Economic Analysis of 

Nirsevimab in Pediatric 

Populations

David W. Hutton, PhD, MS

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

Associate Professor of Global Public Health, School of Public Health

Associate Professor, Industrial and Operations Engineering, College of Engineering

University of Michigan

ACIP General Meeting

February 23, 2023
Research Team

University of Michigan

• David Hutton, PhD

• Lisa Prosser, PhD

• Angela Rose, MPH

• Kerra Mercon, MS

CDC

• Jefferson Jones, MD, MPH, FAAP

• Mila Prill, MSPH

• Meredith McMorrow, MD, MPH, FAAP

• Jamison Pike, PhD

• Katherine Fleming-Dutra

• Ismael Ortega-Sanchez, PhD

• Fiona Havers, MD

• Betsy Gunnels, MSPH

7
Conflicts of interest statements

– Authors have no known conflict of interests.

8
Methods: Study question

• Determine the cost-effectiveness of nirsevimab by:

• Evaluating the population burden of disease in pediatric US 

population in terms of 

• annual resource utilization 

• total cases

• total costs 

• deaths

• quality-adjusted life years

• Comparing the incremental cost-effectiveness ratio of nirsevimab to 

no prevention.

• Running scenario analyses outcomes that explore key areas of 

uncertainty.

• Perspective: Societal

9
Methods: Intervention(s)

• Target population: US pediatric < 7 months of age entering their 

first RSV season

• Secondary analysis high-risk infants in their second RSV season (7-18 

months old)

• Interventions:

1. No nirsevimab (Natural history)

2. Nirsevimab against RSV illness

• Time horizon: 1 RSV season

• Analytic horizon: lifetime

• Discount rate: 3%

10
Methods: Decision Tree Model

11

No 

Prophylaxis

Nirsevimab

Infection 

Hospitalization

ED

None of the above

Outpatient

Alive

Dead

Infection

Adverse 

Events

Systemic Reaction

Injection Site Reaction

None of the above

Serious Adverse Event Infection 

Infection
Methods: Epidemiology

Hospitalization

12

Base Case Range Source

Respiratory syncytial virus (RSV) 

incidence, per 100,000 See Above See Above CDC NVSN, 

December 2016 to September 2020

Proportion with LRTI

Age 0-5 months 1.0 0.5-1.0 Rainisch, 2020

Age 6-11 months 1.0 0.5-1.0 Rainisch, 2020

CDC New Vaccine Surveillance Network (NVSN) hospitalization rates for children under 2 years of age from December 2016 to September 2020

 -

 1,000

 2,000

 3,000

 4,000

0 2 4 6 8 10 12 14 16 18 20 22

Hospitalization 

rate per 100,000 

children

Age in months
Methods: Epidemiology

ED and Outpatient

13

Respiratory syncytial virus 

(RSV) incidence, per 100,000 

Base 

Case

Range Source

Emergency Department

Age 0-5 months 7,500 5,500 – 7,500 Lively 2019 (base case and range)5, 

Hall 2009 (range)6

Age 6-11 months 5,800 5,700 – 5,800

Age 12 -23 months 3,200 3,200 – 5,300 Hall 2009 (base case and range)6, 

Lively 2019 (range)5

Proportion with LRTI

Age 0-5 months 0.65 0.25-1.0 Rainisch, 20204

Age 6-11 months 0.5 0.25-1.0 Rainisch, 20204

Medically attended 

outpatient

Age 0-5 months 21,600 13,200 –

21,600

Lively 2019 (base case and range)5, 

Hall 2009 (range)6

Age 6-11 months 24,600 17,700 –

24,600

Age 12 -23 months 18,440 6,600 – 29,620 Jackson 2021 (base case and 

range)7, Hall 2009 (range)6

Proportion with LRTI

Age 0-5 months 0.65 0.25-1.0 Rainisch, 20204

Age 6-11 months 0.3 0.1-1.0 Rainisch, 20204
Methods: Epidemiology

Mortality

14

Base 

Case

Range Source

RSV mortality per 

hospitalization

Age 0-5 months 0.04% 0.03-0.05% Doucette 20168

Age 6-11 months 0.04% 0.03-0.05%

Age 12 -23 months 0.3% 0.24%-

0.28%

Gupta 201610
Seasonality

15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

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

Fraction of Annual Infections

Source: National Respiratory and Enteric Virus Surveillance System (NREVSS) (2015-2019)
0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

0 2 4 6 8 10 12 14

Efficacy

Month

Methods: Inputs

average 5-month efficacy 

= trial efficacy 

Sigmoid decay to 

final efficacy

16

Zero efficacy
Methods: Efficacy

17

Variable Base 

case 

value

Range for 

sensitivity 

analysis

Source

Nirsevimab

Initial efficacy 

(months 1-5) against 

RSV-associated 

LRTI 80.0% 68.5% - 86.1%

MELODY trial 

and Phase 2b 

recommended 

dose

Efficacy months 6-

10 25.0% 0.0% - 50.0%

Efficacy after 10 

months 0.0%
Methods: Provision of Nirsevimab

• Base case:

