Economic Analysis of Vaccination

with mRNA Booster Dose 

against COVID-19 Among Adults

University of Michigan 

COVID-19 Vaccination Modeling Team

Presentation to ACIP

September 12, 2023

1
Study Team

University of Michigan

• Lisa A. Prosser, PhD, Principal Investigator

• David W. Hutton, PhD, Co-Investigator

• Acham Gebremariam, MS, Programmer/Analyst

• Angela Rose, MS, MPH, Project Manager

• Kerra Mercon, MS, Research Assistant

Wake Forest University

• Cara Janusz, PhD

Additional contributors to 2021 Covid Vaccination Model:

Marisa Eisenberg, Emily Martin, Grace Chung, Janamarie 

Perroud, Ellen Kim Deluca, Chris Cadham, Huey-Fen Chen, 

Anton L.V. Avancena, Tran Doan, David Suh

Centers for Disease Control and Prevention

• Jamie Pike, PhD, Health Economist, Project officer

• Megan Wallace, DrPH, Epidemiologist

• Ismael Ortega-Sanchez, PhD, Senior Economist

• Andrew Leidner, PhD, Economist

• Fangjun Zhou, PhD, Health Scientist

• Melisa Shah, MD, MPH, Medical Epidemiologist 

• Danielle Moulia, MPH, Health Scientist 

• Ruth Link-Gelles, PhD, Epidemiologist

• Sharon Saydah, PhD, Epidemiologist

2
Conflict of interest statement

3

Authors have no known conflicts of interest. 
Objectives

• Estimate annual disease burden and healthcare utilization associated with 

COVID-19 illness and COVID-19 booster vaccination, including cases of 

symptomatic illness, hospitalizations, deaths, adverse events, costs, and qualityadjusted life years

• Project cost-effectiveness of an updated mRNA booster against COVID-19-

associated illness in persons ages ≥18 years

4
Methods

• Intervention strategies:

o Vaccination against COVID-19 illness with an updated “generic” mRNA booster

o No updated mRNA booster (vaccination against COVID-19 illness with primary series only or 

primary series plus current booster)

• Target population: all US adults, stratified by age

o 18-49 y, 50-64 y, 65+ y

o Pediatric and adolescent age groups excluded from current analysis, insufficient data to 

incorporate into this first phase analysis

• Time horizon: 1 year*

• Perspective: Societal

• Costing year: 2023$

• Discount rate: 3%

* Costs and QALYs lost due to long-term sequelae and deaths beyond one year are included

5
Vaccination

Symptomatic 

COVID-19

(non-hospitalized) 

Hospitalized

COVID-19

Non-medically 

attended*

Outpatient visit

No ICU 

admission

ICU admission

No side 

effects

Systemic 

reaction

Anaphylaxis

Severe 

adverse event

A

A

A

A

No booster

A

B

No 

complications

Long Covid 

No ventilator

Ventilator

B

C

Death

Model schematic

No

COVID-19

COVID-19

No long Covid

Long Covid

Long-term 

sequelae 

C

No 

complications

Long Covid 

Death

6

ED visit B

*Includes probability and costs of testing

ED= emergency department; ICU= intensive care unit
Analysis Plan

• Project health and economic outcomes stratified by intervention strategy and by 

age subgroups (18-49y, 50-64y, 65+y)

o Cases

o Hospitalizations

o Deaths

o Costs

o QALYs

o Adverse events

• Calculate incremental cost-effectiveness ratios comparing updated mRNA booster 

to no booster

• Conduct base case and uncertainty analyses (one-way sensitivity and scenario 

analyses)

