Economic Analysis of RSV 

Vaccination in Older Adults 

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
Research Team

University of Michigan

• David Hutton, PhD

• Lisa Prosser, PhD

• Angela Rose, MPH

• Kerra Mercon, MS

CDC

• Michael Melgar, MD

• Mila Prill, MSPH

• Jamison Pike, PhD

• Ismael Ortega-Sanchez, PhD

• Fiona Havers, MD

• Michael Whitaker, MPH

• Christopher Taylor, PhD

• Amadea Britton, MD 

2
Conflicts of interest statements

– No known conflict of interests.

3
Methods: Study question

• Determine the cost-effectiveness of RSV vaccination by:

• Evaluating the population burden of disease in the US 

population 

• Comparing vaccination to no vaccination using the incremental 

cost-effectiveness ratio

• Scenario analyses exploring uncertainty.

• Perspective: Societal

• Major updates:

• Update to base case incidence of RSV 

• Incorporation of season 2 efficacy of a single vaccine dose

• Alignment of vaccine price with that assumed by manufacturers

4
Methods: Intervention(s)

• Target population: US adults, stratified by age

• Interventions: Pfizer and GSK vaccines

• Each compared to No Vaccination

• Base case assumes the age-based RSV vaccination 

recommendation is for ages ≥65

• Timeframe: 2 years

• Analytic horizon: lifetime

• Discounting rate: 3%

5
Methods: Decision Tree Model

No 

Vaccination

Vaccination

Infection 

Hospitalization

ED

None of the above

Outpatient

Alive

Dead

Infection

Adverse 

Events

Systemic Reaction

Injection Site Reaction

None of the above

Serious Adverse Event Infection 

Infection

6
Methods: Epidemiology

• Incidence of RSV

– Raw reported incidence may be underreported 

because of imperfect PCR sensitivity

▪ Base case assumption: 1.5x multiplier was applied to 

crude incidence estimates

▪ Lower bound: lower multiplier assuming 95% PCR 

sensitivity (fewer missed cases)

▪ Higher bound: upper bound from base case assumption

7

For incidence of inpatient (RSV-NET), outpatient, and ED visits (McLaughlin et al. 2022), this applies the McLaughlin et al. multiplier of 1.5x to the crude 

incidence estimates.

• McLaughlin JM, et al. Rates of Medically Attended RSV Among US Adults: A Systematic Review and Meta-analysis. Open Forum Infect Dis. 2022 Jun 17;9(7):ofac300. doi: 

10.1093/ofid/ofac300. PMID: 35873302; PMCID: PMC9301578.

Other studies speak directly to under-detection of RSV infection through use of upper respiratory PCR alone:

• Onwuchekwa C, Moreo LM, Menon S, Machado B, Curcio D, Kalina W, Atwell JE, Gessner BD, Siapka M, Agarwal N, Rubbrecht M. Under-ascertainment of Respiratory Syncytial 

Virus infection in adults due to diagnostic testing limitations: A systematic literature review and meta-analysis. The Journal of Infectious Diseases. 2023 Jan 20.

• Ramirez J, Carrico R, Wilde A, Junkins A, Furmanek S, Chandler T, Schulz P, Hubler R, Peyrani P, Liu Q, Trivedi S. Diagnosis of Respiratory Syncytial Virus in Adults Substantially 

Increases When Adding Sputum, Saliva, and Serology Testing to Nasopharyngeal Swab RT–PCR. Infectious Diseases and Therapy. 2023 May 6:1-1.
Methods: Epidemiology

Hospitalization

Variable Value Range Source

age 60 to <65 years 65.5 47.2 – 101.3

CDC RSV-NET

age 65 to <70 years 93.8 65.9 – 149.1

age 70 to <75 years 118.7 85.5 – 183.1

age ≥75 years 302.9 212.6 – 489

•

CDC RSV-NET data from RSV seasons: 2016-17, 2017-18, 2018-19, and 2019-2020.

•

Base value is based upon the average burden adjusted rate over those four seasons where 

“burden adjusted” means it is adjusted for 1.5x based on a reduced PCR test sensitivity * 

•

Range lower bound is based upon the average burden adjusted rate over those four seasons, 

but it uses a different “burden adjustment” multiplier of a "Standard" PCR test sensitivity of 

95%**.

