Cost-effectiveness analysis of a vaccination program for the prevention of herpes zoster and post-herpetic neuralgia in adults aged 50 and over in Germany

Figures & data

Table 3. Model input parameters

Age groups (years)	Base case analysis		DSA
	HZ	PHN	HZ	PHN
HZ and PHN incidence	Annual incidence (%) Hillebrand et al.^28	Proportion per HZ case (%) Hillebrand et al.^28	Annual incidence (%) Ultsch et al.^21	Proportion per HZ case (%) Ultsch et al.^21
50–54	0.66	12.00	0.66	3.56
55–59	0.83	13.84	0.66	3.56
60–64	0.96	15.40	0.92	5.18
65–69	1.14	17.46	0.92	5.18
70–74	1.26	18.71	1.12	8.26
75–79	1.34	20.56	1.12	8.26
80–84	1.39	21.18	1.28	8.21
84–89	1.41	20.88	1.28	8.21
90–94	1.41	18.27	1.28	8.21
95–99	1.43	15.36	1.28	8.21
≥ 100	1.43	15.36	1.28	8.21
Recurrent HZ episodes	Annual incidence (%)	Proportion per HZ case (%)	Annual incidence (%) Tseng et al.^38	Proportion per HZ case (%)
50–54	0	—	0.10	—
55–59	0	—	0.10	—
60–64	0	—	0.10	—
65–69	0	—	0.10	—
70–74	0	—	0.27	—
75–79	0	—	0.27	—
80–84	0	—	0.27	—
84–89	0	—	0.27	—
90–94	0	—	0.27	—
95–99	0	—	0.27	—
≥ 100	0	—	0.27	—
Gender split	Ultsch et al.^37	Weinke et al.^39
% female	65	81	50	50
Mean duration of disease (months)	Oxman et al.^5	Oxman et al.^5	Drolet et al.^29
60–69	1	8.3	1.08
≥ 70	1	10.9	1.08
Pain severity split (%)	Oxman et al.^5	Own calculations based on Oxman et al.^5	Drolet et al.^29	Drolet et al.^29
60–69
No pain	27	—	5	—
Mild pain	41	42	11	16
Moderate pain	18	9	39	69
Severe pain	14	49	45	15
≥ 70
No pain	26	—	5	—
Mild pain	32	17	11	16
Moderate pain	23	16	39	69
Severe pain	19	67	45	15
Mortality (%)	Ultsch et al.^37	Assumption	Gonzalez Chiappe et al.^56	Assumption
50–54	0.00002	0.00	0.00003	0.00
55–59	0.00000	0.00	0.00007	0.00
60–64	0.00002	0.00	0.00007	0.00
65–60	0.00006	0.00	0.00024	0.00
70–74	0.00011	0.00	0.00024	0.00
75–79	0.00030	0.00	0.00125	0.00
80–84	0.00054	0.00	0.00125	0.00
84–89	0.00120	0.00	0.00724	0.00
90–94	0.00386	0.00	0.00724	0.00
95–99	0.00386	0.00	0.01948	0.00
≥ 100	0.00386	0.00	0.01948	0.00
Utilities	Oster et al.^13		Oster et al.^13		Bala et al.^19; Oxman et al.^5		Bala et al.^19; Oxman et al.^5; van Seventer^20
	Utility	Decrement	Utility	Decrement	Utility	Decrement	Utility	Decrement
No pain	0.864	—	—	—	0.748^19 0.864^5	—	—	—
Mild pain	0.709	0.085	0.709	0.085	0.730^19; 0.770^5	0.024^19; 0.109^5	0.730^19; 0.770^5; 0.720^20	0.024^19; 0.109^5; 0.071^20
Moderate pain	0.582	0.249	0.582	0.249	0.600^19; 0.680^5	0.198^19; 0.213^5	0.600^19; 0.680^5; 0.630^20	0.198^19; 0.213^5; 0.187^20
Severe pain	0.249	0.678	0.249	0.678	0.470^19; 0.550^5	0.371^19; 0.363^5	0.470^19; 0.550^5; 0.270^20	0.371^19; 0.363^5; 0.652^20
Vaccine efficacy (%)	Oxman et al.^5,45	Oxman et al.^5,45Oxman et al.^5,57
50–59	70.00	5.0
60–64	64.00	5.0
65–69	64.00	5.0
70–74	41.00	55.0
75–79	41.00	55.0
≥ 80	18.00	26.0
Vaccine duration (years)	Not fixed (Li et al.^27)	10	10; Lifetime	7.5; 10; 20; Lifetime
Waning rate (%)	Not fixed (Li et al.^27)	—	0; 4.15; 8.3	—
Vaccine coverage (%)	20	—	10	—
Discount rate (%)	3	3	0; 5; 7	0; 5; 7

DSA = deterministic sensitivity analyses; HZ = herpes zoster; PHN = post-herpetic neuralgia.

