Modeling the Cost of Vaccinating a Measles Zero-Dose Child in Zambia Using Three Vaccination Strategies

Joshua Mak International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Bryan N. Patenaude International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Simon Mutembo International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Monica E. Pilewskie Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Center for Indigenous Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Amy K. Winter Department of Epidemiology & Biostatistics, University of Georgia College of Public Health, Athens, Georgia;

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William J. Moss International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

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Andrea C. Carcelen International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Countries with moderate to high measles-containing vaccine coverage face challenges in reaching the remaining measles zero-dose children. There is growing interest in targeted vaccination activities to reach these children. We developed a framework for prioritizing districts for targeted measles and rubella supplementary immunization activities (SIAs) for Zambia in 2020, incorporating the use of the WHO’s Measles Risk Assessment Tool (MRAT) and serosurveys. This framework was used to build a model comparing the cost of vaccinating one zero-dose child under three vaccination scenarios: standard nationwide SIA, targeted subnational SIA informed by MRAT, and targeted subnational SIA informed by both MRAT and measles seroprevalence data. In the last scenario, measles seroprevalence data are acquired via either a community-based serosurvey, residual blood samples from health facilities, or community-based IgG point-of-contact rapid diagnostic testing. The deterministic model found that the standard nationwide SIA is the least cost-efficient strategy at 13.75 USD per zero-dose child vaccinated. Targeted SIA informed by MRAT was the most cost-efficient at 7.63 USD per zero-dose child, assuming that routine immunization is just as effective as subnational SIA in reaching zero-dose children. Under similar conditions, a targeted subnational SIA informed by both MRAT and seroprevalence data resulted in 8.17–8.35 USD per zero-dose child vaccinated, suggesting that use of seroprevalence to inform SIA planning may not be as cost prohibitive as previously thought. Further refinement to the decision framework incorporating additional data may yield strategies to better target the zero-dose population in a financially feasible manner.

Author Notes

Financial support: This work was supported by the Bill and Melinda Gates Foundation (OPP1094816).

Authors’ contributions: J. Mak created the base framework, managed the data, developed the analytic model, interpreted the results, and wrote the manuscript. B. N. Patenaude verified the analytic model and study assumptions. S. Mutembo facilitated the provision of district-level administrative data from Zambia’s Ministry of Health and advised the team in finding additional data sources. M. E. Pilewskie configured MRAT using Zambia’s administrative measles data and advised on how to apply it in the framework. A. K. Winter aided in framework development and built the model used to estimate district-level measles seroprevalence estimates. W. J. Moss and A. C. Carcelen conceptualized the study, supervised the project, contributed to the framework, assisted with the analysis plan, and substantially edited the manuscript.

Authors’ addresses: Joshua Mak, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, E-mail: jmak@g.harvard.edu. Bryan N. Patenaude, Simon Mutembo, and Andrea C. Carcelen, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mails: bpatena1@jhu.edu, smutemb1@jhmi.edu, and acarcel1@jhmi.edu. Monica E. Pilewskie, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and Center for Indigenous Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: mpilews1@jh.edu. Amy K. Winter, Department of Epidemiology & Biostatistics, University of Georgia College of Public Health, Athens, GA, E-mail: awinter@uga.edu. William J. Moss, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: wmoss1@jhu.edu.

Address correspondence to Andrea C. Carcelen, 415 N Washington St., 5th Floor, Baltimore, MD 21231. E-mail: Acarcel1@jh.edu
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