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The findings and conclusions in this report are those of the authors and do not necessarily represent the official positon of the Centers for Disease Control and Prevention. Continued indirect effects provided by the childhood pneumococcal conjugate vaccine (13-valent pneumococcal conjugate vaccine [PCV13]) program in the United States have decreased disease in the adult population, reducing the potential direct effects of vaccinating older adults. We examined the incremental cost-effectiveness of continuing to recommend PCV13 in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) at age 65 compared to a strategy that only included a recommendation for PPSV23 at age 65. We used a probabilistic model following a cohort of 65 year olds in 2019. We used vaccination coverage and disease incidence estimates for healthy adults and adults with chronic medical conditions. We incorporated continued indirect effects from the childhood PCV13 program on adult disease incidence. In the base case scenario, continuing to recommend PCV13 at age 65 cost $561,682 per quality-adjusted life year (QALY) gained. In a scenario where PPSV23 provided modest protection against non-invasive pneumococcal pneumonia, costs increased to $2.3 million per QALY. These estimates are larger than our prior estimates for cost-effectiveness of this recommendation in the context of predicted indirect effects due to new data indicating PCV13 provided limited impact on serotype 3, the major cause of the remaining PCV13-type disease. Under our prior assumptions about PCV13 effectiveness against serotype 3 disease, the cost of continuing the recommendation is $207,607 per QALY. Indirect effects from the childhood PCV13 program have dramatically increased the cost per QALY of continuing to recommend PCV13 at age 65 after only a few years.

In June 2021, the Advisory Committee on Immunization Practices (ACIP) recommended use of either 20-valent pneumococcal conjugate vaccine (PCV20) alone or 15-valent pneumococcal conjugate vaccine (PCV15) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) for all PCV-unvaccinated adults aged ≥65 years (age-based) and for adults aged 19–64 years with conditions that increase the risk for pneumococcal disease (risk-based). This recommendation replaced a previous recommendation for PPSV23 with or without 13-valent pneumococcal conjugate vaccine (PCV13) for these groups. We conducted a cost-effectiveness analysis of age-based and risk-based use of either PCV15 in series with PPSV23 or PCV20 alone when compared to previous recommendations. We utilized probabilistic cohort models of all 65-year-olds (age-based) and 19-year-olds (risk-based through age 64 years and age-based at age 65 years). A spreadsheet-based Monte Carlo simulation software was used to estimate immunization costs, medical costs, non-medical costs, and overall disease burden under different vaccine strategies. The model tracked inpatient invasive pneumococcal disease (IPD) and non-bacteremic pneumonia (NBP) in inpatient and outpatient settings. One-way sensitivity analyses incorporated indirect effects of prospective pediatric vaccination with PCV15 and PCV20 on adult IPD and NBP incidence. Costs were reported in 2021 US dollars. All future costs and outcomes were discounted at 3 % per year. Age-based use of either PCV20 alone or PCV15 in series with PPSV23 at age 65 years were both shown to be cost-saving (improved health outcomes and saved costs). Combined cost-effectiveness of risk-based (19–64 years) plus age-based (65 years) (risk-and-age-based) use of PCV20 alone was cost-saving, whereas use of PCV15 in series with PPSV23 increased quality-adjusted life years (QALYs) but cost $412,111 (95 % CI: 270,295, 694,869) per QALY gained. In U.S. adults, replacing the previous recommendations with PCV20 alone or PCV15 in series with PPSV23 improved health outcomes. Except for risk-and-age-based use of PCV15 in series with PPSV23 that resulted in increased cost per QALY gained, the interventions also reduced costs.

