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.

Pre-vaccination IgG screening for mumps is the most cost-effectiveness immunization strategy among Health Care Workers.

Health Care Workers (HCWs) have an increased risk of contracting contagious disease, including mumps. In January 2017 the Italian National Vaccine Prevention Plan 2017-2019, recommended the administration of a dose of MMR vaccine (Measles-Mumps-Rubella) to the Health Care Workers (HCWs) that, working in a risky environment, did not carry out the complete vaccination cycle of MMR or that are seronegative for at least one of the three vaccine viruses. In October of the same year, the Advisory Committee on Immunization Practices (ACIP) recommended a third dose of a vaccine containing Mumps Virus for people previously vaccinated with 2 doses, belonging to a group or to a population at increased risk of acquire mumps in the event of an epidemic. We analyzed the clinical records and values of mumps-specific IgG antibodies of 3032 HCWs (mean age 32.80 ± 10.75 years), that underwent occupational health surveillance between January 1st 2017 and March 31th 2018. The HCWs were also screened for measles, rubella, mumps using serological methods. 13% (405) was seronegative for mumps, especially among HCWs between 18 and 36 years. We calculated the cost-effectiveness of two-doses and three-doses MMR vaccination. The cost of vaccination without screening was significantly more expensive (cost difference: 99 712 € and 184 996 €) both in case of two-dose and three-dose MMR vaccination respectively. Our study suggests that, in HCWs, the assessment of the mumps antibody titer before vaccination may be a useful complement to vaccination itself, because it is more accurate and cost-effective than direct immunization of unvaccinated subjects.

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.

Socioeconomic factors influencing childhood vaccination in two northern Italian regions.

BACKGROUND: Infant vaccination rates have been declining in Italy over the past 5-7years. The aims of this study were to assess the trend in the proportions of children unvaccinated at 24months old, to identify sociodemographic factors associated with non-vaccination; and to examine changes in parental attitudes to vaccination over time. METHODS: We conducted a population-based birth cohort study by combining existing electronic data sets. The study population consisted of children born from 1995 to 2010 in the Friuli-Venezia Giulia (FVG) region, and from 2007 to 2011 in part of the Emilia Romagna (ER) region, in north-eastern Italy. The immunization registers were linked with the medical birth registers, which contain sociodemographic data on both parents and the newborn. Unconditional logistic regressions were used to identify associations between vaccine uptake at 24months and maternal sociodemographic variables. RESULTS: Of 145,571 babies born in FVG and 75,308 in ER, there were 4222 (1.9%) who had not been vaccinated at all, and 23,948 (11.0%) without the optional measles, mumps and rubella (MMR) vaccination. The number of unvaccinated infants increased over time. Mothers who were over 35 or under 25years old, unmarried, with a higher formal education, and citizens of highly-developed countries were less compliant with vaccination recommendations in both the regions. A cohort effect was observed in FVG, for both educational level and citizenship: babies born between 1995 and 2000 to mothers without an Italian citizenship and with a lower formal education were more likely to refuse vaccination for their offspring, while this association was reversed between 2006 and 2010. CONCLUSIONS: Mothers who are Italian citizens and have a good formal education have begun to refuse vaccination for their children in recent years. Future public health action in this setting should target highly educated parents.

[Economic evaluation on different two-dose-vaccination-strategies related to Measles, Mumps and Rubella Combined Attenuated Live Vaccine].

OBJECTIVE: To evaluate the economic effect of Measles, Mumps and Rubella Combined Attenuated Live Vaccine (MMR) under different two-dose vaccination programs. METHODS: A hypothetical birth cohort of 750 000 infants over their lifetime, was followed up from birth through death in Zhejiang province. The current MMR vaccination strategie would include three different ones: 1) Childlern were vaccinated with Measles-Rubella Combined Attenuated Live Vaccine and MMR, respectively at the age of 8 months and 18 months. 2) Children receive MMR at 8 months and 18 months, 3) Strategy 1 plus an additional vaccination of MMR at 4 years of age. Incremental cost-effectiveness ratio (ICER), incremental cost-benefit ratio (ICBR) and incremental net benefit (INB) were applied to calculate the health economic difference for Strategy 2 and Strategy 3 as compared to Strategy 1. Univariate sensitivity analysis was used to assess the robustness of results with main parameters, including the rate of immunization coverage, effectiveness of the vaccines, incidence and burdens of the related diseases, cost of vaccines and the vaccination program itself. RESULTS: ICER, ICBR and INB for Strategy 2 and Strategy 3 appeared as 2 012.51∶1 RMB Yuan per case and 4 238.72∶1 RMB Yuan per case, 1∶3.14 and 1∶1.58, 21 277 800 RMB Yuan and 9 276 500 RMB Yuan, respectively. Only slight changes (<20%) were found under the univariate sensitivity analysis, with varied values on main parameters. CONCLUSION: Based on the current national immunization program, infants vaccinated with MMR at 8 months of age, generated more health economic effects than the Strategy 3.

