An economic evaluation of universal pertussis vaccination in Italy.

An economic evaluation was performed of universal acellular pertussis vaccination in Italy, where until recently the overall coverage of pertussis vaccination was estimated at 50%. Over the last two years coverage seems to have increased rapidly. By means of a mathematical simulation model, the consequences of pertussis vaccination in terms of both health effects and economic costs were calculated for a single birth cohort followed for 6 years. Incremental analyses were performed for each additional 10% increase in coverage from 50-90%. The results indicate that a 50% coverage rate of pertussis vaccination in Italy was not optimal on the basis of cost-effectiveness and cost-benefit considerations. Additional increases in coverage were found to yield extra health gains at modest net costs or even potential net savings to the health care sector. For example, an increase in coverage to 90% would yield direct net savings of US$42 per extra vaccinee in comparison to a situation of 50% coverage. The total net savings for this strategy would be well over US$100 per additional vaccinee. In the sensitivity analysis, the positive relationship between incremental coverage and incremental efficiency remained unchanged.

An economic evaluation of hepatitis A vaccination in Dutch military personnel.

We analyzed the cost-effectiveness of hepatitis A vaccination regimens using a mathematical simulation model. Passive immunization and two active vaccination strategies (with and without prior screening) were compared with "doing nothing." Hepatitis A antibodies were determined in 2,325 Dutch marines; other input data were retrieved from published and unpublished sources. The prevalence of hepatitis A antibody was 14%. Screening before vaccination was identified as appropriate at a prevalence > 20%. Passive immunization was the cheapest prevention for a single 6-month deployment per 10 years. The inactivated vaccine containing 1,440 enzyme-linked immunosorbent assay units without prior screening was identified as the best option for more frequent deployments. It was cost-saving with two or more missions per 10 years. A 5.3% hepatitis A attack rate validated the investment for this policy. Overall, immunization with inactivated hepatitis A vaccine without prior screening proved to be the optimum strategy for troops at regular risk.

Economic evaluation of pertussis prevention by whole-cell and acellular vaccine in Germany.

UNLABELLED: Acellular pertussis vaccines are less reactogenic than whole cell pertussis vaccines, but they are also more expensive. Based on simulation models, we compared the costs and effects of three alternative pertussis vaccination strategies in German children to "no prevention": (1) vaccination with whole-cell vaccine at 45% coverage (vaccine efficacy 90%), (2) vaccination with acellular vaccine at 45% coverage (vaccine efficacy 85%), and (3) vaccination with acellular vaccine at 90% coverage. In the two low coverage scenarios expected annual savings in direct medical costs through prevention of disease were larger for whole-cell than for acellular vaccination (252 vs 216 million DM, respectively). Direct costs for treating the more important adverse events induced by whole-cell vaccination (16.9 million DM annually) did not outweigh the higher direct costs of pertussis infections not prevented with the acellular vaccine and the higher price of the acellular vaccine. However, vaccination with acellular pertussis vaccine rapidly becomes as cost saving as vaccination with whole-cell vaccine as soon as vaccination coverage can be raised from 45% to 52.5% with acellular vaccine. Acellular vaccination is also the superior alternative when considering indirect cost savings resulting from reduction in work-loss due to adverse events. CONCLUSION: In our simulations, the most cost-effective pertussis prevention strategy was the use of an effective whole-cell vaccine with a high coverage rate. Introduction of the more expensive acellular pertussis vaccines becomes cost saving if at least a 7.5% increase in coverage is achieved. If also non-medical indirect costs to parents resulting from vaccine associated side-effects are accounted for, acellular vaccines may be more cost-effective also in countries with already high whole-cell vaccine coverage.

Costs and benefits of routine varicella vaccination in German children.

This study assessed the costs and benefits of introducing routine varicella vaccination to healthy children in Germany. Three vaccination strategies were compared with that of no prevention: vaccination of all 15-month-old children: vaccination of susceptible 12-year-olds (adolescent); and a combination of strategies (children including catch-up). From a purely economic viewpoint, the adeolescent strategy was optimal: It was the only one that resulted in net direct cost savings. However, since this strategy may be less acceptable from a medical or organizational point of view and because total net savings were the highest, a second option was to begin immunization starting with the 15-month-old children and to use the catch-up strategy for 11 years (total benefit-to-cost ratio (BCR), 4.72:1; cost-effectiveness ratio (CER), DM 6915 per life-year saved) and from year 12 on to use the first strategy (BCR, 4.60:1; CER, DM 19,735 per life-year saved).

Economic evaluation of antifungal agents in the treatment of toenail onychomycosis in Germany.

