Search

Seasonal influenza vaccines protect against 3 (trivalent influenza vaccine [IIV3]) or 4 (quadrivalent influenza vaccine [IIV4]) viruses. IIV4 costs more than IIV3, and there is a trade-off between incremental cost and protection. This is especially the case in low- and middle-income countries (LMICs) with limited budgets; previous reviews have not identified studies of IIV4-IIV3 comparisons in LMICs. We summarized the literature that compared health and economic outcomes of IIV4 and IIV3, focused on LMICs.We systematically searched 5 databases for articles published before October 6, 2021, that modeled health or economic effects of IIV4 versus IIV3. We abstracted data and compared findings among countries and models.Thirty-eight studies fit our selection criteria; 10 included LMICs. Most studies (N = 31) reported that IIV4 was cost-saving or cost-effective compared with IIV3; we observed no difference in health or economic outcomes between LMICs and other countries. Based on cost differences of influenza vaccines, only one study compared coverage of IIV3 with IIV4 and reported that the maximum IIV4 price that would still yield greater public health impact than IIV3 was 13% to 22% higher than IIV3.When vaccination coverage with IIV4 and IIV3 is the same, IIV4 tends to be not only more effective but more cost-effective than IIV3, even with relatively high price differences between vaccine types. Alternatively, where funding is limited as in most LMICs, higher vaccine coverage can be achieved with IIV3 than IIV4, which could result in more favorable health and economic outcomes.

This study aimed to estimate the cost-effectiveness of the use of recombinant zoster vaccine (RZV) (Shingrix), which protects against herpes zoster (HZ), among immunocompromised adults aged 19 to 49 years, as a contribution to deliberations of the Advisory Committee on Immunization Practices.Hematopoietic cell transplant (HCT) recipients experience a high incidence of HZ, and the efficacy of RZV in preventing HZ has been studied in clinical trials. The cost-effectiveness model calculated incremental cost-effectiveness ratios that compared vaccination with RZV with a no vaccination strategy among adults aged 19 to 49 years. Costs and outcomes were calculated until age 50 years using the healthcare sector perspective and summarized as cost per quality-adjusted life-year (QALY) gained. The base case represents HCT recipients, with scenario analyses representing persons with other immunocompromising conditions, including hematologic malignancies, human immunodeficiency virus, and autoimmune and inflammatory conditions. Uncertainty was investigated using univariate, multivariate, and probabilistic sensitivity analyses.Base-case results indicated vaccination with RZV would avert approximately 35% of HZ episodes and complications, while saving approximately 11% of net costs. Compared with no vaccination, vaccination of HCT recipients with RZV generated cost-savings (ie, lower costs and improved health) in the base case and in 81% of simulations in the probabilistic analysis. In scenario analyses, vaccination cost US dollar ($) 9500/QALY among patients with hematologic malignancies, $79 000/QALY among persons living with human immunodeficiency virus, and $208 000/QALY among persons with selected autoimmune and inflammatory conditions.Generally favorable economic estimates supported recommendations for vaccination of immunocompromised adults with RZV to prevent episodes of HZ and related complications.

Background Although effective against hepatitis B virus (HBV) infection, hepatitis B (HepB) vaccination is only recommended for infants, children, and adults at higher risk. We conducted an economic evaluation of universal HepB vaccination among US adults. Methods Using a decision analytic model with Markov disease progression, we compared current vaccination recommendations (baseline) with either 3-dose or 2-dose universal HepB vaccination (intervention strategies). In simulated modeling of 1 million adults distributed by age and risk groups, we quantified health benefits (quality-adjusted life years, QALYs) and costs for each strategy. Multivariable probabilistic sensitivity analyses identified key inputs. All costs reported in 2019 US dollars. Results With incremental base-case vaccination coverage up to 50% among persons at lower risk and 0% increment among persons at higher risk, each of 2 intervention strategies averted nearly one-quarter of acute HBV infections (3-dose strategy, 24.8%; 2-dose strategy, 24.6%). Societal incremental cost per QALY gained of $152 722 (interquartile range, $119 113–$235 086) and $155 429 (interquartile range, $120 302–$242 226) were estimated for 3-dose and 2-dose strategies, respectively. Risk of acute HBV infection showed the strongest influence. Conclusions Universal adult vaccination against HBV may be an appropriate strategy for reducing HBV incidence and improving resulting health outcomes.

Objective Noroviruses are the leading cause of acute gastroenteritis in the United States and outbreaks frequently occur in daycare settings. Results of norovirus vaccine trials have been promising, however there are open questions as to whether vaccination of daycare children would be cost-effective. We investigated the incremental cost-effectiveness of a hypothetical norovirus vaccination for children in daycare settings compared to no vaccination. Methods We conducted a model-based cost-effectiveness analysis using a disease transmission model of children attending daycare. Vaccination with a 90% coverage rate in addition to the observed standard of care (exclusion of symptomatic children from daycare) was compared to the observed standard of care. The main outcomes measures were infections and deaths averted, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER). Cost-effectiveness was analyzed from a societal perspective, including medical costs to children as well as productivity losses of parents, over a two-year time horizon. Data sources included outbreak surveillance data and published literature. Results A 50% efficacious norovirus vaccine averts 571.83 norovirus cases and 0.003 norovirus-related deaths per 10,000 children compared to the observed standard of care. A $200 norovirus vaccine that is 50% efficacious has a net cost increase of $178.10 per child and 0.025 more QALYs, resulting in an ICER of $7,028/QALY. Based on the probabilistic sensitivity analysis, we estimated that a $200 vaccination with 50% efficacy was 94.0% likely to be cost-effective at a willingness-to-pay of $100,000/QALY threshold and 95.3% likely at a $150,000/QALY threshold. Conclusion Due to the large disease burden associated with norovirus, it is likely that vaccinating children in daycares could be cost-effective, even with modest vaccine efficacy and a high per-child cost of vaccination. Norovirus vaccination of children in daycare has a cost-effectiveness ratio similar to other commonly recommended childhood vaccines.

Background and objectives Although acute respiratory illness (ARI) is a leading cause of hospitalization among young children, few data are available about cost of hospitalization in middle-income countries. We estimated direct and indirect costs associated with severe ARI resulting in hospitalization among children aged Methods During 2012 and 2013, we surveyed caregivers of children hospitalized with ARI about their direct medical (i.e., outpatient consultation, medications, hospital fees), non-medical (transportation, childcare), and indirect costs (lost wages) at discharge and 7 days after discharge. We multiplied subsidized hospital bed costs derived from administrative data by hospitalization days to estimate provider costs. Results Overall, 638 children were enrolled with a median age of 12 months (IQR 6–23). Their median length of hospitalization was 4 days (IQR 3–6). In El Salvador, caregivers incurred a median of US$38 (IQR 22–72) in direct and indirect costs per illness episode, while the median government-paid hospitalization cost was US$118 (IQR 59–384) generating an overall societal cost of US$219 (IQR 101–416) per severe ARI episode. In Panama, caregivers incurred a median of US$75 (IQR 39–135) in direct and indirect costs, and the health-care system paid US$280 (IQR 150–420) per hospitalization producing an overall societal cost of US$393 (IQR 258–552). Conclusions The cost of severe ARI to caregivers and the health care system was substantive. Our estimates will inform models to estimate national costs of severe ARI and cost-benefit of prevention and treatment strategies.

