Table 1. Why to eliminate/eradicate: costs, benefits and economic evaluations of eliminating/eradicating infectious diseases.
| Study and Year | Perspective | Content | Costs included | Health outcomes | Economic benefits | Methodological approach | Main Findings |
|---|---|---|---|---|---|---|---|
| Bart, 1996 [64] | Health system | Economic evaluation of the poliomyelitis eradication initiative to facilitate national and international decision-making on financial support. | Programme costs, treatment and rehabilitation costs, and vaccine costs included stratified by developing and industrialized countries | Number of cases of paralytic poliomyelitis | Treatment and rehabilitation costs | CBA. The base case examined the net costs and benefits during 1986–2040 based on differential costs for oral poliovirus vaccine and its delivery in industrialized and developing countries and ignored benefits from reductions in direct costs for treatment and rehabilitation | The "break-even" point at which benefits exceeded costs was the year 2007, with savings of US$ 13600 million by the year 2040. Results were robust to large variations in several factors affecting costs and benefits. Poliomyelitis Eradication Initiative was economically justified |
| Kim, 1997 [35] | Health system | Comparison between expenditure on Global dracunculiasis Eradication Campaign (GDEC) activities and estimates of increased agricultural production due to reductions in infection-related morbidity | The estimated expenditures for GDEC include costs incurred by foundations, NGOs, as well and by the WHO between 1987–1998 | Number of cases | Estimate of productivity loss averted | CBA using a project horizon of 1987–1998. Costs based on data from Global 2000, UNICEF, and WHO. Productivity estimates based on the Cobb-Douglas production function | The Economic rate of return was 29%, under the assumption of 5 weeks average degree of incapacitation caused by Guinea worm infection. Elimination to be achieved in Sudan by the year 2001 for economic returns to be consistent with those obtained in other endemic countries |
| Miller, 1998 [33] | Societal | Demonstration of the potential value of measles eradication by identifying the potential cost-savings to the United States resulting from measles eradication | Costs of vaccine and vaccination, travel, indirect costs and costs of adverse events management | Number of cases | Costs of measles disease and outbreak control costs | CBA | Measles eradication would save $45 million annually. If achieved by the year 2010, the US would save up to $4.1 billion. Intensification of measles control efforts in the US would have minimal marginal benefits on disease burden reduction |
| Acharya, 2002 [32] | Health system (PAHO) | Cost-effectiveness of measles elimination in Latin America and the Caribbean | Costs of routine vaccination and costs of follow up campaigns (vaccine delivery, admin costs, mobilization, adverse events management) | Number of cases modelled from available information | Costs of routine vaccination | Prospective CEA of strengthening immunisation based on PAHO costs and health outcomes based on continuation of past trends | Vaccination for measles elimination costs US$ 244 incremental million and prevents a case of measles at the cost of US$ 71.75 and a death at the cost of US$ 15,000. It saves a total of US$ 208 million in treatments costs |
| Khan, 2003 [65] | Health system | Estimate global economic costs and benefits of polio vaccination and eradication by six geographic regions of the world (AFR, AMR, EMR, EUR, SEAR and WPR) | Cost of polio vaccination, eradication and treatment per case estimated using the cost per dose parameters and actual eradication costs reported by the WHO regions | Number of cases and DALYs | Polio medical care cost averted | CEA and cost savings estimates with pre-vaccination polio incidence rates in USA and Italy used to predict the cases that would have occurred in the world for the years 1970–2050 in the absence of immunization | Globally, polio program will cost US$ 67 billion if vaccination is discontinued after 2010. The medical care cost savings will be more than US$ 128 billion, with polio eradication paying for itself in the long run. The program will also prevent 855000 deaths, 4 million paralysis cases and 40 million DALYs over the years 1970–2050 |
| Ramzi, 2005 [23] | Health system, government | Estimate costs for lymphatic filariasis elimination program in Egypt in 2000–2001 | All costs, recurrent and capital, associated with 2 rounds mass drug administration | None | None | Cost data retrospectively gathered from local, regional and national Ministry of Health and Population records. The total estimates for each governorate based on data from a representative district and combined with national programme estimated data | The overall total and government costs for treatment at a coverage of 86% (year 2000) were US$ 3,181,000 and US$ 2,412,000, respectively. In 2001, with a coverage of 88%, total costs were US $3,109,000 while government costs were US $2,331,000. In 2000, the average Total and Government costs per treated subject were US $1.77 and $1.34, respectively. These costs decreased to US $1.34 and $1.00 in 2001 |