***This presentation reports preliminary results from the first phase of an ongoing 

analysis***

7
Natural history: 

probability of symptomatic infection, outpatient/ED 

visits, hospitalization, and critical illness

8
Annual probability of symptomatic infection

9

Overall

0

20000

40000

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5

2021 2022 2023

Rate/100,000/month

18-49y 50-64y 65+y

Last 6 months

Source: HEROES-RECOVER, unpublished data

Annualized probability 

based on last 6 months

12/22-5/23

18-49 y 0.3145

50-64 y 0.2841

65+ y 0.3339
Annual probability of symptomatic infection

10

Annualized probability based on last 6 months

12/22-5/23

Age group Base case Range for sensitivity analysis

Low High

18-49 y 0.3145 0.2858 0.3444

50-64 y 0.2841 0.2438 0.3274

65+ y 0.3339 0.2312 0.4510

Source: HEROES-RECOVER, unpublished data
0

500

1,000

1,500

2,000

2,500

3,000

10

2020

11 12 1

2021

2 3 4 5 6 7 8 9 10 11 12 1 2

2022

3 4 5 6 7 8 9 10

Visits/100,000 Enrollees/month

18 - 49 Years 50 - 64 Years 65+ Years

Probability of an outpatient visit

11

Annualized Probability based on last 6 months

5/22-10/22

Age 

group

Base

Range for sensitivity 

analysis

Low High

18-49 y 0.075 0.022 0.110

50-64 y 0.106 0.041 0.159

65+ y 0.111 0.040 0.150

Last 6 months

Source: MerativeTM MarketScan® Research Database, unpublished data 
Probability of outpatient visits and ED visits given

symptomatic illness

12

Age group Base

Range for sensitivity analysis

Low High

Outpatient visits given symptomatic illness

18 - 49 y 0.157 0.1483 0.1664

50 - 64 y 0.215 0.1991 0.2335

65+ y 0.244 0.1996 0.3088

Emergency department visits given symptomatic illness

18 - 49 y 0.0184 0.0172 0.0196

50 - 64 y 0.0191 0.0175 0.0210

65+ y 0.0394 0.0318 0.0505

Source: Derived using probability of an outpatient visit or ED visit from MarketScan data (MerativeTM MarketScan® Research 

Database, unpublished data) and probability of symptomatic illness in the HEROES-RECOVER data, May 2022 - October 2022 

(unpublished)
0

50

100

150

200

250

300

350

400

9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4

2020 2021 2022 2023

Rate/100,000/month

18-49 years 50-64 years 65+ years

Annual probability of hospitalization

13

Annualized Probability based on last 6 months

10/22-3/23

Age group Base case Range

Low High

18-49 y 0.00144 0.00080 0.00204

50-64 y 0.00335 0.00216 0.00479

65+ y 0.01453 0.00967 0.02090

Last 6 months

Source: COVID-NET, unpublished data

Rate/100,000 based on last 6 months

10/22-3/23

Age group Base case

per 100,000

Range

Low High

18-49 y 144 80 204

50-64 y 335 216 479

65+ y 1453 967 2090
Probability of critical illness given hospitalization

14

Probability Base case

Range for sensitivity analysis (95% CI)

Low High

Probability ICU given hospitalization 

18-49 y 0.123 0.119 0.145

50-64 y 0.200 0.178 0.208

65+ y 0.144 0.138 0.163

Probability ventilator use given ICU

18-49 y 0.525 0.472 0.577

50-64 y 0.488 0.445 0.532

65+ y 0.386 0.342 0.432

Source: COVID-NET, unpublished data

ICU= intensive care unit
Probability of death given hospitalization

15

Source: COVID-NET, unpublished data

ICU= intensive care unit

Probability Base case

Range (95% CI)

Low High

Probability of death given no ICU

18-49 y 0.006 0.002 0.008

50-64 y 0.009 0.007 0.016

65+ y 0.030 0.022 0.035

Probability of death given ICU without ventilator

18-49 y 0.024 0.003 0.040

50-64 y 0.047 0.026 0.077

65+ y 0.166 0.144 0.233

Probability of death given ICU with ventilator

18-49 y 0.284 0.213 0.368

50-64 y 0.379 0.301 0.435

65+ y 0.628 0.476 0.637
Probability of long COVID

16

Age group Base case

Range

Low High

18-49 y 0.072 0.058 0.091

50-64 y 0.072 0.058 0.091

65+ y 0.072 0.058 0.091

Source: Montoy JCC et al. Prevalence of Symptoms ≤12 Months After Acute Illness, by COVID-19 Testing Status Among Adults — United States, December 2020–

March 2023. MMWR 2023; 72 (32): 859- 865.