Although use of the 13-valent pneumococcal conjugate vaccine (PCV13) among children has reduced incidence of pneumococcal disease, a considerable burden of disease remains. PCV15 is a new vaccine that contains pneumococcal serotypes 22F and 33F in addition to serotypes contained in PCV13. To inform deliberations by the Advisory Committee on Immunization Practices on recommendations for PCV15 use among U.S. children, we estimated the health impact and cost-effectiveness of replacing PCV13 with PCV15 within the routine infant immunization program in the United States. We also assessed the impact and cost-effectiveness of a supplementary PCV15 dose among children aged 2–5 years who have already received a full PCV13 series. We estimated the incremental number of pneumococcal disease events and deaths averted, costs per quality adjusted life-year (QALY) gained, and costs per life-year gained under different vaccination strategies using a probabilistic model following a single birth cohort of 3.9 million individuals (based on 2020 U.S. birth cohort). We assumed that vaccine effectiveness (VE) of PCV15 against the two additional serotypes was the same as the VE of PCV13. The cost of PCV15 use among children was informed from costs of PCV15 use among adults and from discussions with the manufacturer. Our base case results found that replacing PCV13 with PCV15 prevented 92,290 additional pneumococcal disease events and 22 associated deaths, while also saving $147 million in costs. A supplementary PCV15 dose among children aged 2–5 years who were fully vaccinated with PCV13 prevented further pneumococcal disease events and associated deaths but at a cost of more than $2.5 million per QALY gained. A further decrease in pneumococcal disease in conjunction with considerable societal cost savings could be expected from replacing PCV13 with PCV15 within the routine infant immunization program in the United States.

Introduction We aim to assess HPV vaccine administration among privately insured populations before and during the COVID‐19 pandemic in the United States and stratify the assessments by demographic and geographic characteristics. Methods Using the Merative MarketScan Commercial Claims and Encounters Database, we estimated monthly and yearly HPV vaccine administration among people aged 9–26 from 2019 to 2022, measured as the proportion of the enrolled population who received ≥ 1 dose of HPV vaccine during that month or year, and their relative percent change from 2020 to 2022, compared to the same period in 2019, overall and stratified by age group, sex, and urbanicity. Results HPV vaccine administration in 2020, 2021, and 2022 was lower than in 2019 and continued to decline for all age groups. The relative percent change in rate in 2022 relative to 2019 was −6.0% among children, −38.3% among adolescents, and −42.5% among young adults. The patterns were similar across subgroups, with certain disparities in magnitude. By subpopulations, the highest percent declines in 2022 relative to 2019 in each age group were observed among children in rural areas (−13.5%), male adolescents (−39.8%), and young adults in rural areas (−46.0%). Conclusion During the COVID‐19 pandemic, HPV vaccine administration dropped substantially and had not exceeded the pre‐pandemic levels by the end of 2022, with larger declines seen among male adolescents and young adults in rural areas. Our results highlight the need for continuing monitoring and targeted intervention strategies to improve HPV vaccine administration.

In the United States, persons ≥11 years are recommended to receive one dose of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine, followed by decennial tetanus- and diphtheria-toxoid (Td) boosters. Many providers use Tdap instead of Td. We evaluated epidemiologic and economic impacts of replacing Td boosters with Tdap. We used a static cohort model to examine replacing Td with Tdap over the lifetime of 4,386,854 adults ≥21 years. Because pertussis is underdiagnosed and true incidence is unknown, we varied incidence from 2.5 cases/100,000 person-years to 500 cases/100,000 person-years. We calculated vaccine and medical costs from claims data. We estimated cost per case prevented and per quality-adjusted life year (QALY) saved; sensitivity analyses were conducted on vaccine effectiveness (VE), protection duration, vaccine cost, disease duration, hospitalization rates, productivity loss and missed work. We did not include programmatic advantages resulting from use of a single tetanus-toxoid containing vaccine. At lowest incidence estimates, administering Tdap resulted in high costs per averted case ($111,540) and QALY saved ($8,972,848). As incidence increased, cases averted increased and cost per QALY saved decreased rapidly. With incidence estimates of 250 cases/100,000 person-years, cost per averted case and QALY saved were $984 and $81,678 respectively; at 500 cases/100,000 person-years, these values were $427 and $35,474. In multivariate sensitivity analyses, assuming 250 cases/100,000 person-years, estimated cost per QALY saved ranged from $971 (most favorable) to $217,370 (least favorable). Our findings suggest that replacing Td with Tdap for the decennial booster would result in high cost per QALY saved based on reported cases. However, programmatic considerations were not accounted for, and if pertussis incidence, which is incompletely measured, is assumed to be higher than reported through national surveillance, substituting Tdap for Td may lead to moderate decreases in pertussis cases and cost per QALY.

