Cost-effectiveness analysis of pneumococcal conjugate vaccine in Taiwan: a transmission dynamic modeling approach

Dynamic Vaccine Allocation for Control of Human-Transmissible Disease

During pandemics, such as COVID-19, supplies of vaccines can be insufficient for meeting all needs, particularly when vaccines first become available. Our study develops a dynamic methodology for vaccine allocation, segmented by region, age, and timeframe, using a time-sensitive, age-structured compartmental model. Based on the objective of minimizing a weighted sum of deaths and cases, we used the Sequential Least Squares Quadratic Programming method to search for a locally optimal COVID-19 vaccine allocation for the United States, for the period from 16 December 2020 to 30 June 2021, where regions corresponded to the 50 states in the United States (U.S.). We also compared our solution to actual allocations of vaccines. From our model, we estimate that approximately 1.8 million cases and 9 thousand deaths could have been averted in the U.S. with an improved allocation. When case reduction is prioritized over death reduction, we found that young people (17 and younger) should receive priority over old people due to their potential to expose others. However, if death reduction is prioritized over case reduction, we found that more vaccines should be allocated to older people, due to their propensity for severe disease. While we have applied our methodology to COVID-19, our approach generalizes to other human-transmissible diseases, with potential application to future epidemics.

Economic evaluations of 13-valent pneumococcal conjugate vaccine: a systematic review

INTRODUCTION

Studies on economic evaluations of the 13-valent pneumococcal conjugate vaccine (PCV13) have been increasing over the last decade. No systematic reviews have synthesized the evidence of economic evaluations of the PCV13.

AREAS COVERED

We systematically searched the literature which published on peer-reviewed journals from January 2010 to June 2022. The literature search was conducted in the following electronic databases: PubMed, Web of Science, Embase, the Cochrane Library, CNKI, Wanfang database, VIP database. We identified 1827 records from the database search. After excluding 511 duplicates, 1314 records were screened, of which 156 records were retained for the full-text reviews. A total of 44 studies were included in the review. Among the included studies, 33 studies were economic evaluations of PCV13 among children, and 11 studies were conducted among adults. The literature search initiated in April, 2022, and updated in June 2022.

EXPERT OPINION

Vaccination with PCV13 was found to significantly reduce the mortality and morbidity of pneumococcal diseases and was cost-effective compared to no vaccine or several other pneumococcal vaccines (e.g. PCV10, PPV23). Future research is advised to expand economic evaluations of PCV13 combined with dynamic model to enhance methodologic rigor and prediction accuracy.

Impacts of Catch-Up Immunization program with the 13-Valent pneumococcal Conjugate vaccine in Taiwan: Focus on age-stratified differences and high-risk population (2001-2015)

BACKGROUND

Taiwan commenced a national catch-up immunization program with a 13-valent pneumococcal conjugate vaccine (PCV13) in 2013 for children aged 2-5 years old and in 2014 for children aged 1-5 years old. However, real-world nationwide evidence of both the direct protection and indirect protection of all-cause pneumonia and pneumococcal pneumonia has been scarce, especially among high-risk populations, defined as patients with chronic diseases or immunosuppression. The aim of this study was to examine the impact of the national PCV13 catch-up program on all-cause pneumonia and pneumococcal pneumonia among overall and high-risk populations using interrupted time series analysis.

METHODS

Using the National Health Insurance Research Database (NHIRD) from January 2001 to December 2015, we assessed the impact of this catch-up program by interrupted time-series analyses age-stratified (0-1, 2-4, 5-9, 10-17, 18-34, 35-49, 50-64, 65 + years old) incidence of pneumococcal pneumonia and all-cause pneumonia (100,000 person-quarter) among the overall and high-risk populations.

RESULTS

The impact of this program was most profound on the incidence of pneumococcal pneumonia in children aged 2-4 years old (level change -10.56 per 100,000 person-quarters, p = 0.04; trend change -2.93, p less than 0.01). Indirect protection among unvaccinated children (0-1 years old: trend change -1.19, p = 0.01; 5-9 years old: trend change -1.04, p = 0.03; 10-17 years old: level change -1.42 per 100,000 person-quarters, p = 0.03) was also found. The incidence of all-cause pneumonia also decreased in children aged 2-4 (level change -234.91 per 100,000 person-quarter, p = 0.058) and 5-9 years old (level change -173.96 per 100,000 person-quarter, p = 0.0424). However, we did not find a significant impact among most high-risk populations.

CONCLUSIONS

Our study suggests that the introduction of this catch-up program with PCV13 was associated with significant declines in the incidence of pneumococcal pneumonia and all-cause pneumonia in vaccinated children, and indirect protection from the program was also found in unvaccinated children.

