[Table of Contents]

Volume: 23S4 - May 1997

Canadian National Report on Immunization, 1996

15. Cost-Benefit Analyses of Immunization Programs for Vaccine-Preventable Diseases

The World Bank has stated that immunization should be among the first public-health initiatives in which governments around the world invest⁽³⁴⁾. Indeed, vaccines are considered to be the most cost-beneficial health intervention and one of the few that systematically demonstrates more benefits than costs by far. A review of 587 life-saving interventions and their cost-effectiveness indicated that routine immunization programs for children were among the ones with better cost-effectiveness⁽³⁵⁾. They were also one of the very few programs with a cost of < $0 per year of life saved. The 587 interventions ranged from those that save more resources than they cost, i.e. a cost of < $0 per year of life saved, to those that cost > $10 billion per year of life saved. Overall, median intervention costs were US $42,000 per year of life saved. Many cost-benefit studies of immunization programs almost invariably demonstrate a very positive cost-benefit ratio, often in the range of 7 to 80 per 1. However, very few studies of immunization programs have been or are being conducted in the Canadian context; findings on Haemophilus influenzae type b, hepatitis B, measles, mumps, rubella, pertussis and invasive pneumococcal diseases are presented below.

15.1 Haemophilus influenzae type b

A study was undertaken in 1986 by Connaught Laboratories Ltd. to assess the effects of various vaccination programs on Hib systemic diseases in Canada. The morbidity, mortality, and cost impact of the disease in Ontario was examined extensively, and a model was developed to predict the morbidity, mortality, and cost impact of the disease under different circumstances. These included different hypothetical vaccination programs, including a routine single-dose program with a polysaccharide-conjugate PRP vaccine used at 24 months of age, a routine single-dose program at 18 months of age with a conjugate vaccine, and a routine three-dose primary series with a single booster at 18 months of age using a conjugate vaccine. The study indicated that all programs would be cost beneficial but that the most effective program would be the latter one, which would result in a net saving of $37,000,000 annually. This program is the one currently applied across Canada. More information on this study can be obtained from Dr. Van Exan, Connaught Laboratories Ltd.

15.2 Hepatitis B

A cost-effectiveness analysis of universal vaccination of infants against hepatitis B in Canada was conducted in 1993⁽³⁶⁾. If the cost of a dose of vaccine was approximately $7, the analysis concluded that universal vaccination would result in a net cost saving to society.  Universal vaccination against hepatitis B in infancy was concluded to be economically attractive and comparable in cost-effectiveness to existing health-care interventions. Lower vaccine prices (in 1993, the cost was approximately $30 per dose) would also greatly improve the attractiveness of universal immunization. Today the cost of vaccine is substantially lower, and provinces have started universal immunization, mostly of adolescents.

15.3 Measles, mumps, and rubella

Health Canada commissioned a cost-benefit study of a routine two-dose MMR immunization program together with a mass campaign using MR vaccine, compared to the current one-dose immunization strategy. The use of MR and MMR vaccines (instead of monovalent measles vaccine) was based on the recommendation of a federal/provincial working group on measles elimination.

The benefits included all direct health-care costs which would be averted by a two-dose program and a mass campaign. Also included were all indirect costs incurred by patients or their families, such as loss of productivity. The estimated direct and indirect costs added up to $929 on average for each measles case. The averted costs related to outbreak-control activities by using a two-dose program and a mass campaign were also taken in consideration; they averaged $520 for each outbreak- related case of measles. Costs of the program included the price of the vaccine, its administration, the direct and indirect costs of VAAEs, and other mass-campaign costs such as planning, management, promotional activities, and evaluation.

