Simplifying Adult Pneumococcal Vaccination in India: A Cost-Effectiveness Analysis of the 20-Valent Conjugate Vaccine

In India, adult pneumococcal disease prevention relies on the 23‑valent pneumococcal polysaccharide vaccine (PPSV23) and the 13‑ and 20‑valent pneumococcal conjugate vaccines (PCV13, PCV20). Before PCV20 introduction, adults at older age or high risk typically received PCV13 followed by PPSV23, although no national recommendation exists and uptake has been low. This study evaluated the cost‑effectiveness of a single‑dose PCV20 strategy compared with the sequential PCV13→PPSV23 regimen from private and public perspectives. Incremental cost‑effectiveness ratios (ICERs) per quality‑adjusted life‑year (QALY) gained were estimated for PCV20 versus PCV13→PPSV23. Analyses were conducted from the private perspective for high‑risk adults aged 18–49 years and all adults aged ≥ 50 years, and from the government perspective for high‑risk adults aged 18–59 years and all adults aged ≥ 60 years. Compared with PCV13→PPSV23, PCV20 was projected to reduce pneumococcal disease cases and deaths and was cost‑effective under the 3× GDP per capita threshold. PCV20 generated 18,186 and 44,659 additional QALYs from the private and public perspectives, with incremental costs of ₹2.0 billion (Indian Rupees; medical: −₹17.4B; vaccine: ₹19.4B) and ₹25.5B (medical: −₹3.6B; vaccine: ₹29.1B), yielding ICERs of ₹110,790 and ₹570,327 per QALY, respectively. PCV20 was cost‑effective in 92.4% and 75.0% of probabilistic simulations from the private and government perspectives. Extending vaccination to at‑risk adults aged 18–49 years remained cost‑effective from the private perspective (ICER: ₹292,531/QALY). A single‑dose PCV20 strategy for high‑risk and older adults in India is cost‑effective compared with the current sequential regimen and may simplify pneumococcal vaccination and potentially improve uptake.