The broader economic impact of vaccination: reviewing and appraising the strength of evidence.
BACKGROUND
Microeconomic evaluations of public health programmes such as immunisation typically only consider direct health benefits and medical cost savings. Broader economic benefits around childhood development, household behaviour, and macro-economic indicators are increasingly important, but the evidence linking immunization to such benefits is unclear.


METHODS
A conceptual framework of pathways between immunisation and its proposed broader economic benefits was developed through expert consultation. Relevant articles were obtained from previous reviews, snowballing, and expert consultation. Articles were associated with one of the pathways and quality assessed using modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.


RESULTS
We found 20 studies directly relevant to one or more pathways. Evidence of moderate quality from experimental and observational studies was found for benefits due to immunisation in improved childhood physical development, educational outcomes, and equity in distribution of health gains. Only modelling evidence or evidence outside the immunization field supports extrapolating these benefits to household economic behaviour and macro-economic indicators.


CONCLUSIONS
Innovative use of experimental and observational study designs is needed to fill evidence gaps around key pathways between immunisation and many of its proposed economic benefits.
Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. mark.jit@lshtm.ac.uk.|Modelling and Economics Unit, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK. mark.jit@lshtm.ac.uk.
Mark
M
Jit
Initiative for Vaccine Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, 27, Switzerland. hutubessyr@who.int.
Raymond
R
Hutubessy
Saw Swee Hock School of Public Health, Tahir Foundation Building, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore. mayee.png@u.nus.edu.
May Ee
ME
Png
Saw Swee Hock School of Public Health, Tahir Foundation Building, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore. neisha_sundaram@nuhs.edu.sg.
Neisha
N
Sundaram
Saw Swee Hock School of Public Health, Tahir Foundation Building, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore. jananie@nuhs.edu.sg.
Jananie
J
Audimulam
Saw Swee Hock School of Public Health, Tahir Foundation Building, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore. Safiyyy@hotmail.com.
Safiyah
S
Salim
Saw Swee Hock School of Public Health, Tahir Foundation Building, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore. joanne_yoong@nuhs.edu.sg.
Joanne
J
Yoong
D003362:Cost-Benefit Analysis; D006801:Humans; D014611:Vaccination / Q000191:economics*