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Jordana Schmier, Su Li, James C. King, Jr., Kristin Nichol, and Parthiv J. Mahadevia Benefits And Costs Of Immunizing Children Against Influenza At School: An Economic Analysis Based On A Large-Cluster Controlled Clinical Trial Health Affairs, March/April 2008; 27(2): w96-w104. [Abstract] [Full Text] [PDF] [Online Appendix] [Reprints & Permissions]

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Are The Costs Of School-Based Immunization Programs Understated?

Katherine Harris, Laurie Martin and Nicki Lurie   ( 28 January 2008 )

Overestimating The Economic Benefits Of School-Based Influenza Vaccination

Martin I. Meltzer   ( 1 February 2008 )

Costs Of School-Based Influenza Vaccination

Jordana K. Schmier, Su Li, James C. King Jr., Kristin Nichol, and Parthiv J. Mahadevia   ( 7 March 2008 )

Are The Costs Of School-Based Immunization Programs Understated? 28 January 2008
Katherine Harris, Economist RAND Corporation, Laurie Martin and Nicki Lurie Send letter to journal: Re: Are The Costs Of School-Based Immunization Programs Understated? kharris{at}rand.org Katherine Harris, et al.	We agree with Schmier and colleagues regarding the potential benefits of mass vaccination in school-based settings. In our view, however, the authors' analysis may overestimate potential cost savings in two ways. First, the analysis omits the costs of implementing school-based immunization programs outside the context of a controlled research study. These costs include securing school participation, coordinating public health departments and school administrators, obtaining signed parental consent and parental acknowledgment of the receipt of vaccine-related information, boosting student participation with incentives, and updating vaccination records [1]. We estimate that just 40 hours of school nurse time spent on administrative matters and 15 minutes spent by homeroom teachers distributing and collecting consent forms could easily add between $9 and $12 per household, depending on class size and assumptions about the opportunity costs associated with school staff time. Costs of this magnitude do not negate the cost savings demonstrated by the authors. However, they may wipe out savings in situations where vaccine take-up rates are lower than those observed by the authors. Second, the cost savings in the paper are driven by extremely low immunization rates among the control group, rather than the relative efficiency of school-based programs over other mass vaccination strategies. For example, a more relevant comparison might be made to existing initiatives [2,3] where schools aggressively promote vaccination sites in easily accessible community settings, where parental consent is obtained at the time of the immunization, multiple family members may be immunized simultaneously, and administrative burdens on already taxed school staff are minimized. In closing, to be credible and influential, research should realistically reflect the complexities of program implementation and minimize the likelihood of unanticipated expenditures. Notes 1. Lynda Boyer-Chu and Susan Wooley, 2006. Give It A Shot: Toolkit for Nurses and Other Immunization Champions Working with Secondary Schools, American School Health Assocation. http://www.ashaweb.org/pdfs/august.pdf. Accessed January 23, 2008. 2. Caring for Children Foundation of Texas, About the Care Van Program, Texas, http://www.carevan.org. Acessed January 23, 2008. 3. PHP Home Page. Super Shot. http://www.phpni.com/supershot.htm. Assessed January 23, 2008.
Overestimating The Economic Benefits Of School-Based Influenza Vaccination 1 February 2008
Martin I. Meltzer, Senior Health Economist Centers for Disease Control and Prevention (CDC) Send letter to journal: Re: Overestimating The Economic Benefits Of School-Based Influenza Vaccination qzm4{at}cdc.gov Martin I. Meltzer	Schmier et al.’s recently presented results, from a mathematical model, suggest that it would be cost-saving to vaccinate children against influenza at school. However, they may have overestimated the benefits of such a plan. For example, they used $214 to value a lost workday. Yet daily wages (median hourly earnings, 8-hour day, 2006, all occupations) in Maryland, Minnesota, Texas, and Washington were $134, $129, $106, and $134 per day, respectively.[1] Further, for every workday lost, the authors added a dollar value for an assumed 1.5 days of 50% reduction of work productivity (“presenteeism”).[2] However, the lost productivity attributed to presenteeism is often based on self-reported qualitative measures.[3] I know of no study that measured the actual dollar losses to the economy due to presenteeism. In a service-sector-dominated economy, a worker can minimize loss of revenue by selecting the “most essential tasks,” as well as delaying completion of some tasks to when they feel better. The authors also used mean values of the epidemiological inputs (e.g., rate of medically attended visits). However, such epidemiological data are very rarely normally distributed (a few cases often right-skew the distributions). The use of median values often gives a better sense of what is “typically” experienced. The authors did conduct sensitivity analyses, but only by altering the value of one variable at a time. Disease spread and impact is more complex than that, and simultaneous varying of several inputs instructs the reader as to the probability of the intervention's being cost saving. As a first step toward a multivariable sensitivity analysis, could the authors provide results in which they used median values of all epidemiological inputs, the simple average of median daily income ($126), and with and without a value for presenteeism? Notes and References: Acknowledgement: The comments in this letter are those of the author and do not necessarily reflect those of the Centers for Disease Control and Prevention. 1. Bureau of Labor Statistics: “May 2006 State Occupational Employment and Wage Estimates” U.S. Dept. of Labor: available at: http://www.bls.gov/oes/current/oessrcst.htm (Accessed on 01/31/2008). 2. See Schmier and colleagues' online appendix, available at: http://content.healthaffairs.org/cgi/content/full/hlthaff.27.2.w96/DC2). 3. M. Keech et al. “The impact of influenza and influenza-like illness on productivity and healthcare resource utilization in a working population” Occup Med 48 (1998):85-90.
