Cost-utility of 20-valent pneumococcal conjugate vaccine compared to no vaccination and recommended alternative vaccines among Belgian adults

Figures & data

Table 1. Epidemiological, effectiveness, and (dis)utility inputs in the population recommended for vaccination by SHC.

	18–49 years	50–64 years	65–74 years	75–84 years	85–99 years
Risk profile
% low risk	NA	NA	49.3%	35.9%	28.9%
% moderate risk	NA	30.0%	45.6%	58.4%	66.4%
% high risk	1.8%	3.8%	5.1%	5.7%	4.7%
Incidence of IPD (per 100,000)
In low risk	NA	NA	14.3	16.2	43.0
In moderate risk	NA	22.0	33.0	45.4	92.0
In high risk	12.6	40.6	56.2	70.1	130.9
Incidence of all-cause/pneumococcal NBP (per 100,000) – hospitalized
In low risk	NA	NA	247.9/72.5	465.9/83.3	1,468.3/222.8
In moderate risk	NA	270.1/105.4	572.7/167.5	1,303.1/233.0	3,140.8/476.6
In high risk	184.5/60.3	497.4/194.0	976.9/285.7	2,014.2/360.0	4,471.5/678.6
Incidence of all-cause/pneumococcal NBP (per 100,000) – outpatient
In low risk	NA	NA	1,060.6/111.4	1,095.9/115.1	2,338.4/245.5
In moderate risk	NA	1,758.3/184.6	2,450.0/257.3	3,065.2/321.9	5,001.9/525.2
In high risk	1,648.0/173.0	3,238.1/340.0	4,179.4/438.8	4,737.9/497.5	7,121.9/747.7
Vaccine serotype coverage in IPD in year 1
PCV20	79.9%	71.0%	66.4%	66.4%	63.3%
PCV15	22.6%	29.7%	33.8%	33.8%	39.4%
PPV23	87.6%	75.8%	70.9%	70.9%	69.2%
Mortality rates with bacteremia (per 100 hospitalized cases)*
In low risk	NA	NA	6.9	15.1	22.4
In moderate risk	NA	10.8	14.6	16.4	22.4
In high risk	4.0	10.8	14.6	16.4	22.4
Mortality rates with meningitis (per 100 hospitalized cases)*
In low risk	NA	NA	6.3	20.6	50.0
In moderate risk	NA	13.7	13.4	22.5	50.0
In high risk	21.9	13.7	13.4	22.5	50.0
Mortality rates with NBP (per 100 hospitalized cases)
In low risk	NA	NA	1.9	4.7	6.2
In moderate risk	NA	2.1	3.4	5.0	8.6
In high risk	1.8	3.3	6.9	6.8	6.9
Mortality rate with NBP (per 100 outpatient cases)
In low risk	NA	NA	0.4	2.3	1.6
In moderate risk	NA	0	2.1	1.6	1.6
In high risk	0	0	3.0	1.7	2.5
Utility values per age and risk group
In low risk	NA	NA	0.838	0.766	0.652
In moderate risk	NA	0.820	0.819	0.748	0.637
In high risk	0.699	0.673	0.671	0.613	0.522
Disutility due to IPD	−0.020	−0.020	−0.174	−0.174	−0.174
Disutility due to NBP (hospitalized)	−0.049	−0.049	−0.068	−0.068	−0.068
Disutility due to NBP (outpatient)	−0.009	−0.008	−0.007	−0.006	−0.003
PCV20/PCV15 effectiveness in IPD
In low risk	NA	NA	75% 75% 60%
In moderate risk	NA	79.2%
In high risk	65.2%	63.3%
PPV23 Effectiveness in IPD
In low risk	NA	NA	55.7%	50.8%	37.9%
In moderate risk	NA	32.3%	50.8%	28.1%	20.5%
In high risk	17.1%	16.8%	37.9%	14.6%	10.6%
PCV20/PCV15 effectiveness in pneumococcal NBP
In low risk	NA	NA	45% 45% 36%
In moderate risk	NA	51.3%
In high risk	44.5%	41.1%
Vaccine uptake
In low risk	0.19%	0.81%	8.04%	9.00%	-
In moderate risk	0.14%	6.00%	15.19%	17.94%	-
In high risk	6.00%	7.20%	10.96%	11.97%	-

*some regroupings were required due to the low number; IPD = invasive pneumococcal disease; NBP = non-bacteremic pneumonia; NA: not applicable as not considered in the analysis; PCV20: 20-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate vaccine; PPV23: 23-valent pneumococcal non conjugate vaccine.

