Retrospective Cost-Effectiveness Analyses for Polio Vaccination in the United States

The history of polio vaccination in the United States spans 50 years and includes different phases of the disease, multiple vaccines, and a sustained significant commitment of resources. We estimated cost-effectiveness ratios and assessed the net benefits of polio vaccination applicable at various points in time from the societal perspective and we discounted these back to appropriate points in time. We reconstructed vaccine price data from available sources and used these to retrospectively estimate the total costs of the U.S. historical polio vaccination strategies (all costs reported in year 2002 dollars). We estimate that the United States invested approximately US dollars 35 billion (1955 net present value, discount rate of 3%) in polio vaccines between 1955 and 2005 and will invest approximately US dollars 1.4 billion (1955 net present value, or US dollars 6.3 billion in 2006 net present value) between 2006 and 2015 assuming a policy of continued use of inactivated poliovirus vaccine (IPV) for routine vaccination. The historical and future investments translate into over 1.7 billion vaccinations that prevent approximately 1.1 million cases of paralytic polio and over 160,000 deaths (1955 net present values of approximately 480,000 cases and 73,000 deaths). Due to treatment cost savings, the investment implies net benefits of approximately US dollars 180 billion (1955 net present value), even without incorporating the intangible costs of suffering and death and of averted fear. Retrospectively, the U.S. investment in polio vaccination represents a highly valuable, cost-saving public health program. Observed changes in the cost-effectiveness ratio estimates over time suggest the need for living economic models for interventions that appropriately change with time. This article also demonstrates that estimates of cost-effectiveness ratios at any single time point may fail to adequately consider the context of the investment made to date and the importance of population and other dynamics, and shows the importance of dynamic modeling.     

Daily Variation in Natural Disaster Casualties: Information Flows,Safety, and Opportunity Costs in Tornado Versus Hurricane Strikes

Casualties from natural disasters may depend on the day of the week they strike. With data from the Spatial Hazard Events and Losses Database for the United States (SHELDUS), daily variation in hurricane and tornado casualties from 5,043 tornado and 2,455 hurricane time/place events is analyzed. Hurricane forecasts provide at‐risk populations with considerable lead time. Such lead time allows strategic behavior in choosing protective measures under hurricane threat; opportunity costs in terms of lost income are higher during weekdays than during weekends. On the other hand, the lead time provided by tornadoes is near zero; hence tornados generate no opportunity costs. Tornado casualties are related to risk information flows, which are higher during workdays than during leisure periods, and are related to sheltering‐in‐place opportunities, which are better in permanent buildings like businesses and schools. Consistent with theoretical expectations, random effects negative binomial regression results indicate that tornado events occurring on the workdays of Monday through Thursday are significantly less lethal than tornados that occur on weekends. In direct contrast, and also consistent with theory, the expected count of hurricane casualties increases significantly with weekday occurrences. The policy implications of observed daily variation in tornado and hurricane events are considered.     

Effects of Increased Auto Safety Belt Use Levels on Fatalities

To reduce the annual toll of highway deaths, more than 30 states have passed laws mandating the use of safety belts. All have been effective at raising safety belt use; equipped with different provisions and enforced with unequal care, however, they have done so to different degrees. The article estimates the relationship between attained belt use and fatalities averted. Monthly 1982-1986 fatality, collision, belt use, and other data from 64 areas in nine states were collected, then analyzed using a Poisson multiple regression model. The analysis indicates that an increase in belt use from 14-40% averts about 13% of fatalities; a more pronounced increase to 50% averts about 18%. An increase from 50-75% averts about 16% of remaining fatalities. Three significant conclusions emerge. First, previous estimates appear to have understated, in general, the overall effectiveness of belt use laws. Second, the benefits of programs to boost safety belt use in this country from its current level of about 50% to up to 75%, estimated on the basis of more direct evidence from U.S. data than previously available, appear to be very large. Third, Poisson and other multiple regression models including explicit allowance for other causal factors can usefully complement other statistical approaches in traffic safety studies.     

