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Graduate students in JHSPH’s Vaccine Policy Issues class examine current national and international policy issues across the spectrum of vaccine work. As a part of the course, students selected topics for analysis. Selected entries will appear in a series on the IVAC blog. This is the first in the series. Guest post by Sally Ann Iverson, DVM, MPH By the time you’ve reached your golden years, diseases you experienced in your childhood have likely been reduced to distant memories of unpleasantness. However, chickenpox is one childhood disease that should not be forgotten. Long after the painful pox have cleared, the virus remains dormant in your nerves waiting for an opportunity to wreak havoc on your adult life in the form of shingles. Shingles occurs when the Varicella zoster virus reactivates and causes a painful and sometimes debilitating rash. Although it’s unknown exactly what causes the virus to reactivate, it’s thought to be associated with a weakened immune system and older age. The majority of the US population is susceptible to shingles, as 90% of Americans have experienced chickenpox by the age of 15. Almost one out of every three of these people will go on to develop shingles, resulting in about one million cases every year. About half of these cases occur in men and women over 60 years of age. You may ask, “What’s so terrible about a rash?” Imagine tingling, burning, and stabbing sensations as the virus dances along your nerves and blisters your skin. People who have experienced shingles have described it as “the demon’s hand” and women have declared it more painful than childbirth. About 20% of the people who experience shingles will suffer from permanent damage to the nervous system, a condition known as post-herpetic neuralgia, that can persist for months or even years after the rash has resolved. Given the nightmare that shingles is capable of producing, you may be relieved to learn that there is a vaccine for adults that can cut your risk of shingles in half. You may also expect that people would be lining up around the corner to receive this vaccine, especially since the US Advisory Committee on Immunization Practices (ACIP) has made formal recommendations that all adults over 60 should receive the shingles vaccine. Yet surprisingly, only 10% of people in the recommended age group have been vaccinated for shingles. Although there are many reasons for underutilization of the vaccine, multiple studies have found one factor that seems to be a root cause: money. The herpes-zoster vaccine is the most expensive vaccine recommended for older adults. At around $160-$200, it cost four times as much as the pneumococcal vaccine and ten to twenty times as much as the flu vaccine. It’s also the only routinely recommended vaccine for older adults not covered under Medicare part B; instead, shingles vaccine has been relegated to coverage under Medicare part D prescription drug plan. The distinction between “part B” and “part D” vaccines is substantial, and affects the 93% of the US population over 65 that is currently covered by Medicare. For vaccines covered under Medicare part B, such as the flu and pneumococcal vaccines, a patient can go to his or her doctor to get vaccinated. The doctor will then bill Medicare and will be fully reimbursed for the cost of the vaccine. However, the process is much more complicated for a vaccine covered under part D. Doctors cannot bill Medicare directly for the cost of the vaccine, so they must either require the patient to pay the full price of the vaccine upfront (and later submit for reimbursement to Medicare), or they will ask the patient to go and purchase the vaccine from a pharmacy, and bring it back to the office to be vaccinated. This later scenario is highly discouraged by the CDC, as the vaccine must be kept at specific temperatures that may be violated during transport from the pharmacy. This complex system is confusing, inefficient, and expensive for both patients and doctors. Patients may be required to pay initial high costs out of pocket, as well as any co-pays that remain after reimbursement. Doctors are less than enthusiastic about regularly stocking and administering the vaccine due to the complicated process associated with current Medicare coverage. Additionally, financial loopholes in the current system may result in physicians covering up to 25% of the cost of the vaccine, which is more than the full cost of any other vaccine they would be administering! Transferring coverage of the shingles vaccine to Medicare part B would greatly reduce the burden to patients, and would pave the way for the breakdown of other barriers to vaccination. Surveys of physicians have found that a simpler system would encourage more doctors to regularly stock the vaccine, resulting in improved access for patients. We can also expect that more people will be motivated to receive a vaccine that is affordable and easy to obtain. On the whole, vaccines have proven themselves as one of the most cost-effective preventative health interventions we have available, and the CDC has also endorsed the shingles vaccine as a cost-saving health intervention. By allocating Medicare resources to preventative measures such as shingles vaccine, we have the opportunity to avert higher healthcare costs later on. Shingles is a disease not soon forgotten by those who experience its wrath, and it should not be forgotten by our healthcare system either. The inclusion of the shingles vaccine under Medicare part D has been the first step in addressing this debilitating disease, but it is not good enough. Our healthcare system can do a better job and reach more than 10% of the target population. It’s time to dig the shingles vaccine out from under all the paperwork, and slate it for coverage under Medicare part B. Dr. Sally Ann Iverson recently graduated from the Johns Hopkins Bloomberg School of Public Health with a Master of Public Health degree and a certificate in vaccine science and policy. She will begin a fellowship as a veterinarian at the Plum Island Animal Disease Center this July.
