Vaccine delivery to newly arrived refugees and estimated costs in selected U.S. clinics, 2015

BackgroundNewly arrived refugees are offered vaccinations during domestic medical examinations. Vaccination practices and costs for refugees have not been described with recent implementation of the overseas Vaccination Program for U.S.-bound Refugees (VPR). We describe refugee vaccination during the domestic medical examination and the estimated vaccination costs from the US government perspective in selected U.S. clinics.MethodsSite-specific vaccination processes and costs were collected from 16 clinics by refugee health partners in three states and one private academic institution. Vaccination costs were estimated from the U.S. Vaccines for Children Program and Medicaid reimbursement rates during fiscal year 2015.ResultsAll clinics reviewed overseas vaccination records before vaccinating, but all records were not transferred into state immunization systems. Average vaccination costs per refugee varied from $120 to $211 by site. The total average cost of domestic vaccination was 15% less among refugees arriving from VPR- vs. nonVPR-participating countries during a single domestic visit.ConclusionOur findings indicate that immunization practices and costs vary between clinics, and that clinics adapted their vaccination practices to accommodate VPR doses, yielding potential cost savings.     

Influenza vaccination health impact and cost effectiveness among adults aged 50 to 64 and 65 and older

BACKGROUND: Influenza causes approximately 36,000 deaths per year in the United States despite the presence of an effective vaccine. This assessment of the value of influenza vaccination to the U.S. population is part of an update to the 2001 ranking of clinical preventive services recommended by the U.S. Preventive Services Task Force. The forthcoming ranking will include the new recommendation of the Advisory Committee on Immunization Practices to extend influenza vaccination to adults aged 50 to 64 years. METHODS: This service is evaluated on the two most important dimensions: burden of disease prevented and cost effectiveness. Study methods, described in a companion article, are designed to ensure consistency across many services. RESULTS: Over the lifetime of a birth cohort of 4 million, it is estimated that about 275,000 quality-adjusted life years (QALYs) would be saved if influenza vaccination were offered annually to all people after age 50. Eighty percent of the QALYs saved (220,000) would be achieved by offering the vaccine only to persons aged 65 and older. In year 2000 dollars, the cost effectiveness of influenza vaccination is $980 per QALY saved in persons aged 65 and older, and $28,000 per QALY saved in persons aged 50 to 64. When the costs of patient time and travel are excluded, the cost effectiveness ratio of vaccinating 50- to 64-year-olds decreases to $7200 per QALY saved, and vaccinating those aged 65 and older saves $17 per person vaccinated. CONCLUSIONS: Influenza vaccination is a high-impact, cost-effective service for persons aged 65 and older. Vaccinations are also cost effective for persons aged 50 to 64.     

Direct costs of a single case of refugee-imported measles in Kentucky

Background

Refugees are highly vulnerable populations with limited access to health care services. The United States accepts 50,000-75,000 refugees for resettlement annually. Despite residing in camps and other locations where vaccine-preventable disease outbreaks, such as measles, occur frequently, refugees are not required to have any vaccinations before they arrive in the United States.

Purpose

We estimated the medical and public-health response costs of a case of measles imported into Kentucky by a refugee.

Methods

The Kentucky Refugee Health Coordinator recorded the time and labor of local, state, and some federal personnel involved in caring for the refugee and implementing the public health response activities. Secondary sources were used to estimate the labor and medical care costs of the event.

Results

The total costs to conduct the response to the disease event were approximately $25,000. All costs were incurred by government, either public health department or federal, because refugee health costs are paid by the federal government and the event response costs are covered by the public health department.

Conclusion

A potentially preventable case of measles that was imported into the United States cost approximately $25,000 for the public health response.

Recommendation

To maintain the elimination of measles transmission in the United States, U.S.-bound refugees should be vaccinated overseas. A refugee vaccination program administered during the overseas health assessment has the potential to reduce the risk of importation of measles and other vaccine-preventable disease and would eliminate costs associated with public health response to imported cases and outbreaks.     

