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Cost-effectiveness of rotavirus and human papillomavirus vaccines in children and girls, in Mozambique
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Introdução: A gastroenterite associada a rotavírus (RVGE) e o câncer cervical (CC) são globalmente doenças com elevada carga de mortalidade em crianças e mulheres, respetivamente, sobretudo em países de baixa e média renda. Para prevenir estas doenças, em 2015 e 2021, Moçambique introduziu no Programa Alargado de Vacinação as vacinas contra Rotavirus, Rotarix® e contra o Papilomavírus Humano (HPV) Gardasil® tetravalente (Gardasil-4®). Porém, antes deste projeto não havia evidências de longo prazo das implicações da RVGE e do CC, nem sobre o custo-efetividade da vacinação de crianças e raparigas contra o RV e o HPV (agente causal do CC). Objetivou-se estimar o impacto e o custo-efetividade da vacinação com Rotarix® e Gardasiil-4® atualmente usados no país, e de potencias alternativas futuras, como Rotavac® e Rotasiil® contra RV, e CervarixTM e Cecolin® contra HPV.
Métodos: Usou-se um modelo de coorte estático de análise de decisão (UNIVAC), para estimar o impacto e o custo-efetividade das vacinas Rotarix, Rotasiil e Rotavac em crianças, (2021 a 2030), e das vacinas Gardasiil-4, Cecolin e Cervarix em raparigas de 9 anos, incluindo uma campanha de vacinação multietária em raparigas dos 10-14 anos (2022 a 2031). O resultado primário foi o custo incremental por ano de vida ajustado para incapacidade (DALY) prevenido, na perspetiva governamental. Cada vacina foi comparada à ausência de vacina e entre si. Análises de sensibilidade determinística e probabilística foram realizadas para avaliar as incertezas do modelo.
Resultados: A projeção de dez anos revelou que sem a vacina contra RV, 11.000 mortes infantis ocorreriam em Moçambique. As vacinas potencialmente reduzem a carga de RVGE em 41% (Rotarix) e 48% (Rotavac e Rotasiil). Com o suporte da Gavi, o custo da vacinação foi menor com a Rotarix (US$ 31 milhões), porém, sem suporte, Rotasiil foi menos dispendiosa (US$ 75,8 milhões). Com o suporte da Gavi todas as vacinas foram custo-efetivas (limiar 0,5 vezes o Produto Interno Bruto (PIB) per capita (p.c) (US$ 224,3)). Rotarix dominou as demais (US$ 102/DALY evitado), apresentando 98% de probabilidade de ser custo-efetiva. Porém, sem o apoio da Gavi, Rotasiil foi a melhor, com 30% de probabilidade de ser custo-efetiva. Quanto ao CC, sem a vacinação contra o HPV, 282.687 mortes associadas à doença decorreriam no país. Considerando a proteção cruzada, as vacinas preveniriam entre 53% e 70% dos casos e mortes pelo CC. Sem o subsídio da Gavi o custo do programa de vacinação é menos dispendioso com Cecolin (US$ 60 milhões). Todas as vacinas foram custo-efetivas. Com o suporte da Gavi e proteção cruzada, Cervarix foi dominante, mas, sem suporte da Gavi, Cecolin foi a melhor (US$ 26/ DALY evitado), com 100% de probabilidade de ser custo-efetiva ao limiar de 0,35xPIB p.c. (US$ 175).
Conclusão: As vacinas contra RV e HPV têm potencial para reduzir a carga de RVGE em crianças e CC em mulheres. As vacinas são custo-efetivas considerando uma variedade de assunções. Com o suporte da Gavi, Rotarix é a opção mais custo-efetiva, inversamente, sem o suporte, Rotasiil seria a melhor opção. Quanto às vacinas contra HPV, todas as vacinas foram custo-effectivass, contudo sem o suporte da Gavi Cecolin foi dominante. Para melhorar a eficiência da tomada de decisão, estas vacinas devem ser reavaliadas usando estimativas atualizadas.
