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1Economic Analysis and Public Health Impact of PCV
use for Adults Aged ≥50 Years
Charles Stoecker
Tulane University
Celia Scott Weatherhead School of Public Health and Tropical
Medicine
ACIP
October 23, 2024
2Conflicts of Interest
❑Dr. Stoecker has no conflicts of interest to declare.
3Acronyms
❑ PCV: pneumococcal conjugate vaccine
❑ PCV20: 20 valent PCV
❑ PCV21: 21 valent PCV
❑ VE: vaccine effectiveness
❑ VT: vaccine type
❑ ST: serotype
❑ NBP: non -bacteremic pneumonia
❑ IPD: invasive pneumococcal disease
❑ IPT: inpatient
❑ OPT: outpatient
❑ QALY: quality adjusted life year
❑ IC: immunocompromised
❑ CMC: chronic medical conditions, but not IC
❑ NIS: National Immunization Survey
❑ ABCs: Active Bacterial Core Surveillance System
4Methods: Study Question
❑Evaluate cost effectiveness of an age -based
recommendation for PCV20 or PCV21 in adults younger
than age 65
▪Motivation is to get higher coverage among risk -based adults
•Additionally get coverage among general population
❑Evaluate
▪Program cost/savings
▪Changes in disease, medical costs, nonmedical costs, and work
productivity costs
•Limited societal perspective
▪Population
•Cohort of 4,051,078 50 -year -olds
•Separate model buckets for:
oImmunocompromised (IC) –HIV, Cancer, Organ Transplants,
Dialysis
oChronic medical conditions (CMC) –Diabetes, Heart Disease, Lung
Disease, Liver Disease, Alcoholism
oOthers –”General”
5Two Modeling Strategies
❑Moving Strategies
▪Moving age -based recommendation from 65 to age 50
▪Shifts disease burden from younger to older adults
▪Moving strategy will overcount benefits
•Overstates savings from not vaccinating at age 65 years
•Overstates unprotected time if waning is longer than 15 years
•If the future policy considerations will add a later age -based vaccination
after reevaluation in the future
oReevaluations could be motivated by waning evaluation or higher
valency vaccinations
❑Adding Strategies
▪Adding vaccination at 50 in addition to 65
▪In the future, clinicians may prefer to administer a booster dose at age
65 years in the "moving strategy" to ensure protection for older adults
▪Maintains protective benefits for older adults from current age -based
recommendation
6Specific Strategies to Evaluate
❑Moving Strategies
❑Adding Strategies
❑Repeat with PCV21Intervention Comparator
PCV20 at age 50 PCV20 at CMC/IC & PCV20 at age 65
PCV20 at age 60 PCV20 at CMC/IC & PCV20 at age 65
Intervention Comparator
PCV20 at ages 50 & 65 PCV20 at CMC/IC & PCV20 at age 65
PCV20 at ages 60 & 75 PCV20 at CMC/IC & PCV20 at age 65
7Conceptual Model
NBP
Background mortality from non -pneumococcus related illness is included in all branches, but not displayed in the model for brevi ty.
Abbreviations: IPT -inpatient case, OPT -outpatient case, IPD -invasive pneumococcal disease, NBP -non -bacteremic pneumoniaIPT Case
IPT Case
OPT Case
8Model Inputs
❑IPD rates, all -cause IPT and OPT NBP rates, IPD cases resulting in
fatality were estimated by age - and risk group (general/CMC/IC).
❑Age -group specific IPT NBP case fatality rates were applied to the 3
risk groups
❑Vaccine effectiveness (VE) was estimated by risk group and
outcome (IPD/NBP)
▪VE against serotype 3 was lower than other VT
▪Vaccine serotype effectiveness was the same across PCV20 and PCV21
❑Vaccine coverage was estimated separately by age group (50 –64,
65+) and for existing risk -based recommendations (age 50 -64)
▪Updated from June 2024 presentation with more granular data
See supplemental slides for the specific estimates used in the model. Additional details are also available in the earlier v ersion
of the model that was presented at ACIP in June 2024 (Stoecker 2024 "Economic Assessment of PCV21 in US Adults")
9Vaccine Price
❑PCV20 $288.66a
❑PCV21 $319.43b
❑Administration 50 -64 years: $30.49c
❑Administration 65+ years: $21.07d
❑Travel + patient time cost: $44.46e
a Payment Allowance Limits for Medicare Part B for PCV20.
b Applied ratio of PCV21 to PCV20 price from manufacturer model and applied to PCV20 Medicare price. Sensitivity analysis uses upper bound of manufacturer
PCV21 price range.
c Tsai et al. AJPM 2019. Updated to 2023 dollars.
d Average Medicare maximum allowable reimbursement for immunization administration (HCPCS code 90471) across all Medicare Admin istrative Contractors,
2023.
e Travel cost from Maciosek et al. Am J Prev Med 2006. Updated to 2023 dollars.