The cost-effectiveness of using hepatitis A/B combined vaccine versus hepatitis B vaccine alone for high-risk heterosexuals

Previous studies estimated that vaccinating high-risk heterosexuals (HRH) with combination hepatitis A/B vaccine was a cost-effective alternative to vaccinating HRH against hepatitis B alone. Since then, the incidence of hepatitis A has declined dramatically in the United States. We re-estimate the cost-effectiveness of this policy accounting for modern declines in incidence. According to our estimates, vaccinating with combination vaccine resulted in a cost of $120,000 per quality adjusted life year gained (2.79 times the 2005 United States Gross Domestic Product per capita), a ratio that is less favorable than those for most other vaccination strategies.     

Cost–benefit comparison of two proposed overseas programs for reducing chronic Hepatitis B infection among refugees: Is screening essential?

BackgroundRefugees are at an increased risk of chronic Hepatitis B virus (HBV) infection because many of their countries of origin, as well as host countries, have intermediate-to-high prevalence rates. Refugees arriving to the US are also at risk of serious sequelae from chronic HBV infection because they are not routinely screened for the virus overseas or in domestic post-arrival exams, and may live in the US for years without awareness of their infection status.MethodsA cohort of 26,548 refugees who arrived in Minnesota and Georgia during 2005–2010 was evaluated to determine the prevalence of chronic HBV infection. This prevalence information was then used in a cost–benefit analysis comparing two variations of a proposed overseas program to prevent or ameliorate the effects of HBV infection, titled ‘Screen, then vaccinate or initiate management’ (SVIM) and ‘Vaccinate only’ (VO). The analyses were performed in 2013. All values were converted to US 2012 dollars.ResultsThe estimated six year period-prevalence of chronic HBV infection was 6.8% in the overall refugee population arriving to Minnesota and Georgia and 7.1% in those ≥6 years of age. The SVIM program variation was more cost beneficial than VO. While the up-front costs of SVIM were higher than VO ($154,084 vs. $73,758; n = 58,538 refugees), the SVIM proposal displayed a positive net benefit, ranging from $24 million to $130 million after only 5 years since program initiation, depending on domestic post-arrival screening rates in the VO proposal.ConclusionsChronic HBV infection remains an important health problem in refugees resettling to the United States. An overseas screening policy for chronic HBV infection is more cost–beneficial than a ‘Vaccination only’ policy. The major benefit drivers for the screening policy are earlier medical management of chronic HBV infection and averted lost societal contributions from premature death.     

Planning influenza vaccination programs: a cost benefit model

ABSTRACT: BACKGROUND: Although annual influenza vaccination could decrease the significant economic and humanistic burden of influenza in the United States, immunization rates are below recommended levels, and concerns remain whether immunization programs can be cost beneficial. The research objective was to compare cost benefit of various immunization strategies from employer, employee, and societal perspectives. METHODS: An actuarial model was developed based on the published literature to estimate the costs and benefits of influenza immunization programs. Useful features of the model included customization by population age and risk-level, potential pandemic risk, and projection year. Various immunization strategies were modelled for an average U.S. population of 15,000 persons vaccinated in pharmacies or doctor's office during the 2011/12 season. The primary outcome measure reported net cost savings per vaccinated (PV) from the perspective of various stakeholders. RESULTS: Given a typical U.S. population, an influenza immunization program will be cost beneficial for employers when more than 37% of individuals receive vaccine in non-traditional settings such as pharmacies. The baseline scenario, where 50% of persons would be vaccinated in non-traditional settings, estimated net savings of $6 PV. Programs that limited to pharmacy setting ($31 PV) or targeted persons with high-risk comorbidities ($83 PV) or seniors ($107 PV) were found to increase cost benefit. Sensitivity analysis confirmed the scenario-based findings. CONCLUSIONS: Both universal and targeted vaccination programs can be cost beneficial. Proper planning with cost models can help employers and policy makers develop strategies to improve the impact of immunization programs.     

