KUALA LUMPUR, Jan 6 — Putrajaya should not use cost-effectiveness as the only factor in deciding which pneumococcal vaccine to list in Malaysia’s national immunisation programme (NIP), public health experts say.
Pneumococcal conjugate vaccines (PCV) are currently provided by pharmaceutical giants Pfizer (PCV13) and GlaxoSmithKline’s (GSK) PCV10. Independent medical humanitarian organisation MSF, however, announced last December that the first alternative pneumococcal vaccine from an Indian manufacturer could be available in the next few months, at a purportedly much cheaper price than Pfizer and GSK’s products.
Malaysia’s Ministry of Health (MOH) tweeted last Friday that children born this year onwards would receive free pneumococcal vaccination from June, but Deputy Health Minister Dr Lee Boon Chye did not specify which vaccine MOH would provide.
The PCV10 vaccine protects against 10 serotypes, or strains, of Streptococcus pneumoniae bacteria (called pneumococcus) that causes pneumococcal disease. The more expensive PCV13 vaccine covers the same pneumococcal strains as PCV10, plus an additional three serotypes — 19A, 6A, and 3.
Serotypes 19A and 6A were among the most common pneumococcal serotypes in Malaysia from 2014 to 2017 at 11.8 per cent and 10.6 per cent of children five years or below respectively, according to a study by A. Revathy et al from MOH’s Institute for Medical Research.
World Society of Pediatric Infectious Diseases founding member Dr Ron Dagan warned that even if serotype 19A isn’t very common, using the PCV10 vaccine actually serves to strengthen serotype 19A by removing 10 other competing strains, causing further disease. Serotype 19A is also very resistant to antibiotics.
“If you don’t have much 19A, then PCV13 is still very good because it covers. But if you don’t have much 19A but you give PCV10, you’re guaranteed to have a lot of 19A in a few years,” Dr Dagan told CodeBlue.
“This is the reason why a lot of countries now move from PCV10 to PCV13 — because they saw this rise of 19A and another strain, which is not in [both] vaccines, but is very close to 6A which is in PCV13, it’s called 6C. That one also goes up with PCV10, but goes down with PCV13.”
Most countries, he said, use PCV13 instead of PCV10, like the United States, the United Kingdom, Australia, and most Asian countries like Singapore, Hong Kong, and South Korea. Some nations have also switched from PCV10 to PCV13, like Belgium, Austria, Finland, and several Latin American countries because of problems with increased serotype 19A.
A World Health Organization (WHO) position paper on PCV published in February 2019 found insufficient evidence of a difference in the net impact of the PCV10 and PCV13 vaccines on overall disease burden.
“PCV13 may have an additional benefit in settings where disease attributable to serotype 19A or serotype 6C is significant,” the WHO added.
Dr Dagan said, however, that the WHO paper did not look at the overall impact of the pneumococcal vaccines or the indirect protection of other people in the community. Publications after 2017 were not examined either.
“Overall, you do see a superiority of PCV13.”Dr Ron Dagan, a founding member of World Society of Pediatric Infectious Diseases
Pharmaceutical companies charge different prices to different countries for their products. Rich OECD countries pay the full price for PCV13, Dr Dagan said, while impoverished nations buy pneumococcal vaccines at very cheap prices, subject to availability. Malaysia, on the other hand, is an upper middle-income economy.
“Remember, the most important thing in vaccine is not to pay less. The most important in vaccine is to promote health and reduce disease,” said the president of the European Society for Paediatric Infectious Diseases.
“So the consideration of money is not cheaper or not. I’m not an economist, but as a scientist and physician and paediatrician, my point is how much health can I buy with one vaccine or another? One vaccine buys more health.”
David E. Bloom, the Clarence James Gamble Professor of Economics and Demography in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health, praised the Malaysian government and MOH for deciding to include a pneumococcal vaccine in Malaysia’s NIP.
“That decision will directly protect hundreds of thousands of Malaysian babies from pneumococcal disease. And it will have the added benefit of indirectly protecting many millions of Malaysian children, adolescents, and adults,” Bloom told CodeBlue.
He also said the differences in serotype coverage between PCV10 and PCV13 are important, especially because of pneumococcal disease caused by serotypes 6A and 19A in many countries and the tendency for serotype 19A infections to show antibiotic resistance.
“There are also some indications that PCV13 affords variable protection against serotype 3,” Bloom added.
The economist said he could not comment in general terms on value-for-money for either PCV10 or PCV13, in part because he did not know the differing prices of the vaccines in various countries.
“All I can offer here is the speculation that, if PCV10 and PCV13 were priced equally, PCV13 would likely offer more value-for-money than PCV10 in most country settings.”David E. Bloom, the Clarence James Gamble Professor of Economics and Demography in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health
Bloom also stressed that cost-effectiveness was not the only factor health policymakers should consider in choosing which vaccine to list in their country’s NIP.
“There is no denying that vaccine safety, efficacy, and cost-effectiveness from the perspective of health payers (i.e., how much health is reasonably expected to improve per dollar/ringgit spent on vaccination, net of offsetting health system costs associated, for example, with averted illnesses) are natural factors to include in assessing new vaccines for possible inclusion in NIPs.
“However, insofar as public resources are being allocated, it is appropriate to consider the full range of societal benefits that potentially follow from the introduction of a vaccine. Such benefits, which are typically neglected in policy decisions, include a long list of health benefits, economic benefits, and social benefits (and are inclusive of any negative benefits associated with adverse effects due to vaccination).”
Bloom highlighted benefits from vaccination like slowing down antimicrobial resistance, keeping adults healthy and productive, ensuring higher levels of schooling for healthy children, and boosting social equity as protection provided by vaccines tends to disproportionately benefit the poor. The full societal advantages, he said, appear to significantly outweigh narrow health payer-centric benefits.
“Judicious policymaking requires resisting any temptation to judge the price of one vaccine as high simply because it is higher than the price of some alternative vaccine,” he said. “Rather, vaccines are best assessed by comparing their prices to the full benefits generated by the vaccine.”
The WHO estimates that pneumococcal disease kills about one million children globally every year. According to the US’ Centers for Disease Control and Prevention, pneumococcus is the most common cause of pneumonia, bloodstream infections, meningitis, and middle ear infections in young children.
David E. Bloom’s research on vaccination has been funded by Pfizer, GSK, Merck, Sanofi-Pasteur, Welcome Trust, and the WHO.