Benefits, risks and costs of immunization for measles, mumps and rubella

For a single year, 1983, we compared the actual and estimated morbidity, mortality, and costs attributable to measles, mumps, and rubella with having or not having a childhood immunization program using the combined measles-mumps-rubella (MMR) vaccine. Without an immunization program, an estimated 3,325,000 cases of measles would occur as compared to 2,872 actual cases in 1983 with a program. Instead of an expected 1.5 million rubella cases annually, there were only 3,816 actual cases. Mumps cases were lowered from an expected 2.1 million to 32,850 actual cases. Comparable reductions in disease-associated complications, sequelae, and deaths are gained with an immunization program. Without a vaccination program, disease costs would have been almost $1.4 billion. Based on the actual incidence of disease in 1983, costs were estimated to be approximately +14.5 million. Expenditures for immunization, including vaccine administration costs and the costs associated with vaccine reactions, totaled $96 million. The resulting benefit-cost ratio for the MMR immunization program is approximately 14:1. The savings realized due to the use of combination rather than single antigen vaccine total nearly $60 million.

Measles: not just another viral exanthem

Measles is the most frequent cause of vaccine-preventable childhood deaths. Infants younger than the recommended age for vaccination are susceptible to the disease, and in developing countries they have a high risk of complications and mortality. Vaccine coverage in excess of 95% interrupts endemic transmission of measles in many countries, but achievement of such coverage almost always requires coordinated supplementary mass vaccination campaigns. There are substantial health gains if countries improve measles vaccine coverage, irrespective of whether or not high coverage is achieved; these gains include much lower measles complication and case fatality rates, long-term interepidemic duration, and possibly non-specific improvements in survival of children. Investigation into the cost-effectiveness of different strategies for measles control, including mass campaigns, two-dose schedules, and young-infant doses, would help countries to formulate control policies appropriate to their setting. Pneumonia is the most common fatal complication associated with measles, and at least 50% of measles-related pneumonias are due to bacterial superinfection. WHO has developed standard case management programmes for measles, but there are several unresolved clinical issues, including optimum indications for antibiotic treatment, the importance of intravenous immunoglobulin, the role of viral coinfection, and the risk of tuberculosis after measles. The priority in worldwide efforts to control measles is to lend support to poor countries, helping them to increase vaccine coverage and sustain improvements to vaccination infrastructure, and to address technical issues with respect to optimum vaccination schedules. Measles represents a specific challenge, whereby partnerships between high-income and developing nations would reduce child mortality in developing countries; such partnerships are not without incentive for high-income countries, since without them imported measles cannot be prevented.

An Economic Analysis of the Current Universal 2-dose measles-mumps-rubella Vaccination Program in the United States

To evaluate the economic impact of the current 2-dose measles-mumps-rubella (MMR) vaccination program in the United States, a decision tree-based analysis was conducted with population-based vaccination coverage and disease incidence data. All costs were estimated for a hypothetical US birth cohort of 3803295 infants born in 2001. The 2-dose MMR vaccination program was cost-saving from both the direct cost and societal perspectives compared with the absence of MMR vaccination, with net savings (net present value) from the direct cost and societal perspectives of US dollars 3.5 billion and US dollars 7.6 billion, respectively. The direct and societal benefit-cost ratios for the MMR vaccination program were 14.2 and 26.0. Analysis of the incremental benefit-cost of the second dose showed that direct and societal benefit-cost ratios were 0.31 and 0.49, respectively. Varying the proportion of vaccines purchased and administered in the public versus the private sector had little effect on the results. From both perspectives under even the most conservative assumptions, the national 2-dose MMR vaccination program is highly cost-beneficial and results in substantial cost savings.