The economic impact of pandemic influenza in the United States: priorities for intervention.

We estimated the possible effects of the next influenza pandemic in the United States and analyzed the economic impact of vaccine-based interventions. Using death rates, hospitalization data, and outpatient visits, we estimated 89,000 to 207,000 deaths; 314,000 to 734,000 hospitalizations; 18 to 42 million outpatient visits; and 20 to 47 million additional illnesses. Patients at high risk (15% of the population) would account for approximately 84% of all deaths. The estimated economic impact would be US$71.3 to $166.5 billion, excluding disruptions to commerce and society. At $21 per vaccinee, we project a net savings to society if persons in all age groups are vaccinated. At $62 per vaccinee and at gross attack rates of 25%, we project net losses if persons not at high risk for complications are vaccinated. Vaccinating 60% of the population would generate the highest economic returns but may not be possible within the time required for vaccine effectiveness, especially if two doses of vaccine are required.     

Seroprevalence of Histoplasmosis in Somali,Burmese, and Hmong Refugees Residing in Thailand and Kenya

Histoplasmosis is known to be endemic to the Midwestern United States, but cases have been reported throughout much of the world. Somali, Hmong, and Burmese (ethnically Karen) persons make up some of the largest refugee populations coming the United States in recent years. Yet, information about risk of Histoplasma capsulatum infection amongst these populations is limited. This study used the CDC Migrant Serum Bank to test ~100 samples from each of Somali, Burmese, and Hmong U.S.-bound refugees. Samples were tested by enzyme immunoassay for Histoplasma capsulatum IgG. Overall 1% (2/299) of refugee serum samples were positive for H. capsulatum IgG. One of 99 samples obtained from Hmong refugees was positive, and the other positive sample came from among 100 Burmese refugee samples. H capsulatum IgG positivity was detected at low levels in Hmong and Burmese refugees. No IgG positivity was detected among 100 Somali refugees.     

Predicting Cost-Benefits Before Programs Are Started: Looking at Conjugate Vaccine for Invasive Pneumococcal Infections

This analysis uses existing data to examine how an analysis to predict the net financial impact for an emerging medical program, namely a conjugate vaccine against Streptococcus pneumoniae, and to identify which key variables will have the greatest impact on the program's costs and benefits. Using data available on the prevalence and case fatality rates for invasive diseases caused by S pneumoniae, we examined the theoretical economic impact of vaccinating all newborns versus not vaccinating. Effectiveness estimates for conjugated pneumococcal vaccines and disease incidence and fatality rates were obtained from published sources. Because of scanty or inconclusive data for otitis media and pneumonia, the analysis was limited to cases of meningitis and bacteremia due to S pneumoniae. Based on these two diseases alone, immunization with conjugate pneumococcal vaccine could save an estimated 222 lives per million children vaccinated per year. Analysis of direct costs (projected immunization costs minus savings from reduced illness) show that a pneumococcal vaccine program will result in net direct costs between $0.08 and $2.42 per child. When indirect costs are included in the analysis, the vaccine is cost savings for all cases except when the two year incidence of disease and death rates are lowest and the cost of the vaccine series is $150. Further research should focus on these key issues as the vaccine is introduced into use, as expected in the next few years.     

U.S.-incurred costs of wild poliovirus infections in a camp with U.S.-bound refugees--Kenya, 2006

Routine predeparture vaccinations are not required for U.S.-bound refugees, a policy that potentially leaves U.S. communities vulnerable to importation of vaccine-preventable diseases. During October-December 2006, an outbreak of poliomyelitis associated with wild poliovirus type 1 (WPV1) occurred in a camp occupied by refugees awaiting resettlement to the United States. This report describes the costs of domestic and international activities borne by U.S. federal and state governments, U.S.-funded organizations, and U.S. voluntary agencies during their response to this outbreak. Requiring predeparture polio vaccinations for U.S.-bound refugees might reduce the risk for poliovirus importation and reduce the costs associated with responses to polio outbreaks among refugees.     

