SETTING: In 2007, the US Centers for Disease Control and Prevention (CDC) revised its tuberculosis (TB) technical instructions for panel physicians who administer mandatory medical examinations among US-bound immigrants. Many US-bound immigrants come from the Philippines, a high TB prevalence country. OBJECTIVE: To quantify economic and health impacts of smear- vs. culture-based TB screening. DESIGN: Decision tree modeling was used to compare three Filipino screening programs: 1) no screening, 2) smear-based screening, and 3) culture-based screening. The model incorporated pre-departure TB screening results from Filipino panel physicians and CDC databases with post-arrival follow-up outcomes. Costs (2013 $US) were examined from societal, immigrant, US Public Health Department and hospitalization perspectives. RESULTS: With no screening, an annual cohort of 35 722 Filipino immigrants would include an estimated 450 TB patients with 264 hospitalizations, at a societal cost of US$9.90 million. Culture-based vs. smear-based screening would result in fewer imported cases (80.9 vs. 310.5), hospitalizations (19.7 vs. 68.1), and treatment costs (US$1.57 million vs. US$4.28 million). Societal screening costs, including US follow-up, were greater for culture-based screening (US$5.98 million) than for smear-based screening (US$3.38 million). Culture-based screening requirements increased immigrant costs by 61% (US$1.7 million), but reduced costs for the US Public Health Department (22%, US$750 000) and of hospitalization (70%, US$1 020 000). CONCLUSION: Culture-based screening reduced imported TB and US costs among Filipino immigrants.

Background On August 24, 2011, 31 U.S.-bound refugees from Kuala Lumpur, Malaysia (KL) arrived in Los Angeles. One of them was diagnosed with measles post-arrival. He exposed others during a flight, and persons in the community while disembarking and seeking medical care. As a result, nine cases of measles were identified. Methods We estimated costs of response to this outbreak and conducted a comparative cost analysis examining what might have happened had all U.S.-bound refugees been vaccinated before leaving Malaysia. Results State-by-state costs differed and variously included vaccination, hospitalization, medical visits, and contact tracing with costs ranging from $621 to $35,115. The total of domestic and IOM Malaysia reported costs for U.S.-bound refugees were $137,505 [range: $134,531 - $142,777 from a sensitivity analysis]. Had all U.S.-bound refugees been vaccinated while in Malaysia, it would have cost approximately $19,646 and could have prevented 8 measles cases. Conclusion A vaccination program for U.S.-bound refugees, supporting a complete vaccination for U.S.-bound refugees, could improve refugees' health, reduce importations of vaccine-preventable diseases in the United States, and avert measles response activities and costs.

BACKGROUND: Many U.S.-bound refugees travel from countries where intestinal parasites (hookworm, Trichuris trichuria, Ascaris lumbricoides, and Strongyloides stercoralis) are endemic. These infections are rare in the United States and may be underdiagnosed or misdiagnosed, leading to potentially serious consequences. This evaluation examined the costs and benefits of combinations of overseas presumptive treatment of parasitic diseases vs. domestic screening/treating vs. no program. METHODS: An economic decision tree model terminating in Markov processes was developed to estimate the cost and health impacts of four interventions on an annual cohort of 27,700 U.S.-bound Asian refugees: 1) "No Program," 2) U.S. "Domestic Screening and Treatment," 3) "Overseas Albendazole and Ivermectin" presumptive treatment, and 4) "Overseas Albendazole and Domestic Screening for Strongyloides". Markov transition state models were used to estimate long-term effects of parasitic infections. Health outcome measures (four parasites) included outpatient cases, hospitalizations, deaths, life years, and quality-adjusted life years (QALYs). RESULTS: The "No Program" option is the least expensive ($165,923 per cohort) and least effective option (145 outpatient cases, 4.0 hospitalizations, and 0.67 deaths discounted over a 60-year period for a one-year cohort). The "Overseas Albendazole and Ivermectin" option ($418,824) is less expensive than "Domestic Screening and Treatment" ($3,832,572) or "Overseas Albendazole and Domestic Screening for Strongyloides" ($2,182,483). According to the model outcomes, the most effective treatment option is "Overseas Albendazole and Ivermectin," which reduces outpatient cases, deaths and hospitalization by around 80% at an estimated net cost of $458,718 per death averted, or $2,219/$24,036 per QALY/life year gained relative to "No Program". DISCUSSION: Overseas presumptive treatment for U.S.-bound refugees is a cost-effective intervention that is less expensive and at least as effective as domestic screening and treatment programs. The addition of ivermectin to albendazole reduces the prevalence of chronic strongyloidiasis and the probability of rare, but potentially fatal, disseminated strongyloidiasis.

