impact and cost effectivene of rotavirus vaccine introduction in afghanistan

Draft for Discussion

IMPACT AND COST-

EFFECTIVENESS

ANALYSIS

O

F ROTAVIRUS VACCINE

INTRODUCTIONAFGHANISTAN, 13th June 2017

Outlin

e Introduction

Study objectives

Introduction to the economic model

Key model parameters and study

inputs

Preliminary results

Sensitivity analysis

Conclusion

2

Introduction to Cost-Effectiveness

Analysis

3

What is “cost-effectiveness”

(CE)?Analysis of the costs and benefits of rotavirus (RV)

vaccination to determine whether investment in rotavirus

vaccine introduction achieves greater or lesser health

outcomes relative to no intervention.

DALY: Disability-adjusted life-year

DALYs measure the total years lost to death and disability,

attributable to a particular disease.

Incremental cost-effectiveness ratio (ICER): The cost to avert one DALY

This ratio is then compared to per capita GDP to determine the country

specific (or WHO) threshold values for cost-effectiveness*

• Compare ICER to threshold to determine if it is a good value from the country’s

perspective

4

Disability-adjusted life-year5

Incremental cost-effectiveness ratio

(ICER)6

Assessing COSTS…Vaccine procurement

Immunization program incremental costTreatment cost (economic burden of disease)

… and BENEFITSBased on vaccine effectiveness and impact:

Reduction in cases, Outpatient and inpatient visits,

Deaths

Important questions which cost-effectiveness can

help to

answer What would be the budget impact of introducing RV

vaccine?

How many lives would be saved by introducing RV

vaccine?

How many hospital admissions? Cases?

What is the cost associated with RV disease and

with a RV vaccine program?

What is the added value in terms of costs and benefits

of RV

vaccine?

7

Study

Objectives

8

Study

objectives1. Evaluate the impact and cost-effectiveness of introducing

RV

vaccine into Afghanistan’s national immunization program

(NIP).

2. Develop and consolidate the evidence base to support a

decision about introducing rotavirus vaccine into the NIP.

3. Provide evidence to enable government’s buy-in,

support, and commitment to the vaccination program.

4. Strengthen Afghanistan’s national capacity to perform

economic

evaluations.

Strengthen evidence-based vaccine decision making.

9

Snapshot:

Illustrative Afghanistan RV

burdenOutcomes related to rotavirus in children

aged 1-59 months during one year (without vaccination)

Annual incidence per 100,000 10,000

Cases 497,999

Outpatient visits 269,898

Hospital admissions 20,069

Deaths 4,880

Total health service costs

government/societyUS$640,836/ US$14,280,283

10

Introduction to the Economic Model:

UNIVAC

11

Economic model:

UNIVAC UNIVAC (version 1.2.09)

A single universal vaccine impact and cost-effectiveness decision support model

Developed by Andrew Clark from the London School of Hygiene andTropical Medicine

Excel-based static cohort model

Evaluates vaccine introduction impact, costs, and cost-effectiveness/cost- utility

Building on prior economic tools developed for PAHO’s ProVac initiative and used widely in the America’s and beyond since 2006

12

Country decisions supported by ProVac

tools13

Model compares

scenarios14

Model

overview15

Key Model Parameters and Study

Inputs

16

Key model parameters and study

inputs Study population: children 1-59 months of age

10 cohorts starting in 2017 through 2027

Demographic data from UN population division,2015revision

Governmental perspective and societal

perspective

Severe rotavirus gastroenteritis (RVGE) and non-severe RVGE cases (with 7 and 3 days duration,respectively)

Disease event age distribution based on

17

Key model parameters and study inputs

(cont.)Rotarix (RV1)

2-dose schedule at 6 and 10 weeks of age

Vaccine efficacy against outcomes53% vaccine efficacy after two doses

28% vaccine efficacy after one dose

77.3% dose 1 coverage (70.5% dose 2) in year of introduction, with assumption to reach 90% coverage by end of 2020

18


(cont.) Vaccine price per dose: US$2.02 vs US$0.2 (co-

financing)

International handling: 5% of vaccine price

International delivery: 7% of vaccine price

Incremental delivery cost: US$1.06 per dose

Vaccine wastage rate: 8%

All monetary units in US$ and adjusted to 2017

3% discount rate

19


(cont.)Burden of disease Estimate Source(s)

Age-specific rates per 100,000 per year in age group 1-59 months

Non-severe RVGE cases 8,275 Platts-Mills, et al. MAL ED study,

2013

Non-severe RVGE visits 4,485 AfDHS 2015 [54.2% seek

treatment]

Severe RVGE cases 1,725 Platts-Mills, .et al MAL ED study,

2013

Severe RVGE visits 935 AfDHS 2015 [54.2% seek

treatment]

Severe RVGE hospitalized 403HIMS-MoPH 2015 and EMR-GBD

2015 unpublished paper

20


(cont.)

