NIHR Signal Dealing with a measles outbreak cost 20 times that of increasing vaccination cover

Published on 7 June 2016

New research show that the total cost of the 2012-13 measles outbreak in Merseyside (£4.4 million) was more than twenty times the cost of the vaccinations that could have prevented it (£182,909).

The cost incorporated for the first time estimates of lost employment from having measles or looking after someone with it, and accounted for 44% (£2 million) of the total.

Other costs included treatment of patients and public health costs, such as tracing and vaccinating people in contact with measles cases.

Measles vaccinations work, but need to reach 95% or more of a group to prevent measles outbreaks in the population. If the proportion of vaccinated people in an area falls below this level, immunity falls and an outbreak may occur.

This study supports investment in measles vaccination and targeting areas that are under vaccinated as a good use of resources.

Share your views on the research.

Why was this study needed?

Measles is a highly infectious viral disease that mainly affects children under five. Most people recover in around seven to 10 days, but rarely it can cause serious brain or lung infections, or death.

Liverpool has a population of about 78,000 aged less than 16 years and over 65% of the population live in socioeconomically deprived areas. Uptake of vaccination in the UK fell from 92% in 1996 to 80% in 2003. Outbreaks in recent years have mainly occurred in areas of the country or specific groups in which uptake of vaccine was low. Prior to the 2012 outbreak, uptake by the age of five years of the second dose of the vaccine (normally offered from the age of three years and four months to five years) had been around 85%.

Vaccines offered to all children in the UK prevent measles. Public health services aim to achieve 95% population immunity through vaccination, but some people refuse or otherwise do not access vaccination resulting in clusters of measles-susceptible individuals and outbreaks.

This study aimed to estimate the total societal cost of dealing with a measles outbreak in Merseyside (England) in 2012-13 relative to the cost of preventing it through achieving 95% vaccination coverage.  Economic analyses had been done before on vaccination but those taking into account indirect and wider costs or the costs of an actual as opposed to potential outbreak are unusual.

What did this study do?

This economic modelling study combined a literature review and workshop to build a consensus picture of the costs involved in managing the measles outbreak in Merseyside.

This informed an assessment of the treatment cost to NHS hospital and GP services, public health control and containment, and societal productivity losses (see Definitions).

Costs were estimated for the first four month period and extrapolated to cover the whole outbreak period of 18 months.

There were 2,458 reported cases of measles in the Merseyside outbreak, of which 652 cases were confirmed and 1,808 were probable or possible (see Definitions).

The cost of preventing the outbreak included an extra 11,793 vaccinations over five years, the number thought necessary to achieve the desired public immunity coverage of 95%.

Some assumptions of costs are up for debate, but even if they contain small error, the overall conclusions are unlikely to change.

What did it find?

  • Total cost of the outbreak was £4.4 million ranging from £3.9 to £5.2 million depending on the underlying assumptions used (sensitivity analysis).
  • The £4.4 million comprised 15% NHS treatments costs (£0.7 million, range £0.6 to £0.7), 40% public health costs (£1.8 million, range £1.8 to £1.9) and 44%, the largest proportion, on societal productivity losses (£2.0 million, range £1.4 to £2.6 million)
  • There were few cases affecting those with suppressed immunity, pregnant women or other vulnerable groups, and there were no serious complications or measles-related deaths. Had this not been the case, treatment costs would have been higher.
  • The extra 11,793 vaccinations needed to protect 95% of the population from measles was £182,909, 4% of the total cost of the measles outbreak.

What does current guidance say on this issue?

To help identify possible outbreaks, medical practitioners are duty bound to notify their local council or health protection team of suspected measles cases.

Vaccination, treatment and public health responses during the outbreak were carried out in line with detailed Health Protection Agency measles guidelines from 2010. The Health Protection Agency has been superseded by Public Health England, who has published fact sheet-based summaries of the guidance.

What are the implications?

Investing in measles vaccination to achieve immunity coverage of 95% or more appears a very sensible use of resources, based on the experience in Merseyside.

The study authors reinforced the need to commission well-resourced, co-ordinated and robust vaccination programmes that consistently reach at least 95% of people in all communities of the population.

Immunising those children in areas where uptake is poor and developing programmes to maintain coverage can lead to additional costs, but from the societal point of view would deliver a good return on any investment.

Well-co-ordinated health service and public health responses in the event of an outbreak are also important to minimise the spread and the likelihood of severe complications.