Assumptions:

• Derived to reflect 5-month median duration of episode of long covid for individuals who experience 

symptoms for 3+ months

• Average prevalence of HEENT, constitutional, pulmonary, musculoskeletal, cognitive, and fatigue symptoms 

at 5 months

• Current estimates do not reflect higher risk associated with age or with severity of illness
Vaccine effectiveness & adverse events

17
Vaccine effectiveness: hospitalization, 18+ y

18

62%

47%

24%

57%

41%

12%

67%

53%

33%

0%

20%

40%

60%

80%

100%

0 73 146 219 292 365

Vaccine Efficacy Against Hospitalization (%)

Interval Days since Last Dose (days)

VISION(Sep 2022-May 2023)

62%

47%

24%

0%

20%

40%

60%

80%

100%

Vaccine Efficacy Against Hospitalization (%)

0 73 146 219 292 365

Interval Days since Last Dose (days)

VISION (Sep 2022-May 2023)

Source: VISION, bivalent booster, Sept 2022- May 2023. Link-Gelles R. Monovalent and bivalent VE against hospitalization among adults aged 

≥18 years. Paper presented at: Advisory Committee on Immunization Practices. June 2023

Conservative scenario

Optimistic scenario
Vaccine effectiveness: hospitalization, 18+ y

19

54%

34%

6%

39%

15%

65%

50%

30%

0%

20%

40%

60%

80%

100%

0 73 146 219 292 365

Vaccine Efficacy against Hospitalization (%)

Interval Time since Last Dose (days)

IVY (Sep 2022-May 2023)

54%

34%

6%

0%

20%

40%

60%

80%

100%

0 73 146 219 292 365

Vaccine Efficacy against Hospitalization (%) 

Interval Time since Last Dose (days)

IVY (Sep 2022-May 2023)

Source: IVY, bivalent booster, Sept 2022- May 2023. Link-Gelles R. Monovalent and bivalent VE against hospitalization among adults aged 

≥18 years. Paper presented at: Advisory Committee on Immunization Practices. June 2023

Conservative scenario

Optimistic scenario
Vaccine effectiveness: hospitalization, 18+ y

20

Source: VISION and IVY, bivalent vaccination, 

Sept 2022- May 2023. Link-Gelles R. Monovalent 

and bivalent VE against hospitalization among 

adults aged ≥18 years. Paper presented at: 

Advisory Committee on Immunization Practices. 

June 2023

Area under the curve: 0.269

0%

20%

40%

60%

80%

100%

0 73 146 219 292 365

Vaccine Efficacy Against Hospitalization (%)

Interval Days since Last Dose (days)

Lower bound

Upper bound

VISION (Sep 2022-May 2023)

0%

20%

40%

60%

80%

100%

0 73 146 219 292 365

Vaccine Efficacy Against Hospitalization (%)

Interval Days since Last Dose (days)

Lower bound

Upper bound

IVY (Sep 2022-May 2023)

61%

46%

22%

0%

20%

40%

60%

80%

100%

0 73 146 219 292 365

Vaccine Efficacy Against Hospitalization (%)

Interval Days since Last Dose (days)

Combined-VISION and IVY (Sep 2022-May 2023)
Vaccine effectiveness, hospitalization, 18+ y

