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Volume 7, Number 5—October 2001
Synopsis

Cost-Effectiveness of a Potential Vaccine for Coccidioides immitis

Amber E. Barnato*Comments to Author , Gillian D. Sanders†, and Douglas K. Owens†‡
Author affiliations: *University of Pittsburgh, Pittsburgh, Pennsylvania, USA; †Stanford University, Stanford, California, USA; ‡VA Palo Alto Health Care System, Palo Alto, California, USA

Main Article

Table A1

Input variables, quality of data, and sourcesa

Input variable Base-case estimate (range) Quality of evidenceb Source
Epidemiology (%)
  Vaccine effectiveness 75 (20-90) I 77
  Skin-test sensitivity 70 (50-80) II-2 78-80
  Skin-test specificity 90 (70-97) II-2 79, 81, 82
  Annual infection rate 2 (0.25-3) II-3 80, 83-91
  Annual emigration among vaccinees out of highly endemic region 0.5 (0-4.2) II-2, III c
  Symptomatic primary pulmonary disease after infection 40 II-2 93
  Diagnosed symptomatic primary pulmonary disease 10 (5-15) III d
  Death from primary pulmonary disease, given diagnosis 0.5 (0-26) II-2 94-101
  Chronic pulmonary disease after diagnosed primary infection 5 (1-10) III 99
  Death from chronic pulmonary disease 5 (0-20) III 99e
  Dissemination after infection 0.38(0.25-0.55) II-2 92
  Meningitis, given dissemination 33 (23-44) II-2 96, 101
  Death from meningeal dissemination 7 (5-40) II-2, III 102d,e
  Moderate disability after meningeal dissemination 50 (40-60) III 102d,e
  Severe disability after meningeal dissemination 17 (10-30) III 102d,e
  Annual meningeal dissemination relapse rate, on treatment 2 (0-5) I, II-2 103-105
  Death from nonmeningeal dissemination 2 (0-10) III e
  Moderate disability after nonmeningeal dissemination 33 (20-50) III d,e
  Annual nonmeningeal dissemination relapse rate, On treatment 2 (0-5) I, II-2, III 79c
    Off treatment 50 (35-65) I, II-2, III 106-109c
  Mild vaccine side effects 25 (10-40) II-2 110
  Vaccine anaphylaxis, x 10-4 1.67 (0.1-10) II-2 110
Direct medical costs ($)
  Three doses of vaccine 180 (100-400) III 111,112
  Skin test 12 (9-15) III 113
  Home care, per month 2,450 (1,840-3,060) II-2 114
  Diagnosed pulmonary disease 2,090 (1,570-2,610) II-2, III 115
  Incident meningeal dissemination 9,510 (7,130-11,890) II-2 115
  Medication and follow-up after Coccidioides immitis meningitis,f per month 1,510 (1,130-1,890) II-2 116e,g
  Incident nonmeningeal dissemination 6,950 (5,210-8,690) II-2 115
  Medication and follow-up for chronic pulmonary infection and nonmeningeal dissemination,f per month 530 (290-790) II-2 116e,g
  Inpatient vaccine anaphylaxis treatment 2,180 (1,640-2,730) II-2 115
Time costsh
  Average wage ($ per hour) 12 (9-15) II-2 d
  Average clinic visit (hours) 1.25 (0.5-2) III Assumed
  Lost work due to undiagnosed primary pulmonary disease (days) 5 (0-10) III Assumed
  For parents of sick children (days) 3 (0-5) III Assumed
Utilities
  Well 0.94 to 0.70i II-2 117
  Diagnosed primary pulmonary infection 0.90 (0.85-0.95) III d
  Chronic pulmonary infection (proxy, pulmonary tuberculosis) 0.57 (0.29-0.84) II-2, III 117
  Meningeal dissemination (proxy, paraplegia) 0.40 (0.21-0.52) II-2, III 117
  Nonmeningeal dissemination (proxy, orthopedic impairment) 0.59 (0.34-0.84) II-2, III 117
  Severe disability after meningitis (proxy, hemiplegia) 0.27 (0.10-0.38) II-2, III 117
  Moderate disability after meningitis (proxy, sciatica) 0.72 (0.52-0.92) II-2, III 117
  Moderate disability after nonmeningeal dissemination (proxy, arthritis) 0.69 (0.51-0.92) II-2, III 117
  Chronic azole treatment (proxy, warfarin treatment) 0.98 (0.92-1.0) II-2, III 118
  Dead 0 III Assumed
  Vaccine side effect quality-of-life decrement (days) 0.1 (0-0.2) III Assumed
Other variables (%)
  Discount rate 3 (0-5) III 119

aThe base-case estimate represents our best estimate for each value. All costs are in 2000 U.S. dollars.
bThe quality rating is derived from the U.S. Preventive Services Task Force Guide to Clinical Preventive Services (76). Source of evidence: I: at least one properly randomized controlled trial; II-1: well-designed controlled trial without randomization; II-2: well-designed cohort or case-control analytic studies; II-3: multiple time series with or without intervention; III: opinions of respected authorities; descriptive studies and case reports; or reports of expert committees (76).
cInternal Revenue Service, unpub. data.
dJohn Galgiani, pers. comm.
eHans Einstein, pers. comm.
fWe assumed that meningitis patients were treated with 800 mg of daily fluconazole, and chronic pulmonary and nonmeningeal dissemination patients with either 400 mg fluconazole or 400 mg ketoconazole daily (Royce Johnson, pers. comm., 1999). A 50:50 distribution of fluconazole and ketoconazole use represents our base case; the upper end of the range assumes all nonmeningeal dissemination patients receive fluconazole in follow-up, whereas the lower end assumes they receive the less expensive ketoconazole.
gRon Talbot, pers. comm.
hBased on a weighted adjusted gross income of $24,105 from taxpayers in the 10 highly endemic counties (Internal Revenue Service, unpub. data).
iMean HALex scores for healthy persons, by age group (when men and women had differing mean scores, we chose the higher of the two scores): <5=0.94; 5-17=0.93; 18-24= 0.92; 25-34=0.91; 35-44=0.90; 45-54=0.87; 55-64=0.81; 65-74=0.78; >75=0.70 (43).

Main Article

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