Loss of Life Caused by the Flooding of New Orleans After Hurricane Katrina: Analysis of the Relationship Between Flood Characteristics and Mortality

In this article a preliminary analysis of the loss of life caused by Hurricane Katrina in the New Orleans metropolitan area is presented. The hurricane caused more than 1,100 fatalities in the state of Louisiana. A preliminary data set that gives information on the recovery locations and individual characteristics for 771 fatalities has been analyzed. One-third of the analyzed fatalities occurred outside the flooded areas or in hospitals and shelters in the flooded area. These fatalities were due to the adverse public health situation that developed after the floods. Two-thirds of the analyzed fatalities were most likely associated with the direct physical impacts of the flood and mostly caused by drowning. The majority of victims were elderly: nearly 60% of fatalities were over 65 years old. Similar to historical flood events, mortality rates were highest in areas near severe breaches and in areas with large water depths. An empirical relationship has been derived between the water depth and mortality and this has been compared with similar mortality functions proposed based on data for other flood events. The overall mortality among the exposed population for this event was approximately 1%, which is similar to findings for historical flood events. Despite the fact that the presented results are preliminary they give important insights into the determinants of loss of life and the relationship between mortality and flood characteristics.     

Cognitive Components of Risk Ratings

This study examined what lay people mean when they judge the "risk" of activities that involve the potential for accidental fatalities (e.g., hang gliding, living near a nuclear reactor). A sample of German and American students rated the "overall risk" of 14 such activities and provided 3 fatality estimates: the number of fatalities in an "average year," the individual yearly fatality probability (or odds), and the number of fatalities in a "disastrous accident." Subjects' fatality estimates were reasonably accurate and only moderately influenced by attitudes towards nuclear energy. Individual fatality probability correlated most highly with intuitive risk ratings. Disaster estimates correlated positively with risk ratings for those activities that had a low fatality probability and a relatively high disaster potential. Annual average fatality rates did not correlate with risk ratings at all. These findings were interpreted in terms of a two-dimensional cognitive structure. Subjective notions of risk were determined primarily by the personal chance of death; for some activities, "disaster potential" played a secondary role in shaping risk perception.     

Risk Analysis of Chemical, Biological, or Radionuclear Threats: Implications for Food Security

If the food sector is attacked, the likely agents will be chemical, biological, or radionuclear (CBRN). We compiled a database of international terrorist/criminal activity involving such agents. Based on these data, we calculate the likelihood of a catastrophic event using extreme value methods. At the present, the probability of an event leading to 5,000 casualties (fatalities and injuries) is between 0.1 and 0.3. However, pronounced, nonstationary patterns within our data suggest that the "reoccurrence period" for such attacks is decreasing every year. Similarly, disturbing trends are evident in a broader data set, which is nonspecific as to the methods or means of attack. While at the present the likelihood of CBRN events is quite low, given an attack, the probability that it involves CBRN agents increases with the number of casualties. This is consistent with evidence of "heavy tails" in the distribution of casualties arising from CBRN events.     

Should Cities Invest in Sheltering‐in‐Place Measures Against Chlorine Truck Attacks by Terrorists?

After an intentional release of chlorine in an office district, public responses such as sheltering‐in‐place could save many lives if rapid enough. However, previous work does not estimate how fast and effective such responses would be for several possible investments in attack detection, public alert, and building ventilation, nor whether such measures would be cost effective. We estimate public response times with investment options in place, and resulting changes in fatalities as well as system costs, including false alarm costs, and cost effectiveness in terms of cost per net death avoided. The measures do have life‐saving potential, especially if all response times are at or near the lower limits of the ranges assumed in this article. However, due to uncertainties, it is not clear that responses would be rapid enough to save many people. In some cases total fatalities would increase, since sheltering after chlorine vapor has already entered buildings can increase occupants’ chlorine exposure. None of the options considered have median cost per statistical life saved meeting a cost‐effectiveness threshold of $6.5 million across all of the chlorine exposure dose‐response and ingress‐delay models considered here, even if there were one attack per year in the area covered by the system. Given these and other issues discussed in this article, at this point investments to improve sheltering‐in‐place capability appear not to be robust strategies for reducing fatalities from chlorine attack in an office district.     

