Economic evaluations of varicella vaccination programmes: a review of the literature

Chickenpox infections are generally mild but due to their very high incidence among healthy children they give rise to considerable morbidity and occasional mortality. With the development of a varicella vaccine in the early 1970s and its progressive licensing in many countries, interest in the efficiency of varicella immunisation programmes grew. The objective of this review was to discuss the methodological aspects and results of published economic evaluations of varicella vaccination. From this, we attempted to make recommendations. A computerised search was carried out; 17 full economic evaluations of varicella vaccination were retrieved. The review identified the methodological divergences and similarities between the articles in four areas: study design, epidemiological data, economic data and model characteristics. We assessed to what extent the applied methods conform to general guidelines for the economic evaluation of healthcare interventions and compared the studies' results. The desirability of a universal vaccination programme depends on whose perspective is taken. Despite variability in data and model assumptions, the studies suggest that universal vaccination of infants is attractive to society because large savings occur from averted unproductive days for parents. For the healthcare payer, universal vaccination of infants does not generate savings. Vaccination of susceptible adolescents has been proposed by some authors as a viable alternative; the attractiveness of this is highly dependent on the negative predictive value of anamnestic screening. Targeted vaccination of healthcare workers and immunocompromised individuals appears relatively cost effective. Findings for other target groups are either contradictory or provide insufficient evidence for any unequivocal recommendations to be made. High sensitivity to vaccine price was reported in most studies. This review highlights that some aspects of these studies need to be further improved before final recommendations can be made. First, more transparency, completeness and compliance to general methodological guidelines are required. Second, because of the increasing severity of varicella with age, it is preferable and in some cases essential to use dynamic models for the assessment of universal vaccination strategies. Third, most studies focused on the strategy of vaccinating children only while their results depended heavily on disputable assumptions (regarding vaccine effectiveness and impact on herpes zoster). Since violation of these assumptions could have important adverse public health effects, we suggest pre-adolescent vaccination as a more secure alternative. This option deserves more attention in future analyses.     

Economic evaluation of vaccination

With increasing expenditures in healthcare, in absolute terms as well as in relative terms, interest in the efficiency of certain interventions in healthcare has also increased. Faced with the limitations of the healthcare budget, budget holders try to find the optimal way of dividing their funds over different healthcare provisions, without discarding human and medical considerations. In economic terms, this process could be called the 'optimal allocation of scarce resources over the inputs of a function of production'. The means of production would then be 'the provision of healthcare', whereas the output would be 'improvement of health'. Clearly choices have to be made with regard to spending the healthcare budget. One of the instruments that can help in making such choices is the economic evaluation. In economic evaluations of vaccinations, different vaccination strategies are defined. The consequences in terms of costs and effects of each strategy are being calculated and compared with a reference strategy, which is often the nonintervention strategy, i.e. 'no vaccination'. According to the way in which the benefit or the output of vaccination-'improvement of health'-is measured, a distinction is made between various methods of economic evaluation: in a cost-effectiveness analysis, health gains are measured in natural units (e.g. prevented infections, prevented illness days, life-years gained, etc.); in a cost-utility analysis, the quality of the health gains is taken into account (e.g. quality-adjusted life-year); and in a cost-benefit analysis, health gains are converted into monetary units. Costs can be divided into direct and indirect costs. Direct costs are directly related to medical treatments (medication, laboratory tests, consultations, etc.) or to vaccination (e.g. purchasing price of the vaccine, costs for administering the vaccine, treatment of side effects, etc.). Costs indirectly related to treatments and vaccination are mainly costs of lost productivity due to disease morbidity or mortality, and opportunity costs. In comparison with other vaccine-preventable infections, influenza vaccination for the elderly seems acceptable from an economic point of view (about $US650 per life-year gained, in 1981). Cost-effectiveness ratios of other vaccinations range from about $US720 per life-year gained for universal hepatitis B vaccination to about $US190,000 per life-year gained for universal Haemophilus influenzae type by vaccination. Because of differences in methods, the representation of results, and country-specific parameters, different economic evaluations of the same vaccination strategy may show divergent results. Therefore, until sufficient standardisation of economic evaluations exists, comparisons of the sort we are making here should be interpreted with prudence.     

