Summary of three economic analyses of the use of 

20-valent pneumococcal conjugate vaccine (PCV20) 

in children in the United States

Diepreye V. Ayabina

Division of Bacterial Diseases

CDC/NCIRD

Advisory Committee on Immunization Practices 

June 22, 2023
Acknowledgements

• This presentation summarizes work conducted by three modeling teams

• Tulane-CDC team

• Charles Stoecker (Tulane University), Miwako Kobayashi (CDC), Andrew Leidner (CDC), Diepreye

Ayabina

• Pfizer team

• Mark Rozenbaum, Liping Huang, Alejandro Cane, Erica Chilson, Adriano Arguedas, Maria J. Tort, 

Raymond Farkouh, Vincenza Snow

• Merck team

• Min Huang, Jessica Weaver, Elamin Elbasha

Views and opinions expressed in this presentation are the authors and do not necessarily represent the 

views and opinions of the Centers for Disease Control and Prevention. 2
Conflicts of interest statement

• Diepreye Ayabina: None.

• Tulane-CDC team: None.

• Pfizer team:

• Pfizer manufactures the PCV13 and PCV20 vaccines.

• Merck team:

• Merck manufactures the PCV15 and PPSV23 vaccines

3
Terminology

Abbreviation Full term/Meaning

AOM Acute otitis media

CMC Chronic medical conditions but not immunocompromised1

IC Immunocompromising conditions2

ICER Incremental cost-effectiveness ratio

IPD Invasive pneumococcal disease

PCV13 13-valent pneumococcal conjugate vaccine

PCV15 15-valent pneumococcal conjugate vaccine

PCV20 20-valent pneumococcal conjugate vaccine

PPSV23 Pneumococcal polysaccharide vaccine (23 serotypes)

QALYs Quality-adjusted life-years

1

Includes chronic heart, lung, and liver diseases, diabetes.

2

Includes chronic renal failure, nephrotic syndrome, congenital immunodeficiency, congenital or acquired asplenia, or splenic dysfunction, diseases associated with treatment of immunosuppressive drugs 

or radiation therapy such as Hodgkin disease, leukemia, lymphoma, malignant neoplasm and solid organ transplant, HIV and sickle cell disease. 4
Outline

• Introduction

• Policy question #1: (Routine use of PCV20)

• Model description

• Estimated health outcomes and cost results

• Overview of cost-effectiveness results 

• Model assumptions driving differences + sensitivity analysis

• Policy question #2: (Use of PCV20 in with underlying medical conditions that increase the risk of 

pneumococcal disease)

• Estimated health outcomes and cost results

• Overview of cost-effectiveness results 

• Model assumptions driving differences + sensitivity analysis

• Summary

5
Introduction

• This presentation describes three cost-effectiveness models that have been used to examine the costs and 

benefits of including PCV20 as an option in the childhood immunization schedule developed. 

• Tulane-CDC, Pfizer, and Merck

• Results of this presentation focus on routine use of PCV20 among <2-year-olds, and among 2-18-year-olds 

with underlying conditions. 

• Assessments of a supplemental PCV20 dose in children who completed the PCV series with PCV13 or PCV15 are not included

• All three reports went through the CDC economic review following the ACIP Guidance for Health Economics 

Studies

• Completion of the economic review does not confer any explicit or implied approval of the model

6
Policy question 1

Routine use of PCV20 in children
Policy question #1

Should PCV20 be recommended as an option for pneumococcal

conjugate vaccination according to currently recommended dosing and

schedules, for children aged <2 years in the United States?

CostsIntervention − CostsComparator

OutcomesIntervention − OutcomesComparator

= Incremental cost−effectiveness ratio (ICER)

Intervention (dosing) Comparator (dosing)

PCV20 (3+1) PCV13 (3+1) /PCV15 (3+1)

8
Description of models

Policy question #1

Model characteristics Tulane-CDC Merck Pfizer

Cohort type Single birth cohort Single birth cohort Multi-cohort

Analytic model time frame 17 years 100 years 10 years

Include indirect effects Yes Yes (only to IPD incidence) Yes

Base case perspective Societal Societal Societal

Currency year 2022 $ US 2022 $ US 2022 $ US

aVaccine price PCV13: $184

PCV15: $183

PCV20: $213

PCV13: $192

PCV15: $189

PCV20: $213

PCV13: $182

PCV15: $184

PCV20: $204

Other vaccine costs per dose Admin: $30; travel: $36 Admin: $19 Admin: $18

aAll three models used blended vaccine prices (vaccine price was weighted average of private and public market prices, weights were private and public market shares, which 

varied across the models).