A benefit-cost analysis of two-dose measles immunization in Canada

In 1992, because of the limitations of the one-dose measles immunization program, the National Advisory Committee on Immunization (NACI) recommended a two-dose measles immunization program to eliminate measles. More recently, NACI recommended also a special catch-up program to prevent predicted measles outbreaks and to achieve an earlier elimination of measles. The objective of this study was to complete a benefit-cost analysis of a two-dose immunization program with and without a mass catch-up compaign compared with the current one-dose program. The resulting benefit: cost ratios vary between 2.61:1 and 4.31:1 depending on the strategy used and the age of the children targeted. Given the parameters established for this analysis, the benefits of a second-dose vaccination program against measles far outweight the costs of such a program under all scenarios.

Impact of measles in the United States

Measles has had a severe impact on children in the United States since colonial times. In the early decades of the 20th century, thousands of fatal measles infections were reported each year. During the 1950s an annual average of greater than 500,000 cases of measles and nearly 500 deaths due to measles were reported in the United States. Surveys indicated that 95% of the population had been infected with measles by the age of 15 years. The introduction of measles vaccine and its widespread use, which began in 1963, has had a major impact on the occurrence of measles in the United States. Reported numbers of cases, deaths due to measles, and complications of measles (e.g., encephalitis) have declined dramatically. Accompanying the decline in reported incidence of measles and following it by approximately seven years, has been a decline in the reported incidence of subacute sclerosing panencephalitis (SSPE). In recent years, the incidence of measles has dropped to levels that are less than 1% of those seen in the prevaccine era. In 1981, provisional figures indicated that only 10% of counties in the United States reported any cases of measles. The reported incidence in 1981 was 1.3 cases per 100,000 population, compared with an average incidence of 336.3 cases per 100,000 population in the decade 1950-1959. Thus, the impact of measles in the United States has been markedly reduced, and it is anticipated that indigenous transmission will be eliminated entirely from the country within the year.

Cost-effectiveness of measles elimination in Latin America and the Caribbean: a prospective analysis

BACKGROUND

In 1994, the Americas set a goal of interrupting indigenous measles transmission from the Western Hemisphere by 2000. To accomplish this goal, the Pan American Health Organization (PAHO) developed an enhanced measles vaccination strategy.

METHODS

Cost data was collected at PAHO for Latin American and Caribbean (LAC) countries covering 96% of the region's population on components of the routine programs, and the 'follow-up' activities from member countries. In order to interpret our findings we have compared the present scenario regarding measles with one that would have ensued if past trends continued.

RESULTS

For the entire LAC population, estimated cost of elimination program will be US$ 571 million in present value terms.

INTERPRETATION

The vaccination strategy toward achieving elimination of measles costs USD 244 million, incremental from the cost of vaccination before the elimination program. Within 2000-2020, the current program will have prevented the occurrence of 3.2 million cases of measles and 16,000 deaths. Thus, vaccination strategy prevents a single case of measles at the cost of USD 71.75 and prevents a death due to measles at the cost of USD 15,000. The case fatality rate depends on a well functioning treatment program for measles cases. The vaccination strategy saves a total of USD 208 million in treatments costs due to reduced incidence of measles.

Research priorities for global measles and rubella control and eradication

In 2010, an expert advisory panel convened by the World Health Organization to assess the feasibility of measles eradication concluded that (1) measles can and should be eradicated, (2) eradication by 2020 is feasible if measurable progress is made toward existing 2015 measles mortality reduction targets, (3) measles eradication activities should occur in the context of strengthening routine immunization services, and (4) measles eradication activities should be used to accelerate control and elimination of rubella and congenital rubella syndrome (CRS). The expert advisory panel also emphasized the critical role of research and innovation in any disease control or eradication program. In May 2011, a meeting was held to identify and prioritize research priorities to support measles and rubella/CRS control and potential eradication activities. This summary presents the questions identified by the meeting participants and their relative priority within the following categories: (1) measles epidemiology, (2) vaccine development and alternative vaccine delivery, (3) surveillance and laboratory methods, (4) immunization strategies, (5) mathematical modeling and economic analyses, and (6) rubella/CRS control and elimination.

