to the editor: American Family Physician published recommendations from the American Academy of Pediatrics (AAP) on the prevention and treatment of Lyme disease.¹ These recommendations appear straightforward. As usual, however, it is the fine print that trips us up. Here in the state of Maine, insurers have decided that the southern most county in the state is the only high-risk area; therefore, they will only pay for the Lyme vaccine for residents of that county.

A second problem is achieving compliance with yet another vaccine. Even worse is the problem of complying with a vaccine that consists of multiple doses.

A third problem is the price of the vaccine. I called my medical center pharmacy and the price for a single dose of the vaccine is $63.99. For three doses, $191.97 is a fairly pricey intervention. The suggestion in this practice guideline that the protective immunity is not known to last more than one year beyond dose 3 raises more questions about cost-effectiveness.

I found only one study evaluating cost-effectiveness of vaccination,² and it concluded that the mean cost of vaccination per case of Lyme disease averted is $4,466 based on the following assumptions: 0.80 probability of diagnosing and treating early Lyme disease, 0.005 probability of contracting Lyme disease and a vaccination cost of $50 per year.

I take issue with these assumptions as follows: I think 0.80 probability of diagnosing is an extremely high estimate; it is more likely to be 0.80 of those 50 to 60 percent of patients who have the erythema migrans rash of Lyme disease. Keeping the same attack rate as cited in the guidelines, and raising the vaccine cost per year to the $96, my patients would be charged a total of $383.94 (three doses over two years at $63.99 per dose). This is a fourfold reduction in benefit (or a cost of approximately $17,900 per case averted). I am omitting the nursing charge for vaccine administration, which would add another $10 per dose, because I assume there to be a slight mark up by my pharmacy.