Economic Analysis of RSV 

Vaccination in Older Adults 

David W. Hutton, PhD, MS

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

Associate Professor of Global Public Health, School of Public Health

Associate Professor, Industrial and Operations Engineering, College of Engineering

University of Michigan
Research Team

University of Michigan

• David Hutton, PhD

• Lisa Prosser, PhD

• Angela Rose, MPH

• Kerra Mercon, MS

CDC

• Michael Melgar, MD

• Mila Prill, MSPH

• Jamison Pike, PhD

• Ismael Ortega-Sanchez, PhD

• Fiona Havers, MD

• Michael Whitaker, MPH

• Christopher Taylor, PhD

2
Conflicts of interest statements

– No known conflict of interests.

3
Methods: Study question

• Determine the cost-effectiveness of RSV vaccination by:

• Evaluating the population burden of disease in the US population 

• ≥60 years old 

• ≥65 years old

• ≥70 years old

• ≥75 years old

• Examining outcomes:

• resource utilization 

• total cases

• total costs 

• deaths

• quality-adjusted life years

• Comparing vaccination to no vaccination using the incremental costeffectiveness ratio

• Scenario analyses exploring uncertainty.

• Perspective: Societal

4
Methods: Intervention(s)

• Target population: US adults, stratified by age

• Interventions: GSK and Pfizer vaccines

• Each compared to No Vaccination

• Base case assumes the age-based RSV vaccination recommendation is 

for ages ≥65

• Time horizon: 1 year

• Analytic horizon: lifetime

• Discounting rate: 3%

5
Methods: Decision Tree Model

No 

Vaccination

Vaccination

Infection 

Hospitalization

ED

None of the above

Outpatient

Alive

Dead

Infection

Adverse 

Events

Systemic Reaction

Injection Site Reaction

None of the above

Serious Adverse Event Infection 

Infection

6
Methods: Epidemiology

• Incidence of RSV

–

o

Raw reported incidence may be underreported because of imperfect 

PCR sensitivity

 Base case assumption: 95% sensitivity

 Additional scenario: lower sensitivity

Zhang et al study which found decreased RSV PCR sensitivity when paired serology 

testing was added as an additional testing method. 

7

Zhang Y, Sakthivel SK, Bramley A, Jain S, Haynes A, Chappell JD, Hymas W, Lenny N, Patel A, Qi C, Ampofo K, Arnold SR, Self WH, Williams DJ, Hillyard D, 

Anderson EJ, Grijalva CG, Zhu Y, Wunderink RG, Edwards KM, Pavia AT, McCullers JA, Erdman DD. Serology Enhances Molecular Diagnosis of Respiratory Virus 

Infections Other than Influenza in Children and Adults Hospitalized with Community-Acquired Pneumonia. J Clin Microbiol. 2016 Dec 28;55(1):79-89. doi: 

10.1128/JCM.01701-16. PMID: 27795341; PMCID: PMC5228265
Methods: Epidemiology

Hospitalization

Variable Value Range Source

60≤ age ≤64 years 42 29 – 103

65≤ age ≤74 years 67 48 – 203 CDC RSVnet

age ≥75 years 193 133 – 575

• CDC RSVnet data from RSV seasons: 2015-16, 2016-17, 2017-18, and 2018-19.

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

• “burden adjusted” means it is adjusted for a "Standard" PCR test sensitivity of 95%*. 

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

• Range upper bound is based on the upper 95% confidence limit but also uses a different 

“burden adjustment” multiplier of 1.4x based on a reduced PCR test sensitivity **

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

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

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

** Zhang Y, Sakthivel SK, Bramley A, Jain S, Haynes A, Chappell JD, Hymas W, Lenny N, Patel A, Qi C, Ampofo K, Arnold SR, Self WH, Williams DJ, Hillyard D, Anderson EJ, 

Grijalva CG, Zhu Y, Wunderink RG, Edwards KM, Pavia AT, McCullers JA, Erdman DD. Serology Enhances Molecular Diagnosis of Respiratory Virus Infections Other than 

Influenza in Children and Adults Hospitalized with Community-Acquired Pneumonia. J Clin Microbiol. 2016 Dec 28;55(1):79-89. doi: 10.1128/JCM.01701-16. PMID: 

27795341; PMCID: PMC5228265.

