Vaccine economics diseases dollars and dilemmas
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Vaccine Economics: Diseases, Dollars, and Dilemmas. Tracy Lieu, MD, MPH. Center for Child Health Care Studies, Depts of Ambulatory Care and Prevention and Pediatrics, Harvard Medical School and Harvard Pilgrim Health Care. Topics. Economic factors pose barriers to optimal vaccine use

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Vaccine economics diseases dollars and dilemmas

Vaccine Economics:Diseases, Dollars, and Dilemmas

Tracy Lieu, MD, MPH

Center for Child Health Care Studies, Depts of Ambulatory Care and Prevention and Pediatrics,

Harvard Medical School and Harvard Pilgrim Health Care


Topics

Topics

  • Economic factors pose barriers to optimal vaccine use

  • Placing the right value on vaccines

  • Making the right recommendations for vaccines in the U.S.

  • Getting the right vaccines made for developing countries


Topics1

Topics

  • Economic factors pose barriers to optimal vaccine use

  • Placing the right value on vaccines

  • Making the right recommendations for vaccines in the U.S.

  • Getting the right vaccines made for developing countries


Vaccine economics diseases dollars and dilemmas

Source: USA Today, Thursday, October 28, 2004; 1A


Prices of old and new vaccines

Prices of Old and New Vaccines


Contrasts between old and new vaccines

Contrasts Between Old and New Vaccines

Old

  • Biologically simpler

  • Two or more manufacturers

  • Lower cost

  • New

  • Biologically complex

  • Single manufacturer

  • Higher cost


Benefit to cost ratios for childhood vaccines us health care system

Benefit-to-cost ratiosfor childhood vaccines, US health care system

DTP 6:1

MMR16:1

Polio 3:1

Hib3:1


Cost of immunizing a us child

Cost of immunizing a US child

CDC/NIP


Projected deaths prevented by vaccination of us children

Projected deaths prevented by vaccination of US children


Topics2

Topics

  • Economic factors pose barriers to optimal vaccine use

  • Placing the right value on vaccines

  • Making the right recommendations for vaccines in the U.S.

  • Getting the right vaccines made for developing countries


Cost effective cost saving

Cost-Effective = Cost-Saving

Health Outcomes

or =

Costs


Different perspectives different costs

Different Perspectives, Different Costs


Pneumococcal conjugate vaccine background

Pneumococcal Conjugate Vaccine Background

  • Leading bacterial cause of meningitis, pneumonia, otitis media

  • New vaccine found effective in randomized trial in 1999

  • Vaccine price announced at $58 per dose


Cost of immunizing a us child1

Cost of immunizing a US child

CDC/NIP


Vaccine economics diseases dollars and dilemmas

Projected Benefits and Costs of Routine Pneumococcal Vaccination of U.S. Children

Decision analysis

  • Decision tree

  • Probabilities

  • Costs

  • Base case analysis

  • Sensitivity analyses

Lieu JAMA 2000;283:1460-68


Vaccine economics diseases dollars and dilemmas

Death

Disability

Meningitis

Deafness

No sequelae

Bacteremia

Pneumonia

Complex otitis media

Simple otitis media

Pneumococcal

infection


Projected benefits

Projected Benefits

Lieu JAMA 2000;283:1460-68


Medical savings

Medical Savings


Cost effectiveness

Cost-Effectiveness

  • Net cost = $172 million

  • Cost-effectiveness ratio = $80,000 per life-year saved

  • Problem: Doesn’t give credit for preventing meningitis, bacteremia, pneumonia, or otitis media

Lieu JAMA 2000;283:1460-68


Quality adjusted life years qalys

Quality-adjusted life-years (QALYs)

  • Simplified definition:1 QALY = 1 year in perfect health

  • QALYs are a standardized measure to:

    • Give credit for preventing disease

    • Weigh benefit of preventing disease against the harm of vaccine reactions

    • Make comparisons with other vaccines and health services


Time tradeoff question to measure qalys

Time-Tradeoff Questionto Measure QALYs

Example: Meningitis

  • Imagine that you have a 1-year-old child

    • Very fussy with high fever for 1-2 days

    • Pediatrician does tests, including spinal tap

    • Hospitalized for IV antibiotics for 10 days

    • No additional problems

  • How much of your life, if any, would you trade to prevent this?

