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 DISEASEYEAR Diphtheria1923* Pertussis1926* Tetanus1927* Poliomyelitis1955** Measles1963** Mumps1967** Rubella1969** Hepatitis B1981** Hib1985** * Vaccine developed ** Vaccine licensed for use in US

Vaccine Age Birth 1 mo 2 mos 4 mos Hepatitis B 1 Diphtheria, Tetanus, Pertussis 2 Haemophilus influenzae Type b 3 Inactivated Polio Measles, Mumps, Rubella 4 Varicella 5 Pneumococcal 6 Hepatitis A 7 Influenza 8 HepB #1 HepB #2 4-6 yrs 6 mos 12 mos 15 mos 18 mos 24 mos yrs yrs HepB #3 DTaP TdDTaP Hib IPV MMR #1MMR #2 Varicella PCV 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* VACCINECOVERAGE (%) 3+DTP Hib Polio MMR HepB88.9 *National Immunization Survey 2001

U.S. Diphtheria Cases * *2001 data provisional

U.S. Tetanus Cases * *2001 data provisional

U.S. Pertussis Cases * *2001 data provisional

U.S. Haemophilus influenzae Type b Cases * *2001 data provisional

U.S. Polio Cases

U.S. Measles Cases * *2001 data provisional

U.S. Mumps Cases * *2001 data provisional

U.S. Rubella Cases * *2001 data provisional

U.S. Hepatitis B Cases * *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: 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 Sources SourcesData MarketScan® database Medical cost HCUPnet Medical cost Published literature Medical cost Work loss costs Other direct non-medical costs Disease incidence Vaccination CDC data Disease incidence Vaccination Interviews of experts Disease incidence

Preliminary Results

Number of Cases and Deaths Disease Without Immunization Program With Immunization Program CasesDeathsCasesDeaths Diphtheria247,21424,72120 Tetanus Pertussis2,662,3071,04947,43341 Polio60, Measles3,433,7222, Mumps2,100,718114,8010 Rubella1,786,334142,3040 CRS Hib17, Hepatitis B232,0013,42727, Total10,541,56933,49482,966494

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 Tetanus$8$29$0$1 Pertussis$2,608$3,704$78$123 Polio$1,183$3,427$0 Measles$3,751$7,001$1 Mumps$936$1,456$2$3 Rubella$88$379$0$1 CRS$115$173$3$4 Hib$1,434$2,696$3$7 Hepatitis B$168$1,272$21$167 Total$12,649$44,964$109$307

Prevented or Saved by Immunization Program (One cohort) DiseaseCasesDeaths Direct costs (Million $) Societal Costs (Million $) Diphtheria247,21224,721$2,358$24,828 Tetanus14622$8$28 Pertussis2,614,8741,008$2,530$3,582 Polio60,974723$1,183$3,427 Measles3,433,0362,794$3,750$7,000 Mumps2,095,91711$934$1,453 Rubella1,784,03014$88$378 CRS60266$112$169 Hib17,469661$1,430$2,689 Hepatitis B204,3432,980$147$1,105 Total10,458,60333,000$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/C6.3 : : 1

Univariate Sensitivity Analysis Direct Benefit Cost Ratios Societal Benefit Cost Ratios Base Case* % of vaccine purchased by private providers % of base case administration cost Wastage rate=0% Wastage rate=25% *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