Overcoming perceptions of financial barriers to rotavirus vaccine introduction in Asia

The impact of rotavirus vaccination on acute diarrhea in Thai children under 5 years of age in the first year of universal implementation of rotavirus vaccines in the National Immunization Program (NIP) in Thailand: a 6-year analysis

BACKGROUND

Two types of rotavirus vaccines (RVs), Rotarix (RV1) and RotaTeq (RV5), were licensed as optional vaccines in 2012 and became part of the National Immunization Program (NIP) in the fiscal year 2020 in Thailand. The main objective was to evaluate the impact of rotavirus vaccines on the burden of acute diarrheal severity ranging from outpatient visits, diarrheal-related admission or deaths in the pre-NIP period (fiscal year 2015-2019) and in the fiscal year 2020. The minor objectives were assessed on the monthly admission rate, rotavirus vaccine coverage rate and rotavirus vaccine completed dose (RotaC).

METHODS

Data regarding OPD, admission, and death cases under the Thailand National Health Coverage (NHC) from fiscal year 2015-2020, which were recorded as International Classification of Diseases and Related Health Problem 10th (ICD-10), were analyzed.

RESULTS

The burden of diarrheal-related disease diminished after the rotavirus vaccine was introduced in the fiscal year 2020 when compared to the previous 5 fiscal years. The OPD visit rate decreased from 10.1 to 8.3 visits per 100 person-years (P < 0.001), or a 17.8% reduction (incidence rate ratio (IRR) = 0.82; 95% confidence interval (CI): 0.81 to 0.82). The admission rate significantly declined from 31.4 to 30.5 cases per 1,000 person-years, (P < 0.001), or a 2.9% reduction (IRR = 0.97; 95% CI: 0.96 to 0.98). The diarrheal-related mortality rate also subsided from 10.2 to 8.1 cases per 100,000 person-years (P 0.3), or a 20.0% reduction (IRR = 0.88; 95% CI: 0.50 to 1.22). The major population in both admissions and deaths was infants under 1 year of age (P < 0.001). Seasonality was seen as a constant bimodal pattern, with a significant decrease in monthly admissions after 6 months of rotavirus vaccine introduction to NIP (P < 0.001). RotaC was 37.4% in the first year of NIP.

CONCLUSIONS

The rotavirus vaccine had a potential benefit for reducing the diarrheal disease burden, especially in infants under one year of age. Seasonality outbreaks of acute diarrhea subsided after the rotavirus vaccine was introduced. The RotaC was fairly low in the first year of the NIP. The quality of the rotavirus vaccine should be warranted.

TRIAL REGISTRATION

Number TCTR20220120003 , date of registration: 20/01/2022, site: Thai Clinical Trials Registry.

Willingness to pay for HPV vaccine among female health care workers in a Chinese nationwide survey

Background

Payment methods for human papillomavirus (HPV) vaccine could substantially influence vaccination behavior. In China, HPV vaccination uptake remains currently low. This study aims to determine willingness to pay (WTP) for HPV vaccines among Chinese female health care workers under different payment scenarios.

Methods

This is a nationwide online survey recruiting female health care workers aged 18–45 years from 31 provinces throughout China. We collected the respondents’ vaccination status of HPV vaccines and their sociodemographics. Two WTPs were defined and estimated in the study. A general WTP for HPV vaccination was determined using the contingent valuation method with double dichotomous choice bidding. A WTP out-of-pocket was estimated for each HPV vaccine under two scenarios, including partial coverage by governmental subsidy or partial incorporation in basic medical insurance. Accordingly, a multivariable linear regression model was employed to determine the association between sociodemographis and general WTP. Then the maximum WTP out-of-pocket was compared among the respondents’ attitude shift towards HPV vaccination, payment scenarios, and levels of vaccine attributes, using non-parametric Kruskal-Wallis test.