BACKGROUND: The strategies for the management of onychomycosis have changed since the availability of the newer generation of antifungal agents, particularly, itraconazole and terbinafine. Itraconazole (1-week pulse) therapy may have higher efficacy and an improved adverse-effects profile compared to the continuous therapy regimen. OBJECTIVE: We performed a pharmacoeconomic evaluation of the most commonly used treatments in Germany for toenail onychomycosis from a health care payer perspective. METHODS: A 5-step approach was used. Firstly, the purpose of the study, the comparator drugs, their dosage regimens and the time frame of the analysis were defined. Next, the medical practice and resource consumption patterns associated with the treatment of onychomycosis were identified. In step III, a meta-analysis was used to determine the relative efficacy of the comparator drugs. In step IV, a decision tree of the treatment algorithms was constructed for each comparator. The expected cost analysis and cost-effectiveness analysis were also performed. Finally, a sensitivity analysis was carried out. RESULTS: For the four main comparator drugs used to treat toenail onychomycosis in Germany, the clinical response rates (clinical cure plus marked improvement) at the end of the follow-up period (month 12 after starting therapy) were, for itraconazole (1-week pulse dosing): 89.8 +/- 3% (mean +/- SE), terbinafine: 79.4 +/- 10%, itraconazole (continuous dosing): 77.5 +/- 9%, and ciclopirox nail varnish: 55 +/- 5%. Itraconazole (1-week pulse dosing) was most cost-effective at DM 1,107 per successful treatment, followed by oral terbinafine at DM 1,224, ciclopirox nail varnish and itraconazole (continuous dosing). Sensitivity analyses indicated that itraconazole (1-week pulse dosing) and terbinafine had similar cost-effectiveness ratios. CONCLUSION: Itraconazole is an effective, broad-spectrum triazole used as continuous or pulse therapy in the treatment of onychomycosis. Itraconazole (1-week pulse) and terbinafine are the most cost-effective therapies for toenail onychomycosis.

Hepatitis B prevention in Europe: a preliminary economic evaluation.

The World Health Organization (WHO) estimates that about 350 million people in the world are carriers of the hepatitis B virus (HBV), 60 million of whom may die from liver cancer and about 45 million from cirrhosis. In the WHO European Region, which has a total population of 839 million inhabitants, the average number of acute hepatitis B cases reported in 1991 was approximately 160,000, giving an incidence of 19 per 100,000 population. This incidence rate varies from 5 per 100,000 in western Europe to 22 per 100,000 in central Europe and 92 per 100,000 in eastern Europe. Because of under-reporting and the fact that two-thirds of infections are asymptomatic, the reported incidence rate considerably underestimates the true incidence of HBV in Europe. For this reason, we may multiply the number of reported cases by a factor of 6 (by 2 for under-reporting and by 3 for the symptomatic/asymptomatic ratio): an estimated 900,000 to 1,000,000 infections of HBV occur in Europe each year. Approximately 90,000 chronic infections will develop from these new cases. The spread of HBV can be controlled by universal infant or adolescent vaccination. A decision-tree-based analytical model was used to assess the clinical and economic impact of these two interventions. The model took into account incidence and prevalence rates of HBV, natural history of infection, compliance and effectiveness of vaccination, and direct and indirect costs. Data were obtained from the literature and from a WHO European survey. The cost-effectiveness ratio amounts to 6443 pounds and 4745 pounds per infection prevented for neonatal and adolescent vaccination, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-effectiveness analysis of vaccination against hepatitis A in travellers.

Hepatitis A virus (HAV) infection is a substantial risk for travellers from low endemic countries to high endemic destinations. Costs and effects of alternative options for prevention were compared using formal decision analysis. General indications for the optimal prevention of hepatitis A were derived from a cost-effectiveness analysis. Various possible strategies for prevention of hepatitis A in travellers were compared to doing nothing: active immunisation using either the existing vaccine (HAVRIX 720) or the new vaccine (HAVRIX 1440); first screening for the presence of HAV antibodies and then vaccinating only susceptibles; and passive immunisation with immunoglobulin. Using a number of assumptions as baseline and for an average duration and frequency of travel from low to high endemic countries, threshold values were obtained for the choice between passive and active immunisation. Passive immunisation remains the most cost-effective prevention strategy for those expected to travel not more frequently than twice over the next 10 years and for short stays (7,000-9,000 pounds per infection prevented). For travellers expected to travel three or more times in 10 years or for trips exceeding a period of 6 months, active immunisation before the first trip is the most cost-effective option (7,500 pounds or less per infection prevented). When travel frequency increases to once a year in the next 10 years, costs per infection prevented decrease to about 3,500 pounds. Screening for the presence of antibodies before vaccination is only justified for older travellers or those leaving from countries with moderate endemicity, i.e., with an average HAV prevalence of at least 30%.

Recommendations for Prevention of Hepatitis A Based on a Cost-Effectiveness Analysis.

Hepatitis A viral infection poses a substantial risk for travelers from low-endemic countries visiting high-endemic destinations. In this study, the general indications for the optimal prevention of hepatitis A are derived using a cost-effectiveness analysis based on the risk exposure determined by frequency and duration of travel as well as natural immunity. Three possible hepatitis A prevention strategies are compared to no prophylaxis: active immunization; an initial screening for HAV followed by active immunization of susceptible travelers; and passive immunization with immune globulins. Using a number of baseline assumptions, a scenario for travel from low- to high-endemic countries and an average travel duration and frequency rate, threshold values were obtained comparing active versus passive immunization. The study shows that, for travelers not expected to journey more than twice in a 10-year period, passive immunization is the most cost-effective prophylaxis for travel from both very-low or low-to-high endemic areas. For more frequent travel, vaccination is more cost effective, as well as for journeys of 6-months' duration or longer. As well, pretravel screening before vaccination was shown to be worthwhile, except when the probability of natural immunity is low. As the results indicate, the cost effectiveness of a strategy is related to several considerations: the prices of vaccine and screening tests, travel destinations and endemic conditions, frequency and duration of travel, and natural immunity. A decision-tree-based simulation model is helpful in determining the strategy to employ.