Prosser Pediatrics 2004;113:283-90


Time tradeoff results from community respondents

Time-Tradeoff Resultsfrom Community Respondents

Prosser Pediatrics 2004;113:283-90


How qalys change the appraisal of cost effectiveness

How QALYs Change the Appraisal of Cost-Effectiveness

Prosser Pediatrics 2004;113:283-90; Lieu Health Affairs in press


Comparisons with other preventive health services

Comparisons with Other Preventive Health Services


Impact

Impact

  • Policy

    • Pneumococcal vaccination recommended for U.S. infants in 2000

  • Scientific

    • Need to measure nonmonetary benefits to place appropriate value on vaccines


Institute of medicine 2004 financing vaccines in the 21 st century

Institute of Medicine 2004Financing Vaccines in the 21st Century

“ACIP (or some other advisory body) should conduct an analysis to determine the monetary value to society of each vaccine.”

“The calculation of nonmonetary benefits can draw on a substantial literature that suggests monetary values for years of life gained. Quality-of life and disability measurements are also standard in the literature.”


Issues to discuss

Issues to Discuss

  • Whose values to use?

    • Community members, patients or parents, providers

  • How to value short-term, vs. chronic, health states?

  • How to address skepticism about economic approaches to measuring health benefit (utility assessment, contingent valuation)?


Topics3

Topics

  • Economic factors pose barriers to optimal vaccine use

  • Placing the right value on vaccines

  • Making the right recommendations for vaccines in the U.S.

  • Getting the right vaccines made for developing countries


Vaccine economics diseases dollars and dilemmas

300,000

250,000

200,000

Number of cases

150,000

100,000

50,000

0

1922

1930

1940

1950

1960

1970

1980

1990

2000

Year

Reported Pertussis Cases

U.S., 1922-2004*

DTwP

* 2004 provisional


Vaccine economics diseases dollars and dilemmas

20,000

18,000

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

0

1980

1990

2000

Number of cases

All ages

<7 yrs

Year


Pertussis background

Pertussis -- Background

  • Increases in infant pertussis, with 16 deaths in 2004

  • Suggests pertussis circulation is increasing due to waning immunity

  • Acellular pertussis vaccines for adolescents and adults developed


Pertussis policy decision

Pertussis Policy Decision

Pertussis

No vaccination

No pertussis

Adolescents one dose

Adolescents + adults every 10y

Adults one dose

Adults every 10y

Parents of infants (Cocoon)

Public

health

policy


Incidence cost and qalys

Incidence, Cost, and QALYs

  • Empirical studies via Massachusetts enhanced pertussis surveillance system

  • Retrospective analysis of 2600 cases for medical costs

  • Prospective telephone interviews of 500 cases for time costs and QALYs

Lee Clin Infect Dis 2004;39:1572-80


Pertussis incidence and cost

Pertussis Incidence and Cost

Lee Clin Infect Dis 2004;39:1572-80


Medical costs of adolescent pertussis

Medical Costs of Adolescent Pertussis


Pertussis vaccine

Pertussis Vaccine


Measuring qalys time tradeoff method

Measuring QALYs:Time-Tradeoff Method

Example: Severe cough

How many days or weeks would you be willing to give up from the end of your life to avoid severe cough for 8 weeks? The cough can cause vomiting several times a week, difficulty eating or drinking, and difficulty sleeping.

Lee Health Qual Life Outcomes 2005;3:17


Time tradeoff results

Time-Tradeoff Results

Lee Health Qual Life Outcomes 2005;3:17


Cost effectiveness in us 2004 dollars at vaccine price 15

Cost-Effectiveness in US 2004 dollars, at vaccine price = $15

Lee Pediatrics in press


Comparisons with other vaccines

Comparisons with Other Vaccines

  • From the societal perspective:

    • $ per$ per

    • caseQALY or life-yrpreventedsaved

  • Varicella 1 doseSavingSaving

  • Hepatitis BSavingSaving

  • Pneumococcal200*4,700 per QALY

  • Pertussis1,10019,000 per QALY

  • Meningococcal600,000120,000 per life-yr

  • * Includes otitis media, pneumonia, meningitis, and bacteremia.


