Economic benefits of hepatitis B vaccination at sexually transmitted disease clinics in the U.S

OBJECTIVE: This study assessed the long-term economic implications of a national program to vaccinate all adults treated at sexually transmitted disease (STD) clinics in a single year. METHODS: A model was developed to track the long-term disease outcomes and costs among a hypothetical cohort of 2 million STD clinic clients accessing services in one year, using data from published sources and demonstration projects at STD clinics in San Diego (California), Illinois, and Denver (Colorado). The model estimated net economic benefits of a routine hepatitis B vaccination policy at STD clinics nationwide compared with no vaccination. RESULTS: Without a vaccination program, an estimated 237,021 new hepatitis B virus (HBV) infections would occur over the lifetimes of the 2 million STD clinic clients seen in a single year. HBV-related medical costs and productivity losses would be $1.6 billion. In a national program for routine vaccination at STD clinics, 1.3 million adults would be expected to receive at least one vaccine dose, and an estimated 45% of the new HBV infections expected without vaccination would be prevented. The vaccination program would cost $138 million, HBV infections occurring despite the program would cost $878 million, and clients' time and travel would cost $45 million. The net economic benefit (savings) of routine vaccination would be $526 million. If the indirect costs of lost productivity due to HBV infection are not considered, routine vaccination would have a net cost of $28 million. CONCLUSIONS: Estimates from this model suggest a national program for routine hepatitis B vaccination of adults at STD clinics would be a cost saving to society.     

An outbreak of chickenpox at a child care centre in Western Australia. Costs to the community and implications for vaccination policy

OBJECTIVE: Between May and June 2002 an outbreak of chickenpox (CP) occurred at a child care centre in Perth, Western Australia. An epidemiological study was undertaken in order to determine the characteristics of the outbreak, assess vaccine effectiveness, and to define the direct and indirect costs associated with CP infections in young children. METHODS: A cohort study of the outbreak utilising attendance records and a telephone survey of parents was conducted. RESULTS: Of the 211 children attending the child care centre at the time of the outbreak, 44 contracted CP (attack rate 25.7%). In addition, two staff members, five secondary household contacts (secondary attack rate 38.5%) and four secondary non-household associated contacts were infected. There were no severe complications or any hospitalisations recorded in infected persons. Two cases had been vaccinated previously. Vaccine effectiveness for CP of any severity was 78.0% (95% CI 15.4-94.3%) while vaccine effectiveness against severe CP was 100%. Direct costs during this outbreak were estimated to be $54 per case and the total costs, including cost of parental time off work or study, were estimated to be $525.73 per case. CONCLUSIONS AND IMPLICATIONS: Although morbidity associated with CP in young children is not great, infection in childhood is almost universal. This study found that the average costs associated with each CP case were considerable. Since varicella vaccine affords good protection against CP, the recent inclusion of this vaccine in the Australian childhood vaccination schedule should save the community a considerable amount in direct and indirect costs if high coverage rates can be achieved.     

Cost-effectiveness and socio-economic aspects of childhood influenza vaccination

Children have high rates of healthcare utilization due to influenza. In addition, children also transmit influenza to others in their households and the community. The costs of influenza in children include the direct medical care costs from increased outpatient visits and hospitalizations, and also indirect costs due to productivity losses especially for their parents and due to transmission of the virus to others. A variety of studies using different methods and assumptions have assessed the cost-effectiveness of influenza vaccination of children, and many find that vaccination is either cost saving or cost effective.     

Costs of a hepatitis A outbreak affecting homosexual men: Franklin County, Ohio, 1999

BACKGROUND: Hepatitis A is one of the most commonly reported, vaccine-preventable diseases in the United States. Many cases occur in association with community-wide outbreaks, but societal costs to the community are seldom documented. METHODS: Hepatitis A case-patients available for a follow-up interview as part of an outbreak investigation were asked about hospitalization, healthcare costs, missed work, and lost wages associated with their illness, as well as healthcare insurance coverage and sick-leave reimbursement. Average costs were calculated by case-patient age, gender, and hospitalization status for lost wages, and by age and hospitalization status for medical costs, and then assigned to case-patients not re-interviewed to provide an estimate of overall costs. Health departments provided outbreak-associated costs. RESULTS: Between the weeks of November 2, 1998, and May 17, 1999, a total of 136 cases of hepatitis A were reported. Of the 89 (65.4%) case-patients available for interview, 74 (83%) were male; of those, 47 (64%) identified themselves as men who have sex with men (MSM). The average cost of the outbreak per case-patient was $2894 US dollars, of which 51% was associated with lost wages, 40% with medical costs, and 9% with health department costs. Case-patients incurred 44% of total outbreak costs; employers, 29%; healthcare insurers, 18%; and health departments, 9%. CONCLUSIONS: In this community-wide hepatitis A outbreak, case-patients incurred the largest portion of costs, followed by employers, healthcare insurers, and health departments.     