Background Pregnant women, healthcare workers (HW), and adults >= 60 years have shown an increased vulnerability to seasonal influenza virus infections and/or complications. In 2012, the Lao People's Democratic Republic (Lao PDR) initiated a national influenza vaccination program for these target groups. A cost-effectiveness evaluation of this program was undertaken to inform program sustainability. Methods We designed a decision-analytical model and collected influenza-related medical resource utilization and cost data, including indirect costs. Model inputs were obtained from medical record abstraction, interviews of patients and staff at hospitals in the national influenza sentinel surveillance system and/or from literature reviews. We compared the annual disease and economic impact of influenza illnesses in each of the target groups in Lao PDR under scenarios of no vaccination and vaccination, and then estimated the cost-effectiveness of the vaccination program. We performed sensitivity analyses to identify influential variables. Results Overall, the vaccination of pregnant women, HWs, and adults >= 60 years could annually save 11,474 doctor visits, 1,961 days of hospitalizations, 43,027 days of work, and 1,416 life-years due to laboratory-confirmed influenza illness. After comparing the total vaccination program costs of 23.4 billion Kip, to the 18.4 billion Kip saved through vaccination, we estimated the vaccination program to incur a net cost of five billion Kip (599,391 USD) annually. The incremental cost per life-year saved (ICER) was 44 million Kip (5,295 USD) and 6.9 million Kip (825 USD) for pregnant women and adults >= 60 years, respectively. However, vaccinating HWs provided societal cost-savings, returning 2.88 Kip for every single Kip invested. Influenza vaccine effectiveness, attack rate and illness duration were the most influential variables to the model. Conclusion Providing influenza vaccination to HWs in Lao PDR is cost-saving while vaccinating pregnant women and adults >= 60 is cost-effective and highly cost-effective, respectively, per WHO standards.

Objective: This is a critical review of published economic analyses on congenital cytomegalovirus infection and strategies for its detection and prevention. Findings: The review identified four cost-of-illness studies and nine cost-effectiveness analyses: three of vaccination of young women, two of prenatal screening, and four of newborn screening. All reported either large economic costs or favorable cost-effectiveness of interventions. However, sensitivity analyses did not address some of the most critical assumptions. Conclusions: Reviewed economic analyses overattributed certain adverse long-term outcomes to congenital cytomegalovirus infection, while other long-term costs were not included. Overall, limited conceptual frameworks, unrepresentative data sources, and unsupported or inadequately documented assumptions regarding outcomes and costs hinder the ability of policymakers to draw conclusions. A major challenge is the limited information on long-term outcomes and costs for representative cohorts of individuals with congenital cytomegalovirus, which further research could helpfully address.

1AbstractBackgroundNorovirus outbreaks are notoriously explosive, with dramatic symptomology and rapid disease spread. Children are particularly vulnerable to infection and drive norovirus transmission due to their high contact rates with each other and the environment. Despite the explosive nature of norovirus outbreaks, attack rates in schools and daycares remain low with the majority of students not reporting symptoms.MethodsWe explore immunologic and epidemiologic mechanisms that may underlie epidemic norovirus transmission dynamics using a disease transmission model. Towards this end, we compared different model scenarios, including innate resistance and acquired immunity (collectively denoted ‘immunity’), stochastic extinction, and an individual exclusion intervention. We calibrated our model to daycare and school outbreaks from national surveillance data.ResultsRecreating the low attack rates observed in daycare and school outbreaks required a model with immunity. However, immunity alone resulted in shorter duration outbreaks than what was observed. The addition of individual exclusion (to the immunity model) extended outbreak durations by reducing the amount of time that symptomatic people contribute to transmission. Including both immunity and individual exclusion mechanisms resulted in simulations where both attack rates and outbreak durations were consistent with surveillance data.ConclusionsThe epidemiology of norovirus outbreaks in daycare and school settings cannot be well described by a simple transmission model in which all individuals start as fully susceptible. Interventions should leverage population immunity and encourage more rigorous individual exclusion to improve venue-level control measures.

Our objective was to develop comprehensive national estimates of the total burden of herpes zoster (HZ) among U.S. adults, including direct (ie, medical costs) and indirect (ie, productivity losses) costs, as well as its psychosocial impact (ie, quality of life losses). Using a patient-level microsimulation model, we projected health and economic outcomes among U.S. adults aged 18 years and older using a 10-year time horizon. We conducted a comprehensive systematic literature review to generate parameter values and conducted simulation modeling to generate our outcomes, including numbers of cases of uncomplicated HZ, postherpetic neuralgia (PHN), and ocular complications, productivity losses, and losses in quality-adjusted life years (QALYs). We used a societal perspective for outcomes; the costing year was 2015. Projected outcomes for an unvaccinated population included 1.1 million HZ cases, 114,000 PHN cases, and 43,000 ocular complications annually, resulting in approximately 67,000 QALYs lost. HZ and its complications would incur costs of $2.4 billion in direct medical costs and productivity losses annually. Projected QALY losses were most sensitive to HZ and PHN health utility values in the model. Cost estimates were most sensitive to the probability of HZ and to the costs per episode of PHN. The national burden of direct, indirect, and psychosocial HZ costs is substantial. Our results can inform economic analyses for HZ vaccines. Comprehensive, national assessments of the total burden of other painful conditions would be very informative.

The U.S. Advisory Committee on Immunization Practices recently developed recommendations for use of a new recombinant zoster vaccine (RZV).To evaluate the cost-effectiveness of vaccination with RZV compared with zoster vaccine live (ZVL) and no vaccination, the cost-effectiveness of vaccination with RZV for persons who have previously received ZVL, and the cost-effectiveness of preferential vaccination with RZV over ZVL.Simulation (state-transition) model using U.S. epidemiologic, clinical, and cost data.Published data.Hypothetical cohort of immunocompetent U.S. adults aged 50 years or older.Lifetime.Societal and health care sector.Vaccination with RZV (recommended 2-dose regimen), vaccination with ZVL, and no vaccination.The primary outcome measure was the incremental cost-effectiveness ratio (ICER).For vaccination with RZV compared with no vaccination, ICERs ranged by age from $10 000 to $47 000 per quality-adjusted life-year (QALY), using a societal perspective and assuming 100% completion of the 2-dose RZV regimen. For persons aged 60 years or older, ICERs were less than $60 000 per QALY. Vaccination with ZVL was dominated by vaccination with RZV for all age groups 60 years or older.Results were most sensitive to changes in vaccine effectiveness, duration of protection, herpes zoster incidence, and probability of postherpetic neuralgia. Vaccination with RZV after previous administration of ZVL yielded an ICER of less than $60 000 per QALY for persons aged 60 years or older. In probabilistic sensitivity analyses, RZV remained the preferred strategy in at least 95% of simulations, including those with 50% completion of the second dose.Few data were available on risk for serious adverse events, adherence to the recommended 2-dose regimen, and probability of recurrent zoster.Vaccination with RZV yields cost-effectiveness ratios lower than those for many recommended adult vaccines, including ZVL. Results are robust over a wide range of plausible values.Centers for Disease Control and Prevention.

