Evidence to Recommendations Framework:

PCV20 Use among Adults who Previously Received PCV13

Miwako Kobayashi, MD, MPH

Advisory Committee on Immunization Practices

Pneumococcal Vaccines

October 19, 2022

National Center for Immunization & Respiratory Diseases
Serotypes Contained in Pneumococcal Vaccines

• PCV15: contains PCV13 serotypes and 22F and 33F

• PCV20: contains PCV13 serotypes and 22F, 33F, 8, 10A, 11A, 12F, and 15B

• PPSV23 non-PCV20: includes serotypes 2, 9N, 17F, and 20

1 3 4 5 6A 6B 7 F 9V 14 18

C

19

A

19

F

23

F

22

F

33

F

8 10

A

11

A

12

F

15

B

2 9N 17

F

20

PCV13

PCV15

PCV20

PPSV23
Adults Who Were Previously Recommended to 

Receive PCV13 and PPSV23

19–64 years ≥65 years

None of the conditions listed 

below

No recommendation

PPSV23 and PCV13* based on 

Chronic medical conditions† shared clinical decision-making

(CMC)

PPSV23

Cochlear implant, CSF leak Both PCV13* and PPSV23

Immunocompromising Both PCV13* and PPSV23

conditions

Both PCV13* and PPSV23, repeat 

PPSV23 after 5 years

PCV13: 13-valent pneumococcal conjugate vaccine, PCV15: 15-valent pneumococcal conjugate vaccine, PCV20: 20-valent 

pneumococcal conjugate vaccine, PPSV23: 23-valent pneumococcal polysaccharide vaccine

*If not previously given; †Examples include alcoholism, chronic heart/liver/lung disease, diabetes, cigarette smoking

https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
Adults Who Were Previously Recommended to 

Receive PCV13 and PPSV23

19–64 years ≥65 years

None of the conditions listed 

below

No recommendation

PPSV23 and PCV13* based on 

Chronic medical conditions† shared clinical decision-making

(CMC)

PPSV23

Cochlear implant, CSF leak Both PCV13* and PPSV23

Immunocompromising Both PCV13* and PPSV23

conditions

Both PCV13* and PPSV23, repeat 

PPSV23 after 5 years

PCV13: 13-valent pneumococcal conjugate vaccine, PCV15: 15-valent pneumococcal conjugate vaccine, PCV20: 20-valent 

pneumococcal conjugate vaccine, PPSV23: 23-valent pneumococcal polysaccharide vaccine

*If not previously given; †Examples include alcoholism, chronic heart/liver/lung disease, diabetes, cigarette smoking

https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
Policy Questions

Question 1 Question 2 Question 3

U.S. adults aged ≥19 years U.S. adults aged 19–64 years with an 

immunocompromising condition, 

cerebrospinal fluid leak, or cochlear 

implant

U.S. adults aged ≥65 years

Who previously received 

PCV13 only

Who previously received both 

PCV13 and PPSV23

Who previously received both 

PCV13 and PPSV23

Should they be recommended to receive a dose of PCV20 to 

complete their pneumococcal vaccine series? 

Should they be recommended to 

receive a dose of PCV20? 

PCV13=13-valent pneumococcal conjugate vaccine, PCV20=20-valent pneumococcal conjugate vaccine, 
Policy Questions

Group 1 Group 2 Group 3

U.S. adults aged ≥19 years U.S. adults aged 19–64 years with an 

immunocompromising condition, 

cerebrospinal fluid leak, or cochlear 

implant

U.S. adults aged ≥65 years

Who previously received 

PCV13 only

Who previously received both 

PCV13 and PPSV23

Who previously received both 

PCV13 and PPSV23

Should they be recommended to receive a dose of PCV20 to 

complete their pneumococcal vaccine series? 

Should they be recommended to 

receive a dose of PCV20? 

PCV13=13-valent pneumococcal conjugate vaccine, PCV20=20-valent pneumococcal conjugate vaccine, 

Adults who have NOT completed their 

recommended pneumococcal vaccine series 
Pneumococcal Vaccine Timing for Adults-April 1, 2022 (cdc.gov)
Pneumococcal Vaccine Timing for Adults-April 1, 2022 (cdc.gov)

No more PPSV23 doses recommended after 1 dose at age 65 years or older.
Policy Questions

Group 1 Group 2 Group 3

U.S. adults aged ≥19 years U.S. adults aged 19–64 years with an 

immunocompromising condition, 

cerebrospinal fluid leak, or cochlear 

implant

U.S. adults aged ≥65 years

Who previously received 

PCV13 only

Who previously received both 

PCV13 and PPSV23

Who previously received both 

PCV13 and PPSV23

Should they be recommended to receive a dose of PCV20 to 

complete their pneumococcal vaccine series? 

Should they be recommended to 

receive a dose of PCV20? 

PCV13=13-valent pneumococcal conjugate vaccine, PCV20=20-valent pneumococcal conjugate vaccine, 

Adults who have completed their 

recommended pneumococcal vaccine series 
Evidence to Recommendations (EtR) Framework

EtR Domain Question

Public Health Problem • Is the problem of public health importance?

Benefits and Harms • How substantial are the desirable anticipated effects?

• How substantial are the undesirable anticipated effects?

• Do the desirable effects outweigh the undesirable effects?

• What is the overall certainty of this evidence for the critical outcomes?

Values • Does the target population feel the desirable effects are large relative to the 

undesirable effects?

• Is there important variability in how patients value the outcomes?

Acceptability • Is the intervention acceptable to key stakeholders?

Feasibility • Is the intervention feasible to implement?

Resource Use • Is the intervention a reasonable and efficient allocation of resources?

Equity • What would be the impact of the intervention on health equity?

Problem: pneumococcal disease, Intervention: PCV20 use among adults who previously received PCV13
Public Health Problem

Is pneumococcal disease of public health importance for adults who have previously received PCV13?
1. Characteristics of the target population
Estimated number of adults who have already 

received ≥1 dose of PCV13

• Adults aged ≥65 years: ~27 million

• Population size: 54.1 million1

• Adults who received ≥1 dose of PCV13: ~50%2

• Adults aged 19–64 years with immunocompromising conditions: ~0.4 million

• Population size: 7.7 million3

• Eligible adults who received ≥1 PCV13 dose:~5%4

1. United States Census Bureau

2. Hoehner et al. https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/pcv13-medicare-beneficiaries2010-2019.html

3. Estimated from census data and Pelton et al. CID 2019 to estimate the proportion with immunocompromising conditions

4. Deb et al. Expert Review of Vaccines 2021
Estimated incidence of pneumococcal disease in 

adults aged ≥65 years

Disease Estimated incidence 

(per 100,000 population)

All-cause hospitalized pneumonia1 847–3,365 

All-cause hospitalized noninvasive pneumococcal 

pneumonia2

105

Invasive pneumococcal disease (IPD)3 24

1. McLaughlin et al. Vaccine 2020 (limited to studies that collected data during or after 2010) 

2. Gierke et al. IDweek 2020. CDC’s Surveillance for NonInvasive Pneumococcal Pneumonia (SNiPP), 2017 

3. CDC ABCs, 2018–2019 

Case fatality ratio from IPD: 14%3
Adults aged 19–64 years with immunocompromising 

conditions have 9–18 times the risk of pneumococcal disease 

compared with healthy adults.

