**_<u>Table 14 Disease outbreaks: estimates of business losses due to local disruption :</u>_**

|_Location_<br>(Year)|_Length of_<br>_disruption _|_Sectors Affected_|_Estimated Lo_<br>_ss_|_Disease_|
|---|---|---|---|---|
|Surat, India<br>(1994)|Two‐three<br>weeks|Local demand (during the<br>festivalseason)|US$ 260 mn.<sup>67</sup>|Pneumonic plague (1391<br>cases<sup>*</sup>, 52‐68 deaths)|
|Beijing, PRC<br>(2003)|Nine months<br>(April‐Dec)|Decline in domestic tourists<br>ation of<br>(87%) and cancell<br>Labor Dayholiday (13%)|US$ 2.8 bn.<sup>68</sup><br>2<br>(7.5% of 200<br>Beijing GDP)|SARS<br>cases, 190 deaths)<br>(2521|
|Taiwan<br>(2003)|Two m<br>(May‐Jun<br>onths<br>e)|Tourism revenue<br>al)<br>(domestic andinternation|US $350 mn.<sup>69</sup>|SARS<br>(346 cases, 37deaths)|
|Hong Kong,<br>PRC (2003)|Three<br>months<br>(March‐May)|Local demand<br>(metric: total retail sales)|‐6.1% in March,<br>‐15.1% in April, &<br>‐11.1% in May,<br>year onyear<sup>70</sup>|SARS<br>(1755 cases, 398 deaths)|

* Probable cases for Gujarat state.

While the effects on the local economy dissipate in subsequent financial periods as demand picks up and workers report back, in the shortest term the possibility of severe losses to the local business sector can ‘stay the hand’ of city governments, imposing unnecessary added risk of epidemic escalation<sup>71</sup> . This is crucial for effectiveness, since studies have repeatedly stressed mti eliness and completeness for all control policies.

_Cost­effectiveness studies_ : Meltzer _et al_ . (1999)<sup>9</sup> estimated the net returns to vaccination policies in the US – targeted (mortality‐based) or mass vaccination – using an assumed range for cost of vaccine per person. Vaccine efficacy was defined in terms of reductions in the health outcomes (death, types of healthcare utilization) in the vaccinated group. A high scenario of vaccine efficacy reduced death in those vaccinated by 60‐75% (higher in the younger age groups) from baseline, and hospitalization from 50‐55%. Benefits of vaccination were estimated as the avoided costs of excess mortality, accounting for 83% of economic losses in the no‐intervention scenario, as well as the avoided costs of excess healthcare utilization (17% of losses). This approach did not include avoided costs due to demand or supply disruptions discussed above. The former costs were estimated using the present value of lost earnings, varied by age group, while the costs of hospitalization varied depending on the severity of symptoms, and were aggregated from the numbers of individuals with different health outcomes from the baseline scenario. The following discussion should be read in light of the review of their ‘mathematical scenario’ methodology in a previous section.

If maximizing calculable net returns is an objective (other objectives: minimizing the total case attack rate, minimizing risk for death) then the following results apply. Since the largest amount of losses in their model emerged from deaths, a policy aiming to reduce total cases/deaths would produce the largest returns – e.g. a policy aiming at 60% coverage of the US population (320 million doses of vaccine to be produced and delivered in a 2‐3 month period). Given resource constraints for such coverage, especially if a well‐matched vaccine requires two doses, certain targeting policies are considered. Vaccinating those at high risk of complications – e.g., comorbidities – in the _0­64_ age group (a priority under the new NVAC/ACIP plan) would generate higher returns regardless of the cost of vaccine compared to vaccinating those 65+ at _any_ risk (also priority under NVAC/ACIP), or those 0‐ 64 not at high risk (lowest priority under NVAC/ACIP).

The results in van Genugten _et al._ (2003)<sup>42</sup> are presented at a higher level of generalization. They find no relative benefits in terms of deaths and hospitalizations of 36