Characterizing the health and financial costs of measles and rubella

1. Dr. Kimberly M. Thompson Kid Risk, Inc., www.kidrisk.org Characterizing the health and financial costs of measles and rubella

2. Topics • Context • Integrated dynamic disease and economic modeling • Discussion http://www.wpro.who.int/vietnam/topics/immunization/measles_rubella/measles_rubella_big.png?ua=1

3. www.kidrisk.org(21 measles and rubella related publications)

4. Human burden Measles: Severe complications include pneumonia, diarrhea, wasting, blindness, encephalitis, death Measles Ward in Somalia, 2011 outbreak http://www.somaliareport.com/index.php/post/1060/Measles_Takes_Toll_on_Somali_Children American woman with congenital rubella syndrome (CRS), ages 1 to 40 Images from Dr. Louis Cooper Rubella: Infection in early pregnancy can result in congenital rubella syndrome (CRS- characterized by heart defects, cataracts, hearing impairment, mental retardation), life long morbidity, pregnancy loss, death

5. Economic studies of measles and rubella vaccination • Control (i.e., paying costs for vaccines to prevent cases) started (M: 1963, R: 1969), global for M by 1988 (EPI), still 40 countries yet to introduce R • Large literature demonstrates measles and rubella immunization highly cost-effective and net beneficial • Thompson KM, Odahowski CL. Systematic review of health economic analyses of measles and rubella immunization interventions. Risk Analysis 2016; 36(7):1297-1314, online Dec 24, 2014, doi: 10.1111/risa.12331 • Measles vaccine gives highest returns on investment in relatively lower income countries • Ozawa S et al. Return on investment from childhood immunization in low- and middle-income countries, 2011–20. Health Affairs 2016; 35(2):199-207 “Immunizations will yield a net return about 16 times greater than costs” “The highest returns were associated with averting measles, at 58 times the cost (uncertainty range: 28-105) through two routine immunization doses and outreach campaigns” (94 countries)

6. Economic perspective • Economic literature demonstrates “high control” is not optimal if eradication is feasible • GeoffardP-Y, Philipson T. Disease eradication private versus public vaccination. American Economic Review 1997;87(1):222-230 • Barrett S. Eradication versus control: the economics of global infectious disease policies. Bulletin of the World Health Organization 2004;82(9):683-688 • Thompson KM, DuintjerTebbens RJ. Eradication versus control for poliomyelitis: An economic analysis. The Lancet 2007;369(9570):1363-1371 • Eradication generally requires paying large short-term costs to get long-term benefits • Regional/global commitment and coordination essential to achieving and maintaining elimination

7. Eradication feasibility • WHO • 2010 - “SAGE concluded that measles can and should be eradicated. A goal for measles eradication should be established with a proposed target date based on measurable progress made towards existing goals and targets.” (WER 2011; 86(1-2):11) • International Taskforce for Disease Eradication • 14th meeting (2009) – “…measles eradication is biologically possible, using tools that are currently available, as already demonstrated in the Americas…” (http://www. cartercenter.org/ resources/pdfs/news/health_publications/itfde/ITFDEsum0609.pdf) • 24th meeting (2015) – “The ITFDE still firmly believes that both measles and rubella eradication are technically feasible, but the very high contagiousness of measles is the biggest challenge to success, and measles and rubella eradication would require a sustained global commitment and a clear accountability framework such as exists for the GPEI.” (WER 2016; 91(6):69)

8. Economic perspective • World currently pursuing “high control” for measles and heading toward “high control” for rubella (as global equity improves) • Thompson KM, Odahowski CL. The costs and valuation of health impacts of measles and rubella risk management policies, Risk Analysis, 2016; 36(7):1357-1382, online Aug 6, 2015 “immunization activities will cost governments and donors over 2013$US 2.3 billion per year for the foreseeable future” (at the current “plateau” that still leads to millions of estimated infections and over 100,000 estimated deaths per year), estimates based on 2013 WHO-UNICEF coverage estimates available on July 15, 2014, excludes outbreak response immunization

