Economic aspects of vaccination.
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Bacterial Vaccines↗
Biomedical subjects
V Demicheli
Publications and source records attributed to V Demicheli.
Economic aspects of a small epidemic of hepatitis A in a religious community in Northern Italy.
We report on a small (11 cases) outbreak of hepatitis A (HA) which occurred in the village of Narzole in the province of Cuneo, Northern Italy. Cases were reported during the period December 1993-March 1994 and centred around a Christian community centre caring for broken homes. Eight cases were children aged 7-13 and three were adults. The incidence for all ages was 354.8 per 100,000 inhabitants. Due to local resistance to the investigation of the outbreak we were unable to identify the source of the outbreak. Marginal and average costs were identified during the outbreak using a proforma and include costs of the investigation. The mean costs per case were $7899 (average) and $1793 (marginal). The main cost generators were costs of care if average costs only are considered (81% of total costs) or loss of productivity if only marginal costs are calculated (60% of total marginal costs). Small epidemics such as the one described appear to use a considerable amount of health care and personal resources. However, when marginal and opportunity considerations are applied (value of opportunities foregone for alternative use of resources), such costs decrease. This is especially valid for all treatment costs, as the majority of hospital running costs are fixed. The small number of cases and the high hospitalization rate (100%) make the epidemic of uncertain extrapolation.
Adolescent↗
Pilot study of the introduction of the J95 health data collection system.
J95 is a health data collection system aimed at gathering information on the weight of health problems facing the Army in order to allow rational and effective prioritization. Before implementing the system Army-wide, a pilot study has been undertaken to validate the J95 ICD 9-based classification system, to test the practical problems encountered with operating the system and its practical value to decision-makers. Both internal and external coding validity were tested in terms of agreement with a "gold standard' and in terms of repeatability and they scored highly. A number of problems were identified analysing discordances and using the comments raised by the participants. A final shortened version of the classification was developed accordingly. The report also contains a number of examples of the potential of the system which is due to be implemented by 1 January 1996.
Humans↗
Economic evaluation of influenza vaccination and economic modelling. Can results be pooled?
Scientific reviewing methods were applied to economic studies of influenza vaccination, and an economic model of influenza vaccination was developed from these primary sources. Issues arising from the secondary literature review include the quality of evidence on the effectiveness of the vaccines, the absence of a traditional population-based approach to reviewing economic data, confusion in terminology, and how to generalise from resource data contained in primary evaluations. Data from the literature review were summarised in terms of resource units used in the prevention and treatment of influenza. An economic model was constructed using local unit costs (from the Emilia region of Italy) and applying the data to a notional population. The model was sensitive to length of stay in hospital but not to variation in incidence of influenza, days off work or number of medical consultations. The model was predicated on and is sensitive to an estimate of 80% vaccine effectiveness. The approach is constrained by the available data, but could be more generally useful in that it allows variations in the quantity of inputs to be considered separately from variations in their values. The model may be used locally as a decision-making tool, although the method needs further development.
Humans↗
Assessing quality of economic submissions to the BMJ.
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Health Care Costs↗
A panel priority rating exercise for the British Forces Germany Health Services Market test.
We report on the application to the BFG Health Services Market Testing (MT) study of the response to a users' questionnaire and panel discussions to determine in which priority and how services should be provided. The questionnaire served to inform lay and health care panel members on users' views on the relative importance of future health services and the way they will be provided. Based on the questionnaire results and data contained in the BAOR Report of Public Health for 1992/93 the panel assigned the highest priorities to emergency services, followed by routine General Practitioner services and essential hospital services. The lowest ranking were non-essential hospital services, health care for children with special needs and provision of designated transport. There was a high consistency in views between the lay and health care members of the panel.
Adult↗
Should British soldiers be vaccinated against hepatitis A? An economic analysis.
We conducted a study to analyse the efficiency of introducing vaccination against hepatitis A to the schedule for troops in the British Army. The study design included a cost-effectiveness analysis (CEA) of cost per case avoided comparing active and passive immunization and a cost-benefit analysis (CBA). The study population comprised all British Army personnel as well as those soldiers assumed to be deployed to high-risk areas a variable number of times in 5 years. The average cost of one case of hepatitis A avoided by vaccination was calculated and compared with the average cost of achieving the same outcome by passive immunization. In a 5-year four-exposure scenario at a low incidence and using a 3% discount rate, avoiding one case of hepatitis A by vaccination would cost 52,865 pounds, against 97,305 pounds by passive immunization. The equivalent cost-benefit ratios are 13.4 for gammaglobulin and 7.2 for vaccine. For fewer exposures the break-even point for vaccine is two exposures in 4 years. Although our estimates are sensitive to direct costs and relatively sensitive to the estimated incidence, vaccinating troops against hepatitis A appears to be a more efficient procedure than passive immunization, especially as a long-term investment in troops likely to effect several operational deployments. Given the difficulty of forecasting which troops would deploy, the best-buy strategy may be vaccination of troops most likely to deploy repeatedly.
