Cost-Effectiveness of Pneumococcal Vaccination among Patients Age 50 to 64 with CKD

Due to high morbidity and mortality risk, pneumococcal disease is a major public health concern. Vaccination against Streptococcus pneumoniae reduces the risk for pneumococcal disease by 30% to 50%, according to results of earlier studies. The vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention for all adults ≥65 years of age and for younger adults with clinical conditions such as diabetes, heart disease, lung disease, liver disease, and cancer.

Recommendations from the ACIP for adults with chronic kidney disease (CKD) call for pneumococcal vaccination in kidney failure and nephrotic syndrome. However, according to Junichi Ishigami , MD, MPH, and colleagues, patients with mild and moderate CKD are at increased risk for infection, including pneumonia and bloodstream infections, and may benefit from pneumococcal vaccination.

There are few data on the cost-effectiveness of pneumococcal vaccination in a population with mild to moderate CKD. The researchers recently conducted a cost-effectiveness analysis of pneumococcal vaccination targeted to patients with CKD in the United States. The analysis included an estimate of the prevalence of pneumococcal vaccination across CKD risk status and the number needed to vaccinate to prevent pneumococcal disease. The researchers sought to test the hypothesis that pneumococcal vaccination is cost-effective when targeted to patients with CKD, including adults <65 years of age in the United States. Results were reported in the American Journal of Kidney Diseases [2019;74(1):23-35].

Estimates of the prevalence of pneumococcal vaccination were made using data from the National Health and Nutrition Examination Survey (NHANES) in groups stratified by age: 50 to 64 years or 65 to 79 years. Based in the estimated prevalence of pneumococcal vaccination, the researchers estimated the incidence rate of pneumococcal disease among unvaccinated patients using the Monte-Carlo simulation. They then estimated the number needed to vaccinate for pneumococcal disease and performed cost-effectiveness analysis of pneumococcal vaccination targeted to adults with CKD.

The cost-effective analysis was structured according to the Second Panel on Cost Effectiveness in Health and Medicine. The researchers established a hypothetical cohort of 100,000 US adults with no history of pneumococcal vaccination for a vaccine group and for a nonvaccine group. The hypothetical vaccine group included individuals vaccinated at baseline and assumed to stay immunized for the first 10 years of the analysis time horizon.

Vaccination costs were calculated as vaccine costs plus administrative costs and estimated in the base case as $132 as of 2016, according to the CDC and the Centers for Medicare & Medicaid Services. Costs for medical care were derived from a study using data in the Medicare population and costs for hospitalization for pneumococcal disease were derived from the Healthcare Cost and Utilization Project. An incremental cost-effectiveness ratio (ICER) was measured at a willingness-to-pay threshold of US $100,000 per quality-adjusted life-year (QALY) gain.

In the NHANES 1999 to 2004 data, the proportion of patients with CKD, including kidney failure or nephrotic-range albuminuria, was higher in the group 65 to 79 years of age than among those 50 to 64 years of age (34% vs 14%). In the 50 to 64 years of age group, 41% had at least one clinical indication of pneumococcal vaccination. The most prevalent condition was lung disease (17%), followed by diabetes (12%), cancer (11%), heart disease (10%), and liver disease (5%); only <1% had kidney failure or nephrotic-range albuminuria.

Across CKD risk status, the vaccinated prevalence was highest for ages 65 to 79 years (56.6%; 95% confidence interval [CI], 54.2%-58.9%), followed by 50 to 64 years with clinical indication (28.5%; 95% CI, 25.5%-31.8%), and lowest for 50 to 64 years without clinical indication (9.7%; 95% CI, 8.1%-11.5%). In the group 50 to 64 years, there were no evident gradients across CKD risk status among those without the clinical indication and those with the indication. When separate assessments were performed according to estimated glomerular filtration rate (eGFR) categories (≥90, 60-890, and 15-59 mL/min/1.73 m2) and urinary albumin-creatinine ratio (UACR) (<30, 30-299, and 300-1999 mg/g) among patients without kidney failure, the vaccination prevalence was higher in lower eGFRs but not in higher UACR.

Pneumococcal vaccination was cost-effective overall (<US $100,000/QALY) for adults 65 to 79 years of age (US $15,000/QALY); it was also cost-effective (US $38,000/QALY) for adults 50 to 64 years of age. Among those in the 50 to 64 years of age group, incremental cost-effectiveness ratios were lowest for those with kidney failure or nephrotic-range albuminuria (US $1000/QALY), followed by CKD with high risk (US %17,000/QALY), CKD with moderate risk (US $25,000/QALY), and no CKD (US $43,000/QALY). Even when assuming the lowest vaccine efficacy or 50% higher vaccine costs, pneumococcal vaccination was cost-effective among adults with CKD 50 to 64 years of age.

Citing limitations to the study, the researchers included extrapolating the prevalence of pneumococcal vaccination from NHANES 1999 to 2004 due to lack of pertinent data in later cycles, not capturing all clinical indications for pneumococcal vaccination, use of nephrotic-range albuminuria as a surrogate for nephrotic syndrome, and not considering costs associated with progression of kidney disease.

“In conclusion, adherence to the current recommendations for pneumococcal vaccination should be improved in general. Moreover, our results demonstrated that the vaccine indication could be expanded to adults aged 50 to 64 years with CKD with high and moderate risk,” the researchers said.

Takeaway Points

  1. Researchers conducted a cost-effectiveness analysis of pneumococcal vaccination targeted to patients with chronic kidney disease (CKD) in the United States. Cost-effectiveness was defined as below the willingness-to-pay threshold of US $100,000 per quality-adjusted life-year.
  2. The prevalence of pneumococcal vaccination in adults 65 to 79 years of age was 56.6%; prevalence in adults 50 to 74 years of age was 28.5% in those with clinical indication for vaccination and 9.7% in those without a clinical indication; prevalence was similar across CKD risk status.
  3. Even when assuming the lowest vaccine efficacy or 50% higher vaccine costs, pneumococcal vaccination was cost-effective among adults 50 to 64 years of age with CKD.