Cost-effectiveness and benefit-risk of rotavirus vaccination in Afghanistan: a modelling analysis informed by post-licensure surveillance

Introduction Afghanistan added ROTARIX to the routine national immunization programme in 2018. We aimed to estimate the cost-effectiveness and benefit-risk of ROTARIX and compare its continued use with other rotavirus vaccines that could be used in the future. Methods We used a static cohort model with a finely disaggregated age structure (weeks of age < 5 years) to assess the use of ROTARIX (1-dose vial) over a seven-year period (2018–2024) in Afghanistan. The primary outcome measure was the discounted cost (2022 US$) per Disability Adjusted Life Year (DALY) averted (from government and societal perspectives) compared to no vaccination. We also calculated the benefit-risk ratio i.e., the number of RVGE deaths prevented per one excess intussusception death. Model inputs were informed by pre- and post-licensure surveillance data, new analyses of household survey data, and updated estimates from the international literature. We ran a separate analysis to compare the potential cost-effectiveness and benefit-risk of ROTARIX (1-dose vial), ROTASIIL (1-dose vial), ROTASIIL (2-dose vial), and ROTAVAC (5-dose vial) over a ten-year period (2025–2034). Each product was compared to no rotavirus vaccination and each other. We ran deterministic and probabilistic uncertainty analyses and interpreted our results over a range of cost-effectiveness thresholds. Findings We estimated that routine use of ROTARIX between 2018 and 2024 has prevented 4,600 RVGE deaths (a 41% reduction), 86,400 hospital admissions, and 1.72 million outpatient visits. For every 1,493 RVGE deaths prevented by the vaccine, we estimated one potential excess intussusception death. With a heavily reduced vaccine dose cost (Gavi’s support) the net cost to the Afghanistan government vaccine programme was estimated to be US$ 4.4 million per year. The cost per DALY averted was US$ 125 (0.25 times the national GDP per capita) when using a Gavi-subsidised vaccine cost and including household costs averted by vaccination. This increased to US$ 471 (0.94 times the national GDP per capita) when incorporating the full vaccine price without Gavi's subsidy and excluding household costs averted by vaccination. When assuming continued Gavi support over the period 2025–2034, the dominant product would be ROTARIX. Without Gavi support, ROTASIIL (2-dose vial) dominates. Conclusion Our study supports the sustained use of rotavirus vaccination in Afghanistan. The rotavirus vaccine is cost-effective and is health benefits greatly exceed its potential health risks.