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Vaccines for the 21st Century: A Tool for Decisionmaking (2000)

Chapter: Appendix 26: Streptococcus pneumoniae

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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

APPENDIX 26
Streptococcus pneumoniae

DISEASE BURDEN

Epidemiology

For the purposes of the calculations in this report, the committee estimated that there are approximately 6.4 million cases of Streptococcus pneumoniae in children 4 years of age and under each year in the United States. An additional 1 million cases were assumed to occur in people between the ages of 5 and 64 years of age and 400,000 cases in people 65 years of age and older. The number of deaths in those 3 age groups were estimated to be 1,450, 16,000, and 30,000, respectively. See Table A26–1.

Disease Scenarios

For the purposes of the calculation in this report, the committee assumed that S. pneumoniae disease manifests as bacteremia and sepsis, pneumonia, otitis media/sinusitis/bronchitis, and meningitis. The percentage of cases in the 3 age groups who experience these disease states can be found in Table A26–2. The health utility index (HUI) associated with these various scenarios ranges from .9 for sinusitis (10 days duration) to .16 for hospitalization for severe bacteremia and sepsis and .6 for neurologic sequelae of meningitis (lasting for the lifetime).

Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

Table A26–1 Incidence of Streptococcus pneumoniae for Age Groups <5, 5–64, and >65

Age Groups

Population

Incidence rates (per 100,000)

% Distribution of Cases

Cases

LESS THAN 5 YEARS

 

<1

3,963,000

18,167.74

0.1128

719,987

1–4

16,219,000

34,905.47

0.8872

5,661,319

Total

 

2,422.35

1.0000

6,381,306

5–64 YEARS

 

5–14

38,056,000

467.19

0.1676

177,796

15–24

36,263,000

467.19

0.1597

169,419

25–34

41,670,000

467.19

0.1835

194,680

35–44

42,149,000

467.19

0.1856

196,918

45–54

30,224,000

467.19

0.1331

141,205

55–64

21,241,000

852.19

0.1706

181,015

Total

 

402.77

1.0000

1,061,032

GREATER THAN 65 YEARS

 

65–74

18,964,000

 

1,182.19

224,191

75–84

11,088,000

1,182.19

 

131,082

85+

3,598,000

1,182.19

 

42,535

Total

 

151.01

 

397,808

COST INCURRED BY DISEASE

Table A26–3 summarizes the health care costs incurred by S. pneumoniae infections. For the purposes of the calculations in this report, it was assumed that general patterns of health care are the same for each age group in a scenario. Outpatient care for bacteremia/sepsis and for pneumonia was assumed to involve two physician visits, prescription medication, and an inexpensive diagnostic test. Hospitalization costs are also assumed in be incurred for some patients. For more severe cases (e.g., those requiring hospitalization), specialist physicians are included instead of generalists, who would be utilized for less severe infections.

Milder manifestations of S. pneumoniae (e.g., otitis media in children under 5 years of age and sinusitis/bronchitis in people over 5 years of age) were assumed to be associated with costs for general physician visits, prescription mediation, and (in half the cases) a diagnostic procedure (culture).

Acute treatment of meningitis was assumed to require hospitalization, specialist physicians, and expensive diagnostic procedures. It was assumed that a small percentage of patients with meningitis experience lifelong neurologic sequelae requiring multiple visits to a specialist and some sort of physical or other rehabilitative therapies for the disability.

Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

Table A26–2 Disease Scenarios for Streptococcus pneumoniae Infection

 

No. of Cases

% of Cases

Committee HUI Values

Duration (years)

<5 YEARS OF AGE

 

Total Deaths (from acute infection)

1,450

 

Total Cases

6,381,306

 

BACTEREMIA/SEPSIS

6,216

0.10%

 

Bacteremia/Sepsis

1,243

0.02%

 

outpatient care only

 

0.93

0.0274 (10 days)

ICU

 

0.16

0.0055 (2 days)

inpatient after ICU

 

0.46

0.0137 (5 days)

Bacteremia/Sepsis—inpatient (no ICU)

3,730

0.06%

0.71

0.0110 (4 days)

Bacteremia/Sepsis—inpatient; complications

1,243

0.02%

0.59

0.0137 (5 days)

PNEUMONIA

62,161

0.97%

 

Pneumonia—outpatient care only

6,216

0.10%

0.82

0.0274 (10 days)

Pneumonia

55,944

0.88%

 

inpatient

 

0.71

0.0137 (5 days)

outpatient after inpatient

 

0.81

0.0137 (5 days)

