Economic evaluation of rotavirus vaccination in children of Bhutan

Comparative analysis of immunogenicity between first-dose measles-mumps-rubella (MMR) vaccine administration and combined MMR-rotavirus vaccination

This study compared the immunogenicity of the measles-mumps-rubella (MMR) vaccine when administered alone versus when co-administered with the rotavirus vaccine in infants aged 8-9 months. In this prospective cohort study, 1,198 infants were enrolled: 800 received combined MMR and rotavirus vaccines (experimental group), while 398 received the MMR vaccine alone (control group). A Hurdle Gamma model analyzed vaccination impact on antibody levels in both groups and the correlation between antibody responses. Geometric mean concentrations of measles, rubella, and mumps IgG antibodies increased significantly in both groups after vaccination. The experimental group demonstrated 209-fold, 25-fold, and 12-fold increases, respectively, with comparable increases in the control group. Hurdle Gamma model analysis revealed significant positive effects of vaccination on all three antibody levels, with no significant differences between MMR-rotavirus combined vaccination and MMR vaccination alone. Random effects analysis showed strong negative correlations for measles and rubella IgG antibodies (correlation coefficients: -1.00 and -0.99, respectively) and a moderate negative correlation for mumps IgG antibodies (correlation coefficient: -0.56). This study represents the first application of a Hurdle Gamma model to compare immunogenicity between standalone MMR vaccination and combined MMR-rotavirus vaccination. The results demonstrate equivalent MMR antibody responses between these two vaccination approaches.

Advancing evidence-based decision-making in Bhutan: development of a health technology assessment framework

Bhutan is currently transforming its health system and has updated its Health Technology Assessment (HTA) framework. This revision is designed to prioritize health initiatives and ensure the sustainability of the health system. This updated framework has been developed through an iterative process involving a desk-based review and stakeholder consultations at the beginning and after the development of the draft framework. The framework outlines the stages of the HTA process and identifies the stakeholders with their roles and responsibilities. The framework has been contextualised to Bhutan's needs and has been endorsed by the high-level decision-making authority for the health sector. The experience highlights diverse challenges and solutions including international collaborations for the institutionalisation of HTA and the lessons learned from this process offer insights for HTA efforts in other settings.

Funding

UNDP-led Access and Delivery Partnership (ADP).

Systematic review of cost projections of new vaccine introduction

BACKGROUND

A recent review of guidance documents on vaccine delivery costing revealed current guidance on cost projections for new vaccine introduction has gaps on methods of sampling, data collection and analysis. In preparation for updating the respective guidance, this systematic review was undertaken to qualitatively assess methodologies used in new vaccine cost projection studies. This will inform researchers and stakeholders about the methods of new vaccine introduction cost projections for strategic directions in countries where cost data are not available.

METHODS

We systematically searched four search engines (PubMed, Cochrane Open Access, Mendeley and Google Scholar) for articles on cost projections for new vaccines published between 1999 and 15 June 2022. We developed inclusion and exclusion criteria for the selection of articles and analyzed the results using a PRISMA 2020 flow diagram.

RESULTS

Out of 1,108 articles identified, 171 met the criteria for inclusion in the study. Half of the articles were from high-income countries (50%), and most cost projections were part of cost-effectiveness analysis (84%). The most common source of cost data was secondary national information (43%), followed by author's assumptions (17%), secondary international information (14%), and primary data collection (7%). 19% of studies didn't include costs to deliver vaccines in their cost estimation. Among studies that included secondary vaccine delivery costs, approximately half only calculated vaccine administration costs (50%), while 35% included incremental system costs and 15% utilized ingredients data. Two thirds of the studies were conducted to inform policymakers of the cost-effectiveness or cost-benefit of introducing the vaccine.

CONCLUSIONS

Half of the economic evaluations on new vaccine introductions only included partial vaccine delivery costs. Thus, total costs of vaccine introduction were often being underestimated in economic evaluations. This suggests that guidelines on economic evaluations and journals should recommend that authors include more extensive vaccine delivery costs in their studies.

Critical Analysis of Economic Evaluation of the Childhood Rotavirus Vaccination in Low- and Lower-Middle-Income Countries: A Systematic Review

OBJECTIVES

To identify, critically appraise, and summarize the use of different methods and results of economic evaluations to assess the efficiency of rotavirus vaccination programs in low- and lower-middle-income countries.

METHODS

A systematic literature search was performed in 3 bibliographic databases, including PubMed, ProQuest, Cochrane Library, and Science Direct (Elsevier) journal website, using key search terms. The study selection process was based on predefined inclusion criteria. The search results were presented using the research flow diagram based on guidelines of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The quality assessment of the selected studies was carried out using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) checklist.

RESULTS

A total of 21 studies were selected for review. All the studies, except 1, reported rotavirus vaccination to be a cost-effective intervention and a high-impact strategy to reduce substantial rotavirus disease burden. A decision analysis model was considered appropriate by all studies, although there were variabilities in the analytic horizon used. Lack of country-level data was highlighted by most studies. Multiples of gross domestic product of respective countries were used as a threshold to interpret cost-effectiveness.

