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Cost –effectiveness analysis of a Universal Rotavirus Immunization Program in Japan
Authors: Sato T, Nakagomi T And
Nakagomi O.Article :-Jpn.
Journal of infectious
disease, 64, 277-283,2011
Moderator:Dr. Subodh Gupta
Introduction
• Rotavirus is the major cause of severe dehydrating diarrhea
• Estimated 611,000 deaths annually among under-five in developing countries.
• Two live oral rotavirus vaccines - Rota Teq and Rota Trix licensed in >100 countries
• Incorporated in routine childhood immunization programs of >20 countries.
Objective:
• To evaluate cost-effectiveness analysis of rotavirus vaccination, with view to facilitate the decision of whether rotavirus vaccine should be included in the universal immunization program in Japan.
My learning objective:
• To learn about cost-effectiveness analysis.
Mathematical Modeling:
Becoming an increasingly important subject as computers expand our ability to translate mathematical equations and formulations into concrete conclusions concerning the world, both natural and artificial, that we live in.
Process of mathematical Modeling
Method Mathematical modeling
Using hypothetical 2009 birth cohort of 1.1 million Japanese children
Follow-up model for 5 years.
A Markov model was constructed
The costs and outcomes of vaccination was compared for 2 different scenarios:
- Absence of rotavirus immunization program and
- Implementation of a universal rotavirus immunization program
Cost-effectiveness analysis
Interpretation and explanation of the result
Cont…
• The model evaluated the potential impact of rotavirus vaccination on – direct medical costs– indirect costs– quality of life (for hospitalization and outpatient visits)
• The immunization program was evaluated - From a societal perspective and
- The Health perspective.
Assumptions
• The complete course of Rotarix (2 doses) or RotaTeq (3 doses) would be administered concomitantly with other vaccines to all children at 0–5 months of age.
• The same efficacy levels were assumed for both vaccines
• Vaccine efficacy – Hospitalizations - 95%– Outpatients Visits - 85%
• Vaccination cost of ¥ 20,000 per course was assumed for both vaccines (based on CDC price list including cost of administration)
Assumptions (cont…)Direct medical cost
– outpatient visit - ¥ 13,830
– Hospitalization - ¥ 138,298
Indirect medical cost• Productivity loss (number of days)
– Outpatient visit – 2 days– Hospitalization – 5 days
• Productivity loss per day– Hospitalization - ¥ 38,544 per caregiver – Outpatient visit - ¥ 15,418 per caregiver
Annual discount rate - 5%
Measure of benefit:
• The benefit measure was the number of quality-adjusted life-years (QALYs).
• Program was considered cost-effective if the ICER was less than ¥ 6 million per QALY gained.
Analysis of uncertainty:
• One-way sensitivity analyses were performed to examine the effects of changes in following variables on the base results.
The direct medical cost and the productivity loss per case (±25%from the base case),
The utility (95% confidence interval) , The vaccine efficacy (95%CI), The vaccine cost per course (±25% from the base case), and The discount rate (3% used in studies conducted in other
industrialized countries.
Result and Discussion
Table3: Base case result
Outcome No program With program Difference Reduction(%)
No. of events
Hospitalizations 32,900 1,592 -31,308 95
Outpatients Visits 6,78,218 1,01,731 -576,487 85
Direct medical cost ¥
Vaccination cost 0 22,000,000,000 22,000,000,000
Hospitalizations 4,281,782,278 207,097,440 -4,074,684,838 95
Outpatients Visits 8,828,124,134 1,324,196,483 - 7,503,927,651 85
Indirect medical cost, ¥
Hospitalizations 1,193,343,477 57,718,577 - 1,135,624,900 95
Outpatients Visits 9,841,794,497 1,476,244,496 - 8,365,550,001 85
Table 3 Cont…Outcome No Program With Program Difference Reduction(%)
Total cost, ¥
Healthcare system 13,109,906,412 23,531,293,923 10,421,387,511 -79
Societal 24,145,044,386 25,065,256,995 920,212,609 - 4
QALY loss 1,219 153 -1,066 87
ICER per QALY gained, ¥
Healthcare system 9,780,524 (Not cost-effective)
Societal 8,63,624 (Highly cost-effective)
Fig 1: Cost structure of rotavirus hospitalizations and out patient visit before the implementation of rotavirus vaccination
Fig 2 : The direct medical cost and indirect medical cost of rotavirus hospitalization and out patient visits according to the incidence of the hospitalization and outpatient visit
Fig 3 : Sensitivity Analysis result
Fig 4 : Sensitivity Analysis result (Health care perspective)
Fig 4 : Sensitivity Analysis result (Societal perspective)
Conclusion:
• A universal rotavirus immunization program would prevent 85% of the rotavirus-associated hospitalizations and outpatient visits.
• The universal immunization program was found to be cost-effective from the societal perspective for any of the previously reported incidence rates of rotavirus-associated hospitalization.
• Thus, the introduction of the rotavirus vaccine into the childhood immunization schedule and its co-administration with other childhood vaccines will be a cost-effective public health intervention in Japan.
Limitation of this study
Authors did not consider any effects that may arise from the differences in the serotypes.
The events of rotavirus deaths, nosocomial infections, and home care cases were not included because of the non-
availability of the relevant data. This model did not take herd immunity into account.
Success story
• Australia, where rotavirus vaccine was introduced into the universal immunization program since 2007, a cost-effectiveness analysis showed that the ICER per QALY gained from the implementation of the immunization program was lesser than the maximum cost-effectiveness threshold when the base case incidence of rotavirus- associated hospitalizations was applied.