Pneumonia with emphysema

932

0.01%

 

inpatient

 

0.64

0.0384 (14 days)

outpatient after inpatient

 

0.82

0.0384 (14 days)

OTHER RESPIRATORY

6,312,729

98.93%

 

Otitis Media

 

0.74

0.0110 (4 days)

Sinusitis, bronchitis

 

0.90

0.0274 (10 days)

MENINGITIS

200

0.0031%

 

Meningitis

160

0.003%

 

ICU

 

0.24

0.0055 (2 days)

inpatient after ICU

 

0.28

0.0274 (10 days)

Meningitis—inpatient (no ICU)

40

0.001%

0.39

0.0137 (5 days)

Meningitis—inpatient acute complications

30

0.0005%

0.27

0.0384 (14 days)

Meningitis—neurologic sequelae

60

0.001%

0.60

26.6824 (quality-adjusted life expectancy); 73.4869 (unadjusted life expectancy)

5–64 YEARS OF AGE

 

Total Deaths (from acute infection)

15,584

 

Total Cases

1,061,032

 

BACTEREMIA/SEPSIS

17,915

1.6884%

 

Bacteremia/Sepsis—outpatient care only

3,583

0.34%

0.93

0.0274 (10 days)

Bacteremia/Sepsis

3,583

0.34%

 

ICU

 

0.16

0.0055 (2 days)

inpatient after ICU

 

0.46

0.0137 (5 days)

Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

 

No. of Cases

% of Cases

Committee HUI Values

Duration (years)

Bacteremia/Sepsis—inpatient (no ICU)

10,749

1.01%

0.71

0.0110 (4 days)

Bacteremia/Sepsis—inpatient, complications

3,583

0.34%

0.59

0.0137 (5 days)

PNEUMONIA

179,145

16.8840%

 

Pneumonia—outpatient care only

71,658

6.75%

0.82

0.0274 (10 days)

Pneumonia

107,487

10.13%

 

inpatient

 

0.71

0.0137 (5 days)

outpatient after inpatient

 

0.81

0.0137 (5 days)

Pneumonia with emphysema

2,687

0.25%

 

inpatient

 

0.64

0.0384 (14 days)

outpatient after inpatient

 

0.82

0.0384 (14 days)

OTHER RESPIRATORY

861,667

81.2103%

 

Sinusitis, bronchitis

 

0.90

0.0274 (10 days)

MENINGITIS

2,306

0.2173%

 

Meningitis

1,845

0.17%

 

ICU

 

0.24

0.0055 (2 days)

inpatient after ICU

 

0.28

0.0274 (10 days)

Meningitis—inpatient (no ICU)

461

0.04%

0.39

0.0137 (5 days)

Meningitis—inpatient, acute complications

346

0.03%

0.27

0.0384 (14 days)

Meningitis—neurologic sequelae

692

0.07%

0.60

19.8289 (quality adjusted life expectancy at onset); 43.3814 (unadjusted life expectancy at onset)

65 YEARS AND OLDER

 

Total Deaths (from acute infection)

29,592

 

Total Cases

397,808

 

BACTEREMIA/SEPSIS

23,555

5.92%

 

Bacteremia/Sepsis

4,711

1.18%

 

outpatient care only

 

0.93

0.0274 (10 days)

ICU

 

0.16

0.0055 (2 days)

inpatient after ICU

 

0.46

0.0137 (5 days)

Bacteremia/Sepsis

14,133

3.55%

 

inpatient (no ICU)

 

0.71

0.0110 (4 days)

Bacteremia/Sepsis—inpatient; complications

4,711

1.18%

0.59

0.0137 (5 days)

PNEUMONIA

235,550

59.21%

 

Pneumonia—outpatient care only

141,330

35.53%

0.82

0.0274 (10 days)

Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

 

No. of Cases

% of Cases

Committee HUI Values

Duration (years)

Pneumonia

94,220

23.68%

 

inpatient

 

0.71

0.0137 (5 days)

outpatient after inpatient

 

0.81

0.0137 (5 days)

Pneumonia with emphysema

3,533

0.89%

 

inpatient

 

0.64

0.0384 (14 days)

outpatient after inpatient

 

0.82

0.0384 (14 days)

OTHER RESPIRATORY

138,333

34.77%

 

Sinusitis, bronchitis

 

0.90

0.0274 (10 days)

MENINGITIS

370

0.09%

 

Meningitis

296

0.07%

 

ICU

 

0.24

0.0055 (2 days)

inpatient after ICU

 

0.28

0.0274 (10 days)

Meningitis—inpatient (no ICU)

74

0.02%

0.39

0.0137 (5 days)

Meningitis—inpatient, acute complications

56

0.01%

0.27

0.0384 (14 days)

Meningitis—neurologic sequelae

111

0.03%

0.60

6.9071 (remaining quality adjusted life expectancy); 11.2664 (unadjusted life expectancy at onset)

VACCINE DEVELOPMENT

The committee assumed that it will take 3 years until licensure of an S. pneumoniae vaccine and that $240 million needs to be invested. Table 4–1 summarizes vaccine development assumptions for all vaccines considered in this report.

