# Presentation: 643031

## 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

## Recommended Childhood and Adolescent Immunization Schedule—United States, 2003

**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**

**11-12 **
**yrs**

**13-18 **
**yrs**

**HepB #3**

**DTaP**

**DTaP**

**DTaP**

**DTaP**

**Td**

**DTaP**

**Hib**

**Hib**

**Hib**

**Hib**

**IPV**

**IPV**

**IPV**

**IPV**

**MMR #1**

**MMR #2**

**Varicella**

**PCV**

**PCV**

**PCV**

**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*

| 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 Cases1923-2001*

- *2001 data provisional

## U.S. Tetanus Cases1927-2001*

- *2001 data provisional

## U.S. Pertussis Cases1926-2001*

- *2001 data provisional

## U.S. Haemophilus influenzae Type b Cases1985-2001*

- *2001 data provisional

## U.S. Polio Cases1955-2001

## U.S. Measles Cases1963-2001*

- *2001 data provisional

## U.S. Mumps Cases1968-2001*

- *2001 data provisional

## U.S. Rubella Cases1969-2001*

- *2001 data provisional

## U.S. Hepatitis B Cases1981-2001*

- *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:

- 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

| Sources | Data |
| --- | --- |
| 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 |  |
| --- | --- | --- | --- | --- |
|  | 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 | 2 |
| Hepatitis 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 | $7 |
| Hepatitis B | $168 | $1,272 | $21 | $167 |
| Total | $12,649 | $44,964 | $109 | $307 |

## Prevented or Saved by Immunization Program (One cohort)

| Disease | Cases | Deaths | Direct 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