Cost-Effectiveness of Meningococcal Quadrivalent Conjugate Vaccination Campaign among Men Who Have Sex With Men in New York City Matthew S. Simon1*, Don Weiss2, Anita Geevarughese2, Molly Kratz2, Blayne Cutler3, Roy M. Gulick1, Jane R. Zucker2, Jay K. Varma2, Bruce R. Schackman1 1
Weill Cornell Medical College, New York, NY; 2 New York City Department of Health and Mental Hygiene; 3Public Health Foundation Enterprises *Corresponding author. email:
[email protected]
500,000 Monthly cases predicted with herd immunity
Vaccination campaign initiated
No vaccination
Monthly cases predicted without herd immunity Number of cases observed
2
Vaccination
Difference
Difference range
no herd immunity
450,000 herd immunity
IMD cases
400,000
Herd immunity
9.6
No herd immunity
IMD cases
6.9
8.6
2.7
8.5
0.9-.60
1.1
1
0.5-2.1
Herd immunity
3.7
2.7
1.0
0.2-2.5
$/QALY 250,000
No herd immunity
3.7
3.3
0.4
0.1-0.9
200,000
Strategy
No vaccination
KEY MODEL INPUTS
METHODS
Variable IMD Incidence in NYC MSM (per 100,000) HIV positive HIV negative
0 1
66,000
7.6
4.0-24.0
No herd immunity
2,345,400
1,551,600
1,096,099
9
177,000
20.1
13.0-25.0
75-95%
17%
10-40%
20%
0-63%
IMD mortality HIV positive
42%
10-60%
HIV negative
20%
5-40%
34%
5-75%
Vaccination (variable and fixed costs) Herd immunity
2,789,200
1,995,400
1,096,112
22
93,000
No herd immunity
2,922,400
2,128,600
1,096,099
9
243,000
ICER ($/QALY) 0
$55,600 $53,800 $120 $577,000
+/- 50% +/- 50%
IMD case fatality ratio
+/- 50%
IMD incidence
+/- 50%
Vaccine cost
50,000
100,000
150,000
200,000
0.83-0.88 0.89-0.95
0.70
0.5-0.8
Vaccine effectiveness
Proportion of HIV in target population
5
7
9
11
13
15
17
19
LIMITATIONS • Actual impact of herd immunity, if any, is unknown • Herd immunity not evident since introduction of meningococcal quadrivalent conjugate (MCV4) vaccination in US adolescent population4 • Herd immunity and critical vaccination threshold assumptions based on modeling data from United Kingdom5 • IMD transmission dynamics within MSM communities are poorly understood. • MCV4 effectiveness in HIV-infected adults based on limited data in HIV-infected adolescents6 • Unable to characterize effect of fixed costs on vaccination rates • Did not evaluate cost-effectiveness of routine vaccination of high-risk MSM with or without HIV
CONCLUSIONS • Targeted vaccination of NYC MSM in the context of an IMD outbreak may have averted IMD cases and deaths • Vaccination was cost-effective at a $100,000/QALY threshold but depended on: • Herd immunity • IMD incidence > 12 per 100,000 • Case fatality >18% • At a cost-effectiveness threshold consistent with adolescent meningococcal program ($220,000/QALY)4, vaccination was cost-effective even without herd immunity, but was sensitive to the inclusion of fixed costs.
ACKNOWLEDGEMENTS • Marcelle Layton, Sarah Braunstein, Colin Shepard ,NYC Department of Health and Mental Hygiene • Ankur Pandya and Jared Leff, Weill Cornell Medical College
Probability of long-term neurological disability
0.86 0.92
3
Incidence (IMD cases per 100,000 persons)
Tornado analysis depicting results of 1-way sensitivity analysis of key variables (variable costs only)
Herd immunity
costs8
Vaccine costs (includes labor/administration fee) Fixed costs of DOHMH vaccination program (labor, media, community outreach) Baseline QALY weight HIV positive9 HIV negative10 QALY weight long-term IMD disability10
-----
22
90%
Long-term disability
50,000
1,096,112
HIV negative7
Acute
1,096,090
ICER ($/QALY)
1,418,400
25-95%
IMD treatment
----
793,800
Incremental QALYs
2,212,000
62%
IMD long-term disability8
Total QALYs
Herd immunity
HIV positive6
Herd immunity risk reduction in unvaccinated MSM
Incremental cost
Vaccination (variable costs only)
Vaccine effectiveness
Vaccine coverage
Cost
Range
Base case
$100,000/QALY threshold
150,000 100,000
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
• To estimate the cost-effectiveness of meningococcal vaccination among HIV-infected and HIV-uninfected MSM based on the NYC experience.
Base case incidence
$220,000/QALY threshold
300,000
Projected cost-effectiveness of meningococcal vaccination in 60,000 NYC MSM 0
ACIP recommendation to vaccinate
350,000
IMD deaths
STUDY OBJECTIVE
• Decision analytic model • Simulated cohort • 60,000 NYC MSM (estimated size of target population) • Mean age 35 years • HIV positive 65% (87% CD4>200 and 13% CD4