Economic evaluation of second measles containing vaccine (MCV) dose: a systematic review of available evidence.

INTRODUCTION: The global measles incidence has decreased from 145 to 49 cases per 1 million population from 2000 to 2018, but evaluating the economic benefits of a second measles-containing vaccine (MCV2) is crucial. This study reviewed the evidence and quality of economic evaluation studies to guide MCV2 introduction. METHODS: The systematic review of model-based economic evaluation studies was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search yielded 2231 articles, with 876 duplicates removed and 1355 articles screened, with nine studies included for final analysis. RESULTS: Six studies reported a positive benefit-cost ratio with one resulting in net savings of $11.6 billion, and two studies estimated a 2-dose MMR vaccination program would save $119.24 to prevent one measles case, and a second dose could prevent 9,200 cases at 18 months, saving $548.19 per case. The most sensitive variables were the discount rate and vaccination administration cost. CONCLUSIONS: Two MCV doses or a second opportunity with an additional dose of MCV were highly cost-beneficial and resulted in substantial cost savings compared to a single routine vaccine. But further research using high-quality model-based health economic evaluation studies of MCV2 should be made available to decision-makers. PROSPERO REGISTRATION: CRD42020200669.

Modeling the Cost of Vaccinating a Measles Zero-Dose Child in Zambia Using Three Vaccination Strategies.

Countries with moderate to high measles-containing vaccine coverage face challenges in reaching the remaining measles zero-dose children. There is growing interest in targeted vaccination activities to reach these children. We developed a framework for prioritizing districts for targeted measles and rubella supplementary immunization activities (SIAs) for Zambia in 2020, incorporating the use of the WHO's Measles Risk Assessment Tool (MRAT) and serosurveys. This framework was used to build a model comparing the cost of vaccinating one zero-dose child under three vaccination scenarios: standard nationwide SIA, targeted subnational SIA informed by MRAT, and targeted subnational SIA informed by both MRAT and measles seroprevalence data. In the last scenario, measles seroprevalence data are acquired via either a community-based serosurvey, residual blood samples from health facilities, or community-based IgG point-of-contact rapid diagnostic testing. The deterministic model found that the standard nationwide SIA is the least cost-efficient strategy at 13.75 USD per zero-dose child vaccinated. Targeted SIA informed by MRAT was the most cost-efficient at 7.63 USD per zero-dose child, assuming that routine immunization is just as effective as subnational SIA in reaching zero-dose children. Under similar conditions, a targeted subnational SIA informed by both MRAT and seroprevalence data resulted in 8.17-8.35 USD per zero-dose child vaccinated, suggesting that use of seroprevalence to inform SIA planning may not be as cost prohibitive as previously thought. Further refinement to the decision framework incorporating additional data may yield strategies to better target the zero-dose population in a financially feasible manner.

Cost-effectiveness analysis of an intervention project engaging Traditional and Religious Leaders to improve uptake of childhood immunization in southern Nigeria.

Vaccination is a cost-effective public health intervention, yet evidence abounds that vaccination uptake is still poor in many low- and middle-income countries. Traditional and Religious Leaders play a substantial role in improving the uptake of health services such as immunization. However, there is paucity of evidence on the cost-effectiveness of using such strategies. This study aimed to assess the cost-effectiveness of using a multi-faceted intervention that included traditional and religious leaders for community engagement to improve uptake of routine immunisation services in communities in Cross River State, Southern Nigeria. The target population for the intervention was traditional and religious leaders in randomly selected communities in Cross River State. The impact of the intervention on the uptake of routine vaccination among children 0 to 23 months was assessed using a cluster randomized trials. Outcome assessments were performed at the end of the project (36 months).The cost of the intervention was obtained from the accounting records for expenditures incurred in the course of implementing the intervention. Costs were assessed from the health provider perspective. The cost-effectiveness analysis showed that the incremental cost of the initial implementation of the intervention was US$19,357and that the incremental effect was 323 measles cases averted, resulting in an incremental cost-effectiveness ratio (ICER) of US$60/measles case averted. However, for subsequent scale-up of the interventions to new areas not requiring a repeat expenditure of some of the initial capital expenditure the ICER was estimated to be US$34 per measles case averted. Involving the traditional and religious leaders in vaccination is a cost-effective strategy for improving the uptake of childhood routine vaccinations.

Societal Costs of a Measles Outbreak.