Background The United States is experiencing mumps outbreaks in settings with high 2-dose measles-mumps-rubella (MMR) vaccine coverage, mainly universities. The economic impact of mumps outbreaks on public health systems is largely unknown. During a 2015–2016 mumps outbreak at the University of Iowa, we estimated the cost of public health response that included a third dose of MMR vaccine. Methods Data on activities performed, personnel hours spent, MMR vaccine doses administered, miles traveled, hourly earnings, and unitary costs were collected using a customized data tool. These data were then used to calculate associated costs. Results Approximately 6300 hours of personnel time were required from state and local public health institutions and the university, including for vaccination and laboratory work. Among activities demanding time were case/contact investigation (36%), response planning/coordination (20%), and specimen testing and report preparation (13% each). A total of 4736 MMR doses were administered and 1920 miles traveled. The total cost was >$649 000, roughly equally distributed between standard outbreak control activities and third-dose MMR vaccination (55% and 45%, respectively). Conclusions Public health response to the mumps outbreak at the University of Iowa required important amounts of personnel time and other resources. Associated costs were sizable enough to affect other public health activities.

At its June 2015 meeting, the Advisory Committee on Immunization Practices (ACIP) recommended that adolescents and young adults aged 16–23 years may be vaccinated with a serogroup B meningococcal (MenB) vaccine to provide short-term protection against most strains of serogroup B meningococcal disease. This report summarizes the deliberations of ACIP, the rationale for its decision, and recommendations for use of MenB vaccines in adolescents and young adults. Two MenB vaccines have recently been licensed by the Food and Drug Administration (FDA) for use in the United States and approved for use in persons aged 10–25 years: MenB-FHbp (Trumenba, Wyeth Pharmaceuticals, Inc.) and MenB-4C (Bexsero, Novartis Vaccines). Both MenB vaccines were licensed based on statutory regulations for accelerated approval, which enabled FDA to approve the MenB vaccines for serious or life-threatening diseases based on safety and demonstration that vaccine effectiveness, as measured by bactericidal antibody responses with assays using several MenB test strains that were representative of prevalent strains in the United States, is reasonably likely to predict clinical benefit. As a requirement for accelerated approval, confirmatory studies in the postmarketing period will be conducted to verify and further describe the effectiveness of the vaccines against an extended number of MenB strains that represent a broader diversity of endemic disease. Additional postlicensure safety data are also needed and will be reviewed by ACIP as they become available.

Background Respiratory syncytial virus (RSV) is the leading cause of acute respiratory illness in young children and results in significant economic burden. There is no vaccine to prevent RSV illness but a number of vaccines are in development. We conducted this study to estimate the costs of severe RSV illness requiring hospitalization among children 50% families borrowed money to meet treatment cost. We estimated that the median direct cost of RSV–associated hospitalization in children aged

BACKGROUND An estimated 3600 infants born with congenital cytomegalovirus (cCMV) infection annually in the United States are symptomatic at birth. The proportion of infants with symptomatic cCMV infection who require hospitalization is unknown yet important for understanding the full disease and economic burdens of cCMV. METHODS Data from the Healthcare Cost and Utilization Project Kids' Inpatient Databases were analyzed to determine numbers and rates of cCMV-related hospitalizations among infants for 1997, 2000, 2003, 2006 and 2009, the years the survey was conducted. A cCMV-related hospitalization was defined as a hospitalization with an International Classification of Diseases, 9th revision, Clinical Modification code of 771.1 in an infant without HIV or transplant-related codes. After applying hospital type-specific cost-to-charge ratios and adjusting to 2012 US dollars, total medical costs associated with cCMV-related hospitalizations were assessed. Results were extrapolated to represent national estimates. RESULTS Among infants

To determine the medical costs of laboratory-confirmed rotavirus hospitalizations and emergency department (ED) visits and estimate the economic impact of the rotavirus vaccine program.During 4 rotavirus seasons (2006-2009), children3 years of age hospitalized or seen in the ED with laboratory-confirmed rotavirus were identified through active population-based rotavirus surveillance in three US counties. Medical costs were obtained from hospital and physician billing data, and factors associated with increased costs were examined. Annual national costs were estimated using rotavirus hospitalization and ED visit rates and medical costs for rotavirus hospitalizations and ED visits from our surveillance program for pre- (2006-2007) and post-vaccine (2008-2009) time periods.Pre-vaccine, for hospitalizations, the median medical cost per child was $3581, the rotavirus hospitalization rate was 22.1/10,000, with an estimated annual national cost of $91 million. Post-vaccine, the median medical cost was $4304, the hospitalization rate was 6.3/10,000 and the estimated annual national cost was $31 million. Increased costs were associated with study site, age3 months, underlying medical conditions and an atypical acute gastroenteritis presentation. For ED visits, the pre-vaccine median medical cost per child was $574, the ED visit rate was 291/10,000 resulting in an estimated annual national cost of $192 million. Post-vaccine, the median medical cost was $794, the ED visit rate was 71/10,000 with an estimated annual national cost of $65 million.After implementation of rotavirus immunization, the total annual medical costs decreased from $283 million to $96 million, an annual reduction of $187 million.

At its June 2016 meeting, the Advisory Committee on Immunization Practices (ACIP) recommended routine use of meningococcal conjugate vaccine (serogroups A, C, W, and Y; including MenACWY-D [Menactra, Sanofi Pasteur] or MenACWY-CRM [Menveo, GlaxoSmithKline]) for persons aged ≥2 months with human immunodeficiency virus (HIV) infection. ACIP has previously recommended routine vaccination of persons aged ≥2 months who have certain medical conditions that increase risk for meningococcal disease (1), including persons who have persistent (e.g., genetic) deficiencies in the complement pathway (e.g., C3, properdin, Factor D, Factor H, or C5-C9); persons receiving eculizumab (Soliris, Alexion Pharmaceuticals) for treatment of atypical hemolytic uremic syndrome or paroxysmal nocturnal hemoglobinuria (because the drug binds C5 and inhibits the terminal complement pathway); and persons with functional or anatomic asplenia (including persons with sickle cell disease). Routine vaccination with meningococcal conjugate vaccine is also recommended for all healthy adolescents in the United States (1). This report summarizes the evidence considered by ACIP in recommending vaccination for HIV-infected persons, and provides recommendations and guidance for use of meningococcal conjugate vaccines (serogroups A, C, W, and Y) among HIV-infected persons aged ≥2 months; the majority of meningococcal disease among HIV-infected persons is caused by these four serogroups.