21

Linear waning Conservative Optimistic

VISION

Base case 0.278 0.217 0.339

Lower bound 0.210 0.180 0.240

Upper bound 0.334 0.250 0.418

IVY

Base case 0.168 0.153 0.183

Lower bound 0.088 0.088 0.088

Upper bound 0.313 0.237 0.389

Base Case* 0.269 0.088 0.418

* Base case includes a weighted average of the area under the vaccine effectiveness (VE) curve with the assumption that VE wanes linearly after 180 days. Ranges were

selected by taking the minimum and maximum of the individual dataset VEs, applying a conservative approach (assuming VE drops to 0 at 180 days) for the lower bound 

and an optimistic approach for the upper bound (assuming VE at 365 days=VE at 180 days)
Summary, vaccine effectiveness

22

Base case Low High

Symptomatic illness (non-hospitalized)*

Hospitalization, uncomplicated 0.269 0.088 0.418

Hospitalization, critical illness** 0.403 0.191 0.671

Death 0.403 0.191 0.671

Source: VISION and IVY, Link-Gelles R. Monovalent and bivalent VE against hospitalization among adults aged ≥18 years. Paper 

presented at: Advisory Committee on Immunization Practices. June 2023

* Non-medically attended illness, illness that includes an outpatient or ED visit

** Intensive care unit with or without mechanical ventilation 
Summary, vaccine effectiveness

23

Base case Low High

Symptomatic illness (non-hospitalized)* 0.269 0.088 0.418

Hospitalization, uncomplicated 0.269 0.088 0.418

Hospitalization, critical illness** 0.403 0.191 0.671

Death 0.403 0.191 0.671

Source: VISION and IVY, Link-Gelles R. Monovalent and bivalent VE against hospitalization among adults aged ≥18 years. Paper 

presented at: Advisory Committee on Immunization Practices. June 2023

* Non-medically attended illness, illness that includes an outpatient or ED visit

** Intensive care unit with or without mechanical ventilation 
Probability of adverse events 

24

Base case

Range for sensitivity analysis

Source

Low High

Systemic reaction

18-49 y 0.106 0.073 0.148

50-64 y 0.106 0.073 0.148 1,2

≥65 y 0.137 0.107 0.171

Anaphylaxis (all ages) 0.00000495 0.0000032 0.0000074 3

Death given anaphylaxis 0 0 0.00966 Assumption, 4

Myocarditis

18 - 29 y 0.0000238 0.0000085 0.0000838 5

30-39 y 0.0000087 0.0000008 0.0000375 5

40+ y 0 0 0 Assumption

Death given myocarditis 0.0005 0 0.001 Expert opinion

1. U.S. Food and Drug Administration. Fact Sheet for Healthcare Providers Administering Vaccine: Emergency Use Authorization of Moderna COVID-19 Vaccine, Bivalent (Original 

and Omicron BA.4/BA.5). In: U.S. Department of Health and Human Services, ed2023.

2. U.S. Food and Drug Administration. Fact Sheet for Healthcare Providers Administering Vaccine: Emergency Use Authorization of Pfizer- Biontech COVID-19 Vaccine, Bivalent 

(Original and Omicron BA.4/BA.5). In: U.S. Department of Health and Human Services, ed2023.

3. Klein NP, Lewis N, Goddard K, et al. Surveillance for Adverse Events After COVID-19 mRNA Vaccination. JAMA. 2021;326(14):1390-1399.

4.Su JR, Moro PL, Ng CS, Lewis PW, Said MA, Cano MV. Anaphylaxis after vaccination reported to the Vaccine Adverse Event Reporting System, 1990-2016. J Allergy Clin Immunol. 

2019;143(4):1465-1473.

