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5 Immunisation Programs: Measles and Hib Disease

5.1 Introduction

Immunisation is an important dimension of public health policy. This chapter evaluates the impact of childhood immunisation coverage in reducing the prevalence of two vaccine preventable diseases: measles and haemophilus influenzae type b disease (Hib disease).1 The evaluations cover the period 1970-2003 for measles and 1993-2003 for Hib.

Measles was selected for evaluation because of the importance of the disease and its infectiousness and because there is almost no Australian work on the longer-term impact of immunisation upon measles. Immunisation for Hib disease was selected because of its comparatively recent introduction and the availability of comparable national time series data on the incidence of disease, before and after the introduction of Hib vaccine in 1993.

Unlike other public health programs considered in this study, there are good clinical data to support a direct causal relationship between health gain and a public health program (Bower et al 1998; Mast et al 1990). Although a successful immunisation program requires people to participate in it, the impact of immunisation on health depends less on behavioural change than on the effectiveness of the vaccine. The object of most immunisation programs is to promote coverage of at least 90-95 per cent. At such levels, most vaccine-preventable infections stop spreading and herd immunity is likely to protect those who are not successfully vaccinated. Moreover, once herd levels of immunisation coverage have been achieved and sustained, even if coverage later falls temporarily below required herd levels of coverage, susceptibility to disease outbreaks is reduced.

In this chapter, we start with a description of the nature of the immunisation programs, their funding, and data availability. Section 5.3 examines the incidence of measles and the impacts of immunisation programs for measles. Section 5.4 discusses the benefits and costs of these programs. Section 5.5 and 5.6 discuss the impacts of immunisation programs on Hib diseases and the benefits and costs of these programs respectively.

5.2 Immunisation Programs and Data for Measles and Hib

There are striking differences between the modes of transmission and patterns of measles and Hib disease. Measles is highly contagious and liable to sudden, sharp and unpredictable outbreaks, especially where immunisation coverage is low (Herceg et al., 1994; Srirajalingam and Sheridan, 1998). It is a highly infectious disease that spreads rapidly through susceptible populations (Russell, 1988). On the other hand, Hib disease is uncommon but endemic.

Sir Richard May has said of measles that:

'… ultimately one may conclude that the dynamics of measles transmission are chaotic, best explained as a nonlinear system, which cannot be accurately anticipated by the best mathematical logic and epidemiologic investigation' (quoted in Thacker et al. 1991).

The average duration of the acute phase of childhood measles is five days. About 10 per cent of measles cases are admitted to hospital for re-hydration and 2 per cent are admitted to intensive care (Shiell et al, 1998). About one per 1000 cases develops into measles encephalitis and about one in 25 000 develops into sub acute schelerosing panencephalitis2. Because it is associated with the risk of severe, albeit rare, complications, measles must be regarded as a serious disease.

In relation to Hib disease, McIntyre et al (2000, p.9) report that:

'… prior to the introduction of Hib vaccination the most common manifestation of invasive Hib disease was meningitis, with children aged less than 18 months most at risk. Survivors of Hib meningitis commonly had neurological sequelae such as deafness and intellectual impairment. Epiglottitis was the other major category of infection, most often occurring in children over the age of 18 months. Less common manifestations of Hib disease included cellulitis, septic arthritis, pneumonia, pericarditis, osteomyelitis and septicaemia'.

To achieve full immunisation coverage for measles in accordance with the Australian Standard Vaccination Schedule (NHMRC, 2000), two childhood doses of vaccine are required—one at 12 months and another at 4–5 years (4 years since 2000). The second measles infant dose was introduced in 1998. This brought forward an adolescent dose, following the 1993/94 measles outbreak in Australia. With this change to the schedule, the Measles Control Campaign was implemented in order to ensure that children aged 5-12 years received their second dose. The vaccine for measles is a multivalent vaccine, administered with vaccines for mumps and rubella, and usually referred to as 'MMR'.

For Hib disease, vaccine may be administered as a HibTITER or Pedvax dose. The former is given at 2, 4, 6 and 18 months; the latter at 2, 4 and 12 months. Almost all Hib vaccinations in Australia were of the HibTITER type and our modelling below allows only for the HibTITER dose. From May 2000 the Schedule changed to Pedvax only. This required three shots instead of four. However the total cost of completing the Hib schedule remained the same. The major chronologies associated with the adoption of measles and Hib immunisations in Australia are shown in Tables 5.1 and 5.2.

Immunisation funding

Before 1988, the Commonwealth directly funded States/Territories for childhood vaccines for distribution to providers in the public sector. Private practitioners who gave vaccines were required to issue prescriptions for the private supply of vaccines by a pharmacist.

In July 1988 the Commonwealth withdraw from direct funding of vaccines and instead increased funding to States/Territories by way of Finance Assistance Grants (FAGs) and Hospital Funding Grants (HFGs). The FAG funding was designed to cover the bulk of the vaccines on the National Health and Medical Research Council (NHMRC) Immunisation Schedule, whether publicly or privately provided (DHAC, 2000a).

Table 5.1 Vaccination programs for measles

1968

Measles vaccine first gained marketing approval in Australia through the Australian Drug Evaluation Committee.

1970

Measles vaccine became available without charge.

 

Incorporation of measles vaccine into the first NHMRC Recommended Immunisation Schedule.

1982

Conjugate measles/mumps (MM) vaccine was introduced to the NHMRC Schedule.

1989

Conjugate measles/mumps/rubella (MMR) vaccine replaced MM vaccine on the NHMRC Schedule.

1994

MMR adolescent dose incorporated into the Schedule, replacing the Rubella dose for schoolgirls.

1998

MMR adolescent dose moved forward to 4 -5 years.

 

Measles Control Campaign.

1999

MMR vaccine became available free of charge in the improved PRIORIX version (less injection pain).

2000

MMR infant dose moved from 4 -5 years to 4 years.

Table 5.2 Vaccination programs for Hib disease

1992

Hib vaccine first gained marketing approval in Australia through the Australian Drug Evaluation Committee.

1993

Hib vaccine first incorporated into NHMRC Schedule and available free of charge.

 

Direct funding from the Commonwealth to the States/Territories for co-ordinating the central purchasing of Hib vaccine. In the year following this became a model for Specific Purpose Payments to States/Territories for the purchase of other vaccines.