Mathematical assessment of the impact of cohort vaccination on pneumococcal carriage and serotype replacement

Although pneumococcal vaccines are quite effective in reducing disease burden, factors such as imperfect vaccine efficacy and serotype replacement present an important challenge against realizing direct and herd protection benefits of the vaccines. In this study, a novel mathematical model is designed and used to describe the dynamics of two Streptococcus pneumoniae (SP) serotypes, in response to the introduction of a cohort vaccination program which targets one of the two serotypes. The model is fitted to a pediatric SP carriage prevalence data from Atlanta, GA. The model, which is rigorously analysed to investigate the existence and asymptotic stability properties of the associated equilibria (in addition to exploring conditions for competitive exclusion), is simulated to assess the impact of vaccination under different levels of serotype-specific competition and illustrate the phenomenon of serotype replacement. The calibrated model is used to forecast the carriage prevalence in the pediatric cohort over 30 years.

Cost-Effectiveness and Budget Impact Analyses of Pneumococcal Vaccination in Indonesia

As a country with the high number of deaths due to pneumococcal disease, Indonesia has not yet included pneumococcal vaccination into the routine program. This study aimed to analyse the cost-effectiveness and the budget impact of pneumococcal vaccination in Indonesia by developing an age-structured cohort model. In a comparison with no vaccination, the use of two vaccines (PCV10 and PCV13) within two pricing scenarios (UNICEF and government contract price) was taken into account. To estimate the cost-effectiveness value, a 5-year time horizon was applied by extrapolating the outcome of the individual in the modelled cohort until 5 years of age with a 1-month analytical cycle. To estimate the affordability value, a 6-year period (2019-2024) was applied by considering the government's strategic plan on pneumococcal vaccination. In a comparison with no vaccination, the results showed that vaccination would reduce pneumococcal disease by 1,702,548 and 2,268,411 cases when using PCV10 and PCV13, respectively. Vaccination could potentially reduce the highest treatment cost from the payer perspective at $53.6 million and $71.4 million for PCV10 and PCV13, respectively. Applying the UNICEF price, the incremental cost-effectiveness ratio (ICER) from the healthcare perspective would be $218 and $162 per QALY-gained for PCV10 and PCV13, respectively. Applying the government contract price, the ICER would be $987 and $747 per QALY-gained for PCV10 and PCV13, respectively. The result confirmed that PCV13 was more cost-effective than PCV10 with both prices. In particular, introduction cost per child was estimated to be $0.91 and vaccination cost of PCV13 per child (3 doses) was estimated to be $16.61 and $59.54 with UNICEF and government contract prices, respectively. Implementation of nationwide vaccination would require approximately $73.3-$75.0 million (13-14% of routine immunization budget) and $257.4-$263.5 million (45-50% of routine immunization budget) with UNICEF and government contract prices, respectively. Sensitivity analysis showed that vaccine efficacy, mortality rate, and vaccine price were the most influential parameters affecting the ICER. In conclusion, pneumococcal vaccination would be a highly cost-effective intervention to be implemented in Indonesia. Yet, applying PCV13 with UNICEF price would give the best cost-effectiveness and affordability values on the routine immunization budget.

A systematic literature review of economic evaluations of pneumococcal conjugate vaccines in east and southeast Asia (2006-2019)

INTRODUCTION

Pneumococcal infections can lead to serious invasive diseases such as meningitis, septicemia and pneumonia, as well as milder but more common illnesses such as sinusitis and otitis media. The World Health Organization (WHO) recommends the inclusion of pneumococcal conjugate vaccines (PCVs) in infant National Immunization Program (NIP) programs worldwide. Decision-makers in Asian countries planning to introduce PCVs in their respective NIP will need a comprehensive evidence of effectiveness of PCVs at the population level and economic evidence including cost-effectiveness.

AREAS COVERED

A systematic literature review (from 1/1/2016 to 10/11/2019) of PCVs in East and Southeast Asia to understand (1) the contributing factors to cost-effectiveness results of PCVs and (2) whether gaps in evidence exist suggesting why the region may have yet to implement full NIPs.

EXPERT OPINION

In East and Southeast Asia, vaccination with PCVs was found to significantly reduce the mortality and morbidity of pneumococcal diseases and was cost-effective compared to no vaccination. Study assumptions, specifically vaccine local acquisition, the inclusion or exclusion of indirect effects (serotype replacement and herd effect), cross-protection, and protection against nontypeable haemophilus influenzae and serotype 3, were the main drivers of cost-effectiveness.

