Method: We developed a static, compartmental model of rotavirus disease with and without a vaccination program for annual birth cohorts followed over five years at the national level and in the ten states with the highest pediatric rotavirus mortality rates. Rotavirus deaths, and deaths due to other causes, were estimated by combining previously published verbal autopsy data from the nationally and state-representative Million Death Study with data from the Indian Rotavirus Strain Surveillance Network. The incidence of rotavirus infections was estimated from an Indian birth cohort that used laboratory confirmation to identify asymptomatic and symptomatic infections. Rotavirus immunization uptake was based on state-specific immunization rates for existing childhood vaccines at age two- and four-months. Children could receive one or two doses of vaccine, which conferred 25% and 50% protection respectively. Up to five rotavirus infections were modeled, each resulting in increased protection against subsequent infections. The cost of the vaccine was $1 per dose in the base-case scenario, the recently publicly announced price in India. Costs were not discounted.
Result: Following 141 million births over five years, an estimated 233 million rotavirus infections would occur nationally, resulting in 238,100 children dying. A universal vaccination campaign would avert approximately 88,000 deaths at a cost of approximately $42.8 million USD per year. At the national level and in all states, implementing this vaccine universally would be cost-effective, at a cost between $1,406 to $4,367 USD per death averted. In the five states with the highest mortality rates (Bihar, Uttar Pradesh, Madhya Pradesh, Jharkhand and Rajasthan), implementing a universal vaccination program would be cost-saving, given reductions in hospitalizations and out-patient visits. These findings were sensitive to vaccine efficacy, the cost of the vaccine and the cost of hospitalizations and clinic visits.
Conclusion: Our findings confirm that universal rotavirus immunization would be cost-effective, particularly in states with a high burden of rotavirus. These findings may inform the Indian government’s strategy to implement rotavirus vaccination, by targeting states with high rotavirus mortality rates and where cost-savings could be potentially realized.