Health burden and economic impact of measles-related hospitalizations in Italy in 2002-2003

Background

A large measles outbreak occurred in Italy in 2002–2003. This study evaluates the health burden and economic impact of measles-related hospitalizations in Italy during the specified period.

Methods

Hospital discharge abstract data for measles hospitalizations in Italy during 2002–2003 were analysed to obtain information regarding number and rates of measles hospitalizations by geographical area and age group, length of hospital stay, and complications. Hospitalization costs were estimated on the basis of Diagnosis-Related Groups.

Results

A total of 5,154 hospitalizations were identified, 3,478 (67%) of which occurred in children <15 years of age. Most hospitalizations occurred in southern Italy (71 %) and children below 1 year of age presented the greatest hospitalization rates (46.2/100,000 and 19.0/100,000, respectively in 2002 and 2003). Pneumonia was diagnosed in 594 cases (11.5%) and encephalitis in 138 cases (2.7%). Total hospital charges were approximately € 8.8 million.

Conclusion

The nationwide health burden associated with measles during the 2002–2003 outbreak was substantial and a high cost was incurred by the Italian National Health Service for the thousands of measles-related hospitalizations which occurred. By assuming that hospital costs represent 40–50% of the direct costs of measles cases, direct costs of measles for the two years combined were estimated to be between €17.6 – 22.0 million, which equates to the vaccination of 1.5–1.9 million children (3–4 birth cohorts) with one dose of MMR. The high cost of measles and the severity of its complications fully justify the commitment required to reach measles elimination.

Nosocomial measles infection in a pediatric hospital during a community-wide epidemic

From Jan. 1, 1988, through Dec. 31, 1988, a total of 89 cases of measles were observed at Childrens Hospital of Los Angeles, and 37 patients were admitted to the hospital. Of the 37 patients, six were not initially thought to have measles, which resulted in exposure of 107 patients and 24 personnel. Of the exposed patients, measles developed in four. One nosocomially infected infant died of pneumonia. Another exposed patient was subsequently admitted to another hospital with unrecognized measles, which led to exposure of an additional eight patients. Of seven employees in whom measles developed, two required hospitalization because of pneumonia. Two hundred eleven employee days were lost because of measles exposure or infection. Infection control interventions included prophylaxis of exposed patients, employee education, and measles immunization for susceptible personnel. Of 1103 hospital personnel considered susceptible to measles, 800 received monovalent measles vaccine. No secondary cases of measles occurred in hospital personnel who received appropriate prophylaxis. We conclude that infection control programs aimed at mandating measles immunity in hospital employees at risk should be instituted.

The average cost of measles cases and adverse events following vaccination in industrialised countries

BACKGROUND

Even though the annual incidence rate of measles has dramatically decreased in industrialised countries since the implementation of universal immunisation programmes, cases continue to occur in countries where endemic measles transmission has been interrupted and in countries where adequate levels of immunisation coverage have not been maintained. The objective of this study is to develop a model to estimate the average cost per measles case and per adverse event following measles immunisation using the Netherlands (NL), the United Kingdom (UK) and Canada as examples.

METHODS

Parameter estimates were based on a review of the published literature. A decision tree was built to represent the complications associated with measles cases and adverse events following immunisation. Monte-Carlo Simulation techniques were used to account for uncertainty.

RESULTS

From the perspective of society, we estimated the average cost per measles case to be US$276, US$307 and US$254 for the NL, the UK and Canada, respectively, and the average cost of adverse events following immunisation per vaccinee to be US$1.43, US$1.93 and US$1.51 for the NL, UK and Canada, respectively.

CONCLUSIONS

These average cost estimates could be combined with incidence estimates and costs of immunisation programmes to provide estimates of the cost of measles to industrialised countries. Such estimates could be used as a basis to estimate the potential economic gains of global measles eradication.