Cost-effectiveness of a national immunization program with the 13-valent pneumococcal conjugate vaccine compared with the 10-valent pneumococcal conjugate vaccine in South Korea

Introduction

Globally, pneumococcal disease represents a significant burden. South Korea implemented the 7-valent pneumococcal conjugate vaccine (PCV7) in 2003, replaced with the 10-valent (PCV10) and 13-valent (PCV13) vaccine in 2010. In 2014, both vaccines were introduced in the national immunization program (NIP) for infants with 3 primary doses and one booster dose We performed a cost-effectiveness evaluation to elucidate which vaccine may be expected to provide greater impact if included in a NIP.

Methodology

Using an established model, we estimated the impact of introducing either PCV13 or PCV10 into the South Korean NIP in 2015. Vaccine impact was based on historic observed impact of PCV13 from 2010 to 2015 in Korea given high uptake of PCV13, and PCV10 impact was estimated based on experiences in countries using PCV10. Incidence and costs for all ages and including invasive pneumococcal disease, pneumonia, and acute otitis media were derived from the literature and Health Insurance Review and Assessment database.

Results

In the base-case, over 5-years PCV13 was estimated to avert 550,000 more cases of pneumococcal disease compared to PCV10, driven by broader serotype coverage and less replacement due to serotypes 3 and 19A. This translated to a cost-savings of $47.4 million USD despite PCV13’s higher cost. Sensitivity analysis found incremental cost-effectiveness ratios (ICERs) ranged from cost-saving to $7,300 USD per quality-adjusted life year (QALY).

Conclusion

A NIP using PCV13 was estimated to have a more substantial public health impact and be cost-saving compared to a program with PCV10 due to broader serotype coverage.

Pneumococcal Vaccination for Children in Asian Countries: A Systematic Review of Economic Evaluation Studies

Background: Evidence on costs and health benefits of pneumococcal conjugate vaccine (PCV) for children in Asian countries is limited but growing. As a region with a considerably high burden of pneumococcal disease, it is prominent to have a comprehensive overview on the cost-effectiveness of implementing and adopting a PCV vaccination program. Methods: We conducted a systematic review from Pubmed and Embase to identify economic evaluation studies of PCV for children in Asian countries up to May 2020. Data extraction included specific characteristics of the study, input parameters, cost elements, cost-effectiveness results, and key drivers of uncertainty. The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement was followed for this systematic review. The reporting quality of the included studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Results: After the screening process on both the title and abstract and full text of 518 records, a total of 25 studies fulfilled the inclusion criteria, and were included in the review. The majority of included studies demonstrates that PCV for children is cost-effective in most of the Asian region, and even cost-saving in some countries. Most of the included studies implemented cost utility analysis (CUA) using either quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs). Overall, the main drivers affecting the cost effectiveness were vaccine price, burden regarding pneumonia-related parameters, and the inclusion of herd effects. Conclusion: The children pneumococcal vaccination program appears to be a cost-effective intervention in Asia, and even cost-saving in certain conditions. Vaccine price, pneumonia-related disease burden, and the inclusion of the herd effect are observed as important key drivers in estimating cost-effectiveness in this region. Incorporating PCV in vaccination programs in this region was found to be highly favorable.

Deterministic epidemic model for ( S V C S y C A s y I R ) pneumonia dynamics, with vaccination and temporal immunity

Streptococcus pneumonia is one of the leading causes of mobility and mortality in children under 6 years and the elderly especially in developing countries in which Ghana, the study area is not an exception.In this paper, a model of the spread and control of bacterial pneumonia that include symptomatic carriers, asymptomatic carriers and vaccination is formulated and analyzed to determine the effect of the vaccination intervention.Analysis of the system show that the disease free equilibrium is stable if and only if the basic reproductive number R0<1. For R0≥1, the endemic equilibrium is globally stable and the disease persist. Numerical simulation on the system show that with effective vaccine intervention pneumonia infection can be eradicated in the long term.

Impact and cost effectiveness of pneumococcal conjugate vaccine in India

BACKGROUND

World Health Organization has recommended the introduction of pneumococcal conjugate vaccine (PCV) in the childhood immunisation programme of all the countries in the world. In lieu of its introduction in India, there is a need to generate evidence on cost-effectiveness of this vaccine. The current study looks into the impact and cost-effectiveness of PCV vaccine in India.

