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Nosocomial Pertussis: Costs of an Outbreak and Benefits of Vaccinating Health Care Workers

  1. Angela Calugar1,
  2. Ismael R. Ortega-Sánchez2,
  3. Tejpratap Tiwari2,
  4. Liisa Oakes3,
  5. Jeffrey A. Jahre4, and
  6. Trudy V. Murphy2
  1. 1Immunization Services Division, Atlanta, Georgia
  2. 2Epidemiology and Surveillance Division, National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia
  3. 3IMPAC Medical Systems, Mount View, California
  4. 4St. Luke's Bethlehem Hospital, Bethlehem, Pennsylvania
  1. Reprints or correspondence: Dr. Angela Calugar, Immunization Services Div., National Immunization Program, Centers for Disease Control and Prevention, 1600 Clifton Rd., Mail Stop E-52, Atlanta, GA 30333 (ACalugar{at}cdc.gov).
 
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Abstract

Background. In September 2003, 17 symptomatic cases of pertussis among health care workers (HCWs) resulted from a 1-day exposure to an infant who was later confirmed to have pertussis. These HCWs identified 307 close contacts. The hospital implemented extensive infection-control measures. The objective of this study was to determine direct and indirect costs incurred by the hospital and symptomatic HCWs as a result of the September 2003 outbreak and to estimate possible benefits of vaccinating HCWs from the hospital perspective.

Methods. We determined costs by interviewing infection-control and hospital personnel, reviewing billing records, and surveying symptomatic HCWs. We calculated the benefits and costs of a vaccination program for HCWs, using a probabilistic model to estimate the number of pertussis exposures that would require control measures annually. Sensitivity and threshold analyses were performed.

Results. The outbreak cost to the hospital was $74,870. The total measured cost of the outbreak was $81,382, including costs incurred by HCWs ($6512). Our model predicted that vaccinating HCWs against pertussis would prevent >46% of exposures from HCWs with pertussis per year and would provide net savings. The benefit for the hospital was estimated to be 2.38 times the dollar amount invested in vaccinating HCWs. The number of exposures prevented and the benefit-cost ratio were sensitive to the number of exposures identified, the incidence of pertussis among HCWs, and HCW turnover.

Conclusions. A single nosocomial pertussis outbreak resulted in substantial disruption and costs to the hospital and to HCWs. Our model suggests that cost savings and benefits could be accrued by vaccinating HCWs against pertussis.

Adults become susceptible to pertussis because of waning vaccine or infection-acquired immunity [1]. In recent years, there have been increasing reports of nosocomial pertussis following community or hospital exposures of health care workers (HCWs) [2–4]. De Serres et al. [5] found that HCWs in Quebec, Canada, had an ∼1.7-times higher risk of pertussis than that of the general adult population. Pertussis among HCWs is of special concern because of the potential for nosocomial exposures for patients and other HCWs.

Since the 1940s, vaccines against pertussis have been available in the United States for infants and children between 2 months and 7 years of age. In June and October 2005, newly licensed vaccines for pertussis were recommended for adolescents and adults by the Advisory Committee on Immunization Practices. A vaccination recommendation for HCWs has yet to be made. Reports and anecdotal data suggest that controlling pertussis outbreaks is resource intensive; however, few analyses have assessed the economic burden of nosocomial pertussis, and no studies have examined both the possible costs and the possible benefits of vaccinating HCWs.

In September 2003, at a tertiary health care facility with adult and pediatric beds (“hospital A”), 17 symptomatic cases of pertussis among HCWs resulted from a 1-day exposure to an infant with pertussis [6]. When the infant's diagnosis was confirmed by culture 16 days later, an investigation identified 307 exposed close contacts among patients, family members, and friends of the symptomatic HCWs. Hospital A implemented outbreak-containment measures, and resources, including laboratory tests, prophylactic medications, and personnel time, were diverted from normal activities to infection-control tracking and to prophylaxis for the contacts. Hospital personnel with pertussis were placed on administrative leave. These personnel missed work and incurred nonreimbursed medical and nonmedical costs, and some lost additional income and schooling [6].

Most conventional analyses of the cost of pertussis have been limited to the investigation of the ill case patient and the immediate family [7, 8], and they have seldom included the costs incurred by noncases or by institutions (e.g., hospitals or health departments) in efforts to prevent further transmission. Despite the considerable efforts required to contain nosocomial pertussis, few data are available about the costs borne by different stakeholders. We focused our analysis on the hospital and HCW perspectives to determine the cost of pertussis outbreak-control activities in a hospital, and we examined whether health care facilities might accrue economic benefits through a program of vaccinating HCWs who have direct patient contact (i.e., frontline HCWs).

