Estimating the population health and economic impacts of introducing a pneumococcal conjugate vaccine in Malaysia- an economic evaluation

Burden of Pneumococcal Disease in Young Children Due to Serotypes Contained in Different Pneumococcal Conjugate Vaccines in Eight Asian Countries and Territories

BACKGROUND

Pneumococcal disease (PD) is a major cause of morbidity and mortality in young children in Asia and globally. Pneumococcal conjugate vaccines (PCVs) have significantly reduced the burden of PD when included in pediatric national immunization programs (NIPs). This study estimates the clinical and economic burden of PD due to serotypes contained in different PCVs in children aged < 5 years in eight Asian countries/territories.

METHODS

Based on published data, a cohort-based decision analytic model was used to estimate annual PD cases, deaths, and direct medical costs associated with serotypes contained in PCV10, PCV13, PCV15, and PCV20.

RESULTS

PD incidence rates were lower in regions with PCV13 in their NIP than those without. Serotypes contained in higher but not lower valency PCVs resulted in a significant incremental clinical and economic burden, although the difference between PCV13 and PCV15 serotypes was generally small. Moving from PCV13 to PCV20 was estimated to result in greater clinical and economic burden reductions.

CONCLUSIONS

This study demonstrates the remaining and incremental burden of PD from PCV10 to PCV20 serotypes in young children in selected Asian regions. Extending NIP access to higher-valency PCVs with broader serotype coverage and improving vaccine uptake will help prevent morbidity and deaths and save healthcare costs.

Detection of Macrolide-Resistant Streptococcus pneumoniae Genes and Its Clinical Outcomes in a Tertiary Teaching Hospital in Malaysia

Background

Streptococcus pneumoniae is one of the leading causes of mortality and morbidity worldwide. The dramatic increase in in-vitro resistance of antimicrobial agents, particularly beta-lactams and macrolides, makes pneumococcal infections difficult to treat. The aim of this study was to describe the drug resistance rate, assess the prevalence of macrolide-resistant genes and review the clinical complications of pneumococcal infections among patients presented to Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia.

Methods

This is a descriptive cross-sectional study. All S. pneumoniae isolates collected from clinical specimens within a 1-year period were subjected to selected antimicrobial susceptibility testing using E-test strips. Polymerase chain reaction (PCR) analysis was conducted to detect macrolide-resistant determinants. The patient's clinical data were obtained from clinical notes.

Results

A total of 113 patients with a positive growth of S. pneumoniae were included in the study. The most common predisposing factors among them were bronchopulmonary diseases (15.9%). The penicillin-resistant rate was 7.1%, with minimal inhibitory concentration (MIC) ranging between 0.012 μg/mL and >32 μg/mL, and the erythromycin-resistant rate was 26.5%, with a MIC range of 0.03 μg/mL-> 256 μg/mL. Most of the erythromycin-resistant isolates were found to have the mef(A) gene (50.4%) and the erm(B) gene (20%); 16.7% had a combination of genes mef(A) and erm(B), and 13.3% had none of the two genes. Community-acquired pneumonia is the predominant type of pneumococcal infection. There was no significant association between the presence of macrolide resistance determinants and mortality (P = 0.837) or complications (P > 0.999 for empyema and cardiac complication; P = 0.135 for subdural abscess).

Conclusion

The majority of erythromycin-resistant isolates were found to have the mef(A) gene, followed by the erm(B) gene and a combination of genes mef(A) and erm(B).

A brief history of and future prospects for pneumococcal vaccination in Malaysia

Pneumococcal pneumonia remains a significant global public health issue. Malaysia has recently added the 10 valent pneumococcal conjugate vaccine to its national immunisation programme. Data on pneumococcal serotype epidemiology is vital for informing national vaccination policy. However, there remains a lack of representative population-based pneumococcal surveillance in Malaysia to help both the assessment of vaccine effectiveness in the country and to shape future vaccine policy. This review explores the history of pneumococcal vaccination, the burden of pneumococcal disease in Malaysia, and offers an insight into the prospects for reducing pneumococcal disease in Malaysia.

Assessing Public Health Impact of Four Pediatric Pneumococcal Conjugate Vaccination Strategies in the Netherlands

INTRODUCTION

The 10-valent pneumococcal conjugate vaccine (PCV10, Synflorix) was introduced into the Dutch pediatric national immunization program (NIP) starting in 2011. However, there is substantial pneumococcal disease burden due to increases in non-PCV10 covered serotypes. Higher-valent vaccines for pediatrics (PCV13, PCV15, and PCV20) may alleviate much of the remaining disease burden upon implementation through broader serotype coverage. This article assesses the public health impact of different pediatric vaccination strategies (switching to PCV13, PCV15 or PCV20) versus maintaining PCV10 at different time intervals in the Netherlands.