METHODS

We evaluated the cost effectiveness of implementation of PCV 13 vaccination program at national level by comparing with no vaccination program for a period of 10 birth cohorts from 2018 to 2027. UNIVAC, a deterministic static cohort model is developed by giving the conservative estimates of vaccine program related to mortality, disease event rates, vaccine efficacy and coverage projections, system and health care costs for the first five years of life. Cost effectiveness is reported as Incremental Cost Effectiveness Ratio (ICER). Further scenario and sensitivity analysis were done. Probability of PCV intervention to be cost effective at a willingness to pay (WTP) threshold equal to per capita gross domestic product (GDP) is calculated using the government perspective.

RESULTS

We found that the introduction of PCV vaccination program can cost an additional $467 (INR 31,666) for averting per DALY which is less than one time GDP per capita of India. Even with the most unfavourable scenario for PCV vaccine, cost per DALY averted is found to be $2323 (INR 1,57,520) which is still a cost effective intervention in India. Probabilistic sensitivity analysis found the ICER for PCV to be $649 (INR 44,008) with 95% CI: $374-$1161.

CONCLUSION

This study shows that the PCV program is a highly cost effective intervention and justifies the introduction of PCV into routine immunisation schedule in some of the states and recommends introducing it throughout the country to reduce morbidity and mortality among the under-five children.

Cost-effectiveness analysis of routine 13-valent pneumococcal conjugate vaccinations in Chinese infants

BACKGROUND

This study aimed to evaluate the cost-effectiveness of the 13-valent pneumococcal conjugate vaccine (PCV-13) compared to a no vaccination strategy in Chinese infants.

METHODS

A Markov process model was developed to examine the outcomes of PCV-13 against a no vaccination strategy using data and assumptions adapted for relevance to China. Outcomes over a lifetime horizon are presented. One-way and probabilistic sensitivity analyses were performed to determine the uncertainty.

RESULTS

Compared to no vaccination, a PCV-13 vaccination program would provide a gain of 0.009 additional quality-adjusted life years (QALYs) per subject. From the health care and societal perspectives, the incremental costs per QALY were $20,709 and 18,483, respectively. When herd effect was included, the cost effectiveness of the PCV-13 vaccination strategy was notably improved. The lower price of PCV-13 will improve the cost-effectiveness.

CONCLUSIONS

The PCV-13 vaccination is likely to be cost-effective at the current Chinese prices and ceiling threshold ($8,382).

Towards the introduction of pneumococcal conjugate vaccines in Bhutan: A cost-utility analysis to determine the optimal policy option

BACKGROUND

Due to competing health priorities and limited resources, many low-income countries, even those with a high disease burden, are not able to introduce pneumococcal conjugate vaccines.

OBJECTIVE

To determine the cost-utility of 10- and 13-valent pneumococcal conjugate vaccines (PCV10 and PCV13) compared to no vaccination in Bhutan.

METHODS

A model-based cost-utility analysis was performed in the Bhutanese context using a government perspective. A Markov simulation model with one-year cycle length was used to estimate the costs and outcomes of three options: PCV10, PCV13 and no PCV programmes for a lifetime horizon. A discount rate of 3% per annum was applied. Results are presented using an incremental cost-effectiveness ratio (ICER) in United State Dollar per quality-adjusted life year (QALY) gained (USD 1 = Ngultrum 65). A one-way sensitivity analysis and a probabilistic sensitivity analysis were conducted to assess uncertainty.

RESULTS

Compared to no vaccination, PCV10 and PCV13 gained 0.0006 and 0.0007 QALYs with additional lifetime costs of USD 0.02 and USD 0.03 per person, respectively. PCV10 and PCV13 generated ICERs of USD 36 and USD 40 per QALY gained compared to no vaccination. In addition, PCV13 produced an ICER of USD 92 compared with PCV10. When including PCV into the Expanded Programme on Immunization, the total 5-year budgetary requirement is anticipated to increase to USD. 3.77 million for PCV10 and USD 3.75 million for PCV13. Moreover, the full-time equivalent (FTE) of one health assistant would increase by 2.0 per year while the FTE of other health workers can be reduced each year, particularly of specialist (0.6-1.1 FTE) and nurse (1-1.6 FTE).

CONCLUSION

At the suggested threshold of 1xGDP per capita equivalent to USD 2708, both PCVs are cost-effective in Bhutan and we recommend that they be included in the routine immunization programme.

Inclusion of the value of herd immunity in economic evaluations of vaccines. A systematic review of methods used

OBJECTIVE

The objectives of this review were to identify vaccine economic evaluations that include herd immunity and describe the methodological approaches used.

METHODS

We used Kim and Goldie's search strategy from a systematic review (1976-2007) of modelling approaches used in vaccine economic evaluations and additionally searched PubMed/MEDLINE and Embase for 2007-2015. Studies were classified according to modelling approach used. Methods for estimating herd immunity effects were described, in particular for the static models.

