Impact and cost-effectiveness of different vaccination strategies to reduce the burden of pneumococcal disease among elderly in the Netherlands

Investigation on the correlation factors of positive Streptococcus pneumoniae antibody and IgG antibody level of Streptococcus pneumoniae in the elderly over 60 years old in Shenzhen

BACKGROUND

Pneumococcal Polysaccharide Vaccine (PPV-23), designed to protect against the most common serotype of Streptococcus pneumoniae, is intended to protect the elderly and other high-risk groups. However, the immunogenicity of all 23 pneumococcal polysaccharide vaccines in older adults has not been thoroughly studied.

OBJECTIVE

The purpose of this study is to look into the factors that influence the effect of the pneumonia vaccine on the elderly over 60 years old in Shenzhen, as well as their IgG antibody level against Streptococcus pneumoniae.

METHODS

To determine the immune effectiveness of pneumococcal vaccination in older adults over 60 years old, we used the 3rd generation enzyme-linked immunosorbent assay to detect the antibody level of older adults to all 23 pneumococcal polysaccharide vaccines following pneumococcal immunization.

RESULTS

Vaccination, the number of physical examinations, pneumonia knowledge, and the pneumonia vaccination policy of the elderly in Shenzhen were all positively correlated with Streptococcus pneumoniae antibody positivity. The distribution of subtypes did not differ between elderly adults (over 65) and younger adults (under 65). The GMCs of IgG antibodies to PPS were significantly lower in males than in females for types 7f, 18c and 19a. At the same time, we found that people with chronic respiratory disease have lower type 9n than people without chronic respiratory disease. Other chronic diseases, such as hypertension and diabetes, had no difference in subtype distribution.

CONCLUSION

There was a statistically significant difference in antibody positivity rates for older people with more frequent medical check-ups in Shenzhen, indicating that publicity is playing a role. The effects of age, gender, and chronic diseases on naturally acquired anti-PPS IgG differ.

Higher-valency pneumococcal conjugate vaccines in older adults, taking into account indirect effects from childhood vaccination: a cost-effectiveness study for the Netherlands

BACKGROUND

New 15- and 20-valent pneumococcal vaccines (PCV15, PCV20) are available for both children and adults, while PCV21 for adults is in development. However, their cost-effectiveness for older adults, taking into account indirect protection and serotype replacement from a switch to PCV15 and PCV20 in childhood vaccination, remains unexamined.

METHODS

We used a static model for the Netherlands to assess the cost-effectiveness of different strategies with 23-valent pneumococcal polysaccharide vaccine (PPV23), PCV15, PCV20, and PCV21 for a 65-year-old cohort from a societal perspective, over a 15-year time horizon. Childhood vaccination was varied from PCV10 to PCV13, PCV15, and PCV20. Indirect protection was assumed to reduce the incidence of vaccine serotypes in older adults by 80% (except for serotype 3, no effect), completely offset by an increase in non-vaccine serotype incidence due to serotype replacement.

RESULTS

Indirect effects from childhood vaccination reduced the cost-effectiveness of vaccination of older adults, depending on the serotype overlap between the vaccines. With PCV10, PCV13, or PCV15 in children, PCV20 was more effective and less costly for older adults than PPV23 and PCV15. PCV20 costs approximately €10,000 per quality-adjusted life year (QALY) gained compared to no pneumococcal vaccination, which falls below the conventional Dutch €20,000/QALY gained threshold. However, with PCV20 in children, PCV20 was no longer considered cost-effective for older adults, costing €22,550/QALY gained. As indirect effects progressed over time, the cost-effectiveness of PCV20 for older adults further diminished for newly vaccinated cohorts. PPV23 was more cost-effective than PCV20 for cohorts vaccinated 3 years after the switch to PCV20 in children. PCV21 offered the most QALY gains, and its cost-effectiveness was minimally affected by indirect effects due to its coverage of 11 different serotypes compared to PCV20.

CONCLUSIONS

For long-term cost-effectiveness in the Netherlands, the pneumococcal vaccine for older adults should either include invasive serotypes not covered by childhood vaccination or become more affordable than its current pricing for individual use.

Recent changes to adult national immunization programs for pneumococcal vaccination in Europe and how they impact coverage: A systematic review of published and grey literature

Despite widespread use of pneumococcal vaccines throughout Europe, the burden of pneumococcal disease (PD) in adults is considerable. To mitigate this burden, National Immunization Technical Advisory Groups (NITAGs) and Health Technology Assessment (HTA) agencies assess the value of different vaccine schedules for protecting against PD. The aim of this review was to assess the evidence and rationales used by NITAGs/HTA agencies, when considering recent changes to National Immunization Programs (NIPs) for adults, and how identified changes affected vaccine coverage rates (VCRs). A systematic review was conducted of published literature from PubMed® and Embase®, and gray literature from HTA/NITAG websites from the last 5 y, covering 31 European countries. Evidence related to NIP recommendations, epidemiology (invasive PD, pneumonia), health economic assessments and VCRs were collected and synthesized. Eighty-four records providing data for 26 countries were identified. Of these, eight described explicit changes to NIPs for adults in seven countries. Despite data gaps, some trends were observed; first, there appears to be a convergence of NIP recommendations in many countries toward sequential vaccination, with a pneumococcal conjugate vaccine (PCV), followed by pneumococcal polysaccharide vaccine 23. Second, reducing economic or healthcare burden were common rationales for implementing changes. Third, most health economic analyses assessing higher-valency PCVs for adults found its inclusion in NIPs cost-effective. Finally, higher coverage rates were seen in most cases where countries had expanded their NIPs to cover at-risk populations. The findings can encourage agencies to improve surveillance systems and work to reach the NIP's target populations more effectively.

