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Stephen J.LurieMD, PhD, Contributing EditorIndividualAuthor
To the Editor: Dr Lieu and colleagues1 used pneumococcal vaccine efficacy estimates of
7%, 19%, and 20% for the prevention of simple otitis media (OM), complex OM,
and OM requiring tympanostomy tube placement, respectively. These estimates
are extrapolations of the vaccine efficacy against OM when the vaccine was
given to infants in a 4-dose series as conducted in the Northern California
Kaiser Permanente trial.2 Although the conjugate
vaccine is immunogenic in older children, I question the validity of using
the same efficacy data to calculate the cost-effectiveness of a single "catch-up"
dose in older children.
Cost-effectiveness analyses should also take into consideration assumptions
such as the natural history of the disease and the variation in medical practice
settings. The decrease in the incidence of OM in older children compared with
infants and toddlers, the fact that 80% of cases of OM can improve without
antibiotics,3 and new shorter courses of
treatment can significantly affect cost-analysis equations.
Parents and practitioners would welcome any measure that reduces the
incidence of OM and decreases the use of antibiotics. I suspect that the demand
for the conjugate pneumococcal vaccine could be high if it were promoted as
"the OM vaccine for children attending day care." However, in an era of competing
health care priorities, promotion of the use of this expensive vaccine without
solid data in older children may not be the most cost-effective strategy.
Fontanarosa PB, Le C. Cost-effectiveness of Pneumococcal Vaccine. JAMA. 2000;284(4):440–441. doi:10.1001/jama.284.4.436
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