COST-EFFECTIVE PRICE OF DENGUE VACCINATION IN MALAYSIA

Transcription

1 COST-EFFECTIVE PRICE OF DENGUE VACCINATION IN MALAYSIA Assoc Prof Dr Asrul Akmal Shafie International Fellow, International Society for Pharmacoeconomics & Outcomes Research Program Chairman, Universiti Sains Malaysia

2 Outline What is cost-effective price & how to assess it? How do we measure the economic impact of dengue vaccination? Which dengue vaccination strategies give the best value?

3 What is Cost-Effective Price?: How Much Would You Pay for We put price to reflect the value of the benefit we think it should be Price value = cost-effective Price > value cost-effective Cost-effective price is the max price for the expected value of benefit Price threshold = upper limit of the vaccination price for the intervention to be considered cost-effective as defined by decision makers/who* *

4 What is Cost-Effective Price?: Translating to Research Value = NET MONETARY BENEFIT (NMB) = Benefit Cost So, BENEFIT Avoidance of dengue treatment Avoidance of productivity losses Avoidance of HRQoL losses Avoidance of death DALY - COSTS Vaccine administration Economic Impact

5 What is Cost-Effective Price?: Translating to Research effectiveness P threshold = DALYs lost X CE Threshold+ disease costs+ adm.costs Number of doses : difference between standard of care ie. here no vaccination and vaccination strategy DALYs and costs are discounted

6 How to Determine the CE Price of Dengue Vaccine? = Avoidance of dengue treatment + Public Provider s Perspective CRITERIA ITEM VALUATION PUBLISHED COST (US$) COST PER CASE 2013 (US$) Ambulatory/ Direct Medical Average operating budget in public clinics (2009) Dengue Treatment Hospitalized/ Direct Medical Weighted average operating expenditure in UMMC, public district hospitals and WHO- CHOICE (2009) Suaya, J. A., et al. (2009). "Cost of dengue cases in eight countries in the Americas and Asia: a prospective study." Am J Trop Med Hyg 80(5): Shepard, D. S., et al. (2012). "Use of multiple data sources to estimate the economic cost of dengue illness in Malaysia." Am J Trop Med Hyg 87(5):

7 Loss of school day How to Determine the CE Value of Dengue Vaccine? = + Avoidance of Productivity Losses + Loss of work productivity Ambulatory Mean±SD loss of school day: 3.2±2.3 days Hospitalized Mean±SD loss of school day: 4.1±2.1 days Ambulatory Mean±SD loss of work productivity: 7.2±2.6 days Hospitalized Mean±SD loss of work productivity: 8.8±2.7 days Suaya, J. A., et al. (2009). Am J Trop Med Hyg 80(5):

8 How to Determine the CE Price of Dengue Vaccine? = + Avoidance of productivity losses to receive treatment Societal Perspective CRITERIA ITEM VALUATION PUBLISHED COST (US$) COST PER CASE 2013 (US$) Dengue Treatment Ambulatory/ Indirect Hospitalized/ Indirect Minimum wages or cost/ school day Minimum wages or cost/ school day (2009) (2009)

9 Administration SCHOOL OF How to Determine the CE Price of Dengue Vaccine? = - cost of Administering Vaccine Public Provider & Societal Perspective CRITERIA ITEM VALUATION SOURCE / REFERENCE COST 2013 PER DOSE (US$) PUBLIC PROVIDER COST PER DOSE (US$) SOCIETAL COST PER DOSE (US$) Dengue Vaccination Program Personnel Equipment & consumable items Treatment of adverse events MOH salary scale MOH price list Average cost in Malaysia public healthcare center Ministry of Health Clinician s opinion Clinician s opinion WHO-CHOICE (Provider) 5.96 (Societal) Indirect Weighted minimum wages and cost per school day Ministry of Human Resource Malaysia Suaya