10Waning Immunity Assumptions
❑No decline in effectiveness for first five years a
❑Wane to zero over next 10 or 15 years b
aPatterson S, Webber C, Patton M, Drews W, Huijts SM, Bolkenbaas M, et al. A post hoc assessment of duration of protection in CAPiTA (Community
Acquired Pneumonia immunization Trial in Adults). Trials in Vaccinology. 2016;5.:92 -96.
b van Werkhoven CH, Huijts SM, Bolkenbaas M, Grobbee DE, Bonten MJ. The Impact of Age on the Efficacy of 13 -valent Pneumococcal Conjugate
Vaccine in Elderly. Clin Infect Dis 2015;61(12):1835 -8.00.10.20.30.40.50.60.70.80.91
01234567891011121314151617181920% Initial Effectiveness
Years Since Initial Vaccination
Wane by 15 Wane by 20
11Herd Effects from PCV20 in Children
❑Apply serotype group -specific declines observed in
PCV13 types (+6C, -3, -19F) in adults after PCV13
introduction in children
❑Apply to additional types in PCV20 but not in PCV13
❑Run versions of the model with and without these herd
effects to assess importance
Year Remaining Proportion of Disease
1 0.755161
2 0.496227
3 0.339094
4 0.244074
5 0.187125
6 0.156599
7+ No further declines
Source: Kobayashi et al. Poster presented at: 13th Meeting of the International Society of Pneumonia & Pneumococcal Diseases, March 2024
12Moving Strategies
1315 Y ear Waning, With Herd Effects
PCV20 PCV20 PCV21 PCV21
50 vs. 65 60 vs. 65 50 vs. 65 60 vs. 65
IPD Cases 44 32 458 464
Hospitalized Pneumonia Cases 871 808 1,925 1,977
Non -hospitalized Pneumonia Cases
722 590 1,498 2,017
Deaths due to IPD 12 9 69 66
Deaths due to Hospitalized Pneumonia 37 35 83 83
QALYs 66 -102 -210 -671
Total Cost (million$) -$76 -$206 -$121 -$218
$ Saved / QALY Lost Cost -Saving 2,023,745 575,614 324,164
Undiscounted Cases 50 -64 -4,031 -3,217 -9,338 -6,265
Undiscounted Cases 65+ 9,681 6,374 22,261 14,735
Undiscounted Deaths 50 -64 -69 -54 -154 -106
Undiscounted Deaths 65+ 203 136 530 356
Note: Undiscounted cases include invasive pneumococcal disease cases as well as non -bacteremic pneumonia cases (both inpatient and outpatient).
14Adding Strategies
1515 Y ear Waning, With Herd Effects
PCV21 at Age
50 and 65PCV21 at Age
60 and 75PCV20 at Age
50 and 65PCV20 at Age
60 and 75
IPD Cases -932 -941 -434 -354
Hospitalized Pneumonia Cases -1,367 -4,117 -600 -1,868
Non -hospitalized Pneumonia Cases -6,000 -7,233 -2,635 -3,467
Deaths due to IPD -100 -133 -46 -46
Deaths due to Hospitalized Pneumonia -38 -171 -17 -77
QALYs 2,070 1,581 956 741
Life-years
2,633 2,407 1,214 1,092
Costs (million $)
Total Cost $444 $189 $523 $270
Medical Costs -$141 -$177 -$64 -$82
Vaccine Costs $689 $403 $635 $372
Work Loss -$103 -$37 -$48 -$20
Cost Ratios ($)
Cost/QALY 214,430 119,665 546,811 364,497
Cost/Life -year 168,533 78,612 430,913 247,411
Note: All strategies are compared to current recommendations; risk -based use between ages 50 -64 and age -based use at age 65.