Background The United States Territory of Guam reported a large mumps outbreak of 505 cases during 2009–2010. We assessed the economic impact of the outbreak from the perspectives of the local public health sector and affected families. Methods Using standard cost analysis methods, we retrospectively identified all public health personnel involved in the outbreak response and surveyed them about their outbreak-related activities. We then estimated the costs of outbreak-related personnel hours and materials. We also assessed out-of-pocket costs and costs incurred for work-time missed for persons with mumps and their families. We defined the analysis period as February 25–October 22, 2010. Results Seventy-six public health personnel were involved in outbreak response activities. Overall, the response required approximately 8264 person-hours, 2380 miles driven, and 3000 doses of measles-mumps-rubella vaccine ordered. The cost to the public health sector was 256,785 U.S. dollars (USD). Families of 102 persons with mumps were interviewed. An estimated 761 USD per person with mumps was spent by families; 88% of this cost was due to missed days of work. The estimated total cost to families of the 470 persons with mumps during the analysis period was 357,670 USD. Total outbreak-related costs were 614,455 USD. Conclusions The costs reported underscore the impact of mumps outbreaks in highly vaccinated populations and the need for effective mumps prevention and control strategies.

Studies have documented direct medical costs of influenza-related illness in young children, however little is known about the out-of-pocket and indirect costs (e.g., missed work time) incurred by caregivers of children with medically attended influenza.To determine the indirect, out-of-pocket (OOP), and direct medical costs of laboratory-confirmed medically attended influenza illness among young children.Using a population-based surveillance network, we evaluated a representative group of children aged5 years with laboratory-confirmed, medically attended influenza during the 2003-2004 season. Children hospitalized or seen in emergency department (ED) or outpatient settings in surveillance counties with laboratory-confirmed influenza were identified and data were collected from medical records, accounting databases, and follow-up interviews with caregivers. Outcome measures included work time missed, OOP expenses (e.g., over-the-counter medicines, travel expenses), and direct medical costs. Costs were estimated (in 2009 US Dollars) and comparisons were made among children with and without high risk conditions for influenza-related complications.Data were obtained from 67 inpatients, 121 ED patients and 92 outpatients with laboratory-confirmed influenza. Caregivers of hospitalized children missed an average of 73 work hours (estimated cost $1456); caregivers of children seen in the ED and outpatient clinics missed 19 ($383) and 11 work hours ($222), respectively. Average OOP expenses were $178, $125 and $52 for inpatients, ED-patients and outpatients, respectively. OOP and indirect costs were similar between those with and without high risk conditions (p0.10). Medical costs totaled $3990 for inpatients and $730 for ED-patients.Out-of-pocket and indirect costs of laboratory-confirmed and medically attended influenza in young children are substantial and support the benefits of vaccination.

OBJECTIVE:In January 2008, an intentionally unvaccinated 7-year-old boy who was unknowingly infected with measles returned from Switzerland, resulting in the largest outbreak in San Diego, California, since 1991. We investigated the outbreak with the objective of understanding the effect of intentional undervaccination on measles transmission and its potential threat to measles elimination.METHODS:We mapped vaccination-refusal rates according to school and school district, analyzed measles-transmission patterns, used discussion groups and network surveys to examine beliefs of parents who decline vaccination, and evaluated containment costs.RESULTS:The importation resulted in 839 exposed persons, 11 additional cases (all in unvaccinated children), and the hospitalization of an infant too young to be vaccinated. Two-dose vaccination coverage of 95%, absence of vaccine failure, and a vigorous outbreak response halted spread beyond the third generation, at a net public-sector cost of $10 376 per case. Although 75% of the cases were of persons who were intentionally unvaccinated, 48 children too young to be vaccinated were quarantined, at an average family cost of $775 per child. Substantial rates of intentional undervaccination occurred in public charter and private schools, as well as public schools in upper-socioeconomic areas. Vaccine refusal clustered geographically and the overall rate seemed to be rising. In discussion groups and survey responses, the majority of parents who declined vaccination for their children were concerned with vaccine adverse events.CONCLUSIONS:Despite high community vaccination coverage, measles outbreaks can occur among clusters of intentionally undervaccinated children, at major cost to public health agencies, medical systems, and families. Rising rates of intentional undervaccination can undermine measles elimination.

Background and Objectives: A clear sense of what society is willing to pay for a QALY could enhance the usefulness of cost-effectiveness analysis as a field. Scant information exists on willingness to pay (WTP) for a QALY based on direct elicitation of preferences from community members or patients. We had the opportunity to evaluate WTP per QALY using data from a survey on temporary health outcomes related to herpes zoster. Our aims were to (i) describe how much community members are willing to pay to save a QALY based on scenarios describing temporary health states; (ii) evaluate how WTP per QALY varies based on experience with the disease being described and with demographic variables; and (iii) evaluate how the duration and intensity of pain in a scenario influences WTP per QALY. Abstract: Methods: Community members drawn from a nationally representative survey research panel (n - 478) completed an Internet-based survey using time trade-off (TTO) and WTP questions to value a series of scenarios that described herpes zoster cases of varying pain intensity (on a scale of 0-10) and duration (30 days to 1 year). Patients with shingles (n - 354) or postherpetic neuralgia (PHN; n - 120) [defined as having symptoms for 90 days or more] from two large healthcare systems completed telephone interviews with similar questions. Mean and median WTP per QALY values were calculated by dividing the WTP amount by the discounted time traded for each scenario. Responses with a WTP value of more than zero and a TTO value of zero (which would have resulted in an undefined value) were excluded. TTO values were discounted by 3% per year. WTP per QALY means were calculated after trimming the top and bottom 2.5% of responses. Multivariate analyses were conducted using generalized linear mixed models that assumed a negative binomial distribution. Results: Among all respondents, the WTP per QALY ranged from a median of $US7000 to $US11 000 and a trimmed mean of $US26 000 to $US45 000 (year 2005 values), depending on the scenario described. WTP per QALY values varied significantly with respondent characteristics, as well as among respondents with similar characteristics. In multivariate analyses, the mean WTP per QALY was higher among respondents who were younger, male or had higher educational or income levels. After adjusting for these demographic variables, patients who had experienced shingles gave responses with the highest WTP per QALY values. Patients who had experienced PHN gave the lowest values, and community members gave values intermediate to the shingles and PHN groups. In multivariate models that evaluated the effects of pain and duration of the hypothetical zoster scenario, lower duration was associated with higher WTP per QALY. This effect appeared to be due to people increasing the amounts of time they would be willing to trade as duration increased, without proportional increases in the amounts of money they would be willing to pay. Abstract: Conclusions:Conclusions: Community members and patients gave mean WTP per QALY values that varied significantly based on age, sex, socioeconomic status, experience with shingles and duration of the health state evaluated. The variability in WTP per QALY suggests that it may be difficult to define a unitary threshold of dollars per QALY for policy making based on cost-effectiveness analyses.

Of >39,000 civilian public health responders vaccinated against smallpox in 2003, 203 reported cardiovascular adverse events (CAEs). An association exists between the US vaccinia strain and myocarditis and/or pericarditis ("myo/pericarditis" [MP]). Other associations are inconclusive. We used surveillance and follow-up survey data of CAE case patients to estimate the resources used during the 2003 smallpox vaccination program and used a probabilistic model to estimate the potential costs of CAEs in a mass vaccination campaign. For every million adult vaccinees, 3001 CAEs (including 351 MP cases) would occur, with >92% in revaccinees. CAEs would require a median of 5934 outpatient visits, 1786 emergency department visits, 533 days in general wards, 132 days in intensive care units, 5484 cardiac enzymes tests, 3504 electrocardiograms, 3049 chemistry tests, 2828 complete blood counts, and 1444 transthoracic echocardiograms, among other procedures. CAEs would reduce productivity (15,969 work days lost) and cost $11 per vaccinee. In a mass vaccination campaign, the care of a sizable number of CAEs would be resource intensive.