5. Kristin Goddard KEH, Ned Lewis,. Incidence of Myocarditis/Pericarditis Following mRNA COVID-19 Vaccination Among Children and Younger Adults in the United States. Annals of 

Internal Medicine. 2022;175(12):1169-1771.
Costs: Direct medical costs and productivity losses 

25
Direct medical costs

Variable Base case

Range for sensitivity analysis

Source 

Low High

Testing

Test cost $8 $8 $62 1,2

Probability of testing 0.05 0.02 0.20 3

Recipient time (hours) 0.50 0.25 1.50 Assumption

Outpatient visit

18-49 y $372 $370 $375

50-64 y $380 $377 $384 4

65+ y $391 $386 $396

Long Covid $1091 $1018 $1165 5

26

1. Justin Lo CC, Krutika Amin, Imani Telesford, Lindsey Dawson, and Jennifer Kates. Prices for COVID-19 testing. 2023; https://www.healthsystemtracker.org/brief/prices-for-covid-19-

testing/#Prices%20for%20COVID-19%20tests%20in%20the%20outpatient%20setting,%20among%20people%20with%20large%20employer%20health%20coverage,%202021.

2. Walmart. COVID-19 Test Kits. https://www.walmart.com/browse/home-diagnostic-tests/covid-19-test-kits/976760_1005860_542089_3092061. Accessed September 1, 2023.

3. Rader B GA, Iuliano AD,. Use of At-Home COVID-19 Tests — United States, August 23, 2021–March 12, 2022

4. MerativeTM MarketScan® Research Database, unpublished data 

5. Pike J et al. Direct Medical Costs Associated With Post–COVID-19 Conditions Among Privately Insured Children and Adults. Prev Chronic Dis. 2023;20 (6) 
Direct medical costs, cont.

Variable Base case

Range for Sensitivity Analysis

Low High

Hospitalization episode

18-49 y $32,514 $28,505 $36,523

50-64 y $32,854 $31,450 $34,258

65+ y $20,648 $20,295 $21,000

ICU episode (no ventilator)

18-49 y $37,159 $30,116 $44,203

50-64 y $46,727 $40,269 $53,186

65+ y $23,220 $22,408 $24,032

ICU (with ventilator) episode

18-49 y $245,432 $168,362 $322,503

50-64 y $169,189 $140,250 $198,129

65+ y $55,257 $50,705 $59,809

27

ICU= Intensive care unit

Source: MerativeTM MarketScan® Research Database, unpublished data 
Medication costs

Variable Base case

Range for Sensitivity Analysis

Source 

Low High

Over the counter medication* $4.12 - - 1

Probability of nirmatrelvir-r prescription 

given an outpatient visit

18-49 years 0.1751 0.10 0.30

50-64 years 0.2696 0.10 0.50 2,3, Assumption

65+ years 0.2739 0.10 0.50

Cost, nirmatrelvir-r $530 $530 $1200 4, 5

28

*5 days of generic cold/flu medicine

1. Target.com Accessed August 29, 2023.

2. HealthVerity, Inc. COVID-19 database licensed by CDC, unpublished data

3. MerativeTM MarketScan® Research Database, unpublished data

4. Recht H. Paxlovid Has Been Free So Far. Next Year, Sticker Shock Awaits. 2022; https://kffhealthnews.org/news/article/paxlovid-covid-sticker-shockinsurance/#:~:text=The%20U.S.%20government%20has%20so,in%20a%20July%20earnings%20call.

5. Murez C. Paxloid soon won’t be free for Americans. 2022 https://www.usnews.com/news/health-news/articles/2022-12-07/paxlovid-soon-wont-be-free-for-americans. Accessed September 7, 2023
Vaccine receipt, costs

Variable Base case

Range for Sensitivity Analysis

Source 

Low High

mRNA monovalent booster, per dose* $120 $30 $200 1, expert opinion

Administration, per dose** $20.33 $18.07 $26.58 2

Vaccination setting

Proportion, pharmacy 0.644 0.625 0.663 3

Proportion, physician office visit 0.256 0.221 0.294 3

Proportion, mass vaccination 0.100 0.075 0.155 3

Recipient time by vaccination setting (hours)

