Benefit-cost analysis of rubella vaccination policy

Impact of Routine Childhood Immunization in Reducing Vaccine-Preventable Diseases in the United States

BACKGROUND AND OBJECTIVES

Current routine immunizations for children aged ≤10 years in the United States in 2019 cover 14 vaccine-preventable diseases. We characterize the public-health impact of vaccination by providing updated estimates of disease incidence with and without universally recommended pediatric vaccines.

METHODS

Prevaccine disease incidence was obtained from published data or calculated using annual case estimates from the prevaccine period and United States population estimates during the same period. Vaccine-era incidence was calculated as the average incidence over the most recent 5 years of available surveillance data or obtained from published estimates (if surveillance data were not available). We adjusted for underreporting and calculated the percent reduction in overall and age-specific incidence for each disease. We multiplied prevaccine and vaccine-era incidence rates by 2019 United States population estimates to calculate annual number of cases averted by vaccination.

RESULTS

Routine immunization reduced the incidence of all targeted diseases, leading to reductions in incidence ranging from 17% (influenza) to 100% (diphtheria, Haemophilus influenzae type b, measles, mumps, polio, and rubella). For the 2019 United States population of 328 million people, these reductions equate to >24 million cases of vaccine-preventable disease averted. Vaccine-era disease incidence estimates remained highest for influenza (13 412 per 100 000) and Streptococcus pneumoniae-related acute otitis media (2756 per 100 000).

CONCLUSIONS

Routine childhood immunization in the United States continues to yield considerable sustained reductions in incidence across all targeted diseases. Efforts to maintain and improve vaccination coverage are necessary to continue experiencing low incidence levels of vaccine-preventable diseases.

A study of adult rubella outbreak and its implications on increasing number of women in uniform

Background

Rubella, although a fairly innocuous disease, is a known cause of severe birth defects in newborn. With number of women in uniform on the rise and they being assigned instructional and medical care duties, adult rubella outbreak in a training centre as in this study poses grave threat to them; besides, having disruption potential for their training.

Methods

This study was conducted at an Airmen Training Centre of the Indian Air Force having more than 2500 recruits, in five squadrons. All cases of fever with rash and/or lymphadenopathy were included in the study. The demographic, epidemiological and clinical data of all the cases were analyzed and medical records reviewed.

Results

A total of 31 male recruits reported over 5 days. Among those, 21 cases were from a single squadron to which the index belonged. Twelve women officers were doing instructional duties at the time of outbreak though none became infected. Fever with a rash (90.32%) was the commonest presentation, and lymphadenopathy (64.51%) was the most common sign. Attack rate (AR) with-in the squadron most affected was 4.18%, with an overall AR of 1.23%. The case fatality rate of the disease was nil.

Conclusion

Till the fully immunized cohort of young recruits start getting enrolled, it will be prudent to introduce rubella vaccine to limit the loss of vital training man-hours and prevent the possibility of congenital rubella syndrome in the women instructors and medical caregivers, working in the line of their duty.

Cost-benefit analysis of vaccination: a comparative analysis of eight approaches for valuing changes to mortality and morbidity risks

BACKGROUND

There is increasing interest in estimating the broader benefits of public health interventions beyond those captured in traditional cost-utility analyses. Cost-benefit analysis (CBA) in principle offers a way to capture such benefits, but a wide variety of methods have been used to monetise benefits in CBAs.

METHODS

To understand the implications of different CBA approaches for capturing and monetising benefits and their potential impact on public health decision-making, we conducted a CBA of human papillomavirus (HPV) vaccination in the United Kingdom using eight methods for monetising health and economic benefits, valuing productivity loss using either (1) the human capital or (2) the friction cost method, including the value of unpaid work in (3) human capital or (4) friction cost approaches, (5) adjusting for hard-to-fill vacancies in the labour market, (6) using the value of a statistical life, (7) monetising quality-adjusted life years and (8) including both productivity losses and monetised quality-adjusted life years. A previously described transmission dynamic model was used to project the impact of vaccination on cervical cancer outcomes. Probabilistic sensitivity analysis was conducted to capture uncertainty in epidemiologic and economic parameters.

RESULTS

Total benefits of vaccination varied by more than 20-fold (£0.6-12.4 billion) across the approaches. The threshold vaccine cost (maximum vaccine cost at which HPV vaccination has a benefit-to-cost ratio above one) ranged from £69 (95% CI £56-£84) to £1417 (£1291-£1541).