VACCINE PROGRAM CONSIDERATIONS

Target Population

For the purposes of the calculations in this report, it is assumed that the target population for this vaccine is the annual birth cohort and people 65 years of age. It was assumed that utilization would be 90% and 60% respectively.

Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

Table A26–3 Health Care Costs Associated with Streptococcus pneumoniae Infection

 

Cost per Case

Cost per Unit

Units per Case

Form of Treatment

<5 YEARS OF AGE

 

Bacteremia/Sepsis

 

outpatient care only

$100

$50

2.0

physician a

 

$50

$50

1.0

medication b

$50

$50

1.0

diagnostic a

ICU and post-phase

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$100

$100

1.0

diagnostic b

inpatient (no ICU)

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$100

$100

1.0

diagnostic b

inpatient; complications

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$500

$500

1.0

diagnostic c

Pneumonia

 

outpatient care only

$100

$50

2.0

physician a

 

$50

$50

1.0

diagnostic a

$50

$50

1.0

medication b

inpatient

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$100

$100

1.0

diagnostic b

outpatient after inpatient

$100

$50

2.0

physician a

 

$50

$50

1.0

medication b

$50

$50

1.0

diagnostics

Other Respiratory

 

otitis media

$50

$50

1.0

physician visits

 

$50

$50

1.0

medication b

$50

$50

1.0

diagnostic a

Meningitis

 

ICU and non-ICU

$7,000

$7,000

1.0

hospitalization

combine meningitis for costs

$450

$150

3.0

physician b

 

$50

$50

1.0

medication b

$100

$100

1.0

diagnostic b

$500

$500

1.0

diagnostic c

inpatient, acute complications

$7,000

$7,000

1.0

hospitalization

 

$900

$150

6.0

physician b

$50

$50

1.0

medication b

$100

$100

1.0

diagnostic b

$500

$500

1.0

diagnostic c

Meningitis: sequelae

 

lifelong annual costs

$600

$100

6.0

physician b

 

$300

$50

6.0

physical therapy, other services

Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

 

Cost per Case

Cost per Unit

Units per Case

Form of Treatment

5–64 YEARS OF AGE

 

Bacteremia/Sepsis

 

outpatient care only

$100

$50

2.0

physician visits

 

$50

$50

1.0

medication b

$50

$50

1.0

diagnostic a

ICU and post- phase

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$100

$100

1.0

diagnostic b

inpatient (no ICU)

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$100

$100

1.0

diagnostic b

inpatient; complications

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$500

$500

1.0

diagnostic c

Pneumonia

 

outpatient care only

$200

$100

2.0

physician b

 

$100

$50

2.0

diagnostic a

$50

$50

1.0

medication b

Pneumonia with and without emphysema

 

inpatient

$4,000

$4,000

1.0

hospitalization

 

$450

$150

3.0

physician c

$100

$100

1.0

diagnostic b

$50

$50

1.0

medication b

outpatient after inpatient

$100

$50

2.0

physician visits

 

$50

$50

1.0

medication b

sinusitis, bronchitis

 

 

$100

$50

2.0

physician a

$50

$50

1.0

medication b

$50

$50

1.0

diagnostic b

Meningitis

 

ICU, post-ICU, and non-ICU

$7,000

$7,000

1.0

hospitalization

 

$450

$150

3.0

physician c

$50

$50

1.0

medication b

$100

$100

1.0

diagnostic b

$500

$500

1.0

diagnostic c

Meningitis: sequelae

 

cost per year for life

$300

$50

6.0

physical therapy

 

$600

$100

6.0

physician b

>65 YEARS OF AGE+

 

Bacteremia/Sepsis

 

outpatient care only

$100

$50

2.0

physician a

 

$50

$50

1.0

medication b

$50

$50

1.0

diagnostic a

ICU and post ICU phase: inpatient

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$100

$100

1.0

diagnostic b

Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

 

Cost per Case

Cost per Unit

Units per Case

Form of Treatment

inpatient (no ICU)