Public health department (PHD) led COVID-19 vaccination clinics can be a critical component of pandemic response as they facilitate high volume of vaccination. However, few patient-time analyses examining patient throughput at mass vaccination clinics with unique COVID-19 vaccination challenges have been published. During April and May of 2021, 521 patients in 23 COVID-19 vaccination sites counties of 6 states were followed to measure the time spent from entry to vaccination. The total time was summarized and tabulated by clinic characteristics. A multivariate linear regression analysis was conducted to evaluate the association between vaccination clinic settings and patient waiting times in the clinic. The average time a patient spent in the clinic from entry to vaccination was 9 min 5 s (range: 02:00–23:39). Longer patient flow times were observed in clinics with higher numbers of doses administered, 6 or fewer vaccinators, walk-in patients accepted, dedicated services for people with disabilities, and drive-through clinics. The multivariate linear regression showed that longer patient waiting times were significantly associated with the number of vaccine doses administered, dedicated services for people with disabilities, the availability of more than one brand of vaccine, and rurality. Given the standardized procedures outlined by immunization guidelines, reducing the wait time is critical in lowering the patient flow time by relieving the bottleneck effect in the clinic. Our study suggests enhancing the efficiency of PHD-led vaccination clinics by preparing vaccinators to provide vaccines with proper and timely support such as training or delivering necessary supplies and paperwork to the vaccinators. In addition, patient wait time can be spent answering questions about vaccination or reviewing educational materials on other public health services.

Infants younger than 6 months are at increased risk of complications and mortality from pertussis infection. In October 2012, the Advisory Committee on Immunization Practices revised its recommendation to include a Tdap dose during each pregnancy, ideally between 27 and 36 weeks gestation. Assess trends in Tdap vaccination coverage among privately insured pregnant women from 2009 to 2016 including timing of Tdap vaccination (before, during, or after pregnancy), trimester of vaccination for women vaccinated during pregnancy, and missed vaccination opportunities for unvaccinated women. Identify factors associated with vaccination during the optimal period of 27–36 weeks gestation. Retrospective analysis of privately insured women 15–49 years who delivered live births during 2009–2016 conducted using 2009–2016 MarketScan data. Tdap vaccination coverage and the timing of Tdap vaccine administration were assessed for women continuously enrolled from 6 months before pregnancy to 1 month after delivery. Multivariable logistic regression was performed to identify factors independently associated with receipt of Tdap vaccine at 27–36 weeks gestation. Tdap vaccination coverage during pregnancy increased from 0.4% in 2009 to 6.2% in 2012 and to 53.2% in 2016. The proportion of vaccinated women receiving Tdap at 27–36 weeks gestation increased from <10% in 2009 to nearly 90% in 2016, with most vaccination occurring at 27–32 weeks gestation. Women of older age, residing in a metropolitan statistical area, residing outside the South, and having a capitated health insurance plan were more likely to receive Tdap at 27–36 weeks gestation than their counterparts. Among women not vaccinated during pregnancy, 77.7% had a pregnancy-related medical claim between 27 and 36 weeks gestation. Tdap vaccination coverage during pregnancy increased significantly from 2009 to 2016, with the greatest increase occurring after the revised Advisory Committee on Immunization Practices recommendation. Most women who did not receive Tdap vaccine had a missed vaccination opportunity during pregnancy, indicating potential for much higher vaccination coverage and consequent infant protection against pertussis.

•A modest impact on burden of pertussis is expected by adding a second Tdap dose.•A second Tdap given at age 16 or 21 years had high dollar per QALY saved.•Under-reporting of pertussis incidence most influenced the model.•Similar limited impact of a second Tdap is expected with other target groups. The United States experienced a substantial increase in reported pertussis cases over the last decade. Since 2005, persons 11 years and older have been routinely recommended to receive a single dose of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine. The objective of this analysis was to evaluate the potential impact and cost-effectiveness of recommending a second dose of Tdap. A static cohort model was used to calculate the epidemiologic and economic impact of adding a second dose of Tdap at age 16 or 21 years. Projected costs and outcomes were examined from a societal perspective over a 20-year period. Quality-adjusted Life Years (QALY) saved were calculated. Using baseline pertussis incidence from the National Notifiable Diseases Surveillance System, Tdap revaccination at either age 16 or 21 years would reduce outpatient visits by 433 (5%) and 285 (4%), and hospitalization cases by 7 (7%) and 5 (5%), respectively. The costs per QALY saved with a second dose of Tdap were approximately US $19.7 million (16 years) and $26.2 million (21 years). In sensitivity analyses, incidence most influenced the model; as incidence increased, the costs per QALY decreased. To a lesser degree, initial vaccine effectiveness and waning of effectiveness also affected cost outcomes. Multivariate sensitivity analyses showed that under a set of optimistic assumptions, the cost per QALY saved would be approximately $163,361 (16 years) and $204,556 (21 years). A second dose of Tdap resulted in a slight decrease in the number of cases and other outcomes, and that trend is more apparent when revaccinating at age 16 years than at age 21 years. Both revaccination strategies had high dollar per QALY saved even under optimistic assumptions in a multivariate sensitivity analysis.