RESULTS

We identified 625 economic evaluations of vaccines against human-transmissible diseases from 1976 to 2015. Of these, 172 (28%) included herd immunity. While 4% of studies included herd immunity in 2001, 53% of those published in 2015 did this. Pneumococcal, human papilloma and rotavirus vaccines represented the majority of studies (63%) considering herd immunity. Ninety-five of the 172 studies utilised a static model, 59 applied a dynamic model, eight a hybrid model and ten did not clearly state which method was used. Relatively crude methods and assumptions were used in the majority of the static model studies.

CONCLUSION

The proportion of economic evaluations using a dynamic model has increased in recent years. However, 55% of the included studies used a static model for estimating herd immunity. Values from a static model can only be considered reliable if high quality surveillance data are incorporated into the analysis. Without this, the results are questionable and they should only be included in sensitivity analysis.

A comparison of average wages with age-specific wages for assessing indirect productivity losses: analytic simplicity versus analytic precision

OBJECTIVES

Numerous approaches are used to estimate indirect productivity losses using various wage estimates applied to poor health in working aged adults. Considering the different wage estimation approaches observed in the published literature, we sought to assess variation in productivity loss estimates when using average wages compared with age-specific wages.

METHODS

Published estimates for average and age-specific wages for combined male/female wages were obtained from the UK Office of National Statistics. A polynomial interpolation was used to convert 5-year age-banded wage data into annual age-specific wages estimates. To compare indirect cost estimates, average wages and age-specific wages were used to project productivity losses at various stages of life based on the human capital approach. Discount rates of 0, 3, and 6 % were applied to projected age-specific and average wage losses.

RESULTS

Using average wages was found to overestimate lifetime wages in conditions afflicting those aged 1-27 and 57-67, while underestimating lifetime wages in those aged 27-57. The difference was most significant for children where average wage overestimated wages by 15 % and for 40-year-olds where it underestimated wages by 14 %.

CONCLUSIONS

Large differences in projecting productivity losses exist when using the average wage applied over a lifetime. Specifically, use of average wages overestimates productivity losses between 8 and 15 % for childhood illnesses. Furthermore, during prime working years, use of average wages will underestimate productivity losses by 14 %. We suggest that to achieve more precise estimates of productivity losses, age-specific wages should become the standard analytic approach.

Cost-effectiveness analysis of infant universal routine pneumococcal vaccination in Malaysia and Hong Kong

Pneumococcal disease causes large morbidity, mortality and health care utilization and medical and non-medical costs, which can all be reduced by effective infant universal routine immunization programs with pneumococcal conjugate vaccines (PCV). We evaluated the clinical and economic benefits of such programs with either 10- or 13-valent PCVs in Malaysia and Hong Kong by using an age-stratified Markov cohort model with many country-specific inputs. The incremental cost per quality-adjusted life year (QALY) was calculated to compare PCV10 or PCV13 against no vaccination and PCV13 against PCV10 over a 10-year birth cohort's vaccination. Both payer and societal perspectives were used. PCV13 had better public health and economic outcomes than a PCV10 program across all scenarios considered. For example, in the base case scenario in Malaysia, PCV13 would reduce more cases of IPD (+2,296), pneumonia (+705,281), and acute otitis media (+376,967) and save more lives (+6,122) than PCV10. Similarly, in Hong Kong, PCV13 would reduce more cases of IPD cases (+529), pneumonia (+172,185), and acute otitis media (+37,727) and save more lives (+2,688) than PCV10. During the same time horizon, PCV13 would gain over 74,000 and 21,600 additional QALYs than PCV10 in Malaysia and Hong Kong, respectively. PCV13 would be cost saving when compared against similar program with PCV10, under both payer and societal perspective in both countries. PCV13 remained a better choice over PCV10 in multiple sensitivity, scenario, and probabilistic analyses. PCV13s broader serotype coverage in its formulation and herd effect compared against PCV10 were important drivers of differences in outcomes.

Do Pneumococcal Conjugate Vaccines Represent Good Value for Money in a Lower-Middle Income Country? A Cost-Utility Analysis in the Philippines

Objectives

The objective of this study is to assess the value for money of introducing pneumococcal conjugate vaccines as part of the immunization program in a lower-middle income country, the Philippines, which is not eligible for GAVI support and lower vaccine prices. It also includes the newest clinical evidence evaluating the efficacy of PCV10, which is lacking in other previous studies.