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Methods

Data collection. To evaluate the economic impact of the pertussis outbreak at hospital A, we obtained information about the investigation and containment activities from several sources: (1) hospital personnel, including the chief of the infection-control service and administrative and clinical staff who managed the outbreak-control activities; (2) hospital billing records; and (3) symptomatic HCWs. These data were collected immediately after the outbreak-containment activities were completed.

Data collected during the outbreak included data on the chronology, type, and duration of the outbreak activities, the material and human resources used, and the number of contacts of pertussis cases. We classified activities into 3 categories: (1) investigational activities—that is, contact identification, notification, interview, and screening of suspected cases; (2) emergency response—that is, information delivery to the public, treatment of cases, prophylaxis of contacts, enhanced surveillance, furlough of HCWs, and follow-up of suspected cases; and (3) other activities—that is, the informational telephone hotline, press conferences, letters to inform patients and health care providers of potential exposures, etc. When possible, the costs of personnel time, materials, equipment, and ancillary services were identified for each activity. Each activity could potentially generate costs in ⩾1 cost category. On the basis of the information collected, we designed a cost-survey questionnaire for the interviews with the chief of the hospital infection-control service and hospital personnel involved in the outbreak. A second questionnaire was given to symptomatic HCWs to obtain demographic and epidemiologic information as well as data on expenditures attributed to the illness (uncompensated lost time from primary and/or secondary work, time missed from leisure activities, time spent obtaining medical care, nonreimbursed medical costs, and related expenses, including prescription and over-the-counter medicines).

For the cost analysis, we grouped data obtained from hospital billing records and from symptomatic HCWs into 4 categories: (1) the hospital's direct costs—that is, costs of laboratory tests, antibiotics for treatment and prophylaxis, incremental time of personnel assigned to outbreak-control activities, and the incremental overhead expenses for risk-communication activities; (2) the hospital's indirect costs—that is, the costs of hours lost from work by the symptomatic HCWs when furloughed; (3) the individual HCW's direct costs—that is, the costs of uncompensated medical care and travel expenses to health facilities for counseling and treatment; and (4) the individual HCWs' indirect costs—that is, the costs of uncompensated time lost from work for obtaining medical care and for uncompensated work required to control the outbreak. In this group, we included wages lost from primary and secondary employment and time lost from profession-related unpaid activities because of illness (e.g., clinical training missed by a nursing student).

The majority of direct costs were calculated using primary cost data. For example, the cost of personnel time was based on the hospital payroll, and the cost of drugs was obtained from the hospital pharmacy. For the HCWs' travel costs, we used a mileage rate of $0.37/mile [9].

Analysis. Two measures were employed to assess containment costs (1) an efficiency measure using the estimated number of cases preventable by outbreak-control activities and their associated medical cost savings and (2) a benefit-cost measure using a hypothetical vaccination program of frontline HCWs to prevent nosocomial pertussis exposures.

For the efficiency measure, we calculated expected medical costs per pertussis case, using 2 available sets of values [10, 11]. The expected costs took into account the age-specific incidence rates of pertussis [10], the probability of mild and severe cough illness, the probability of pneumonia, neurological complications, and fatality outcomes after pertussis infection [10]. Medical cost estimates were weighted by average and age-specific US reported incidence rates by use of national passive-surveillance data from 1983 to 2002 [12]. We estimated the number of cases that would be prevented if the containment and medical costs were equal, using the nosocomial outbreak-containment costs at hospital A and the weighted medical costs per pertussis case. In our analysis, we assumed that the total containment costs of a nosocomial pertussis outbreak remained constant for a range of attack rates among HCWs and their contacts. We then projected containment and medical costs for a larger and a smaller number of cases.

For the benefit-cost measure, we calculated the cost of vaccinating frontline HCWs and estimated the net return from prevention of nosocomial pertussis. We used a probabilistic model consisting of a cohort of 1000 HCWs observed for 10 years. Data from the literature were used to determine mean values for the incidence of pertussis in HCWs [4, 13], percentage of symptomatic seroconfirmed HCWs [4], the ratio of identified exposures per HCW case [14–17], employment turnover rates [18, 19], vaccine efficacy [20, 21], vaccine coverage [22, 23], adverse events [21, 24, 25], and the costs of vaccine ($30 per dose) [21, 26] (table 1). For each year, the number of nosocomial pertussis exposures requiring investigation and control interventions was calculated for 2 scenarios, 1 with and 1 without an HCW vaccination program:

Table 1
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Table 1

Analysis of pertussis incidence and exposures, vaccination costs, and benefit-cost thresholds.

