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Background Discrete choice experiments (DCEs) are frequently used to study preferences and quantify tradeoffs in decision making. It is important to understand how stable their results are. Objective To investigate to what extent an extreme change in context, the COVID-19 pandemic, affected preferences for vaccine priority setting, as observed in an earlier DCE. Methods We replicated a DCE in which participants had to prioritize vaccination programs for public funding. The initial DCE was executed in Flanders (Belgium) right before the onset of the SARS-CoV-2 pandemic (December 2019, N = 1,636). The replicated DCE was executed 6 months later when the population was in lockdown (April 2020, N = 1,127). A total of 612 respondents participated in both waves of the DCE. We used panel mixed logit models to quantify attribute and level importance and compared utility estimates for consistency. Results The number of vaccine-preventable deaths became less important during the pandemic than before, whereas the influential attributes, the vaccine’s contribution to disease eradication and certainty about vaccine effectiveness became even more important. Respondents attached equal importance to the number of patients with transient or permanent morbidity, to the disease’s economic impact as well as to its equity profile. Conclusion Different preferences for vaccine priority setting were observed during the first COVID-19 lockdown as compared with before, although these differences were, given the extreme nature of the changing circumstances, relatively small. Highlights We replicated a discrete choice experiment (DCE) about vaccine priority setting during the first COVID-19 lockdown and compared results with those from the original setting. The major attributes, contribution to disease eradication, and scientific certainty about vaccine effectiveness became even more important than they already were, whereas avoidable mortality became less important. Respondents attached equal importance to the number of patients with transient or permanent morbidity, to the disease’s economic impact as well as to its equity profile. An extreme change in directly related context to the choice assignment led to changes in stated preferences, although these changes were relatively small, given the extreme change in context. Priorities in the second DCE were even less aligned with cost-effectiveness analysis than those observed initially.

Background Mental health problems during and after pregnancy such as depression, anxiety, post-traumatic stress disorder (PTSD), or addiction are common and can have lifelong implications for both parents and offspring. This review investigates the cost-effectiveness of interventions tackling these problems, assesses the methodological quality of included studies, and indicates suggestions for further research. Methods Thirteen databases were searched for economic evaluations of interventions related to antenatal, perinatal, and postnatal mental health conditions, published between 2000 and September 2021, in high-income countries. Results Thirty-nine studies met all inclusion criteria. Interventions considered were screening programs, pharmacological treatments, and various forms of psychosocial and psychological support. Six studies reported that the intervention was cost-saving. Eighteen were cost-effective and seven likely to be cost-effective. Only six studies included health outcomes for the child; one study considered paternal health. The time horizon for which costs and consequences were considered was for most evaluations limited to 1 year (n = 18) or 2 years (n = 11) postpartum. Conclusions Given the importance of the subject, a relatively low number of studies have investigated the cost-effectiveness of interventions tackling mental health problems during and after pregnancy. The scant evidence available suggests good overall value for money. Likely, cost-effectiveness is underestimated as costly long-term consequences on offspring are systematically excluded. No evidence was found for several frequently occurring conditions. Further research is required to obtain reliable, long-term effectiveness data and to address the methodological challenges related to measuring all relevant health outcomes for all parties affected.

IntroductionChildren become ill quite often, mainly because of infections, most of which can be managed in the community. Many children are prescribed antibiotics which contributes to antimicrobial resistance and reinforces health-seeking behaviour. Point-of-care C reactive protein (POC CRP) testing, prescription guidance and safety-netting advice can help safely reduce antibiotic prescribing to acutely ill children in ambulatory care as well as save costs at a systems level.Methods and analysisThe ARON (Antibiotic prescribing Rate after Optimal Near-patient testing in acutely ill children in ambulatory care) trial is a pragmatic cluster randomized controlled superiority trial with a nested process evaluation and will assess the clinical and cost effectiveness of a diagnostic algorithm, which includes a standardised clinical assessment, a POC CRP test, and safety-netting advice, in acutely ill children aged 6 months to 12 years presenting to ambulatory care. The primary outcome is antibiotic prescribing at the index consultation; secondary outcomes include clinical recovery, reconsultation, referral/admission to hospital, additional testing, mortality and patient satisfaction. We aim to recruit a total sample size of 6111 patients. All outcomes will be analysed according to the intent-to-treat approach. We will use a mixed-effect logistic regression analysis to account for the clustering at practice level.Ethics and disseminationThe study will be conducted in compliance with the principles of the Declaration of Helsinki (current version), the principles of Good Clinical Practice and in accordance with all applicable regulatory requirements. Ethics approval for this study was obtained on 10 November 2020 from the Ethics Committee Research of University Hospitals Leuven under reference S62005. We will ensure that the findings of the study will be disseminated to relevant stakeholders other than the scientific world including the public, healthcare providers and policy-makers. The process evaluation that is part of this trial may provide a basis for an implementation strategy. If our intervention proves to be clinically and cost-effective, it will be essential to educate physicians about introducing the diagnostic algorithm including POC CRP testing and safety-netting advice in their daily practice.Trial registration numberClinicalTrials.gov Identifier: NCT04470518. Protocol V.2.0 date 2 October 2020. (Pre-results)

