Perspective

Herpes zoster subunit vaccine cost-effective among older patients

Herpes zoster subunit vaccine is an effective, cost-saving option for shingles prevention compared with live-attenuated herpes zoster vaccine among adults aged 60 years or older, recent findings suggest.

“The live-attenuated herpes zoster vaccine (ZVL) is recommended for immunocompetent adults 60 years or older, but the efficacy wanes with age and over time,” Phuc Le, PhD, MPH, and Michael B. Rothberg, MD, MPH, both from the Center for Value-Based Care Research at Cleveland Clinic, wrote in JAMA Internal Medicine. “A new adjuvanted herpes zoster subunit vaccine (HZ/su) has higher efficacy but might be more expensive. The choice of vaccines depends on their relative values.”

HZ/su, marketed as Shingrix (GlaxoSmithKline), was approved by the FDA in October 2017. The CDC’s Advisory Committee on Immunization Practices, or ACIP, then voted to recommend HZ/su over the only other FDA-approved vaccine, ZVL (Zostavax, Merck).

Using a Markov decision model, Le and Rothberg investigated the cost-effectiveness of HZ/su (two-dose series) in comparison with no vaccination and vaccination with ZVL (single dose) among a cohort of immunocompetent adults aged 60 years or older.

Data showed that at all ages, HZ/su was more effective and less expensive ($280 per series) than ZVL ($213 per dose). Based on vaccination age, the incremental cost-effectiveness ratios for HZ/su ranged from $20,038 to $30,084 per quality-adjusted life-year (QALY) compared with no vaccination. The researchers said the incremental cost-effectiveness ratio was insensitive to most model inputs, especially those that had considerable uncertainty and where adherence to the second dose was more than 50%.

They noted that HZ/su would have lower overall costs than ZVL up to a price of $350 per series. For older adults, HZ/su was 73% likely to be cost-effective at $50,000 per QALY.

“Because of its superior efficacy, HZ/su was cost-saving compared with ZVL and cost-effective compared with no vaccination in most scenarios,” Le and Rothberg wrote.

However, they warned that the ACIP’s recommendation stating a preference for HZ/su over ZVL could lead to future price increases, which would render the vaccine no longer cost-effective. “Therefore, a recommendation linked to periodic reassessment of cost-effectiveness based on the vaccine price might help to mitigate the effect of the recommendation on vaccine affordability,” they concluded.

In an accompanying editorial, Mehdi Najafzadeh, PhD, from Brigham and Women’s Hospital and Harvard Medical School, wrote that the findings by Le and Rothberg demonstrate the clear benefits of HZ/su over ZVL in disease prevention and high economic value.

“The value of HZ/su vaccine would be even higher if it could be marketed at a price comparable to that of ZVL,” Najafzadeh concluded. “A lower price would avoid additional budget implications for patients and payers and would allow wider use of this innovative product in the U.S. elderly population.” – by Alaina Tedesco

Disclosures: The authors report no relevant financial disclosures.

Herpes zoster subunit vaccine is an effective, cost-saving option for shingles prevention compared with live-attenuated herpes zoster vaccine among adults aged 60 years or older, recent findings suggest.

“The live-attenuated herpes zoster vaccine (ZVL) is recommended for immunocompetent adults 60 years or older, but the efficacy wanes with age and over time,” Phuc Le, PhD, MPH, and Michael B. Rothberg, MD, MPH, both from the Center for Value-Based Care Research at Cleveland Clinic, wrote in JAMA Internal Medicine. “A new adjuvanted herpes zoster subunit vaccine (HZ/su) has higher efficacy but might be more expensive. The choice of vaccines depends on their relative values.”

HZ/su, marketed as Shingrix (GlaxoSmithKline), was approved by the FDA in October 2017. The CDC’s Advisory Committee on Immunization Practices, or ACIP, then voted to recommend HZ/su over the only other FDA-approved vaccine, ZVL (Zostavax, Merck).

