Disease Control Priorities and Rotavirus Presentation Vaccines Title Presentation Sub-title Seventh International Rotavirus Symposium Lisbon June 12, 2006 1
What is the DCPP? DCPP is an alliance of organizations designed to review, generate and disseminate information on how to improve population health in developing countries. 2
DCPP Partners Fogarty International Center World Bank World Health Organization Bill & Melinda Gates Foundation 3
History and Genesis of DCPP 1993 First edition of Disease Control Priorities in Developing Countries published; mainly a World Bank effort and tied to World Development Report, 1993 2001 Fogarty International Center conceptualizes DCPP and mobilizes partners and team January 2002 Bill & Melinda Gates Foundation awards first of three grants to FIC in support of DCPP April 2002 Beginning of consultations, Working Paper Series 4
Objectives of DCPP Developing an evidence base to inform decision-making by: Providing estimates of the costeffectiveness and impact of single interventions and packages Collaborating in defining disease burdens globally and regionally Summarizing implementation experience in different regions and globally 5
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Main Messages 1. Average life expectancy in low- and middleincome countries increased dramatically in the past half-century, while cross-country health inequalities decreased. 8
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Main Messages 2. Improved health has contributed significantly to economic welfare. 10
Main Messages 3. Although health improvements constituted an enormous success for human welfare in the 20th century, four critical challenges face developing countries (and the world) at the dawn of the 21st century: high levels and rapid growth (for mostly demographic reasons) of non-communicable conditions in the disease profiles of developing countries the still unchecked HIV/AIDS pandemic the possibility of a successor to the influenza pandemic of 1918 the persistence in many countries and many population subgroups of high but preventable levels of mortality and disability from diseases such as malaria, TB, diarrhea, and pneumonia; from micronutrient malnutrition; and, for both mothers and infants, from childbirth. 11
Disease Burden from Selected Causes Low- and Middle-Income Countries, 2001 % of Deaths % of DALYs (total deaths = (total DALYs = Cause 48.4 million) 1.39 billion) I. Selected Infections Tuberculosis 3.3 % 2.6 % HIV/AIDS 5.3 5.1 Malaria 2.5 2.9 II. Selected NCDs Malignant Neoplasms 10.2 5.4 Ischaemic Heart Disease 11.8 5.2 Cerebrovascular Disease 9.5 4.5 III. Selected Injuries Road traffic accidents 2.2 2.3 Suicide 1.5 1.3 Source: Mathers, et. al., DCPP Burden of Disease volume, 2006. 12
Figure 1.4: The Rate of Progress in Reducing Under-5 Mortality, 1960-2000: China, India, Latin America and Sub-Saharan Africa 7.00 Rate of decline of under-5 mortality rates 6.00 5.00 4.00 3.00 2.00 1.00 60-70 70-80 80-90 90-00 0.00 China India MDG Requirement Sub-Saharan Africa Latin America & Caribbean Region Source: Calculations based on data in the World Development Indicators CD-ROM version (World Bank, 2004). Note: 4.3% per year equals the rate of decline required for the period 1990 2015 to meet MDG4 of reducing under-5 mortality by 2/3. 13
Main Messages 4. DCPP s conclusions concerning interventions points to a range of very good buys. 14
How Much Health Will a Million Dollars Buy? Service or Intervention DALYs Averted ($ per DALY) Preventing and Treating Non-Communicable Disease Taxation of tobacco products 24,000-330,000 ($3-50) Treatment of MI or heart 40,000-100,000 ($10-25) attacks with an inexpensive set of drugs Lifelong treatment of heart 1,000-1,400 ($700-1,000) attack and stroke survivors with daily polypill Bypass surgery for less severe Very small (Very high) coronary artery disease 15
Main Messages 5. DCPP s findings concerning health services include: Increased provision of surgical facilities at the district hospital level would be highly attractive. Middle-income countries should, in general, move toward the prevalent OECD pattern of public sector finance for health. 16
Main Messages 6. The generation and diffusion of new knowledge and products underpinned the enormous improvements in health of the 20th century. Every reason exists to believe that continued progress meeting the challenges of non-communicable disease, HIV/AIDS, potential pandemics, and neglected populations will continue to rely heavily on new knowledge. 17
ROTAVIRUS VACCINES (with thanks to Jeff Chow) 18
CAUSES OF UNDER-5 MORTALITY, WORLDWIDE IN 2001, ESTIMATES FROM THE GBD AND CHERG/WHO (in thousands) Total deaths Neonatal deaths Cause GBD CHERG/WHO GBD CHERG/WHO HIV/AIDS 340 318 Diarrheal Disease 1600 1920 116 117 Measles 557 424 Tetanus 187 273 187 273 Malaria 1087 848 Respiratory infection (and sepsis) 1945 3028 1013 1013 Low birth weight 1301 1091 1098 1091 Birth asphyxia and birth trauma 739 896 739 896 Congenital anomalies 439 312 321 312 Injuries 310 318 Other 2101 1178 446 194 TOTAL 10606 10606 3896 3896 Source: Lopez, et. al., Global Burden of Disease and Risk Factors, p. 461; author's calculations. 19
ALL-CAUSE AND DIARRHEAL DISEASE DEATH RATES IN CHILDREN, 1990 AND 2001 Death Rates Per 1,000 Births All-Cause Diarrheal disease Region 1990 2001 % change 1990 2001 % change Low- and Middle- Income Countries 97 86-11.3% 19 13-31.6% South Asia 127 97-23.6% 28 17-39.3% Sub-Saharan Africa 180 172-4.4% 36 25-30.1% Source: Lopez, et. al., 2006, Global Burden of Disease and Risk Factors. 20
RV Disease burden Risk Events 1 : 285 610,000 deaths 1 : 58 1 : 5 1 : 1 Source: Glass, Parashar et. al., Lancet, 2006. 2.3 million inpatient visits 24 million outpatient visits 114 million episodes 5% of all deaths in children < 5 1 in 285 children will die of RV 21
Cost-effectiveness analysis Cost and effects of inoculating single cohort of babies born in given year Disability-adjusted life years / cost DALYs = YLD + YLL (discounted) Discount rate = 3% 22
Averted mortality (YLL) assumptions Averted diarrheal mortality over the first five years of life 33.3% of all diarrhea mortality due to rotavirus Individuals whose deaths are averted live to regionand sex-specific life-expectancy 23
Averted mortality (YLL) assumptions Rotarix effectiveness rate = 100% rotavirus diarrhea mortality; 33.3% all diarrhea mortality Rotateq effectiveness rate = 98% rotavirus diarrhea mortality; 32.6% all diarrhea mortality 24
Cost assumptions Modeled as a one-time cost for vaccination of all babies born in a given year $14 per child fully inoculated In the future, the price may be as low as $2-3 per child fully inoculated 25
Cost-effectiveness: Rotarix vaccine 1400 Cost-effectiveness ratio (US$/DALY) 1200 1000 800 600 400 200 $14/child $2.5/child 0 LMIC EAP LAC MNA SAR SSA Region 26
Cost-effectiveness: Rotateq vaccine 1400 Cost-effectiveness ratio (US$/DALY) 1200 1000 800 600 400 200 $14/child $2.5/child 0 LMIC EAP LAC MNA SAR SSA Region 27
Issues in CEA 1. Inclusion of costs for hospital and outpatient visits 2. Inclusion of value of parents time as caretaker 3. Death of a child versus a young adult 4. Marginal versus monopoly (or duopoly) price for vaccine 28
Please visit our website: www.dcp2.org All book chapters freely and easily available as pdf downloads. 29