Methods

A cost-utility analysis was conducted. A Markov simulation model was constructed to examine the costs and consequences of PCV10 and PCV13 against the current scenario of no PCV vaccination for a lifetime horizon. A health system perspective was employed to explore different funding schemes, which include universal or partial vaccination coverage subsidized by the government. Results were presented as incremental cost-effectiveness ratios (ICERs) in Philippine peso (Php) per QALY gained (1 USD = 44.20 Php). Probabilistic sensitivity analysis was performed to determine the impact of parameter uncertainty.

Results

With universal vaccination at a cost per dose of Php 624 for PCV10 and Php 700 for PCV13, both PCVs are cost-effective compared to no vaccination given the ceiling threshold of Php 120,000 per QALY gained, yielding ICERs of Php 68,182 and Php 54,510 for PCV10 and PCV13, respectively. Partial vaccination of 25% of the birth cohort resulted in significantly higher ICER values (Php 112,640 for PCV10 and Php 84,654 for PCV13) due to loss of herd protection. The budget impact analysis reveals that universal vaccination would cost Php 3.87 billion to 4.34 billion per annual, or 1.6 to 1.8 times the budget of the current national vaccination program.

Conclusion

The inclusion of PCV in the national immunization program is recommended. PCV13 achieved better value for money compared to PCV10. However, the affordability and sustainability of PCV implementation over the long-term should be considered by decision makers.

Cost-effectiveness analysis of the available pneumococcal conjugated vaccines for children under five years in Colombia

Background

Pneumococcal diseases in children under five years are common and preventable. In Colombia there are two pneumococcal conjugate vaccines (PCV) that have proved clinical efficacy. The aim was to estimate the cost-effectiveness of 13-valent PCV (PCV13) and 10-valent PCV (PCV10) in terms of prevention of Invasive Pneumococcal Diseases (IPD), radiologically-confirmed pneumonia, and their related mortality, as well as, acute otitis media (AOM) in a cohort of newborns in Colombia.

Methods

We developed an analytical decision tree model with national data including the distribution of pneumococcal serotypes in Colombia between 2009 and 2013. A simulation of vaccination of 90% of newborns in Colombia took place with a time horizon of 5 years. The analysis was done from the Colombian health system perspective. Vaccines efficacy parameters were measured as life-years gained (LYG) and avoided morbidity by pneumococcal diseases; they were determined by a systematic review of literature. A health insurance company provided the costs. A probabilistic and a univariate sensitivity analysis for epidemiological, efficacy and cost parameters were done.

Results

After 5 years projection, PCV13 would prevent 437 deaths due to pneumococcal infections versus 321 that would be prevented by PCV10, compared to no vaccination. PCV13 would generate 25 396 LYG, and PCV10 would generate 18 708 LYG. Medical costs avoided would be US$ 19 479 395 for PCV13 and US$ 13 703 271 for PCV10. Compared to no vaccination, PCV13 and PCV10 were cost-effective, with an incremental cost-effectiveness ratio (ICER) of US$ 489.26 and US$ 813.41 per additional LYG, respectively; besides, PCV13 was dominant over PCV10 due to lower costs and better outcomes.

Conclusion

PCV13 is a cost-saving strategy compared with PCV10, as part of a universal coverage vaccination program in Colombian children under one year. PCV13 is expected to lead to a greater decrement in infant mortality from pneumococcal diseases, and a higher cost saving by preventing more pneumococcal diseases compared with PCV10 in a 5 years projection.

Four new vaccines for routine immunization in India: what about hemophilus influenza B and pneumococcal vaccine?

Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. The Expanded Program on Immunization (EPI) was flagged off in India in 1978. According to the recommendation of National technical advisory group of India (NATGI), Government of India is going to include four new vaccines in the UIP for whole India. The four new vaccines are Inactivated Poliomyelitis Vaccine (IPV) for polio, rota viral vaccine, vaccine against rubella, and Japanese encephalitis vaccine (179 districts in India). Here, authors have tried to show a comparative descriptive analysis of the hemophilus influenza and pneumococcal pneumonia with rota virus, so that in near future Government of India can also consider their inclusion in the national UIP. In India, 39.2% of all diarrheal death are due to rota virus, whereas 0.72 million deaths are due to hemophilus influenza B and 1.3 million are due to pneumococcal pneumonia in <5 years age-group. India's indigenous developed rota viral vaccine's (Rotavac) efficacy is 56% in 1(st) year compared to H influenza B (Hib) efficacy 95% and PCV13 vaccine "3 + 1" dose efficacy 100% (South Africa). Rotarix incremental cost-effectiveness ratio is US $21.4 to US $34 per disability-adjusted life years (DALYs) compared to Hib US $ 819 per DALYs in India. In case of pneumococcal vaccine, India needs more trails on the serotype specificity, efficacy, and cost-effectiveness but there is enough evidence that hemophilus influenza burden is high in India and the present Hib vaccine is safe and highly effective. In future with the help of donor agencies, India should include the hemophilus influenza B and pneumococcal pneumonia vaccine in national UIP which will save millions of poor children's life.

