streptococcus pneumoniae ( spn ) may cause a wide spectrum of diseases ranging from otitis and pneumonia to invasive forms such as meningitis or sepsis . among pneumococcal diseases , pneumonia has the higher clinical burden in terms of morbidity , mortality and hospitalization rate , with heavy implications for worldwide health systems . in particular , higher incidence and mortality rates of pneumococcal community - acquired pneumonia ( cap ) cases , with related costs , are registered among elderly . incidence values vary among different countries and surveys , but generally mortality rate increases with age and comorbidities . in the future , this will lead to an inevitable increase of hospitalizations , with an economic burden that should not be underestimated . therefore , pneumococcal vaccination is extensively recommended for subjects aged 65 y and for those aged 5064 y at high risk ( hr ) for specific health conditions , such as diabetes , cardiovascular diseases , nephropathies , hypertension and chronic obstructive pulmonary disease ( copd ) . in italy , the ministry of health recommends the use of conjugated 13-valent vaccine ( pcv13 ) for children aged < 2 y , while the immunization with 23-valent polysaccharide vaccine ( ppv23 ) is recommended for adults aged 65 y and for hr subjects aged 2 y. however , the levels of immunization coverage among adults are so far insufficient , and probably this depends on the doubts about polysaccharide vaccine efficacy . in fact , clinical studies showed that this formulation is unable to induce an adequate and durable immune response , especially in hr individuals and against non - invasive pneumococcal diseases . the 13-valent conjugate vaccine , recently indicated for the immunization of all the ages , has showed adequate safety and immunogenicity levels and seems to induce a durable protection against pneumococcal diseases , both invasive and not . several studies suggest that immunological properties of pcv are higher than those of ppv23 , while safety and tolerability are comparable . this study aimed to realize an economic evaluation about the immunization with pcv13 in the adult population in campania region , south italy . for this purpose we performed , considering a period of 5 y , a budget impact analysis ( bia ) and a cost - effectiveness analysis which considered 2 immunization targeted cohorts . figure  1 shows the pneumococcal cap cases expected in the first group ( hr subjects aged 5079 ) with and without vaccination . figure  1 . expected cases with and without vaccination in the first targeted group ( hr subjects aged 5079 ) . costs needed for the vaccination of the first targeted cohort in 5 y of follow - up are reported in table 1 . the total costs per year with or without immunization of the first cohort are reported in table 2 . during the first year , the implementation of the vaccination program requires more than 2-fold the resources needed for the treatment of pneumococcal cap cases expected without vaccination . the bia for the base case scenario confirms the great initial expense and the following savings , up to  29  005  660 after 5 y ( table 3 ) . table 4 considers savings and avoided cases achievable in 5 y with vaccination . for the first targeted group , total pneumococcal cap cases expected with a vaccination program were assumed to be 509 , while those expected without vaccination were estimated to be 4083 ( with a reduction of 3574 cases ) . therefore , the final savings per pneumococcal cap case is equal to  8116 , what relationship between avoided costs and avoided cases . the sensitivity analysis was performed by varying the effectiveness of the vaccine ( + /10% ) : estimated savings after 5 y could be  34  662  134 in the first case , and  23  402  745 in the worst scenario ( data not shown ) . as for the second targeted group ( hr subjects aged 5064 plus 65 y - old subjects ) , expected cases with and without vaccination in the second targeted group ( hr individuals aged 5064 + those aged 65 y ) . table 5 shows vaccination costs in 5 y. the costs per year with or without immunization of the second cohort are reported in table 6 . in this case also , at the first year the costs with vaccination seem to be higher than those for the treatment of pneumococcal cap cases in the second scenario ; however , even from the second year it s possible to observe notable savings . * bia showed at the end of the follow - up achievable savings equal to  10  006  017 ( table 7 ) . the number of expected cases ( 2694 ) among the second targeted cohort without vaccination could be reduced by vaccination to 337 . with this strategy , sensitivity analysis showed savings equal to  10  879  772 when considering a 10% increase in the effectiveness of the vaccine and equal to  9  132  263 with a 10% decrease ( data not shown ) . the new paradigm of evidence based medicine for decision - making has widely grown in recent years , making available to public health care policies  and to professionals and managers as well  tools to assess the clinical and welfare rationality of public choices . the evidence - based health care approach currently support most of the control activities and decision - makers choices , thus becoming a real asset in all health care organization levels : national first , and then regional . this study represents an example of how these indicators could be useful to manage and control diseases with a high burden . although pneumococcal diseases are assumed to be not always correctly identified and/or notified , they represent one of the main cause of morbidity and mortality . in order to reduce their burden , and the great number of risk factors for pneumococcal diseases and their interactions highlight the