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  1. The mixed public-private vaccination program described in Chapter 7.

  2. Times to licensure and adoption, and delay of vaccination benefits presented in Chapter 7.

  3. Calculations of health benefits and costs as described in Chapters 4 and 7, and Appendixes C through P (including calculation of the incremental benefits from new influenza vaccines and the benefits of an improved pertussis vaccine, i.e., the elimination of current adverse effects).

  4. Use of a 5 percent discount rate for future health benefits and costs.

  5. Adoption, for illustrative purposes only, of the committee median perspective on the undesirability of various morbidity conditions and mortality.

  6. Consideration of the development of each vaccine candidate (for each target population) as an independent project.

  7. Expression of health benefits in units considered equivalent in undesirability to the death of an infant (i.e., infant mortality equivalents, IMEs) (see Chapter 4).

Findings

The results of the central analysis, using the committee median perspective (Chapter 7 and Tables 9.1 and 9.2), have been interpreted for a hypothetical situation in which five vaccines are to be selected for highest priority (with no more than one vaccine per disease/target population combination).

First, we rule out vaccines that are dominated in both benefits and costs by another vaccine against the same disease (Table 9.2, columns 1 and 3). Thus, the RSV glycoprotein vaccine is dominated by the RSV attenuated live virus (ALV) vaccine; the hepatitis A subunit vaccine is dominated by the hepatitis A ALV vaccine; and the human rotavirus ALV vaccine is dominated by the bovine rotavirus ALV vaccine.

Table 9.3 displays the patterns of dominance between the remaining 19 vaccine candidates. Procedures described in Chapter 3 are used to select the desired number of candidates.

Thus, of the remaining 19 vaccines, we can as a second step rule out those that are dominated by at least five other vaccines (see Table 9.3). On this basis, we eliminate from consideration: CMV (all target populations); herpes simplex (all vaccines); B. pertussis; N. gonorrhoeae; hepatitis A; rotavirus (bovine ALV); and Coccidioides immitis.

These two steps leave the following nine vaccines (eight diseases) in contention for the top five positions: hepatitis B; RSV (ALV); Hemophilus influenzae type b; influenza (subunit or ALV); Herpesvirus varicellae (for high-risk individuals); Herpesvirus varicellae (for normals and children); streptococcus group B; parainfluenza viruses. RSV dominates six others, so it must be among the top five, regardless of the weight given to benefits and costs.

The selection of the remaining four vaccines depends on the relative weight of health benefits versus costs. In particular, if the



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