Table 2. Cost inputs in the population recommended for vaccination by the SHC, from all health-care payers’ perspective (NIHDI + patient).

	18–49 years	50–64 years	65–74 years	75–84 years	85–99 years
Cost of outpatient NBP
in low risk	NA	NA	€97.44	€95.94	€95.46
in moderate risk	NA	€101.03	€100.36	€100.73	€101.19
in high risk	€111.83	€113.23	€117.90	€115.12	€117.42
Cost of NBP requiring hospitalization
in low risk	NA	NA	€8,135	€8,236	€9,126
in moderate risk	NA	€8,928	€9,395	€10,432	€10,666
in high risk	€8,344	€9,402	€12,455	€11,451	€9,778
Cost of bacteremia managed in hospital
in low risk	NA	NA	€11,901	€15,470	€12,195
in moderate risk	NA	€16,119	€16,782	€16,645	€11,274
in high risk	€9,469	€14,981	€15,688	€13,034	€6,299
Cost of meningitis managed in hospital
in low risk	NA	NA	€12,312	€16,951	€19,816
in moderate risk	NA	€20,868	€17,392	€18,239	€18,319
in high risk	€13,566	€19,395	€16,230	€14,282	€10,236
Cost for vaccination
Visit to GP (50%)	€15 €66.91
PCV20
PCV15+PPV23	€ 108.21

SHC: Superior Health Council; NIHDI: National Institute for Health and Disability Insurance; NBP = non-bacteremic pneumonia; NA: not applicable as not considered in the analysis; GP: General Practitioner; PCV20: 20-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate vaccine; PPV23: 23-valent pneumococcal non conjugate vaccine.

Table 3. Clinical and economic outcomes in the adult population recommended for pneumococcal vaccination by the SHC, lifetime horizon (NIHDI + patient perspective).

Adult population recommended by SHC (3,274,597)	No pneumococcal vaccination	PCV15+PPV23	PCV20	Incremental PCV20 vs. no vaccination	Incremental PCV20 vs. PCV15+PPV23
Effects
N of infections	2,275,343	2,272,870	2,270,873	-4,471	-1,997
IPD	21,269	20,939	20,761	−509	−178
Hospitalized all causes NBP	701,782	700,767	699,958	−1,824	−809
Outpatient all causes NBP	1,552,292	1,551,164	1,550,154	−2,138	−1,010
N of premature deaths due to infection	77,487	77,350	77,260	−227	−90
Healthcare costs
Vaccination costs	€0	€44,787,623	€27,194,533	€27,194,533	−€17,593,091
Medical costs	€5,157,281,221	€5,144,524,007	€5,135,209,291	-€22,071,930	−€9,314,716
Total healthcare costs	€5,157,281,221	€5,189,311,631	€5,162,403,824	€5,122,603	-€26,907,807
Incremental cost-effectiveness (per person)
Life years	13.03869	13.0392	13.03918	0.00048	0.00020
QALYs	9.49381	9.4942	9.49418	0.00038	0.00016
Total healthcare costs	€1,575	€1,585	€1,577	€1.56	−€8,22
Incremental cost/QALY				€4,164	Dominant (Cost-saving)

SHC:Superior Health Council; NIHDI: National Institute for Health and Disability Insurance; N: number; IPD: invasive pneumococcal disease; NBP: non-bacteremic pneumonia; QALY: Quality Adjusted Life Years. PCV20: 20-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate vaccine.

Table 4. Clinical and economic outcomes in the 65–84 year olds with moderate risk, lifetime horizon (NIHDI perspective).

