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Abstract

Background

Given that measles is eliminated in Canada and measles immunisation coverage in Ontario is high, it has been questioned whether Ontario’s measles outbreak response is worthwhile.

Aim

Our objective was to determine cost-effectiveness of measles containment protocols in Ontario from the healthcare payer perspective.

Methods

We developed a decision-analysis model comparing Ontario’s measles containment strategy (based on actual 2015 outbreak data) with a hypothetical ‘modified response’. The modified scenario assumed 10% response costs with reduced case and contact tracing and no outbreak-associated vaccinations; it was based on local and provincial administrative and laboratory data and parameters from peer-reviewed literature. Short- and long-term health outcomes, quality-adjusted life years (QALYs) and costs discounted at 1.5%, were estimated. We conducted one- and two-way sensitivity analyses.

Results

The 2015 outbreak in Ontario comprised 16 measles cases and an estimated 3,369 contacts. Predictive modelling suggested that the outbreak response prevented 16 outbreak-associated cases at a cost of CAD 1,213,491 (EUR 861,579). The incremental cost-effectiveness ratio was CAD 739,063 (EUR 524,735) per QALY gained for the outbreak response vs modified response. To meet the commonly accepted cost-effectiveness threshold of CAD 50,000 (EUR 35,500) per QALY gained, the outbreak response would have to prevent 94 measles cases. In sensitivity analyses, the findings were robust.

Conclusions

Ontario’s measles outbreak response exceeds generally accepted cost-effectiveness thresholds and may not be the most efficient use of public health resources from a healthcare payer perspective. These findings should be balanced against benefits of increased vaccine coverage and maintaining elimination status.

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/content/10.2807/1560-7917.ES.2019.24.11.1800370
2019-03-14
2024-10-13
http://instance.metastore.ingenta.com/content/10.2807/1560-7917.ES.2019.24.11.1800370
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References