However, these arrangements resulted in a fragmented delivery of immunisation services and wide variations in the prices that States/Territories paid for vaccines, with the smaller jurisdictions paying higher prices (McIntrye, et al, 2000). The NHRMC considered that these arrangements contributed to a low level of immunisation. In January 1993, a new Hib vaccine became available. As there were no existing funding arrangements for purchase of this vaccine by States and Territories, the Commonwealth introduced a Specific Purpose Payment. Commonwealth funding was conditional on vaccines being provided to all public and private practitioners and was formalised in Bilateral Agreements with each State and Territory.

From 1997–1998 the Commonwealth started to fund certain vaccines through the Public Health Outcome Funding Agreements (PHOFAs) and by 1999–2000, PHOFA funding included coverage for all vaccines on the NHMRC Schedule. This funding is a 'special appropriation' under s9B of the National Health Act for vaccine to cover 105 per cent of each eligible population cohort, allowing for 100 per cent coverage and 5 per cent wastage (DHAC, 2000a).

Funding for the delivery and reporting of immunisation services is met at both State and Commonwealth levels. The Commonwealth funds the overhead expenses of the Australian Childhood Immunisation Register (ACIR) and shares the ACIR reporting payments with the States. Immunisation providers receive $6.00 for correctly reporting each immunisation encounter to the ACIR (except in Queensland where it is $3.00, with $3.00 going directly to VIVAS, which Queensland continues to operate as a sub register).3

States provide funding for provision of immunisation services by local councils (as predominantly occurs in Victoria), public health units and community health centres. The Commonwealth funds services by general practitioners through Medicare and by special incentive payments under the General Practice Immunisation Incentive (GPII) scheme. This scheme was introduced in July 1988. It includes a Service Incentive Payment of $18.50 for completing an age appropriate series immunisation according to the Schedule and a Practice Outcomes Payment that is designed to increase the overall coverage of children seen by a practice (even if they are not immunised in that practice). Separate funding ($8 million) was provided to divisions of general practice to educate GPs about the GPII scheme and to encourage their participation.

The introduction of the GPII scheme led to an increased share of immunisation services in the hands of general practitioners, largely at the expense of local councils. Some local councils are now quitting involvement in immunisation. Between the mid-1990s and 1999, the proportion of childhood immunisation services delivered by general practitioners grew from 56 per cent to 69 per cent (Human Capital Alliance, 1997; HIC, 2000).

In addition to vaccine and delivery costs, immunisation also attracts various one-off program costs, such as the Commonwealth’s Measles Control Campaign, mounted between August and November 1998 at a cost of $30 million (DHAC, 2000b).

Data on immunisation programs

The paucity of effective time series data on disease notification and vaccine coverage poses a challenge for researchers seeking to estimate the historical impact of immunisation coverage on morbidity associated with vaccine–preventable diseases.

Before 1991, data on the occurrence of vaccine preventable disease was not collated nationally. In that year the States and Territories amended their respective Public Health Acts to ensure systematic collection and proper definition and notification of data. As described below, in order to estimate the incidence of measles disease, we draw on some comparable disease data from the United Kingdom.

The NHRMC’s Australian Standard Vaccination Schedule contains a list of the vaccines for children 0-6 years and prescribes ages at which they should be administered for a child to be considered 'fully immunised'. However, before the ACIR was established in 1996, data on coverage was maintained on local registers such as VIVAS in Queensland and in a fragmentary way, in smaller local government and public health systems and by some Divisions of General Practice. The Australian Bureau of Statistics undertook surveys of national immunisation coverage in 1983, 1989/90 and 1995. There are, nevertheless, inconsistencies between ABS estimates of coverage and the early data captured on the ACIR. Some commentators consider that because some providers do not always report to the ACIR, its records underestimate actual levels of coverage (Human Capital Alliance, 2000).

Since 1996, the ACIR has maintained comprehensive national records of immunisation coverage. This is a joint Commonwealth / State project and is centrally administered by the Health Insurance Commission (HIC). The centralised administration and management of statistical information by the ACIR enables national tracking of immunisation coverage.

Coupled with the Immunise Australia: Seven Point Plan (1997), which included several initiatives to increase immunisation rates as well as the eradication of measles, the aim of the ACIR is to promote age appropriate immunisation throughout Australia and to improve the level of immunisation service delivery through provision of payments and information. This enables recognised immunisation service providers and parents to determine the immunisation status of individual children. The ACIR and the HIC also administer financial incentives (see above) to providers to monitor, promote and provide appropriate immunisation services to children under seven in their practices and to report immunisations to the ACIR.

Concurrent with the implementation of the ACIR, the introduction of a national educational campaign on cold chain management improved the handling of vaccines by providers and considerably enhanced the effectiveness of vaccines. Cold chain improvement grew out of the work of the National Immunisation Committee and the publication, Keep it cool (1994).

5.3 The Impact of Immunisation Programs on Measles

Evaluation of the economic impact of measles would ordinarily involve identifying the trend in notifications before and after the introduction of measles vaccine in 1970. By extrapolating the trend in notifications that would likely have occurred without the vaccine, it would be possible to develop a counterfactual scenario that could be compared with what actually occurred with the vaccine.

This approach is not feasible because data on notifications commenced in 1991, some 20 years after the introduction of a vaccine for measles. The best available indicator of the impact of measles vaccine is therefore the series on measles deaths, which started in 1905 (AIHW).

The trend in measles deaths since 1940 (Figure 5.1) reveals a secular decline. This reflects a reduction in case fatality associated with a general improvement in health status as well as the introduction of antibiotics in the late 1940s (Russell, 1988). By fitting a trend to measles deaths for the period 1940–69 and extrapolating it from 1970 onwards, we can estimate the deaths that would have occurred without immunisation (Figure 5.1). A trend can also be fitted to actual deaths that occurred with immunisation (Figure 5.2). The difference between these two trend curves is our estimate of the lives saved because of immunisation (Table 5.4)4.

We also estimate a data series for Australian measles notifications by relating Australian deaths to known deaths and notifications in an environment comparable to that in Australia. There are excellent data for this purpose collected in England and Wales, which introduced measles immunisation at the same time as Australia.

Using the case fatality rate for England and Wales we construct a series for Australian measles notifications. This is done in Table 5.3 by multiplying Australian measles deaths by the reciprocal of the England and Wales case fatality rate.

Source: AIHW

Figure 5.1 Australia, measles deaths, 1940-2003

Source: AIHW

Figure 5.2 Australia, measles deaths after immigration, 1970-2003

Source: Table 5.4.