Citation and Funding

Ghebrehewet S, Thorrington D, Farmer S, et al. The economic cost of measles: Healthcare, public health and societal costs of the 2012-13 outbreak in Merseyside, UK. Vaccine. 2016;34(15):1823-31.

The study was commissioned by Health Protection Agency (Public Health England predecessor organisation).

Bibliography

HPA. HPA National measles guidelines. London: Health Protection Agency; 2010.

NHS Choices. Measles. London: Department of Health; last updated 2015.

NHS Choices. Measles outbreak: what to do. London: Department of Health; last updated 2015.

PHE. Measles: guidance, data and analysis. Health protection - collection.. London: Public Health England; 2014.

Vivancos R, Keenan A, Farmer S, et al. An ongoing large out-break of measles in Merseyside, England, January to June 2012. Euro Surveill. 2012;17(29). pii:20226.

Why was this study needed?

Measles is a highly infectious viral disease that mainly affects children under five. Most people recover in around seven to 10 days, but rarely it can cause serious brain or lung infections, or death.

Liverpool has a population of about 78,000 aged less than 16 years and over 65% of the population live in socioeconomically deprived areas. Uptake of vaccination in the UK fell from 92% in 1996 to 80% in 2003. Outbreaks in recent years have mainly occurred in areas of the country or specific groups in which uptake of vaccine was low. Prior to the 2012 outbreak, uptake by the age of five years of the second dose of the vaccine (normally offered from the age of three years and four months to five years) had been around 85%.

Vaccines offered to all children in the UK prevent measles. Public health services aim to achieve 95% population immunity through vaccination, but some people refuse or otherwise do not access vaccination resulting in clusters of measles-susceptible individuals and outbreaks.

This study aimed to estimate the total societal cost of dealing with a measles outbreak in Merseyside (England) in 2012-13 relative to the cost of preventing it through achieving 95% vaccination coverage.  Economic analyses had been done before on vaccination but those taking into account indirect and wider costs or the costs of an actual as opposed to potential outbreak are unusual.

What did this study do?

This economic modelling study combined a literature review and workshop to build a consensus picture of the costs involved in managing the measles outbreak in Merseyside.

This informed an assessment of the treatment cost to NHS hospital and GP services, public health control and containment, and societal productivity losses (see Definitions).

Costs were estimated for the first four month period and extrapolated to cover the whole outbreak period of 18 months.

There were 2,458 reported cases of measles in the Merseyside outbreak, of which 652 cases were confirmed and 1,808 were probable or possible (see Definitions).

The cost of preventing the outbreak included an extra 11,793 vaccinations over five years, the number thought necessary to achieve the desired public immunity coverage of 95%.

Some assumptions of costs are up for debate, but even if they contain small error, the overall conclusions are unlikely to change.

What did it find?

  • Total cost of the outbreak was £4.4 million ranging from £3.9 to £5.2 million depending on the underlying assumptions used (sensitivity analysis).
  • The £4.4 million comprised 15% NHS treatments costs (£0.7 million, range £0.6 to £0.7), 40% public health costs (£1.8 million, range £1.8 to £1.9) and 44%, the largest proportion, on societal productivity losses (£2.0 million, range £1.4 to £2.6 million)
  • There were few cases affecting those with suppressed immunity, pregnant women or other vulnerable groups, and there were no serious complications or measles-related deaths. Had this not been the case, treatment costs would have been higher.
  • The extra 11,793 vaccinations needed to protect 95% of the population from measles was £182,909, 4% of the total cost of the measles outbreak.

What does current guidance say on this issue?

To help identify possible outbreaks, medical practitioners are duty bound to notify their local council or health protection team of suspected measles cases.

Vaccination, treatment and public health responses during the outbreak were carried out in line with detailed Health Protection Agency measles guidelines from 2010. The Health Protection Agency has been superseded by Public Health England, who has published fact sheet-based summaries of the guidance.

What are the implications?

Investing in measles vaccination to achieve immunity coverage of 95% or more appears a very sensible use of resources, based on the experience in Merseyside.

The study authors reinforced the need to commission well-resourced, co-ordinated and robust vaccination programmes that consistently reach at least 95% of people in all communities of the population.

Immunising those children in areas where uptake is poor and developing programmes to maintain coverage can lead to additional costs, but from the societal point of view would deliver a good return on any investment.

Well-co-ordinated health service and public health responses in the event of an outbreak are also important to minimise the spread and the likelihood of severe complications.

