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      Systematic Review of Economic Evaluations of Preparedness Strategies and Interventions against Influenza Pandemics


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          Although public health guidelines have implications for resource allocation, these issues were not explicitly considered in previous WHO pandemic preparedness and response guidance. In order to ensure a thorough and informed revision of this guidance following the H1N1 2009 pandemic, a systematic review of published and unpublished economic evaluations of preparedness strategies and interventions against influenza pandemics was conducted.


          The search was performed in September 2011 using 10 electronic databases, 2 internet search engines, reference list screening, cited reference searching, and direct communication with relevant authors. Full and partial economic evaluations considering both costs and outcomes were included. Conversely, reviews, editorials, and studies on economic impact or complications were excluded. Studies were selected by 2 independent reviewers.


          44 studies were included. Although most complied with the cost effectiveness guidelines, the quality of evidence was limited. However, the data sources used were of higher quality in economic evaluations conducted after the 2009 H1N1 pandemic. Vaccination and drug regimens were varied. Pharmaceutical plus non-pharmaceutical interventions are relatively cost effective in comparison to vaccines and/or antivirals alone. Pharmaceutical interventions vary from cost saving to high cost effectiveness ratios. According to ceiling thresholds (Gross National Income per capita), the reduction of non-essential contacts and the use of pharmaceutical prophylaxis plus the closure of schools are amongst the cost effective strategies for all countries. However, quarantine for household contacts is not cost effective even for low and middle income countries.


          The available evidence is generally inconclusive regarding the cost effectiveness of preparedness strategies and interventions against influenza pandemics. Studies on their effectiveness and cost effectiveness should be readily implemented in forthcoming events that also involve the developing world. Guidelines for assessing the impact of disease and interventions should be drawn up to facilitate these studies.

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          Most cited references81

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          The economic impact of pandemic influenza in the United States: priorities for intervention.

          We estimated the possible effects of the next influenza pandemic in the United States and analyzed the economic impact of vaccine-based interventions. Using death rates, hospitalization data, and outpatient visits, we estimated 89,000 to 207,000 deaths; 314,000 to 734,000 hospitalizations; 18 to 42 million outpatient visits; and 20 to 47 million additional illnesses. Patients at high risk (15% of the population) would account for approximately 84% of all deaths. The estimated economic impact would be US$71.3 to $166.5 billion, excluding disruptions to commerce and society. At $21 per vaccinee, we project a net savings to society if persons in all age groups are vaccinated. At $62 per vaccinee and at gross attack rates of 25%, we project net losses if persons not at high risk for complications are vaccinated. Vaccinating 60% of the population would generate the highest economic returns but may not be possible within the time required for vaccine effectiveness, especially if two doses of vaccine are required.
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            Controlling Pandemic Flu: The Value of International Air Travel Restrictions

            Background Planning for a possible influenza pandemic is an extremely high priority, as social and economic effects of an unmitigated pandemic would be devastating. Mathematical models can be used to explore different scenarios and provide insight into potential costs, benefits, and effectiveness of prevention and control strategies under consideration. Methods and Findings A stochastic, equation-based epidemic model is used to study global transmission of pandemic flu, including the effects of travel restrictions and vaccination. Economic costs of intervention are also considered. The distribution of First Passage Times (FPT) to the United States and the numbers of infected persons in metropolitan areas worldwide are studied assuming various times and locations of the initial outbreak. International air travel restrictions alone provide a small delay in FPT to the U.S. When other containment measures are applied at the source in conjunction with travel restrictions, delays could be much longer. If in addition, control measures are instituted worldwide, there is a significant reduction in cases worldwide and specifically in the U.S. However, if travel restrictions are not combined with other measures, local epidemic severity may increase, because restriction-induced delays can push local outbreaks into high epidemic season. The per annum cost to the U.S. economy of international and major domestic air passenger travel restrictions is minimal: on the order of 0.8% of Gross National Product. Conclusions International air travel restrictions may provide a small but important delay in the spread of a pandemic, especially if other disease control measures are implemented during the afforded time. However, if other measures are not instituted, delays may worsen regional epidemics by pushing the outbreak into high epidemic season. This important interaction between policy and seasonality is only evident with a global-scale model. Since the benefit of travel restrictions can be substantial while their costs are minimal, dismissal of travel restrictions as an aid in dealing with a global pandemic seems premature.
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              WHO Guide for standardisation of economic evaluations of immunization programmes.

              Traditional EPI vaccines are considered to be among the most efficient uses of scarce health care resources. Today, there are many under-used and new vaccines available. In the short- to medium-term, these vaccines will not cost the few cents per dose the traditional vaccines do, but will be 'multi-dollar' vaccines. Decision-makers will need information, among other things, on their relative cost-effectiveness. A number of reviews have indicated that there is scope for improving the transparency, completeness and comparability of economic evaluations of vaccination programmes. Thus, there is a need to improve the quality of economic evaluations of vaccination programmes. Adherence to general guidelines would increase the quality, interpretability and transferability of future analyses. However, there is reason to believe that there might also be a need for more specific advice for vaccination programmes. For example, there are inconsistencies in the methods used to estimate the future benefits of vaccination programmes and the relative efficiency of these programmes can be sensitive to some of the more controversial aspects of general guidelines, such as the inclusion of indirect costs and the discounting of health outcomes. This guide has been developed in order to meet the needs of decision-makers for relevant, reliable and consistent economic information. They aim to provide clear and concise, practical and high quality guidance for those who conduct economic evaluations. Copyright 2009 Elsevier Ltd. All rights reserved.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                29 February 2012
                : 7
                : 2
                : e30333
                [1 ]Health Intervention and Technology Assessment Program, Department of Health, Ministry of Public Health, Muang, Nonthaburi, Thailand
                [2 ]Information, Training and Pandemic Preparedness, Global Influenza Program, World Health Organization, Geneva, Switzerland
                University of Hong Kong, Hong Kong
                Author notes

                Conceived and designed the experiments: YT ST HH CV. Performed the experiments: RPV KW NP SK AM. Analyzed the data: RPV KW NP SK AM ST YT. Contributed reagents/materials/analysis tools: RPV KW NP SK AM. Wrote the paper: YT ST RPV KW NP SK AM CV HH. Coordinated the review team: YT RPV KW. The third reviewer to resolve disagreements: YT. Wrote to the authors of published papers and conference abstracts: RPV.

                World Health Organization; licensee Public Library of Science (PLoS). This is an Open Access article in the spirit of the Public Library of Science (PLoS) principles for Open Access http://www.plos.org/oa/, without any waiver of WHO's privileges and immunities under international law, convention, or agreement. This article should not be reproduced for use in association with the promotion of commercial products, services, or any legal entity. There should be no suggestion that WHO endorses any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.
                : 9 June 2011
                : 14 December 2011
                Page count
                Pages: 9
                Research Article
                Clinical Research Design
                Global Health
                Infectious Diseases
                Non-Clinical Medicine
                Health Economics
                Science Policy
                Research Assessment
                Science Policy and Economics



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