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.

Cost-effectiveness of the 13-valent pneumococcal conjugate vaccine compared to the 10-valent vaccine in children: predictive analysis in the Ecuadorian context

Objective

To evaluate the cost-effectiveness and economic impact of changing childhood vaccination from the 10-valent pneumococcal conjugate vaccine (PCV10) to the 13-valent pneumococcal conjugate vaccine (PCV13) in the context of the Ecuadorian health system.

Methods

A Markov model was developed based on a hypothetical cohort of children <1 year old with a 2 + 1 vaccination schedule. The model incorporates the most impactful chronic sequelae of invasive pneumococcal disease: bilateral hearing loss, spasticity, neurological deficit, hydrocephalus and epilepsy. At the end of each annual Markov cycle, the children heal with/without sequelae or die. A time horizon of 5 years was considered. The analysis was done from the perspective of the Ministry of Health.

Key findings

Vaccination with PCV13 is cost-saving (US$ −2940/QALY) in relation to PCV10 considering indirect effects (‘herd effect’) of childhood vaccination over adult population (>65 years). So, PCV13 reduces incident cases of IPD in this adult population by 27.8% compared to PCV10. Simulation of the model in a cohort of 100 000 children <1 year old showed an incidence of 25 cases of IPD with PCV13 versus 40 cases with PCV10, that is, a reduction of 37.5%. A reduction compared to PCV10 in the incidence of pneumonia and meningitis of 30.2 and 57.1%, respectively, was demonstrated. PCV13 decreased mortality by 32% compared to PCV10.

Conclusions

Vaccination with PCV13 is cost-saving in the Ecuadorian health context and significantly reduces morbidity and mortality in children <5 years and in adults >65 years due to the herd effect. The probabilistic analysis showed consistency in the results.

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 and budget impact analysis of PPV23 vaccination for the Malaysian Hajj pilgrims

The potential occurrence of disease outbreaks during the hajj season is of great concern due to extreme congestion in a confined space. This promotes the acquisition, spread and transmission of pathogenic microorganisms and pneumococcal disease are one of the most frequent infections among Hajj pilgrims. This study aimed to assess the cost-effectiveness and budget impact of introducing the PPV23 to Malaysian Hajj pilgrims. A decision tree framework with a 1-year cycle length was adapted to evaluate the cost-effectiveness of a PPV23 vaccination program with no vaccination. The cost information was retrieved from the Lembaga Tabung Haji Malaysia (LTH) database. Vaccine effectiveness was based on the locally published data and the disease incidence specifically related to Streptococcus pneumoniae was based on a literature search. Analyses were conducted from the perspective of the provider: Ministry of Health and LTH Malaysia. The incremental cost-effectiveness ratios (ICER), cases averted, and net cost savings were estimated. Findings from this study showed that PPV23 vaccination for Malaysian Hajj pilgrims was cost-effective. The PPV23 vaccination programme has an ICER of MYR -449.3 (US$-110.95) per case averted. Based on the national threshold value of US$6,200-US$8,900 per capita, the base-case result shows that introduction of the PPV23 vaccine for Malaysian Hajj pilgrims is very cost-effective. Sensitivity analysis revealed parameters related to annual incidence and hospitalised cost of septicemia and disease without vaccination as the key drivers of the model outputs. Compared with no vaccination, the inclusion of PPV23 vaccination for Malaysian Hajj pilgrims was projected to result in a net cost saving of MYR59.6 million and 109,996 cases averted over 5 years period. The PPV23 vaccination program could substantially offer additional benefits in reducing the pneumococcal disease burden and healthcare cost. This could be of help for policymakers to consider the implementation of PPV23 vaccination for Malaysian performing hajj.

The Health Professional's View on the Inclusion of Age in the Recommendations for Pneumococcal Vaccination: Results of a Cross-Sectional Survey in France

Elderly people are at high risk for pneumococcal infections. However, older age is not an eligibility factor for pneumococcal vaccination in France. Adults with certain co-morbidities or immunocompromised states are eligible for vaccination, which leaves adults aged ≥65 years without comorbidities at-risk for pneumococcal infections. The objective of the study was to evaluate the acceptability to healthcare professionals (HCPs) of extending pneumococcal vaccination to all individuals ≥65 years. Based on themes identified in semi-structured interviews with 24 HCPs, a representative sample of 500 general practitioners and pharmacists were surveyed about their knowledge, attitudes and beliefs with respect to pneumococcal vaccination for individuals ≥65 years. Current recommendations for pneumococcal vaccination are poorly understood by participants (mean score: 5.8/10). Respondents were generally supportive of inclusion of age in vaccination recommendations (7.5/10), with 58% being very supportive. For 72% of HCPs, this would contribute to improved vaccination coverage. The strategy could be facilitated by associating pneumococcal vaccination with the influenza vaccination campaign (8.3/10). Pharmacists were favourable to participating in pneumococcal vaccination (8.5/10). In conclusion, extension of pneumococcal vaccination to all people aged ≥65 years would be welcomed by HCPs, simplifying identification of patients to be vaccinated and potentially improving vaccination coverage.