    Comparisons with other preventive health services1

    Comparisons with Other Preventive Health Services


    Impact1

    Impact

    • Policy – ACIP this June

      • Decision on adolescent vaccination?

      • Discussion of adult vaccination

    • Scientific

      • Disease burden, cost, and cost-effectiveness are only a few of the key factors


    Upcoming decisions advisory committee on immunization practices

    Upcoming DecisionsAdvisory Committee on Immunization Practices


    Policy related factors

    Policy-Related Factors

    Feudtner & Marcuse Pediatrics 2001;107:1158-64


    Issues to discuss1

    Issues to Discuss

    • How should we incorporate these policy-related factors in vaccine decisions?

      • Explicit measurement

      • Explicit process

    • Should ACIP continue to issue “one size fits all” recommendations?

      • Current approach leads to gaps in financing

      • How should clinicians deal with “optional” vaccines?


    Topics4

    Topics

    • Economic factors pose barriers to optimal vaccine use

    • Placing the right value on vaccines

    • Making the right recommendations for vaccines in the U.S.

    • Getting the right vaccines made for developing countries


    Vaccine economics diseases dollars and dilemmas

    Black Lancet 2003;361:2226-34


    Childhood mortality in developing countries excluding neonatal deaths

    Childhood Mortality in Developing Countries, Excluding Neonatal Deaths

    Bryce Lancet 2005;365:1147-52


    Vaccines for developing countries

    Vaccines for Developing Countries


    Vaccine uptake lags in developing countries

    Vaccine uptake lags in developing countries

    HepB all developing countries

    HepB available

    Hib available

    The Vaccine Fund established

    HepB all developing countries, excl. India, China, Indonesia

    Million

    doses

    Hib all developing countries

    1983

    1985

    1987

    1989

    1991

    1993

    1995

    1997

    1999

    2001

    2003

    2005

    GAVI forecasts

    Alan Brooks; WHO; Katie Brewer


    Push and pull mechanisms

    Push and Pull Mechanisms

    • Push – Subsidize development costs

      • Examples: Direct financing, research facilitation, tax credits, harmonizing regulatory requirement

    • Pull – Increase demand

      • Examples: Guaranteed prices, guaranteed purchase quantities, subsidization, tax credits


    Accelerated development and introduction programs adips virtuous cycle

    Accelerated Development and Introduction Programs (ADIPs): Virtuous cycle

    Prerequisites

    • Set time frame

    • Acceptance that the process is iterative

    Predictable (and lower) price

    Predictable (and growing) demand

    Predictable(and growing) capacity

    Price can’t be established before demand is known, but demand can’t be established without a price…

    Desired end product

    • Lower price


    Vaccine economics diseases dollars and dilemmas

    Cutts Lancet 2005;365:1139-46


    Issues to discuss2

    Issues to Discuss

    • What is the role of economic analysis in promoting vaccine research and development for poor countries?

      • Data are sparse

      • Governments may have competing priorities

    • How well will pull mechanisms work?


    Conclusions

    Conclusions

    • Placing the right value on vaccines requires including non-monetary benefits of morbidity prevented

    • Making the right recommendations for vaccines in the U.S. may need explicit ways of incorporating policy factors

    • Getting the right vaccines made for developing countries will require creative, multilateral approaches


    Vaccine economics diseases dollars and dilemmas

    Extra slides follow this one


    Who infects infants

    Who Infects Infants?

    Unknown

    Lett S, Massachusetts 2000-2002


    Health benefits dynamic modeling

    Health Benefits – Dynamic Modeling

    Natural

    Immunity

    Susceptible

    Infected

    Waning

    Vaccine-

    induced

    immunity

    Vaccinated

    Waning


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