Rate per 100,000 person-years, 2013–2015 

Healthy1 High-risk2 Rate Ratio

18–49 years

Hospitalized IPD 0.6 (0.5, 0.7) 8.6 (6.7, 11.2) 15.4 (11.3, 20.9)

Hospitalized pneumococcal 

pneumonia

1.2 (1.1, 1.3) 21.1 (17.9, 24.9) 17.6 (14.4, 21.5)

50–64 years 

Hospitalized IPD 1.9 (1.6, 2.1) 16.4 (14.4, 18.7) 8.8 (7.4, 10.6)

Hospitalized pneumococcal 

pneumonia

3.9 (3.5, 4.2) 43.0 (39.7, 46.6) 11.1 (9.9, 12.6)

Reference: Pelton et al. CID 2019

IPD=invasive pneumococcal disease

1. Adults without any conditions with risk-based pneumococcal vaccine indications

2. Adults with immunocompromising condition or with cochlear implant 
2. Impact of PCV13 use against pneumococcal disease in adults
0

5

10

15

20

25

30

35

40

45

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Cases per 100,000

Year

ALL IPD PCV13+6C PPSV23 non-PCV13 Non-vaccine type

PCV13-type IPD incidence among adults aged ≥65 years decreased 

after PCV13 use in children but remained stable in 2014–2019

PCV13 introduction 

for children

PCV13 introduction for 

adults aged ≥65 years 

Serotype 6C assessed together with PCV13 serotypes due to cross-protection from serotype 6A.

CDC Active Bacterial Core surveillance, 2007–2019 
0

5

10

15

20

25

30

35

40

45

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Cases per 100,000

Year

ALL IPD PCV13+6C PPSV23 non-PCV13 Non-vaccine type

Non-PCV13-type IPD incidence among adults aged ≥65 years

remained stable.

PCV13 introduction 

for children

PCV13 introduction for 

adults aged ≥65 years 

CDC Active Bacterial Core surveillance, 2007–2019 

Non-PCV13-type IPD incidence
0

5

10

15

20

25

30

35

40

45

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Cases per 100,000

Year

ALL IPD PCV13+6C PPSV23 non-PCV13 Non-vaccine type

PCV13-type IPD incidence among adults aged ≥65 years decreased 

after PCV13 use in children but remained stable in 2014–2019

PCV13 introduction 

for children

PCV13 introduction for 

adults aged ≥65 years 

Serotype 6C assessed together with PCV13 serotypes due to cross-protection from serotype 6A.

CDC Active Bacterial Core surveillance, 2007–2019 
Among remaining PCV13 serotypes*, serotype 3 caused >60% of 

IPD among adults ≥65 years old in 2018–2019 

0

2

4

6

8

10

12

14

16

2011 2012 2013 2014 2015 2016 2017 2018 2019

Cases per 100,000

Year

001 005

PCV7 (except 19F) 19F

06C 003

07F 19A

PCV13 introduction for 

adults aged ≥65 years 

2018-2019 % 

of PCV13+6C 

serotypes

003 62%

06C* 12%

19F 9%

19A 10%

Serotype 3

*Serotype 6C assessed together with PCV13 serotypes due to cross-protection from serotype 6A.

CDC Active Bacterial Core surveillance, 2007–2019 
Pneumococcal serotypes contained in PCV20 but not in PCV13 caused 

27% of Invasive Pneumococcal Disease in Adults in 2018–2019

24 27

14

15

13

12

14 8

35 38

0

10

20

30

40

50

60

70

80

90

100

Age 19-64 years (w/ at least one

immunocompromising condition) n=1031

Age ≥65 years (all cases) n=2211

Pecent IPD

Age group (Years)

PCV13+6C PCV15 non-PCV13 PCV20 non-PCV15 PPV23 non-PCV20 NVT

CDC Active Bacterial Core surveillance

PCV15 non-PCV13 serotypes: 22F, 33F

PCV20 non-PCV15 serotypes: 8, 10A, 11A, 12F, 15B

PPSV23 non-PCV20 serotype: 2, 9N, 17F ,20 

27%
0

20

40

60

80

100

120

140

160

180

2013 2014 2015 2016 2017

Case per 100,000

Year

18-49 50-64 ≥65

Hospitalized pneumococcal pneumonia incidence in adults did not 

decrease after routine PCV13 use among adults aged ≥65 years.

PCV13 introduction for 

adults >65 years old

Gierke et al. IDweek 2020. CDC’s Surveillance for NonInvasive Pneumococcal Pneumonia (SNiPP), 2013–

2017 
Reduction in incidence of hospitalized PCV13-type 

pneumococcal pneumonia was observed after routine PCV13 

use among a cohort of adults aged ≥65 years.

Louisville cohort study: among ≥65 years old, 2014-2016

• 31.5% reduction (95%CI: 8.3, 48.9) in PCV13-type hospitalized pneumococcal 

pneumonia1*

Swerdlow Jun 2018 ACIP meeting presentation* *Pfizer funded study
In 2013–2016, additional serotypes contained in PCV20 but not 

in PCV13 caused 3–4% of all-cause hospitalized communityacquired pneumonia in adults. 

4.2

5.2

2.9

4.0 0.9

0.8

0.0

2.0

4.0

6.0

8.0

10.0

12.0

≥65 years 18-64 years, immunocompromised

% All Cause CAP

PCV13+6C PCV20 non-PCV13 PPSV23 non-PCV20

N=6347

N=1864

Serotype 3: 0.9% Serotype 3: 1.1%

Isturiz et al. CID 2021

*Pfizer funded study

PCV15 non-PCV13 serotypes: 22F, 33F

PCV20 non-PCV15 serotypes: 8, 10A, 11A, 12F, 15B/15C (15B and C are identified together in the assay)

PPSV23 non-PCV20 serotype: 2, 9N, 17F ,20 
3. Impact of the COVID-19 pandemic on pneumococcal disease 

incidence
0

5

10

15

20

25

30

2014 2015 2016 2017 2018 2019 2020 2021

Cases per 100,000 population

Year

Age <5 Age ≥65

+30%

Overall Invasive Pneumococcal Disease (IPD) incidence decreased 

in both adults and children early during the COVID-19 pandemic.