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$100

$100

1.0

diagnostic b

inpatient; complications

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$500

$500

1.0

diagnostic c

Pneumonia

 

outpatient care only

$100

$50

2.0

physician a

 

$50

$50

1.0

medication b

$50

$50

1.0

diagnostic a

inpatient

$4,000

$4,000

1.0

hospitalization

 

$300

$100

3.0

physician b

$100

$100

1.0

diagnostic b

outpatient after inpatient

$100

$50

2.0

physician a

 

$50

$50

1.0

medication b

$50

$50

1.0

diagnostic a

Sinusitis, bronchitis

 

 

$100

$50

2.0

physician a

$50

$50

1.0

medication b

$50

$50

1.0

diagnostic b

Meningitis

 

all meningitis combined

$7,000

$7,000

1.0

hospitalization

% cases now corrected

$450

$150

3.0

physician c

 

$50

$50

1.0

medication b

$100

$100

1.0

diagnostic b

$500

$500

1.0

diagnostic c

annual costs for life

$300

$50

6.0

physical therapy

Vaccine Schedule, Efficacy, and Costs

For the purposes of the calculations in this report, it was estimated that this vaccine would cost $50 per dose and that administration costs would be $10 per dose. Default assumptions of a 3-dose series and 75% effectiveness were accepted. Table 4–1 summarizes vaccine program assumptions for all vaccines considered in this report.

RESULTS

If a vaccine program for S. pneumoniae were implemented today and the vaccine were 100% efficacious and utilized by 100% of the target population, the annualized present value of the QALYs gained would be 265,000. Using committee assumptions of less-than-ideal efficacy and utilization and including time and monetary costs until a vaccine program is implemented, the annualized present value of the QALYs gained would be 120,000.

Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

Although the number of cases of disease are much higher in children under 5 years of age, the largest number of lost QALYs are associated with disease in people 65 years of age and older. This discrepancy is caused by the much higher mortality rate and more severe morbidity in the older individuals compared to younger people.

If a vaccine program for S. pneumoniae were implemented today and the vaccine was 100% efficacious and utilized by 100% of the target population, the annualized present value of the health care costs saved would be $1.6 billion. Using committee assumptions of less-than-ideal efficacy and utilization and including time and monetary costs until a vaccine program is implemented, the annualized present value of the health care costs saved would be $815 million.

If a vaccine program for S. pneumoniae were implemented today and the vaccine was 100% efficacious and utilized by 100% of the target population, the annualized present value of the program cost would be $1.1 billion. Using committee assumptions of less-than-ideal efficacy and utilization and including time and monetary costs until a vaccine program is implemented, the annualized present value of the program cost would be $675 million.

Using committee assumptions of time and costs until licensure, the fixed cost of vaccine development has been amortized and is $7.2 million for a S. pneumoniae vaccine.

If a vaccine program were implemented today and the vaccine was 100% efficacious and utilized by 100% of the target population, the annualized present value of the cost per QALY gained is -$2,000. A negative value represents a saving in costs in addition to a saving in QALYs. Using committee assumptions of less-than-ideal utilization and including time and monetary costs until a vaccine program is implemented, the annualized present value of the cost per QALY gained is $1,000.

See Chapters 4 and 5 for details on the methods and assumptions used by the committee for the results reported.

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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
×

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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Suggested Citation:"Appendix 26: Streptococcus pneumoniae." Institute of Medicine. 2000. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: The National Academies Press. doi: 10.17226/5501.
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Page 322
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Vaccines have made it possible to eradicate the scourge of smallpox, promise the same for polio, and have profoundly reduced the threat posed by other diseases such as whooping cough, measles, and meningitis.

What is next? There are many pathogens, autoimmune diseases, and cancers that may be promising targets for vaccine research and development.

This volume provides an analytic framework and quantitative model for evaluating disease conditions that can be applied by those setting priorities for vaccine development over the coming decades. The committee describes an approach for comparing potential new vaccines based on their impact on morbidity and mortality and on the costs of both health care and vaccine development. The book examines:

  • Lessons to be learned from the polio experience.
  • Scientific advances that set the stage for new vaccines.
  • Factors that affect how vaccines are used in the population.
  • Value judgments and ethical questions raised by comparison of health needs and benefits.

The committee provides a way to compare different forms of illness and set vaccine priorities without assigning a monetary value to lives. Their recommendations will be important to anyone involved in science policy and public health planning: policymakers, regulators, health care providers, vaccine manufacturers, and researchers.

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