Cost-Effectiveness of Pneumococcal Vaccines for Adults Aged 65 Years and Older in Argentina

OBJECTIVES

In 2017, the Argentine Ministry of Health incorporated a sequential 13-valent pneumococcal conjugate vaccine (PCV13)-23-valent pneumococcal polysaccharide vaccine (PPSV23) regimen for adults aged ≥65 years to reduce pneumococcal disease burden. Cost-effectiveness analysis of PCV13-PPSV23 schedule for adults aged ≥65 years in Argentina was performed compared with PPSV23 only.

METHODS

Markov model was developed. Local data were incorporated for costs and disease burden analysis. Vaccine efficacy or effectiveness was obtained from a systematic review adjusted to current local vaccine serotype circulation and vaccines coverage. A total of 3 scenarios were evaluated: main scenario according to published literature of pneumonia incidence, epidemiologic surveillance scenario based on Argentine Ministry of Health data, and an alternative scenario assuming a 50% hypothetical pneumonia incidence reduction resulting from herd immunity induced by childhood vaccination. Sensitivity analyses were done.

RESULTS

Sequential PCV13-PPSV23 schedule showed cost-savings results in the main scenario with -$1 667 742.23 saved and 716 life-years gained (LYG). The epidemiologic surveillance scenario showed an incremental cost-effectiveness ratio of $2141.92 per LYG and an alternative scenario with $3740.30 per LYG. Tornado diagram shows widest bars related to adjustment for vaccine-type pneumococcal pneumonia (urine analysis) pneumonia at risk cost and pneumonia incidence rate. Monte Carlo simulation shows that >98% of simulations were cost-saving for the main scenario.

CONCLUSIONS

In the main scenario, cost-saving results were obtained considering only reduction of vaccine serotype coverage after the introduction of childhood PCV13 vaccination. In the epidemiologic surveillance and alternative scenarios, assuming a hypothetical incidence reduction, highly cost-effective results were observed.

Invasive pneumococcal disease among adults with hematological and solid organ malignancies: A population-based cohort study

OBJECTIVES

To determine the risk of invasive pneumococcal disease (IPD) in adult cancer patients stratified by type of underlying malignancy, age, and capsular serotype and to assess herd effects of childhood pneumococcal vaccination.

METHODS

All adult IPD cases reported to the Dutch pneumococcal surveillance system between 2004 and 2016 were included in this study. IPD incidence rates (IR) stratified by subtype of malignancy were calculated per 100 000 patient-years of follow-up. Incidence rate ratios (IRR) were calculated to compare IRs between groups.

RESULTS

A total of 7167 IPD cases were included, of which 1453 were in patients with malignancies. For patients with hematological malignancies (HM) and solid organ malignancies (SOM), IRs were 482/100 000 and 79/100 000, respectively, compared with 15/100 000 in controls. The highest incidence was observed among patients with multiple myeloma, non-Hodgkin lymphoma, chronic lymphocytic leukemia, pancreatic cancer, and lung cancer (3299/100 000, 2717/100 000, 538/100 000, 559/100 000, and 393/100 000, respectively), and in patients ≥50 years old. Among HM patients, the incidence of IPD declined significantly after the implementation of infant pneumococcal vaccination (IRR 0.65, 95% confidence interval 0.51-0.84); among SOM patients, the decline was not statistically significant (IRR 0.88, 95% confidence interval 0.72-1.07).

CONCLUSIONS

The IPD disease burden in cancer patients remains high. Large differences in IPD incidence between the different types of cancer demand tailored guidance regarding pneumococcal vaccination.

Vaccines for older adults

The proportion of the global population aged 65 and older is rapidly increasing. Infections in this age group, most recently with SARS-CoV-2, cause substantial morbidity and mortality. Major improvements have been made in vaccines for older people, either through the addition of novel adjuvants-as in the new recombinant zoster vaccine and an adjuvanted influenza vaccine-or by increasing antigen concentration, as in influenza vaccines. In this article we review improvements in immunization for the three most important vaccine preventable diseases of aging. The recombinant zoster vaccine has an efficacy of 90% that is minimally affected by the age of the person being vaccinated and persists for more than four years. Increasing antigen dose or inclusion of adjuvant has improved the immunogenicity of influenza vaccines in older adults, although the relative effectiveness of the enhanced influenza vaccines and the durability of the immune response are the focus of ongoing clinical trials. Conjugate and polysaccharide pneumococcal vaccines have similar efficacy against invasive pneumococcal disease and pneumococcal pneumonia caused by vaccine serotypes in older adults. Their relative value varies by setting, depending on the prevalence of vaccine serotypes, largely related to conjugate vaccine coverage in children. Improved efficacy will increase public confidence and uptake of these vaccines. Co-administration of these vaccines is feasible and important for maximal uptake in older people. Development of new vaccine platforms has accelerated following the arrival of SARS-CoV-2, and will likely result in new vaccines against other pathogens in the future.