Fear of a reduced exogenous boosting effect of varicella vaccination and its impact on population health and wellbeing seems to be the main reason why many countries have hesitated to implement thi...

In the face of limited COVID-19 vaccine supply, governments have had to identify priority groups for vaccination. In October 2020, when it was still uncertain whether COVID-19 vaccines would be shown to work in trials, we conducted a discrete choice experiment and a best-worst ranking exercise on a representative sample of 2060 Belgians in order to elicit their views on how to set fair vaccination priorities. When asked directly, our respondents prioritized the groups that would later receive priority: essential workers, the elderly or those with pre-existing conditions. When priorities were elicited indirectly, through observing choices between individuals competing for a vaccine, different preferences emerged. The elderly were given lower priority and respondents divided within two clusters. While both clusters wanted to vaccinate the essential workers in the second place, one cluster (N = 1058) primarily wanted to target virus spreaders in order to control transmission whereas the other cluster (N = 886) wanted to prioritize those who were most at risk because of a pre-existing health condition. Other strategies to allocate a scarce resource such as using a "lottery", "first-come, first-served" approach or highest willingness-to-pay received little support.

Governments regularly have to decide whether new vaccines should be adopted in their national immunization program. These choices imply complex trade-offs of epidemiological, medical and socio-economic criteria. We investigated how the population in Flanders (Belgium) wants their government to set vaccine-funding priorities. In December 2019, we executed a discrete choice experiment in a sample of the Flemish population (N = 1636). In total, we analysed 16 360 choices between vaccines competing for funding, described in terms of eight characteristics. Using a panel mixed logit model, we quantified the relative importance of each characteristic and investigated differences in preferences across respondent groups. The observed vaccine priorities were different from those that would be identified through cost-effectiveness analysis. People valued the health impact from infectious diseases differently than their weight expressed in QALYs would suggest. Mortality and frequently occurring mild illness were valued higher, whereas lasting morbidity received lower weight. Contribution of the vaccine to disease eradication and uncertainty in vaccine effectiveness were both highly influential factors. Health equity impact was also important whereas the economic impact of the disease did not matter at all. Our results can be used to incorporate public values into vaccine decision-making. ispartof: Social Science & Medicine vol:303 ispartof: location:England status: Published online

Background: High uptake of Covid-19 vaccination is required to reach herd immunity. Methods: A representative sample of 2,060 Belgians were surveyed in October 2020. Regression analyses identified the predictors associated with willingness to get vaccinated against Covid-19, and attitudes toward vaccination in general. Results: 34% of the participants reported that they will definitely get vaccinated against Covid-19 and 39% that they would "probably". Intended uptake was strongly associated with age, opinion on the government's dealing with the Covid-19 pandemic, medical risk, spoken language, gender, and to a lesser extent with having known someone who was hospitalised because of Covid-19. Similar predictors were identified for attitudes to vaccination in general. Covid-19 vaccine hesitancy was more marked in age groups below 54 years old. We further analysed a sample of 17% (N = 349) found favourable to vaccination in general but not willing to be vaccinated against Covid-19. They were mainly female, young, French speaking, slightly less educated, working, and did not belong to a Covid-19 risk group. They were very dissatisfied with the government's dealing with the pandemic, and did not know someone who was hospitalised because of Covid-19. Conclusions: Vaccine hesitancy was higher for Covid-19 vaccines than for other vaccines. The part of the population being convinced of the utility of vaccination in general but hesitant about the Covid-19 vaccine is a primary interest group for tailored communication campaigns in order to reach the vaccine coverage needed for herd immunity. (c) 2021 Elsevier Ltd. All rights reserved.

