The use of Zostavax in Spain: the economic case for vaccination of individuals aged 50 years and older

Figures & data

Figure 1. Model health states.

Table 1. Input parameters and values for the base case analysis of the Spanish VZV model.

Input parameter	(Example) value	Comment		Reference
Population 50+ in 5-year age groups	Data from January 1, 2012			Instituto Nacional de Estadística (INE)66
Annual mortality by age	Data from 2010. Weighted by gender and adjusted to 5-year age bands			Instituto Nacional de Estadística (INE)66
Life tables: data by age	Data from 2010. Weighted by gender			Instituto Nacional de Estadística (INE)66
Working population in Spain	Data from 2011 by gender by age. Weighted in the model. Over the age of 70 it was assumed that no more than 1.1% of males and 0.6% of women were employed			Instituto Nacional de Estadística (INE)66
Incidence of HZ by age group (per 1000 individuals)	50–54: 6.00 55–59: 6.00 60–64: 7.30 65–69: 9.50 70–74: 10.30 75–79: 10.90 80–84: 10.50 ≥ 85: 10.00		Average by 5-year age group from two sources as described above	Red de Médicos Centinela de la Comunidad Autónoma de Madrid29; and SIA-GAIA30
Percentage of HZ patients developing PHN (%)	50–59: 30.93% 60–69: 45.52% 70–79: 49.84% 80+: 52.83%		EPIZOD -1 month definition	Mick et al.35
Recurrence of HZ	0%			Cebrian-Cuenca et al.2
Average duration of HZ (months)	1 month		From SPS	SPS17
Average duration of PHN (months)	9 months		From SPS	SPS17
Percentage of women experiencing HZ (%)	58.46%		Average of the two studies	SPS17 and Abucasis30
Percentage of women experiencing PHN(%)	50.93%		Only available from SPS study	SPS17
HZ-related mortality (%)	0%			Assumption
Pain split HZ (%)	50–69: No pain: 27% Mild pain: 41% Moderate pain: 18% Severe pain: 14%		70+: No pain: 26% Mild pain: 32% Moderate pain: 23% Severe pain: 19%	SPS17
Pain split PHN (%)	50–69: Mild pain: 42% Moderate pain: 9% Severe pain: 49%		70+: Mild pain: 17% Moderate pain: 16% Severe pain: 67%	SPS17
Hospitalization for HZ rate (per 1000 individuals)	50–59: 7.44 60–69: 16.56 70–79: 32.87 ≥ 80: 54.33		Conjunto Mínimo Básico de Datos (CMBD) from 1998–2004	Gil et al.33
Hospitalizations due to PHN	0%		No information found	Assumption
Absenteeism due to HZ (days)	HZ No pain: 4.5 Mild pain: 5.2 Moderate pain: 7.4 Severe pain: 11.3		Average of three studies	Annemans et al.22 Moore et al.23 Szucs et al.57
Absenteeism due to PHN	PHN Mild pain: 4.0 Moderate pain: 13.1 Severe pain: 28.6		Average of three studies	Annemans et al.22 Moore et al.23 Szucs et al.57
Vaccine efficacy	HZ 50–59: 69.8% 60–69: 64.0% 70–79: 41.0% ≥ 80: 18.0%		PHN 50–59: 0% 60–69: 5.0% 70–79: 55.0% ≥ 80: 26.0%	ZEST19; SPS17
Age-specific utility	50–54: 0.842 (men)/0.833 (women) 55–59: 0.798/0.778 60–64: 0.802/0.782 65–69: 0.816/0.775 70–74: 0.784/0.745 75–79: 0.793/0.740 80–84: 0.727/0.680 ≥ 85: 0.588/0.549			Canada. National Population Health survey (NPHS, 1996–1997 health survey for England 1996–1997)67
Utilities HZ	Utility No pain: 0.864 Mild pain: 0.690 Moderate pain: 0.580 Severe pain: 0.250		Decrement No pain: 0.00 Mild pain: 0.201 Moderate pain: 0.329 Severe pain: 0.711	Oster et al.38
Utilities PHN	Utility Mild pain: 0.690 Moderate pain: 0.580 Severe pain: 0.250		Decrement Mild pain:0.201 Moderate pain: 0.329 Severe pain: 0.711	Oster et al.38
Vaccine coverage rage	30%		Same for all age-groups	Assumption (Expert panel)
Costs of vaccination administration	Physician: €4.16 Nurse: €2.61 Total cost: €6.77			eSALUD42
Vaccine cost	€130 (TPP perspective) €182.95 (Societal perspective)		Pharmaceutical company sale price (Precio de Venta de Laboratorio (PVL))	Ex-factory price and official public price
Cost of HZ management	Primary care costs: €205.45 Medication costs: €114.68		2012 cost level	Cebrián-Cuenca et al.2
Cost of PHN management (per month)	Primary care costs: €45.98 Medication costs: €32.30		2012 cost level	Cebrián-Cuenca et al.2
Hospitalization costs	€3812.89		2010 cost level	Registro de altas del Ministerio de Salud (CIE9 MC – CMBD 2010)43
Productivity losses (per hour)	€7.81		2010 data; based on average annual earnings of working individuals of all ages assuming an 8-h work day	Instituto Nacional de Estadística66

Table 2. Values used for sensitivity analyses.