Two nosocomial pertussis outbreaks and their associated costs - King County, Washington, 2004.

OBJECTIVE: Pertussis outbreaks in healthcare settings result in resource-intensive control activities, but studies have rarely evaluated the associated costs. We describe and estimate costs associated with 2 nosocomial pertussis outbreaks in King County, Washington, during the period from July 25 to September 15, 2004. One outbreak occurred at a 500-bed tertiary care hospital (hospital A), and the other occurred at a 250-bed pediatric hospital (hospital B). METHODS: We estimated the costs of each outbreak from the hospitals' perspective through standardized interviews with hospital staff and review of contact tracing logs. Direct costs included personnel time and laboratory and medication costs, whereas indirect costs were those resulting from hospital staff furloughs. RESULTS: Hospital A incurred direct costs of $195,342 and indirect costs of $68,015; hospital B incurred direct costs of $71,130 and indirect costs of $50,000. Cost differences resulted primarily from higher personnel costs at hospital A ($134,536), compared with hospital B ($21,645). Total cost per pertussis case was $43,893 for hospital A (6 cases) and $30,282 for hospital B (4 cases). Total cost per person exposed to a pertussis patient were $357 for hospital A (738 exposures) and $164 for hospital B (737 exposures). CONCLUSIONS: Nosocomial pertussis outbreaks result in substantial costs to hospitals, even when the number of pertussis cases is low. The cost-effectiveness of strategies to prevent nosocomial pertussis outbreaks, including vaccination of healthcare workers, should be evaluated.     

Vaccination of Sexually Active Homosexual Men Against Hepatitis A: Analysis of Costs and Benefits

Objective: To estimate costs and benefits of vaccinating young homosexual men against hepatitis A. Design and setting: A decision-analytic model was used to assess vaccination from the societal perspective. Effects of vaccination at age 20 were modeled through each person's lifetime, with costs discounted at 3% annually. Intervention: Two doses of formalin-inactivated vaccine (Havrix, Smithkline Beecham Pharmaceuticals) administered by intramuscular injection 6–12 months apart. Results: Vaccination of 10,000 men would cost $959,000. Over the lifetimes of cohort members, hepatitis A-related hospitalizations would decline from 366 to 76, and treatment costs would decline from $2,577,000 to $363,000. Treatment cost reduction would fully offset vaccination costs within 10 years. Productivity losses associated with hepatitis A morbidity, primarily work absenteeism, would decline by $5,231,000. Vaccination would prevent an estimated 8.6 premature deaths, saving 213 life-years and $2,836,000 in mortality-related productivity losses. Results are only modestly affected when model assumptions are varied within plausible ranges. Conclusions: Hepatitis A vaccine provides improved patient outcomes and cost reduction. From a societal perspective, vaccination provides $10.72 in economic benefits for every $1 spent on vaccination. Physicians should counsel homosexual men to be vaccinated against hepatitis A. Health insurers would find it in their own financial interest to cover vaccination.     

The economic costs of Alzheimer's disease.

This paper estimates the economic costs of Alzheimer's Disease to individuals and to society, based on review of published Alzheimer's Disease-related research. The analysis is derived from epidemiological projections and cost information for the United States population in 1983. Estimated costs include both direct medical care and social support costs, as well as indirect costs, such as support services provided by family or volunteers, and the value of lost economic productivity in Alzheimer's Disease patients. Mid-range estimates of net annual expected costs for an Alzheimer's Disease patient, excluding the value of lost productivity, are $18,517 in the first year and $17,643 in subsequent years, with direct medical and social services comprising about half of these costs. Under base case assumptions, the total cost of disease per patient in 1983, was $48,544 to $493,277, depending upon patient's age at disease onset. The estimated present value of total net costs to society for all persons first diagnosed with Alzheimer's Disease in 1983 was $27.9-31.2 billion. Development of a public or private insurance market for the economic burdens of Alzheimer's Disease would fill some of the gaps in the current US system of financing long-term chronic disease care.     