Pharmacy 0.25 0.083 0.50 4, expert opinion

Physician office 1.19 0.17 2 4

Mass vaccination 0.195 0 0.390 4

Mean hourly earnings $33.74 $23.98 $50.16 5

29

*Lower bound reflects current price of COVID-19 boosters

**CPT 90471

1. Kates J et al. How much could COVID-19 vaccines cost the US after commercialization? 2023. https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-could-covid-19-vaccines-cost-the-u-s-aftercommercialization/

2. Centers for Medicare & Medicaid Service. Search the Physician Fee Schedule. 2023; https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=0&HT=0&CT=3&H1=90471&M=5

3. CDC national survey data, 2/10/23-5/1/23, unpublished

4. Prosser L, O'Brien M, Molinari N, et al. Non-traditional settings for influenza vaccination of adults: Costs and cost-effectiveness. Pharmacoeconomics. 2008;26(2):163-178.

5. US Bureau of Labor Statistics. Average hourly and weekly earnings of all employees on private nonfarm payrolls by industry sector, seasonally adjusted. 2023; https://www.bls.gov/news.release/empsit.t19.htm
Vaccination-associated adverse events, costs

Variable Base case

Range for Sensitivity Analysis

Source 

Low High

Systemic reaction

Physician visit $90.82 $82.72 $115.84 1

Productivity loss (days) 1 - - Assumption

Anaphylaxis

Hospitalization $5035 2*

Productivity loss (days) 1 1 3 3

Myocarditis/pericarditis

Hospitalization $75,927 4**

Productivity loss (days) 4 0 14 5, 6, Expert opinion

30

* HCUP-NIS 2012 estimates (mean LOS = 4.9 days) adjusted to 1 days LOS

** HCUP-NIS 2014 estimates (mean LOS = 7.4 days) adjusted to 4 days LOS

1. Centers for Medicare & Medicaid Service. Search the Physician Fee Schedule. 2023; https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=0&HT=0&CT=3&H1=90471&M=5

2. Candrilli S, Kurosky SK. Recent Trends In Anaphylaxis-Related Hospitalization In The United States. Value in Health. 2015;18(7):A503.

3. Shimabukuro T, Cole M, Su JR. Reports of Anaphylaxis After Receipt of mRNA COVID-19 Vaccines in the US- December 14, 2020-January 18, 2021. Jama. 2021;325(11):1101-1102.

4. Khorolsky C, Shi J, Chkhikvadze T. Trends In Hospitalization Costs, Length Of Stay And Complications Among Patients With Acute Myocarditis: A 10-Year United States Perspective. Journal of the American College 

of Cardiology. 2019;73(9_Supplement_1):935-935.

5. Marshall M, Ferguson I, Lewis P, et al. Symptomatic Acute Myocarditis in Seven Adolescents Following Pfizer-BioNTech COVID-19 Vaccination. Pediatrics. 2021.

6. Shimabukuro T. COVID-19 Vaccine Safety Updates. In. Advisory Committee on Immunization Practices (ACIP)2021.
Quality adjustments

31
QALY losses, COVID-19 illness

32

Variable Base Case

Range for Sensitivity Analysis

QALDs lost

Low High

Symptomatic illness* 0.006 0.004 0.008 2.2 (1.5 - 2.9)

Hospitalization 0.027 - - 9.9 

Critical illness** 0.054 - - 19.7

Long COVID 0.067 0.038 0.088 24.3 (13.7 - 31.9)

* Non-medically attended and outpatient illness

** Intensive care unit with mechanical ventilation. Derived by applying the ratio of ICU to hospitalization QALY loss (2x) to the 

hospitalization QALY loss from SARS CoV-2 EQ5D Study. The model also includes a health state for ICU care without ventilator use for 

which QALY loss is interpolated using QALY loss for hospitalization and critical illness

DRAFT

Source: Coronavirus Household Evaluation and Respiratory Testing (C-HEaRT) and Prospective Assessment of COIVD-19 in a Community (PACC), unpublished data
QALY loss, vaccination-associated AEs

