In 2018 and 2019, the United States weathered a resurgence of measles, with >1600 cases reported to the Centers for Disease Control and Prevention. Most of these cases were associated with large outbreaks in New York and a smaller outbreak in Washington.1 For the 2018–2019 school year, kindergarten coverage with two doses of the measles, mumps, and rubella vaccine was 94.7% nationwide, 97.2% in New York, and 90.8% in Washington.2 These recent outbreaks confirmed modeling studies revealing that localized pockets of undervaccination and higher vaccine exemption rates plus exposure to travel create fertile conditions for measles spread.3,4 In previous measles studies, the significant cost of public health response activities needed to control these preventable outbreaks have been quantified.5,6
In this issue of Pediatrics, Pike et al7 expand on previous outbreak assessments to present a comprehensive cost evaluation of the 2019 measles outbreak in Clark County, Washington. These authors include direct medical costs; economic consequences of lost productivity due to illness, quarantine, and caregiving; and public health response costs. The 2019 outbreak comprised 72 confirmed measles cases in Clark County, and the outbreak investigation included >4000 contacts, ∼20% of whom were potentially susceptible to measles. Two patients with confirmed measles were hospitalized, and the remaining cases were managed in the outpatient setting. This cost assessment included Centers for Disease Control and Prevention and state and local health department expenditures in public health costs, estimated direct medical costs for inpatient and outpatient measles cases based on previously published studies, and estimated productivity lost on the basis of ages of cases and contacts, average wages, and average measles illness and quarantine durations.
The authors estimated the overall cost of the 2019 Clark County measles outbreak to be $3.4 million with a large majority of costs related to the public health response, followed by productivity losses and then direct medical costs. The significant economic burden of one measles outbreak and a contemporary cost assessment at a time when the risk of additional US measles outbreaks remains high are highlighted in the study. The authors also present a framework for a robust, although admittedly not exhaustive, assessment of costs associated with outbreaks of communicable diseases.
Because of a few limitations, Pike et al7 may have been biased toward underestimating the cost of the outbreak. This cost assessment was limited to cases in Washington and did not include linked cases that occurred elsewhere. Public health response included volunteer time that may not have been accurately reported or accurately translated to representative wages for paid work. In addition to presenting an accounting challenge for this study, reliance on volunteer time for critical public health work illustrates a shortcoming of public health funding. The authors also note medical cost estimates did not include some direct patient costs, such as over-the-counter medications and travel to seek care.
This study illustrates the substantial cost of one measles outbreak and the range of people who bear that cost. Productivity losses by those who cannot work because of illness, quarantine, or caregiving responsibilities impact employers and the economy more broadly. Individuals who do not have paid sick leave may suffer personal financial losses. Direct medical costs differ in magnitude and distribution depending on a patient’s insurance and may be borne by private or public insurance programs, the patient, or the health care facility. Public health costs mostly come from state and local government budgets funded by tax dollars. In addition, outbreak response activities may disrupt or divert resources from the provision of routine public health services, such as disease surveillance, nutrition programs, and vaccination promotion. The broad distribution of the economic burden of an outbreak is a reminder that health is a community resource and liability. Pike et al.7 remind us that, just as health risks of vaccine-preventable diseases are shared, so too are the economic risks associated with disease spread. We often discuss the shared benefits of herd immunity as a way to protect the health of others, and perhaps we do not emphasize enough the associated shared economic benefits of disease prevention.
These authors assert the need to invest in public health departments to ensure they have the capacity to respond to outbreaks and also point out that measles outbreaks are readily preventable. A resurgence of measles in the United States calls for continued investigation of the economic costs of undervaccination. Burden of disease estimates and economic projections are used to justify the development of new vaccines or the addition of existing vaccinations to national immunization programs. Similar cost assessment studies are now needed to make the case for investment to bolster vaccine confidence and uptake through research, educational and communication campaigns, and policy efforts.
The United States narrowly maintained measles elimination status in 2019, but the risk of measles importation from international travel leading to outbreaks in underimmunized communities persists. In their study, Pike et al7 reinforce the ongoing need to invest in public health and the costs of undervaccination.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-027037.
POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.