Human Vaccines & Immunotherapeutics

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Why vaccines matter: understanding the broader

health, economic, and child development benefits
of routine vaccination

Arindam Nandi & Anita Shet

To cite this article: Arindam Nandi & Anita Shet (2020) Why vaccines matter: understanding
the broader health, economic, and child development benefits of routine vaccination, Human
Vaccines & Immunotherapeutics, 16:8, 1900-1904, DOI: 10.1080/21645515.2019.1708669

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HUMAN VACCINES & IMMUNOTHERAPEUTICS
2020, VOL. 16, NO. 8, 1900–1904
https://doi.org/10.1080/21645515.2019.1708669

COMMENTARY

Why vaccines matter: understanding the broader health, economic, and child
development benefits of routine vaccination
a b
Arindam Nandi and Anita Shet
a
Center for Disease Dynamics, Economics & Policy, Washington, DC, USA; bDepartment of International Health, Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD, USA

ABSTRACT ARTICLE HISTORY

The direct benefits of childhood vaccination in reducing the burden of disease morbidity and mortality Received 8 November 2019
in a cost-effective manner are well-established. By preventing episodes of vaccine-preventable diseases, Revised 30 November 2019
vaccination can also help avert associated out-of-pocket medical expenses, healthcare provider costs, Accepted 18 December 2019
and losses in wages of patients and caregivers. Studies have associated vaccines positively with KEYWORDS
cognition and school attainment, suggesting benefits of long-term improved economic productivity. Routine immunization; child
New evidence suggests that the measles vaccine may improve immunological memory and prevent co- development; broader
infections, thereby forming a protective shield against other infections, and consequently improving benefits of vaccines; measles
health, cognition, schooling and productivity outcomes well into the adolescence and adulthood in low- vaccine; cost-effectiveness;
income settings. Systematically documenting these broader health, economic, and child development benefit-cost
benefits of vaccines is important from a policy perspective, not only in low and middle-income countries
where the burden of vaccine-preventable diseases is high and public resources are constrained, but also
in high-income settings where the emergence of vaccine hesitancy poses a threat to benefits gained
from reducing vaccine-preventable diseases. In this paper, we provide a brief summary of the recent
evidence on the benefits of vaccines, and discuss the policy implications of these findings.

Introduction health policy can be envisaged in three broad areas. First, as

Childhood vaccines save an estimated 2–3 million lives world- vaccine coverage improves, and there is increasing protection
wide every year, which has contributed substantially to the of both vaccinated and unvaccinated populations through the
reduction in global infant mortality rate from 65 per 1,000 live phenomenon of community immunity, we are likely to see
births in 1990 to 29 in 2018.1,2 Vaccines are found to be the fewer vaccine-preventable diseases in the general population.
most cost-effective approach for reducing childhood disease For example, polio has been eliminated from almost all coun-
burden, especially when compared with interventions such as tries and is at the verge of complete global eradication.
clean water and improved sanitation which can also reduce However, the growing recognition of the importance of health
disease transmission but require expensive and time- equity has shown that clusters of susceptible populations
consuming infrastructural investment.3Cross-national policy within vaccinated societies can preempt disease outbreaks,
efforts such as the World Health Organization’s (WHO) such as the reemergence of diphtheria infections in
Expanded Programme on Immunization (EPI) of 1974, and Bangladesh and India.6,7 Second, the decreasing incidence of
the multi-agency Global Alliance for Vaccines and vaccine-preventable diseases has diminished the public’s
Immunization (Gavi), established in 1999, have supported memory of the devastation caused by the diseases, leading to
several countries with research, logistical planning, supply a rise in vaccine hesitancy. Therefore, national programs will
chain management, and financing of national vaccination have to refocus on maintaining the momentum, although in
programs. In recent times, routine vaccination has been sup- a world with limited government resources, health policy-
plemented with additional efforts to optimize community makers may find it difficult to financially and operationally
coverage. An example is the government of India’s Mission justify large vaccination programs. Third, the shifting focus
Indradhanush campaign initiated in 2015, that resulted in an from child mortality to morbidity will lead to a greater
increase of full vaccination coverage in target districts by emphasis on children’s physical, cognitive, and socioemo-
10 percentage points in just six months.4 As a result of these tional development as compared with survival.8,9
combined in-country and international initiatives, full vacci- Due to changing focus from child survival benefits of
nation rates of children in low-income countries have vaccines to child development benefits, along with greater
increased from under 50% to close to 80% during the past reliance on multi-criteria decision-making tools, it is more
two decades.5 important than ever before to quantify the broader social and
With such improvements in vaccination rates and reduc- individual benefits of vaccination. In this paper, we discuss
tion in child mortality, future changes in the global child evidence from a few key studies, and summarize the benefits

