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Understanding Vaccine Perceptions and Willingness to Receive COVID-19 Vaccination: Opportunities to Strengthen Public Health Responses and COVID-19 Services for People Who Use Drugs

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Vaccines are essential to ensuring a nation’s health, wellbeing and prosperity. After the coronavirus pandemic commenced, the Australian Government introduced social restrictions to constrain virus transmission, seeing significant economic impacts. Reflecting the extraordinary circumstances, subsequent vaccination rollout forwent usual health technology assessment (HTA) processes, facilitating restrictions removal and leading to societal and economic recovery. However, in ‘usual’ circumstances, HTA may not consider such broader effects of vaccines, making it challenging for them to achieve timely funding. We used detailed modelling to compare economic impacts under continued lockdowns against population-wide vaccination rollout between January 2020 and June 2023 and examined global HTA vaccine evaluation methodologies and efforts to develop broader valuation approaches. Australian gross domestic product reduces by approximately AUD 395 billion with lockdowns. With vaccination rollout, this effect is approximately AUD 214bn, a positive incremental impact of AUD 181bn. Vaccination contributes to large estimated positive effects for tourism (AUD 28bn) and education (AUD 26bn) exports, employment (142, 000 jobs) and government finances (AUD 259bn). Conversely, global HTA methods generally only consider direct patient health outcomes and healthcare system-related costs, with broader effects usually not impacting funding decisions. Our results suggest that recent efforts to propose broader HTA valuation frameworks warrant further policy consideration.

Since the mid-20th century, vaccination has been an essential component of national strategies to eradicate or reduce the impact of infectious diseases [1]. After the Severe Acute Respiratory Syndrome (SARS) coronavirus (COVID-19) pandemic commenced in December 2019, the Australian Commonwealth Government, along with state and territory governments, employed comprehensive social restrictions to contain disease spread and minimise healthcare system pressures [2]. As of November 2022, the pandemic is estimated to have resulted in 642 million confirmed cases and 6.63 million deaths [3]; in Australia, this has been estimated to be 10.7 million cases and 16, 119 deaths (i.e., approximately 0.15% of all cases) [4]. The pandemic has led not only to significant adverse health outcomes and healthcare system strains, but global contraction in economic activity, with Australia experiencing its first recession since 1991 [5]. This subsequently led Australia’s Government to enact large-scale fiscal policy measures to support its economy and healthcare system [6].

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Subsequently, like other countries, Australia’s Government sought to rapidly acquire and distribute vaccines, bypassing established health technology assessment (HTA) procurement processes [7] and using Advanced Purchase Agreements to secure vaccine supply [8, 9]. HTA is a formal process that uses explicit methods to determine the value of a health technology, with considerations of value ‘often including clinical effectiveness, safety, costs and economic implications, ethical, social, cultural and legal issues, organizational and environmental aspects, as well as wider implications for the patient, relatives, caregivers, and the population’ [10]. Over time, it has become increasingly used by independent agencies and payers such as governments to inform, recommend or make funding decisions by evaluating health intervention (including vaccines) ‘value for money’ relative to existing medical management approaches. HTA is well established in Australia [11], the United Kingdom (UK) [12], Europe [13], Canada [14], some parts of the United States healthcare system [15], and increasingly, in Asia [16].

In Australia, vaccines reimbursement follows a lengthy, multi-stepped process. After initial clinical consideration by the Australian Technical Advisory Group on Immunisation [17], the Pharmaceutical Benefits Advisory Committee (PBAC), an independent expert advisory body, undertakes formal HTA [18]. A positive PBAC recommendation, with cost-effectiveness a key quantitative PBAC decision making criteria [19], followed by Commonwealth Government approval, is required before a vaccine can be listed on the National Immunisation Program [20] for subsidised use by eligible patients. As of November 2022, the PBAC has not considered COVID-19 vaccination funding submissions. However, it has considered COVID-19 therapies for mild-to-moderate patients at risk of hospitalisation, as well as pre-exposure prophylaxis for individuals who are severely immunocompromised or for whom available funded vaccinations were contraindicated [21, 22, 23]. In the UK, HTA advice processes have been used to inform COVID-19 vaccine coverage recommendations [24], albeit without inclusion of cost-effectiveness analysis (in contrast to prior vaccine funding decisions [25]). As the world moves from pandemic to pandemic recovery, it remains to be seen when and how COVID-19 vaccines will be evaluated as a manner of course through established HTA processes.

A key methodological consideration of HTA is defining the evaluation ‘perspective’, i.e., the scope of costs and outcomes considered. While there may be practical variations, HTA generally takes one of two approaches, reflecting where costs and outcomes occur and whether they are directly or indirectly attributable to the condition and medical intervention being considered. The narrower ‘healthcare system perspective’ generally includes health care costs (including those incurred by the patient) and health-related outcomes directly attributable to the treatment, disease and patient being considered. In many countries, this perspective reflects the government role as ‘payer’ for health care (i.e., a ‘payer perspective’). In addition to these, the broader ‘societal perspective’ may also consider additional costs and outcomes that impact patients, family and carers of patients, governments and payers, and society overall, with potentially various elements of value being able to be considered [26] (Figure 1).

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HTA methods in many countries, including Australia, generally only consider direct patient health outcomes and healthcare system-related costs directly associated with the patient and condition, with broader impacts on society not necessarily included in ‘base case’ analysis [27, 28]. Therefore, depending on the relative distribution or ‘location’ of costs and outcomes for a particular condition and treatment, this may affect HTA economic evaluation outcomes and ultimately, societal resource allocation decisions.

This is especially relevant for vaccines. Infectious diseases, including COVID-19, have unique characteristics that must be considered when valuing vaccine interventions: disease transmissibility, evolution in their nature over time, large-scale population health outcome impacts and as COVID-19 has demonstrated, the risk of widespread societal effects, including those which are felt beyond the immediate patient. Similarly, the positive effects of vaccines may be felt beyond the scope of health and the healthcare system and be long term in nature.

We believe, therefore, that as a HTA methodological consideration, an appropriate perspective is critical to ensuring the conferral of the broad range of positive effects and outcomes of vaccines to society. With the COVID-19 pandemic, it is timely to consider the broader economic and societal impacts of vaccines and the importance of considering these in HTA. This study estimates the economic impacts of the COVID-19 pandemic and the subsequent mitigating effects of population-wide COVID vaccination in Australia. Current HTA approaches for assessing the value of vaccines (both for COVID-19 vaccines and more generally), along with recent efforts to consider broader HTA valuation frameworks to capture the true value of medical interventions, are then considered. In doing so, we demonstrate the value of vaccines extends beyond the traditional dimensions of direct health and healthcare system impacts, that current HTA value frameworks are too limited and that they should be expanded to capture the true broader societal value of vaccines.

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We used the Victoria University Regional Model (VURM) [29], a Computable General Equilibrium (CGE) model, to estimate the comparative economic effects of maintaining and removing (following population-wide vaccination rollout) Australian government (Commonwealth, and State and Territory) social distancing restrictions, including border closures (‘shocks’), across the period January 2020 to June 2023.

CGE modelling is an established macroeconomic technique commonly used by government agencies to inform policy discussions and decisions [30]. It uses actual economic data to estimate how economic activity might react to changes in policy, technology, or other external factors (‘shocks’). The modelling aims to show the difference between two alternative future economic states, i.e., ‘with’ and ‘without’ the proposed change, by considering interactions between sections of the economy [31]. The VURM has been used extensively by government and private decision makers to evaluate the economic costs and benefits of policy changes and other external factors (such as pandemics) on the Australian economy. Recently, it has been used to evaluate