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Cost-Effectiveness of Pneumococcal Polysaccharide Vaccine Among Healthcare Workers During an Influenza Pandemic
Kenneth J. Smith, MD, MS; Mahlon Raymund, PhD; Mary Patricia Nowalk, PhD, RD;Mark S. Roberts, MD, MPP; and Richard K. Zimmerman, MD, MPH
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Cost-Effectiveness of Pneumococcal Polysaccharide Vaccine Among Healthcare Workers During an Influenza Pandemic

Kenneth J. Smith, MD, MS; Mahlon Raymund, PhD; Mary Patricia Nowalk, PhD, RD;Mark S. Roberts, MD, MPP; and Richard K. Zimmerman, MD, MPH

Pneumococcal polysaccharide vaccination of healthcare workers during an influenza pandemic is cost-effective from a societal perspective but not from a hospital perspective without external subsidy.

From a hospital perspective, the PPV strategy had a total cost per vaccinated worker that was $20.71 greater than no vaccination, while avoiding 0.01236 absence day per worker, for a cost-effectiveness ratio of $1676 per employee absence day avoided (Table 3). This figure could be an overestimate given the assumption of no vaccine efficacy for noninvasive pneumonia, and that does not account for lost revenue due to reduced hospital manpower and capacity, as well as the intangible costs of negative public perception if hospital services were to be curtailed. Pneumococcal polysaccharide vaccination in healthcare workers costs $4103 per employee absence day avoided if their IPD risk is 50% of the general population risk and costs $867 per employee absence day avoided if their IPD risk is 150% of the general population risk. In a probabilistic sensitivity analysis, the 95% probability range for vaccination compared with no  vaccination was $20 to $10,800 per employee absence day avoided.


In this analysis, PPV is an economically reasonable strategy to be considered for healthcare workers during an influenza pandemic from a societal perspective, with robust results in 1-way sensitivity analyses and a high likelihood of cost-effectiveness in a probabilistic sensitivity analysis. Our results are comparable to findings of a recent analysis by the CDC examining PPV use in critical infrastructure personnel (eg, healthcare workers and utility  workers).17,26 The investigators estimated 35,000 invasive and non-IPD cases in a population of 20 million, or an attack rate of 175 per 100,000. Using their age-specific hospitalization rates and assuming that 25% of workers are 50 years or older, the pneumococcal disease hospitalization rate was about 25.8  per 100,000. If half of those hospitalized had IPD, then the IPD rate was 12.9 cases per 100,000, slightly less than our calculated IPD rate in healthcare workers, 13.7 cases per 100,000. Using 0.942 (ie, 12.9 of 13.7), the IPD relative risk derived from their study, in our analysis produces an incremental cost-effectiveness ratio of $6419 per QALY gained. This value falls within the range of their discounted life-years saved result of $37,320 (95% confidence interval, $5865-$80,359). Unlike our analysis, the CDC study did not use utilities or account for disability or PPV effects beyond the pandemic year.17

On the other hand, from the hospital perspective, PPV of healthcare workers costs $1676 per employee absence day avoided, which most hospitals would consider  a steep premium to pay for a small expected return. Our analysis highlights the dilemma many hospital systems face in trying to do the right thing from a societal standpoint, while at the same time attempting to remain fiscally sound. Managed care faces this tension of hospital versus societal perspectives as it seeks to maximize health in a cost-effective way. Even with a heightened risk of pneumococcal disease during an influenza pandemic, the risk of IPD would probably remain less than 1% for healthcare workers, and this fact might lead hospital systems to defer PPV for their workers unless some subsidy to defray vaccination costs was available. We did not include the possibility that healthcare workers would infect other workers or patients or that hospitals would be  unable to meet staffing needs due to absenteeism; therefore, our estimates are conservative. Maintenance of appropriate staffing levels is a priority in managed care. Although expensive from the hospital perspective, vaccination may lead workers to perceive themselves as better protected and to be more willing to work in the face of a pandemic. Given that PPV is less expensive than many other occupationally indicated vaccines, it may be reasonable to consider PPV as a means to allay worker concerns about complications of pandemic influenza.