By Dan Thomas Have you ever been to the movies and seen a trailer for a film that you previously had no interest in seeing and then suddenly thought to yourself “That is a film I CANNOT MISS”? That was the idea behind GAVI’s most recent production. It’s a three-minute film by a talented young American film maker called Ryan Youngblood that I stumbled across in Kigali one day and I think he and producer Doune Porter more than fulfilled their brief. On April 26, during WHO’s first-ever World Immunization Week, Ghana will introduce not just one but two new vaccines into its immunisation programme. The pneumococcal and rotavirus vaccines will protect infants against the leading causes of the two biggest killers of children in Ghana and throughout the developing world – pneumonia and diarrhea. The GAVI Alliance and our partners UNICEF andWHO are working with Ghana’s Ministry of Health to plan a massive celebration in Accra at which the first children will be vaccinated. On the same day, halfway across the world in Atlanta, Georgia, USA, our friends at the UN Foundation will be launching the Shot@Life campaign to encourage the American public to champion vaccines as one of the most cost-effective ways to save children’s lives around the world. It’s such an exciting time to be working in global health and, as more and more power brokers embrace the value of investing in people’s health, we are literally seeing progress across the world on a daily basis. As you can imagine, back in Ghana our colleagues are feeling more than a little pressure and this film brilliantly captures the careful, methodical planning process that is involved in introducing new vaccines into the national health programme. It also portrays the skill, wit and energy that Ghanaian health professionals are investing in this extraordinary initiative. Like the best movie trailers, our little film has all the right ingredients to get you interested in wanting to know what happens next: handsome men, beautiful women, tragedy, suspense, despair, hope and raw determination! Watch it now, you won’t be disappointed. (It's also available in French and German) Dan Thomas is Head of Media and Communications at the GAVI Alliance, a public-private partnership which aims to save children’s lives and protect people’s health by increasing access to vaccines in the world’s poorest countries.
By Dr. Dagna Constenla
Few illnesses have as much power to cause panic among the population as meningococcal disease. And the facts are scary: meningococcal disease is one of the most severe and rapidly progressive community acquired infections. At any given time, 10 to 25 percent of the global population carry meningococcal bacteria in the back of their throats or in their noses, but this percentage may be much higher during an epidemic. Up to 20 percent of patients who come down with the disease die, typically within 24-48 hours of the onset of symptoms. The disease, which infects the membranes of the brain and spinal cord, is debilitating and potentially fatal for children, adolescents and people living in overcrowded conditions. And while meningococcal disease is considered a disease of mandatory notification in most countries, the exceedingly low rates of the disease reported by some countries and the high proportion of meningitis reported by others send conflicting messages about its real burden. Information about the true burden of this disease is usually neither published nor easily accessible.
What can we do about it?
Today, I write from Buenos Aires, where Latin American researchers, economists and global health leaders have gathered to focus on meningococcal disease in the region – 181 experts attended the meeting, representing 21 countries. Latin America has high meningococcal-associated morbidity and mortality, even in the face of early therapeutic intervention. But we still need to have a greater understanding of the true burden of meningococcal disease in the region so that we can help promote programs and introduce vaccines to fight this killer.
Our work on this project, coordinated by the Sabin Vaccine Institute in partnership with the Pan American Health Organization, the International Vaccine Access Center at Johns Hopkins University and the Centers for Diseases Control and Prevention, set out to accomplish two primary goals: to estimate the burden of disease in the region by reviewing available epidemiological data on meningococcal disease in Latin America and the Caribbean (LAC); and to estimate the costs associated with management of meningococcal disease cases and outbreaks in selected countries of the LAC region.
Through this first-ever study, by estimating the burden and costs of meningococcal disease in Latin America, we can begin to determine what obstacles impede its prevention through vaccination.
What did we find?