BACKGROUND AND OBJECTIVES: Between December 31, 2018, and April 26, 2019, 72 confirmed cases of measles were identified in Clark County. Our objective was to estimate the economic burden of the measles outbreak from a societal perspective, including public health response costs as well as direct medical costs and productivity losses of affected individuals. METHODS: To estimate costs related to this outbreak from the societal perspective, 3 types of costs were collected or estimated: public health response (labor, material, and contractor costs used to contain the outbreak), direct medical (third party or patient out-of-pocket treatment costs of infected individuals), and productivity losses (costs of lost productivity due to illness, home isolation, quarantine, or informal caregiving). RESULTS: The overall societal cost of the 2019 Clark County measles outbreak was ∼$3.4 million ($47 479 per case or $814 per contact). The majority of the costs (∼$2.3 million) were incurred by the public health response to the outbreak, followed by productivity losses (∼$1.0 million) and direct medical costs (∼$76 000). CONCLUSIONS: Recent increases in incident measles cases in the United States and across the globe underscore the need to more fully understand the societal cost of measles cases and outbreaks and economic consequences of undervaccination. Our estimates can provide valuable inputs for policy makers and public health stakeholders as they consider budget determinations and the substantial value associated with increasing vaccine coverage and outbreak preparedness as well as the protection of society against vaccine-preventable diseases, such as measles, which are readily preventable with high vaccination coverage.

Challenges related to resources mobilization for measles outbreak response: Madagascar experience during the 2018-2019 measles outbreak.

INTRODUCTION: on October 4th, 2018, a measles outbreak was declared in Madagascar. This study describes challenges related to resources mobilization for the outbreak response. METHODS: data were collected using minutes of coordination committee meetings, activities reports, operational action plans and situation reports. RESULTS: the total cost of the outbreak response was estimated to US$ 11,281,381. Operational cost was the leading cost driver (42.45%) followed by vaccine cost (33.74%). Cases management, epidemiological surveillance, communication and social mobilization and routine immunization strengthening represented 23.81% of the total cost. The main funder of the outbreak response was the measles and rubella initiative. CONCLUSION: good coordination, open dialogue, good use of financial resources and accountability of government and partners have enabled to gain the confidence of national and international donors.

The economic burden of measles in children under five in Bangladesh.

BACKGROUND: This study estimated the economic cost of treating measles in children under-5 in Bangladesh from the caregiver, government, and societal perspectives. METHOD: We conducted an incidence-based study using an ingredient-based approach. We surveyed the administrative staff and the healthcare professionals at the facilities, recording their estimates supported by administrative data from the healthcare perspective. We conducted 100 face-to-face caregiver interviews at discharge and phone interviews 7 to 14 days post-discharge to capture all expenses, including time costs related to measles. All costs are in 2018 USD ($). RESULTS: From a societal perspective, a hospitalized and ambulatory case of measles cost $159 and $18, respectively. On average, the government spent $22 per hospitalized case of measles. At the same time, caregivers incurred $131 and $182 in economic costs, including $48 and $83 in out-of-pocket expenses in public and private not-for-profit facilities, respectively. Seventy-eight percent of the poorest caregivers faced catastrophic health expenditures compared to 21% of the richest. In 2018, 2263 cases of measles were confirmed, totaling $348,073 in economic costs to Bangladeshi society, with $121,842 in out-of-pocket payments for households. CONCLUSION: The resurgence of measles outbreaks is a substantial cost for society, requiring significant short-term public expenditures, putting households into a precarious financial situation. Improving vaccination coverage in areas where it is deficient (Sylhet division in our study) would likely alleviate most of this burden.

How much does it cost to measure immunity? A costing analysis of a measles and rubella serosurvey in southern Zambia.

BACKGROUND: Serosurveys are a valuable surveillance tool because they provide a more direct measure of population immunity to infectious diseases, such as measles and rubella, than vaccination coverage estimates. However, there is concern that serological surveys are costly. We adapted a framework to capture the costs associated with conducting a serosurvey in Zambia. METHODS: We costed a nested serosurvey in Southern Province, Zambia that collected dried blood spots from household residents in a post-campaign vaccine coverage survey. The financial costs were estimated using an ingredients-based costing approach. Inputs included personnel, transportation, field consumable items, social mobilization, laboratory supplies, and capital items, and were classified by serosurvey function (survey preparation, data collection, biospecimen collection, laboratory testing, and coordination). Inputs were stratified by whether they were applicable to surveys in general or attributable specifically to serosurveys. Finally, we calculated the average cost per cluster and participant. RESULTS: We estimated the total nested serosurvey cost was US $68,558 to collect dried blood spots from 658 participants in one province in Zambia. A breakdown of the cost by serosurvey phase showed data collection accounted for almost one third of the total serosurvey cost (32%), followed by survey preparation (25%) and biospecimen collection (20%). Analysis by input categories indicated personnel costs were the largest contributing input to overall serosurvey costs (51%), transportation was second (23%), and field consumables were third (9%). By combining the serosurvey with a vaccination coverage survey, there was a savings of $43,957. We estimated it cost $4,285 per average cluster and $104 per average participant sampled. CONCLUSIONS: Adding serological specimen collection to a planned vaccination coverage survey provided a more direct measurement of population immunity among a wide age group but increased the cost by approximately one-third. Future serosurveys could consider ways to leverage existing surveys conducted for other purposes to minimize costs.

