1129: The Rising Cost of Falling Vaccination Rates

JOHN SHEEHAN:

This is Public Health Review Morning Edition for Tuesday, May 19, 2026. I'm John Sheehan with news from the Association of State and Territorial Health Officials.

Today, the growing health and economic consequences of vaccine-preventable diseases. Ben Lopman, professor of epidemiology, global health, and environmental health at Emory University's Rollins School of Public Health, discusses the new Vaccine Impact Map, an interactive tool designed to help public health officials visualize how declining vaccination coverage could affect their states over time. Later, Bryan Patenaude, associate professor of economic evaluation and health economics at Johns Hopkins Bloomberg School of Public Health, breaks down the financial realities of measles outbreaks and why even relatively small outbreaks can carry massive costs for public health systems, hospitals, insurers, and families. Let's start with Ben Lopman and Emory University's new interactive Vaccine Impact Map.

BEN LOPMAN:

You know, we're obviously in a rather unusual policy and cultural environment right now with routine childhood vaccines. And, you know, we've been hearing all these things about how vaccination rates are dropping, you know, kindergarten vaccine coverage is going down one survey after another. And, you know, sometimes these numbers seem quite small, 1-2% drop. But, you know, my instinct as an epidemiologist is that, you know, this declines in the number of kids getting vaccinated may not be small at all. And as those numbers, as those coverage comes down, you know, we're likely to see cases, hospitalizations, et cetera, rising. But we didn't see that there was a tool out there that was showing what those potential real world consequences would be. So, my group built this tool, which we call Vaccine Impact Map, where you can look at the map and see how many children in your state, you know, might become cases, become hospitalized, even deaths, if let's say vaccination rates go down by 5, 10, 20%, you know, what will be the real consequences of that. So, we were trying to fill that gap between what we see happening with vaccine coverage and what that means in terms of real public health consequences.

SHEEHAN:

Yeah, and that sounds really helpful. I'm reminded of one of those flood maps where if you plug in a variable like sea level rises, two inches, what does that mean for my neighborhood? And you can see a visual representation of it.

LOPMAN:

No, that's exactly the idea behind it is that, and these impacts will vary from state to state, right? Both in terms of just the number of kids in the state, what their birth rates are like. Also, where their vaccine coverage is now, right? States with high vaccine coverage will be affected potentially in different ways to those with relatively low vaccine coverage. And so, you know, you can come to this map and say in my state, what will happen if vaccine coverage goes down by 1, 5, 10 percentage points? And also those impacts don't happen immediately. The consequences can kind of accrue. So you can say what will be the impact in one year or in five years, you know, if this trend continues.

SHEEHAN:

Wow. Yeah. And that seems like it would make an impact you can see taking those small percentage points and translating it onto, you know, when it's overlaid onto your community.

LOPMAN:

Yeah, no, precisely. And, you know, you mentioned percentages. And the thing about percentages when you think about vaccine coverage rates, for example, is I think, you know, they make sense to us as epidemiologists, but they often kind of hide the real, you know, the real human impact. You know, a 10% decline in a state with 5 million kids is very different than a 10% decline in a small state, for example, just in terms of sheer numbers. And so, you know, what this tool does is it kind of runs those numbers through epidemiological models. So this is kind of based on, you know, epidemiological theory and the kind of tools that we frequently use. And we calibrated those models to each state's population, like I mentioned already, birth rates, current vaccine coverage, et cetera. And so then what you get instead of just like a percentage is how many actual kids are projected to be hospitalized, how many projected additional deaths, and the dollars spent as well, you know, what are the economic consequences. And I think some of the numbers that this shows are quite sobering. You know, after, for example, a five-year 20% sustained drop in pertussis vaccination, we'd be talking on the order of 3,000 additional hospitalizations and maybe 25 to 30 deaths every year across the country. So, you know, real substantial numbers.

SHEEHAN:

My gosh, yeah. And, you know, hospitalizations and deaths are awful, and there's no debating that. But I think it's useful that the tool also includes those economic costs. And it's not just sort of the hospital bill costs. It's not, you know, the direct money out of pocket necessarily. It's spread across other variables.

