Affordability of Adult Tuberculosis Vaccination in India and China: A Dynamic Transmission Model-Based Analysis

New tuberculosis vaccines have made substantial progress in the development pipeline. Previous modelling suggests that adolescent/adult mass vaccination may cost-effectively contribute towards achieving global tuberculosis control goals. These analyses have not considered the budgetary feasibility of vaccine programmes. We estimate the maximum total cost that the public health sectors in India and China should expect to pay to introduce a M72/AS01_E-like vaccine deemed cost-effective at country-specific willingness to pay thresholds for cost-effectiveness. To estimate the total disability adjusted life years (DALYs) averted by the vaccination programme, we simulated a 50% efficacy vaccine providing 10-years of protection in post-infection populations between 2027 and 2050 in India and China using a dynamic transmission model of M. tuberculosis. We investigated two mass vaccination strategies, both delivered every 10-years achieving 70% coverage: Vaccinating adults and adolescents (age ≥10y), or only the most efficient 10-year age subgroup (defined as greatest DALYs averted per vaccine given). We used country-specific thresholds for cost-effectiveness to estimate the maximum total cost (C_max) a government should be willing to pay for each vaccination strategy. Adult/adolescent vaccination resulted in a C_max of $21 billion (uncertainty interval [UI]: 16-27) in India, and $15B (UI:12-29) in China at willingness to pay thresholds of $264/DALY averted and $3650/DALY averted, respectively. Vaccinating the highest efficiency age group (India: 50-59y; China: 60-69y) resulted in a C_max of $5B (UI:4-6) in India and $6B (UI:4-7) in China. Mass vaccination against tuberculosis of all adults and adolescents, deemed cost-effective, will likely impose a substantial budgetary burden. Targeted tuberculosis vaccination, deemed cost-effective, may represent a more affordable approach.