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My understanding of developing health systems (who stand to benefit the most from this) is regrettably limited but colleagues who participate in global health i

My understanding of developing health systems (who stand to benefit the most from this) is regrettably limited but colleagues who participate in global health initiatives tell me that material costs are the biggest barrier rather than local labour which is relatively cheap in these economies. Perhaps I'm a bit too jaded but I'm always skeptical of [new drug delivery technology for old medicine] as being a cash-grab since this is almost certainly more expensive than injections. It's more that I'm pleasantly surprised this will greatly simplify the supply-chain and hopefully offset the added unit cost in a non-insignificant way, in addition to making delivery of care easier and the other benefits you mention. Painless is nice but a subcutaneous injection isn't really that painful so I'm skeptical payers will see the value-proposition for that benefit in isolation if the vaccine costs substantially more per dose. As an example we've had intranasal flu vaccinations for a while now but my hospital still gives me the injection every year, presumably as it's cheaper.

inferiorhuman 3y ago
Painless is nice but a subcutaneous injection isn't really that painful so I'm skeptical payers will see the value-proposition for that benefit in isolation I'd expect that folks funding vaccination programs in underdeveloped countries won't look at any one cost or benefit in isolation. Well, I hope so anyways. Dropping the cold storage requirement is potentially huge IMO. As for pain, I suppose that for some folks their fear of needles has more to do with the expected vs actual pain (or perhaps nothing to do with pain at all). No needles and thus one fewer excuse to avoid vaccination is a huge win IMO. As an example we've had intranasal flu vaccinations This was offered to me by my GP once and I wasn't a fan. It left me feeling worse than any flu shot I can remember. A quick look reveals that it's an attenuated ("live") virus vaccine (the common injected vaccines aren't) and carries a higher risk of side effects and lower efficacy. It's not recommended for children and comes with more contraindications than the injectable vaccines which goes a long way to explaining why it's not more commonly available.
- haldujai 3y ago
  As for pain, I suppose that for some folks their fear of needles has more to do with the expected vs actual pain (or perhaps nothing to do with pain at all). No needles and thus one fewer excuse to avoid vaccination is a huge win IMO. True but in their protocol they mention the government of Gambia paid $1.3m (and that even the modest $80,000 on this trial was significant for them) for 802,000 patients of injectable MMR putting the cost at 1.67/person. Depending how much more expensive the transdermal version may have been (US/Can reformulations are usually significantly more expensive) I would be skeptical of how much you just have people "tough it out" in these economies in order to vaccinate more people. The fact this drug is cheaper and better is really impressive. A quick look reveals that it's an attenuated ("live") virus vaccine (the common injected vaccines aren't) and carries a higher risk of side effects and lower efficacy. I mean the evidence isn't really compelling for healthy adults 18-49 and kids for efficacy to begin with so I'm not sure we can make that statement with confidence. In any case the ACIP (and UpToDate) makes no preference for live attenuated vs recombinant/inactivated in adults > 18 or children > 2 (with some exceptions in kids). You are right though that there is a recommendation for healthcare workers to get an inactivated vaccine so that would explain my circumstances. Thanks, I learned something new today (actually two things, I had no idea we could use code blocks on HN). So you were offered both as an covered options?