Healthcare costsGovernme

nt cost(estimates in

US$)

Societal

cost (government

and

households

costs,

estimates in

US$)

Sources

Non-severe cases(facility

outpatient)

1.72 3.69BPHS costing –Integrated

child illness (IMCI)

/caseSevere cases (facility

outpatient)1.72 8.80 BPHS costing – IMCI

/caseHouseholds cost from

21

Preliminary

Results

22

Potential changes in outcomes with RV

vaccine

introduction (10 cohorts)23

Benefits among vaccinated infants only, no indirect effect

considered

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

CASES VISITS HOSPITALIZATION DALYS

5,045,332

2,734,395

203,327

3,130,230

3,824,319

2,072,648

154,120

2,373,577

No Vaccine With RV1

50,000

45,000

40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

0

49,444

37,478

Deaths

Without vaccine

With RV1

Potential changes in outcomes with RV

vaccine

introduction (10 cohorts)24

Summary of outcomes and cost averted (10

cohorts)

OutcomesOutcom

es

averted

Cost /

outcome averted

from government

perspect.

Cost /

outcome

averted from

societal

perspect.

Cases 1,22 million cases - -

Outpatient visits 661,746 visits US$1,138,204 US$34,228,547

Hospital

admissions

49,207 hospital

admissionsUS$433,020 US$784,357

DALYs 756,653 - -

Deaths 11,966 - -

25

All figures undiscounted

Rotavirus vaccination program

cost Over 10 years, the rotavirus vaccination program is estimated

to cost US$79,789,755or US$7.98 million per year on averageif considering full vaccine price

If accounting for Gavi support Afghanistan can benefit, the cost over 10 years is of US$41,879,563or US$4.2 million per year on average

cMYP total cost projection for 2017 = US$77,723,947

Rotavirus vaccination program would represent 5.4%

Total health expenditures (2014) = US$1,847,853,457

Rotavirus vaccination program would represent 0.2%

26

All figures undiscounted

From the government perspective, ICER = US$103 per DALY

averted

From the societal perspective, ICER = US$59 per DALY

averted

Incremental cost-effectiveness

ratio27

All figures discounted

Interpreting cost-effectiveness of an intervention: use of

thresholds

Former WHO guidance, updated in 2016 highlighting the need to consider

factors other than CE (affordability, feasibility, etc…) as well as developing

country specific thresholds

What economic study threshold should be used for Afghanistan?

28

1 - <3 x GDP per capita

0 - <1 x GDP per capita

>3 x GDP per capita

US$ / DALY avertedis negative

Cost-EffectiveHighly Cost-

EffectiveNot Cost-EffectiveCost Savings

US$0 US$594 US$1,782

US$103

Sensitivity

Analysis

29

Sensitivity

analysis30

We presented the results of a base case scenario calculated

from the

most realistic set of inputs

Each parameter introduces an additional range of uncertainty

in the

analysis

Uncertainty analysis allows us to evaluate different policy

scenarios and/or ranges of parameter estimates by creating

a series of ‘what if’ scenarios

Alternative

scenariosScenarios Description

Scenario 1 Base case -

Scenario 2Base case

accounting for

Gavi subsidy

Vaccine price lowered to US$0.20 per dose to reflect co-financing

amount paid by the country.

Scenario 3Higher burden

of disease

Incidence of rotavirus disease was increased by 15% for all sorts of

cases, visits, hospitalizations, and deaths. Vaccine price per dose

US$0.20.

Scenario 4Lower

coverage

rates

Accounting for lower coverage rates in the first four years of the

vaccination program to reflect 2015 DHS data. Vaccine price per

dose US$0.20.

Scenario 5

Low burden of

disease and

high vaccine

delivery costs

Accounting for a reduced burden of disease (accounting for a reduced

number of severe cases visits and number of deaths based on IHME

GBD data).

Double incremental health system cost per dose (US$2.12 instead of

initial

31

Resul

ts

Threshold used is 1 time Afghanistan GDP per capita

(US$594)

32

Conclusi

on

33

Summary of

results In Afghanistan, the introduction of RV vaccine is highly cost-effective

compared to the current situation, with incremental cost-effectiveness

ratios ranging from US$59 to US$103 per DALY averted depending

on the study perspective

Considering the support the country can receive from Gavi, the Vaccine

Alliance,

ICER ranges from US$53 to US$9

The average yearly cost of a RV vaccination program would represent

5.4% of the total immunization cost expected in 2017 and 0.2% of the

total health expenditures

A RV vaccination program has the potential to avert 1.22M RV cases;

661,746 outpatient visits; 49,207 hospitalizations; and 11,966 deaths

over 10 years

34

Discussi

onEconomic study threshold (GDP vs. country-

specific)

Study limitations mainly linked to local data

availability: vaccine efficacy, cost of illness…

Other alternative scenarios?

What other information would be important for

buy-in

and support to the program from the government?

Other questions?

35

Thank

you36