| Thompson, 2007 [66] | Health system | Economic evaluation of worldwide eradication of wild polioviruses against control in the four remaining endemic areas where elimination has not been achieved yet (Afghanistan, Pakistan, India and Nigeria). | Vaccination and surveillance costs | Paralytic poliomyelitis cases | Treatment costs of cases averted | CEA, based on a dynamic model of the current endemic areas in India. An extended model assesses the economic implications and disease burden of a change in policy from eradication to control | A control routine immunisation policy for 20 years with costs of approx $3500 million may lead to 200 000 paralytic poliomyelitis cases every year; a control policy keeping the number of cases at about 1500 per year could cost around $10 000 million. Immunization intensity must be increased to achieve eradication implying to pay higher short-run costs than currently spent |
| Michael, 2008 [67] | Ministry of Health | Different scenarios of global disease control and elimination/eradication of Lymphatic filariasis are compared. | Unit costs taken from published sources (excluding cost of drugs donated) and total costs based on modelling | Number of individuals cured of microfilarial infection (estimated through mathematical modelling) | Not included | CEA | In 10 years control more cost-effective than elimination because of high marginal cost of curing the last few individuals to achieve elimination and low additional health outcomes |
| Chu, 2010 [24] | Individuals and health system | Economic benefits, in terms of treatment savings due to the first 8 years of Global Programme to Eliminate Lymphatic Filariasis (GPELF) (2000–2007) through annual mass drug administration (MDA) | Costs of MDA not estimated | Individuals and person-years protected from acquiring infection or from disease progression | Individual direct and indirect and health system savings from infection or disease progression averted | The number of cases averted quantified by assuming a 10% infection rate and by considering that just a fraction seeks treatment at public health centres. Associated savings in terms of treatment costs refer to medicines, consultation fees, transport, food, accommodation and indirect costs of lost-labour | US$21.8 billion of direct economic benefits gained over the lifetime of 31.4 million individuals treated. Of these, over US$2.3 billion is a consequence of nearly 3 million babies born in areas free of LF. US$19.5 billion is the lifetime economic benefit from stopping disease progression of more than 28 million infected individuals. US$2.2 billion are health system savings due to reduced LF morbidity |
| Sabot, 2010 [22] | Health system/government | To present a conceptual framework to analyse short to medium term financial savings consequent to malaria elimination based on data from eight countries either pursuing or recently achieving elimination | Costs data from several sources, including both actual and programmatic costs either from budgets or mathematical models | Incremental reduction in malaria incidence comparing elimination and control scenarios | Benefits estimated based on yearly cost data and assigned to one of the three elimination phases: baseline, interruption of transmission (10 years) and post-elimination (15 years) | Review of published works and datasets from elimination programmes in eight countries. Costs modelled to the elimination phases context. Minimum-maximum sensitivity analysis was applied | The probability that elimination is cost-saving over 50 years ranged from 0% to 42%. Financial savings should not be a primary rationale for elimination, but elimination still is a worthy investment if total benefits are sufficient to outweigh marginal costs |
| Adhikari, 2010 [36] | Societal | A cost benefit analysis of elimination of kala-azar (KA) in Nepal | Costs of interventions are the values of inputs used to control KA for a year, including costs of treatment and of prevention | Number of cases prevented due to interventions of KA in a year | Estimates of productivity gains due to cases prevented and treatment costs saved. | CBA | Total discounted net benefit of KA intervention was in Nepalese Rupees (NRs) 65,287 million with 35% investment return. Every rupee invested in KA intervention at present will yield NRs 71. Elimination of KA is a good investment opportunity |