CONTACT Arindam Nandi [email protected] Center for Disease Dynamics, Economics & Policy, 1400 Eye St. NW, Suite 500, Washington, DC 20005, USA
© 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
 HUMAN VACCINES & IMMUNOTHERAPEUTICS 1901

of childhood vaccines beyond the intended reduction in dis- fever – in 73 LMICs.10 The authors considered averted med-
ease burden and child mortality. ical expenses, transportation costs, and productivity gains in
their analysis, and estimated that during 2001–2020, the vac-
cines together would provide a social and economic value of
Economic, equity, and global health benefits of $820 billion (2010 US$).10 During 2011–2020, the rate of
vaccines return for investment on these vaccines was estimated to be
up to 44 times of the initial cost.32Routine vaccination has
Vaccines can have several economic benefits.3,10 One of the a positive effect on social and health equity among popula-
most discernible benefits is averted medical expenditure. By tions. Infectious disease incidence and mortality are often
preventing an episode of the disease through a vaccine, the associated with poverty, and exacerbated by lack of access to
economic costs of treatment, such as physician fees, drugs and clean water, sanitation, and basic hygiene among the poor.
hospitalization expenses, and associated travel costs and wage Routine childhood vaccinations are, thus, estimated to avert
loss of caregivers could be averted. This is particularly impor- the largest burden of diseases, associated medical expenses,
tant for low and middle-income countries (LMICs) where and loss in economic productivity in the poorest segments of
a large part of medical expenditure is out-of-pocket. A clear the society.13,14,17-19,33,34 A recent study in 41 Gavi-eligible
example is the situation in India, where 65% of health expen- LMICs found that universal coverage of the measles, rota-
diture is private, with extreme costs in some cases, which virus, and pneumococcal conjugate vaccines would avert
thrusts 51 million people into poverty every year.2,11,12 It is a total of 12.6 million cases of catastrophic health expenditure
estimated that the measles, rotavirus, and pneumococcal con- which might have otherwise propelled patients into poverty.13
jugate vaccines could help avert $4.6 billion (2016 US$, Of those, 75%, 40%, and 22% of cases respectively for the
adjusted for purchasing power parity) in out-of-pocket med- three diseases were from the poorest wealth quintile.13
ical expenses in 41 Gavi-eligible LMICs during 2016–2030.13 New research shows that vaccines can also tackle global
Vaccines could also reduce the number of people who fall into health threats such as antimicrobial resistance (AMR). If left
poverty due to a catastrophic medical expense which is unchecked, AMR-related infections are estimated to result in
defined as a large proportion (typically, more than 10% to as many as 10 million deaths per year worldwide by 2050,
25%) of household income or expenditure.12,14-20 with an associated global economic cost of US$100 trillion.35
The protection which vaccines provide against the financial Vaccines could prevent infections – either sensitive or resis-
risk from a large medical expense can be measured in addi- tant – and also reduce the use of antimicrobials, which in turn
tional ways. The so-called extended cost-effectiveness (ECEA) could slow the growth of AMR.36-46
studies have estimated large money-metric value of insurance
provided by vaccines.13,14,16,19 The value of insurance is
equivalent to risk premium, which is defined as the amount
Child development benefits of vaccines
of money one would be willing to pay in order to avoid the
financial uncertainty from a vaccine-preventable disease.21 Persistent or recurrent infections in early life can lead to poor
Paying for vaccines, in this context, is akin to paying for growth and stunting, which in turn can adversely affect adult
a health insurance premium. health, cognitive capacity, and economic productivity.47-49
Benefit-cost analysis (BCA) studies of vaccines consider The theoretical basis of the long-term benefits of vaccines is
a full range benefits as measured by gains in economic pro- anchored in the widely accepted “fetal origins” hypothesis50,51
ductivity. Several alternative BCA methods exist, including which links conditions in utero and during early childhood
a human capital approach which uses the average annual with later life outcomes.48,49,52-66 Malnutrition, infection,
economic contribution of workers, and a friction cost pregnancy and birth complications, and under-stimulation
approach which considers productivity lost during the period during the first 1000 days of life can have lasting impact on
when a job position remains unfilled due to sickness.22,23 health, cognitive, and economic outcomes well into the old
Mortality and morbidity risk reduction benefits of vaccines age. In addition to appropriate nutrition and nurturing, health
have also been measured in terms the value of statistical interventions such as routine vaccinations could reduce infec-
life year (VSLY).24,25 VSLY is equivalent to the willingness tious disease burden in early childhood and thereby help
to pay in order to avoid one disability adjusted life year break the intergenerational cycle of poverty, poor health,
(DALY) from the disease.26,27 It is typically measured as and low income.
a multiple (approximately 2–4 times) of the per capita There is a small but growing literature on the potential
national income of a country.28-30 Newer studies such as child development benefits of routine vaccines. The measles
those commissioned by the Copenhagen Consensus Center vaccine is especially important in this context as episodes of
have considered a fixed value of either $1,000 or $5,000 per measles could damage protective immune memory for
DALY across all countries and contexts.29-31 a period of 2–3 years, increasing susceptibility to future
One of the most comprehensive vaccine BCA studies pub- measles and non-measles infections.67-69 Using sophisticated
lished recently used the VSLY method and examined the techniques, scientists have showed that measles infection in
economic benefits of 10 vaccines – for Haemophilus influen- children wipes out preexisting antibodies to different patho-
zae type b, hepatitis B, human papillomavirus, Japanese ence- gens in the months after the infectious episode, leaving
phalitis, measles, Neisseria meningitidis serogroup A, them vulnerable to multiple other infections and possible
rotavirus, rubella, Streptococcus pneumoniae, and yellow death.70A recent longitudinal study of approximately 2,000
1902 A. NANDI AND A. SHET

children each in Ethiopia, India, and Vietnam has linked ORCID

measles vaccination at ages 6–18 months of life with 0.1–0.2 Arindam Nandi http://orcid.org/0000-0002-3967-2424
higher anthropometric z-scores, 1.7–4.5 percentage points Anita Shet http://orcid.org/0000-0002-7204-8164
higher scores on standardized cognition tests, and 0.2–0.3
additional schooling grades at ages 7–8 and 11–12 years.71
The vaccine has also been associated with 0.2 more school-
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