The current evolutionary path of our society, namely the increase in the proportion of the elderly, strengthens the value of indirect protection conferred by vaccines in reducing the transmission of diseases within the family environment and the society as a whole. Moreover, preventing disease in working adults reduces the burden of absenteeism – not showing up to work – and presenteeism – being sick at work- increasing productivity and contributing consecutively to economic growth. Furthermore, preventing common diseases in adults and the elderly also enhances their quality of life and helps to assure healthy aging for populations that, overall, are becoming older. These wider societal values, albeit not easily measurable, should be taken into consideration when assessing the social and economic value of vaccination programs.
The importance of indirect protection and its costs One of the unique benefits of vaccination is its ability to grant indirect protection through the phenomenon of ’herd effect’ to vaccinated or unvaccinated individuals and groups [18]. This effect is increasingly important given today’s globalization and large population movements around the globe. Socially, vaccination of children can reduce transmission to parents and, particularly and perhaps more importantly, older grandparents who can be more susceptible to infectious diseases (i.e., measles, pneumococcal disease, rubella) and have a higher risk of serious complications. Indirect protection is also very significant for wider protection across society, extending protection from infectious diseases to population groups that cannot be vaccinated (i.e., immunocompromised individuals, newborn children and pregnant women). This kind of protection may be especially important in public places, such as health care centers, public transports, schools, and workplaces. On a larger scale, the dynamic nature of population mixing is a solid argument in favour of vaccination to provide both direct, and subsequent indirect protection to avoid disease transmission across the entire society. Financially, the benefits of vaccinations’ indirect protection become clear — in Germany, a vaccination cost-effectiveness study reported that, when herd effect benefits are considered, the total costs from pneumococcal disease were e1281.4 million with no vaccination, and e1288 million with vaccination[19]. The costs are very similar, proving that vaccination programs are extremely cost-effective while providing much better health outcomes — when considering herd immunity effects, it was estimated that offering vaccination for all children would reduce adult deaths by 3,027 per year.
When the benefits of herd effect were not considered, in the same study, the costs of pneumococcal disease were e808,3 million with no vaccination, and 928,1 million euros with vaccination — not cost-effective. Excluding herd effects in economic evaluations of vaccines underestimates the value of vaccination, as it limits the concept of value to direct effects only. This can lead to inefficient public health decisions and planning. 4.2 Social and economical impacts of absenteeism and presenteeism It is increasingly acknowledged that the costs of disease not only fall on the patients themselves, but also on caregivers including friends, family, communities, and the wider society. For example, varicella disease in children leads to considerable indirect costs as a result of parent absenteeism and loss of productivity [20]. In Germany, the total annual costs of varicella were estimated to be e78 million, from which the largest portion was due to the significant work loss costs incurred by parents’ absenteeism to care for their sick children. For the society, the annual costs were estimated to be e187,5 million, 82% of which corresponded to indirect costs.[21] . In France, the total economic burden of productivity loss amounts to almost 50% of the overall costs of rotavirus gastroenteritis (RVGE) [22].
In the UK, each absent employee cost their employer an average of £975 in 2012, while absenteeism direct costs alone amounted to more than £14 billion across the economy during that year. [6] . 6 Loss of productivity is a crucial cost associated with absenteeism, accompanied by the cost of replacing staff to cover the absent employee and the cost of payments for sickness leave. The reduction in productivity in the form of presenteeism may potentially even outweigh the cost of absenteeism. For example, the total cost of presenteeism to the Australian economy was estimated to be AU$34.1 billion in 2009-2010, which equates to a almost 2.7% decrease in the 2010 GDP [7]. The negative impact of labour productivity losses due to presenteeism flows throughout the economy, leading to a general reduction in levels of exports, imports and investments. In the health sector, vaccination of health care workers can help to improve the productivity of healthcare systems, where the level of absenteeism and presenteeism is becoming increasingly problematic, affecting the quality of care and resource management. As populations grow older and the retirement age is increased to endure the financial pressure of retirement subsidization of social security, avoiding preventable diseases in the working population and the ‘young’ elderly becomes more important. Vaccination could help to contribute to healthy aging, ensuring that people remain active, independent, and continue to be an asset for society. Reducing absenteeism from preventable diseases and enhancing productivity are, therefore, essential for generating economic growth and making health care systems more affordable.
Vaccination can strongly contribute to these societal challenges. 4.3 Improving quality of life: healthy aging One of the main objectives of public health policy is to protect lives by reducing the burden of infectious diseases and preventing premature deaths. Vaccination has successfully contributed to these key goals. Additionally, public health policy also aims to improve the quality of life and promote healthy aging for all citizens. Governments across Europe have recognized the importance of healthy aging as part of the inevitable demographic changes occurring in many countries [23] As populations age, there is an inevitable increase in individuals with chronic, long-term conditions. Healthy aging is important, not just in terms of contributing to health care systems sustainability and affordability, but also from the point of view that elderly individuals often constitute the most active group of volunteers in a society and are central to many community-based projects. In fact, older adults contribute significantly as care-providers, they apply their experience to contemporary problems of society and of their own lives, and are one of the most active and productively-involved demographic.[24]. Preventing disease, although unquestionably important from an economic and employment perspective, is potentially even more fundamental to protecting and enhancing social, personal, and family activities. Effective vaccination of the elderly against important infectious diseases represents a growing public health priority to reduce the high morbidity and mortality caused by them. Indeed, the number of elderly people worldwide is expected to increase from 650 million (2017) to nearly 2 billion by the time we reach 2050. Demands on health services will expand as a result of this demographic shift.
Vaccination thus represents a major preventive strategy that must be emphasized now and especially in the future, not only as a direct measure but also, and maybe even more importantly, as an indirect measure through the benefits of herd effect, conferred by younger vaccinated individuals. Healthy aging is obviously a meritable objective on its own to improve welfare and quality of life, but it is also specifically recognized as necessary to counter the healthcare costs consequent on the demographic shift underway, but populations are reluctant to accept recommendations or are misinformed. A study conducted in the United States in 2013 reported that the economic impact attributable to adult vaccine-preventable diseases for US adults aged 65 and older was $15.3 Billion. The authors suggest that this is a result of barriers that exist at the patient, provider, and system level.
The most salient patient barriers include lack of awareness of the need for the vaccine, lack of recommendation by a healthcare provider, fear of side effects, busy schedules, and lack of belief that receiving the vaccine is ‘wise’.[25]. In the EU, out of approximately 180 million European adults for whom influenza vaccination is recommended, only about 80 million persons are vaccinated. If vaccination coverage increased from the current 44% to 75%, seasonal influenza vaccination could result in 1.6–2.1 million cases prevented, 25,000–37,000 influenza-related deaths avoided and savings of healthcare costs amounting to e153–219 million annually [26]. Full implementation of influenza vaccination could immediately reduce an important public health and economic burden. Many infectious diseases inflict a disproportionate burden of disease in older adults, but may be prevented 7 or attenuated by vaccination. This implies that vaccination can serve as a strategy to support healthy aging, alongside healthy diet and exercise.
However, the uptake of vaccination by the target population is generally low and must be substantially improved if the potential of vaccines to reduce the morbidity, mortality, loss of quality of life and healthcare costs caused by vaccine-preventable diseases is to be realized. Increasing vaccination coverage of older adults against vaccine-preventable diseases can be expected to promote healthy aging.