LOPMAN:

No, that's exactly right. So, I think when we think about the economic costs, like you mentioned, we often think of the hospital bill of kind of a child being, you know, severe case being hospitalized. But that's really only kind of one part of the economic story. And it's especially true for infections, pathogens, where most cases are relatively mild. Most don't require hospitalization. But still, you know, a kid misses school. A parent has to stay home. Days of work are missed. There's lost wages potentially. Sometimes jobs are lost even. And so, you know, we wanted to include both of those so-called, you know, direct medical costs, but as well a lot of these kinds of indirect or societal costs, productivity losses as economists call them. And so you can add up, you know, these impacts both in terms of medical bills, but also these societal costs. And the numbers can become large really very, very quickly. And it's also kind of a reminder that, you know, vaccines, yes, they protect children directly, but they also contribute to kind of economic stability, productivity, because you can count on your kid not getting sick from a given vaccine-preventable disease if they're vaccinated.

SHEEHAN:

And in the context of your map, you can see what happens and how those costs can balloon when vaccination rates go down even by as little as 5%.

LOPMAN:

No, that's exactly right. And there are these clear, again, both health and economic consequences. I mean, vaccines are, you know, amongst the most extraordinary tools for public health, but they also have these really substantial economic benefits. And the converse of that, of course, is true too. If we vaccinate fewer kids, those costs will kind of come back on the ledger. Now, in this vaccine impact map, we have so far only included three diseases, three vaccine-preventable diseases, rotavirus, a main cause of diarrheal disease, pertussis, whooping cough, and invasive bacterial disease, which can be prevented by the pneumococcal conjugate vaccine. Actually, just those three vaccine-preventable diseases, we estimate that over five years of sustained coverage decline on the order of, you know, if it's as high as 20%, could cost upwards of a billion dollars per year just for those three diseases. So, you know, in the context of the enormous savings that you quoted earlier, if we choose to vaccinate less, those costs come back on society. And how can public health officials take advantage of the map? So, I'm not sure I said where people can find the website yet, and that's at vaximpactmap.org, and that's Vax with an X. And it's an online, freely available, interactive tool that really anyone can use. But we really built it with kind of state and other public health officials and public health practitioners in mind. So, you can go to vaximpactmap.org right now. And what you can do is you can select your state. You can choose a disease. There's a slider to decide to look at different projections of what would happen if vaccine coverage goes down by 5%, 10%, 15%, 20%, and see what that decline looks like in your state's population. And the idea is that, you know, you can take the data from this, a public health practitioner can take this data and, you know, put it in front of a governor's office or bring it to a legislative committee and use it in a town hall or even, you know, potentially for a discussion in a doctor's office. You know, I think this is exactly what this tool is for. It's kind of taking the abstract idea of vaccine coverage and making it concrete in terms of disease and economic outcomes and in doing so putting people in a position to kind of act, giving them the information that they need.

SHEEHAN:

And you mentioned that so far, the map only includes a few diseases. It seems like the opportunity is there to add to it. Are there plans to evolve it?

LOPMAN:

Yeah, there certainly are. You know, maybe first explain why we chose these three diseases to start with. And it's a little bit technical, I suppose, in that, you know, these three vaccine-preventable diseases, again, rotavirus, diarrhea, pertussis, and invasive bacterial disease, they are endemic infections, right? They're always with us. They're always being transmitted. And what that means is there's a pretty predictable relationship between vaccine coverage and how many cases there would be. That's very different from measles, for example, where outbreaks occur. It's a bit random where cases might occur. And so measles is actually much harder to predict. So, we started with these three mainly for that reason, is that we're quite confident in what the predictions would be. But clearly, you know, there's this  phenomenon of declining vaccine coverage is potentially going to affect many vaccines. First and foremost, the ones that have been affected by this sort of changing policy landscape, vaccines going from universal recommendation to shared clinical decision-making or for high-risk recommendations. So, we're looking at including vaccine-preventable diseases like hepatitis B, where there's been policy changes, potentially the seasonal respiratory viruses like influenza, COVID, RSV, respiratory syncytial virus. All of these are kind of on our kind of landscape of things that we're looking at including in the map in future iterations. And we'll also be keeping a close eye on the policy environment to see where the kind of priority is there.