Immunization Coverage of Inmates in Spanish Prisons

The correct immunization of the inmate population minimizes the risk of transmission of vaccine-preventable diseases in prisons. The objective of this study was to evaluate the vaccine coverage of long-term prisoners in the Spanish penitentiary system through a retrospective longitudinal study. One-thousand and five prisoners were selected, who were imprisoned from 2008 and 2018 in three Spanish prisons. Their degree of immunization was evaluated as related to hepatitis A (HAV), hepatitis B (HBV), tetanus, diphtheria, pneumococcus and seasonal flu. The state of vaccination of the prisoners with a serological diagnosis of HBV, hepatitis C (HCV) and human immunodeficiency virus (HIV) was also evaluated. The vaccination coverage obtained for hepatitis B was 52.3%, and for tetanus–diphtheria, it was 71.9%. However, for hepatitis A and pneumococcus infection, it was insignificant (<2% of the prisoners). Vaccination against seasonal flu was lower than 16%. The HCV and HIV-positive inmates were not correctly vaccinated either. The insufficient level of immunization obtained reflects the lack of interest and marginalization of this population by the penitentiary system and the health authorities. The lack of reliable records is combined with the lack of planned strategies that promote stable and well-defined programs of active vaccination.

Effectiveness of the 23-valent pneumococcal polysaccharide vaccine against vaccine serotype pneumococcal pneumonia in adults: A case-control test-negative design study

BACKGROUND

Vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPV23) is available in the United Kingdom to adults aged 65 years or older and those in defined clinical risk groups. We evaluated the vaccine effectiveness (VE) of PPV23 against vaccine-type pneumococcal pneumonia in a cohort of adults hospitalised with community-acquired pneumonia (CAP).

METHODS AND FINDINGS

Using a case-control test-negative design, a secondary analysis of data was conducted from a prospective cohort study of adults (aged ≥16 years) with CAP hospitalised at 2 university teaching hospitals in Nottingham, England, from September 2013 to August 2018. The exposure of interest was PPV23 vaccination at any time point prior to the index admission. A case was defined as PPV23 serotype-specific pneumococcal pneumonia and a control as non-PPV23 serotype pneumococcal pneumonia or nonpneumococcal pneumonia. Pneumococcal serotypes were identified from urine samples using a multiplex immunoassay or from positive blood cultures. Multivariable logistic regression was used to derive adjusted odds of case status between vaccinated and unvaccinated individuals; VE estimates were calculated as (1 - odds ratio) × 100%. Of 2,357 patients, there were 717 PPV23 cases (48% vaccinated) and 1,640 controls (54.5% vaccinated). The adjusted VE (aVE) estimate against PPV23 serotype disease was 24% (95% CI 5%-40%, p = 0.02). Estimates were similar in analyses restricted to vaccine-eligible patients (n = 1,768, aVE 23%, 95% CI 1%-40%) and patients aged ≥65 years (n = 1,407, aVE 20%, 95% CI -5% to 40%), but not in patients aged ≥75 years (n = 905, aVE 5%, 95% CI -37% to 35%). The aVE estimate in relation to PPV23/non-13-valent pneumococcal conjugate vaccine (PCV13) serotype pneumonia (n = 417 cases, 43.7% vaccinated) was 29% (95% CI 6%-46%). Key limitations of this study are that, due to high vaccination rates, there was a lack of power to reject the null hypothesis of no vaccine effect, and that the study was not large enough to allow robust subgroup analysis in the older age groups.

CONCLUSIONS

In the setting of an established national childhood PCV13 vaccination programme, PPV23 vaccination of clinical at-risk patient groups and adults aged ≥65 years provided moderate long-term protection against hospitalisation with PPV23 serotype pneumonia. These findings suggest that PPV23 vaccination may continue to have an important role in adult pneumococcal vaccine policy, including the possibility of revaccination of older adults.

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.

A global agenda for older adult immunization in the COVID-19 era: A roadmap for action

Given our global interconnectedness, the COVID-19 pandemic highlights the urgency of building a global system that can support both routine and pandemic/epidemic adult immunization. As such, a framework to recommend vaccines and build robust platforms to deliver them to protect the rapidly expanding demographic of older adults is needed. Adult immunization as a strategy has the broad potential to preserve and improve medical, social, and economic outcomes, including maintaining functional ability that benefits older adults, their families, communities, and countries. While we will soon have multiple vaccines against COVID-19, we must recognize that we already have a variety of vaccines against other pathogens that can keep adults healthier. They can prevent simultaneous co-infection with COVID-19, and may favorably impact- the outcome of a COVID-19 illness. Further, administering a vaccine against COVID-19 requires planning now to determine delivery strategies impacting how older adults will be immunized in a timely manner. A group of international experts with various backgrounds from health and aging disciplines met to discuss the evidence case for adult immunization and crucial knowledge gaps that must be filled in order to implement effective policies and programs for older adult immunization. This group, coming together as the International Council on Adult Immunization (ICAI), outlined a high-level roadmap to catalyze action, provide policy guidance, and envision a global adult immunization platform that can be adapted by countries to fit their local contexts. Further meetings centered around the value of adult immunization, particularly in the context of COVID-19. There was agreement that programs to deliver existing influenza, pneumococcal, herpes zoster vaccines, and future COVID-19 vaccines to over a billion older adults who are at substantially higher risk of death and disability due to vaccine-preventable diseases are more urgent than ever before. Here we present a proposed framework for delivering routine and pandemic vaccines. We call upon the global community and governments to prioritize action for integrating robust adult immunization programs into the public health agenda.

