Introduction of rotavirus vaccination in Palestine: An evaluation of the costs, impact, and cost-effectiveness of ROTARIX and ROTAVAC

PLoS One. 2020 Feb 5;15(2):e0228506. doi: 10.1371/journal.pone.0228506. eCollection 2020.


Introduction: The Palestinian Ministry of Health (MOH) started a routine rotavirus immunization program with ROTARIX in May 2016, with support for vaccine procurement and introduction provided through a global development organization. In 2018, financial responsibility for rotavirus vaccine procurement was transferred to the Palestinian government, which elected to shift to ROTAVAC vaccine because of its lower price per dose. This study aims to assess the cost, impact, and cost-effectiveness of rotavirus vaccination, specifically evaluating the economic implications of the change in vaccine product, accounting for the different characteristics of each rotavirus vaccine used.

Methods: We conducted primary and secondary data collection to assess the introduction, procurement, supply chain, and service delivery costs related to each vaccine. We used the UNIVAC model to project costs and benefits of rotavirus vaccination over a 10-year period comparing the use of ROTARIX versus no vaccination; ROTAVAC versus no vaccination; and ROTAVAC versus ROTARIX. We undertook scenario and probabilistic analyses to capture uncertainty in some of the study parameters. We used a 3% discount rate, and all costs are in 2018 US$.

Results: The cost to deliver one dose was lower for ROTAVAC than ROTARIX (US$2.36 versus $2.70), but the total cost per course, excluding vaccine cost, favored ROTARIX ($7.09 versus $5.39). Both vaccines had high probability of being cost-effective interventions in Palestine compared to no vaccine. Because of lower vaccination program costs for ROTAVAC, however, switching from ROTARIX to ROTAVAC was cost-saving.

Conclusion: National decision-makers should consider systematically assessing multiple criteria beyond vaccine price when comparing the health and economic value of several products in order to fully account for all characteristics including product presentation, number of doses per course, cold chain volume, cost of delivery, and wastage.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child
  • Child, Preschool
  • Cost-Benefit Analysis*
  • Humans
  • Immunization Programs / economics*
  • Infant
  • Infant, Newborn
  • Middle East / epidemiology
  • Rotavirus / immunology*
  • Rotavirus Infections / economics*
  • Rotavirus Infections / epidemiology
  • Rotavirus Infections / prevention & control
  • Rotavirus Infections / virology
  • Rotavirus Vaccines / classification
  • Rotavirus Vaccines / economics*
  • Rotavirus Vaccines / therapeutic use
  • Vaccination / economics*


  • Rotavirus Vaccines

Grant support

This work was supported by the Bill & Melinda Gates Foundation, Seattle, WA [grant number OPP1199552]