Results

A total of 15,969 respondents were included in the study. The median general WTP was 2000 CNY (interquartile range, 1000–3200 CNY), positively associated with younger age, unmarried status, higher monthly income, fewer children, more positive vaccination behavior, working in tertiary hospital, higher local GDP and HDI (each P < 0.05). Moreover, the median WTP out-of-pocket was 1250 CNY (540–2000 CNY). It was significantly higher for vaccines partly covered by governmental subsidy (median, 1250 CNY; interquartile range, 560–2000 CNY), imported vaccines (1260 CNY; 630–1960 CNY), and 9-valent vaccines (1400 CNY; 750–2240 CNY) (each P < 0.001). Additionally, majority of respondents did not change their attitude towards HPV vaccination between two payment scenarios; those remaining with more expensive HPV vaccines (51.1%) had higher WTP out-of-pocket (1400 CNY; 560–2250 CNY) than those with cheaper vaccines (39.0%) (1120 CNY; 490–1960 CNY) (P < 0.001).

Conclusion

Chinese female health care workers have high WTP for HPV vaccines. A direct public funding for HPV vaccination is more preferable. Our findings may facilitate the adjustment of HPV vaccination strategy and payment mechanism in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08716-6.

Understanding Rotavirus Vaccine Efficacy and Effectiveness in Countries with High Child Mortality

Rotavirus claims thousands of lives of children globally every year with a disproportionately high burden in low- and lower-middle income countries where access to health care is limited. Oral, live-attenuated rotavirus vaccines have been evaluated in multiple settings in both low- and high-income populations and have been shown to be safe and efficacious. However, the vaccine efficacy observed in low-income settings with high rotavirus and diarrheal mortality was significantly lower than that seen in high-income populations where rotavirus mortality is less common. Rotavirus vaccines have been introduced and rolled out in more than 112 countries, providing the opportunity to assess effectiveness of the vaccines in these different settings. We provide an overview of the efficacy, effectiveness, and impact of rotavirus vaccines, focusing on high-mortality settings and identify the knowledge gaps for future research. Despite lower efficacy, rotavirus vaccines substantially reduce diarrheal disease and mortality and are cost-effective in countries with high burden. Continued evaluation of the effectiveness, impact, and cost-benefit of rotavirus vaccines, especially the new candidates that have been recently approved for global use, is a key factor for new vaccine introductions in countries, or for a switch of vaccine product in countries with limited resources.

National stakeholder preferences for next-generation rotavirus vaccines: Results from a six-country study

BACKGROUND

Currently available live, oral rotavirus vaccines (LORVs) have significantly reduced severe rotavirus hospitalizations and deaths worldwide. However, LORVs are not as effective in low- and middle-income countries (LMIC) where rotavirus disease burden is highest. Next-generation rotavirus vaccine (NGRV) candidates in development may have a greater public health impact where they are needed most. The feasibility and acceptability of possible new rotavirus vaccines were explored as part of a larger public health value proposition for injectable NGRVs in LMICs.

OBJECTIVE

To assess national stakeholder preferences for currently available LORVs and hypothetical NGRVs and understand rationales and drivers for stated preferences.

METHODS

Interviews were conducted with 71 national stakeholders who influence vaccine policy and national programming. Stakeholders from Ghana, Kenya, Malawi, Peru, Senegal, and Sri Lanka were interviewed using a mixed-method guide. Vaccine preferences were elicited on seven vaccine comparisons involving LORVs and hypothetical NGRVs based on information presented comparing the vaccines' attributes. Reasons for vaccine preference were elicited in open-ended questions, and the qualitative data were analyzed on key preference drivers.

RESULTS

Nearly half of the national stakeholders interviewed preferred a highly effective standalone, injectable NGRV over current LORVs. When presented as having similar efficacy to the LORV, however, very few stakeholders preferred the injectable NGRV, even at substantially lower cost. Similarly, a highly effective standalone injectable NGRV was generally not favored over an equally effective oral NGRV following a neonatal-infant schedule, despite higher cost of the neonatal option. An NGRV-DTP-containing combination vaccine was strongly preferred over all other options, whether delivered alone with efficacy similar to current LORVs or co-administered alongside an LORV (LORV + NGRV-DTP) to increase efficacy.

CONCLUSION

Results from these national stakeholder interviews provide valuable insights to inform ongoing and future NGRV research and development.

Impact of Rotavirus Vaccine Introduction in Children Less Than 2 Years of Age Presenting for Medical Care With Diarrhea in Rural Matlab, Bangladesh

BACKGROUND

Following the conclusion of a human rotavirus vaccine (HRV) cluster-randomized, controlled trial (CRT) in Matlab, Bangladesh, HRV was included in Matlab's routine immunization program. We describe the population-level impact of programmatic rotavirus vaccination in Bangladesh in children <2 years of age.