  - inferiorhuman 3y ago
    I would be skeptical of how much you just have people "tough it out" in these economies in order to vaccinate more people. The fact this drug is cheaper and better is really impressive. How does this compare to the price of the injectable vaccines? Retail cost out here seems to be $30–$40, of which I'd expect a large chunk of that goes to labor. So you were offered both as an covered options? I did this outside of insurance. Up until California started taxing people who didn't carry private health insurance it made sense to see a GP at a fee-for-service practice that didn't take insurance. This was long enough ago that I don't remember the exact cost, but it was in line with the more common injected flu vaccines. I can't think of another time I've been offered the nasal spray. Megacorp had Kaiser nurses on site annually, and they only offered the injection. I'm with (ick) Kaiser now and they were making some noise about covering COVID and flu vaccinations at CVS and Walgreens. If the nasal spray is offered there then presumably it would be covered by insurance. However… https://www.cdc.gov/flu/prevent/nasalspray.htm https://www.cdc.gov/flu/prevent/nasalspray.htm After the 2009 pandemic, several U.S. studies among 2 through 17-year-olds found that the nasal spray vaccine was as effective against influenza B viruses and influenza A(H3N2) viruses as inactivated influenza vaccines but was less effective than inactivated flu vaccines against the 2009 pandemic H1N1 viruses. These data led ACIP and CDC to recommend against use of the nasal spray vaccine for the 2016-17 and 2017-18 seasons. Since the 2017-2018 season, the manufacturer of nasal spray vaccine has used new influenza A(H1N1) vaccine virus ingredients in production. Because of limited use, there have been no effectiveness estimates in the United States since LAIV was recommended again in the 2018-2019 influenza season. Data from other countries have demonstrated protection from LAIV to be similar to that of standard-dose, egg-based inactivated flu vaccine in children. Which sounds to me like there aren't a lot of compelling reasons to use the flu spray unless you're severely afraid of needles and thus most places don't offer it.
SoftTalker 3y ago
> Painless is nice but a subcutaneous injection isn't really that painful Painfulness aside, after you have kids and experienced needing two adults to pin down a writhing, screaming two year old to get vaccine injections, you might appreciate a sticker.
- askiiart 3y ago
  Or a 10 year old at the dentist. I was... a bit of an arsehol when it came to shots and the dentist.
  - fruit2020 3y ago
    For this reason I refused dentist shots as a kid. The dentist was wondering how I could handle the pain without anesthesia, but for me the needle was more scary. This led to the most extreme pain I had when she did a root canal and I saw the worm like nerve coming out from my mouth.
    - peteradio 3y ago
      That is the biggest "you asked for it kid" I've ever heard.
    - selcuka 3y ago
      I didn't know that that was even an option!
    - vidarh 3y ago
      I regularly refused as a kid, not so much out of fear but because I didn't feel like it was painful enough to be worth the hassle, coupled, I think, with a smug satisfaction of showing the dentist I could take it without complaint. That quickly changed once I needed more extensive work done on adult teeth.
      - SoftTalker 3y ago
        I opted out once, for a shallow filling, because I didn't want to have a numb face for the next 4 hours. Pain got unpleasant for a few moments but overall wasn't bad. For extractions or anything that gets into the nerves or pulp I get the shot.

