Health impact and cost-effectiveness of a domestically-produced rotavirus vaccine in India: A model based analysis

Effect of rotavirus vaccination on the burden of rotavirus disease and associated antibiotic use in India: A dynamic agent-based simulation analysis

BACKGROUND

Rotavirus is a leading cause of diarrhea in infants and young children in many low- and middle-income countries. India launched a childhood immunization program for rotavirus in 2016, starting with four states and expanding it to cover all states by 2019. The objective of this study was to estimate the effects of the rotavirus vaccination program in India on disease burden and antibiotic misuse.

METHODS

We built a dynamic agent-based model of rotavirus progression in children under five within each district in India. Simulations were run for various scenarios of vaccination coverage in the context of India's Universal Immunization Programme. Population data were obtained from the National Family Household Surveys and used to calibrate the models. Disease parameters were obtained from published studies. We estimated past and projected future reduction of disease burden and antibiotic misuse due to full vaccination nationwide, by state, and by wealth quintile.

RESULTS

We estimate that rotavirus vaccination in India has reduced the prevalence of rotavirus cases by 33.7% (prediction interval: 30.7-36.0%), total antibiotic misuse due to rotavirus by 21.8% (18.6-25.1%), and total deaths due to rotavirus by 38.3% (31.3-44.4%) for children under five. We estimate total antibiotic misuse due to rotavirus infection to be 7.6% (7.5-7.9%) of total antibiotic consumption in this demographic versus 9.6% (9.4-9.9%) in the absence of vaccination. We project rotaviral prevalence to drop to below one case for every 100,000 individuals in those below five if vaccination coverage is increased by 50.3% (45.2-58.5%) to 68.1% (63.1-76.4) nationwide.

CONCLUSION

Universal coverage of childhood rotavirus vaccination can substantially reduce inappropriate antibiotic use in India.

Estimating the global impact of rotavirus vaccines on child mortality

OBJECTIVES

We estimated the global impact of rotavirus vaccines on deaths among children under five years old by year.

METHODS

We used a proportionate outcomes model with a finely disaggregated age structure to estimate rotavirus deaths prevented by vaccination over the period 2006-2019 in 186 countries. We ran deterministic and probabilistic uncertainty analyses and compared our estimates to surveillance-based estimates in 20 countries.

RESULTS

We estimate that rotavirus vaccines prevented 139,000 under-five rotavirus deaths (95% uncertainty interval 98,000-201,000) in the period 2006-2019. In 2019 alone, rotavirus vaccines prevented 15% (95% uncertainty interval 11-21%) of under-five rotavirus deaths (0.5% of child mortality). Assuming global use of rotavirus vaccines and coverage equivalent to other co-administered vaccines could prevent 37% of under-five rotavirus deaths (1.2% of child mortality). Our estimates were sensitive to the choice of rotavirus mortality burden data and several vaccine impact modeling assumptions. The World Health Organization's recommendation to remove age restrictions in 2012 could have prevented up to 17,000 rotavirus deaths in the period 2013-2019. Our modeled estimates of rotavirus vaccine impact were broadly consistent with estimates from post-vaccination surveillance sites.

CONCLUSION

Rotavirus vaccines have made a valuable contribution to global public health. Enhanced rotavirus mortality prevention strategies are needed in countries with high mortality in under-5-year-old children.

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.

Cost-effectiveness of a direct to beneficiary mobile communication programme in improving reproductive and child health outcomes in India

INTRODUCTION

Kilkari is the largest maternal messaging programme of its kind globally. Between its initiation in 2012 in Bihar and its transition to the government in 2019, Kilkari was scaled to 13 states across India and reached over 10 million new and expectant mothers and their families. This study aims to determine the cost-effectiveness of exposure to Kilkari as compared with no exposure across 13 states in India.

METHODS

The study was conducted from a programme perspective using an analytic time horizon aligned with national scale-up efforts from December 2014 to April 2019. Economic costs were derived from the financial records of implementing partners. Data on incremental changes in the practice of reproductive maternal newborn and child health (RMNCH) outcomes were drawn from an individually randomised controlled trial in Madhya Pradesh and inputted into the Lives Saved Tool to yield estimates of maternal and child lives saved. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty.