Economic analysis of the 1996–1997 mass measles immunization campaigns in South Africa

To evaluate economic implications of conducting a "catch-up" measles vaccination campaign, we conducted an economic analysis of the 1996-1997 measles immunization campaign in two provinces of South Africa comparing the baseline two-dose routine immunization program to the combined vaccination strategy (routine two-dose immunization program, plus the 1996-1997 campaign). The study findings indicate that the 1996-1997 mass measles immunization campaign was cost-effective in both study provinces, and cost-saving in the province with higher pre-campaign disease incidence and lower routine vaccination coverage. An early investment in effective vaccination strategies that rapidly reduce disease burden apparently results in better returns, both epidemiologically and economically.

Impact of alternative approaches to accelerated measles control: experience in the African region, 1996-2002

From 1996 to 2000, several African countries accelerated measles control by providing a second opportunity for measles vaccine through supplemental campaigns. Fifteen countries completed campaigns in children aged 9 months to 14 years. Seven countries completed campaigns in children aged 9-59 months. In almost all countries that conducted campaigns in children aged 9 months to 14 years, measles deaths were reduced to near zero. In six countries, near-zero measles mortality has been maintained for 4-6 years. Supplemental immunization in children <5 years old was only partially effective (range, 0-67%) in reducing mortality. Measles cases decreased by 50% when routine vaccination coverage increased from 50% to 80%. Initial measles campaigns in children aged 9 months to 14 years, follow-up campaigns in those aged 9-59 months every 3-5 years, and increased routine coverage to 80% will be needed to reduce and maintain measles deaths in African countries at near zero.

A model to estimate the potential economic benefits of measles eradication for the United States

Measles incidence is at a nadir in many parts of the world due to vaccination efforts. Although the technical feasibility of eradication has been acknowledged, financial and political commitment need to be concomitantly identified on the national and global level. We demonstrate the potential value of measles eradication by identifying the potential cost-savings to one country resulting from measles eradication. For the US, measles eradication would save $45 million annually. If achieved by the year 2010, the US would save $500 million to $4.1 billion depending on the year of elimination, post-eradication schedule and discount rate. Intensification of measles control efforts in the US beyond current levels would have minimal marginal benefits on disease burden reduction. Allocation of resources to achieve global measles eradication is the next level of efficiency which would provide substantial savings. Countries may adapt this model to estimate their savings for consideration of the required political and financial contribution towards a global measles eradication program.

Economic Costs of Measles Outbreak in the Netherlands, 2013-2014

In 2013 and 2014, the Netherlands experienced a measles outbreak in orthodox Protestant communities with low measles–mumps–rubella vaccination coverage. Assessing total outbreak costs is needed for public health outbreak preparedness and control. Total costs of this outbreak were an estimated $4.7 million.

Screening hospital employees for measles immunity is more cost effective than blind immunization

OBJECTIVE

To examine alternative strategies in developing a cost-effective program to assure measles immunity among hospital employees.

DESIGN

Observational.

SETTING

Referral teaching hospital.

PARTICIPANTS

Eighteen hundred "established" hospital employees with potential patient contact and 630 newly hired hospital employees.

INTERVENTIONS

Established employees born after 1 January 1957 and all newly hired employees were screened for serologic evidence of measles immunity and immunized if necessary.

MEASUREMENTS

Cost analysis.

RESULTS

The cost of screening and directed immunization of established employees was $3.98 per employee compared with a potential cost of $10.03 to $42.80 per employee if all employees were "blindly" immunized with monovalent measles vaccine or trivalent mumps-measles-rubella vaccine. The cost of the screening and directed immunization of new employees was $2.42 per employee compared with potential costs of $8.30 to $39.34 per employee for blind immunization. These analyses assumed that varying percentages of employees would be able to produce documentation of having received a previous dose of vaccine or of having had measles.