Figure 5.3 Australia, imputed measles notifications immunisation, 1940-2003

Source: Table 5.4.

Figure 5.4 Australia, imputed measles notifications after immunisation, 1970-2003

There is some presumption that secular reductions in case fatality in Australia and England and Wales would have occurred pari passu with comparable overall health improvements occurring simultaneously in each of these countries. The residual case fatality could therefore be attributed to the impact of immunisation. It is accordingly used as tracer for Australian notifications. The difference between the trends fitted to notifications, before and after the subsidised availability of measles immunisation in 1970, is used to represent the impact of immunisation (Figures 5.3 and 5.4 and Table 5.4).

Because of the deficiency in hard data on which the overall projection relies, the forward projection is restricted to 2003. This is five years ahead of the last year for which actual data are available.

Based on our method, between 1970 and 2003, the introduction of measles immunisation could be expected to have saved some 95 lives and to have averted 4.0 million cases (Table 5.4). These values are derived from trend data that smooth considerable year-to-year volatility associated with sporadic outbreaks. Two further points should be borne in mind:

  • Imputing the Australian trend data relies on a relatively small number of deaths to generate a much larger number for notifications. In conjunction with random year-to-year variations in the case fatality rate for England and Wales, this may be responsible for considerable instability in estimated Australian notifications. The potential standard errors are significant.5

The gradient of the trend in measles notifications is sensitive to the base year selected. This study picked 1940 as base year because it yielded a time series of significant duration before the advent of vaccine. The longer the time series, the greater it's influence in mitigating adverse or propitious base year selection.

To evaluate the economic impact of measles immunisation, lives saved and cases averted, the benefits accruing need to be related to the increasing level of measles coverage, the number of doses involved and their associated cost.

Table 5.3 Estimated Australian measles notifications drawing on England and Wales data

 

Australian deaths

 

Estimated
Australian
Notifications

Actual

Year

Males

Females

Total

Notifications

Deaths

Rate

Notificationsa

Notifications

1940

69

57

126

409,521

857

0.00209

60,210

 

1941

11

8

19

409,715

1,145

0.00279

6,799

 

1942

123

122

245

286,341

458

0.00160

153,174

 

1943

52

55

107

376,104

773

0.00206

52,061

 

1944

6

5

11

158,479

243

0.00153

7,174

 

1945

14

11

25

446,796

729

0.00163

15,322

 

1946

50

59

109

160,402

204

0.00127

85,705

 

1947

23

13

36

393,787

644

0.00164

22,013

 

1948

33

47

80

399,606

327

0.00082

97,763

 

1949

31

25

56

385,935

307

0.00080

70,399

 

1950

28

32

60

367,725

221

0.00060

99,835

 

1951

28

20

48

616,182

317

0.00051

93,302

 

1952

16

16

32

389,502

141

0.00036

88,398

 

1953

12

15

27

545,050

242

0.00044

60,811

 

1954

24

19

43

146,995

45

0.00031

140,462

 

1955

15

16

31

693,803

174

0.00025

123,609

 

1956

23

21

44

160,556

28

0.00017

252,302

 

1957

10

5

15

633,678

94

0.00015

101,119

 

1958

10

4

14

259,308

49

0.00019

74,088

 

1959

9

11

20

539,524

98

0.00018

110,107

 

1960

8

8

16

159,364

31

0.00019

82,252

 

1961

20

10

30

763,531

152

0.00020

150,697

 

1962

7

4

11

184,895

39

0.00021

52,150

 

1963

10

16

26

601,255

127

0.00021

123,092

 

1964

8

6

14

306,801

73

0.00024

58,839

 

1965

6

14

20

502,209

115

0.00023

87,341

 

1966

4

13

17

343,642

80

0.00023

73,024

 

1967

13

11

24

460,407

99

0.00022

111,614

 

1968

6

9

15

236,154

51

0.00022

69,457

 

1969

15

19

34

142,111

36

0.00025

134,216

 

1970b

4

5

9

307,408

42

0.00014

65,873

 

1971

11

7

18

135,241

28

0.00021

86,941

 

1972

4

2

6

145,916

29

0.00020

30,190

 

1973

2

4

6

152,578

33

0.00022

27,741

 

1974

6

6

12

109,636

20

0.00018

65,782

 

1975

4

1

5

143,072

16

0.00011

44,710

 

1976

7

4

11

55,502

14

0.00025

43,609

 

1977

4

1

5

173,361

23

0.00013

37,687

 

1978

3

5

8

124,067

20

0.00016

49,627

 

1979

3

8

11

77,363

17

0.00022

50,058

 

1980

3

2

5

139,487

26

0.00019

26,824

 

1981

2

4

6

52,979

15

0.00028

21,192

 

1982

2

3

5

94,195

13

0.00014

36,229

 

1983

1

1

2

103,700

16

0.00015

12,963

 

1984

2

2

4

62,079

10

0.00016

24,832

 

1985

4

1

5

97,408

11

0.00011

44,276

 

1986

3

2

5

82,054

10

0.00012

41,027

 

1987

1

5

6

42,158

6

0.00014

42,158

 

1988

   

6

86,001

13

0.00015

39,693

 

1989

   

2

26,222

3

0.00011

17,481

 

1990

   

4

13,302

1

0.00008

53,208c

 

1991

   

3

9,680

0

0.00000

1,815

1,380

1992

   

3

10,268

1

0.00010

1,925

1,425

1993

   

1

9,612

0

0.00000

601

4,536

1994

   

3

16,375

1

0.00006

1,535

4,895

1995

   

3

7,447

0

0.00000

698

1,324

1996

   

0

5,614

0

0.00000

526

498

1997

   

0

3,962

0

0.00000

371

852

1998

0

3,728

0

0.00000

350

306

a. Australian deaths multiplied by the reciprocal of the England and Wales death rate
b. Immunisation introduced
c. Outlier value ignored in trend analysis.
Source
: AIHW; Office of Population Censuses and Surveys (UK); Department of Health (UK); NCIRS

Table 5.4 Trend data for measles deaths and notifications

 

Deaths

Notifications

Year

Without

with

Estimated lives

Without

with

Estimated cases

Immunisationa

immunisationb

savedc

immunisationd

Immunisatione

avertedc

1940

74

   

21,331

   

1941

70

   

29,741

   

1942

67

   

36,124

   

1943

63

   

41,467

   

1944

60

   

46,150

   

1945

57

   