57% decline in overall IPD in 2020,

30% increase in 2021

50% decline in overall IPD in 2020, 

additional 25% decline in 2021

-50%

-57%

-25%

Children < 5 years Adults ≥ 65 years

CDC Active Bacterial Core surveillance unpublished data
Incidence of pneumococcal pneumonia hospitalizations among 

adults may have decreased during the COVID-19 pandemic.

Year Location Association with COVID-19 

pandemic

Hospitalizations per 100,000 adult 

population per year (95% CI)

All-cause 

pneumonia

Pneumococcal 

pneumonia

Sep 2018–Aug 2019 Nashville Before pandemic 470 (422-517) 43 (39-47)

Sep 2019–Aug 2020 Nashville During pandemic 613 (524-702) 27 (23-32)

Nov 2020–Oct 2021 Nashville During Pandemic 484 (411-557) 9 (8-11)

Self et al. ISPPD 2022, study funded by Merck
Public Health Problem

Is pneumococcal disease of public health importance in adults 

who received PCV13? 

□ No 

□ Probably no

□ Probably yes

□ Yes

□ Varies

□ Don’t know
Public Health Problem

• Vaccine-preventable pneumococcal disease burden remains (especially pneumonia)

• Reduction in pneumococcal disease incidence due to COVID-19 is likely time-limited1

• Group 1. Adults who have received PCV13 only:

• Protection against limited serotype coverage

• Group 2. Adults aged 19–64 years with immunocompromising conditions:

• Protection from PPSV23 in this group may be limited

• Group 3. Adults aged ≥65 years: 

• Population size is substantial

• Significance depends on factors that determine the risk of pneumococcal disease, 

such as time since last pneumococcal vaccination, underlying conditions, or age

1. Perniciaro et al. CID 2022
Benefits and Harms
Pneumococcal Vaccines: PCVs vs. PPSV23

1 3 4 5 6A 6B 7 F 9V 14 18

C

19

A

19

F

23

F

22

F

33

F

8 10

A

11

A

12

F

15

B

2 9N 17

F

20

PCV13

PCV15

PCV20

PPSV23

PCV PPSV23

Basic Vaccine Composition Capsular polysaccharides 

conjugated to CRM197 Carrier 

Protein

Capsular polysaccharide 

antigens

Mechanism of action T-cell dependent T-cell independent

Memory B cell production Yes No

PCV: pneumococcal conjugate vaccine, PPSV23: 23-valent pneumococcal polysaccharide vaccine
1. Patterson et al. Trials in Vaccinology 2016.

2. World Health Organization. Strategic Advisory Group of Experts on Immunization 5-7 October 2020. 

https://terrance.who.int/mediacentre/data/sage/SAGE_eYB_October_2020.pdf?ua=1

3. French et al. NEJM 2000; Andrews et al. Vaccine 2012; Rudnick et al. Vaccine 2013; Djennad et al. EClinicalMedicine 2018

4. Bonten et al. NEJM 2015

5. Farrar et al. https://www.medrxiv.org/content/10.1101/2022.10.06.22280772v1.full

PCV PPSV23

Duration of protection No decline for 5 yrs1 Variable findings, waning reported 

as early as 2 years since 

vaccination2

Vaccine Effectiveness vs.

Vaccine-type IPD

Supported by clinical 

efficacy/effectiveness data

Supported by clinical 

efficacy/effectiveness data; limited 

effectiveness reported in 

immunocompromised adults3

Vaccine Effectiveness vs.

Vaccine-type noninvasive/non-bacteremic

pneumonia

Supported by clinical efficacy data

• Moderate protection (45%: 

95% CI 14 to 63)4

Variable clinical effectiveness data

• Modest protection (18%: 95% CI 

-4 to 35%) from a meta-analysis5

Pneumococcal Vaccines: PCVs vs. PPSV23
Estimated time since PCV13 or PPSV23 vaccination: 

Medicare beneficiaries aged ≥65 years, June 2022

• Time since last PCV13 vaccination (with/without PPSV23): 

• Median 5.6 (range 0–8.5) years 

• Time since last PPSV23 vaccination (adults who received PCV13 → PPSV23):

• Median 3.1 (range 0–8.4) years 

CMS unpublished Fee-For-Service data (available on August 1, 2022)
PICO Questions for GRADE

Population U.S. adults aged 19–64 years with an 

immunocompromising condition, 

cerebrospinal fluid leak, or cochlear implant

U.S. adults aged ≥65 years

Who previously received PCV13

Intervention One dose of PCV20

Comparison Use of PPSV23 based on currently recommended dosing and schedule

Outcomes 

(critical)

VT-IPD, VT-nonbacteremic pneumococcal pneumonia, VT-pneumococcal mortality, SAE 

following vaccination 

PCV13=13-valent pneumococcal conjugate vaccine, PCV20=20-valent pneumococcal conjugate vaccine, 

PPSV23=23-valent pneumococcal polysaccharide vaccine, SAE= serious adverse events, VT=vaccine type
Evidence Retrieval

Clinicaltrials.gov

(«20-valent pneumococcal vaccine», adults)

n=7

17 studies identified for full-text 

review

Pubmed

(«PCV20» or «20-valent pneumococcal vaccine»)

n=38

Total included: 2

Immunogenicity* (n=2)

SAE (n=1)

Exclusions:

Vaccine-naive adults n=5

Did not assess outcomes of 

interest n=9

Duplicate n=1

PCV20=20-valent pneumococcal conjugate vaccine, SAE= serious adverse events, VT=vaccine type

*No PCV20 efficacy 

or effectiveness data. 
Summary of included studies

▪ Both from Phase 3 clinical trials among adults aged ≥65 years without IC

▪ Cannon et al. 2021 (safety and immunogenicity)1

• Immunogenicity: 

• Response to PCV20 by prior vaccine status (PCV13, PPSV23, PCV13+PPSV23)

• No PCV20 vs PPSV23 comparison

• Safety: PCV20 vs PPSV23 in PCV13 group; PCV20 in PCV13+PPSV group

▪ B7471004 post-hoc analysis (immunogenicity), unpublished2

• Post-hoc analysis of a phase 3 trial assessing PCV20 and QIV coadministration

• Response to PCV20 stratified by previous vaccination status

See GRADE tables in appendix for details.

