I thank Fiona Nicholson, M.Perleth, Amit Ghosh, and Jon Wilcox for their
responses. The queries suggest that I need to draw a suitable analogy, to
describe the dilemma.
I have struggled a bit with this and seek your comments to sharpen the
analogy.
Once the analogy is refined we may be in a better position to discuss the
problem.
My own reasoning is also stated.
Analogy 1
If a new vaccine is available (made in the USA) which gives 80% protection
against HIV infection, and it costs Pounds 1280 per person , would the WHO
recommend it for universal immunization in the UK? Will the British
Pediatric Association recommend that it be part of the Government funded
immunization schedule?
Premises and Reasoning
1. I had written in the earlier posting that 3 doses of Hepatitis B
vaccine costs Rupees 750 (SmithKline Beecham).
A Cuban vaccine ("Panacea Biotec" -the real name of the company) is
available for Rupees 490. I have used the price of this cheaper vaccine for
my calculations.
2. A third of the Indian population earn less than Rupees 57 per capita
per month. Thus the vaccine costs 8 times their monthly income.
3. To arrive at the corresponding cost in the UK I have multiplied the
unemployment benefit of Pounds 160 by the same factor 8. (The figure Pounds
160 corresponds to the income of the lowest 10% of the population. The
average for the lower third of the population would be higher.) 160
multiplied by 8=1280.
4. The prevalence of HIV in the UK is much less than that of Hepatitis B
in India.
(Prevalence of Hepatitis B in India - 2.6% HBsAg positive in blood donors -
Irshad M. Nat. Med J. India 1994: 7: 210-12. 2.6% in pregnant mothers in
an urban center - Sehgal A Acta Virol 1992: 36: 359-66.)
However over 50% of those with HIV will develop disease which is fatal.
Only 1% of those with Hepatitis B develop chronic hepatitis and 0.25%
develop cirrhosis. If cirrhosis is considered fatal (with no facility for
liver transplants) we have one death per 400 infected. With a prevalence of
3% of Hepatitis B in India this would mean 1 death per 13000 population.
The same death rate would be achieved if the prevalence of HIV in the UK
is 1 per 6500 population.
Analogy 2.
There is also the problem of infrastructure development and the difference
in the levels of medical care available between India and UK
Polio vaccine costs Rupee one per dose. This is one by fifty of the per
capita income of the lower third of the population in India. Yet 10% of the
population is not covered by polio vaccine.( Kalpana Jain Times Of India
Delhi 8 Feb 1999)
By analogy if 10% of the UK population cannot be given polio drops that cost
Pounds 3 (160 divided by 50) would the country consider undertaking a
National Aids Immunization program costing Pounds 1280 per person.
In conclusion
If the prevalence of HIV in the UK is 1 per 6500 population.
And the vaccination program costs 1280 pounds per person. (That would mean
an expenditure of pounds 8320000 for each life saved.)
Would universal immunization against HIV be a cost effective program?
If the answer is no, then with a prevalence of 1 per 6500 how low must the
vaccine cost come to, to be considered cost effective.
Then again, if the cost of the vaccine is to remain fixed at Pounds 1280
per person how high must the prevalence rise for universal immunization to
be considered cost beneficial?
Is there any study of such models?
Economists may find this an easy question to answer
Does any one know the Email address of Dr Amryta Sen?
Jacob M. Puliyel
Head Department of Pediatrics
St Stephens Hospital
Tis Hazari Delhi 110054
India
Email [log in to unmask]
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