Cost-effectiveness of childhood rotavirus vaccination in Taiwan

Objective

Rotavirus is the most common cause of severe diarrhea in children. Two rotavirus vaccines (RotaTeq and Rotarix) have been licensed in Taiwan. We have investigated whether routine infant immunization with either vaccine could be cost-effective in Taiwan.

Methods

We modeled specific disease outcomes including hospitalization, emergency department visits, hospital outpatient visits, physician office visits, and death. Cost-effectiveness was analyzed from the perspectives of the health care system and society. A decision tree was used to estimate the disease burden and costs based on data from published and unpublished sources.

Results

A routine rotavirus immunization program would prevent 146,470 (Rotarix) or 149,937 (RotaTeq) cases of rotavirus diarrhea per year, and would prevent 21,106 (Rotarix) and 23,057 (RotaTeq) serious cases (hospitalizations, emergency department visits, and death). At US$80 per dose for the Rotarix vaccine, the program would cost US$32.7 million, provided an increasing cost offset of US$19.8 million to the health care system with $135 per case averted. Threshold analysis identified a break-even price per dose of US$27 from the health care system perspective and US$41 from a societal perspective. At US$60.0 per dose of RotaTeq vaccine, the program would cost US$35.4 million and provide an increasing cost offset of US$22.5 million to the health care system, or US$150 per case averted. Threshold analysis identified a break-even price per dose of US$20.0 from the health care system perspective and $29 from the societal perspective. Greater costs of hospitalization and lower vaccine price could increase cost-effectiveness.

Conclusions

Despite a higher burden of serious rotavirus disease than estimated previously, routine rotavirus vaccination would unlikely be cost-saving in Taiwan at present unless the price fell to US$41 (Rotarix) or US$29 (RotaTeq) per dose from societal perspective, respectively. Nonetheless, rotavirus immunization could reduce the substantial burden of short-term morbidity due to rotavirus.     

Cost-effectiveness of rotavirus vaccination programs in Taiwan

Background

In Taiwan, two rotavirus vaccines are available on the private market, but are not included in the National Immunization Program (NIP). To help assess whether to include rotavirus vaccines in the NIP, we examined the potential impact and cost-effectiveness of vaccination, from the health care system perspective alone.

Methods

We used a Microsoft Excel-based model to assess rotavirus vaccination impact on rotavirus disease burden and the cost-effectiveness of 2-dose and 3-dose vaccination programs among a birth cohort of Taiwanese children followed for 5 years. Principal model inputs included data on rotavirus disease burden and related healthcare costs, vaccination cost and coverage rates, and vaccine efficacy. Principal model outputs included the number of health-related events and costs averted and incremental cost per disability-adjusted life year averted.

Results

A national rotavirus vaccination program, regardless of number of doses per course, would prevent 4 deaths, >10,500 hospitalizations, and >64,000 outpatient visits due to rotavirus infection among children <5 years annually, resulting in ∼80%, 90%, and 70% declines in these outcomes, respectively, and a ∼$7 million decline in annual medical costs. A national 2- or 3-dose vaccination program would be cost-saving up to $13.30/dose ($26.60/course) or $7.98/dose ($23.94/course), respectively; very cost-effective up to $24.08 per dose ($48.16/course) or $15.18/dose ($45.54/course), respectively; and cost-effective up to $45.65/dose ($91.30/course) or $29.59/dose ($88.77/course), respectively.

Conclusions

A national rotavirus vaccination program could substantially reduce rotavirus disease burden among Taiwanese children and be potentially cost-effective, depending on the vaccine price.     

Evaluation of cost-effectiveness of live oral pentavalent reassortant rotavirus vaccine introduction in Ghana

Background

Globally, rotavirus gastroenteritis is the most common identifiable cause of severe diarrhea in children under 5. Recently introduced rotavirus vaccines from Merck &; Co. and GlaxoSmithKline have the potential to save hundreds of thousands of lives. Efficacy results in Ghana suggest Merck &; Co.’s live oral pentavalent rotavirus vaccine (RotaTeq^®) prevents 65.0% of severe gastroenteritis due to rotavirus infection in children under 5. The announcement by Merck and GSK to make their rotavirus vaccines available for developing nations at reduced prices provides Ghana with the opportunity to introduce rotavirus vaccines into the national immunization program after investigation of the medical, economic and political implications.

