Featured Journal Content

JAMA Pediatrics
New Online – July 24, 2017
Original Investigation
Public Health and Economic Consequences of Vaccine Hesitancy for Measles in the United States
Nathan C. Lo, BS1; Peter J. Hotez, MD, PhD2,3,4,5
doi:10.1001/jamapediatrics.2017.1695
Key Points
Question
How does vaccine hesitancy affect annual measles cases and economic costs in the United States?
Findings
In this modeling study of children (age 2-11 years), a 5% reduction in measles, mumps, and rubella vaccination coverage resulted in a 3-fold increase in annual measles cases with an additional US$2.1 million in public sector costs.
Meaning
Even small declines in vaccination coverage in children owing to vaccine hesitancy may have substantial public health and economic consequences that will be larger when considering unvaccinated infants, adolescents, and adults.
Abstract
Importance
Routine childhood vaccination is declining in some regions of the United States due to vaccine hesitancy, which risks the resurgence of many infectious diseases with public health and economic consequences. There are ongoing policy debates on the state and national level, including legislation around nonmedical (personal-belief) exemptions for childhood vaccination and possibly a special government commission on vaccine safety, which may affect vaccine coverage.
Objective
To estimate the number of measles cases in US children and the associated economic costs under scenarios of different levels of vaccine hesitancy, using the case example of measles, mumps, and rubella (MMR) vaccination and measles.
Design, Setting, and Participants
Publicly available data from the US Centers for Disease Control and Prevention were used to simulate county-level MMR vaccination coverage in children (age 2-11 years) in the United States. A stochastic mathematical model was adapted for infectious disease transmission that estimated a distribution for outbreak size as it relates to vaccine coverage. Economic costs per measles case were obtained from the literature. The predicted effects of increasing the prevalence of vaccine hesitancy as well as the removal of nonmedical exemptions were estimated. The model was calibrated to annual measles cases in US children over recent years, and the model prediction was validated using an independent data set from England and Wales.
Main Outcomes and Measures
Annual measles cases in the United States and the associated public sector costs.
Results
A 5% decline in MMR vaccine coverage in the United States would result in an estimated 3-fold increase in measles cases for children aged 2 to 11 years nationally every year, with an additional $2.1 million in public sector costs. The numbers would be substantially higher if unvaccinated infants, adolescents, and adult populations were also considered. There was variation around these estimates due to the stochastic elements of measles importation and sensitivity of some model inputs, although the trend was robust.
Conclusions and Relevance
This analysis predicts that even minor reductions in childhood vaccination, driven by vaccine hesitancy (nonmedical and personal belief exemptions), will have substantial public health and economic consequences. The results support an urgent need to address vaccine hesitancy in policy dialogues at the state and national level, with consideration of removing personal belief exemptions of childhood vaccination.

BMC Medicine
http://www.biomedcentral.com/bmcmed/content
(Accessed 29 July 2017)
Opinion
The public health value of vaccines beyond efficacy: methods, measures and outcomes
Wilder-Smith, I. Longini, P. L. Zuber, T. Bärnighausen, W. J. Edmunds, N. Dean, V. Masserey Spicher, M. R. Benissa and B. D. Gessner

BMC Medicine 2017 15:138
Published on: 26 July 2017
Abstract
Background
Assessments of vaccine efficacy and safety capture only the minimum information needed for regulatory approval, rather than the full public health value of vaccines. Vaccine efficacy provides a measure of proportionate disease reduction, is usually limited to etiologically confirmed disease, and focuses on the direct protection of the vaccinated individual. Herein, we propose a broader scope of methods, measures and outcomes to evaluate the effectiveness and public health impact to be considered for evidence-informed policymaking in both pre- and post-licensure stages.
Discussion
Pre-licensure: Regulatory concerns dictate an individually randomised clinical trial. However, some circumstances (such as the West African Ebola epidemic) may require novel designs that could be considered valid for licensure by regulatory agencies. In addition, protocol-defined analytic plans for these studies should include clinical as well as etiologically confirmed endpoints (e.g. all cause hospitalisations, pneumonias, acute gastroenteritis and others as appropriate to the vaccine target), and should include vaccine-preventable disease incidence and ‘number needed to vaccinate’ as outcomes.
Post-licensure: There is a central role for phase IV cluster randomised clinical trials that allows for estimation of population-level vaccine impact, including indirect, total and overall effects. Dynamic models should be prioritised over static models as the constant force of infection assumed in static models will usually underestimate the effectiveness and cost-effectiveness of the immunisation programme by underestimating indirect effects. The economic impact of vaccinations should incorporate health and non-health benefits of vaccination in both the vaccinated and unvaccinated populations, thus allowing for estimation of the net social value of vaccination.
Conclusions
The full benefits of vaccination reach beyond direct prevention of etiologically confirmed disease and often extend across the life course of a vaccinated person, prevent outcomes in the wider community, stabilise health systems, promote health equity, and benefit local and national economies. The degree to which vaccinations provide broad public health benefits is stronger than for other preventive and curative interventions.