Asteroid Risk Assessment: A Probabilistic Approach

Following the 2013 Chelyabinsk event, the risks posed by asteroids attracted renewed interest, from both the scientific and policy‐making communities. It reminded the world that impacts from near‐Earth objects (NEOs), while rare, have the potential to cause great damage to cities and populations. Point estimates of the risk (such as mean numbers of casualties) have been proposed, but because of the low‐probability, high‐consequence nature of asteroid impacts, these averages provide limited actionable information. While more work is needed to further refine its input distributions (e.g., NEO diameters), the probabilistic model presented in this article allows a more complete evaluation of the risk of NEO impacts because the results are distributions that cover the range of potential casualties. This model is based on a modularized simulation that uses probabilistic inputs to estimate probabilistic risk metrics, including those of rare asteroid impacts. Illustrative results of this analysis are presented for a period of 100 years. As part of this demonstration, we assess the effectiveness of civil defense measures in mitigating the risk of human casualties. We find that they are likely to be beneficial but not a panacea. We also compute the probability—but not the consequences—of an impact with global effects (“cataclysm”). We conclude that there is a continued need for NEO observation, and for analyses of the feasibility and risk‐reduction effectiveness of space missions designed to deflect or destroy asteroids that threaten the Earth.     

Terrorism Risks and Cost‐Benefit Analysis of Aviation Security

We evaluate, for the U.S. case, the costs and benefits of three security measures designed to reduce the likelihood of a direct replication of the 9/11 terrorist attacks. To do so, we assess risk reduction, losses, and security costs in the context of the full set of security layers. The three measures evaluated are installed physical secondary barriers (IPSB) to restrict access to the hardened cockpit door during door transitions, the Federal Air Marshal Service (FAMS), and the Federal Flight Deck Officer (FFDO) Program. In the process, we examine an alternate policy measure: doubling the budget of the FFDO program to $44 million per year, installing IPSBs in all U.S. aircraft at a cost of $13.5 million per year, and reducing funding for FAMS by 75% to $300 million per year. A break‐even cost‐benefit analysis then finds the minimum probability of an otherwise successful attack required for the benefit of each security measures to equal its cost. We find that the IPSB is costeffective if the annual attack probability of an otherwise successful attack exceeds 0.5% or one attack every 200 years. The FFDO program is costeffective if the annual attack probability exceeds 2%. On the other hand, more than two otherwise successful attacks per year are required for FAMS to be costeffective. A policy that includes IPSBs, an increased budget for FFDOs, and a reduced budget for FAMS may be a viable policy alternative, potentially saving hundreds of millions of dollars per year with consequences for security that are, at most, negligible.     

Effect of Providing the Uncertainty Information About a Tornado Occurrence on the Weather Recipients’ Cognition and Protective Action: Probabilistic Hazard Information Versus Deterministic Warnings

Currently, a binary alarm system is used in the United States to issue deterministic warning polygons in case of tornado events. To enhance the effectiveness of the weather information, a likelihood alarm system, which uses a tool called probabilistic hazard information (PHI), is being developed at National Severe Storms Laboratory to issue probabilistic information about the threat. This study aims to investigate the effects of providing the uncertainty information about a tornado occurrence through the PHI's graphical swath on laypeople's concern, fear, and protective action, as compared with providing the warning information with the deterministic polygon. The displays of color‐coded swaths and deterministic polygons were shown to subjects. Some displays had a blue background denoting the probability of any tornado formation in the general area. Participants were asked to report their levels of concern, fear, and protective action at randomly chosen locations within each of seven designated levels on each display. Analysis of a three‐stage nested design showed that providing the uncertainty information via the PHI would appropriately increase recipients’ levels of concern, fear, and protective action in highly dangerous scenarios, with a more than 60% chance of being affected by the threat, as compared with deterministic polygons. The blue background and the color‐coding type did not have a significant effect on the people's cognition of the threat and reaction to it. This study shows that using a likelihood alarm system leads to more conscious decision making by the weather information recipients and enhances the system safety.     

