Elsevier

Vaccine

Volume 30, Issue 8, 14 February 2012, Pages 1521-1528
Vaccine

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

https://doi.org/10.1016/j.vaccine.2011.11.052Get rights and content

Abstract

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.

Highlights

Rotavirus vaccination using RotaTeq® is cost-effective in Vietnam. ► GAVI's support for rotavirus vaccination in developing countries is crucial. ► Mass universal rotavirus vaccination and no vaccination were compared.

Introduction

Diarrhoea is a leading cause of child mortality. Globally, around 1.8 million children under the age of five die from diarrhoeal-related diseases per year and rotavirus has been identified as the most common cause of severe diarrhoea [1], [2]. Rotavirus infection has been reported to be responsible for more than 2 million hospitalizations worldwide and roughly 527,000 deaths annually [3]. A large share of the mortality and morbidity occurs in developing countries, such as Vietnam [4].

Vietnam was one of the two countries in Asia, besides Bangladesh, where the efficacy of the pentavalent rotavirus vaccine, RotaTeq® was assessed in 2009 under a joint partnership between the PATH Rotavirus Vaccine Program and Merck [4]. A major outcome of this clinical trial was the establishment of vaccine efficacy against severe disease at 48.3% (95% CI 22.3%–66.1%) in Asia [4] or 63.9% (95% CI 7.6%–90.9%) in Vietnam. This supported the WHO's expanded immunization recommendations to promote the global use of rotavirus vaccines. Notably, Vietnam established sentinel hospital surveillance to assess the burden of rotavirus already back in 1998 [5]. The sentinel surveillance for rotavirus was carried out in 6 hospitals in 4 major cities, namely Hanoi, Hai Phong, Nha Trang and Ho Chi Minh City in Vietnam. Stool samples were obtained from more than 10,000 children of age less than 5 years old, who were admitted to hospitals with diarrhoea and were screened for rotavirus. This surveillance network later served as a model for 8 other countries in the Asian Rotavirus Surveillance Network [5], [6].

Up to now, two cost-effectiveness studies on rotavirus immunization have been conducted in Vietnam [7], [8], confirming that implementing rotavirus vaccination in the Expanded Programme on Immunization (EPI) would be a cost-effective health-care intervention. However, these studies only evaluated the use of the monovalent Rotarix™ vaccine while ignoring the possible use of the pentavalent rotavirus vaccine in the EPI. Additionally, these previous studies did not account for between-dose vaccine efficacies and used vaccine efficacy data, which was done in other countries rather than Vietnam.

Considering the limitations of both studies, we performed a cost-effectiveness analysis on rotavirus immunization in Vietnam focussing explicitly on the use of RotaTeq® as one of the recommended vaccines to be introduced into countries’ EPI. A major advantage of this approach is that it allows us to utilize the most updated and recently released results on RotaTeq® vaccine efficacy, which was conducted in Vietnam [4]. We applied a cost-effectiveness model developed by University of Groningen, but different from previous studies using this model [9], [10], we additionally assessed the affordability of implementing universal rotavirus immunization based on the GAVI-subsidized price and market price in the context of the Vietnamese healthcare system for the next 5 years [11]. Finally, as a novel data source we included publications and reports written in the Vietnamese language, thus incorporating literature that is not internationally accessible and was not previously applied in the models.

Section snippets

Model

We applied the CoRoVa model (the Concensus Model on Rotavirus Vaccination) developed by University of Groningen for our analysis [10], see Fig. 1. This model has been used previously to calculate the cost-effectiveness of rotavirus vaccination for both developing and developed countries [9], [10]. We selected CoRoVa instead of other models for the Vietnamese context because of its ability to account for waning immunity and to take in-between dose efficacies explicitly into account [9]. In

Base-case results

Assuming 93% coverage, vaccination of a birth cohort of 1,485,000 would reduce rotavirus-related mild, moderate, severe cases by 44% (579,602 cases), 49% (72,193 cases), 54% (17,471 cases), respectively and save 832 (54%) deaths (Table 3). This reduction corresponds to a gain of 25,825 discounted QALYs and a saving of US$ 6.4 million in burden cost-of-illness due to rotavirus infection.

At the per-dose-GAVI-subsidized price of US$ 0.3 for the RotaTeq® vaccine, rotavirus immunization would become

Discussion

Our economic analysis indicates that inclusion of rotavirus vaccination in the EPI in Vietnam would be cost-effective or even cost-saving depending on the cost of the vaccine. At the base-case GAVI-subsidized price of US$ 0.3 per dose, rotavirus vaccination would be cost-saving from both analyzed perspectives (health care and societal). Rotavirus vaccination would reduce rotavirus-related mild, moderate, severe cases by 72,193, 579,602, 17,471, respectively and save 832 lives from rotavirus

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