RESULTS

Inflation adjusted programme costs were US$8.4 million for the period of December 2014-April 2019, corresponding to an average cost of US$264 298 per year of implementation in each state. An estimated 13 842 lives were saved across 13 states, 96% among children and 4% among mothers. The cost per life saved ranged by year of implementation and with the addition of new states from US$392 ($385-$393) to US$953 ($889-$1092). Key drivers included call costs and incremental changes in coverage for key RMNCH practices.

CONCLUSION

Kilkari is highly cost-effective using a threshold of India's national gross domestic product of US$1998. Study findings provide important evidence on the cost-effectiveness of a national maternal messaging programme in India.

TRIAL REGISTRATION

NCT03576157.

M. Eljaro Z, Abu-Awwad F, Bozya Y, Hjaija D, Bhat N, Leader T, Ramlawi A, Marzouqa H. Introducing ROTAVAC® to the occupied Palestinian Territories: Impact on diarrhea incidence, rotavirus prevalence and genotype composition

BACKGROUND

Rotavirus infection remains an important cause of morbidity and mortality in children. The introduction of vaccination programs in more than 100 countries has contributed to a decrease in hospitalizations and mortality. This study investigates the epidemiological impact of the rotavirus vaccine ROTAVAC® in the Palestinian Territories, the first country to switch from ROTARIX® to this new vaccine.

METHODS

Clinical surveillance data was collected fromchildren younger than 5attendingoutpatient clinics throughout Gaza withdiarrhea between 2015 and 2020. The incidence of all-cause diarrhea was assessed using an interrupted time-series approach. Rotavirus prevalence was determined at the Caritas Baby Hospital in the West Bank usingELISA on stool specimen of children younger than 5with diarrhea. Genotyping was performed on 325 randomly selected rotavirus-positive samples from January 2015 through December 2020 using multiplex PCR analysis.

RESULTS

Average monthly diarrhea casesdropped by 16.7% annually fromintroduction of rotavirus vaccination in May 2016 to the beginning of the SARS-CoV-2 epidemic in March 2020 for a total of 53%. Case count declines were maintained afterthe switchto ROTAVAC® in October 2018. Rotavirus positivity in stool samples declined by 67.1% over the same period without change followingthe switch to ROTAVAC®. The distribution of predominant genotypes in rotavirus-positive stool samples changed from a pre-vaccination G1P [8] to G9P[8] and G12P[8] during the ROTARIX® period and G2P[4] after the introduction of ROTAVAC®.

CONCLUSION

ROTAVAC® has shown epidemiological impact on par with ROTARIX® after its introduction to the national immunization schedule in the Palestinian Territories. A molecular genotype shift from a pre-vaccination predominance of G1P[8] to a current predominance of G2P[4] requires more long-term surveillance.

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.

Predicting the long-term impact of rotavirus vaccination in 112 countries from 2006 to 2034: A transmission modeling analysis

Rotavirus vaccination has been shown to reduce rotavirus burden in many countries, but the long-term magnitude of vaccine impacts is unclear, particularly in low-income countries. We use a transmission model to estimate the long-term impact of rotavirus vaccination on deaths and disability adjusted life years (DALYs) from 2006 to 2034 for 112 low- and middle-income countries. We also explore the predicted effectiveness of a one- vs two- dose series and the relative contribution of direct vs indirect effects to overall impacts. To validate the model, we compare predicted percent reductions in severe rotavirus cases with the percent reduction in rotavirus positivity among gastroenteritis hospital admissions for 10 countries with pre- and post-vaccine introduction data. We estimate that vaccination would reduce deaths from rotavirus by 49.1 % (95 % UI: 46.6-54.3 %) by 2034 under realistic coverage scenarios, compared to a scenario without vaccination. Most of this benefit is due to direct benefit to vaccinated individuals (explaining 69-97 % of the overall impact), but indirect protection also appears to enhance impacts. We find that a one-dose schedule would only be about 57 % as effective as a two-dose schedule 12 years after vaccine introduction. Our model closely reproduced observed reductions in rotavirus positivity in the first few years after vaccine introduction in select countries. Rotavirus vaccination is likely to have a substantial impact on rotavirus gastroenteritis and its mortality burden. To sustain this benefit, the complete series of doses is needed.

