Cost-Effectiveness of Conjugate Meningococcal Vaccination Strategies in the United States

Abstract

Shepard CW, Ortega-Sanchez IR, Scott RD, Rosenstein NE, and the ABCs Team. Pediatrics 2005;115:1220-32 Context The US Food and Drug Administration approved a meningococcal conjugate A/C/Y/W-135 vaccine (MCV-4) for use in persons 11 to 55 years of age in January, 2005; licensure for use in younger age groups is expected in 2 to 4 years. Objective To evaluate and compare the projected health and economic impact of MCV-4 vaccination of US adolescents, toddlers, and infants. Design Cost-effectiveness analysis from a societal perspective based on data from Active Bacterial Core Surveillance (ABCs) and other published and unpublished sources. Sensitivity analyses in which key input measures were varied over plausible ranges were performed. Participants A hypothetical 2003 US population cohort of children 11 years of age and a 2003 US birth cohort. Interventions: Hypothetical routine vaccination of adolescents (1 dose at 11 years of age), toddlers (1 dose at 1 year of age), and infants (3 doses at 2, 4, and 6 months of age). Each vaccination scenario was compared with a “no-vaccination” scenario. Main Outcome Measures Meningococcal cases and deaths prevented, cost per case prevented, cost per life-year saved, and cost per quality-adjusted life-year saved. Results Routine MCV-4 vaccination of US adolescents (11 years of age) would prevent 270 meningococcal cases and 36 deaths in the vaccinated cohort over 22 years, a decrease of 46% in the expected burden of disease. Before program costs are counted, adolescent vaccination would reduce direct disease costs by $18 million and decrease productivity losses by $50 million. At a cost per vaccination (average public-private price per dose plus administration fees) of $82.50, adolescent vaccination would cost society $633,000 per meningococcal case prevented and $121,000 per life-year saved. Key variables influencing results were disease incidence, case-fatality ratio, and cost per vaccination. The cost-effectiveness of toddler vaccination is essentially equivalent to adolescent vaccination, whereas infant vaccination would be much less cost-effective. Conclusions Routine MCV-4 vaccination of US children would reduce the burden of disease in vaccinated cohorts but at a relatively high net societal cost. The projected cost-effectiveness of adolescent vaccination approaches that of recently adopted childhood vaccines under conditions of above-average meningococcal disease incidence or at a lower cost per vaccination. Comment The peak incidence of meningococcal disease in the United States occurs during infancy, but the peak fatality rate from meningococcal disease falls during adolescence and young adulthood. The American Academy of Pediatrics and the Centers for Disease Control's (CDC) Advisory Committee on Immunization Practices have recommended that quadrivalent MCV-4 be administered to adolescents at routine visits for 11- to 12-year-olds, and at visits before high school entry and before living in college dormitories or entering the military for those not previously immunized. The authors, from the CDC, conducted a cost-effectiveness analysis from the societal perspective (accounting for both medical and nonmedical [ie, work loss] costs), comparing an adolescent MCV-4 immunization program with other program options targeted at infants and toddlers. They conclude from their mathematical models that the adolescent strategy is the most cost-effective of these options, at $121,000 per life-year saved. Such a program would cost almost $5 million per death averted, and would be expected to save 36 lives over the 22-year time horizon of their study. As the authors indicate, the cost-effectiveness ratio in excess of $100,000 per life-year saved compares unfavorably with ratios for other currently recommended childhood vaccines. For example, varicella vaccination and hepatitis B vaccination programs are cost-saving, and vaccination with 7-valent pneumococcal conjugate vaccine has been estimated to cost $80,000 per life-year saved. Nonetheless, the specter of meningococcal disease may spur providers, parents, and payers to invest in the protection that the MCV-4 vaccine offers, which is superior to that provided by the meningococcal polysaccharide vaccine that preceded it. In our increasingly cost-constrained healthcare environment, the eventual adoption rates of vaccines such as MCV-4—as well as others such as combined tetanus-diphtheria-acellular pertussis and human papillomavirus vaccines that are currently pending either licensure or review for possible recommendation—will likely depend on their economic costs and benefits, in addition to anticipated health effects and safety. Studies such as this will help multiple stakeholders weigh their options carefully.