Cost-effectiveness analysis of vaccination strategies against meningococcal disease for children under nine years of age in China

Figures & data

Table 1. Vaccination strategies in preventing meningococcal disease.

Strategy	Vaccines in NIP	Vaccination schedule
Current Practice	MPV-A MPV-AC	2 doses of MPV-A at 6 months and 9 months of age 2 doses of MPV-AC at 3 years and 6 years of age
Universal MPV4	MPV-A MPV-4	2 doses of MPV-A at 6 months and 9 months of age 2 doses of MPV-4 at 3 years and 6 years of age
Universal MCV-AC	MCV-AC MPV-AC	2 doses of MCV-AC at 6 months and 7 months of age 1 dose of MPV-AC at 6 years of age
Universal MCV-4	MCV-4 MPV-AC	3 doses of MCV-4 at 3 months, 4 months, and 5 months of age 1 dose of MPV-AC at 6 years of age

The current practice was adopted as the benchmark strategy and was compared to each of the other three alternative strategies using non-NIP vaccines.

Figure 1. Decision tree-markov model.

Figure 2. Markov chains simulating the health status of individuals.

Individuals protected by vaccines refer to those who were vaccinated and immunized, and individuals not protected by vaccines include those who have not been vaccinated and those for whom vaccination has not produced a protective effect.

Table 2. Parameter inputs in the model.

Variable	Base case	Range	Distribution	Reference
EPIDEMIOLOGY
Incidence of meningococcal meningitis per 100,000	1.9028	0.8762–3.7565	Beta	GBD
Incidence of meningococcemia per 100,000	0.8034	0.3700–1.5861	Beta	GBD Horino et al.^Citation24
Serogroup distribution of meningococcal cases (%)
Proportion of MenA in all cases	4.73	Base ± 25%	Beta	Li et al.^Citation25
Proportion of MenC in all cases	22.97	Base ± 25%	Beta	Li et al.^Citation25
Proportion of MenY in all cases	1.69	Base ± 25%	Beta	Li et al.^Citation25
Proportion of MenW in all cases	6.08	Base ± 25%	Beta	Li et al.^Citation25
Sequelae in meningitis (%)
Hearing loss	4.6	3–7.3	Beta	Edmond et al.^Citation26
Cognitive difficulties	2.9	1–7.2	Beta	Edmond et al.^Citation26
Visual disturbance	2.7	1.1–4.1	Beta	Edmond et al.^Citation26
Motor deficit	1.8	1–4.1	Beta	Edmond et al.^Citation26
Seizure disorder	0.9	0.1–2	Beta	Edmond et al.^Citation26
Sequelae in Meningococcemia (%)
Skin scarring	9	Base ± 25%	Beta	Vyse et al.^Citation27
Amputations	28.6	Base ± 25%	Beta	Horino et al.^Citation24 Martinón-Torres et al.^Citation28
Case fatality rate, meningococcal meningitis (%)	4.8	2.86–7.31	Beta	Wahl et al.^Citation29
Case fatality rate, meningococcemia (%)	26.3	13.2–40	Beta	Horino et al.^Citation24
All-cause mortality rate (‰)
<1y	2.8	Base ± 25%	Beta	Health Statistical Yearbook
1–4y	1.2	Base ± 25%	Beta	Health Statistical Yearbook
5–9y	0.14	Base ± 25%	Beta	Population census
COST (RMB)
Cost of vaccination program
MPV-A price, per dose	0.209	0.157–0.261	Gamma	China CDC
MPV-AC price, per dose	1.728	1.296–2.160	Gamma	China CDC
MPV-4 price, per dose	16.815	6.958–21.019	Gamma	Centralized procurement
MCV-AC price, per dose	22.904	10.872–28.629	Gamma	Centralized procurement
MCV-4 price, per dose	60.883	12.177–102.486	Gamma	Centralized procurement
Syringe price	0.174	0.036–0.652	Gamma	Centralized procurement
Vaccine service cost, per dose	3.714	Base ± 25%	Gamma	Yu et al.^Citation30
Indirect cost, per dose	6.303	Base ± 25%	Gamma	Yu et al.^Citation30
Vaccine wastage (%)	5	Base ± 25%	Beta	WHO^Citation31
Economic burden of the disease
Cost of Meningococcal meningitis	8373.310	Base ± 25%	Gamma	Liu et al.^Citation32
Cost of Meningococcemia	11866.435	Base ± 25%	Gamma	Martinón-Torres et al.^Citation28 Liu et al.^Citation32
Cost of cognitive difficulties	36544.495	Base ± 25%	Gamma	CHIRA
Cost of seizure disorder	832.911	Base ± 25%	Gamma	CHIRA
Cost of hearing loss	22624.275	Base ± 25%	Gamma	CHIRA
Cost of motor deficit	1755.341	Base ± 25%	Gamma	CHIRA
Cost of visual disturbance	6435.342	Base ± 25%	Gamma	Yang et al.^Citation34
Cost of amputation	4659.918	Base ± 25%	Gamma	Wang et al.^Citation33
Cost of productivity lost due to death	111626.703	Base ± 25%	Gamma	Population census
Discount rate (%)	3	2.25–5	Uniform	WHO^Citation23
USD to RMB exchange rate in 2019	6.8985			National Bureau of Statistics
VACCINE EFFICACY (%)
MPV-A vaccine efficacy-A	55.56	Base ± 25%	Beta	Xie et al.^Citation8
MPV-AC vaccine efficacy-A	75.36	Base ± 25%	Beta	Tang et al.^Citation35
MPV-AC vaccine efficacy-C	94.2	Base ± 25%	Beta	Tang et al.^Citation35
MPV-4 vaccine efficacy-A	82.15	Base ±25%	Beta	Xie et al.^Citation8
MPV-4 vaccine efficacy-C	90.57	Base ± 25%	Beta	Xie et al.^Citation8
MPV-4 vaccine efficacy-Y	50.84	Base ± 25%	Beta	Xie et al.^Citation8
MPV-4 vaccine efficacy-W	54.88	Base ± 25%	Beta	Xie et al.^Citation8
MCV-AC vaccine efficacy-A	87.43	Base ± 25%	Beta	Xie et al.^Citation8
MCV-AC vaccine efficacy-C	92.81	Base ± 25%	Beta	Xie et al.^Citation8
MCV-4 vaccine efficacy-A	91.42	Base ± 25%	Beta	Xie et al.^Citation8
MCV-4 vaccine efficacy-C	88.76	Base ± 25%	Beta	Xie et al.^Citation8
MCV-4 vaccine efficacy-Y	88.17	Base ± 25%	Beta	Xie et al.^Citation8
MCV-4 vaccine efficacy-W	99.41	Base ± 25%	Beta	Xie et al.^Citation8
UTILITY
Utility of Health	1	–	N/A
Utility of Death	0	–	N/A
Utility of meningitis	0.9768	0.597–1	Beta	Bennett et al.^Citation36
Utility of meningococcemia	0.9921	0.7825–1	Beta	Bennett et al.^Citation36
Utility of Sequelae
Cognitive difficulties	0.62	0.51–0.73	Beta	Oostenbrink et al.^Citation37
Seizure disorder	0.83	0.75–0.91	Beta	Oostenbrink et al.^Citation37
Hearing loss	0.91	0.83–1	Beta	Oostenbrink et al.^Citation37
Motor deficit	0.67	0.55–0.79	Beta	Oostenbrink et al.^Citation37
Visual disturbance	0.26	0.19–0.33	Beta	Brown et al.^Citation38
Skin scarring	1	Base ±25%	Beta	Blakeney et al.^Citation39
Amputation	0.69	0.69–0.8	Beta	Erickson et al.^Citation40
THRESHOLD
China’s GDP per capital in 2019 (RMB)	70078			National Bureau of Statistics