SHEEHAN:

And based on the map, have you seen any other interesting takeaways or been able to make any forecasts regarding declining vaccination rates?

LOPMAN:

Yeah, great question. And, you know, this might be a little bit semantic, but I think of these as like possible projections rather than forecasts or predictions. What we want to do with this map is to kind of outline, you know, what are the possible future paths? What happens if, in this scenario, declining vaccine coverage? So we are, of course, not, the future is not determined here and it's our choice, you know, as a society, what happens in terms of vaccine coverage. But, you know, the point of this map is to kind of really show the consequences of declining vaccination. And so, I, you know, just give a few examples of what some of the findings from these three pathogens. I mean, one is, you know, rotavirus, again, a cause of diarrheal disease. I think what's most shocking about rotavirus is how frequent it is. And so we predict if vaccine coverage drops by 20% and it's sustained for five years, it would be over 800,000 additional cases nationally per year. And that's the majority of the costs, on the order of $900 million in costs just from that one vaccine-preventable disease. Pertussis, I think the story is really about hospitalizations, up to 3,000 or more hospitalizations per year nationally. And invasive pneumococcal disease, which is the most, tends to be the most severe of these, we would predict on the order of 140 additional deaths per year with that kind of decline in vaccine coverage. So, again, the point of this map is to really show what the health and economic impacts would be. And, you know, they're not hypothetical. It would be quite consequential to have these kinds of impacts.

SHEEHAN:

Absolutely. Well, Ben Lopeman, thanks so much for joining us.

LOPMAN:

My pleasure. Thanks so much for having me.

SHEEHAN:  

Ben Lopman is professor of epidemiology, global health, and environmental health at Emory University's Rollins School of Public Health. Find a link to the VaxImpactMap in the show notes.

Now let's hear from Bryan Patenaude, associate professor of economic evaluation and health economics at Johns Hopkins Bloomberg School of Public Health on the real costs of measles outbreaks. So, Bryan, I suspect I know the answer to this, but why is now the time to explain the cost of measles?

BRYAN PATENAUDE:

Well, we're seeing more measles outbreaks than ever before in the United States. In the last 60 years, we have not had outbreak situations that have looked like we're seeing today. So, it's particularly important to understand what are the implications of this for health budgets? What are the implications of this for households, for health systems, for insurance, for everyone?

SHEEHAN:  

Yeah. What are the big findings?

PATENAUDE:

What we're seeing is that these outbreaks, even if they're very small, can cost a lot. And there's sort of a cost that's incurred immediately by just getting the resources moving, like getting contact tracers in place, getting people moving, that's substantial. And so, the more outbreaks you have, the more those costs accrue. Those don't necessarily scale evenly with the size of outbreaks, but they are large at the very beginning. And so the more you have popping up in different states, different areas, the greater

 he cost that you're incurring.

SHEEHAN:  

Certainly. And there's that, as you mentioned, there's that upfront cost of the actual person who's been infected. And then there's, you know, the cost to health agencies to manage contacts from that person.

PATENAUDE:  

Yeah, exactly. So, we're concerned with both costs that are incurred due to somebody going to a hospital, seeking treatment, all of the protocols that need to be put in place at that hospital to quarantine the patient and prevent the infection from spreading to other individuals at the hospital, as well as all of the costs associated with contact tracing, following up and making sure that we can connect people more fluidly to care to prevent people randomly showing up at facilities and causing issues, and also to notify people, schools, et cetera, where a person has been.

SHEEHAN:  

Yeah. And your study found that the average cost of responding to a measles outbreak is more than $766,000. How is that different from previous estimates?

