, Volume 29, Issue 3, pp 199–211

Cost Effectiveness of Pneumococcal Conjugate Vaccination against Acute Otitis Media in Children

A Review
  • Chantal W.B. Boonacker
  • Pieter H. Broos
  • Elisabeth A.M. Sanders
  • Anne G.M. Schilder
  • Maroeska M. Rovers
Review Article Cost Effectiveness of PCV against AOM in Children


While pneumococcal conjugate vaccines have shown to be highly effective against invasive pneumococcal disease, their potential effectiveness against acute otitis media (AOM) might become a major economic driver for implementing these vaccines in national immunization programmes. However, the relationship between the costs and benefits of available vaccines remains a controversial topic. Our objective is to systematically review the literature on the cost effectiveness of pneumococcal conjugate vaccination against AOM in children.

We searched PubMed, Cochrane and the Centre for Reviews and Dissemination databases (Database of Abstracts of Reviews of Effects [DARE], NHS Economic Evaluation Database [NHS EED] and Health Technology Assessment database [HTA]) from inception until 18 February 2010. We used the following keywords with their synonyms: ‘otitis media’, ‘children’, ‘cost-effectiveness’, ‘costs’ and ‘vaccine’. Costs per AOM episode averted were calculated based on the information in this literature.

A total of 21 studies evaluating the cost effectiveness of pneumococcal conjugate vaccines were included. The quality of the included studies was moderate to good. The cost per AOM episode averted varied from €168 to €4214, and assumed incidence rates varied from 20952 to 118000 per 100000 children aged 0–10 years. Assumptions regarding direct and indirect costs varied between studies. The assumed vaccine efficacy of the 7-valent pneumococcal CRM197-conjugate vaccine was mainly adopted from two trials, which reported 6–8% efficacy. However, some studies assumed additional effects such as herd immunity or only took into account AOM episodes caused by serotypes included in the vaccine, which resulted in efficacy rates varying from 12% to 57%. Costs per AOM episode averted were inversely related to the assumed incidence rates of AOM and to the estimated costs per AOM episode. The median costs per AOM episode averted tended to be lower in industry-sponsored studies.

Key assumptions regarding the incidence and costs ofAOMepisodes have major implications for the estimated cost effectiveness of pneumococcal conjugate vaccination against AOM. Uniform methods for estimating direct and indirect costs of AOM should be agreed upon to reliably compare the cost effectiveness of available and future pneumococcal vaccines against AOM.

Supplementary material

40273_2012_29030199_MOESM1_ESM.pdf (104 kb)
Supplementary material, approximately 106 KB.
40273_2012_29030199_MOESM2_ESM.pdf (110 kb)
Supplementary material, approximately 113 KB.