1620 Y ear Waning, With Herd Effects
PCV21 at Age
50 and 65PCV21 at Age
60 and 75PCV20 at Age
50 and 65PCV20 at Age
60 and 75
IPD Cases -989 -949 -449 -355
Hospitalized Pneumonia Cases -1,455 -3,595 -618 -1,649
Non -hospitalized Pneumonia Cases -6,386 -7,075 -2,710 -3,389
Deaths due to IPD -106 -153 -48 -51
Deaths due to Hospitalized Pneumonia -40 -155 -17 -70
QALYs 2,144 1,445 967 676
Life-years
2,747 2,199 1,234 992
Costs (million $)
Total Cost $433 $206 $521 $278
Medical Costs -$150 -$162 -$66 -$75
Vaccine Costs $689 $403 $635 $372
Work Loss -$105 -$35 -$48 -$19
Cost Ratios ($)
Cost/QALY 202,019 142,373 539,097 411,202
Cost/Life -year 157,728 93,531 422,657 280,039
1715 Y ear Waning, No Herd Effects
PCV21 at Age
50 and 65PCV21 at Age
60 and 75PCV20 at Age
50 and 65PCV20 at Age
60 and 75
IPD Cases -1,283 -1,275 -795 -704
Hospitalized Pneumonia Cases -1,781 -6,587 -1,115 -5,139
Non -hospitalized Pneumonia Cases -7,819 -10,216 -4,892 -7,346
Deaths due to IPD -137 -184 -84 -100
Deaths due to Hospitalized Pneumonia -49 -281 -31 -223
QALYs 2,778 2,177 1,725 1,480
Life-years
3,541 3,390 2,193 2,310
Costs (million $)
Total Cost $364 $109 $433 $170
Medical Costs -$189 -$253 -$118 -$178
Vaccine Costs $689 $403 $635 $372
Work Loss -$136 -$41 -$84 -$25
Cost Ratios ($)
Cost/QALY 131,028 50,122 251,037 114,909
Cost/Life -year 102,804 32,186 197,417 73,619
18Limitations
❑Uncertainty around waning & herd effects
❑Sequelae from IPD not modeled explicitly
❑Uncertainties about the pneumococcal disease trends due to
pneumococcal serotypes that are no longer included in PCV21
(e.g., serotype 4, 19F)
❑Disruption from changing pneumococcal schedule not modeled
19Moving Strategy Summary
❑Moving age -based vaccination from age 65 to lower ages:
▪All scenarios result in increased net cases
•Lowers cases and deaths in ages 50 -64
•Increases cases and deaths in ages 65+
▪Lower cost
▪Also true under longer vaccine waning scenarios and scenarios without herd
immunity from childhood program (Appendix)
20Adding Strategy Summary
❑Adding a second age -based vaccination results in increased QAL Ys
and costs compared with the current recommendation
▪ICERs range from $50k/QALY to $500k/QALY
▪ICERs are always lower for PCV21 recommendations than PCV20 recommendations
❑Assuming no herd effects improves economic efficiency of both
PCV20 & PCV21
▪Change in $/QALY is greater in PCV20 than PCV21
▪But this change is not large enough to make PCV20 more efficient than PCV21
❑Assumptions surrounding vaccine waning are minimally impactful
on ICERs
▪Waning is extended in both the intervention and comparison strategies
❑Vaccination at later ages is more economically efficient
▪Vaccination at 60 & 75 is lower $/QALY than vaccination at 50 & 65 (or 55 & 70)
21Thank you!
Please send comments to:
[email protected]
Contributors:
Andrew Leidner
Miwako Kobayashi
Bo-Hyun Cho
Yin Wang
Cheryl Ward
National Center for Immunization & Respiratory Diseases
HSREB – Econ Team
22Serotype Group18-49
Years50-64
Years65-74
Years75-84
Years85+
Years
% PCV20 only -4-19F
(1, 5, 6B, 9V, 14, 18C, 23F, 15B, including
isolates reported as 15BC)1.99% 1.52% 3.09% 1.01% 1.08%
% PCV20 & PCV21 -3
(6A, 7F, 19A, 22F, 33F, 8, 10A, 11A, 12F) +6C 34.44% 41.95% 32.72% 32.32% 33.33%
% PCV21 only -35B
(9N, 17F, 20, 15A, 15C, 16F, 23A, 23B, 24F, 31)30.13% 30.70% 31.48% 29.29% 35.48%
% serotype 3 13.91% 12.46% 17.28% 21.21% 14.25%
% serotype 4 4.97% 2.43% 1.23% 0.00% 0.00%
% serotype 19F 4.97% 4.56% 3.70% 3.03% 3.01%
% serotype 35B 2.65% 0.91% 4.32% 5.05% 3.23%
Ratio PCV21 only:PCV20 only serotypes 2.75 3.71 4.46 8.50 9.46
Source: Active Bacterial Core Surveillance 2018 -2019. For multivariate sensitivity analyses distributions are beta -pert with -/+20% for low and high.IPD Serotype Distributions, General
23Serotype Group18-49
Years50-64
Years65-74
Years75-84
Years85+
Years
% PCV20 only -4-19F
(1, 5, 6B, 9V, 14, 18C, 23F, 15B, including
isolates reported as 15BC)0.49% 0.71% 1.88% 2.17% 1.81%
% PCV20 & PCV21 -3
(6A, 7F, 19A, 22F, 33F, 8, 10A, 11A, 12F) +6C 36.99% 33.62% 30.36% 32.79% 28.62%
% PCV21 only -35B
(9N, 17F, 20, 15A, 15C, 16F, 23A, 23B, 24F, 31)30.33% 32.67% 30.83% 32.52% 33.70%
% serotype 3 11.34% 17.96% 21.91% 17.07% 17.39%
% serotype 4 9.99% 4.35% 1.25% 0.27% 0.72%
% serotype 19F 3.08% 2.45% 2.66% 2.44% 2.17%
% serotype 35B 2.59% 3.01% 4.23% 5.15% 6.88%
Ratio PCV21 only:PCV20 only serotypes 2.43 4.75 6.06 7.72 8.63IPD Serotype Distributions, CMC
Source: Active Bacterial Core Surveillance 2018 -2019. For multivariate sensitivity analyses distributions are beta -pert with -/+20% for low and high.
