Cost-effectiveness analysis of infant universal routine pneumococcal vaccination in Malaysia and Hong Kong

Figures & data

Table 1. Health and Economic Outcomes of Pneumococcal Vaccination Strategies in Malaysia for Base Case Scenario

	Cumulative 10 years
	No Vaccination	PCV10 vs. No Vaccination	PCV13 vs. No vaccination	PCV13 vs. PCV10
Pneumococcal Cases
IPD	8,792	(1,638)	(4,034)	(2,396)
Pneumonia
Hospitalized	1,096,892	(30,262)	(143,570)	(113,308)
Non-hospitalized	11,583,205	(33,188)	(625,161)	(591,973)
All pneumonia	12,680,097	(63,450)	(768,731)	(705,281)
AOM	4,726,634	(202,797)	(579,764)	(376,967)
Pneumococcal Deaths
IPD	1,647	(383)	(823)	(440)
Pneumonia, hospitalized	38,682	(1,251)	(6,933)	(5,682)
Total deaths	40,329	(1,634)	(7,756)	(6,122)
Composite Measures
Life Years (LY) Saved	n.a.	49,339	129,489	80,150
QALYs Saved	n.a.	46,504	120,576	74,072
Costs
Direct medical excluding vaccination	$ 3,159,743,854	$ (62,977,917)	$ (289,612,306)	$ (226,634,389)
Vaccination program^**	n.a.	$ 1,059,927,861	$ 1,059,946,438	$18,577
Non-medical	$ 2,424,145,432	$ (35,836,655)	$ (181,555,052)	$ (145,718,397)
Net Total Cost Perspective
Payer	$ 3,159,743,854	$ 996,949,944	$ 770,334,132	$ (226,615,812)
Societal	$ 5,583,889,285	$ 961,113,290	$ 588,779,080	$ (372,334,210)
Incremental Cost-Effectiveness Ratios
Cost/ LY Gained
Payer perspective	n.a.	$20,206	$ 5,949	$(2,827)
Societal perspective	n.a.	$19,480	$ 4,547	$(4,645)
Cost/QALY Gained
Payer perspective (net medical)	n.a.	$21,438	$ 6,389	$(3,059)
Societal perspective	n.a.	$20,667	$ 4,883	$(5,027)

Notes. Abbreviations: n.a., not applicable. Base Case scenario assumes direct effect of PCV10 and PCV13 adjusted by serotype coverage and herd effect for PCV13 only. All monetary values are in US dollars.

* PCV10 and PCV13 vaccine per dose cost were assumed similar (price parity at US$55/dose).

** As PCV13 strategy is associated with fewer deaths, more children are expected to receive full PCV13 course compared with PCV10. Numbers in parenthesis ( ) are either health outcomes averted or cost savings. Incremental cost-effectiveness ratios with numbers in parenthesis ( ) means cost-savings, i.e., more net health benefits and lower net cost than the comparing vaccination strategy. Societal perspective includes net medical costs.

Table 2. Health and Economic Outcomes of Pneumococcal Vaccination Strategies in Hong Kong for Base Case Scenario

	Cumulative 10 years
	No Vaccination	PCV10 vs. No Vaccination	PCV13 vs. No vaccination	PCV13 vs. PCV10
Pneumococcal Cases
IPD	1,838	(125)	(654)	(529)
Pneumonia
Hospitalized	834,017	(2,461)	(70,083)	(67,622)
Non-hospitalized	3,004,594	(21,528)	(126,091)	(104,563)
All pneumonia	3,838,611	(23,989)	(196,174)	(172,185)
AOM	596,848	(18,293)	(56,020)	(37,727)
Pneumococcal Deaths
IPD	424	(7)	(136)	(129)
Pneumonia, hospitalized	33582	(5)	(2,564)	(2,559)
Total deaths	34,006	(12)	(2,700)	(2,688)
Composite Measures
Life Years (LY) Saved	n.a.	242	26,529	26,287
QALYs Saved	n.a.	443	22,089	21,646
Costs
Direct medical excluding vaccination	$3,197,275,209	$(14,847,921)	$(255,192,931)	$(240,345,010)
Vaccination program**	n.a.	$ 35,594,376	$ 56,744,757	$ 21,150,381
Non-medical	$402,682,892	$ (2,617,558)	$ (28,283,056)	$ (25,665,498)
Net Total Cost Perspective
Payer (net medical)	$3,197,275,209	$ 20,746,455	$(198,448,174)	$(219,194,629)
Societal	$3,599,958,101	$ 18,128,897	$(226,731,230)	$(244,860,127)
Incremental Cost-Effectiveness Ratios
Cost/ LY Gained
Payer perspective	n.a.	$ 85,729	$ (7,480)	$ (8,339)
Societal perspective	n.a.	$ 74,913	$ (8,547)	$ (9,315)
Cost/QALY Gained
Payer perspective	n.a.	$ 46,832	$ (8,984)	$ (10,126)
Societal perspective	n.a.	$ 40,923	$ (10,264)	$ (11,312)