| Duintjer Tebbens, 2010 [68] | Health system | Economic analysis of the Global Polio Eradication Initiative (GPEI) and full consideration of post-eradication policies. GPEI consists in a global scaling up of polio vaccination | Vaccine and non-vaccine costs child, including for personnel, training, transportationand cold chain, building andequipment | Disability-adjusted life-years associated paralyticpoliomyelitis cases | Average direct treatment costs associated with one paralytic poliomyelitis case | CEA, CBA. GPEI compared against routine vaccination. Costs of eradication were based on actual and projected expenditures Polio incidence estimated using a dynamic infection transmission model and costs based on numbers of vaccinated children | GPEI vs routine vaccination was highly cost-effective. Incremental net benefits of the GPEI between 1988 and 2035 were of 40–50 billion dollars (2008 US dollars). Despite the high costs of achieving eradication in low-income countries, these account for 85% of the total net benefits generated by the GPEI |
| Levine, 2011 [30] | Societal | Economic evaluation of measles eradication with costs of vaccination collected in Bangladesh, Brazil, Colombia, Ethiopia, Tajikistan, and Uganda, comparing eradication with 3 scenarios: (1) 90% mortality reduction by 2013 (baseline);(2) 95% mortality reduction by 2015;(3) 98% mortality reduction by 2020. Data globally extrapolated | Annual program costs were summed for the immunizationuntil measles eradication. Costs of routine immunization estimated through ingredient approach. Indirect and societal costs estimated based on interviews and/or published data | Measles cases, deaths avertedand DALYs averted for each strategy for each country obtained from dynamic transmission modelling | The direct costs and/or savings from not treating averted measlescases were estimated using available data on the costs oftreatment | Prospective CEA comparing eradication with different scenarios of mortality reduction at different time points and health outcomes based on a transmission model. A global analysis was undertaken by using the existing transmission model | Measles eradication by 2020 was found to be the most cost-effective scenario, both in the six countries and globally. Eradicating measles by 2020 is projected to cost an additional discounted $7.8 billion andavert a discounted 346 million DALYs between 2010 and 2050 |
| Babigumira, 2011 [31] | Health system and household | Economic evaluation of measles elimination in Uganda as part of a global eradication program based on immunization scale-up by comparing different scenarios: 90% mortality reduction by 2013; 95% mortality reduction by 2015; 98% mortality reduction by 2020; elimination in 2020; and elimination in 2025. | The cost of each scenario was estimated as the sum of: (1) cost of measles immunization activities, including measles surveillance and outbreak response;and (2) household costs of immunization | Measles incidence, cases of measles averted, deaths averted, DALYs averted (estimated through modelling) | The cost savings fromreduced measles treatment for cases averted were calculated by multiplying the average cost of treatment | Prospective CEA based on a transmission model and on immunisation costs associated with progressive scale-up | Measles elimination by 2020 was the most cost-effective scenario compared to different scenarios of mortality rate reduction and of later elimination. |
| Bishai, 2012 [34] | Societal | To estimate the global cost-effectiveness of measles eradication versus control | Total costs include costs of scaling up routine vaccination, other immunization activities, outbreak control, routine surveillance, health sector costs of treating measles cases, and societal costs of lost productivity | Measles DALYs | Costs for measles control saved | CEA based on a dynamic age-tiered measles transmission model for 6 countries (Bangladesh,Brazil, Colombia, Ethiopia, Tajikistan, and Uganda) extrapolated globally. Alternatives compared were constant vaccine coverage at 2010 levels, eradication by 2020, eradication by 2025, 95% mortality reduction by 2015, and 98% mortality reduction by 2020. Cumulative discounted societal costs, caseloads, lives, and DALYS saved with each policy option were compared | Strategies to eradicate measles in Bangladesh, Ethiopia, and Uganda cost more than twice as much as control strategies, but have similar costs per death averted. For Brazil, Colombia and Tajikistan, eradication by 2020 would prevent deaths and save $800 million more than measles control from 2010–2050. Measles eradication and measles control are both cost effective and have equivalent costs per life saved in low income countries, but high income countries derive savings only if measles is eradicated and imported cases stop |