BACKGROUND: This study explored the effect of screening and treatment of refugees for latent tuberculosis infection (LTBI) before entrance to the United States as a strategy for reducing active tuberculosis (TB). The purpose of this study was to estimate the costs and benefits of LTBI screening and treatment in United States bound refugees prior to arrival. METHODS: Costs were included for foreign and domestic LTBI screening and treatment and the domestic treatment of active TB. A decision tree with multiple Markov nodes was developed to determine the total costs and number of active TB cases that occurred in refugee populations that tested 55, 35, and 20 % tuberculin skin test positive under two models: no overseas LTBI screening and overseas LTBI screening and treatment. For this analysis, refugees that tested 55, 35, and 20 % tuberculin skin test positive were divided into high, moderate, and low LTBI prevalence categories to denote their prevalence of LTBI relative to other refugee populations. RESULTS: For a hypothetical 1-year cohort of 100,000 refugees arriving in the United States from regions with high, moderate, and low LTBI prevalence, implementation of overseas screening would be expected to prevent 440, 220, and 57 active TB cases in the United States during the first 20 years after arrival. The cost savings associated with treatment of these averted cases would offset the cost of LTBI screening and treatment for refugees from countries with high (net cost-saving: $4.9 million) and moderate (net cost-saving: $1.6 million) LTBI prevalence. For low LTBI prevalence populations, LTBI screening and treatment exceed expected future TB treatment cost savings (net cost of $780,000). CONCLUSIONS: Implementing LTBI screening and treatment for United States bound refugees from countries with high or moderate LTBI prevalence would potentially save millions of dollars and contribute to United States TB elimination goals. These estimates are conservative since secondary transmission from tuberculosis cases in the United States was not considered in the model.

The Centers for Disease Control and Prevention (CDC) works in conjunction with state, territorial, local and tribal agencies (STLTAs) to prevent the transmission of infectious agents. Issuance of confinement agreements using CDC Form 75.37 'Notice to Owners and Importers of Dogs' to importers of dogs that are not vaccinated or incompletely vaccinated against rabies is part of the agency's regulatory programme to prevent the entry of dogs infected with rabies. Although this is a regulatory programme that depends heavily on partnerships between CDC and STLTAs, CDC had never formally evaluated the acceptability of the confinement agreement process with these partners. Thus, a short survey of nine STLTAs was conducted to evaluate whether these partners have enough personnel and resources to implement the regulation and their general opinions of the confinement agreement process. The results illustrate that CDC partners are dissatisfied to some extent with the process, and there are multiple issues limiting their success in enforcing the regulation.

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 $2.7 million in savings. From the combined perspective, screening programs for Chinese students would cost more than $2.8 million annually and screening programs for Indian students nearly $440,000 annually. From the combined perspective, the incremental cost for each tuberculosis case averted by screening Chinese and Indian students was $22,187 and $15,063, respectively. Implementing screening programs for German students would prevent no cases in most years, and would result in increased costs both overseas and in the United States. The domestic costs would occur because public health departments would need to follow up on students identified overseas as having an elevated risk of tuberculosis. CONCLUSIONS: Tuberculosis screening and treatment programs for students seeking long term visas to attend United States schools would reduce the number of tuberculosis cases imported. Implementing screening in high-incidence countries could save the United States millions of dollars annually; however there would be increased costs incurred overseas for students and their families.

BACKGROUND: Refugees are at an increased risk of chronic Hepatitis B virus (HBV) infection because many of their countries of origin, as well as host countries, have intermediate-to-high prevalence rates. Refugees arriving to the US are also at risk of serious sequelae from chronic HBV infection because they are not routinely screened for the virus overseas or in domestic post-arrival exams, and may live in the US for years without awareness of their infection status. METHODS: A cohort of 26,548 refugees who arrived in Minnesota and Georgia during 2005-2010 was evaluated to determine the prevalence of chronic HBV infection. This prevalence information was then used in a cost-benefit analysis comparing two variations of a proposed overseas program to prevent or ameliorate the effects of HBV infection, titled 'Screen, then vaccinate or initiate management' (SVIM) and 'Vaccinate only' (VO). The analyses were performed in 2013. All values were converted to US 2012 dollars. RESULTS: The estimated six year period-prevalence of chronic HBV infection was 6.8% in the overall refugee population arriving to Minnesota and Georgia and 7.1% in those ≥6 years of age. The SVIM program variation was more cost beneficial than VO. While the up-front costs of SVIM were higher than VO ($154,084 vs. $73,758; n=58,538 refugees), the SVIM proposal displayed a positive net benefit, ranging from $24 million to $130 million after only 5 years since program initiation, depending on domestic post-arrival screening rates in the VO proposal. CONCLUSIONS: Chronic HBV infection remains an important health problem in refugees resettling to the United States. An overseas screening policy for chronic HBV infection is more cost-beneficial than a 'Vaccination only' policy. The major benefit drivers for the screening policy are earlier medical management of chronic HBV infection and averted lost societal contributions from premature death.