The cost-effectiveness of introducing a varicella vaccine to the New Zealand immunisation schedule.

This study examined the cost-effectiveness of adding a varicella vaccine to an existing childhood immunisation schedule relative to a counterfactual where the varicella vaccine is available on a user-pays basis (the current New Zealand situation). The costs and consequences of chickenpox in an annual cohort of 57,200, 15-month old children were simulated for a 30-year period. The cohort simulation design captures the 'phasing-in' effects of routine varicella vaccination on the population. From a health care payer's perspective (medical costs only) every dollar invested in a vaccination programme would return NZ $0.67. However, from a societal point of view (which includes the value of work-loss), a vaccination programme would return NZ $2.79 for every dollar invested. To implement a varicella vaccination programme covering 80% of 15-month old children in New Zealand would add more than NZ $1 million in net direct (health care) costs each year. However, the indirect cost savings from reduced losses of work-time exceed NZ $2 million annually. The net average health care cost per child vaccinated over the 30-year modelling period was $54 whereas the cost-savings from work-loss averted averaged $101 per child vaccinated. Total cost-savings to society of $47 per child vaccinated, on average, could be gained from a vaccination programme. The finding that the addition to vaccination costs resulting from a routine programme (including the cost of complications from the vaccine) were greater than the offsetting health care cost savings from reduced incidence of chickenpox were robust to a sensitivity analysis on all assumptions within plausible ranges. Overall cost-effectiveness estimates were most sensitive to assumptions regarding lost work-time, the discount rate, and the price and efficacy of the vaccine. Estimates were relatively insensitive to changes in assumptions regarding health care utilisation.     

Cost-effectiveness of hepatitis B screening in a mental health institution.

In 1982, the Ohio Department of Health Screening established guidelines for hepatitis B screening and vaccination for intermediate mental health care facilities. The present study was developed to evaluate the cost-effectiveness of these guidelines. Data from an intermediate mental health care institution in Champaign/Urbana, Illinois, were used. The analysis considered the direct costs and benefits accrued over a 3-year period and a range of transmission rates. At a 3-year transmission rate of 0.030, the screening and vaccination policy cost $7300 per case of hepatitis B avoided (or $345,800 per hepatitis B fatality avoided). At a more likely 3-year transmission rate of 0.271, the screening and vaccination policy cost $300 per case of hepatitis B avoided (or $12,100 per hepatitis B fatality avoided). Either way, the active prevention policy compares very well with the amounts of money spent by the US Government on other life-saving programs. A general cost-effectiveness model is given that can be adapted for institution-specific analyses at other mental health care facilities.     

Costs of occupational injuries in agriculture

OBJECTIVE: This study was conducted to estimate the costs of job-related injuries in agriculture in the United States for 1992. METHODS: The authors reviewed data from national surveys to assess the incidence of fatal and non-fatal farm injuries. Numerical adjustments were made for weaknesses in the most reliable data sets. For example, the Bureau of Labor Statistics (BLS) Annual Survey estimate of non-fatal injuries is adjusted upward by a factor of 4.7 to reflect the BLS undercount of farm injuries. To assess costs, the authors used the human capital method that allocates costs to direct categories such as medical expenses, as well as indirect categories such as lost earnings, lost home production, and lost fringe benefits. Cost data were drawn from the Health Care Financing Administration and the National Council on Compensation Insurance. RESULTS: Eight hundred forty-one (841) deaths and 512,539 non-fatal injuries are estimated for 1992. The non-fatal injuries include 281,896 that led to at least one full day of work loss. Agricultural occupational injuries cost an estimated $4.57 billion (range $3.14 billion to $13.99 billion) in 1992. On a per person basis, farming contributes roughly 30% more than the national average to occupational injury costs. Direct costs are estimated to be $1.66 billion and indirect costs, $2.93 billion. CONCLUSIONS: The costs of farm injuries are on a par with the costs of hepatitis C. This high cost is in sharp contrast to the limited public attention and economic resources devoted to prevention and amelioration of farm injuries. Agricultural occupational injuries are an underappreciated contributor to the overall national burden of health and medical costs.     