Recent setbacks in measles elimination: the importance of investing in innovations for immunizations.

The recent setbacks in efforts to achieve measles elimination goals are alarming. To reverse the current trends, it is imperative that the global health community urgently intensify efforts and make resource commitments to implement evidence-based elimination strategies fully, including supporting research and innovations. The Immunization Agenda 2030: A Global Strategy to Leave No One Behind (IA2030) is the new global guidance document that builds on lessons learned and progress made toward the GVAP goals, includes research and innovation as a core strategic priority, and identifies measles as a "tracer" for improving immunisation services and strengthening primary health care systems. To achieve vaccination coverage and equity targets that leave no one behind, and accelerate progress toward disease eradication and elimination goals, sustained and predictable investments are needed for the identified research and innovations priorities for the new decade.

Inpatient morbidity and mortality of measles in the United States.

BACKGROUND: Measles is an extremely contagious, vaccine-preventable infection that was officially declared eradicated in the US in 2000. However, measles outbreaks are increasingly occurring in the US. Measles cases have considerable morbidity requiring hospitalization, yet little is known about hospitalization and complications from measles in recent years. OBJECTIVES: To analyze the frequency, predictors, costs and other outcomes of hospitalization for measles in the US. METHODS: The 2002-2016 Nationwide Inpatient Sample, containing a 20% sample of US hospitalizations (n = 96,568,625), was analyzed. Measles and comorbidities were defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) or ICD-10-CM codes. Multivariable survey logistic regression and linear regression models controlling for sociodemographic demographic factors were constructed to understand associations with organ-specific complications, and cost of care and length of stay, respectively. RESULTS: Overall, 1,018 measles hospitalizations occurred in 2002-2016, and hospitalizations increased over time. In multivariable logistic regression models, measles was associated with higher odds of gastrointestinal, hematologic, infectious, neurologic, ophthalmologic, pulmonary, and renal complications, with the strongest association observed with encephalitis (39.84 [16.51-96.12], P<0.0001). Increased length of stay (LOS) and similar cost of care (mean [95% CI]; 4.8 [4.4-5.4]; $7,438 [$6,446-$8,582]) were observed versus (vs.) all other admissions (4.5 [4.4-4.5]; P<0.01; $7,854 [$7,774-$7,935], P>0.05). There were 34 deaths in hospitalized measles patients; inpatient mortality was numerically higher in those with vs. without measles (proportion ± SEM: 3.3±1.2% vs. 2.3±0.01%, P = 0.333). LIMITATIONS: Lack of outpatient or prescription data. CONCLUSIONS: Measles continues to pose a substantial and preventable health care burden, with serious complications, hospitalization and inpatient mortality. Further studies are needed to improve the prevention and management of measles.

Resurgence of measles in the United States: how did we get here?

PURPOSE OF REVIEW: In September 2019, the United States was at risk of losing measles elimination status due to several large-scale outbreaks resulting in more than 1200 confirmed cases across 31 states. This resurgence caps approximately 10 years of increasing incidence, marked by a highly publicized outbreak in 2015 associated with Disneyland when an infected traveler from the Philippines unknowingly spread the virus to susceptible park visitors and the recently ended large outbreak in undervaccinated Orthodox Jewish communities in New York City and Rockland counties. This review highlights current literature elucidating factors associated with current trends in measles epidemiology in the United States, the public health implications of current measles outbreaks and a path forward for addressing challenges contributing to the resurgence of measles in the United States and globally. RECENT FINDINGS AND SUMMARY: As the most highly transmissible vaccine preventable disease, measles is especially sensitive to changes in herd immunity, the impact of vaccine refusal and globalization. Results highlight the confluence of these factors in current outbreaks, provide tools to predict outbreak risk, demonstrate the growing impact of misinformation and evaluate the impact of policy approaches for outbreak control and prevention.