Multidrug-resistant tuberculosis in Hmong refugees resettling from Thailand into the United States, 2004-2005

In December 2003, the U.S. Department of State initiated a resettlement program for 15,707 Hmong refugees who had been displaced from Laos and were living on the grounds of Wat Tham Krabok, a Buddhist temple in Thailand. In January 2005, reports of tuberculosis (TB) cases among refugees still in Thailand and refugees who had arrived in the United States, including some cases caused by multidrug-resistant (MDR) strains, prompted a 1-month travel suspension. After enhanced screening in Thailand and intensified TB-control measures in the United States, resettlement resumed on February 16. A majority of the Hmong refugees in Thailand and the United States with TB diagnosed were started on treatment and monitored. As of July 15, no additional TB cases had been diagnosed among newly resettled Hmong refugees. U.S. health departments should continue to ensure careful monitoring for TB among this refugee group.     

Cost-effectiveness of a potential vaccine for human papillomavirus

Human papillomavirus (HPV) infection, usually a sexually transmitted disease, is a risk factor for cervical cancer. Given the substantial disease and death associated with HPV and cervical cancer, development of a prophylactic HPV vaccine is a public health priority. We evaluated the cost-effectiveness of vaccinating adolescent girls for high-risk HPV infections relative to current practice. A vaccine with a 75% probability of immunity against high-risk HPV infection resulted in a life-expectancy gain of 2.8 days or 4.0 quality-adjusted life days at a cost of $246 relative to current practice (incremental cost effectiveness of $22,755/quality-adjusted life year [QALY]). If all 12-year-old girls currently living in the United States were vaccinated, >1,300 deaths from cervical cancer would be averted during their lifetimes. Vaccination of girls against high-risk HPV is relatively cost effective even when vaccine efficacy is low. If the vaccine efficacy rate is 35%, the cost effectiveness increases to $52,398/QALY. Although gains in life expectancy may be modest at the individual level, population benefits are substantial.     

Malaria in refugees from Tanzania--King County, Washington, 2007

Recent immigrants and refugees constitute a substantial proportion of malaria cases in the United States, accounting for nearly one in 10 imported malaria cases involving persons with known resident status in 2006. This report describes three cases of Plasmodium falciparum malaria and two cases of Plasmodium ovale malaria that occurred during June 27-October 15, 2007 in King County, Washington. The infections were diagnosed in Burundian refugees who had recently arrived in the United States from two refugee camps in Tanzania. Since 2005, CDC has recommended presumptive malaria treatment with artemisinin-based combination therapy (ACT) (e.g., artemether-lumefantrine) for refugees from sub-Saharan Africa before their departure for the United States (2). Rising levels of resistance to the previous mainstays of treatment, chloroquine and sulfadoxine-pyrimethamine, prompted CDC to make this recommendation. Implementation has been delayed in some countries, including Tanzania, where predeparture administration of presumptive ACT for refugees started in July 2007. The cases in this report highlight the need for health-care providers who care for recently arrived Burundian and other refugee populations to be vigilant for malaria, even among refugees previously treated for the disease.     

Million hearts: strategies to reduce the prevalence of leading cardiovascular disease risk factors--United States, 2011

Cardiovascular disease (CVD) causes one in three (approximately 800,000) deaths reported each year in the United States. Annual direct and overall costs resulting from CVD are estimated at $273 billion and $444 billion, respectively. Strategies that address leading CVD risk factors, such as hypertension, high cholesterol levels, and smoking, can greatly reduce the burden of CVD. To estimate the U.S. prevalence of these three risk factors, CDC analyzed data from the National Health and Nutrition Examination Survey (NHANES) on uncontrolled hypertension, uncontrolled high levels of low-density lipoprotein cholesterol (LDL-C), and current smoking. This report summarizes the results of that analysis, which found that 49.7% of U.S. adults aged ≥20 years (an estimated 107.3 million persons) have at least one of the three risk factors. To reduce the prevalence of CVD risk factors among persons in the United States, the U.S. Department of Health and Human Services, in collaboration with nonprofit and private organizations, is launching Million Hearts, a multifaceted combination of evidence-based interventions and strategies aimed at preventing 1 million heart attacks and strokes over the next 5 years.     

