سود و زیان بهداشتی پیش بینی شده از واکسیناسیون پنوموکوک و روتاویروس در اوگاندا

We determined impact and cost-effectiveness of pneumococcal and rotavirus vaccination programs among children < 5 years of age in Uganda from the public health system perspective. Disease-specific models compared the disease burden and cost with and without a vaccination program. If introduced, pneumococcal and rotavirus vaccine programs will save 10,796 and 5265 lives, respectively, prevent 94,071 Streptococcus pneumoniae and 94,729 rotavirus cases in children < 5 years, and save 3886 and 996 million Ugandan shillings ($2.3 and $0.6 million US dollars), respectively, in direct medical costs annually. At the GAVI price ($0.15/dose), pneumococcal vaccine will be cost-saving and rotavirus vaccine highly cost-effective.

Disease-specific, decision-tree models were used to estimate the impact and cost-effectiveness of national pneumococcal and rotavirus immunization programs, respectively, by comparing the cost and burden of disease with and without such programs [9] and [10]. The models were created for use in developing country settings and estimate health outcomes and direct medical costs associated with pneumococcal and rotavirus disease for an annual birth cohort of 1.4 million followed for a 5-year period. Principle model inputs included disease burden, direct healthcare treatment costs, and vaccine coverage, efficacy, and cost. These models estimated the incremental cost-effectiveness ratio (cost per Disability-Adjusted Life Year (DALY) averted) expressed in 2008 inflation-adjusted Ugandan shillings (Ushs) and US dollars (USD) (1 USD = 1658 Ushs) and all future costs and DALY estimates were discounted at a rate of 3%. Only direct medical costs were included in the model.

The 10-valent pneumococcal conjugate vaccine will be cost-saving to the health-care system and monovalent rotavirus vaccine will be highly cost-effective if introduced into the national immunization program in Uganda at the GAVI subsidized price of $0.15 per dose. Annually, a pneumococcal vaccination program would save 622 million Ushs ($0.4 million USD) and a rotavirus vaccination program would have a net cost of 1071 million Ushs ($0.6 million USD). Both vaccines would have substantial health benefits for children < 5 years in Uganda. A pneumococcal vaccine program would save 10,796 lives and prevent 94,071 cases of S. pneumoniae. A rotavirus vaccination program would save 5265 lives and prevent 94,729 rotavirus cases annually. Findings from these analyses agree with findings from previous cost-effectiveness analyses for pneumococcal and rotavirus vaccine introduction into developing countries that both vaccines would be highly cost-effective or cost-saving in developing countries [10] and [23]. This analysis has several limitations. First, because this analysis was performed from the public health system perspective, non-medical costs to households, costs of informal medical treatment, and productivity losses of caregivers were not included in either model. Inclusion of these costs would have made the pneumococcal vaccination program more cost-savings and the rotavirus vaccination program more cost-effective from a broader, societal perspective. Second, rates of disease most likely underestimate the true incidence of rotavirus disease in Uganda. For example, the annual rate of hospitalization due to rotavirus diarrhea of 204 per 100,000 is just 60% of the global estimate of the rotavirus hospitalization rate (340 per 100,000) [24]. If the true disease incidence is higher than the estimated disease incidence, then the cost per DALY averted is underestimated and the vaccine would actually be more cost-effective with a higher disease burden. Further study of the rotavirus disease burden in Uganda is needed. Additionally, while the rates of pneumococcal disease were estimated using high quality, available data, it is possible that these estimates may not reflect the current disease burden. Third, there was also uncertainty in the patterns of healthcare utilization in Uganda. A different distribution of healthcare seeking behavior than that used in our models will influence the economic burden and cost-effectiveness of the vaccination programs. Lower proportions of children receiving secondary and tertiary care would result in pneumococcal and rotavirus vaccine programs that are less cost-saving and less cost-effective, respectively. We also did not consider any barriers to access that would prevent ill children from seeking care. Fourth, if Uganda introduces the 13-valent rather than the 10-valent pneumococcal vaccine, the impact of vaccination and subsequent cost-effectiveness will likely be greater than the base–case scenario presented here. Fifth, we assumed children were vaccinated on-time. Children whose vaccinations are delayed will be at-risk of disease for longer periods of time. For rotavirus vaccine, limited age windows during which the child can be vaccinated may result in lower vaccination coverage than that of other childhood vaccines. However, changes in vaccine coverage did not have a substantial impact on cost-effectiveness estimates in the sensitivity analysis. Sixth, we did not include any indirect effects such as herd protection in the cost-effectiveness model for either vaccine which may further increase the benefits of vaccination [25] and [26]. However, serotype replacement following the introduction of pneumococcal vaccine may result in decreased effectiveness of the vaccine over time and therefore decrease the long-term cost-saving from this vaccine [27]. Finally, our analysis was done from the Ugandan government perspective and we therefore used the GAVI-subsidized price of $0.15 per dose in our analysis. This price is subsidized by the international community and will only be available to the country for five years. Since the final market prices are not available for these vaccines, we examined prices of $3.50 USD per dose and $5.50 per dose for pneumococcal and rotavirus vaccines, respectively. Both vaccines were highly cost-effective at these prices.