24IPD Serotype Distributions, IC
Serotype Group18-49
Years50-64
Years65-74
Years75-84
Years85+
Years
% PCV20 only -4-19F
(1, 5, 6B, 9V, 14, 18C, 23F, 15B, including
isolates reported as 15BC)6.02% 3.92% 3.30% 2.88% 0.00%
% PCV20 & PCV21 -3
(6A, 7F, 19A, 22F, 33F, 8, 10A, 11A, 12F) +6C 28.92% 31.63% 30.03% 37.50% 48.31%
% PCV21 only -35B
(9N, 17F, 20, 15A, 15C, 16F, 23A, 23B, 24F, 31)31.33% 33.73% 33.99% 26.44% 25.84%
% serotype 3 15.66% 8.43% 11.55% 10.10% 4.49%
% serotype 4 1.20% 1.20% 1.32% 0.00% 0.00%
% serotype 19F 3.61% 3.61% 3.30% 1.44% 5.62%
% serotype 35B 6.02% 6.63% 8.91% 9.62% 5.62%
Ratio PCV21 only:PCV20 only serotypes 3.45 4.62 5.42 8.35 5.60
Source: Active Bacterial Core Surveillance 2018 -2019. For multivariate sensitivity analyses distributions are beta -pert with -/+20% for low and high.
25NBP Serotype Distributions
Serotype Group18-49
Years50-64
Years65+
Years
% PCV20 only -4-19F
(1, 5, 6B, 9V, 14, 18C, 23F, 15B)0.6% 0.7% 1.1%
% PCV20 & PCV21 -3
(6A, 7F, 19A, 22F, 33F, 8, 10A, 11A, 12F) +6C 3.0% 4.5% 3.9%
% PCV21 only -35B
(9N, 17F, 20, 15A, 15C, 16F, 23A, 23B, 24F, 31)3.2% 4.2% 2.4%
% serotype 3 1.1% 2.0% 1.4%
% serotype 4 0.0% 0.2% 0.2%
% serotype 19F 0.1% 0.9% 0.7%
% serotype 35B 0.8% 0.6% 0.7%
Ratio PCV21 only:PCV20 only serotypes 5.7 2.7 1.6
Source: Merck adjusted SSUAD serotype distribution data.
Note that the serotype distribution is among all community -acquired pneumonia, not limited to pneumococcal pneumonia.
For multivariate sensitivity analyses distributions are beta -pert with -/+20% for low and high.
26IPD Rates per 100k
Source: Active Bacterial Core Surveillance System, 2017 -2018; NHIS 2017 –2018. For multivariate sensitivity analyses distributio ns are beta -pert with -/+20% for
low and high. Risk Group19-49
Years50-64
Years65-74
Years75-84
Years85+
Years
General 2.09 6.09 8.25 13.90 33.06
CMC 8.09 24.04 25.89 33.34 58.57
IC 16.22 37.28 35.10 36.81 46.38
27NBP Hospitalization Rates per 100k
Source: MarketScan & Optum databases. 2013 -2015 data. (Pelton et al. CID 2019) (95% CIs in parenthesis)Risk
Group19-49
Years50-64
Years65-74
Years75+
Years
General 35 (35, 36) 88 (87, 90) 191 (185, 197) 957 (938, 975)
CMC 207 (202, 212) 429 (423, 425) 941 (925, 957) 2745 (2717, 2774)
IC 701 (681, 721) 1226 (1207, 1244) 2124 (2087, 2162) 3992 (3944, 4040)
28NBP Outpatient Rates per 100k
Source: Tong et al. 2014 data. BMC Health Serv Res 2018. For multivariate sensitivity analyses distributions are beta -pert with -/+20% f or low and high.Risk Group19-49
Years50-64
Years65-74
Years75-84
Years85+
Years
General 322.92 385.04 491.98 1366.22 2378.97
CMC 1872.91 1886.72 2410.70 3962.03 6899.00
IC 6361.40 5352.10 5461.00 5738.10 9991.70
29IPD Cases Resulting in Fatality
Source: Active Bacterial Core Surveillance System, 2017 -2018. For multivariate sensitivity analyses distributions are beta -pert with -/+20% for low and high.Risk Group19-49
Years50-64
Years65-74
Years75-84
Years85+
Years
General 5.54% 8.73% 7.93% 11.25% 17.30%
CMC 7.24% 11.06% 12.22% 12.82% 22.97%
IC 10.04% 14.27% 13.97% 11.33% 17.62%
30IPT NBP Cases Resulting in Fatality
Base Low High
18-49 Years 1.6 0.4 2.9
50-64 Years 2.8 1.1 4.4
65-74 Years 3.5 1.5 5.5
75-84 Years 4.1 2.2 6.0
85+ Years 5.3 3.3 7.2
Source: NIS2018 (lower bound: ICD -10 code J13 or J181 for primary diagnosis; upper bound: ICD -10 code J13 or J181 in ANY locatio n; base: mean of LB and UB).
