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Key Evidence: Providing a birth dose of hepatitis B vaccine to all newborns (in addition to routine HepB immunization) was found to be a highly cost-effective means of preventing hepatitis B-related deaths in three refugee populations in Africa which are at extremely high risk of hepatitis B infection. Providing a birth dose only to newborns whose mothers test positive on a rapid diagnostic test was less cost-effective than vaccinating all newborns automatically. Thus, universal hepatitis B vaccination of newborns should remain a priority in refugee camps, despite competing humanitarian needs.

Key Evidence: Children living in the Yida refugee camp in South Sudan in 2013 were found to have an elevated rate of pneumonia infections likely due to malnutrition, overcrowding, and inadequate shelter. Using these data, the CDC estimated that the use of Hib and pneumococcal vaccines in children under 2 years of age in the camp would be cost-effective under all dosing scenarios evaluated. Medecines Sans Frontiers (MSF) provided medical services to this refugee camp and found delivery of these vaccines to be feasible and effective in this setting.

Key Evidence: In a study of different strategies for preventing hepatitis B infections in newborns in a Burmese refugee population with a high infection rate, administering hepatitis B immune globulin to newborns whose mothers test positive through a rapid diagnostic test -- in addition to vaccinating all newborns with a birth dose -- prevented twice as many infections in newborns than vaccination alone and was cost-effective (while the current strategy of providing immune globulin only after a confirmatory lab test was done was not). Thus, this strategy could be considered for similar marginalized or poor populations.

Key Evidence: A comprehensive review of the economics of cholera and cholera prevention concluded that vaccination using oral cholera vaccines can be cost-effective, especially when herd effects are taken into account and when vaccination is administered to populations and age groups with high incidence rates (e.g., children) and to areas with high cholera case fatality rates.

Key Evidence: A study using local epidemiological and economic data found that vaccinating children 1-14 years old in high-risk slum areas in Dhaka, Bangladesh using a locally-produced oral cholera vaccine provided through periodic campaigns would be a highly cost-effective means of controlling endemic cholera -- reducing cholera incidence in the entire population by 45% over 10 years and costing US$440-635 per DALY averted. Vaccinating all persons aged one and above would reduce incidence much further (by 91%) but would be less cost-effective.

Key Evidence: An outreach strategy in Kenya to vaccinate children against measles in hard-to-reach areas (e.g., beyond 5 km from a vaccination post) would be highly cost-effective, despite the higher cost per child to reach these children. The estimated cost per DALY averted ranged from US$122 (if 50% of these children receive the first dose and one-half of them the second dose) to US$274 (if 100% receive the first dose) -- considerably less than the country's GDP per capita of US$1,865 used as the threshold of cost-effectiveness.

Key Evidence: An analysis of the impact of rotavirus vaccine in 25 countries found that the rates of vaccination in all countries were highest and risk mortality lowest in the top two wealth quintile's coverage. Countries differed in the relative inequities in these two underlying variables. Cost per DALYs averted in substantially greater in the higher quintiles. In all countries, the greatest potential vaccine benefit was in the poorest quintiles; however, reduced vaccination coverage lowered the projected vaccine benefit.

Key Evidence: In an analysis of the impact and cost-effectiveness of pneumococcal conjugate vaccines (PCV) in preventing disease and deaths in children under five years in 180 countries, the vaccination was most cost-effective in low income regions and Gavi-eligible countries. The average cost per disability adjusted life year (DALY) was $118 in Africa, $853 in Asia, and $16,000 in Europe. PCV introduction throughout Africa would account for nearly 70% of lives saved globally, but requires only 12% of the global investment.

From the VoICE Editors: The cost estimates were calculated in international dollars. 

Key Evidence: Children in the poorest 20% of households in Laos have a 4-5 times greater risk of dying from rotavirus than the richest 20%. Consequently, rotavirus vaccination was almost five times more cost-effective in the lowest income groups in the Central Region than in the richest households in the wealthier North region. Thus, rotavirus vaccination has a greater potential for health gains and greater cost-effectiveness among marginalized populations.

From the VoICE Editors: Note that these gains are dependent on improving vaccination coverage, access to health care and environmental health in these populations.

Key Evidence: According to a cost-effectiveness study of rotavirus vaccination in Pakistan, the vaccine would be the most cost-effective in the poorer provinces of Sindh and Balochistan (that also have the highest rates of death from rotavirus)- with a cost per disability-adjust life year averted $155-$167 compared to almost $600 in the wealthier region of Islamabad. Within all regions, vaccination was the most cost-effective among the two poorest income groups (quintiles), and was almost 12 times more cost-effective in the poorest households in the most marginalized region than in the wealthiest households in the most advantaged region (cost/DALY averted of $76 vs. $897).

Key Evidence: A study looking at the impact of pneumococcal vaccine introduction and scaling up pneumonia treatment in Ethiopia found that 30-40% of all deaths averted by these interventions would be expected to occur in the poorest wealth quintile. The greatest resulting financial risk protection would also be concentrated among the bottom income quintile.

Key Evidence: A study of measles vaccine in Bangladesh found that children from the poorest quintile were more than twice as likely to die as those from the least quintile in the absence of measles vaccination. The difference in mortality between unvaccinated and vaccinated was statistically significant (p<0.10) and robust across alternative measures of socioeconomic status.

