Preparing for pandemics using cost-effective public health measures

Key results from a €1million European Commission project have been presented at the Fifth ESWI Influenza Conference in Riga (Latvia), attended by around 700 scientific experts and decision makers. These results will help policymakers develop more reliable plans for responding to flu epidemics, including pandemics. The world's first extensive cost-effectiveness analysis of epidemic responses has created a new approach, which will help governments avoid costly and ineffectual policies.

Helping epidemic planners make informed decisions

The objective of this project was to provide a new decision making tool to encourage and assist governments to better manage seasonal flu but also to prepare for pandemics. This will help them to deal with outbreaks effectively without unnecessary expense to the taxpayer.

The key to the project was assessing all potential responses using the same measure: 'Cost per Public Health Success'. This defines all responses in terms of the financial cost to achieve a defined reduction in mortality (death) or morbidity (illness). Healthcare planners must use a meaningful measure to assess responses to allow comparison across situations and countries. Cost per Success ratios are recommended, rather than complex metrics such as costs per Quality Adjusted Life Years (QALY), which are the subject of an international methodological controversy and based on a number of poorly validated theoretical assumptions leading to dramatically divergent results using the same dataset, as demonstrated by another EU project (ECHOUTCOME).

For the very first time, economical evidence has been established that vaccination programmes targeting the general population ("universal vaccination") appear more cost-effective than targeting only at-risk people or health professionals. This finding challenges existing international or national recommendations to vaccinate only "priority" groups. If resistances against a universal vaccination include difficulties of vaccine supply, implementation of effective strategies for vaccine delivery or public acceptability, the economical factor should no longer be a barrier as this universal approach appears to be more cost-effective than targeting only at-risk groups.

Project Lead, Dr Ariel Beresniak, Paris-Descartes University, says: "Costs and ethics are the principle considerations in public health. Without robust information and a systematic approach to compare costs and effectiveness of different measures or combination of measures, governments cannot make the right choices. The Fluresp project provides models based on rigorous data analysis for governments to develop a tailored response plan, so when an outbreak or pandemic hits, they are ready to make an informed response." Beresniak concludes: "We aim to work with health policy makers to promote robust cost-effectiveness studies to support their decisions. Our findings will help them develop an appropriate approach for assessing the most efficient strategies for different epidemic scenarios".

Background to influenza epidemics

Annual epidemics are estimated to cause 3-5 million cases of severe illness and 250-500,000 deaths worldwide (WHO, fact sheet 211; March 2014). When an epidemic hits, the main factor limiting our response is cost. Governments must take tough decisions on how to allocate limited resources.

Data on epidemic responses across Europe have been collected using different approaches and success measures, making past responses very difficult to compare. This makes developing efficient preparedness plans extremely difficult and has resulted in a history of poor decisions, such as rolling out vaccination programmes through ad hoc vaccination centres without communicating them properly, or stockpiling antivirals for mild outbreaks at great cost.

Background to the research

The project brought together experts in public health, influenza, health economics and computer sciences from ten European countries, who analysed large datasets on past responses. The project looked at six levels of outbreak severity - from seasonal flu to a severe pandemic. It examined 18 common public health responses including: sanitation (eg hand washing campaigns), controlling infection spread (eg closing schools), immunisation of different groups, antiviral distribution, and care for the sick. And finally it looked at how effectively each response type reduced mortality and morbidity. Each scenario was then given a 'Cost per Success' ratio. This provides a robust way to compare different scenarios in different situations and allows the development of reliable models. The project was tested in four pilot European target countries (France, Italy, Poland and Romania).

Supporting quotes

Dr Sylvie Briand, Pandemic and Epidemic Disease department (PED) Director at the World Health Organisation, and collaborating partner on the project: "Governments must have a regularly updated plan for different scenarios that they can implement when a pandemic looms. Whilst they can't plan for everything, it is very important to define response scenarios in advance so they have a framework to work from."

Dr Pasi Penttinen, Head of disease programme, Influenza and other respiratory viruses, European Centre for Disease Prevention and Control: "We live under the constant threat of a pandemic and we need robust tools in place for proper preparedness. We have not yet appreciated the possibilities which large datasets can offer in healthcare planning, and the Fluresp project is the first step towards effectively harnessing them. Furthermore, its success may provide a systematic approach for developing new evidences in public health decision making."

Dr Jean-Paul Kress, CEO, Sanofi Pasteur MSD: "The Fluresp approach confirms that vaccination programmes against human influenza are effective not only in reducing flu mortality and morbidity, but are also cost effective when targeting the general population".

About the project and consortium

The FLURESP European project "Cost-Effectiveness Assessment of European Influenza Human Pandemic Alert and Response Strategies" (1,185,628 Euro budget) has developed and tested original methods in Public Health for prioritisation of interventions against human influenza.

The project partners are:

Associated partners:

• Paris Descartes University, France
• Instituto Vasco de Investigacion y Desarrollo Agrario (NEIKER), Spain
• Retroscreen Virology Ltd, UK
• Istituto Superiore di Sanita, Italy
• Open Rome, France
• Laurent Niddam Europai Közössegi Jogasz Iroda, Hungary
• National Institute of Public Health, Poland
• Institutul National de Sanatate Publica, Romania
• Claude Bernard University Lyon 1, France

Collaborating partners:

• World Health Organisation (WHO)
• European Centre for Disease Prevention and Control (ECDC)
• University of Crete, Greece
• Ministry for Health, Elderly and Community Care, Malta

Disclaimer

This project has received funding from the European Union in the framework of the Health Program 2008-2013 through the Directorate General for Health and Consumers of the European Commission under grant agreement 2010 11 01.

The sole responsibility for the content of these recommendations lies with the authors and does not necessarily reflect the opinion of the European Union (EC), the World Health Organization (WHO), and the European Centre for Disease Prevention and Control (ECDC).