title: What Pertussis Mortality Rates Make Maternal Acellular Pertussis Immunization Cost-Effective in Low- and Middle-Income Countries? A Decision Analysis.
abstract: BACKGROUND
  Despite longstanding infant vaccination programs in low- and middle-income countries (LMICs), pertussis continues to cause deaths in the youngest infants. A maternal monovalent acellular pertussis (aP) vaccine, in development, could prevent many of these deaths. We estimated infant pertussis mortality rates at which maternal vaccination would be a cost-effective use of public health resources in LMICs.
  
  
  METHODS
  We developed a decision model to evaluate the cost-effectiveness of maternal aP immunization plus routine infant vaccination vs routine infant vaccination alone in Bangladesh, Nigeria, and Brazil. For a range of maternal aP vaccine prices, one-way sensitivity analyses identified the infant pertussis mortality rates required to make maternal immunization cost-effective by alternative benchmarks ($100, 0.5 gross domestic product [GDP] per capita, and GDP per capita per disability-adjusted life-year [DALY]). Probabilistic sensitivity analysis provided uncertainty intervals for these mortality rates.
  
  
  RESULTS
  Infant pertussis mortality rates necessary to make maternal aP immunization cost-effective exceed the rates suggested by current evidence except at low vaccine prices and/or cost-effectiveness benchmarks at the high end of those considered in this report. For example, at a vaccine price of $0.50/dose, pertussis mortality would need to be 0.051 per 1000 infants in Bangladesh, and 0.018 per 1000 in Nigeria, to cost 0.5 per capita GDP per DALY. In Brazil, a middle-income country, at a vaccine price of $4/dose, infant pertussis mortality would need to be 0.043 per 1000 to cost 0.5 per capita GDP per DALY.
  
  
  CONCLUSIONS
  For commonly used cost-effectiveness benchmarks, maternal aP immunization would be cost-effective in many LMICs only if the vaccine were offered at less than $1-$2/dose.
authors.affiliation: Department of Economics and Institute for Health, New Brunswick.
authors.forename: Louise B
authors.initials: LB
authors.lastname: Russell
authors.affiliation: Department of Surgery, New Jersey Medical School, Rutgers University, Newark.
authors.forename: Sri Ram
authors.initials: SR
authors.lastname: Pentakota
authors.affiliation: Department of Community Health, Federal University of Goiás, Brazil.
authors.forename: Cristiana Maria
authors.initials: CM
authors.lastname: Toscano
authors.affiliation: Consultant, Westfield.
authors.forename: Ben
authors.initials: B
authors.lastname: Cosgriff
authors.affiliation: Department of Health Systems and Policy, School of Public Health, Rutgers University, Piscataway, New Jersey.
authors.forename: Anushua
authors.initials: A
authors.lastname: Sinha
mesh_terms: D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D003906:Developing Countries; D022681:Diphtheria-Tetanus-acellular Pertussis Vaccines / Q000008:administration & dosage / Q000276:immunology*; D005260:Female; D006801:Humans; D017589:Immunization Programs; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008297:Male; D018811:Maternal Exposure; D008962:Models, Theoretical; D009026:Mortality; D017063:Outcome Assessment, Health Care; D011159:Population Surveillance; D014917:Whooping Cough / Q000453:epidemiology / Q000401:mortality* / Q000517:prevention & control*
chemical_list: D022681:Diphtheria-Tetanus-acellular Pertussis Vaccines
keywords: cost-effectiveness; decision analysis; maternal immunization; mortality; pertussis