Methods

We estimated the average costs of treating children with diarrhea in the Ashanti region of Ghana as inpatients and outpatients. Using these results, data from rotavirus surveillance studies, and recent rotavirus vaccine efficacy evaluation, we estimated the cost-effectiveness of introducing RotaTeq in Ghana.

Results

Based on our prospective calculations, we estimated an average inpatient and outpatient costs of $233.97 and $17.09, respectively, for treating childhood diarrhea. Using the 2003 birth cohort, RotaTeq introduction could save 1554 lives and avert 93,109 disability-adjusted life-years (DALYs) annually. At a market price of $5 per dose, introducing RotaTeq would have a base-case cost of $62.26 per DALY averted, at a market price of $3.50 per dose, a base-case cost of $39.59 per DALY averted and at market cost of $1 per dose, a base-case cost of $1.81 per DALY averted. All three values are below the 2009 Ghana per capita GDP. Thus, RotaTeq introduction into Ghana will be very cost-effective. Sensitivity analyses suggest these results are robust.

Conclusions

RotaTeq vaccination for children under five in Ghana would be a highly cost-effective public health intervention. Ghanaian health officials should seek GAVI funding and evaluate how to maximize RotaTeq access.     

Projected impact,cost-effectiveness,and budget implications of rotavirus vaccination in Mongolia

Introduction

Rotavirus disease in Mongolia is estimated to cause more than 50 deaths yearly and many more cases and hospitalizations. Mongolia must self-finance new vaccines and does not automatically access Gavi prices for vaccines. Given the country’s limited resources for health, it is critical to assess potential new vaccine programs. This evaluation estimates the impact, cost-effectiveness, and budget implications associated with a nationwide rotavirus vaccine introduction targeting infants as part of the national immunization program in Mongolia, in order to inform decision-making around introduction.

Rotavirus-associated hospitalization and emergency department costs and rotavirus vaccine program impact

Objectives

To determine the medical costs of laboratory-confirmed rotavirus hospitalizations and emergency department (ED) visits and estimate the economic impact of the rotavirus vaccine program.

Patients and methods

During 4 rotavirus seasons (2006–2009), children <3 years of age hospitalized or seen in the ED with laboratory-confirmed rotavirus were identified through active population-based rotavirus surveillance in three US counties. Medical costs were obtained from hospital and physician billing data, and factors associated with increased costs were examined. Annual national costs were estimated using rotavirus hospitalization and ED visit rates and medical costs for rotavirus hospitalizations and ED visits from our surveillance program for pre- (2006–2007) and post-vaccine (2008–2009) time periods.

Results

Pre-vaccine, for hospitalizations, the median medical cost per child was $3581, the rotavirus hospitalization rate was 22.1/10,000, with an estimated annual national cost of $91 million. Post-vaccine, the median medical cost was $4304, the hospitalization rate was 6.3/10,000 and the estimated annual national cost was $31 million. Increased costs were associated with study site, age <3 months, underlying medical conditions and an atypical acute gastroenteritis presentation. For ED visits, the pre-vaccine median medical cost per child was $574, the ED visit rate was 291/10,000 resulting in an estimated annual national cost of $192 million. Post-vaccine, the median medical cost was $794, the ED visit rate was 71/10,000 with an estimated annual national cost of $65 million.

Conclusions

After implementation of rotavirus immunization, the total annual medical costs decreased from $283 million to $96 million, an annual reduction of $187 million     

Public finance of rotavirus vaccination in India and Ethiopia: An extended cost-effectiveness analysis

Background

An estimated 4% of global child deaths (approximately 300,000 deaths) were attributed to rotavirus in 2010. About a third of these deaths occurred in India and Ethiopia. Public finance of rotavirus vaccination in these two countries could substantially decrease child mortality and also reduce rotavirus-related hospitalizations, prevent health-related impoverishment and bring significant cost savings to households.

Methods

We use a methodology of ‘extended cost-effectiveness analysis’ (ECEA) to evaluate a hypothetical publicly financed program for rotavirus vaccination in India and Ethiopia. We measure program impact along four dimensions: 1) rotavirus deaths averted; 2) household expenditures averted; 3) financial risk protection afforded; 4) distributional consequences across the wealth strata of the country populations.