33

Variable Base Case

Range for Sensitivity Analysis

QALDs lost Source

Low High

Systemic reaction (QALY loss)*

All ages 0.0004 0.0003 0.0005 0.15 (0.11 - 0.18) Assumption 

Anaphylaxis (QALY loss)

All ages 0.0137 0.0135 0.0139 5.0 (0.93 - 5.08) 1

Myocarditis/pericarditis (QALY loss)

Acute illness** 0.010 0.0086 0.0112 3.65 (3.14 - 4.09) 2

* QALY loss equal to one day of COVID-19 illness

** Derived from health utility for COVID-19 related myocarditis. Assumed 2-week illness

QALY= Quality-adjusted life year; QALD= Quality-adjusted life day

1. Prosser LA, Payne K, Rusinak D, Shi P, Uyeki TM, Messonnier ML. Valuing health across the lifespan: health state preferences for seasonal influenza illnesses in patients of different ages. Value in 

Health. 2011;14(1):135-143.

2. Morrow AJ, Sykes R, McIntosh A, et al. A multisystem, cardio-renal investigation of post-COVID-19 illness. Nature Medicine. 2022;28(6):1303-1313
Results

preliminary estimates

34
Disaggregated results, per 100,000

preliminary estimates

Age 

group

Strategy

Cases Cases Averted

Cases Hosp ICU Deaths Cases Hosp ICU Deaths

18-49 y No booster 31,450 144 17.7 3.6 - - - -

Booster dose 22,990 105 10.6 2.2 8,460 39 7.1 1.4 

50-64y No booster 28,410 335 67.1 16.4 - - - -

Booster dose 20,768 245 40.0 9.9 7,642 90 27.0 6.6 

65+ y No booster 33,390 1,453 209.3 109.4 - - - -

Booster dose 24,408 1,062 124.9 66.0 8,982 391 84.3 43.4 

35
Incremental cost-effectiveness ratios, 

societal perspective, per 1000

preliminary estimates

Age group Strategy

Projected

Costs

Incremental

Costs

Projected

QALYs

Incremental 

QALYs

$/QALY

18-49 y No booster $192,335 - 20207.0670 - -

Booster vaccination $293,503 $101,168 20207.9423 0.8752 $115,588

50-64y No booster $385,752 - 12275.8345 - -

Booster vaccination $421,249 $35,498 12277.2111 1.3766 $25,787

65+ y No booster $642,488 - 6519.9466 - -

Booster vaccination $598,857 -$43,630 6523.5511 3.6046 Cost-saving

36

QALY= quality-adjusted life year
Incremental cost-effectiveness ratios, 

societal perspective, per 1000

preliminary estimates, w/pooled 18+ 

Age group

Booster Dose,

$/QALY

18-49 y $115,588

50-64 y $25,787

65+ y Cost-saving

18+ y $33,437

37

QALY= quality-adjusted life year
One way sensitivity analyses, 18-49 y

preliminary estimates

38

*Non-hospitalized cases Base case: $115,588

Note: Numbers next to bars indicate input values for sensitivity analysis

VE=vaccine effectiveness; QALY=Quality-adjusted life year

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

Probability, symptomatic COVID-19

Time (h), vaccination, doctor's office

Lifetime productivity cost

VE, hospitalization

Probability, death given ICU with ventilator

QALYs lost symptomatic COVID

Probability, hospitalization

VE, critical illness

VE, symptomatic COVID-19

Cost, vaccine

$/QALY

$30 $200

0.418 0.088

0.671 0.191

0.002 0.0008

0.008 0.004

0.368 0.213

0.418 0.088

$2,382,347

0.17 2

0.344 0.286

*
VE scenario analyses 

preliminary estimates

Base case Scenario 1 Scenario 2 Scenario 4 Scenario 5

VE inputs

Symptomatic illness 0.269 0.088 0.418 0.269 0.403

Hospitalization, uncomplicated 0.269 0.088 0.418 0.269 0.403

Hospitalization, critical illness 0.403 0.191 0.671 0.269 0.403

Death 0.403 0.191 0.671 0.269 0.403

$/QALY

18-49 y $115,588 $435,886 $45,376 $141,155 $70,928

50-64 y $25,787 $199,830 Cost-saving $51,792 $3,001

65+ y Cost-saving $51,782 Cost-saving Cost-saving Cost-saving

39

VE= vaccine effectiveness; QALY= quality-adjusted life year
Scenario analyses: 