9
Health outcomes and cost resultsa

PCV20 vs PCV15, base case

PCV20 vs PCV15

Outcomes and cost Tulane-CDC Merck ++Pfizer

Health outcomes

IPD cases -360 -400 -30,000*

Pneumonia cases -13,000 -2,300 -1,400,000*

AOM cases -150,000 -201,000 -3,000,000*

Deaths -160 -28 -9,700*

QALYs 1,900 1,400 280,000

Costs ($ millions)

Cost of disease + sequelae -210 -180 -12,000

Vaccine costs 440 330 2,100

Total cost 230 150 -10,000

10

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

All other values were discounted at 3%.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15.

++Pfizer base case results involve vaccination of 10 cohorts of children, results from single cohort shown in supplemental slide.
PCV20 vs PCV15

Outcomes and cost Tulane-CDC Merck ++Pfizer

Health outcomes

IPD cases -360 -400 -30,000*

Pneumonia cases -13,000 -2,300 -1,400,000*

AOM cases -150,000 -201,000 -3,000,000*

Deaths -160 -28 -9,700*

QALYs 1,900 1,400 280,000

Costs ($ millions)

Cost of disease + sequelae -210 -180 -12,000

Vaccine costs 440 330 2,100

Total cost 230 150 -10,000

11

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

All other values were discounted at 3%.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15

++Pfizer base case results involve vaccination of 10 cohorts of children, results from single cohort shown in supplemental slide.

Health outcomes and cost resultsa

PCV20 vs PCV15, base case
PCV20 vs PCV15

Outcomes and cost Tulane-CDC Merck ++Pfizer

Health outcomes

IPD cases -360 -400 -30,000*

Pneumonia cases -13,000 -2,300 -1,400,000*

AOM cases -150,000 -201,000 -3,000,000*

Deaths -160 -28 -9,700*

QALYs 1,900 1,400 280,000

Costs ($ millions)

Cost of disease + sequelae -210 -180 -12,000

Vaccine costs 440 330 2,100

Total cost 230 150 -10,000

12

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

All other values were discounted at 3%.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15.

++Pfizer base case results involve vaccination of 10 cohorts of children, results from single cohort shown in supplemental slide.

Health outcomes and cost resultsa

PCV20 vs PCV15, base case
PCV20 vs PCV15

Outcomes and cost Tulane-CDC Merck ++Pfizer

Health outcomes

IPD cases -360 -400 -30,000*

Pneumonia cases -13,000 -2,300 -1,400,000*

AOM cases -150,000 -201,000 -3,000,000*

Deaths -160 -28 -9,700*

QALYs 1,900 1,400 280,000

Costs ($ millions)

Cost of disease + sequelae -210 -180 -12,000

Vaccine costs 440 330 2,100

Total cost 230 150 -10,000

13

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

All other values were discounted at 3%.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15.

++Pfizer base case results involve vaccination of 10 cohorts of children, results from single cohort shown in supplemental slide.

Health outcomes and cost resultsa

PCV20 vs PCV15, base case
PCV20 vs PCV15

Outcomes and cost Tulane-CDC Merck ++Pfizer

Health outcomes

IPD cases -360 -400 -30,000*

Pneumonia cases -13,000 -2,300 -1,400,000*

AOM cases -150,000 -201,000 -3,000,000*

Deaths -160 -28 -9,700*

QALYs 1,900 1,400 280,000

Costs ($ millions)

Cost of disease + sequelae -210 -180 -12,000

Vaccine costs 440 330 2,100

Total cost 230 150 -10,000

14

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

All other values were discounted at 3%.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15

++Pfizer base case results involve vaccination of 10 cohorts of children, results from single cohort shown in supplemental slide.

