Cost-Effectiveness of Quadrivalent vs Monovalent Vaccination against Meningococcal Disease in Canada
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1 Cost-Effectiveness of Quadrivalent vs Monovalent Vaccination against Meningococcal Disease in Canada Derek Weycker, Ph.D. 1 Mark Atwood, M.S. 1 Thomas E. Delea, M.S.I.A. 1 Anoush Youssoufian, B.A. 1 Dion Neame, M.D. 2 Vivian Ng, Ph.D. 2 Fabian Alvarez, Ph.D. 2 Evelyn Forget, Ph.D. 3 Ayman Chit, Ph.D. 2 1 Policy Analysis Inc. (PAI), Brookline, Massachusetts 2 Sanofi Pasteur, Toronto ON 3 University of Manitoba, Winnipeg, Manitoba
2 Disclosure Statement Disclosure of Relationship* I am a member of an Advisory Board or equivalent with a commercial organization. I am a member of a Speaker Bureau. I have received payment from a commercial organization (including gifts or other consideration or in kind compensation). I hold a patent for a product referred to in the CME/CPD program or that is marketing by a commercial organization I hold investments in a pharmaceutical organization, medical devices company or communications firms. I am currently participating in or have participated in a clinical trial within the past two years.). *Provided for all authors No No Sanofi Pasteur GSK Company/Organization Some authors are employees of Sanofi Pasteur which holds patents and patent applications related to quadrivalent vaccines Sanofi Pasteur GSK No
3 Background Recommendations for immunization against meningococcal disease with monovalent conjugate vaccines (MCV-C) and quadrivalent conjugate vaccines (MCV-4) vary across provinces in Canada
4 Background Province/ Population*, Infants, Months Adolescents, Grade Territory in 000s (%) Other ON 13,506 (39) MCV-C MCV-4 QC 8,055 (23) MCV-C MCV-C** BC 4,623 (13) MCV-C MCV-C MCV-C AL 3,874 (11) MCV-C MCV-C MCV-C MCV-4 MB 1,267 (4) MCV-C MCV-C SA 1,080 (3) MCV-C MCV-4 NS 949 (3) MCV-C MCV-C NB 756 (2) MCV-C MCV-4 NF 513 (2) MCV-C MCV-4 PEI 146 (<1) MCV-C MCV-4 NWT 43 (<1) MCV-C MCV-C MCV-C YU 36 (<1) MCV-C MCV-C MCV-C NU 34 (<1) MCV-C MCV-C MCV-C: meningococcal conjugate vaccine - serogroup C; MCV-4: meningococcal conjugate vaccine - quadrivalent (serogroups A, C, Y, W135) **Vaccination recommended before age 18 years *Source: Statistics Canada, Population and Demography
5 Objective To estimate the cost effectiveness of MCV-4 vs. MCV-C vaccination of adolescents and infants in Canada
6 Model Overview Approach Population Comparisons Perspective Probabilistic cohort model Prevalent cohort of 35 mm Canadians of all ages 1. MCV-C/MCV-C: Infant (1y) and adolescent (15 y) MCV-C 2. MCV-C/MCV-4: Infant (1y) MCV-C and adolescent (15 y) MCV-4 3. MCV-4/MCV-4: Infant (1y) and adolescent (15 y) MCV-4 Societal Time horizon Lifetime (up to 100 y) Outcomes Discounting 5% Cases of IMD (C, Y, and W135) IMD deaths LYs and QALYs lost to IMD Lifetime costs of IMD (direct and indirect) ($ CAN 2012) Cost per QALY gained
7 Model Schematic Population Incidence rates IMD Cases Vaccine Effectiveness Mortality Vaccine Costs Input Life Expectancy IMD Costs Intermediate Outcome Utilities Probability of Sequelae Indirect Costs Final Outcome QALYs Expected Lifetime Costs Cost Effectiveness
8 Incidence of IMD, per 100K SOURCES: Bettinger J, et al. IMPACT enhanced population-based surveillance of meningococcal invasive infections at participating centers across Canada Adjusted upward by 10% to account for underreporting. PHAC. Invasive Meningococcal Disease (IMD), Available at: Accessed 14 January Annual Incidence of IMD in Canada Months Months 2-4 Years 5-17 Years >=18 Years Age C Y W135
9 IMD Case Fatality, per 100 IMD Case Fatality in Canada Months Months 2-4 Years 5-17 Years >=18 Years Age C Y W135 SOURCE: Bettinger J, et al. IMPACT enhanced population-based surveillance of meningococcal invasive infections at participating centers across Canada
10 Vaccine Effectiveness by Age 87.8% 66.7% SOURCES: De Wals P, et al. Effectiveness of serogroup C meningococcal conjugate vaccine: A 7-year follow-up in Quebec, Canada. Ped Infect Dis J
11 Bauch CT et al. Incorporating herd immunity effects into cohort models of vaccine cost-effectiveness. Med Decis Making Van Vlaenderen I et al. An approximation of herd effect due to vaccination children against seasonal influenza a potential solution to the incorporation of indirect effects into static models. BMC Infectious Diseases Herd Effects Based on conservative first order approximation of herd effects described by Bauch et al. (2009) and further described by Van Vlaenderen et al. (2013) Takes into account only the reduction in the number of susceptible individuals due to vaccination
12 Vaccine Prices ** Infant MCV-4 assumed to require 2 doses ** SOURCES: MCV-C and MCV-4 Estimated by fitting exponential to unpublished data.
