Elsevier

Vaccine

Volume 35, Issue 34, 3 August 2017, Pages 4307-4314
Vaccine

Cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) in older Australians

https://doi.org/10.1016/j.vaccine.2017.06.085Get rights and content

Abstract

Background

The 23-valent pneumococcal polysaccharide vaccine (PPV23) has been funded under the Australia National Immunisation Program (NIP) since January 2005 for those aged >65 years and other risk groups. In 2016, PCV13 was accepted by the Pharmaceutical Benefits Advisory Committee (PBAC) as a replacement for a single dose of PPV23 in older Australian adults.

Methods

A single-cohort deterministic multi-compartment (Markov) model was developed describing the transition of the population between different invasive and non-invasive pneumococcal disease related health states. We applied a healthcare system perspective with costs (Australian dollars, A$) and health effects (measured in quality adjusted life-years, QALYs) attached to model states and discounted at 5% annually. We explored replacement of PPV23 with PCV13 at 65 years as well as other age based vaccination strategies. Parameter uncertainty was explored using deterministic and probabilistic sensitivity analysis.

Results

In a single cohort, we estimated PCV13 vaccination at the age of 65 years to cost ∼A$11,120,000 and prevent 39 hospitalisations and 6 deaths from invasive pneumococcal disease and 180 hospitalisations and 10 deaths from community acquired pneumonia. The PCV13 program had an incremental cost-effectiveness ratio of ∼A$88,100 per QALY gained when compared to a no-vaccination, whereas PPV23 was ∼A$297,200 per QALY gained. To fall under a cost-effectiveness threshold of A$60,000 per QALY, PCV13 would have to be priced below ∼A$46 per dose. The cost-effectiveness of PCV13 in comparison to PPV23 was ∼A$35,300 per QALY gained.

Conclusion

In comparison to no-vaccination, we found PCV13 use in those aged 65 years was unlikely to be cost-effective unless the vaccine price was below A$46 or a longer duration of protection can be established. However, we found that in comparison to the PPV23, vaccination with PCV13 was cost-effective. This partly reflects the poor value for money estimated for PPV23 use in Australia.

Introduction

Pneumococcal diseases are due to infection with the bacterium Streptococcus pneumoniae and have a spectrum of clinical severity, with invasive pneumococcal disease (IPD) and pneumonia without IPD being most severe [1]. Community-acquired pneumonia (CAP) is a frequent non-invasive disease type [2] responsible for a large burden of hospitalisation and death in older adults [3]. Pneumococcal disease remains a leading cause of death globally [4] and is highest at the extremes of age, including children <5 years old and the elderly [1], [5].

In 2005, pneumococcal polysaccharide vaccine (PPV23) was fully funded by the Australian government for all Australians aged  65 years and placed on the Australian National Immunisation Program (NIP) [6]. Prior to 2005 there had been moderate uptake (49.5%) in older Australians [7] as a result of private purchase, public funding in one state (Victoria), as well as targeted PPV23 programs (e.g. in Aboriginal and Torres Strait Islanders >50 years old [5]). After universal funding, a national survey in 2009 estimated self-reported uptake of ∼60% among Australians aged ≥65 years [8]. However, the impact and value for money of PPV23 programs has been questioned in Australia and in other settings [9], [10], [11].

The 7-valent pneumococcal conjugate vaccine (PCV7) was also publicly funded from January 2005 for all Australian infants (on a 3+0 schedule at 2, 4, 6 months [6], with a catch-up program for children <5 years). PCV7 was replaced by PCV13 in July 2011 to combat increases in IPD caused by serotypes not included in PCV7 [6]. Both infant PCV programs have resulted in major reductions in IPD incidence in infants and among adults through herd protection [5].

In 2015, the Community Acquired Pneumonia Immunisation Trial in Adults (CAPiTA) provided new evidence for the efficacy of PCV13 in the prevention of vaccine-type IPD and CAP in older adults [12]. Cost-effectiveness studies published prior to CAPiTA typically overestimated the efficacy of PCV13 against vaccine-type CAP [13] and only a small number of studies have been published since the new CAPiTA data became available [14], [15], [16], [17].

