Economic evaluation of vaccination: capturing the full benefits, with an
application to human papillomavirus
T. Ba ¨rnighausen1,2, D. E. Bloom1, E. T. Cafiero1and J. C. O’Brien1
1) Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA and 2) Africa Centre for Health and Population Studies,
University of KwaZulu-Natal, Mtubatuba, South Africa
Vaccination has been among the greatest contributors to the past century’s dramatic improvements in health and life expectancy.
Recent advances in vaccinology have resulted in new vaccines that will likely lead to substantial future health gains. However, the high
cost of these new vaccines, such as the human papillomavirus (HPV) vaccine, poses an obstacle to their widespread adoption in many
countries. Economic evaluation can help to determine if investment in vaccine introduction is worthwhile. However, existing economic
evaluations usually focus on a narrow set of vaccination-mediated benefits—most notably avoided medical-care costs—and fail to
account for several categories of potentially important gains. We consider three sources of such benefit and discuss them with respect
to HPV vaccination: (i) outcome-related productivity gains, (ii) behaviour-related productivity gains, and (iii) externalities. We also high-
light that HPV vaccination protects against more than just cervical cancer and that these other health gains should be taken into
account. Failing to account for these broader benefits of HPV vaccination could result in substantial underestimation of the value of
HPV vaccination, thereby leading to ill-founded decisions regarding its introduction into national immunization programmes.
Keywords: Benefit–cost analysis, economic evaluation, economics, externalities, human papillomavirus vaccine, vaccination
Original Submission: 5 May 2012; Revised Submission: 18 June 2012; Accepted: 23 June 2012
Editor: M. Paul
Clin Microbiol Infect 2012; 18 (Suppl. 5): 70–76
Corresponding author: D. E. Bloom, 665 Huntington Avenue,
Building 1, Boston, MA 02115, USA
Vaccination has been among the greatest contributors to the
past century’s dramatic improvements in health and life
expectancy. The start of the World Health Organization’s
(WHO) Expanded Programme on Immunization (EPI) in
1974 played a key role in this success. The EPI aimed to
improve worldwide vaccination coverage [1,2] and estab-
lished standard immunization policies and schedules that
helped to guide national immunization programmes world-
wide . The original EPI schedule contained six vaccines,
including diphtheria–tetanus–pertussis vaccine, measles-con-
taining vaccine, polio vaccine and bacillus Calmette–Gue ´rin
vaccine. Some countries have since updated their EPI sched-
ules to include vaccines that protect against Haemophilus in-
fluenzae type b, yellow fever, hepatitis B and other infectious
In recent years, a number of new vaccines such as the
pneumococcal conjugate vaccine and the human papillomavi-
rus (HPV) vaccine have come onto the market. Compared
with the original EPI vaccines, these new vaccines are more
costly, partly as the result of their complex, patent-protected
technologies, such as recombination techniques, carrier pro-
teins and adjuvants [4,5]. In addition, recent analyses suggest
that increased regulatory oversight is another factor driving
up the price of new vaccines [6,7]. As Table 1[8,9] shows,
the per-dose prices of pneumococcal conjugate and HPV
vaccines are each more than five times that of diphtheria–
For today’s policymakers facing tight healthcare budget
constraints, economic evaluation could help to determine
whether new vaccines should be added to national immuni-
zation programmes . Indeed, national policymakers and
international organizations commonly use the results of eco-
nomic evaluation to inform spending decisions on vaccination
ª2012 The Authors
Clinical Microbiology and Infection ª2012 European Society of Clinical Microbiology and Infectious Diseases
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76Clinical Microbiology and Infection, Volume 18 Supplement 5, October 2012
ª2012 The Authors
Clinical Microbiology and Infection ª2012 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18 (Suppl. 5), 70–76