Parameter	Alternative values: lower limit			Alternative values: Upper limit			References
Discount rate	Costs: 0% Benefits: 0%			Costs: 5% Benefits: 5% Costs 3%/ Benefits: 1.5%			Assumption and Heinz et al.68
Incidence of HZ per 1000 individuals	50–54: 3.44 55–59: 4.08 60–64: 4.90 65–69: 5.96 70–74: 6.34 75–79: 7.09 80–84: 7.39 ≥ 85: 6.22			50–54: 5.85 55–59: 5.85 60–64: 8.42 65–69: 8.42 70–74: 12.50 75–79: 12.50 ≥ 80: 13.55	50–54: 6.28 55–59: 6.67 60–64: 6.81 65–69: 7.13 70–74: 10.35 ≥ 75: 10.05		From left to right: Gauthier et al.65 GPRD- UK, Mick et al.35 (EPIZOD), Promedio G^a-Cenoz-Cebrián et al.2,69
Incidence of PHN (%)	50–54: 14.1 55–59: 18.8 60–64: 21.5 65–69: 25.6 70–74: 30.4 75–79: 36.0 80–84: 39.0 ≥ 85: 35.0		50–64: 18.49 ≥ 65: 26.99	50–59: 40.0 60–69: 68.0 ≥ 70: 59.2			From left to right: Gauthier et al.65 GPRD-UK, Sicras-Mainar et al.36, and Cebrián-Cuenca et al.2 NPH1
HZ-related mortality	50–54: 0.009% 55–59: 0.009% 60–64: 0.0027% 65–69: 0.0027% 70–74: 0.0035% 75–79: 0.0092% 80–84: 0.0487% ≥ 85: 0.2018%			0.6% per 1000 individuals			From left to right: Edmunds and Brisson32, Gil et al.33
No hospitalization	0%						Assumption
Cost of hospitalization				€4449.86			Gil et al.33
Vaccine coverage rate	10%			60%			Assumption
Vaccine Price	€104€(TPP perspective) €146.36 (Societal perspective)						−20%
Utility rates HZ	No pain: 0.81 Mild pain: 0.70 Moderate pain: 0.66 Severe pain: 0.52		No pain: 0.864 Mild pain: 0.73 Moderate pain: 0.60 Severe pain: 0.47	No pain: 0.864 Mild pain: 0.77 Moderate pain: 0.68 Severe pain: 0.55		No pain: 0.855 Mild pain: 0.778 Moderate pain: 0.607 Severe pain: 0.274	From left to right: Gater et al.70, Bala et al.63, Pellissier64, Van Hoek et al.58
Utility rates PHN	Mild pain: 0.730 Moderate pain: 0.650 Severe pain: 0.380		Mild pain: 0.73 Moderate pain: 0.60 Severe pain: 0.47	Mild pain: 0.77 Moderate pain: 0.68 Severe pain: 0.55		Mild pain: 0.77 Moderate pain: 0.68 Severe pain: 0.55	From left to right: Serpell et al.71, Bala et al.63, Pellissier64
Management costs (includes primary and secondary care, hospitalization and medication costs)	Healthcare resources: −25%			Healthcare resources: +25%			Assumption
Vaccine protection duration and waning rate	Vac Dur = 10 years for HZ and PHN; Waning rate = 0%	Vac Dur = lifetime or HZ, 10 years for PHN; Waning rate = 8.3%		Vac Dur = Lifetime for HZ and PHN; Waning rate = 8.3%			Pellissier64

Table 3. Base case (lifetime horizon).

Results	Lifetime	Vac Policy	No Vac Policy	Difference	Relative difference
Cost	Costs - Societal Perspective	€2,564,013,673	€1,842,736,720	€721,276,953	39.1%
	Costs - TPP Perspective	€2,171,356,785	€1,677,050,625	€494,306,161	29.5%
Effectiveness	QALYs	179,119,109	179,089,290	29,819	0.0%
	HZ Cases	2,661,087	2 905 133	244,046	−8.4%
	PHN Cases	851,359	939 718	88,359	−9.4%

HZ, Herpes Zoster; ICER, incremental cost-effectiveness ratio; PHN, post-herpetic neuralgia; QALY, quality-adjusted life year; TPP, third party payer.

Table 4. ICER from TPP and societal perspective (lifetime horizon).

Results	Lifetime	TPP	Societal
ICERs	Cost per QALY	€16,577	€24,189
	Cost per HZ case avoided	€2025	€2955
	Cost per PHN case avoided	€5594	€8163

HZ, Herpes Zoster; ICER, incremental cost-effectiveness ratio; PHN, post-herpetic neuralgia; QALY, quality-adjusted life year; TPP, third party payer.

Figure 2. Base case ICERs by age group.

Figure 3. Tornado diagram from the TPP (third party payer) perspective.

Figure 4. Tornado diagram from the societal perspective.

Figure 5. Cost-effectiveness acceptability curves.

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