| Goldman, 2007 [25] | National Lymphatic Filariasis programme | Estimate of annual mass drug administration (MDA) costs for the elimination of lymphatic filariasis (LF) in 7 countries | Financial and economic (including value of donated goods, such as drugs) costs considered. Recurrent costs included and capital costs | Number of persons treated | Not quantified | Ingredient approach used for cost estimates per activity carried out. Capital costs annualized. Costs estimated per MDA round | Financial costs per person treated ranged $ 0.06–2.23; economic costs ranged $ 0.40–5.87. MDA for LF elimination appeared inexpensive compared to most other public health programs |
| Wagner, 2010 [26] | Health system | Estimate of treatment costs associated with elimination of HIV in South Africa referred to a previous study (Granich et al [69] | Maximum cost of treating a patient is US$1163 and $4083 per year with first (97% of patients) and second-line drugs (3% of patients), respectively | Number of individuals on antiretroviral treatment | Not quantified | Cost curve constructed for 40 year time period based on the projected number of individuals on antiretroviral treatment | Annual costs present a pick at the year 5 but then drop considerably. The critic to Granich et al. is that costs for HIV elimination have been underestimated as they include treatment costs only ignoring, among others, screening costs |
| Sleigh, 1998 [27] | Health government administration | Costs of the Guangxi (China) schistosomiasis Control Programme for 40 years (1952–1992) | Fixed costs were excluded. Running costs were included except wages and fringe benefits for staff at provincial and prefectural levels | Not included | Not included | The total mean annual cost per county was calculated as the sum of 7 annual cost categories averaged across selected historical intervals. For grand totals the annual sums per county was multiplied by the number of counties each year. | In US$ 1991, the highest costs occurred during the period 1976–80, with a mean annual total of US$ 46,702 per county, with environmental change being the most expensive cost item. Costs declined by 33% over the last 10 years. The total cost for the whole Guangxi programme was US$ 241,944 |
| Naik, 1998 [29] | Health system | Review of studies to explore the socio-economic factors associated with the worldwide eradication of leprosy | Not included | Not included | Drug and treatment costs; operational costs such as transportation, staff training and salary, laboratory and referral services | The expected cost of eliminated the disease worldwide is US$ 200 million. If operational costs included (staff training, salaries, transportation, lab and referral services) such costs may be twice or three times higher | |
| Huda, 2012 [28] | Health system | Estimate costs associated with active case detection in national visceral leishmaniasis (VL) elimination programs inBangladesh, India, and Nepal | Costing ingredients included training, development and production of training materials, diagnostic kits, per diems, transport, communication and material | New VL case detected | Not included | Ingredients costing method | The cost (training costs excluded) of detecting a new VL case was of US$ 22 in Bangladesh, US$ 199 in Nepal and US$ 320 in India. Despite the cost, adequate resources for training, planning, etc were indicated as priorities |
| Wutzler, 2002 [37] | Societal and payer perspectives | Based on an age-structured decision analytic model, to estimate costs, benefits and cost-effectiveness of varicella immunization programme for a period of 30 years, within the framework of determining feasibility of varicella elimination through universal coverage | Resources used and unit costs (direct costs) for treatment and intervention of each model outcome plus the value of days off work | Varicella cases, death avoided and life year gained | Costs averted | Human capital approach for estimate of productivity loss; ingredient approach for estimate of treatment and intervention direct costs, health impact based on an age-based analytical disease model | With a routine varicella programme targeting children with a coverage level of 85%, the disease could be eliminated in 18 years. Average yearly discounted net cost savings are 51 million euros with a benefit-cost ratio of 4.12. After initial higher costs, net positive savings, both from societal and payer perspectives, can be achieved after 3 years of the programme starting |
Abbreviations: CBA = cost-benefit analysis; DALY = disability-adjusted life year; CEA = cost-effectiveness analysis; MDA = mass drug administration; GPEI = global polio eradication initiative; KA = kala-azar; GPELF = global programme to eliminate lymphatic filariasis; VL = visceral leishmaniasis.