Low and High parameters used in beta -pert distribution
31Vaccine Effectiveness
a. Bonten NEJM 2015 (per protocol)
b. Point estimate from Pilishvili et al. ISPPD2018 abstract, lower bound set to 0, upper bound from Lewis 2020 ISPPD poster
c. Suaya Vaccine 2018; 1477 -1483.
d. Applied the ratio of IPD VE/Pneumonia VE for all PCV13 types to the point estimate for ST3 IPD VE. General CMC IC
PCV vs VT ( -ST3) IPDa 75.0 (41.4, 90.8) 75.0 (41.4, 90.8) 25.0 (13.8, 30.3)
PCV vs ST3 IPDb 26.0 (0, 53.4) 26.0 (0, 53.4) 8.7 (0, 17.8)
PCV vs VT ( -ST3) NBPc 66.7 (11.8, 89.3) 40.3 (11.4, 60.2) 15.0 (4.7, 21.8)
PCV vs ST3 NBPd 15.6 (0, 32.0) 15.6 (0, 32.0) 5.2 (0, 10.7)
32Coverage Rates
June 2024
Inputs Updated
PCV Age -based 50 -64 39.65b 47.6e
PCV Age -based 65+ 56c 70f
Risk -based (50 -64) 22.2a 37.5f
a. NHIS 2021 data https://www.cdc.gov/vaccines/imz -managers/coverage/adultvaxview/pubs -resources/vaccination -coverage -adults -2021.html ;
b. Mean of NHIS 2021 for Zoster Vaccine in adults 60 -64 years; and estimate for PCV15/PCV20 coverage in adults 65 years and older
c. Mean of NHIS 2021 any pneumococcal coverage; and any PCV13 coverage data in Medicare beneficiaries aged ≥65 years, 2019
e. Applied the ratio of vaccine coverage among ages 50 -64/65+ for Influenza and COVID -19 vaccines to age -based pneumococcal vaccine coverage in
adults aged 65+years
f. BRFSS 2022, any pneumococcal vaccine coverage
33Utility Decrements
Variable QAL Y DecrementsaImplied Healthy Days
Lostb
IPD0.0709
(0.0509, 0.0909)25.9
IPT NBP0.0709
(0.0509, 0.0909)25.9
OPT NBP0.0045
(0.00399, 0.00501)1.6
a QALY values from Mangen et al. 2015 Eur Respir J (95% CIs in parenthesis)
b Health days lost were include on this slide to illustrate in relatable terms the magnitude of health loss associated with QAL Y decrements. Healthy days lost
calculated by multiplying QALY decrement by 365.
c Alternate values are inverse variance weighted values from Tang et al. 2021 J Pub Health. Source material places higher decre ment on outpatient disease
than inpatient disease for age 65+.Pneumococcal Disease
Treatment Intensity, AgeQALY
Decrement
Outpatient, 19 -64 0.0094
Inpatient, 19 -64 0.0396
Outpatient, 65+ 0.0586
Inpatient, 65+ 0.0087Alternate Utility Decrementsc
34Baseline QAL Y Values
Age General CMC/IC
50-55 0.83 (0.78,0.88) 0.72 (0.67,0.77)
56-60 0.81 (0.76,0.86) 0.69 (0.64,0.74)
61-65 0.77 (0.72,0.82) 0.63 (0.58,0.68)
66-70 0.76 (0.71,0.81) 0.57 (0.52,0.62)
71-75 0.74 (0.69,0.79) 0.54 (0.49,0.59)
76-80 0.7 (0.65,0.75) 0.52 (0.47,0.57)
81-85 0.63 (0.58,0.68) 0.51 (0.46,0.56)
86+ 0.51 (0.46,0.56) 0.51 (0.46,0.56)
Sisk, 2003.
