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

Abstract

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.

Indirect costs of adult pneumococcal disease and the productivity-based rate of return to the 13-valent pneumococcal conjugate vaccine for adults in Turkey

“…Of the four studies that evaluate the addition of PCV13 Adult to adult PPV23 (as was the case in Turkey), van Hoek and Miller (2016), 20 Blommaert et al (2016), 21 and Willem et al (2018) 22 found doing so to be cost-ineffective, while Stoecker et al (2016) 23 found it to be cost-effective only in the short run before herd effects fully set in. Treskova et al (2019) 18 conclude from this evidence that PCV13 Adult is not cost-effective in the presence of herd effects from PCV13 Pediatric.…”

“…Dirmesropian et al (2015) 19 review pre-2015 studies a majority of which found PCV13 adult to be cost-effective but all of which were hampered by not having access to the important CAPITA trial estimates of vaccine efficacy. A more recent review by Treskova et al (2019) 18 stratifies the newer literature according to assumptions about herd effects from pediatric vaccination (i.e., whether effects were ongoing or completed, whether effects were from pediatric PCV13 (PCV13 Pediatric) or from pediatric 10-valent pneumococcal conjugate vaccine (PCV10 Pediatric), or whether there was a switch in pediatric vaccination from PCV10 to PCV13 or vice versa), and according to the policy being evaluated (PPV23 versus no vaccination, PCV13 versus no vaccination, and adding PCV13 to PPV23). Of the four studies that evaluate the addition of PCV13 Adult to adult PPV23 (as was the case in Turkey), van Hoek and Miller (2016), 20 Blommaert et al (2016), 21 and Willem et al (2018) 22 found doing so to be cost-ineffective, while Stoecker et al (2016) 23 found it to be cost-effective only in the short run before herd effects fully set in.…”

“…The literature on the economic evaluation of PCV13 Adult typically adopts the health payer's perspective, 18 uses CUA, ignores indirect costs, and where indirect costs are considered uses the friction approach and ignores unpaid work. Dirmesropian et al (2015) 19 review pre-2015 studies a majority of which found PCV13 adult to be cost-effective but all of which were hampered by not having access to the important CAPITA trial estimates of vaccine efficacy.…”

Cost-Effectiveness Analysis of Routine Use of 15-Valent Pneumococcal Conjugate Vaccine in the US Pediatric Population

“…The model also accounted for the vaccine effect waning in the base case. It was assumed that vaccinated children received the full benefit of the vaccine (i.e., no waning effectiveness) during the first five years after vaccination and then the VE decreased linearly to 0% over the next 10 years (i.e., from Year 6 to Year 15 after the last vaccine dose) [ 51 ].…”

The cost-effectiveness of using pneumococcal conjugate vaccine (PCV13) versus pneumococcal polysaccharide vaccine (PPSV23), in South African adults

“…In the dynamic transmission model, the force of infectivity can change over time due to changes in the size of the susceptible population. A recent systematic review paper [78] of cost-effectiveness analysis publications for adult PCV13 included only static models. The dynamic transmission model requires more data on the transmission aspects and this data is scarce, which leads to many assumptions.…”