The costs of introducing a vaccine in sub-Saharan Africa: a systematic review of the literature

Purpose

This study provides a systematic literature review and categorization of the costs reported in the literature for the introduction of new vaccines, focusing on sub-Saharan Africa within LMICs, where vaccines are highly needed, financial resources are scarce and data are lacking and scattered.

Design/methodology/approach

A systematic literature search of PubMed and Web of Science databases was conducted according to the PRISMA requirements. Searches also included the relevant grey literature. In total, 39 studies were selected and nine cost categories were investigated to build a comprehensive framework.

Findings

The paper considers nine cost categories that cover the whole life of the vaccine, from its initial study to its full implementation, including for each of them the relevant subcategories. The systematic review, besides providing specific quantitative data and allowing to assess their variability within each category, points out that delivery, program preparation, administration and procurement costs are the most frequently estimated categories, while the cost of the good sold, costs borne by households and costs associated to AEFI are usually overlooked. Data reported on R&D costs and investment in the production plant differ significantly among the selected contributions.

Originality/value

The literature contributions on cost estimation tend to focus on a precise vaccine, a specific geographic area, or to adopt a narrow approach that captures only a subset of the costs. This article presents a rich and inclusive set of the economic quantitative data on immunization costs in limited-resource countries.

Inclusion of Additional Unintended Consequences in Economic Evaluation: A Systematic Review of Immunization and Tuberculosis Cost-Effectiveness Analyses

OBJECTIVE

Our objective was to review economic evaluations of immunization and tuberculosis to determine the extent to which additional unintended consequences were taken into account in the analysis and to describe the methodological approaches used to estimate these, where possible.

METHODS

We sourced the vaccine economic evaluations from a previous systematic review by Nymark et al. (2009-2015) and searched PubMed/MEDLINE and Embase from 2015 to 2019 using the same search strategy. For tuberculosis economic evaluations, we extracted studies from 2009 to 2019 that were published in a previous review by Siapka et al. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Studies were classified according to the categories and subcategories (e.g., herd immunity, non-specific effects, and labor productivity) defined in a framework identifying additional unintended consequences by Nymark and Vassall. Where possible, methods for estimating the additional unintended consequences categories and subcategories were described. We evaluated the reporting quality of included studies according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) extraction guideline.

RESULTS

We identified 177 vaccine cost-effectiveness analyses (CEAs) between 2009 and 2019 that met the inclusion criteria. Of these, 98 included unintended consequences. Of the total 98 CEAs, overall health consequence categories were included 73 times; biological categories: herd immunity 43 times; pathogen response: resistance 15 times; and cross-protection 15 times. For health consequences pertaining to the supply-side (health systems) categories, side effects were included five times. On the nonhealth demand side (intrahousehold), labor productivity was included 60 times. We identified 29 tuberculosis CEAs from 2009 to 2019 that met the inclusion criteria. Of these, six articles included labor productivity, four included indirect transmission effects, and one included resistance. Between 2009 and 2019, only 34% of tuberculosis CEAs included additional unintended consequences, compared with 55% of vaccine CEAs.

CONCLUSIONS

The inclusion of additional unintended consequences in economic evaluations of immunization and tuberculosis continues to be limited. Additional unintended consequences of economic benefits, such as those examined in this review and especially those that occur outside the health system, offer valuable information to analysts. Further work on appropriate ways to value these additional unintended consequences is still warranted.

On the vaccine supply chain coordination under subsidy contract

In this paper, we analyze the vaccine supply chain of child immunization program of India under stochastic production yield. We show that the wholesale price contract cannot achieve channel coordination. We propose a subsidy contract to coordinate the vaccine supply chain. A case analysis in the Indian context is presented to illustrate the impact of the proposed subsidy contract.