Costs Of School-Based Influenza Vaccination 7 March 2008
Jordana K. Schmier, Managing Scientist Exponent, Su Li, James C. King Jr., Kristin Nichol, and Parthiv J. Mahadevia Send letter to journal: Re: Costs Of School-Based Influenza Vaccination jschmier{at}exponent.com Jordana K. Schmier, et al.	We appreciate the interest in the economics of school-based influenza vaccination and believe that Harris and colleagues and Meltzer raise important points. The broader issue implied by Harris et al. is how intensive of a vaccination program is warranted for vaccinating children against influenza at school. There are historical precedents for school-based vaccination programs, beginning with the polio vaccine in the 1950s, continuing on with rubella and hepatitis B, and, more recently, county and statewide influenza vaccination programs.[1] In estimating the programmatic costs for our study, we used costs based on recent county- and statewide influenza vaccination programs. The programmatic cost of a school-based vaccination program had expenses just over $1,600 per school ($1,500 for school supplies and $103 for a standing order). In addition, we estimated the cost associated with vaccination and potential vaccine- related adverse events. These programs described by King et al. and used in our cost-consequence analysis resulted in vaccination rates approaching 50%. At this vaccination rate, significant reductions were seen in household influenza-like illnesses and subsequent use of health care resources. While more intensive intervention programs that require sophisticated coordination efforts by public health agencies could further increase vaccination rates, the question is at what benefit and at what cost? Setting up capital infrastructure and human resources to monitor school-based vaccination will undoubtedly require additional time and effort. However, even this type of program, once up and running, may not require as much effort in ensuing years. In a public health effort there would be an economy of scale. In addition, some of the effort by and costs of medical personnel could be absorbed into existing nursing duties of the school system or local health department without increasing the costs. Also, each year of experience would likely lead to streamlining these costs as personnel become accustomed to the program. Finally, medical volunteers could be used to assist the public health nurses, thus reducing the overall costs. In response to comments about the background rates of influenza vaccination, we believe that the observed influenza vaccination rate in the control schools (averaging 12% in our study) is consistent with the national average among the recommended household contacts of high-risk groups ages 5-17, which is 10%.[2] In response to Meltzer’s comments, we used national estimates for wages (not state-specific) and also considered the value of benefits. Our assigning a dollar value to presenteeism is consistent with multiple other studies that have calculated its impact on work.[3] We did not have access to detailed job descriptions and do not know what proportion of parents in this study might have been able to make up some of their lost or otherwise unproductive time. Given that the Panel on Cost- effectiveness in Health and Medicine does not recommend incorporation of make-up time, we are adhering to current standards of economic analyses.[4] We appreciate these thoughtful comments and hope that future studies will continue to explore the potential cost savings of school-based immunization. References 1. J.C. King Jr, G.E. Cummings, J. Stoddard, B.X. Readmond, L.S. Magder, M. Stong, M. Hoffmaster, J. Rubin, T. Tsai, E. Ruff; SchoolMist Study Group. A pilot study of the effectiveness of a school-based influenza vaccination program. Pediatrics. 2005 Dec;116(6):e868-73.; and M.C. Lindley, L. Boyer-Chu, D.B. Fishbein, M. Kolasa, A.B. Middleman, T. Wilson, J. Wolicki, S. Wooley; Working Group on the Role of Schools in Delivery of Adolescent Vaccinations. “The role of schools in strengthening delivery of new adolescent vaccinations.” Pediatrics 121 Suppl 1 (2008):S46-54. 2. “Influenza vaccination coverage among children with asthma--United States, 2004-05 influenza season.” Morbidity and Mortality Weekly Report 56, no. 9 (2007): 193-6. 3. A. Cyr, S. Hagen, "Measurement and quantification of presenteeism," Journal of Occupational and Environmental Medicine 49, no. 12 (2007): 1299; S. Battke, A. Balakrisnan, G. Bergamo, S.J. Newberry, "A review of methods to measure health-related productivity loss," American Journal of Managed Care 13, no. 4 (2007): 211-7. 4. M. R. Gold, J. E. Siegel, L. B. Russell and M. C. Weinstein eds., Cost-effectiveness in Health and Medicine (New York: Oxford University Press, 1996).