PATENAUDE:  

So, it's not significantly different from previous estimates. We were able to leverage a bunch of other data that's been collected more recently because there have been more outbreaks. And one of the problems that we were really seeking to address with this study wasn't necessarily to try and completely differ in terms of averages we were getting from previous studies, but to break that average down to determine what's incurred up front, what's incurred on average over time, and what costs actually scale as the outbreak gets larger. And previous studies weren't able to do that because most of the data came from pretty small outbreaks or was from like a partial perspective. So it wasn't fully taking into account all of the costs that we'd like to account for. There have been more studies. There have been more outbreaks since the kind of previous evidence was done. So our average outbreak cost is roughly the same as in the past that we're seeing, but those are mostly small outbreaks. What's particularly interesting is in our study, we were able to separate sort of the costs that are occurred up front, which are like in the ballpark of $200,000 up front, and then the cost that scale as the outbreak grows in size, which is about $16,000 per additional case. So before when organizations were interested in being like how much might an outbreak cost us, they were taking some old averages, which was about $43,000 per case, and they were using that, or $30,000 to $40,000 per case, and they were using that to sort of project out costs. What we're saying is like immediately, you should probably consider budgeting for more than that at the up front, but then as the scale goes up, it might not be as much as $43,000, but you do have that sort of initial up front cost that's best to mobilize quickly and have available quickly. And so the benefit of this knowledge is really to help people plan better than they were able to plan before.

SHEEHAN:

And how can enumerating that kind of help leaders and officials better plan for these outbreaks going forward?

PATENAUDE:   

Well, one, it lets you have an idea of the resources you would need based on scenarios that might be predicted based on outbreak size and how at risk your population is. So we work a lot with epidemiologists, obviously. They have sort of risk projections for different areas where they're trying to figure out, okay, what does vaccination coverage look like? What is sort of previous measles exposure look like in the population? How likely is it if we had somebody come in with active measles into that group that an outbreak would occur? What do we think based on some scenarios that size might be? And then you can use our data to predict like in order to be able to respond to that outbreak, how much money would you need to be able to tap into and how much do you think that would cost? So, that's how we kind of work from a planning aspect with epidemiologists to use this data. But another thing that's important is just understanding what the burden of this is and who bears that burden and what would those individuals or organizations be otherwise doing with this money if they didn't need to do it and just to have an idea at scale of what the implications are of things that affect measles outbreak potential because those are causing resources to be diverted away from things that they otherwise would be funding. We don't have a ton of excess floating around in our healthcare budgets. Healthcare is expensive. So we call this opportunity cost in economics, but the opportunity cost is particularly important to understand. So part of what we're doing is to help people be prepared and know what to budget. But part of it is just so that policymakers and decision makers understand what the opportunity costs of the situation we're in is.

SHEEHAN:

Yeah, absolutely. I mean, make the case to the legislators and policymakers that, by the way, the cost of not making certain legislation or not enforcing certain regulations is going to be X number of dollars in potential outbreak scale however many times.

PATENAUDE:   

Yep, exactly. And to help people think about this, we've actually produced what will be released shortly as an open access web-based application that you can work with models and you can work with our data and kind of project out costs and who would bear the burden. So we break it down by, is this something that hospital systems pay and are reimbursed for? Does it come from federal dollars or state dollars likely in your setting? How much is expected to be a sort of public health department expense? And how much is like for treatment costs or something going to be reimbursed by Medicaid or by one of those organizations directly to the patient or to the hospital system who's providing care? So we try to break those out to be informative about where these resources might be coming from. And so not the full cost of all of this is going to be borne by one entity, as I'd mentioned before. And this sort of helps people who are involved with planning tease that out a little bit.

SHEEHAN:

Well, Bryan Patenaude, thanks so much.

PATENAUDE:    

Yeah, thank you for having me. Happy to chat.

SHEEHAN:  

Bryan Patenaude is an associate professor of economic evaluation and health economics at Johns Hopkins Bloomberg School of Public Health. Earlier, we heard from Ben Lopman, professor of epidemiology, global health, and environmental health at Emory University's Rollins School of Public Health.

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This has been Public Health Review Morning Edition. I'm John Sheehan for the Association of State and Territorial Health Officials.