50,366

   

1946

54

   

54,230

   

1947

52

   

57,815

   

1948

49

   

61,175

   

1949

46

   

64,344

   

1950

44

   

67,353

   

1951

42

   

70,223

   

1952

40

   

72,970

   

1953

38

   

75,610

   

1954

36

   

78,153

   

1955

34

   

80,610

   

1956

32

   

82,987

   

1957

31

   

85,293

   

1958

29

   

87,533

   

1959

28

   

89,713

   

1960

26

   

91,837

   

1961

25

   

93,908

   

1962

24

   

95,931

   

1963

22

   

97,909

   

1964

21

   

99,844

   

1965

20

   

101,740

   

1966

19

   

103,598

   

1967

18

   

105,420

   

1968

17

   

107,209

   

1969

16

   

108,966

   

1970

16

10

6

110,693

77,000

33,693

1971

15

10

5

112,391

67,459

44,932

1972

14

10

4

114,061

59,100

54,961

1973

13

10

3

115,706

51,777

63,929

1974

13

9

4

117,325

45,362

71,964

1975

12

9

3

118,921

39,741

79,180

1976

11

9

2

120,494

34,817

85,677

1977

11

8

3

122,044

30,503

91,542

1978

10

8

2

123,574

26,723

96,851

1979

10

7

3

125,083

23,412

101,671

1980

9

7

2

126,573

20,511

106,062

1981

9

7

2

128,044

17,969

110,075

1982

8

6

2

129,497

15,743

113,754

1983

8

6

2

130,932

13,792

117,140

1984

8

6

2

132,351

12,083

120,268

1985

7

5

2

133,753

10,586

123,167

1986

7

5

2

135,139

9,274

125,865

1987

6

4

2

136,511

8,125

128,385

1988

6

4

2

137,867

7,118

130,749

1989

6

4

2

139,209

6,236

132,973

1990

6

4

2

140,537

5,464

135,074

1991

5

3

2

141,852

4,787

137,065

1992

5

3

2

143,153

4,194

138,960

1993

5

2

3

144,442

3,674

140,768

1994

5

2

3

145,719

3,219

142,500

1995

4

2

2

146,983

2,820

144,163

1996

4

1

3

148,236

2,470

145,765

1997

4

1

3

149,477

2,164

147,313

1998

4

0

4

150,707

1,896

148,811

1999

3

0

3

151,927

1,661

150,266

2000

3

0

3

153,136

1,455

151,680

2001

3

0

3

154,335

1,275

153,059

2002

3

0

3

155,523

1,117

154,406

2003

3

0

3

156,702

979

155,723

a From trend fitted to actual deaths prior to immunisation b From trend fitted to actual deaths after the introduction of immunisation c Period and cohort effects not taken into consideration
d From trend fitted to notifications imputed from Australian deaths prior to immunisation
e From trend fitted to notifications imputed from Australian deaths after the introduction of immunisation

Measles immunisation coverage

Apart from the ABS surveys on measles coverage, no systematic national data on measles coverage were collected between 1970 and 1996. Moreover, such data as are available from the ABS conflict with those collected by the ACIR after 1996. For instance, the level of coverage estimated by the ABS in 1995 (91.5 per cent at 24 months, ABS, 1996) exceeds that revealed by ACIR records for 1997 and 1998. Although, as remarked above, the ACIR may have underestimated coverage, it provides the first systematic, ongoing national collection on measles immunisation coverage. This source is therefore used as the anchor for this study.

We accordingly project numbers of measles doses with reference to ACIR recorded coverage for the period 1996 to 1999—the first four years of operations by the ACIR for which full-year data are available. Between 1970 and 1995 we estimate measles coverage by assuming the uptake of the vaccine adopted a monotonic trend over the period 1970 – 1999 (Figure 5.5).6 We then estimate actual doses delivered by applying coverage to the age appropriate population cohorts. For the period 1999–2003 we make a simple linear forward projection of doses from doses recorded between 1997 and 1999. The estimated overall trend in measles vaccine doses delivered over the period 1970–2003 is set out in Table 5.5 and Figure 5.6. The striking rise in doses provided between 1994 and 1998—when immunisations grew from 206,000 to 253,000—may be related to the effect of bringing the second measles dose forward in 1999 to 4–5 years, which was part of the impact of the 1998 measles control campaign.

Source: 1996 – 1999, ACIR

Table 5.5 Estimated trend in measles vaccines doses

Year

No

Year

No

Year

No

Year

No

1970

19,480

1979

105,411

1988

168,771

1997

257,876

1971

32,384

1980

113,042

1989

175,240

1998

253,109

1972

43,597

1981

120,490

1990

181,623

1999

246,002

1973

53,837

1982

127,774

1991

187,926

2000

240,455

1974

63,408

1983

134,910

1992

194,152

2001

234,518

1975

72,478

1984

141,911

1993

200,307

2002

228,581

1976

81,152

1985

148,788

1994

206,394

2003

222,644

1977

89,500

1986

155,552

1995

212,416

   

1978

97,574

1987

162,211

1996

229,922

   

Source: 1996 – 1999, ACIR

Source: 1996 – 1999, ACIR

5.4 Benefits and Costs of Immunisation for Measles

Benefits of immunisation programs

To estimate the benefits from the reduction in the number of measles cases attributable to immunisation we attach a valuation to lives saved, disability averted and resulting treatment savings at constant mid-1990s prices. As we assume that all the deaths are child deaths, a death saved represents the gain of a whole life, which in this study we value at $1 million (Chapter 1).

The estimated cost of treating a measles case without complications is $2982 (see Table 5.6) with a disability weight of 0.152. There are long ongoing costs associated with each of measles encephalitis and sub acute schelerosing panencephalitis, for which the respective (lifetime) disability weights are an estimated 0.338 and 0.938 respectively.

Table 5.6 Characteristics of measles notifications, their sequelae and their cost (mid 1990 $s)

 

Prevalence per notification

Estimated case cost

DALY

Uncomplicated measles

0.99896a

$2,982b

0.152c

Measles encephalitis

0.00101a

$10,000 for 20 years @ 5% = $124,622a

0.338c

Sub acute schelerosing panencephalitis

0.00004a

$55,480 for 5 years, 10 years after onset @ 5% = $140,440a

0.938c

Source: (a) Personal communication, Gerard Fitzsimmons, AIHW
(b) Sheill et al (1998); (c) Mathers et al 1999, p 187.