•

Range upper bound is based on the upper 95% confidence limit for the base estimates

* Kujawski SA, Whitaker M, Ritchey MD, Reingold AL, Chai SJ, Anderson EJ, Openo KP, Monroe M, Ryan P, Bye E, Como-Sabetti K, Barney GR, Muse A, Bennett NM, Felsen 

CB, Thomas A, Crawford C, Talbot HK, Schaffner W, Gerber SI, Langley GE, Kim L. Rates of respiratory syncytial virus (RSV)-associated hospitalization among adults with 

congestive heart failure-United States, 2015-2017. PLoS One. 2022 Mar 9;17(3):e0264890. doi: 10.1371/journal.pone.0264890. PMID: 35263382; PMCID: PMC8906631.

** McLaughlin JM, et al. Rates of Medically Attended RSV Among US Adults: A Systematic Review and Meta-analysis. Open Forum Infect Dis. 2022 Jun 17;9(7):ofac300. 

doi: 10.1093/ofid/ofac300. PMID: 35873302; PMCID: PMC9301578. 8

RSV incidence, per 100,000, Hospitalization
Methods: Epidemiology

ED and Outpatient

Variable Value Range Source

RSV incidence, per 100,000 

Emergency Department

age 60 to <65 years 110.4 74 – 132

McLaughlin 2022 age 65 to <74 years 200 133 – 478

age ≥75 years 200 133 – 478

RSV Incidence, per 100,000

Outpatient

age 60 to <65 years 1722 1148 – 2041

age 65 to <74 years 2278 1519 – 2893 McLaughlin 2022

age ≥75 years 2278 1519 – 2893

9

•

McLaughlin et. al. is a Pfizer-sponsored meta-analysis

McLaughlin JM, Khan F, Begier E, Swerdlow DL, Jodar L, Falsey AR. Rates of Medically Attended RSV Among US Adults: A 

Systematic Review and Meta-analysis. Open forum infectious diseases 2022 Jul (Vol. 9, No. 7, p. ofac300). 
Methods: Incidence

Seasonality

Source: NREVSS (2015-19)

0%

5%

10%

15%

20%

25%

30%

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

Fraction of Annual Infections

10
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36

Efficacy

Month

Against medically-attended RSV- LRTI/LRTD (hospitalization and ED)

Est. Against medically-attended RSV- LRTI/LRTD (hospitalization and ED)

Against medically-attended RSV-associated ARI (outpatient)

Est. Against medically-attended RSV-associated ARI (outpatient)

11

Efficacy of a single vaccine dose 

over time: Pfizer

Linear decay to 

0% by 24 months

84.6%

65.2%

75.0%

55.0%
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36

Efficacy

Month

Against medically-attended RSV- LRTI/LRTD (hospitalization and ED)

Est. Against medically-attended RSV- LRTI/LRTD (hospitalization and ED)

Against medically-attended RSV-associated ARI (outpatient)

Est. Against medically-attended RSV-associated ARI (outpatient)

12

Efficacy of a single vaccine dose 

over time: GSK

87.5%

52.9%

79.0%

27.8%

Linear decay to 

0% by 24 months
Upper and Lower Bound Efficacy 

Duration Scenarios

13

Pfizer GSK

0%

20%

40%

60%

80%

100%

0 20 40

Efficacy

Month

Against medically-attended 

RSV- LRTI/LRTD 

(hospitalization and ED)

Base Shorter Longer

0%

20%

40%

60%

80%

100%

0 20 40

Efficacy

Month

Against medically-attended 

RSV- LRTI/LRTD 

(hospitalization and ED)

Base Shorter Longer
Methods: RSV Medical Costs

Variable Value Range Source

Disease-specific 

hospitalization costs (per 

hospitalization)

age 60 to <65 years $21,417 9,288 – 45,454

age 65 to <75 years $21,417 10,491 – 43,619 Ackerson 2020*

age ≥75 years $22,425 10,491 – 43,619

Disease-specific ED costs 

(per ED visit)

age 60 to <65 years $1,210 -

age 65 to <75 years $1,210 - 2016 Marketscan*

age ≥75 years $1,210 -

Disease-specific 

outpatient costs (per 

outpatient visit)

age 60 to <65 years $117.58 65.88-145.38 MarketScan

and Medicare FFS, 2020-

2021

age 65 to <75 years $100.86 50.48-120.08

age ≥75 years $100.86 50.48-120.08

*Updated to Q3 2022$ using GDP Deflator

14
Methods: Additional Inputs

• Also included 

– RSV mortality

– RSV QALYs lost

– RSV illness productivity costs

– Vaccination healthcare and productivity costs

– Vaccination adverse events

• Systemic reactions

• Injection site reactions

• Serious adverse events

• Medical costs

• Productivity costs

• These assumption remain unchanged from 

February

15
Methods: Sensitivity analyses

• Sensitivity analyses conducted

– One-Way and Two-Way

– Age-based recommendation for RSV vaccination

• age ≥65 years

• age 60 to <65 years

– Vaccine cost

▪ $180-$340

• Scenario analysis: shorter and longer duration of 

efficacy

16
Results: Base Case

• Cohort of US adult population age 65+ as 

of 2020 Census

• Vaccine Cost:

– Pfizer: $200

– GSK: $270

• Two Year Timeframe

17
Number Needed to Vaccinate, 

Pfizer

18

Two Year Timeframe

52 

617 

1,040 

5,201 

26,671 

173 

1,734 

40 

340 

401 

2,007 

7,842 

67 

669 

 -

 5,000

 10,000

 15,000

 20,000

 25,000

 30,000

Number Needed to Vaccinate

 Age 60-64 age ≥65 years 
Net Cost per Outcome Averted, 

Pfizer

19

Two Year Timeframe

Age-based vaccination recommendation: ≥65 years

Pfizer vaccine cost: $200

Outpatient ED Hospitalizations ICU Stays Deaths

≥65 years $5,600 $48,000 $57,000 $280,000 $1,100,000 

60 to <65 $9,400 $110,000 $190,000 $930,000 $4,800,000 
Number Needed to Vaccinate, 

GSK

20 Two Year Timeframe 57 669 1,128 5,639 28,919 188 1,880 43 369 435 2,176 8,503 73 725 

 -

 5,000

 10,000

 15,000

 20,000

 25,000

 30,000

 35,000

Number Needed to Vaccinate

 age 60 to <65 years age ≥65 years 
Net Cost per Outcome Averted, 

GSK

21

Two Year Timeframe

Age-based vaccination recommendation: ≥65 years

GSK vaccine cost: $270

Outpatient ED Hospitalizations ICU Stays Deaths

≥65 years $9,300 $80,000 $94,000 $470,000 $1,800,000 

60 to <65 $14,000 $170,000 $290,000 $1,400,000 $7,300,000 
Summary measure(s)

Pfizer

Age-based vaccination 

recommendation: ≥65 years ICER ($/QALY) ICER ($/LY)

94,673 112,806

22

QALY = Quality-Adjusted Life-Year

ICER = Incremental Cost-Effectiveness Ratio

LY = Life-Year

ICER values do not depend on cohort size or uptake

$200 vaccine cost

Two Year Timeframe 

Age-based vaccination 

recommendation: 60 to <65

years ICER ($/QALY) ICER ($/LY)

218,350 313,379
Summary measure(s)

GSK

Age-based vaccination 

recommendation: ≥65 years ICER ($/QALY) ICER ($/LY)

167,301 187,853

23

QALY = Quality-Adjusted Life-Year

ICER = Incremental Cost-Effectiveness Ratio

LY = Life-Year

ICER values do not depend on cohort size or uptake

$270 vaccine cost

Two Year Timeframe 

Age-based vaccination 

recommendation: 60 to <65

years ICER ($/QALY) ICER ($/LY)

372,656 478,947
Results: Sensitivity analyses, 

• Tornado Diagrams 

– one parameter varied at a time

• Age and Vaccine Cost

• Vaccine Duration

24
Sensitivity analyses, Pfizer 

Tornado Diagram

25

$200 vaccine cost

Two Year Timeframe

Age-based vaccination recommendation: ≥65 years, VE=Vaccine Efficacy LRTD= Lower Respiratory 

Tract Disease, S1=Season 1, S2=Season 2.