Results

In India and Ethiopia, the program would lead to a substantial decrease in rotavirus deaths, mainly among the poorer; it would reduce household expenditures across all income groups and it would effectively provide financial risk protection, mostly concentrated among the poorest. Potential indirect benefits of vaccination (herd immunity) would increase program benefits among all income groups, whereas potentially decreased vaccine efficacy among poorer households would reduce the equity benefits of the program.

Conclusions

Our approach incorporates financial risk protection and distributional consequences into the systematic economic evaluation of vaccine policy, illustrated here with the case study of public finance for rotavirus vaccination. This enables selection of vaccine packages based on the quantitative inclusion of information on equity and on how much financial risk protection is being bought per dollar expenditure on vaccine policy, in addition to how much health is being bought.     

Cost-effectiveness of rotavirus vaccination in Bolivia from the state perspective

Background

In Bolivia, in 2008, the under-five mortality rate is 54 per 1000 live births. Diarrhea causes 15% of these deaths, and 40% of pediatric diarrhea-related hospitalizations are caused by rotavirus illness (RI). Rotavirus vaccination (RV), subsidized by international donors, is expected to reduce morbidity, mortality, and economic burden to the Bolivian state. Estimates of illness and economic burden of RI and their reduction by RV are essential to the Bolivian state's policies on RV program financing. The goal of this report is to estimate the economic burden of RI and the cost-effectiveness of the RV program.

Methods

To assess treatment costs incurred by the healthcare system, we abstracted medical records from 287 inpatients and 6751 outpatients with acute diarrhea between 2005 and 2006 at 5 sentinel hospitals in 4 geographic regions. RI prevalence rates were estimated from 4 years of national hospital surveillance. We used a decision-analytic model to assess the potential cost-effectiveness of universal RV in Bolivia.

Results

Our model estimates that, in a 5-year birth cohort, Bolivia will incur over US$3 million in direct medical costs due to RI. RV reduces, by at least 60%, outpatient visits, hospitalizations, deaths, and total direct medical costs associated with rotavirus diarrhea. Further, RV was cost-savings below a price of US$3.81 per dose and cost-effective below a price of US$194.10 per dose. Diarrheal mortality and hospitalization inputs were the most important drivers of rotavirus vaccine cost-effectiveness.

Discussion

Our data will guide Bolivia's funding allocation for RV as international subsidies change.     

Monitoring of rotavirus vaccination in Morocco: Establishing the baseline burden of rotavirus disease

Background

Rotavirus is a leading cause of childhood morbidity and mortality worldwide. Clinical trials for two rotavirus vaccines recommended by the WHO for global use since 2009 have successfully demonstrated the safety and efficacy of these vaccines in a wide range of countries. To control the burden of severe and fatal diarrheal disease, the Ministry of Health of Morocco introduced the single strain rotavirus vaccine into their national immunization program in 2010.

Methods

We employed a standard WHO case definition to identify children under 5 hospitalized with AGE at four hospitals from June 2006 to May 2010 to establish baseline burden of rotavirus disease before introduction of vaccine. Stool samples were collected and tested for rotavirus using a standard enzyme immunoassay.

Results

Overall, 40% (741 of 1841) of the children hospitalized with AGE tested positive for rotavirus, making it the single most common cause of severe gastroenteritis among children in Morocco. Applying this prevalence to the estimates of diarrheal hospitalizations and deaths in Morocco, we estimate that rotavirus annually causes 19,646 hospitalizations and 1604 deaths in children under 5 years of age.

Discussion

On the basis of these surveillance data, we estimate that 1 in 389 Moroccan children died and 1 in 32 was hospitalized due to rotavirus before their fifth birthday. A considerable proportion of these deaths and hospitalizations should be preventable through vaccination, and the 4 years of stable prevaccine surveillance in Morocco will be a tremendously useful platform for assessing potential changes in the epidemiology of rotavirus disease and measuring impact of the new rotavirus vaccine program in Morocco.     