  1. 1.
    Bondy J, Berman S, Glazner J, et al. Direct expenditures related to otitis media diagnoses: extrapolations from a pediatric medicaid cohort. Pediatrics 2000 Jun; 105 (6): E72CrossRefGoogle Scholar
  2. 2.
    Rovers MM, Schilder AG, Zielhuis GA, et al. Otitis media. Lancet 2004 Feb 7; 363 (9407): 465–73PubMedCrossRefGoogle Scholar
  3. 3.
    Gates GA. Cost-effectiveness considerations in otitis media treatment. Otolaryngol Head Neck Surg 1996 Apr; 114 (4): 525–30PubMedCrossRefGoogle Scholar
  4. 4.
    Black S, Shinefield H, Fireman B, et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. Pediatr Infect Dis J 2000 Mar; 19 (3): 187–95Google Scholar
  5. 5.
    Prymula R, Peeters P, Chrobok V, et al. Pneumococcal capsular polysaccharides conjugated to protein D for prevention of acute otitis media caused by both Streptococcus pneumoniae and non-typable Haemophilus influenzae: a randomised double-blind efficacy study. Lancet 2006 Mar 4; 367 (9512): 740–8PubMedCrossRefGoogle Scholar
  6. 6.
    De Carvalho GH, Muscat M, Monnet DL, et al. Use of seven-valent pneumococcal conjugate vaccine (PCV7) in Europe, 2001–2007. Euro Surveill 2009 Mar 26; 14 (12): 19159Google Scholar
  7. 7.
    O’Brien MA, Prosser LA, Paradise JL, et al. New vaccines against otitismedia: projected benefits and cost-effectiveness. Pediatrics 2009 Jun; 123 (6): 1452–63PubMedCrossRefGoogle Scholar
  8. 8.
    Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J 2010 Apr; 29 (4): 304–9PubMedGoogle Scholar
  9. 9.
    Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med 2001 Feb 8; 344 (6): 403–9PubMedCrossRefGoogle Scholar
  10. 10.
    Jansen AG, Hak E, Veenhoven RH, et al. Pneumococcal conjugate vaccines for preventing otitis media. Cochrane Database Syst Rev 2009 Apr 15; (2): CD001480Google Scholar
  11. 11.
    Pichichero ME, Casey JR. Evolving microbiology and molecular epidemiology of acute otitis media in the pneumococcal conjugate vaccine era. Pediatr Infect Dis J 2007 Oct; 26 (10 Suppl.): S12–6Google Scholar
  12. 12.
    Organisation for Economic Co-operation and Development (OECD). Price indices (MEI) [online]. Available from URL: [Accessed 2010 Nov 24]Google Scholar
  13. 13. [online]. Available from URL: [Accessed 2010 Apr 6]
  14. 14.
    Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ 1996 Aug 3; 313 (7052): 275–83Google Scholar
  15. 15.
    Asensi F, De Jose M, Lorente M, et al. A pharmacoeconomic evaluation of seven-valent pneumococcal conjugate vaccine in Spain. Value Health 2004 Jan; 7 (1): 36–51PubMedCrossRefGoogle Scholar
  16. 16.
    Bergman A, Hjelmgren J, Ortqvist A, et al. Cost-effectiveness analysis of a universal vaccination programme with the 7-valent pneumococcal conjugate vaccine (PCV-7) in Sweden [abstract]. Scand J Infect Dis 2008; 40 (9): 721–9PubMedCrossRefGoogle Scholar
  17. 17.
    Bos JM, Rumke H, Welte R, et al. Epidemiologic impact and cost-effectiveness of universal infant vaccination with a 7-valent conjugated pneumococcal vaccine in the Netherlands. Clin Ther 2003 Oct; 25 (10): 2614–30PubMedCrossRefGoogle Scholar
  18. 18.
    Bos JM, Rumke HC, Welte R, et al. Combination vaccine against invasive meningococcal B and pneumococcal infections: potential epidemiological and economic impact in the Netherlands. Pharmacoeconomics 2006; 24 (2): 141–53PubMedCrossRefGoogle Scholar
  19. 19.
    Butler JR, McIntyre P, MacIntyre CR, et al. The cost-effectiveness of pneumococcal conjugate vaccination in Australia. Vaccine 2004; 22 (9-10): 1138–49PubMedCrossRefGoogle Scholar
  20. 20.
    Claes C, Graf von der Schulenburg JM. Cost effectiveness of pneumococcal vaccination for infants and children with the conjugate vaccine PnC-7 in Germany. Pharmacoeconomics 2003; 21 (8): 587–600PubMedCrossRefGoogle Scholar
  21. 21.