CONCLUSIONS

In a large referral hospital, screening for measles immunity followed by directed immunization was considerably less expensive than immunizing all potentially susceptible employees.

The Costs and Valuation of Health Impacts of Measles and Rubella Risk Management Policies

National and global health policymakers require good information about the costs and benefits of their investments in measles and rubella immunization programs. Building on our review of the existing measles and rubella health economics literature, we develop inputs for use in regional and global models of the expected future benefits and costs of vaccination, treatment, surveillance, and other global coordination activities. Given diversity in the world and limited data, we characterize the costs for countries according to the 2013 World Bank income levels using 2013 U.S. dollars (2013$US). We estimate that routine immunization and supplemental immunization activities will cost governments and donors over 2013$US 2.3 billion per year for the foreseeable future, with high-income countries accounting for 55% of the costs, to vaccinate global birth cohorts of approximately 134 million surviving infants and to protect the global population of over 7 billion people. We find significantly higher costs and health consequences of measles or rubella disease than with vaccine use, with the expected disability-adjusted life year (DALY) loss for case of disease generally at least 100 times the loss per vaccine dose. To support estimates of the economic benefits of investments in measles and/or rubella elimination or control, we characterize the probabilities of various sequelae of measles and rubella infections and vaccine adverse events, the DALY inputs for health outcomes, and the associated treatment costs. Managing measles and rubella to achieve the existing and future regional measles and rubella goals and the objectives of the Global Vaccine Action Plan will require an ongoing commitment of financial resources that will prevent adverse health outcomes and save the associated treatment costs.

Costs and benefits of a second measles inoculation of children in Israel, the West Bank, and Gaza

STUDY OBJECTIVE

Measles has been targeted by the WHO as a disease which should be eradicated. Use of existing vaccines during infancy has resulted in a substantial decline in cases in Israel, the West Bank, and Gaza. However the disease continues to occur in epidemic waves with large scale morbidity and mortality in all of these populations. This paper estimates the costs and benefits of three alternative strategies of adding immunisation at school age, and during young adult life to the present vaccination at 15 months.

MEASUREMENTS AND MAIN RESULTS

A policy of immunising all Israeli children aged 6 (option A) would cost around $1 million and have estimated benefits of $4.5 million, yielding a benefit cost ratio of 4.53/1. Despite relatively lower medical care costs and work absence costs (as a result of the lower per capita GNP and lower female participation rate in the workforce), the West Bank and Gaza situations yield benefit to cost ratios of 5.74/1 and 9.59/1 respectively because of their relatively higher incidence rates. If implemented in Israel, a vaccination programme (such as option A) would prevent, over the next 10 years, approximately 28,700 simple cases, 3400 hospital admissions, eight non-fatal cases of encephalitis, and 2.2 cases of SSPE. It would save 28 lives. The adoption of option A, is expected to reduce incidence and mortality by around 13,600 and 32 cases in the West Bank, and by 18,000 and 64 cases in Gaza.

CONCLUSION

The adoption of a two dose policy appears to be economically justifiable.

Epidemiology and economic burden of measles, mumps, pertussis, and varicella in Germany: a systematic review

OBJECTIVES

Despite the availability of vaccines and the existence of public vaccination recommendations, outbreaks of vaccine-preventable childhood diseases still cause public health debate. The objective of this systematic review was to provide an overview of the current epidemiology and economic burden of measles, mumps, pertussis, and varicella in Germany.

METHODS

We systematically reviewed studies published since 2000. The literature search was conducted using PubMed and EMBASE. Also, we used German notification data to give an up-to-date overview of the epidemiology of the four diseases under consideration.

RESULTS

Thirty-six studies were included in our review. Results suggest that there is still considerable morbidity due to childhood diseases in Germany. Studies providing cost estimates are scarce. Comparative analyses of different data sources (notification data vs. claims data) revealed a potential underestimation of incidence estimates when using notification data. Furthermore, several studies showed regional differences in incidence of some of the diseases under consideration.