Retrospective estimate of the nursing cost of autonomy impairment and cost benefit in clinical trials: feasibility and application of piracetam in demented elderly patients.

The aims of this study were to determine whether the nursing costs of functional disability could be assessed retrospectively and, if so, whether this method was sensitive enough to show the influence of a treatment on economic costs. Four studies were available for this purpose: three randomized, double-blind, placebo-controlled, clinical trials measuring, among others, the influence of piracetam on activities of daily living (ADL) of elderly demented patients in Italy, Austria, and Belgium, and one large population-based survey measuring the costs of providing basic nursing, hygienic, and therapeutic needs to 6000 elderly according to ADL scores. The items on the different ADL scales used in each trial were recoded to a common denominator, and an overall dependency score was calculated for each patient. The survey data showed a highly significant linear correlation between ADL status and nursing expenses. Nursing costs of noninstitutionalized patients were calculated by assigning each patient the average nursing cost of all persons from the survey who matched by sex, age, and dependency score. Retrospective economic assessment was possible for ambulatory patients when there were functional assessments and a survey with nursing costs gauged according to those functional assessments. Objective classification criteria for hospital or retirement home patients are needed for the level of reimbursement of nursing costs. Piracetam treatment decreased dependency, compared with placebo. The economic improvement continued over the entire duration of all three clinical trials, lasting up to 6 months in the Italian trial in both ambulatory and residential settings. The decrease in nursing costs remained stable during the same period for patients treated with piracetam, whereas nursing costs of placebo patients steadily increased. After 6 months this difference increased a monthly average of 820 Belgian francs (BF {35 BF = 1 US $}) for ambulatory patients in favor of piracetam, 1650 BF for residential patients, and 2580 BF for hospitalized individuals.

Cost-effectiveness analysis of prenatal screening and vaccination against hepatitis B virus--the case of Belgium.

The study examines the cost-effectiveness of screening pregnant women in Belgium for the presence of hepatitis B virus (HBV) and of vaccinating the newborns if necessary. The alternative strategy considered is 'doing nothing'. The rate of carriership among a sample of pregnant women in Belgium amounts to 0.67%. If a pregnant woman is a carrier of the virus, there is an average probability of 30% that she will transmit the virus to her newborn. Later in life, this baby will be at risk from serious complications, such as chronic active hepatitis, cirrhosis and primary hepatocellular cancer. However, medical costs will be induced by screening and vaccination campaigns, lab-tests, vaccine costs, etc. On the other hand, resources will be saved by the prevention of severe complications of the disease. However, costs dominate savings, the incremental cost-effectiveness ratio for the screening and vaccination strategy amounting to 583,581 BEF per life-year saved. To check the stability of the cost-effectiveness ratio, a sensitivity analysis has been performed on some crucial parameters: the ratio is found to be sensitive to the prevalence of HBV among pregnant women, to the costs for screening and vaccination and to the discount rate. Increasing the treatment costs for a HBV complication hardly changes the cost-effectiveness ratio.

Cost-effectiveness analysis of hepatitis A prevention in travellers.

The advent of new vaccines and the changing epidemiology of hepatitis A call for an update of the economic evaluation of costs and benefits associated with the various alternative preventative strategies. A decision-tree-based model has been developed which enables the calculation of expected costs and expected numbers of hepatitis A virus HAV infections based on different intervention strategies. The model is sufficiently generic to allow for the evaluation of both population-wide strategies and strategies targeted at particular risk groups. An economic analysis focusing on travellers from Europe to high-endemic countries compared a non-intervention strategy to the following three strategies: active immunization with HAV vaccine; screening for HAV antibodies and vaccinating only susceptibles; passive immunization by means of immunoglobulin. The net cost per HAV infection prevented proved very sensitive to a number of important input parameters of the model. These included epidemiological characteristics such as HAV attack rate and prevalence of immunity, behavioural characteristics such as compliance with the vaccination scheme and vaccine characteristics such as rate and duration of protection. Our estimated expected cost per HAV infection prevented among Belgian travellers to high-endemic countries for three weeks per year over ten years amounts to approximately US$4880 for active immunization, US$5621 for screening followed by vaccination of susceptibles and US$29932 for passive immunization. Although these estimates are clearly sensitive to a number of crucial assumptions pertaining to the input parameters of the model, it seems safe to conclude that vaccination is more cost-effective than the currently recommended passive immunization with immunoglobulin.(ABSTRACT TRUNCATED AT 250 WORDS)