importance of immunoprophylaxis . therefore , contrarily to other analyses , focused on age - based vaccination strategies , this study considered some risk groups as targeted cohorts for adult vaccination . the inclusion of these groups followed indications of the italian ministry of health , which suggests the consideration of risk conditions for pneumococcal immunization in adults . multimorbidity patterns were difficult to apprise , due to the absence of appropriate data collection systems ; this would produce artificial estimates and information far from adhering to reality . the economic evaluation of pneumococcal vaccine for adult groups represents an essential instrument to support health policies . in fact , due to the cost restriction , stakeholders should know the value for money of a new immunization strategy , but also its budget impact as in the short as in the long period . as described above , this impact comes from the difference between cost of vaccination program and savings achievable through the vaccine - related reduction of cases . the pharmacoeconomics evaluation performed in this study showed that both hypothesized immunization strategies could produce savings . results showed that the vaccination of hr subjects of 5079 y could allow about 28 million euro of savings . however , this strategy requires a high investment in a short period . on the contrary it has to be noted that the present analysis did not consider the serotype coverage , which could be considered a limitation of the procedure . however , the analysis considered only direct costs using the perspective of the national health service . therefore , the conservative nature of this evaluation disregards further implications that could be advantageous for the local health system . moreover , the analysis takes into account only the pneumococcal pneumonia cases and does not include the other vaccine - preventable pneumococcal diseases , and it referred only to hospitalized cases  however , the impact of vaccination may be wider , both clinically and economically , if non - hospitalized pneumococcal pneumonia cases are included . furthermore , the infection in high - risk subjects is likely more severe than considered and , consequently , the economic impact of vaccination is more extensive . lastly , vaccination advantages do not interest only immunized subjects but also the community , due to the herd immunity effects . also regarding this aspect , the present analysis is conservative , because further savings deriving from the increase of targeted cohorts were not considered . in the health care system , policy - makers choices basically depend on 2 elements which are concatenated together . on the one hand , there are the financial resources available ; on the other , the epidemiological context of reference that will decree the priorities on the allocation of resources . findings of this study support the vaccination for hr adults , as recommended by ema . our findings could help to choice between the 2 proposed hypotheses , in order to better address economical resources . this economic evaluation was developed to analyze for a 5-y period the impact of an adult pneumococcal vaccination program in the campania region . the model considered 2 vaccination strategies : at first , the group of hr subjects aged 5079 ( about 1 million of individuals in the region ) , and later hr individuals aged 5064 , together with all those aged 65 y ( about 400  000 subjects ) . hr subjects were considered those with chronic diseases such as diabetes , hypertension , nephropathies , copd and cardiovascular diseases . the analyses were performed on the resident population in campania on january 1 , 2009 , as reported by the national institute for statistics ( istituto nazionale di statistica , istat ) , without considering sex and origin . on the base of the average national coverage for the last influenza immunization program in italy in the elderly , vaccination coverage of the targeted cohorts the clinical outcome of the analysis were hospitalized pneumococcal cap cases in adult population ( 5079 y ) . data were obtained from the hospital discharge forms ( scheda di dimissione ospedaliera , sdo ) of respiratory departments which participate to the training regional network . during the years 20102011 , 18  965 cap cases were reported on these sdos . assuming that the overall rate of cap due to spn is about 40% , the number of pneumococcal cap per year among reported cases was estimated to be 3793 . on the basis of previous studies , the vaccine efficacy against pneumococcal pneumonia was assumed to be 87.5% , then this value was used to calculate the number of avoided cases for each vaccination strategy . expected cases were corrected for the global mortality rate , as obtained from 2010 istat data . the economic model was based on the difference between the costs sustained with ( vaccine plus treatment for expected cases ) and without ( only expected cases ) a vaccination program . as regard the first vaccination strategy , all the subjects at risk aged 5079 y were considered for immunization at first year ; since the second year only 50 y old were included in the vaccination program . as for the second strategy , individuals at risk aged 5064 y and those aged 65 y were considered for immunization at first year , while 50 y old and 65 y old were included for subsequent years . the cost of the vaccine was 42.5 euro per dose ; the cost of a cap case due to spn was assumed to be the average of costs for complicated and non - complicated pneumonia cases , equal to  3809 . costs were updated to a rate of 3% . to test the strength of results , a sensitivity analysis was applied by considering a + / 10% variation in the vaccine efficacy .