Number of exposures without vaccination = incidence rate × percentage symptomatic × (1 + rate of exposure per symptomatic HCW).

Number of exposures with vaccination = [1 - (vaccine efficacy × vaccine coverage × percentage full-time HCWs)] × number of exposures with no vaccination.

The exposures prevented with vaccination were calculated as the difference between the products of the 2 equations. With the vaccination program, 66% of HCWs were vaccinated at the beginning of the first year. The HCWs leaving each year—including some who had been vaccinated—were replaced with new HCWs to maintain a stable cohort. New HCWs were assumed to be unvaccinated but were vaccinated when hired at the same coverage rate.

Containment costs per exposure were taken from hospital A and from the literature [15, 27]. The present value of all costs and benefits was calculated in 2004 dollars with 3% as the discount rate [28]. Net costs (or savings) and returns accrued to the vaccination program were estimated.

In the sensitivity analysis, probability distributions were specified for key parameters with a range of values, varied simultaneously in Monte Carlo simulations. We selected the median and the 5th and 95th percentiles to approximate a confidence interval for the results. Threshold analyses were conducted to determine break-even values for which the vaccination program benefits equal the costs (i.e., net costs equal to 0) (table 1).

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Results

Seventeen symptomatic pertussis cases among HCWs resulted from a 1-day exposure to an ill infant with initially unrecognized pertussis. When pertussis was confirmed 16 days later, control measures were implemented, including droplet precautions and identification of close contacts of HCWs.

Symptomatic HCWs (n = 17) were treated with a 5-day course of azithromycin (500 mg on day 1 and 250 mg on days 2–5) and were furloughed for 5 days. Azithromycin prophylaxis was offered to 307 close contacts of the symptomatic HCWs. Contacts included other HCWs, household members, patients, residents of an institution for the mentally impaired, and residents of a dormitory for the student nurses. The hospital administration distributed risk information to discharged patients and the community through letters, media briefs and press conferences and answered questions at a dedicated telephone hotline [6].

Outbreak costs. The largest direct hospital costs were for laboratory tests (33%) and additional activities (44%) (table 2). Additional activities included 725 h of labor diverted from normal work to identify cases and contacts and to provide counseling (∼205 h), to obtain specimens and process laboratory tests (∼42 h), to answer community inquires (∼55 h), to conduct related infection-control and public health activities (∼407 h), and so forth. Direct hospital costs totaled $63,670. Indirect hospital costs were primarily due to the furloughs of 17 symptomatic HCWs, and the total cost for the hospital was $74,870 (table 2).

Table 2
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Table 2

Direct and indirect costs borne by the hospital as a result of the pertussis outbreak.

Of the 17 symptomatic HCWs, 16 answered the cost questionnaire; 1 declined. The HCWs' direct medical costs were $4679 (table 3). One HCW was hospitalized with exacerbated asthma and incurred charges of >$4000. The HCWs' indirect costs ($1730) were primarily for uncompensated work and personal time lost to obtain medical care. The HCWs' total costs were estimated to be $6409 (table 3).

Table 3
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Table 3

Direct and indirect medical costs borne by health care workers (HCWs) as a result of the pertussis outbreak.

The measured and estimated costs of pertussis control activities for the pertussis outbreak at hospital A were $81,382, including an additional $103 in transportation costs to HCWs for obtaining medical care. We did not factor in the cost of 72 h of unpaid activities accrued by HCWs. Given the 434-bed capacity at the time of the outbreak, the costs of containment activities per hospital bed were between $158 (from the hospital perspective) and $188 (from the combined hospital and HCW perspectives).

Economic evaluation. In the efficiency measure, we estimated that medical costs of 25–65 pertussis cases would be equivalent to the outbreak-containment costs at hospital A ($81,382) (figure 1). This range (25–65 cases) was derived from the range of expected medical costs per case reported in the literature: from $1217 [10] to $3217 [11]. Given the hospital A containment costs level, a hospital would have to have 25 cases before the costs of containment would equal the costs of disease. However, the containment costs would be higher than the medical costs for a smaller number of cases (<25) (figure 1).

Figure 1
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Figure 1

Comparison of disease costs and outbreak-containment costs (in thousands of dollars). Disease costs are calculated on the basis of recent publications [10, 11]. For projected series of values from Lee and Pichichero [11] (squares) and from Lee et al. [10] (triangles), we used weighted, age-specific reported incidence rates of pertussis in the United States, 1983–2002. The probability of mild and severe cough illness and the probability of pneumonia, neurological complications, and fatality outcomes after pertussis infection are factored into the disease cost projections. Cost figures for Lee and Pichichero [11] were converted to December 2004 dollars by use of the medical care service component of the Consumer Price Index. Outbreak-containment costs (diamonds) are based on the current analysis and are presumed to be constant for the projected range of cases.