CONCLUSIONS

Applying different approaches to monetise benefits in CBA can lead to widely varying outcomes on public health interventions such as vaccination. Use of CBA to inform priority setting in public health will require greater convergence around appropriate methodology to achieve consistency and comparability across different studies.

Systematic Review of Health Economic Analyses of Measles and Rubella Immunization Interventions

Economic analyses for vaccine-preventable diseases provide important insights about the value of prevention. We reviewed the literature to identify all of the peer-reviewed, published economic analyses of interventions related to measles and rubella immunization options to assess the different types of analyses performed and characterize key insights. We searched PubMed, the Science Citation Index, and references from relevant articles for studies in English and found 67 analyses that reported primary data and quantitative estimates of benefit-cost or cost-effectiveness analyses for measles and/or rubella immunization interventions. We removed studies that we characterized as cost-minimization analyses from this sample because they generally provide insights that focused on more optimal strategies to achieve the same health outcome. The 67 analyses we included demonstrate the large economic benefits associated with preventing measles and rubella infections using vaccines and the benefit of combining measles and rubella antigens into a formulation that saves the costs associated with injecting the vaccines separately. Despite the importance of population immunity and dynamic viral transmission, most of the analyses used static models to estimate cases prevented and characterize benefits, although the use of dynamic models continues to increase. Many of the analyses focused on characterizing the most significant adverse outcomes (e.g., mortality for measles, congenital rubella syndrome for rubella) and/or only direct costs, and the most complete analyses present data from high-income countries.

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.

Population-based versus practice-based recall for childhood immunizations: a randomized controlled comparative effectiveness trial

OBJECTIVES

We compared the effectiveness and cost-effectiveness of population-based recall (Pop-recall) versus practice-based recall (PCP-recall) at increasing immunizations among preschool children.

METHODS

This cluster-randomized trial involved children aged 19 to 35 months needing immunizations in 8 rural and 6 urban Colorado counties. In Pop-recall counties, recall was conducted centrally using the Colorado Immunization Information System (CIIS). In PCP-recall counties, practices were invited to attend webinar training using CIIS and offered financial support for mailings. The percentage of up-to-date (UTD) and vaccine documentation were compared 6 months after recall. A mixed-effects model assessed the association between intervention and whether a child became UTD.

RESULTS

Ten of 195 practices (5%) implemented recall in PCP-recall counties. Among children needing immunizations, 18.7% became UTD in Pop-recall versus 12.8% in PCP-recall counties (P < .001); 31.8% had documented receipt of 1 or more vaccines in Pop-recall versus 22.6% in PCP-recall counties (P < .001). Relative risk estimates from multivariable modeling were 1.23 (95% confidence interval [CI] = 1.10, 1.37) for becoming UTD and 1.26 (95% CI = 1.15, 1.38) for receipt of any vaccine. Costs for Pop-recall versus PCP-recall were $215 versus $1981 per practice and $17 versus $62 per child brought UTD.

CONCLUSIONS

Population-based recall conducted centrally was more effective and cost-effective at increasing immunization rates in preschool children.

Health economics of rubella: a systematic review to assess the value of rubella vaccination

Background

Most cases of rubella and congenital rubella syndrome (CRS) occur in low- and middle-income countries. The World Health Organization (WHO) has recently recommended that countries accelerate the uptake of rubella vaccination and the GAVI Alliance is now supporting large scale measles-rubella vaccination campaigns. We performed a review of health economic evaluations of rubella and CRS to identify gaps in the evidence base and suggest possible areas of future research to support the planned global expansion of rubella vaccination and efforts towards potential rubella elimination and eradication.

Methods

We performed a systematic search of on-line databases and identified articles published between 1970 and 2012 on costs of rubella and CRS treatment and the costs, cost-effectiveness or cost-benefit of rubella vaccination. We reviewed the studies and categorized them by the income level of the countries in which they were performed, study design, and research question answered. We analyzed their methodology, data sources, and other details. We used these data to identify gaps in the evidence and to suggest possible future areas of scientific study.

Results

We identified 27 studies: 11 cost analyses, 11 cost-benefit analyses, 4 cost-effectiveness analyses, and 1 cost-utility analysis. Of these, 20 studies were conducted in high-income countries, 5 in upper-middle income countries and two in lower-middle income countries. We did not find any studies conducted in low-income countries. CRS was estimated to cost (in 2012 US$) between $4,200 and $57,000 per case annually in middle-income countries and up to $140,000 over a lifetime in high-income countries. Rubella vaccination programs, including the vaccination of health workers, children, and women had favorable cost-effectiveness, cost-utility, or cost-benefit ratios in high- and middle-income countries.