The economic cost of senile dementia in the United States, 1985

Senile dementia is a progressive and irreversible decline of mental functions. The symptoms are mental confusion, memory loss, disorientation, cognitive decline, and inappropriate social behavior. It is one of the most common, costly, and distressful diseases among the elderly in the United States. Information on the economic costs of senile dementia is essential for determining research priorities and the allocation of resources to support aging and medical research. Economic consequences, such as direct medical and nonmedical expenditures by patients' families and the amount of time by third parties in caring for patients with senile dementia, are substantial. However, little systematic accounting to estimate these consequences has been undertaken. This paper attempts to estimate various costs associated with the care of senile dementia, based on available secondary data. We have used the direct cost and indirect cost approach and avoided double counting to identify the additional economic costs due to senile dementia. The total, direct national cost of senile dementia is $13.26 billion, which includes $6.36 billion of medical care costs, $2.56 billion of nursing home care costs, and $4.34 billion of social agency service costs. The indirect cost for community home care alone is $31.46 billion, more than twice the total direct costs. The costs of premature death and loss of productivity due to senile dementia are about $43.17 billion. Although most of the indirect costs were imputed from the value of housekeeping or productivity loss, the magnitude of indirect costs reflects the serious consequences and burden on society's resources of this disease.     

Economic and social impact of epidemic and pandemic influenza

Amidst the human suffering caused an influenza epidemic it is all too easy to overlook the disease's wider social and economic impact. Not only does influenza impose huge infrastructure demands on health care systems, but it exacts substantial economic costs in terms of sickness-related absenteeism, disrupted work schedules and lost productivity to society at large. Influenza accounts for around 10% of sickness-related absence from work in Europe where the likely cost of lost productivity in France and Germany, for example, ranges from 5.6 billion pounds to 8.5 billion pounds per year, according to ESWI estimates. But how to assess the full economic impact of influenza? The direct costs are easily enough identified, but what about the indirect costs? How should these be measured? How for example, does one assess the cost of lost opportunities, and what are the economic gains of vaccination regarding avoided costs? Finally, which target groups for vaccination would generate the greatest avoided costs? Leaving aside the moral implications of such a question, the fact remains that politicians and health policymakers need the cold hard figures to optimally allocate the costs of vaccination and preventative health campaigns. These issues and more were clearly delineated during this session, co-chaired by Drs. T. Szucs of the University of Zurich and K. Nichol of the University of Minnesota     

Cost of a measles outbreak in a remote island economy: 2014 Federated States of Micronesia measles outbreak

After 20 years with no reported measles cases, on May 15, 2014 the Centers for Disease Control and Prevention (CDC) was notified of two cases testing positive for measles-specific immunoglobulin M (IgM) antibodies in the Federated States of Micronesia (FSM). Under the Compact of Free Association, FSM receives immunization funding and technical support from the United States (US) domestic vaccination program managed by the Centers for Disease Control and Prevention (CDC). In a collaborative effort, public health officials and volunteers from FSM and the US government worked to respond and contain the measles outbreak through an emergency mass vaccination campaign, contact tracing, and other outbreak investigation activities. Contributions were also made by United Nations Children’s Emergency Fund (UNICEF) and World Health Organization (WHO). Total costs incurred as a result of the outbreak were nearly $4,000,000; approximately $10,000 per case. Direct medical costs (≈$141,000) were incurred in the treatment of those individuals infected, as well as lost productivity of the infected and informal caregivers (≈$250,000) and costs to contain the outbreak (≈$3.5 million). We assessed the economic burden of the 2014 measles outbreak to FSM, as well as the economic responsibilities of the US. Although the US paid the majority of total costs of the outbreak (≈67%), examining each country’s costs relative to their respective economy illustrates a far greater burden to FSM. We demonstrate that while FSM was heavily assisted by the US in responding to the 2014 Measles Outbreak, the outbreak significantly impacted their economy. FSM’s economic burden from the outbreak is approximately equivalent to their entire 2016 Fiscal Year budget dedicated to education.     