35Disease Cost (2023$)
Data for ages 19 -64 from MarketScan 2019 -2022. Data for 65+ from CMS Medicare claims 2019 -2022. 95% CI from bootstrapping mean values with 1,000
iterations. All costs converted to 2023$ using CPI Medical Care before bootstrapping. See appendix slide for ICD -10 codes.Disease Setting Cost 95% CI
19-64 YearsIPD IPT $64,018.10 $61,559.31 $66,424.61
NBP IPT $58,423.99 $55,923.53 $60,908.13
NBP OPT $362.38 $339.44 $385.24
65+ YearsIPD IPT $27,564.22 $27,039.18 $28,149.20
NBP IPT $21,300.64 $20,825.64 $21,800.98
NBP OPT $318.22 $308.06 $328.70
36ICD -10 Codes for Medical Cost Extraction
Disease ICD-10 Codes
IPD A40.3, A40.9+B95.3, A41.9+B95.3, R78.81+B95.3, G00.1, G00.2+B95.3,
G00.9+B95.3, G03.9+B95.3, J86.x+B95.3, J85.1+B95.3, A40.3 + at least one code
from "All -cause", A40.9+B95.3 + at least one code from "All -cause",
A41.9+B95.3 + at least one code from "All -cause", R78.81+B95.3 + at least one
code from "All -cause", A40.9 & J13, A41.9 & J13, R78.81 & J13, M00.1x,
K65.8+B95.3, I30.1+B95.3, I33.0+B95.3, I33.9 +B95.3, K65.2+B95.3,
M86.1x/M86.2x/M86.9+B95.3, M00.0x, M00.2x, M00.8x, M00.9 + B95.3
NBP J13, J15.9+B95.3, J18.0/J18.1+B95.3, J18.8/J18.9+B95.3
All-cause (for
satisfying some
definitions of
IPD)J12.x (J12.0, J12.1, J12.2, J12.3, J12.81, J12.89, J12.9), J13, J18.1, A48.1, J14, J15.0,
J15.1, J15.2x (J15.20, J15.211, J15.212, J15.29), J15.3, J15.4, J15.5, J15.6, J15.8,
J15.9, J15.7, J16.x (J16.0, J16.8), A22.1, A37.X1, B25.0, B44.0, J17, J18.0, J18.2,
J18.8, J18.9, J09.X1, J10.0x (J10.00, J10.01, J10.08), J11.0x (J11.00, J11.08)
37Work Loss
AgeLabor Force
Participation
Rate (%)aMedian Daily
Wage ($)b
19 to 24 71 99.71
25 to 34 83.2 148.86
35 to 44 83 175.57
45 to 54 81.1 176.14
55 to 64 65.2 169.43
65 to 74 26.6 157.29
75+ 8.2 157.29
a US Bureau of Labor Statistics.
b Current Population Survey, 2023.
c Altawalbeh SM, Wateska AR, Nowalk MP, Lin CJ, Harrison LH, Schaffner W, Zimmerman RK, Smith KJ. Societal cost of racial pneumococcal disease disparities in
US adults aged 50 years or older. Applied Health Economics and Health Policy. 2024 Jan;22(1):61 -71.
d Used ratio of days of work loss from outpatient (14) to inpatient pneumonia (18) allowed by Marine Corps policy and applied t o inpatient durations of illness
from Altawalbeh 2024. Vold Pepper P, Owens DK. Cost -effectiveness of the pneumococcal vaccine in the United States Navy and Marine Corps. Clinical
infectious diseases. 2000 Jan 1;30(1):157 -64.Base High Low
Inpatientc 34 17 51
Outpatientd 26.4 13.2 39.7Labor Force Participation and Daily Wage Duration of Work Loss
3815 Y ear Waning, With Herd Effects (Moving)
PCV20 PCV20 PCV20 PCV21 PCV21 PCV21
50 vs. 65 55 vs. 65 60 vs. 65 50 vs. 65 55 vs. 65 60 vs. 65
IPD Cases 44 34 32 458 459 464
Hospitalized Pneumonia Cases 871 897 808 1,925 2,032 1,977
Non -hospitalized Pneumonia Cases
722 647 590 1,498 1,529 2,017
Deaths due to IPD 12 10 9 69 69 66
Deaths due to Pneumonia 37 39 35 83 88 83
QALYs 66 -9 -102 -210 -419 -671
Total Cost (million$) -$76 -$133 -$206 -$121 -$171 -$218