BACKGROUND: In 2011, the Centers for Disease Control and Prevention modified its 2008 protocol for flight-related tuberculosis contact investigation initiation. The 2011 Modified protocol was implemented and replaced the 2008 CDC protocol based on comparative epidemiologic and economic analyses; this publication reports the economic analysis results. METHODS: A return on investment model compared relative changes in tuberculosis disease treatment costs resulting from expenditures on tuberculosis contact investigations and latent tuberculosis infection treatment for the 2008 CDC and Modified protocols. RESULTS: At moderate/high rates of latent tuberculosis infection and tuberculosis disease, positive returns on investment indicated each $1.00 spent on tuberculosis contact investigations and latent tuberculosis treatment resulted in more than $1.00 of savings from reduced tuberculosis disease treatment costs. Low rates of latent tuberculosis infection and tuberculosis disease resulted in negative returns on investment, indicating economic losses from tuberculosis disease treatment costs. There were smaller economic losses at low latent tuberculosis infection and tuberculosis disease rates with the Modified protocol in comparison to the 2008 CDC protocol, while both identified comparable numbers of persons at risk for tuberculosis. CONCLUSION: The Modified protocol for conducting flight-related tuberculosis contact investigations represents a better use of resources and protects public health.

BACKGROUND: In-flight transmission risk of Mycobacterium tuberculosis is not well defined, although studies suggest it is low. The impact of flight-related tuberculosis (TB) contact investigations (TBCIs) on TB prevention and control is not well established, and they compete for resources with activities with established benefits. We sought to determine the risks and cost-benefits of using more restrictive criteria in comparison to the Centers for Disease Control and Prevention (CDC) 2008 protocol for TBCIs. METHODS: The risk-benefits of a modified CDC protocol were analyzed in comparison to the 2008 CDC protocol using data from flight-related TBCIs conducted in the United States from 2007 through 2009. We predicted the numbers and characteristics of case-travelers that would be identified using each protocol's criteria, and results of the associated passenger-contacts' TB screening tests. The economic analysis compared the costs of TBCIs to avoided costs of TB treatment and mortality using a Return on Investment model. RESULTS: The estimated in-flight transmission risk using a modified CDC protocol was 1.4%-19% versus 1.1%-24% for the 2008 protocol. Numbers of TBCIs and immediate costs to health departments were reduced by half. Long-term cost-benefits were comparable. CONCLUSIONS: CDC's modified protocol appears to be a feasible alternative that will conserve public health resources without jeopardizing the public's health.

BACKGROUND: Pretravel health consultations help international travelers manage travel-related illness risks through education, vaccination, and medication. This study evaluated costs and benefits of that portion of the health consultation associated with malaria prevention provided to US travelers bound for West Africa. METHODS: The estimated change in disease risk and associated costs and benefits resulting from traveler adherence to malaria chemoprophylaxis were calculated from 2 perspectives: the healthcare payer's and the traveler's. We used data from the Global TravEpiNet network of US travel clinics that collect de-identified pretravel data for international travelers. Disease risk and chemoprophylaxis effectiveness were estimated from published medical reports. Direct medical costs were obtained from the Nationwide Inpatient Sample and published literature. RESULTS: We analyzed 1029 records from January 2009 to January 2011. Assuming full adherence to chemoprophylaxis regimens, consultations saved healthcare payers a per-traveler average of $14 (9-day trip) to $372 (30-day trip). For travelers, consultations resulted in a range of net cost of $20 (9-day trip) to a net savings of $32 (30-day trip). Differences were mostly driven by risk of malaria in the destination country. CONCLUSIONS: Our model suggests that healthcare payers save money for short- and longer-term trips, and that travelers save money for longer trips when travelers adhere to malaria recommendations and prophylactic regimens in West Africa. This is a potential incentive to healthcare payers to offer consistent pretravel preventive care to travelers. This financial benefit complements the medical benefit of reducing the risk of malaria.

BACKGROUND: Approximately 70,000 refugees are resettled to the United States each year. Providing vaccination to arriving refugees is important to both reduce the health-related barriers to successful resettlement, and protect the health of communities where refugees resettle. It is crucial to understand the process and resources expended at the state/local and federal government levels to provide vaccinations to refugees resettling to the United States. OBJECTIVES: We estimated costs associated with delivering vaccines to refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). METHODS: Vaccination costs were estimated from two perspectives: the federal government and the DeKalb clinic. Data were collected at the DeKalb clinic regarding resources used for vaccination: staff numbers and roles; type and number of vaccine doses administered; and number of patients. Clinic costs included labor and facility-related overhead. The federal government incurred costs for vaccine purchases and reimbursements for vaccine administration. RESULTS: The DeKalb clinic average cost to administer the first dose of vaccine was $12.70, which is lower than Georgia Medicaid reimbursement ($14.81), but higher than the State of Georgia Refugee Health Program reimbursement ($8.00). Federal government incurred per-dose costs for vaccine products and administrative reimbursement were $42.45 (adults) and $46.74 (children). CONCLUSIONS: The total costs to the DeKalb clinic for administering vaccines to refugees are covered, but with little surplus. Because the DeKalb clinic 'breaks even,' it is likely they will continue to vaccinate refugees as recommended by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices.