– At birth for those born 

• October 1 – March 31

– October for those born in 

• April (~6-month visit)

• June (~4-month visit)

• August (~2-month visit)

– November for those born in

• May (~6-month visit)

• July (~4-month visit)

• September (~2-month visit)

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Methods: Medical Costs

Variable Value Range Source

Disease-specific 

hospitalization costs 

(per hospitalization) 

Age 0-11 months $11,487 11042 - 11933

Bowser 2022

Age 12- 23 months $11,469 11029 - 11910

Disease-specific ED 

costs (per ED visit) $563 544 – 581 Bowser 2022

Disease-specific 

outpatient costs (per 

outpatient visit)

$82 46-118 Bowser 2022

19

• Bowser, 2022 is a systematic review using studies from 2014-2021

• Funded by Sanofi

• All numbers updated to 2022 dollars using GDP Deflator
Methods: Productivity Costs

Variable Value Range Source

Productivity burden of 

RSV Disease (caregiver 

losses)

Days of lost productivity

Outpatient* 2.5 0-5

Fragaszy, 2018; Petrie, 2016; 

Van Wormer, 2017

ED* 2.5 0-5

Fragaszy, 2018; Petrie, 2016; 

Van Wormer, 2017

Hospitalization^ 7.4 0-14

Lifetime productivity for 

those <1 year old (lost 

from death)

1,795,936 Grosse, 2019

20

*Productivity for outpatient and ED based on adult influenza

^Hospitalization productivity loss = length of hospitalization + 2 days
Methods: Intervention Cost

Variable Value Range Source

Immunization-related 

costs

Nirsevimab, per dose $300 $50-$600 Assumption

21
Methods: RSV 

Health-Related Quality-of-Life

22

LRTI quality adjusted life DAYS lost Base Lower (Regnier) Upper (JIVE)

Outpatient: Child 3.1 1.8 16.6

Outpatient: Caregiver 1.5 0 9.1

ED: Child 4.9 2.9 16.6

ED: Caregiver 2.5 0 9.1

Hospitalized: Child 6.2 3.7 26.5

Hospitalized: Caregiver 2.4 0 13.6

Measured in 

Days Lost

Most 

Likely
Methods: Additional Inputs

• Also included nirsevimab adverse events

– Systemic reactions

– Injection site reactions

– Serious adverse events

– Medical costs

– Productivity costs

– Quality-adjusted life-years lost

23
Methods: Uncertainty analyses

• One-way sensitivity

• Scenarios:

– Upper respiratory infection effect 

– Timing of administration

• Additional Scenario:

– High-risk children entering the second RSV season

24
Results: Base Case

25

• Base Case:

– Population of 1,000 births

– 100% uptake in the nirsevimab group

– First RSV season

– $300/dose

– Nirsevimab only impacts LRTI
Results: Health Outcomes

26

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

231 

172 

67 46 

13 5 

 -

 50

 100

 150

 200

 250

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Medically attended

outpatient

Emergency

Department

Inpatient

URTI LRTI
Results: Health Outcomes

27

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

59

20.9 

7.8 

1.7 

42.3 

5.2 

0

10

20

30

40

50

60

70

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Events Averted per 1000 births
Results: Health Outcomes

28

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

17 

48 

128 

581 

24 

194 

 -

 100

 200

 300

 400

 500

 600

 700

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Number needed to Prophylax to avoid
Results: Costs

29

Base cost of $300/dose

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

 $-

 $100,000

 $200,000

 $300,000

 $400,000

 $500,000

 $600,000

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Natural History

Nirsevimab

Intervention Outpatient ED Inpatient Deaths Total

Medical Productivity
Results: Health Outcomes

30

Base cost of $300/dose

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

$2,476 

$6,950 

$18,515 

$84,158 

$3,429 

$28,053 

 $-

 $10,000

 $20,000

 $30,000

 $40,000

 $50,000

 $60,000

 $70,000

 $80,000

 $90,000

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Cost per Event Averted
Results: QALYs Lost

31

Adverse 

Events Outpatient ED Inpatient Deaths Total Grand

Child Caregiver Child Caregiver Child Caregiver Child Child Caregiver Total

Natural 

History 1.95 0.98 0.90 0.45 0.22 0.09 0.15 3.22 1.51 4.73 

Nirsevimab 0.03 1.46 0.73 0.62 0.31 0.09 0.03 0.06 2.25 1.07 3.32 

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group
Results: Cost-Effectiveness

32

Overall Costs QALYs

ICER 

($/QALY)