Impact and cost-effectiveness of rotavirus vaccination in Bangladesh

IntroductionDiarrheal disease is a leading cause of child mortality globally, and rotavirus is responsible for more than a third of those deaths. Despite substantial decreases, the number of rotavirus deaths in children under five was 215,000 per year in 2013. Of these deaths, approximately 41% occurred in Asia and 3% of those in Bangladesh. While Bangladesh has yet to introduce rotavirus vaccination, the country applied for Gavi support and plans to introduce it in 2018. This analysis evaluates the impact and cost-effectiveness of rotavirus vaccination in Bangladesh and provides estimates of the costs of the vaccination program to help inform decision-makers and international partners.MethodsThis analysis used Pan American Health Organization’s TRIVAC model (version 2.0) to examine nationwide introduction of two-dose rotavirus vaccination in 2017, compared to no vaccination. Three mortality scenarios (low, high, and midpoint) were assessed. Benefits and costs were examined from the societal perspective over ten successive birth cohorts with a 3% discount rate. Model inputs were locally acquired and complemented by internationally validated estimates.ResultsOver ten years, rotavirus vaccination would prevent 4000 deaths, nearly 500,000 hospitalizations and 3 million outpatient visits in the base scenario. With a Gavi subsidy, cost/disability adjusted life year (DALY) ratios ranged from $58/DALY to $142/DALY averted. Without a Gavi subsidy and a vaccine price of $2.19 per dose, cost/DALY ratios ranged from $615/DALY to $1514/DALY averted.ConclusionThe discounted cost per DALY averted was less than the GDP per capita for nearly all scenarios considered, indicating that a routine rotavirus vaccination program is highly likely to be cost-effective. Even in a low mortality setting with no Gavi subsidy, rotavirus vaccination would be cost-effective. These estimates exclude the herd immunity benefits of vaccination, so represent a conservative estimate of the cost-effectiveness of rotavirus vaccination in Bangladesh.     

Cost-effectiveness of rotavirus immunization in Indonesia: Taking breastfeeding patterns into account

Objective

This study aims to assess the cost-effectiveness of rotavirus immunization in Indonesia, taking breastfeeding patterns explicitly into account.

Method

An age-structured cohort model was developed for the 2011 Indonesia birth cohort. Next, we compared two strategies, the current situation without rotavirus immunization versus the alternative of a national immunization program. The model applies a 5 year time horizon, with 1 monthly analytical cycles for children less than 1 year of age and annually thereafter. Three scenarios were compared to the base case reflecting the actual distribution over the different breastfeeding modes as present in Indonesia; i.e., the population under 2 years old with (i) 100% exclusive breastfeeding, (ii) 100% partial breastfeeding and (iii) 100% no breastfeeding. Monte Carlo simulations were used to examine the economic acceptability and affordability of the rotavirus vaccination.

Results

Rotavirus immunization would effectively reduce severe cases of rotavirus during the first 5 years of life of a child. Under the market vaccine price the total yearly vaccine cost would amount to US$ 65 million. The incremental cost per quality-adjusted-life-year (QALY) in the base case was US$ 174 from the societal perspective. Obviously, it was much lower than the 2011 Indonesian Gross Domestic Product (GDP) per capita of US$ 3495. Affordability results showed that at the Global Alliance for Vaccines and Immunization (GAVI)-subsidized vaccine price, rotavirus vaccination could be affordable for the Indonesian health system. Increased uptake of breastfeeding might slightly reduce cost-effectiveness results.

Conclusion

Rotavirus immunization in Indonesia would be a highly cost-effective health intervention even under the market vaccine price. The results illustrate that rotavirus immunization would greatly reduce the burden of disease due to rotavirus infection. Even within increased uptake of breastfeeding, cost-effectiveness remains favorable.     

Health economics of rotavirus immunization in Vietnam: potentials for favorable cost-effectiveness in developing countries

Introduction

Rotavirus is the most common cause of severe diarrhoea worldwide. Vietnam is situated in the region of high rotavirus infection incidence and eligible for financial support to introduce rotavirus vaccines into the Expanded Program of Immunization (EPI) from the GAVI. This study was designed to assess the cost-effectiveness of rotavirus immunization in Vietnam, explicitly the use of Rotateq^® and to assess the affordability of implementing universal rotavirus immunization based on GAVI-subsidized vaccine price in the context of Vietnamese healthcare system for the next 5 years.