A review of rotavirus vaccine use in Asia and the Pacific regions: challenges and future prospects

Introduction: Rotavirus infection causes a significant proportion of diarrhea disease burden in children <5 years of age in Asia and the Pacific regions. The World Health Organization recommends that rotavirus vaccination should be included in national immunization programs to prevent rotavirus gastroenteritis (RVGE).Areas covered: A literature review was performed to identify and summarize published evidence on RVGE epidemiology and status of rotavirus vaccine use, including the impact and cost-effectiveness of rotavirus vaccination programs in Asia and the Pacific regions (49 countries) during the period 2000-2018.Expert opinion: Rotavirus vaccination programs have successfully reduced the burden of RVGE in many countries. However, such programs still do not exist in most Asia-Pacific countries, and therefore the burden of RVGE remains high in children <5 years of age. Challenges to vaccine implementation include a lack of surveillance data; safety concerns around intussusception; a general lack of awareness about RVGE disease epidemiology and vaccines among physicians, policy-makers, and parents; insufficient cost-effectiveness analyses; and potential issues with vaccine affordability including vaccination costs and lack of political will. Recommendations to overcome these challenges include developing cost-effectiveness analyses for more diverse national and regional settings, providing non-governmental support for low-income countries, and improving advocacy efforts.Plain language summaryWhat is the context?• Rotavirus (RV) infection causes acute gastroenteritis (GE) in children under 5 years of age.• Rotavirus vaccination (RVV) implementation has been slow in Asia and the Pacific (AP) regions, which could be responsible for the region falling behind in their fight against RVGE.What is new?• RVV via national immunization programs (NIPs) is available in 8/49 countries and through the private market or non-governmental support in other countries. Coverage rates vary between countries, possibly driven by the mechanism through which RVV is available.• A substantial positive impact of RVV on RVGE disease burden with a very low risk of intestinal intussusception for up to 7 days after RVV has been documented in the AP regions.• Economic evaluation studies, mainly cost-effectiveness analyses, predict a significant reduction in treatment costs related to RVGE and its complications showing that RVV is good value for money.What is the impact?• The prospect of continued safe and effective use of RVV in the AP regions is promising.• Challenges to RVV implementation include establishing evidence of burden of disease, poor awareness of rotavirus vaccines, limited evidence from cost-effectiveness analyses from several countries, issues of affordability of the vaccine and a lack of political will.• Recommendations for RVV implementation into the NIPs include conducting clinical and cost-effectiveness studies in countries where these are not available, establishing reliable surveillance mechanisms, providing non-governmental support for low-income countries and improving advocacy efforts.• Maintenance of high vaccination coverage is needed in countries that have implemented national RVV programs.Graphical abstract[Formula: see text].

The performance of licensed rotavirus vaccines and the development of a new generation of rotavirus vaccines: a review

Rotavirus, which causes acute gastroenteritis and severe diarrhea, has posed a great threat to children worldwide over the last 30 y. Since no specific drugs and therapies against rotavirus are available, vaccination is considered the most effective method of decreasing the morbidity and mortality related to rotavirus-associated gastroenteritis. To date, six rotavirus vaccines have been developed and licensed by local governments. Notably, Rotarix™ and RotaTeq™ have been recommended as universal agents against rotavirus infection by the World Health Organization; however, lower efficacies were found in less-developed and developing regions with medium and high child mortality than well-developed ones with low child mortality. For now, two promising novel vaccines, Rotavac™ and RotaSiil™ were pre-qualified by the World Health Organization in 2018. Other rotavirus vaccines in the pipeline including neonatal strain (RV3-BB) and several non-replicating rotavirus vaccines with a parenteral delivery strategy are currently undergoing investigation, with the potential to improve the performance of, and eliminate the safety concerns associated with, previous live oral rotavirus vaccines. This paper reviews the important developments in rotavirus vaccines in the last 20 y and discusses problems and challenges that require investigation in the future.

