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.

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.