title: Cost-Effectiveness of Monovalent Rotavirus Vaccination of Infants in Malawi: A Postintroduction Analysis Using Individual Patient-Level Costing Data.
abstract: BACKGROUND
  Rotavirus vaccination reduces childhood hospitalization in Africa, but cost-effectiveness has not been determined using real-world effectiveness and costing data. We sought to determine monovalent rotavirus vaccine cost-effectiveness in Malawi, one of Africa's poorest countries and the first Gavi-eligible country to report disease reduction following introduction in 2012.
  
  
  METHODS
  This was a prospective cohort study of children with acute gastroenteritis at a rural primary health center, a rural first referral-level hospital and an urban regional referral hospital in Malawi. For each participant we itemized household costs of illness and direct medical expenditures incurred. We also collected Ministry of Health vaccine implementation costs. Using a standard tool (TRIVAC), we derived cost-effectiveness.
  
  
  RESULTS
  Between 1 January 2013 and 21 November 2014, we recruited 530 children aged <5 years with gastroenteritis. Costs did not differ by rotavirus test result, but were significantly higher for admitted children and those with increased severity on Vesikari scale. Adding rotavirus vaccine to the national schedule costs Malawi $0.42 per dose in system costs. Vaccine copayment is an additional $0.20. Over 20 years, the vaccine program will avert 1 026 000 cases of rotavirus gastroenteritis, 78 000 inpatient admissions, 4300 deaths, and 136 000 disability-adjusted-life-years (DALYs). For this year's birth cohort, it will avert 54 000 cases of rotavirus and 281 deaths in children aged <5 years. The program will cost $10.5 million and save $8.0 million in averted healthcare costs. Societal cost per DALY averted was $10, and the cost per rotavirus case averted was $1.
  
  
  CONCLUSIONS
  Gastroenteritis causes substantial economic burden to Malawi. The rotavirus vaccine program is highly cost-effective. Together with the demonstrated impact of rotavirus vaccine in reducing population hospitalization burden, its cost-effectiveness makes a strong argument for widespread utilization in other low-income, high-burden settings.
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre Institute of Infection and Global Health, University of Liverpool, United Kingdom.
authors.forename: Naor
authors.initials: N
authors.lastname: Bar-Zeev
authors.affiliation: Epidemiology Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Jacqueline E
authors.initials: JE
authors.lastname: Tate
authors.affiliation: Program for Appropriate Technologies in Health (PATH), Seattle, Washington.
authors.forename: Clint
authors.initials: C
authors.lastname: Pecenka
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre.
authors.forename: Jean
authors.initials: J
authors.lastname: Chikafa
authors.affiliation: Karonga Prevention Study, Chilumba, Karonga.
authors.forename: Hazzie
authors.initials: H
authors.lastname: Mvula
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre.
authors.forename: Richard
authors.initials: R
authors.lastname: Wachepa
authors.affiliation: Ministry of Health, Lilongwe, Malawi.
authors.forename: Charles
authors.initials: C
authors.lastname: Mwansambo
authors.affiliation: Ministry of Health, Lilongwe, Malawi.
authors.forename: Themba
authors.initials: T
authors.lastname: Mhango
authors.affiliation: Ministry of Health, Lilongwe, Malawi.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Chirwa
authors.affiliation: Karonga Prevention Study, Chilumba, Karonga London School of Hygiene and Tropical Medicine.
authors.forename: Amelia C
authors.initials: AC
authors.lastname: Crampin
authors.affiliation: Epidemiology Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Umesh D
authors.initials: UD
authors.lastname: Parashar
authors.affiliation: Institute of Global Health.
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre Division of Infection and Immunity, University College London Liverpool School of Tropical Medicine, United Kingdom.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Heyderman
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre Institute of Infection and Global Health, University of Liverpool, United Kingdom.
authors.forename: Neil
authors.initials: N
authors.lastname: French
authors.affiliation: Program for Appropriate Technologies in Health (PATH), Seattle, Washington.
authors.forename: Deborah
authors.initials: D
authors.lastname: Atherly
authors.affiliation: Institute of Infection and Global Health, University of Liverpool, United Kingdom.
authors.forename: Nigel A
authors.initials: NA
authors.lastname: Cunliffe
mesh_terms: D002675:Child, Preschool; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003906:Developing Countries / Q000706:statistics & numerical data; D005260:Female; D005759:Gastroenteritis / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control* / Q000821:virology; D017048:Health Care Costs / Q000706:statistics & numerical data* / Q000639:trends; D005102:Health Expenditures / Q000706:statistics & numerical data; D006760:Hospitalization / Q000191:economics; D006801:Humans; D017589:Immunization Programs / Q000191:economics; D007223:Infant; D008295:Malawi; D008297:Male; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D012401:Rotavirus / Q000276:immunology; D012400:Rotavirus Infections / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control / Q000821:virology; D022243:Rotavirus Vaccines / Q000008:administration & dosage / Q000191:economics* / Q000276:immunology; D014611:Vaccination / Q000191:economics*; D014613:Vaccines, Attenuated / Q000008:administration & dosage / Q000191:economics / Q000276:immunology
chemical_list: C492457:RIX4414 vaccine; D022243:Rotavirus Vaccines; D014613:Vaccines, Attenuated
keywords: cost-effectiveness; developing countries; rotavirus vaccine