Margaret S. Coleman

Additional Visit Burden for Universal Influenza Vaccination of US School-Aged Children and Adolescents

OBJECTIVE To estimate the additional primary care visits needed for universal influenza vaccination of all US children and adolescents if all vaccinations occurred in primary care settings. DESIGN Cross-sectional design. SETTING Well-child care and other visits to primary care practices from the 2003-2004 Medical Expenditure Panel Survey. PARTICIPANTS Children aged 5 to 18 years (n = 3047) with a usual source of care. Main Outcome Measure Percentage of children needing 0, 1, or 2 additional visits to be immunized against influenza in a 3-, 4-, or 5-month vaccination window. RESULTS In a 3-month window, if only well-child care visits were used for first immunization, 97% of 5- and 6-year-olds and 98% of 7- and 8-year-olds would need 1 or 2 additional visits for complete vaccination; 95% of 9- to 18-year-olds would need 1 visit. If instead all visits were used for immunization, 90% of 5- and 6-year-olds and 91% of 7- and 8-year-olds would need 1 or 2 visits; 78% of 9- to 18-year-olds would need 1 visit. Expanding the window to 4 or 5 months slightly reduces the need for additional visits. Nationally, using all opportunities for vaccination, 42 million additional visits would be needed in a generous 5-month window. CONCLUSIONS Most children and adolescents would need additional visits for universal influenza vaccination, even if all existing visits were used as vaccination opportunities. Efficient methods for vaccinating large numbers of children and adolescents are needed if primary care practices are to provide influenza vaccine for all children.

Primary care physician perspectives on providing adult vaccines.

Recently, several new vaccines have been recommended for adults. Little is known regarding the immunization purchase and stocking practices of adult primary care physicians. To determine the proportion of family practice and internal medicine physicians who routinely stock specific adult vaccines and their rationale for those decisions, we conducted a cross-sectional survey in 2009 of a national random sample of 993 family physicians (FPs) and 997 general internists (IMs) in the US. Of the 1109 respondents, 886 reported that they provide primary care to adults aged 19-64 years and 96% of these physicians stock at least one vaccine recommended for adults. Of those, 2% plan to stop and 12% plan to increase vaccine purchases; the rest plan to maintain status quo. Of the respondents, 27% (31% FPs vs 20% IMs) stocked all adult vaccines. We conclude that many primary care physicians who provide care to adults do not stock all recommended immunizations. Efforts to improve adult immunization rates must address this fundamental issue.

Net Financial Gain or Loss From Vaccination in Pediatric Medical Practices

OBJECTIVE: The goal was to determine the net return (gain or loss after costs were subtracted from revenues) to private pediatric medical practices from investing time and resources in vaccines and vaccination of their patients. METHODS: A cross-sectional survey of a convenience sample of private medical practices requested data on all financial and capacity aspects of the practices, including operating expenses; labor composition and wages/salaries; private- and public-purchase vaccine orders and inventories; Medicaid and private insurance reimbursements; patient population; numbers of providers; and numbers, types, and lengths of visits. Costs were assigned to vaccination visits and subtracted from reimbursements from public- and private-pay sources to determine net financial gains/losses from vaccination. RESULTS: Thirty-four practices responded to the survey. More than one half of the respondents broke even or suffered financial losses from vaccinating patients. With greater proportions of Medicaid-enrolled patients served, greater financial loss was noted. On average, private insurance vaccine administration reimbursements did not cover administration costs unless a child received ≥3 doses of vaccine in 1 visit. Finally, wide ranges of per-dose prices paid and reimbursements received for vaccines indicated that some practices might be losing money in purchasing and delivering vaccines for private-pay patients if they pay high purchase prices but receive low reimbursements. CONCLUSIONS: We conclude that the vaccination portion of the business model for primary care pediatric practices that serve private-pay patients results in little or no profit from vaccine delivery. When losses from vaccinating publicly insured children are included, most practices lose money.

Direct costs of a single case of refugee-imported measles in Kentucky

BACKGROUND Refugees are highly vulnerable populations with limited access to health care services. The United States accepts 50,000-75,000 refugees for resettlement annually. Despite residing in camps and other locations where vaccine-preventable disease outbreaks, such as measles, occur frequently, refugees are not required to have any vaccinations before they arrive in the United States. PURPOSE We estimated the medical and public-health response costs of a case of measles imported into Kentucky by a refugee. METHODS The Kentucky Refugee Health Coordinator recorded the time and labor of local, state, and some federal personnel involved in caring for the refugee and implementing the public health response activities. Secondary sources were used to estimate the labor and medical care costs of the event. RESULTS The total costs to conduct the response to the disease event were approximately

Financing vaccination of children and adolescents: National Vaccine Advisory Committee recommendations

25,000. All costs were incurred by government, either public health department or federal, because refugee health costs are paid by the federal government and the event response costs are covered by the public health department. CONCLUSION A potentially preventable case of measles that was imported into the United States cost approximately

Maternal Knowledge and Attitudes Toward Influenza Vaccination: A Focus Group Study in Metropolitan Atlanta

25,000 for the public health response. RECOMMENDATION To maintain the elimination of measles transmission in the United States, U.S.-bound refugees should be vaccinated overseas. A refugee vaccination program administered during the overseas health assessment has the potential to reduce the risk of importation of measles and other vaccine-preventable disease and would eliminate costs associated with public health response to imported cases and outbreaks.