Cost-effectiveness of pneumococcal vaccination for elderly in Sweden

INTRODUCTION

The aim was to assess cost-effectiveness of including pneumococcal vaccination for elderly in a national vaccination programme in Sweden, comparing health-effects and costs of pneumococcal related diseases with a vaccination programme versus no vaccination.

METHOD

We used a single-cohort deterministic decision-tree model to simulate the current burden of pneumococcal disease in Sweden. The model accounted for invasive pneumococcal disease (IPD) and pneumonia caused by pneumococci. Costs included in the analysis were those incurred when treating pneumococcal disease, and acquisition and administration of the vaccine. Health effects were measured as quality-adjusted life years (QALY). The time-horizon was set to five years, both effects and costs were discounted by 3% annually. Health-effects and costs were accumulated over the time-horizon and used to create an incremental cost-effectiveness ratio. The 23-valent polysaccharide vaccine (PPV23) was used in the base-case analysis. The 13-valent pneumococcal conjugate vaccine PCV13 was included in sensitivity analyses.

RESULTS

A vaccination programme using PPV23 would reduce the burden of pneumococcal related disease significantly, both when vaccinating a 65-year-old cohort and a 75-year-old cohort. IPD would decrease by 30% in the 65-year-old cohort, and by 29% in the 75-year-old cohort. The corresponding figures for CAP (communicable acquired pneumonia) are 19% and 15%. The cost per gained QALY was estimated to EUR 94,000 for vaccinating 65-year-olds and EUR 29,500 for 75-year-olds. With one dose PCV13 given instead of PPV23, the cost per gained QALY would increase by around 400% for both cohorts. The results were robust in sensitivity analyses.

CONCLUSION

Introducing a vaccination programme against pneumococcal disease for 65-year-olds in Sweden is unlikely to be cost-effective, whereas it for 75 year-olds and using PPV23 can be considered good value for money. Our model indicates that vaccine price needs to be reduced by 55% for vaccination of 65-year-olds to be cost-effective, given a threshold of EUR 50,000.

Estimating the Impact of Switching from a Lower to Higher Valent Pneumococcal Conjugate Vaccine in Colombia, Finland, and The Netherlands: A Cost-Effectiveness Analysis

INTRODUCTION

Widespread use of ten-valent (Synflorix™, GSK) or 13-valent (Prevenar 13™; Pfizer) conjugate vaccination programs has effectively reduced invasive pneumococcal disease (IPD) globally. However, IPD caused by serotypes not contained within the respective vaccines continues to increase, notably serotypes 3, 6A, and 19A in countries using lower-valent vaccines. Our objective was to estimate the clinical and economic benefit of replacing PCV10 with PCV13 in Colombia, Finland, and The Netherlands.

METHODS

Country-specific databases, supplemented with published and unpublished data, informed the historical incidence of pneumococcal disease as well as direct and indirect medical costs. A decision-analytic forecasting model was applied, and both costs and outcomes were discounted. The observed invasive pneumococcal disease (IPD) trends from each country were used to forecast the future number of IPD cases given a PCV13 or PCV10 program.

RESULTS

Over a 5-year time horizon, a switch to a PCV13 program was estimated to reduce overall IPD among 0-2 year olds by an incremental - 37.6% in Colombia, - 32.9% in Finland, and - 26% in The Netherlands, respectively, over PCV10. Adults > 65 years experienced a comparable incremental decrease in overall IPD in Colombia (- 32.2%), Finland (- 15%), and The Netherlands (- 3.7%). Serotypes 3, 6A, and 19A drove the incremental decrease in disease for PCV13 over PCV10 in both age groups. A PCV13 program was dominant in Colombia and Finland and cost-effective in The Netherlands at 1 × GDP per capita (€34,054/QALY).

CONCLUSION

In Colombia, Finland, and The Netherlands, countries with diverse epidemiologic and population distributions, switching from a PCV10 to PCV13 program would significantly reduce the burden of IPD in all three countries in as few as 5 years.

Pneumococcal Vaccination in Adults Aged ≥65 Years: Cost-Effectiveness and Health Impact in U.S. Populations

INTRODUCTION

Recommending both the conjugate and polysaccharide pneumococcal vaccines to all U.S. seniors may have little public health impact and be economically unreasonable. Public health impact and cost-effectiveness of using both vaccines in all adults aged ≥65 years were estimated compared with an alternative strategy (omitting pneumococcal conjugate vaccine in the nonimmunocompromised) and with the newly revised recommendation (giving or omitting conjugate vaccine based on patient-physician shared decision making).