  1. Centers for Disease Control and Prevention (CDC). Epidemiology of Vaccine Preventable Diseases. Measles. Atlanta: CDC. [Accessed: 25 Aug 2017]. Available from: https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html
  2. Reportable disease trends in Ontario: Measles rates and cases for all ages, for all sexes, in Ontario. Toronto: Public Health Ontario. [Accessed: 2 Feb 2018]. Interactive web report: Measles. Toronto: Public Health Ontario. [Accessed: 18 Sep 2017]. Available from: https://www.publichealthontario.ca/en/data-and-analysis/infectious-disease/reportable-disease-trends-annually#/36
  3. Papania MJ, Orenstein WA. Defining and assessing measles elimination goals. J Infect Dis. 2004;189(s1) Suppl 1;S23-6.  https://doi.org/10.1086/381556  PMID: 15106085 
  4. Shane A, Hiebert J, Sherrard L, Deehan H. Measles surveillance in Canada: Trends for 2013. Can Commun Dis Rep. 2014;40(12):219-32.  https://doi.org/10.14745/ccdr.v40i12a01  PMID: 29769844 
  5. Chen SY, Anderson S, Kutty PK, Lugo F, McDonald M, Rota PA, et al. Health care-associated measles outbreak in the United States after an importation: challenges and economic impact. J Infect Dis. 2011;203(11):1517-25.  https://doi.org/10.1093/infdis/jir115  PMID: 21531693 
  6. Ortega-Sanchez IR, Vijayaraghavan M, Barskey AE, Wallace GS. The economic burden of sixteen measles outbreaks on United States public health departments in 2011. Vaccine. 2014;32(11):1311-7.  https://doi.org/10.1016/j.vaccine.2013.10.012  PMID: 24135574 
  7. Pan American Health Organization (PAHO). Region of the Americas is declared free of measles. Washington: PAHO; 2016. Available from: http://www.paho.org/hq/index.php?option=com_content&view=article&id=12528%3Aregion-americas-declared-free-measles
  8. Infectious diseases protocol. Appendix A: Disease-specific chapters. Measles. Toronto: Ministry of Health and Long Term Care; 2014. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/measles_chapter.pdf
  9. Thomas S, Hiebert J, Gubbay JB, Gournis E, Sharron J, Severini A, et al. Measles outbreak with unique virus genotyping, Ontario, Canada, 2015. Emerg Infect Dis. 2017;23(7):1063-9.  https://doi.org/10.3201/eid2307.161145  PMID: 28628461 
  10. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Immunization coverage report for school pupils: 2013-14, 2014-15 and 2015-16 school years. Toronto: Queen's Printer for Ontario; 2017. Available from: https://www.publichealthontario.ca/-/media/documents/immunization-coverage-2013-16.pdf?la=en
  11. Canadian Agency for Drugs and Technologies in Health (CADTH). Guidelines for the Economic Evaluation of Health Technologies: Canada. 4th ed. Ottawa: CADTH; 2017.
  12. Vallejo-Torres L, García-Lorenzo B, Castilla I, Valcárcel-Nazco C, García-Pérez L, Linertová R, et al. On the estimation of the cost-effectiveness threshold: why, what, how? Value Health. 2016;19(5):558-66.  https://doi.org/10.1016/j.jval.2016.02.020  PMID: 27565273 
  13. Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res. 2008;8(2):165-78.  https://doi.org/10.1586/14737167.8.2.165  PMID: 20528406 
  14. Open Financial Exchange (OFX). Exchange rates. Canadian dollar. Toronto: OFX. [Accessed: 26 Nov 2018]. Available from: https://www.ofx.com/en-ca/exchange-rates/cad/
  15. Open Financial Exchange (OFX). Yearly average rates. Historical exchange rates. Toronto: OFX. [Accessed: 22 Jan 2018]. Available from: http://www.canadianforex.ca/forex-tools/historical-rate-tools/yearly-average-rates
  16. Allen LJS. An introduction to stochastic epidemic models. In: van den Driessche P, Brauer F, Wu J, editors. Mathematical Epidemiology. Lecture Notes in Mathematics, vol 1945. Berlin, Heidelberg: Springer; 2008. p. 81–130. http://dx.doi.org/10.1007/978-3-540-78911-6_3
  17. Anderson Roy M, May Robert M, Anderson B. Infectious diseases of humans: dynamics and control. Vol 28. Oxford: Oxford University Press; 1992.
  18. Keeling MJ, Rohani P. Modeling infectious diseases in humans and animals. Princeton: Princeton University Press; 2011.
  19. Mossong J, Hens N, Jit M, Beutels P, Auranen K, Mikolajczyk R, et al. Social contacts and mixing patterns relevant to the spread of infectious diseases. PLoS Med. 2008;5(3):e74.  https://doi.org/10.1371/journal.pmed.0050074  PMID: 18366252 
  20. Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis. 2004;189(s1) Suppl 1;S4-16.  https://doi.org/10.1086/377712  PMID: 15106083 
  21. Plotkin SA, Orenstein WA, Offit PA. Vaccines. 6th ed. Elsevier; 2012.
  22. Schönberger K, Ludwig M-S, Wildner M, Weissbrich B. Epidemiology of subacute sclerosing panencephalitis (SSPE) in Germany from 2003 to 2009: a risk estimation. PLoS One. 2013;8(7):e68909.  https://doi.org/10.1371/journal.pone.0068909  PMID: 23874807 
  23. Buchanan R, Bonthius DJ. Measles virus and associated central nervous system sequelae. Semin Pediatr Neurol. 2012;19(3):107-14.  https://doi.org/10.1016/j.spen.2012.02.003  PMID: 22889539 
  24. Carabin H, Edmunds WJ, Kou U, van den Hof S, Nguyen VH. The average cost of measles cases and adverse events following vaccination in industrialised countries. BMC Public Health. 2002;2(1):22.  https://doi.org/10.1186/1471-2458-2-22  PMID: 12241559 
  25. Wolfson LJ, Grais RF, Luquero FJ, Birmingham ME, Strebel PM. Estimates of measles case fatality ratios: a comprehensive review of community-based studies. Int J Epidemiol. 2009;38(1):192-205.  https://doi.org/10.1093/ije/dyn224  PMID: 19188207 