Health outcomes and cost resultsa

PCV20 vs PCV15, base case
Model assumptions

*Indirect effects of pediatric PCV20 vaccination on adult pneumonia incidence

Model

Disease 

outcomes 

impacted by 

indirect effects

Details on the indirect effects methodology

Adjust for 

PCV20 use 

among 65+

Data years 

for indirect 

effect on 

pneumonia

Approximate 

% of PCV20 

only type 

pneumonia

Approximate 

reduction in 

PCV20-only 

pneumonia

per cohort

Merck • IPD

• Assume 8% reduction per year, with a max of 

33% achieved in year 4 and maintained until the 

end of the cohort No NA (IPD considered only)

• Higher indirect effects as a result of PCV20 use would lead to PCV20 being more cost-effective when compared to other PCV vaccines.

15
Model assumptions

*Indirect effects of pediatric PCV20 vaccination on adult pneumonia incidence

Model

Disease 

outcomes 

impacted by 

indirect effects

Details on the indirect effects methodology

Adjust for 

PCV20 use 

among 65+

Data years 

for indirect 

effect on 

pneumonia

Approximate 

% of PCV20 

only type 

pneumonia

Approximate 

reduction in 

PCV20-only 

pneumonia

per cohort

Merck • IPD

• Assume 8% reduction per year, with a max of 

33% achieved in year 4 and maintained until the 

end of the cohort No NA (IPD considered only)

TulaneCDC

• IPD

• Pneumonia

• AOM

• Based on regression model estimates 

• Estimated impact per vaccinated cohort

• Indirect effect benefit attributed to birth cohort 

of children who receive PCV20

Yes 2013-2014a 0.6 to 2.4% 3.2%

Pfizer

• IPD

• Pneumonia

• AOM

• Based on observed reduction in all-cause 

pneumonia Percentage of PCV20 type disease 

Gradual increase in indirect effect over 10 years

Yes 2008/2009 to 

2018a

Greater than 

1 to 7% 0.5 to 3.4%b

* Higher indirect effects as a result of PCV20 use would lead to PCV20 being more cost effective when compared to other PCV vaccines. The Tulane-CDC and Pfizer models both accounted for the direct protection in all 

adults.

aThe Tulane-CDC model estimated a monthly reduction in disease due to indirect effects, using data from 2013 and the first half of 2014 (Pilishvili 2018a; Pilishvili et al. 2018b). The Pfizer model used a total reduction in 

disease from 2008/2009 to 2018 (Tong et al. 2018, Table 3).

b.These are approximations based on calculations by the presenting author, based on each cohort in the Pfizer model contributing to indirect effects for 5 years. 16
Model assumptions

*Indirect effects of pediatric PCV20 vaccination on adult pneumonia incidence

Model

Disease 

outcomes 

impacted by 

indirect effects

Details on the indirect effects methodology

Adjust for 

PCV20 use 

among 65+

Data years 

for indirect 

effect on 

pneumonia

Approximate 

% of PCV20 

only type 

pneumonia

Approximate 

reduction in 

PCV20-only 

pneumonia

per cohort

Merck • IPD

• Assume 8% reduction per year, with a max of 

33% achieved in year 4 and maintained until the 

end of the cohort No NA (IPD considered only)

TulaneCDC

• IPD

• Pneumonia

• AOM

• Based on regression model estimates 

• Estimated impact per vaccinated cohort

• Indirect effect benefit attributed to birth cohort 

of children who receive PCV20

Yes 2013-2014a 0.6 to 2.4% 3.2%

Pfizer

• IPD

• Pneumonia

• AOM

• Based on observed reduction in all-cause 

pneumonia Percentage of PCV20 type disease 

Gradual increase in indirect effect over 10 years

Yes 2008/2009 to 

2018a

Greater than 

1 to 7% 0.5 to 3.4%b

* Higher indirect effects as a result of PCV20 use would lead to PCV20 being more cost effective when compared to other PCV vaccines. The Tulane-CDC and Pfizer models both accounted for the direct protection in all 

adults.

aThe Tulane-CDC model estimated a monthly reduction in disease due to indirect effects, using data from 2013 and the first half of 2014 (Pilishvili 2018a; Pilishvili et al. 2018b). The Pfizer model used a total reduction in 

disease from 2008/2009 to 2018 (Tong et al. 2018, Table 3).

b.These are approximations based on calculations by the presenting author, based on each cohort in the Pfizer model contributing to indirect effects for 5 years. 17
Cost effectiveness results: base case

PCV20 vs PCV13

aCost-saving means lower costs and improved health outcomes in the intervention, as compared to the comparator.