Risk Preferences,Probability Weighting,and Strategy Tradeoffs in Wildfire Management

Wildfires present a complex applied risk management environment, but relatively little attention has been paid to behavioral and cognitive responses to risk among public agency wildfire managers. This study investigates responses to risk, including probability weighting and risk aversion, in a wildfire management context using a survey‐based experiment administered to federal wildfire managers. Respondents were presented with a multiattribute lottery‐choice experiment where each lottery is defined by three outcome attributes: expenditures for fire suppression, damage to private property, and exposure of firefighters to the risk of aviation‐related fatalities. Respondents choose one of two strategies, each of which includes “good” (low cost/low damage) and “bad” (high cost/high damage) outcomes that occur with varying probabilities. The choice task also incorporates an information framing experiment to test whether information about fatality risk to firefighters alters managers' responses to risk. Results suggest that managers exhibit risk aversion and nonlinear probability weighting, which can result in choices that do not minimize expected expenditures, property damage, or firefighter exposure. Information framing tends to result in choices that reduce the risk of aviation fatalities, but exacerbates nonlinear probability weighting.     

A Revised Economic Analysis of Restrictions on the Use of Cell Phones While Driving

Evidence that cell phone use while driving increases the risk of being involved in a motor vehicle crash has led policymakers to consider prohibitions on this practice. However, while restrictions would reduce property loss, injuries, and fatalities, consumers would lose the convenience of using these devices while driving. Quantifying the risks and benefits associated with cell phone use while driving is complicated by substantial uncertainty in the estimates of several important inputs, including the extent to which cell phone use increases a driver's risk of being involved in a crash, the amount of time drivers spend using cell phones (and hence their aggregate contribution to crashes, injuries, and fatalities), and the incremental value to users of being able to make calls while driving. Two prominent studies that have investigated cell phone use while driving have concluded that the practice should not be banned. One finds that the benefits of calls made while driving substantially exceed their costs while the other finds that other interventions could reduce motor vehicle injuries and fatalities (measured in terms of quality adjusted life years) at a lower cost. Another issue is that cell phone use imposes increased (involuntary) risks on other roadway users. This article revises the assumptions used in the two previous analyses to make them consistent and updates them using recent data. The result is a best estimate of zero for the net benefit of cell phone use while driving, a finding that differs substantially from the previous study. Our revised cost-effectiveness estimate for cell phone use while driving moves in the other direction, finding that the cost per quality adjusted life year increases modestly compared to the previous estimate. Both estimates are very uncertain.     

A Risk-Based Method for Modeling Traffic Fatalities

We describe a risk-based analytical framework for estimating traffic fatalities that combines the probability of a crash and the probability of fatality in the event of a crash. As an illustrative application, we use the methodology to explore the role of vehicle mix and vehicle prevalence on long-run fatality trends for a range of transportation growth scenarios that may be relevant to developing societies. We assume crash rates between different road users are proportional to their roadway use and estimate case fatality ratios (CFRs) for the different vehicle-vehicle and vehicle-pedestrian combinations. We find that in the absence of road safety interventions, the historical trend of initially rising and then falling fatalities observed in industrialized nations occurred only if motorization was through car ownership. In all other cases studied (scenarios dominated by scooter use, bus use, and mixed use), traffic fatalities rose monotonically. Fatalities per vehicle had a falling trend similar to that observed in historical data from industrialized nations. Regional adaptations of the model validated with local data can be used to evaluate the impacts of transportation planning and safety interventions, such as helmets, seat belts, and enforcement of traffic laws, on traffic fatalities.     