Failure-to-success ratios, transition probabilities and phase lengths for prophylactic vaccines versus other pharmaceuticals in the development pipeline

Increases in the number and cost of vaccines routinely recommended for children and adolescents have raised concerns about the ability of the current systems for vaccine financing and delivery to ensure that all children and adolescents have access to all routinely recommended vaccinations without financial barriers. The National Vaccine Advisory Committee (NVAC) was chartered in 1988 to advise and to make recommendations to the director of the National Vaccine Program and the Assistant Secretary for Health at the US Department of Health and Human Services on matters related to the prevention of infectious diseases through vaccination. In October 2006, NVAC established a Vaccine Financing Working Group to explore approaches for child and adolescent vaccine financing. The Vaccine Financing Working Group was charged with establishing a process for obtaining stakeholder input regarding challenges to creating optimal approaches to vaccine financing in both the public and private sectors. The goal of this process was to develop recommendations to ensure that all children and adolescents have access to all routinely recommended vaccinations without financial barriers.

Cost-Effectiveness of Screening and Treating Foreign-Born Students for Tuberculosis before Entering the United States

Objective. To explore the knowledge and attitudes of mothers of school-aged children toward influenza vaccination and assess what methods of communication about vaccination and its delivery work best among this audience. Methods. The authors conducted focus groups with mothers of school-aged children. Prior to the focus groups, investigators agreed on key themes and discussion points. They independently reviewed transcripts using systematic content analysis and came to an agreement on outcome themes. Results. Many study participants had misunderstandings about influenza vaccines and the definition of influenza. A common perception was that flu is a catch-all term for a variety of undefined illnesses, ranging from a severe cold to stomach upset. Few participants saw a societal benefit in vaccinating children to protect other populations (eg, the elderly). Conclusions. This study represents a first step in understanding how mothers perceive influenza vaccination and for crafting effective communication to increase vaccination among school-aged children.

Economics of United States tuberculosis airline contact investigation policies: A return on investment analysis

Research and development of prophylactic vaccines carries a high risk of failure. In the past, industry experts have asserted that vaccines are riskier to produce than other pharmaceuticals. This assertion has not been critically examined. We assessed outcomes in pharmaceutical research and development from 1995 to 2011, using a global pharmaceutical database to identify prophylactic vaccines versus other pharmaceuticals in preclinical, Phase I, Phase II, or Phase III stages of development. Over 16 years of follow-up for 4367 products (132 prophylactic vaccines; 4235 other pharmaceuticals), we determined the failure-to-success ratios for prophylactic vaccines versus all other products. The overall ratio of failures to successes for prophylactic vaccines for the 1995 cohort over 16 years of follow-up was 8.3 (116/14) versus 7.7 (3650/475) for other pharmaceuticals. The probability of advancing through the development pipeline at each point was not significantly different for prophylactic vaccines than for other pharmaceuticals. Phase length was significantly longer for prophylactic vaccines than other pharmaceuticals for preclinical development (3.70 years vs 2.80 years; p<.0001), but was equivalent for all 3 human clinical trial phases between the two groups. We conclude that failure rates, phase transition probabilities, and most phase lengths for prophylactic vaccines are not significantly different from those of other pharmaceutical products, which may partially explain rapidly growing interest in prophylactic vaccines among major pharmaceutical manufacturers.

Private Pediatric Clinic Characteristics Associated with Influenza Immunization Efforts in the State of Georgia: A Pilot Evaluation.

Introduction The Centers for Disease Control and Prevention is considering implementation of overseas medical screening of student-visa applicants to reduce the numbers of active tuberculosis cases entering the United States. Objective To evaluate the costs, cases averted, and cost-effectiveness of screening for, and treating, tuberculosis in United States-bound students from countries with varying tuberculosis prevalence. Methods Costs and benefits were evaluated from two perspectives, combined and United States only. The combined perspective totaled overseas and United States costs and benefits from a societal perspective. The United States only perspective was a domestic measure of costs and benefits. A decision tree was developed to determine the cost-effectiveness of tuberculosis screening and treatment from the combined perspective. Results From the United States only perspective, overseas screening programs of Chinese and Indian students would prevent the importation of 157 tuberculosis cases annually, and result in