9. Integrated modelSystem dynamics + decision, probabilistic risk, and economic analyses • Conditions • • Population immunity • - Immunization and outbreak history3,4 • - Under-vaccinated subpopulations • & Risks9 • • Importations • (Un)intentional release • Thompson et al. National and global options for managing the risks of measles and rubella. Journal of Vaccines and Vaccination 2012; 3:165, doi: 10.4172/2157-7560.1000165. • Thompson and DuintjerTebbens. Framework for optimal global vaccine stockpile design for vaccine-preventable diseases: Application to measles and cholera vaccines as contrasting examples. Risk Analysis 2016; 36(7):1487-1509. • Thompson et al. Synthesis of evidence to characterize national historical measles and rubella immunization and exposure histories. Risk Analysis 2016; 36(7):1427-1458. • Thompson and Odahowski. Systematic review of measles and rubella serology studies. Risk Analysis 2016; 36(7):1459-1486. • Thompson. Evolution and use of dynamic transmission models for measles and rubella risk and policy analysis. Risk Analysis 2016; 36(7):1383-1403. • Thompson and Badizadegan. Modeling the transmission of measles and rubella to support global management policy analyses and eradication investment cases. Risk Analysis2017; 37(6): 1009-1131. • Thompson et al. Characterization of the risks of adverse outcomes following rubella infection in pregnancy. Risk Analysis 2016; 36(7):1315-1331. • Simons et al. Systematic review of the manifestations of Congenital Rubella Syndrome in infants and characterization of disability-adjusted life years (DALYs). Risk Analysis 2016; 36(7):1332-1356. • Thompson and Odahowski. The costs and valuation of health impacts of measles and rubella risk management policies. Risk Analysis 2016; 36(7):1357-1382. • Thompson et al. Enabling implementation of the Global Vaccine Action Plan: Developing investment cases for globally managing measles and rubella. Vaccine 2013; 31S:B149-B156. • Decision options1 • • Routine immunization • • Supplemental immunization activities (SIAs) • • Outbreak response • • Surveillance • • Containment • Vaccine stockpile2 Cases (dynamic model)5,6 & DALYs7,8,9 Costs9,10 • Vaccination costs • Treatment costs • Productivity costs Economic estimates6 • Incremental cost-effectiveness ratios (ICERs) • Incremental net benefits (INBs)

10. Treatment costsThompson KM, Odahowski CL. The costs and valuation of health impacts of measles and rubella risk management policies, Risk Analysis, 2016; 36(7):1357-1382 • Costs per measles or rubella infection or per vaccine dose (MCV or MRCV), by age, sex, and income level in US$2013 • Cost per Congenital Rubella Syndrome (CRS) case • $11,300 for low-income to $934,000 for high-income countries • reflects lifetime of chronic care for individuals with disabilities • Expected costs decrease with income (i.e., receive more treatment and treatment more expensive in relatively higher income countries) • Measles infections more expensive to treat than rubella infections, except in women 15+ years of age • Expected treatment costs significantly higher for infection than for costs per vaccine dose due to adverse events • In high-income countries, approximately $1000-2000 per measles infection compared to approximately $1.50 per vaccine dose

11. Disability-adjusted life yearsThompson KM, Odahowski CL. The costs and valuation of health impacts of measles and rubella risk management policies, Risk Analysis, 2016; 36(7):1357-1382 • Model estimates DALYs lost per CRS case, measles or rubella infection, or vaccine dose (appropriately characterized by type of infection or vaccine, sex, age) including consideration of all sequelae • Better treatment in relatively higher income countries generally leads to fewer DALYs lost despitehigher life expectancy implying more life years to lose (i.e., lose fewer DALYs in relatively higher income countries due to better treatment and payment of associated costs) • CRS cases lead to highest expected DALY loss associated with measles or rubella due to lifelong disability • Expected DALYs lost per measles or rubella infection significantly higher than expected DALYs lost per vaccine dose (e.g., 1000x worse for measles)

12. Global incidence and DALYs by WBIL for 2013Thompson KM, Badizadegan ND. Modeling the transmission of measles and rubella to support global management policy analyses and eradication investment cases, Risk Analysis 2017; 37(6):1109-1131

13. Global cost estimates by WBIL for 2013Thompson KM, Badizadegan ND. Modeling the transmission of measles and rubella to support global management policy analyses and eradication investment cases, Risk Analysis 2017; 37(6):1109-1131 [Additional home care costs]

14. Characterization of costs • Model • Supports estimation of both health and financial costs • Focuses on modeling disease dynamics at the country level • Uses costs based on assumptions for different World Bank Income Levels (i.e., not country level) • Estimates all costs, independent of who pays them (i.e., different scope than FRRs) • Current work • Exploring health and economic outcomes of US investments in measles and rubella control and elimination • Eradication investment case to explore differences in health and economic outcomes associated with ending all measles and rubella virus transmission as soon as possible

15. GPEI sunset and potential impacts on measles and rubella Report on polio transition planning http://www.who.int/entity/mediacentre/events/2017/advance-report-polio-transmission.pdf?ua=1 • 16 countries account for “90% of all the GPEI supported polio infrastructure”: Afghanistan, Angola, Bangladesh, Cameroon, Chad, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Myanmar, Nepal, Nigeria, Pakistan, Somalia, South Sudan, and Sudan • Budget decreases for 2017-2019 (compared to 2016) already leading to “substantial number of staff receiving termination notices, particularly in the African region” • “All of AFRO’s 47 WHO country offices receive GPEI seed surveillance funding on a quarterly basis to allow countries to conduct active surveillance activities for, not only Acute Flaccid Paralysis (AFP) but other VPD surveillance activities” • For 2016, “WHO globally spent US$587 million on polio eradication, which is 27% of its total expenditure in 2016”…. “loss of approximately 20% of WHO’s biennium budget would have grave consequences for WHO’s capacity at the country level in member states that have weak health systems or in fragile states, especially at the provincial and district levels”

16. Discussion • Measles and rubella continue to pose significant (preventable/avoidable) health and financial costs • Individuals find it difficult to see the health costs, particularly as disease burdens decline and with surveillance that does not detect every case • Questions?

17. Thank you www.kidrisk.org