Gastroenteritis in Haryana, India Post Introduction of Rotavirus Vaccine

OBJECTIVE

To evaluate the epidemiology of rotavirus gastroenteritis in Haryana post-introduction of rotavirus vaccine. Expanded National rotavirus surveillance network in India reported high burden of rotavirus diarrhea in India. The Government of India introduced the monovalent rotavirus vaccine made in India by Bharat Biotech in the national immunization programme from 2016 onward along with oral polio vaccine (OPV) and Pentavalent vaccines.

METHODS

A multi-centric, hospital-based surveillance study in the initial vaccine introducing states was started in a phased manner over a period of 3 y. PGIMS, Rohtak is a tertiary care center and was a part of the surveillance from 2016 to 2019. Children aged 0-59 mo admitted with acute gastroenteritis were enrolled into the surveillance and their stool samples were collected. Samples were tested at Christian Medical College (CMC), Vellore to detect rotavirus and reverse transcription-polymerase chain reaction (RT-PCR) was used for G and P typing.

RESULTS

A total of 904 children were enrolled in the present surveillance over a period of 3 y starting 1st July 2016 to 30th June 2019. Stool samples were collected and analyzed for 827 children and out of them 141 samples were positive for rotavirus (17.1%). Maximum rotavirus positivity was observed during the winter months. Rotavirus positivity percentage was observed maximum in 12-23 mo age group. A declining trend was observed in rotavirus positivity from 22.8% in 2016 to 14.5% in 2019. Most common strains of rotavirus isolated were G3P[8] followed by G1P[8].

CONCLUSION

This study highlights that epidemiology of acute gastroenteritis among children less than 5 y of age in Haryana postintroduction of rotavirus vaccination in the state and the decline in rotavirus positivity from 22.8% in 2016 to 14.5% in 2019.

Economic evaluation of rotavirus vaccination in children of Bhutan

BACKGROUND

Diarrhoea remains one of the top ten causes of under-five child morbidity in Bhutan, and rotavirus is a significant cause of child diarrhoeal hospitalisations. This study sought to determine the health outcomes, cost-effectiveness, and budget and human resource implications of introducing rotavirus vaccines in the routine immunisation program to inform Bhutan's decision-making process.

METHODS

We used UNIVAC model (version 1.3.41) to evaluate the cost-effectiveness of a rotavirus vaccination programme compared with no vaccination from a government perspective. We also projected the impact of rotavirus vaccination on human resources and budget. Acost-effectiveness threshold was determined to be 0.5 times the gross domestic product (GDP) per capita (equivalent to the United States dollar ($) 1,537) per Disability-Adjusted Life-Year (DALY) averted.One-way deterministic and probabilistic sensitivity analyses, and threshold analyses were performed to capture parameter uncertainties.

RESULTS

In Bhutan, a rotavirus vaccination programme over 10 years (2020 to 2029) can avert between 104 and 115 DALYs, at an incremental cost ranging from $322,000 to $1,332,000. The incremental cost-effectiveness ratio (ICER) across four vaccination programmes compared to no vaccination scenario were $9,267, $11,606, $3,201, and $2,803 per DALY averted for ROTARIX, RotaTeq, ROTAVAC, and ROTASIIL, respectively. The net five-year budget impact of introducing a rotavirus vaccination programme ranged from $0.20 to $0.81 million. The rotavirus vaccination programme has a potential to reduce the workload of health care workers such as paediatricians, nurses, dieticians, and pharmacists; however, the programme would require an additional 1.93-2.88 full-time equivalent of health assistants.

CONCLUSION

At the current cost-effectiveness threshold, routine rotavirus vaccination in Bhutan is unlikely to be cost-effective with any of the currently available vaccines. However, routine vaccination with ROTASIIL was under the cost-effectiveness threshold of one times the GDP per capita ($3,074). ROTASIIL and ROTAVAC would provide the best value for money in Bhutan.

