Health Economics of Rubella
Health Economics of Rubella
Acquired rubella is a mild disease which only rarely results in serious clinical complications i.e. encephalitis, arthritis and thrombocytopenia. The mild nature of the disease means that vaccination against it would not be medically or economically critical or justifiable if it did not infect pregnant mothers. During pregnancy, particularly in the first trimester, rubella infection is far more dangerous and commonly leads to abortion, fetal death or congenital rubella syndrome (CRS). CRS, which is estimated to affect 110,000 infants annually in low-income countries, is characterized by multiple defects of the brain, heart, eyes and ears and is an important cause of hearing and visual impairment and mental retardation. CRS often causes lifelong physical and mental disability, requiring costly institutional care and special schools, and using a large amount of healthcare and societal resources. Therefore CRS provides the medical and economic rationale for appropriate prophylaxis with a vaccine.
A live attenuated vaccine against rubella has been available for over 40 years. It has a high immunogenicity, produces sero-conversion in close to 100% of vaccines, and confers immunity similar to that of natural infection. Immunity is maintained for at least 20 years and although infection, including CRS, may occur in vaccinated individuals with low antibody titers, this is not an important factor in rubella epidemiology. The rubella vaccine is available in combination with measles (MR) and with measles and mumps (MMR) as well as in monovalent form (R). Combination with other vaccines does not affect immunogenicity.
Most high- and middle-income countries include rubella-containing vaccine (RCV) in their childhood immunization schedules and have made progress in reducing the incidence of rubella or eliminating it. The World Health Organization (WHO) Latin American region (AMR) has eliminated rubella and CRS and the European region (EUR) registered a 98% reduction in cases between 2000 and 2009.
Although WHO published a position paper to guide introduction of RCV into the national childhood immunization schedules of member countries in 2000, only a few low-income countries have included the vaccine in their schedules. This is reflected in the epidemiological trends: the WHO eastern Mediterranean region (EMR) registered only a 35% reduction in rubella cases between 2000 and 2009 and the WHO African region (AFR) and South East Asian region (SEAR) registered 20-fold and 14-fold increases in rubella cases respectively during the same time period. Of the 165 reported cases of CRS in 2009, AFR, with 47, had the highest number.
Low-income countries have been slow to add RCV to their national immunization schedules because of several reasons, two of which stand out. First, despite its relatively low price (as might be supplied to UNICEF or through a GAVI Alliance subsidy), adding rubella to the vaccine schedule might be prohibitively costly in countries where healthcare budgets are already stretched. This suggests that including RCV in immunization schedules in poor countries is not cost-effective compared to other public health interventions. Second, because rubella causes a substantial proportion of its damage in fetuses, a high level of vaccination coverage (over 80%) must be maintained to avoid the risk of increasing the incidence of CRS which would happen if poor vaccine coverage reduced viral circulation in the population enough to shift rubella susceptibility from children to young mothers. This creates a unique policy problem: including RCV in national immunization schedules is likely not enough; the rubella immunization programs need to achieve herd immunity and many countries are unable to feasibly sustain such coverage standards.
A more recent position paper by WHO recommended that countries leverage accelerated measles control and elimination activities to introduce RCV and exploit this synergy to advance rubella and CRS elimination. In line with the WHO recommendation, the GAVI Alliance is supporting large-scale catch up measles-rubella campaigns with the aim of reaching over 700 million children in 49 countries by 2020.
Health economics, the study of how scarce healthcare resources are deployed and should be allocated in healthcare systems, has gained increasing prominence globally in the face of slowing western economies and continued resource constraints in low-income countries. Donors are increasingly scrutinizing the use of resources to assist poor countries in fighting disease and governments in low-income countries are increasingly scrutinizing their healthcare expenditures. Economic evaluations help policy makers to make resource allocation decisions by identifying different policy strategies, transparently evaluating their costs and benefits, quantifying the uncertainty around estimates, and examining different scenarios.
In 2002, Hinman et al. performed a global review of economic analyses of rubella and rubella vaccines published between 1970 and 2000. They found that inclusion of rubella vaccination in national immunization programs is both cost-beneficial and cost-effective and recommended further studies using data from the burden of rubella in developing countries and standardized methodologies.
In this paper, we present findings of an updated review of economic analyses of rubella and rubella vaccination. We examine the evidence on costs of rubella and CRS, the cost-effectiveness of adding RCV to national immunization programs, and the cost-effectiveness of different policy strategies that might be employed to add RCV to national childhood immunization schedules. Our aim is to examine the economic evidence base, assess differences in findings by country income levels, identify gaps in the evidence, and propose potential areas of future enquiry into the economics of rubella and rubella vaccination. Our findings will support the planned global expansion of RCV and the push towards potential rubella elimination and eradication.
