Introduction

Rotavirus is a leading cause of severe diarrhoea among infants and young children, posing a public health challenge and a significant economic burden on healthcare systems worldwide. Effective policing and allocation of health resources necessitate understanding the costing strategies applied. This article sheds light on the direct and indirect economic impacts of rotavirus and highlights the cost-effectiveness of vaccination as a preventive measure.

Understanding rotavirus and its global burden

Rotavirus is a contagious virus that causes gastroenteritis, leading to severe diarrhoea, vomiting, and dehydration, particularly in young children. Although the disease is prevalent globally, low- and middle-income countries (LMICs) experience the highest-burden due to limited access to healthcare services and treatment options.¹ The availability of information on well-documented health implications has provided disease control agencies with the means to monitor and contain the spread of the virus; however, the economic consequences of rotavirus are not often discussed. These are critical to make strategic decisions and affect both healthcare systems and society as a whole.

Global burden of rotavirus: numbers that matter

Prevalence and mortality

• Global impact: A study in The Lancet reported over 108,000 deaths from rotavirus in 2021, with the vast majority of casualties occurring in low- and middle-income countries (LMICs)²
• Infection rates: It is estimated that nearly 95% of children worldwide experienced at least one rotavirus infection by the age of five in the pre-vaccine era¹³
• Hospitalisations: Rotavirus led to over 1,170,000 hospitalisations in 2019, highlighting an ongoing burden of rotavirus, and resulting in healthcare systems being exposed to a strained economic burden¹⁴

Regional disparities

The per capita income and the nation’s wealth dictate the cost of treating a child hospitalised with rotavirus. However, disproportionality exists in some nations where health service providers incur higher costs relative to their national income, illustrating the complications in healthcare systems worldwide.^3,4

Direct economic costs of rotavirus

Hospitalisation and medical care

Hospitalisation and medical treatments constitute direct costs associated with rotavirus infection. Severe cases, especially in infants, often require emergency care, which includes intravenous fluids, medications, and prolonged hospital stays. In countries with universal healthcare, these costs stretch national health budgets thin.

• Per Patient Costs: In upper-middle-income countries in the Americas, the cost per child treated for rotavirus reaches $10.62; in Europe, the cost is around $9.62 per child. Contrary to this, in Africa, the medical cost per child treated for rotavirus averages $1.52. Similarly, in Southeast Asia, the cost is even lower, at approximately $0.94 per child⁵

In summary, even though the direct medical costs are lower in low-income countries, the associated health impact in terms of mortality is significantly higher. On the other hand, high-income countries have a high financial burden, but their operational preparedness presents better healthcare outcomes, with fewer deaths and disability impacts related to rotavirus.

Outpatient and primary care costs

Children with mild infections often receive outpatient care, including visits to paediatricians or primary care physicians. Even though these visits are less costly than hospitalisations, the magnitude of the cases contributes to significant expenses. Not to forget the costs incurred by parents to purchase medications like oral rehydration therapy (ORT), which is essential for preventing dehydration in affected children. In countries with high rotavirus prevalence, outpatient care for rotavirus constitutes a large portion of paediatric care expenses.²

Long-term healthcare costs

On a positive note, rotavirus is typically a short-term illness that can be well managed with appropriate healthcare measures. However, recurrent infections can lead to long-term health issues such as malnutrition and developmental delays, especially in malnourished populations. This adds up healthcare costs over time, as these children require ongoing medical attention and follow-up treatments.

Indirect costs: economic burden from lost wages

Families affected by the virus fall victim to lost wages because of additional caregiving responsibilities. This represents a significant economic burden for families, especially in low- and middle-income countries (LMICs), where the impact is relatively pronounced. For instance, caregivers of families contacted by rotavirus illness in Vietnam lost an average of more than nine working days per child, significantly hampering family income.⁷ In a study performed in Kuala Lumpur, Malaysia, of the total $222 incurred during a rotavirus hospitalisation, lost wages accounted for nearly $107, illustrating the financial strain on households.⁸

This is similar in high-income countries, except for the scale used to measure the impact. A study conducted in Sweden reported that caretakers lost an average of €1,621 (approximately $1,800) due to a child's hospitalisation for rotavirus. This represented 94% of household costs for a single case of illness, highlighting the financial implications even in well-resourced healthcare settings.⁹

Moreover, home-treated cases constitute what is called a “hidden burden” that often goes unaccounted for in cost analyses. In Malaysia, the estimate of home-treated rotavirus cases was $10 million worth of wages lost in 2013, representing 21% of the total societal costs of the disease.⁸

Broader economic impact

Often the implications of disease-related hospitalisation are broader and high absenteeism due to rotavirus outbreaks is a major contributor to this impact. Healthcare systems are overburdened in regions with high prevalence, especially due to public resources being stretched thin. Rotavirus-related hospitalisations and outpatient visits divert funds that could otherwise be used to address other healthcare priorities, such as maternal health or vaccination campaigns for other diseases. In this way, rotavirus contributes to the inefficiency of healthcare resource allocation.

