New vaccines and the rising costs of caring

Vaccines that are used in universal immunization programs for children have been highly effective in controlling, even eliminating, target illnesses. They have done so at remarkably little cost to taxpayers. Relative to the averted costs of caring for patients with the target illnesses and their sequelae, current universal vaccination programs actually save money for governments. The cost-sparing effect was estimated to be 10-fold with diphtheriapertussis-tetanus vaccines, the simple nature of which resulted in manufacturing costs well under $1/dose. Later vaccines involved increasingly sophisticated manufacturing processes and, consequently, higher costs. One can imagine the skill and labour involved in coaxing a batch of live measles or polio vaccine virus to completion in huge tissue culture tanks, and the precise chemistry required to conjugate the Haemophilus influenzae type b polysaccharide to a carrier protein in a consistent fashion. Nevertheless, the newer products were still cost sparing in universal programs. Recombinant hepatitis B vaccine was the first ‘genetically engineered’ vaccine. While it represented a remarkable advance in safety over plasma-derived vaccines, its initial cost was about $150 for a three-dose series for adults. A decade later, large scale production facilities and competition among manufacturers reduced the price to less than $25 per adult series, and facilitated the inclusion of the vaccine in universal programs. With the newest vaccines for children, cost savings are not possible at current prices. For example, varicella vaccine, at about $68 per dose, is estimated to be cost sparing only if the indirect costs to parents caring for a sick child are considered in addition to the direct costs of medical care. As with hepatitis B vaccines, the cost of varicella vaccine will most likely decrease with competition among manufacturers and technological advances, such as varicella vaccine supplied in combination with measles-mumps-rubella vaccines. The seven-valent pneumococcal conjugate vaccine licensed recently in the United States for use in infants is priced at US$58/dose or US$232 for the recommended four-dose series, making it more costly than all of the other childhood vaccines combined. The manufacturer points out that it is really seven new vaccines in one, each with its own new production line and unique challenges. While bulk purchases will, without doubt, result in lower prices, the cost per dose will have to decline by more than two-thirds to US$18 before the vaccine will offer cost savings to governments in universal programs, according to an American study (1). However, at a cost of US$46/dose, the vaccine will result in net savings for society, reflecting the high costs to parents of dealing with children who are ill with meningitis, pneumonia or otitis media (1). Canadians wait for relevant data. It has certainly been advantageous that previous vaccines offered cost savings, but would Canadian parents and policy makers choose not to protect children against a serious pathogen such as pneumococcus given the opportunity, even if cost savings were not attainable? The fact is that almost every other preventive program that is relevant to population health costs taxpayers substantial amounts of money; thus, it does not make sense to hold vaccines to a different standard. Health economists commonly use ‘quality-adjusted life years saved’ as a means of comparing the costs of different types of preventive measures, but pneumococcal conjugate vaccine does not fare well in such comparisons (1) because the mortality rate with pneumococcal infection is low, despite substantial morbidity. Economists can account for costs relating to illness episodes, but they have trouble weighting anticipated outcomes, such as the reduced spread of resistant organisms, reduced transmission of pneumococci to unvaccinated persons and simplified management of febrile infants (fewer blood cultures and empirical antibiotic courses would be needed), all of which are possibilities with the new pneumococcal conjugate vaccine. Any such savings will take some years of experience with the vaccine to determine. Parents offer another perspective on the acceptable cost of an ounce of prevention: what do they voluntarily spend on other preventive measures for their children? Conservative estimates of costs to age five years include $170 for dental hygiene products, $300 for recommended preventive dentistry, $400 on basic sun protection and $130 on generic multivitamins. Other comparators include $200 for boys' basic haircuts, $2,400 for disposable diapers and $300 for disposable wipes. Policy makers need to set aside the long standing expectation that vaccines will spare health care costs if Canadian children are to benefit from new, useful products. Wide use is necessary to reduce vaccine prices, potentially to break-even levels and below, whereas limited use will not have this effect. Defining good value may require value judgments that transcend traditional health economics. Comparing vaccine prices to the net costs of voluntary preventive measures for children, such as vitamins, sunscreen or tooth paste, adds a common sense dimension to these deliberations.

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