[Review of the 2016 Swiss immunization schedule and technology update for improving vaccine management]. / Plan de vaccination 2016 et outils informatiques pour une meilleure gestion des vaccinations.

The 2016 immunization schedule published by the Swiss Federal Office of Public Health includes three new clauses: reimbursement of the additional Human Papillomavirus (HPV) vaccination in young males (11-26 years) as recommended by local canton programs, the end of franchise exemption for the measles, mumps and rubella (MMR) vaccination, and the creation of a new system of indemnities and moral compensation in the event of personal injury resulting from vaccinations. This article presents the main features of the 2016 immunization schedule with details of the technology available to physicians to improve vaccine management.

Costing of immunization service provision in Kalutara district, Sri Lanka: a cross-sectional study.

BACKGROUND: Immunization is regarded as the single most cost-effective way to prevent vaccine-preventable diseases. With the rising cost of the National Immunization Programme (NIP) in Sri Lanka, immunization costing studies could help programme managers to ensure sustainable immunization financing in the country. METHODS: Four medical officer of health (MOH) divisions in Kalutara district were included, to estimate the cost incurred for the NIP programme. Fifteen immunization clinics from urban and rural settings were selected from the selected MOH divisions, by a simple random sampling method. Data were collected for a period of 3 months, using pretested check-lists. In addition, related data at national and district levels were also collected. Cost estimates were made for direct capital and recurrent costs. RESULTS: The cost of vaccines under the national immunization schedule for infants was 1361.84 SL Rs (US$ 10.32). For children under 5 years of age, it was 1535.64 SL Rs (US$ 11.63). The majority of these costs were direct recurrent costs (93.4%). Vaccines (84.3%) and staff salaries (6.4%) were the main components of direct recurrent costs, while cold-chain equipment (5.3%) was the main contributor to direct capital cost. CONCLUSION: The cost of vaccine is the highest proportion among all other cost components in the NIP in Sri Lanka, and this is largely attributable to new costly vaccines. Staff payments are not significant, as they are a shared cost of public health service providers. Studies exploring the costing of the NIP in the country would be beneficial, to ensure sustainable immunization financing.

Cost-effectiveness of routine varicella vaccination using the measles, mumps, rubella and varicella vaccine in France: an economic analysis based on a dynamic transmission model for varicella and herpes zoster.

PURPOSE: Each year in France, varicella and zoster affect large numbers of children and adults, resulting in medical visits, hospitalizations for varicella- and zoster-related complications, and societal costs. Disease prevention by varicella vaccination is feasible, wherein a plausible option involves replacing the combined measles, mumps, and rubella (MMR) vaccine with the combined MMR and varicella (MMRV) vaccine. This study aimed to: (1) assess the cost-effectiveness of adding routine varicella vaccination through MMRV, using different vaccination strategies in France; and (2) address key uncertainties, such as the economic consequences of breakthrough varicella cases, the waning of vaccine-conferred protection, vaccination coverage, and indirect costs. METHODS: Based on the outputs of a dynamic transmission model that used data on epidemiology and costs from France, a cost-effectiveness model was built. A conservative approach was taken regarding the impact of varicella vaccination on zoster incidence by assuming the validity of the hypothesis of an age-specific boosting of immunity against varicella. FINDINGS: The model determined that routine MMRV vaccination is expected to be a cost-effective option, considering a cost-effectiveness threshold of €20,000 per quality-adjusted life-year saved; routine vaccination was cost-saving from the societal perspective. Results were driven by a large decrease in varicella incidence despite a temporary initial increase in the number of zoster cases due to the assumption of exogenous boosting. In the scenario analyses, despite moderate changes in assumptions about incidence and costs, varicella vaccination remained a cost-effective option for France. IMPLICATIONS: Routine vaccination with MMRV was associated with high gains in quality-adjusted life-years, substantial reduction in the occurrences of varicella- and zoster-related complications, and few deaths due to varicella. Routine MMRV vaccination is also expected to provide reductions in costs related to hospitalizations, medication use, and general-practitioner visits, as well as indirect costs, and it is expected to be a cost-effective intervention in France (GSK study identifier: HO-12-6924).