This is the first study in the region to estimate the cost of meningococcal disease, and the numbers are striking, giving us new urgency for our work: Meningococcal disease incurs a considerable societal economic burden in countries of the region, generating up to $6,228 (USD) in costs per patient. This burden represents the cost of treating an endemic case, not a case during an outbreak.
A detailed socioeconomic study during the 2007 epidemic in Burkina Faso showed that each case of meningitis in a family results in a sudden expenditure of about US$90—what amounts to three or four months of the family's disposable income. Families with few resources cycle inexorably downward to the next level of poverty. In addition, about 25 percent of survivors have permanent after-effects such as deafness, leaving them less likely to be economically productive citizens, and they often become wards of an already financially stretched extended family. Furthermore, what is not captured in the above analysis is the chaos to health systems engendered by a meningitis epidemic.
Closer to home, in Brazil, one community had a meningitis outbreak causing nine cases and spent $143,000 (USD) on investigation and outbreak management alone. This study did not consider the cost of treating the outbreak cases, which would bring the costs of the outbreak even higher. The new study concluded that more and better information is needed to help control outbreaks.
What’s next?
Given the availability of new highly effective vaccines, better epidemiological information, carriage studies and characterization of N. meningitidis isolates are critical to understand the epidemiology of meningococcal disease in Latin American countries.
Along with understanding the biology of disease itself, we must also examine the economic impact, which can vary widely across countries in the LAC region. An economic study is one way of providing such information. Yet what is clear from our research is that coordinated vaccination programs would not only significantly reduce outbreaks, but would also reduce the overall financial burden the disease can have on local health systems.
Our work concludes that through improved surveillance and better understanding of meningococcal epidemiology and costs, we can help devise meningitis vaccination programs that can not only save lives but also prevent these extraordinary economic impacts.
We can eliminate meningitis as a public health problem in the LAC region by increasing awareness of the disease and economic burden, and through the development, testing, introduction, and widespread use of meningococcal vaccines.
Update
The meeting has received plenty of great attention! Here are just some of the many links that have appeared in Latin American media:
Dr. Dagna Constenla is the Director of Economics & Finance at IVAC.
By Dr. Dagna Constenla Dengue, also known as breakbone fever, is a painful and sometimes fatal disease spread by the bite of a mosquito. Patients that get dengue fever often have painful headache, skin rash and debilitating muscle and joint pains. In some cases, it can lead to circulatory failure, shock, coma and death. Though early and effective treatment can ease symptoms, there is no specific cure available for dengue. Because the mosquito bites all day and can breed even in small bits of stagnant water, efforts to control dengue by preventing bites and breeding are often expensive and provide limited relief. A vaccine is coming though. After more than 60 years, the development of dengue vaccines has accelerated dramatically. Today, several vaccines are in various stages of advanced development, with clinical trials currently underway on five candidate vaccines. Trials in the most advanced stages are showing encouraging preliminary data, and the leading candidate could be licensed as early as 2015. | Controling dengue by preventing bites and breeding is often expensive and only provides limited relief. A dengue vaccine could prevent illness and change the disease landscape in Latin America and beyond. Photo: CDC/James Gathany |
But unlike a new iteration of an existing vaccine, this is uncharted territory. How do we predict its use? Its cost? Cost-effectiveness? Its affordability? How will countries introduce it? To lay the groundwork for the vaccine's eventual introduction, experts from the Latin America and Caribbean region are gathering in Baltimore on March 6-8, 2012 not only to ask questions, but to develop guidelines and standards for costing dengue so that over the next decade, local, and regional decision-makers will have access to robust information on the true cost of dengue in endemic countries of the region. As a core partner in the Dengue Vaccine Initiative, the International Vaccine Access Center (IVAC) at Johns Hopkins University is pleased to be hosting this workshop in partnership with the Pan-American Health and Education Foundation (PAHEF). For 3 days, more than 15 experts in health economics and epidemiology will work to assess the current evidence of dengue economics research, identify methodological strengths and weaknesses of this evidence, and foster consensus, where possible, on the best way to conduct dengue economics research. In order to make this work valuable to the entire Latin American region, the guidelines and outputs from this workshop will be made available in Spanish, Portuguese and English on the internet in the months ahead. And then the real work begins. Putting these guidelines to use so that we can improve the evidence-base for decisions in Latin America on how to use dengue vaccines. Dr. Dagna Constenla is the Director of Economics & Finance at IVAC.
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