Abstract
BackgroundOral cholera vaccines (OCV) have been recommended as additional measures for the prevention of cholera. However, little is known about the cost-effectiveness of OCV use in sub-Saharan Africa, particularly in reactive outbreak contexts. This study aimed to investigate the cost-effectiveness of the use of OCV Shanchol in response to a cholera outbreak in the Lake Chilwa area, Malawi.MethodsThe Excel-based Vaccine Introduction Cost-Effectiveness model was used to assess the cost-effectiveness ratios with and without indirect protection. Model input parameters were obtained from cost evaluations and epidemiological studies conducted in Malawi and published literature. One-way sensitivity and threshold analyses of cost-effectiveness ratios were performed.ResultsCompared with the reference scenario i.e. treatment of cholera cases, the immunization campaign would have prevented 636 and 1 020 cases of cholera without and with indirect protection, respectively. The cost-effectiveness ratios were US$19 212 per death, US$500 per case, and US$738 per DALY averted without indirect protection. They were US$10 165 per death, US$264 per case, and US$391 per DALY averted with indirect protection. The net cost per DALY averted was sensitive to four input parameters, including case fatality rate, duration of immunity (vaccine’s protective duration), discount rate and cholera incidence.ConclusionRelative to the Malawi gross domestic product per capita, the reactive OCV campaign represented a cost-effective intervention, particularly when considering indirect vaccine effects. Results will need to be assessed in other settings, e.g., during campaigns implemented directly by the Ministry of Health rather than by international partners.
Highlights
Cholera remains endemic in many areas of the world that have poor water, hygiene and sanitation access, and unsafe food practices, sub-Saharan Africa [1,2,3]
Case fatality rate (%, 1.4 to 6.7) Discount rate (%, 1 to 5) Duration of immunity Vaccine efficacy (%, to 69) Cholera incidence Vaccine delivery cost (2016US$, 1.2 to 3.6) Cholera cost to household (2016US$, to 134) Life expectancy at infection Cost of cholera to facility (2016US$, 30 to 61) Disability weight (0.1 to 0.3) Lenght of illness 0 150 300 450 600 750 900 1,050 1,200 1,350 1,500 Fig. 1 Tornado diagram of univariate sensitivity analysis of net cost per DALY averted without indirect protection infection, length of illness and disability weight showed relatively less important influences on the net cost per DALY averted
Case fatality rate (%, 1.4 to 6.7) Duration of immunity Discount rate (%, 1 to 5) Cholera incidence Vaccine delivery cost (2016US$, 1.2 to 3.6) Household cost of cholera (2016US$, 43 to 134) Vaccine efficacy (%, 82 to 99) Cost of cholera to facility (2016US$, 30 to 61) Life expectancy at infection Disability weight (0.1 to 0.3) Length of illness 0 90 180 270 360 450 540 630 720 810 Fig. 2 Tornado diagram of univariate sensitivity analysis of net cost per DALY averted with indirect protection
Summary
Cholera remains endemic in many areas of the world that have poor water, hygiene and sanitation access, and unsafe food practices, sub-Saharan Africa [1,2,3]. The Malawian Ministry of Health, supported by the World Health Organization (WHO) and international partners, including Agence de Médecine Préventive and Médecins sans Frontières, conducted a reactive vaccination campaign in three administrative districts, including Machinga, Phalombe, and Zomba in addition to strengthening surveillance, case management and water and sanitation improvements. Little is known about the cost-effectiveness of OCV use in sub-Saharan Africa, in reactive outbreak contexts. This study aimed to investigate the cost-effectiveness of the use of OCV Shanchol in response to a cholera outbreak in the Lake Chilwa area, Malawi
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