The study presented cost-benefit analyses for two scenarios. The calculations covered a prospective 20 years. The first scenario was a routine two-dose schedule of MMR vaccine at 18 months of age plus a mass-campaign with MR vaccine for all people from 18 months of age to 18 years of age. The cost-benefit ratio for this scenario was that for each $1.00 spent, benefits were $2.61. The second scenario was a routine two-dose schedule of MMR vaccine at 5 years of age plus a mass- campaign with MR vaccine for all people from 5 to 18 years of age. The cost-benefit ratio for this scenario was slightly higher, i.e. for each $1.00 spent, benefits were worth $2.92. A sensitivity analysis, using measles monovalent vaccine for the mass campaign instead of MR vaccine, found a similar ratio, i.e. for each $1.00 spent, benefits were worth $2.92. A further sensitivity analysis, using the MMR vaccine instead of MR vaccine for the mass campaign, found a lower ratio, i.e. for each $1.00 spent, benefits were worth $2.56. The costs of purchasing these vaccines may vary in a ratio of up to 8:1 with costs for MMR vaccine potentially being prohibitive for a mass campaign.

A study of the economic benefits of a routine second dose of MMR vaccine in Canada was also sponsored by Merck-Frosst Canada Inc. and conducted by the Montreal-based health economics company, Benefit Canada Inc. Findings also indicate that a routine second-dose immunization with MMR would result in considerable cost savings in Canada. More information can be obtained by contacting Dr. Marc Rivière of Benefit Canada Inc.

15.4 Pertussis

Acellular pertussis vaccines are currently licensed in Canada for use as the fourth and fifth booster doses at 18 months of age and 4 to 6 years of age, respectively. Licensing of acellular vaccines for primary series in infants is expected in the near future. The relative safety, protection provided from disease, and cost-benefit ratios of the acellular vaccines in comparison with currently available whole-cell vaccines are critical issues related to the introduction of acellular vaccines into routine immunization programs of infants.

A selective license for the use of acellular vaccines as fourth and fifth booster doses was given in 1993 in the United States. An overall direct cost-benefit ratio for the DTP vaccine was estimated as $6.21 saved for each $1.00 spent on immunization; the cost-benefit ratio of the pertussis component alone is $8.39 saved for each $1.00 spent. Recently a cost-benefit study was conducted on the use of DTaP vaccines for all doses. Assuming no additional visits and that the prices of new acellular vaccines would be similar to those already licensed, a direct cost-benefit ratio for immunization with DTaP vaccines was estimated for each $1.00 spent, benefits were worth $5.35; for the acellular pertussis component alone, benefits were worth $5.98 for each $1.00 spent.

The analyses were based on assumed savings of $20.5 million averted from the treatment of common and moderately serious adverse events. However, additional savings (not included in the modelling for the above estimates) could be anticipated: $12 million from lower rates of more serious adverse events; $40 million from reduction of pertussis cases; $15 million from reduction of compensation costs; and potentially $30 to $80 million if more DTaP vaccines were allowed, thus eliminating the one-dose pertussis vaccine.

The Division of Immunization sponsored a study under contract to the Ottawa-based firm of Pran-Manga and Associates regarding the new acellular pertussis vaccines. The purpose was to provide quantitative estimates of the economic benefits and costs of introducing new acellular pertussis vaccine combinations to replace previous whole-cell pertussis vaccine combinations in routine immunization schedules in Canada. The intent was to present estimates in a manner suitable for purposes of provincial and territorial policy and program planning. The analysis assumed that the five-dose schedule for pertussis would continue to be used. Analysis of multiple versus single injections (assuming no additional visits were included) was done based on trivalent or quadravalent products because, at the time, a penta product (i.e. with diphtheria, pertussis, tetanus, Hib and polio) was not licensed. Extra time spent for multiple injections was envisioned as well as the potential negative impact on public acceptance. The results indicated a very favourable cost-benefit ratio for introducing the new products and overall cumulated potential savings of up to $370 million by the year 2007.

15.5 Invasive pneumococcal diseases

The utility and costs of an immunization program against invasive pneumococcal infections is currently being studied. The effectiveness of an immunization program using the pneumococcal polysaccharide vaccine to reduce mortality and morbidity is being evaluated in four categories of high-risk patients: residents in long-term care facilities, patients with chronic illnesses, persons ³ 65 years of age, and HIV-infected persons. Quality-adjusted years of life gained will be used to assess the program's utility. Costs for the program promotion, and supply and administration of vaccines will be estimated from a societal perspective. The principal investigator in this study is Dr. Philippe De Wals, University of Sherbrooke; the work is being conducted under a grant from the Conseil d'évaluation des technologies de la santé du Québec.  A report is expected in the near future.

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