METHODS

Interrupted time series were used to estimate the impact of HRV introduction. We used diarrheal surveillance collected between 2000 and 2014 within the 2 service delivery areas (International Centre for Diarrhoeal Disease Research, Bangladesh [icddr,b] service area [ISA] and government service area [GSA]) of the Matlab Health and Demographic Surveillance System, administered by icddr,b. Age group-specific incidence rates were calculated for both rotavirus-positive (RV+) and rotavirus-negative (RV-) diarrhea diagnoses of any severity presenting to the hospital. We used 2 models to assess the impact within each service area: Model 1 used the pre-vaccine time period in all villages (HRV- and control-only) and Model 2 combined the pre-vaccine time period and the CRT time period, using outcomes from control-only villages.

RESULTS

Both models demonstrated a downward trend in RV+ diarrheal incidences in the ISA villages during 3.5 years of routine HRV use, though only Model 2 was statistically significant. Significant impacts of HRV on RV+ diarrhea incidences in GSA villages were not observed in either model. Differences in population-level impacts between the 2 delivery areas may be due to the varied rotavirus vaccine coverage and presentation rates to the hospital.

CONCLUSIONS

This study provides initial evidence of the population-level impact of rotavirus vaccines in children <2 years of age in Matlab, Bangladesh. Further studies are needed of the rotavirus vaccine impact after the nationwide introduction in Bangladesh.

Thresholds for decision-making: informing the cost-effectiveness and affordability of rotavirus vaccines in Malaysia

Cost-effectiveness thresholds (CETs) based on the Commission on Macroeconomics and Health (CMH) are extensively used in low- and middle-income countries (LMICs) lacking locally defined CETs. These thresholds were originally intended for global and regional prioritization, and do not reflect local context or affordability at the national level, so their value for informing resource allocation decisions has been questioned. Using these thresholds, rotavirus vaccines are widely regarded as cost-effective interventions in LMICs. However, high vaccine prices remain a barrier towards vaccine introduction. This study aims to evaluate the cost-effectiveness, affordability and threshold price of universal rotavirus vaccination at various CETs in Malaysia. Cost-effectiveness of Rotarix and RotaTeq were evaluated using a multi-cohort model. Pan American Health Organization Revolving Fund's vaccine prices were used as tender price, while the recommended retail price for Malaysia was used as market price. We estimate threshold prices defined as prices at which vaccination becomes cost-effective, at various CETs reflecting economic theories of human capital, societal willingness-to-pay and marginal productivity. A budget impact analysis compared programmatic costs with the healthcare budget. At tender prices, both vaccines were cost-saving. At market prices, cost-effectiveness differed with thresholds used. At market price, using 'CMH thresholds', Rotarix programmes were cost-effective and RotaTeq were not cost-effective from the healthcare provider's perspective, while both vaccines were cost-effective from the societal perspective. Using other CETs, both vaccines were not cost-effective at market price, from the healthcare provider's and societal perspectives. At tender and cost-effective prices, rotavirus vaccination cost ∼1 and 3% of the public health budget, respectively. Using locally defined thresholds, rotavirus vaccination is cost-effective at vaccine prices in line with international tenders, but not at market prices. Thresholds representing marginal productivity are likely to be lower than those reflecting human capital and individual preference measures, and may be useful in determining affordable vaccine prices.

Global rotavirus vaccine introductions and coverage: 2006 - 2016

An estimated 215,000 children died of rotavirus infections in 2013, accounting for 37% of diarrhea-related deaths worldwide, 92% of which occurred in low and lower-middle income countries. Since 2009 the World Health Organization (WHO) recommends the use of rotavirus vaccines in all national immunization programs. This review compares rotavirus vaccine (RV) introductions and vaccine coverage by region, country income status and Gavi-eligibility from 2006-2016. Gross National Income data from the World Bank and surviving infant population from United Nations Population Division was obtained for 2016. Data from WHO were collected on rotavirus vaccine coverage, national immunization schedules, and new vaccine introductions for 2016 while estimated rotavirus deaths were collected for 2013, the last year of available WHO data. As of December 2016, the majority of countries (57%, 110/194) had not introduced universal rotavirus vaccine despite WHO's 2009 recommendation to do so. Countries in the WHO African region had the greatest proportion of introductions (37%, 31/84) by December 2016 and a great majority of these (77%, 24/31) were supported by new vaccine introduction (NVI) grants from Gavi. Almost half (48%) of global introductions were in low and lower-middle income Gavi-eligible and Gavi-graduating countries. Conversely, countries in the Southeast Asia WHO region and those not eligible for Gavi NVI support have been slow to introduce rotavirus vaccine. High-income countries, on average, had poorer rotavirus vaccine coverage compared to low and lower-middle income countries. The over-representation of African countries within the Gavi subset and high estimated rotavirus deaths in these African countries, likely explains why introduction efforts have been focused in this region. While much progress has been made with the integration and implementation of rotavirus vaccine into national immunization programs, 110 countries representing 69% of the global birth cohort had yet to introduce the vaccine by December 2016.