Background
Acquired rubella is a mild disease which only rarely results in serious clinical complications i.e. encephalitis, arthritis and thrombocytopenia. The mild nature of the disease means that vaccination against it would not be medically or economically critical or justifiable if it did not infect pregnant mothers. During pregnancy, particularly in the first trimester, rubella infection is far more dangerous and commonly leads to abortion, fetal death or congenital rubella syndrome (CRS). CRS, which is estimated to affect 110,000 infants annually in low-income countries, is characterized by multiple defects of the brain, heart, eyes and ears and is an important cause of hearing and visual impairment and mental retardation. CRS often causes lifelong physical and mental disability, requiring costly institutional care and special schools, and using a large amount of healthcare and societal resources. Therefore CRS provides the medical and economic rationale for appropriate prophylaxis with a vaccine.
A live attenuated vaccine against rubella has been available for over 40 years. It has a high immunogenicity, produces sero-conversion in close to 100% of vaccines, and confers immunity similar to that of natural infection. Immunity is maintained for at least 20 years and although infection, including CRS, may occur in vaccinated individuals with low antibody titers, this is not an important factor in rubella epidemiology. The rubella vaccine is available in combination with measles (MR) and with measles and mumps (MMR) as well as in monovalent form (R). Combination with other vaccines does not affect immunogenicity.
Most high- and middle-income countries include rubella-containing vaccine (RCV) in their childhood immunization schedules and have made progress in reducing the incidence of rubella or eliminating it. The World Health Organization (WHO) Latin American region (AMR) has eliminated rubella and CRS and the European region (EUR) registered a 98% reduction in cases between 2000 and 2009.
Although WHO published a position paper to guide introduction of RCV into the national childhood immunization schedules of member countries in 2000, only a few low-income countries have included the vaccine in their schedules. This is reflected in the epidemiological trends: the WHO eastern Mediterranean region (EMR) registered only a 35% reduction in rubella cases between 2000 and 2009 and the WHO African region (AFR) and South East Asian region (SEAR) registered 20-fold and 14-fold increases in rubella cases respectively during the same time period. Of the 165 reported cases of CRS in 2009, AFR, with 47, had the highest number.
Low-income countries have been slow to add RCV to their national immunization schedules because of several reasons, two of which stand out. First, despite its relatively low price (as might be supplied to UNICEF or through a GAVI Alliance subsidy), adding rubella to the vaccine schedule might be prohibitively costly in countries where healthcare budgets are already stretched. This suggests that including RCV in immunization schedules in poor countries is not cost-effective compared to other public health interventions. Second, because rubella causes a substantial proportion of its damage in fetuses, a high level of vaccination coverage (over 80%) must be maintained to avoid the risk of increasing the incidence of CRS which would happen if poor vaccine coverage reduced viral circulation in the population enough to shift rubella susceptibility from children to young mothers. This creates a unique policy problem: including RCV in national immunization schedules is likely not enough; the rubella immunization programs need to achieve herd immunity and many countries are unable to feasibly sustain such coverage standards.
A more recent position paper by WHO recommended that countries leverage accelerated measles control and elimination activities to introduce RCV and exploit this synergy to advance rubella and CRS elimination. In line with the WHO recommendation, the GAVI Alliance is supporting large-scale catch up measles-rubella campaigns with the aim of reaching over 700 million children in 49 countries by 2020.
Health economics, the study of how scarce healthcare resources are deployed and should be allocated in healthcare systems, has gained increasing prominence globally in the face of slowing western economies and continued resource constraints in low-income countries. Donors are increasingly scrutinizing the use of resources to assist poor countries in fighting disease and governments in low-income countries are increasingly scrutinizing their healthcare expenditures. Economic evaluations help policy makers to make resource allocation decisions by identifying different policy strategies, transparently evaluating their costs and benefits, quantifying the uncertainty around estimates, and examining different scenarios.
In 2002, Hinman et al. performed a global review of economic analyses of rubella and rubella vaccines published between 1970 and 2000. They found that inclusion of rubella vaccination in national immunization programs is both cost-beneficial and cost-effective and recommended further studies using data from the burden of rubella in developing countries and standardized methodologies.
In this paper, we present findings of an updated review of economic analyses of rubella and rubella vaccination. We examine the evidence on costs of rubella and CRS, the cost-effectiveness of adding RCV to national immunization programs, and the cost-effectiveness of different policy strategies that might be employed to add RCV to national childhood immunization schedules. Our aim is to examine the economic evidence base, assess differences in findings by country income levels, identify gaps in the evidence, and propose potential areas of future enquiry into the economics of rubella and rubella vaccination. Our findings will support the planned global expansion of RCV and the push towards potential rubella elimination and eradication.