The cost of sav­ing lives

There’s a dengue vac­cine avail­able now – but should we vac­ci­nate? It’s all a mat­ter of dol­lars and sense.

The Star Malaysia - Star2 - - HEART & SOUL -

SO, dengue is a prob­lem. And it’s grow­ing.

In 2011, there were 19,884 dengue cases with 36 deaths. In 2015 the num­ber rose to over 120,000 cases with 322 fa­tal­i­ties. This rise is part of a world­wide phe­nom­e­non, with cases in­creas­ing 30- fold in the past half cen­tury. Many fac­tors have been blamed, in­clud­ing in­creased ur­ban­i­sa­tion, per­va­sive air travel net­works and the chang­ing weather ef­fects of El Nino.

Thank­fully, there has been hope re­cently in the form of Deng­vaxia, the world’s first vac­cine against dengue. Coun­tries like Brazil, El Salvador, Mex­ico, and the Philip­pines have been ap­prov­ing its use since De­cem­ber 2015. Dr Ce­cilia Mon­tal­ban, pres­i­dent of the Philip­pine Foun­da­tion for Vac­ci­na­tion, praised the de­ci­sion, say­ing in the Philip­pine In­quirer that it could “guar­an­tee that eight out of 10 cases will be pre­vented ( from be­ing hos­pi­talised). And nine out of 10 will be pre­vented from hav­ing se­vere haem­or­rhagic fever with the vac­cine”.

De­spite this, the Malaysian Govern­ment has not yet ap­proved the use of Deng­vaxia in this coun­try. Health Min­istry di­rec­tor- gen­eral Datuk Dr Noor Hisham Ab­dul­lah said in a Dec 11 ar­ti­cle in The Star: “I un­der­stand that the vac­cine is least ef­fec­tive against serotype 2, there­fore the min­istry is hes­i­tant about its ef­fi­cacy.” ( Dengue comes in four serotypes, or virus strains; all four serotypes ex­ist in Malaysia and the Philip­pines.)

This im­plies that, while there isn’t an is­sue with the vac­cine’s safety, there are some con­cerns about its ef­fi­cacy here. But there has been lit­tle dis­cus­sion about the eco­nom­ics of us­ing the vac­cine. In other words, is it worth it?

Be­fore we delve fur­ther into dengue, let’s take a look at a dif­fer­ent virus. The pneu­mo­coc­cal virus causes pneu­mo­nia and menin­gi­tis, and avail­able data sug­gests nearly 2,000 chil­dren un­der five die each year from the dis­eases it causes. For­tu­nately, vac­cines like the pneu­mo­coc­cal con­ju­gate vac­cine ( PCV10 or PCV13) are ef­fec­tive against the virus. The Health Min­istry even con­cluded in a re­port that “A na­tional im­mu­ni­sa­tion pro­gramme with PCV10 or PCV13 was found to be good value for money and es­ti­mated to pre­vent ad­di­tional cases of dis­ease among chil­dren and save ad­di­tional costs.” ( tinyurl. com/ zzh3g6v) How­ever, the vac­cines are not manda­tory in Malaysia, al­though their use is per­mit­ted.

Vac­cines are ex­pen­sive. In Sin­ga­pore, the Straits Times re­ported last year that nearly four in 10 chil­dren had not re­ceived the full course of the pneu­mo­coc­cal vac­cine be­cause the S$ 500 ( RM1,400) to­tal price tag was deemed too high.

Why is the price so high? Rea­sons given are var­ied, but it boils down to this: Vac­cines cost a lot be­cause com­pa­nies can charge a lot.

Ad­mit­tedly, vac­cine tri­als are ex­pen­sive. Ac­cord­ing to BloombergBusi­ness, Deng­vaxia is es­ti­mated to have cost US$ 1.65bil ( RM6.8bil) in re­search, for ex­am­ple.