In Australia, PCV13 was recently recommended for funding by the Pharmaceutical Benefits Advisory Committee (PBAC) as a replacement for PPV23 in older adults [18]. In this study we explore the cost-effectiveness of PCV13 (or PPV23) vaccination at the age of 65 years, as well as the impact of varying key uncertain parameters and the age of vaccination.

Section snippets

Model

A single-cohort deterministic Markov model was developed to describe the impact of pneumococcal disease and vaccination. Costs (Australian dollars, A$) and health effects (measured in Quality Adjusted Life-Years, QALYs) were attached to model states, with each discounted at 5% annually [19]. In the base-case model, a cohort of 65 year olds (∼240,000) was followed up to age 100 years in yearly cycles. The initial population size was based on the 2017 (projected) population initially with

Results

For the cohort we project that 60% coverage with PCV13 at age 65 years would prevent 39 hospitalisations and 6 deaths due IPD as well as 180 hospitalisations, 10 deaths and 453 GP visits due CAP. The PPV23 program in the same cohort was estimated to prevent 27 hospitalisations and 4 deaths from IPD. Further details of the projected impact of PCV13 and PPV23 are presented in Appendix 1 Table 1.

In base-case analysis, the total cost of vaccinating those aged 65 years with PCV13 was ∼A$11,120,000.

Discussion

Our analysis compared PCV13 to PPV23 vaccination as well as no-vaccination. The direct comparison to PPV23 aims to identify the relative value for money of switching to PCV13, with comparison to no-vaccination, providing an estimate of the overall value for money of each program, for comparison with other spending choices. In our base-case model, the implementation of a PCV13 program in Australians aged 65 years was estimated not to be cost-effective (threshold of $60,000 per QALY gained) when

Conclusion

In comparison to no-vaccination, we found that PCV13 use in those aged 65 years was unlikely to be cost-effective unless the vaccine price was below A$46 or a longer duration of protection can be established. However, we found that in comparison to the PPV23, vaccination of 65 year olds with PCV13 was cost-effective. This partly reflects the poor value for money estimated for PPV23 in Australia. The results suggests that replacement of PPV23 with PCV13 may be warranted given the relative better

Potential conflict of interest

Raina MacIntyre has been on advisory boards for both Pfizer and Merck on pneumococcal vaccines and received in kind support in the form of testing of specimens for pneumococcal serology from Pfizer for an investigator-driven trial comparing conjugate and polysaccharide vaccines.

A university chair in Philippe Beutels’ centre at the University of Antwerp was supported in 2009–2016 by a gift from Pfizer, and this chair is now also supported by GSK. There is no connection between either Pfizer, GSK

Acknowledgements

This research was supported by an Australian National Health and Medical Research Council Project grant (1081344). NNDSS data on IPD notification and deaths were provided by the Office of Health Protection, Department of Health on behalf of the Communicable Disease Network Australia and the Enhanced Invasive Pneumococcal Disease Surveillance Working Group.

Mortality data on CAP were sourced from the Australian Bureau of Statistics, Causes of Death. Department of Health provided the data on the

References (41)

  • T.M. File et al.

    Burden of community-acquired pneumonia in North American adults

    Postgrad Med

    (2010)
  • WHO, International travel and health, Pneumococcal disease; 2016....
  • C. Chiu et al.

    Vaccine preventable diseases in Australia, 2005 to 2007

    Commun Dis Intell

    (2010)
  • B. Ultsch

    Health economic evaluation of vaccination strategies for the prevention of herpes zoster and postherpetic neuralgia in Germany

    BMC Health Serv Res

    (2013)
  • Australian Institute of Health and Welfare (AIHW), 2004 Adult Vaccination Survey; 2005...
  • Australian Institute of Health and Welfare (AIHW), 2009 Adult Vaccination Survey; 2011....
  • C. Toms et al.

