key: cord-0019433-7znbs30i authors: Okafor, Charles E; Ekwunife, Obinna I title: Introducing rotavirus vaccine in eight sub-Saharan African countries: a cost–benefit analysis date: 2021-07-21 journal: Lancet Glob Health DOI: 10.1016/s2214-109x(21)00220-5 sha: 864480f10f0167aa304450c1d5bc6c2de83ac540 doc_id: 19433 cord_uid: 7znbs30i BACKGROUND: Stimulated by the economic challenges faced by many sub-Saharan African countries and the changes in the rotavirus burden across these countries, this study aimed to inform the decision of health policy makers of eight sub-Saharan countries, who are yet to introduce the rotavirus vaccine as of Dec 31, 2020, on the health economic consequences of the introduction of the vaccine in terms of the costs and benefits. METHODS: We did a cost–benefit analysis using a simulation-based decision-analytic model for children aged younger than 1 year, who were followed up to 259 weeks, in the Central African Republic, Chad, Comoros, Equatorial Guinea, Gabon, Guinea, Somalia, and South Sudan. Data were collected and analysed between Jan 13, 2020, and Dec 11, 2020. Cost-effectiveness analysis and budget impact analysis were done as secondary analyses. Four rotavirus vaccinations (Rotarix, Rotateq, Rotavac, and Rotasiil) were compared with no vaccination. The primary outcome was disability-adjusted life-years averted, converted to monetary terms. The secondary outcomes include rotavirus gastroenteritis averted, and rotavirus vaccine-associated intussusception. The primary economic evaluation measure was the benefit–cost ratio (BCR). FINDINGS: For the modelling period, Jan 1, 2021, to Dec 31, 2030, we found that the benefits of introducing the rotavirus vaccine outweighed the costs in all eight countries, with Chad and the Central African Republic having the highest BCR of 19·42 and 11·36, respectively. Guinea had the lowest BCR of 3·26 amongst the Gavi-eligible countries. Equatorial Guinea and Gabon had a narrow BCR of 1·86 and 2·06, respectively. Rotarix was the optimal choice for all the Gavi-eligible countries; Rotasiil and Rotavac were the optimal choices for Equatorial Guinea and Gabon, respectively. INTERPRETATION: Introducing the rotavirus vaccine in all eight countries, but with caution in Equatorial Guinea and Gabon, would be worthwhile. With the narrow BCR for Equatorial Guinea and Gabon, cautious, pragmatic, and stringent measures need to be employed to ensure optimal health benefits and cost minimisation of the vaccine introduction. The final decision to introduce the rotavirus vaccine should be preceded by comparing its BCR to the BCRs of other health-care projects. FUNDING: Copenhagen Consensus Center and the Bill & Melinda Gates Foundation. 1. Gavi-eligible countries refer to countries whose three-year average gross national income (GNI) per capita are below or equal to the eligibility threshold (US$1,630). 3 They include low-income countries (LIC), also referred to as countries in the initial self-financing phase, and countries in the preparatory phase 1. 3 Gavi financial support for preparatory phase 1 countries decreases annually as per Gavi policy for phase 1 countries. 3 Phase 2 countries GNI per capita are above the eligibility threshold and the financial support they receive from Gavi decreases annually (until they fully self-finance the vaccines) as per Gavi policy for phase 2 countries. 3 Phase 3 countries are fully self-financing countries but commit with vaccine manufacturers to procure vaccines at the price Gavi pays under specific conditions and period. 3 Non-Gavi countries have crossed phase 3, receive no support from Gavi, and have no commitment to procure vaccines at the Gavi price from vaccine manufacturers. 2. The wastage cost is the cost associated with vaccine damages or losses during transportation, storage, or administration, which has an impact on the total vaccine cost and total immunisation delivery cost. The vaccine wastage cost is the cost of the vaccine multiplied by the wastage rate, whilst the cold-chain volume wastage cost is the cost of the cold chain volume multiplied by the wastage rate. Global Burden of Disease Study 2019 (GBD 2019) Results Systematic review of diarrhea duration and severity in children and adults in low-and middle-income countries Eligibility and transition policy Indicators: Economy & Growth Immunization Costing Action Network (ICAN) CCEMG -EPPI-Centre Cost Converter v.1.6 Global Health Workforce statistics 3. The cost estimates we used from the ICAN review included personnel costs and logistics costs related to immunisation delivery. To estimate the immunisation delivery cost for LIC in this study, we used the cost estimate for Rwanda from the ICAN review, estimated for Rotateq. For Comoros, we used Rotarix estimates for Zambia and Ghana (lower-middle-income countries), whilst for Equatorial Guinea and Gabon (upper-middle-income countries), we used Rotarix estimate for Colombia. We adjusted the costs data obtained from the ICAN review to the cost for each country in this study using their relative price-level ratios. 4 From the ICAN review, a relative vaccination coverage ratio of '2' between countries of the same income classification and population size was associated with a 9% to 15% increase in immunisation delivery cost. 5 This vaccine coverage factor was applied to adjust the cost data of the eight countries being evaluated. We then adjusted the costs based on the number of doses for each vaccine and their waste-adjusted cold-chain volume. The cold-chain volume contributed to about 7%, 10%, 12%, and 16% of the total immunisation delivery cost for Rotavac, Rotarix, Rotasiil, and Rotateq respectively, from our adjustment. 5 The costs were adjusted to 2019 USD as per guidelines of the CCEGM and the EPPI-Centre. 6 4. Distribution of impact:Most remote areas in each country in SSA have a higher RVGE burden compared to the urban areas. 1 These areas are also associated with a higher cost of healthcare due to shortage of health professionals, poor healthcare-seeking and access to care. 7 Thus, it is highly probable that these areas will have a lower share of the RV vaccination impact at the patient level. However, at the population level, if the remote areas have a relatively higher population than the urban areas, they will benefit more from the vaccination program compared to urban areas.