In addition to more narrow criteria such as safety, effectiveness and cost-effectiveness, vaccines can also be evaluated based on broader criteria such as their economic impact, contribution to disease eradication objectives, caregiver aspects, financial protection offered, equity or social acceptability. We summarize a survey executed in a sample of the population (n = 1000) in Flanders, Belgium, in which we investigated support for using these broader criteria to evaluate vaccines for funding decisions. By means of both favourable and unfavourable framings of a hypothetical vaccine across 40 value dimensions, we find support for the view that people indeed consider a broad range of medical and socio-economic criteria relevant. Several of these are not incorporated in standard evaluation frameworks for vaccines. The different results we find for different framings highlight the importance of developing a consistent a priori value framework for vaccine evaluation, rather than evaluating vaccines on an ad hoc basis. ispartof: Vaccines vol:8 issue:4 ispartof: location:Switzerland status: published

Vaccinatieprogramma’s zijn een hoeksteen van de volksgezondheid. De Vlaamse overheid heeft jaarlijks een vast budget gereserveerd om vaccins aan te kopen. Dit budget moet echter verdeeld worden over een steeds groter wordend aantal beschikbare vaccinkandidaten die bovendien ook nog eens gebruikt kunnen worden in een brede waaier aan mogelijke vaccinatiecombinaties en -strategieën. Prioriteiten stellen tussen al deze mogelijkheden is bijzonder moeilijk omdat verschillende aspecten (bv. veiligheid, effectiviteit, ziekte-ernst, besmettelijkheid, incidentie, prijs, maatschappelijke impact, etc.) tegelijkertijd moeten worden afgewogen. Welke vaccins uiteindelijk prioriteit krijgen heeft implicaties voor ziekte en welzijn van de bevolking want ‘kiezen is verliezen’. Een keuze om te investeren in het ene vaccinatieprogramma impliceert dat beschikbare middelen voor andere programma’s vervallen. Het is wenselijk dat deze keuzes gebaseerd worden op een consistent, onderbouwd beslismodel dat rekening houdt met alle relevante facetten van vaccinatie. Het ontwikkelen van een beslismodel dat alles wat van tel is in kaart weet te brengen, zich aan wijzigende omstandigheden kan aanpassen, rekenschap kan geven van verschillende perspectieven en vervolgens een finaal oordeel kan vellen over welke aankoop van vaccins optimaal is, is echter een enorme - zo niet onmogelijke - taak. Beslissingsmodellen zijn m.a.w. altijd beperkt en kunnen dan ook enkel beslissingen assisteren maar ze zelf niet ‘maken’. Niettemin kunnen ze wel belangrijke structuur aanbrengen in de discussie en de beschikbare informatie verduidelijken. Het is de bedoeling van dit rapport om bij te dragen aan de ontwikkeling van zo een ondersteunend beslismodel voor de prioritering van vaccinatie voor de Vlaamse overheid.

Vaccination programs generate direct protection, herd protection and, occasionally, side effects, distributed over different age groups. This study elicits the general public's view on how to balance these outcomes in funding decisions for vaccines. We performed an optimal design discrete choice experiment with partial profiles in a representative sample (N = 1499) of the population in the United Kingdom in November 2016. Using a panel mixed logit model, we quantified, for four different types of infectious disease, the importance of a person's age during disease, how disease was prevented-via direct vaccine protection or herd protection-and whether the vaccine induced side effects. Our study shows clear patterns in how the public values vaccination programs. These diverge from the assumptions made in public health and cost-effectiveness models that inform decision-making. We found that side effects and infections in newborns and children were of primary importance to the perceived value of a vaccination program. Averting side effects was, in any age group, weighted three times as important as preventing an identical natural infection in a child whereas the latter was weighted six times as important as preventing the same infection in elderly aged 65-75 years. These findings were independent of the length or severity of the disease, and were robust across respondents' backgrounds. We summarize these patterns in a set of preference weights that can be incorporated into future models. Although the normative significance of these weights remains a matter open for debate, our study can, hopefully, contribute to the evaluation of vaccination programs beyond cost-effectiveness. ispartof: Social Science and Medicine vol:228 pages:181-193 ispartof: location:England status: published

Background: In any country, part of the population is sceptical about the utility of vaccination. To develop successful vaccination programmes, it is important to study and understand the defining characteristics of vaccine sceptics. Research till now mainly focused either on the underlying motives of vaccine refusal, or on socio-demographic differences between vaccine sceptics and non-sceptics. It remained till now unexplored whether both groups differ in terms of basic psychological dispositions. Methods: We held a population survey in a representative sample of the population in Flanders, Belgium (N = 1050), in which we investigated whether respondents attitude to vaccination was associated with their basic disposition toward other community members or society in general, as measured by the Triandis and Gelfand social orientation scale. Results: We found that sceptics and non-sceptics have a different social orientation, even when several variables are controlled for. More specifically, vaccine sceptics scored significantly lower on both horizontal individualism and horizontal collectivism, indicating a lower disposition to see others as equals. Conclusion: These findings need confirmation in the context of different countries. Such insights can be valuable to optimize the design of effective communication strategies on vaccination programmes.