Key Evidence: The evidence on cholera disease dynamics suggests that significant herd protection can result from a relatively small number of immunizations, particularly in endemic areas where there is some natural immunity among the population.

Key Evidence: In Japan, which has experienced a re-emergence of pertussis among adolescents and adults, vaccinating pregnant women with the Tdap vaccine would be cost effective in preventing the illness in young infants (<3 months of age) and in mothers, according to the WHO definition of cost effectiveness. This is true even if only 50% of pregnant women receive the vaccine.

Key Evidence: Pertussis causes nearly 200,000 deaths in children worldwide, nearly all in infants too young to be vaccinated. Vaccinating pregnant women against pertussis with a single dose of Tdap vaccine would be 89% effective in protecting infants against the disease over their first 2 months of life and would reduce pertussis incidence in newborns in the U.S. by 68% (assuming 75% of mothers are vaccinated). This strategy is cost-effective, whereas vaccinating the father before the birth or vaccinating parents and/or other family members after the child is born would not be.

From the VoICE Editors: The analysis assumes a vaccination cost of ≈$44 per dose.

Key Evidence: The cost-effectiveness of vaccinating infants with PCV-13 in China was estimated to be 21 times greater when the indirect effects of vaccination in reducing invasive pneumococcal disease and hospitalized cases of pneumonia in older (unvaccinated) individuals was taken into account -- with costs per quality of life-year gained (QALY) of around US$564 (Y3,777) vs. $11,836 (Y79,204) when only the direct impact on vaccinated children is considered.

Key Evidence: An analysis of current measles vaccination program in the eastern Chinese province of Zhejiang (which provides 1 dose of measles-rubella vaccine at 8 months of age and 1 dose of MMR at 18 months) estimated that, for every dollar spent on immunization, the health system saves $6.06 in treatment costing, including the costs of treating complications and long-term sequelae, such as hearing loss.

Key Evidence: A multi-site study of cholera vaccination programs found that the vaccine was cost-effective in school- and community-based vaccination programs for children in India, Mozambique, and Indonesia.

Key Evidence:A study assessing the cost-effectiveness of Pneumococcal Conjugate Vaccine (PCV) demonstrated that nealy 38,000 cases of invasive pneumococcal disease were averted in the first five years post introduction of PCV in the US. These results, based on active surveillance data also revealed that the costs averted translated to US $112,000 per life year saved.

Key Evidence: PCV7 use in Argentina resulted in an estimated cost of US$5,599 per life year gained. The purchase of the 4 doses of vaccine for the entire cohort at a cost of US$26.5 per dose would required an investment of US$73,823,806.00. This investment would significantly reduce the number of deaths brought about by cases of meningitis, bacteremia, pneumonia, otitis media and meningitis sequelae. The resultant decrease in morbidity and mortality coupled with herd immunity offered by immunization would contribute substantially to national productivity making PCV immunization a highly cost effective strategy.

Key Evidence: Assuming 90% coverage, a 9-valent PCV (PCV9) program in The Gambia would prevent approximately 630 hospitalizations, 40 deaths, and 1000 DALYs, for the birth cohort over the first 5 years of life. The estimated cost would be $670 per DALY averted in The Gambia.

Key Evidence: A study in Australia estimated that adding dTpa vaccination for pregnant women to the current pertussis immunization program for children would prevent an additional 8,800 symptomatic pertussis cases (mostly unreported) and 146 hospitalizations each year in all ages, including infants and their mothers, as well as one death every 22 months. The study found maternal pertussis vaccination to be cost-effective.

From the VoICE Editors: Note: The formulation used in this study is abbreviated dTpa.

Key Evidence: An impact and cost-effectiveness study of rotavirus vaccination in Mongolia estimated that rotavirus vaccination, from the government perspective, would be highly cost-effective, with a cost per DALY averted of $412 for the low-cost ROTAVAC vaccine produced in India and around $1,000 for the two other available vaccines.

Key Evidence: An analysis in Kenya found that, although the government will need to more than double its current vaccine budget to continue using PCV after GAVI support ends, continuing the vaccination will prevent more than 101,000 cases of invasive pneumoccocal disease and pneumonia, more than 14,000 deaths over an 11-year period, and would be cost-effective (cost per DALY of $153 by 2032), even at the full GAVI price of US$3.05 per dose.

Key Evidence: Measles cases in the US continue to occur due to importation of the disease. In 2009-2014, 74% of US measles cases were among US residents returning from overseas. Vaccinating US travelers with MMR vaccine before traveling internationally would be cost-effective or even cost-saving for those traveling to measles "hot spots", especially if the travelers were previously unvaccinated or returning to US communities with varying MMR coverage rates. However, it would not be cost-effective for all US persons traveling overseas given the large numbers of travelers.

Key Evidence: In Argentina, universal vaccination for Hepatitis A in children, at 95% vaccine coverage, can prevent over 350,000 hepatitis A infections per year and 428 deaths. Benefits persist at coverage rates as low as 70% with over 290,000 prevented infections. At 95% coverage rates, this program would save almost $24,000 annually.