METHODS

A population-based, decision-analytic model was developed using historical pneumococcal disease surveillance data to forecast future invasive pneumococcal disease (IPD), pneumonia, and otitis media (OM) cases over a 7-year period (2023-2029) under the following strategies: continued use of PCV10, switching to PCV13 in 2023, switching to PCV15 in 2023, and switching to PCV20 in 2024. Scenario analyses were performed to account for uncertainties in future serotype distributions, disease incidence reductions, and epidemiologic parameters.

RESULTS

Switching to PCV13 in 2023 was found to avert 26,666 cases of pneumococcal disease compared to continuing PCV10 over a 7-year period (2023-2029). Switching to PCV15 in 2023 was found to avert 30,645 pneumococcal cases over the same period. Switching to PCV20 once available in 2024 was estimated to avert 45,127 pneumococcal cases from 2024-2029. Overall conclusions were maintained after testing uncertainties.

CONCLUSIONS

For the Dutch pediatric NIP, switching to PCV13 in 2023 would be an effective strategy compared with continued use of PCV10 for averting pneumococcal disease cases. Switching to PCV20 in 2024 was estimated to avert the most pneumococcal disease cases and provide the highest protection. However, in the face of budget constraints and the undervaluation of prevention strategies, it remains challenging to implement higher valent vaccines. Further research is needed to understand the cost-effectiveness and feasibility of a sequential approach.

The Molecular Approaches and Challenges of Streptococcus pneumoniae Serotyping for Epidemiological Surveillance in the Vaccine Era

Streptococcus pneumoniae (pneumococcus) belongs to the Gram-positive cocci. This bacterium typically colonizes the nasopharyngeal region of healthy individuals. It has a distinct polysaccharide capsule - a virulence factor allowing the bacteria to elude the immune defense mechanisms. Consequently, it might trigger aggressive conditions like septicemia and meningitis in immunocompromised or older individuals. Moreover, children below five years of age are at risk of morbidity and mortality. Studies have found 101 S. pneumoniae capsular serotypes, of which several correlate with clinical and carriage isolates with distinct disease aggressiveness. Introducing pneumococcal conjugate vaccines (PCV) targets the most common disease-associated serotypes. Nevertheless, vaccine selection pressure leads to replacing the formerly dominant vaccine serotypes (VTs) by non-vaccine types (NVTs). Therefore, serotyping must be conducted for epidemiological surveillance and vaccine assessment. Serotyping can be performed using numerous techniques, either by the conventional antisera-based (Quellung and latex agglutination) or molecular-based approaches (sequetyping, multiplex PCR, real-time PCR, and PCR-RFLP). A cost-effective and practical approach must be used to enhance serotyping accuracy to monitor the prevalence of VTs and NVTs. Therefore, dependable pneumococcal serotyping techniques are essential to precisely monitor virulent lineages, NVT emergence, and genetic associations of isolates. This review discusses the principles, associated benefits, and drawbacks of the respective available conventional and molecular approaches, and potentially the whole genome sequencing (WGS) to be directed for future exploration.

Pneumococcal Vaccination in Children: A Systematic Review and Meta-Analysis of Cost-Effectiveness Studies

OBJECTIVES

Pneumococcal conjugate vaccines (PCVs) have significantly reduced disease burden caused by Streptococcus pneumoniae, a leading cause of childhood morbidity and mortality globally. This systematic review and meta-analysis aimed to assess the incremental net benefit (INB) of the 13-valent PCV (PCV13) and 10-valent PCV (PCV10) in children.

METHODS

We performed a comprehensive search in several databases published before May 2022. Studies were included if they were cost-effectiveness or cost-utility analyses of PCV13 or PCV10 compared with no vaccination or with each other in children. Various monetary units were converted to purchasing power parity, adjusted to 2021 US dollars. The INBs were calculated and then pooled across studies stratified by country income level, perspective, and consideration of herd effects, using a random-effect model.

RESULTS

Seventy studies were included. When herd effects were considered, PCV13 was cost-effective compared with PCV10 from the payer perspective in both high-income countries (HICs) (INB, $103.94; 95% confidence interval, $75.28-$132.60) and low- and middle-income countries (LMICs) (INB, $53.49; 95% confidence interval, $30.42-$76.55) with statistical significance. These findings were robust across a series of sensitivity analyses. PCV13 was cost-effective compared with no vaccination across perspectives and consideration of herd effects in both HICs and LMICs, whereas findings were less consistent for PCV10.

CONCLUSION

PCVs were generally cost-effective compared with no vaccination in HICs and LMICs. Our study found that PCV13 was cost-effective compared with PCV10 when herd effects were considered from the payer perspective in both HICs and LMICs. The results are sensitive to the consideration of herd effects.

