OBJECTIVES : Several vaccines exist for managing pneumococcal-diseases in children and elderly. Some are age-specific (PHiD-CV, PPV-23) or used in both age-groups (PCV-13). Different vaccination schemes, prices and effects can be considered per vaccine and 9 different vaccination dosing schemes can be assembled across both age-groups. The economic question for Brazil is: which combination of vaccination dosing schemes for infants and elderly delivers maximum health gains within the next 10 years with limited annual vaccination budget increase?

METHODS : Constrained optimization (CO) is the most appropriate economic analysis to answer such question. It ranks vaccination schemes according to their health return on budgetary investments. While complying with constraints such as budget, logistics, and maximum vaccine coverage rates, CO identifies the combination of vaccination schemes that maximize the desired health outcome over a defined intervention period. CO for Brazil starts from the current situation: over 5 years of infant universal mass vaccination (UMV) with PHiD-CV 3-dose and an initial budget equaling the current one. Deterministic sensitivity analyses (SA) for budget increase, vaccine efficacy and waning are performed.

RESULTS : With an annual budget increase of 10%, the consecutive sequence of (1) infant PHiD-CV, 3-dose, with elderly PPV-23, 2-dose with 5 years interval and (2) infant UMV replaced by PHiD-CV 4-dose, maximizes the overall QALY-gain (46,208 units over a period of 10 years). The gain in children is marginal (394 QALYs) while substantial in elderly (45,815 QALYs). SA showed most marked increase in QALY-gain with increasing proportion at-risk elderly, vaccination sequences however didn’t change.

CONCLUSIONS : CO is a very helpful instrument for decision makers aiming for best return on investment when different options exist and many constraints must be considered. For Brazil, the highest public health gain with a limited annual vaccination budget increase is provided by UMV combining PHiD-CV in infants with PPV23 in elderly.