Table 3. Incremental cost and effectiveness of strategies compare to Current practice.

	Current Practice	Universal MPV-4	Universal MCV-AC	Universal MCV-4
Meningococcal disease (cases)	3066	2975 (⇩91)	2780 (⇩286)	2611 (⇩455)
Sequelae (cases)	385	374 (⇩11)	349 (⇩36)	328 (⇩57)
Death (cases)	340	330 (⇩10)	309 (⇩31)	290 (⇩50)
Individual effectiveness (QALYs)	29.964177	29.964202 (⇩0.000025)	29.964254 (⇧0.000077)	29.964299 (⇩0.000122)
Incremental effectiveness (QALYs)	–	366.25	1128.05	1801.95
Individual Cost (USD)	744.98	751.17 (⇩6.19)	779.95 (⇧34.97)	932.39 (⇩187.41)
Incremental cost (USD)	–	90,701,898.74	512,362,624.2	2,745,531,291
ICER (USD/QALY)	–	251,085.50	452,746.56	1,527,100.66

Figure 3. Tornado diagrams for replacing Current practice with universal MPV-4, universal MCV-AC, and universal MCV-4.

Figure 4. Cost-effectiveness acceptability curves for Current practice, universal MPV-4, universal MCV-AC, and universal MCV-4..

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Data availability statement

The detailed data source for the model inputs are available in the article, and most parameter inputs are based on published data. The complete model structure and specific data used in the study are available upon request to the corresponding author.