Intervention Comparator Model Cost per QALY gained

PCV20 PCV13 Tulane-CDC 57,000

Merck aCost-saving

Pfizer aCost-saving

PCV20 PCV15 Tulane-CDC 125,000

Merck 105,003

Pfizer aCost-saving

18
Cost effectiveness results: base case

PCV20 vs PCV15

aCost-saving means lower costs and improved health outcomes in the intervention, as compared to the comparator.

Intervention Comparator Model Cost per QALY gained

PCV20 PCV13 Tulane-CDC 57,000

Merck aCost-saving

Pfizer aCost-saving

PCV20 PCV15 Tulane-CDC 125,000

Merck 105,003

Pfizer aCost-saving

19
Sensitivity analysis (Policy question #1)

Cost-effectiveness of routine vaccination with PCV20 for children

Intervention Comparison Model

Cost per QALY gained

Base case Rangeb

PCV20 PCV13 Tulane-CDC 57,000 NA

Merck Cost-saving NA

Pfizer Cost-saving All cost-saving

PCV20 PCV15 Tulane-CDC 125,000 [31,000 210,000]

Merck 105,000 [8,000 dominateda]

Pfizer Cost-saving [Cost-saving 60,000]

a

In one scenario in the Merck model, PCV15 was cost-saving relative to PCV20 (or PCV20 was dominated by PCV15), this scenario assumed re-emergence of IPD associated with certain 

serotypes that PCV20 missed the trial primary endpoint.

b The ranges presented are obtained from the scenario analyses and probabilistic sensitivity analysis.
Sensitivity analysis (Policy question #1)

Cost-effectiveness of routine vaccination with PCV20 for children

Intervention Comparison Model

Cost per QALY gained

Base case Rangeb

PCV20 PCV13 Tulane-CDC 57,000 NA

Merck Cost-saving NA

Pfizer Cost-saving All cost-saving

PCV20 PCV15 Tulane-CDC 125,000 [31,000 210,000]

Merck 105,000 [8,000 dominateda]

Pfizer Cost-saving [Cost-saving 60,000]

a

In one scenario in the Merck model, PCV15 was cost-saving relative to PCV20 (or PCV20 was dominated by PCV15), this scenario assumed re-emergence of IPD associated with certain 

serotypes that PCV20 missed the trial primary endpoint.

b The ranges presented are obtained from the scenario analyses and probabilistic sensitivity analysis.
Policy question 2

Use of PCV20 in children with underlying medical conditions that increase the risk of pneumococcal disease
Policy question #2

Should PCV20 without PPSV23 be recommended as an option for pneumococcal vaccination

according to currently recommended dosing and schedules, for U.S. children 2–18 years with

underlying medical conditions that increase the risk of pneumococcal disease (CMC/IC)?

• 2.1. What is the cost effectiveness of PCV20 alone vs PCV13/15+PPSV23 series among CMC/IC?

• 2.2. What is the cost effectiveness of adding PPSV23 to a PCV20 series among CMC/IC?

CostsIntervention − CostsComparator

OutcomesIntervention − OutcomesComparator

= Incremental cost effectiveness ratio (ICER)

Comparator (dosing) Intervention (dosing) Population

PCV13/15(3+1) + PPSV23 (1) PCV20 (3+1) CMC

PCV13/15(3+1) + PPSV23 (1+1) PCV20 (3+1) IC

PCV20(3+1) + PPSV23 (1) PCV20 (3+1) CMC

PCV20(3+1) + PPSV23 (1+1) PCV20 (3+1) IC

23
Policy question 2.1

PCV20 alone vs PCV13/15+PPSV23 series among CMC/IC
Health outcomes and costs

PCV20 alone vs PCV15+PPSV23 in CMC, base case

Outcomes and cost

PCV20 vs PCV15 + PPSV23

Tulane-CDC Merck Pfizera

Health 

outcomes

IPD cases -26 -15 -5*

Pneumonia cases -780 -260 -1,100*

AOM cases -30,000 -28,000 -4,900*

Deaths -2 -1 -5*

QALYs 200 140 120

Costs

($ millions)