Mortality reduction benefits and intussusception risks of rotavirus vaccination in 135 low-income and middle-income countries: a modelling analysis of current and alternative schedules

Background

Infant rotavirus vaccines have led to substantial reductions in hospital admissions and deaths due to gastroenteritis, but some studies have reported an elevated risk of intussusception, a rare bowel disorder. This analysis aimed to provide evidence on the potential mortality reduction benefits and intussusception risks of current rotavirus vaccination schedules, and to explore whether alternative schedules could have advantages.

Methods

All 135 low-income and middle-income countries, defined by gross national income per capita of less than US$12 236 in the 2018 fiscal year, were included in the model. Mortality reduction benefits and intussusception risks of rotavirus vaccination were modelled by use of an Excel-based static cohort model with a finely disaggregated age structure. Numbers of rotavirus gastroenteritis deaths and intussusception deaths in each week of age were calculated for all infants born in the year 2015 between birth and age 5·0 years, with and without restrictions on age at administration. Benefit–risk ratios (rotavirus gastroenteritis deaths prevented per excess intussusception death) and other indicators were calculated for two vaccination schedules currently recommended by WHO and 16 alternative schedules. Of these schedules, it was assumed that between one and three doses would be given; the first dose of the rotavirus vaccine would be co-administered with either BCG or diphtheria–tetanus–pertussis (DTP)1; and the second or third dose would be co-administered with either DTP1, DTP2, DTP3, or measles (Meas)1.

Findings

A three-dose schedule co-administered with DTP (without age restrictions) could prevent about 74 000 (95% uncertainty interval 59 000–100 000) rotavirus gastroenteritis deaths (38% reduction) and could lead to 201 (77–550) excess intussusception deaths (1·4% increase) compared with no vaccination, resulting in a benefit–risk ratio of 369:1 (160:1–895:1). The benefit–risk ratio was most favourable when the relative risk of intussusception was assumed to decline with the national under-5 mortality rate (2386:1) and least favourable with pessimistic assumptions about access to hospital for intussusception treatment (168:1). Schedules that involve giving the first dose with BCG and the second with DTP1 had the fewest excess intussusception deaths and most favourable benefit–risk ratios.

Interpretation

Rotavirus vaccines have a favourable benefit–risk profile in LMICs. Neonatal schedules have the potential to prevent more rotavirus gastroenteritis deaths and cause fewer excess intussusception deaths than the schedules currently recommended by WHO, but more efficacious rotavirus vaccines would be needed to achieve more substantial mortality reduction benefits.

Funding

Bill & Melinda Gates Foundation.

Systematic Review and Meta-Analysis of Cost-effectiveness of Rotavirus Vaccine in Low-Income and Lower-Middle-Income Countries

BACKGROUND

Rotavirus causes morbidity and mortality in children particularly in low-income countries (LICs) and lower-middle-income countries (LMICs). This systematic review and meta-analysis aimed to assess cost-effectiveness of rotavirus vaccine in LICs and LMICs.

METHODS

Relevant studies were identified from PubMed and Scopus from their inception to January 2019. Studies were eligible if they assessed the cost-effectiveness of rotavirus vaccine in children in LICs and LMICs and reported incremental cost-effectiveness ratios. Risk of bias and quality assessment was assessed based on the Consolidated Health Economic Evaluation Reporting Standard checklist. Incremental net benefits (INBs) were estimated, and meta-analysis based on the DerSimonian and Laird method was applied to pool INBs across studies.

RESULTS

We identified 1614 studies, of which 28 studies (29 countries) were eligible and conducted using cost-utility analysis in LICs (n = 8) and LMICs (n = 21). The pooled INB was estimated at $62.17 (95% confidence interval, $7.12-$117.21) in LICs, with a highly significant heterogeneity (χ2 = 33.96; df = 6; P < .001; I 2 = 82.3%), whereas the pooled INB in LMICs was $82.46 (95% confidence interval, $54.52-$110.41) with no heterogeneity (χ2 = 8.46; df = 11; P = .67; I 2 = 0%).

CONCLUSIONS

Rotavirus vaccine would be cost-effective to introduce in LICs and LMICs. These findings could aid decision makers and provide evidence for introduction of rotavirus vaccination.