Cost-effectiveness analysis of rotavirus vaccination among Libyan children using a simple economic model

Figures & data

Table 1 Proportion of rotavirus diarrhea in children aged≤5

Place	Diarrhea cases	Rotavirus cases	Proportion rotavirus (%)
Zliten city	281	167	59
Khoms city	264	144	55
Hospitals	410 (75%)	239 (77%)	58
Outpatient clinic	135 (25%)	72 (23%)	53
Total number	545	311	57
Male	315	179	57
Female	230	132	57
0–<1 years old	336	175	52
1–<2 years old	142	91	64
2–<3 years old	46	33	72
3–<4 years old	10	6	60
4–≤5 years old	11	6	55

Table 2 Cost of rotavirus treatment among children aged≤5

	Cost (US$)
Variable	Mean	SD	Range	Median
Provider cost
Per diem	332.69 (50%)	254.04	68–2,045	284
Medication	108.61 (16%)	226.26	15–3,284	66
Laboratory tests	33.94 (5%)	12.41	16–108	32
Patient cost
Transportation	74.012 (11%)	80.27	10–912	60
Household	70.99 (11%)	80.52	19–557	30
Lost income (indirect cost)	40.68 (6%)	152.96	0–1,440	0
Total cost per patient	660.92	580.31	141–6,389	623

These costs were estimated in 2012 and adjusted with an annual inflation rate of 4.7% to 2014; SD=standard deviation.

Table 3 Input variables for estimating the cost-effectiveness of rotavirus vaccination with baseline, minimum (Min), and maximum (Max) values

Variables	Baseline	Min	Max	Source
Annual birth cohort	160,000			(28)
Vaccination coverage rate	98%	78%	100%	(26)
Inflation rate	4.7%	3.8%	5.6%	(24)
Cost per consultation GP (US$)	15			Local expert opinion
Cost per consultation pediatrician (US$)	29			Local expert opinion
Proportion going to the GP	70%			(7)
Cost for medical visit (US$)	15*0.7+29*0.3=19.2	15.4	23.0	Calculated
Cost of prescribed drugs (US$)	108.61			This study
Cost for hospital day care (US$)	332.69			This study
Cost for lab test (US$)	33.94			This study
Cost hospitalization (US$)	108.61+332.69+33.94=475.24	380	570	Calculated
Cost labor woman per day (US$)	34	27.2	40.8	This study
Proportion working mothers	35%	28%	42%	(29)
Days lost mild	3	2.4	3.6	(7)
Days lost moderate	1	0.8	1.2	(7)
Days lost severe	3	2.4	3.6	(7)
Cost indirect loss mild/event (US$)	34*3*0.35=36			Calculated
Cost indirect loss moderate/event (US$)	34*1*0.35=12			Calculated
Cost indirect loss severe/event (US$)	34*3*0.35=36			Calculated
Cost for transportation severe (US$)	74	59.2	88.8	This study
Cost for household (US$)	70.99	56.8	85.2	This study
Cost vaccine per course (US$)	27	21.60	32.40	This study
Disutility mild	−0.00016	−0.00013	−0.00020	(25)
Disutility moderate	−0.00068	−0.00055	−0.00082	(25)
Disutility severe	−0.00575	−0.00460	−0.00690	(25)
Life expectancy	75	60	90	(27)
Proportion mild	40%	32%	48%	(23)
Proportion moderate	15.1%	12.1%	18.1%	Local expert opinion
Proportion severe	2.44%	2%	2.9%	Local expert opinion
Proportion deaths	0.0055%	0.0044%	0.0066%	(7)
Vaccine efficacy against mild	75%	60%	90%	(30)
Vaccine efficacy against moderate	85%	68%	100%	(30)
Vaccine efficacy against severe	90%	72%	100%	(30)
Vaccine efficacy against death	100%	80%	100%	(30)

Table 4 Health outcomes and cost of treatment of rotavirus patients in no vaccination and vaccination scenarios

Variable	No vaccination	Vaccination	Difference
Efficacy of rotavirus vaccination	No.	No.	No. (%)
Birth cohort	160,000	160,000
Rotavirus diarrhea events	64,000	16,960	−47,040 (74)
Outpatient visits	24,160	4,035	−20,105 (83)
Rotavirus diarrhea hospitalization	3,904	461	−3,443 (88)
Rotavirus-related deaths	9	0	−9 (100)
Cost of rotavirus cases	US$	US$	US$
Total costs without vaccine	2,318,272	296,286	−2,021,986
Total costs per patient	14	2	−12
Vaccine costs	–	4,233,600	4,233,600
Outpatient visit	463,872	77,467	−386,405
Hospitalizations	1,854,400	218,819	−1,635,581
Total direct cost with vaccine	2,318,272	4,529,886	2,211,614
QALYS
Mild condition	−10.52	−2.78	7.7
Moderate condition	−16.54	−2.76	13.8
Severe condition	−22.46	−2.65	19.8
Deaths	−205.2	0	205.2
Total	−254.7	−8.20	246

Table 5 Incremental cost-effectiveness analysis of rotavirus vaccination

Variables	NV	V	Difference	ICER (US$)
Incremental cost/QALY
Cost (US$)	14.49	28.31	13.82
QALYs	−0.00159	−0.00005	0.00154	8,972
Incremental cost/death avoided
Cost (US$)	14.49	28.31	13.82
Deaths	0.000056	0	0.000056	245,734
Incremental cost/hospitalization avoided
Cost (US$)	14.49	28.31	13.82
Hospitalization	0.0244	0.0029	0.0215	642
Incremental cost/outpatient visit avoided
Cost (US$)	14.49	28.31	13.82
Outpatient visit	0.151	0.0252	0.1257	110
Incremental cost/diarrhea event avoided
Cost (US$)	14.49	28.31	13.82
Diarrhea event	0.400	0.106	0.294	47

NV=no vaccination; V=vaccination; ICER=incremental cost-effectiveness ratio; QALY=quality-adjusted life year.

Table 6 Including the indirect cost (US$) in the economic evaluation of the vaccine

Cost type	NV	V	Difference
Transport cost (US$)	288,896	158,893	−130,003
Household cost (US$)	6,535,623	3,978,223	−2,557,401
Productivity loss (US$)	2,711,677	1,669,970	−1,041,707
Direct medical cost (US$)	2,318,272	3,446,646	1,128,374
Total cost (US$)	11,854,468	9,253,732	2,600,736
Total cost/child (US$)	74.09	57.83	−16.25

NV=no vaccination; V=vaccination.

Fig. 1 Sensitivity analysis (tornado diagram) of the incremental cost per QALY gained analyzed from the health provider perspective (example: the lower the cost of the vaccine, blue color, the lower the cost-effectiveness result; the color changes at the baseline value of $8,972, see Table 5).

Fig. 2 Sensitivity analysis (tornado diagram) on the cost difference per child in the birth cohort (Vaccination – No Vaccination) analyzed from a societal perspective (example: the lower the proportion of mild disease, blue color, the lower the cost savings on the X-axis).

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