Economic Evaluation of Routine Childhood Immunization with DTaP, Hib, IPV, MMR and HepB Vaccines

in the United States, 2001

Fangjun Zhou

Health Services Research and Evaluation Branch, NIP, CDC

Collaborators

Hussain R. Yusuf, MBBS, MPH Abigail Shefer, MD Lance Rodewald, MD Susan Y. Chu, PhD Mark Messonnier, PhD Jeanne Santoli, MD, MPH

Background Vaccine-preventable diseases, by year of vaccine

development or licensure – United States

DISEASE YEAR

Diphtheria 1923*

Pertussis 1926*

Tetanus 1927*

Poliomyelitis 1955**

Measles 1963**

Mumps 1967**

Rubella 1969**

Hepatitis B 1981**

Hib 1985*** Vaccine developed** Vaccine licensed for use in US

VaccineAge

Birth1

mo2

mos4

mos

Hepatitis B1

Diphtheria, Tetanus, Pertussis2

Haemophilus influenzae Type b3

Inactivated Polio

Measles, Mumps, Rubella4

Varicella5

Pneumococcal6

Hepatitis A7

Influenza8

HepB #1

HepB #2

4-6 yrs

6 mos

12mos

15mos

18mos

24mos

11-12 yrs

13-18 yrs

HepB #3

DTaP DTaP DTaP DTaP TdDTaP

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2002, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible. Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

Vaccines below this line are for selected populations

range of recommended ages

PPV

preadolescent assessment

Recommended Childhood and Adolescent Immunization Schedule—United States, 2003

catch-up vaccination

HepB series

MMR #2

Varicella

PCV

only if mother HBsAg ( - )

Estimated U.S. Vaccination Coverage with Individual Vaccines (19-35 months), 2001*

VACCINE COVERAGE (%)

3+DTP 94.3

3+Hib 93.0

3+Polio 89.4

1+MMR 91.4

3+HepB 88.9

*National Immunization Survey 2001

U.S. Diphtheria Cases1923-2001*

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

Year

Nu

mb

er o

f C

ases

*2001 data provisional

U.S. Tetanus Cases1927-2001*

0

2,000

4,000

6,000

8,000

10,000

12,000

Year

Nu

mb

er o

f C

ases

*2001 data provisional

U.S. Pertussis Cases1926-2001*

0

50,000

100,000

150,000

200,000

250,000

300,000

Year

Nu

mb

er o

f C

ases

*2001 data provisional

U.S. Haemophilus influenzae Type b Cases

1985-2001*

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

*2001 data provisional

U.S. Polio Cases1955-2001

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

1955

1958

1961

1964

1967

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

U.S. Measles Cases1963-2001*

050,000

100,000150,000200,000250,000300,000350,000400,000450,000500,000

Year

Nu

mb

er o

f C

ases

*2001 data provisional

U.S. Mumps Cases1968-2001*

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

*2001 data provisional

U.S. Rubella Cases1969-2001*

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

*2001 data provisional

U.S. Hepatitis B Cases1981-2001*

0

5,000

10,000

15,000

20,000

25,000

30,000

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

*2001 data provisional

Objective

To evaluate the economic impact of routine childhood immunization with DTaP, Hib, IPV, MMR and HepB vaccines in the U.S., from direct cost and societal perspectives.

Methods

Cohort based model U.S. birth cohort in 2001 over the lifetime of the cohort

Decision tree Benefit-cost ratio and net present value of

the program Year 2001 $ and 3% discount rate

Simplified Decision Tree

B/C Ratio and Net Present Value

Benefit-cost ratio:

Net Present value:

BCB

r

C

rt

tt

Tt

tt

T

( )

/( )

.1 10 0

.)1()1(0 0

T

t

T

tt

tt

t

r

C

r

BNPV

Program benefit (costs averted by the program) divided by program cost, T: life time, r: discount rate

Program benefit minus program cost

Data

Information was collected on: Demographics (earnings) Vaccination (vaccine, administration,

adverse events, parents’ time lost) Medical costs for diseases Work loss costs (parents’ time lost,

patients’ time) Other direct non-medical costs (special

education)

Data SourcesSources Data

MarketScan® database Medical cost

HCUPnet Medical cost

Published literature

Medical cost

Work loss costs

Other direct non-medical costs

Disease incidence

Vaccination

CDC dataDisease incidence

Vaccination

Interviews of experts Disease incidence

Preliminary Results

Number of Cases and Deaths

Disease

Without Immunization Program

With Immunization Program

Cases Deaths Cases Deaths

Diphtheria 247,214 24,721 2 0

Tetanus 153 23 7 1

Pertussis 2,662,307 1,049 47,433 41

Polio 60,974 723 0 0

Measles 3,433,722 2,795 686 1

Mumps 2,100,718 11 4,801 0

Rubella 1,786,334 14 2,304 0

CRS 616 68 14 2

Hib 17,530 663 61 2Hepatitis B 232,001 3,427 27,658 447

Total 10,541,569 33,494 82,966 494

Direct and Societal Costs

Disease

Without Immunization Program

With Immunization Program

Direct costs

(Million $)

Societal Costs

(Million $)

Direct costs

(Million $)

Societal Costs

(Million $)

Diphtheria $2,358 $24,828 $0 $0

Tetanus $8 $29 $0 $1

Pertussis $2,608 $3,704 $78 $123

Polio $1,183 $3,427 $0 $0

Measles $3,751 $7,001 $1 $1

Mumps $936 $1,456 $2 $3

Rubella $88 $379 $0 $1

CRS $115 $173 $3 $4

Hib $1,434 $2,696 $3 $7Hepatitis B $168 $1,272 $21 $167

Total $12,649 $44,964 $109 $307

Prevented or Saved by Immunization Program (One cohort)

Disease Cases DeathsDirect costs (Million $)

Societal Costs

(Million $)

Diphtheria 247,212 24,721 $2,358 $24,828

Tetanus 146 22 $8 $28

Pertussis 2,614,874 1,008 $2,530 $3,582

Polio 60,974 723 $1,183 $3,427

Measles 3,433,036 2,794 $3,750 $7,000

Mumps 2,095,917 11 $934 $1,453

Rubella 1,784,030 14 $88 $378

CRS 602 66 $112 $169

Hib 17,469 661 $1,430 $2,689

Hepatitis B 204,343 2,980 $147 $1,105

Total 10,458,603 33,000 $12,539 $44,657

Summary

Direct Costs

(million)

Societal Costs

(Direct+Indirect)

(million)W/o immunization program $12,649 $44,964

With immunization program $109 $307

Costs averted $12,539 $44,657

Program costs $1,990 $2,432

Net Present Value (net saving) $10,549 $42,225

B/C 6.3 : 1 18.4 : 1

Univariate Sensitivity Analysis

Direct Benefit Cost Ratios

Societal Benefit Cost Ratios

Base Case* 6.3 18.4

100% of vaccine purchased by private providers

5.0 15.2

200% of base case administration cost 4.3 13.4

Wastage rate=0% 6.6 19.2

Wastage rate=25% 6.0 17.6

*Wastage rate=12%

Limitations

The cost data might not be representative

Underestimate of benefit pain and suffering to family and friends of the

ill patient not included in our analyses

Conclusions

The routine childhood immunization program prevents about 10.5 million cases and 33,000 deaths for one birth cohort

It is cost saving (in terms of direct costs, saves about $10.5 billion, and from societal perspective, saves about $42 billion).

Next Steps …

Validation of the model by external experts Disease experts, epidemiologists Economists

Add Varicella and Pneumococcal conjugate vaccines