Cost-utility and cost-benefit analysis of pediatric PCV programs in Egypt

New vaccine introductions (NVIs) raise issues of value for money (VfM) for self-financing middle-income countries like Egypt. We evaluate a pediatric pneumococcal conjugate vaccine (PCV) NVI in Egypt from health payer and societal perspectives, using cost-utility and cost-benefit analysis (CUA, CBA). We evaluate vaccinating 100 successive birth cohorts with the 13-valent PCV ("PCV13") and the 10-valent PCV ("PCV10") relative to no vaccination and each other. We quantify health effects with a disease incidence projection model and a multiple-cohort static disease model. Our CBA uses a health-augmented lifecycle model to generate willingness-to-pay for health gains from which we calculate rates of return (RoR). We obtain parameters from the published literature. We perform deterministic and probabilistic sensitivity analysis. Our base-case CUA finds incremental cost-effectiveness ratios (ICERs) for PCV13 and PCV10 relative to no program of $926 (95% confidence interval $512-$1,735) and $1,984 ($1,186-$3,805) per quality-adjusted life year (QALY), respectively; and for PCV13 relative to PCV10 of $174 ($88-$331) per QALY. Our base-case CBA finds RoRs to PCV13 and PCV10 relative to no program of 488% (188-993%) and 164% (33-336%), respectively, and to PCV13 relative to PCV10 of 3109% (1410-6602%). Both CUA and CBA find PCV13 to be good VfM relative to PCV10.

Cost-Effectiveness of the 13-Valent Pneumococcal Conjugate Vaccine (PCV13) Versus Lower-Valent Alternatives in Filipino Infants

Introduction

The Philippines pediatric national immunization program (NIP) included the 13-valent pneumococcal conjugate vaccine manufactured by Pfizer (PCV13-PFE) since 2015. Uptake has been slow in particular regions, with coverage only reaching all regions in 2019. Given affordability challenges in the context of higher coverage, this study seeks to determine whether universal coverage across all regions of the Philippines with PCV13-PFE will provide good value for money compared with 10-valent PCV alternatives manufactured by GlaxoSmithKline (PCV10-GSK) or Serum Institute of India (PCV10-SII).

Methods

A decision analytic model is adapted for this cost-effectiveness analysis in the Philippines. Clinical and economic input parameters are taken from published sources. Future disease is predicted using age-stratified and population-level observed serotype dynamics. Total cases of pneumococcal disease, deaths, direct and indirect healthcare costs, and quality-adjusted life years (QALYs) gained are discounted 7% annually and modeled for each PCV. Given clinical uncertainty, PCV10-SII outcomes are reported as ranges. Incremental cost-effectiveness ratios (ICERs) are calculated for PCV13-PFE versus lower-valent PCVs (PCV10-GSK or PCV10-SII) from a societal perspective over 10 years.

Results

Nationwide PCV13-PFE use over 10 years is estimated to avert 375,831 more cases, save 53,189 additional lives, and gain 153,349 QALYs compared with PCV10-GSK. This equates to cost-savings of PHP 12.27 billion after vaccine costs are accounted for. Similarly, PCV13-PFE is more effective and cost-saving compared with PCV10-SII. Switching programs to PCV10-SII would result in more cases of disease (313,797 – 666,889), more deaths (22,759 – 72,435), and lost QALYs (108,061 – 266,108), equating to a net economic loss (PHP 359.82 million – 14.41 billion). PCV13-PFE remains cost-effective in the presence of parameter uncertainty.

Conclusion

PCV13-PFE would prevent exceedingly more cases and deaths compared with lower-valent PCVs. Additionally, the PCV13-PFE program is estimated to continue providing cost-savings, offering the best value for money to achieve universal PCV coverage in the Philippines.

Validation of a Novel Forecasting Method for Estimating the Impact of Switching Pneumococcal Conjugate Programs: Evidence from Belgium

Introduction

Since 2010, 10-valent (PCV10) and 13-valent pneumococcal conjugate vaccines (PCV13) have been available as part of infant national immunization programs. Belgium is as one of the few countries that implemented PCV13 (2007–2015), switched to PCV10 (2015–2018) and then switched back to PCV13 (2018–present) after observing increases in disease. We assessed the impacts of both historical and prospective PCV choice in the context of the Belgian health care system and used this experience to validate previously developed economic models.

Methods

Using historical incidence (2007–2018) of pneumococcal disease for Belgian children aged < 16 years, observed invasive pneumococcal disease (IPD) trends from surveillance data were used to estimate future disease in a given PCV13- or PCV10-based program. We compared observed incidence data with two modeled scenarios: (1) the 2015 switch to PCV10 and (2) a hypothetical continuation of PCV13 in 2015. Finally, we explored the potential impact of PCV choice from 2019 to 2023 by comparing three scenarios: (3) continued use of PCV10; (4) a switch back to PCV13; (5) a hypothetical scenario in which Belgium never switched from PCV13.