IC=immunocompromising conditions; QIV=quadrivalent inactivated influenza vaccine

1. Cannon et al. Vaccine 2021. Funded by Pfizer. 

2. Safety and Immunogenicity of 20vPnC Coadministered With SIIV in Adults ≥65 Years of Age - Full Text View - ClinicalTrials.gov. Funded by Pfizer
GRADE Summary of Findings: Immunogenicity

▪ OPA GMT ratios1

• Previous PCV13 > previous PPSV23 for all 20 serotypes

• Previous PCV13+PPSV23 > previous PPSV23 for 15 to 19 (of 20) 

serotypes

▪ % seroresponders2

• Previous PCV13 > previous PPSV23 for 13 to 18 (of 20) serotypes

• Previous PCV13+PPSV23 > previous PPSV23 for 3 to 6 (of 20) 

serotypes

OPA GMT=opsonophagocytic activity geometric mean titer

1. Defined as [GMT (PCV20, previous PCV13 with or without PPSV23)]/[GMT (PCV20, previous PPSV23 only)]; blood draws occurred 

1-month post-dose

2. Defined as percentage of participants with a ≥4-fold rise in OPA titers from before to 1 month after vaccination
GRADE Summary of Findings: Safety

▪ Proportion reporting serious adverse events (SAEs) through 6 months after 

vaccination was similar across groups

• PCV13 + PCV20 (n=246) vs. PCV13 + PPSV23 (n=127)

• 2.4% vs 1.6%

• PCV13 + PPSV23 + PCV20 (n=325, no comparator group)

• 1.6%

▪ No vaccine-related SAEs

▪ No deaths reported

Cannon et al. Vaccine 2021. Funded by Pfizer
Benefits and Harms

How substantial are the desirable anticipated effects?

□ Minimal

□ Small

□ Moderate

□ Large

□ Varies

□ Don’t know

□ Minimal

□ Small

□ Moderate

□ Large

□ Varies

□ Don’t know

Group 1. Adults with PCV13 only

Group 2. Adults aged 19–64 years with IC with 

PCV13+PPSV23

Group 3. Adults aged ≥65 years with PCV13+PPSV23
Benefits and Harms

How substantial are the desirable anticipated effects?

□ Minimal

□ Small

□ Moderate

□ Large

□ Varies

□ Don’t know

• These adults have not completed the recommended 

PPSV23 series

• Immunologic benefits of PCV vs PPSV23

• Group 1. Adults with PCV13 only: 

• Depends on type of underlying risk of disease

• Group 2. Adults aged 19 –64 years with IC: 

• May have inadequate response to PPSV23 and 

shorter duration of protection

IC= immunocompromising conditions

Group 1. Adults with PCV13 only

Group 2. Adults aged 19–64 years with IC with PCV13+PPSV23
Benefits and Harms

How substantial are the desirable anticipated effects?

□ Minimal

□ Small

□ Moderate

□ Large

□ Varies

□ Don’t know

Small anticipated effects Group 3. Adults aged ≥65 years with PCV13+PPSV23

▪ Incremental benefits of PCV20 use among these 

adults is likely modest 

Moderate anticipated effects

▪ Based on understanding of immunologic benefits of 

PCV vs PPSV23

Others

▪ Depends on factors such as:

• time since vaccination

• age of patient

• presence of underlying medical conditions 

• indirect effects of pediatric PCV20 vaccination
Benefits and Harms

How substantial are the undesirable anticipated effects?

□ Minimal

□ Small

□ Moderate

□ Large

□ Varies

□ Don’t know
Benefits and Harms

Do the desirable effects outweigh the undesirable effects?

- What is the balance between the desirable effects relative to the undesirable 

effects?

□ Favors intervention*

□ Favors current recommendation

□ Favors both

□ Favors neither

□ Varies

□ Don’t know

*Intervention: a dose of PCV20
Benefits and Harms

What is the overall certainty of this evidence for the 

critical outcomes?

Group 1.

Adults with PCV13 only

Group 2.

IC adults aged 19–64 years

PCV13+PPSV23

Group 3.

Adults aged ≥65 years

PCV13+PPSV23

Effectiveness 3 (low) 3 (low) 2 (moderate)

Safety 3 (low) 3 (low) 2 (moderate)
Certainty assessment No of patients Results

No of Certainty Importance

studies Study design

Risk 

of 

bias

Inconsistency Indirectness Imprecision Other 

considerations

PCV20 

following 

previous 

PCV13

Previous 

PPSV23 receipt

Relative

(95% CI)

Absolute

(95% CI)

VT-IPD, VT-nonbacteremic pneumococcal pneumonia, VT-pneumococcal mortality Outcome (Assessed with: Immunogenicity)

2 Randomized 

studies

Not 

serious

Not serious Seriousa Not serious Not serious 754 - 898 296 - 340 OPA GMT ratios

•Previous PCV13 > 

previous PPSV23 for all 

20 serotypes

•Previous 

PCV13+PPSV23 > 

previous PPSV23 for 15 

to 19 (of 20) serotypes

% seroresponders

•Previous PCV13 > 

previous PPSV23 for 13 

to 18 (of 20) serotypes

•Previous 

PCV13+PPSV23 > 

previous PPSV23 for 3 to 

6 (of 20) serotypes

2

(moderate)

Critical

Serious adverse events following immunization

1 Randomized 

studies

Not 

serious

Not serious Not serious Seriousb Not serious 8/371 2/127 -- 0.8 to 1.6% 2

(moderate)

Critical

a. These are all immunogenicity studies and there are no correlates of protection for the critical outcomes considered

b. Few vaccine-related serious adverse events reported do not meet the optimal information size

GRADE Summary of Findings (Adults Aged ≥65 years)
Certainty assessment No of patients Results

No of Certainty Importance

studies Study design

Risk 

of 

bias

Inconsistency Indirectness Imprecision Other 

considerations

PCV20 

following 

previous 

PCV13

Previous 

PPSV23 receipt

Relative

(95% CI)

Absolute

(95% CI)

VT-IPD, VT-nonbacteremic pneumococcal pneumonia, VT-pneumococcal mortality Outcome (Assessed with: Immunogenicity)

2 Randomized 

studies

Not 

serious

Not serious Very seriousa,b Not serious Not serious 754 - 898 296 - 340 OPA GMT ratios

•Previous PCV13 > 

previous PPSV23 for all 

20 serotypes

•Previous PCV13+PPSV23 

> previous PPSV23 for 15 

to 19 (of 20) serotypes

%seroresponders

•Previous PCV13 > 

previous PPSV23 for 13 

to 18 (of 20) serotypes

•Previous PCV13+PPSV23 

> previous PPSV23 for 3 

to 6 (of 20) serotypes

3

(low)

Critical

Serious adverse events following immunization

1 Randomized 

studies

Not 

serious

Not serious Seriousb Seriousc Not serious 8/371 2/127 -- 0.8 to 1.6% 3

(low)

Critical

a. These are all immunogenicity studies and there are no correlates of protection for some critical outcomes considered

b. No studies among adults 19 – 64 years of age with underlying medical conditions; study populations are adults 65 years of age and older without immunocompromising conditions 

c. Few vaccine-related serious adverse events reported do not meet the optimal information size

GRADE Summary of Findings (IC Adults Aged 19–64 years)
Values
Values and Preferences

Criterion 1: Do adults who previously received PCV13 (with or 

without PPSV23) feel that the desirable effects from PCV20 

vaccination are large relative to undesirable effects?