From a societal standpoint, PPV administration to healthy healthcare workers at the onset of a pandemic has pros and cons. Vaccination is likely to reduce IPD27-30 and in healthy workers may reduce pneumococcal pneumonia.31 However, concerns exist about vaccine efficacy against noninvasive pneumonia and about hyporesponsiveness to subsequent vaccination, also known as tolerance.4 If hyporesponsiveness occurs following PPV, it might simply shift the burden of pneumococcal disease from the time of the pandemic to later in the life of the healthcare worker, without changing the cumulative incidence. Repeat doses of PPV later in life are generally safe18; therefore, the concern is not safety at the time of vaccination or of repeat vaccination years later but of potential  hyporesponsiveness. Another potential limitation of our analysis is that recent PPV recommendations32 have added smoking and asthma to the list of comorbid conditions for which vaccination before age 65 years is recommended and could further lessen the effect of healthcare worker vaccination given the considerable proportion of workers falling into these categories.

Because of the current absence of clinical trial data and for the foreseeable future, we used a Markov model to synthesize available data. We also used a series of conservative estimates and assumptions, including PPV effectiveness against IPD, not pneumococcal pneumonia, although some data suggest that PPV may have effectiveness against pneumonia in healthy adults.31 Despite these assumptions, vaccination of healthcare workers with PPV was cost-effective from the societal perspective. Limitations include the unknown increased IPD risk in a pandemic and the inability to address PPV effect on hyporesponsiveness to future pneumococcal vaccines, either polysaccharide or conjugate, the latter of which may be licensed for adults in the future. We used longer time horizons than prior analyses; this has the advantage of not being limited to pandemic effects but has the disadvantage of not accounting for future new vaccines and changes in epidemiology. Because we used a 15-year time frame and a single PPV in those who were previously unvaccinated and because current CDC recommendations only call for PPV revaccination at age 65 years for those vaccinated before that age, we did not include revaccination as part of our analyses of current workers. If a longer time horizon was examined or if hyporesponsiveness occurred, greater costs per QALY gained would result.

In conclusion, vaccinating all healthcare workers to protect against pneumococcal disease during a pandemic influenza outbreak is likely to be economically reasonable according to a societal perspective in an analysis biased against vaccination. However, when analyzed from a hospital perspective, PPV is expensive, and the small risk of illness might prevent hospital implementation unless vaccination is externally subsidized.

Author Affiliations: From the Section of Decision Sciences and Clinical Systems Modeling (KJS, MSR), the Department of Family Medicine and Clinical Epidemiology (MR, MPN, RKZ), and the Department of Behavioral and Community Health Sciences (RKZ), University of Pittsburgh, Pittsburgh PA.


Funding Source: This study was supported by grant R01AI076256 from the National Institute of Allergy and Infectious Diseases. Its contents are the responsibility of the authors and do not necessarily reflect the official views of the National Institutes of Health.


Author Disclosures: Drs Nowalk and Zimmerman report receiving grants from Merck & Co, Inc, and MedImmune. The other authors (KJS, MR, MSR) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.


Authorship Information: Concept and design (KJS, MSR, RKZ); acquisition of data (KJS, MR, RKZ); analysis and interpretation of data (KJS, RKZ); drafting of the manuscript (KJS, MPN, RKZ); critical revision of the manuscript for important intellectual content (KJS, MPN, MSR); statistical analysis (MR); obtaining funding (KJS, RKZ); and administrative, technical, or logistic support (MR).


Address correspondence to: Kenneth J. Smith, MD, MS, Section of Decision Sciences and Clinical Systems Modeling, University of Pittsburgh, 200 Meyran Ave, Ste 200, Pittsburgh, PA 15213. E-mail:


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