Cost effectiveness sensitivity
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Contents
 1 Question
 2 Answer
 3 Rationale
 4 A.Vaccine effects on IPD, QALYs and costs by age group for alternative scenarios
 5 B. Vaccine effects on IPD, QALYs and costs for alternative scenarios, summary
 6 C. Acceptable price level under alternative scenarios for PCV13 when price of PCV10 set at 20 and 30
 7 See also
Question
The effects of alternative vaccine compositions on the outcomes of the costeffectiveness analysis were assessed. Results are reported for PCV10 with modified effects for serotypes 19A and 6A and for PCV13 with modified effects for serotypes 3 and 6C.
Answer
Conclusion: The assumption about serotype 3 in PCV13 is crucial. In addition, assumptions about the role of 6A in PCV10 is important.
If serotype 3 is not included as a vaccine type in PCV13, then the differences between PCV10 and PCV13 in IPD, quality adjusted life years gained and medical costs are small (see Tables 17 in Section A below). Considering the magnitudes of these differences in view of the intrinsic uncertainties in the model, PCV10 and PCV13 can be regarded as equally effective.
Rationale
Costeffectiveness sensitivity analysis results are divided into sections A,B and C.
A.Vaccine effects on IPD, QALYs and costs by age group for alternative scenarios
Quantities tabulated:
IPD = number of IPD cases per year in Finland IPD decrease = decrease in IPD due to the first mentioned vaccine QALYs lost = QALYs lost due to IPD per year in Finland, in years (QALYs related to IPD only) QALY = quality adjusted life year QALYs gained = QALYs gained due to the first mentioned vaccine Medical costs = Medical costs due to IPD per year in Finland in 1000 euros (costs related to IPD only) Medical savings = Difference in medical costs in 1000 euros per year in favor of the first mentioned vaccine
Vaccine formulation considered:
PCV10 includes the 10 serotypes in PCV10 and direct effects for serotypes 6A and 19A PCV10(6Af) includes the 10 serotypes in PCV10 amended by serotype 6A and direct effects (##) for 19A PCV13 includes 12 serotypes in PCV13, serotype 3 excluded. Assumes direct effects for serotypes 3 and 6C. PCV13(6Cf) includes 12 serotypes in PCV13, serotype 3 excluded and 6C added. Assumes direct effects for serotypes 3.
Results:
* 1.No Vaccination  age group 0 4 5 19 20 44 44 64 65 100 Total       IPD 330 26 124 236 302 1017 QALYs lost 156 12 284 605 558 1615 Medical costs (#) 918 70 1279 2431 2146 6843
* 2.PCV10 vs "No Vaccination"  age group 0 4 5 19 20 44 44 64 65 100 Total       IPD decrease 225 15 49 30 45 362 QALYs gained 105 7 102 76 86 376 Medical savings(#) 608 37 504 306 320 1774
* 3.PCV13 vs "No Vaccination"  age group 0 4 5 19 20 44 44 64 65 100 Total       IPD decrease 246 15 43 16 47 366 QALYs gained 114 7 86 39 89 334 Medical savings 656 38 443 160 335 1631
* 4.PCV13 vs PCV10  age group 0 4 5 19 20 44 44 64 65 100 Total       IPD decrease 21 0 6 14 2 4 QALYs gained 9 0 16 37 3 42 Medical savings 48 1 61 146 15 143
* 5.PCV13(6Cf) vs PCV10  age group 0 4 5 19 20 44 45 64 65100 Total       IPD decrease 11 1 11 29 10 40 QALYs gained 4 1 29 76 21 123 Medical savings 17 2 116 299 74 474
* 6.PCV13 vs PCV10(6Af)  age group 0 4 5 19 20 44 45 64 65 100 Total       IPD decrease 31 2 1 6 14 54 QALYs gained 15 1 1 13 28 57 Medical savings 83 5 10 55 103 256
* 7.PCV13(6Cf) vs PCV10(6Af)  age group 0 4 5 19 20 44 45 64 65 100 Total       IPD decrease 21 1 4 9 2 10 QALYs gained 10 0 12 26 4 24 Medical savings 52 2 45 98 14 75
Interpretation:
Table 1 displays quantities when no vaccination is applied and Tables 23 display results for
the default scenarios PCV10 and PCV13. The vaccines decrease QALYs and medical costs
by approximately 2025%.