□ No 

□ Probably no

□ Probably yes

□ Yes

□ Varies

□ Don’t know

No research evidence identified
Values and Preferences

Criterion 1. Does the target population feel that the desirable effects are large 

relative to undesirable effects? 

▪ These are adults who have already received PCV13 (with or without PPSV23):

• Likely to have some understanding of the importance of receiving pneumococcal 

vaccines

▪ Additional Work Group comments:

• Not enough information to make the decision

• Interpretation will vary among the target population
Values and Preferences

Criterion 2: Is there important uncertainty about, or variability 

in, how much adults value the main outcomes?

□ Important uncertainty or variability

□ Probably important uncertainty or variability

□ Probably not important uncertainty or variability

□ No important uncertainty or variability

□ No known undesirable outcomes

Group 1. Adults who received PCV13 only?

Group 2. Adults aged 19–64 years with IC who received both PCV13 and PPSV23?

• No research evidence

• Previously vaccinated adults probably do not have important uncertainty or variability
Values and Preferences

Criterion 2: Is there important uncertainty about, or variability 

in, how much adults value the main outcomes?

□ Important uncertainty or variability

□ Probably important uncertainty or variability

□ Probably not important uncertainty or variability

□ No important uncertainty or variability

□ No known undesirable outcomes

No research evidence identified.

• Adults aged ≥65 years who received both PCV13 and PPSV23?

Variable responses by Work Group members
Values and Preferences

Criterion 2. Is there important uncertainty about or variability in how much people 

value the main outcomes? 

▪ These are adults who have already received PCV13 (with or without PPSV23):

• Probably no important uncertainty or variability about receiving another dose of 

a pneumococcal vaccine

▪ There could be uncertainty or variability depending on the age, life expectancy, 

time since the last vaccination, or perceived severity of pneumococcal disease 

among adults aged ≥65 years who have completed their recommended vaccine 

series.
Acceptability

Is the option acceptable to key stakeholders? 
Findings from Healthcare Provider (HCP) Surveys

• Two web-based HCP surveys using a commercial survey panel

• Limited to HCPs who administer pneumococcal vaccines to adults

• ≥65% of respondents approved use (strongly/somewhat) of higher-valent PCV 

for prior PCV13 recipients1

• Providers were more agreeable to administering PCV20 for2:

IC adults aged 19–64 years,

PCV13 only 

IC adults aged 19–64 years,

PCV13 +PPSV23 

Adults aged ≥65 years,

PCV13 only 

Adults aged ≥65 years 

PCV13 + PPSV23 

IC=immunocompromised

1. Pfizer HCP preference survey 2021

2. University of Iowa HCP preference survey 2022. Respondents were asked if they “Strongly disagree”, “Disagree”, “Neither agree or disagree”, 

“Agree”, or “Strongly agree” with administering PCV20 for adults who were previously vaccinated.

> > >
Acceptability

Is recommending PCV20 for adults who previously received 

PCV13 (with or without PPSV23) acceptable to key 

stakeholders?

□ No 

□ Probably no

□ Probably yes

□ Yes

□ Varies

□ Don’t know
Resource Use

Is recommending PCV20 for adults who previously received PCV13 a reasonable and efficient 

allocation of resources?
Acknowledgements

• Informed by work conducted by three modeling groups

• CDC Team

• Charles Stoeckera, Miwako Kobayashib, Bo-Hyun Chob, Namrata Prasadb

• Merck Team

• Kwame Owusu-Eduseic, Elamin Elbashac

• Arijita Debc, Kelly Johnsonc, Oluwaseun Sharomic, Thomas Weissc, Temi Folaranmic, Craig 

Robertsc, Donald Yinc, Richard Hauptc, Tufail Malikc

• Pfizer Team

• Derek Weyckerd, Ahuva Averind, Mark Atwoodd, Melody Shaffd, Reiko Satoe, Erica 

Chilsone, Vincenza Snowe, Alejandro Canee, Raymond Farkouhe

57

Slide courtesy of Andrew Leidner, CDC

a. Tulane University; b. CDC; c. Merck; d. Policy Analysis Inc (PAI); e. Pfizer; 
Conflict of interest statements

• Andrew J. Leidner: None.

• CDC team: None.

• Pfizer team:

• Pfizer manufacturers the PCV13 and PCV20 vaccines.

• PAI team members are funded by Pfizer, other team members are employed 

by Pfizer.

• Merck team:

• Merck manufacturers the PPSV23 and PCV15 vaccines.

58
Comparison will focus on assessment of PCV20 use among 

adults aged ≥65 years who previously received PCV13 and 

PPSV23.

59

Note(s): Population levels by year of age come from US Census, 2021 projections. Portions of population in a risk status (Healthy, CMC, IC) by year of age come from the Pfizer model report. 

Portions of population with a past pneumococcal vaccinations come from the CDC model report.

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

19 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 99

Population

Age (years)

Adult US population by pneumococcal vaccine status

IC, PCV13+PPSV23

IC, PCV13-only

IC, no PCV13

Healthy & CMC, PCV13+PPSV23

Healthy & CMC, PCV13-only

Healthy & CMC, no PCV13
Selected key assumptions that can impact 

Incremental Cost Effectiveness Ratios (ICERs)

Model characteristics CDC Pfizer Merck

Indirect effects from pediatric 

vaccination Yesa Yesa No

PCV VE vs. serotype 3 disease 9-26%b 60-75%b 5-26%b

PPSV23 VE vs NBP 7-20%c 0% 3-67%c

Inpatient NBP case fatality ratios 

among 65+ 3-5%d 3-11%d 7-12%d

QALY loss for IPD and 

inpatient NBP 0.071e 0.130e 0.071e

a. The CDC and Pfizer models included scenarios where no herd effects from pediatric vaccinations occurred. 

b. The PCV ST3 VE assumptions could vary by age, risk group, and disease outcome (IPD, NBP), depending on the model. The CDC model investigated PCV ST3 VE = 0% in scenarios.

c. The CDC model varied PPSV23 NBP VE across 2 risk groups. The Merck model varied PPSV23 NBP VE across 3 risk groups and 23 serotypes of disease.

d. The CDC and Merck model varied inpatient NBP CFRs by age. The Pfizer model varied inpatient NBP CFRs by age and risk group.

e. For added context, a QALY losses of 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.