Costs associated with measles in healthcare personnel during the 2017-2018 epidemic in Greece: a real-world data cost-of-illness analysis.

Measles represents an occupational risk for healthcare personnel (HCP). A total of 117 cases of measles among HCP were notified in Greece during 2017-2018. We were able to contact 46 of them. Most of those contacted had a serious clinical course with complications, necessitating hospitalization in 67% of cases. All HCP reported absenteeism, for a mean duration of 21.2 working days (range: 3-60 days); 54.3% of HCP reported being at work while symptomatic for a mean duration of 2.3 working days (range: 1-7 days). The average total cost-of-illness was €4,739 per HCP. The total direct and indirect costs of the 117 notified cases among HCP amount to €554,494, which is likely to be an underestimate of the true cost.

Cost-effectiveness of measles treatment: a systematic review.

OBJECTIVE: Measles is still common in many developing countries, and its outbreaks have been on the rise since 2009 even though the disease is almost entirely preventable through safe and effective vaccination. This paper aims to provide evidence about the systematic review of the cost-effectiveness of measles treatment in different regions worldwide. METHODS: The methodical search began on 10th January 2019 to look for all articles on the cost-effectiveness of measles treatment published from January 2019 to April 2019 in SCOPUS, Pubmed (www.ncbi.nlm.nih.gov) and Cochrane (www.cochrane.org).We summarised the articles by using a data table to extract all information using health economic evaluation methods. RESULTS: We identified 14 articles from the 69 total articles searched. These articles showed favourable costeffectiveness or cost-benefit ratios in high- and middle-income countries based on data organised by World Bank Income Level in 2018: the United States, Canada, Japan, India and Zambia. However, research is still limited in lowincome countries and thus the effectiveness of vaccination programmes cannot be conclusively identified. CONCLUSIONS: This review shows the overview of the research in health economic evaluations of measles in different places, years and using different methods of intervention. Overall, it evaluates the cost-effectiveness of measles treatment.

Indirect costs associated with deaths of children aged 0-14 years from measles in a weak health system and conflict and fragile zone: the case of Somalia.

This study recognises periodic outbreaks of measles continue to affect conflict and fragile zones in the least developed countries. This study set out to provide evidence for the indirect costs or economic loss associated with measles-related deaths among children aged 0-14 years in Somalia. Using epidemiologic and economic data, the indirect cost was calculated based on the framework of the World Health Organisation guide of identifying the economic consequences of disease and injury. The baseline indirect cost was computed as the product of discounted future productive years of life lost (PYLL), non-health gross domestic product per capita (NHGDPPC) and the estimated total measles deaths (ETMD). The model was adjusted for conflict and fragility conditions and further extension considered a finite and stable upper limit growth of the instability-adjusted NHGDPPC. To discount future costs, a rate of 3% was applied. Using a ±20% variability assumption of the epidemiologic and economic factor inputs, a sensitivity analysis was conducted to account for uncertainty. In 2015 values, the ETMD of 3723 measles deaths of children aged 0-14 years could decrease non-health GDP of the country by $23.46 million, a potential loss of $6303 per death over the discounted PYLL. The loss would increase by 5.3% when adjusted for conflict and fragility conditions. Assuming growth, the future adjusted loss is expected to be $35.91 million in 2015 values. Girl-child deaths accounted for 51.2% of the burden. Results are robust to the variations in the model inputs, although sensitivity analyses suggest the proportion of total measles deaths and the discount rate accounted for greater uncertainty of the loss than do the proportion of growth and instability assumption. Conflict and fragility accounted for the least uncertainty, perhaps confirming their relative perpetuity in Somalia. Results show significant indirect cost related to measles deaths of children, exacerbated by conflict and fragility. This is an economic burden, but one which the health system, policy-makers, government and other stakeholders should be prepared to colossally discount by collectively taking measles surveillance and security measures now to reduce further deaths in the future.

Differences between coverage of yellow fever vaccine and the first dose of measles-containing vaccine: A desk review of global data sources.

