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10 ? How About the Indirect Effect ? Cost-Effectiveness of Various Additions to Current Flu Programme

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10 ? How About the Indirect Effect ? Cost-Effectiveness of Various Additions to Current Flu Programme Hanna Nohynek, Chief physician, Infectious Diseases Control and Vaccinations, Department of Health Protection www.thl.fi @HNohynek ESWI 28 September 2018 Influenza vaccine cost effectiveness in children in Finland 26.05.2018 ESWI CEA infl child FInland 1 ESWI September 2018 Faculty Disclosure Secretary of NITAG THL Finland X No, nothing to disclose: Hanna Nohynek Team co-lead Influenza, THL * Yes, please specify: THL Mother of 4 and grandmother of 6 Consulting/ Ownershi Honoraria/ Funded Royalties/ Stock Other Company Name Advisory p/ Equity Employee Expenses Research Patent Options (please specify) Board Position * GlaxoSmithKline * * Pfizer, Inc * IMI projects DRIVE RESECEU * ADVANCE Why did THL Finland perform cost effectiveness analysis of influenza vaccination in children in early 2000? 26.05.2018 ESWI CEA infl child FInland 3 The Four step approach of NIP decision making in Finland since 2000 How does a new vaccine end up in the national universal vaccination programme ? Main questions are 1. Can one expect that universal vaccination provides sufficient reduction of a significant public health disease burden, when taking into consideration the epidemiology and severity of the disease, and the effectiveness of the vaccine ? 2. Is the vaccine safe enough to those vaccinated ? 3. Is the vaccine safe enough on population level ? 4. Is the balance between the vaccination related health benefits and economic costs acceptable ? NITAG Finland 2003 26.05.2018 ESWI CEA infl child FInland 4 yes Vaccine safety on Impact on disease the individual and Cost-effectiveness burden Decision on a population level vaccine-specific expert group no Transmission model Expert opinion NIP CEA of the yes Surveillance vaccination Evaluation programme Expert group of Influenza recommendation Decision on no vaccination programme Vaccine-specific expert group report (MSAH statute) NITAG recommendation Parliament decision Advisory Board on on the budget Communicable National Institute Diseases consultation for Health and Welfare recommendation Ministry of Social MSAH MSAH Affairs and Health budget proposal opinion (MSAH) procedure THL, Heini Salo Salo H. 5 Cost saving in < 13 yr olds 26.05.2018 ESWI CEA infl child FInland 6 Methodology and assumptions Salo et al 2006 26.05.2018 ESWI CEA infl child FInland 7 Estimated costs of influenza from registers, publications and expert opinion 26.05.2018 ESWI CEA infl child FInland 8 Annual savings per vaccinated child and total annual savings depending on perspective 26.05.2018 ESWI CEA infl child FInland 9 Annual savings / vaccinated child Sensitivity analysis 26.05.2018 ESWI CEA infl child FInland 10 ? How about the indirect effect ? Cost-effectiveness of various additions to current flu programme All additions involving 70.000 vaccination of children 60.000 were cost-effective even 50.000 at low uptake (30%) 40.000 Little additional benefit 30.000 by adding older age 20.000 groups but big increase 10.000 in programme costs 0 6m-4 yrs 5-16yrs 6m-16 yrs 6m-16 and 50- 50-64 yrs 6m-64 yrs 64 yrs Baguelin M BMC Med 2015 Cost in £ per QALY gained 12 Influenza Europe How successful has the childhood influenza vaccination programme been ? Influenza Europe 13 Influenza vaccine coverage in Finland during seasons 2009/18 among young children and elderly as of 26 May 2018 LAIV introduction Postpandemic * ... Fully vaccinated (2 doses if not given min. 2 doses before, otherwise 1 dose as for all the other age groups) 26.05.2018 ESWI CEA infl child FInland National Vaccine Register14 Timeline of influenza vaccine recommendations in the Finnish national immunization programme Year Vaccine Target group Main reason for recommendation 1980 SIV Medical risk groups Burden of Disease (BoD) 2002 SIV > 65 year old BoD 2007 SIV Children 6 – 35 mo Cost saving when given to children <13 yrs (Salo et al 2006) 2009 AH1N1 + Everyone according to Pandemic threat, expected BoD AS03 prioritization order Obs! not part of NIP 2010 SIV Pregnant women BoD HCW taking care of at Indirect protection (IP) risk patients 2011 SIV All HCW and social BoD; IP – 2018 CommDis Act workers mandates Employer responsibility 2012 SIV Close contacts IP Army conscripts BoD 2014 SIV Pharmacy workers in BoD direct customer contact IP 2018 SIV Children < 7 yrs of age CEA (2006) Prisoners 26.05.2018 ESWI CEA infl child FInland 15 How effective has the childhood influenza vaccination programme been ? Has it been cost-effective ? 