60

IPD: invasive pneumococcal disease, NBP: non-bacteremic pneumococcal pneumonia, IPD: invasive pneumococcal disease, QALY: quality-adjusted life-year, VE: vaccine effectiveness
Averted disease burden, PCV20 usea vs. no vaccine

65+, PCV13+PPSV23, single cohort

CDC Pfizerb Merckc

Age of PCV20 vaccination 71 years 72 years 73 years

Time since last vaccination 5 years 7 years 5 years

QALYs gained 375 876 584

Deaths averted 65 293b 131

Hospitalization averted 1,252 3,318b 1,444

Cases averted 2,628 6,269b 3,143

QALY: Quality-Adjusted Life Year

a. These scenarios presented assume a PCV20 vaccination coverage rate of 73% in the CDC and Merck models, and 69% in the Pfizer model.

b. In the Pfizer model, QALYs were discounted, but deaths, hospitalizations, and cases were not discounted; QALY losses per hospitalized disease episode were greater than in the other models.

c. The Merck model did not assume herd effects.

61

• All models find that health outcomes improve with use of PCV20 (vs. no vaccination). 

• Differences in estimated averted outcomes appear to be due to differences in assumptions on VE, CFRs, QALY loss, 

discounting, and population size. 
Cost-effectiveness ratios, PCV20

65+, PCV13+PPSV23, single cohort

62

CDCa Pfizerb Merckc

Age of PCV20 vaccination 71 and 81 years 72 years 73 years

Time since last vaccination 5 years 7 years 5 years

$/QALYs 153,000 to 414,000 81,000 to 159,000 217,000

a. The CDC model assumed PPSV23 was moderately protective against NBP. Range are due to different assumptions on herd effects, and age at PCV20 vaccination (71, 81).

b. The Pfizer model assumed QALY losses per IPD and hospitalized NBP case were greater than the other models. Range of estimates is with and without herd effects, higher ICER estimate includes 

herd effects.

c. The Merck model assumed no herd effects. If herd effects were included, the ICER would likely be higher.

• Models appear to be somewhat consistent across several summary measures. 

• Lower $/QALY were found in the Pfizer model, which assumed higher PCV-ST3-VE, lower PPSV23-NBP-VE, 

and higher QALY loss from IPD and inpatient NBP (more severe disease).
Cost-effectiveness ratios, PCV20

65+, PCV13+PPSV23, single cohort

63

CDCa Pfizerb Merckc

Age of PCV20 vaccination 71 and 81 years 72 years 73 years

Time since last vaccination 5 years 7 years 5 years

$/QALYs 153,000 to 414,000 81,000 to 159,000 217,000

a. The CDC model assumed PPSV23 was moderately protective against NBP. Range are due to different assumptions on herd effects, and age at PCV20 vaccination (71, 81).

b. The Pfizer model assumed QALY losses per IPD and hospitalized NBP case were greater than the other models. Range of estimates is with and without herd effects, higher ICER estimate includes 

herd effects.

c. The Merck model assumed no herd effects. If herd effects were included, these ICERs would be higher.

• Models appear to be somewhat consistent across several summary measures. 

• Lower $/QALY were found in the Pfizer model, which assumed higher PCV-ST3-VE, lower PPSV23-NBP-VE, 

and higher QALY loss from IPD and inpatient NBP (more severe disease).

Cost-effectiveness ratios for previous policy questions among adults aged ≥65 years:

• Continuing routine PCV13 + PPSV23 use, 20191

• CDC model: $562,000/QALY 

• Pfizer model: $199,000/QALY

• Use of PCV20 only or PCV15 + PPSV23 vs previous recommendations, 20212

• Cost-saving in most scenarios

1. Leidner February 2019 ACIP meeting presentation

2. Leidner September 2021 ACIP meeting presentation 
Resource Use

▪ Is recommending PCV20 for adults who previously received PCV13 a 

reasonable and efficient allocation of resources?

□ No 

□ Probably no

□ Probably yes

□ Yes

□ Varies

□ Don’t know

Group1. Adults with PCV13 only Yes/Probably Yes

▪ Benefits of recommending PCV20 still outweigh the 

cost for adults who have received PCV13 only

Probably No

▪ The cost-effectiveness analysis findings do not 

justify the use of resources except for the 

immunocompromised
Resource Use

▪ Is recommending PCV20 for adults who previously received PCV13 a 

reasonable and efficient allocation of resources?

IC= immunocompromising conditions

□ No 

□ Probably no

□ Probably yes

□ Yes

□ Varies

□ Don’t know

Variable responses among Work 

Group members

Group 2. Adults aged 19–64 years with IC with 

PCV13+PPSV23

Group 3. Adults aged ≥65 years with PCV13+PPSV23

Yes/Probably Yes

▪ Anticipated benefits from adding PCV20 outweigh the 

cost.

Probably No

▪ Anticipated added benefits from recommending 

PCV20 instead of PPSV23 for adults who have already 

received PCV13 and PPSV23 are not large enough to justify 

the use of resources.

Varies

▪ Depends on the time since the last vaccination, age, 

and underlying conditions. 
Equity

What would be the impact on health equity?
67

Effect of PCV13 

on racial 

disparities in 

IPD burden

CDC Active Bacterial Core 

surveillance

PCV13 introduction in children 
68

Racial 

disparities in 

PCV13-type IPD 

incidence were 

reduced

CDC ABCs
69

Racial 

disparities in 

non-PCV13-type 

IPD incidence 

remain

CDC ABCs
The proportion receiving any pneumococcal vaccine was significantly 

lower among Hispanics and Asians compared with Whites among 

adults aged 19–64 years with risk-based pneumococcal vaccine 

indications1

Sample size % (95% CI)

Overall 5,202 23.9 (22.4-25.3)

White 3,514 26.3 (24.5-28.1)

Black 699 23.3 (19.5-27.7)

Hispanic 624 16.7 (13.4-20.6)*

Asian 179 13.8 (8.8-21.2)*

Other 186 23.5 (16.8-31.7)

1. Includes adults without immunocompromising conditions such as diabetes, chronic heart/lung disease, or smokers 

*p<0.05 for comparisons with White as the reference.