8

RSV incidence, per 100,000 

Hospitalization
Methods: Epidemiology

ED and Outpatient

Variable Value Range Source

RSV incidence, per 100,000 

Emergency Department

60≤ age ≤64 years 74 59 – 132

McLaughlin 2022 65≤ age ≤74 years 133 0 – 478

age ≥75 years 133 0 – 478

RSV Incidence, per 100,000

Outpatient

60≤ age ≤64 years 1148 935 – 2041

65≤ age ≤74 years 1519 1109 – 2893 McLaughlin 2022

age ≥75 years 1519 1109 – 2893

9

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

• Range upper bound is based on the upper 95% confidence limit but also uses the authors’ 

multiplier of 1.5x to adjust for PCR sensitivity

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

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

Variable Value Range Source

RSV mortality per hospitalization

60≤ age ≤64 years 3.9% 3.12% – 4.68%

65≤ age ≤74 years 4.3% CDC RSVnet 3.44% – 5.16%

age ≥75 years 5.7% 4.56% – 6.84%

10

CDC RSVnet data includes the following RSV seasons: 2015-16, 2016-17, 2017-18, and 2018-19.

Ranges incorporate a 20% increase/reduction from the base case value
Methods: Incidence

Seasonality

Source: NREVSS (2015-19)

0%

5%

10%

15%

20%

25%

30%

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

Fraction of Annual Infections

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Methods: Efficacy

Variable Value Range Source

Vaccine Efficacy (%)

GSK

Medically attended RSV 

LRTI/LRTD (ED, and 

hospitalization)

87.5% 58.4% – 96.2% GSK phase 3 trial

Medically attended RSV ARI 

(outpatient) 79.0% 54.3% – 91.5% GSK phase 3 trial

Pfizer

Medically attended RSV 

LRTI/LRTD (ED, and 

hospitalization)

80.0% 6.3% – 97.9% Pfizer phase 3 trial

Medically attended RSV ARI 

(outpatient) 69.2% 30.0% – 88.0% Pfizer phase 3 trial

12
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2 4 6 8 10 12

Efficacy

Month

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

Against hospitalization and ED Est. Against hospitalization and ED

Efficacy: GSK

average 6-month 

efficacy = trial efficacy 

Exponential decay

13
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2 4 6 8 10 12

Efficacy

Month

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

Against hospitalization and ED Est. Against hospitalization and ED

Efficacy: Pfizer

average 6-month 

efficacy = trial efficacy 

Exponential decay

14
Methods: RSV Medical Costs

Variable Value Range Source

Disease-specific 

hospitalization costs (per 

hospitalization)

60≤ age ≤64 years $20,330 9,288 – 45,454

65≤ age ≤74 years $20,330 10,491 – 43,619 Ackerson 2020*

age ≥75 years $21,339 10,491 – 43,619

Disease-specific ED costs 

(per ED visit)

60≤ age ≤64 years $1,210 -

65≤ age ≤74 years $1,210 - 2016 Marketscan*

age ≥75 years $1,210 -

Disease-specific 

outpatient costs (per 

outpatient visit)

60≤ age ≤64 years $117.58 65.88-145.38 MarketScan

and Medicare FFS, 2020-

2021

65≤ age ≤74 years $100.86 50.48-120.08

age ≥75 years $100.86 50.48-120.08

*Updated to Q3 2022$ using GDP Deflator

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Methods: Vaccination-Related Costs

Variable Value Range Source

Vaccine, per dose $100 $50-$200 Assumption

Vaccine administration $16.96 - HCPCS 90460 (Physician Fee 

Schedule 2022)

16 And productivity costs for individuals time at clinic or pharmacy
Methods: RSV Health-Related Quality-of-Life

Variable Value Range Source

QALYs lost due to 

Outpatient RSV 0.0185 0.0053-0.0347 JIVE COVID/RSV 

utilities study 

Hospitalized RSV 0.0193 0.0095-0.0316 (unpublished)

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Methods: Additional Inputs

• Also included 

– RSV illness productivity costs

– Vaccination productivity costs

– Vaccination adverse events

• Systemic reactions

• Injection site reactions

• Serious adverse events

• Medical costs

• Productivity costs

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Methods: Sensitivity analyses

