Cost-effectiveness of Adult Vaccination Strategies: Pneumococcal Conjugate vs. Polysaccharide Vaccine

JAMA   
February 22/29, 2012, Vol 307, No. 8, pp 749-874
http://jama.ama-assn.org/current.dtl

Original Contributions
Cost-effectiveness of Adult Vaccination Strategies Using Pneumococcal Conjugate Vaccine Compared With Pneumococcal Polysaccharide Vaccine
Kenneth J. Smith, Angela R. Wateska, Mary Patricia Nowalk, Mahlon Raymund, J. Pekka Nuorti, Richard K. Zimmerman
JAMA. 2012;307(8):804-812.doi:10.1001/jama.2012.169

Abstract
Context  The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear.

Objective  To estimate the cost-effectiveness of PCV13 vaccination strategies in adults.

Design, Setting, and Participants A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included Centers for Disease Control and Prevention Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey.

Main Outcome  Measures Pneumococcal disease cases prevented and incremental costs per quality-adjusted life-year (QALY) gained.

Results In the base case scenario, administration of PCV13 as a substitute for PPSV23 in current recommendations (ie, vaccination at age 65 years and at younger ages if comorbidities are present) cost $28 900 per QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost $45 100 per QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 years to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing $496 000 per QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored.

Conclusion  Overall, PCV13 vaccination was favored compared with PPSV23, but the analysis was sensitive to assumptions about PCV13 effectiveness against nonbacteremic pneumococcal pneumonia and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution.