Economics of combined use of Pfizer 

maternal RSVpreF vaccine and 

nirsevimab

David W. Hutton, PhD, MS

Associate Professor, Health Management and Policy, School of Public Health

Associate Professor of Global Public Health, School of Public Health

Associate Professor, Industrial and Operations Engineering, College of Engineering

University of Michigan

Presentation to the ACIP 

June 22, 2023
Research team

University of Michigan

• David Hutton, PhD

• Lisa Prosser, PhD

• Angela Rose, MPH

• Kerra Mercon, MS

CDC

• Jefferson Jones, MD, MPH, FAAP

• Mila Prill, MSPH

• Meredith McMorrow, MD, MPH, 

FAAP

• Jamison Pike, PhD

• Katherine Fleming-Dutra, MD, 

FAAP

• Ismael Ortega-Sanchez, PhD

• Fiona Havers, MD

• Betsy Gunnels, MSPH

• Andrew Leidner, PhD

2
Conflicts of interest statements

• Authors have no known conflict of interests.

3
Methods: Study questions

• Determine the cost-effectiveness of:

• Nirsevimab in children born to mothers who received RSVpreF at least 2 

weeks prior to delivery

• RSVpreF for pregnant persons who will give nirsevimab to their newborns

• Single individual

• Evaluate by month of year

• Perspective: Societal

• Timeframe: 1 year (1 RSV season)

• Analytic horizon: infant’s lifetime

• Discount rate: 3%

4
Overview of nirsevimab

changes/additions

• Since February

• Nirsevimab cost $500/dose

• Nirsevimab reduces palivizumab use

• Old base case ICER: $ 102,805/QALY 

• New base case ICER: $157,537/QALY

5
Methods: Intervention effectiveness

• NO evidence of efficacy on the combined use of 

these products

• Assumption:

• Efficacy equal to the highest of nirsevimab or RSVpreF:

• Efficacy would not be higher than from the most effective 

product

6
Methods: Intervention effectiveness

7

* Assuming administration of nirsevimab at birth

0%

20%

40%

60%

80%

100%

0 2 4 6 8 10 12 14

Hospitalization Efficacy

Months since birth

RSVPreF Both Nirsevimab
Incremental benefit of adding 

nirsevimab on top of RSVpreF

8

• For infants of persons vaccinated with RSVpreF

during pregnancy
0%

20%

40%

60%

80%

100%

0 2 4 6 8 10 12 14

Hospitalization Efficacy

Months since birth

RSVPreF Both Nirsevimab

Methods: Intervention effectiveness

9

Additional benefit of adding nirsevimab

* Assuming administration of nirsevimab at birth
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2 4 6 8 10 12

Hospitalization Efficacy

Month

Both RSVpreF Only

Methods: Intervention effectiveness

Example: Off-peak (Aug) birth

Additional benefit of adding nirsevimab

Note: Peak infections are typically Dec-Feb 10
11

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Fraction of Annual Infections

Source: National Respiratory and Enteric Virus Surveillance System (NREVSS) (2015-2019)

Reminder: Seasonality
Results: Incremental benefit of adding 

nirsevimab on top of RSVpreF

Nirsevimab given in Oct-Mar

ICER= Incremental cost effectiveness ratio ($/QALY)

Birth Month

 $-

 $500,000

 $1,000,000

 $1,500,000

 $2,000,000

 $2,500,000

 $3,000,000

ICER ($/QALY)

12
Results: Adding nirsevimab to all 

infants born to vaccinated mothers

Nirsevimab given at birth for infants born October-March, and in October/November for infants born in April through 

September 13
Results: Adding nirsevimab to all 

infants born to vaccinated mothers

Nirsevimab given at birth for babies born October-March, and in October/November for babies born in April through 

September 14
Results: Adding nirsevimab to all 

infants born to vaccinated mothers

QALYs 

Gained

Additional 

Costs

ICER

($/QALY)

0.000781 $522.12 $ 668,735 

Notes: Nirsevimab given at birth for babies born October-March, and in October/November for babies born in April 

through September

ICER= Incremental cost effectiveness ratio; QALY= Quality-adjusted life-year

15
Results: Adding nirsevimab only for 

infants born during Apr-Sept

Nirsevimab given in October/November for babies born in April through September born to mothers who received 

RSVpreF 16
Nirsevimab given in October/November for babies born in April through September born to mothers who received 

RSVpreF

Results: Adding nirsevimab only for 

infants born during Apr-Sept

17
Nirsevimab given in October/November for babies born in April through September born to mothers who received 

RSVpreF

ICER= Incremental cost effectiveness ratio; QALY= Quality-adjusted life-year

QALYs 

Gained

Additional 

Costs

ICER

($/QALY)

0.001032 $502.40 $486,882 

Results: Adding nirsevimab only for 

infants born during Apr-Sept

18
• Marginal additional benefit beyond RSVpreF

protection

• ICER is very high

Summary: Incremental benefit of 

adding nirsevimab on top of RSVpreF

19
Incremental benefit of adding RSVpreF

on top of nirsevimab

20
0%

20%

40%

60%

80%

100%

0 2 4 6 8 10 12 14

Hospitalization Efficacy

Months since birth

RSVPreF Both Nirsevimab

Methods: Intervention effectiveness

21

Additional benefit of adding RSVpreF

* Assuming administration of nirsevimab at birth
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2 4 6 8 10 12

Hospitalization Efficacy

Month

Both Nirsevimab Only

Methods: Intervention effectiveness

example: Off-peak (Aug) birth

Additional benefit of adding RSVpreF

22
Results: Incremental benefit of adding 

RSVpreF on top of nirsevimab

Birth Month

 $-

 $1

 $2

 $3

 $4

 $5

 $6

 $7

 $8

 $9

 $10

ICER ($ Millions)

ICER= Incremental cost effectiveness ratio

23
• Very marginal additional benefit beyond 

Nirsevimab protection

• ICERs are extremely high

Summary: Incremental benefit of 

adding RSVpreF on top of nirsevimab

24
• Limitation:

• No efficacy data for combination of products

• Combinations of RSVpreF and Nirsevimab add 

marginal effectiveness at very high cost in the 

general population

Overall summary: Combinations

25
Thank You

• Please send comments to:

• dwhutton@umich.edu

26
Appendix

27
Additional Input 

Assumptions

28
Methods: Provision of Nirsevimab

• Base case:

• At birth for those born 

• October 1 – March 31

• October for those born in 

• April (~6-month visit)

• June (~4-month visit)

• August (~2-month visit)

• November for those born in

• May (~6-month visit)

• July (~4-month visit)

• September (~2-month visit)

29
Methods: Intervention effectiveness

30

• Assuming Administration of Nirsevimab at birth

• MA-LRTI= medically attended lower respiratory tract infection

0%

20%

40%

60%

80%

100%

0 2 4 6 8 10 12 14

MA

-LRTI Efficacy

Months since birth

RSVPreF Nirsevimab Both
Additional combination 

Results
Incremental benefit of adding on 

nirsevimab top of RSVpreF
Results: Incremental benefit of adding 

nirsevimab on top of RSVpreF

by month of birth

Birth Month

0.000

0.010

0.020

0.030

0.040

0.050

0.060

0.070

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Events Averted per Birth

October November December January February March

April May June July August September

0.000

0.001

0.001

0.002

ICU

Nirsevimab given at birth for babies born October-March, and in October/November for babies born in April through September
Results: Incremental benefit of adding 

nirsevimab on top of RSVpreF

Birth Month

0

100

200

300

400

500

600

700

800

900

Outpatient ED Inpatient

Number Needed to Immunize to Avoid One...

November December January February March April

May June July August September

0

1000

2000

3000

4000

ICU Inpatient

Day

ICU Day

Nirsevimab given at birth for babies born October-March, and in October/November for babies born in April through September
Results: Incremental benefit of adding 

nirsevimab on top of RSVpreF

Birth Month

 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $450,000

 $500,000

Outpatient ED Inpatient

Cost per Event Averted

October November December January February March

April May June July August September

 $-

 $500,000

 $1,000,000

 $1,500,000

 $2,000,000

 $2,500,000

ICU Inpatient

Day

ICU Day

Nirsevimab given at birth for babies born October-March, and in October/November for babies born in April through September
Incremental benefit of adding RSVpreF

on top of nirsevimab
0

0.0005

0.001

0.0015

0.002

0.0025

0.003

0.0035

0.004

0.0045

0.005

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Events Averted per Birth

October November December January February March

April May June July August September

Results: Incremental benefit of adding 

RSVpreF on top of nirsevimab

Impact of adding RSVpreF in addition 

to nirsevimab is bigger for births in 

April-Sept since nirsevimab does not 

provide protection in April-Sept for 

those born in those months 

Birth Month
Results: Incremental benefit of adding 

RSVpreF on top of nirsevimab

Birth Month

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Number Needed to Immunize to Avoid One...

October November December January February March

April May June July August September
Results: Incremental benefit of adding 

RSVpreF on top of nirsevimab

Birth Month

 $-

 $100,000

 $200,000

 $300,000

 $400,000

 $500,000

 $600,000

 $700,000

 $800,000

 $900,000

 $1,000,000

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Cost per Event Averted 

October November December January February March

April May June July August September
Results: Adding RSVpreF

What if RSV season is early?

• Scenario:

• RSVpreF provided in off-peak

• RSV season starts 2 months early

• Nirsevimab still provided in October

0.0%

10.0%

20.0%

30.0%

Apr Jun Aug Oct Dec Feb

Incidence

(% of annual)

Seasonality

Original Model
$6.86 

$2.72 

$2.25 

$0.71 

$1.42 

$0.43 

 $-

 $2.00

 $4.00

 $6.00

 $8.00

 $10.00

ICER ($ Millions)

ICER (Millions)

Results: Adding RSVpreF

What if RSV season is early?

ICERs improve, but still 

very expensive

Birth Month

ICER- Incremental cost-effectiveness ratio
Nirsevimab base case 

update
Nirsevimab results: Base case

43

• Base case:

• Population of 1,000 births

• 50% uptake in the nirsevimab group

• First RSV season

• $500/dose

• Nirsevimab only impacts LRTI

LTRI= Lower respiratory tract infection
Results: Health outcomes

44

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 50% uptake in nirsevimab group

URTI- Upper respiratory tract infection; LRTI- Lower respiratory tract infection

 -

 50

 100

 150

 200

 250

 Natural

History

 Nirsevimab Natural

History

 Nirsevimab Natural

History

 Nirsevimab

Medically attended

outpatient

Emergency Department Inpatient

Number of Events in Cohort

URTI LRTI
Results: Health outcomes

45 Cohort:1,000 nirsevimab and 1,000 natural history, assuming 50% uptake in nirsevimab group

29.3

10.4

3.9

0.9

21.1

2.6

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Events Averted per 1000 births

Nirsevimab
Results: Health outcomes

46

17 

48 

128 

581 

24 

194 

 -

 100

 200

 300

 400

 500

 600

 700

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Number needed to Prophylax to avoid

Nirsevimab
Results: Costs

47 Base costs of nirsevimab: $500/dose, Cost of palivizumab for high-risk included in “Natural History”

Cohort:1,000 births, assuming 50% uptake in nirsevimab group

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Intervention Outpatient ED Inpatient Deaths Total

Total Costs in Cohort

Medical Productivity
Results: Health outcomes

48 Base costs of nirsevimab: $500/dose

$3,794 

$10,650 

$28,372 

$128,963 

$5,254 

$42,988 

 $-

 $20,000

 $40,000

 $60,000

 $80,000

 $100,000

 $120,000

 $140,000

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Cost per Event Averted

Nirsevimab
Results: QALYs lost

49

Adverse 

Events Outpatient ED Inpatient Deaths Total Grand

Child Caregiver Child Caregiver Child Caregiver Child Child Caregiver Total

Natural 

History 1.95 0.98 0.90 0.45 0.22 0.09 0.15 3.22 1.51 4.73 

Nirsevimab 0.01 1.70 0.85 0.76 0.38 0.15 0.06 0.10 2.73 1.29 4.03 

Cohort:1,000 births, assuming 50% uptake in nirsevimab group
Results: Cost-effectiveness

50

Cohort:1,000 births, assuming 50% uptake in nirsevimab group

 $-

 $100,000

 $200,000

 $300,000

 $400,000

 $500,000

 $600,000

 (4.80) (4.60) (4.40) (4.20) (4.00) (3.80)

Costs 

QALYs (lost) from RSV 

Natural History Nirsevimab

Base costs of nirsevimab: $500/dose, Cost of palivizumab for high-risk included in “Natural History”
Results: Cost-effectiveness

51

Overall Costs ($) QALYs ICER ($/QALY)Vs. NH

Natural History 418,556 4.73 

Nirsevimab 529,597 4.03 157,537 

Cohort:1,000 births, assuming 50% uptake in nirsevimab group

Base costs of nirsevimab: $500/dose, Cost of palivizumab for high-risk included in “Natural History”
Sensitivity: Tornado nirsevimab

52 Base cost of $500/dose

$0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000

nirsevimab cost/dose

Disease-specific inpatient costs (per inpatient case) Age 0-5 months

RSV QALYS Lost

Initial Efficacy

RSV-related QALYs lost Outpatient Child

Fraction Receiving Palivizumab Natural History

RSV-related QALYs lost Outpatient Child caregiver

Proportion of RSV infections with an LRTI diagnosis Outpatient Age 0-5 months

Disease-specific inpatient costs (per inpatient case) Age 6-11 months

RSV-related QALYs lost ED Child

Incremental Cost-Effectiveness Ratio

Low High
 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

$0 $100 $200 $300 $400 $500 $600

ICER

Total Cost of Nirsevimab (drug + administration)

Sensitivity: Cost nirsevimab

53 Base cost of $500/dose
Scenario: Upper respiratory infection 

effect

54

55.4

17.1

3.9

0.9

21.1

2.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Events Averted per 1000 births

Nirsevimab
 $-

 $20,000

 $40,000

 $60,000

 $80,000

 $100,000

 $120,000

 $140,000

$0 $100 $200 $300 $400 $500 $600

ICER

Total Cost of Nirsevimab (drug + administration)

Scenario: Upper respiratory infection 

effect

Nirsevimab 55 is assumed to be equally efficacious in preventing upper respiratory tract infections as lower respiratory tract infections.
Scenario: Timing analysis

56

• Cost-effectiveness of an infant receiving nirsevimab 

as a newborn in 

• Oct-Feb

• Oct-March

• Oct-April

• With varying efficacy in months 6-10

• 0%

• 25%

• 50%

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 50% uptake in nirsevimab group
57

Scenario: Timing and efficacy in months 6-10

Slightly lower ICERs for Oct-Mar Base cost of $500/dose

ICER= Incremental cost-effectiveness ratio

Cohort:1,000 nirsevimab and 1,000 

natural history, assuming 50% uptake in 

nirsevimab group

 $-

 $20,000

 $40,000

 $60,000

 $80,000

 $100,000

 $120,000

 $140,000

 $160,000

 $180,000

0% efficacy 25% efficacy 50% efficacy

ICER

Oct-Feb Oct-Mar Oct-Apr