Expanding rotavirus vaccine uptake in sub-Saharan Africa
Authors: Edward Nketiah-Amponsah
Journal: The Lancet Global Health (2021)

It has been proven without equivocation that simple and yet cost-effective medical interventions, such as inoculation against contagious diseases including rotavirus, have the potential to avert substantial morbidity and mortality cases in low-income countries. In the absence of such an intervention, human capital development is adversely affected since children are the most vulnerable to rotavirus. In their paper,1Okafor CE Ekwunife OI Introducing rotavirus vaccine in eight sub-Saharan African countries: a cost–benefit analysis.Lancet Glob Health. 2021; 9: e1088-e1100Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Charles Okafor and Obinna Ekwunife evaluate the costs and ensuing benefits associated with the introduction of rotavirus vaccine in eight sub-Saharan African countries (Central African Republic, Chad, Comoros, Equatorial Guinea, Gabon, Guinea, Somalia, and South Sudan) contemplating introducing the vaccine. The relevance of this study is particularly informed by the need to provide evidence-based results to advice policy makers about the potential monetary gains to society by implementing rotavirus vaccination, especially against the backdrop of resource constraints and competing societal needs. The need to ensure judicious use of scarce health resources in sub-Saharan Africa is further amplified by the COVID-19 pandemic, which has put undue pressure on government expenditures and donor funding. It is, therefore, pertinent that any money investment in the health sector generates the greatest social benefit. This is exactly what the study by Okafor and Ekwunife does—provides evidence to support the implementation of the rotavirus vaccine in the selected countries. Currently, 35 countries in sub-Saharan Africa have already introduced the rotavirus vaccine, of which evidence points to significant reductions in rotavirus gastroenteritis and mortality in these countries.2Opolot G Zhang W Amponsem-Boateng C Bonney Oppong T Zhao Q Li D Evidence of rotavirus vaccine impact in sub-Saharan Africa: systematic review and meta-analysis.PLoS One. 2020; 15e0232113PubMed Google Scholar The spill-over effect on countries yet to introduce the vaccine in the region has manifested in a general decline in rotavirus gastroenteritis, a testament to the efficacy of the vaccine. The paper thus makes a compelling contribution to the literature by doing a comprehensive ex-ante cost–benefit analysis on the introduction of rotavirus vaccines in eight countries using two outcome variables: disability-adjusted life-years and health-care cost averted. For Equatorial Guinea and Gabon, this study is a trailblazer since it is the first attempt to evaluate the feasibility of introducing rotavirus vaccines in these countries. Of particular note is the fact that the study evaluates and ranks four different vaccines (Rotarix, Rotateq, Rotavec, and Rotasill) to determine their viability. The authors also employ cost-effectiveness analysis as a robustness check, and the result is in sync with the benefit–cost ratios (BCRs), albeit cost–benefit analysis proves superior in terms of the BCRs that necessitate the ranking of the vaccines to determine where scarce resources should be prioritised. The findings from this paper, based on the robust BCRs, make a prima facie case for policy makers to introduce the rotavirus vaccine in these countries. Although the paper makes a substantial contribution to the literature, there are a few questions that ought to be addressed in future studies. More conspicuously, the study does not take into consideration individual or household costs and focuses on government as the payer or co-payer in the case of counterpart funding from donors. This omission has the tendency to inflate the BCRs, rendering the interventions more viable than they would have otherwise been. For instance, there could be substantial treatment costs to the household, both direct and indirect, if patients who were infected develop severe symptoms, in addition to medical care that has to be taken care of by a caregiver with its concomitant opportunity costs. It will be more discerning if future studies incorporate household costs into the cost–benefit analysis to broaden our understanding on the rotavirus vaccination intervention. In addition to the 5% discount rate, future studies could consider using a discount rate of 8%, and perhaps 14% for sensitivity analysis in line with the standard literature.3Nketiah-Amponsah E Awine T Silal S Wong B Cost benefit analysis of selected malaria, interventions in Ghana. Ghana Priorities, Copenhagen Consensus Center, Tewksbury, MA, USA2020Google Scholar I commend the authors for a well researched paper that follows a standard WHO framework for costing the introduction of new vaccines within the context of their respective national immunisation programmes. The Copenhagen Consensus Centre has established country priorities in the health and education sectors among others for several low-income countries based on studies that used the cost–benefit analysis tool. For instance, three malaria interventions evaluated in Ghana pointed to high BCRs between 14 and 134, providing a useful decision support to policy makers.3Nketiah-Amponsah E Awine T Silal S Wong B Cost benefit analysis of selected malaria, interventions in Ghana. Ghana Priorities, Copenhagen Consensus Center, Tewksbury, MA, USA2020Google Scholar The paper by Okafor and Ekwunife shows that introducing the vaccines in all the eight countries is socially beneficial given that the BCRs for all the four vaccines exceeds 1, with the highest ratios recorded for Chad (36·3) and the Central African Republic (23·1). Even the lowest BCRs of 1·24 for Equatorial Guinea and 1·36 for Gabon warrant implementation barring resource constraints, since every dollar investment in rotavirus vaccine will yield at least 24% returns. The study has also shown that the optimal vaccine that maximises the health gains of the population across the countries is Rotarix. Therefore, a well coordinated supply chain for procuring and supplying Rotarix for all the countries that have introduced the vaccine, and those intending to introduce it, will further yield some efficiency gains. I declare no competing interests. Introducing rotavirus vaccine in eight sub-Saharan African countries: a cost–benefit analysisIntroducing the rotavirus vaccine in all eight countries, but with caution in Equatorial Guinea and Gabon, would be worthwhile. With the narrow BCR for Equatorial Guinea and Gabon, cautious, pragmatic, and stringent measures need to be employed to ensure optimal health benefits and cost minimisation of the vaccine introduction. The final decision to introduce the rotavirus vaccine should be preceded by comparing its BCR to the BCRs of other health-care projects. Full-Text PDF Open Access