Notes. Abbreviations: n.a., not applicable. Base Case scenario assumes direct effect of PCV10 and PCV13 adjusted by serotype coverage and herd effect for PCV13 only. All monetary values are in US dollars.

* PCV10 and PCV13 vaccine per dose cost were assumed to be US$25 and $41 per dose respectively). Numbers in parenthesis ( ) are either health outcomes averted or cost savings. Incremental cost-effectiveness ratios with numbers in parenthesis ( ) means cost-savings, i.e., more net health benefits and lower net cost than the comparing vaccination strategy. Societal perspective includes net medical costs.

Table 3. Sensitivity Analysis of the Impact of Various PCV13s Herd Effect Assumptions on the Incremental Cost Effectiveness Ratios for Infant Universal Routine Vaccination with PCV13 in Malaysia and Hong Kong

	Malaysia		Hong Kong
Herd effect assumption	PCV13 vs. No vaccination	PCV13 vs. PCV10	PCV13 vs. No vaccination	PCV13 vs. PCV10
Payer perspective
Base Case	$6,389/QALY	Cost-saving	Cost-saving	Cost-saving
No herd effects	$15,752/QALY	Cost-saving	$52,391/QALY	$65,407/QALY
Only herd effect for IPD	$14,203/QALY	Cost-saving	$22,504/QALY	$9,437/QALY
IPD and pneumonia only	$6,842/QALY	Cost-saving	Cost-saving	Cost-saving
Only children <5	$10,507/QALY	Cost-saving	$22,680/QALY	Cost-saving
Societal perspective
Base Case	$4,883/QALY	Cost-saving	Cost-saving	Cost-saving
No herd effects	$14,981/QALY	Cost-saving	$48,657/QALY	$65,413/QALY
Only herd effect for IPD	$13,502/QALY	Cost-saving	$17,900/QALY	$9,438/QALY
IPD and pneumonia only	$5,673/QALY	Cost-saving	Cost-saving	Cost-saving
Only children <5	$9,416/QALY	Cost-saving	$17,950/QALY	Cost-saving

Notes. Abbreviations: QALY, quality adjusted life year. All monetary values are in US dollars. Cost saving means that PCV13 has a higher net public health impact (more benefit) and lower net cost (less cost) than PCV10. Societal perspective includes net medical costs.

Table 4. Sensitivity Analysis of the Impact of Various Parameters Assumptions on the Incremental Cost Effectiveness Ratios for Infant Universal Routine Vaccination with PCV13 compared to PCV10 in Malaysia and Hong Kong

