van Hoek Albert Jan, Miller Elizabeth
Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel street, WC1E 7HT, London, England.
Immunisation, Hepatitis and Blood Safety Department, Public Health England, 61 Colindale Avenue, NW9 5EQ, London, England.
PLoS One. 2016 Feb 25;11(2):e0149540. doi: 10.1371/journal.pone.0149540. eCollection 2016.
Recently a large clinical trial showed that the use of 13-valent pneumococcal conjugate vaccine (PCV13) among immunocompetent individuals aged 65 years and over was safe and efficacious. The aim of this study was to assess the cost-effectiveness of vaccinating immunocompetent 65 year olds with PCV13 vaccine in England. England is a country with universal childhood pneumococcal conjugate vaccination programme in place (7-valent (PCV7) since 2006 and PCV13 since 2010), as well as a 23-valent pneumococcal polysaccharide (PPV23) vaccination programme targeting clinical risk-groups and those ≥65 years.
A static cohort cost-effectiveness model was developed to follow a cohort of 65 year olds until death, which will be vaccinated in the autumn of 2016 with PCV13. Sensitivity analysis was performed to test the robustness of the results.
The childhood vaccination programme with PCV7 has induced herd protection among older unvaccinated age groups, with a resultant low residual disease burden caused by PCV7 vaccine types. We show similar herd protection effects for the 6 additional serotypes included in PCV13, and project a new low post-introduction equilibrium of vaccine-type disease in 2018/19. Applying these incidence projections for both invasive disease and community-acquired pneumonia (CAP), and using recent measures of vaccine efficacy against these endpoints for ≥65 year olds, we estimate that vaccination of a cohort of immunocompetent 65 year olds with PCV13 would directly prevent 26 cases of IPD, 69 cases of CAP and 15 deaths. The associated cost-effectiveness ratio is £257,771 per QALY gained (using list price of £49.10 per dose and £7.51 administration costs) and is therefore considered not cost-effective. To obtain a cost-effective programme the price per dose would need to be negative. The results were sensitive to disease incidence, waning vaccine protection and case fatality rate; despite this, the overall conclusion was robust.
Vaccinating immunocompetent individuals aged ≥65 years with PCV13 is efficacious. However the absolute incidence of vaccine-type disease will likely become very low due to wider benefits of the childhood PCV13 vaccination programme, such that a specific PCV13 vaccination programme targeting the immunocompetent elderly would not be cost-effective.
最近一项大型临床试验表明，在65岁及以上免疫功能正常的个体中使用13价肺炎球菌结合疫苗（PCV13）是安全有效的。本研究的目的是评估在英格兰为65岁免疫功能正常的人群接种PCV13疫苗的成本效益。英国实施了针对儿童的普遍肺炎球菌结合疫苗接种计划（自2006年起为7价（PCV7），自2010年起为PCV13），以及针对临床风险人群和65岁及以上人群的23价肺炎球菌多糖（PPV23）疫苗接种计划。
建立了一个静态队列成本效益模型，以跟踪一组65岁的人群直至死亡，这些人将于2016年秋季接种PCV13。进行了敏感性分析以检验结果的稳健性。
PCV7儿童疫苗接种计划在未接种疫苗的老年人群中产生了群体保护作用，导致由PCV7疫苗血清型引起的残留疾病负担较低。我们显示了PCV13中另外6种血清型具有类似的群体保护作用，并预测在2018/19年引入疫苗后疫苗型疾病将达到新的低平衡水平。将这些侵袭性疾病和社区获得性肺炎（CAP）的发病率预测应用于≥65岁人群针对这些终点的近期疫苗效力测量，我们估计为一组65岁免疫功能正常的人群接种PCV13将直接预防26例侵袭性肺炎球菌病（IPD）、69例CAP和15例死亡。相关的成本效益比为每获得一个质量调整生命年（QALY）257,771英镑（使用每剂49.10英镑的标价和7.51英镑的接种成本），因此被认为不具有成本效益。要获得具有成本效益的计划，每剂价格需要为负。结果对疾病发病率、疫苗保护作用减弱和病死率敏感；尽管如此，总体结论仍然稳健。
为65岁及以上免疫功能正常的个体接种PCV13是有效的。然而，由于儿童PCV13疫苗接种计划的更广泛益处，疫苗型疾病的绝对发病率可能会变得非常低，因此针对免疫功能正常的老年人的特定PCV13疫苗接种计划将不具有成本效益。