CONCLUSIONS

Rotavirus vaccination was found to be cost-efficient in most settings, including complex humanitarian emergencies. The use of thresholds for interpreting incremental cost-effectiveness ratios and lack of local-level disease incidence and cost of illness data remains a point of contention. Lack of reporting probabilistic sensitivity analysis renders limited robustness to study results.

Rotavirus vaccine product switch in Ghana: An assessment of service delivery costs, switching costs, and cost-effectiveness

Ghana introduced rotavirus vaccine (ROTARIX 1-dose presentation) into the routine national immunization program in 2012 and switched to a different product (ROTAVAC 5-dose presentation) in 2020. ROTAVAC has a lower price per dose (US$0.85 versus US$2.15 for ROTARIX) and smaller cold chain footprint but requires more doses per regimen (three versus two). This study estimates the supply chain and service delivery costs associated with each product, the costs involved in switching products, and compares the cost-effectiveness of both products over the next ten years. We estimated the supply chain and service delivery costs associated with ROTARIX and ROTAVAC (evaluating both the 5-dose and 10-dose presentations) using primary data collected from health facilities in six of the 14 regions in the country. We estimated the costs of switching from ROTARIX to ROTAVAC using information collected from key informant interviews and financial records provided by the government. All costs were reported in 2020 US$. We used the UNIVAC decision-support model to evaluate the cost-effectiveness (US$ per disability-adjusted life-year (DALY) averted from government and societal perspectives) of ROTARIX and ROTAVAC (5-dose or 10-dose presentations) compared to no vaccination, and to each other, over a ten-year period (2020 to 2029). We ran probabilistic sensitivity analyses and other threshold analyses. The supply chain and service delivery economic cost per dose was $2.40 for ROTARIX, $1.81 for ROTAVAC 5-dose, and $1.76 for ROTAVAC 10-dose. The financial and economic cost of switching from ROTARIX to ROTAVAC 5-dose was $453,070 and $883,626, respectively. Compared to no vaccination, the cost per DALY averted was $360 for ROTARIX, $298 for ROTAVAC 5-dose, and $273 for ROTAVAC 10-dose. ROTAVAC 10-dose was the most cost-effective option and would be cost-effective at willingness-to-pay thresholds exceeding 0.12 times the national GDP per capita ($2,206 in the year 2020). The switch from ROTARIX to ROTAVAC 5-dose in 2020 was cost-saving. Rotavirus vaccination is highly cost-effective in Ghana. A switch from ROTAVAC 5-dose to ROTAVAC 10-dose would be cost-saving and should be considered.

Potential impact and cost-effectiveness of injectable next-generation rotavirus vaccines in 137 LMICs: a modelling study

While current live, oral rotavirus vaccines (LORVs) are reducing severe diarrhea everywhere, their effectiveness is lower in high burden settings. Alternative approaches are in advanced stages of clinical development, including injectable next-generation rotavirus vaccine (iNGRV) candidates, which have the potential to better protect children, be combined with existing routine immunizations and be more affordable than current LORVs. In an effort to better understand the real public health value of iNGRVs and to help inform decisions by international agencies, funders, and vaccine manufacturers, we conducted an impact and cost-effectiveness analysis examining 20 rotavirus vaccine use cases. We evaluated several currently licensed LORVs, one neonatal oral NGRV (oNGRV), one iNGRV, and one iNGRV-DTP (iNGRV comprising part of a DTP-containing combination) over a ten-year timeframe in 137 low- and middle-income countries. The most promising use case identified was a high efficacy iNGRV-DTP, predicted to have the lowest vaccine program cost (US$1.4 billion), the highest vaccine benefit (750,000 rotavirus deaths averted, 13 million rotavirus hospital admissions averted, US$ 2.7 billion health-care cost averted), and most favorable cost-effectiveness (cost-saving). iNGRV-DTP vaccine remained the most affordable, safe, and cost-effective option even when it was assumed to have equivalent efficacy to the current LORVs. This study shows that while the development of iNGRVs with superior efficacy to currently licensed LORVs would be ideal, iNGRVs with similar efficacy to LORVs would offer substantial public health value. It also highlights the economic value of accelerating the development of DTP-based combination vaccines that include iNGRV to provide rotavirus protection.

Public health impact and cost-effectiveness of rotavirus vaccination in China: Comparison between private market provision and national immunization programs

In China, progress to include the RV vaccine in the national immunization program (NIP) is slow. The only two vaccines, the Lanzhou lamb rotavirus vaccine (LLR) and Rotateq, are provided through the private market. This study aims to assess the health impact and cost-effectiveness of using three vaccines in the NIP, Rotateq, Rotarix, and LLR, compared to the status quo. A decision-tree Markov model was adopted to follow the 2019 birth cohort, and a societal perspective was used. Input parameters were based on the latest local data when possible. Outcomes included cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICER). Sensitivity analyses and scenario analyses to consider herd immunity and vaccine price reduction were performed. Including Rotateq in the NIP was projected to prevent 348 million RVGE cases (62.6% reduction) and 4251 deaths (72.6% reduction) compared to the status quo. Rotarix through the NIP would prevent 48.7% of cases and 63.2% of deaths, and LLR would avert 20.3% of cases and 22.4% of deaths. The ICERs per QALY gained were US$ 8833 for Rotateq through the NIP, US$ 9503 for Rotarix, and US$ 26,759 for LLR. In uncertainty analyses, the reduction of vaccine prices and the incorporation of herd immunity further improved the cost-effectiveness of the NIPs, especially Rotateq or Rotarix. In conclusion, introducing the RV vaccine in China's NIP is expected to be cost-effective compared to the GDP per capita. Reducing vaccine prices and adopting vaccines with better efficacy would be the future focus.