$0 $50,000 $100,000 $150,000 $200,000

Vaccine Cost

VE against hospitalization and ED S2

Incidence of RSV hospitalization

VE against hospitalization and ED S1

Cost per Hospitalization

Outpatient QALYs Lost, Adult

Incidence of outpatient visits for RSV

Mortality, adults hospitalized with RSV

VE against oupatient illness S2

ED Incidence

ICER

Age ≥65

Low Assumption High Assumption
Sensitivity analyses, GSK 

Tornado Diagram

26

$270 vaccine cost

Two Year Timeframe

Age-based vaccination recommendation: ≥65 years, VE= Vaccine Efficacy, LRTD= Lower Respiratory 

Tract Disease, S1=Season 1, S2=Season 2.

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

Incidence of RSV hospitalization

VE against hospitalization and ED S2

Vaccine Cost

Outpatient QALYs Lost, Adult

Cost per Hospitalization

VE against hospitalization and ED S1

Incidence of outpatient visits for RSV

Mortality, adults hospitalized with RSV

VE against oupatient illness S2

ED Incidence

ICER

Age ≥65

Low Assumption High Assumption
 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $450,000

 $500,000

 $150 $175 $200 $225 $250 $275 $300 $325 $350

ICER

Vaccine Cost

Age 60-64 age ≥65 years

Sensitivity analysis: Vaccine 

Cost, Pfizer

27 Two Year Timeframe
 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $450,000

 $500,000

 $150 $175 $200 $225 $250 $275 $300 $325 $350

ICER

Vaccine Cost

Age 60-64 age ≥65 years

Sensitivity analysis: Vaccine 

Cost, GSK 

28 Two Year Timeframe
0%

20%

40%

60%

80%

100%

0 20 40

Efficacy

Month

Against medically-attended RSVLRTI/LRTD (hospitalization and ED)

Base Shorter Longer

0%

20%

40%

60%

80%

100%

0 20 40

Efficacy

Month

Against medically-attended RSVLRTI/LRTD (hospitalization and ED)

Base Shorter Longer

Vaccine Efficacy Duration 

Scenarios

29

Pfizer GSK
Sensitivity analyses, Pfizer: 

Varying Duration of Efficacy

30 Age-based vaccination recommendation: ≥65 years

 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $450,000

 $500,000

 $150 $175 $200 $225 $250 $275 $300 $325 $350

ICER

Vaccine Cost

Pfizer Base age ≥65 years

Pfizer Zero Efficacy after 14 months age ≥65 years

Pfizer Zero Efficacy after 36 months age ≥65 years
Sensitivity analyses, GSK: 

Varying Duration of Efficacy

31 Age-based vaccination recommendation: ≥65 years

 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $450,000

 $500,000

 $150 $175 $200 $225 $250 $275 $300 $325 $350

ICER

Vaccine Cost

GSK Base age ≥65 years

GSK Zero Efficacy after 18 months age ≥65 years

GSK Zero Efficacy after 36 months age ≥65 years
Limitations

• Model Structure

– No risk groups

– No dynamic transmission. No impact of the vaccine 

on transmission and indirect effects

• Uncertain inputs

– Vaccine cost 

– RSV Incidence

– Long-term efficacy 

32
Summary

• Vaccination potentially Cost-Effective

• Results vary based on:

– Vaccine Cost

• ICER: 80,000– 220,000 $/QALY

– Incidence of RSV Hospitalization

• $50,000 - 230,000 $/QALY

– Vaccine Efficacy

• ICER: ~80,000 - 270,000 $/QALY

– Ages Vaccinated

• ICER: ~50,000 - 370,000 $/QALY

– Duration of Efficacy

• ICER: ~80,000 - 170,000 $/QALY 33
Thank You

• Please send comments to:

• dwhutton@umich.edu

34