$ Saved / QALY Lost Cost -Saving 14,014,611 2,023,745 575,614 407,176 324,164
Undiscounted Cases 50 -64 -4,031 -4,269 -3,217 -9,338 -9,579 -6,265
Undiscounted Cases 65+ 9,681 8,757 6,374 22,261 20,177 14,735
Undiscounted Deaths 50 -64 -69 -72 -54 -154 -160 -106
Undiscounted Deaths 65+ 203 184 136 530 482 356
3920 Y ear Waning, With Herd Effects (Moving)
PCV20 PCV20 PCV20 PCV21 PCV21 PCV21
50 vs. 65 55 vs. 65 60 vs. 65 50 vs. 65 55 vs. 65 60 vs. 65
IPD Cases 71 59 65 560 559 571
Hospitalized Pneumonia Cases 1,269 1,299 1,129 2,742 2,890 2,655
Non -hospitalized Pneumonia Cases
1,193 1,131 1,042 2,283 2,479 2,915
Deaths due to IPD 16 14 13 84 83 80
Deaths due to Pneumonia 54 56 48 118 124 111
QALYs -20 -96 -184 -376 -606 -848
Total Cost (million$) -$67 -$121 -$194 -$106 -$145 -$194
$ Saved / QALY Lost 3,325,061 1,252,046 1,056,802 283,008 239,889 228,155
Undiscounted Cases 50 -64 -4,263 -4,095 -2,999 -10,237 -9,311 -5,866
Undiscounted Cases 65+ 12,226 10,605 7,643 27,976 24,322 17,557
Undiscounted Deaths 50 -64 -73 -70 -51 -168 -155 -99
Undiscounted Deaths 65+ 261 228 165 678 594 432
4015 Y ear Waning, No Herd Effects (Moving)
PCV20 PCV20 PCV20 PCV21 PCV21 PCV21
50 vs. 65 55 vs. 65 60 vs. 65 50 vs. 65 55 vs. 65 60 vs. 65
IPD Cases 418 438 482 796 825 881
Hospitalized Pneumonia Cases 3,598 3,747 3,432 3,941 4,134 3,928
Non -hospitalized Pneumonia Cases
5,861 5,917 5,638 5,226 5,327 5,730
Deaths due to IPD 63 64 66 116 118 120
Deaths due to Pneumonia 141 148 135 160 169 158
QALYs -830 -1,038 -1,185 -876 -1,203 -1,537
Total Cost (million$) -$40 -$86 -$136 -$101 -$141 -$165
$ Saved / QALY Lost 48,348 82,895 114,542 114,808 116,909 107,388
Undiscounted Cases 50 -64 -7,694 -8,032 -4,831 -12,353 -12,711 -7,613
Undiscounted Cases 65+ 30,465 27,551 20,002 38,099 34,498 25,117
Undiscounted Deaths 50 -64 -130 -134 -80 -211 -217 -131
Undiscounted Deaths 65+ 586 534 396 847 771 571
4120 Y ear Waning, No Herd Effects (Moving)
PCV20 PCV20 PCV20 PCV21 PCV21 PCV21
50 vs. 65 55 vs. 65 60 vs. 65 50 vs. 65 55 vs. 65 60 vs. 65
IPD Cases 489 514 567 938 974 1,038
Hospitalized Pneumonia Cases 4,845 4,991 4,408 5,391 5,625 5,100
Non -hospitalized Pneumonia Cases
7,221 7,246 6,845 6,659 6,921 7,202
Deaths due to IPD 74 75 77 137 139 140
Deaths due to Pneumonia 194 201 176 222 232 207
QALYs -1,059 -1,280 -1,402 -1,143 -1,508 -1,819
Total Cost (million$) -$18 -$54 -$107 -$77 -$100 -$128
$ Saved / QALY Lost 16,782 42,282 76,328 67,272 66,407 70,122
Undiscounted Cases 50 -64 -8,627 -7,815 -4,503 -13,830 -12,398 -7,117
Undiscounted Cases 65+ 38,671 33,563 24,125 48,108 41,795 30,100
Undiscounted Deaths 50 -64 -146 -131 -75 -236 -212 -122
Undiscounted Deaths 65+ 770 677 493 1,096 962 700
4215 Y ear Waning, With Herd Effects (Adding)
PCV21 at Age
50 and 65PCV21 at Age
55 and 70PCV21 at Age
60 and 75PCV20 at Age
50 and 65PCV20 at Age
55 and 70PCV20 at Age
60 and 75
IPD Cases -932 -930 -941 -434 -402 -354
Hospitalized Pneumonia Cases -1,367 -2,584 -4,117 -600 -1,141 -1,868
Non -hospitalized Pneumonia Cases -6,000 -6,699 -7,233 -2,635 -2,990 -3,467
Deaths due to IPD -100 -104 -133 -46 -44 -46