In Belgian 65–84 years population with moderate risk (=1,037,349)	No pneumococcal vaccination	PCV20	Incremental
Effects
N of infections	745,059	742,728	-2,332
IPD	6,950	6,671	−279
Hospitalized all causes NBP	246,845	245,829	−1,016
Outpatient all causes NBP	491,265	490,227	−1,038
N of premature deaths due to infection	27,237	27,109	−128
Healthcare costs
Vaccination costs	€0	€10,461,746	€10,461,746
Medical costs	€1,939,027,715	€1,926,823,241	-€12,204,474
Total healthcare costs	€1,939,027,715	€1,937,284,987	-€1,742,727
Incremental cost-effectiveness (per person)
Life years	10.8377	10.8385	0.0008
QALYs	7.7464	7.7471	0.0007
Total healthcare costs	€1,869	€1,868	−€1.68
Incremental cost/QALY			Dominant (cost-saving)

NIHDI: National Institute for Health and Disability Insurance; N: number; IPD: invasive pneumococcal disease; NBP: non-bacteremic pneumonia; QALY: Quality Adjusted Life Years. PCV20: 20-valent pneumococcal conjugate vaccine.

Table 5. Clinical and economic outcomes in the immunocompromised adults, the 50–64 year olds with underlying conditions and the healthy 65–84 year olds, lifetime horizon (patient perspective).

In the immunocompromised adults, the 50–64 year olds with co-morbidities and the healthy 65–84 year olds (=1,884,275)	No pneumococcal vaccination	PCV20	Incremental
Effects
N of infections	1,372,179	1,370,408	-1,771
IPD	12,695	15,529	−166
Hospitalized all causes NBP	392,652	392,730	−623
Outpatient all causes NBP	966,833	965,851	−982
N of premature deaths due to infection	42,605	42,541	−64
Healthcare costs
Vaccination costs	€0	€10,287,880	€10,287,880
Medical costs	€74,321,586	€74,133,279	-€188,307
Total healthcare costs	€74,321,586	€84,421,159	€10,099,573
Incremental cost-effectiveness (per person)
Life years	15.81602	15.81633	0.00032
QALYs	11.71061	11.71086	0.00025
Total healthcare costs	€39.44	€44.80	€5.36
Incremental cost/QALY			€21,378

N: number; IPD: invasive pneumococcal disease; NBP: non-bacteremic pneumonia; QALY: Quality Adjusted Life Years. PCV20: 20-valent pneumococcal conjugate vaccine.

Figure 1. Tornado around the ICER in the adults recommended for vaccination by the SHC (NIHDI + patient perspective).

Figure 2. Tornado around the ICER in the adults recommended for vaccination but not reimbursed (patient perspective).

Figure 3. Cost-effectiveness plane – All adults recommended by the SHC (NIHDI + patient perspective), PCV20 vs. no vaccination. X-axis represents difference in QALYs and y-axis represents the difference in costs; red line represents willingness to pay (€35,000).

Figure 4. Cost-effectiveness plane – Adults recommended for vaccination and reimbursed (NIHDI perspective), PCV20 vs no vaccination. X-axis represents difference in QALYs; y-axis represents difference in costs; red line represents willingness to pay (€35,000).

Figure 5. Cost-effectiveness plane – Adults recommended for vaccination but who have to fully finance access to vaccine (patient perspective), PCV20 vs. no vaccination. X-axis represents difference in QALYs; y-axis represents difference in costs; red line represents the willingness to pay (€35,000).

Figure 6. Cost-effectiveness plane – All adults recommended by the SHC (NIHDI + patient perspective), PCV20 vs. PCV15+PPV23. X-axis represents the difference in QALYs; y-axis represents difference in costs; red line represents willingness to pay (€35,000).

Table 6. Scenario analysis.

ICER in cost/QALY	All risk groups recommended by the SHC (NIHDI + patient)	65–84 years old adults with chronic underlying conditions (NIHDI)	All risk groups recommended by the SHC, excluding the 65–84 years old adults with underlying conditions (patient)
Base case	€4,164	Cost-saving	€21,378
Discount rate 0% on both effects and costs 5% on both effects and costs	€1,025 €8,018	Cost-saving Cost-saving	€17,485 €26,386
Higher medical cost for outpatient NBP	€1,979	Cost-saving	€18,315
Vaccine uptake similar to influenza vaccine uptake	€4,217	Cost-saving	€20,978
Comparator PCV15 followed by PPV23	Cost-saving	Cost-saving	Cost-saving
100% serotype replacement	€4,353	Cost-saving	€21,651

ICER: Incremental Cost-Effectiveness Ratio; NBP: non-bacteremic pneumonia; QALY: Quality Adjusted Life Years. PCV15: 15-valent pneumococcal conjugate vaccine; PPV23: 23-valent pneumococcal non conjugate vaccine ; NIHDI: National Institute for Health and Disability Insurance; SHC: Superior Health Council.