How might immunization rates change if cost sharing is eliminated?

OBJECTIVES: There is a debate regarding the effect of cost sharing on immunization, particularly as the Affordable Care Act will eliminate cost sharing for recommended vaccines. This study estimates changes in immunization rates and spending associated with extending first-dollar coverage to privately insured children for four childhood vaccines. METHODS: We used the 2008 National Immunization Survey and peer-reviewed literature to generate estimates of immunization status for each vaccine by age group and insurance type. We used the Truven Health Analytics 2006 MarketScan Commercial Claims and Encounters Database of line-item medical claims to estimate changes in immunization rates that would result from eliminating cost sharing, and we used the Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey to determine the prevalence of coverage for patients with first-dollar coverage, patients who face office visit cost sharing, and patients who face cost sharing for all vaccine cost components. We assumed that once cost sharing is removed, coverage rates in plans that impose cost sharing will rise to the level of plans that do not. RESULTS: We estimate that immunization rates would increase modestly and result in additional direct spending of $26.0 million to insurers/employers. Further, these payers would have an additional $11.0 million in spending associated with eliminating cost sharing for children already receiving immunizations. CONCLUSIONS: The effects of eliminating cost sharing for vaccines vary by vaccine. Overall, immunization rates will rise modestly given high insurance coverage for vaccinations, and these increases would be more substantial for those currently facing cost sharing. However, in addition to the removal of cost sharing for immunizations, these findings suggest other strategies to consider to further increase immunization rates.

Cost-effectiveness analysis of MMR immunization in health care workers.

BACKGROUND: Assessment of measles, mumps and rubella (MMR) status is an essential part of occupational health clearance for new health care workers (HCWs). At the time of this study the policy at Sheffield Occupational Health Service (SOHS) was to perform serological testing of HCWs without evidence of previous immunization prior to MMR vaccination. AIMS: To identify the cost implications of changing policy to offer vaccination without prior serological testing to HCWs without evidence of previous immunization. METHODS: A retrospective cohort analysis of all MMR serological results from individuals attending SOHS for pre-placement assessment between 1 April 2010 and 31 March 2012. RESULTS: Seven thousand five hundred and sixty-nine individuals attended SOHS for pre-placement screening. Of these, 52% (3921) had no evidence of prior vaccination to at least one MMR disease and underwent serological testing. Thirty-three per cent (1204) of these HCWs were sero-negative to at least one condition requiring vaccination. With the suggested change in policy, our data indicate a cost-saving of over £105 000 per year may currently be achieved at SOHS. CONCLUSIONS: Our findings highlight significant savings through offering vaccination without prior serology for HCWs with no evidence of prior immunization to MMR. An awareness of costs associated with serology, vaccination and staff clinics, as well as the wider impact of population vaccination campaigns, are important factors determining the most cost-effective strategy in this area.

Economic analysis of measles elimination program in the Republic of Korea, 2001: a cost benefit analysis study.

