David W Hutton, Lisa A Prosser, Ismael R Ortega-Sanchez, Andrew J Leidner, Fiona P Havers, Mila M Prill, Michael Whitaker, Lauren E Roper, Jamison Pike, Michael Melgar, Amadea Britton
Respiratory syncytial virus (RSV) disproportionately affects older adults with chronic conditions. RSV vaccines are effective but costly, and post-licensure studies suggest increased risk of Guillain-Barre syndrome (GBS). We evaluated cost-effectiveness and risk-benefit trade-offs of RSV vaccination by simulating RSV vaccination in adults aged ≥75 years and in adults aged 50-74 years with chronic conditions associated with increased risk of severe RSV disease. Data came from vaccine trials, peer-reviewed literature, observational vaccine effectiveness (VE) studies, and surveillance networks such as RSV-NET. Vaccine protection was assumed to last between 2 and 3 years. We estimated RSV vaccination averts more quality-adjusted life-years (QALYs) from RSV than vaccine-associated GBS. Societal cost-effectiveness varies substantially depending on age, risk condition, and duration of VE. RSV vaccination of adults aged ≥75 years costs $45,769 (95% uncertainty interval, UI: $25,505-$84,871) per quality-adjusted life-year (QALY) for protein subunit vaccines with 3 years of effectiveness; $100,571 (UI: $58,277-$225,885)/QALY for mRNA vaccine with 2 years of effectiveness; and $70,731 (UI: $42,069-$159,451) for mRNA vaccine with 3 years of effectiveness. Vaccination of adults aged 60-74 years with at least one chronic condition costs $21,721 (UI: cost-saving-$120,989)/QALY for protein subunit vaccines with 3 years effectiveness; $85,781 (UI: $3368-$409,467)/QALY for mRNA vaccine with 2 years of effectiveness; and $50,864 (UI: $3668-$249,938)/QALY for mRNA vaccine with 3 years of effectiveness. Vaccination of adults aged 50-59 years with at least one chronic condition costs $43,070 (UI: cost-saving-$266,769)/QALY for protein subunit vaccines with 3 years of effectiveness; $152,293 (UI: $1154-$811,138)/QALY for mRNA vaccine with 2 years of effectiveness; and $95,182 (UI: cost-saving-$682,508) for mRNA vaccine with 3 years of effectiveness. Regardless of the vaccine used, vaccination of adults aged 60-74 years without chronic conditions has high incremental cost effectiveness ratios ($287,793 to $503,328/QALY). If RSV disease had higher incidence, costs, or mortality, vaccination would be more cost-effective.