Natural 

History $ 357,151 4.73 

Nirsevimab $ 502,077 3.32 $ 102,805 

Base cost of $300/dose

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group
Sensitivity: Tornado

33

Base cost of $300/dose

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

Cost QALYs Efficacy

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

Nirsevimab cost/dose

Initial Efficacy

Proportion of Outpatient visits (age 0-5 months) with an LRTI

diagnosis

Proportion of hospitalizations (age 0-5 months) with an LRTI

diagnosis

Proportion of ED Visits (age 0-5 months) with an LRTI

diagnosis

Proportion of outpatient visits (age 6-11 months) with an LRTI

diagnosis

RSV child QALYs lost due to outpatient visit

RSV caregiver QALYs lost due to outpatient visit

RSV child QALYs lost due to ED visit

RSV caregiver QALYs lost due to ED visit

Incremental Cost-Effectiveness Ratio ($/QALY)

Low High
 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

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

ICER ($/QALY)

Total Cost of Nirsevimab (drug + administration)

Sensitivity: Cost

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group 34
Scenario: Upper Respiratory Infection Effect

35 Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

57

20.4

7.7

1.7

41.4

5.1

108

33.5

7.7

1.7

41.4

5.1

0

20

40

60

80

100

120

Outpatient ED Inpatient ICU Inpatient Day ICU Day

Events Averted per 1000 births

Events Averted

Averted Base Averted URTI

Only Outpatient and ED 

are impacted by upper 

respiratory impact
 $-

 $20,000

 $40,000

 $60,000

 $80,000

 $100,000

 $120,000

 $140,000

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

ICER ($/QALY)

Total Cost of Nirsevimab (drug + administration)

Scenario: Upper Respiratory Infection Effect

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group 36

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

37

• Cost-effectiveness of an infant receiving nirsevimab as a 

newborn in 

– Oct-Feb

– Oct-March

– Oct-April

• With varying efficacy in months 6-10

– 0%

– 25%

– 50%

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group
38

Scenario: Timing and Efficacy in 

months 6-10

Slightly Lower ICERs for Oct-Mar Base cost of $300/dose

Cohort:1,000 nirsevimab and 1,000 

natural history, assuming 100% 

uptake in nirsevimab group

 $-

 $20,000

 $40,000

 $60,000

 $80,000

 $100,000

 $120,000

0% efficacy 25% efficacy 50% efficacy

ICER ($/QALY)

Oct-Feb Oct-Mar Oct-Apr
Scenario: Reduction in Palivizumab

39

Overall Costs QALYs

ICER 

($/QALY)

Natural 

History $ 418,551 4.73 

Nirsevimab $ 502,077 3.32 $ 59,250 

Base cost of $300/dose

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

• Potential cost impact if clinicians choose to use nirsevimab in 

palivizumab-eligible infants

• Savings assumptions:

– 1.6% are high-risk (palivizumab-eligible)

– 75% uptake in high-risk

– 4.1 palivizumab doses/person on average

– $1,228/palivizumab dose
Higher-risk children entering the second 

RSV season

40

• Immunization in October (under 19 months old in 

October)

• Incidence of RSV-associated hospitalization and mortality 

per hospitalization: 

– 1x, 2x, 4x 6x, 10x higher

• Cost

– $600 nirsevimab costs (2x $300/dose)

– $1000 nirsevimab costs (2x $500/dose)

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group
Second Season, High-Risk 

41

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

0

20

40

60

80

100

Inpatient ICU Inpatient Days ICU Days

Events Averted per 1000 

Children

Events Averted

Base 2x 4x 6x 10x
Second Season, High-Risk 

42

Cost is per overall course, for 2 doses

Cohort:1,000 nirsevimab and 1,000 natural history, assuming 100% uptake in nirsevimab group

ICER by cost of nirsevimab

(product plus administration) ($/QALY)

Hospitalization and 

Mortality rate $600 $1000

1x (base) $ 815,051 $ 1,410,155 

2x $ 449,238 $ 800,666 

4x $ 145,014 $ 282,945 

6x $ 53,061 $ 122,409 

10x $ 404 $ 27,390 
Limitations

• Model Structure

– No risk groups

– No dynamic transmission. No impact of the vaccine on transmission and 

indirect effects

• Uncertain inputs

– Nirsevimab cost 

– QALYs lost 

– Upper respiratory tract infections

– Palivizumab utilization

43
Summary

• Nirsevimab may be cost-effective

• Results sensitive to:

– Cost per dose (Cost-Saving – 316,000 $/QALY)

– Efficacy (75,000 - 153,000 $/QALY)

• URTI/LRTI 

– Proportion of infections with LRTI

– Or efficacy of nirsevimab against URTI

– QALYs lost (41,000 - 125,000 $/QALY)

• Hospitalization, Outpatient, ED

• Child, Parent

44

URTI: Upper Respiratory Tract Infection

LRTI: Lower Respiratory Tract Infection

QALY: Quality-Adjusted Life-Year
Thank You

• Please send comments to:

• dwhutton@umich.edu

45