METHODS

Strategies were examined in hypothetical U.S. 65-year-old population cohorts and segmented into health states based on age- and population-specific data in a Markov state-transition model with a lifetime time horizon from a healthcare perspective. Black population cohorts were examined separately given greater illness risk and lower vaccine uptake. Model parameters came from the Centers for Disease Control Active Core Bacterial Surveillance network, National Health Interview Survey, and Nationwide Inpatient Sample data. Outcomes included incremental costs per quality-adjusted life year gained and pneumococcal disease outcomes for each strategy. Data were gathered and analysis performed in 2018.

RESULTS

Giving both vaccines, either routinely or with shared decision making, was most effective, reducing pneumococcal disease incidence compared with no vaccination, but costing $765,000-$2.18 million/quality-adjusted life year gained. Depending on examined population and scenario, the alternative strategy cost $65,700-$226,700/quality-adjusted life year gained (less in black populations) and reduced cases and deaths by 0.3%-0.9%.

CONCLUSIONS

A vaccination strategy that omits pneumococcal conjugate vaccine in immunocompetent U.S. seniors may be economically reasonable, particularly for black seniors. Use of both pneumococcal vaccines was more effective but substantially more expensive.

State-of-the-art in the pneumococcal field: Proceedings of the 11th International Symposium on Pneumococci and Pneumococcal Diseases (ISPPD-11)

The International Symposium on Pneumococci and Pneumococcal Diseases (ISPPD) is the premier global scientific symposium dedicated to the exchange, advancement and dissemination of the latest research on the pneumococcus, one of the world's deadliest bacterial pathogens. Since the first ISPPD was held in 1998, substantial progress has been made to control pneumococcal disease, for instance, more than half of surviving infants (78.6 million) from 143 countries now have access to the life-saving pneumococcal conjugate vaccine (PCV). The 11th ISPPD (ISPPD-11) was held in Melbourne, Australia in April 2018 and the proceedings of the symposium are captured in this report. Twenty years on from the first ISPPD, there remain many challenges and unanswered questions such as the continued disparity in disease incidence in Indigenous populations, the slow roll-out of PCV in some regions such as Asia, the persisting burden of disease in adults, serotype replacement and diagnosis of pneumococcal pneumonia. ISPPD-11 also put the spotlight on cutting-edge science including metagenomic, transcriptomic, microscopy, medical imaging and mathematical modelling approaches. ISPPD-11 was highly diverse, bringing together 1184 delegates from 86 countries, representing various fields including academia, primary healthcare, pharmaceuticals, biotechnology, policymakers and public health.

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

Pneumococcal disease is a potentially fatal bacterial infection that is vaccine-preventable. Malaysia has yet to adopt a pneumococcal conjugate vaccine (PCV) into its national immunization program (NIP). In 2016, pneumonia was the 3^rd leading cause of death in children under five in Malaysia, accounting for 3.8% of under-five deaths. Introducing a pneumococcal conjugate vaccine (PCV) is an effective strategy to reduce the disease burden. This study used a decision-analytic model to assess the potential impacts of introducing the available PCVs (13-valent and 10-valent) in Malaysia. Epidemiological and costs inputs were sourced from published literature. For each vaccination program, health outcomes and associated healthcare costs were estimated. The scenarios of initiating PCV13 vs. PCV10 and the status quo (no pneumococcal vaccine) were compared. Serotype trends of Finland and the U.K. were used to model the clinical impacts of PCV10 and PCV13 respectively. The base-case analysis used a societal perspective over a 5-year time horizon. Compared with PCV10, PCV13 was projected to avert an additional 190,628 cases of pneumococcal disease and 1126 cases of death. The acquisition of PCV13 was estimated to cost an incremental US$89,904,777, offset by a cost reduction of -US$250,219,914 on pneumococcal disease-related medical care and lost productivity. PCV13 demonstrated a higher cost-saving potential over PCV10. Compared with no vaccination, PCV13 was estimated as cost-saving. Results were robust across a series of sensitivity analyses. The introduction of PCV13 in a NIP was estimated to reduce a significant burden of disease and to be a cost-saving for the Malaysian health system.

[Alterations in responses to vaccines in older people]

The aging population raises a number of public health issues including a need to address the severity and frequency of infections observed in older people. Vaccines play an important role in prevention. However, immunosenescence alters the intensity and quality of vaccine responses, thus limiting the impact of recommendations directed after 65 years for vaccination against flu, pneumococci, pertussis, tetanus and zoster. Immunosenescence, aggravated by co-morbidities, varies with age, becoming apparent after 60-65 years and more profound after 85 years. All stages of vaccine responses are affected by immunosenescence, from the innate immunity required to activate these responses to the induction of protective antibody responses and immune memory. Nevertheless, the capacity to develop new responses to primary vaccination is more affected than the ability to respond to recalls, although this is also impaired. Responses to vaccines are differentially altered depending on vaccine and age. Influenza vaccines are modestly immunogenic and several meta-analyses agree an estimate for efficacy of about 50% against virologically-proven flu and 40% against flu-related deaths. The anti-pneumococcal 23-valent non-conjugated vaccine does not induce memory while the 13-valent conjugated one does, but their efficacy are likely to be similar between 70 to 52% before 75 years. A sequential vaccination program with the 13-valent primo-vaccination followed by the 23-valent, recommended in immune-suppressed patients, is currently being studied in France. The waning of immunity to pertussis makes recalls necessary in the elderly who develop good antibody responses. Several research avenues are currently being pursued to try improve the degree of protection conferred by these vaccines in elderly.

