The cost-effectiveness of rotavirus vaccination: Comparative analyses for five European countries and transferability in Europe
Introduction
Rotavirus is the leading cause of acute gastroenteritis in young children, accounting for almost four million episodes of disease a year in children under 5 years old in Europe [1]. Two vaccines against rotavirus – RotaTeq® (Merck & Co. Inc., Readington, New Jersey, USA) and Rotarix® (GlaxoSmithKline plc., Brentford, United Kingdom) – were efficacious against severe rotavirus disease in clinical trials [2], [3], and are being considered for routine vaccination in many European countries. In order to inform the decisions about routine vaccination, public health authorities in Belgium (BE [4]), England and Wales (EW [5]), Finland (FI [6]), France (FR [7]) and the Netherlands (NL [8]) have conducted cost-effectiveness analyses of rotavirus vaccination in their respective countries. One study (for FI) found rotavirus vaccination to be cost effective, another (for BE) found it to be cost effective from a societal perspective but not a health care provider perspective, while three others (for EW, FR and NL) found it not to be cost effective. Based partly on these analyses, two countries (BE, FI) have recommended routine infant rotavirus vaccination while three others (EW, FR, NL) have recommended against it at current listed prices. However, more recent analyses based on alternative modelling assumptions have reached different conclusions from some of the earlier government-funded studies [9], [10].
Cost-effectiveness analyses conducted between and even within the same European country are not directly comparable because each study follows a different framework for economic analysis (based on national recommendations) and different modelling assumptions (based on the authors’ own preferences). Some of the assumptions that differ between analyses include the discount rate for costs and benefits, the perspective from which costs are valued (health care provider or societal), assumptions about caregivers’ quality of life as a result of rotavirus disease in children (which are not often incorporated into cost-effectiveness evaluations of childhood interventions), and assumptions about quality of life in children with rotavirus who do not present to the health service [11]. In addition, the vaccine price and threshold at which an intervention is considered cost effective differ between countries. Hence it is unclear to decision makers the extent to which the advice presented in different studies is due to the different modelling assumptions being used, rather than actual variations in the health care and vaccine-preventable disease burden between countries.
In order to facilitate comparisons between countries as well as explore the implications of some of the differences in country-specific guidelines and study-specific modelling assumptions, we investigated the cost-effectiveness of rotavirus vaccination using a single model and a subset of common assumptions. Key analytical assumptions were then varied to investigate the impact on the cost-effectiveness profile of rotavirus vaccination in each country. Findings when the assumptions are varied one or two at a time are discussed, while results of multivariate analysis are given in Appendix 2. Based on these analyses, we provide policy information for five European countries under a range of methodological and modelling assumptions.
Section snippets
Model
An age structured cohort model was used to follow vaccinated and unvaccinated cohorts over the first 5 years of life in BE, EW, FI, FR and NL. The model structure was similar to previously published models used to evaluate rotavirus vaccination in BE [4] and EW [5]. It incorporated an age-dependent probability of a rotavirus-related outcome or a non-rotavirus-related death for each age category. The cohort was stratified into one month age bands in the first year of life, and one year age bands
Base case and effect of discount rates
The cost per QALY saved of vaccination under base case assumptions (as given in Table 1) is indicated by the leftmost bar for each country in Fig. 1, while the other bars show the effect of alternative discounting assumptions. Under base case assumptions, infant rotavirus vaccination in the five countries considered is likely to be cost effective in FI only. Changing the discount rate has little effect on this conclusion in BE, EW and FI, because almost all the outcomes prevented by vaccination
Discussion
The cost-effectiveness of infant rotavirus vaccination was evaluated in five European countries, using burden of disease estimates supplied by national public health agencies, and a common methodological framework for economic modelling. Under base case assumptions and a threshold for cost-effectiveness of €30,000 per QALY gained, our model results agreed qualitatively with the economic analyses conducted by national public health agencies in order to inform policy about rotavirus vaccination.
Acknowledgments
We thank Thierry van Effelterre (GSK Biologicals Belgium) for sharing results from his dynamic model of rotavirus vaccination in Belgium. This study formed part of POLYMOD, a European Commission project funded within the Sixth Framework Programme, Contract number: SSP22-CT-2004–502084. MJ was funded by the Policy Research Programme in the Department of Health, England (grant number 039/0031). WJE's partner works for GlaxoSmithKline. YY has received travel grants and honoraria for presentations
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