26.05.2018 ESWI CEA infl child FInland 16 Influenza vaccine effectiveness against laboratory confirmed influenza and ILI among children 6-35 mo of age – nation wide register linkage cohort study Annual birth cohort ~55 000, coverage 13 – 36 % 26.05.2018 ESWI CEA infl child FInland 17 Laboratory confirmed influenza reported to NIDR National Infectious Disease Register 26.05.2018 ESWI CEA infl child FInland 18 Influenza vaccine effectiveness cohort of 54,611 children 24-35 mo of age register linkage cohort study, season 2017/18 Inactivated vaccine (IIV3) Live-attenuated vaccine (LAIV4) § Vacc coverage = 9% § Vacc coverage = 22% Cases* VE** and Cases* VE** and 95%CI 95%CI Influenza 318/ 44 -10.4 Influenza 318/ 67 30.8 (-51.5; 19.5) (9.9; 46.9) … type A 145/ 19 -4.5 … type A 145/ 59 -32.1 (-68.9; 35.3) (-79.0; 2.4) … type B 177/ 25 -12.2 … type B 177/ 11 79.5 (-70.9; 26.3) (62.2; 88.8) 159/ 18 ‘ILI’ 9.4 ‘ILI’ 159/ 30 37.9 (-47.7; 44.4) (8.3; 58.0) * Not vaccinated/ vaccinated ** in %, adjusted for age and sex 30.05.2018 Influenza Europe 19 Laboratory confirmed influenza A/B findings (N=37,508) by age by end of season 2018 (as of 27.9.2018) Age group yrs Influenza A Influenza B 0-4 1211 1298 5-14 1466 3398 15-64 6770 9979 65+ 7209 6177 12.000,00 10.000,00 8.000,00 6.000,00 Infl A 4.000,00 2.000,00 Infl B 0,00 National Infectious Disease Register 0-4 65+ 26.05.2018 ESWI CEA infl child FInland 5.-14 15-64 20 Given the differences in observed effectiveness of available vaccines, what role economic analysis should play in choosing influenza vaccines for the National immunization programme? 26.05.2018 ESWI CEA infl child FInland 21 Assumption = QIV prevents 8 % units more Children 6 – 35 mo old Lab+ influenza Willingness to pay 26.05.2018 ESWI CEA infl child FInland Salo H, Auranen K 3/201822 Salo H, Auranen K 3/2018 26.05.2018 ESWI CEA infl child FInland 23 Brand / Product specific Effectiveness data requested 30.05.2018 Influenza Europe 24 Development of Robust and Innovative Vaccine Effectiveness (DRIVE) www.drive-eu.org @26.05.2018drive_eu #driveflu Acknowledgement DRIVE project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777363, This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA. DRIVE Consortium is expanding 15 partners: 3 PHIs+ 6 Public Partners/Academia+ 2 SMEs+ 4 EFPIA Public coordinator: Project Leader: Future plans to improve influenza programme in Finland Next season § Continue refining IVE estimation in light of § Finland has purchased QIV propensity, health status, 1,7 mi doses (all) and LAIV previous vaccination history, (2-6 yr olds) and circulating strains § Expand IMI-DRIVE network § Establish hospital based IVE and activities surveillance for children § TND study among adults § Improve understanding on who olds (DRIVE) ? gets influenza vaccine, why / why not § Repeated dose immunological study among § Study impact of real-time IVE HCW communications on uptake and willingness to get § IVE among immune- vaccinated compromized patients § Behavioral economics 26.05.2018 ESWI CEA infl child FInland 27 Take home messages § Cost effectiveness analysis (CEA) is a useful tool to justify health interventions on population level § Economic analyses are sensitive to the assumptions made § Secondary use of health records data allows real time estimation of vaccine 1) coverage and 2) impact § Register data can be used both for programme monitoring and development, as well as guiding decision making, and informing society at large § We need to better understand bias and confounding in interpreting IVE before we make conclusions on preferential recommendations 26.05.2018 ESWI CEA infl child FInland 28 Acknowledgements Ulrike Baum Anu Haveri Niina Ikonen Jukka Jokinen Susanna Jääskeläinen Richard Pebody Saila Pitkänen Heini Salo Jonas Sundman Ritva Syrjänen This work has received funding from the taxpayers in Finland via THL, ECDC contract to Epiconcept (OJ/16/07/2014-Proc/2014/024) and two specific contracts No7 ECD.6594 and No8 ECD.6646 via contract No ECDC/2014/026. 26.05.2018 ESWI CEA infl child FInland 30 Backup slides 26.05.2018 ESWI CEA infl child FInland 31 §Parental attitudes towards SIV 2015 Miten suhtautuu kausi-influenssarokotteen antamiseen lapselle §Positive §Negative 5) Erittäin 4) Melko 3) Ei myönteisesti 2) Melko 1) Erittäin Keskiarvo myönteisesti myönteisesti eikä kielteisesti kielteisesti kielteisesti 5-1 §N = 697 Kaikki, n=697 13 31 27 28 3,29 0 10 20 30 40 50 60 70 80 90 100 n=kaikki vastaajat % 32 26.05.2018 IVE Children FInland THL & Terveystutkimus Oy, 2015 Influenza vaccine coverage among children 6- 35 mo and elderly 65 year+, season 2017/18 Children 6 – 35 months Elderly 65+ years 26.05.2018 IVE Children FInland 33 2018-05-11 Vacc&Narcolepsy / HNohynek 34 Countries recommending seasonal influenza vaccine for children and adolescents (n=29) No recommendation >6 months - 2 years >6 months - 3 years >6 months - 5 years >6 months - 12 years Different age groups between > 2- 11 years Data
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