INTRODUCTION: The strategy to Eliminate Yellow Fever Epidemics (EYE) is a global initiative that includes all countries with risk of yellow fever (YF) virus transmission. Of these, 40 countries (27 in Africa and 13 in the Americas) are considered high-risk and targeted for interventions to increase coverage of YF vaccine. Even though the World Health Organization (WHO) recommends that YF vaccine be given concurrently with the first dose of measles-containing vaccine (MCV1) in YF-endemic settings, estimated coverage for MCV1 and YF vaccine have varied widely. The objective of this study was to review global data sources to assess discrepancies in YF vaccine and MCV1 coverage and identify plausible reasons for these discrepancies. METHODS: We conducted a desk review of data from 34 countries (22 in Africa, 12 in Latin America), from 2006 to 2016, with national introduction of YF vaccine and listed as high-risk by the EYE strategy. Data reviewed included procured and administered doses, immunization schedules, routine coverage estimates and reported vaccine stock-outs. In the 30 countries included in the comparitive analysis, differences greater than 3 percentage points between YF vaccine and MCV1 coverage were considered meaningful. RESULTS: In America, there were meaningful differences (7-45%) in coverage of the two vaccines in 6 (67%) of the 9 countries. In Africa, there were meaningful differences (4-27%) in coverage of the two vaccines in 9 (43%) of the 21 countries. Nine countries (26%) reported MVC1 stock-outs while sixteen countries (47%) reported YF vaccine stock-outs for three or more years during 2006-2016. CONCLUSION: In countries reporting significant differences in coverage of the two vaccines, differences may be driven by different target populations and vaccine availability. However,these were not sufficient to completely explain observed differences. Further follow-up is needed to identify possible reasons for differences in coverage rates in several countries where these could not fully be explained.

Cost Analysis of 3 Concurrent Public Health Response Events: Financial Impact of Measles Outbreak, Super Bowl Surveillance, and Ebola Surveillance in Maricopa County.

OBJECTIVE: To generate estimates of the direct costs of mounting simultaneous emergency preparedness and response activities to respond to 3 major public health events. DESIGN: A cost analysis was performed from the perspective of the public health department using real-time activity diaries and retrospective time and activity self-reporting, wage and fringe benefit data, and financial records to track costs. SETTING: Maricopa County Department of Public Health (MCDPH) in Arizona. The nation's third largest local public health jurisdiction, MCDPH is the only local health agency serving Maricopa's more than 4 000 000 residents. Responses analyzed included activities related to a measles outbreak with 2 confirmed cases, enhanced surveillance activities surrounding Super Bowl XLIX, and ongoing Ebola monitoring, all between January 22, 2015, and March 4, 2015. PARTICIPANTS: Time data were sought from all MCDPH staff who participated in activities related to any of the 3 relevant responses. In addition, time data were sought from partners at the state health department and a community hospital involved in response activities. Time estimates were received from 128 individuals (response rate 88%). MAIN OUTCOME MEASURE: Time and cost to MCDPH for each response and overall. RESULTS: Total MCDPH costs for measles-, Super Bowl-, and Ebola-related activities from January 22, 2015, through March 4, 2015, were $224 484 (>5800 hours). The majority was for personnel ($203 743) and the costliest response was measles ($122 626 in personnel costs). In addition, partners reported working more than 700 hours for these 3 responses during this period. CONCLUSIONS: Funding for public health departments remains limited, yet public health responses can be cost- and time-intensive. To effectively plan for future public health responses, it may be necessary to share experiences and financial lessons learned from similar public health responses. External partnerships represent a key contribution for responses such as those examined. It can be expensive for local public health departments to mount effective responses, especially when multiple responses occur simultaneously.

Economic burden and associated factors of measles patients in Zhejiang Province, China.

This study aimed to figure out the economic burden of measles patients and explore the associated factors for total cost in measles cases that occurred in the year 2015 from Jiaxing, Jinhua, and Taizhou cities in Zhejiang Province, China. Direct interviews were conducted to collect information on patient expenses during treatment, including outpatient expenses, hospitalization expenses, self-treatment fees, productivity loss, and transportation fees. Descriptive epidemiological methods and chi-square tests were used to assess the direct and indirect cost of measles patients. Ordinal logistic regression was applied to explore the possible factors contributing to cost. A total of 136 measles cases were investigated and the average direct cost, indirect cost, and total cost were #747.14, #520.12, and #1,267.26, respectively. Direct cost accounted for 58.96% of the total cost, which was significantly higher than the indirect cost (P < 0.001). In 2015, 1,386 confirmed cases were reported in the Zhejiang Province, and the overall direct, indirect, and total economic burden reached #1.04 million, #0.72 million, and #1.76 million, respectively. Quality-adjusted life years for measles patient were calculated to be 76.06 in Zhejiang, 2015. Hospitalization, occupation, complication, disease duration, age, and site had a significant influence on the total cost according to ordinal logistic regression, with the maximum contribution from hospitalization. Measles resulted in heavy economic burdens, and local public health departments or community health service centers should spare no effort to maintain a high rate of vaccination coverage and protect susceptible populations.