Deaths due to Pneumonia -38 -93 -171 -17 -41 -77
QALYs 2,070 1,768 1,581 956 829 741
Life-years
2,633 2,420 2,407 1,214 1,116 1,092
Costs (million $)
Total Cost $444 $330 $189 $523 $416 $270
Medical Costs -$141 -$171 -$177 -$64 -$77 -$82
Vaccine Costs $689 $570 $403 $635 $526 $372
Work Loss -$103 -$69 -$37 -$48 -$33 -$20
Cost Ratios ($)
Cost/QALY 214,430 186,838 119,665 546,811 501,851 364,497
Cost/Life -year 168,533 136,496 78,612 430,913 372,691 247,411
4320 Y ear Waning, With Herd Effects (Adding)
PCV21 at Age
50 and 65PCV21 at Age
55 and 70PCV21 at Age
60 and 75PCV20 at Age
50 and 65PCV20 at Age
55 and 70PCV20 at Age
60 and 75
IPD Cases -989 -995 -949 -449 -419 -355
Hospitalized Pneumonia Cases -1,455 -2,522 -3,595 -618 -1,115 -1,649
Non -hospitalized Pneumonia Cases -6,386 -6,966 -7,075 -2,710 -3,083 -3,389
Deaths due to IPD -106 -123 -153 -48 -49 -51
Deaths due to Pneumonia -40 -93 -155 -17 -41 -70
QALYs 2,144 1,798 1,445 967 827 676
Life-years
2,747 2,480 2,199 1,234 1,120 992
Costs (million $)
Total Cost $433 $333 $206 $521 $418 $278
Medical Costs -$150 -$169 -$162 -$66 -$75 -$75
Vaccine Costs $689 $570 $403 $635 $526 $372
Work Loss -$105 -$69 -$35 -$48 -$33 -$19
Cost Ratios ($)
Cost/QALY 202,019 184,959 142,373 539,097 505,534 411,202
Cost/Life -year 157,728 134,122 93,531 422,657 373,616 280,039
4415 Y ear Waning, No Herd Effects (Adding)
PCV21 at Age
50 and 65PCV21 at Age
55 and 70PCV21 at Age
60 and 75PCV20 at Age
50 and 65PCV20 at Age
55 and 70PCV20 at Age
60 and 75
IPD Cases -1,283 -1,284 -1,275 -795 -765 -704
Hospitalized Pneumonia Cases -1,781 -3,846 -6,587 -1,115 -2,776 -5,139
Non -hospitalized Pneumonia Cases -7,819 -8,896 -10,216 -4,892 -5,715 -7,346
Deaths due to IPD -137 -145 -184 -84 -85 -100
Deaths due to Pneumonia -49 -143 -281 -31 -106 -223
QALYs 2,778 2,357 2,177 1,725 1,490 1,480
Life-years
3,541 3,285 3,390 2,193 2,096 2,310
Costs (million $)
Total Cost $364 $247 $109 $433 $318 $170
Medical Costs -$189 -$237 -$253 -$118 -$155 -$178
Vaccine Costs $689 $570 $403 $635 $526 $372
Work Loss -$136 -$86 -$41 -$84 -$52 -$25
Cost Ratios ($)
Cost/QALY 131,028 104,656 50,122 251,037 213,705 114,909
Cost/Life -year 102,804 75,085 32,186 197,417 151,924 73,619
4520 Y ear Waning, No Herd Effects (Adding)
PCV21 at Age
50 and 65PCV21 at Age
55 and 70PCV21 at Age
60 and 75PCV20 at Age
50 and 65PCV20 at Age
55 and 70PCV20 at Age
60 and 75
IPD Cases -1,389 -1,382 -1,278 -860 -818 -699
Hospitalized Pneumonia Cases -1,931 -3,780 -5,748 -1,209 -2,749 -4,499
Non -hospitalized Pneumonia Cases -8,476 -9,491 -10,120 -5,305 -6,258 -7,363
Deaths due to IPD -148 -173 -212 -91 -100 -113
Deaths due to Pneumonia -53 -145 -256 -33 -109 -204
QALYs 2,928 2,422 1,958 1,817 1,526 1,305
Life-years
3,761 3,394 3,046 2,328 2,150 2,028
Costs (million $)
Total Cost $344 $247 $133 $421 $319 $188
Medical Costs -$205 -$235 -$230 -$127 -$154 -$161
Vaccine Costs $689 $570 $403 $635 $526 $372
Work Loss -$140 -$87 -$39 -$87 -$53 -$23
Cost Ratios ($)
Cost/QALY 117,514 102,083 68,174 231,438 208,701 144,205
Cost/Life -year 91,491 72,848 43,822 180,616 148,188 92,771