Introduction: Rotavirus gastroenteritis (RVGE) and cervical cancer (CC) are life-threatening diseases in children and women worldwide, respectively, with the largest mortality burden in low- and middle-income countries. To prevent these diseases, Mozambique introduced vaccines against Rotavirus (RV), Rotarix® and Human Papillomavirus (HPV), Gardasil® tetravalent (Gardasil-4®) vaccines, into the Expanded Program on Immunization, in 2015 and 2021, respectively. However, before this project, there was no long-term evidence on the implications of RVGE and CC, neither the cost-effectiveness of vaccination of children and girls against RV and HPV (causal agent of CC). We aimed to estimate the impact and cost-effectiveness of the currently used Rotarix® and Gardasiil-4®, and other alternatives that could be used in the future, in Mozambique, such as Rotavac® and Rotasiil® for RVGE and CervarixTM and Cecolin® for HPV. Methods: An Excel proportionate outcomes static cohort decision-support model (UNIVAC) was used to estimate the lifetime benefits and costs of using Rotarix, Rotasiil and Rotavac in infants from 2021-2030, and HPV vaccines Gardasiil-4, Cecolin and Cervarix in girls aged 9 years, including a Multiple-Age Cohort catch-up campaign in 10–14-year-old girls, from 2022 to 2031. The primary outcome was the incremental cost per disability-adjusted life-year (DALY) averted from the government perspective. Each vaccine was compared to no vaccination and to each other. Uncertainty was assessed through deterministic and probabilistic sensitivity analyses. Results: Ten-year-projections revealed that without RV vaccine 11.000 deaths would occur in Mozambique. The vaccines potentially reduce RVGE burden by 41% (Rotarix) and 48% (Rotavac and Rotasiil). With Gavi support, the vaccine program cost is lowest for Rotarix (USD31 million), however without Gavi support, Rotasiil (USD75.8 million) is less expensive. At 0.5 times Gross Domestic Product (GDP) per capita (p.c.) threshold (USD224.3), considering Gavi support, the vaccines are cost-effective, with Rotarix dominating others (USD 102/DALY averted), with 98% probability of being cost-effective. Nevertheless, without Gavi support, Rotasiil is close to the threshold, with 30% probability to be cost-effective. Regarding CC, without HPV vaccination 282,687 disease-related deaths would happen nationwide. Considering cross-protection, the three vaccines could prevent between 53 and 70% CC cases and deaths. The program cost without the Gavi subsidy was cheapest for Cecolin (USD60 million). The HPV vaccines were cost-effective at a WTP threshold of 0.35xGDP p.c. (USD175). With Gavi support and cross protection, Cervarix dominated others (cost saving), however without support, Cecolin dominated (USD26/DALY averted), with 100% probability to be cost-effective. Conclusion: RV and HPV vaccines have potential for reducing burden of RVGE in children and cervical cancer in women. Similarly, the studied vaccines are cost-effective considering a variety of assumptions. With the Gavi subsidy, Rotarix is the most cost-effective choice, conversely, without Gavi support Rotasiil would be the best option. Among the HPV vaccines, all the vaccines were potentially cost-effective, however without the Gavi subsidy Cecolin was dominant. To improve decision-making efficiency, the studied vaccines should be re-evaluated using updated estimates.
Introduction: Rotavirus gastroenteritis (RVGE) and cervical cancer (CC) are life-threatening diseases in children and women worldwide, respectively, with the largest mortality burden in low- and middle-income countries. To prevent these diseases, Mozambique introduced vaccines against Rotavirus (RV), Rotarix® and Human Papillomavirus (HPV), Gardasil® tetravalent (Gardasil-4®) vaccines, into the Expanded Program on Immunization, in 2015 and 2021, respectively. However, before this project, there was no long-term evidence on the implications of RVGE and CC, neither the cost-effectiveness of vaccination of children and girls against RV and HPV (causal agent of CC). We aimed to estimate the impact and cost-effectiveness of the currently used Rotarix® and Gardasiil-4®, and other alternatives that could be used in the future, in Mozambique, such as Rotavac® and Rotasiil® for RVGE and CervarixTM and Cecolin® for HPV. Methods: An Excel proportionate outcomes static cohort decision-support model (UNIVAC) was used to estimate the lifetime benefits and costs of using Rotarix, Rotasiil and Rotavac in infants from 2021-2030, and HPV vaccines Gardasiil-4, Cecolin and Cervarix in girls aged 9 years, including a Multiple-Age Cohort catch-up campaign in 10–14-year-old girls, from 2022 to 2031. The primary outcome was the incremental cost per disability-adjusted life-year (DALY) averted from the government perspective. Each vaccine was compared to no vaccination and to each other. Uncertainty was assessed through deterministic and probabilistic sensitivity analyses. Results: Ten-year-projections revealed that without RV vaccine 11.000 deaths would occur in Mozambique. The vaccines potentially reduce RVGE burden by 41% (Rotarix) and 48% (Rotavac and Rotasiil). With Gavi support, the vaccine program cost is lowest for Rotarix (USD31 million), however without Gavi support, Rotasiil (USD75.8 million) is less expensive. At 0.5 times Gross Domestic Product (GDP) per capita (p.c.) threshold (USD224.3), considering Gavi support, the vaccines are cost-effective, with Rotarix dominating others (USD 102/DALY averted), with 98% probability of being cost-effective. Nevertheless, without Gavi support, Rotasiil is close to the threshold, with 30% probability to be cost-effective. Regarding CC, without HPV vaccination 282,687 disease-related deaths would happen nationwide. Considering cross-protection, the three vaccines could prevent between 53 and 70% CC cases and deaths. The program cost without the Gavi subsidy was cheapest for Cecolin (USD60 million). The HPV vaccines were cost-effective at a WTP threshold of 0.35xGDP p.c. (USD175). With Gavi support and cross protection, Cervarix dominated others (cost saving), however without support, Cecolin dominated (USD26/DALY averted), with 100% probability to be cost-effective. Conclusion: RV and HPV vaccines have potential for reducing burden of RVGE in children and cervical cancer in women. Similarly, the studied vaccines are cost-effective considering a variety of assumptions. With the Gavi subsidy, Rotarix is the most cost-effective choice, conversely, without Gavi support Rotasiil would be the best option. Among the HPV vaccines, all the vaccines were potentially cost-effective, however without the Gavi subsidy Cecolin was dominant. To improve decision-making efficiency, the studied vaccines should be re-evaluated using updated estimates.
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