Economic impacts of rotavirus vaccination programs: cost-effectiveness analysis

Rotavirus vaccines were introduced in the early 2000s, and it didn't take long enough to prove that the approach was an effective way to reduce both the disease burden and the associated economic costs. These programs prevent hospital admissions, medical visits, and deaths, leading to significant savings for both governments and societies.⁶

Predictions of cost-effectiveness: what studies had forecasted

Studies in the past have leveraged economic modelling to project the potential economic impact of rotavirus vaccination programs. The table shown below was extracted from multiple studies that predicted the number of cases, hospitalisations, deaths prevented, and treatment costs averted for a birth cohort of children up to age 5 across different countries. The model measures economic returns as a function of costs and health benefits, providing insights into the vaccination program across various income-level countries

The model suggested significant cost savings due to the prevention of hospitalisations and deaths, particularly in countries with larger birth cohorts, such as Indonesia and Germany.

Real-world impact: evidence from high-income and LMICs

As the vaccination programs rolled out globally, the modellers were quite happy to learn that the actual data from countries confirmed and in some cases exceeded these predictions. The greater-than-expected benefits as real-life consequences are a result of indirect protection (herd immunity) and the mitigation of rotavirus transmission to older generations.

In Australia, a notable study (2007–2012) demonstrated an overall cost savings of AU$66 million, far exceeding initial cost-effectiveness estimates. Similar trends were observed in England and Finland, where significant reductions in hospitalisations and treatment costs were achieved within just a few years.¹⁰

Case study snippets: real-world cost savings

A waterfall chart providing a clear comparison of the total healthcare costs, hospitalisations, and medical visits averted by rotavirus vaccination in Australia, between the term 2007 and 2012.

England¹¹

Year: 2013 (First year after vaccine introduction)

• Cases averted: 87,000
• Hospitalizations prevented: ~13,000
• Savings in treatment costs: £12.5 million (US$21.4 million)

Finland¹²

Years: 2009–2014

• Decline in hospitalisations:
  • 92% for rotavirus-confirmed cases
  • 84% for unspecified gastroenteritis
• Average annual savings: €4.5 million
• Vaccination cost: €2.3 million/year
• Return on Investment (ROI): 2x cost saved annually

The table below presents a comparison of the predicted healthcare costs averted due to rotavirus vaccination programs over a 10-year period (2018-2027), across different global regions. The data is categorised into costs averted from the government perspective (direct medical savings to public healthcare systems) and the societal perspective (overall financial benefits including direct and indirect costs saved, such as household and wage loss prevention). Additionally, the cost of vaccine programs is included to highlight the return on investment (ROI).

Key insights:

• High ROI: In regions like Africa and Southeast Asia, vaccination programs are predicted to yield significant cost savings from both government and societal perspectives, far exceeding the investment made into the vaccine programs
• Cost-Effectiveness: The averted costs outweigh the expenditures on vaccination, particularly in low- and middle-income countries where healthcare systems benefit greatly from reductions in hospitalisations and outpatient visits

The graph clearly demonstrates that the economic benefits of rotavirus vaccination programs extend far beyond direct healthcare savings, offering substantial societal returns as well.

Economic disparities and challenges in LMICs

Healthcare access and costs

• Low vaccine coverage: Despite the cost-effectiveness of the rotavirus vaccine, coverage remains low in many LMICs due to logistical and financial challenges
• Healthcare system strain: In LMICs, the economic burden of rotavirus is disproportionately high due to the overwhelming number of cases⁵

Summary

The economic impact of rotavirus on healthcare systems is undeniable, with both direct medical costs and indirect productivity losses significantly straining national economies. However, data consistently shows that vaccination offers a high return on investment, with widespread use of the vaccine dramatically reducing hospitalisations, outpatient visits, and overall healthcare costs.

From high-income countries like the United States, which has saved nearly $900 million annually since introducing the vaccine, to LMICs like Malawi, where a 65% reduction in severe cases has been reported, the data is clear: rotavirus vaccination not only saves lives but also presents a financially sound strategy for reducing healthcare costs worldwide.

Investing in rotavirus vaccination, particularly in LMICs will continue to generate economic benefits, reduce the financial burden on already stretched healthcare systems, and improve productivity on a global scale.