Methodology

An age-structured cohort model was developed for the 2009 birth cohort in Vietnam. Two strategies were compared: one being the current situation without vaccination, and the other being mass universal rotavirus vaccination. The time horizon of the model was 5 years with time cycles of 1 month for children less than 1 year of age and annual analysis thereafter. Outcomes included mild, moderate, severe cases and death. Multiple outcomes per rotavirus infection are possible in the model. Monte Carlo simulations were used to examine the acceptability and affordability of the rotavirus vaccination. All costs were expressed in 2009 US$.

Results

Rotavirus vaccination would not completely protect young children against rotavirus infection due to partial nature of vaccine immunity, however, would effectively reduce severe cases of rotavirus by roughly 55% during the first 5 years of life. Under GAVI-subsidized vaccine price (US$ 0.3/dose), the vaccine cost would amount to US$ 5.5 million per annum for 3-dose of the Rotateq^® vaccine. In the base-case, the incremental cost per quality-adjusted-life-year (QALY) was US$ 665 from the health system perspective, much lower than per-capita GDP of ∼US$ 1150 in 2009. Affordability results showed that at the GAVI-subsidized vaccine price, rotavirus vaccination could be affordable for Vietnamese health system.

Conclusion

Rotavirus vaccination in Vietnam would be a cost-effective health intervention. Vaccination only becomes affordable if the country receives GAVI's financial support due to the current high market vaccine price. Given the high mortality rate of under-five-year children, the results showed that rotavirus immunization is the “best hope” for prevention of rotavirus-related diarrhoeal disease in Vietnam. In the next five years, Vietnam is definitely in debt to financial support from international organizations in implementing rotavirus immunization. It is recommended that new rotavirus vaccine candidates be developed at cheaper price to speed up the introduction of rotavirus immunization in the developing world in general.     

Cost-effectiveness of potential infant vaccination against respiratory syncytial virus infection in The Netherlands

Introduction

Respiratory syncytial virus (RSV) infection is one of the major causes of respiratory illness in infants, infecting virtually every child before the age of 2 years. Currently, several Phase 1 trials with RSV vaccines in infants are ongoing or have been completed. As yet, no efficacy estimates are available for these vaccine candidates. Nevertheless, cost-effectiveness estimates might be informative to enable preliminary positioning of an RSV vaccine.

Methods

A decision analysis model was developed in which a Dutch birth cohort was followed for 12 months. A number of potential vaccination strategies were reviewed such as vaccination at specific ages, a two- or three-dosing scheme and seasonal vaccination versus year-round vaccination. The impact of the assumptions made was explored in various sensitivity analyses, including probabilistic analysis. Outcome measures included the number of GP visits, hospitalizations and deaths, costs, quality-adjusted life years and incremental cost-effectiveness ratios (ICERs).

Results

Currently, without vaccination, an annual number of 28,738 of RSV-related GP visits, 1623 hospitalizations, and 4.5 deaths are estimated in children in the age of 0–1 year. The total annual cost to society of RSV in the non-vaccination scenario is €7.7 million (95%CI: 1.7–16.7) and the annual disease burden is estimated at 597 QALYs (95%CI: 133–1319). In case all infants would be offered a potentially safe and effective 3-dose RSV vaccination scheme at the age of 0, 1 and 3 months, the total annual net costs were estimated to increase to €21.2 million, but 544 hospitalizations and 1.5 deaths would be averted. The ICER was estimated at €34,142 (95%CI: € 21,652–€ 87,766) per QALY gained. A reduced dose schedule, seasonal vaccination, and consideration of out-of-pocket expenses all resulted in more favorable ICER values, whereas a reduced vaccine efficacy or a delay in the timing of vaccination resulted in less favorable ICERs.

Discussion

Our model used recently updated estimates on the burden of RSV disease in children and it included plausible utilities. However, due to the absence of clinical trial data, a number of crucial assumptions had to be made related to the characteristics of potential RSV vaccine. The outcomes of our modeling exercise show that vaccination of infants against RSV might be cost-effective. However, clinical trial data are warranted.     

How cost effective is universal varicella vaccination in developing countries? A case-study from Colombia

Objective

Varicella vaccination has not been introduced worldwide, especially in developing countries. The present study assesses the potential epidemiological and economic impact of one-dose and two-dose varicella vaccination schemes in Colombia, a south American upper middle-income country.