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 $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 $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.

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; 4325 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.

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 [greater-than or equal to]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. Copyright copyright 2009 by the American Academy of Pediatrics.

OBJECTIVES: The goals were to estimate nationally representative pediatric practices' costs of providing influenza vaccination during the 2006 -2007 season and to simulate the costs pediatric practices might incur when implementing universal influenza vaccination for US children aged 6 months to 18 years. METHODS: We surveyed a stratified, random sample of New York State pediatric practices (N = 91) to obtain information from physicians and office managers about all practice resources associated with provision of influenza vaccination. We estimated vaccination costs for 2 practice sizes (small and large) and 3 geographic areas (urban, suburban, and rural). We adjusted these data to obtain national estimates of the total practice cost (in 2006 dollars) for providing 1 influenza vaccination to children aged 6 months to 18 years. RESULTS: Among all respondents, the median total cost per vaccination was $28.62 (interquartile range: $18.67- 45.28). The median component costs were as follows: clinical personnel labor costs, $2.01; nonclinical personnel labor costs, $7.96; all other (overhead) costs, $10.43. Vaccine purchase costs averaged $8.22. Smaller practices and urban practices had higher costs than larger or suburban practices. With the assumption of vaccine administration reimbursement for all Vaccines for Children (VFC)-eligible children at the current Medicaid median of $8.40, the financial loss across all US pediatric practices through delivery of VFC vaccines would be $98 million if one third of children received influenza vaccine. CONCLUSION: The total cost for pediatric practices to provide influenza vaccination is high, varies according to practice characteristics, and exceeds the average VFC reimbursement. Copyright copyright 2009 by the American Academy of Pediatrics.

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. | The NVAC considered several overarching principles in formulating its recommendations. First, vaccine-preventable diseases are not constrained by geographic boundaries, and policies on vaccine financing should be national in scope. Second, vaccine financing solutions should address near-term problems with vaccine financing and should anticipate continued changes in recommended child and adolescent immunization schedules and the health care delivery system. Third, because vaccine financing problems are multifactorial, their solutions also should be multifactorial and all stakeholders will need to participate in implementing the solutions. Finally, because it is difficult to achieve uniform national implementation of policies that require state-based legislative or budgetary action, legislative or policy actions at the federal level, when appropriate, are recommended for achieving vaccine financing goals.

Successful launches of recently licensed vaccines contrast with pharmaceutical industry concerns about unfavorable market conditions, making the status and future of vaccine development uncertain. We assessed trends in private-sector vaccine research and development for the period 1995-2008, using a global pharmaceutical database to identify prophylactic vaccines in preclinical, Phase I, Phase II, or Phase III stages of development. We counted companies that research and/or manufacture vaccines ("vaccine originators") and their vaccine products in each year. The global number of vaccine originators doubled (to 136), as did the number of prophylactic vaccine products in development (to 354); the majority of this growth was in preclinical and early phase clinical research. Because rapid growth in earlier research phases has not yet led to growth in Phase III, it is not yet clear whether recent industry expansion will translate to an increase in the number of available vaccines in the near future.

Recently, it has been recommended that all persons 6 months to 18 years be vaccinated annually against influenza. To assess support for this universal recommendation leading up to its implementation, a cross-sectional survey of healthcare workers at private pediatric clinics (N = 44) and public health departments (N = 75) was conducted. The survey, conducted in the state of Georgia during 2005-2006, asked about (a) support for universal childhood vaccination against influenza, (b) general and influenza-specific immunization practices in 2004-2005, and (c) types of assistance needed to implement a universal childhood recommendation. Our response rate was 70 percent for private clinics and 71 percent for public health departments. The majority of providers supported universal childhood vaccination against influenza; agreement was especially pronounced at public health departments. Public health departments employed more nurses and were more likely to have a policy of vaccinating parents along with their children; private clinics were more likely to use patient reminders or add extra hours during the influenza vaccination season. Respondents from both types of clinics indicated they would need multiple forms of assistance to implement a universal recommendation for childhood vaccination against influenza. Given the strong support for universal vaccination among healthcare workers at public health departments, these facilities may be instrumental for reaching the large number of children recently added to the recommendations. However, these facilities will need multiple forms of assistance.