CONCLUSIONS

Our findings underline the need for improved vaccination and communication strategies targeting all susceptible age and risk groups on a national and local level.

Measles in the Southern Health Board--implications for resources

During a recent epidemic of measles in the Southern Health and Social Services Board in Northern Ireland it became apparent that the level of notifications of measles by general practitioners did not reflect the true incidence of the disease at that time. In trying to establish a more accurate measure of the incidence of measles it became clear that much money and manpower had been used to treat this outbreak. We tried to cost a defined period covering 1 January to 30 June 1983 to draw attention to the possible benefits of a more effective measles vaccination programme in preventing disease and saving resources. The implications of our present poor rate of vaccination were measured for hospital services, primary medical care services, and related consequences. The costs for the defined period were approximately pounds 175 931, and if the outcome had been worse in a few cases it might have been as high as pounds 1 375 931.

Cost-effectiveness of the expanded programme on immunization in the Ivory Coast: a preliminary assessment

A preliminary calculation was made of the cost-effectiveness of the measles component of the Expanded Programme on Immunization (EPI) in the Ivory Coast. The calculation is based on existing data (program budgets, coverage surveys, counts of vaccinations provided and subjective estimates) and applies to the first three demonstration and training zones (Abidjan, Abengourou and Korhogo) with a combined population of 1.75 million people. The average annual cost of the measles program (assumed to be 75% of all EPI costs, including supplies, personnel and equipment) in these three zones was $527,000 at 1980 prices. Having achieved an average coverage rate of 61%, the cost per vaccine was moderately high, $12. Yet, vaccinees are a sufficiently small part of the population that the cost per capita is only $0.30. The program is estimated to prevent 38,000 cases of measles and 1100 deaths per year in these three zones. Thus, the cost per measles case averted is $14, and the cost per death averted is $479. This means that the measles component of the EPI Program is highly effective in preventing deaths for the sums expended compared to many alternative health programs in developing countries.

The difficult quest for data on "vanishing" vaccine-preventable infections in Europe: the case of measles in Flanders (Belgium)

We aimed to describe the impact of vaccination on the epidemiology of measles infection in Flanders (Belgium), to document probable vaccination coverage based on this evidence, compare these epidemiological data with those generated by a mathematical model and estimate the costs of morbidity from measles. In contrast to previous analyses, we included the costs of long-term care for sequelae due to encephalitis and subacute sclerosing panencephalitis (SSPE). We estimated the direct health care costs per average measles case at 227, 212, 210, 200 and 194 for the age groups of 0-4, 5-9, 10-14, 15-19 and > or=20 years, respectively. Excluding long-term care lowers these estimates by 22-51%, depending on the age group. By including indirect time costs, we arrive at total costs per measles case of 320, 305, 210, 200 and 625, respectively. In addition to registering vaccination coverage more rigorously in the future, it seems necessary to undertake seroprevalence studies to document the age-specific immunity to measles. By using such information, current vaccination strategies can be adapted to prevent future outbreaks and to help eliminate measles from Europe in an efficient way. We noted throughout that many of the data sources are flawed. Better and accessible data bases are required to improve the reliability of similar studies in the future.

The cost of measles in industrialised countries

The aim of this study is to estimate the costs of measles and measles control in 11 industrialised countries with varying levels of measles vaccine coverage. Country-specific annual incidence of measles, measles immunization policy, coverage and costs data were collected. The average societal costs of measles cases and immunisation programme per capita were calculated. These 11 countries spend together over US$ 151 million every year to treat and control measles. Per capita costs of measles control tend to be higher in countries with poorer measles control programmes (for instance, Italy has the highest incidence and highest overall costs), though many other factors, such as the number of antigens given per clinic visit and the local price of MMR also affect the efficiency of the programme. The costs estimates presented here can be used to estimate potential savings that might accrue from changes to measles control programmes.