• Sensitivity analyses conducted

– One-Way and Two-Way

– Age-based recommendation for RSV vaccination

• age ≥60 years

• age ≥65 years

• age ≥70 years

• age ≥75 years

– Vaccine cost

 $50-$200

• Scenario analysis: Higher incidence

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Results: Base Case

• Cohort of 100,000

• 20% vaccination coverage

• Age-based vaccination recommendation: ≥65 years

• $100 vaccine cost

• One Year Time Horizon

20
Health Outcomes

21

$100 vaccine cost

One Year Time Horizon

Cohort:100,000, 20% uptake

Age-based vaccination recommendation: ≥65 years

1519

133 108

22 6

649

65

1280

111 90

18 5

540

54

1308

114 93

19 5

555

56

0

200

400

600

800

1000

1200

1400

1600

No Vaccination GSK Pfizer
Number Needed to Vaccinate, GSK

One Year Time Horizon 22 90 1,032 1,348 6,740 27,284 225 2,247 84 893 1,097 5,486 21,442 183 1,829 84 893 895 4,475 16,691 149 1,492 84 893 615 3,076 10,794 103 1,025 

 -

 5,000

 10,000

 15,000

 20,000

 25,000

 30,000

 35,000

 40,000

 45,000

Number Needed to Vaccinate

age ≥60 years age ≥65 years age ≥70 years age ≥75 years 
Number Needed to Vaccinate, Pfizer

23

One Year Time Horizon103 

1,200 

1,567 

7,835 

31,717 

261 

2,612 

95 

1,038 

1,275 

6,377 

24,927 

213 

2,126 

95 

1,038 

1,040 

5,202 

19,404 

173 

1,734 

95 

1,038 

715 

3,576 

12,548 

119 

1,192 

 -

 5,000

 10,000

 15,000

 20,000

 25,000

 30,000

 35,000

 40,000

 45,000

Number Needed to Vaccinate

age ≥60 years age ≥65 years age ≥70 years age ≥75 years 
Cost per Outcome Averted

($ thousands)

24

$100 vaccine cost

One Year Time Horizon

Age-based vaccination recommendation: ≥65 years

$8 $83 $101 

$507 

$1,982 

$17 

$169 

$9 $100 $123 

$614 

$2,402 

$20 

$205 

 $-

 $500

 $1,000

 $1,500

 $2,000

 $2,500

 $3,000

Cost per Outcome Averted

Thousands

GSK Pfizer
Summary measure(s)

GSK

Costs (M) QALYs Lost ICER 

($/QALY) LYs Lost

ICER 

($/LY)

No 

Vaccination 3.75 75 55

Vaccine 5.59 64 180,720 46 198,676 

25

QALY = Quality-Adjusted Life-Year

ICER = Incremental Cost-Effectiveness Ratio

LY = Life-Year

Cost, QALY, and LY Results per 100,000 (20% of whom are vaccinated)

Costs in Millions of 2022 dollars

ICER values do not depend on cohort size or uptake

$100 vaccine cost

One Year Time Horizon 

Age-based vaccination recommendation: ≥65 years
Summary measure(s)

Pfizer

Costs (M) QALYs Lost ICER 

($/QALY) LYs Lost

ICER 

($/LY)

No 

Vaccination 3.75 75 55

Vaccine 5.67 64 189,407 47 240,699 

26

QALY = Quality-Adjusted Life-Year

ICER = Incremental Cost-Effectiveness Ratio

LY = Life-Year

Cost, QALY, and LY Results per 100,000 (20% of whom are vaccinated)

Costs in Millions of 2022 dollars

ICER values do not depend on cohort size or uptake

$100 vaccine cost

One Year Time Horizon 

Age-based vaccination recommendation: ≥65 years
Results: Sensitivity analyses, 

• Tornado Diagrams 

– one parameter varied at a time

• Age and Vaccine Cost

• Higher Incidence / Lower PCR Sensitivity

27
Sensitivity analyses, GSK Tornado Diagram

28 $100 vaccine cost

One Year Time Horizon

Age-based vaccination recommendation: ≥65 years

$0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000

Vaccine Cost

Incidence of RSV hospitalization

Outpatient QALYs Lost

GSK Vaccine Effectiveness LRTD

Incidence of outpatient visits for RSV

Cost per Hospitalization

Mortality, adults hospitalized with RSV

GSK Vaccine Effectiveness ARI

ED Incidence

QALYs lost Injection Site Reaction

ICER ($/QALY)