Vaccination programs increasingly have to comply with standards of evidence-based decision making. However, such a framework tends to ignore social and ethical sensitivities, risking policy choices that lack crucial public support. Research is needed under which circumstances and to which extent equity and autonomy should prevail over effectiveness and cost-effectiveness in matters of infectious disease prevention. We report on a study investigating public preferences over various vaccination policy options, based on a population survey held in Flanders, Belgium (N = 1049) between March and July 2011. We found (1) that public support varied considerably between policies that were equally efficient in preventing disease but differed according to target group or incentives to improve uptake and (2) that preferences over the use of legal compulsion, financial accountability or the offering of rewards appear to be driven by individuals' social orientation.

Objectives To explore the impact of applying different non-standardized analytical choices for quality of life measurement to obtain quality-adjusted life years (QALYs). In addition to more widely discussed issues such as the choice of instrument (e.g. EQ-5D or SF-6D?) researchers must also choose between different recall periods, scoring algorithms and interpolations between points of measurement. Methods A prospective survey was made among 114 Belgian patients with acute hepatitis A illness. Using non-parametric tests and generalized linear models (GLM's), we compared four different methods to estimate QALY losses, two based on the EQ-5D (administered during the period of illness without recall period) and two based on the SF-6D (administered after illness with 4 weeks recall period). Results We found statistically significant differences between all methods, with the non-parametric SF-6D-based method yielding the highest median QALY impact (0.032 QALYs). This is more than five times as high as the EQ-5D-based method with linear health improvement, which yields the lowest median QALY impact (0.006 QALYs). Conclusions Economic evaluations of health care technologies predominantly use QALYs to quantify health benefits. Non-standardised analytical choices can have a decision-changing impact on cost-effectiveness results, particularly if morbidity takes up a substantial part of the total QALY loss. Yet these choices are rarely subjected to sensitivity analysis. Researchers and decision makers should be aware of the influence of these somewhat arbitrary choices on their results.

Setting fair health care priorities counts among the most difficult ethical challenges our societies are facing. To elicit through a discrete choice experiment the Belgian adult population's (18-75 years; N = 750) preferences for prioritizing health care and investigate whether these preferences are different for prevention versus cure. We used a Bayesian D-efficient design with partial profiles, which enables considering a large number of attributes and interaction effects. We included the following attributes: 1) type of intervention (cure vs. prevention), 2) effectiveness, 3) risk of adverse effects, 4) severity of illness, 5) link between the illness and patient's health-related lifestyle, 6) time span between intervention and effect, and 7) patient's age group. All attributes were statistically significant contributors to the social value of a health care program, with patient's lifestyle and age being the most influential ones. Interaction effects were found, showing that prevention was preferred to cure for disease in young adults, as well as for severe and lethal disease in people of any age. However, substantial differences were found in the preferences of respondents from different age groups, with different lifestyles and different health states. Our study suggests that according to the Belgian public, contextual factors of health gains such as patient's age and health-related lifestyle should be considered in priority setting decisions. The studies, however, revealed substantial disagreement in opinion between different population subgroups.Copyright (c) 2015 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Human papillomavirus (HPV) is one of the most common sexually transmitted infections. It is a leading cause of cervical cancer in women but the virus is increasingly being linked to several other cancers in men and women alike. Since the introduction of safe and effective but also expensive vaccines, many developed countries have implemented selective vaccination programs for girls. Some however argue that these programs should be expanded to include boys, since (1) HPV constitutes non-negligible health risks for boys as well and (2) protected boys will indirectly also protect girls. In this paper we approach this discussion from an ethical perspective. First, on which moral grounds can one justify not reimbursing vaccination for the male sex? We develop an ethical framework to evaluate selective vaccination programs and conclude that, in the case of HPV, efficiency needs to be balanced against non-stigmatization, non-discrimination and justice. Second, if vaccination programs were to be expanded to boys as well, do the latter then also have a moral duty to become immunized? Two arguments in favor of such a moral duty are well known in vaccination ethics: the duty not to harm others and to contribute to the public good of public health. However, we argue that these are not particularly convincing in the context of HPV. In contrast, we believe a third, more powerful but also more controversial argument is possible. In our view, the sexual mode of transmission of HPV constitutes an additional reason to believe that boys in fact may have a moral obligation to accept vaccination.