Cost-effectiveness analysis on elderly pneumococcal vaccination in the Netherlands: Challenging the Dutch Health Council's advice

Recently, the Dutch Health Council advised on elderly pneumococcal vaccination favouring the conventional polysaccharide vaccine over the novel conjugated vaccine. This advice was strongly inspired by a cost-effectiveness analysis considered to show favourable outcomes for the polysaccharide but not for the conjugated vaccine. We argue that using the same data and methods as presented by the Health Council, a different perspective on the results leads to a conclusion that not only the polysaccharide but also the conjugated pneumococcal vaccine is cost-effective. Our alternative perspective concerns the use of realistic vaccine prices, and applying an adequate time horizon for cost-effectiveness modelling. Notably, for one-off vaccination of 65-years old elderly, in all investigated analyses, also the conjugated vaccine seems cost-effective; i.e. well below the threshold of €20,000 per quality-adjusted life year, reflecting the most stringent threshold used for vaccines in the Netherlands.

Twelve years of pneumococcal conjugate vaccination in the Netherlands: Impact on incidence and clinical outcomes of invasive pneumococcal disease

INTRODUCTION

In 2006, the Netherlands introduced the 7-valent pneumococcal conjugate vaccine (PCV7) in their national immunisation programme. In 2011, PCV7 was replaced by the 10-valent vaccine (PCV10). We report on the impact of PCV on invasive pneumococcal disease (IPD) incidence, clinical syndromes and patient outcomes.

METHODS

Pneumococcal isolates of hospitalised IPD patients between June 2004 and May 2018 were obtained from nine sentinel laboratories, covering 25% of the Dutch population. All isolates were serotyped. IPD incidence and clinical outcome were determined before and after introduction of PCV7 and after the switch to PCV10, stratified by age and serotype.

RESULTS

Compared to before PCV7 introduction, significant declines in IPD incidence were observed in 2016-2018 in children <5 years (69%), 18-49 year olds (31%) and ≥65 year olds (19%). Compared to before PCV10 introduction, the IPD incidence in 2016-2018 declined in children <5 years (RR:0.68, 95%CI:0.42-1.11), 5-17 year olds (RR:0.58, 95%CI:0.29-1.14) and 18-49 year olds (RR:0.72, 95%CI:0.57-0.90), but not in 50-64 year olds (RR:0.94, 95%CI:0.81-1.10) and ≥65 year olds (RR:1.04, 95%CI:0.0.93-1.15). While the case fatality rate (CFR) decreased from 16.2% pre-PCV to 13.4% post-PCV10 (RR:0.83, 95%CI:0.70-0.99), the switch to PCV10 had no further impact on CFR (RR:1.14, 95%CI:0.96-1.36).

CONCLUSION

Twelve years of PCV in the Netherlands has resulted in a sustained reduction of IPD incidence in children and younger adults. The switch from PCV7 to PCV10 did not have additional impact on the IPD incidence in older adults and CFR due to emerging non-vaccine serotypes.

Cost Effectiveness of Elderly Pneumococcal Vaccination in Presence of Higher-Valent Pneumococcal Conjugate Childhood Vaccination: Systematic Literature Review with Focus on Methods and Assumptions

BACKGROUND

Previous systematic reviews concluded that pneumococcal vaccination in the elderly was cost effective. However, recently published economic evaluations state that it may not be cost effective when children are vaccinated with higher-valent pneumococcal conjugate vaccines. The literature suggests that the outcomes of vaccination in the elderly are strongly influenced by the vaccine effectiveness (VE) against the vaccine-type pneumococcal diseases (PD) and the impact of childhood vaccination on the vaccine-type PD incidence in the elderly, but the extent remains unclear.

METHODS

We conducted a systematic literature search of cost-effectiveness studies on vaccination in the elderly in the PubMed database starting from 2006. We included studies that consider the presence of a childhood vaccination with pneumococcal conjugate vaccine (PCV) 10 and PCV13. We focus on methods and assumptions used in modeling VE and epidemiology of PD over time.

RESULTS

Twenty-eight economic evaluations underwent full-text review and data extraction. Thirteen were selected for quality assessment. The studies with a higher quality score provide evidence that vaccinating the elderly with PCV13 is not cost effective, when an ongoing rapid decline in the incidence of PCV13-type PD is modeled. A moderate persistence of PCV13 serotypes, in particular due to PCV10 childhood vaccination, makes vaccination of the elderly with PCV13 more attractive. There is no agreement that combining PCV13 with polysaccharide vaccine PPSV23 is cost effective. PPSV23 is attractive when it is effective against non-invasive PD.

CONCLUSION

Methodological approaches and assumptions in modeling VE and the indirect effects of childhood vaccination have a major impact on outcomes of decision-analytic models and cost-effectiveness estimates. Considering recently observed trends in the epidemiology of pneumococcal serotypes, there is currently inconclusive evidence regarding the cost effectiveness of pneumococcal vaccination of the elderly due to lack of studies that model key serotypes such as serotype 3 separately from other groups of serotypes.

