Vaccine 30S (2012) A15–A23 Contents lists available at SciVerse ScienceDirect Vaccine jou rn al h om epa ge: www.elsevier.com/locate/vaccine Distributional impact of rotavirus vaccination in 25 GAVI countries: Estimating disparities in benefits and cost-effectiveness Richard Rheingans a,∗ , Deborah Atherly b , John Anderson a a Department of Environmental and Global Health, Center for African Studies, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA b PATH, Seattle, WA, USA a r t i c l e i n f o Article history: Received 20 July 2011 Received in revised form 12 December 2011 Accepted 6 January 2012 Keywords: Rotavirus Cost-effectiveness Equity Disparities Vaccination a b s t r a c t Background: Other studies have demonstrated that the impact and cost effectiveness of rotavirus vacci- nation differs among countries, with greater mortality reduction benefits and lower cost-effectiveness ratios in low-income and high-mortality countries. This analysis combines the results of a country level model of rotavirus vaccination published elsewhere with data from Demographic and Health Surveys on within-country patterns of vaccine coverage and diarrhea mortality risk factors to estimate within- country distributional effects of rotavirus vaccination. The study examined 25 countries eligible for funding through the GAVI Alliance. Methods: For each country we estimate the benefits and cost-effectiveness of vaccination for each wealth quintile assuming current vaccination patterns and for a scenario where vaccine coverage is equalized to the highest quintile’s coverage. In the case of India, variations in coverage and risk proxies by state were modeled to estimate geographic distributional effects. Results: In all countries, rates of vaccination were highest and risks of mortality were lowest in the top two wealth quintiles. However countries differ greatly in the relative inequities in these two underlying variables. Similarly, in all countries examined, the cost-effectiveness ratio for vaccination ($/Disability- Adjusted Life Year averted, DALY) is substantially greater in the higher quintiles (ranging from 2–10 times higher). In all countries, the greatest potential benefit of vaccination was in the poorest quintiles. However, due to reduced vaccination coverage, projected benefits for these quintiles were often lower. Equitable coverage was estimated to result in an 89% increase in mortality reduction for the poorest quintile and a 38% increase overall. Conclusions: Rotavirus vaccination is most cost-effective in low-income groups and regions. However in many countries, simply adding new vaccines to existing systems targets investments to higher income children, due to disparities in vaccination coverage. Maximizing health benefits for the poorest children and value for money require increased attention to these distributional effects. © 2012 Elsevier Ltd. All rights reserved. 1. Introduction Global and regional level analysis of rotavirus vaccination demonstrates that the impact and cost-effectiveness of vac- cination is heterogeneous [1–4]. In general there are greater benefits and better cost-effectiveness ratios in low-income coun- tries and regions, primarily due to higher estimated mortality. At the same time, lower vaccination coverage, along with reduced efficacy and great delays in timing mean that the percent reduc- tion in rotavirus burden would be lowest in these countries [5]. ∗ Corresponding author. Tel.: +1 352 294 5110; fax: +1 352 273 6070. E-mail address: rrheing@ufl.edu (R. Rheingans). However this global pattern of disparities is likely to be repeated within as well as between countries [6]. Poorer households and poorer regions within a particular country are likely to have high diarrhea mortality risk and lower levels of timely vaccination cover- age. This suggests that distribution of the benefit, cost-effectiveness and residual (post-vaccination) rotavirus mortality are also likely to differ after vaccine introduction. This paper estimates the geographic and socio-economic distri- butional effects of rotavirus vaccine introduction within a subset of countries eligible for funding by the GAVI Alliance. This includes the distribution of benefits, cost-effectiveness, and residual (post- vaccine introduction) mortality risk. The main research question is ‘how do outcomes differ across geographic and socio-economic gradients at the regional, national, and sub-national scales?’ Bet- ter understanding of distributional effects is essential in tackling the substantial remaining rotavirus mortality burden, even with 0264-410X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.vaccine.2012.01.018