Using Probabilistic Terrorism Risk Modeling for Regulatory Benefit-Cost Analysis: Application to the Western Hemisphere Travel Initiative in the Land Environment

This article presents a framework for using probabilistic terrorism risk modeling in regulatory analysis. We demonstrate the framework with an example application involving a regulation under consideration, the Western Hemisphere Travel Initiative for the Land Environment, (WHTI‐L). First, we estimate annualized loss from terrorist attacks with the Risk Management Solutions (RMS) Probabilistic Terrorism Model. We then estimate the critical risk reduction, which is the risk‐reducing effectiveness of WHTI‐L needed for its benefit, in terms of reduced terrorism loss in the United States, to exceed its cost. Our analysis indicates that the critical risk reduction depends strongly not only on uncertainties in the terrorism risk level, but also on uncertainty in the cost of regulation and how casualties are monetized. For a terrorism risk level based on the RMS standard risk estimate, the baseline regulatory cost estimate for WHTI‐L, and a range of casualty cost estimates based on the willingness‐to‐pay approach, our estimate for the expected annualized loss from terrorism ranges from $2.7 billion to $5.2 billion. For this range in annualized loss, the critical risk reduction for WHTI‐L ranges from 7% to 13%. Basing results on a lower risk level that results in halving the annualized terrorism loss would double the critical risk reduction (14–26%), and basing the results on a higher risk level that results in a doubling of the annualized terrorism loss would cut the critical risk reduction in half (3.5–6.6%). Ideally, decisions about terrorism security regulations and policies would be informed by true benefit‐cost analyses in which the estimated benefits are compared to costs. Such analyses for terrorism security efforts face substantial impediments stemming from the great uncertainty in the terrorist threat and the very low recurrence interval for large attacks. Several approaches can be used to estimate how a terrorism security program or regulation reduces the distribution of risks it is intended to manage. But, continued research to develop additional tools and data is necessary to support application of these approaches. These include refinement of models and simulations, engagement of subject matter experts, implementation of program evaluation, and estimating the costs of casualties from terrorism events.     

The financial burden of psychosocial workplace aggression: A systematic review of cost-of-illness studies

Understanding the economic impact of psychological and social forms of workplace aggression to society could yield important insights into the magnitude of this occupational phenomenon. The objective of this systematic review was to collate, summarise, review and critique, and synthesise the cost of psychosocial workplace aggression at the individual- and societal-level. A peer-reviewed research protocol detailing the search strategy, study selection procedures and data extraction process was developed a priori. Both the academic and grey literatures were examined. To allow for basic comparison, all costs were converted and adjusted to reflect 2014 US dollars. Twelve studies, from 5 national contexts, met the inclusion criteria and were reviewed: Australia (n?=?2), Italy (n?=?1), Spain (n?=?1), the United Kingdom (n?=?3) and the United States (n?=?5). The annual cost of psychosocial workplace aggression varied substantially, ranging between $114.64 million and $35.9 billion. Heterogeneity across studies was found, with noted variations in stated study aims, utilised prevalence statistics and included costs. The review concludes that existing evidence attests to the substantial cost of psychosocial workplace aggression to both the individual and society, albeit such derived estimates are likely gross under-estimates. The findings highlight the importance of interpreting such figures within their conceptual and methodological contexts.     

Residential Building Codes,Affordability, and Health Protection: A Risk-Tradeoff Approach

Residential building codes intended to promote health and safety may produce unintended countervailing risks by adding to the cost of construction. Higher construction costs increase the price of new homes and may increase health and safety risks through income and stock effects. The income effect arises because households that purchase a new home have less income remaining for spending on other goods that contribute to health and safety. The stock effect arises because suppression of new-home construction leads to slower replacement of less safe housing units. These countervailing risks are not presently considered in code debates. We demonstrate the feasibility of estimating the approximate magnitude of countervailing risks by combining the income effect with three relatively well understood and significant home-health risks. We estimate that a code change that increases the nationwide cost of constructing and maintaining homes by $150 (0.1% of the average cost to build a single-family home) would induce offsetting risks yielding between 2 and 60 premature fatalities or, including morbidity effects, between 20 and 800 lost quality-adjusted life years (both discounted at 3%) each year the code provision remains in effect. To provide a net health benefit, the code change would need to reduce risk by at least this amount. Future research should refine these estimates, incorporate quantitative uncertainty analysis, and apply a full risk-tradeoff approach to real-world case studies of proposed code changes.     