The cost-effectiveness of rotavirus vaccination in Armenia

The cost-effectiveness of introducing infant rotavirus vaccination in Armenia in 2012 using Rotarix(R) was evaluated using a multiple birth cohort model. The model considered the cost and health implications of hospitalisations, primary health care consultations and episodes not leading to medical care in children under five years old. Rotavirus vaccination is expected to cost the Ministry of Health $220,000 in 2012, rising to $830,000 in 2016 following termination of GAVI co-financing, then declining to $260,000 in 2025 due to vaccine price maturity. It may reduce health care costs by $34,000 in the first year, rising to $180,000 by 2019. By 2025, vaccination may be close to cost saving to the Ministry of Health if the vaccine purchase price declines as expected. Once coverage has reached high levels, vaccination may prevent 25,000 cases, 3000 primary care consultations, 1000 hospitalisations and 8 deaths per birth cohort vaccinated. The cost per disability-adjusted life year (DALY) saved is estimated to be about $650 from the perspective of the Ministry of Health, $850 including costs accrued to both the Ministry and to GAVI, $820 from a societal perspective excluding indirect costs and $44 from a societal perspective including indirect costs. Since the gross domestic product per capita of Armenia in 2008 was $3800, rotavirus vaccination is likely to be regarded as “very cost-effective” from a WHO standpoint. Vaccination may still be “very cost-effective” if less favourable assumptions are used regarding vaccine price and disease incidence, as long as DALYs are not age-weighted.     

Relationship between obesity and school absenteeism in Australian children: Implications for carer productivity

BackgroundEconomic evaluations of childhood obesity interventions are often used to assist decision making when presented with alternative course of action. Including indirect costs related to productivity losses is recommended; in children this would include school absenteeism. Our aim was to determine the association between school absenteeism and weight status among Australian children and estimate the indirect costs of this.MethodsWe used data from a nationally representative sample of 8551 Australian children in the Longitudinal study of Australian Children (LSAC) with follow-up between 2006 and 2018. A mixed-effects negative binomial regression model was used to investigate the relationship between school absenteeism and weight status, controlling for age, sex, socio-economic position, indigenous status, rural/remote status and long-term medical conditions. We used average daily wages for the year 2018 to value the indirect costs of school absenteeism (through caregiver lost productivity).ResultsAustralian children with obesity aged 6−13 years missed on average an extra day of school annually compared to children of a healthy weight (p = 0.004), while adolescents with obesity aged 14−17 years missed on average an extra 0.69 days of school annually (p = 0.006). The estimated national cost for children with obesity aged 6−13 years was approximately $64 million AUD ($43 million USD) or $338 AUD ($230 USD) per child through caregiver lost productivity in 2018.ConclusionsThere is a small but significant association between school absenteeism and childhood obesity in Australia which is estimated to generate a considerable national cost through caregiver productivity losses. Our results will assist health economists evaluating childhood obesity interventions capture the full extent of the associated costs with this condition.     

Health care and lost productivity costs of overweight and obesity in New Zealand

Objective: To estimate the costs of health care and lost productivity attributable to overweight and obesity in New Zealand (NZ) in 2006. Methods: A prevalence‐based approach to costing was used in which costs were calculated for all cases of disease in the year 2006. Population attributable fractions (PAFs) were calculated based on the relative risks obtained from large cohort studies and the prevalence of overweight and obesity. For each disease, the PAF was multiplied by the total health care cost. The costs of lost productivity associated with premature mortality were estimated using both the Human Capital approach (HCA) and Friction Cost approach (FCA). Results: Health care costs attributable to overweight and obesity were estimated to be NZ$624m or 4.4% of New Zealand's total health care expenditure in 2006. The costs of lost productivity using the FCA were estimated to be NZ$98m and NZ$225m using the HCA. The combined costs of health care and lost productivity using the FCA were $722m and $849m using the HCA. Conclusion: The cost burden of overweight and obesity in NZ is considerable. Implications: Policies and interventions are urgently needed to reduce the prevalence of obesity thereby decreasing these substantial costs.     

Economic burden of influenza illness among children under 5 years in Suzhou,China: Report from the cost surveys during 2011/12 to 2016/17 influenza seasons