BACKGROUND: In this study, we modeled the cost benefit analysis for three different measles vaccination strategies based upon three different measles-containing vaccines in Korea, 2001. We employed an economic analysis model using vaccination coverage data and population-based measles surveillance data, along with available estimates of the costs for the different strategies. In addition, we have included analysis on benefit of reduction of complication by mumps and rubella. METHODS: We evaluated four different strategies: strategy 1, keep-up program with a second dose measles-mumps-rubella (MMR) vaccine at 4-6 years without catch-up campaign; strategy 2, additional catch-up campaign with measles (M) vaccine; strategy 3, catch-up campaign with measles-rubella (MR) vaccine; and strategy 4, catch-up campaign with MMR vaccine. The cost of vaccination included cost for vaccines, vaccination practices and other administrative expenses. The direct benefit of estimated using data from National Health Insurance Company, a government-operated system that reimburses all medical costs spent on designated illness in Korea. RESULTS: With the routine one-dose MMR vaccination program, we estimated a baseline of 178,560 measles cases over the 20 years; when the catch-up campaign with M, MR or MMR vaccines was conducted, we estimated the measles cases would decrease to 5936 cases. Among all strategies, the two-dose MMR keep-up program with MR catch-up campaign showed the highest benefit-cost ratio of 1.27 with a net benefit of 51.6 billion KRW. CONCLUSION: Across different vaccination strategies, our finding suggest that MR catch-up campaign in conjunction with two-dose MMR keep-up program was the most appropriate option in terms of economic costs and public health effects associated with measles elimination strategy in Korea.

A game dynamic model for vaccine skeptics and vaccine believers: measles as an example.

Widespread avoidance of Measles-Mumps-Rubella vaccination (MMR), with a consequent increase in the incidence of major measles outbreaks, demonstrates that the effectiveness of vaccination programs can be thwarted by the public misperceptions of vaccine risk. By coupling game theory and epidemic models, we examine vaccination choice among populations stratified into two behavioral groups: vaccine skeptics and vaccine believers. The two behavioral groups are assumed to be heterogeneous with respect to their perceptions of vaccine and infection risks. We demonstrate that the pursuit of self-interest among vaccine skeptics often leads to vaccination levels that are suboptimal for a population, even if complete coverage is achieved among vaccine believers. The demand for measles vaccine across populations driven by individual self-interest was found to be more sensitive to the proportion of vaccine skeptics than to the extent to which vaccine skeptics misperceive the risk of vaccine. Furthermore, as the number of vaccine skeptics increases, the probability of infection among vaccine skeptics increases initially, but it decreases once the vaccine skeptics begin receiving the vaccination, if both behavioral groups are vaccinated according to individual self-interest. Our results show that the discrepancy between the coverages of measles vaccine that are driven by self-interest and those driven by population interest becomes larger when the cost of vaccination increases. This research illustrates the importance of public education on vaccine safety and infection risk in order to maintain vaccination levels that are sufficient to maintain herd immunity.

Replacing the measles ten-dose vaccine presentation with the single-dose presentation in Thailand.

Introduced to minimize open vial wastage, single-dose vaccine vials require more storage space and therefore may affect vaccine supply chains (i.e., the series of steps and processes involved in distributing vaccines from manufacturers to patients). We developed a computational model of Thailand's Trang province vaccine supply chain to analyze the effects of switching from a ten-dose measles vaccine presentation to each of the following: a single-dose measles-mumps-rubella vaccine (which Thailand is currently considering) or a single-dose measles vaccine. While the Trang province vaccine supply chain would generally have enough storage and transport capacity to accommodate the switches, the added volume could push some locations' storage and transport space utilization close to their limits. Single-dose vaccines would allow for more precise ordering and decrease open vial waste, but decrease reserves for unanticipated demand. Moreover, the added disposal and administration costs could far outweigh the costs saved from preventing open vial wastage.

Universal mass vaccination against varicella in Germany using an MMRV combination vaccine with a two-dose schedule: an economic analysis.

Former economic analyses have shown that universal mass vaccination of infants against varicella using a one-dose schedule is cost-saving in Germany. In July 2006, an MMRV combination vaccine has been approved in Germany which shall be given in a two-dose schedule. We re-analysed our former analysis with the EVITA model in order to prove whether our former conclusion that universal mass vaccination against varicella is cost-saving is still valid when using a two-dose schedule vaccine. Indeed we found that universal mass vaccination of infants against varicella with a two-dose vaccine is cost-saving from societal as well as from health care perspective.

Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP).

