The Volokh Conspiracy - Cost-Effectiveness of HPV Immunizations:

Not everything that improves health, or even saves lives, is worth mandating or even strongly pressuring (even if your philosophy is social welfare maximization; I'll speak later about how those with a more libertarian bent might view this). Saving a few lives at the costs of billions of dollars may end up not being cost-effective, especially given that the expense could reduce people's ability to spend on much more cost-effective health improvements.

But my very rough back-of-the-envelope calculation suggests that the HPV vaccination is pretty cost-effective. The CDC reports that the retail price of the HPV vaccine is about $360; let's assume this ends up being roughly the cost, setting aside bulk discounts, extra labor costs for administering the vaccine and the like. About 2500 American women die of HPV each year, which means that the lifetime risk for a typical American woman is roughly 2500 x 75 / 150,000,000 = one in a thousand.

Given that most estimates of value of life saved I've seen run in the $5 million to $10 million range, avoiding a 1/1000 risk of premature death for $360 sounds pretty cost-effective. Of course a more full analysis would have to include many other factors: It should consider years of life lost rather than just deaths. It should consider the possibility that the people who die of cervical cancer are also the ones least likely to get the immunizations; cervical cancer can largely be avoided through regular pap smears, so it stands to reason that women who get it tend to be ones who are least likely to have good health insurance coverage, and they may be the ones who are most likely not to get immunized when they are girls. It should also consider, as a factor countervailing to this one, the possibility that herd immunity provided by very broad immunization will benefit even those who aren't immunized. And it should doubtless consider a bunch of other things, too.

Still, given that $360,000 is way under $5 to $10 million, it seems safe to say that include all the other factors will still yield a judgment that the HPV immunization is likely cost-effective.

Related Posts (on one page):

Transmission of Genital HPV Through the Hands:
"100% Preventable by Behavioral Change":
Libertarianism and Communicable Disease:
HPV Immunization and Risky Personal Choices:
Perverse Effects of HPV Immunizations?
Cost-Effectiveness of HPV Immunizations:
HPV Immunization in Texas:

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Tillman Fan (mail):

This post raises an issue that has bothered me for a while. When a tortfeasor's actions result in someone's death, the legal system often assesses a value of that lost life in the millions of dollars. But at the same time I've seen a lot of bad press in the past 15 years for drug manufacturers who sell their life-saving medications at a (relatively) great expense -- for example, $20,000 a year, or similar figures. My wife attended a medical conference on AIDS some years back and returned with a t-shirt for me that was put out by AIDS activists, depicting a number of AIDS drugs with the slogan "your money or your life!"

My question is why does society place a greater value on a life lost due to negligence than it is willing to pay to save a life?

2.5.2007 6:48pm

Francis (mail):

I think you're missing a big chunk of money saved. You've covered the cost of life saved. But you haven't covered the cost of treatment or pain and suffering for those who would have survived the cancer but now will not even get it.

2.5.2007 7:54pm

Hattio (mail):

Shouldn't the lifetime risk be more like 2,500 X 60/150 Million. I'm assuming here that there is no risk of cervical cancer w/out HPV, no risk of HPV w/out sex, and an average loss of virginity age of 15. Actually, 15 seems low to me, but it made the math easy. Also, if there is an "incubation" time for the disease, wouldn't that have to be added to average loss of virginity age before it is subtracted from average age of 75?

2.5.2007 8:44pm

Eugene Volokh (www):

I don't think so, because if you multiply by 60, you'll have to set the denominator at the number of women age 15-to-75. But even if I'm wrong, the difference is too slight to change the result.

2.5.2007 9:25pm

Lev:

Do your calculations take into account the news reports that the vaccination is only effective for 3-5 years, which would mean at least one mandatory revaccination for the sub 18 receiving the initial vaccination at 10-12.

2.6.2007 12:52am

TJIT (mail):

Link to article on HPV vaccine economics from a physicians website

A couple of interesting quotes from the comments on that post

But folks should also pay attention to the fact that Merck is openly funding a lot of drives in state legislatures to make the vaccine mandatory for schoolgirls. Talk about the abuses of direct-to-consumer advertising; this is direct-to-consumer legislating. Paternalism, anyone?