Cost-effectiveness analysis of introducing universal childhood rotavirus vaccination in Bangladesh

Diarrhea is one of the world's leading killers of children, and globally, rotavirus is the most common cause of severe diarrhea among under 5 children. In Bangladesh, rotavirus kills nearly 6,000 under 5 children in each year. To reduce the burden of childhood rotavirus diseases, universal rotavirus vaccination is recommended by World Health Organization. The objective of this study is to assess the cost-effectiveness of introducing universal childhood rotavirus vaccination with the newly developed ROTAVAC vaccine in national Expanded Programme of Immunization in Bangladesh. We developed a decision model to examine the potential impact of vaccination in Bangladesh and to examine the effect if the vaccination is applied in the nationwide immunization program schedule. Introduction of childhood universal rotavirus vaccination in Bangladesh scenario appears as highly cost-effective and would offer substantial future benefits for the young population if vaccinated today. The cost per DALY averted of introducing the rotavirus vaccine compared with status quo is approximately US$ 740.27 and US$ 728.67 per DALY averted from the health system and societal perspective respectively which is "very cost-effective" using GDP threshold level according to World Health Organization definition. The results of this analysis seek to contribute to an evidence-based recommendation about the introduction of universal rotavirus vaccination in national Expanded Programme of Immunization (EPI) in Bangladesh.

Evaluating the first introduction of rotavirus vaccine in Thailand: Moving from evidence to policy

BACKGROUND

We assessed the effectiveness and possible impact of introducing rotavirus vaccine into the routine immunization program.

METHODS

Two provinces were selected for an observational study, one where vaccine was introduced and another where vaccine was not available. In these areas, two sub-studies were linked. The prospective cohort study enrolled children 2month old and followed them to the age of 18months to detect all diarrhea episodes. The hospital surveillance study enrolled all children up to age 5 hospitalized with diarrhea whose fecal samples were tested for rotavirus. Rates of rotavirus hospitalizations in older children who had not been vaccinated in both settings provided data to determine whether immunization had an indirect herd effect. The key endpoints for the study were both vaccine effectiveness (VE) based upon hospitalized rotavirus diarrhea and herd protection.

FINDINGS

From the cohort study, the overall VE for hospitalized rotavirus diarrhea was 88% (95%CI 76-94). Data from hospital surveillance indicated that for 2 consecutive years, the seasonal peak of rotavirus admissions was no longer present in the vaccinated area. Herd protection was observed among older children born before the rotavirus vaccine program was introduced, who experienced a 40-69% reduction in admission for rotavirus.

CONCLUSIONS

Rotavirus vaccine was highly effective in preventing diarrheal hospitalizations and in conferring herd protection among older children who had not been vaccinated.

Cost-effectiveness analysis of rotavirus vaccination in China: Projected possibility of scale-up from the current domestic option

Background

Rotavirus infection causes considerable disease burden of acute gastroenteritis (AGE) hospitalization and death among children less than 5 years in China. Although two rotavirus vaccines (Rotarix and RotaTeq) have been licensed in more than 100 countries in the world, the Lanzhou Lamb rotavirus vaccine (LLR) is the only vaccine licensed in China. This study aims to forecast the potential impacts of the two international vaccines compared to domestic LLR.

Methods

An economic evaluation was performed using a Markov simulation model. We compared costs at the societal aspect and health impacts with and without a vaccination program by LLR, Rotarix or RotaTeq. Parameters including demographic, epidemiological data, costs and efficacy of vaccines were obtained from literature review. The model incorporated the impact of vaccination on reduction of incidence of rotavirus infection and severity of AGE indicated by hospitalization, inpatient visits and deaths. Outcomes are presented in terms of quality-adjusted life years (QALYs) gained and incremental cost-effectiveness ratio (ICER) compared to status quo.

