近日,，《美國醫(yī)學(xué)會(huì)雜志》JAMA上的一項(xiàng)研究揭示,，一項(xiàng)基于電腦的成本效益分析提示,，與目前的23價(jià)肺炎球菌多糖疫苗(PPSV23)的接種建議相比，使用13價(jià)肺炎球菌結(jié)合疫苗 (PCV13) 可在保持經(jīng)濟(jì)上合理的同時(shí)預(yù)防更多的肺炎球菌性疾??；盡管文章的作者指出，他們的發(fā)現(xiàn)對(duì)許多假設(shè)是敏感的,。
根據(jù)文章的背景資料,，自1983年以來,，有關(guān)方面就建議用PPSV23疫苗來預(yù)防成人中的侵入性肺炎球菌疾病(IPD)。 “大多數(shù)的研究顯示,，PPSV23可提供人體對(duì)IPD的某種保護(hù),，但有關(guān)研究在其預(yù)防非菌血癥性肺炎球菌性肺炎（NPP）的能力上所得出的結(jié)論是有矛盾的；在美國,，NPP每年會(huì)引起數(shù)百萬例的疾病。”
匹茨堡大學(xué)醫(yī)學(xué)院的Kenneth J. Smith,，M.D. M.S及其同事開展了一項(xiàng)研究,，旨在對(duì)50歲或以上的成年人中接種肺炎球菌疫苗的策略的有效性和成本效益進(jìn)行評(píng)估。 研究人員應(yīng)用不同的模型方法在一個(gè)假設(shè)的美國的50歲的組群中進(jìn)行了模擬運(yùn)作,。 疫苗接種策略及有效性評(píng)估是由一個(gè)專家組研發(fā)的,；由兒時(shí)接種PCV13所致的間接（群體免疫）效應(yīng)則根據(jù)所觀察到的7價(jià)肺炎球菌結(jié)合疫苗（PCV7）的效應(yīng)來進(jìn)行推斷。 模型參數(shù)的數(shù)據(jù)源包括疾病控防中心有效細(xì)菌核心監(jiān)測(cè),、全國醫(yī)院出院調(diào)查和全國住院病人樣本數(shù)據(jù)及國民健康采訪調(diào)查,。
在沒有獲得疫苗接種的情況下，從50歲開始因?yàn)镹PP而住院的估測(cè)的終身風(fēng)險(xiǎn)為9.3%,，發(fā)生IPD的風(fēng)險(xiǎn)為0.86%,，因肺炎球菌性疾病而死亡的風(fēng)險(xiǎn)為1.8%。 在該分析中所比較的不同疫苗接種的策略中,，那些使用PPSV23的人估計(jì)可比僅使用PCV13者可預(yù)防更多的IPD,，而應(yīng)用2劑排定的PCV13的接種策略估計(jì)能夠預(yù)防更多的NPP。
就成本效益而言,，在基本案例的情況中,，與沒有疫苗接種相比，接種PCV13來替代目前建議的PPSV23的接種（即在65歲時(shí)接種,，如果有同時(shí)存在的疾病則在較為年輕的時(shí)候接種）對(duì)每個(gè)得到的質(zhì)量修正生命年 (QALY) 的估計(jì)成本為2萬8900美元,，這比目前建議的PPSV23的接種策略要更具成本效益。 與目前建議的替代PCV13相比,，在50歲和65歲時(shí)給予常規(guī)的疫苗接種的 PCV13的估計(jì)成本為每QALY需4萬5100美元,。 在50歲和65歲時(shí)給予PCV13并接著在75歲的時(shí)候接種PPSV23，其估計(jì)的每增加一個(gè)QALY的成本為46萬6000美元,。
文章的作者寫道：“就成本效益而言沒有絕對(duì)的標(biāo)準(zhǔn),，但一般來說，那些成本低于2萬美元就可獲得一個(gè)QALY的干預(yù)會(huì)被人們感到有很強(qiáng)的采用證據(jù),，那些每個(gè)QALY的成本為2萬至10萬美元的干預(yù)有著中度的采用證據(jù),，而那些每個(gè)QALY的成本超過10萬美元的干預(yù)則有著較弱的采用證據(jù)。”（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.