These prevalences, health care costs and disability weights are applied to lives saved and notifications averted (as calculated in Table 5.4). The estimated economics benefits accruing to the community as a whole between 1970 and 2003, discounted back to 1970 at 5 per cent at mid-1990s prices is $9204 million (Table 5.7).

A high proportion of these benefits accrues to government in the form of reduced health care treatment costs. Using a five per cent discount rate, the estimated present value of the savings to government is $8531 million.

Table 5.7 also shows the estimated total benefits and the savings to government with a zero, 3 and 7 per cent discount rate.

Costs of immunisation programs

The cost of providing measles immunisation consists of the following elements:

  • Cost of delivering age appropriate dose I (12 months), 1970–2003 by general practitioners, for 56 per cent of doses 1970–98 and for 69 per cent of doses 1999–2003 @ $23.28 per MBS item 23 (standard consultation) (assumes that 80 per cent of services were bulk billed @ Schedule Fee of $26.457) level of coverage of relevant population cohort8

Cost of delivering age appropriate dose II (4- 5 years), 1994–2003 by general practitioners under same conditions as for dose I

Cost of delivering age appropriate dose I (12 months), 1970–2003 by non-GP immunisation providers for 44% of doses, 1970–98 and for 31% of doses, 1999–2003 @ $11.64 (an estimated half the cost of a GP service) level of coverage of relevant population cohort

Cost of delivering age appropriate dose II (4-5 years), 1994–2003 by non-GP immunisation providers under same conditions as for dose I

Cost of vaccine for doses 1 and II @ $2.02, assuming the measles component of the MMR dose @ 1/3 of unit cost used by DHAC for purposes of PHOFA vaccine appropriations (DHAC, 2000a) level of coverage of relevant population cohort.

Measles component of the cost of ACIR administration, ACIR reporting and GPII SIP and outcome payments, and payments to divisions of general practice, weighted in accordance with the share that measles vaccine bears in relation to the cost of all childhood vaccine doses listed on the Australian Standard Vaccination Schedule

The program costs associated with the Measles Control Campaign, August–November, 1998

A vaccine reaction rate of 4.1 per million immunisations, costed at $100 per reaction9

Some campaigns initiated at State/Territory levels may not be captured by the costs identified above. However, no data for these costs are centrally collected, let alone capable of attribution to measles. The above calculations allow for most State/Territory delivery costs and the cost of VIVAS in Queensland is captured in 50 per cent of Queensland’s ACIR reporting fee.

The costs of the immunisation programs are summarised in Table 5.8. Their estimated NPV, discounting back to 1970 at 5 per cent, is approximately $55 million. Table 5.8 also shows the estimated total costs of the programs with a zero, 3 and 7 per cent discount rate.

Overall evaluation of benefits and costs: central case

Adopting a 5 per cent discount rate, and drawing on our most likely assumptions, the estimated net benefit of the measles immunisation programs to the community is about $9.1 billion (Table 5.9).

Drawing on the same inputs, the estimated net benefit of the measles immunisation programs to the government sector is in the order of $8.5 billion.

Sensitivity analysis

There are uncertainties in the cost elements associated with variability in doses administered (due to year to year variability in coverage) and with variability in proportions of immunisations delivered by general practitioners and local councils. To account for this, we allow that costs may have been 25 per cent higher or lower than in our central case. Thus total discounted costs of the programs, with a 5 per cent discount rate, could be between $39 million and $66 million (see Table 5.8).

On the benefit side, there are potentially significant errors arising because of the way in which we have imputed the decline in the Australian morbidity from measles from the case fatality rate in England and Wales. Despite the likely similarities between the two sets of case fatality rates, there would inevitably be random discrepancies between the rates. There may also have been variations in measles case severity and their associated treatment costs. These variations are allowed for by varying the estimated benefits by 25 per cent in Table 5.7. Thus the total discounted benefits could be in the range $6.9 billion to $11.5 billion.

Clearly, the net benefit of the measles immunisation program has been high whatever the possible variations in assumptions that might be made (see Table 5.9).

Table 5.7 Estimated benefits from measles immunisation, $m (mid-1990 $s)

       

Disability savings

   
 