Frequent varicella outbreaks with sizable impact on the US public health system have continued to occur despite the success of the country's 1-dose varicella vaccination program. The Advisory Committee on Immunization Practices recently recommended adding a routine second dose of varicella vaccine and weighed economic projections as well as public health goals in their deliberations. This decision-tree-based analysis was conducted to evaluate the economic impact of the projected 2-dose varicella vaccination program as well as the existing 1-dose program. The analysis used population-based vaccination coverage and disease incidence data to make projections for a hypothetical US birth cohort of 4,100,000 infants born in 2006. Compared with no vaccination, both the 1-dose program (societal benefit-cost ratio [BCR], 4.37) and 2-dose program (BCR, 2.73) were estimated to be cost saving from the societal perspective. Compared with the 1-dose program, the incremental second dose was not cost saving (societal incremental BCR, 0.56). The incremental cost-effectiveness ratio for the second dose was $343 per case prevented, or approximately $109,000 per quality-adjusted life-year saved, and these results were sensitive to assumptions about vaccine effectiveness and prices.

Background In June 2005, the Advisory Committee on Immunization Practices recommended the newly licensed quadrivalent meningococcal conjugate vaccine for routine use among all US children aged 11 years. A 1-time catch-up vaccination campaign for children and adolescents aged 11-17 years, followed by routine annual immunization of each child aged 11 years, could generate immediate herd immunity benefits. The objective of our study was to analyze the cost-effectiveness of a catch-up vaccination campaign with quadrivalent meningococcal conjugate vaccine for children and adolescents aged 11-17 years. Methods We built a probabilistic model of disease burden and economic impacts for a 10-year period with and without a program of adolescent catch-up meningococcal vaccination, followed by 9 years of routine immunization of children aged 11 years. We used US age- and serogroup-specific surveillance data on incidence and mortality. Assumptions related to the impact of herd immunity were drawn from experience with routine meningococcal vaccination in the United Kingdom. We estimated costs per case, deaths prevented, life-years saved, and quality-adjusted life-years saved. Results With herd immunity, the catch-up and routine vaccination program for adolescents would prevent 8251 cases of meningococcal disease in a 10-year period (a 48% decrease). Excluding program costs, this catch-up and routine vaccination program would save US$551 million in direct costs and $920 million in indirect costs, including costs associated with permanent disability and premature death. At $83 per vaccinee, the catch-up vaccination would cost society approximately $223,000 per case averted, approximately $2.6 million per death prevented, approximately $127,000 per life-year saved, and approximately $88,000 per quality-adjusted life-year saved. Targeting counties with a high incidence of disease decreased the cost per life-year saved by two-thirds. Conclusions Although costly, catch-up and routine vaccination of adolescents can have a substantial impact on meningococcal disease burden. Because of herd immunity, catch-up and routine vaccination cost per life-year saved could be up to one-third less than that previously assessed for routine vaccination of children aged 11 years.

The US Advisory Committee on Immunization Practices has recently recommended a new vaccine against herpes zoster (shingles) for routine use in adults aged ≥60 years. However, estimates of the cost effectiveness of this vaccine vary widely, in part because of gaps in the data on the value of preventing herpes zoster. Our aims were to (i) generate comprehensive information on the value of preventing a range of outcomes of herpes zoster; (ii) compare these values among community members and patients with shingles and post-herpetic neuralgia (PHN); and (iii) identify clinical and demographic characteristics that explain the variation in these values. Community members drawn from a nationally representative survey research panel (n = 527) completed an Internet-based survey using time trade-off and willingness-to-pay questions to value a series of scenarios that described cases of herpes zoster with varying pain intensities (on a scale of 0 to 10, where 0 represents no pain and 10 represents the worst imaginable pain) and duration (30 days to 1 year). Patients with shingles (n = 382) or PHN (n = 137) [defined as having symptoms for =90 days] from two large healthcare systems completed telephone interviews with similar questions to the Internet-based survey and also answered questions about their current experience with herpes zoster. We constructed generalized linear mixed models to evaluate the associations between demographic and clinical characteristics, the length and intensity of the health states and time trade-off and willingness-to-pay values. In time trade-off questions, community members offered a mean of 89 (95% CI 24, 182) discounted days to avoid the least severe scenario (pain level of 3 for 1 month) and a mean of 162 (95% CI 88, 259) discounted days to avoid the most severe scenario (pain level of 8 for 12 months). Compared with patients with shingles, community members traded more days to avoid low-severity scenarios but similar numbers of days to avoid high-severity scenarios. Compared with patients with PHN, community members traded fewer days to avoid high-severity scenarios. In multivariate analyses, older age was the only characteristic significantly associated with higher time trade-off values. In willingness-to-pay questions, community members offered a mean of $US450 (95% CI 203, 893) to avoid pain of level 3 for 1 month and a mean of $US1384 (95% CI 873, 2050) [year 2005 values] to avoid pain of level 8 for 12 months. Community members traded less money than patients with either shingles or PHN to avoid both low- and high-severity scenarios (p-values

Background Despite preventive efforts, influenza epidemics are responsible for substantial morbidity and mortality every year in the United States (US). Vaccination strategies to reduce disease burden have been implemented. However, no previous studies have systematically estimated the annual economic burden of influenza epidemics, an estimate necessary to guide policy makers effectively. Objective We estimate age- and risk-specific disease burden, and medical and indirect costs attributable to annual influenza epidemics in the United States. Methods Using a probabilistic model and publicly available epidemiological data we estimated the number of influenza-attributable cases leading to outpatient visits, hospitalization, and mortality, as well as time lost from work absenteeism or premature death. With data from health insurance claims and projections of either earnings or statistical life values, we then estimated healthcare resource utilization associated with influenza cases as were their medical and productivity (indirect) costs in $2003. Results Based on 2003 US population, we estimated that annual influenza epidemics resulted in an average of 610,660 life-years lost (undiscounted), 3.1 million hospitalized days, and 31.4 million outpatient visits. Direct medical costs averaged $10.4 billion (95% confidence interval [C.I.], $4.1, $22.2) annually. Projected lost earnings due to illness and loss of life amounted to $16.3 billion (C.I., $8.7, $31.0) annually. The total economic burden of annual influenza epidemics using projected statistical life values amounted to $87.1 billion (C.I., $47.2, $149.5). Conclusions These results highlight the enormous annual burden of influenza in the US. While hospitalization costs are important contributors, lost productivity from missed work days and lost lives comprise the bulk of the economic burden of influenza.