The comments from a family practioner provided additional information I had not heard elsewhere

If I remember correctly, the estimate of the cost/benefit break even for Gardisil panned out at about $450-$500. Meaning the cost of the shot vs. the extra cost of colposcopies, Paps, cryotherapy, etc. that would be prevented by the shot. The manufacturer priced it about $360 trying to make as much money as possible, but unfortunately too closely to make it financially viable in an office.

2.6.2007 10:38am

Everyone seems to be missing what is to me the absolutely crucial issue in this case.

Merck decided not to wait for clinical results and a science based cost benefit analysis and recommendation from groups like the CDC, gynecologists, and pediatricians.

Merck short circuited that process by immediately pushing for legislative mandates. This is an extreme example of rent seeking and is a very bad precedent. I would prefer to have more science and less application of brute political power when it comes to health care decisions.

2.6.2007 10:46am

Money is fungible so an honest assessment of the cost benefit ratio of the mandate would have to evaluate the possibility that other interventions might provide a better return on investment.

For example what returns would spending an equivalent amount of money on something like free bike helmets, or free car seats, or more automatic external defibrillators in public areas, etc.

2.6.2007 12:54pm

markm (mail):

You also have to factor in whatever the risks are of bad reactions to the vaccine. If Merck hasn't identified such problems, they just haven't done a big enough test yet over enough years. There are always side effects. Of course, these need to be balanced against the risks of being unvaccinated. Smallpox vaccine has always been riskier than most vaccines, but it's such a deadly and virulent disease that as long as there was an appreciable chance of contracting smallpox the benefit far outweighed the risk. (Smallpox once killed 10% of each new generation and left another 20% with scarred faces - among people of European descent that had evolved a fair degree of natural resistance after centuries of exposure. It sometimes killed 100% of native american villages.) With an approximately 0.1% lifetime risk of cervical cancer from HPV, the vaccine had better be much, much safer.

2.6.2007 1:56pm

arbitraryaardvark (mail) (www):

For a different, and possibly useful, set of numbers, don't look at the choices as "mandated vaccination at age 12 versus none", but, mandated vaccination at age 12 versus waiting until planned onset of sexual activity, by which point the vaccine may be cheaper and safer, plus the time value of money factor. There is a non-trivial risk of rape by an HPV carier in the 12-to-whatever years. I've also heard that the cost might not be $360 per person, but $360 per shot.

On another matter, I've been tested for hiv and hepatisis and syphillus, but not HPV, herpes, or some of the others.
What would it cost me to get tested for HPV?
Should, as a public health matter, males be required to test for the their HPV status and disclose the results to prospective sex partners?

Can one conscienciously object to paying the fee for the vaccine? Is the fee a taking under the texas constitution?

2.6.2007 7:20pm

lindaseebach (mail):

If you could just vaccinate the subset of women who later in life would otherwise pick up one of the strains of HPV that are associated with cervical cancer, it would possibly be cost effective but you don't know now who they are. And since cervical cancer is very rare (and 30 percent of the cases are not associated with the virus anyway) you have to do hundreds of vaccinations for each diagnosis/death prevented.

Even mammography, whose cost-benefit analysis is very robust, costs about $14,000 for each breast cancer discovered. This vaccine, given present costs, is more like $300,000 per case.

Furthermore, the costs have to be paid upfront now, in today's dollars, while the benefits accrue 25-45 years down the road, and have a very small net present value, depending on how you choose the discount rate.

And worse, or really it is better, if the number of cases continues its long decline, the cost per prevented case will soar. And if sometime in the next 25 years, diagnosis and treatment improve so nobody ever gets cervical cancer or dies of it, whatever billions we've decided to spend on this vaccine will have been utterly wasted.

2.6.2007 9:04pm

Rich Rostrom (mail):

"cervical cancer can largely be avoided through regular pap smears..." Wrong!! Cervical cancer can be detected in time for treatment through regular pap smears; thus death can be avoided. (Though pap smears are not 100% accurate.) But the cancer still occurs and must be treated at a cost of $20-50,000, plus serious pain and suffering, plus in many cases loss of fertility by hysterectomy.

2.8.2007 3:32am