Two live, attenuated varicella zoster virus-containing vaccines are available in the United States for prevention of varicella: 1) a single-antigen varicella vaccine (VARIVAX, Merck & Co., Inc., Whitehouse Station, New Jersey), which was licensed in the United States in 1995 for use among healthy children aged > or = 12 months, adolescents, and adults; and 2) a combination measles, mumps, rubella, and varicella vaccine (ProQuad, Merck & Co., Inc., Whitehouse Station, New Jersey), which was licensed in the United States in 2005 for use among healthy children aged 12 months-12 years. Initial Advisory Committee on Immunization Practices (ACIP) recommendations for prevention of varicella issued in 1995 (CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 1996;45 [No. RR-11]) included routine vaccination of children aged 12-18 months, catch-up vaccination of susceptible children aged 19 months-12 years, and vaccination of susceptible persons who have close contact with persons at high risk for serious complications (e.g., health-care personnel and family contacts of immunocompromised persons). One dose of vaccine was recommended for children aged 12 months-12 years and 2 doses, 4-8 weeks apart, for persons aged > or = 13 years. In 1999, ACIP updated the recommendations (CDC. Prevention of varicella: updated recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 1999;48 [No. RR-6]) to include establishing child care and school entry requirements, use of the vaccine following exposure and for outbreak control, use of the vaccine for certain children infected with human immunodeficiency virus, and vaccination of adolescents and adults at high risk for exposure or transmission. In June 2005 and June 2006, ACIP adopted new recommendations regarding the use of live, attenuated varicella vaccines for prevention of varicella. This report revises, updates, and replaces the 1996 and 1999 ACIP statements for prevention of varicella. The new recommendations include 1) implementation of a routine 2-dose varicella vaccination program for children, with the first dose administered at age 12-15 months and the second dose at age 4-6 years; 2) a second dose catch-up varicella vaccination for children, adolescents, and adults who previously had received 1 dose; 3) routine vaccination of all healthy persons aged > or = 13 years without evidence of immunity; 4) prenatal assessment and postpartum vaccination; 5) expanding the use of the varicella vaccine for HIV-infected children with age-specific CD4+ T lymphocyte percentages of 15%-24% and adolescents and adults with CD4+ T lymphocyte counts > or = 200 cells/microL; and 6) establishing middle school, high school, and college entry vaccination requirements. ACIP also approved criteria for evidence of immunity to varicella.

Measles, rubella, mumps, and varicella seroprevalence among health care workers in Turkey: is prevaccination screening cost-effective?

BACKGROUND: To investigate the immune status of health care workers (HCWs) against measles, rubella, mumps, and varicella zoster (MMRV) in Turkey and to define an appropriate vaccination program among HCWs. METHODS: Voluntary HCWs from a children's hospital and a general hospital were included in the study between March and May 2005. The specific IgG antibodies against MMRV viruses were screened by ELISA. RESULTS: Three hundred sixty-three HCWs participated in the study; 186 (51%) were physicians, 118 (33%) were nurses, 36 (10%) were housekeeping staff, and 23 (6%) were medical technicians. The proportion of HCWs who had antibodies against measles was 98.6%; rubella, 98.3%; mumps, 92.2%; and varicella, 98%. No association was found between the susceptibility to at least 1 of MMRV virus infections and gender, age, duration of work, profession, and department of work in analysis either among the whole study group, or each hospital. The positive predictive value for the history of varicella was 100%, whereas it was 92% for MMR. The cost of vaccination for varicella was significantly expensive without screening before vaccination. However, there was not much difference for MMR infections. CONCLUSION: A policy based on obtaining the history of varicella infection from the staff and then screening the ones with negative history and vaccination of only seronegative HCWs was found to be appropriate.

Assessing the introduction of universal varicella vaccination in the Netherlands.

Although varicella is seen as a benign disease in the Netherlands, about 40,000 visits to a general practitioner (GP) are made, over 200 hospital admission occur, and 2.3 persons die on average each year. Most of this burden of disease can be prevented by universal varicella childhood vaccination. Ten years after the introduction of the single-shot, single-component varicella childhood vaccination in the USA, a major reduction in hospitalization, mortality, and burden of disease has been reported. Using our recently vaccine evaluation model for the introduction of a new vaccine in our national immunization program, we have analyzed the feasibility of universal varicella vaccination by replacing the measles-mumps-rubella (MMR) vaccine with a measles-mumps-rubella-varicella (MMRV) vaccine. After structuring and reviewing the available data, two major points of uncertainty remain: (1) the influence of universal childhood vaccination on the incidence of zoster later in life; (2) the cost-effectiveness ratio for the Dutch situation. Despite these uncertainties it is clear that universal childhood vaccination will prevent most of the varicella related GP-visits, hospitalizations, and deaths.