Conclusions

Treatment of CRS is costly and rubella vaccination programs are highly cost-effective. However, in order for research to support the global expansion of rubella vaccination and the drive towards rubella elimination and eradication, additional studies are required in low-income countries, to tackle methodological limitations, and to determine the most cost-effective programmatic strategies for increased rubella vaccine coverage.

Economic benefits of a routine second dose of combined measles, mumps and rubella vaccine in Canada

OBJECTIVE

To evaluate the potential economic benefits of a program for a second routine dose of combined measles, mumps and rubella (MMR) vaccine, administered to children in Canada.

DESIGN

Both published and unpublished data from the United States and Canada were incorporated into a linear model. This information was supplemented with opinions on probability and resource use from interviews with a Canadian panel of physicians and practitioners. The province of Quebec was used as a model for resource use and costs.

MATERIAL AND METHODS

Data were based on a vaccination program for Canadian children at 18 months, with an estimated annual birth cohort of 400,000. Further data were also collected for the lifetime costs of complications arising from these diseases or from vaccination, for both patients and family caregivers.

OUTCOME MEASURES

Outcomes were reviewed from the perspectives of a provincial ministry of health (direct medical costs) and of society (all direct and indirect medical and nonmedical costs).

RESULTS

It was estimated that a second dose of MMR vaccine administered at 18 months of age would prevent 9200 cases of measles, 6120 cases of mumps and 1960 cases of rubella, producing a savings of $6.34 for every dollar spent from the ministry of health perspective, and $3.25 from the societal perspective.

CONCLUSIONS

A routine second dose immunization with MMR vaccine would result in considerable cost savings in Canada.

[Economic evaluation in health: applications in infectious diseases]

The rise in healthcare expenditures due to the incorporation of new diagnostic and therapeutic technologies and increasing life expectancy is a major concern, particularly in developing countries. The role of economic evaluation in health is to optimize the benefits of available resources. This article aims to allow readers to identify the basic characteristics and types of economic evaluation in health and understand its methods, with an emphasis on infectious diseases. We thus review the following concepts: study perspective, analytic scope, costs, and discount rate. We also focus on characteristics of cost-minimization, cost-effectiveness, cost-utility, and cost-benefit analyses, with examples. The article describes the most popular study designs for economic evaluation, discusses different models, and examines the importance of sensitivity analysis. Our final comments address the importance of adopting economic evaluations in health in Brazil.

Will disease prevention spare the medical commons?

Everywhere the disparity grows between what modern medicine can achieve, on the one hand, and what society can afford, on the other. In industrialized nations health resource allocation questions now focus primarily on diagnostic, therapeutic and rehabilitative medical programmes. With increases both in our capabilities in preventive medicine and in public awareness of those capabilities, soon that realm is likely to be demanding more resources from the health budget. These considerations and others make urgent the development of better methods for setting priorities for the allocation of health resources. A common thread in the consideration of competing programmes will be issues of trade-offs. Beneficial programmes that save more health resources than they consume are much to be desired, but resource saving should not be regarded as a necessary condition for giving high priority to a programme. Cost-effectiveness ratios provide one approach to measuring the ability of competing programmes to use health-care resources to produce health benefits. Application of cost-effectiveness principles suggests that prevention programmes merit a greater share of resources, even though such programmes generally consume more health resources than they save. For the process of priority-setting to be equitable and rational, more and better data will be required on programmatic costs and benefits. Furthermore, the process should be flexible, allowing priorities to differ from one geographic area to another, and from time to time within the same area. Finally, the process must be understood by a majority of the population, and perceived as fair.