Treatment Savings

Death savings

Sequelai Savings

No complications

Complications

Total

Savings to government

1970

100.5

5.7

4.2

70.2

12.8

193.3

174.9

1971

134.0

4.9

5.7

93.6

17.1

255.2

233.2

1972

163.9

4.1

6.9

114.4

20.9

310.3

285.2

1973

190.6

3.4

8.1

133.1

24.3

359.5

331.8

1974

214.6

3.7

9.1

149.8

27.4

404.6

373.5

1975

236.1

3.1

10.0

164.9

30.1

444.1

411.0

1976

255.5

2.5

10.8

178.4

32.6

479.7

444.7

1977

273.0

2.9

11.5

190.6

34.8

512.8

475.1

1978

288.8

2.3

12.2

201.7

36.8

541.8

502.7

1979

303.2

2.8

12.8

211.7

38.7

569.2

527.7

1980

316.3

2.3

13.4

220.8

40.3

593.1

550.5

1981

328.2

1.9

13.9

229.2

41.8

615.0

571.3

1982

339.2

2.4

14.3

236.9

43.2

636.1

590.4

1983

349.3

2.0

14.8

243.9

44.5

654.5

608.0

1984

358.6

1.6

15.2

250.4

45.7

671.5

624.2

1985

367.3

2.2

15.5

256.5

46.8

688.3

639.3

1986

375.3

1.8

15.9

262.1

47.9

703.0

653.3

1987

382.8

2.5

16.2

267.3

48.8

717.6

666.3

1988

389.9

2.2

16.5

272.2

49.7

730.5

678.6

1989

396.5

1.9

16.8

276.9

50.6

742.6

690.1

1990

402.8

1.6

17.0

281.2

51.4

754.0

701.1

1991

408.7

2.3

17.3

285.4

52.1

765.8

711.4

1992

414.4

2.0

17.5

289.3

52.8

776.1

721.2

1993

419.8

2.8

17.7

293.1

53.5

786.9

730.6

1994

424.9

2.5

18.0

296.7

54.2

796.3

739.6

1995

429.9

2.3

18.2

300.2

54.8

805.3

748.2

1996

434.7

3.1

18.4

303.5

55.4

815.0

756.5

1997

439.3

2.9

18.6

306.7

56.0

823.5

764.6

1998

443.8

3.7

18.7

309.9

56.6

832.6

772.4

1999

448.1

3.5

18.9

312.9

57.1

840.5

779.9

2000

452.3

3.3

19.1

315.8

57.7

848.2

787.2

2001

456.4

3.1

19.3

318.7

58.2

855.7

794.4

2002

460.4

3.0

19.5

321.5

58.7

863.1

801.4

2003

464.4

2.8

19.6

324.2

59.2

870.3

808.2

PV@5%

4,901.6

48.2

207.1

3,422.5

624.9

9,204.3

8,531.1

+25%

6,127.0

60.2

258.9

4,278.0

781.1

11,505.2

10,663.9

-25%

3,676.2

36.1

155.3

2,566.8

468.7

6,903.1

6,398.3

PV@ 0%

11,863.6

94.9

501.2

8,283.6

1,512.5

22,255.7

20,648.4

PV@3%

6,780.7

61.0

286.5

4,734.5

864.5

12,727.2

11,801.7

PV@7%

3,671.8

39.5

155.1

2,563.8

468.1

6,898.3

6,390.7

Table 5.8 Cost of providing measles immunisation, $s’000s (mid-1990 $s)

 

Measles dose delivery costs

Vaccine

       
 

I GPs

I Others

II GPs

II Others

I

II

ACIR,

etc

Campaign

Scale effects

TOTAL

1970

254

99

0

0

39

0

0

0

0.008

393

1971

422

165

0

0

65

0

0

0

0.008

653

1972

568

223

0

0

88

0

0

0

0.008

879

1973

701

275

0

0

108

0

0

0

0.008

1,086

1974

826

324

0

0

128

0

0

0

0.008

1,279

1975

944

371

0

0

146

0

0

0

0.008

1,462

1976

1,058

415

0

0

163

0

0

0

0.008

1,637

1977

1,166

458

0

0

180

0

0

0

0.008

1,806

1978

1,272

499

0

0

197

0

0

0

0.008

1,968

1979

1,374

539

0

0

212

0

0

0

0.008

2,127

1980

1,473

579

0

0

228

0

0

0

0.008

2,281

1981

1,570

617

0

0

243

0

0

0

0.008

2,431

1982

1,665

654

0

0

258

0

0

0

0.008

2,578

1983

1,758

691

0

0

272

0

0

0

0.008

2,722

1984

1,850

726

0

0

286

0

0

0

0.008

2,863

1985

1,939

762

0

0

300

0

0

0

0.008

3,002

1986

2,027

796

0

0

314

0

0

0

0.008

3,138

1987

2,114

830

0

0

327

0

0

0

0.008

3,273

1988

2,200

864

0

0

340

0

0

0

0.008

3,405

1989

2,284

897

0

0

354

0

0

0

0.008

3,536

1990

2,367

930

0

0

366

0

0

0

0.008

3,664

1991

2,450

962

0

0

379

0

0

0

0.008

3,792

1992

2,531

994

0

0

392

0

0

0

0.008

3,917

1993

2,611

1,025

0

0

404

0

0

0

0.008

4,041

1994

2,690

1,057

1,183

465

416

366

0

0

0.008

6,180

1995

2,769

1,087

1,225

481

429

379

0

0

0.008

6,372

1996

2,997

1,177

1,265

497

464

392

162

0

0.008

6,957

1997

3,361

1,320

1,305

512

520

404

274

0

0.008

7,701

1998

3,299

1,296

1,345

528

511

416

391

30,000

0.008

37,789

1999

3,951

887

1,706

383

496

429

1,130

0

0.008

8,984

2000

3,862

867

1,846

414

485

464

1,416

0

0.008

9,358

2001

3,767

846

2,071

465

473

520

1,409

0

0.008

9,553

2002

3,671

824

2,032

456

461

511

1,549

0

0.008

9,508

2003

3,576

803

1,978

443

449

496

1,624

0

0.008

9,370

PV @5%

26,360

9,687

3,711

1,118

3,968

1,032

1,696

7,288

0.130

54,865

+ 25%

32,950

12,109

2,932

727

4,960

761

2,121

9,110

0.162

65,673

- 25%

19,770

7,265

1,759

436

2,976

456

1,272

5,466

0.097

39,404

PV@0%

71,383

24,876

10,977

2,692

10,510

2,839

7,958

30,000

0.273

161,239

PV@3%

38,155

13,756

4,306

1,063

5,698

1,116

3,117

12,730

0.170

79,945

PV@7%

18,893

7,056

1,293

322

2,863

336

935

4,216

0.103

35,918

Table 5.9: Summary of results for measles immunisations $m (mid-1990 $s)

 

Costs

Benefits

Net benefits

NPV @ 5%

54.9

9,204.3

9,149.4

+ 25%

65.7

11,505.2

11,439.5

- 25%

39.4

6,903.1

6,863.7

NPV @ 3%

79.9

12,727.2

12,647.3

NPV @ 7%

35.9

6,898.7

6,862.6

5.5 The Impact of Immunisation Programs on Hib Disease

Because the vaccine for Hib disease was adopted after systematic national data collection on notifiable diseases commenced, the task of making forward projections is less speculative than for measles.

One consideration in identifying Hib cases is that the number and rate of hospitalisations have been consistently higher than for notifications. McIntyre et al.(2000, p.12) report that:

… notifications probably underestimate Hib cases (especially cases of epiglottitis, which are often diagnosed clinically) while hospitalisations probably overestimate them. This is because the hospitalisation codes (a) lack specificity (as non-Hib cases may be included) and (b) may count cases twice if the patient is transferred to another hospital (more frequent for epiglottitis). Overall it is likely that notifications, because they are usually linked to laboratory identification of Hib, more closely represent the true incidence of Hib disease than hospitalisations.

This study accordingly uses notification data as the basis for evaluating the impact of Hib immunisation. Moreover, following McIntyre et al (2000), only children 0–14 years of age are included. This is because vaccines are targeted at reducing disease in children and the diagnosis of children for Hib infection is likely to be more specific.

Monthly plots of Hib disease notifications are set out in Figures 5.7 and 5.8, commencing in 1991 and projected forward until 2003. There is a noticeable fall in notifications after the introduction of Hib vaccine in February 1993—from some 39 cases per month between 1991–92 to about 9 cases between 1993–98. To develop a counterfactual proposition, separate trends are fitted to the monthly series both before and after the introduction of Hib vaccine. In the latter case, a forward projection is made until the year 2003. These trend data are collapsed into annual observations in Table 5.10, from which it will be seen that, between 1993–98, 3614 Hib cases are likely to be averted and about 87 lives saved.