    Ess SM, Schaad UB, Gervaix A, et al. Cost-effectiveness of a pneumococcal conjugate immunisation program for infants in Switzerland. Vaccine 2003; 21 (23): 3273–81Google Scholar
  22. 22.
    Giglio ND, Cane AD, Micone P, et al. Cost-effectiveness of the CRM-based 7-valent pneumococcal conjugated vaccine (PCV7) in Argentina. Vaccine 2010; 28 (11): 2302–10PubMedCrossRefGoogle Scholar
  23. 23.
    Lebel MH, Kellner JD, Ford-Jones EL, et al. A pharmacoeconomic evaluation of 7-valent pneumococcal conjugate vaccine in Canada. Clin Infect Dis 2003; 36 (3): 259–68PubMedCrossRefGoogle Scholar
  24. 24.
    Lieu TA, Ray GT, Black SR, et al. Projected cost-effectiveness of pneumococcal conjugate vaccination of healthy infants and young children. JAMA 2000; 283 (11): 1460–8PubMedCrossRefGoogle Scholar
  25. 25.
    Lloyd A, Patel N, Scott DA, et al. Cost-effectiveness of heptavalent conjugate pneumococcal vaccine (Prevenar) in Germany: considering a high-risk population and herd immunity effects. Eur J Health Econ 2008; 9 (1): 7–15PubMedCrossRefGoogle Scholar
  26. 26.
    McIntosh ED, Conway P, Willingham J, et al. The costburden of paediatric pneumococcal disease in the UK and the potential cost-effectiveness of prevention using 7-valent pneumococcal conjugate vaccine. Vaccine 2003; 21 (19-20): 2564–72PubMedCrossRefGoogle Scholar
  27. 27.
    Navas E, Salleras L, Gisbert R, et al. Cost-benefit and cost-effectiveness of the incorporation of the pneumococcal 7-valent conjugated vaccine in the routine vaccination schedule of Catalonia (Spain). Vaccine 2005 Mar 18; 23 (17-18): 2342–8PubMedCrossRefGoogle Scholar
  28. 28.
    Ray GT, Pelton SI, Klugman KP, et al. Cost-effectiveness of pneumococcal conjugate vaccine: an update after 7 years of use in the United States. Vaccine 2009 Nov 5; 27 (47): 6483–94PubMedCrossRefGoogle Scholar
  29. 29.
    Salo H, Sintonen H, Nuorti JP, et al. Economic evaluation of pneumococcal conjugate vaccination in Finland. Scand J Infect Dis 2005; 37 (11-12): 821–32PubMedCrossRefGoogle Scholar
  30. 30.
    Silfverdal SA, Berg S, Hemlin C, et al. The cost-burden of paediatric pneumococcal disease in Sweden and the potential cost-effectiveness of prevention using 7-valent pneumococcal vaccine. Vaccine 2009; 27 (10): 1601–8PubMedCrossRefGoogle Scholar
  31. 31.
    Sohn HS, Suh DC, Jang E, et al. Economic evaluation of childhood 7-valent pneumococcal conjugate vaccination in Korea. J Manag Care Pharm 2010 Jan; 16 (1): 32–45PubMedGoogle Scholar
  32. 32.
    Vespa G, Constenla DO, Pepe C, et al. Estimating the cost-effectiveness of pneumococcal conjugate vaccination in Brazil. Rev Panam Salud Publica 2009 Dec; 26 (6): 518–28PubMedCrossRefGoogle Scholar
  33. 33.
    De Wals P, Black S, Borrow R, et al. Modeling the impact of a new vaccine on pneumococcal and nontypable Haemophilus influenzae diseases: a new simulation model. Clin Ther 2009 Oct; 31 (10): 2152–69PubMedCrossRefGoogle Scholar
  34. 34.
    Wisloff T, Abrahamsen TG, Bergsaker MA, et al. Cost effectiveness of adding 7-valent pneumococcal conjugate (PCV-7) vaccine to the Norwegian childhood vaccination program. Vaccine 2006; 24 (29-30): 5690–9PubMedCrossRefGoogle Scholar
  35. 35.
    Riquelme PM, Gasquez Abad CI, Mena ME, et al. Acute otitis media in a pediatrics consulting office [in Spanish]. An Esp Pediatr 1996 May; 44 (5): 433–6Google Scholar
  36. 36.
    Joki-Erkkila VP, Laippala P, Pukander J. Increase in paediatric acute otitis media diagnosed by primary care in two Finnish municipalities: 1994–5 versus 1978–9. Epidemiol Infect 1998 Dec; 121 (3): 529–34PubMedCrossRefGoogle Scholar
  37. 37.
    Vlug AE, van der Lei J, Mosseveld BM, et al. Postmarketing surveillance based on electronic patient records: the IPCI project. Methods Inf Med 1999 Dec; 38 (4-5): 339–44PubMedGoogle Scholar