Vaccine costs -1 7 5

Cost of disease + sequelae -32 -23 -18

Total cost -33 -16 -12

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15+PPSV23.

a. The Pfizer model does not directly assess policy question 2 but compares the receipt of PCV20 with and without PPSV23 to the receipt of PPSV23 on six-yearold children with a history of PCV13 vaccination. 
Health outcomes and costs

PCV20 alone vs PCV15+PPSV23 in CMC, base case

Outcomes and cost

PCV20 vs PCV15 + PPSV23

Tulane-CDC Merck Pfizera

Health 

outcomes

IPD cases -26 -15 -5*

Pneumonia cases -780 -260 -1,100*

AOM cases -30,000 -28,000 -4,900*

Deaths -2 -1 -5*

QALYs 200 140 120

Costs

($ millions)

Vaccine costs -1 7 5

Cost of disease + sequelae -32 -23 -18

Total cost -33 -16 -12

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15+PPSV23.

a. The Pfizer model does not directly assess policy question 2 but compares the receipt of PCV20 with and without PPSV23 to the receipt of PPSV23 on six-year-old 

children with a history of PCV13 vaccination. 
Health outcomes and costs

PCV20 alone vs PCV15+PPSV23 in CMC, base case

Outcomes and cost

PCV20 vs PCV15 + PPSV23

Tulane-CDC Merck Pfizera

Health 

outcomes

IPD cases -26 -15 -5*

Pneumonia cases -780 -260 -1,100*

AOM cases -30,000 -28,000 -4,900*

Deaths -2 -1 -5*

QALYs 200 140 120

Costs

($ millions)

Vaccine costs -1 7 5

Cost of disease + sequelae -32 -23 -18

Total cost -33 -16 -12

In these assessments, 

all three models 

estimate higher health 

and lower total costs

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15+PPSV23.

a. The Pfizer model does not directly assess policy question 2 but compares the receipt of PCV20 with and without PPSV23 to the receipt of PPSV23 on six-year-old 

children with a history of PCV13 vaccination. 
Cost-effectiveness results, policy question

base case

Risk group Intervention Comparator Model Cost per 

QALY

CMC

PCV20

PCV13 + PPSV23 Tulane-CDC

& 

PCV15 +PPSV23 Merck Cost-saving

PCV13 + PCV20 PCV13 + PPSV23 Pfizera

IC

PCV20

PCV13 + PPSV23 +PPSV23 Tulane-CDC

&

PCV15 + PPSV23 + PPSV23 Merck Cost-saving

PCV13 + PCV20 PCV13 + PPSV23 + PPSV23 Pfizera

aPfizer model had a different set of comparisons: in CMC: PCV13 (3+1) + PCV20 vs. PCV13 (3+1)+ PPSV23; in IC: PCV13 (3+1) + PCV20 vs. PCV13 (3+1)+ PPSV23 + PPSV23 ,because it started at age 

6.6.

28
Sensitivity analyses policy question #2.1

PCV20 alone vs PCV13/15+PPSV23

Cost-saving means lower costs and improved health outcomes in the intervention, as compared to the comparator.

*Aside from the base case, no additional scenarios were conducted for this comparison.

a

In the scenarios where the Merck model assumed a re-emergence of IPD associated with certain serotypes that PCV20 missed the trial primary endpoint, PCV15 was found to be cost-saving relative to PCV20 (or 

PCV20 was dominated by PCV15).

bPfizer model had a different set of comparisons: in CMC: PCV13 + PCV20 vs. PCV13(3+1)+ PPSV23; in IC: PCV13 + PCV20 vs. PCV13(3+1)+ PPSV23 ,because it started at age 6.

