Potential impact and cost-effectiveness of injectable next-generation rotavirus vaccines in 137 LMICs: a modelling study

Figures & data

Figure 1. Cumulative and instantaneous efficacy curves per mortality setting.

Table 1. Vaccination scenarios evaluated

*The 137 LMICs were stratified as: low (<13.5 deaths per 1000 live births), medium (13.5–28.1 deaths per 1000 live births), and high (>28.1 deaths per 1000 live births), consistent with a recent meta-analysis.³²

** Equivalent to licensed LORVs with infant schedules. Scenarios of iVE (instantaneous vaccine efficacy) are based on gamma fits of pooled efficacy from a meta-analysis of RCTs (2/3 doses, LORVs, infant schedules).³² Gamma fits were chosen to be consistent with the assumptions used in a recent multi-country cost-effectiveness analysis and benefit-risk analysis.^6,16

Table 2. Vaccine characteristics, price per dose, and other inputs

		ROTARIX	ROTAVAC	ROTASIIL	oNGRV	iNGRV	iNGRV-DTP*
		Vaccine presentations
		5 tubes liquid	5-dose liquid	5 tubes liquid	2-dose vial	2-dose vial	Bulk
Vaccine price per dose
Country groups
Non-Gavi and Non PHS	Base	$14.77	$1.25	$1.63	$1.25	$.81	$.43
	Low range	$4.80	$.94	$1.22	$.94	$.60	$.32
	High range	$16.96	$1.56	$2.04	$1.57	$1.01	$.54
Non-Gavi and PHS	Base	$14.77	$1.25	$1.63	$1.25	$.75	$.40
	Low range	$4.80	$.94	$1.22	$.94	$.56	$.30
	High range	$16.96	$1.56	$2.04	$1.57	$.94	$.50
PAHO Revolving Fund	Base	$6.50	$1.25	$1.63	$1.25	$.75	$.40
	Low range	$4.88	$.94	$1.22	$.94	$.56	$.30
	High	$8.13	$1.56	$2.04	$1.57	$.94	$.50
Gavi FSF w/o access to ROTARIX Gavi price	Base	$14.77	$1.14	$1.55	$1.17	$.75	$.40
	Low range	$4.80	$.86	$1.16	$.88	$.56	$.30
	High range	$16.96	$1.43	$1.94	$1.46	$.94	$.50
Gavi FSF**	Base	$2.13	$1.14	$1.55	$1.17	$.75	$.40
	Low range	$1.60	$.86	$1.16	$.88	$.56	$.30
	High range	$2.66	$1.43	$1.94	$1.46	$.94	$.50
Gavi AT**	Base	$2.13	$1.14	$1.55	$1.17	$.75	$.40
(low = 75% of Gavi price)	Low range	$1.60	$.86	$1.16	$.88	$.56	$.30
	High range	$2.66	$1.43	$1.94	$1.46	$.94	$.50
Gavi PT	Base	$2.13	$1.14	$1.55	$1.17	$.75	$.40
(low = 40% of Gavi price)	Low range	$.85	$.46	$.62	$.47	$.30	$.16
	High range	$2.66	$1.43	$1.94	$1.46	$.94	$.50
Gavi ISF	Base	$2.13	$1.14	$1.55	$1.17	$.75	$.40
(low = .20 or .13 a dose)	Low range	$.20	$.13	$.13	$.13	$.13	$.00
	High range	$2.66	$1.43	$1.94	$1.46	$.94	$.50
Other vaccine parameters
Wastage rate		4% (2%; 6%)	10% (5%; 15%)	4% (2%; 6%)	10% (5%; 15%)	10% (5%; 15%)	N/A
Syringe cost (low range; high range)		N/A	N/A	N/A	N/A	$.04 ($.03; $.06)	N/A
Safety box cost (low range; high range)		$.45 ($0;$.84)	$.45 ($0;$.84)	$.45 ($0;$.84)	$.45 ($0;$.84)	$.45 ($.42;$.84)	N/A
International handling (low range; high range)		3% (1.4%;4.5%)
International transportation (low range; high range)		6% (2%;15%)
Immunization delivery cost per dose
Low-Income (low range; high range)		$1.33 ($1;$2.50)					$0
Lower- & Upper-Middle Income (low range; high range)		$2.05 ($1;$2.50)					$0

*Only includes the incremental rotavirus vaccine-associated costs. **Excludes countries without access to ROTARIX Gavi price: Azerbaijan, Bhutan, Cuba, India, Indonesia, Kiribati, Mongolia, Nigeria, Papua New Guinea, Sao Tome, Sri Lanka, Timor Leste, Vietnam. PHS: Public Health Sector, FSF: Fully self-financing, AT: Accelerated transition, PT: Preparatory transition, ISF: Initial self-financing.

Figure 2. Deterministic cost-effectiveness and probabilistic uncertainty analysis results for all LMICs over 10 years starting in 2025.