Citation and Funding

Ghebrehewet S, Thorrington D, Farmer S, et al. The economic cost of measles: Healthcare, public health and societal costs of the 2012-13 outbreak in Merseyside, UK. Vaccine. 2016;34(15):1823-31.

The study was commissioned by Health Protection Agency (Public Health England predecessor organisation).

Bibliography

HPA. HPA National measles guidelines. London: Health Protection Agency; 2010.

NHS Choices. Measles. London: Department of Health; last updated 2015.

NHS Choices. Measles outbreak: what to do. London: Department of Health; last updated 2015.

PHE. Measles: guidance, data and analysis. Health protection - collection.. London: Public Health England; 2014.

Vivancos R, Keenan A, Farmer S, et al. An ongoing large out-break of measles in Merseyside, England, January to June 2012. Euro Surveill. 2012;17(29). pii:20226.

The economic cost of measles: Healthcare, public health and societal costs of the 2012-13 outbreak in Merseyside, UK

Published on 6 March 2016

Ghebrehewet, S.,Thorrington, D.,Farmer, S.,Kearney, J.,Blissett, D.,McLeod, H.,Keenan, A.

Vaccine , 2016

BACKGROUND: Measles is a highly contagious vaccine-preventable infection that caused large outbreaks in England in 2012 and 2013 in areas which failed to achieve herd protection levels (95%) consistently. We sought to quantify the economic costs associated with the 2012-13 Merseyside measles outbreak, relative to the cost of extending preventative vaccination to secure herd protection. METHODS: A costing model based on a critical literature review was developed. A workshop and interviews were held with key stakeholders in the Merseyside outbreak to understand the pathway of a measles case and then quantify healthcare activity and costs for the main NHS providers and public health team incurred during the initial four month period to May 2012. These data were used to model the total costs of the full outbreak to August 2013, comprising those to healthcare providers for patient treatment, public health and societal productivity losses. The modelled total cost of the full outbreak was compared to the cost of extending the preventative vaccination programme to achieve herd protection. FINDINGS: The Merseyside outbreak included 2458 reported cases. The estimated cost of the outbreak was pound4.4m (sensitivity analysis pound3.9m to pound5.2m) comprising 15% ( pound0.7m) NHS patient treatment costs, 40% ( pound1.8m) public health costs and 44% ( pound2.0m) for societal productivity losses. In comparison, over the previous five years in Cheshire and Merseyside a further 11,793 MMR vaccinations would have been needed to achieve herd protection at an estimated cost of pound182,909 (4% of the total cost of the measles outbreak). INTERPRETATION: Failure to consistently reach MMR uptake levels of 95% across all localities and sectors (achieve herd protection) risks comparatively higher economic costs associated with the containment (including healthcare costs) and implementation of effective public health management of outbreaks. FUNDING: Commissioned by the Cheshire and Merseyside Public Health England Centre.

In the study, treatment cost to NHS hospital and GP services, public health control and containment, and societal productivity losses were defined as follows.

Treatment costs included GP consultation, Accident and Emergency time, and treatment in hospital.

Public health control and containment included tracing contacts of people suspected of having measles, screening people to see if they had immunity to measles, vaccinating people who did not already have immunity, and excluding health staff from work if they did not have immunity to measles.

Societal productivity losses were costs to employers for sickness absence related to measles treatment or care, and costs of health workers’ extra time spent dealing with measles rather than usual work.

The authors adapted definitions for cases of measles from the Health Protection Agency’s National Measles Guidelines (2010).

  • Confirmed case: an individual testing positive for measles antibodies in blood or saliva, who had not been recently vaccinated, or who carried wild measles genetic material in any sample.
  • Probable case: an individual with signs and symptoms of measles who was in contact with a confirmed case 7-18 days before onset of symptoms, or assessed as likely to have measles by Health Protection Team staff.
  • Possible case: an individual with some symptoms not specific to measles, where another diagnosis could be possible.

Expert commentary

The introduction of MMR in the UK was dogged by controversy leading to difficulties reaching the 95% levels of vaccination in the population required to prevent outbreaks.

This study demonstrates the value of MMR vaccination using the modelled total costs of a large outbreak of measles in Merseyside, England in 2012-13. The model uses a total cost model that includes societal costs due to productivity losses and compares this to the costs of achieving herd immunity. Importantly, the study uses a methodology that could be applied to other vaccination programmes to quantify total societal costs of outbreaks of vaccine preventable infections.

Dr Allison Duggal, Consultant in Public Health at Enfield Council