Benefits, risks and costs of immunization programmes

Prevention of disease by vaccination has been one of the major triumphs of medicine. Studies have been done on many vaccines to determine their benefits, risks, and costs. These studies have demonstrated that the benefits outweigh the risks and costs for many vaccines including polio, pertussis, measles, mumps and rubella. Thus, the use of these vaccines provides a net saving to society. Other vaccines such as those influenza and pneumococcal disease are cost-effective relative to other health expenditures. The value of benefit-risk, benefit-cost, and cost-effectiveness analyses lies not in providing the definitive basis for a decision on vaccine use or evaluation. Rather, these analytic techniques provide a structured framework which permits decision-makers to consider all relevant components of the decision in perspective to their relative contributions and subsequent effects. It forces key assumptions to be made explicit and identifies areas in which data are inadequate. The results of such analyses can assist in justifying a vaccination programme (poliomyelitis), in disseminating a programme more widely (measles), in changing health policy (smallpox), and in planning for how a vaccine might be used (hepatitis B). Cost analyses of vaccination may suggest the value of a vaccination programme, but the programme may not be widely adopted (influenza and pneumococcal vaccines). The reasons for this gap between study conclusions and application may be: disagreement with the estimates and assumptions used in the analysis; skepticism over the methodology itself; or subjective views of the vaccine or disease which remains resistant to analytical exercises.

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.

Neurologic disorders after measles-mumps-rubella vaccination

OBJECTIVE

The possibility of adverse neurologic events has fueled much concern about the safety of measles-mumps-rubella (MMR) vaccinations. The available evidence concerning several of the postulated complications is controversial. The aim of this study was to assess whether an association prevails between MMR vaccination and encephalitis, aseptic meningitis, and autism.

METHODS

A retrospective study based on linkage of individual MMR vaccination data with a hospital discharge register was conducted among 535 544 1- to 7-year-old children who were vaccinated between November 1982 and June 1986 in Finland. For encephalitis and aseptic meningitis, the numbers of events observed within a 3-month risk interval after vaccination were compared with the expected numbers estimated on the basis of occurrence of encephalitis and aseptic meningitis during the subsequent 3-month intervals. Changes in the overall number of hospitalizations for autism after vaccination throughout the study period were searched for. In addition, hospitalizations because of inflammatory bowel diseases were checked for the children with autism.

RESULTS

Of the 535 544 children who were vaccinated, 199 were hospitalized for encephalitis, 161 for aseptic meningitis, and 352 for autistic disorders. In 9 children with encephalitis and 10 with meningitis, the disease developed within 3 months of vaccination, revealing no increased occurrence within this designated risk period. We detected no clustering of hospitalizations for autism after vaccination. None of the autistic children made hospital visits for inflammatory bowel diseases.

CONCLUSIONS

We did not identify any association between MMR vaccination and encephalitis, aseptic meningitis, or autism.

Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up

BACKGROUND

Several disorders have been attributed to measles-mumps-rubella (MMR) vaccination during the past decade. The aim of this prospective follow-up study was to identify serious adverse events causally related to MMR vaccination.

METHODS

When the MMR vaccination program was launched in Finland in 1982, a countrywide surveillance system was set up to detect serious adverse events associated with MMR. To obtain detailed case histories vaccinees' clinical charts were reviewed. Serum samples were analyzed to trace concurrent infections.

SETTING

All hospitals and health centers in Finland from 1982 through 1996.

RESULTS

Immunization of 1.8 million individuals and consumption of almost 3 million vaccine doses by the end of 1996 gave rise to 173 potentially serious reactions claimed to have been caused by MMR vaccination. In all, 77 neurologic, 73 allergic and 22 miscellaneous reactions and 1 death were reported, febrile seizure being the most common event. However, 45% of these events proved to be probably caused or contributed by some other factor, giving an incidence of serious adverse events with possible or indeterminate causal relation with MMR vaccination of 5.3 per 100,000 vaccinees or 3.2 per 100,000 vaccine doses.

CONCLUSIONS

Causality between immunization and a subsequent untoward event cannot be estimated solely on the basis of a temporal relation. Comprehensive analysis of the reported adverse reactions established that serious events causally related to MMR vaccine are rare and greatly outweighed by the risks of natural MMR diseases.

Thrombolysis for acute stroke

Thrombolysis for acute stroke is effective if administered according to the approved protocol. Since the initial report of success in 1995, a number of subsequent reports confirmed the safety and efficacy of this treatment. There is no particular subgroup of patients at increased likelihood of benefit or hemorrhage that can be identified at baseline. Unlike many expensive therapies, thrombolysis for acute stroke saves the health care system considerable long-term costs. The search for even safer and more effective thrombolytics continues.