probability of symptomatic illness, non-hospitalized*

preliminary estimates

40

Age group Base case 0.1 0.2 0.3 0.4 0.5

18-49 y $115,588 $229,724 $160,000 $120,013 $94,082 $75,905

50-64 y $25,787 $48,937 $34,724 $24,324 $16,384 $10,123

65+ y Cost-saving Cost-saving Cost-saving Cost-saving Cost-saving Cost-saving

QALY=Quality-adjusted life year

*One-way sensitivity analysis of non-hospitalized symptomatic illness varied separately from hospitalization and critical illness; 

base case probability of symptomatic illness: 18-49 y, 0.3145; 50-64 y, 0.2841; 65+ y, 0.3339
Scenario analysis: 

probability of hospitalization

preliminary estimates

41

Age group Base case* 2x base case 3x base case 4x base case

18-49 y $115,588 $51,978 $14,541 Cost-saving

50-64 y $25,787 Cost-saving Cost-saving Cost-saving

65+ y Cost-saving Cost-saving Cost-saving Cost-saving

QALY=Quality-adjusted life year

*Base case probability of hospitalization 18-49 y- 0.00144; 50-64 y-0.00335; 65+ - 0.01453
Scenario analysis: probability of critical care

preliminary estimates

42

Age group

Probability of ICU given hospitalization

Base case* 2x 3x 4x

18-49 y $115,588 $71,487 $42,307 $21,570

50-64 y $25,787 Cost-saving Cost-saving Cost-saving

65+ y Cost-saving Cost-saving Cost-saving Cost-saving

QALY=Quality-adjusted life year; ICU= Intensive care unit

* Base case probability of ICU given hospitalization: 18-49 y- 0.123; 50-64 y- 0.200, 65+ y- 0.144
Scenario analysis: vaccine setting

preliminary estimates

43

Age group Base case* 100% 

pharmacy

100% 

physician office

100% 

mass vaccination

18-49 y $115,588 $106,523 $142,759 $104,403

50-64 y $25,787 $20,024 $43,063 $18,676

65+ y Cost-saving Cost-saving Cost-saving Cost-saving

QALY=Quality-adjusted life year

* Base case: Physician office visit- 0.256, Pharmacy- 0.644, Mass vaccination- 0.100 
Limitations

▪ Unpublished data used to derive key parameters in the model: vaccine effectiveness, 

symptomatic illness, probabilities of hospitalization and critical illness

▪ Data sources vary in representativeness, generalizability

▪ VE estimates derived from data on bivalent booster 

▪ Hospitalization rates may overestimate cases due to COVID-19 for younger age groups

▪ MarketScan data for ages 65+ only includes those with supplemental insurance

▪ Evidence base for long covid is especially scarce – future analyses will incorporate adjustments 

to reflect differences in probability and duration of long covid by age and severity of illness

▪ Cost estimates for long covid may not reflect current practice patterns or rates of HC utilization

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Summary - preliminary estimates

• Vaccination averts substantial morbidity and mortality as 

demonstrated through estimated disaggregated outcomes

• ICERs for 50-64y and 65+ age groups are robust to changes in 

parameter inputs across plausible ranges in all but one scenario 

(<$51,800 or cost-saving)

• ICERs for 18-49y are sensitive to changes in parameter inputs; more 

favorable for higher VE, higher risk of hospitalization and critical 

illness

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