Issues in benefit-cost analyses for public health preparedness and pandemic mitigation

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Aileen Alexander
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1 Issues in benefit-cost analyses for public health preparedness and pandemic mitigation Joe Cook October 19, Developing Standards for Benefit-Cost Analysis Conference Soldiers at Ft. Riley, KS 1918

2 Thought experiment Most of the deaths in the influenza pandemic of 1918 were caused by sudden and severe pneumonia (the cytokine storm ), largely in young healthy people. The majority of these deaths could have been prevented (and many were averted with the H1N1 outbreak) with the use of a ventilator. It has been estimated that there are 105,000 ventilators in the U.S., or 1 for every 2895 people. A ventilator costs ~ $30,000 (and of course requires trained personnel to operate it). If you re HHS director and planning for a future pandemic, how many ventilators should you require hospitals and clinics to hold?

3 Policies and programs Prepare Contain Mitigate Stockpiling antiviral medicines Stockpiling lowefficacy vaccines Disease surveillance networks Emergency preparedness plan formation and drills Programs targeted at changing prevention behavior Close borders to people Close borders to goods Ground airplane travel Quarantine existing cases Production and distribution of targeted high-efficacy vaccines Antiviral distribution Social distancing policies, such as: School closures Ban on public gatherings Mandatory closures of some types of private business General recommendations to stay home and avoid contact.

4 Macroeconomic impacts Traditional health economic analysis is ill-equipped to estimate the cost-effectiveness and cost-benefit of interventions that aim at controlling and/or preventing public health emergencies of international concern (such as pandemic influenza)...since traditional economic forms of evaluation are being used to inform decisions about controlling and preparing for these emergencies, they do not appear to be fit for the purpose. Beutels, Edmunds and Smith Partially wrong? Partial equilibrium and the economic analysis of health emergencies of international concern. Health Econ. 17: (2008)

Previous pandemics 1918: The worst case (so far). Very rapid spread. 15 100 million deaths worldwide (excess mortality 0.4% in US, 0.8% - 5.5% worldwide.

5 Previous pandemics 1918: The worst case (so far). Very rapid spread million deaths worldwide (excess mortality 0.4% in US, 0.8% - 5.5% worldwide. Widespread social disruptions (closure of schools, churches, theaters, sporting events). 1957: Milder than 1918, though perhaps more widespread. Excess mortality ~0.04% 1968: Milder than Excess mortality 0.02%. 2009: H1N1.?, but at least 18,500 deaths worldwide (2117 in US)

6 FOR ASSA Add the Keogh-Brown results to the graph

7 Year-on-year decreases in real U.S. GDP Range of U.S. GDP impacts of pandemic: -0.4% to -5.5% 1930: -8.6% 1931: -6.5% 1932: -13.1% 1933: -1.3% 1938: -3.4% 1980: -0.3% 1982: -1.9% 1991: -0.2% 2009: -2.6% 5.5% of ~$14T US GDP = $700B US Bureau of Economic Analysis, accessed October 2010

8 School closure Sadique et al (2008): Cost of absenteeism from primary caregivers 0.2% - 1.0% of UK GDP for a 12-week closure Blendon et al (2008) found 86% of households with a child in school and one working adult said they could arrange childcare so one adult could continue working Johnson et al (2008) find modest work absenteeism from a 1-week closure in NC schools

9 Sander et al (2009) Stochastic, agent-based epi model Cost-effectiveness ($ per QALY gained) of prevaccination, targeted antiviral prophylaxis, school closure (and in combinations) Assume 2.5 works day lost for parents (if sick kid or school closure), 5 days for teachers and other professionals if school closure Value workdays lost at average compensation per day 26 week outbreak

10 Sander et al (2009) Direct and indirect medical costs of outbreak: $59 B (0.4% of ~$14T US GDP) Cost with school closure: $840 B (6%) Cost of stockpiling 1 course of antiviral for each American: $7 B They find school closure is most effective policy at preventing illness, but low-efficacy vaccination and prophylactic antivirals are more cost-effective.

11 Including macroeconomic effects Proportionate analysis Judgment: Adaptation more likely for slowergrowing pandemics, up to a point? Macro impacts still very uncertain, especially the extent demand is just displaced Need more current analysis on effects of school closures and other social distancing measures.

12 Other issues (I) Distributional: No evidence of disparate impacts of pandemic influenza by socioeconomic status within the U.S., but not implausible to think pandemic influenza could impact the poor the most. Shadow values for reducing mortality risk and morbidity. Discounting

13 Other issues (2): Externalities Indirect protection from vaccination, i.e. herd immunity Resistance to antimicrobials, including antivirals (302 resistant cases to oseltamivir in 2009, though all susceptible to another antiviral) Containment strategies + concerns about equity in poor countries

14 Questions & Discussion Joe Cook

Emergency Preparedness and Response: School Dismissals to Reduce Transmission of Pandemic Influenza

Emergency Preparedness and Response: School s to Reduce Transmission of Influenza Summary Evidence Tables Economic Review Actual Studies: School s to Reduce the Transmission of Influenza in Communities