title: Cost-effectiveness of a new rotavirus vaccination program in Pakistan: a decision tree model.
abstract: BACKGROUND
  Rotavirus gastroenteritis places a significant health and economic burden on Pakistan. To determine the public health impact of a national rotavirus vaccination program, we performed a cost-effectiveness study from the perspective of the health care system.
  
  
  METHODS
  A decision tree model was developed to assess the cost-effectiveness of a national vaccination program in Pakistan. Disease and cost burden with the program were compared to the current state. Disease parameters, vaccine-related costs, and medical treatment costs were based on published epidemiological and economic data, which were specific to Pakistan when possible. An annual birth cohort of children was followed for 5 years to model the public health impact of vaccination on health-related events and costs. The cost-effectiveness was assessed and quantified in cost (2012 US$) per disability-adjusted life-year (DALY) averted and cost per death averted. Sensitivity analyses were performed to assess the robustness of the incremental cost-effectiveness ratios (ICERs).
  
  
  RESULTS
  The base case results showed vaccination prevented 1.2 million cases of rotavirus gastroenteritis, 93,000 outpatient visits, 43,000 hospitalizations, and 6700 deaths by 5 years of age for an annual birth cohort scaled from 6% current coverage to DPT3 levels (85%). The medical cost savings would be US$1.4 million from hospitalizations and US$200,000 from outpatient visit costs. The vaccination program would cost US$35 million at a vaccine price of US$5.00. The ICER was US$149.50 per DALY averted or US$4972 per death averted. Sensitivity analyses showed changes in case-fatality ratio, vaccine efficacy, and vaccine cost exerted the greatest influence on the ICER.
  
  
  CONCLUSIONS
  Across a range of sensitivity analyses, a national rotavirus vaccination program was predicted to decrease health and economic burden due to rotavirus gastroenteritis in Pakistan by ~40%. Vaccination was highly cost-effective in this context. As discussions of implementing the intervention intensify, future studies should address affordability, efficiency, and equity of vaccination introduction.
authors.affiliation: James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, United States; Epidemiology and Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States. Electronic address: hitenpatel@jhmi.edu.
authors.forename: Hiten D
authors.initials: HD
authors.lastname: Patel
authors.forename: Eric T
authors.initials: ET
authors.lastname: Roberts
authors.forename: Dagna O
authors.initials: DO
authors.lastname: Constenla
mesh_terms: D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005260:Female; D005759:Gastroenteritis / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control; D006801:Humans; D017589:Immunization Programs / Q000191:economics; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010154:Pakistan / Q000453:epidemiology; D012400:Rotavirus Infections / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control*; D022243:Rotavirus Vaccines / Q000008:administration & dosage* / Q000191:economics*; D014611:Vaccination / Q000191:economics* / Q000379:methods
chemical_list: D022243:Rotavirus Vaccines
keywords: Cost-effectiveness; DALYs; DPT3; EMR; Eastern Mediterranean region; GAVI; GDP; Gastroenteritis; Global Alliance for Vaccines and Immunization; ICER; PATH; Pakistan; Program for Appropriate Technology in Health; RVGE; Rotavirus; Vaccination; WHO; World Health Organization; disability-adjusted life-years; final dose of diphtheria, pertussis, and tetanus vaccination; gross domestic product; incremental cost-effectiveness ratio; rotavirus gastroenteritis