EDITORIAL Is virology cost-effective

Having recently organised and analysed ananonymous questionnaire [1] for the Royal Col-lege of Pathologists on the future training needsfor Virologists in the UK, I was intrigued to readthe comment; ``Virologists are a luxury we can nolonger afford''. While the two microbiologists whoeach made this comment appear to be under-whelmed by the achievements of their virologicalcolleagues, I wonder if their nihilistic view can bejusti®ed objectively?

For debate, I would argue that Virology is themost cost-effective of all medical specialities!Virologists have collaborated to eradicate small-pox from the globe, and the costs of the globaleradication campaign were repaid within 30 days[2]. This great achievement may be repeated soonif poliomyelitis can be eradicated from the worldin the next year or so. Can any other medicalspeciality lay claim to having eradicated onedisease, let alone two? Do surgeons have plansto eradicate varicose veins from the globe orphysicians to eradicate lung cancer? Note that(most) lung cancer is potentially preventable byeliminating tobacco exposure, yet progress herehas been lamentably slow due to the failure to faceup effectively to the ®nancial clout and politicalpower of tobacco companies. In contrast, previousgenerations of Virologists faced up to all vestedinterests, including political forces manifest in theextreme as wars [3], in all countries world-wide toachieve their set objectives.

Other achievements of Virologists may not beof global signi®cance yet demonstrate cost-effectiveness in their own way. For example,targeted immunisation campaigns rely on virolo-gical tests to identify those in whom vaccination isunnecessary. An example is screening of womenof child-bearing age for rubella antibodies, inwhom costs would increase dramatically if vac-cine was given empirically to all women instead ofto the few per cent identi®ed by serologicalscreening. Costs are incurred in laboratory testing,but these are greatly repaid by the saving in

vaccinations avoided. Likewise, screening of preg-nant women for hepatitis B and for HIV canidentify those neonates who would bene®t fromvaccination and post-exposure prophylaxisagainst each virus, respectively [4,5]. The costs ofadministering such a programme are far less thanthe future costs of liver transplantation or treat-ment of paediatric AIDS, respectively. Further-more, virological tests for genotyping hepatitis Cvirus can save money by reserving 12 months' ofcombination therapy only for patients with geno-type 1 virus [6]. Hepatitis C viral load tests canalso be used to identify patients in whom anantiviral response has not occurred by 3 months,so that expensive and toxic interferon therapy canbe stopped [6]. In the ®eld of HIV, recentcontrolled studies have shown that prescriptionof antiviral cocktails are more likely to succeed incontrolling viral replication if drugs are selectedby the Virologist on the basis of genetic changes ofresistance found in the plasma of each individualpatient [7].

So, by extension, practising Virologists (pro-vided they are competent) must be an essentialcomponent of this process, not a luxury whichcannot be justi®ed. If this premise is true, thesemultiple examples must demonstrate that Virol-ogy is cost-effective; so why is this not moregenerally appreciated? While many can see thecurrent costs of the laboratory assays performed,few realise the value that they represent, particu-larly if bene®ts which arise in the future arediscounted ®nancially (reviewed in [8]). Further-more, the savings made by preventing viraldisease accrue to the budgets of others, such asimmigration (reduced time per person questionedbecause smallpox vaccination certi®cates nolonger need to be inspected); education (decreasedcost of caring for children with hearing lossfollowing intrauterine rubella infection); trans-plantation (reduced numbers requiring livertransplant secondary to vertical transmission ofHBV); AIDS (reduced costs of treatment of disease

Reviews in Medical Virology Rev. Med. Virol. 2000; 10: 139±140.

Copyright # 2000 John Wiley & Sons, Ltd.

acquired perinatally); hepatology (pharmacysavings from reduced duration of prescribingcombination therapy for HBV). Perhaps weshould ask for funding of programmes (controlof rubella, etc), so that savings in one budgetwithin the programme (e.g. pharmacy budget forvaccines) can be vired to others (diagnosticvirological assays) within the programme ratherthan focussing parochially on individualbudgets.

Ultimately, we should require that specialitiesare judged by their overall effectiveness atachieving pre-determined objectives, includingtheir successes from the past, not by how busytheir practitioners appear to be at the present time.After all, the microbiological colleagues whoreplied to the questionnaire mentioned aboveprobably have a heavy workload because of thefailure of previous generations from their speci-alty to control the selection of microbes resistant toantibiotics.

P. D. Grif®ths

REFERENCES1. Grif®ths PD. Review of virological training for

candidates for MRCPath (Virology) and MRCPath(Microbiology). Bulletin of the Royal College of Pathol-ogists, 2000; 109: 34±38.

2. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID.Smallpox and its eradication. World Health Organisa-tion: Geneva, 1988.

3. Progress toward poliomyelitis eradicationÐAfghani-stan, 1994±1999. MMWR, 1999; 48(37): 825±828.

4. Burk RD, Hwang LY, Ho GY, Shafritz DA, BeasleyRP. Outcome of perinatal hepatitis B virus exposureis dependent on maternal virus load. J Infect Dis 1994;170(6): 1418±1423.

5. Mofenson LM. Short-course zidovudine for preven-tion of perinatal infection. Lancet 1999; 353: 766±767.

6. Consensus Statement. EASL International ConsensusConference on hepatitis C. J Hepatol 1999; 30: 956±961.

7. Durant J, Clevenbergh P, Halfon P, et al. Drug-resistance genotyping in HIV-1 therapy: the VIRA-DAPT randomised controlled trial. Lancet 1999; 353:2195±2199.

8. West RR. Economic rate of discount and estimatingcost bene®t of viral immunisation programmes. RevMed Virol 1999; 9(1): 51±55.

140 Editorial

Copyright # 2000 John Wiley & Sons, Ltd. Rev. Med. Virol. 2000; 10: 139±140.