# Should we be considering costs when recommending vaccines? **URL:** \ **Category:** Great Debates\ **Created:** [July 26, 2011, 5:06pm UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400 "2011-07-26T17:06:31Z")\ **Posts on this page:** 8\ **Page:** 1
**Author:** ![Strassia](https://avatars.discourse-cdn.com/v4/letter/s/e8c25b/32.png) [@Strassia](https://boards.straightdope.com/u/Strassia)\ **Post date:** [July 26, 2011, 5:06pm UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400/1 "2011-07-26T17:06:31Z")
First a note: I am fully in support of vaccines in general and have kept both my children up to date. The MMR and autism scares make me furious. That said, I think we can all agree that not all vaccines are appropriate for all populations all the time. Some vaccines are more dangerous than others and it would be ridiculous to give a vaccine with a 1 in 1000 risk of serious reaction for a disease that has a 1 in 10000 risk serious harm. Targeting vaccines to specific at risk populations is also done, but this is currently done only considering medical risk/benefit. But as medical science advances, the cheaper vaccines with high impacts are already done. Newer vaccines are becoming more expensive and address lower risk afflictions. This has lead the group that advises on vaccines in the U.S. to begin to debate considering cost in its recommendations (which affect which vaccines are paid for by government programs). Consider the newly introduced meningitis booster shot: [ > [@](#): > > Other speakers noted that it would cost $189 dollars per vaccination and that the annual cost to the government alone would be $387 million dollars. All that spending would prevent just 23 deaths, they said. ]([Rising Costs Complicate Vaccine Guidelines : NPR](http://www.npr.org/2011/07/20/138474107/rising-costs-complicate-vaccine-guidelines)) That would mean a cost of over $16 million per life saved. And that does not include the cost borne by those paying into the insurance system. I think that no one would argue with $100 per life saved is completely justified. And we could also, I think agree that $1 trillion dollars per life is not feasible. But where should the limit be put? ---
**Author:** ![Great\_Antibob](https://avatars.discourse-cdn.com/v4/letter/g/e47c2d/32.png) [@Great\_Antibob](https://boards.straightdope.com/u/Great_Antibob)\ **Post date:** [July 26, 2011, 6:23pm UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400/2 "2011-07-26T18:23:42Z")
> [@Strassia](#): > > That would mean a cost of over $16 million per life saved. And that does not include the cost borne by those paying into the insurance system. Just to be pedantic, while the figure might be $16 million per life saved, it’s not just a matter of living or dying. You can survive meningitis and suffer life long physical problems - brain damage, hearing damage, etc. The benefit of preventing the disease for one healthy adult is potentially huge. Imagine the difference between a healthy adult and somebody who needs to be taught to deal with hearing loss? Or somebody who requires at least some level of moderate medicare care for the rest of their life? Is it worth the money if several hundred or thousand people don’t suffer life long physical impairment? I’m not sure how to calculate the benefit for fractions of a life, but the cost of the vaccine is almost surely less than $16 million per life affected. And that’s the hardest part about any of these calculations. Nobody actually has a good way of measuring the actual bottom line impact. Just my $0.02, but it’s a worthwhile debate. We can talk about death panels and rationed care all day, but we already ration care based on cost and some treatments can end up costing lives. There can be expensive treatments for the few that take resources away from less expensive treatments for the many. Where to draw the line? I’m not sure, but it seems like the UK and other countries with single payer type systems provide at least a good starting point for the debate. ---
**Author:** ![Tastes\_of\_Chocolate](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/tastes_of_chocolate/32/3232_2.png) [@Tastes\_of\_Chocolate](https://boards.straightdope.com/u/Tastes_of_Chocolate)\ **Post date:** [July 26, 2011, 9:45pm UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400/3 "2011-07-26T21:45:42Z")
Not just vaccines, but lots of healthcare needs to be evaluated. But we also need to decide what counts towards the benefits side of the equation. Treatment divided by lives saved doesn’t tell the whole story. > [@](#): > > Other speakers noted that it would cost $189 dollars per vaccination and that the annual cost to the government alone would be $387 million dollars. All that spending would prevent just 23 deaths, they said. From [Voices of Meningitis](http://www.voicesofmeningitis.com/get-the-facts-teen-at-risk.html) > [@](#): > > In fact, about 10% of the 1000 to 2600 Americans who get meningococcal meningitis each year will die From the[National Meningitis Association](http://www.nmaus.org/meningitis/) > [@](#): > > Meningococcal disease is a serious, potentially fatal bacterial infection that strikes an average of 1,500 Americans annually I knew a young woman who got meningitis while in college. After a long hospital stay, she ended up wheelchair bound, unable to live on her own. About 7 years later, she died, not attributed to meningitis, but definately weakened by it. I’m sure that in those 7+ years, her medical care totalled up to multiple hundreds of thousands of dollars. I’m going to assume (probably making an ass out of me) that if the linked article talks about 23 lives saved / year (about 1/5 of the number of US deaths that I found) due to government paid vaccination, then about 1/5 of the cases in the US are in people that would be covered by the US governemt. So what if the medical care savings / case avoided was $100k-$200k? Does it make sense to spend $387 million, if 300 people don’t get ill. That’s probably closer to the total cost/infected person value. ---