Risk 

group

Intervention Comparator Model Ranges including sensitivity 

analyses ($/QALY)

CMC

PCV20 PCV13 + PPSV23

Tulane-CDC *Cost-saving

Merck *Cost-saving

PCV13 + PCV20 PCV13 + PPSV23 Pfizer Cost-savingb

IC

PCV20 PCV13 + PPSV23 + PPSV23

Tulane-CDC *Cost-saving

Merck Cost-saving

PCV13 + PCV20 PCV13 + PPSV23 + PPSV23 Pfizer Cost-savingb

CMC

PCV20

PCV15 + PPSV23

Tulane-CDC Cost-saving to $19,000

Merck Cost-saving to dominateda

IC PCV15 + PPSV23 + PPSV23

Tulane-CDC Cost-saving

Merck Cost-saving to dominateda

29
Sensitivity analyses policy question #2.1

PCV20 alone vs PCV13/15+PPSV23

Risk 

group

Intervention Comparator Model Ranges including sensitivity 

analyses ($/QALY)

CMC

PCV20 PCV13 + PPSV23

Tulane-CDC *Cost-saving

Merck *Cost-saving

PCV13 + PCV20 PCV13 + PPSV23 Pfizer Cost-savingb

IC

PCV20 PCV13 + PPSV23 + PPSV23

Tulane-CDC *Cost-saving

Merck Cost-saving

PCV13 + PCV20 PCV13 + PPSV23 + PPSV23 Pfizer Cost-savingb

CMC

PCV20

PCV15 + PPSV23

Tulane-CDC Cost-saving to $19,000

Merck Cost-saving to dominateda

IC PCV15 + PPSV23 + PPSV23

Tulane-CDC Cost-saving

Merck Cost-saving to dominateda

30

Cost-saving means lower costs and improved health outcomes in the intervention, as compared to the comparator.

*Aside from the base case, no additional scenarios were conducted for this comparison.

a

In the scenarios where the Merck model assumed a re-emergence of IPD associated with certain serotypes that PCV20 missed the trial primary endpoint, PCV15 was found to be cost-saving relative to PCV20 (or 

PCV20 was dominated by PCV15).

bPfizer model had a different set of comparisons: in CMC: PCV13 + PCV20 vs. PCV13(3+1)+ PPSV23; in IC: PCV13 + PCV20 vs. PCV13(3+1)+ PPSV23 ,because it started at age 6.
Policy question 2.2

PCV20 +PPSV23 series vs PCV20 alone among CMC/IC
Risk 

group

Intervention Comparator Model Cost per 

QALY

CMC

PCV20 + PPSV23 PCV20

Tulane-CDC $4 million

Merck $1.9 milliona

PCV13 + PCV20 + PPSV23 PCV13+ PCV20 Pfizerb $6 million

IC

PCV20 + PPSV23 +PPSV23 PCV20

Tulane-CDC $690,000

Merck $204,000a

PCV13 + PCV20 + PPSV23 + 

PPSV23 PCV13 + PCV20 Pfizerb $535,000

aValues calculated by presenter using results in Merck technical report.

bPfizer model had a different set of comparisons: in CMC: PCV13 + PCV20 vs. PCV13(3+1)+ PPSV23; in IC: PCV13 + PCV20 vs. PCV13(3+1)+ PPSV23 ,because it started at age 6. 32

Cost-effectiveness results, policy question #2.2

PCV20+ PPSV23 vs PCV20 alone, base case
Risk 

group

Intervention Comparator Model

Cost per 

QALY

CMC

PCV20 + PPSV23 PCV20

Tulane-CDC $4 million

Merck $1.9 milliona

PCV13 + PCV20 + PPSV23 PCV13+ PCV20 Pfizerb $6 million

IC

PCV20 + PPSV23 +PPSV23 PCV20

Tulane-CDC $690,000

Merck $204,000a

PCV13 + PCV20 + PPSV23 + 

PPSV23 PCV13 + PCV20 Pfizerb $535,000

aValues calculated by presenter using results in Merck technical report.

bPfizer model had a different set of comparisons: in CMC: PCV13 + PCV20 vs. PCV13(3+1)+ PPSV23; in IC: PCV13 + PCV20 vs. PCV13(3+1)+ PPSV23 ,because it started at age 6. 33

Cost-effectiveness results, policy question #2.2

PCV20+ PPSV23 vs PCV20 alone, base case
Summary
Summary

35 Cost-saving means lower costs and improved health outcomes in the intervention, as compared to the comparator.

• Policy question #1

• Vaccination with PCV20 is expected to improve health outcomes 

compared to PCV13 or PCV15.