When do the "dollars" make sense? Toward a conceptual framework for contingent valuation studies in health care

There is growing interest in the application of cost-benefit analysis (CBA) as a technique for the economic evaluation of health care programs. A distinguishing feature of CBA is that costs and benefits are expressed in the same units of value--typically money. A popular method for estimating money values for health care programs is the use of willingness-to-pay (or accept) survey techniques known as contingent valuation. This paper presents a conceptual framework to help in the interpretation or design of contingent valuation studies in health care. To be consistent with the theory upon which CBA is built, the authors consider what types of questions should be asked of what populations. They conclude that studies undertaking contingent valuation should distinguish between compensating variation and equivalent variation, and recognize that respondents can be gainers or losers in utility and therefore should be asked willingness-to-pay (or accept) questions as appropriate. Current critical-appraisal guidance in the health care literature for CBA is poor and unlikely to offer useful demarcation between good and bad CBA studies. More work is needed exploring whether recently issued guidelines for contingent valuation in environment damage assessment are applicable to health care studies.

Childhood vaccination against chickenpox: an analysis of benefits and costs

OBJECTIVE

To estimate the economic costs and benefits of routine childhood vaccination against varicella infection.

DESIGN

Decision-analytic model of the incidence and costs of chickenpox in children assumed to receive varicella vaccine at age 15 months in conjunction with the measles-mumps-rubella vaccine, or not to be vaccinated against varicella.

PATIENTS

Hypothetical cohort of 100,000 children.

MAIN OUTCOME MEASURES

Costs of vaccination, cumulative incidence of chickenpox to age 25 years, and related disease costs, including medical treatment and work loss.

RESULTS

Vaccination of 100,000 children against varicella at age 15 months would cost $4,812,000. The expected number of cases of chickenpox to age 25 years would be reduced from 95,400 to 4800; costs of medical treatment and work loss would correspondingly decline by $1,678,000 and $9,781,000, respectively. On balance, vaccination is estimated to yield net economic benefits of $6,647,000, or $66.47 per vaccinee.

CONCLUSION

Vaccination against varicella infection is cost-effective and should be part of the routine immunization schedule for U.S. children.

Towards a new approach for estimating indirect costs of disease

Many researchers in the field of evaluation of health care doubt the usefulness of estimates of indirect costs of disease in setting priorities in health care. This paper attempts to meet part of the criticism on the concept of indirect costs, which are defined as the value of production lost to society due to disease. Thus far in cost of illness studies and cost-effectiveness analyses the potential indirect costs of disease were calculated. In the following a first step will be taken towards a new method for estimating indirect costs which are expected to be effectuated in reality: the friction cost method. This method explicitly takes into account short and long run processes in the economy which reduce the production losses substantially as compared with the potential losses. According to this method production losses will be confined to the period needed to replace a sick worker: the so called friction period. The length of this period and the resulting indirect costs depend on the situation on the labour market. Some preliminary results are presented for the indirect costs of the incidence of cardiovascular disease in the Netherlands for 1988, both for the friction costs and the potential costs. The proposed methodology for estimating indirect costs is promising, but needs further development. The consequences of illness in people without a paid job need to be incorporated in the analysis. Also the relation between internal labour reserves and costs of disease should be further investigated. Next to this, more refined labour market assumptions, allowing for diverging situations on different segments of the labour market are necessary.

Applications of cost-benefit analysis to health care. Departures from welfare economic theory

In applying the principles of cost-benefit analysis to real world problems of resource allocation particular care must be taken to ensure that the welfare economic theory which underlies the cost-benefit technique is adhered to. Major problems arise where costs and benefits are used interchangeably to represent the good and bad attributes of a programme. Furthermore, in the presence of mutually exclusive projects, focussing attention upon the net benefits (or cost-benefit ratios) of individual projects as opposed to the net benefits of the use of budgeted resources can lead to biased estimates of the shadow price of projects and, consequently, errors in analysts' conclusions. As a result, economic appraisals of individual projects are not directly relevant for choosing between mutually exclusive projects of different sizes. Both types of problem are illustrated by reference to both simple examples and published economic appraisals of health care techniques. Integer programming is proposed and demonstrated as a method of selecting between mutually exclusive projects.