Table 4. Cost input parameters

	Base case analysis		DSA
Parameter	HZ	PHN	HZ	PHN
Outpatient visit costs	Ultsch et al.^21	Own calculations, based on Ultsch et al.^21
Outpatient visit rate (%)	99,9	100
Outpatient visit costs (€)	77.79	160.23	+/− 20%	+/− 20%
Inpatient care	Ultsch et al.^21	Ultsch et al.^21
Inpatient care rate (%)	3.2	14.6
Inpatient care costs (€)	3,080.85	3,890.62	+/− 20%	+/− 20%
Medication	Ultsch et al.^21	Ultsch et al.^21
Medication consumption rate (%)	89.2	100
Medication costs (€)	55.72	219.79	+/− 20%	+/− 20%
Diagnostic testing	Cebrian-Cuenca et al.^52 and NASHIP.^53	Cebrian-Cuenca et al.^52 and NASHIP^.^53
Diagnostic testing consumption rate (%)	22	56
Diagnostic testing costs (€)	19.2	19.2	+/− 20%	+/− 20%
Co-payment (only societal perspective)	Ultsch et al.^21	Ultsch et al.^21
Co-payment rate (%)	96	93
Co-payment costs (€)	11.63	38.04	+/− 20%	+/− 20%
Productivity costs (only societal perspective)	Ultsch et al.^21; Drolet et al.^58; German Federal Statistical Office.^54	Ultsch et al.^21; Drolet et al.^58; German Federal Statistical Office.^54
Productivity costs age group 50–54 (€)	810.69	386.39
Productivity costs age group 55–59 (€)	724.47	345.30
Productivity costs age group 60–64 (€)	411.25	199.47
Productivity costs age group 65–69 (€)	40.69	19.73
Vaccination costs (€)	147	—	132; 162	—
Vaccine administration costs (€)	6	—	10; 15	—
Vaccine co-payment costs (€)	0		10; 25
Discount rate (%)	3	3	0; 5; 7	0; 5; 7

DSA = deterministic sensitivity analyses; HZ = herpes zoster; NASHIP = National Association of Statutory Health Insurance Physicians and the regional Associations of Statutory Health Insurance Physicians PHN = post-herpetic neuralgia.

Table 2. Base case ICER (lifetime time horizon)

Results	Outcome	SHI perspective	Societal perspective
Population aged ≥ 60 years
	Cost (€) per QALY	39,306	37,417
ICER	Cost (€) per HZ case avoided	3,114	2,917
	Cost (€) per PHN case avoided	16,006	15,901
Population aged ≥ 50 years
	Cost (€) per QALY	39,782	32,848
ICER	Cost (€) per HZ case avoided	2,262	1,834
	Cost (€) per PHN case avoided	15,649	12,894

HZ = herpes zoster; ICER = incremental cost-effectiveness ratio; PHN = post-herpetic neuralgia; QALY = quality adjusted life year; SHI = statutory health insurance; Vac = Vaccination.

Table 1. Base case results related to the cost and effectiveness outcomes

Outcome	Lifetime results	Vac Policy	No Vac Policy	Difference^†
Population aged ≥ 60 years
Cost	Societal Perspective	€ 2,077,158,779	€ 1,532,437,377	€ 544,721,402
	SHI Perspective	€ 1,672,282,659	€ 1,165,574,811	€ 506,707,848
Effectiveness Societal perspective (N=21,778,791)	QALYs	177,608,837	177,594,279	14,558
	HZ Cases	3,654,489	3,841,221	−186,732
	PHN Cases	473,195	508,988	−35,793
Effectiveness SHI perspective (N=19,364,217)	QALYs	155,831,074	155,818,182	12,891
	HZ Cases	3,213,659	3,376,373	−162,713
	PHN Cases	416,489	448,146	−31,657
Population aged ≥ 50 years
Cost	Societal Perspective	€ 4,045,355,969	€ 3,322,166,338	€ 723,189,631
	SHI Perspective	€ 2,622,504,402	€ 1,861,399,601	€ 761,104,801
Effectiveness Societal perspective (N=33,751,798)	QALYs	348,804,818	348,782,802	22,016
	HZ Cases	6,729,013	7,123,388	−394,575
	PHN Cases	833,390	889,477	−56,087
Effectiveness SHI perspective (N=29,382,613)	QALYs	299,089,761	299,070,629	19,132
	HZ Cases	5,786,377	6,122,845	−336,468
	PHN Cases	717,888	766,525	−48,637

HZ = herpes zoster; ICER = incremental cost-effectiveness ratio; PHN = post-herpetic neuralgia; QALY = quality adjusted life year; SHI = statutory health insurance; Vac = Vaccination.

^†Differences due to rounding.

Figure 6. Basic decision tree Markov Model.

Figure 7. Markov model structure HZ = herpes zoster; PHN = post-herpetic neuralgia.

Figure 8. Evolution of vaccine efficacy over time DSA = Deterministic sensitivity analysis; yo = years old.

Figure 1. Sensitivity analysis overview: SHI perspective for 60+ population DSA = deterministic sensitivity analyses; HZ = herpes zoster; ICER = incremental cost-effectiveness ratio; PHN = post-herpetic neuralgia; SHI = statutory health insurance.

Figure 2. Sensitivity analysis overview: SHI perspective for 50+ population DSA = deterministic sensitivity analyses; HZ = herpes zoster; ICER = incremental cost-effectiveness ratio; PHN = post-herpetic neuralgia; SHI = statutory health insurance.

Figure 3. Sensitivity analysis overview: societal perspective for 60+ population DSA = deterministic sensitivity analyses; HZ = herpes zoster; ICER = incremental cost-effectiveness ratio; PHN = post-herpetic neuralgia.

Figure 4. Sensitivity analysis overview: societal perspective for 50+ population DSA = deterministic sensitivity analyses; HZ = herpes zoster; ICER = incremental cost-effectiveness ratio; PHN = post-herpetic neuralgia.

Figure 5. Cost-effectiveness acceptability curves ICER = incremental cost-effectiveness ratio; SHI = statutory health insurance.

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