Cost of Delivering Tetanus Toxoid and Tetanus-Diphtheria Vaccination in Vietnam and the Budget Impact of Proposed Changes to the Schedule

Figures & Tables

TABLE 1.

Comparison Between WHO Recommended Tetanus and Diphtheria Vaccinations and EPI

WHO Recommendations for Routine Immunization Against Tetanus and Diphtheria	Pre-2020 EPI Immunization Schedule	Transition Period 2018–2025	Planned EPI Schedule Post-2025
DTP3: 3 doses before the age of 6	Yes	Yes	Yes
DTP4 booster: at age 12–23 months	Yes	Yes	Yes
TT during pregnancy: 3 doses for all pregnant women	Yes	Yes	Yes
TT vaccine for girls aged 15–16 years	1 dose of TT vaccine for girls aged 15–16 years in high-risk areas on a semiannual basis	Discontinued	Discontinued
Td (or diphtheria-tetanus containing) vaccine booster dose	Td campaigns targeting people aged 5–40 years in areas with diphtheria outbreaks (Td response campaigns)	A routine Td booster dose for children aged 7 years Scaling down of the Td response campaigns	A routine Td booster dose for children aged 7 years Scaling down of the Td response campaigns Planning for a Td booster dose for children aged 9–15 years (not yet decided)

Abbreviations: DTP3, third dose of diphtheria-tetanus-pertussis vaccine; DTP4, fourth dose of diphtheria-tetanus-pertussis vaccine; EPI, Vietnam Expanded Program on Immunization; Td, tetanus-diphtheria; TT, tetanus toxoid; WHO, World Health Organization.

TABLE 2.

Projected Targeted Population and Coverage Assumption for Tetanus Toxoid Vaccine and Tetanus-Diphtheria Vaccine Campaign in Vietnam

	Maintaining the 2017 Schedule				Changes in Vaccination Schedule
	One Dose of TT Vaccine Girls Aged 15–16 Years in High-Risk Areas on a Semiannual Basis		Td Diphtheria Outbreak Response Campaigns Targeting People Aged 5–40 Years		One Dose of Td Vaccine for Children Aged 7 Years		Transition for Td Diphtheria Outbreak Response Campaigns^{^a}
	Projected Targeted Population	Coverage Assumption	Projected Targeted Population	Coverage Assumption	Projected Targeted Population	Coverage Assumption	Projected Targeted Population	Coverage Assumption
2017 (present study)	1,100,000		82,603				82,603
2018	1,286,634	100%	83,429	100%	1,697,105	50%	83,429	50%
2019	1,299,500	100%	84,263	100%	1,714,076	60%	84,263	50%
2020	1,312,495	100%	85,106	100%	1,731,217	70%	85,106	50%
2021	1,325,620	100%	85,957	100%	1,748,529	80%	85,957	50%
2022	1,338,876	100%	86,817	100%	1,766,014	90%	86,817	50%
2023	1,352,265	100%	87,685	100%	1,783,674	100%	87,685	0%
2024	1,365,788	100%	88,562	100%	1,801,511	100%	88,562	0%
2025	1,379,446	100%	89,448	100%	1,819,526	100%	89,448	0%

Abbreviations: Td, tetanus-diphtheria; TT, tetanus toxoid.
↵a This transitional period aims to help control diphtheria outbreaks while the new schedule of Td vaccine for children is still to be fully implemented.

TABLE 3.

Percentages of the Fiscal Cost Components TT and Td Delivery and Cost Inputs by Levels of Implementation

	By Level of Implementation
	National Level	Average Regional	Average Provincial	Average District	Average Facility
Average total cost 2018 US$	749,363	75,158	41,044	7,720	2,693
Cost Components
Facility-based vaccination^{^a}	0.0%	0.0%	0.0%	0.0%	62.8%
Outreach vaccination^{^b}	0.0%	0.0%	0.0%	0.0%	7.9%
School-based vaccination^{^c}	0.0%	0.0%	0.0%	0.0%	1.2%
Td campaign^{^d}	0.0%	0.0%	2.5%	2.4%	3.4%
Supply storage	32.4%	10.8%	5.9%	5.6%	2.5%
Transport	20.8%	17.8%	7.3%	10.8%	6.8%
Immunization safety	3.4%	1.8%	4.1%	0.3%	0.0%
Waste management	0.0%	0.0%	0.3%	0.2%	0.7%
Supervision	13.6%	22.1%	22.6%	55.6%	0.4%
Training	10.4%	7.8%	24.6%	3.7%	1.8%
Recordkeeping	12.6%	13.6%	17.4%	11.2%	6.4%
Cold chain maintenance	2.9%	18.3%	5.0%	2.2%	1.2%
Program management	3.0%	6.9%	5.7%	6.3%	4.5%
Social mobilization and advocacy	0.8%	1.0%	4.5%	1.6%	0.9%
Cost Inputs
Salaried labor	14.2%	26.2%	27.7%	72.9%	83.0%
Per diems	1.7%	15.9%	13.9%	7.8%	4.5%
General supplies	1.8%	0.0%	2.1%	2.3%	1.4%
Transport and fuel	14.7%	28.8%	9.4%	2.8%	0.2%
Vehicle maintenance	0.2%	2.0%	0.1%	2.4%	0.0%
Cold chain energy costs	2.9%	5.7%	4.4%	0.6%	1.2%
Printing	9.0%	2.4%	12.5%	0.1%	0.0%
Building overheads	5.1%	1.9%	2.4%	4.7%	2.6%
Other recurrent	23.1%	16.9%	23.0%	2.5%	2.5%
Vehicles	0.0%	0.0%	0.0%	0.0%	0.0%
Cold chain equipment	27.2%	0.2%	2.0%	1.5%	0.8%
Buildings	0.0%	0.0%	0.0%	0.0%	0.5%

Abbreviations: Td, tetanus-diphtheria; TT, tetanus toxoid.
↵a Routine facility-based vaccination for the TT vaccine for girls aged 15–16 years.
↵b Routine outreach vaccination for the TT vaccine for girls aged 15–16 years in some remote areas.
↵c Non-routine school-based vaccination events for the TT vaccine for girls aged 15–16 years.
↵d Td vaccination campaign for adults in outbreak areas.

TABLE 4.

Average Cost Per Vaccine Dose Delivered in Vietnam Using the 2017 Schedule

Delivery Strategy	No. of Facilities	No. Doses Delivered in 2017 (%)	Fiscal Cost of Delivery
Delivery Strategy	No. of Facilities	No. Doses Delivered in 2017 (%)	Cost Per Dose, 2018 US$	Standard Error	95% CI
Routine: TT vaccination for girls aged 15–16-years in high-risk areas		1,100,000 (100)
Facility-based vaccination	37	305,723 (27.8)	1.76	0.01	1.74, 1.79
Outreach vaccination	5	137,354 (12.5)	3.86	0.12	3.63, 4.09
School-based vaccination	18	656,923 (59.7)	1.49	0.02	1.46, 1.52
Td vaccination through campaigns	4	82,603 (100)	3.56	0.06	3.35, 3.57

Abbreviations: CI, confidence interval; Td, tetanus-diphtheria; TT, tetanus toxoid.

TABLE 5.

Cost Per Vaccine Dose Delivered by Delivery Strategy, Location, and Level of the Health System in Vietnam