Economic Impact of Introducing the RTS,S Malaria Vaccine: Cost-Effectiveness and Budget Impact Analysis in 41 Countries

Background. Malaria is a major public health burden in sub-Saharan Africa. This study estimated the cost-effectiveness and budget impact of adding four-dose malaria vaccination in infants or children to existing interventions in 41 endemic countries in sub-Saharan Africa. Methods. A static Markov cohort model followed a simulated 2017 birth cohort (36.5 million children) for 15 years in 5-day cycles, comparing three strategies: child vaccination (doses at ages 6, 7.5, 9, and 27 months); infant vaccination (doses at ages 6, 10, and 14 weeks and 21 months); no malaria vaccination. The base-case analysis was conducted from the health system perspective with vaccine price assumed at USD5/dose and annual discounting of 3% for costs and disability-adjusted life-years (DALYs). Efficacy was based on the Phase III RTS,S clinical trial. Results. The model projected that 24.6 million children, or 26.2 million infants, would be vaccinated. Compared with no vaccination, child (infant) vaccination was projected to avert 16.8 million (16 million) cases of malaria and 113,000 (107,000) malaria deaths in the birth cohort over the 15-year period. The incremental cost-effectiveness ratio was USD200/DALY averted (USD225/DALY averted) for child (infant) vaccination, which represents 14% (17%) of the gross domestic product (GDP) per capita threshold. The estimated budget impact was overall larger for infant vaccination but mixed situations occurred across countries. Vaccine price, discount rate, and parasite prevalence had the largest effect on cost-effectiveness. Conclusions. Child vaccination with RTS,S would be more cost-effective than infant vaccination across countries. Adding RTS,S malaria vaccination to existing interventions would be cost-effective assuming one GDP per capita threshold for both child and infant vaccination in all examined countries except for 6 countries with lower transmission.