OBJECTIVES:  Streptococcus pneumoniae is a leading cause of life-threatening pneumococcal diseases (PDs). In Germany, PPV23 has been recommended in the elderly (aged 60 and over) since 1998. In 2006, the pneumococcal conjugate vaccine (PCV) was introduced in children. The US experience showed that PCV vaccination of children led, ten years after its introduction, to a decrease in IPD incidence caused by the PCV serotypes not only in vaccinated children but also in unvaccinated adults. This study aimed to re-assess the good cost-effectiveness profile of PPV23 vs. no vaccination (NoVac) in the elderly in Germany, accounting for epidemiological changes in adults due to PCV vaccination of children. METHODS:  A population-based Markov model was developed, consisting of five health states: no PD, IPD (invasive PD), NBPP (non-bacteraemic pneumococcal pneumonia), post-meningitis sequelae (PMS) and death. A cohort of individuals was followed until death assuming vaccination or no vaccination. IPD and NBPP incidence were retrieved from German sources, while the changes in IPD incidence were estimated based on US data. IPD and NBPP case-fatality rates, probability of developing PMS, vaccine effectiveness, vaccine waning function and utilities were retrieved from the published literature. A discount rate of 3% was applied to costs and effects. RESULTS:  PPV23 was associated with a discounted increment of 1,587 QALYs. From the third party payer’s (TPP) perspective, incremental costs were estimated at €28 million and the ICER was €17,700/QALY gained. From the societal perspective, PPV23 was associated with an increment of €14 million, and the ICER was €8579/QALY gained. Results were sensitive to vaccine effectiveness and epidemiological trends assumptions. CONCLUSIONS:  The model suggests that vaccinating the elderly with PPV23 is cost-effective in Germany. As PPV23 covers 80%-90% of all serotypes causing IPD, it is still cost-effective despite the reduction in IPD incidence in adults due to PCV vaccination of children.