Public health impact and cost-effectiveness of 15-valent pneumococcal conjugate vaccine use among the pediatric population of the United States

BackgroundAlthough use of the 13-valent pneumococcal conjugate vaccine (PCV13) among children has reduced incidence of pneumococcal disease, a considerable burden of disease remains. PCV15 is a new vaccine that contains pneumococcal serotypes 22F and 33F in addition to serotypes contained in PCV13. To inform deliberations by the Advisory Committee on Immunization Practices on recommendations for PCV15 use among U.S. children, we estimated the health impact and cost-effectiveness of replacing PCV13 with PCV15 within the routine infant immunization program in the United States. We also assessed the impact and cost-effectiveness of a supplementary PCV15 dose among children aged 2–5 years who have already received a full PCV13 series.MethodsWe estimated the incremental number of pneumococcal disease events and deaths averted, costs per quality adjusted life-year (QALY) gained, and costs per life-year gained under different vaccination strategies using a probabilistic model following a single birth cohort of 3.9 million individuals (based on 2020 U.S. birth cohort). We assumed that vaccine effectiveness (VE) of PCV15 against the two additional serotypes was the same as the VE of PCV13. The cost of PCV15 use among children was informed from costs of PCV15 use among adults and from discussions with the manufacturer.ResultsOur base case results found that replacing PCV13 with PCV15 prevented 92,290 additional pneumococcal disease events and 22 associated deaths, while also saving $147 million in costs. A supplementary PCV15 dose among children aged 2–5 years who were fully vaccinated with PCV13 prevented further pneumococcal disease events and associated deaths but at a cost of more than $2.5 million per QALY gained.ConclusionsA further decrease in pneumococcal disease in conjunction with considerable societal cost savings could be expected from replacing PCV13 with PCV15 within the routine infant immunization program in the United States.     

Cigarette smoking-attributable morbidity---United States, 2000

Each year in the United States, approximately 440,000 persons die of a cigarette smoking-attributable illness, resulting in 5.6 million years of potential life lost, $75 billion in direct medical costs, and $82 billion in lost productivity. To assess smoking-attributable morbidity, the Roswell Park Cancer Institute, Research Triangle Institute, and CDC analyzed data from three sources: the Behavioral Risk Factor Surveillance System (BRFSS), the National Health and Nutrition Examination Survey III (NHANES III), and the U.S. Census. This report summarizes the results of that analysis, which indicate that an estimated 8.6 million persons in the United States have serious illnesses attributed to smoking; chronic bronchitis and emphysema account for 59% of all smoking-attributable diseases. These findings underscore the need to expand surveillance of the disease burden caused by smoking and to establish comprehensive tobacco-use prevention and cessation efforts to reduce the adverse health impact of smoking.     

Perceptions among the U.S. population of value of Japanese encephalitis (JE) vaccination for travel to JE-endemic countries

IntroductionJapanese encephalitis (JE) is a rare but potentially severe disease among travelers. JE vaccine in the United States costs $500–$600 for a 2-dose series and is safe and effective but rare serious adverse events can occur. Our survey investigated likelihood of vaccine receipt for travel.MethodsAn electronically-administered survey was conducted among U.S. adults. Participants were presented a hypothetical scenario on travel to a JE-endemic country and JE vaccine characteristics and responded on likelihood of vaccination.ResultsOverall, 6384 (59%) of 10,904 persons completed the questions. Population estimates indicated 32% would be likely and 42% were unlikely to be vaccinated, and 26% were unsure. Among those likely to get vaccinated, important factors were disease risk and severity, and vaccine safety. Among those unlikely, cost, disease risk, and possibility of serious side effects ranked highest.ConclusionsThere is population heterogeneity in perception of JE disease risk and value of vaccination.     

