Cost-effectiveness of pneumococcal conjugate vaccination in Croatia.

OBJECTIVE: Pneumococcus is a known cause of meningitis, pneumonia, sepsis, and acute otitis media in children and adults globally. Two new vaccines for children have the potential to prevent illness, disability, and death, but these vaccines are expensive. The Croatian Ministry of Health has considered introducing the vaccine in the past, but requires economic evidence to ensure that the limited funds available for health care will be used in the most effective way. METHODOLOGY: Croatia appointed a multidisciplinary team of experts to evaluate the cost-effectiveness of introducing pneumococcal conjugate vaccination (PCV) into the national routine child immunization program. Both 10-valent and 13-valent PCV (PCV10 and PCV13) were compared to a scenario assuming no vaccination. The TRIVAC decision-support model was used to estimate cost-effectiveness over the period 2014-2033. We used national evidence on demographics, pneumococcal disease incidence and mortality, the age distribution of disease in children, health service utilization, vaccine coverage, vaccine timeliness, and serotype coverage. Vaccine effectiveness was based on evidence from the scientific literature. Detailed health care costs were not available from the Croatian Institute for Health Insurance at the time of the analysis so assumptions and World Health Organization (WHO) estimates for Croatia were used. We assumed a three-dose primary vaccination schedule, and an initial price of US$30 per dose for PCV10 and US$ 35 per dose for PCV13. We ran univariate sensitivity analyses and multivariate scenario analyses. RESULTS: Either vaccine is estimated to prevent approximately 100 hospital admissions and one death each year in children younger than five in Croatia. Compared to no vaccine, the discounted cost-effectiveness of either vaccine is estimated to be around US$69,000-77,000 per disability-adjusted life-years (DALYs) averted over the period 2014-2033 (from the government or societal perspective). Only two alternative scenarios were borderline cost-effective (US$ per DALY averted less than 3×GDP per capita of approximately US$40,000). The first was a scenario based primarily on the WHO 2008 pneumococcal disease burden estimates for Croatia. The second was a scenario that assumed a fairly dramatic drop in the price of the vaccine over the period. Both vaccines would need to be priced at approximately US$ 20 per dose or less to be considered cost-effective under base-case assumptions. PCV10 would be more cost-effective than PCV13 with base-case assumptions, but this is sensitive to the price of each vaccine. CONCLUSION: Based on estimated health and economic benefits in children alone, PCV is unlikely to be cost-effective in Croatia. Both vaccines would need to be priced at less than US$ 20 per dose to be considered cost-effective for children. Further analyses should be conducted to estimate the health and economic burden of pneumococcal disease in older age groups, and to assess the influence on cost-effectiveness results when short-term and long-term indirect effects are included for older individuals. While there are important uncertainties around the price and effectiveness of both vaccines, our analysis suggests there is insufficient evidence to warrant a significant difference in the price of the two vaccines

Cost-effectiveness of pneumococcal conjugate vaccination in Georgia.

OBJECTIVE: Financial support from the Global Alliance for Vaccines and Immunization (GAVI) to introduce the 10-valent pneumococcal conjugate vaccine (PCV10) into the routine childhood immunization schedule in Georgia is ending in 2015. As a result, the Interagency Coordination Committee (ICC) decided to carry out a cost-effectiveness analysis to gather additional evidence to advocate for an appropriate evidence-based decision after GAVI support is over. The study also aimed to strengthen national capacity to conduct cost-effectiveness studies, and to introduce economic evaluations into Georgia's decision-making process. METHODOLOGY: A multidisciplinary team of national experts led by a member of the ICC carried out the analysis that compared two scenarios: introducing PCV10 vs no vaccination. The TRIVAC model was used to evaluate 10 cohorts of children over the period 2014-2023. National data was used to inform demographics, disease burden, vaccine coverage, health service utilization, and costs. Evidence from clinical trials and the scientific literature was used to estimate the impact of the vaccine. A 3+0 schedule and a vaccine price increasing to US$3.50 per dose was assumed for the base-case scenario. Alternative univariate and multivariate scenarios were evaluated. RESULTS: Over the 10-year period, PCV10 was estimated to prevent 7170 (8288 undiscounted) outpatient visits due to all-cause acute otitis media, 5325 (6154 undiscounted) admissions due to all-cause pneumonia, 87 (100 undiscounted) admissions due to pneumococcal meningitis, and 508 (588 undiscounted) admissions due to pneumococcal non-pneumonia and non-meningitis (NPNM). In addition, the vaccine was estimated to prevent 41 (48 undiscounted) deaths. This is equivalent to approximately 5 deaths and 700 admissions prevented each year in Georgia. Over the 10-year period, PCV10 would cost the government approximately US$ 4.4 million ($440,000 per year). However, about half of this would be offset by the treatment costs prevented. The discounted cost-effectiveness ratio was estimated to be US$ 1599 per DALY averted with scenarios ranging from US$286 to US$ 7787. DISCUSSION: This study led to better multi-sectoral collaboration and improved national capacity to perform economic evaluations. Routine infant vaccination against Streptococcus pneumoniae would be highly cost-effective in Georgia. The decision to introduce PCV10 was already made some time before the study was initiated but it provided important economic evidence in support of that decision. There are several uncertainties around many of the parameters used, but a multivariate scenario analysis with several conservative assumptions (including no herd effect in older individuals) shows that this recommendation is robust. This study supports the decision to introduce PCV10 in Georgia