Methods

A decision-tree based model was developed. Varicella cases were estimated based on previous reports of seropositivity within the country. Cost per life-year gained (LYG) was the main outcome measure. Costs from the health care system perspective were expressed in 2008 American dollars. Deterministic and probabilistic sensitivity analyses were performed.

Results

In Colombia, there would be 700,197 varicella cases in an average year plus 60 yearly deaths without vaccination. It was estimated that health care costs for all cases during 30 years period could be around US $88,734,735 (with discount). Cost per LYG of one-dose vaccination was US $2519 and using a two-dose scheme was US $5728.

Conclusion

Vaccinating against varicella in Colombia, an upper middle-income South American country is cost-effective under the assumptions used in this study. Decision-makers should consider introducing universal varicella vaccination in Colombia, given the effectiveness, safety and cost-effectiveness of this intervention.     

Comparative cost-effectiveness of the quadrivalent and bivalent human papillomavirus vaccines: A transmission-dynamic modeling study

Background

The quadrivalent and bivalent human papillomavirus (HPV) vaccines are now licensed in several countries. We compared the cost-effectiveness of the HPV vaccines to provide evidence for policy decisions.

Methods

We developed HPV-ADVISE, a multi-type individual-based transmission-dynamic model of HPV infection and disease (anogenital warts, and cervical, anogenital and oropharyngeal cancers). We calibrated the model to sexual behavior and epidemiologic data from Canada, and estimated quality-adjusted life-years (QALYs) lost and costs ($CAN 2010) from the literature. Vaccine-type efficacy was based on a systematic literature review. The analysis was performed from the healthcare provider perspective, and costs and benefits were discounted at 3%. Predictions are presented using the median [10th;90th percentiles] of simulations.

Results

Under base-case assumptions (vaccinating 10-year-old girls, 80% coverage, $95/dose), using the quadrivalent and bivalent vaccines is estimated to cost $15,528 [12,056;19,140] and $20,182 [15,531;25,240] per QALY-gained, respectively. At equal price, the quadrivalent vaccine is more cost-effective than bivalent under all scenarios investigated, except when assuming longer duration of protection for the bivalent and minimal anogenital warts burden. Under base-case assumptions, the maximum additional cost per dose for the quadrivalent vaccine to remain more cost-effective than the bivalent is $32 [17;46] (using a $40,000/QALY-gained threshold). Results were most sensitive to discounting, time-horizon, differences in durations of protection and anogenital warts burden.

Conclusions

Vaccinating pre-adolescent girls against HPV is predicted to be highly cost-effective. If equally priced, the quadrivalent is the most economically desirable vaccine. However, ultimately, the most cost-effective HPV vaccine will be determined by their relative price.     

Economic impact of the introduction of an acellular pertussis vaccine in Canada: A 6-year analysis

Background

Between July 1997 and April 1998, Canadian public health agencies switched from the whole cell vaccine to the acellular vaccine for pertussis immunization. The acellular vaccine provided better efficacy and fewer adverse events than the whole cell vaccine did.

Objective

To determine the economic impact of replacing the whole cell vaccine with an acellular vaccine in Canada.

Methods

A decision analytic model was developed comparing costs and outcomes of pertussis vaccination for Canadian children born in the years 1991–2004. Effectiveness was measured as number of avoided pertussis cases as well as the number of avoided hospital admissions. Incremental costs per avoided pertussis case and per avoided hospital admission were calculated for Ministry of Health (MoH) and societal (SOC) perspectives. Various one-way sensitivity analyses as well as a Monte Carlo simulation were performed by varying key model parameters.

Results

The switch in immunization programs resulted in an incremental cost to the MoH of CAD $108 per pertussis case avoided (CAD $0.96 per child-year). From the SOC perspective, there was a savings of CAD $184 per pertussis case avoided (CAD $0.13 per child-year). The one-way sensitivity analyses provided incremental cost-effective ratios (ICERs) ranging from an incremental cost of CAD $1034 per avoided pertussis case from the MoH perspective to a saving of CAD $1583 per avoided case from the SOC perspective. The Monte Carlo simulation confirmed the robustness of these results.