The role of public health in mental health promotion

Mental illness contributes a substantial burden of disease worldwide. Globally, approximately 450 million persons suffer from mental disorders, and one fourth of the world's population will develop a mental or behavioral disorder at some point during their lives. Mental disorders account for approximately 25% of disability in the United States, Canada, and Western Europe and are a leading cause of premature death. In the United States, approximately 22% of the U.S. adult population has one or more diagnosable mental disorders in a given year. The estimated lifetime prevalences for mental disorders among the U.S. adult population are approximately 29% for anxiety disorders, 25% for impulse-control disorders, 21% for mood disorders, 15% for substance-use disorders, and 46% for any of these disorders. In addition, an estimated one in 10 children in the United States has a mental disorder that causes some level of impairment. The effects of mental illness are evident across the life span, among all ethnic, racial, and cultural groups, and among persons of every socioeconomic level. Moreover, mental illness costs the United States an estimated $150 billion annually, excluding the costs of research.     

Costs of,and reimbursement for,vaccines: A case study at the Board of Health Refugee Services in DeKalb county,Georgia

Background

Approximately 70,000 refugees are resettled to the United States each year. Providing vaccination to arriving refugees is important to both reduce the health-related barriers to successful resettlement, and protect the health of communities where refugees resettle. It is crucial to understand the process and resources expended at the state/local and federal government levels to provide vaccinations to refugees resettling to the United States.

Objectives

We estimated costs associated with delivering vaccines to refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic).

Methods

Vaccination costs were estimated from two perspectives: the federal government and the DeKalb clinic. Data were collected at the DeKalb clinic regarding resources used for vaccination: staff numbers and roles; type and number of vaccine doses administered; and number of patients. Clinic costs included labor and facility-related overhead. The federal government incurred costs for vaccine purchases and reimbursements for vaccine administration.

Results

The DeKalb clinic average cost to administer the first dose of vaccine was $12.70, which is lower than Georgia Medicaid reimbursement ($14.81), but higher than the State of Georgia Refugee Health Program reimbursement ($8.00). Federal government incurred per-dose costs for vaccine products and administrative reimbursement were $42.45 (adults) and $46.74 (children).

Conclusions

The total costs to the DeKalb clinic for administering vaccines to refugees are covered, but with little surplus. Because the DeKalb clinic ‘breaks even,’ it is likely they will continue to vaccinate refugees as recommended by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices.     

A comparative cost analysis of the Vaccination Program for US-bound Refugees

BackgroundVaccination Program for US-bound Refugees (VPR) currently provides one or two doses of some age-specific Advisory Committee on Immunization Practices (ACIP)-recommended vaccines to US-bound refugees prior to departure.MethodsWe quantified and compared the full vaccination costs for refugees using two scenarios: (1) the baseline of no VPR and (2) the current situation with VPR. Under the first scenario, refugees would be fully vaccinated after arrival in the United States. For the second scenario, refugees would receive one or two doses of selected vaccines before departure and complete the recommended vaccination schedule after arrival in the United States. We evaluated costs for the full vaccination schedule and for the subset of vaccines provided by VPR by four age-stratified groups; all costs were reported in 2015 US dollars. We performed one-way and probabilistic sensitivity analyses and break-even analyses to evaluate the robustness of results.ResultsVaccination costs with the VPR scenario were lower than costs of the scenario without the VPR for refugees in all examined age groups. Net cost savings per person associated with the VPR were ranged from $225.93 with estimated Refugee Medical Assistance (RMA) or Medicaid payments for domestic costs to $498.42 with estimated private sector payments. Limiting the analyses to only the vaccines included in VPR, the average costs per person were 56% less for the VPR scenario with RMA/Medicaid payments. Net cost savings with the VPR scenario were sensitive to inputs for vaccination costs, domestic vaccine coverage rates, and revaccination rates, but the VPR scenario was cost savings across a range of plausible parameter estimates.ConclusionsVPR is a cost-saving program that would also reduce the risk of refugees arriving while infected with a vaccine preventable disease.