inferiorhuman 3y ago

Painless is nice but a subcutaneous injection isn't really that painful so I'm skeptical payers will see the value-proposition for that benefit in isolation I'd expect that folks funding vaccination programs in underdeveloped countries won't look at any one cost or benefit in isolation. Well, I hope so anyways. Dropping the cold storage requirement is potentially huge IMO. As for pain, I suppose that for some folks their fear of needles has more to do with the expected vs actual pain (or perhaps nothing to do with pain at all). No needles and thus one fewer excuse to avoid vaccination is a huge win IMO. As an example we've had intranasal flu vaccinations This was offered to me by my GP once and I wasn't a fan. It left me feeling worse than any flu shot I can remember. A quick look reveals that it's an attenuated ("live") virus vaccine (the common injected vaccines aren't) and carries a higher risk of side effects and lower efficacy. It's not recommended for children and comes with more contraindications than the injectable vaccines which goes a long way to explaining why it's not more commonly available.

haldujai 3y ago
As for pain, I suppose that for some folks their fear of needles has more to do with the expected vs actual pain (or perhaps nothing to do with pain at all). No needles and thus one fewer excuse to avoid vaccination is a huge win IMO. True but in their protocol they mention the government of Gambia paid $1.3m (and that even the modest $80,000 on this trial was significant for them) for 802,000 patients of injectable MMR putting the cost at 1.67/person. Depending how much more expensive the transdermal version may have been (US/Can reformulations are usually significantly more expensive) I would be skeptical of how much you just have people "tough it out" in these economies in order to vaccinate more people. The fact this drug is cheaper and better is really impressive. A quick look reveals that it's an attenuated ("live") virus vaccine (the common injected vaccines aren't) and carries a higher risk of side effects and lower efficacy. I mean the evidence isn't really compelling for healthy adults 18-49 and kids for efficacy to begin with so I'm not sure we can make that statement with confidence. In any case the ACIP (and UpToDate) makes no preference for live attenuated vs recombinant/inactivated in adults > 18 or children > 2 (with some exceptions in kids). You are right though that there is a recommendation for healthcare workers to get an inactivated vaccine so that would explain my circumstances. Thanks, I learned something new today (actually two things, I had no idea we could use code blocks on HN). So you were offered both as an covered options?
- inferiorhuman 3y ago
  I would be skeptical of how much you just have people "tough it out" in these economies in order to vaccinate more people. The fact this drug is cheaper and better is really impressive. How does this compare to the price of the injectable vaccines? Retail cost out here seems to be $30–$40, of which I'd expect a large chunk of that goes to labor. So you were offered both as an covered options? I did this outside of insurance. Up until California started taxing people who didn't carry private health insurance it made sense to see a GP at a fee-for-service practice that didn't take insurance. This was long enough ago that I don't remember the exact cost, but it was in line with the more common injected flu vaccines. I can't think of another time I've been offered the nasal spray. Megacorp had Kaiser nurses on site annually, and they only offered the injection. I'm with (ick) Kaiser now and they were making some noise about covering COVID and flu vaccinations at CVS and Walgreens. If the nasal spray is offered there then presumably it would be covered by insurance. However… https://www.cdc.gov/flu/prevent/nasalspray.htm https://www.cdc.gov/flu/prevent/nasalspray.htm After the 2009 pandemic, several U.S. studies among 2 through 17-year-olds found that the nasal spray vaccine was as effective against influenza B viruses and influenza A(H3N2) viruses as inactivated influenza vaccines but was less effective than inactivated flu vaccines against the 2009 pandemic H1N1 viruses. These data led ACIP and CDC to recommend against use of the nasal spray vaccine for the 2016-17 and 2017-18 seasons. Since the 2017-2018 season, the manufacturer of nasal spray vaccine has used new influenza A(H1N1) vaccine virus ingredients in production. Because of limited use, there have been no effectiveness estimates in the United States since LAIV was recommended again in the 2018-2019 influenza season. Data from other countries have demonstrated protection from LAIV to be similar to that of standard-dose, egg-based inactivated flu vaccine in children. Which sounds to me like there aren't a lot of compelling reasons to use the flu spray unless you're severely afraid of needles and thus most places don't offer it.

SoftTalker 3y ago

> Painless is nice but a subcutaneous injection isn't really that painful Painfulness aside, after you have kids and experienced needing two adults to pin down a writhing, screaming two year old to get vaccine injections, you might appreciate a sticker.

askiiart 3y ago
Or a 10 year old at the dentist. I was... a bit of an arsehol when it came to shots and the dentist.
- fruit2020 3y ago
  For this reason I refused dentist shots as a kid. The dentist was wondering how I could handle the pain without anesthesia, but for me the needle was more scary. This led to the most extreme pain I had when she did a root canal and I saw the worm like nerve coming out from my mouth.
  - peteradio 3y ago
    That is the biggest "you asked for it kid" I've ever heard.
  - selcuka 3y ago
    I didn't know that that was even an option!
  - vidarh 3y ago
    I regularly refused as a kid, not so much out of fear but because I didn't feel like it was painful enough to be worth the hassle, coupled, I think, with a smug satisfaction of showing the dentist I could take it without complaint. That quickly changed once I needed more extensive work done on adult teeth.
    - SoftTalker 3y ago
      I opted out once, for a shallow filling, because I didn't want to have a numb face for the next 4 hours. Pain got unpleasant for a few moments but overall wasn't bad. For extractions or anything that gets into the nerves or pulp I get the shot.