In the benefit-cost measure, we estimated the base-case results (median) and the 5th and 95th percentiles, using Monte Carlo simulation. In the absence of vaccination, we estimated that ∼203 (5th–95th percentiles, 34–661) nosocomial exposures would occur per 1000 HCWs annually (table 4). The vaccination program would prevent a median of 93 (5th–95th percentiles, 13–310) annual pertussis exposures by HCWs. In a 10-year period, the 2004 value of costs associated with containment activities would be ∼$388,000 (5th–95th percentiles, $60,000–$1,324,000). During the same period, the 2004 value of costs associated with a vaccination program would be ∼$69,000 (5th–95th percentiles, $29,000–$143,000). Net costs of introducing a vaccination program would likely be at or less than the 25th percentile of the distribution of net savings (not shown). Above the 25th percentile, introduction of a vaccination program would result in net savings as high as $535,000 (95th percentile), with a median of $95,000 during a 10-year period. The benefit-cost ratio of a vaccination program for a hospital setting with 1000 HCWs would be 2.38 : 1—that is, the hospital would save $2.38 (5th–95th percentiles, $0.4–$10.9) in net return for every dollar invested in the vaccination program (table 4).

Table 4
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Table 4

Results of simulation study of pertussis incidence, vaccination costs, projected savings, and benefit-cost ratios.

Figure 2 illustrates the sensitivity of the model outcomes (the number of exposures prevented and the benefit-cost ratio) to changes in other parameters. Significant variables were the number of contacts exposed per HCW case, the incidence of pertussis among HCWs, employee turnover, HCWs' vaccine coverage, vaccine cost, containment costs per exposure, and vaccine effectiveness. Similarly, in the threshold analysis, the net costs (or savings) of vaccination would be 0, other things remaining equal, if the number of exposed contacts per HCW was 2.5 (rather than 8.73, as in the base case), if the pertussis incidence in HCWs was 2.5% (rather than 6.75%), if turnover was >100% (rather than 16.6%), if containment costs were $84 (rather than $231), or if vaccine efficacy was 27% (rather than 71.4%) (tables 1 and 4).

Figure 2
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Figure 2

Regression sensitivity for pertussis exposures prevented and the benefit-cost ratio for vaccination of HCWs. Base-case values are 93 exposures prevented and a benefit-cost ratio of 2.38. The sensitivity of the number of exposures prevented and the benefit-cost ratio for parameters are measured using the standardized b coefficient of regression. The base-case scenario is indicated at the 0 value of the y-axis. For significant variables in the model, bars on the right side indicate the proportional increase in the number of pertussis exposures prevented (black bars) and the increase in the benefit-cost ratio (gray bars) to proportional increments in the input parameters. Bars on the left side indicate the proportional decrease in the number of pertussis exposures prevented (black bars) and the decrease in the benefit-cost ratio (gray bars) to proportional increments in the input parameters.

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Discussion

Major findings. Efforts to control the pertussis outbreak at hospital A were extensive; the cost of these containment activities was estimated to be >$81,000. Using this example and data from the literature, we assessed the minimum conditions under which a vaccination program for frontline HCWs might lead to net savings for the hospital. We estimated that the break-even point for net savings would be reached when infection-control activities related to exposures were deemed unnecessary for an average of 46% of nosocomial exposures per year. Our results underestimated the real cost of nosocomial pertussis outbreaks and, thus, also underestimated the benefits of vaccination, because potential expenses such as liability insurance premiums and outbreak-related revenue loses were not included in the cost analysis.

Comparison with other studies. Containment of hospital-associated outbreaks of infectious disease is resource intensive and affects different stakeholders within the health care system and society [6, 17, 29, 30]. Pertussis outbreaks occur in both adult and pediatric care services, where exposures as well as secondary cases contribute to containment costs. During the epidemic of pertussis in Greater Cincinnati, Ohio, 1993, expenses associated with containment of pertussis in a regional hospital totaled $85,400. Eighty-seven cases and 626 contacts were identified after exposure to an HCW with pertussis [15]. Pertussis among HCWs in an adult hospital in France (2000–2001) [17] resulted in 91 cases, including 77 affected HCWs. Total medical and productivity costs were €46,661. Diagnostic tests accounted for one-third of total costs, similar to the cost distribution for hospital A. A retrospective 1-year study (2003–2004) of a Massachusetts tertiary care medical system serving adults and children identified 20 primary and 3 secondary laboratory-confirmed cases of pertussis (including 3 cases involving employees) [27]. A total of 311 hospital personnel were screened; 270 were given treatment or prophylaxis. The total estimated costs (direct and indirect) to the hospital were between $63,962 and $71,718.

