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Vaccines: Health Affairs' February Issue

Bethesda, MD — The February issue of Health Affairs explores the current environment in which vaccines are discovered, produced, and delivered. The issue also contains several studies examining the economic benefits and value of sustainably financing vaccinations in the United States and globally.

This month's DataGraphic provides a pictorial view of key facts about vaccines, including data from several studies in this month's issue.
The February issue of Health Affairs is supported by Merck, Takeda Pharmaceutical Company, Ltd., PATH, and The Leona M. and Harry B. Helmsley Charitable Trust.
Benefits of childhood immunization 16 to 44 times the investment.  
To quantify the economic benefits of childhood immunization, Sachiko Ozawa of the Johns Hopkins Bloomberg School of Public Health and coauthors assessed return on investment (ROI)--finding that every dollar invested in vaccines during the decade was estimated to result in a return of sixteen times the costs, taking into account treatment costs and productivity losses. They derived the estimates by looking not only at vaccine costs but also supply chain and service delivery costs compared to the associated economic benefits of implementing vaccination programs in ninety-four low- and middle-income countries. When considering broader economic and social benefits, the ROI for immunization was forty-four times the vaccination costs. Projections were for 2011-20, declared the "Decade of Vaccines" by the global health community.
Federal vaccines for children significantly increased immunizations, decreased disparities.
To measure the success of the US Vaccines for Children program, Brendan Walsh of City University in London and coauthors used 1995-2013 data from the National Immunization Survey to assess whether vaccination uptake increased at different rates across income and racial/ethnic groups. At the beginning of the program, children from lower-income, Hispanic families had lower vaccination rates than their better-off, white counterparts. However, over the course of the program, lower-income Hispanic families saw a larger increase in vaccination rates than other groups. In contrast, while higher-income, black children saw large increases in vaccination uptake, the increase among lower-income, black children was more modest, thereby increasing income disparities among black children. The authors found that interventions aimed solely at reducing certain financial barriers to vaccination may fail to address other important aspects that influence vaccination uptake, especially among poorer children. Citing Centers for Disease Control and Prevention data, the authors note that 322 million bouts of illness and 732,000 deaths will be prevented for US children born since the Vaccines for Children program began. (See chart below, which appears in the issue's DataGraphic.)
©2016 Health Affairs
DATAWATCH: Europe slow to eliminate measles and rubella.
The reported incidence of measles and rubella in the World Health Organization (WHO) European Region has declined dramatically over the past two decades, making it possible for all fifty-three member states of the region to commit in early 2012 to the achievable goal of eliminating both diseases by the end of 2015. Using data reported by countries, Robin Biellik and other members of the Regional Verification Commission and the WHO Secretariat report that, as of the end 2013, twenty-two countries had interrupted endemic measles transmission and twenty-three countries had interrupted endemic rubella transmission. There was little change between 2012 and 2013, and the elimination of measles and rubella by the target date of 2015 was unlikely to be met-an unexpected outcome in a region where sufficient resources are available. The authors conclude that until progress toward genuine political commitment, increased technical capacity, and universal public awareness of the benefits of measles and rubella elimination (especially in Western Europe) is urgently accelerated, this important public health initiative will remain unfulfilled.
Measles outbreak at Disneyland increased parental awareness and support for mandates. 
Parents who had high awareness of the 2014-15 measles outbreak linked to Disneyland in California showed more support for vaccine mandates according to research by Michael Cacciatore of the University of Georgia and coauthors. Using national surveys of parents with young children, they looked at parents' awareness of measles during the weeks immediately prior to and following the 2014-15 outbreak. They also examined parents' confidence in-and intention of-vaccinating their children and how awareness of the measles outbreak affected both. Parents were classified as having "no awareness," "low awareness," or "high awareness" of the outbreak. Those who were most aware had more confidence in immunization and showed more support for vaccination mandates. In addition, 76.2 percent planned to have their children receive all recommended future vaccines, compared with 64.9 percent of the parents who had no awareness of the outbreak. The authors conclude that while highly visible outbreaks can positively affect awareness, educational efforts about the safety and value of vaccination must continue.
Mississippi and West Virginia show how states can limit vaccination mandate exemptions.
Researchers say that contrary to conventional wisdom, Mississippi and West Virginia provide evidence that it may be politically tenable to limit childhood vaccination exemptions to medical reasons only. For more than three decades, Mississippi and West Virginia were the only states that did not allow nonmedical exemptions--such as religious or philosophical objections--to mandatory school vaccination laws. Recently, other states, such as California, appear to be moving in a similar direction. James Colgrove of the Columbia University Mailman School of Public Health and Abigail Lowin, a student at the Columbia University School of Law, reviewed accounts from legislative histories, media, and health officials in Mississippi and West Virginia to determine the consequences of allowing only medical exemptions. Because the policy change may be controversial, the authors recommend that states proceed carefully and consider less restrictive options to eliminating nonmedical exemptions, such as making them more difficult for parents to obtain.
Assistance for vaccine development nearly quadrupled over fourteen years.
In examining development assistance and the international vaccine funding provided to low- and middle-income countries, researchers found that aid grew from $822 million in 2000 to $3.6 billion in 2014. Increases in assistance are largely attributed to the creation of the international organization Gavi, the Vaccine Alliance, which saw funding grow 18.8 percent annually since 2001. The United States and the United Kingdom also provided substantial assistance, with contributions increasing each year by 6.7 percent and 13.9 percent, respectively. The study, by Joseph Dieleman, assistant professor at the University of Washington; Annie Haakenstad, doctoral student at the Harvard T.H. Chan School of Public Health; and coauthors, used estimates compiled by the Institute for Health Metrics and Evaluation, which look at development assistance for eight separate health focus areas. The authors conclude that continued increases in development assistance for vaccination are encouraging signs that the goals of the Global Vaccine Action Plan could be realized through increased financing. 
Proportion of vaccines reaching clinical trial status increased between 1990-2012.
Over the past two decades, the proportion of vaccine candidates heading to clinical development globally increased by 3-5 percentage points. Using a comprehensive database of global pharmaceutical research, Thomas Hwang of Bain Capital and Aaron Kesselheim of Harvard Medical School/Brigham and Women's Hospital found that vaccines accounted for 3 percent of new Phase I trials in 1990, while that number jumped to 8 percent in 2012. Roughly two-thirds of early-stage (Phases I-II) vaccine clinical trials emerged from small and medium-size companies, while late-stage (Phase III) trials were dominated by large pharmaceutical companies. The authors conclude that to meet unmet medical needs and emerging public health threats, public-private partnerships and other policies directed at these sources of innovation may be beneficial in assisting the development of new vaccines.
Global HPV vaccine prices show economic benefit, particularly for high-income countries.
Vaccinating 80 percent of twelve-year old females globally against HPV could generate economic returns worth up to $12.5 billion a year, according to Niamh Herlihy of the Centre Virchow-Villermé de Santé Publique in Paris and coauthors. The researchers analyzed the economic surplus--the sum of all health and economic benefits minus the costs of development, production, and distribution--for HPV vaccination of twelve-year-old females. They found that almost all countries receive a share of this surplus. In addition, manufacturers may have seen a return on investment five times greater than their original investment in HPV vaccine development.