近日，《美国医学会杂志》JAMA上的一项研究揭示，一项基于电脑的成本效益分析提示，与目前的23价肺炎球菌多糖疫苗(PPSV23)的接种建议相比，使用13价肺炎球菌结合疫苗 (PCV13) 可在保持经济上合理的同时预防更多的肺炎球菌性疾病；尽管文章的作者指出，他们的发现对许多假设是敏感的。
根据文章的背景资料，自1983年以来，有关方面就建议用PPSV23疫苗来预防成人中的侵入性肺炎球菌疾病(IPD)。 “大多数的研究显示，PPSV23可提供人体对IPD的某种保护，但有关研究在其预防非菌血症性肺炎球菌性肺炎（NPP）的能力上所得出的结论是有矛盾的；在美国，NPP每年会引起数百万例的疾病。”
匹茨堡大学医学院的Kenneth J. Smith，M.D. M.S及其同事开展了一项研究，旨在对50岁或以上的成年人中接种肺炎球菌疫苗的策略的有效性和成本效益进行评估。 研究人员应用不同的模型方法在一个假设的美国的50岁的组群中进行了模拟运作。 疫苗接种策略及有效性评估是由一个专家组研发的；由儿时接种PCV13所致的间接（群体免疫）效应则根据所观察到的7价肺炎球菌结合疫苗（PCV7）的效应来进行推断。 模型参数的数据源包括疾病控防中心有效细菌核心监测、全国医院出院调查和全国住院病人样本数据及国民健康采访调查。
在没有获得疫苗接种的情况下，从50岁开始因为NPP而住院的估测的终身风险为9.3%，发生IPD的风险为0.86%，因肺炎球菌性疾病而死亡的风险为1.8%。 在该分析中所比较的不同疫苗接种的策略中，那些使用PPSV23的人估计可比仅使用PCV13者可预防更多的IPD，而应用2剂排定的PCV13的接种策略估计能够预防更多的NPP。
就成本效益而言，在基本案例的情况中，与没有疫苗接种相比，接种PCV13来替代目前建议的PPSV23的接种（即在65岁时接种，如果有同时存在的疾病则在较为年轻的时候接种）对每个得到的质量修正生命年 (QALY) 的估计成本为2万8900美元，这比目前建议的PPSV23的接种策略要更具成本效益。 与目前建议的替代PCV13相比，在50岁和65岁时给予常规的疫苗接种的 PCV13的估计成本为每QALY需4万5100美元。 在50岁和65岁时给予PCV13并接着在75岁的时候接种PPSV23，其估计的每增加一个QALY的成本为46万6000美元。
文章的作者写道：“就成本效益而言没有绝对的标准，但一般来说，那些成本低于2万美元就可获得一个QALY的干预会被人们感到有很强的采用证据，那些每个QALY的成本为2万至10万美元的干预有着中度的采用证据，而那些每个QALY的成本超过10万美元的干预则有着较弱的采用证据。”（生物谷Bioon.com）
doi:10.1001/jama.2012.169
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Cost-effectiveness of Adult Vaccination Strategies Using Pneumococcal Conjugate Vaccine Compared With Pneumococcal Polysaccharide Vaccine
Kenneth J. Smith, MD, MS; Angela R. Wateska, MPH; Mary Patricia Nowalk, PhD, RD; Mahlon Raymund, PhD; J. Pekka Nuorti, MD, DSc; Richard K. Zimmerman, MD, MPH
Context The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear.
Objective To estimate the cost-effectiveness of PCV13 vaccination strategies in adults.
Design, Setting, and Participants A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included Centers for Disease Control and Prevention Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey. Main Outcome Measures Pneumococcal disease cases prevented and incremental costs per quality-adjusted life-year (QALY) gained.
Results In the base case scenario, administration of PCV13 as a substitute for PPSV23 in current recommendations (ie, vaccination at age 65 years and at younger ages if comorbidities are present) cost $28 900 per QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost $45 100 per QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 years to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing $496 000 per QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored.
Conclusion Overall, PCV13 vaccination was favored compared with PPSV23, but the analysis was sensitive to assumptions about PCV13 effectiveness against nonbacteremic pneumococcal pneumonia and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution.