	Malaysia			Hong Kong
	Cost per QALY gained			Cost per QALY gained
Parameters varied	Lower bound	Upper bound	Interpretation	Lower bound	Upper bound	Interpretation
Epidemiological parameters
IPD incidence	$ (5,081)	$ (4,960)	Cost-saving	$ (11,356)	$ (11,268)	Cost-saving
Case fatality rate of IPD	$ (5,088)	$ (4,953)	Cost-saving	$ (11,366)	$ (11,258)	Cost-saving
Hospitalized pneumonia incidence	$ (5,311)	$ (4,772)	Cost-saving	$ (11,409)	$ (11,196)	Cost-saving
Case fatality rate of hospitalized pneumonia	$ (5,455)	$ (4,649)	Cost-saving	$ (12,434)	$ (10,376)	Cost-saving
Non-hospitalized pneumonia incidence	$ (5,216)	$ (4,822)	Cost-saving	$ (11,340)	$ (11,284)	Cost-saving
Simple AOM incidence	$ (5,141)	$ (4,898)	Cost-saving	$ (11,314)	$ (11,310)	Cost-saving
Complex AOM incidence	$ (5,031)	$ (5,009)	Cost-saving	$ (11,320)	$ (11,304)	Cost-saving
Vaccine effectiveness
Direct effectiveness against IPD	$ (5,073)	$ (4,986)	Cost-saving	$ (11,314)	$ (11,310)	Cost-saving
Direct effectiveness against hospitalized pneumonia	$ (5,264)	$ (4,801)	Cost-saving	$ (11,316)	$ (11,308)	Cost-saving
Direct effectiveness against non-hospitalized pneumonia	$ (5,029)	$ (5,010)	Cost-saving	$ (11,340)	$ (11,283)	Cost-saving
Direct effectiveness against simple AOM	$ (5,099)	$ (4,940)	Cost-saving	$ (11,313)	$ (11,311)	Cost-saving
Direct effectiveness against complex AOM	$ (5,030)	$ (5,010)	Cost-saving	$ (11,315)	$ (11,309)	Cost-saving
Waning of direct effectiveness	$ (5,033)	$ (5,007)	Cost-saving	$ (11,325)	$ (11,299)	Cost-saving
Vaccine coverage-PCV10	$ (6,952)	$ (3,498)	Cost-saving	$ (11,419)	$ (11,205)	Cost-saving
Vaccine coverage-PCV13	$ (6,760)	$ (3,347)	Cost-saving	$ (11,498)	$ (11,126)	Cost-saving
Cost parameters
Direct cost of treating one episode of IPD	$ (5,026)	$ (5,013)	Cost-saving	$ (11,323)	$ (11,301)	Cost-saving
Direct cost of treating one episode of hospitalized pneumonia	$ (5,144)	$ (4,896)	Cost-saving	$ (12,370)	$ (10,254)	Cost-saving
Direct cost of treating one episode of non-hospitalized pneumonia	$ (5,120)	$ (4,919)	Cost-saving	$ (11,344)	$ (11,280)	Cost-saving
Direct cost of treating one episode of simple AOM	$ (5,084)	$ (4,955)	Cost-saving	$ (11,315)	$ (11,309)	Cost-saving
Direct cost of treating one episode of complex AOM	$ (5,029)	$ (5,010)	Cost-saving	$ (11,318)	$ (11,305)	Cost-saving
Indirect cost of treating one episode of IPD	$ (5,022)	$ (5,018)	Cost-saving	$ (11,319)	$ (11,305)	Cost-saving
Indirect cost of treating one episode of hospitalized pneumonia	$ (5,029)	$ (5,010)	Cost-saving	$ (11,395)	$ (11,229)	Cost-saving
Indirect cost of treating one episode of non-hospitalized pneumonia	$ (5,133)	$ (4,906)	Cost-saving	$ (11,330)	$ (11,293)	Cost-saving
Indirect cost of treating one episode of simple AOM	$ (5,089)	$ (4,950)	Cost-saving	$ (11,319)	$ (11,304)	Cost-saving
Indirect cost of treating one episode of complex AOM	$ (5,021)	$ (5,018)	Cost-saving	$ (11,315)	$ (11,309)	Cost-saving

Notes. Abbreviations: QALY, quality adjusted life year. All monetary values are in US dollars. Cost saving means that PCV13 has a higher net public health impact (more benefit) and lower net cost (less cost) than PCV10. Societal perspective includes net medical costs.

Table 5. Sensitivity Analysis of the Impact of Vaccine Cost on Total Net Cost of an Infant Routine Pneumococcal Vaccination Program with PCV13 in Malaysia

	Cumulative 10 years
	No Vaccination	PCV13 vs. No vaccination
Vaccine price per dose	n.a.	$55.08	$44.06	$33.05	$22.03
Price as % of base case	n.a.	100%	80%	60%	40%
If 4-doses per course schedule
Costs
Direct medical excluding vaccination	$ 3,159,743,854	$ (289,612,306)	$ (289,612,306)	$ (289,612,306)	$ (289,612,306)
Vaccination program**	n.a.	$ 1,059,946,438	$ 858,961,814	$ 657,922,387	$ 456,882,959
Non-medical	$ 2,424,145,432	$ (181,555,052)	$ (181,555,052)	$ (181,555,052)	$ (181,555,052)
Net Total Cost Perspective
Payer (net medical cost)	$ 3,159,743,854	$ 770,334,132	$ 569,349,508	$ 368,310,081	$ 167,270,653
Societal	$ 5,583,889,285	$ 588,779,080	$ 387,794,456	$ 186,755,029	$ (14,284,399)
If 3-doses per course schedule
Costs
Direct medical excluding vaccination	$ 3,159,743,854	$ (289,612,306)	$ (289,612,306)	$ (289,612,306)	$ (289,612,306)
Vaccination program	n.a.	$ 811,659,911	$ 657,720,804	$ 503,781,698	$ 349,842,592
Non-medical	$ 2,424,145,432	$ (181,555,052)	$ (181,555,052)	$ (181,555,052)	$ (181,555,052)
Net Total Cost Perspective
Payer (net medical cost)	$ 3,159,743,854	$ 522,047,605	$ 368,108,498	$ 214,169,392	$ 60,230,286
Societal	$ 5,583,889,285	$ 340,492,553	$186,553,446	$ 32,614,340	$ (121,324,766)

