Newer Shingles Vaccine Cheaper, More Effective

Nicola M. Parry, DVM

January 03, 2018

A new herpes zoster (HZ) subunit vaccine (HZ/su) appears to be more effective and less costly than the currently used live attenuated HZ vaccine (ZVL) at all ages, a new study published online January 2 in JAMA Internal Medicine shows.

"At all ages, no vaccination was always the least expensive and least effective, while HZ/su was always the most effective and less expensive than ZVL (ie, ZVL was dominated)," write Phuc Le, PhD, MPH, and Michael B. Rothberg, MD, MPH, Cleveland Clinic, Ohio.

"The HZ/su was highly cost-effective compared with no vaccination, with an ICER [incremental cost-effectiveness ratio] below $50 000 per QALY [quality-adjusted life-year] at all ages."

The US Food and Drug Administration (FDA) approved the ZVL vaccine in 2006 for prevention of postherpetic neuralgia (PHN). However, it does not prevent all HZ, especially in elderly patients, and its efficacy wanes over time.

HZ/su is a new adjuvanted HZ subunit vaccine that was developed to help address these issues; it also recently received FDA approval.

Administered as a two-dose series, HZ/su appears to be more effective than ZVL, especially among elderly patients, but was initially considered likely costlier.

Dr Le and Dr Rothberg therefore conducted a modeled economic evaluation study to help decision makers, including the Advisory Committee on Immunization Practices (ACIP), payers, physicians, and patients, to choose between the two vaccines.

Using data from randomized controlled trials, the researchers compared the value of HZ/su with ZVL vaccine and a no-vaccine strategy for immunocompetent adults aged 60 years or older.

The researchers focused on a one-time vaccine strategy. As HZ/su was not licensed at the time of the study, they assumed a price of $280 for use of a two-dose schedule.

According to Dr Le and Dr Rothberg, the analysis showed that using HZ/su vaccine was a cost-effective strategy compared with no vaccination. In this comparison, HZ/su would cost between $20,038 and $30,084 per QALY, depending on the patient's age at vaccination, they say. 

"In one-way sensitivity analysis, HZ/su sometimes had an ICER greater than $50 000 per QALY but never greater than $100 000 per QALY, unless the price exceeded $465 per series."

And if HZ/su cost less than $160 per series, using this new vaccine would even save money compared with not vaccinating, they add.

The researchers also found that using HZ/su was more effective and less costly than using ZVL at its current cost ($213 per dose), for all age groups.

The high efficacy of the HZ/su vaccine makes it so cost-effective, they emphasize. The vaccine seems to offer levels of protection of at least 90%, even among individuals aged 70 years or older.

"Across conceivable ranges of the efficacy duration, vaccine price, and probability of having PHN 12 months or longer, HZ/su was never more expensive than ZVL," the authors write.

Using HZ/su resulted in lower overall costs than using ZVL, up to a price of $350 per two-dose series.

Dr Le and Dr Rothberg performed a probabilistic sensitivity analysis based on a cost of $280 per HZ/su vaccine series. They found that the probability of HZ/su being cost-effective was between 73% and 91% at $50,000 per QALY and between 78% and 93% at $100,000 per QALY, depending on age at vaccination.

"Because of its superior efficacy, HZ/su was cost saving compared with ZVL and cost-effective compared with no vaccination in most scenarios and should be recommended by the ACIP," the authors conclude.

"This is a timely study that targeted a topical question for the general elderly population, clinicians, and payers," writes Mehdi Najafzadeh, PhD, Harvard Medical School, Boston, Massachusetts, in an accompanying invited commentary.

The FDA Advisory Committee voted unanimously in September 2017 in favor of using the HZ/su vaccine for prevention of HZ in adults aged 50 years and older, he notes, because, unlike ZVL, HZ/su may be used in immunocompromised patients.

The study by Dr Le and Dr Rothberg now provides important information about the economic value of using HZ/su vaccine compared with other available options, Dr Najafzadeh adds.

"Overall, the conclusions of the article are robust and likely can be used by various stakeholders to compare the economic implications of different vaccination strategies."

The greater efficacy of HZ/su compared with ZVL in preventing shingles for a longer duration and across different age groups directly translates into positive economic results, he stresses.

However, he notes that HZ/su would have even higher value if its market price were similar to that of ZVL.

A lower market cost would help reduce expenditure for patients and payers and would thus allow more widespread uptake of this new vaccine among elderly persons in the United States, he explains.

The authors and editorialist have disclosed no relevant financial relationships.  

JAMA Intern Med. Published online January 2, 2018. Abstract, Commentary

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