Age ≥65

Low Assumption High Assumption
Sensitivity analyses, Pfizer Tornado 

Diagram

29

$100 vaccine cost

One Year Time Horizon

Age-based vaccination recommendation: ≥65 years

* At low Pfizer vaccine efficacy, the ICER rises to $574,730/QALY

574,730

$0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000

Pfizer Vaccine Effectiveness LRTD

Vaccine Cost

Incidence of RSV hospitalization

Outpatient QALYs Lost

Pfizer Vaccine Effectiveness ARI

Incidence of outpatient visits for RSV

Mortality, adults hospitalized with RSV

Cost per Hospitalization

ED Incidence

Probability of Serious Adverse Event

ICER ($/QALY)

Age ≥65

Low Assumption High Assumption
Sensitivity analysis: Vaccine Cost, GSK 

30 One Year Time Horizon

 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $450,000

 $500,000

 $50 $75 $100 $125 $150 $175 $200

ICER ($/QALY)

Vaccine Cost

age ≥60 years age ≥65 years age ≥70 years age ≥75 years 
Sensitivity analysis: Vaccine Cost, Pfizer

31 One Year Time Horizon

 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $450,000

 $500,000

 $50 $75 $100 $125 $150 $175 $200

ICER ($/QALY)

Vaccine Cost

age ≥60 years age ≥65 years age ≥70 years age ≥75 years 
Sensitivity analyses, Higher Incidence

32

• Higher incidence in the next 2 slides 

assumes that RT-PCR test sensitivity is 

lower than 95% and that additional RSV 

testing modalities would detect more 

cases at every level of care1,2

1 For incidence of hospitalization (RSV-NET), in lieu of adjusting observed incidence for RT-PCR sensitivity of 95%, a 

1.4x multiplier is implemented based on Zhang et al. 2016 .

Zhang Y, et al. Serology Enhances Molecular Diagnosis of Respiratory Virus Infections Other than Influenza in Children and Adults Hospitalized with 

Community-Acquired Pneumonia. J Clin Microbiol. 2016 Dec 28;55(1):79-89. doi: 10.1128/JCM.01701-16. PMID: 27795341; PMCID: PMC5228265.

2 For incidence of outpatient and ED visits (McLaughlin et al. 2022), this applies the authors’ multiplier of 1.5x to the 

lower (base case) incidence estimates.

McLaughlin JM, et al. Rates of Medically Attended RSV Among US Adults: A Systematic Review and Meta-analysis. Open Forum Infect Dis. 2022 Jun 

17;9(7):ofac300. doi: 10.1093/ofid/ofac300. PMID: 35873302; PMCID: PMC9301578.
Sensitivity analyses, GSK 

Higher Incidence

33 Age-based vaccination recommendation: ≥65 years

One Year Time Horizon

 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $50 $75 $100 $125 $150 $175 $200

ICER ($/QALY)

Vaccine Cost

GSK Base age ≥65 years GSK Higher Incidence age ≥65 years
Sensitivity analyses, Pfizer Higher Incidence

34 Age-based vaccination recommendation: ≥65 years

One Year Time Horizon

 $-

 $50,000

 $100,000

 $150,000

 $200,000

 $250,000

 $300,000

 $350,000

 $400,000

 $450,000

 $50 $75 $100 $125 $150 $175 $200

ICER ($/QALY)

Vaccine Cost

Pfizer Base age ≥65 years Pfizer Higher Incidence age ≥65 years
Limitations

• Model Structure

– No risk groups

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

indirect effects

– No direct medical costs post-discharge (e.g. rehab)

• Uncertain inputs

– Vaccine cost 

– RSV Incidence

– Long-term efficacy 

35
Summary

• Results vary based on:

– Vaccine Cost

• ICER: ~80,000 - 385,000 $/QALY

– Vaccine Efficacy

• ICER: ~150,000 - 575,000 $/QALY

– Ages Vaccinated

• ICER: ~100,000 - 230,000 $/QALY

– Incidence of Hospitalization

• ICER: ~30,000 - 250,000 $/QALY

36
Thank You

• Please send comments to:

• dwhutton@umich.edu

37