SummaryBackgroundIntroduction of pneumococcal conjugate vaccines (PCVs) has substantially reduced disease burden due to Streptococcus pneumoniae, a leading cause of childhood morbidity and mortality globally. However, PCVs are among the most expensive vaccines, hindering their introduction in some settings and threatening sustainability in others. We aimed to assess the effect and cost-effectiveness of introduction of 13-valent PCV (PCV13) vaccination globally.MethodsWe assessed the incremental cost-effectiveness ratio of PCV13 introduction by integrating two models: an ecological model (a parsimonious, mechanistic model validated with data from post-seven-valent PCV introduction in 13 high-income settings) to predict the effect of PCV on childhood invasive pneumococcal disease, and a decision-tree model to predict a range of clinical presentations and economic outcomes under vaccination and no-vaccination strategies. The models followed 30 birth cohorts up to age 5 years in 180 countries from 2015 to 2045. One-way scenario and probabilistic sensitivity analyses were done to explore model uncertainties.FindingsWe estimate that global PCV13 use could prevent 0·399 million child deaths (95% credible interval 0·208 million to 0·711 million) and 54·6 million disease episodes (51·8 million to 58·1 million) annually. Global vaccine costs (in 2015 international dollars) of $15·5 billion could be partially offset by health-care savings of $3·19 billion (2·62 billion to 3·92 billion) and societal cost savings of $2·64 billion (2·13 billion to 3·28 billion). PCV13 use is probably cost-effective in all six UN regions. The 71 countries eligible for support from Gavi, the Vaccine Alliance, account for 83% of PCV13-preventable deaths but only 18% of global vaccination costs. The expected cost of PCV vaccination globally is around $16 billion per year.InterpretationOur findings highlight the value of Gavi's support for PCV introduction in low-income countries and of efforts to improve the affordability of PCVs in countries not eligible for, or transitioning from, Gavi support.FundingWorld Health Organization; Gavi, the Vaccine Alliance; and the Bill & Melinda Gates Foundation.

BackgroundMicroeconomic 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.MethodsA 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.ResultsWe 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.ConclusionInnovative 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0446-9) contains supplementary material, which is available to authorized users.

This study examined sources of psychosocial stress related to the use of toilet facilities or open defecation by women and adolescent girls at home, public places, workplaces and in schools in a rural community in Pune, India. The mixed methods approach included focus group discussions among women, key informant interviews, free listing and a community survey of 306 women. Nine per cent of the study households and most seasonal migrant women workers lacked access to toilets. Fear for personal safety, injury or accidents, lack of cleanliness, indignity, shame and embarrassment due to a lack of privacy were significant sources of stress related to open defecation. Seasonal migrant women workers perceived the lack of privacy as a significant source of psychosocial stress but did not fear for their personal safety or injuries, despite their general lack of access to toilet facilities. Women resorting to open defecation feel stressed and harassed by community leaders trying to enforce open defecation-free policies. Our study highlights the need for sanitation programs to consider the specific needs of women with regard to latrine maintenance, safety and privacy offered by sanitation installations. Specific strategies to address the sanitation and hygiene issues of seasonal migrant populations are also required.