In comparison to these effets, the differences pertaining to pairwise comparisons of various
versions of the vaccines (Tables 47) are small. Negative numbers in Tables 47 indicate
situations favorable to PCV10.
(*)= In the calculations above, the original observed/predicted number of IPD cases among under 3 year old children is multiplied 3.75. This adjustment was made to better reflect the actual disease incidence (reference: Palmu et al. (2014) Vaccine effectiveness of the pneumococcal.., The Lancet Resp. Med.Vol2,9,p.717)
(#)= costs and savings are given in 1000 euros
(##)= a vaccine with "only direct effects" for a particular serotype means that, for vaccinated persons, vaccine efficacy against IPD caused by this serotype is 90% with a waning rate of 10% per year. In practise this means that approximately 70% of the serotypespecific IPD is eliminated among the <5 year olds. The implications of this modification to the results pertaining to the population as a whole are quite small and correspond closely to assuming no vaccine efficacy against the serotype in question.
B. Vaccine effects on IPD, QALYs and costs for alternative scenarios, summary
Quantities tabulated:
IPD decrease = decrease in IPD due to the vaccine appearing in the column label vs the vaccine appearing in the row QALYs gained = same for QALYS gained (QALYs related to IPD only) Medical savings = same for saving in medical costs (costs related to IPD only)
Vaccine formulations considered:
PCV10(a) vaccine including all of the 10 serotypes PCV10 includes the 10 serotypes in PCV10 and direct effects for serotypes 6A and 19A PCV10(6Af) includes the 10 serotypes in PCV10 amended by serotype 6A and direct effects (##) for 19A PCV13(a) vaccine including all of the 13 serotypes, including serotype 3 PCV13 includes 12 serotypes in PCV13, serotype 3 excluded. Assumes direct effects for serotypes 3 and 6C. PCV13(6Cf) includes 12 serotypes in PCV13, serotype 3 excluded and 6C added. Assumes direct effects for serotypes 3.
Results:
IPD decrease  PCV13(a) PCV13 PCV13(6Cf)    PCV10(a) 227 95 50 PCV10 137 4 40 PCV10(6Af) 187 54 10
QALYs gained  PCV13(a) PCV13 PCV13(6Cf)    PCV10(a) 305 5 79 PCV10 260 42 123 PCV10(6Af) 357 57 24
Medical costs saved (in 1000 euros)  PCV13(a) PCV13 PCV13(6Cf)    PCV10(a) 1294 125 215 PCV10 1035 143 474 PCV10(6Af) 1425 256 75
Interpretation:
These are summaries of Tables 47 in Section A now also
including "full" 10 and 13 valent versions of the vaccines.
The crucial effect of inclusion of serotype 3 in PCV13
is clear.
C. Acceptable price level under alternative scenarios for PCV13 when price of PCV10 set at 20 and 30
Quantities tabulated and vaccine formulations considered:
Column and row labels as in tables as in Section B. The entries
are prices acceptable for PCV13 when PCV10 price is 10 or 20.
Any price below the given value is acceptable for PCV13.
In addition, the incremental cost effectiveness ratio (ICER)is given. This is the ICER either when the more effective vaccine is compared to the other or when the less effective is compared to the "no vaccination" scenario. It corresponds to the average price of a QALY gain when either of the vaccines is chosen assuming the indicated price level.
Results:
Max price for PCV13 when price of PCV10 = 20  PCV13(a) PCV13 PCV13(6Cf) ICER(#)     PCV10(a) 38 21 16 6.27 PCV10 33 18 14 4.85 PCV10(6Af) 44 24 18 7.92
Max price for PCV13 when price of PCV10 = 30  PCV13(a) PCV13 PCV13(6Cf) ICER(#)     PCV10(a) 57 31 24 11.6 PCV10 50 27 21 9.63 PCV10(6Af) 66 36 27 14.3
Note:
(#)= in 1000 euros
These tables are calculated taking into account benefits related to IPD only. If other disease entities are taken into accoount, the vaccines may well be cost saving (in terms of total health care costs) and these tables are to be interpreted with caution. Nevertheless, they indicate that if serotype 3 is not included in PCV13, then the differences between the vaccines are much smaller and, depending on assumptions, may be in favor of either one of the vaccines.
See also