Conclusions

Pertussis vaccination with AcE was cost-saving from the societal perspective and cost-effective from the Ministry of Health perspective.     

Effectiveness and cost-effectiveness of pediatric rotavirus vaccination in British Columbia: A model-based evaluation

Background

Rotavirus gastroenteritis (RVGE) is associated with widespread morbidity and mortality in children worldwide. In high-income countries, including Canada, the burden of RVGE relates largely to morbidity and healthcare utilization. Two live rotavirus vaccines (RotaTeq^® (Merck Frosst Canada Ltd.) and Rotarix™ (GlaxoSmithKline Inc.)), are now approved for use in Canada, but their economic attractiveness has not been evaluated in the Canadian context.

Methods

We performed a model-based economic analysis using a Markov chain Monte Carlo simulation of RVGE in populations of British Columbia children. Models were parameterized based on best available data on disease natural history and epidemiology, vaccine effectiveness and cost, and healthcare costs, and calibrated such that projections of healthcare utilization and vaccine coverage closely matched empirical estimates. Robustness of projections was evaluated in deterministic and probabilistic sensitivity analyses.

Results

Based on the best available data, childhood immunization against RVGE was projected to prevent 63–81 infections per 100 children vaccinated, and to prevent substantial numbers of outpatient medical visits. It was projected that either vaccine would prevent 1–2 hospitalizations per 100 children immunized. Vaccination was projected to increase healthcare costs: immunization with Rotarix™ would prevent incident infections at a cost of approximately $10 per infection prevented or $2400 per quality-adjusted life-year gained. Vaccination with RotaTeq™ would be more costly and less effective and would not be preferred. Projections were robust in the face of wide-ranging sensitivity analyses.

Interpretation

The use of currently available vaccines against RVGE in British Columbia children is projected to result in a substantial reduction in the burden of illness and healthcare utilization associated with RVGE, with a modest increase in healthcare costs. RVGE vaccination should be considered “highly cost-effective” relative to other commonly available health interventions.     

Reduction in hospitalizations for diarrhea and rotavirus infections in New York state following introduction of rotavirus vaccine

Objectives

To monitor trends and costs of diarrhea and rotavirus-associated hospitalizations in New York before and after rotavirus vaccine implementation in 2006. To examine rotavirus test results from sentinel hospital-associated laboratories.

Methods

Hospital discharge data and laboratory rotavirus testing data were analyzed for children 1 month up to 18 years of age for 10 sentinel and all statewide hospitals from January 1, 2003 through December 31, 2008.

Results

Among children 1–23 months of age, a 40% reduction in diarrhea-associated hospitalizations and 85% decrease in rotavirus-coded hospitalizations at the 10 sentinel hospitals was observed in 2008 compared with the average of pre-vaccine seasons from 2003 through 2006. For both sentinel and statewide hospitals, the percent of diarrhea admissions due to rotavirus was reduced at least 83% among children 1–23 months (vaccine eligible) and 70% for older unimmunized children. Statewide hospital costs for rotavirus hospitalizations in children <2 years of age were reduced $10 million. Sentinel hospital laboratory data validated the declining trends seen in hospitalizations.

Conclusions

In 2008, New York hospital data showed significant reductions in rotavirus hospitalizations and costs among children aged 1–23 months who were eligible for vaccine. Reductions also occurred among unimmunized older children suggesting the importance of continue monitoring in future seasons to fully assess vaccine impact.     

Comparing the cost-effectiveness of two- and three-dose schedules of human papillomavirus vaccination: A transmission-dynamic modelling study

Background

Recent evidence suggests that two doses of HPV vaccines may be as protective as three doses in the short-term. We estimated the incremental cost-effectiveness of two- and three-dose schedules of girls-only and girls & boys HPV vaccination programmes in Canada.

Methods

We used HPV-ADVISE, an individual-based transmission-dynamic model of multi-type HPV infection and diseases (anogenital warts, and cancers of the cervix, vulva, vagina, anus, penis and oropharynx). We conducted the analysis from the health payer perspective, with a 70-year time horizon and 3% discount rate, and performed extensive sensitivity analyses, including duration of vaccine protection and vaccine cost.