Notes. Abbreviations: n.a., not applicable. Numbers in parenthesis ( ) represent cost savings. Societal perspective includes net medical costs.

Figure 1. Multivariate probabilistic sensitivity analysis for PCV13 vs. PCV10 from both perspectives. (a) Malaysia (payer perspective); (b) Malaysia (societal perspective); (c) Hong Kong (payer perspective); (d) Hong Kong (societal perspective).

Table 6. Epidemiological Parameters of Pneumococcal Diseases in Malaysia and Hong Kong

	Age group (years)
Country/Parameter		<2 yrs.	2–5 yrs.	5–17 yrs.	18–34 yrs.	35–49 yrs.	50–64 yrs.	65+ yrs.
Malaysia
Baseline incidence (per 100,000 population)
	IPD	9.8	15.6	1.2	1.2	1.2	1.2	9.8
	Inpatient pneumonia	766	766	126	93	352	352	2,040
	Outpatient pneumonia	3,473	3,473	2,881	3,546	3,546	3,546	10,468
	Simple AOM	17,267	7,541	—	—	—	—	—
	Complex AOM	392	171	—	—	—	—	—
Case fatality rates
	Meningitis	33.30%	33.30%	10.00%	10.00%	11.00%	11.40%	23.80%
	Bacteremia	23.00%	23.00%	23.00%	13.10%	13.10%	13.10%	13.10%
	Inpatient Pneumonia	4.00%	4.00%	0.30%	0.70%	1.70%	2.50%	6.30%
Hong Kong
Baseline incidence (per 100,000 population)
	IPD	18. Eight	12.8	1	1	1	1	10.2
	Inpatient pneumonia	1,048	848	640	417	334	800	5,686
	Outpatient pneumonia	29,329	43,143	13,592	2,092	718	1,319	2,799
	Simple AOM	15,165	14,791	—	—	—	—	—
	Complex AOM	1,765	1,829	—	—	—	—	—
Case fatality rates
	Meningitis	9.00%	9.00%	9.00%	13.20%	13.20%	132%	30.40%
	Bacteremia	4.60%	4.60%	4.60%	17.50%	17.50%	17.50%	34.80%
	Inpatient Pneumonia	0.20%	0.20%	0.20%	0.10%	3.20%	3.70%	5.20%

Note. Data sources for cost parameters are described in narrative of this paper.

Table 7. Cost parameters of pneumococcal diseases in Malaysia and Hong

		Malaysia (in RM)		Hong Kong (in HKD)
		0–17 yrs.	18+ yrs.	0–17 yrs.	18+ yrs.
Direct medical cost
	Meningitis	6,493	4,214	115,650	36,001
	Bacteremia	8,510	7,386	76,767	36,001
	Inpatient pneumonia	3,117	3,404	47,139	36,001
	Outpatient pneumonia	515	515	700	700
	Simple AOM	515	—	215	—
	Complex AOM	3,072	—	4,704	—
		0–4 yrs.	5+ yrs.	0–4 yrs.	5+ yrs.
Non-medical cost
	Meningitis	925	600	2,972	2,972
	Bacteremia	552	600	3,317	3,317
	Inpatient pneumonia	747	88	2,816	2,816
	Outpatient pneumonia	207	600	386	4386
	Complex AOM	551	—	1,904	—
	Simple AOM	551	—	494	—

Note. Exchange rates used in the study: 1 U.S. dollar = 3.33 RM; 1US$ = 7.78 HKD.

Data sources for cost parameters are described in narrative of this paper.