Source: NCIRS

Source: NCIRS

Table 5.10 Numeric trend data for Hib disease deaths and notifications before and after immunisation

 

Notifications

Apparent cases

Deaths

Apparent lives

 

Before

After

Averted1

Before

After

Saved1

1991

432

   

10

   

1992

434

   

10

   

1993

436

230

206

10

6

5

1994

439

136

303

11

3

7

1995

441

129

312

11

3

7

1996

443

122

321

11

3

8

1997

445

116

330

11

3

8

1998

448

110

338

11

3

8

1999

450

104

346

11

2

8

2000

452

99

354

11

2

8

2001

455

93

361

11

2

9

2002

457

88

368

11

2

9

2003

459

84

375

11

2

9

1 Period and cohort effects not taken into consideration
Hib disease immunisation coverage

Increasing levels of Hib immunisation coverage underpin these favourable trends in mortality and morbidity. The trend in Hib doses associated with increasing levels of coverage is linearly projected backwards to 1993 and forwards to 2003, from observations for the four full-years of ACIR reporting between 1996 and 1999 (Figure 5.9). The number of Hib doses peaked in 1997 and thereafter the number has slightly diminished, as ‘catch up’ campaigns were completed.

Source: 1996 – 1999, ACIR

5.6 Benefits and Costs of Immunisation for Hib Disease

Benefits of reduced Hib incidence

We estimate the benefits from the reduction in Hib morbidity by allocating projected cases averted to three classes of Hib disease, to death, and to four classes of disability (severe disability, less severe disability, hearing aid and less severe hearing loss) in accordance with point prevalences in Table 5.11. As for measles, because all deaths are child deaths, deaths averted are valued in this study at $1 million. We also ascribe quality of life indices to the four classes of disability to account for time avoided at less than full health.

The estimated benefits are summarised in Table 5.12. Discounted back to 1993 at 5 per cent, the present value of the estimated benefits to the community is approximately $165 million. A high proportion of these benefits is attributed to averted deaths and improved quality of life. The present value (in 1993) of the estimated savings to government is $45 million. The estimated savings are also shown with discount rates of 0, 3 and 7 per cent.

Table 5.11 Point prevalence per notification of Hib type disease, their sequelae and their cost

 

Prevalence

Estimated case cost

Quality of life index

Type

     

Meningitis

0.4608

$7,380

 

Epiglottitis

0.36

$5,789

 

Other

0.1792

$2,130

 

Sequelae

     

Death

0.024

$1.0m

0

Severe disability

0.008

$55,480 for 50 years @ 5% = $1.013m

-0.12

Less severe disability

0.0368

$45,400 for 20 years @ 5% = $65,000

0.80

Hearing aid

0.0176

(Cochlear) $16,000

0.86

Less severe hearing loss

0.0176

(Assessment) $1,470

0.91

Source: McIntyre et al (1994).

Table 5.12 Benefits from Hib disease immunisation, $’000s

 

Cases

Treatment

Death

Sequelae

Improved quality

TOTAL

Total savings

 

averted

savings

savings

savings

of life

benefits

to govta

1993

206

1,208

4,944

2,225

4,328

12,707

3,434

1994

303

1,775

7,264

3,270

6,358

18,668

5,045

1995

312

1,830

7,488

3,371

6,555

19,245

5,201

1996

321

1,883

7,704

3,468

6,743

19,799

5,351

1997

330

1,933

7,911

3,561

6,925

20,332

5,495

1998

338

1,982

8,111

3,651

7,100

20,845

5,633

1999

346

2,029

8,303

3,737

7,268

21,339

5,767

2000

354

2,075

8,489

3,821

7,430

21,816

5,896

2001

361

2,118

8,668

3,901

7,587

22,275

6,020

2002

368

2,161

8,840

3,979

7,738

22,719

6,140

2003

375

2,201

9,007

4,054

7,884

23,148

6,256

PV @5%

-

15,713

64,285

28,937

56,271

165,207

44,651

+25%

 

19,642

80,356

36,172

70,338

206,509

55,814

-25%

 

11,785

48,214

21,703

42,203

123,905

33,488

PV @0%

 

21,200

86,733

39,042

75,920

222,897

60,243

PV@3%

 

17,634

72,145

32,475

63,151

185,407

50,110

PV@7%

 

14,080

57,602

25,929

50,421

148,033

40,009

(a) Treatment plus sequelae savings.

Costs of immunisation programs for Hib disease

The cost of providing Hib immunisations consists of the following elements:

  • Cost of delivering age appropriate doses I–IV of HibTITER vaccine (2, 4, 6 and 18 months) by general practitioners for 56 per cent of doses 1993–98 and for 69 per cent of doses 1999–2003 @ $23.28 per MBS item 23 (standard consultation). This assumes that 80 per cent of services were bulk billed @ Schedule Fee of $26.45) 1/3 (because HibTITER doses are delivered concurrently with other Schedule vaccines) number of doses from Figure 5.9.
  • Cost of delivering age appropriate doses I–IV of HibTITER vaccine (2, 4, 6 and 18 months), 1993–2003 by non-GP immunisation providers for 44% of doses, 1993–98 and for 31 per cent of doses, 1999–2003 @ $11.64 (an estimated half the cost of a GP service) under the same conditions as general practitioners
  • Cost of vaccine for doses I-IV @ $9.20 per dose, the price used by DHAC for purposes of PHOFA vaccine appropriations (DHAC, 2000a), number of doses from Figure 5.9.
  • Hib component of the cost of ACIR administration, ACIR reporting and GPII SIP and outcome payments, weighted in accordance with the share that Hib vaccine bears in relation to the cost of all vaccine doses listed on the Australian Standard Vaccination Schedule
  • A vaccine reaction rate of 0.0126 per immunisation, costed at $25 per reaction (McIntyre et al., 1994) number of doses.

These costs are set out in Table 5.13. Discounted back to 1993 at 5 per cent, their present value is approximately $153 million. Estimated present values with 0, 3 and 7 per cent discount rates are also shown.

