Healthcare utilization and cost of pneumococcal disease in the United States
Introduction
Streptococcus pneumoniae (pneumococcus) is a major cause of bacterial disease in children and adults. Its clinical spectrum includes localized disease such as acute otitis media (AOM) and sinusitis, and more serious infections such as pneumonia and meningitis, which cause substantial morbidity and mortality. Because of this, pneumococcal vaccines have been long recommended for widespread use.
The 23-valent pneumococcal polysaccharide vaccine was licensed in 1983 and is 50–85% effective in preventing invasive pneumococcal disease (IPD) among healthy adults [1], [2]. The U.S. licensure of a pediatric 7-valent pediatric conjugate vaccine (PCV7) in 2000, led to a 4-fold decrease in the IPD rate among children <5 years old [3], and a decrease in the IPD rate among adults >50 years old of nearly one-third [4], [5]. Uptake of PCV7 vaccine has been high (>90%) given the addition of this vaccine to the routine pediatric vaccine schedule [6], [7].
Nevertheless, despite extensive vaccination programs, pneumococcus remains a common human pathogen. Surveillance from the Centers for Disease Control and Prevention (CDC) suggests that post-PCV7 reductions in invasive disease plateaued by 2004, with non-vaccine serotypes causing the remaining IPD [4], [8], [9], [10], [11]. Other pneumococcal diseases such as AOM and non-invasive pneumonia have declined modestly [12], [13], but are more common than IPD and are important drivers of healthcare utilization and related costs. Thus, the burden of pneumococcal disease may still be considerable in the current vaccine era [14]. Robust estimates of this burden may help drive further prevention strategies. Currently, only 64% of adults ≥65 and 37% of adults with diabetes aged 18–64 are vaccinated [15], [16].
Pneumococcal disease burden has been estimated in other countries [17], [18]. We sought to estimate U.S. healthcare utilization and costs for IPD and non-invasive pneumococcal infections to identify population targets to reduce pneumococcal disease, and quantify the potential savings of further prevention efforts, such as future vaccines covering non-PCV7 serotypes.
Section snippets
Methods
We developed a decision tree-based model to estimate U.S. healthcare utilization, outcomes, and costs attributable to pneumococcal disease in 2004. We used the most recently available national healthcare utilization and cost data, data from the CDC's Active Bacterial Core Surveillance (ABCs) system, existing literature, and expert panel opinion to inform parameter values (Appendix A Model parameters and sources, Appendix B Outpatient model parameters: incidence and healthcare utilization,
Results
In 2004, pneumococcus caused an estimated 4.0 million disease episodes (Table 2). Over 3.5 million were seen in outpatient settings only, with AOM and sinusitis responsible for 85% of outpatient cases (1.5 million cases each). Of the 445,000 pneumococcal-related hospitalizations, >90% were for pneumonia. All results are rounded to the nearest thousand, or first significant digit if less than a thousand. Slight differences may occur in reported numbers due to rounding.
Comment
S. pneumoniae continues to be responsible for a large disease burden in the U.S. despite introduction of routine childhood pneumococcal vaccination in 2000 and availability of polysaccharide vaccine since 1983. The estimated 4 million cases and $3.5 billion in direct medical costs in 2004 has likely remained stable through 2008 since overall rates of disease have not increased despite modest increases in non-PCV7 serotypes [25]. Introduction of a 13-valent pneumococcal conjugate vaccine (PCV13)
Acknowledgments
We are grateful to the following expert panel members for their time and expertise provided to this project: Dr. Steven Black, Dr. Ralph Gonzales, Dr. Marie Griffin, Dr. Keith Klugman, Dr. Katherine O’Brien, Dr. Lionel Mandel, and Dr. Daniel Musher. We would also like to thank Dr. Antonio Anzueto and Dr. Peter Lindenhauer, and Sara Schoenfeld for their contributions, as well as Dr. Mark Messonnier for advice on economic methods.
This study was funded by a grant from the CDC (TS-1363,
References (30)
- et al.
Decline in pneumonia admissions after routine childhood immunization with pneumococcal conjugate vaccine in the USA: a time-series analysis
Lancet
(2007) - et al.
Hib and Pneumococcal Global Burden of Disease Study Team. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates
Lancet
(2009) - et al.
Criteria-based diagnosis and antibiotic overuse for upper respiratory infections
Ambul Pediatr
(2008) - et al.
Active Bacterial Core Surveillance Program of the Emerging Infections Program Network. Adults with invasive pneumococcal disease: missed opportunities for vaccination
Am J Prev Med
(2006) - et al.
Immunological responses to pneumococcal vaccine in frail older people
Vaccine
(2009) - et al.
Pneumococcal polysaccharide vaccine efficacy. An evaluation of current recommendations
J Am Med Assoc
(1993) - et al.
The protective efficacy of polyvalent pneumococcal polysaccharide vaccine
N Engl J Med
(1991) Pneumonia hospitalizations among young children before and after introduction of pneumococcal conjugate vaccine – United States, 1997–2006
MMWR Morb Mortal Wkly Rep
(2009)- et al.
Changing epidemiology of invasive pneumococcal disease among older adults in the era of pediatric pneumococcal conjugate vaccine
J Am Med Assoc
(2005) - et al.
Decline in invasive pneumococcal disease after the introduction of protein–polysaccharide conjugate vaccine
N Engl J Med
(2003)
Effect of vaccine shortages on timeliness of pneumococcal conjugate vaccination: results from the 2001–2005 National Immunization Survey
Pediatrics
Incidence of pneumococcal disease due to non-pneumococcal conjugate vaccine (PCV7) serotypes in the United States during the era of widespread PCV7 vaccination, 1998–2004
J Infect Dis
Invasive pneumococcal disease among infants before and after introduction of pneumococcal conjugate vaccine
J Am Med Assoc
Population snapshot of emergent Streptococcus pneumoniae serotype 19A in the United States, 2005
J Infect Dis
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