    Invasive Pneumococcal Disease in Australia, 2011 and 2012

    Commun Dis Intell Q Rep

    (2016)
  • R.I. Menzies et al.

    Impact of pneumococcal polysaccharide vaccine in people aged 65 years or older

    Med J Aust

    (2014)
  • R. Hollingsworth et al.

    Pneumococcal vaccination of older adults: conjugate or polysaccharide?

    Hum Vacc Immunother

    (2014)
  • M.J.M. Bonten

    Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults

    New England J Med

    (2015)
  • Cited by (13)

    • Cost-effectiveness of pneumococcal vaccines among adults aged 65 years and older in China: A comparative study

      2023, Vaccine
      Citation Excerpt :

      The efficacy of the PCV13 against VT-CAP and VT-IPD was 45.6 % (95 % CI: 21.8–62.5 %) and 75 % (95 % CI: 41.4–90.8 %), respectively [10]. We assumed that the vaccine efficacy of PPSV23 would stay constant for the first two years after vaccination, decline linearly from the third year, and drop to zero by the sixth year, based on various studies on the duration of vaccine efficacy [35] and relevant cost-effectiveness analysis [36,37]. Similarly, we presumed that the vaccine efficacy of PCV13 would stay constant for the first five years after vaccination, decline linearly from the sixth year, and drop to zero by the eleventh year [37].

    • Cost-effectiveness of meningococcal polysaccharide serogroups A, C, W-135 and Y conjugate vaccine in Australian adolescents

      2019, Vaccine
      Citation Excerpt :

      The occurrence of long-term complications by types and their severity were derived from a South Australian study reporting the occurrence and manifestations of IMD complications among children [13]. In the base-case scenario, we applied a vaccination cost of AU$46 per MenACWY vaccine and administration cost of AU$10 [14], which is generally consistent with the estimated administration costs of $11 for a school-based vaccination program (information provided by Ms. Sue Campbell-Lloyd from the immunisation unit of Health Protection NSW in October 2017). The costs of acute IMD events were derived from data regarding Australian Refined-Diagnostic Related Groups (AR-DRGs) [15].

    • Retrospective cost-effectiveness of the 23-valent pneumococcal polysaccharide vaccination program in Australia

      2018, Vaccine
      Citation Excerpt :

      There are limited available Australian data on the aetiology of CAP, we assumed 13.9% of all CAP was due to pneumococcal infection [18] and (due to a lack of data) we assumed that the proportion of this due to PPV23-types was the same as that observed for IPD in the same year and age group. The rates of CAP general practitioner (GP) visits, hospitalisation, as well as the hospitalisation-fatality rates following CAP were the same as those used in a previous cost-effective analysis of PCV13 vaccination in older Australians [19]. There is no routine collection of PPV23 coverage data at a national level.

    • Evolution over time in the cost-effectiveness of pneumococcal conjugate vaccine (PCV13) in older Australians due to herd protection from infant vaccination

      2018, Vaccine
      Citation Excerpt :

      A detailed outline of parameters and the adapted model can be found in [13]. To summarise briefly, we assumed a $65 price per PCV13 dose and an administration cost of $10 [14]. Age-specific PCV13 efficacy data against serotype specific IPD and pneumococcal CAP were derived from [15].

    • The role of timeliness in the cost-effectiveness of older adult vaccination: a case study of pneumococcal conjugate vaccine in Australia

      2018, Vaccine
      Citation Excerpt :

      Hospitalisation costs for IPD and CAP (see Appendix Table A1) and CAP general practitioners visits costs (see Table 1 [27]) were also included. The age dependent hospitalisation costs were based on a previous study that examined Australian Refined Diagnosis Related Groups (AR-DRGs) codes and the associated public hospital cost [14]. We assumed that each IPD case resulted in a hospitalisation.

    View all citing articles on Scopus
    View full text