Results

Model predictions underestimated observed data from 2015 to 2018 by 100 IPD cases among ages < 16 years. Comparing observed data with scenario 2 suggests that PCV13 would have prevented 105 IPD cases from 2015 to 2018 compared with PCV10. Switching to PCV13 in 2019 would avert 625 IPD cases through 2023 compared with continuing PCV10. Scenario never switching from PCV13 would have resulted in a reduction of 204 cases from 2016 to 2023 compared with switching to PCV10 and switching back to PCV13.

Conclusion

The findings from this study suggest that previously published modeling results of PCV13 versus PCV10 in other countries may have underestimated the benefit of PCV13. These results highlight the importance of continually protecting against vaccine-preventable pneumococcal serotypes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00485-9.

Serotype distribution of invasive, non-invasive and carried Streptococcus pneumoniae in Malaysia: a meta-analysis

Background

Pneumococcal pneumonia is the leading cause of under-five mortality globally. The surveillance of pneumococcal serotypes is therefore vital for informing pneumococcal vaccination policy and programmes. Pneumococcal conjugate vaccines (PCVs) have been available as an option in the private healthcare setting and beginning December 2020, PCV10 was incorporated as part of routine national immunisation programme (NIP) in Malaysia. We searched existing literature on pneumococcal serotype distribution across Malaysia to provide an overall view of this distribution before the implementation of PCV10.

Methods

Online databases (PubMed, Ovid MEDLINE and Scopus), reference lists of articles identified, and grey literature (Malaysian Ministry of Health website, WHO website) were systematically searched for relevant literature on pneumococcal serotype distribution across Malaysia up to 10th November 2020. No lower date limit was set to maximise the number of target reports returned. Results of serotypes were split by age categories, including ≤5 years, > 5 years and unreported for those that did not specify.

Results

The search returned 18 relevant results, with a total of 2040 isolates. The most common serotypes across all disease types were 19F (n = 313, 15.3% [95%CI: 13.8–17.0]), 23F (n = 166, 8.1% [95%CI: 7.0–9.4]), 14 (n = 166, 8.1% [95%CI: 7.0–9.4]), 6B (n = 163, 8.0% [95%CI: 6.9–9.2]) and 19A (n = 138, 6.8% [95%CI: 5.8–7.9]).

Conclusion

Four of the most common serotypes across all isolate sources in Malaysia are covered by PCV10, while PCV13 provides greater serotype coverage in comparison to PCV10. There is still a need for surveillance studies, particularly those investigating serotypes in children under 5 years of age, to monitor vaccine effectiveness and pneumococcal population dynamic following implementation of PCV10 into routine immunisation.

Reply letter to "response to article by Johnna Perdrizet et al." by Gomez and colleagues

This communication seeks to address the questions and criticisms issued by Gomez and colleagues in their letter on our original study “Cost-effectiveness analysis of replacing the 10-valent pneumococcal conjugate vaccine (PCV10) with the 13-valent pneumococcal conjugate vaccine (PCV13) in Brazil infants.” Gomez and colleagues are concerned that the assumptions used in our model may have unintended negative impacts for Brazil decision-making and we intend to clarify any potential misinterpretation of our assessment.

Cost-effectiveness analysis of replacing the 10-valent pneumococcal conjugate vaccine (PCV10) with the 13-valent pneumococcal conjugate vaccine (PCV13) in Brazil infants

Brazil currently has a 10-valent pneumococcal conjugate vaccine (PCV10) pediatric national immunization program (NIP). However, in recent years, there has been significant progressive increases in pneumococcal disease attributed to serotypes 3, 6A, and 19A, which are covered by the 13-valent PCV (PCV13). We sought to evaluate the cost-effectiveness and budget impact of switching from PCV10 to PCV13 for Brazilian infants from a payer perspective. A decision-analytic model was adapted to evaluate the clinical and economic outcomes of continuing PCV10 or switching to PCV13. The analysis estimated future costs ($BRL), quality-adjusted life-years (QALYs), and health outcomes for PCV10 and PCV13 over 5 y. Input parameters were from published sources. Future serotype dynamics were predicted using Brazilian and global historical trends. Over 5 y, PCV13 could prevent 12,342 bacteremia, 15,330 meningitis, 170,191 hospitalized pneumonia, and 25,872 otitis media cases, avert 13,709 pneumococcal disease deaths, gain 20,317 QALYs, and save 172 million direct costs compared with PCV10. The use of PCV13 in the Brazilian NIP could reduce pneumococcal disease, improve population health, and save substantial health-care costs. Results are reliable even when considering uncertainty for possible serotype dynamics with different underlying assumptions.