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Cost effectiveness of pneumococcal vaccination among Dutch infants: economic analysis of the seven valent pneumococcal conjugated vaccine and forecast for the 10 valent and 13 valent vaccines

BMJ 2010; 340 doi: (Published 02 June 2010) Cite this as: BMJ 2010;340:c2509
  1. Mark H Rozenbaum, health economist and modeller of infectious diseases1,
  2. Elisabeth A M Sanders, professor in paediatric immunology and infectious diseases2,
  3. Albert Jan van Hoek, health economist and modeller of infectious diseases1,
  4. Angelique G S C Jansen, research fellow23,
  5. Arie van der Ende, associate professor medical microbiology 4,
  6. Germie van den Dobbelsteen, senior research scientist5,
  7. Gerwin D Rodenburg, research fellow2,
  8. Eelko Hak, associate professor in clinical epidemiology of infectious diseases 1236,
  9. Maarten J Postma, professor in pharmacoeconomics16
  1. 1Unit of PharmacoEpidemiology and PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, Netherlands
  2. 2Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
  3. 3Julius Center for Health Sciences and Primary Care, University of Utrecht, Utrecht, Netherlands
  4. 4Center for Infection and Immunity Amsterdam, Department of Medical Microbiology and the Netherlands Reference Laboratory for Bacterial Meningitis, Academic Medical Center Amsterdam, Amsterdam, Netherlands
  5. 5Netherlands Vaccine Institute, Bilthoven, Netherlands
  6. 6Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
  1. Correspondence to: M H Rozenbaum m.h.rozenbaum{at}
  • Accepted 16 February 2010


Objectives To update cost effectiveness estimates for the four dose (3+1) schedule of the seven valent pneumococcal conjugated vaccine (PCV-7) in the Netherlands and to explore the impact on cost effectiveness of reduced dose schedules and implementation of 10 valent and 13 valent pneumococcal vaccines (PCV-10 and PCV-13).

Design Economic evaluation comparing PCV-7, PCV-10, and PCV-13 with no vaccination using a decision tree analytic model built from data in previous studies.

Setting The Netherlands.

Population A cohort of 180 000 newborns followed until 5 years of age.

Main outcome measures Costs; gains in life years and quality adjusted life years (QALYs); and incremental cost effectiveness ratios.

Results Under base case assumptions—that is, assuming a five year protective period of the vaccine and no assumed net indirect effects (herd protection minus serotype replacement) among children aged over 5 years—vaccination with PVC-7 in a four dose (3+1) schedule was estimated to prevent 71 and 5778 cases of invasive and non-invasive pneumococcal disease, respectively, in children aged up to 5 years. This corresponds with a total net gain of 173 life years or 277 QALYs. The incremental cost effectiveness ratio of PCV-7 was estimated at €113 891 (£98 300; $145 000) per QALY, well over the ratio of €50 000 per QALY required for PCV-7 to be regarded as potentially cost effective. A three dose (2+1) schedule of PCV-7 reduced the incremental cost effectiveness ratio to €82 975 per QALY. For various assumptions and including 10% of the maximum net indirect effects among individuals aged 5 years and over, PCV-10 and PCV-13 had incremental cost effectiveness ratios ranging from €31 250 to €52 947 per QALY.

Conclusions The current Dutch infant vaccination programme of four doses of PCV-7 is not cost effective because of increases in invasive disease caused by non-vaccine serotypes, which reduces the overall direct effects of vaccination and offsets potential positive herd protection benefits in unvaccinated individuals. The 10 valent and 13 valent pneumococcal vaccines could have better net health benefits than PCV-7 through less replacement disease and increased herd protection. Both these effects could substantially reduce the incremental cost effectiveness ratio to possibly acceptable levels, if total programme costs can be lowered by reduced schedules, reductions in vaccine prices, or both.


  • Contributors: MJP, EH, and GvdD designed the study. MHR, A JvH, and MJP designed the computer model and carried out the computer simulations and analysis. Data analyses were performed by AGSCJ, GDR, and MHR under supervision of EAMS, MJP, and AvdE. MHR, MJP, AJvH, and EAMS drafted the manuscript. All authors commented on drafts and contributed to the final version. MHR and MJP are the guarantors of the study.

  • Funding: MHR was funded by an unrestricted grant from Wyeth Hoofddorp. AJvH was financed by the Netherlands Vaccine Institute, Bilthoven. This work has been previously presented at a workshop on pneumococcal vaccines at the European Public Health Association conference in Lisbon, Portugal, which was supported by a research grant from GlaxoSmithKline Netherlands. The authors’ work was independent of the funders, who had no role in the study design, analysis of data, writing of the manuscript, or decision to submit for publication.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: (1) MHR was funded by an unrestricted grant from Wyeth Hoofddorp; and AJvH was financed by the Netherlands Vaccine Institute, Bilthoven; (2) MJP has received travel grants from GlaxoSmithKline and Wyeth to attend expert meetings in Reykjavik, Iceland, and Istanbul, Turkey; EAMS has received unrestricted grants from Wyeth and Baxter for research, consulting fees from Wyeth and GlaxoSmithKline, lecturing fees from Wyeth, and grant support from Wyeth and GlaxoSmithKline for vaccine studies; and AvdE has received unrestricted grants from Wyeth and Novartis; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

  • Data sharing: No additional data available.

  • Accepted 16 February 2010

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