Cost-benefit analysis: dealing with the problems of indivisible projects and fixed budgets

The use of cost-benefit analysis in option appraisals in health care when the decision-maker is faced with indivisible projects and a fixed budget is examined. It is argued that the methods used to overcome the problem of indivisibilities, benefit-cost ratios and the net benefit method, are not suitable for choosing between alternative projects for two reasons. Firstly, the values of benefit-cost ratios are sensitive to the specification of costs and benefits, and the literature abounds with examples of averted costs being added to the benefits of a project or reduced benefits being interpreted as an additional (psychic) cost. We show that such erroneous specification can lead to a relatively inefficient project being accepted as efficient, and vice versa. Secondly, practical applications of CBA have been performed in the absence of budget constraints on available resources. We show that once budget constraints are recognised the shadow price of resources required to implement a project may be affected by the amount of resources remaining in the budget after implementation. Once the budget constraint is recognised, a project which initially appeared to be the most efficient can be rendered relatively inefficient. It is suggested that alternative uses of remaining (or residual) resources should be identified and evaluated, thus ensuring the maximisation of benefits from the use of an overall budget.

The impact of zoonotic diseases transmitted by pets on human health and the economy

In the context of all causes of human morbidity and mortality, or even within the context of all infectious diseases affecting the public health, pet-associated zoonotic infections are of moderate importance. The data documented in Table 1, however, indicate that they do exact significant human health and economic costs. If complete data were available for all of the infections shown in Table 1, the costs would be considerably higher. Moreover, most of these diseases are preventable through educating the public, particularly pet owners, of the zoonotic potential of these diseases, so that they may take precautions to minimize the risks leading to infection. These measures include appropriate health care of pets to eliminate infectious agents, reducing the number of uncontrolled, ownerless pets as well as unwanted or poorly supervised pets, preventing pets from soiling public places with their feces, excluding animals from areas where children play, enforcing leash laws, and promoting responsible pet ownership. Veterinarians, physicians, and public health agencies can aid in these efforts; ultimately, however, the responsibility lies with the pet owner.

Premarital rubella vaccination program

A two-year Vermont program identified 494 (7 per cent) of 6,982 premarital female serologies that were seronegative (less than 1:8) to rubella by hemagglutination inhibition (HI) titer. All 494 susceptible patients and their physicians were notified of their results by letter. The State Health Department received reports that a total of 194 (39 per cent) of the susceptible patients had received rubella vaccinations as a result of their notifications. Intensive follow-up of susceptibles appears to be important factor in the success of premarital rubella screening programs.

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.

Cost-benefit studies of health care programs. Choosing methods for desired results

This article summarizes the results of a critical review of several cost-benefit analyses (CBA) of health care programs. With pertinent examples, it is demonstrated that the results and conclusions of a study depend upon the assumptions and methods underlying the measurement of costs and benefits in a CBA. Given the incentives for an analyst to comply with desires of his sponsor, and given the scope of the choice available to an analyst among alternative assumptions and methods, it seems quite possible that desired results often dictate the assumptions and methods chosen. It is recommended that a policy maker should suspect an advocacy in the results and conclusions of every CBA. If CBAs are to be a true decision aid, a policy maker ought to obtain several of them, each of which assesses the costs and benefits of a given action plan using assumptions and methods substantially different from the other.

Intranasal administration of RA 27/3 rubella virus vaccine. A clinical trial in young adults

Of the vaccines and inoculation routes studied for the prevention of rubella, only the RA27/3 vaccine, administered intranasally, has the ability to stimulate a humoral antibody pattern very similar to that evoked by wild rubella infection. Because information about intranasal (IN) vaccination has only been obtained using the RA 27/3 vaccine manufactured in Europe, we conducted a trial of IN vaccination among young adults using Meruvax II which is manufactured in the USA. Of 597 family planning clinic patients screened in 1980-1981, 71 (11.9%) were susceptible to rubella; forty-one subjects were randomly assigned to receive IN or subcutaneous (SC) vaccine. All 20 SC vaccinees, but only 8/21 (38%) IN vaccinees, were successfully immunized. We conclude that standard doses of commercially available RA 27/3 vaccine are insufficient for IN immunization against rubella. Additional study of the dose-response relationship is needed if IN vaccination is to be recommended.

The economics of prevention

A review of cost-effectiveness studies of prevention supports two conclusions: (1) few prevention programs, if any, reduce medical expenditures; (2) even when prevention costs less per person than acute care, its medical costs per unit of health benefit can be as great or greater. So that future studies will allow comparisons over a wider range of medical choices, the paper proposes some steps toward the greater standardization of cost-effectiveness analyses of medical care.

What can be done to prevent congenital toxoplasmosis?