In June 2024, the Advisory Committee on Immunization Practices recommended 21-valent pneumococcal conjugate vaccine (PCV21) as an alternative to 15-valent or 20-valent PCV (PCV15 or PCV20) for all PCV-unvaccinated adults aged ≥65 years (age-based) and for adults aged 19–64 years with conditions that increase the risk for pneumococcal disease (risk-based). PCV21 is effective against a different set of serotypes than PCV20. We conducted a cost-effectiveness analysis of age-based and risk-based use of PCV21 compared with PCV20 among adults in the US. We utilized probabilistic cohort models of all 65-year-olds (age-based) and 42-year-olds (risk-based through age 64 years and age-based at age 65 years). Monte Carlo simulation was used to estimate immunization costs, medical costs, non-medical costs, and overall disease burden under different vaccine strategies. The model tracked inpatient invasive pneumococcal disease (IPD) and non-bacteremic pneumococcal pneumonia (NBP) in inpatient and outpatient settings. Since PCV21 does not contain serotype 4 (ST4), we examined the sensitivity of our model to ST4 prevalence. Costs were reported in 2023 US dollars. All future costs and outcomes were discounted at 3 % per year. Age-based use of PCV21 costs $4132 (95 % confidence interval [CI]: cost-saving, $18,599) per quality-adjusted life year (QALY) gained. Risk-based use of PCV21 was cost-saving (95 % CI: cost-saving, cost-saving). Age-based use of PCV21 was dominated (had lower QALYs and higher costs) compared with PCV20 when ST4 caused >30 % of pneumococcal disease. Similarly, risk-based use of PCV21 was dominated when ST4 caused >35 % of pneumococcal disease. Among US adults, replacing the previous recommendation of PCV20 with PCV21 improved health outcomes, incurred modest costs at age 65, and decreased costs for risk-based recommendations. In areas where ST4 comprises a high percentage of pneumococcal disease, however, PCV20 is expected to prevent more disease and reduce costs compared to PCV21.

AbstractBackgroundVaccination implementation challenges can lead to lower uptake, reducing health and economic benefits from vaccines. Healthcare provider confidence in receiving timely reimbursement for vaccination is one such potential challenge for newly recommended vaccines. This study investigates the time interval between pneumococcal vaccination and reimbursement. MethodsWe used 2021–2022 Merative™ MarketScan® Commercial Database and Medicare Database (MarketScan) data among those aged 19–64 and ≥65 years for two vaccines: the 13-valent pneumococcal conjugate vaccine (PCV13), recommended in 2012; and the newer 20-valent PCV (PCV20), recommended in 2021. We characterized vaccination claims, patient demographics, and time intervals between vaccination and reimbursement. ResultsDuring the study period, MarketScan® contained 24,508 PCV13 and 53,194 PCV20 outpatient vaccination claims for individuals aged 19–64 years and 14,693 PCV13 and 18,277 PCV20 claims for those aged ≥65 years. Among those aged 19–64 years, mean reimbursement interval of outpatient claims was 25.3 (PCV13) and 26.8 (PCV20) days. Among those aged ≥65 years, mean interval was longer, particularly for PCV20, with 31.5 (PCV13) and 41.3 days (PCV20). Outpatient claims reimbursement intervals were longer in non-metropolitan compared to metropolitan areas. Pharmacy claims had shorter intervals than outpatient claims, across both vaccines and age groups. PCV13 intervals were similar throughout the observation period, while PCV20 intervals were longer immediately following the updated ACIP recommendation and declined over time. Approximately 10 % of outpatient claims had intervals greater than 30 days among those aged 19–64 years and greater than 60 days for those aged ≥65 years. ConclusionDuring the 5 months following the ACIP recommendation, claims for the newer vaccine (PCV20) took longer to reimburse, but the interval stabilized after about 6 months to a length comparable to PCV13. Claims from outpatient settings and non-metropolitan areas took longer to reimburse, with some claims still experiencing longer intervals several months post-recommendation.