• Compared to PCV13, the Pfizer and Merck models estimated 

that PCV20 would be cost-saving, whereas the Tulane-CDC model 

estimated a cost per QALY of $57,000.

• Compared to PCV15, the Pfizer model estimated that PCV20 

would be cost-saving, whereas the Tulane-CDC model and the 

Merck model estimated a cost per QALY of just over $100,000.
Summary

36

• Policy question #2.1

• Compared to PCV13/PCV15+PPSV23 series, PCV20 alone in CMC/IC 

was estimated to be cost-saving in all but two scenarios investigated

• Policy question #2.2

• Compared to PCV20 alone, PCV20 +PPSV23 series in CM/IC was estimated to 

cost between $204,000 to $7 million dollars for each QALY gained 

Cost-saving means lower costs and improved health outcomes in the intervention, as compared to the comparator.
Summary

37 Cost-saving means lower costs and improved health outcomes in the intervention, as compared to the comparator.

bAdditional details on these model inputs provided in supplemental slides.

• Main differences across models appear to be related to indirect effects

•

bOther important factors: model structure, Vaccine effectiveness, QALY 

losses due to disease
Thank you!

Contributors

• Miwako Kobayashi

• Andrew Leidner
Supplemental slides

39
References

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pneumococcal conjugate vaccination at age 65 in the context of indirect effects from the childhood immunization program." Vaccine 38, 

no. 7 (2020): 1770-1777.

3. Tong S, Amand C, Kieffer A, Kyaw MH. Trends in healthcare utilization and costs associated with pneumonia in the United States during 

2008–2014. BMC Health Services Research. 2018 Dec;18(1):1-8.

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5. Stoecker, Charles, Lee M. Hampton, Ruth Link-Gelles, Mark L. Messonnier, Fangjun Zhou, and Matthew R. Moore. "Cost-effectiveness of 

using 2 vs 3 primary doses of 13-valent pneumococcal conjugate vaccine." Pediatrics 132, no. 2 (2013): e324-e332.

6. Pilishvili T. 2018a. “Estimating PCV13 direct and indirect effects on IPD among adults ≥65 years”. Presented at the meeting of the Advisory 

Committee on Immunization Practices, February 22, 2018. Atlanta, Georgia.

7. Pilishvili T, Girke R, Xing W, Farley M, Schaffner W, Thomas A, Reingold A, Harrison L, Lynfield R, Zansky S, Petit S, Barnes M, Bareta J, Beal 

B, Shang N, Whitney C. 2018b. “Changes in invasive pneumococcal disease (IPD) among adults following 6 years of 13-valent 

pneumococcal conjugate vaccine use in the U.S.” Presented at the International Symposium on Pneumococci and Pneumococcal Diseases, 

2018. Melbourne, Australia.

8. Prasad, Namrata, Charles Stoecker, Wei Xing, Bo-Hyun Cho, Andrew J. Leidner, and Miwako Kobayashi. "Public health impact and costeffectiveness of 15-valent pneumococcal conjugate vaccine use among the pediatric population of the United States." Vaccine 41, no. 18 

(2023): 2914-2921.
Health outcomes and cost resultsa

PCV20 vs PCV15, base case

PCV20 vs PCV15 PCV20 vs PCV13

Outcomes and cost Tulane-CDC Merck ++Pfizer

Health outcomes

IPD cases -360 -400 -430*

Pneumonia cases -13,000 -2,300 -25,000*

AOM cases -150,000 -201,000 -238,000*

Total deaths -160 -28 -93*

QALYs 1,900 1,400 5,600

Costs ($ millions)

Cost of disease + sequelae -210 -180 NA

Vaccine costs 440 330 NA

Total cost 230 150 NA

41

aThese are discounted values (rounded up to 2 significant figures) for the complete horizon for the base case of each model 

*Outcomes not reported as discounted values.