There is a great deal of confusion within the medical and lay communities regarding Toxoplasma infection in the pregnant woman. Many physicians are not aware of the significance of this infection in pregnant women or of measures that may decrease the likelihood of the birth of an infant with congenital toxoplasmosis. Data regarding the morbidity, incidence, cost, and measures for the prevention of congenital toxoplasmosis are discussed.

Cost effectiveness of vaccination against pneumococcal pneumonia

We used cost-effectiveness analysis to examine the medical-care costs of vaccination against pneumococcal pneumonia in relation to its effects on health. Vaccination could add a year of healthy life among all age groups for about $4,800 in net medical-care costs. Cost-effectiveness ratios vary according to the age of the person vaccinated--from $1,000 per year of healthy life for an adult 65 years old or older to $77,000 per year of healthy life for a child between the ages of two and four. These ratios may change substantially with variations in such factors as the cost of vaccination, the duration of immunity, the efficacy and composition of the vaccine, and the percentage of pneumonia that is pneumococcal. This analysis has particular relevance for the Medicare program, since present legislation excludes coverage of most immunizations and other preventive services. Provision of pneumococcal vaccine to the elderly and inclusion of the vaccine as a Medicare benefit merit serious consideration.

Application of benefit-to-cost analysis to an X-linked recessive cardiac and humeroperoneal neuromuscular disease

Benefit-to-cost analysis (using standard economic methods) and the predictive tools of genetics are important in the assessment of genetic services for high burden, single gene disorders. We have studied 6 generations of a 167-member, stable, North Georgia kindred at risk for X-linked recessive humeroperoneal neuromuscular disease with cardiac conduction defects. This disorder began in affected males in the teen years, with total disability expected by the 3rd decade and death by age 50. Using known fecundity rates and Mendelian probabilities, 26.6 heterozygous females and 9.4 hemizygous affected males were expected in the currently developing generation. We compared the compensatory costs for families with affected males against costs of genetic intervention for this disorder. All costs and benefits were discounted to present values at 6% and 10% and a benefit-to-cost ratio was derived. At a 6% discount rate the benefit-to-cost ratio was 21 to 1 while at a 10% discount rate the benefit-to-cost ratio was 14 to 1. We conclude that although this is an unusual X-linked muscular dystrophy, it constitutes a prototypic public and private expense which is largely preventable. The method of cost accounting within pedigrees has wide applicability. The results reemphasize the economic benefit of comprehensive public health programs in genetics, particularly in areas with stable, high risk-populations.

Benefit--cost methodology in the evaluation of therapeutic services for alcoholism

Benefit--cost analysis as a form of "social profitability analysis" can be a powerful tool in the overall evaluation of alcoholism treatment efforts. Alcoholism treatment potentially leads to a multiplicity of benefits in addition to sobriety. Benefit--cost analysis provides a methodology for converting many of these diverse benefits into a common metric (dollars), thereby allowing the comparison of aggregate benefits and treatment costs. The analysis thus leads to the expression of treatment outcome in terms of the return on investment. A benefit--cost analysis conducted on 3034 clients from the Oklahoma data base indicated a return to society of $1.98 for every $1 invested in alcoholism treatment. Such data may represent a critical portion of the information required for responsible resource allocation decisions.

Implications of rubella susceptibility in young adults

Rubella history and antibody titre were determined for 457 medical, graduate, and physician assistant students. Eighteen per cent were estimated at risk for rubella. There were no male-female differences. Health-profession students did not differ in rubella immune status from the general population. History was not helpful in assessing immune status. Approximately one-half of persons with low antibody titres had considered themselves immune, while one-half with moderate to high antibody titres had considered themselves at risk. Less than one-half of students with low antibody titres available themselves of immunization which was recommended and offered. With a high percentage of adult females at risk for rubella even in a health-motivated population and with poor follow-up on recommended immunization, current immunization practices must be improved if congenital rubella syndrome is to be further reduced. Mass inoculation of school age males and prepubertal school age females without prior determination of rubella antibody titres is suggested as a cost-effective means of decreasing incidence of congenital rubella syndrome.

Self-care in urban settings

A variety of indicators favors the development of self-care systems for inner-city populations. This cannot be conceived as an isolated individual or a family enterprise. To be effective, self-care must be a community concept. This type of system requires (1) an information base; (2)an organized method of dissemination in a community; (3) support structures; and (4) an evaluation sybsystem. A community-oriented system would be an alternative and a complement to formal health services; individuals and families would manage common health problems, but would have ready access to formal services through community organizations. Links must also be provided between personal self-care and other forms of community development.