  38. 38.
    Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J Infect Dis 1989 Jul; 160 (1): 83–94PubMedCrossRefGoogle Scholar
  39. 39.
    Swiss Federal Office of Public Health; Swiss Sentinel Surveillance Network [online]. Available from URL: [Accessed 2010 Apr 6]
  40. 40.
    Wang EE, Einarson TR, Kellner JD, et al. Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clin Infect Dis 1999 Jul; 29 (1): 155–60PubMedCrossRefGoogle Scholar
  41. 41.
    Hardy AM. Incidence and impact of selected infectious diseases in childhood. Vital Health Stat 10 1991 Oct; (180): 1–22PubMedGoogle Scholar
  42. 42.
    Claes C, Reinert R, Graf von der Schulenburg JM. Cost-effectiveness of the conjugate vaccine PnC7 against pneumococcal infections in Germany. Discussion paper no. 25 of the Research Institute for Health Economics and Health Systems Research (in cooperation with the Medical High School Hanover). Version 1.2 [online]. Available from URL: [Accessed 2010 Apr 6]Google Scholar
  43. 43.
    General Practice Research Database (GPRD) [online]. Available from URL: [Accessed 2010 Apr 6]
  44. 44.
    Garcés-Sánchez M, Díez-Domingo J, Alvarez de Labiada T, et al. Epidemiology and burden of acute otitis media in Valencia (Spain) [in Spanish]. An Pediatr (Barc) 2004 Feb; 60 (2): 125–32CrossRefGoogle Scholar
  45. 45.
    Grijalva CG, Poehling KA, Nuorti JP, et al. National impact of universal childhood immunization with pneumococcal conjugate vaccine on outpatient medical care visits in the United States. Pediatrics 2006 Sep; 118 (3): 865–73PubMedCrossRefGoogle Scholar
  46. 46.
    National Board of Health and Welfare [online]. Available from URL: [Accessed 2010 Apr 6]
  47. 47.
    Health Insurance Review & Assessment Service Agency. National health insurance statistical yearbook. Seoul: HIRA, 2006Google Scholar
  48. 48.
    Petit G, De Wals P, Law B, et al. Epidemiological and economic burden of pneumococcal diseases in Canadian children. Can J Infect Dis 2003 Jul; 14 (4): 215–20PubMedGoogle Scholar
  49. 49.
    Stangerup SE, Tos M. Epidemiology of acute suppurative otitis media. Am J Otolaryngol 1986 Jan; 7 (1): 47–54PubMedCrossRefGoogle Scholar
  50. 50.
    Dagan R. The potential effect of widespread use of pneumococcal conjugate vaccines on the practice of pediatric otolaryngology: the case of acute otitis media. Curr Opin Otolaryngol Head Neck Surg 2004 Dec; 12 (6): 488–94PubMedCrossRefGoogle Scholar
  51. 51.
    Beutels P. Economic evaluations of hepatitis B immunization: a global review of recent studies (1994–2000). Health Econ 2001 Dec; 10 (8): 751–74PubMedCrossRefGoogle Scholar
  52. 52.
    Campbell H, Andrews N, Borrow R, et al. Updated postlicensure surveillance of the meningococcal C conjugate vaccine in England and Wales: effectiveness, validation of serological correlates of protection, and modeling predictions of the duration of herd immunity. Clin Vaccine Immunol 2010 May; 17 (5): 840–7PubMedCrossRefGoogle Scholar
  53. 53.
    Brouwer CN, Maille AR, Rovers MM, et al. Health-related quality of life in children with otitis media. Int J Pediatr Otorhinolaryngol 2005 Aug; 69 (8): 1031–41PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2011

Authors and Affiliations

  • Chantal W.B. Boonacker
    • 1
  • Pieter H. Broos
    • 1
  • Elisabeth A.M. Sanders
    • 2
  • Anne G.M. Schilder
    • 1
    • 3
  • Maroeska M. Rovers
    • 1
    • 3
  1. 1.Julius Center for Health Sciences and Primary Care & Department of OtorhinolaryngologyUniversity Medical Center UtrechtUtrechtthe Netherlands
  2. 2.Clinical Department of Clinical Immunology and Infectious DiseasesWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
  3. 3.Department of OtorhinolaryngologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands

Personalised recommendations