Vaccination Coverage among Adults in the United States, National Health Interview Survey, 2019–2020 | CDC
Compared to Whites, PCV13 and PCV13 + PPSV23 coverage were lower in 

other racial/ethnic groups among Medicare beneficiaries aged ≥65 years.

Adapted from https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubsresources/pcv13-medicare-beneficiaries-2010-2019.html

0 10 20 30 40 50 60

Hispanic

Black

Native American

Asian

White

Both PCV13 and PPSV23 PCV13 only (including multiple doses)
Equity

What would be the impact of recommending PCV20 for adults 

who previously received PCV13 on health equity?

□ Reduced

□ Probably reduced

□ Probably no impact

□ Probably increased

□ Increased

Variable Work Group interpretation and divided between “probably 

reduced” and “probably no impact”. 
Equity

Increased or probably increased health equity

▪ Conditions that increase risk of pneumococcal disease are more 

prevalent in non-White populations

▪ PCV20 use will decrease remaining disparities in pneumococcal 

disease burden

▪ Access to vaccines is likely better for minority populations compared 

with access to care for the disease 
Equity

Probably no impact on health equity

▪ Vaccine access and utilization are likely to follow existing patterns. 

▪ Limited impact at the population level due to small number of adults 

aged 19–64 years with IC who received both PCV13 and PPSV23 

▪ Small incremental benefits of PCV20 among adults who already 

received PCV13 and PPSV23

Reduced/probably reduced health equity

▪ PCV20 uptake will likely be higher among those with good access to 

care and could worsen existing disparities

IC=immunocompromising conditions
Feasibility

Are the options feasible to implement?
Feasibility

▪ Is recommending PCV20 for adults who previously received 

PCV13 feasible to implement? 

□ No 

□ Probably no

□ Probably yes

□ Yes

□ Varies

□ Don’t know

Group 1. Adults with PCV13 only

Group 2. Adults aged 19–64 years with IC with 

PCV13+PPSV23

• These are adults who have not completed the 

recommended vaccine series with PPSV23:

• May simplify recommendations if adults can 

complete the recommended vaccine series 

with a dose of PCV20

• May reduce need to determine vaccination 

status of patients

• May reduce need to stock multiple types of 

vaccines
Feasibility

▪ Is recommending PCV20 for adults who previously received 

PCV13 feasible to implement? 

□ No 

□ Probably no

□ Probably yes

□ Yes

□ Varies

□ Don’t know

Group 3. Adults aged ≥65 years with PCV13+PPSV23

• These are adults who have completed the 

recommended vaccine series:

• Adding a dose of PCV20 may complicate 

the recommendation

• Compliance with the recommendation 

may be an issue
Feasibility: additional considerations

▪ Access to PCV20

• Poll among Association of Immunization Managers (AIM) members*, Sept 2022: 

• 7 of 22 jurisdictions currently offer PCV20 through their adult immunization 

program

▪ Vaccine coverage by insurance

• Under the Affordable Care Act, new ACIP recommendations required to be covered 

without cost-sharing starting one year after the date the recommendation is issued

*Members are primarily state, local, and territorial immunization program managers/directors

Affordable Care Act Implementation FAQs - Set 12 | CMS
Summary of Work Group Interpretation

EtR Domains Group1. Adults with PCV13 only Group 2. IC adults aged 19–64 years

PCV13+PPSV23

Group 3. Adults aged ≥65 years

PCV13+PPSV23

Public Health Problem Yes

Benefits and Harms

a. Benefits Moderate Small/Moderate

b. Harms Minimal

c. Benefit>Harm? Favors intervention

d. Certainty: effectiveness 3 (low) 2 (moderate)

e. Certainty: safety 3 (low) 2 (moderate)

Values

a. Desirable>Undesirable? Probably Yes

b. Uncertainty? Probably not important uncertainty or variability Variable responses among WG 

members

Acceptability Probably Yes

Resource Use Probably Yes/Yes, but with variability Variable responses by WG members

Equity Split between “probably no impact” and “probably increased health equity”

Feasibility Yes Probably Yes
Summary: Work Group Interpretations

Should PCV20 be recommended for: 

Group 1. adults aged ≥19 years who previously received PCV13 only 

Group 2. adults aged 19–64 years with IC who previously received PCV13+PPSV23

Group 3. adults aged ≥65 years who previously received PCV13+PPSV23

Balance of 

consequences

Undesirable 

consequences 

clearly 

outweigh 

desirable 

consequences 

in most 

settings

Undesirable 

consequences 

probably 

outweigh 

desirable 

consequences 

in most 

settings

The balance 

between 

desirable and 

undesirable 

consequences 

is closely 

balanced or 

uncertain

Desirable 

consequences 

probably 

outweigh 

undesirable 

consequences 

in most 

settings

Desirable 

consequences 

clearly 

outweigh 

undesirable 

consequences 

in most 

settings

There is 

insufficient 

evidence to 

determine the 

balance of 

consequences
Acknowledgements

• ACIP and the Pneumococcal Vaccines Work Group

• University of Iowa

• Charles Stoecker

• CDC contributors and consultants: Ryan Gierke, Jennifer Farrar, Emma Accorsi, 

Namrata Prasad, Shriya Bhatnagar, Jacquline Risalvato, Adam Cohen, Noele 

Nelson, Dale Rose, Pedro Moro, Megan Lindley, Elizabeth Velazquez, Marc 

Fischer, Rebecca Morgan, Doug Campos-Outcalt
For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the 

official position of the Centers for Disease Control and Prevention.
GRADE Summary of Studies: Immunogenicity

Author, year Study design; 

population and age

Intervention N intervention N comparison Comparator 

vaccine

OPA GMT ratios 

[range (serotype)]1

Absolute difference in % 

seroresponders (serotype)2

Interpretation Study 

limitations 

(Risk of Bias)

Cannon 2021 RCT (Phase III); U.S. and 

Swedish adults ≥65 

years with prior 

pneumococcal 

vaccination

PCV20 (1 dose) after 

previous PCV13 

201 - 243 216 - 246 PCV20 (1 dose), 

previous 

PPSV23 vaccine

1.30 (11A) to 2.97 

(23F)

-5.10 (6A) to 34.90 (33F) OPA GMT ratios

• Previous PCV13 > previous 

PPSV23 for all 20 serotypes; 

significantly higher for 17/20 

serotypes

%seroresponders

• Previous PCV13 > previous 

PPSV23 for 18/20 serotypes (not 

for 6A or 19A); significantly 

higher for 8/18 serotypes

Low

PCV20 (1 dose) after 

previous 

PCV13+PPSV23

102 -121 216-246 PCV20 (1 dose), 

previous 

PPSV23 vaccine

0.91 (7F) to 1.93 

(23F)