Results

In a hypothetical cohort of 100,000 infants, the two international vaccines showed very good cost-effectiveness, with ICER of Rotateq and Rotarix shifting from LLR of $1715.11/QALY and $2105.66/QALY, respectively. Rotateq and Rotarix had significantly decreased incidence compared to LLR, particularly among infants aged 6 months to 2 years.

Conclusions

RotaTeq is expected to introduce in the national routine immunization program to reduce disease burden of rotavirus infection with universal coverage.

Rotavirus vaccines contribute towards universal health coverage in a mixed public-private healthcare system

OBJECTIVES

To evaluate rotavirus vaccination in Malaysia from the household's perspective. The extended cost-effectiveness analysis (ECEA) framework quantifies the broader value of universal vaccination starting with non-health benefits such as financial risk protection and equity. These dimensions better enable decision-makers to evaluate policy on the public finance of health programmes.

METHODS

The incidence, health service utilisation and household expenditure related to rotavirus gastroenteritis according to national income quintiles were obtained from local data sources. Multiple birth cohorts were distributed into income quintiles and followed from birth over the first five years of life in a multicohort, static model.

RESULTS

We found that the rich pay more out of pocket (OOP) than the poor, as the rich use more expensive private care. OOP payments among the poorest although small are high as a proportion of household income. Rotavirus vaccination results in substantial reduction in rotavirus episodes and expenditure and provides financial risk protection to all income groups. Poverty reduction benefits are concentrated amongst the poorest two income quintiles.

CONCLUSION

We propose that universal vaccination complements health financing reforms in strengthening Universal Health Coverage (UHC). ECEA provides an important tool to understand the implications of vaccination for UHC, beyond traditional considerations of economic efficiency.

The Hidden Health and Economic Burden of Rotavirus Gastroenteritis in Malaysia: An Estimation Using Multiple Data Sources

BACKGROUND

Rotavirus gastroenteritis (RVGE) results in substantial mortality and morbidity worldwide. However, an accurate estimation of the health and economic burden of RVGE in Malaysia covering public, private and home treatment is lacking.

METHODS

Data from multiple sources were used to estimate diarrheal mortality and morbidity according to health service utilization. The proportion of this burden attributable to rotavirus was estimated from a community-based study and a meta-analysis we conducted of primary hospital-based studies. Rotavirus incidence was determined by multiplying acute gastroenteritis incidence with estimates of the proportion of gastroenteritis attributable to rotavirus. The economic burden of rotavirus disease was estimated from the health systems and societal perspective.

RESULTS

Annually, rotavirus results in 27 deaths, 31,000 hospitalizations, 41,000 outpatient visits and 145,000 episodes of home-treated gastroenteritis in Malaysia. We estimate an annual rotavirus incidence of 1 death per 100,000 children and 12 hospitalizations, 16 outpatient clinic visits and 57 home-treated episodes per 1000 children under-5 years. Annually, RVGE is estimated to cost US$ 34 million to the healthcare provider and US$ 50 million to society. Productivity loss contributes almost a third of costs to society. Publicly, privately and home-treated episodes consist of 52%, 27% and 21%, respectively, of the total societal costs.

CONCLUSIONS

RVGE represents a considerable health and economic burden in Malaysia. Much of the burden lies in privately or home-treated episodes and is poorly captured in previous studies. This study provides vital information for future evaluation of cost-effectiveness, which are necessary for policy-making regarding universal vaccination.

Economics and financing of vaccines for diarrheal diseases

The considerable burden of infectious disease-caused diarrhea around the world has motivated the continuing development of a number of vaccine candidates over the past several decades with some reaching the market. As with all major public health interventions, understanding the economics and financing of vaccines against diarrheal diseases is essential to their development and implementation. This review focuses on each of the major infectious pathogens that commonly cause diarrhea, the current understanding of their economic burden, the status of vaccine development, and existing economic evaluations of the vaccines. While the literature on the economics and financing of vaccines against diarrhea diseases is growing, there is considerable room for more inquiry. Substantial gaps exist for many pathogens, circumstances, and effects. Economics and financing studies are integral to vaccine development and implementation.