10 Using Dynamic Transmission Model to Determine the Susceptible DHF/DSS Susceptible DHF/DSS Hosts Dengue 1 Latent infection Dengue Fever Short-term immunity Long-term immunity Hosts Dengue 2 Latent infection Dengue Fever Short-term immunity Long-term immunity Vaccinated Asymptomatic Infection Vaccinated Asymptomatic Infection Flow diagram - 4 serotypes - Incub 1 Infec 1 Vectors Susceptible Incub 2 Infec 2 Incub Incub 3 4 Infec Infec 3 4 Susceptible DHF/DSS Susceptible DHF/DSS Hosts Dengue 3 Latent infection Dengue Fever Short-term immunity Long-term immunity Hosts Dengue 4 Latent infection Dengue Fever Short-term immunity Long-term immunity Vaccinated Asymptomatic Infection Vaccinated Asymptomatic Infection Key features Compartmental model (deterministic) Host-vector interactions Interaction between the 4 serotypes Age-specific level of incidence & disease transmission Host and vector population growth Seasonality Serotype-specific impact of vaccination 1. Coudeville L, Garnett G [2012] PloS One 2. Amaku M, Coudeville L, Massad E [2012] Rev. Inst. Med. trop. S. Paulo

11 WHAT IS THE ECONOMIC IMPACT & COST- EFFECTIVE PRICE OF DENGUE VACCINE IN MALAYSIA? R13C30

12 Evaluated Strategies NATIONWIDE HOTSPOT Strategy R9C17 R9C30 R13C30 R9C17 R9C30 R13C30 Compliance 95% 66% 60% 95% 64% 59% N 8,429,404 12,572,912 10,619,309 1,531,057 2,283,654 1,928,816 *Hotspots: Kuala Lumpur, Petaling, Putrajaya, Klang, Hulu Langat & Gombak **Catchup within 1 year

13 Simulation Parameters Simulation Parameters Values Reporting factors Hospitalized Reporting factors Ambulatory Vaccine Wastage 1 20% Discount Rate 3 3% Vaccine Protection 4 10 years GDP/capita 2013 (IMF 2014) $ 1. Ministry of Health Malaysia key personnel expert opinion. 2. Shepard, D.S., et al. [2012] Am J Trop Med Hyg, 87(5): p Malaysia Pharmacoeconomics Guidelines. 4. Assumptions.

14 THS R13C30 Health Impact No No Vaccination With Vaccination Vaccination Dengue cases 904, ,983 50% (95%CI 33-65%) Dengue deaths % (95%CI 35-68%) Life Year Lost 22, ,551 53% (95%CI 36-68%) Disability-Adjusted-Life-Year (DALY) 32, ,528 52% (95%CI 35-67%) No Vaccine With Vaccine No Vaccine With Vaccine No Vaccine With Vaccine No Vaccine With Vaccine

15 Summary : Economic Impact Period US$ MILLIONS % (95%CI 61-39%) 50% (95%CI 60-38%) 50% (95%CI 60-39%) % (95%CI 60-38%) 52% (95%CI 60-38%) 52% (95%CI 60-39%) 0 Targeted Hotspot R13C30 Nationwide R13C30 Disease Cost Without Vaccine (Provider) Disease Cost Without Vaccine (Societal) Productivity Loss Without Vaccine Disease Cost With Vaccine (Provider) Disease Cost With Vaccine (Societal) Productivity Loss With Vaccine

16 Scenario Summary : Health Impact Dengue Cases Averted Period Dengue Deaths Averted Life Year Lost Averted DALY Averted THS R13C30 448,124 (50%) 509 (52%) 11,785 (53%) 16,751 (52%) THS R9C30 474,857 (52%) 537 (56%) 12,427 (56%) 17,721 (55%) THS R9C17 365,510 (41%) 415 (43%) 9,747 (44%) 13,815 (43%) NW R13C30 1,060,222 (50%) 1,202 (53%) 27,834(56%) 39,584(52%) NW R9C30 1,122,456 (53%) 1,271 (56%) 29,432 (56%) 41,918 (55%) NW R9C17 858,559 (41%) 976 (43%) 22,927 (44%) 32,479 (43%)

17 Summary : Economic Impact Public Provider Period Scenario Total Disease Cost Reduction US$ % Reduction THS R13C30 163,859,846 51% THS R9C30 173,952,237 54% THS R9C17 132,487,470 41% NW R13C30 386,962,641 52% NW R9C30 410,918,544 55% NW R9C17 311,284,079 42%