灾后不确定需求下应急医疗移动医院鲁棒选址问题研究

我国灾害医学救援主要采用"现场救治"模式，应急医疗移动医院的选址是否合理直接影响救援效率，但各受灾点伤员数量的不确定性增加了决策的困难。本文引入多面体不确定集合刻画伤员数量的不确定性，同时考虑伤员分类及移动医院分型，构建一个以伤员总生存概率最大化为目标的鲁棒选址模型。利用鲁棒优化理论，将模型转化为等价的混合整数规划问题，通过GAMS软件编程并调用CPLEX求解器求解。最后，以四川芦山地震应急医疗救援为例，验证模型和求解方法的可行性和鲁棒性。结果表明，扰动比例和不确定水平对移动医院的选址和伤员的分配方案有显著影响，决策者可根据自己对不确定性风险的偏好程度选择最佳的扰动比例和不确定水平组合，以获得最优的选址分配方案。     

Car Occupant Life Expectancy: Car Mass and Seat Belt Effects

Average human life expectancies for the U.S. resident population are calculated using tabulated population and survival rate data. These life expectancies are recalculated assuming elimination of various types of motor vehicle fatalities using Fatal Accident Reporting System (FARS) data. The differences between the original and recalculated values provide estimates of life expectancy reductions due to the motor vehicle fatalities. These estimates are combined with prior work relating the likelihood of an occupant fatality to car mass, so that reductions in life expectancy are determined as a function of car mass. The estimates of life expectancy reductions are also used to determine the effect of seat belt use on life expectancy. The estimates, which are based on data for 1978, assume that survival rates remain unchanged. Estimates of the changes in life expectancy associated with switching from a large (1800 kg) car to a small (900 kg) car, and switching from not using to using a seat belt are presented as functions of the age at which an individual makes the switch.     

考虑灾民痛苦感知的应急避难所选址与物资分配优化

大规模灾害发生初期，应急物资往往不能及时供应，受灾群众因缺乏物资和服务产生痛苦感知。针对该问题，设计数值评定量表（NRS）构建痛苦函数，刻画灾民痛苦感知成本，将灾民感知因素纳入应急总成本的决策考量。提出以总社会成本（物流成本和痛苦心理成本之和）最小为应急救援目标，构建了一个考虑灾民疏散与重新安置、临时避难所选址和物资分配的集成优化模型。设计经典混合整数规划方法和改进的遗传算法对所构模型进行求解，并应用于海南威马逊台风案例。案例分析表明，模型和算法能有效解决考虑灾民痛苦的避难所选址与物资分配问题，揭示了随着受灾规模的增加和疏散时间的减少，遗传算法的求解结果优于经典求解方法。     

The Use of Individual and Societal Risk Criteria Within the Dutch Flood Safety Policy—Nationwide Estimates of Societal Risk and Policy Applications

The Dutch government is in the process of revising its flood safety policy. The current safety standards for flood defenses in the Netherlands are largely based on the outcomes of cost‐benefit analyses. Loss of life has not been considered separately in the choice for current standards. This article presents the results of a research project that evaluated the potential roles of two risk metrics, individual and societal risk, to support decision making about new flood safety standards. These risk metrics are already used in the Dutch major hazards policy for the evaluation of risks to the public. Individual risk concerns the annual probability of death of a person. Societal risk concerns the probability of an event with many fatalities. Technical aspects of the use of individual and societal risk metrics in flood risk assessments as well as policy implications are discussed. Preliminary estimates of nationwide levels of societal risk are presented. Societal risk levels appear relatively high in the southwestern part of the country where densely populated dike rings are threatened by a combination of river and coastal floods. It was found that cumulation, the simultaneous flooding of multiple dike rings during a single flood event, has significant impact on the national level of societal risk. Options for the application of the individual and societal risk in the new flood safety policy are presented and discussed.