Person:

Garber, Alan

Pandemic (H1N1) 2009 has caused 182 166 confirmed infections and 1799 deaths in more than 150 countries to date (1). Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have declared public health emergencies in response to global circulation of this virus, and the WHO has raised the influenza pandemic alert level from 3 to 6 (2).

As a result of the strain's novelty, most people lack innate immunity to pandemic (H1N1) (3); currently available vaccines do not protect against the virus; and the time needed to manufacture, test, and distribute a matched vaccine is several months (4–5).

In the absence of a matched vaccine, infections and deaths from pandemic (H1N1) will continue globally until a sufficient proportion of the population has developed immunity through infection and recovery, inducing “herd immunity” (population immunity that decreases the effective reproductive rate of the virus below 1, ending the pandemic by epidemiologic definitions [6]). Public health officials were planning to begin vaccination campaigns in mid-October 2009 (7); however, the National Biodefense Science Board, a group of advisors to the U.S. Department of Health and Human Services, recommended moving large-scale vaccine administration to mid-September 2009 (8). Decisions on vaccination timing and distribution are complicated: It is unclear how many individuals would require vaccination to substantially reduce transmission once vaccine is available (some scientists note that the first epidemic wave may in fact already be complete by this time [9]), and it could be expensive to manufacture and administer the vaccine and to treat its side effects.

To help guide policymakers in advising vaccine manufacturers, we developed a model of progression of the 2009 (H1N1) pandemic to determine how vaccination in October or November 2009 would affect the course of the pandemic. We compared the effectiveness and cost-effectiveness of no vaccination, vaccination in mid-October, and vaccination in mid-November.

Background Teriparatide is a promising new agent for the treatment of osteoporosis.

Methods The objective of this study was to evaluate the cost-effectiveness of teriparatide-based strategies compared with alendronate sodium for the first-line treatment of high-risk osteoporotic women. We developed a microsimulation with a societal perspective. Key data sources include the Study of Osteoporotic Fractures, the Fracture Intervention Trial, and the Fracture Prevention Trial. We evaluated postmenopausal white women with low bone density and prevalent vertebral fracture. The interventions were usual care (UC) (calcium or vitamin D supplementation) compared with 3 strategies: 5 years of alendronate therapy, 2 years of teriparatide therapy, and 2 years of teriparatide therapy followed by 5 years of alendronate therapy (sequential teriparatide/alendronate). The main outcome measure was cost per quality-adjusted life-year (QALY).

Results For the base-case analysis, the cost of alendronate treatment was $11 600 per QALY compared with UC. The cost of sequential teriparatide/alendronate therapy was $156 500 per QALY compared with alendronate. Teriparatide treatment alone was more expensive and produced a smaller increase in QALYs than alendronate. For sensitivity analysis, teriparatide alone was less cost-effective than alendronate even if its efficacy lasted 15 years after treatment cessation. Sequential teriparatide/alendronate therapy was less cost-effective than alendronate even if fractures were eliminated during the alendronate phase, although its cost-effectiveness was less than $50 000 per QALY if the price of teriparatide decreased 60%, if used in elderly women with T scores of −4.0 or less, or if 6 months of teriparatide therapy had comparable efficacy to 2 years of treatment.

Conclusions Alendronate compares favorably to interventions accepted as cost-effective. Therapy with teriparatide alone is more expensive and produces a smaller increase in QALYs than therapy with alendronate. Sequential teriparatide/alendronate therapy appear expensive but could become more cost-effective with reductions in teriparatide price, with restriction to use in exceptionally high-risk women, or if short courses of treatment have comparable efficacy to that observed in clinical trials.