Cost-effectiveness of rotavirus vaccination in Mozambique

Introduction

Rotavirus is one of the most common cause of severe gastroenteritis in children, with the largest mortality burden in low- and middle-income countries. To prevent rotavirus gastroenteritis, Mozambique introduced ROTARIX® vaccine in 2015, however, its cost-effectiveness has never been established in the country. In 2018, additional vaccines became available globally. This study estimates the cost-effectiveness of the recently introduced ROTARIX in Mozambique and compares the cost-effectiveness of ROTARIX®, ROTAVAC®, and ROTASIIL® to inform future use.

Methods

We used a decision-support model to calculate the potential cost-effectiveness of vaccination with ROTARIX compared to no vaccination over a five-year period (2016–2020) and to compare the cost-effectiveness of ROTARIX, ROTAVAC, and ROTASIIL to no vaccination and to each other over a ten-year period (2021–2030). The primary outcome was the incremental cost per disability-adjusted life-year (DALY) averted from a government perspective. We assessed uncertainty through sensitivity analyses.

Results

From 2016 to 2020, we estimate the vaccine program with ROTARIX cost US$12.3 million, prevented 4,628 deaths, and averted US$3.1 million in healthcare costs. The cost per DALY averted was US$70. From 2021 to 2030, we estimate all three vaccines could prevent 9,000 deaths and avert US$7.8 million in healthcare costs. With Global Alliance for Vaccines and Immunization (Gavi) support, ROTARIX would have the lowest vaccine program cost (US$31 million) and 98 % probability of being cost-effective at a willingness-to-pay threshold of 0.5x GDP per capita. Without Gavi support, ROTASIIL would have the lowest vaccine program cost (US$75.8 million) and 30 % probability of being cost-effective at the same threshold.

Conclusion

ROTARIX vaccination had a substantial public health impact in Mozambique between 2016 and 2020. ROTARIX is currently estimated to be the most cost-effective product, but the choice of vaccine should be re-evaluated as more evidence emerges on the price, incremental delivery cost, wastage, and impact associated with each of the different rotavirus vaccines.

Cost-effectiveness of rotavirus vaccination in the Philippines: A modeling study

Introduction

Rotavirus gastroenteritis (RVGE) remains a leading cause of hospitalization and death in children under five years of age in the Philippines. Rotavirus (RV) vaccination was introduced into the national immunization program (NIP) in 2012 but has since been limited to one region due to cost considerations and conflicting local cost-effectiveness estimates. Updated estimates of the cost-effectiveness of RV vaccination are required to inform prioritization of national immunization activities.

Methods

We calculated the potential costs and benefits of rotavirus vaccination over a 10-year-period (2021–2031) from a government and societal perspective, comparing four alternative rotavirus vaccines: Rotavac, Rotasiil, Rotarix and Rotateq. For each vaccine, a proportionate outcomes model was used to calculate the expected number of disease events, DALYs, vaccination program costs, and healthcare costs, with and without vaccination. The primary outcome measure was the cost per DALY averted. Assuming each product would generate similar benefits, the dominant (lowest cost) product was identified. We then calculated the cost-effectiveness (US$ per Disability Adjusted Life Year [DALY] averted) of the least costly product and compared it to willingness-to-pay thresholds of 0.5 and 1 times the national GDP per capita ($3,485), and ran deterministic and probabilistic sensitivity analyses.

Results

Introducing any of the four rotavirus vaccines would avert around 40% of RVGE visits, hospitalizations, and deaths over the period 2021–2031. Over the same ten-year period, the incremental cost of vaccination from a government perspective was estimated to be around $104, $105, $220, and $277 million for Rotavac, Rotasiil, Rotarix and Rotateq, respectively. The equivalent cost from a societal perspective was $58, $60, $178 and $231 million. The cost-effectiveness of the least costly product (Rotavac) was $1,148 ($830–$1682) from a government perspective and $646 ($233–1277) from a societal perspective. All other products offered similar benefits but at a higher cost. There is a >99% probability that Rotavac would be cost-effective at a willingness-to-pay threshold set at 0.5 times the national GDP per capita.

Conclusion

Both Rotavac and Rotasiil are likely to be cost-effective options in the Philippines, but it is not possible to say definitively which product should be preferred. Rotarix and Rotateq are expected to offer similar benefits at more cost, so would need to be priced far more competitively to be considered for introduction.