Yangyel Lhaden

In 2018, the government decided to introduce three vaccines—pneumococcal (PCV), flu, and rotavirus. Pneumococcal and flu vaccines have been introduced but not rotavirus. What happened?

The cost-effectiveness, budget impact, and human resource impact study on the rotavirus vaccination by the health ministry’s essential medicine technology division (EMTD) in collaboration with Health Intervention Technology Assessment Programme (HITAP), Mahidol Oxford Research Unit (MORU), and PATH found that introducing rotavirus vaccine in Bhutan was not cost-effective.

All biologics, before introduction in the country, has to go under health technology assessment. EMTD used one of the health technology assessment methods called economic evaluation.

Rotavirus is one of the agents that causes diarrhoea. In Bhutan, diarrhoeal visits to health facilities and diarrhoeal morbidity have decreased over the last decade due to improvement in the country’s public health system.

However, diarrhoea still remains one of the top ten causes of morbidity in children under five.

Cost evaluation

The benefit of the vaccine and the price of the vaccine and its associated costs are compared against the threshold ratio of the country’s Gross Domestic Product (GDP). The vaccine is cost-effective only if the ratio comes below 0.5 of GDP.

Four rotavirus (RV) vaccines are currently being used—RotaTeq, ROTARIX, ROTAVAC, and ROTASILL.

The findings established that, at the current prices, none of the evaluated rotavirus vaccines would be cost-effective in Bhutan at a willingness-to-pay threshold of 0.5 times the gross domestic product (GDP) per capita (Nu 111,908).

Among the four RV vaccines, ROTASIIL has the potential of giving the best value-for-money result with the lowest net budget impact of US$ 40,600 per year at the current price.

ROTASIIL and ROTAVAC would only be cost-effective at 0.5 GDP per capita if the disease burden was higher.

The study found that in the last few years, there was only one diarrhoeal death each year according to the Health Management and Information System (HMIS) database.

The study also found that the workload of the health workers—paediatricians, medical officers, pharmacists, and nurses—would reduce while the workload of the health assistants would increase.

Pemba, laboratory officer with the health ministry, said that the case burden in the country was not so high and investing on the vaccine would only be reasonable if the mortality rate due to rotavirus diarrhoea was high and morbidity cases out of control.

Deepika Adhikari, senior laboratory officer, said that investing on a vaccine would only be effective if health benefit gained was in line with the price paid.

The current health interventions and strengthening of the WASH (water, sanitation and hygiene) programme by UNICEF were rather more effective in preventing the overall communicable diseases, she added.

How was the study carried out?

To assess the cost-effectiveness, budget and human resource impact of rotavirus vaccination programme compared with no vaccination, a cost-effectiveness analysis was performed using UNIVAC, a deterministic static cohort model developed at the London School of Hygiene and Tropical Medicine.

The costs and health outcomes were the incremental cost-effectiveness ratio.

The cost-effectiveness thresholds of 0.5 (Nu 111, 908) and 1.0 (Nu 223, 815) times the GDP per capita were used for the base case analysis and sensitivity analysis, respectively.

The country’s disease burden was studied using HMIS database from all health facilities in Bhutan. Children under five were the subject of interest and children under one the target of population for the vaccination programme.

The model assumed that the children could experience one of three states of rotavirus gastroenteritis (RVGE)—no RVGE, non-severe RVGE, and severe RVGE.

For non-severe RVGE, it was assumed that they would either forego treatment or visit health facilities. Severe RVGE would seek medical treatment.

From the HMIS data, five percent of all diarrhoeal visits were hospitalised. The study assumed that non-severe RVGE visit was 95 percent and, severe, 5 percent.

Diarrhoeal deaths reported were assumed to have been caused by rotavirus because of relatively higher prevalence of rotavirus compared with other causes of severe diarrhoeal death.

The total number of RVGE cases, hospital visits, hospitalisation with or without vaccine were studied for the report.

The qualified output of cases and death averted, incremental cost due to vaccination programme, treatment cost averted, and health workers’ personal time to treat rotavirus cases was studied.

Strength and limitation of the study

Strength: The usage of local data and meta-analysis with a validated tool (UNIVAC) gives insight on cost-effectiveness, choice of vaccine product, financial feasibility and impact on human resources. Evaluation of all WHO pre-qualified rotavirus vaccine. The input parameters and result are verified by a group of local experts through stakeholder consultation meeting.

Limitation: High probability of underreporting of rotavirus diarrhoea due to poor surveillance and a low number of samples. Lack of laboratory confirmation for diarrhoea deaths included as rotavirus deaths.  The indirect benefits of vaccination such as herd protection and societal costs were not accounted for in the analysis.