**Author:** ![Zephyurs](https://avatars.discourse-cdn.com/v4/letter/z/dfb087/32.png) [@Zephyurs](https://boards.straightdope.com/u/Zephyurs)\ **Post date:** [July 26, 2011, 11:29pm UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400/4 "2011-07-26T23:29:01Z")
> [@Strassia](#): > > That would mean a cost of over $16 million per life saved. And that does not include the cost borne by those paying into the insurance system. > > I think that no one would argue with $100 per life saved is completely justified. And we could also, I think agree that $1 trillion dollars per life is not feasible. But where should the limit be put? Just as a matter of comparison, IIRC most government agencies aim for $4 to $9 million per life saved. ---
**Author:** ![StephenG](https://avatars.discourse-cdn.com/v4/letter/s/7feea3/32.png) [@StephenG](https://boards.straightdope.com/u/StephenG)\ **Post date:** [July 27, 2011, 12:13am UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400/5 "2011-07-27T00:13:36Z")
> [@Tastes\_of\_Chocolate](#): > > I’m going to assume (probably making an ass out of me) that if the linked article talks about 23 lives saved / year (about 1/5 of the number of US deaths that I found) due to government paid vaccination, then about 1/5 of the cases in the US are in people that would be covered by the US governemt. > > So what if the medical care savings / case avoided was $100k-$200k? Does it make sense to spend $387 million, if 300 people don’t get ill. That’s probably closer to the total cost/infected person value. Yup, $387 million divided by 23 lives saved is $16 million. Except that, as you say, that’s for only ~1/5 of the US populace who dies from this, as per your earlier inks. So, really, it’s $16 million / 5, or about $3.2 million per life saved. And, as others have pointed out, there are a lot more effects than just death. Your ink said only about 10% of those afflicted die, so we could potentially be saving 10x a many people – that’s only 0.32 million, or $320,000 per case prevented.\* Going by **Zephyur** ’s reported metric, that seems well worth it. \*These calculations assume that the vaccine is 100% effective. I’m aware that’s unlikely. Even if it’s only 90% effective, that means it’s about $3.52 million per life saved, or $352,000 per case prevented. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [July 27, 2011, 3:15am UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400/6 "2011-07-27T03:15:52Z")
The basic question is a good one. Yes, we should be concerned about cost and cost effectiveness should be part of the decision process before a vaccine is advised. And the numbers get crunched, but often policy makers decide that it is not them to decide if the money is worth it, just if it would work. [Here](http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/02-3-mening-CostEffect.pdf) is a power point from the CDC site that summarized some discussion about meningococcal vaccination with information on other vaccine cost effectiveness thrown in. Note the meaningful metric is generally not number of lives saves, but “life-years” or even more so “quality adjusted life-years” ([QALY](http://www.nice.org.uk/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp)) - saving a life at age 18 saves more years of life than saving one at 80 and a poor quality of life year is worth less than one with good health. For the current two shot meningococcal vaccine series the estimate is that it will cost $157K/QALY. [Here](http://pediatrics.aappublications.org/content/121/Supplement_1/S63.full) is a review that puts it into some context. HepA cost savings to society. HepB $9K/QALY. Influenza $119/QALY gained for 12- to 17-year-olds who were not at high risk (not factoring in the secondary benefits to higher risk populations from avoiding exposure, which is where the benefit actually accrue; [universal influenza vaccine](http://centerforvaccineethicsandpolicy.wordpress.com/2011/06/20/cost-effectiveness-universal-mass-vaccination-for-seasonal-influenza-in-u-s/) expected to come in at only $15.9K/QALY over targeted vaccination) and $10K targeting high risks only. HPV vaccination of females at age 12 $15 to 24/QALY. Of males the value varies according to the female vaccination rate. Under conditions of high vaccination of females little additional benefit but under lower vaccination rates more cost effective. That study quotes $88K/QALY for a catch up meningococcal vaccine program. The standard childhood vaccines all pretty much cost savings, some dramatically so. How they put the broad discussion: > [@](#): > > The rule has been that interventions that cost less than $50000 per QALY saved are defined as societally cost-effective and that interventions between $50000 and $100000 