Table 3. Impact and cost-effectiveness results per vaccination scenario for all LMICs over 10 years starting in 2025

	Burden						Cost			Cost-effectiveness
	RVGE deaths			IS deaths	DALY’s (discounted)		Vaccine program costs	Healthcare costs	Net cost	ACER (compared to no vaccine)	ICER
Without vaccine	1,503,595			104,009	41,533,033		0	4,397,988,171	4,397,988,171
With vaccination scenario (ordered by net cost)
iNGRV-DTP		749,102	104,009			21,890,021	1,393,076,679	1,681,304,079	−1,323,607,413	−67	Cost saving
iNGRV		749,102	104,009			21,890,021	8,250,913,730	1,681,304,079	5,534,229,638	282	Dominated by 1 alternative
oNGRV		867,463	104,479			24,882,839	9,440,011,145	1,817,110,810	6,859,133,784	412	Dominated by 2 alternatives
ROTAVAC		947,380	105,544			27,008,818	9,375,358,555	2,103,650,007	7,081,020,390	488	Dominated by 2 alternatives
iNGRV-DTP with oNGRV		755,954	104,479			22,023,238	10,833,087,824	1,585,929,516	8,021,029,169	411	Dominated by 4 alternatives
iNGRV-DTP with ROTAVAC		749,102	105,544			21,928,902	10,768,435,234	1,683,860,407	8,054,307,471	411	Dominated by 4 alternatives
ROTASIIL		947,380	105,544			27,008,818	10,403,577,859	2,103,650,007	8,109,239,694	558	Dominated by 4 alternatives
iNGRV-DTP with ROTASIIL		749,102	104,009			21,928,902	11,796,654,538	1,683,860,407	9,082,526,774	463	Dominated by 7 alternatives
1 dose iNGRV with ROTAVAC		749,102	105,544			21,928,902	12,049,676,888	1,683,860,407	9,335,549,124	476	Dominated by 8 alternatives
1 dose iNGRV with ROTASIIL		749,102	105,544			21,928,902	13,077,896,192	1,683,860,407	10,363,768,428	529	Dominated by 9 alternatives
iNGRV with oNGRV		755,954	104,479			22,023,238	17,690,924,875	1,585,929,516	14,878,866,220	763	Dominated by 10 alternatives
iNGRV with ROTAVAC		749,102	105,544			21,928,902	17,626,272,285	1,683,860,407	14,912,144,521	761	Dominated by 10 alternatives
iNGRV with ROTASIIL		749,102	105,544			21,928,902	18,654,491,589	1,683,860,407	15,940,363,825	813	Dominated by 12 alternatives
ROTARIX		947,380	105,544			27,008,818	24,075,202,764	2,103,650,007	21,780,864,599	1,500	Dominated by 13 alternatives
iNGRV-DTP with ROTARIX		749,102	105,544			21,928,902	25,468,279,443	1,683,860,407	22,754,151,679	1,161	Dominated by 14 alternatives
1 dose iNGRV with ROTARIX		749,102	105,544			21,928,902	26,749,521,097	1,683,860,407	24,035,393,333	1,226	Dominated by 15 alternatives
iNGRV with ROTARIX		749,102	105,544			21,928,902	32,326,116,494	1,683,860,407	29,611,988,730	1,510	Dominated by 16 alternatives
Alternative scenarios
iNGRV-M-DTP		930,869	104,009			26,542,409	1,393,076,679	2,065,152,955	-939,758,537	-63
iNGRV-M		930,869	104,009			26,542,409	8,250,913,730	2,065,152,955	5,918,078,513	395
oNGRV-H		755,954	104,479			22,023,238	9,440,011,145	1,585,929,516	6,627,952,490	340

oNGRV-H = high efficacy oNGRV.

iNGRV-M = iNGRV with equivalent efficacy to LORVs.

iNGRV-M-DTP = iNGRV-DTP, where the iNGRV component has equivalent efficacy to LORVs.

ICER = Incremental Cost-Effectiveness Ratio.

ACER = Average Cost-Effectiveness Ratio.

Table 4. Percentage of LMICs and Gavi countries with deterministic cost-effectiveness results below alternative national GDP per capita thresholds

		iNGRV-DTP	iNGRV (in the absence of iNGRV-DTP)	oNGRV (in the absence of any iNGRVs)	ROTAVAC (in the absence of any NGRVs)
137 LMICs*	0.25 GDP p.c.	100%	63%	45%	37%
	0.5 GDP p.c.	100%	84%	75%	67%
	0.75 GDP p.c.	100%	93%	87%	84%
	1 GDP p.c.	100%	98%	93%	92%
73 Gavi countries*	0.25 GDP p.c.	100%	54%	35%	25%
	0.5 GDP p.c.	100%	79%	68%	59%
	0.75 GDP p.c.	100%	89%	83%	77%
	1 GDP p.c.	100%	99%	92%	89%

*No GDP data could be retrieved for the Democratic People’s Republic of Korea and Somalia.

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Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. The model used is available online at https://www.paho.org/en/provac-toolkit