The Costs and Cost-Effectiveness of a Two-Dose Oral Cholera Vaccination Campaign: A Case Study in a Refugee Camp Setting in Thailand.

Oral cholera vaccination (OCV) campaigns are increasingly used to prevent cholera outbreaks; however, little is known about their cost-effectiveness in refugee camps. We conducted a cost-effectiveness analysis of a pre-emptive OCV campaign in the Maela refugee camp in Thailand, where outbreaks occurred with an annual incidence rate (IR) of up to 10.7 cases per 1000. Data were collected via health sector records and interviews and household interviews. In the base-case scenario comparing the OCV campaign with no campaign, we estimated the campaign effect on the cholera IR and case fatality rate (CFR: 0.09%) from a static cohort model and calculated incremental cost-effectiveness ratios for the outcomes of death, disability-adjusted life-years (DALYs), and cases averted. In sensitivity analyses, we varied the CFR and IR. The household economic cost of illness was USD 21, and the health sector economic cost of illness was USD 51 per case. The OCV campaign economic cost was USD 289,561, 42% attributable to vaccine costs and 58% to service delivery costs. In our base case, the incremental cost was USD 1.9 million per death averted, USD 1745 per case averted, and USD 69,892 per DALY averted. Sensitivity analyses that increased the CFR to 0.35% or the IR to 10.4 cases per 1000 resulted in a cost per DALY of USD 15,666. The low multi-year average CFR and incidence of the cholera outbreaks in the Maela camp were key factors associated with the high cost per DALY averted. However, the sensitivity analyses indicated higher cost-effectiveness in a setting with a higher CFR or cholera incidence, indicating when to consider campaign use to reduce the outbreak risk.