18 CE Price of All Dengue Vaccine 120 CE Price DEN Vac CE Price in Literature Price of Other Vaccine $ $93.00 $95.00 $ $ $62.81 $ $46.00 $40.92 $38.13 $ $26.82 $17.63 $23.52 $21.61 $15.49 $14.23 $ $8.13 $3.81 US$ per dose PROVIDER US$ per dose SOCIETAL * Source: Bahagian Perkhidmatan Farmasi, MOH. Updated December 2013

19 Cost-Effectiveness Threshold Price: Univariate Sensitivity Analysis Public Provider s Perspective: Highly Cost-Effective Price Reporting factors - Ambulatory (1/10.38) Vaccine protection duration (5/30 years) Model time horizon (5/30 years) Reporting factors - Hospitalized (1/2.45) Discount rate (0%/5%) Upper Vaccine Wastage (10%/30%) Lower Cost of dengue disease (80%/120%) Vaccine coverage rate for catch up (20%/80%) Vaccine administration cost (80%/120%) THS R13C Highly Cost-Effectiveness Threshold Price/dose, US$

20 Conclusion Dengue vaccination in Malaysia reduces the dengue related health and economic burden ranging from 41-56% for different strategies. A vaccination program would be highly cost-effective at a price below US$46 from the provider perspective in the targeted hotspot R13C30 scenario. The presence of assumptions and uncertainties in key parameters, but have been assessed through DSA and PSA Burden of dengue disease in this study only captures dengue treatment. Other factors such as dengue related deaths, longterm sequelae of dengue disease, vector prevention & control, surveillance, loss in tourism and loss in foreign investment were not included.

21 Acknowledgement and appreciation to: Ms Yeo Hui Yee, MSc Candidate Sanofi for the research grant. Laurent Coudeville, Lucas Steinberg, Sanofi Pasteur Dr Balvinder, Dr Amar, Dr Rohani, MoH Malaysia Shafie AA, Yeo HY, Coudeville L, Gill BS, Steinberg L. A dynamic transmission model for dengue virus in Malaysia. (in submission) Yeo HY, Shafie AA, Coudeville L, Steinberg L, Gill BS, Jahis R, Amar-Singh HSS. The potential cost-effectivenss of different dengue vaccination program in Malaysia: assessment using dynamic transmission model (in submission) THANK YOU

22 Vaccine Administration Cost Estimates (Provider Perspective) Sectors Items Costs/Dose Reference Notes Personnel Variable Fixed Medical Officer x1 Staff Nurses x2 Community Nurses x3 Healthcare Assistant x1 Driver x1 Syringe x1 Needle x1 Gloves x1 Alcohol Swab x1 Sharp Bin + Disposal Pharmaceutical Fridge x1 Vehicle x2 Portable Ice Box x10 Dial Thermometer x10 US$ 2.72 US$ 0.30 US$ 0.55 Adverse Events Ambulatory Treatment US$ 0.01 Total Cost/ Dose = US$ 3.58 Clinician s opinion Ministry of Health salary scale Clinician s opinion Ministry of Health purchase price Clinician s opinion Ministry of Health purchase price Malaysia NIP Handbook Clinician s opinion CPG Dengue WHO-CHOICE 1 This team can vaccinate 100 subjects per day. Vaccine will be marketed as 5-dose vial with diluent supplied. These equipment would cover the vaccination of 100 subjects per day over their useful lifespan. 1% with minor adverse event will seek treatment. 1. WHO-CHOICE = World Health Organization Choosing Intervention That Are Cost-Effective

23 Summary : Total Vaccine Administration Cost Provider & Societal Period Scenario Provider Perspective US$ Societal Perspective US$ THS R13C30 25,164,652 6,998,654 THS R9C30 29,050,475 8,099,966 THS R9C17 24,739,279 6,891,059 NW R13C30 139,368,344 38,772,172 NW R9C30 161,080,465 44,895,612 NW R9C17 136,204,786 37,939,473