Table 5.13 Cost of providing Hib disease immunisation, $‘000s

 

GPs

Others

Vaccine

ACIR, etc

Side effects

TOTAL

1993

2,978

1,169

6,304

0

215.9

10,668

1994

3,275

1,286

6,934

0

237.4

11,734

1995

3,573

1,403

7,564

0

259.0

12,800

1996

3,870

1,520

8,194

1,248

280.6

15,115

1997

4,168

1,637

8,824

2,103

302.1

17,035

1998

4,136

1,624

8,756

3,001

299.8

17,818

1999

5,116

1,149

8,790

8,663

301.0

24,020

2000

5,096

1,144

8,756

10,858

299.8

26,156

2001

5,086

1,142

8,739

10,804

299.2

26,071

2002

5,076

1,140

8,722

11,875

298.6

27,113

2003

5,066

1,138

8,705

12,456

298.1

27,664

PV@5%

34,873

10,934

67,270

39,959

2,303

155,341

+25%

43,591

13,667

84,088

49,949

2,879

194,176

-25%

26,154

8,200

50,453

29,969

1,727

116,506

PV @ 0%

47,443

14,358

90,293

61,012

3,091

216,198

PV@3%

39,265

12,142

75,343

47,169

2,579

176,500

PV@7%

31,148

9,897

60,396

33,998

2,067

137,508

Overall evaluation of benefits and costs: central case

Adopting a 5 per cent discount rate, and drawing on our most likely assumptions, the estimated net benefit of the Hib immunisation programs to the community as a whole is approximately $10 million (see Table 5.14).

However, because a high proportion of the benefits accrued in averted deaths and improved quality of life, the to the community, the present value of the estimated savings to government ($45 million) were below the present vale of the costs of the programs ($155 million).

Table 5.14: Summary of results for Hib immunisations $m (mid-1990 $s)

 

Costs

Benefits

Net benefits

NPV @ 5%

155.3

165.2

9.9

+ 25%

194.2

206.5

11.3

- 25%

116.5

123.9

7.4

NPV @ 3%

176.5

185.4

8.9

NPV @ 7%

137.5

148.0

10.5

Sensitivity analysis

Unlike the analysis for measles, the results are sensitive to the assumptions made. For the costs of the programs we allow conservatively for a 25 per cent range due to possible variations in doses administered and in proportions of immunisations delivered by general practitioners and local councils. With a 5 per cent discount rate, the present value of the costs ranges from $117 million to $194 million.

There is also uncertainty about the Hib related diseases that would have occurred in the absence of immunisation (Figure 5.7). The projection of the ‘no-immunisation’ case relies on a small period of pre-immunisation experience. The explanatory power of the trend fitted in Figure 5.7 is therefore low. McIntye et al. (1994) also remark on the uncertainties associated with Hib diseases and their severity. Again, we allow for a 25 per cent variation in the estimated benefits. As shown in Table 5.14, the present value of the total economic benefits varies from $124 million to $207 million.

5.7 Conclusions

The study reports on the evaluation of two immunisation programs: immunisations for measles from 1970 to 2003 and immunisations for Hib disease from 1991 to 2003.

Between 1970 and 2000, measles notifications fell from around 100 000 cases a year to under 2000 cases a year. The introduction of subsidised immunisations for measles in 1970 saved an estimated 95 lives and averted approximately 4.0 million cases between 1970 and 2003. The estimated net present value of these immunisation programs for measles is about $9.2 billion.

On the other hand, the estimated present value of the costs of the measles immunisation programs was only $52 million. Therefore the net benefit of the program exceeded $9.1 billion. The overall result is not sensitive to the assumptions made.

In the case of measles immunisation programs, savings in health treatment expenditures accounted for a high proportion of the estimated benefits. Accordingly, the government made very substantial savings as a result of these immunisation programs.

Hib notifications also fell substantially after the introduction of the Hib immunisation programs. Our study estimates that approximately 350 cases were averted annually in the 1990s. We estimate that the introduction of immunisation for Hib-related diseases saved 78 lives and averted 3600 cases between 1993 and 2003.

In the central case evaluation, the estimated present value of the Hib immunisation programs is $165 million. On the other hand, the present value of the expenditure on the programs is $155 million. The estimated net present value of the immunisation programs for Hib disease is a marginal $10 million. However, this result is sensitive to the assumptions made, especially to the estimates to the benefits of the Hib immunisation programs.

In the case of Hib immunisation programs, savings in health treatment expenditures accounted for about a third of the estimated benefits. Accordingly, the government recovered less than it outlaid in expenditures on these immunisation programs.

1 These two immunisation programs were chosen after consultation with the National Centre for Immunisation Research and Surveillance and agreed by the Department of Health and Aged Care following the consultant's Study Method and Design Report (Applied Economics, 1999).

2 Personal communication, Gerard Fitzsimmons, AIHW.

3 Although the ACT and NT also maintain their own registers, ACT and NT providers receive the full $6.00 reporting fee.

4 The implicit assumption of the counterfactual projection in the left hand column in Table 5.3 is that measles mortality increases with population growth, hence that the age distribution of the population from 1970 onwards is roughly comparable with that for 1940– 69. The effect of the post- war baby boom may exaggerate lives saved; low birth rates during the war would have had the opposite effect.

5 Note, for example, that a significant outlier value for imputed measles notifications in 1990 (Table 5.3) is excluded for purposes of fitting the trend to estimated notifications after immunisation (Figure 5.4).

6 The extrapolation in Figure 5.5 is not intended to imply that immunisation coverage is expected to attain 100 per cent. The highest attainable coverage is probably about 95 per cent.

7 Medicare Benefit Schedule Fee as at October 2000.

8 This costing is an overestimate in so far as it ignores immunisations given ‘opportunistically’ during consultations occasioned for reasons unrelated to immunisation. The DHAC advises that 23 per cent of immunisations in children below 15 years of age are given at a consultation where another problem was addressed.

9 During the Australian measles control campaign 1998, 1.7 million doses of MMR vaccine were used. There was a very low incidence of adverse effects during the campaign with only 7 per cent of children with anaphylaxis / anaphylactoid reactions, each of whom recovered fully following administration of adrenalin (NHMRC, 2000). Based on this result, a reaction rate of 4.1 per million was adopted in this report. The costing of each reaction rate at $100 to cover the cost of administering adrenalin and associated care is a notional figure adopted by the consultant in the absence of other cost information. This reaction cost does not necessarily reflect the views of the DHAC. The consultant has been advised that hypersensitive reactions such as wheal and flare reaction and uriticaria at the injection site can also occur because of MMR vaccinations, However such reactions are mild and rare and are not included in this analysis.

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