적정기술학회 2020 적정기술학회지(Journal of Appropriate Technology) Vol.6 No.2

Renewable energy (RE) is essential to comprise sustainable societies, especially, in rural villages of developing countries. Furthermore, application of off-grid RE systems to health care can improve the quality of life. In this research, a RE-based vaccination supply management system was constructed to enlarge the cold-chain in developing countries for the safe storage and delivery of vaccines. The system was comprised of the construction of RE plants and development of vaccine carriers. RE plants were constructed and connected to health posts in local villages. The cooling mechanism of vaccine carriers was improved and monitoring devices were installed. The effect of the system on vaccine cold-chain was evaluated from the field test and topographical analysis in the southern village of Nepal. RE plants were normally operated for the vaccine refrigerator in the health post. The modified vaccine carriers had a longer operation time and better temperature control via monitoring and RE-based recharging functionality. The topographical analysis estimated that the system can cover larger region. The system prototype showed great potential regarding the possibility of a sustainable and enlarged cold-chain. Thus, RE-based vaccine supply management is expected to facilitate vaccine availability while minimizing waste in the supply chain.

Mass Vaccination with a New, Less Expensive Oral Cholera Vaccine Using Public Health Infrastructure in India: The Odisha Model

Kar, Shantanu K.,Sah, Binod,Patnaik, Bikash,Kim, Yang Hee,Kerketta, Anna S.,Shin, Sunheang,Rath, Shyam Bandhu,Ali, Mohammad,Mogasale, Vittal,Khuntia, Hemant K.,Bhattachan, Anuj,You, Young Ae,Puri, Mah Public Library of Science 2014 PLoS neglected tropical diseases Vol.8 No.2

<▼1><P><B>Introduction</B></P><P>The substantial morbidity and mortality associated with recent cholera outbreaks in Haiti and Zimbabwe, as well as with cholera endemicity in countries throughout Asia and Africa, make a compelling case for supplementary cholera control measures in addition to existing interventions. Clinical trials conducted in Kolkata, India, have led to World Health Organization (WHO)-prequalification of Shanchol, an oral cholera vaccine (OCV) with a demonstrated 65% efficacy at 5 years post-vaccination. However, before this vaccine is widely used in endemic areas or in areas at risk of outbreaks, as recommended by the WHO, policymakers will require empirical evidence on its implementation and delivery costs in public health programs. The objective of the present report is to describe the organization, vaccine coverage, and delivery costs of mass vaccination with a new, less expensive OCV (Shanchol) using existing public health infrastructure in Odisha, India, as a model.</P><P><B>Methods</B></P><P>All healthy, non-pregnant residents aged 1 year and above residing in selected villages of the Satyabadi block (Puri district, Odisha, India) were invited to participate in a mass vaccination campaign using two doses of OCV. Prior to the campaign, a <I>de jure</I> census, micro-planning for vaccination and social mobilization activities were implemented. Vaccine coverage for each dose was ascertained as a percentage of the censused population. The direct vaccine delivery costs were estimated by reviewing project expenditure records and by interviewing key personnel.</P><P><B>Results</B></P><P>The mass vaccination was conducted during May and June, 2011, in two phases. In each phase, two vaccine doses were given 14 days apart. Sixty-two vaccination booths, staffed by 395 health workers/volunteers, were established in the community. For the censused population, 31,552 persons (61% of the target population) received the first dose and 23,751 (46%) of these completed their second dose, with a drop-out rate of 25% between the two doses. Higher coverage was observed among females and among 6–17 year-olds. Vaccine cost at market price (about US$1.85/dose) was the costliest item. The vaccine delivery cost was $0.49 per dose or $1.13 per fully vaccinated person.</P><P><B>Discussion</B></P><P>This is the first undertaken project to collect empirical evidence on the use of Shanchol within a mass vaccination campaign using existing public health program resources. Our findings suggest that mass vaccination is feasible but requires detailed micro-planning. The vaccine and delivery cost is affordable for resource poor countries. Given that the vaccine is now WHO pre-qualified, evidence from this study should encourage oral cholera vaccine use in countries where cholera remains a public health problem.</P></▼1><▼2><P><B>Author Summary</B></P><P>Cholera – an acute life-threatening diarrheal illness – continues to disrupt public health in resource poor countries. The devastating outbreaks in Haiti and Zimbabwe – to name just two of many occurrences – calls for the use of available oral cholera vaccines as an additional tool in the arsenal of cholera control measures. An oral cholera vaccine (Shanchol) has been licensed in India since 2009; however, there has only been limited use of this vaccine in government public health programs. A vaccination campaign using 2 doses of Shanchol was conducted in Odisha, India, during May and June, 2011, where 31,552 persons (61% of the target population) received the first dose and 23,751 of them completed their second dose. The vaccine delivery cost was $0.49 per dose. Through our findings and experience, we discuss the organization of the cholera vaccination campaign in Odisha, the challenges met for conducting the campaign and the strategies designed to overcome those challenges, and the delivery costs incurred in the use of this vaccine, the first of