Cost-Benefit Analysis↗
An economic evaluation of the introduction of vaccination against hepatitis A in a peacekeeping operation. The case of the United Nations Protection Force in Yugoslavia.
The costs and benefits of vaccinating troops on United Nations tours in Yugoslavia against hepatitis A were compared. The marginal cost of one case of hepatitis A avoided by vaccination was calculated and compared with the marginal cost of achieving the same outcome by passive immunization. The cost-benefit ratio (medium estimate) for troops at low risk of contracting hepatitis A was 0.01 and for those at high risk was 0.03. Vaccinating troops against hepatitis A for a single deployment appears to be an inefficient procedure, especially in troops at low risk. However, in professional troops from countries of low hepatitis A endemicity who are likely to be involved in several operational deployments, vaccination becomes more efficient the more times the same troops are deployed.
Cost-Benefit Analysis↗
Economic burden of communicable disease outbreak in a military unit.
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Communicable Diseases↗
Cost-benefit analysis of the introduction of mass vaccination against hepatitis B in Italy.
The aim of the study was to evaluate the costs and benefits of introducing mass vaccination against hepatitis B in Italy, given the announcement of compulsory vaccination of all newborn babies from 1991. Benefits were calculated by summarizing the clinical course of hepatitis B in Italy and projecting its incidence rates to the next 30 years using Brown's exponential smoothing technique. Incidence rates were then applied to the survivors of a cohort of newborns in 1992, and the total number of cases avoidable through vaccination was derived. Direct and indirect marginal costs were estimated for these cases. The marginal costs of the vaccination campaign were estimated. Cost and benefits were compared for 99 years following the introduction of the vaccination, using an 8 per cent discount rate and a sensitivity analysis. Despite difficulties in data gathering, susceptibility to discounting and estimating costs, results show an unfavourable cost-benefit ratio which is influenced by a declining incidence of the disease. Vaccination of high-risk groups is probably more efficient.
Cost-Benefit Analysis↗
[Screening and vaccination against hepatitis B among health personnel. Short-term results].
In the framework of the campaign for anti-HBV vaccination conducted by the Regione Piemonte, the Mauriziano Hospital in Valenza and the Unità Sanitaria Locale 71, screened and then vaccinated a group of 199 medical workers at risk of HBV. It was found that the infection was asymptomatic in the vaccinated subjects (16%) and the chronic HBsAg carriers (1.5%), that the risk of infection increases with age (p less than 0.01) and length of service (p less than 0.05) and that there is a connection with the mean figures produced by other studies conducted on hospital staff. Vaccination gave satisfactory results, with protective antibody responses in 87% of the cases, of whom about half presented levels over 1000 mIU/ml and no significant side effects.
Adult↗
An exercise on the feasibility of carrying out secondary economic analyses.
Purchasers of health services need up to date information on cost-effectiveness of interventions to help in prioritising spending. But economists have not yet developed a formal methodology for reviewing and summing up evidence from individual economic evaluations which may have been conducted at different times and in different places, or indeed for assessing whether such systematic reviews are possible in this context. This paper discusses the problems of reviewing available economic information, using a body of literature on the economics of influenza vaccination to illustrate some relevant issues. First, the paper examines alternative methods for adjusting prices to take into account differences in currency and time periods: Retail Price Indices are compared with health specific inflation indices, and exchange rates are compared with Purchasing Power Parity (PPP) data. For the studies reviewed, the choice of conversion method made little practical difference. Secondly, the paper explores the possibility of summarising the results of a review in terms of quantities of resources used, rather than prices. This method is constrained by the available data, but could be more generally useful as it allows direct comparison of underlying technologies, and calculation of costs by attaching local unit costs to the resources associated with an intervention. These two exercises highlight many of the problems that arise in generalising from economic studies. Both methods need to be developed further if they are to be useful to decision makers.
Cost-Benefit Analysis↗
Is vaccination against hepatitis B efficient? A review of world literature.