BackgroundData are limited on the economic burden of seasonal influenza in China. We estimated the cost due to influenza illness among children < 5-year-old in Suzhou, China.MethodsThis study adopted a societal perspective to estimate direct medical cost, direct non-medical cost, and indirect cost related to lost productivity. Data to calculate costs and rates of three influenza illness outcomes (non-medically attended, outpatient and hospitalization) were collected from prospective community-based cohort studies and hospital-based enhanced laboratory-confirmed influenza surveillance in Suzhou during the 2011/12 to 2016/17 influenza seasons. We used mean cost-per-episode, annual incidence rates of episodes of each outcome, and annual population size to estimate the total annual economic burden of influenza illnesses among children < 5-year-old for Suzhou. All costs were reported in 2017 U.S. dollars.ResultsThe mean cost-per-episode (standard deviation) was $9.92 (13.26) for non-medically attended influenza, $161.05 (176.98) for influenza outpatient illnesses, and $1425.95 (603.59) for influenza hospitalizations. By applying the annual incidence rates to the population size, we estimated an annual total of 4,919 episodes of non-medically attended influenza, 21,994 influenza outpatient, and 2,633 influenza hospitalization. Total annual economic burden of influenza to society among children < 5-year-old in Suzhou was $7.37 (95% confidence interval, 6.9–7.8) million, with estimated costs for non-medically attended influenza of $49,000 (46,000–52,000), influenza outpatients $3.5 (3.3–3.8) million, and influenza hospitalizations $3.8 (3.6–3.9) million. Among outpatients, the indirect cost was 36.3% ($1.3 million) of total economic burden, accounting for 21,994 days of lost productivity annually. Among inpatients, the indirect cost was 22.1% ($829,000), accounting for 18,431 days of lost productivity annually.ConclusionsOur findings show that influenza in children < 5-year-oldcauses substantial societal economic burden in Suzhou, China. Assessing the potential economic benefit of increasing influenza vaccination coverage in this population is warranted.     

Economic costs of HIV infection: an employer's perspective

The introduction of highly active antiretroviral therapy has proven highly effective in treating patients with HIV/AIDS. However, the high cost of the advanced antiretroviral therapy has led to increased financial constraints on both patients and payers. From business firms'perspective, especially those with operations in developing countries, it is crucial to determine the long-term economic cost implications of alternative employment and benefit policies for HIV-infected workers or those at high risk for the disease. A simulation model is developed to predict the comprehensive lifetime economic costs of HIV-infected workers to an employer. This model employs age,CD4⁺ cell counts,and plasma HIV-1 RNA level as major predictors of the disease progression and patient survival in the determination of various cost functions.Major cost components considered include direct expenses on health insurance premium,life insurance premium, short-term disability benefits, long-term disability benefits, hiring/training expenses, and indirect costs resulting from reduced or lost productivity at work. An individual model and a group model are derived to estimate the costs of an individual and a group of HIV-infected patients, respectively.Over a 10-year period, following the nonadvanced antiretroviral treatment regimen, the group model predicts that the total lifetime cost of an HIV-infected worker can be as high as U.S. $90,000 to his/her employer, of which $60,000 would be various explicit costs and $30,000 lost work productivity. Sensitivity analysis further demonstrated that changes in the initial level of age,CD4⁺ cell count, HIV-1 RNA viral load,CD4⁺ cell decline rate, and the costs of medical care influence the dynamics of the cost functions. HIV infection can result in sizable economic costs to an employer over the lifetime course of an infected employee if not treated with the advanced antiretroviral therapy.These cost estimates provide a rational economic basis for an employer to optimally assess the longrun costs and benefits of alternative employment and insurance policies in the care of employees with HIV infection. Gordon G. Liu Pharmaceutical Policy and Evaluative Sciences, Beard Hall, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7360, USA, e-mail: ggliu@unc.edu     

Cost-utility analysis of hepatitis A prevention among health-care workers in Israel

This study was conducted to evaluate the efficiency of different strategies of preventing hepatitis A (HA) among physicians, nurses, and paramedical staff by means of cost-effectiveness analysis. The strategies compared were passive immunization during a hepatitis A outbreak, systematic mass vaccination of all workers, and screening for antibodies to HA virus followed by vaccination of nonimmune employees. To predict the prevented number of HA cases, an epidemiological model was incorporated based on our previous nationwide study on clinical HA cases, seroepidemiological survey, and other scientific medical literature. Under the model assumptions, the lowest cost per prevented HA case ($6240) was achieved by screening prior vaccination among 18- to 39-year-old physicians and paramedical workers, and highest ($61,858) by mass vaccination of nurses over age 39 years. Because the price per prevented case may show that mass vaccination is highly cost-effective, especially among 18- to 39-year-old physicians and paramedical workers ($6399 and $8196, respectively), the cost per gained quality-adjusted life-year seems less attractive ($56,532 and $61,350, respectively). This cost per saved quality-adjusted life-year is similar to many other medical interventions but is markedly higher than other primary prevention vaccines, which are mostly associated with a negative ratio. In view of the conducted study, and taking $60,000 as a limit cost per saved quality-adjusted life-year, we propose selective vaccination for physicians and for paramedical workers. Mass vaccination should be offered to all health care workers, aside from nurses 40+ years of age, once the active HA vaccine price is reduced to $23.