Choosing between 7-, 10- and 13-valent pneumococcal conjugate vaccines in childhood: a review of economic evaluations (2006-2014)

BACKGROUND

Seven-valent pneumococcal conjugate vaccines (PCV7) have been used in children for more than a decade. Given the observed increase in disease caused by pneumococcal serotypes not covered by PCV7, an increasing number of countries are switching from 7-valent to 10- and 13-valent PCVs ("PCV10" and "PCV13"). Economic evaluations are important tools to inform decisions and price negotiations to make such a switch.

OBJECTIVE

This review aims to provide a critical assessment of economic evaluations involving PCV10 or PCV13, published since 2006.

METHODS

We searched Scopus, ISI Web of Science (SCI and SSCI) and Pubmed to retrieve, select and review relevant studies, which were archived between 1st January 2006 and 31st January 2014. The review protocol involved standard extraction of assumptions, methods, results and sponsorships from the original studies.

RESULTS

Sixty-three economic evaluations on PCVs published since January 2006 were identified. About half of these evaluated PCV10 and/or PCV13, the subject of this review. At current prices, both PCV13 and PCV10 were likely judged preferable to PCV7. However, the combined uncertainty related to price differences, burden of disease, vaccine effectiveness, herd and serotype replacement effects determine the preference base for either PCV10 or PCV13. The pivotal assumptions and results of these analyses also depended on which manufacturer sponsored the study.

CONCLUSION

A more thorough exploration of uncertainty should be made in future analyses on this subject, as we lack understanding to adequately model herd and serotype replacement effects to reliably predict the population impact of PCVs. The introduction of further improved PCVs in an environment of evolving antibiotic resistance and under the continuing influence of previous PCVs implies that the complexity and data requirements for relevant analyses will further increase. Decision makers using these analyses should not just rely on an analysis from a single manufacturer.

The definition of a prolonged intensive care unit stay for spontaneous intracerebral hemorrhage patients: an application with national health insurance research database

Introduction. Length of stay (LOS) in the intensive care unit (ICU) of spontaneous intracerebral hemorrhage (sICH) patients is one of the most important issues. The disease severity, psychosocial factors, and institutional factors will influence the length of ICU stay. This study is used in the Taiwan National Health Insurance Research Database (NHIRD) to define the threshold of a prolonged ICU stay in sICH patients. Methods. This research collected the demographic data of sICH patients in the NHIRD from 2005 to 2009. The threshold of prolonged ICU stay was calculated using change point analysis. Results. There were 1599 sICH patients included. A prolonged ICU stay was defined as being equal to or longer than 10 days. There were 436 prolonged ICU stay cases and 1163 nonprolonged cases. Conclusion. This study showed that the threshold of a prolonged ICU stay is a good indicator of hospital utilization in ICH patients. Different hospitals have their own different care strategies that can be identified with a prolonged ICU stay. This indicator can be improved using quality control methods such as complications prevention and efficiency of ICU bed management. Patients' stay in ICUs and in hospitals will be shorter if integrated care systems are established.

A retrospective study to assess the epidemiological and economic burden of pneumococcal diseases in adults aged 50 years and older in Taiwan

OBJECTIVE

Invasive pneumococcal disease (IPD) and pneumococcal pneumonia cause substantial morbidity and mortality worldwide. This retrospective study was conducted to estimate the disease burden from pneumococcal disease in older adults in Taiwan from a health insurer's perspective.

METHODS

Data for the years 2002-2009 from patients aged ≥50 years with insurance records indicating pneumococcal meningitis, pneumococcal bacteremia, or hospitalized or outpatient pneumonia were obtained from the National Health Insurance Research Database in Taiwan. Admission data for inpatients, visit data for outpatients, and associated costs were extracted from the database to estimate the incidence, case fatality rates, and direct and indirect costs of pneumococcal disease episodes. These data were applied to the estimated population of Taiwan in 2010 to provide an estimated disease burden for a single year from the payer perspective.

RESULTS

The average incidence per 100,000 person years was 2.4 for IPD, 278.8 for hospitalized pneumococcal pneumonia, and 1376.4 for outpatient pneumococcal pneumonia. The average case fatality rate was 12.3% for IPD and 10.0% for hospitalized pneumonia. Hospitalized pneumonia accounted for over 90% of direct medical costs. The incidence of hospitalized pneumococcal pneumonia per 100,000 person years was 84.4 for adults of 50-64 years, 313.1 for adults of 65-74 years, 820.3 for adults of 75-84 years, and 1650.9 for adults of 85+ year of age. In 2010, it was estimated there were over 113,000 episodes of pneumococcal disease, causing almost 2000 deaths, with direct medical costs of more than NT$3.4 billion annually.