13 Costs and Utility Values Age<18y Age 18y Vaccine administration, per dose, $CAN Vaccine AEs, per dose, $CAN 0.07 IMD per case, $CAN Treatment 13,839 Public health response 4,159 Sequelae, per case, per year, $CAN 18,712 3,997 Indirect, per case, $CAN Utilities Premature death 1.8 mm 848 k Short-term indirect costs 2,930 Persons without IMD Disutility from sequelae *All costs adjusted to 2012 price levels SOURCES: De Wals P, et al. Vaccinating adolescents against meningococcal disease in Canada: A cost-effectiveness analysis. Vaccine, 2007; Statistics Canada, CANSIM, table
14 Results IMD Cases & Deaths
15 Results QALYs Lost to IMD
16 Costs, $ CAN (mm) Results Costs Adverse Events Public Health Response MCV-C / MCV-C MCV-C / MCV-4 MCV-4 / MCV-4 Vaccine Strategy *All costs adjusted to 2012 price levels IMD Sequelae Administration Vaccine Indirect Costs
17 Results Incremental Cost-Effectiveness Comparator MCV-C/ MCV-C MCV-C/ MCV-4 Vaccination Strategy MCV-C/ MCV-4/ Measure MCV-4 MCV-4 ΔCosts, CAN$ (mm) ΔQALYs ICER-QALY, CAN$ 39,700 54,100 ΔCosts, CAN$ (mm) ΔQALYs ICER-QALY, CAN$ ,300 *All costs adjusted to 2012 price levels. Costs and QALYs are discounted at 5%
18 Results Tornado Diagram MCV-C/MCV-4 vs. MCV-C/MCV-C No Herd Effects IMD Case Rate +/-50% Discount Rates 0-5% IMD Case-Fatality Rate +/-40% Price of MCV-4-25% Utilities +/- 25% Vaccine Effectiveness in First Year 95% CI Vaccine Coverage +/-10% IMD Sequelae Rate +/-10% Medical Care Costs +/- 25% Waning of Vaccine Effectiveness +/-50% Timing of Vx Administration 9 mos./grade 8 or 10 Base Case=$39, Cost per QALY Gained, $ Thousands
19 Results - Sensitivity Analysis on Durability of Benefit for MCV-4/MCV-4 vs. MCV-C/MCV-C Assumed Durability of Benefit ICER $CAN Costs $CAN mm QALYs $39,700 $ $42,100 $ $43,700 $ $44,700 $
20 Conclusions Infant MCV-4 is not likely to be cost-effective Adolescent MCV-4 may be cost-effective, but depends on assumption of herd effects Analyses to be updated Using actual vaccine prices over time provided generously by PHAC Accounting for new birth cohorts in addition to prevalent cohort
21 Extra Slides
22 Results Cost-Effectiveness Plane MCV-4 / MCV-4 ICER=$CAN 369,300 /QALY ICER = $CAN 54,100/QALY MCV-C / MCV-4 ICER=$CAN 39,700/QALY MCV-C / MCV-C
23 Results Incremental Cost-Effectiveness Prevalent and Successive Birth Cohorts Comparat or MCV-C/ MCV-C MCV-C/ MCV-4 Measure Vaccination Strategy MCV-C/ MCV-4 MCV-4/ MCV-4 ΔCosts, CAN$ (mm) ΔQALYs 925 1,072 ICER-QALY, CAN$ 13,300 74,500 ΔCosts, CAN$ (mm) ΔQALYs ICER-QALY, CAN$ ,300
24 Results LYs Lost to IMD
25 Results Incremental Cost-Effectiveness Vaccination Strategy Comparator Measure MCV-C/MCV-4 MCV-4/MCV-4 MCV-C/MCV-C ΔCosts, CAN$ (mm) ΔLYs ΔQALYs ICER-QALY, CAN$ 39,700 54,100 MCV-C/MCV-4 ΔCosts, CAN$ (mm) ΔLYs ΔQALYs ICER-QALY, CAN$ ,300
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