Management protocol of venomous snakebite in India: a consensus statement

Venomous snakebite is a significant cause of mortality and morbidity in South East Asia. The WHO, in 2009 declared venomous snakebite as one of the “neglected diseases of the tropics”. It is estimated that there are over 300 000 snakebites in India alone leading to between 45 000 and 50 000 deaths annually. The majority of venomous bites could be attributed to the big four – Daboia russellii (Russell’s viper), Bungarus caerulus (common krait), Naja naja (Indian cobra) and the Echis carinatus (saw scaled viper). Hemostatic abnormalities are prima facie evidence of hemotoxic snakebite. This could range from a mild cutaneous bleed to catastrophic intra-cerebral bleeds. Hemotoxic snakebite could also lead to Acute Kidney Injury (AKI) and Disseminated Intravascular Coagulation (DIC). A descending paralysis starting as a ptosis, which could progress on to life threatening respiratory paralysis is what is seen in neurotoxic snakebites. Anti-snake venom is started at 10 vials (100?ml) and most bites require up to 20 vials.     

Review article: vaccination and viral hepatitis - current status and future prospects

BACKGROUND: Viral hepatitis is the most common cause of liver disease in the world. In the past 25 years, vaccines have become available for two of the five hepatitis viruses, and, where implemented, vaccination has become a key component of hepatitis prevention. AIMS: To provide an update on recent advances in the use of current hepatitis vaccines and to examine progress in the development of vaccines for the remaining hepatitis viruses. METHODS: A Medline search was undertaken to identify the recent relevant literature. Search terms included hepatitis vaccines, hepatitis vaccination and hepatitis A-E vaccines. RESULTS: Dramatic vaccine-induced declines in the incidence of both hepatitis A and B have occurred in the USA. Strategies to integrate hepatitis A vaccine into universal childhood immunization are being adopted. Similarly, strategies with the goal of eliminating transmission of hepatitis B have been promulgated. A vaccine for hepatitis E has been reported to be effective and safe, but progress in the development of vaccines for hepatitis C and D has been limited. CONCLUSION: During the next few decades, the goals of eliminating hepatitis A and B virus transmission may be reached in the USA and elsewhere.     

Economic evaluation of vaccination against influenza in New Zealand

The objective of this study was to evaluate the costs and benefits of influenza vaccination for the population aged 65 years and over, from the perspectives of individuals and health insurers, government and society. The annual incremental direct medical costs and benefits of influenza vaccination (compared with the nonvaccination, or 'do nothing', option) were evaluated using New Zealand healthcare resource usage and unit cost data [in 1992 New Zealand dollars ($NZ); $NZ1 = $US0.5458, June 1992] applied to cohort studies reported in the literature. The costs and benefits to society as a result of vaccination of people aged 65 years and older (20% of people in this age group are currently vaccinated) were estimated to be: (i) additional direct medical costs of vaccination of $NZ1.42 million [$NZ17.78 per vaccination]; (ii) direct medical costs avoided of $NZ5.35 million ($NZ67.18 per vaccination); and (iii) net benefits of $NZ3.93 million ($NZ49.40 per vaccination). The direct medical costs avoided per dollar cost of vaccination were $NZ1.04 for individuals, $NZ4.69 for government and $NZ3.78 for society as a whole. If the vaccination uptake for this group is increased in 20% increments, the net benefit to society increases by a further $NZ3.93 million per year at each step. If the economic evaluation is extended to include vaccination of at-risk individuals under 65 years of age, net benefits to society increase by 15%. Influenza vaccination for people aged 65 years and over is cost effective from the perspective of society, government and the individual. If the vaccination rate for at-risk individuals in New Zealand could be increased to 60%, the net benefits reported in this study would increase by 200%. However, the costs of promotion and education to achieve this vaccination rate would need to be deducted from the net benefits. Strategies to increase the vaccination rate include altering the cost of vaccinations to the individual, intensifying education and promotion programmes, and changing the mode of delivery.     