But pa­tents also are a fac­tor. Orig­i­nally, vac­cines could not be patented in the US be­cause they were deemed to be “nat­u­ral prod­ucts”. How­ever, times have changed, and it’s pos­si­ble for even old vac­cines to be patented with new for­mu­la­tions and new de­liv­ery mech­a­nisms. And once com­pa­nies have mo­nop­o­lies, it’s easy to raise prices.

So how much does the dengue vac­cine cost? The Philip­pine Govern­ment will spend about 3.5bil Philip­pine pe­sos ( RM308mil) a year to vac­ci­nate 1.07 mil­lion chil­dren at slightly over 3,250 Philip­pine pe­sos ( RM280) per child. A sim­i­lar pro­gramme in Malaysia to vac­ci­nate all nine- year- olds ( as­sum­ing about 500,000 chil­dren) would cost roughly RM150mil a year – that is, if we could ne­go­ti­ate the same price.

If the vac­cine com­pletely erad­i­cated deaths, we would be spend­ing just over RM400,000 per life saved.

But the ac­cepted method to cal­cu­late the cost ef­fi­ciency of vac­cines is not to cal­cu­late the cost per life saved, but to cal­cu­late whether the money you save out­weighs the cost of the vac­cine.

There are sav­ings be­cause you don’t need to hos­pi­talise peo­ple. A 2013 study done jointly by Bran­deis Univer­sity and Univer­siti Malaya ( tinyurl. com/ jk­m2w59) es­ti­mated that it costs an av­er­age of RM3,600 to treat one pa­tient with dengue in Malaysia ( at 2009 prices), al­though it may be as high as RM11,000. The same study as­sumed that 58% of re­ported cases are hos­pi­talised. As­sum­ing an 80% drop in hos­pi­tal­i­sa­tion rates, you are look­ing at sav­ings be­tween RM140mil and RM200mil.

How­ever, the 80% re­duc­tion in hos­pi­tal­i­sa­tion and 90% re­duc­tion in haem­or­rhagic fever is what the man­u­fac­tur­ers claim. An un­pub­lished study done by Univer­sity of the Philip­pines- Na­tional In­sti­tute of Health’s Prof Hil­ton Lam pre­dicts only an es­ti­mated 24.2% drop in dengue cases over five years as a re esult of a na­tion­wide an­nual vac­ci­na­tionn of nine- year- olds in the Philip­pinesP ( tinyurl. com/ h3yyvxo), sl lash­ing all the ben­e­fits above by morem than two- thirds.

Where a cost ar­gu­ment may be­gin to make sense is in pre­vent­ing lost pro­duc­tiv­ity. And when you fac­tor loss in pro­duc­tiv­ity to the na­tional econ­omy due to death, it’s even higher. I es­ti­mate around RM160mil saved per year for the for­mer, and RM260mil a year for the lat­ter. How­ever, th­ese cal­cu­la­tions are not easy to jus­tify and come with large caveats.

So, ba­si­cally, even if the dengue vac­cine works per­fectly, the cost of it needs to be taken into se­ri­ous con­sid­er­a­tion. ( Note that sales of Deng­vaxia are es­ti­mated to reach US$ 1.4bil by 2020.)

And mak­ing the vac­cine manda­tory in Malaysia may ac­tu­ally raise, not lower, the price of the vac­cine it­self. Part of the rea­son why the pneu­mo­coc­cal vac­cine costs so much is that when Sin­ga­pore’s na­tional vac­cine ad­vi­sory group in­cluded one brand of the vac­cine in the re­quired na­tional sched­ule, its price sud­denly jumped by about 50%. A re­searcher from Bran­deis Univer­sity who was ad­vis­ing the board said: “It didn’t make any sense.”

Un­less of course you are the phar­ma­ceu­ti­cal com­pany sell­ing the stuff.

Logic is the an­tithe­sis of emo­tion but math­e­ma­ti­cian- turned- scriptwriter Dzof Azmi’s the­ory is that peo­ple need both to make sense of life’s va­garies and con­tra­dic­tions.

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