Cost-effectiveness of measles control during elimination in Ontario, Canada, 2015.

BackgroundGiven that measles is eliminated in Canada and measles immunisation coverage in Ontario is high, it has been questioned whether Ontario's measles outbreak response is worthwhile.AimOur objective was to determine cost-effectiveness of measles containment protocols in Ontario from the healthcare payer perspective.MethodsWe developed a decision-analysis model comparing Ontario's measles containment strategy (based on actual 2015 outbreak data) with a hypothetical 'modified response'. The modified scenario assumed 10% response costs with reduced case and contact tracing and no outbreak-associated vaccinations; it was based on local and provincial administrative and laboratory data and parameters from peer-reviewed literature. Short- and long-term health outcomes, quality-adjusted life years (QALYs) and costs discounted at 1.5%, were estimated. We conducted one- and two-way sensitivity analyses.ResultsThe 2015 outbreak in Ontario comprised 16 measles cases and an estimated 3,369 contacts. Predictive modelling suggested that the outbreak response prevented 16 outbreak-associated cases at a cost of CAD 1,213,491 (EUR 861,579). The incremental cost-effectiveness ratio was CAD 739,063 (EUR 524,735) per QALY gained for the outbreak response vs modified response. To meet the commonly accepted cost-effectiveness threshold of CAD 50,000 (EUR 35,500) per QALY gained, the outbreak response would have to prevent 94 measles cases. In sensitivity analyses, the findings were robust.ConclusionsOntario's measles outbreak response exceeds generally accepted cost-effectiveness thresholds and may not be the most efficient use of public health resources from a healthcare payer perspective. These findings should be balanced against benefits of increased vaccine coverage and maintaining elimination status.

The Clinical Impact and Cost-effectiveness of Measles-Mumps-Rubella Vaccination to Prevent Measles Importations Among International Travelers From the United States.

BACKGROUND: Measles importations and the subsequent spread from US travelers returning from abroad are responsible for most measles cases in the United States. Increasing measles-mumps-rubella (MMR) vaccination among departing US travelers could reduce the clinical impact and costs of measles in the United States. METHODS: We designed a decision tree to evaluate MMR vaccination at a pretravel health encounter (PHE), compared with no encounter. We derived input parameters from Global TravEpiNet data and literature. We quantified Riskexposure to measles while traveling and the average number of US-acquired cases and contacts due to a measles importation. In sensitivity analyses, we examined the impact of destination-specific Riskexposure, including hot spots with active measles outbreaks; the percentage of previously-unvaccinated travelers; and the percentage of travelers returning to US communities with heterogeneous MMR coverage. RESULTS: The no-encounter strategy projected 22 imported and 66 US-acquired measles cases, costing $14.8M per 10M travelers. The PHE strategy projected 15 imported and 35 US-acquired cases at $190.3M per 10M travelers. PHE was not cost effective for all international travelers (incremental cost-effectiveness ratio [ICER] $4.6M/measles case averted), but offered better value (ICER <$100 000/measles case averted) or was even cost saving for travelers to hot spots, especially if travelers were previously unvaccinated or returning to US communities with heterogeneous MMR coverage. CONCLUSIONS: PHEs that improve MMR vaccination among US international travelers could reduce measles cases, but are costly. The best value is for travelers with a high likelihood of measles exposure, especially if the travelers are previously unvaccinated or will return to US communities with heterogeneous MMR coverage.

The Dust Bowl in the US: An Analysis Based on Current Environmental and Clinical Studies.

The Dust Bowl occurred in the Central Plains states in the United States between 1930 and 1940. Prolonged drought, intense recurrent dust storms and economic depression had profound effects on human welfare. The causes included increased farming on marginal land, poor land management, and prolonged drought. There was a significant increase in the number of cases of measles, increased hospitalization for respiratory disorders and increased infant and overall mortality in Kansas during the Dust Bowl. Recent scientific studies have demonstrated that dust transmits measles virus, influenza virus and Coccidioides immitis, and that mortality in the United States increases following dust storms with 2-3-day lag periods. Advances in technology have provided information about the composition of dust and the transfer of microbial pathogens in dust and provided the framework for reducing the economic and health consequences of the next prolonged drought in the United States.