Trends in governmental expenditure on vaccination programmes in the Netherlands, a historical analysis

BACKGROUND: Health economic evaluations are often required before implementing a vaccination programme. Such evaluations rarely consider the historical context of a vaccination programme. We review the financial history of vaccination programmes in the Netherlands, and compare these to demographic and macroeconomic developments as well as avoided mortality burden. METHODS: Previously uncatalogued historical expenditures on the Dutch National Immunisation Programme (NIP) and influenza vaccination were obtained from official reports. Costs were adjusted for inflation using Consumer Price Indices and expressed in Euro of 2016. Estimates on mortality burden averted were obtained from previous research and used to calculate the ratio of expenses to averted mortality burden for vaccinations against diphtheria, tetanus, pertussis, polio, measles, mumps and rubella for birth cohorts 1953-1992. RESULTS: Developments towards a uniform government funded NIP started early 1950s with vaccinations against diphtheria, pertussis and tetanus, culminating in its official launch in 1957 together with polio vaccinations. Since the 1980s, expenditure increased nearly five-fold mostly due to the addition of new vaccines, while spending on already implemented vaccinations tended to decline. Overall, expenditure increased from € 5 million in 1957 to € 93 million in 2014. Relative to total healthcare expenditure, the NIP contributed little, ranging between 0.05% and 0.14%. Spending on influenza vaccination increased from € 37 million in 1996 to € 52 million in 2014, while relative to total healthcare expenditure it decreased from 0.069% to 0.055%. In 2014, 0.15% of healthcare expenditure and € 533 per birth was spent on vaccination programmes. Overall, for birth cohorts 1953-1992, € 5.4 thousand (95% confidence interval: 4.0-7.3) was expended per year-of-life-lost averted. CONCLUSION: The actual costs per year-of-life gained are more favorable than estimated here since averted medical costs were not included. Although expenditure on vaccination programmes increased substantially, the contribution to overall healthcare expenditure remained small

Estimating the population-level effectiveness of vaccination program in the Netherlands

BACKGROUND: There are few estimates of the effectiveness of long-standing vaccination programs in developed countries. To fill this gap, we investigate the direct and indirect effectiveness of childhood vaccination programs on mortality at the population level in the Netherlands. METHODS: We focused on three communicable infectious diseases, diphtheria, pertussis, and poliomyelitis, for which we expect both direct and indirect effects. As a negative control, we used tetanus, a non-communicable infectious disease for which only direct effects are anticipated. Mortality data from 1903-2012 were obtained from Statistics Netherlands. Vaccination coverage data were obtained from various official reports. For the birth cohorts 1903 through 1975, all-cause and cause-specific childhood mortality burden was estimated using restricted mean lifetime survival methods, and a model was used to describe the pre-vaccination decline in burden. By projecting model results into the vaccination era, we obtained the expected burden without vaccination. Program effectiveness was estimated as the difference between observed and expected mortality burden. RESULTS: Each vaccination program showed a high overall effectiveness, increasing to nearly 100% within ten birth cohorts. For diphtheria, 14.9% (95% uncertainty interval [UI]: 12.3%, 17.6%) of mortality burden averted by vaccination was due to indirect protection. For pertussis, this was 32.1% (95% UI: 31.3%, 32.8%). No indirect effects were observed for poliomyelitis or tetanus with -2.4% (UI: -16.7%, 7.1%) and 0.6% (UI: -17.9%, 10.7%) respectively. CONCLUSION: Vaccination programs for diphtheria and pertussis showed substantial indirect effects, providing evidence for herd protection