CONCLUSIONS

Pneumococcal disease is a significant cause of mortality and excess healthcare expense among the elderly in Taiwan. Disease burden in older adults increases with advancing age.

Modeling the impact of the 7-valent pneumococcal conjugate vaccine in Chinese infants: an economic analysis of a compulsory vaccination

Background

The purpose of this study was to compare, from a Chinese societal perspective, the projected health benefits, costs, and cost-effectiveness of adding pneumococcal conjugate heptavalent vaccine (PCV-7) to the routine compulsory child immunization schedule.

Methods

A decision-tree model, with data and assumptions adapted for relevance to China, was developed to project the health outcomes of PCV-7 vaccination (compared with no vaccination) over a 5-year period as well as a lifetime. The vaccinated birth cohort included 16,000,000 children in China. A 2 + 1 dose schedule at US$136.51 per vaccine dose was used in the base-case analysis. One-way sensitivity analysis was used to test the robustness of the model. The impact of a net indirect effect (herd immunity) was evaluated. Outcomes are presented in terms of the saved disease burden, costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio.

Results

In a Chinese birth cohort, a PCV-7 vaccination program would reduce the number of pneumococcus-related infections by at least 32% and would prevent 2,682 deaths in the first 5 years of life, saving $1,190 million in total costs and gaining an additional 9,895 QALYs (discounted by 3%). The incremental cost per QALY was estimated to be $530,354. When herd immunity was taken into account, the cost per QALY was estimated to be $95,319. The robustness of the model was influenced mainly by the PCV-7 cost per dose, effectiveness herd immunity and incidence of pneumococcal diseases. With and without herd immunity, the break-even costs in China were $29.05 and $25.87, respectively.

Conclusions

Compulsory routine infant vaccination with PCV-7 is projected to substantially reduce pneumococcal disease morbidity, mortality, and related costs in China. However, a universal vaccination program with PCV-7 is not cost-effective at the willingness-to-pay threshold that is currently recommended for China by the World Health Organization.

Potential cost-effectiveness of pneumococcal conjugate vaccine (PCV) in Turkey

BACKGROUND

Pneumococcal infection is an important and preventable cause of morbidity and mortality. The Turkish government introduced 7-valent pneumococcal conjugate vaccine (PCV) into the national immunization program in 2009. This suggests that replacing 7-valent PCV with a higher-valent version could at least maintain "standard of care" if not improve it, and that it could be affordable.

OBJECTIVES AND METHODS

The aim of this analysis was to assess the potential direct cost-effectiveness of 13-valent PCV in Turkey, a country with a birth cohort of 1.4 million, against a "no vaccine" state, against the default 7-valent PCV state, and against a 10-valent PCV state, using a published cohort model with a 5-year horizon.

RESULTS AND CONCLUSIONS

The cost per life-year gained is below the 1 × per-capita gross domestic product threshold across large changes in key input parameters, indicating that the model is stable and suggesting that any PCV would be very cost-effective in a Turkish national pediatric immunization schedule.

Use of the 13-valent pneumococcal conjugate vaccine in infants and young children

INTRODUCTION

The inclusion of the heptavalent pneumococcal conjugate vaccine (PCV7) in the immunization schedule of infants and young children has greatly reduced the incidence of invasive and non-invasive diseases due to Streptococcus pneumoniae. However, as PCV7 has some limitations, new vaccines containing more pneumococcal serotypes have been developed. Only two of these have so far reached the market: a 10-valent preparation containing the PCV7 serotypes plus serotypes 1, 5 and 7F (PCV10), and a 13-valent vaccine containing the PCV7 serotypes plus serotypes 1, 3, 5, 6A, 7F and 19A (PCV13).

AREAS COVERED

The main aim of this review is to discuss the reasons that have led to the formulation of PCV13, its immunogenicity, safety and tolerability and the recommendations concerning its use in children.

EXPERT OPINION

There is no doubt that a pneumococcal conjugate vaccine with the composition of PCV13 has significantly increased the possibility of preventing pneumococcal disease. Its immunogenicity, safety and tolerability seem to be optimal, as does its cost-effectiveness. However, despite these favorable premises, it cannot be considered the final preparation for the prevention of pneumococcal disease, and it is likely that a new vaccine capable of covering all pneumococcal serotypes will be needed in the future.