The varicella-zoster virus (VZV) causes two diseases: varicella ('chickenpox') and herpes zoster ('shingles'). VZV vaccination of children reduces exposure to chickenpox in the population and it has been hypothesized that this could increase the prevalence of shingles. This 'exogenous boosting' effect of VZV raises an important equity concern: introducing a vaccination program could advance the health of one population group (children) at the expense of another (adults and elderly). We discuss the program's justifiability from two ethical perspectives, classic utilitarianism and contractualism. Whereas the former framework might offer a foundation for the case against introducing this vaccination, the latter offers a basis to justify it. (C) 2014 Elsevier Ltd. All rights reserved.

Not so long ago health policy was about little more than the provision of medical care. The availability of treatment is important for those in need of cure, but by now it is a well-shown fact that health is generally determined to a much greater extent by other factors. Genetic constitution, lifestyle choices and socio-economic environment largely explain why some of us become ill or die earlier than others who remain healthy (Mackenbach 1996; McKeown 1976; Wilkinson and Marmot 2003). While some of these factors fall under the control of an individual, the majority does not. Research increasingly indicates how remarkably sensitive our health seems to be to what has become known as the ‘social determinants of health’. These factors generally fall beyond the control of an individual, but can nonetheless be influenced on a population level. This causes a shift in the focus of health policy from the classic provision of health care to policies specifically designed to influence the causal factors of ill-health in different non-medical fields. The flipside of that evolution is a significant increase of the state’s influence in the sphere of individual lives. A pertinent question remains the one that asks for the legitimate role of governments in modifying, discouraging or prohibiting behaviors that lead to ill-health. To what extent can and should we hold public policy responsible for us leading a healthy life? Most scholars will argue that governments indeed have a role to play, but that the limits will be reached when public health measures would imply large sacrifices of individual liberty.

Hepatitis A vaccination targeting adults (or adult risk-groups like e.g. travellers, health care workers, soldiers or teachers) could be considered an alternative to a universal infant or adolescent vaccination program in low endemic countries. We estimated the current disease burden of hepatitis A in Belgium, and evaluated whether adult vaccination is cost-effective. We used a Markov cohort model to simulate the costs and effects of (1) vaccination of adults and (2) serological screening of adults and vaccination of susceptibles and compared these with the current situation. The results indicated that these expanded vaccination strategies are not cost-effective in the epidemiological circumstances of a typical low-endemic western country. In order to gain 1 quality-adjusted life year the health care payer would have to pay 185,000 for vaccination and 223,000 for screening and vaccination of seronegatives. For adult vaccination to be cost-effective, risk-groups would need to be exposed to a force of infection that is 3.54 times higher than currently estimated in the general population; or the total costs of vaccination would have to drop with approximately 75%.

Vaccination policy is an ethically challenging domain of public policy. It is a matter of collective importance that reaches into the most private sphere of citizens and unavoidably conflicts with individual-based ethics. Policy makers need to walk a tight rope in order to complement utilitarian public health values with individual autonomy rights, protection of privacy, non-discrimination and protection of the worst-off. Whether vaccination is voluntary or compulsory, universal or targeted, every option faces complex ethical hurdles because of the interdependence of humans in infectious disease matters. In this article, we explore the following three policy questions. (i) Ethically, which policy measures should be addressed when vaccination coverage is insufficient in a population? Information campaigns, legal compulsion, or the use of financial incentives can all be effective, but also controversial policy options. (ii) Is it ethical to target vaccination programs at certain risk-groups? If such measures are necessary, we argue that policymakers will often have to decide which is more important to uphold: non-discrimination or the protection of privacy. And (iii), what is the ethical significance of adverse herd immunity effects? Some vaccination programs will improve average population health, but will at the same time increase the risk of severe morbidity and mortality for individuals in the worst-off groups of society.

With the aim to understand and estimate the economic impact of outbreaks of community-acquired infections, we performed a review focusing on hepatitis A outbreaks, and retained 13 papers that had collected relevant cost information during such outbreaks. All costs in this article are expressed in $US, year 2007 values. The costs of hepatitis A outbreaks ranged from $US140 000 to $US36 million, and the costs per case in an outbreak situation ranged from $US3824 to $US200 480. These costs were typically found to be substantially higher than estimates from cost-of-illness studies (i.e. costs for sporadic cases) and estimates used in cost-effectiveness analyses, mostly because of costly outbreak-control measures. Post-exposure prophylaxis is a major cost factor, especially for food-borne outbreaks. As a result of the increasing proportion of those susceptible to hepatitis A in low-incidence countries, future outbreaks could, on average, increase in size. The increasing occurrence of hepatitis A cases in outbreak situations and the associated control costs should appropriately be accounted for in economic evaluations of vaccination programmes in low-incidence countries. In order to do this, more studies documenting such outbreak-control strategies in terms of costs and resource use are needed.