title: Comparison of impact and cost-effectiveness of rotavirus supplementary and routine immunization in a complex humanitarian emergency, Somali case study.
abstract: BACKGROUND
  A humanitarian emergency involves a complete breakdown of authority that often disrupts routine health care delivery, including immunization. Diarrheal diseases are a principal cause of morbidity and mortality among children during humanitarian emergencies. The objective of this study was to assess if vaccination against rotavirus, the most common cause of severe diarrhea among children, either as an addition to routine immunization program (RI) or supplemental immunization activity (SIA) would be cost-effective during a humanitarian emergency to decrease diarrhea morbidity and mortality, using Somalia as a case study.
  
  
  METHODS
  An impact and cost-effectiveness analysis was performed comparing no vaccine; two-dose rotavirus SIA and two-dose of RI for the 424,592 births in the 2012 Somali cohort. The main summary measure was the incremental cost per disability-adjusted life-year (DALY) averted. Univariate sensitivity analysis examined the extent to which the uncertainty in the variables affected estimates.
  
  
  RESULTS
  If introduced in Somalia, a full-series rotavirus RI and SIA would save 908 and 359 lives, respectively, and save US$63,793 and US$25,246 in direct medical costs, respectively. The cost of a RI strategy would be US$309,458. Because of the high operational costs, a SIA strategy would cost US$715,713. US$5.30 per DALY would be averted for RI and US$37.62 per DALY averted for SIA. Variables that most substantially influenced the cost-effectiveness for both RI and SIA were vaccine program costs, mortality rate, and vaccine effectiveness against death.
  
  
  CONCLUSIONS
  Based on our model, rotavirus vaccination appears to be a cost-effective intervention as either RI or SIA, as defined by the World Health Organization as one to three times the per capita Gross Domestic Product (Somalia $112 in 2011). RI would have greater health impact and is more cost effective than SIA, assuming feasibility of reaching the target population. However, given the lack of infrastructure, whether RI is realistic in this setting remains unanswered, and alternative approaches like SIA should be further examined.
authors.affiliation: Center for Global Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341 USA.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Gargano
authors.affiliation: National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA USA.
authors.forename: Jacqueline E
authors.initials: JE
authors.lastname: Tate
authors.affiliation: National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA USA.
authors.forename: Umesh D
authors.initials: UD
authors.lastname: Parashar
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, GA USA.
authors.forename: Saad B
authors.initials: SB
authors.lastname: Omer
authors.affiliation: Center for Global Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341 USA.
authors.forename: Susan T
authors.initials: ST
authors.lastname: Cookson
keywords: Cost-effectiveness; Humanitarian emergency; Rotavirus vaccine; Routine immunization; Somalia