-19.40 (11A) to 1.00 (15B) OPA GMT ratios

• Previous PCV13+PPSV23 > 

previous PPSV23 for 19/20 

serotypes (not for 7F); 

significantly higher for 23F

%seroresponders

• Previous PCV13+PPSV23 > 

previous PPSV23 for 3/20 

serotypes (14, 15B, 33F); none 

significantly higher

B7471004 RCT (Phase III); U.S. 

adults ≥65 years with 

prior pneumococcal 

vaccination; received 

influenza vaccination 1 

month prior to PCV20

PCV20 (1 dose) after 

previous PCV13

123 - 146 80 – 94 PCV20 (1 dose), 

previous 

PPSV23 vaccine

1.15 (5) to 2.60 

(23F)

-10.4 (4) to 22.7 (15B) OPA GMT ratios

• Previous PCV13 > previous 

PPSV23 for all 20 serotypes; 

significantly higher for 6/20 

serotypes

%seroresponders

• Previous PCV13 > previous 

PPSV23 for 13/20 serotypes; 

significant for 15B

PCV20 (1 dose) after 

previous 

PCV13+PPSV23

328 -388 80 - 94 PCV20 (1 dose), 

previous 

PPSV23 vaccine

0.83 (11A) to 2.26 

(23F)

-12.90 (4) to 7.40 (23F) OPA GMT ratios

• Previous PCV13+PPSV23 > 

previous PPSV23 for 15/20 

serotypes; significantly higher for 

6B, 18C, and 23F

%seroresponders

• Previous PCV13+PPSV23 > 

previous PPSV23 for 6/20 

serotypes; none significantly 

higher

Low

1. Ratio calculated as [GMT (PCV20)]/[GMT (comparator vaccine)]; blood draws occurred 1 month post-dose.

2. Seroresponse: percentage of participants with ≥4-fold rise in pneumococcal OPA titers from before to after 1 month vaccination.
GRADE Summary of Studies: Safety

Author, year Study Design; population and age

N 

interve

ntion

N 

compariso

n

Comparato

r vaccine

Absolute % 

difference

(% SAE 

PCV20 –

% SAE 

comparato

r)*

N 

relate

d to 

vacci

ne

Study 

limitati

ons 

(Risk of 

Bias)

Cannon 2021

RCT (Phase III); U.S. and Swedish 

adults ≥65 years with previous 

PCV13 vaccination

246 127

PPSV23, 

previous 

PCV13

0.8% 0

Low RCT (Phase III); U.S. and Swedish 

adults ≥65 years with previous 

PCV13 + PPSV23 vaccination

125 0 none 1.6% 0

*Reported serious adverse events include those that occurred after dose 1 through completion of study 

participation.
Model overview, selected key assumptions 

a. In any given scenario, the CDC and Merck models start the model with a single-aged cohort of individuals, not a full population composed of many different ages. For this reason, these models 

have one specific starting age. For example, a 70-year-old cohort may be used to represent and estimate values in the 65+ age group.

b. The Pfizer model base case used a multi-cohort, but single cohort results were provided in a scenario.

c. The CDC model includes one societal perspective component, travel cost added to the cost of vaccine administration. The Merck model provide a scenario using the societal perspective that 

was similar to the CDC model.

Model characteristics CDC Merck Pfizer

Model type Single cohorta, lifetime Single cohorta, lifetime Multi-cohortb

, lifetime

(SA: Single cohort)

Perspective Societalc Health carec Health care

Adverse events No No No

Sensitivity analyses

Univariate, scenario & 

probabilistic sensitivity 

analyses

Univariate, scenario & 

probabilistic sensitivity 

analyses

Univariate & 

scenario analyses

Time since previous 

vaccination 1, 5, 10 years 5 years (SA: 1 and 8 years)

7 years 

(SA: 5 and 9 years)

Age in years at PCV20 

vaccination

65+ cohort: 66, 71, 75, 76, 77, 

80, 81 65+ cohort: 73 All ages (65+ average: 75)

85
0

200,000

400,000

600,000

800,000

1,000,000

0 2 4 6 8 10 12 14

ICER ($/QALY)

Number of scenarios

PCV13+PPSV23, 65+ years (IC)

0

200,000

400,000

600,000

800,000

1,000,000

0 5 10 15 20 25

ICER ($/QALY)

Number of scenarios

PCV13+PPSV23, 65+ years (Alla or Healthy/CMC)

PCV13+PPSV23, summary of economic 

analyses among 65+ population

Scenario assumptions:

Age at PCV20 is 71 (not IC)

5 year since PCV13+PPSV23

Herd effects

Moderate PCV-ST3-VE

Moderate PPSV23-NBP-VE

ICER = $414,000/QALY

Scenario assumptions:

Age at PCV20 is 81 (not IC)

5 years since PCV13+PPSV23

Herd effects

Moderate PCV-ST3-VE

Moderate PPSV23-NBP-VE

ICER = $188,000/QALY

a. Most results from the Pfizer model did not separate IC and healthy/CMC populations, and did not separate 19-64 and 65+ populations. So the Pfizer scenarios capture an average ICER that 

is weighted by the population size of the different subgroups, where the largest of the subgroups is PCV13+PPSV23 recipients who are 65+ years.

86

Scenario assumptions:

Age at PCV20 is 67 (not IC)

1 year since PCV13+PPSV23

Herd effects

Moderate PCV-ST3-VE

Moderate PPSV23-NBP-VE

ICER = $874,000/QALY
75,684

181,800

0

100,000

200,000

300,000

400,000

500,000

600,000

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

ICER ($/QALY)

Number of scenarios

PCV13-only, 65+ years 

(Alla or Healthy/CMC)

PCV20 for adults aged ≥65 years with PCV13 only 

ICER range: $76,000 to $493,000 per QALY gained

Scenario assumptions:

Age at PCV20 is 80

5 years since PCV13

Herd effects

ICER = $168,000/QALY

87

Scenario assumptions:

Age at PCV20 is 66

1 year since PCV13

Herd effects

ICER = $493,000/QALY

a. Most results from the Pfizer model did not separate IC and healthy/CMC populations, and did not separate 19-64 and 65+ populations. These results represent an average ICER that is 

weighted by the population size of the different subgroups, where the largest of the subgroups is PCV13+PPSV23 recipients who are 65+ years.

Pfizer model: $75,684/QALY

• Includes adults aged 19–64 years with IC

• PCV20 given 7 years after PCV13 vs. no 

additional vaccine 

Merck model: $181,800/QALY

• PCV20 given at age 73 years, 5 years after 

PCV13 vs. no additional vaccine