This review of published economic analyses of rubella, CRS, and rubella vaccination suggests some general themes about economics of the disease and the value of vaccination. In high- and middle-income countries, CRS is such a costly disease that rubella vaccination is a high value intervention.
The review revealed that a broad consensus over four decades and in a variety of high- and middle-income countries has existed, i.e., rubella vaccination (including different programmatic approaches to vaccination) is cost-effective or cost-beneficial. This has been true for vaccination of children of both genders (to interrupt rubella transmission) [24, 25, 28–33]; vaccination of teenage girls or adult women (to prevent CRS) [39, 41]; and vaccination of children, adolescent girls, or adult women [22, 24, 25, 28, 30–32]. In general, vaccination to prevent CRS was more cost-beneficial or cost-effective than vaccination to interrupt rubella transmission.
With regard to testing and vaccination of hospital workers, earlier studies [17, 18] suggested that blind vaccination was preferable to targeted vaccination (after serological screening). But more recent studies found that blind vaccination is only slightly more costly  or less costly than targeted vaccination . Cost analyses also suggest that vaccination is affordable for health workers, [17, 18] among children  and among postpartum women . This finding suggests that as vaccine prices have fallen over the years, blind vaccination has become more favorable compared to targeted vaccination.
The use of mass campaigns was modeled in Canada  and the Caribbean [16, 33, 34, 36] and in conjunction with routine immunization. One study evaluated the use of monovalent rubella vaccine  and another MR in an evaluation of adding childhood immunization to an already-existing program of immunizing 12-yr old girls . The others used MMR only, [26, 28, 32, 37, 38] MMR and monovalent rubella vaccine [25, 33, 34, 36] or MMR for routine and MR for campaigns . Both campaigns in conjunction with routine immunization and routine programs, regardless of the vaccine presentation used, were cost-beneficial.
One of the most striking findings was that no studies have been performed in low-income countries where the highest burden of rubella and CRS exists. This may be due to the limited treatment options for CRS and use of RCV in these countries. However, now that the GAVI Alliance has introduced funding for RCV into its program , demand for these analyses should increase.
Conducting economic analysis of introducing RCV in low-income countries would provide useful information for program managers and policymakers on which service delivery strategies are cost-effective and cost-beneficial and which age groups should be targeted. Economic analyses on RCV will not be needed in every country before RCV since studies from countries with similar socio-demographic circumstances can be informative [42, 43]. However, given the high cost of CRS and the low cost of vaccination, as well as increasing price inflation of healthcare and other services used in the care of disabled children, that the net economic benefit of rubella vaccination will remain substantial in analyses in this setting .
Economic analyses of RCV should examine, for example, whether efficiencies can be gained from using a combination vaccine (MMR) compared to monovalent vaccine . Since measles vaccination is already part of the routine immunization program in all low-income countries , studies could assess the cost-effectiveness of substituting MMR and MR for monovalent measles vaccine. Plotkin  suggests that there will be a large opportunity cost if measles immunization activities do not take advantage of reducing rubella simultaneously and that the cost-effectiveness of rubella vaccination in low-income countries should be taken into account within the context of measles control and elimination.
There are two ways of implementing new rubella vaccine initiatives in countries: vaccinating adolescent girls and/or women of childbearing age to reduce CRS and vaccinating children using combined measles and rubella vaccines (MR or MMR) to interrupt rubella transmission altogether [42, 43]. It would be worthwhile to perform economic analyses to determine which option should be implemented in low-income countries. Three factors make it likely that vaccination of teenage girls and women of childbearing age will be more efficient in low-income than in high-income countries: 1) later immunization reduces the time to benefits because there are fewer years to discount; 2) the costs of acute childhood rubella are so small that the net benefit of early vaccination is diminished; and 3) since the vaccine provides immunity for at least twenty years, immunity would increase among adults .
We also found some methodological issues related to discounting. Studies differed as to whether or not discounting was performed and which discount rate was used. Discounting allows analysts to value current costs more than future costs given the opportunity cost associated with current relative to future expenditure . It is desirable to avert healthcare costs today because such savings can be invested for a future return . Many of the older studies used discount rates as high as 5%  or 10% [26, 30] although these still found that vaccination was associated with net economic benefits. Future studies should consider using lower discount rates since the choice of discount rate and number of years of discounting affects the potential cost-effectiveness of childhood vaccination.
None of the economic studies reviewed considered herd immunity or potential adverse outcomes associated with vaccination. When herd immunity is taken into account, it increases the attractiveness of mass vaccination campaigns at the onset of programs and on-going vaccination of children . On the other hand, as mentioned earlier, if rubella coverage is too low, RCV could increase the rubella susceptibility of women. Future studies might consider using dynamic modeling methods as the basis of economic evaluations to capture the potential effects of coverage and herd immunity.
Only one of the studies, a cost-effectiveness analysis , included adjustments for disability. Because rubella has potentially significant impacts on the quality of life of CRS patients and their caretakers, future studies might consider estimating the cost per DALY saved or cost per QALY gained.
Rubella has both maternal and child health consequences because maternal infection can cause abortion. Some studies measured the costs of abortions  but most did not. In low-income countries where the burden of rubella and CRS are high and induced abortions are illegal, many more babies with CRS may be born without the option of therapeutic abortion and this would have economic consequences. Moreover, models may need to consider levels of fertility and induced abortion as they relate to CRS burden, as well as the economic consequences of safe or unsafe abortions or abortions performed in response to a diagnosis of CRS. Since vaccination may prevent many medically-indicated abortions in developed countries and clandestine abortions in developing countries, studies might quantify this potential economic and health outcomes impact.