Findings

Assuming 80% coverage and a vaccine cost per dose of $85, two-dose girls-only vaccination (vs. no vaccination) produced cost/quality-adjusted life-year (QALY)-gained varying between $7900–24,300. The incremental cost-effectiveness ratio of giving the third dose to girls (vs. two doses) was below $40,000/QALY-gained when: (i) three doses provide longer protection than two doses and (ii) two-dose protection was shorter than 30 years. Vaccinating boys (with two or three doses) was not cost-effective (vs. girls-only vaccination) under most scenarios investigated.

Interpretation

Two-dose HPV vaccination is likely to be cost-effective if its duration of protection is at least 10 years. A third dose of HPV vaccine is unlikely to be cost-effective if two-dose duration of protection is longer than 30 years. Finally, two-dose girls & boys HPV vaccination is unlikely to be cost-effective unless the cost per dose for boys is substantially lower than the cost for girls.     

Uptake of oral rotavirus vaccine and timeliness of routine immunization in Brazil's National Immunization Program

Introduction

In March, 2006, oral rotavirus vaccine was added to Brazil's infant immunization schedule with recommended upper age limits for initiating (by age 14 weeks) and completing (by age 24 weeks) the two-dose series to minimize age-specific risk of intussusception following rotavirus vaccination. Several years after introduction, estimated coverage with rotavirus vaccine (83%) was lower compared to coverage for other recommended childhood immunizations (≥94%).

Methods

We analyzed data from Brazil's national immunization program on uptake of oral rotavirus vaccine by geographic region and compared administrative coverage estimates for first and second doses of oral rotavirus vaccine (Rota1 and Rota2) with first and second doses of diphtheria-tetanus-pertussis-Haemophilus influenzae type b vaccine (DTP-Hib1 and DTP-Hib2). For 27 Brazilian cities, we compared differences between estimated rotavirus and DTP-Hib coverage in 2010 with delayed receipt of DTP-Hib vaccine among a cohort of children surveyed before rotavirus introduction.

Results

In 2010, infant vaccination coverage was 99.0% for DTP-Hib1 versus 95.2% for Rota1 (3.8% difference), and 98.4% for DTP-Hib2 versus 83.0% for Rota2 (15.4% difference), with substantial regional variation. Differences between DTP-Hib and rotavirus vaccination coverage in Brazilian cities correlated with delay in DTP-Hib vaccination among children surveyed. Age restrictions for initiating and completing the rotavirus vaccination series likely contributed to lower coverage with rotavirus vaccine in Brazil.

Conclusion

To maximize benefits of rotavirus vaccination, strategies are needed to improve timeliness of routine immunizations; monitoring rotavirus vaccine uptake and intussusception risk is needed to guide further recommendations for rotavirus vaccination.     

Estimating and comparing the clinical and economic impact of paediatric rotavirus vaccination in Turkey using a simple versus an advanced model

Background

The burden of rotavirus disease is high in Turkey, reflecting the large birth cohort (>1.2 million) and the risk of disease. Modelling can help to assess the potential economic impact of vaccination. We compared the output of an advanced model with a simple model requiring fewer data inputs. If the results are similar, this could be helpful for countries that have few data available.

Methods

The advanced model was a previously published static Markov cohort model comparing costs and quality-adjusted life-year (QALY) outcomes of vaccination versus no vaccination. In contrast, the simple model used only a decision tree. Both models included data on demography, epidemiology, vaccine efficacy, resource use, unit costs, and utility scores from national databases and published papers. Only the perspective of the health care payer was considered in the analysis. The simple model had 23 variables, compared with 103 in the advanced model to allow additional comparisons of different vaccine types, dose schemes and vaccine waning.

Results

With the same input data, both models showed that rotavirus vaccination in Turkey would improve health outcomes (fewer QALYs lost to rotavirus disease). The projected annual cost offsets were $29.9 million in the simple and $29.4 million in the advanced model. Sensitivity analysis indicated that in both models the main cost driver was disease incidence followed by cost for hospital care and medical visits. Vaccine efficacy had a smaller effect.

Conclusion

Both models reached similar conclusions. Both projected that rotavirus vaccination in Turkey would improve health outcomes and may result in savings in direct healthcare costs to offset the cost of vaccination. The analysis indicated that the simple model can produce meaningful economic results in conditions where few data are available.