Measles is highly infectious; prompt containment of illnesses is necessary to prevent spread. In August 2013, a 13-year-old male with measles exposed patients and employees in a pediatric clinic. We studied containment costs to identify avoidable costs.Measles exposure was defined as in-person contact with or presence in the same room2 hours after the measles patient. Costs were calculated retrospectively using published costs of measles-mumps-rubella vaccine, cost-to-charge ratios for inpatient care in urban Washington State and local emergency department charges for post-exposure immunoglobulin (IG). Personnel costs were calculated by multiplying hourly wages by time for employees who worked on the response; overhead was excluded.Fifty-two patients, 60 caretakers and 10 employees were exposed. Personnel time cost $1961. Exposed patients had a mean age of 9.6 years (range: 2 months-19 years); 34 (65%) were fully vaccinated, and 18 (35%) were12 months of age and too young to be vaccinated. Five patients (10%) were6 months of age and required IG; 13 infants (25%) 6-11 months of age required measles-mumps-rubella vaccination. Caretakers followed up with their physicians for evidence of immunity. One employee had documented evidence of immunity; 9 required measles antibody testing or vaccination. Management of exposed persons cost $3694; overall clinic costs were $5655.Responding to 1 measles case cost the pediatric clinic more than $5000, despite isolating the patient promptly after examination. Documentation of employee immunity, vaccination of eligible patients and strict infection control precautions might reduce ambulatory costs associated with measles containment.

Background In September 2003, 17 symptomatic cases of pertussis among health care workers (HCWs) resulted from a 1-day exposure to an infant who was later confirmed to have pertussis. These HCWs identified 307 close contacts. The hospital implemented extensive infection-control measures. The objective of this study was to determine direct and indirect costs incurred by the hospital and symptomatic HCWs as a result of the September 2003 outbreak and to estimate possible benefits of vaccinating HCWs from the hospital perspective. Methods We determined costs by interviewing infection-control and hospital personnel, reviewing billing records, and surveying symptomatic HCWs. We calculated the benefits and costs of a vaccination program for HCWs, using a probabilistic model to estimate the number of pertussis exposures that would require control measures annually. Sensitivity and threshold analyses were performed. Results The outbreak cost to the hospital was 74,870 dollars. The total measured cost of the outbreak was 81,382 dollars, including costs incurred by HCWs (6512 dollars). Our model predicted that vaccinating HCWs against pertussis would prevent >46% of exposures from HCWs with pertussis per year and would provide net savings. The benefit for the hospital was estimated to be 2.38 times the dollar amount invested in vaccinating HCWs. The number of exposures prevented and the benefit-cost ratio were sensitive to the number of exposures identified, the incidence of pertussis among HCWs, and HCW turnover. Conclusions A single nosocomial pertussis outbreak resulted in substantial disruption and costs to the hospital and to HCWs. Our model suggests that cost savings and benefits could be accrued by vaccinating HCWs against pertussis.

Studies assessing the economic burden of a mumps outbreak in a highly vaccinated population are limited. The Orange County Health Department (OCHD), New York State Department of Health (NYS DOH), and the Centers for Disease Control and Prevention conducted a mumps investigation in an affected village with a highly vaccinated population. To understand the epidemiology, standardized mumps case definition and active surveillance were used to identify mumps cases. In addition, an economic assessment of a combined outbreak investigation and third dose measles-mumps-rubella (MMR) vaccine intervention conducted by OCHD and NYS DOH was performed; estimated by retrospectively evaluating public health response-related activities including use of a third dose of MMR vaccine. From September 24, 2009, through June 15, 2010, 790 mumps cases were reported-64% were male and highest attack rate was among 11-17 year age group (99.1 cases per 1000 individuals). Of the 658 cases with known vaccination history, 83.6% had documentation of 2 doses of mumps containing vaccine. No deaths were reported. The 2 major exposure settings were schools (71.8%) and households (22.5%). Approximately 7736 h of public health personnel time were expended with the total approximate cost of US $463,000, including US $34,392 for MMR vaccine-the estimated cost per household was US $827. Mumps continues to be endemic in many parts of the world, resulting in importations into the United States. Large mumps outbreaks similar to this in highly vaccinated populations may require considerable investigation and control activities.

Understanding the potential for vaccination to change cytomegalovirus (CMV) epidemiology is important for developing CMV vaccines and designing clinical trials.We constructed a deterministic, age-specific and time-dependent mathematical model of pathogen transmission, parameterized using CMV seroprevalence from the United States and Brazil, to predict the impact of vaccination on congenital CMV infection.Concurrent vaccination of young children and adolescents would result in the greatest reductions in congenital CMV infections in populations with moderate and high baseline maternal seroprevalence. Such a vaccination strategy, assuming 70% vaccine efficacy, 90% coverage and 5-year duration of protection, could ultimately prevent 30-50% of congenital CMV infections. At equilibrium, this strategy could result in a 30% reduction in congenital CMV infections due to primary maternal infection in the United States but a 3% increase in Brazil. The potential for an increase in congenital CMV infections due to primary maternal infections in Brazil was not predicted with use of a vaccine that confers protection for greater than 5 years.Modeling suggests that vaccination strategies that include young children will result in greater declines in congenital CMV infection than those restricted to adolescents or women of reproductive age. Our study highlights the critical need for better understanding of the relative contribution of type of maternal infection to congenital CMV infection and disease, the main focus of vaccine prevention.

The recent impact of influenza on the working-age population of the US has led to changes in the recommendations for vaccination against seasonal influenza; however, the implications of vaccinating such a population have been debated. A review of cost-effectiveness analyses of vaccinating the working-age population of the US against seasonal influenza was conducted using articles published between January 1990 and January 2010. Studies considered for inclusion were identified using MEDLINE, EMBASE and Econlit. Reviewers worked in pairs, and each team member independently extracted relevant data using a standard abstraction form. The source and appropriateness of parameters (epidemiological data, probabilities and costs), the designs employed and the sufficiency of sensitivity analysis were considered during review. Key inputs extracted from the selected studies included influenza or influenza-like illness attack rates, outpatient visits averted, total vaccination days and lost workdays. Seven studies were identified as appropriate for this review. All studies were conducted in the US and from the societal perspective; three were randomized controlled trials and the remaining four were economic simulation models comparing vaccination and influenza antiviral drugs or no intervention; analyses focused on healthy working-age adults aged 18–49 years. Results ranged from net savings of $US68.96 to net costs of $US85.92 per person vaccinated (four studies) and net costs of $US 104-1005 per episode of influenza averted (one study). Only two studies reported cost-effectiveness ratios; these ranged from $US26 565 to $US50 512 per quality-adjusted life-year gained. Nearly all of the studies conducted sensitivity analysis; results were most sensitive to variation in wage rates, levels of worker productivity, the costs and effectiveness of vaccination, and the rate of influenza illness. Review of the included studies suggests that seasonal influenza vaccination of healthy, working-age adults is generally not cost saving, requiring an investment to generate health benefits. The decision to vaccinate such a group will depend upon the societal and payer valuation of those benefits.

