Section of Decision Sciences and Clinical Systems Management, University of Pittsburgh School of Medicine, 200 Meyran Ave, Ste 200, Pittsburgh, PA 15213, USA.
JAMA. 2012 Feb 22;307(8):804-12. doi: 10.1001/jama.2012.169.
CONTEXT: The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear. OBJECTIVE: To estimate the cost-effectiveness of PCV13 vaccination strategies in adults. DESIGN, SETTING, AND PARTICIPANTS: A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included Centers for Disease Control and Prevention Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey. MAIN OUTCOME MEASURES: Pneumococcal disease cases prevented and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS: In the base case scenario, administration of PCV13 as a substitute for PPSV23 in current recommendations (ie, vaccination at age 65 years and at younger ages if comorbidities are present) cost $28,900 per QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost $45,100 per QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 years to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing $496,000 per QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored. CONCLUSION: Overall, PCV13 vaccination was favored compared with PPSV23, but the analysis was sensitive to assumptions about PCV13 effectiveness against nonbacteremic pneumococcal pneumonia and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution.
背景：13 价肺炎球菌结合疫苗（PCV13）与 23 价肺炎球菌多糖疫苗（PPSV23）相比，在美国成年人中的成本效益尚不清楚。 目的：评估 PCV13 疫苗接种策略在成年人中的成本效益。 设计、地点和参与者：马尔可夫状态转移模型，终生时间范围，社会视角。模拟在美国 50 岁的假设队列中进行。疫苗接种策略和有效性估计由德尔菲专家小组制定；基于观察到的 PCV7 效果，推断儿童时期 PCV13 接种产生的间接（群体免疫）效应。模型参数的数据来源包括疾病控制和预防中心的活跃细菌核心监测、国家医院出院调查和全国住院患者样本数据以及国家健康访谈调查。 主要观察指标：预防肺炎球菌疾病病例数和每获得一个质量调整生命年（QALY）的增量成本。 结果：在基本情况下，用 PCV13 替代现行建议中的 PPSV23（即 65 岁时接种，如有合并症则在较年轻时接种），每获得一个 QALY 的成本为 28900 美元，比不接种疫苗更具成本效益，也优于目前推荐的 PPSV23 策略。50 岁和 65 岁时常规接种 PCV13 的成本为每获得一个 QALY 45100 美元，与用 PCV13 替代现行建议的情况相比。在 50 岁和 65 岁时接种 PCV13 并在 75 岁时接种 PPSV23，可获得 0.00002 个 QALY，每获得一个 QALY 的成本为 496000 美元。在敏感性分析和替代方案中，结果都是稳健的，但假设 PCV13 对非菌血症性肺炎球菌肺炎的有效性较低或假设儿童时期 PCV13 的潜在间接效应较大时，结果则不然。在这些情况下，目前推荐的 PPSV23 更受青睐。 结论：总体而言，PCV13 疫苗接种优于 PPSV23，但分析结果对 PCV13 对非菌血症性肺炎球菌肺炎的有效性以及儿童时期 PCV13 对肺炎球菌血清型分布的潜在间接效应的大小假设较为敏感。
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