Using a Markov decision model, Le and Rothberg investigated the cost-effectiveness of HZ/su (two-dose series) in comparison with no vaccination and vaccination with ZVL (single dose) among a cohort of immunocompetent adults aged 60 years or older.

Data showed that at all ages, HZ/su was more effective and less expensive ($280 per series) than ZVL ($213 per dose). Based on vaccination age, the incremental cost-effectiveness ratios for HZ/su ranged from $20,038 to $30,084 per quality-adjusted life-year (QALY) compared with no vaccination. The researchers said the incremental cost-effectiveness ratio was insensitive to most model inputs, especially those that had considerable uncertainty and where adherence to the second dose was more than 50%.

They noted that HZ/su would have lower overall costs than ZVL up to a price of $350 per series. For older adults, HZ/su was 73% likely to be cost-effective at $50,000 per QALY.

“Because of its superior efficacy, HZ/su was cost-saving compared with ZVL and cost-effective compared with no vaccination in most scenarios,” Le and Rothberg wrote.

However, they warned that the ACIP’s recommendation stating a preference for HZ/su over ZVL could lead to future price increases, which would render the vaccine no longer cost-effective. “Therefore, a recommendation linked to periodic reassessment of cost-effectiveness based on the vaccine price might help to mitigate the effect of the recommendation on vaccine affordability,” they concluded.

In an accompanying editorial, Mehdi Najafzadeh, PhD, from Brigham and Women’s Hospital and Harvard Medical School, wrote that the findings by Le and Rothberg demonstrate the clear benefits of HZ/su over ZVL in disease prevention and high economic value.

“The value of HZ/su vaccine would be even higher if it could be marketed at a price comparable to that of ZVL,” Najafzadeh concluded. “A lower price would avoid additional budget implications for patients and payers and would allow wider use of this innovative product in the U.S. elderly population.” – by Alaina Tedesco

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    William Schaffner

    William Schaffner

    A new vaccine to prevent shingles and post-herpetic neuralgia was approved by the FDA in late 2017. An adjuvanted subunit vaccine, Shingrix is administered in two doses separated by at least 8 weeks. The new vaccine has several distinctive advantages over the live-attenuated vaccine. Shingrix was shown to be 97% effective in preventing shingles in persons aged 50 years and older. Strikingly, it also was highly effective among those aged 70 years and older. The early immunogenicity data suggest that the protection will persist solidly for a substantial number of years. In addition, as indicated in the study, Shingrix performed well in cost-effectiveness analyses.

    On the basis of all this information, the ACIP voted to recommend the use of Shingrix for all immunocompetent persons aged 50 years and older. Indeed, the committee determined that the use of Shingrix was preferred over Zostavax. Further, all persons who previously had been vaccinated with Zostavax should now be vaccinated with Shingrix.

    Note that Shingrix can be associated with substantial local reactions of pain and redness; systemic symptoms of headache and fatigue also have been reported. Thus, patients ought to be informed before they receive the vaccine, so they are not surprised. Remind them that this transient discomfort is trivial compared with the distress caused by shingles and post-herpetic neuralgia.

    It will take several months for medical insurance programs to integrate coverage of Shingrix into their benefits packages, so it is best to check with them before providing the vaccine. Unfortunately, as it did with Zostavax, Medicare will put Shingrix into Part D, making it difficult for many physicians to provide Shingrix to patients aged 65 years and older. Please refer these patients to their local pharmacy where the provision of the vaccine is easiest for Medicare patients. Once it starts to be covered by insurance, concentrate on providing the vaccine to persons aged 50 through 64 years.

    • William Schaffner, MD
    • Infectious Disease News Editorial Board Member

    Disclosures: Disclosure: Schaffner reports being a member of data safety monitoring boards for Pfizer and Merck and having consulted for Dynavax, Seqirus, SutroVax and Shionogi.