should only be adopted if there are additional unpriced benefits such as relieving fear in the community.55 This rule and its cost thresholds are highly contested as baseless of any economic theory or expert support.55 Indeed, recent extensive and theoretical studies may suggest threshold values that are much higher56,57 and/or context specific.58 Thus, assessments of cost-effectiveness of any vaccine and, for that matter, of any health intervention that uses this rule of thumb should be avoided. > > A more reliable alternative is to perform cost-effectiveness comparisons with other vaccines, as attempted here (see Fig 1), or with other health services. [Screening mammography](http://www.ncbi.nlm.nih.gov/pubmed/16757702) as actually done in the US $165K/QALY. [Prostate specific antigen screening for prostate cancer](http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102271766.html) actually decreases QALY compared to no screening. Screening the obese for [diabetes](http://care.diabetesjournals.org/content/30/11/2874.full.pdf) about $8-9K/QALY. [Colonoscopy](http://www.gastrojournal.org/article/S0016-5085(10)00339-2/abstract) every 3y for those at high risk and every 10y for those at low risk, $5.7K/QALY So we are pretty much all over the board. Not as costly as mammography but still meningococcal vaccination does not come cheap. ---
**Author:** ![clairobscur](https://avatars.discourse-cdn.com/v4/letter/c/839c29/32.png) [@clairobscur](https://boards.straightdope.com/u/clairobscur)\ **Post date:** [July 27, 2011, 1:25pm UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400/7 "2011-07-27T13:25:11Z")
> [@Strassia](#): > > I think that no one would argue with $100 per life saved is completely justified. And we could also, I think agree that $1 trillion dollars per life is not feasible. But where should the limit be put? In other areas, administrations use a “bureaucratic” estimate of the value of a life saved. For instance, for major safety works on roads or such things. I don’t remember the figure at all (and besides, it probably changes somewhat from one country to another) but it’s significantly lower than the 16 millions you mentioned (could be 1 million, $ 5 millions, something in this range). But it’s true that when it comes to medical expenses this concept isn’t generally applied, as far as I can tell (or else some major surgeries, and probably even some life-long drug treatments would never be proposed). ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [July 28, 2011, 1:00am UTC](https://boards.straightdope.com/t/should-we-be-considering-costs-when-recommending-vaccines/590400/8 "2011-07-28T01:00:43Z")
[More comparison](http://knowledge.wharton.upenn.edu/article.cfm?articleid=1949). > [@](#): > > A thorny question lies at the heart of meaningful health care reform. How much is human life worth? > > New research from Wharton and Stanford based on Medicare kidney dialysis data shows that the average figure – $129,090 per additional year of quality life – is higher than prior studies have shown. … > > … However, the distribution of cost effectiveness across the entire population is wide. For the lowest percentile, it costs only $65,496 to provide an additional quality-adjusted life year. For the top percentile, the figure is $488,360. The higher costs per quality adjusted life year were strongly associated with old age and additional chronic illnesses in addition to end-stage renal disease, the researchers found. > > “I don’t believe that any health economist or the strongest advocate for providing coverage will argue that half a million dollars for one year of life is reasonable,” says Lee. “This would inflate health care spending by a large amount – 10 to 15 times what we currently spend. Obviously that’s not feasible.” … > > … Up until now, according to the paper, the most commonly used number to place a value on a year of quality life has been $50,000. It, too, is based on a study of dialysis patients. The 1984 Canadian study used an accounting ledger for 44 patients at one center during a time span of one year. A more recent study adjusted that number to $93,500 per year, inflating the earlier number to 2002 U.S. dollars. … > > … Another approach is based on the cost effectiveness of life saving interventions in non-medical fields such as occupational health, transportation safety or environmental hazard control, the paper states. Estimates using these methods ranged from a cost-effective $56,000 per life year saved for transportation programs to a more extravagant $4.2 million per life year saved for environmental programs. … > > … Lee notes that the $129,090 figure his research came up with compares to a range of $50,000 to $100,000 used in other countries, such as Australia and the UK, which run national health care systems in guiding their coverage decisions. The World Health Organization has proposed $108,609 as the value of a disability-adjusted life year, Lee says, adding that even though other countries have adopted the use of “pseudo-official” spending thresholds in coverage decisions, they do not apply them rigidly and without exceptions. And while other nations are more oriented toward universal health care, the United States has favored a market-based system. “But it has not been as successful as we might have liked. Perhaps it is time to revisit the pros and cons of this approach,” says Lee. …