Similar experience has been reported for other nosocomial vaccine-preventable infectious diseases. For example, the containment costs totaled ∼$689,314 in a nosocomial outbreak of hepatitis A in Denver, Colorado [30]. The majority of this cost was borne by the hospital, and only 7% of the cost was born by the 43 case patients. This relative distribution of costs among the hospital and patients was similar to the cost distribution for the pertussis outbreak at hospital A.

We identified 5 cost-effectiveness studies of HCW vaccination against varicella and hepatitis. Vaccinating HCWs against varicella was more costly than no-vaccine strategies, from the hospital perspective [31]. Another study estimated that vaccination could generate ∼$59 dollars in net savings per person [32]. For hepatitis prevention in HCWs, 2 studies showed net benefits of vaccination; benefit-cost ratios were 2.05 : 1 for hepatitis B vaccination in high-occupational-exposure-risk groups [33] and 1.4 : 1 for combined hepatitis A and B vaccination in regions highly endemic for hepatitis A [34]. Another study estimated the net cost for the hospital to immunize against hepatitis A, although vaccinating HCWs was still the most cost-effective strategy [35].

Limitations. Several costs related to the pertussis outbreak in hospital A were not measured in our assessment. We did not determine the hospital's overhead expenses—for example, utility bills, security, and cleaning personnel—or expenses related to the HCW with pertussis who did not participate in the evaluation. We focused on the hospital and HCW perspectives, and we did not evaluate the time to obtain medical care for asymptomatic contacts or the costs of the outbreak to local or state public health departments and the community. Data from the community and/or local and state health department prospectives would have substantially increased the overall economic impact of the outbreak.

Our benefit-cost evaluation relied on 2 assumptions: (1) vaccine efficacy and coverage were assumed to have an inverse correlation with the probability of nosocomial exposures and outbreaks, and (2) the number of frontline HCWs and the ratio of HCWs to hospital beds were assumed to be constant in time. Although the duration of protective effectiveness of pertussis vaccine in adults is assumed to remain sufficiently high to prevent transmission over a 10-year period, employment turnover and continuous vaccination of new HCWs make prolonged vaccine efficacy less relevant in the model. Low vaccination coverage of HCWs might result in lower effectiveness of the vaccination program, increasing the probability of pertussis. Our model did not address other factors such as the cost of booster doses (if these doses would be required to maintain protection), the acceptance of the vaccination program, and the hospital's organizational culture.

The majority of pertussis hospitalizations involve infants [36], and many of the nosocomial pertussis outbreaks described in the literature involve infants; thus, the benefit of vaccinating HCWs could vary, depending on the type of hospital. Also, if the recent pertussis vaccine recommendation for adolescents changes the epidemiology of pertussis, the containment costs for hospitals and HCWs could change in the future.

In summary, our economic evaluation of the nosocomial pertussis at hospital A and a vaccination program for HCWs may provide a useful approach for decision makers who evaluate disease-control strategies in hospital settings. As seen in this study and elsewhere [37], containment costs to the hospital can exceed, by many fold, the cost of individual illness cases. Additional economic research on nosocomial pertussis outbreaks is needed to understand the costs from the perspective of patients (including HCWs) as well as from institutional perspectives (hospitals, public health governmental organizations, and others).

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Acknowledgments

We acknowledge the contributions of Steven J. Schweon, Cindy Kalman, Bonnie Coyle, Terry Lynn Burger, Shana Stites, Susanne Madeja, Perrianne Lurie, Heather Stafford, Phuoc Tran, Kris Bisgard, John S. Moran, Robert Chen, Marty Roper, Margaret Cortese, Gregory Wallace, John Iskander, Susan Chu, Jim Alexander, St. Luke's Bethlehem Hospital staff, and National Immunization Program (NIP) staff.

Financial support. This research was completed while A.C., I.R.O.-S., T.T., L.O., and T.V.M. were employees of the Centers for Disease Control and Prevention (Atlanta, GA) and J.A.J. was an employee of the St. Luke's Hospital (Bethlehem, PA).

Potential conflicts of interest. All authors: no conflicts.

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Footnotes

  • a A.C. and I.R.O.-S. are both first authors of this article.

  • Received August 5, 2005.
  • Accepted November 29, 2005.
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  1. Clin Infect Dis. (2006) 42 (7): 981-988. doi: 10.1086/500321
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