(See the editorial commentary by Ostroff, on pages 1507–9.)Background. On 12 February 2008, an infected Swiss traveler visited hospital A in Tucson, Arizona, and initiated a predominantly health care–associated measles outbreak involving 14 cases. We investigated risk factors that might have contributed to health care–associated transmission and assessed outbreak-associated hospital costs.Methods. Epidemiologic data were obtained by case interviews and review of medical records. Health care personnel (HCP) immunization records were reviewed to identify non–measles-immune HCP. Outbreak-associated costs were estimated from 2 hospitals.Results. Of 14 patients with confirmed cases, 7 (50%) were aged ≥18 years, 4 (29%) were hospitalized, 7 (50%) acquired measles in health care settings, and all (100%) were unvaccinated or had unknown vaccination status. Of the 11 patients (79%) who had accessed health care services while infectious, 1 (9%) was masked and isolated promptly after rash onset. HCP measles immunity data from 2 hospitals confirmed that 1776 (25%) of 7195 HCP lacked evidence of measles immunity. Among these HCPs, 139 (9%) of 1583 tested seronegative for measles immunoglobulin G, including 1 person who acquired measles. The 2 hospitals spent US$799,136 responding to and containing 7 cases in these facilities.Conclusions. Suspecting measles as a diagnosis, instituting immediate airborne isolation, and ensuring rapidly retrievable measles immunity records for HCPs are paramount in preventing health care–associated spread and in minimizing hospital outbreak–response costs.

This study determined direct medical costs for influenza-associated hospitalizations and emergency department (ED) visits. For 3 influenza seasons, children

The study evaluates the benefits of meningococcal conjugate vaccine (MCV4) vaccination against the burden of vaccine-associated Guillain-Barre Syndrome (GBS) using simulation. An 11-year-old cohort was followed over an 8-year period in a simulation model Table 3 Figs. 1 and 2 to estimate health outcomes to assist decision makers in setting policy. Applying a 3% discount rate, MCV4 vaccination would save 2397 quality-adjusted life years (QALYs) while vaccine-attributable GBS could result in 5 QALYs lost. Based on the result, MCV4 vaccination is strongly favored despite possible vaccine-associated GBS risk.

These recommendations represent the first statement by the Advisory Committee on Immunization Practices (ACIP) on the use of a live attenuated vaccine for the prevention of herpes zoster (zoster) (i.e., shingles) and its sequelae, which was licensed by the U.S. Food and Drug Administration (FDA) on May 25, 2006. This report summarizes the epidemiology of zoster and its sequelae, describes the zoster vaccine, and provides recommendations for its use among adults agedor =60 years in the United States. Zoster is a localized, generally painful cutaneous eruption that occurs most frequently among older adults and immunocompromised persons. It is caused by reactivation of latent varicella zoster virus (VZV) decades after initial VZV infection is established. Approximately one in three persons will develop zoster during their lifetime, resulting in an estimated 1 million episodes in the United States annually. A common complication of zoster is postherpetic neuralgia (PHN), a chronic, often debilitating pain condition that can last months or even years. The risk for PHN in patients with zoster is 10%-18%. Another complication of zoster is eye involvement, which occurs in 10%-25% of zoster episodes and can result in prolonged or permanent pain, facial scarring, and loss of vision. Approximately 3% of patients with zoster are hospitalized; many of these episodes involved persons with one or more immunocompromising conditions. Deaths attributable to zoster are uncommon among persons who are not immunocompromised. Prompt treatment with the oral antiviral agents acyclovir, valacyclovir, and famciclovir decreases the severity and duration of acute pain from zoster. Additional pain control can be achieved in certain patients by supplementing antiviral agents with corticosteroids and with analgesics. Established PHN can be managed in certain patients with analgesics, tricyclic antidepressants, and other agents. Licensed zoster vaccine is a lyophilized preparation of a live, attenuated strain of VZV, the same strain used in the varicella vaccines. However, its minimum potency is at least 14-times the potency of single-antigen varicella vaccine. In a large clinical trial, zoster vaccine was partially efficacious at preventing zoster. It also was partially efficacious at reducing the severity and duration of pain and at preventing PHN among those developing zoster. Zoster vaccine is recommended for all persons agedor =60 years who have no contraindications, including persons who report a previous episode of zoster or who have chronic medical conditions. The vaccine should be offered at the patient's first clinical encounter with his or her health-care provider. It is administered as a single 0.65 mL dose subcutaneously in the deltoid region of the arm. A booster dose is not licensed for the vaccine. Zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing PHN, or to treat ongoing PHN. Before administration of zoster vaccine, patients do not need to be asked about their history of varicella (chickenpox) or to have serologic testing conducted to determine varicella immunity.

In June 2005, the Advisory Committee on Immunization Practices (ACIP) recommended administering a second dose of varicella vaccine during outbreaks, supplementing the routine 1-dose requirement. From October 2005 to January 2006, a varicella outbreak occurred in Maine in a highly vaccinated elementary school population. We investigated the outbreak, held a school-based vaccination clinic, and assessed costs in implementing ACIP's outbreak-response recommendation. Parents completed questionnaires and case investigation interviews. Personnel at the Maine Center for Disease Control and Prevention, the school in which the outbreak occurred ("school A"), and physician offices completed economic surveys. Forty-eight cases occurred, with no hospitalizations or deaths. Vaccine effectiveness was 86.6% (95% confidence interval, 82.0%-90.1%). Of 240 eligible students, 132 (55.0%) received second-dose vaccination. Implementing ACIP's outbreak-response recommendation was challenging and cost approximately $26,875. Additionally, the routine 1-dose varicella vaccination policy did not confer adequate population immunity to prevent this outbreak. These findings support ACIP's June 2007 recommendation for a routine 2-dose varicella vaccination program.

Two national surveys were conducted to evaluate the status of varicella case-based surveillance and outbreak response. Although progress toward national surveillance has been significant, a large number of jurisdictions are still without case-based surveillance. For jurisdictions beginning case-based surveillance with limited resources, a staged approach is recommended. The national outbreak survey showed that a significant number of varicella outbreaks continue to occur. The majority of jurisdictions respond to these outbreaks, although the response varies considerably. Depending on the outbreak-response approach, costs per outbreak ranged from $3000 for a typical, or passive, response to $6000 for a more active response. As varicella surveillance and outbreak control improves, jurisdictions may benefit from more-standardized outbreak-control practices. The recent recommendation by the Advisory Committee on Immunization Practices for a routine second dose of varicella vaccine should lead to better varicella disease control, making case-based surveillance and appropriate outbreak response even more feasible.

BACKGROUND. Economic assessments that guide policy making on immunizations are becoming increasingly important in light of new and anticipated vaccines for adolescents. However, important considerations that limit the utility of these assessments, such as the diversity of approaches used, are often overlooked and should be better understood. OBJECTIVE. Our goal was to examine economic studies of adolescent vaccines and compare cost-effectiveness outcomes among studies on a particular vaccine, across adolescent vaccines, and between new adolescent vaccines versus vaccines that are recommended for young children. METHODS. A systematic review of economic studies on immunizations for adolescents was conducted. Studies were identified by searching the Medline, Embase, and EconLit databases. Each study was reviewed for appropriateness of model design, baseline setup, sensitivity analyses, and input variables (ie, epidemiologic, clinical, cost, and quality-of-life impact). For comparison, the cost-effectiveness outcomes reported in key studies on vaccines for younger children were selected. RESULTS. Vaccines for healthy adolescents were consistently found to be more costly than the health care or societal cost savings they produced and, in general, were less cost-effective than vaccines for younger children. Among the new vaccines, pertussis and human papillomavirus vaccines were more cost-effective than meningococcal vaccines. Including herd-immunity benefits in studies significantly improved the cost-effectiveness estimates for new vaccines. Differences in measurements or assumptions limited further comparisons. CONCLUSION. Although using the new adolescent vaccines is unlikely to be cost-saving, vaccination programs will result in sizable health benefits.