Early intervention for obsessive compulsive disorder: An expert consensus statement

Obsessive-compulsive disorder (OCD) is common, emerges early in life and tends to run a chronic, impairing course. Despite the availability of effective treatments, the duration of untreated illness (DUI) is high (up to around 10 years in adults) and is associated with considerable suffering for the individual and their families. This consensus statement represents the views of an international group of expert clinicians, including child and adult psychiatrists, psychologists and neuroscientists, working both in high and low and middle income countries, as well as those with the experience of living with OCD. The statement draws together evidence from epidemiological, clinical, health economic and brain imaging studies documenting the negative impact associated with treatment delay on clinical outcomes, and supporting the importance of early clinical intervention. It draws parallels between OCD and other disorders for which early intervention is recognized as beneficial, such as psychotic disorders and impulsive-compulsive disorders associated with problematic usage of the Internet, for which early intervention may prevent the development of later addictive disorders. It also generates new heuristics for exploring the brain-based mechanisms moderating the ‘toxic’ effect of an extended DUI in OCD. The statement concludes that there is a global unmet need for early intervention services for OC related disorders to reduce the unnecessary suffering and costly disability associated with under-treatment. New clinical staging models for OCD that may be used to facilitate primary, secondary and tertiary prevention within this context are proposed.     

Statin toxicity: a situation that mimics viral hepatitis

A case is presented involving a female patient who experienced rhabdomyolysis following high-dose therapy with a statin. Acute renal failure was a complicating factor necessitating the use of hemodialysis. The patient recovered fully within about 6 weeks.     

Economic evaluations of childhood influenza vaccination: a critical review

The potential benefits of influenza vaccination programmes targeted at children have gained increasing attention in recent years. We conducted a literature search of economic evaluations of influenza vaccination in those aged ≤18 years. The search revealed 20 relevant articles, which were reviewed. The studies differed widely in terms of the costs and benefits that were included. The conclusions were generally favourable for vaccination, but often applied a wider perspective (i.e. including productivity losses) than the reference case for economic evaluations used in many countries. Several evaluations estimated outcomes from a single-year epidemiological study, which may limit their validity given the year-to-year variation in influenza transmissibility, virulence, vaccine match and prior immunity. Only one study used a dynamic transmission model able to fully incorporate the indirect herd protection to the wider community. The use of dynamic models offers great scope to capture the population-wide implications of seasonal vaccination efforts, particularly those targeted at children.     

Usage of inhalation devices in asthma and chronic obstructive pulmonary disease: a Delphi consensus statement

Objectives: The study aimed to assess usage of inhalation devices in asthma and chronic obstructive pulmonary disease (COPD).

Methods: In this two-round Delphi survey, 50 experts in asthma and COPD completed a 13-item, Internet-based, self-administered questionnaire about choice of inhalation device, training and monitoring of inhalation techniques, the interchangeability and the role of costs in the selection of inhalation devices. For each item, the median (central tendency) and interquartile ranges (degree of consensus) were calculated.

Results: Experts considered that the choice of inhalation device was as important as that of active substance (very good consensus) and should be driven by ease of use (good to very good consensus) and teaching (very good consensus). Experts recommended giving oral and visual instructions (good consensus) and systematic monitoring inhalation techniques. Pulmonologists and paramedics have predominantly educational roles (very good consensus). Experts discouraged inhalation device interchangeability (good consensus) and switching for cost reasons (good to very good consensus) without medical consultation (good consensus).

Conclusions: The results of this survey thus suggested that inhalation devices are as important as active substances and training and monitoring are essential in ensuring effective treatment of asthma and COPD. Inhalation device switching without medical consultation should be avoided.     

Differences in the methodology and data of economic evaluations of a health programme. The case of hepatitis B vaccination programmes in Spain

Economic evaluations of hepatitis B vaccination programmes in Spain or particular regions of Spain were identified and analysed, and their methodologies and data were compared. The results revealed important differences in methodology and the way in which different parameters, such as duration of immunity, costs and sources of cost data, were defined and measured. Some of these variations could be justified by the need to adapt studies to specific contexts, while others appeared arbitrary. Although it is understandable that there should be a substantial amount of heterogeneity between studies, greater efforts need to be made to reduce unnecessary variations in the way in which different parameters are measured. Increasing standardisation in methodology, which nevertheless takes into account inevitable variations due to changing circumstances and perspectives, will help to make economic evaluation a more attractive proposition for decision makers.