Cost-effectiveness of the 13-valent pneumococcal conjugate vaccine in adults in Portugal versus "no vaccination" and versus vaccination with the 23-valent pneumococcal polysaccharide vaccine

The burden of pneumococcal disease in adults is substantial from a social and economic point of view. This study assessed the cost-effectiveness of the 13-valent pneumococcal conjugate vaccine (PCV13) for the prevention of invasive pneumococcal disease and pneumococcal pneumonia in adults versus "no vaccination" and versus vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23). A Markov model was used to simulate three strategies: no vaccination, complete vaccination with PPSV23 and complete vaccination with PCV13. The comparison between strategies allowed the estimation of clinical and economic outcomes including incremental cost-effectiveness ratios (ICER) and incremental cost-utility ratios (ICUR). The model took into account the distributions of age, risk profile, vaccination status, type of immunization and time since vaccination in the population. A societal perspective was adopted and a lifetime horizon was considered. Different sources of data and assumptions were used to calibrate PPSV23 and PCV13 effectiveness. Inpatient costs were based on the 2013 diagnosis-related group (DRG) database for National Health Service (NHS) hospitals and expert opinion; NHS official tariffs were the main source for unitary costs. PCV13 shows ICURs of €17,746/QALY and €13,146/QALY versus "no vaccination" and vaccination with PPSV23, respectively. Results proved to be robust in univariate sensitivity analyses, where all ratios were below a €20,000 threshold, with the exception of the scenario with PCV13 effectiveness halved. In a probabilistic sensitivity analysis, 94% of simulations showed cost-effectiveness ratios lower than €20,000/QALY, in both strategies. It was found that PCV13 is a cost-effective strategy to prevent pneumococcal disease in adults in Portugal.

Comment on Gomez et. al. "Response to article by Wasserman et. al. (2018) 'Modelling the sustained use of the 13-valent pneumococcal conjugate vaccine compared to switching to the 10-valent vaccine in Mexico'"

In a recent Letter, Gomez et. al. provided a critique of our original analysis estimating the clinical and economic impact of switching from the 13-valent (PCV13) to the 10-valent (PCV10) pneumococcal conjugate vaccine in Mexico. This comment addresses Gomez et. al.'s comments with additional information and clarifies potential misinterpretations.

Modeling the sustained use of the 13-valent pneumococcal conjugate vaccine compared to switching to the 10-valent vaccine in Mexico

Introduction: Pneumococcal diseases caused by Streptococcus pneumoniae represent a significant health and economic burden. Mexico has benefited from the inclusion of the 7-valent (PCV7) and 13-valent pneumococcal conjugate vaccines (PCV13) since their inclusion in the National Immunization Program (NIP) in 2006 and 2010, respectively. The objective of this study is to estimate the impact of the existing program and predict future implications of a change in the current program.

Methods: A previously published model was updated to estimate the historic impact of the PCV programs relative to pre-PCV implementation. Future disease trends were forecasted based on historical serotype behaviors for each PCV13 serotype and non-vaccine serotypes across different age groups. Costs and outcomes were estimated over a 10-year period based on continued use of PCV13 compared to a switch to PCV10.

Results: The PCV7 and subsequent PCV13 NIP were estimated to prevent over 1.5 million cases of pneumococcal disease and 1,854 deaths, corresponding to a net savings of $34.50 Billion MXN. Continued use of PCV13 was estimated to save over 300 thousand cases of pneumococcal disease and 373 deaths compared to switching to PCV10 over a 10-year period. Despite a higher vaccine cost, maintaining PCV13 was cost-saving compared to PCV10, saving $6.71 billion MXN over 10 years.

Conclusion: The PCV program in Mexico has provided a significant return on investment. Sustained PCV13 use was estimated to provide the greatest healthcare and economic impact in Mexico. Changes to the pneumococcal vaccination program could result in serotype replacement and reduction in herd effects.

Dynamic transmission modelling to address infant pneumococcal conjugate vaccine schedule modifications in the UK

The 13-valent pneumococcal conjugate vaccine (PCV) has been part of routine immunisation in a 2 + 1 schedule (two primary infant doses and one booster during the second year of life) in the UK since 2010. Recently, the UK's Joint Committee on Vaccination and Immunisation recommended changing to a 1 + 1 schedule while conceding that this will increase disease burden; however, uncertainty remains on how much pneumococcal burden – including invasive pneumococcal disease (IPD) and non-invasive disease – will increase. We built a dynamic transmission model to investigate this question. The model predicted that a 1 + 1 schedule would incur 8777–27 807 additional cases of disease and 241–743 more deaths over 5 years. Serotype 19A caused 55–71% of incremental IPD cases. Scenario analyses showed that booster dose adherence, effectiveness against carriage and waning in a 1 + 1 schedule had the most influence on resurgence of disease. Based on the model assumptions, switching to a 1 + 1 schedule will substantially increase disease burden. The results likely are conservative since they are based on relatively low vaccine-type pneumococcal transmission, a paradigm that has been called into question by data demonstrating an increase of IPD due to several vaccine serotypes during the last surveillance year available.