All other values were discounted at 3%.

Negative values indicate averted cases/deaths or reduced costs of PCV20, as compared to PCV15.

++Pfizer scenario analyses with single cohort and no indirect effects applied, and comparison is between PCV20 and PCV13
Model assumptions: Selected base case assumptionsa

Policy question #1

Model input Tulane-CDC Merck Pfizer

Vaccine effectiveness • lower VE for ST3 and 

ST19F across all 

vaccines.

• the serotype specific 

VEs in PCV20 were the 

same as the serotype 

specific VEs in PCV15 

and PCV13 .

• serotype specific VE 

was lower in PCV20 for 

six 

serotypes (3,12F,1,4,2

3F,9V) than it was in 

PCV15.

• the serotype specific 

VEs in PCV20 were the 

same as the serotype 

specific VEs in PCV15 

and PCV13 .

QALY loss due to 

hospitalized pneumonia in 

adults

0.0105 0.071 0.13

Model structure Single cohort (17 years) Single cohort (100 years) Multiple cohorts (10 

years)

aFrom the review, in addition to indirect effects, these assumptions appear to be the important in terms of determining differences between model results for policy question #1.

For added context, a QALY losses of 0.0016, 0.071 and 0.130 could be considered as representing a 32-day hospitalization 59-day hospitalization, respectively, where 20% health-related quality 

of life is experienced for the duration of hospitalization. 42
Description of models

Policy question #2

Model characteristics Tulane-CDC Merck aPfizer

Cohort type Single birth cohort Single birth cohort Single-cohort (6-year-olds)

• ~90 % have history of PCV13

Indirect effects Yes (vaccinated CMC/IC contribute 

to indirect effect benefits)

In scenarios only (not in base case) Yes (vaccinated CMC/IC experience 

reduced incidence)b

Vaccine coverage PCV (3rd dose): 94 %

PCV(4th dose): 82 %

cPPSV23(1st dose): 78 %

dPPSV23(2nd dose): 64 %

PCV (3+1): 93 %

PPSV23(1st dose): 64 %

PPSV23(2nd dose): 53 %

PCV20: 20%

PPSV23: 20%

eWeighted

vaccine price ($)

PPSV23: 85 PPSV23: 91 PPSV23: 85

aThe Pfizer model does not directly assess policy question 2, but compares the receipt of PCV20 with and without PPSV23 to the receipt of PPSV23 on children with a history of PCV13 vaccination

b

Incidence among 6+ year olds was reduced after year 2, assuming routine use of PCV20 would occur, so VPD burden declines from routine use.

cVaccine coverage of first PPSV23 dose is a percentage of those who got 4 doses of PCVs.

dCoverage of second PPSV23 dose is a percentage of those who got the first PPSV23 dose.

eAll three models used blended vaccine prices (combined using private and public market prices share weights which varied across the models). 43
Summary

44

Policy Question

Base case estimates ($/QALY)

*Range across all 

models 

Tulane-CDC Merck Pfizer

1. PCV20 vs 

PCV13/PCV15

57,000 to 125,000 Cost-saving to 105,000 Cost-saving Cost-saving to 

dominateda

2.1 PCV20 alone (in 

CMC/IC)

Cost-saving Cost-saving to 

dominateda

2.2 PCV20+PPSV23 vs 

PCV20 (in CMC/IC)

690,000 to 4 

million

204,000 to 1.9 million 535,000 to 6 million 204,000 to 7 million

Cost-saving means lower costs and improved health outcomes in the intervention, as compared to the comparator.

*The ranges presented are obtained from the scenario analyses and probabilistic sensitivity analyses across all models

aThe Merck model found PCV15 was cost-saving relative to PCV20 (or PCV20 was dominated by PCV15) in scenarios where they assumed a resurgence of specific PCV20-only serotype IPD 

disease.

bAdditional details on these model inputs provided in supplemental slides.

• Main differences across models appear to be related to indirect effects

•

bOther important factors: model structure, Vaccine effectiveness, QALY losses due to disease