We report on the result of a study aimed at assessing the variability of assumptions upon which economic models for the introduction of vaccination against Hepatitis B are based, the conclusions reached and define a minimum set of methodological standards upon which future economic studies on vaccines should be based. We identified 116 published and unpublished works by Medline literature searches, consulting private databases and corresponding with all authors and researchers active in economic evaluation of vaccines. All works were assessed but we included in our review only those which were original economic analyses (90 studies). Principal epidemiological and economic variables were extracted and compared where possible. Rough manipulations were carried out to make the data comparable. We found profound variability on the main parameters of the efficiency equation (disease incidence, costing methods, use of marginal theory, discounting and study time-span, sensitivity analysis and reporting methods). We also found inconsistencies in definition and study design in 38% of a subset of studies. Although we found scarce decision-making impact, we believe that due to uncertain or unclear methodology, few studies reach valid conclusions. In future decisions may be based on biased evidence and scarce resources committed to untested programmes. There is an urgent need to standardise study methods and define a common set of procedures.
Cost-Benefit Analysis↗
QALY league tables.
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Cost-Benefit Analysis↗
Are guidelines for peer-reviewing economic evaluations necessary? A survey of current editorial practice.
We report the results of a postal survey of 150 editors of medical journals aimed at assessing editorial policy on peer-review of economic studies. 70 editors (47%) responded to the anonymous questionnaire which contained six questions. 16 (23% or respondents) claimed to have an editorial policy, most claiming acceptance of 'good evaluations'. Few (36%) had trained economists as referees and none had criteria or guidelines for peer-reviewing economic studies. This situation helps to explain the variable quality of international economic literature. There is an urgent need to produce internationally accepted sets of guidelines for authors, editors and peer-reviewers.
Costs and Cost Analysis↗
Assessment of the efficacy and effectiveness of influenza vaccines in healthy children: systematic review.
BACKGROUND: We aimed to assess evidence of efficacy and effectiveness of live attenuated and inactivated influenza vaccines in children up to 16 years of age. METHODS: We searched the Cochrane Library, MEDLINE, EMBASE Biological Abstracts, and Science Citation Index to June, 2004, in any language, and contacted vaccine manufacturers and authors of relevant studies to identify additional data. We included randomised, cohort, and case-control studies comparing efficacy of vaccines against influenza (reduction in laboratory-confirmed cases), effectiveness of vaccines against influenza-like illness (reduction in symptomatic cases), or both, with placebo or no intervention. We analysed the following outcomes: influenza, influenza-like illness, admissions, school absences, complications, and secondary transmission. FINDINGS: We included 14 randomised controlled trials, eight cohort studies, one case-control study, and one randomised controlled trial of intraepidemic use of the vaccines. Live attenuated influenza vaccines had 79% efficacy and 38% effectiveness in children older than 2 years compared with placebo or no immunisation. Inactivated vaccines had lower efficacy (65%) than live attenuated vaccines, and in children aged 2 years or younger they had similar effects to placebo. Effectiveness of inactivated vaccines was about 28% in children older than 2 years. Vaccines were effective in reducing long school absences (relative risk 0.14 [95% CI 0.07-0.27]). Studies assessing the effects of vaccines against secondary cases, lower-respiratory tract disease, acute otitis media, and hospital stay suggested no difference with placebo or standard care, but lacked statistical power. INTERPRETATION: Influenza vaccines (especially two-dose live attenuated vaccines) are efficacious in children older than 2 years. Efficacy and effectiveness of the vaccines differed strikingly. Only two small studies assessed the effects of influenza vaccines on hospital admissions and no studies assessed reductions in mortality, serious complications, and community transmission of influenza. If influenza immunisation in children is to be recommended as public-health policy, large-scale studies assessing such important outcomes and undertaking direct comparisons of vaccines are urgently needed.
Adolescent↗
Safety of influenza vaccines in children.
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Child, Preschool↗
The effectiveness and safety of vaccines against human anthrax: a systematic review.
We report on the results of a systematic review of existing controlled clinical trials undertaken to assess the effectiveness and safety of vaccines against human anthrax in relation to disease incidence and side-effects. Two articles retrieved by electronic and hand search fulfilling some of the inclusion criteria underwent a quality assessment by a group of reviewers. Data synthesized from the two trials showed that estimates of overall effectiveness and safety favour treatment (overall odds ratio 0.16; 95% confidence interval 0.07-0.34). The route of inoculation appears to make little difference to the effectiveness of the vaccines; however, one study shows that the incidence and severity of side-effects are significantly higher with the killed vaccine than with the alum-based placebo (overall odds ratio 0.16; 95% confidence interval 2.38-27.17).
Animals↗