Background Measles was declared eliminated from the United States in 2000 but remains endemic worldwide. In 2005, a 17-year-old unvaccinated girl who was incubating measles returned from Romania, creating the largest documented outbreak of measles in the United States since 1996. Methods We conducted a case-series investigation, molecular typing of viral isolates, surveys of rates of vaccination coverage, interviews regarding attitudes toward vaccination, and cost surveys. Results Approximately 500 persons attended a gathering with the index patient one day after her return home. Approximately 50 lacked evidence of measles immunity, of whom 16 (32 percent) acquired measles at the gathering. During the six weeks after the gathering, a total of 34 cases of measles were confirmed. Of the patients with confirmed measles, 94 percent were unvaccinated, 88 percent were less than 20 years of age, and 9 percent were hospitalized. Of the 28 patients who were 5 to 19 years of age, 71 percent were home-schooled. Vaccine failure occurred in two persons. The virus strain was genotype D4, which is endemic in Romania. Although containment measures began after 20 persons were already infectious, measles remained confined mostly to children whose parents had refused to have them vaccinated, primarily out of concern for adverse events from the vaccine. Seventy-one percent of patients were from four households. Levels of measles-vaccination coverage in Indiana were 92 percent for preschoolers and 98 percent for sixth graders. Estimated costs of containing the disease were at least 167,685 dollars, including 113,647 dollars at a hospital with an infected employee. Conclusions This outbreak was caused by the importation of measles into a population of children whose parents had refused to have them vaccinated because of safety concerns about the vaccine. High vaccination levels in the surrounding community and low rates of vaccine failure averted an epidemic. Maintenance of high rates of vaccination coverage, including improved strategies of communication with persons who refuse vaccination, is necessary to prevent future outbreaks and sustain the elimination of measles in the United States.

Objective.Pertussis outbreaks in healthcare settings result in resource-intensive control activities, but studies have rarely evaluated the associated costs. We describe and estimate costs associated with 2 nosocomial pertussis outbreaks in King County, Washington, during the period from July 25 to September 15, 2004. One outbreak occurred at a 500-bed tertiary care hospital (hospital A), and the other occurred at a 250-bed pediatric hospital (hospital B).Methods.We estimated the costs of each outbreak from the hospitals' perspective through standardized interviews with hospital staff and review of contact tracing logs. Direct costs included personnel time and laboratory and medication costs, whereas indirect costs were those resulting from hospital staff furloughs.Results.Hospital A incurred direct costs of $195,342 and indirect costs of $68,015; hospital B incurred direct costs of $71,130 and indirect costs of $50,000. Cost differences resulted primarily from higher personnel costs at hospital A ($134,536), compared with hospital B ($21,645). Total cost per pertussis case was $43,893 for hospital A (6 cases) and $30,282 for hospital B (4 cases). Total cost per person exposed to a pertussis patient were $357 for hospital A (738 exposures) and $164 for hospital B (737 exposures).Conclusions.Nosocomial pertussis outbreaks result in substantial costs to hospitals, even when the number of pertussis cases is low. The cost-effectiveness of strategies to prevent nosocomial pertussis outbreaks, including vaccination of healthcare workers, should be evaluated.

Background. In February 2004, students from a college in Iowa, with a high proportion of nonmedical exemptions to vaccination, traveled to India; one fourth of the students contracted measles while there. One exposed, susceptible student returned home during his infectious period, necessitating 2 months of containment efforts in Iowa. Objective. The objective of this study was to measure the direct costs of measles containment from a public health system perspective. Methods. We evaluated activities performed, personnel time/materials allocated, and direct costs incurred in 2004 US dollars by the Iowa public health infrastructure. The study period was defined as March 5, 2004 (when the Iowa Department of Public Health was first contacted about the case), through May 12, 2004 (when a final meeting was held on the containment effort). Results. A total of 2525 hours of personnel time were expended to review flight manifests, contact exposed passengers, set up vaccination clinics, trace >1000 potentially exposed contacts, and institute and enforce quarantine orders for vaccination refusers. Two thousand twenty-five phone calls were received from the public, and 2243 miles were driven by staff. The temporal distribution of personnel time was characterized by marked peaks at the report of potential secondary cases. The total estimated cost was $ 142452. Conclusions. The direct cost to the public health infrastructure of containing 1 case of measles was far greater than the estimated cost of uncomplicated individual illness (less than $100). Economic analyses of vaccine-preventable diseases may need to go beyond the costs of individual illness to account for the costs of protecting society.

Context. The US Food and Drug Administration approved a meningococcal conjugate A/C/Y/W-135 vaccine (MCV-4) for use in persons aged 11 to 55 years in January, 2005; licensure for use in younger age groups is expected in 2 to 4 years. Objective. To evaluate and compare the projected health and economic impact of MCV-4 vaccination of US adolescents, toddlers, and infants. Design. Cost-effectiveness analysis from a societal perspective based on data from Active Bacterial Core Surveillance (ABCs) and other published and unpublished sources. Sensitivity analyses in which key input measures were varied over plausible ranges were performed. Setting and Patients. A hypothetical 2003 US population cohort of children 11 years of age and a 2003 US birth cohort. Interventions. Hypothetical routine vaccination of adolescents (1 dose at 11 years of age), toddlers (1 dose at 1 year of age), and infants (3 doses at 2, 4, and 6 months of age). Each vaccination scenario was compared with a “no-vaccination” scenario. Main Outcome Measures. Meningococcal cases and deaths prevented, cost per case prevented, cost per life-year saved, and cost per quality-adjusted life-year saved. Results. Routine MCV-4 vaccination of US adolescents (11 years of age) would prevent 270 meningococcal cases and 36 deaths in the vaccinated cohort over 22 years, a decrease of 46% in the expected burden of disease. Before program costs are counted, adolescent vaccination would reduce direct disease costs by $18 million and decrease productivity losses by $50 million. At a cost per vaccination (average public-private price per dose plus administration fees) of $82.50, adolescent vaccination would cost society $633000 per meningococcal case prevented and $121000 per life-year saved. Key variables influencing results were disease incidence, case-fatality ratio, and cost per vaccination. The cost-effectiveness of toddler vaccination is essentially equivalent to adolescent vaccination, whereas infant vaccination would be much less cost-effective. Conclusions. Routine MCV-4 vaccination of US children would reduce the burden of disease in vaccinated cohorts but at a relatively high net societal cost. The projected cost-effectiveness of adolescent vaccination approaches that of recently adopted childhood vaccines under conditions of above-average meningococcal disease incidence or at a lower cost per vaccination.

Background One of the United States' national health objectives for 2010 is that 95% of children aged