  26. Baker CJ, American Academy of Pediatrics. Red book atlas of pediatric infectious diseases. 3rd ed. Itasca: American Academy of Pediatrics; 2017.
  27. Salisbury DRM, editor. Measles: the green book, chapter 21. London: Public Health England; 2013. Available from: https://www.gov.uk/government/publications/measles-the-green-book-chapter-21
  28. Armstrong J, Arajs A, Bailey N, Wang HL. A community outbreak of travel-acquired measles, Ontario 2009. Can Commun Dis Rep. 2014;40(12):251-6.  https://doi.org/10.14745/ccdr.v40i12a05  PMID: 29769848 
  29. De Serres G, Markowski F, Toth E, Landry M, Auger D, Mercier M, et al. Largest measles epidemic in North America in a decade--Quebec, Canada, 2011: contribution of susceptibility, serendipity, and superspreading events. J Infect Dis. 2013;207(6):990-8.  https://doi.org/10.1093/infdis/jis923  PMID: 23264672 
  30. Kershaw T, Suttorp V, Simmonds K, St Jean T. Outbreak of measles in a non-immunizing population, Alberta 2013. Can Commun Dis Rep. 2014;40(12):243-50.  https://doi.org/10.14745/ccdr.v40i12a04  PMID: 29769847 
  31. Antona D, Lévy-Bruhl D, Baudon C, Freymuth F, Lamy M, Maine C, et al. Measles elimination efforts and 2008-2011 outbreak, France. Emerg Infect Dis. 2013;19(3):357-64.  https://doi.org/10.3201/eid1903.121360  PMID: 23618523 
  32. Centers for Disease Control and Prevention (CDC). Epidemiology and prevention of vaccine-preventable diseases. Atkinson W, Hamborsky J, Wolfe S, eds. 12th ed. Washington DC: Public Health Foundation; 2012. Available from: http://www.paho.org/immunization-toolkit/spanish/wp-content/uploads/2017/05/Cover-and-table-of-contents.pdf
  33. National Advisory Committee on Immunization, Public Health Agency of Canada. Canadian immunization guide: Part 4 - active vaccines. Ottawa: Public Health Agency of Canada. [Accessed: 25 Aug 2017]. Available from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines.html
  34. World Health Organization Regional Office for Europe (WHO/Europe). Centralized information system for infectious diseases (CISID). Copenhagen; WHO/Europe. [Accessed: 21 Jun 2017]. Available from: http://data.euro.who.int/cisid/
  35. Thorrington D, Ramsay M, van Hoek AJ, Edmunds WJ, Vivancos R, Bukasa A, et al. The effect of measles on health-related quality of life: a patient-based survey. PLoS One. 2014;9(9):e105153.  https://doi.org/10.1371/journal.pone.0105153  PMID: 25202905 
  36. Lee GM, Salomon JA, LeBaron CW, Lieu TA. Health-state valuations for pertussis: methods for valuing short-term health states. Health Qual Life Outcomes. 2005;3(1):17.  https://doi.org/10.1186/1477-7525-3-17  PMID: 15780145 
  37. Mittmann N, Trakas K, Risebrough N, Liu BA. Utility scores for chronic conditions in a community-dwelling population. Pharmacoeconomics. 1999;15(4):369-76.  https://doi.org/10.2165/00019053-199915040-00004  PMID: 10537955 
  38. Centers for Disease Control and Prevention (CDC). Vaccines for Children Program (VFC). CDC vaccine price list. Atlanta: CDC. [Accessed: 19 Jul 2017]. Available from: https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html
  39. Centers for Disease Control and Prevention (CDC). Viral hepatitis. Sources for IG and HBIG. Atlanta: CDC. [Accessed: 12 Jul 2017]. Available from: https://www.cdc.gov/hepatitis/ig-hbig_sources.htm
  40. National Ambulatory Care Reporting System (NACRS) - Measles 2003 to 2015 data. Toronto: Public Health Ontario; 2017.
  41. Database DA. (DAD) - Measles 2003 to 2015 data. Toronto: Public Health Ontario; 2017.
  42. Ontario HIP. (OHIP) - Measles 2003 to 2015 data. Toronto: Public Health Ontario; 2017.
  43. World Health Organization Regional Office for Europe (WHO/Europe). Measles cases hit record high in the European Region. Copenhagen; WHO/Europe. 2018. Available from: http://www.euro.who.int/en/media-centre/sections/press-releases/2018/measles-cases-hit-record-high-in-the-european-region
  44. Dabbagh A, Patel MK, Dumolard L, Gacic-Dobo M, Mulders MN, Okwo-Bele J-M, et al. Progress toward regional measles elimination - worldwide, 2000-2016. MMWR Morb Mortal Wkly Rep. 2017;66(42):1148-53.  https://doi.org/10.15585/mmwr.mm6642a6  PMID: 29073125 
  45. Monthly infectious diseases surveillance reports: Volume 1 Issue 2. Toronto: Public Health Ontario; 2012.
  46. Reportable disease trends in Ontario: Mumps rates and cases for all ages, for all sexes, in Ontario. Toronto: Public Health Ontario. [Accessed: 2 Feb 2018]. Available from: https://www.publichealthontario.ca/en/data-and-analysis/infectious-disease/reportable-disease-trends-annually#/38
  47. Centers for Disease Control and Prevention (CDC). Transcript for CDC telebriefing: Measles in the United States, 2015. Atlanta: CDC; 2014. Available from: https://www.cdc.gov/media/releases/2015/t0129-measles-in-us.html
  48. Suijkerbuijk AWM, Woudenberg T, Hahné SJM, Nic Lochlainn L, de Melker HE, Ruijs WLM, et al. Economic costs of measles outbreak in the Netherlands, 2013-2014. Emerg Infect Dis. 2015;21(11):2067-9.  https://doi.org/10.3201/eid2111.150410  PMID: 26488199 
  49. Miller CL. Deaths from measles in England and Wales, 1970-83. Br Med J (Clin Res Ed). 1985;290(6466):443-4.  https://doi.org/10.1136/bmj.290.6466.443  PMID: 3918622 
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