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Provincial stratification and equity-weighted cost-effectiveness of malaria vaccines in Zambia under climate
1Mathematics, The Copperbelt University School of Mathematics and Natural Sciences, Kitwe, Zambia.
Introduction:
Malaria remains a major public health burden in Zambia, with 5-6 million cases annually. Heterogeneous transmission complicates vaccine deployment. While RTS,S/AS01 has been piloted, the impact and cost-effectiveness of RTS,S and next-generation R21 require rigorous provincial-level evaluation.
Methods:
We developed a province-stratified susceptible, exposed, infectious and recovered (SEIR)-mosquito transmission model incorporating entomological inoculation rates, calibrated to routine surveillance data. The model generated expressions for the basic reproduction number (R₀) and herd immunity thresholds. Cost-effectiveness was assessed from the Zambia Ministry of Health perspective over a 5-year analytic horizon (2024-2028), with 3% annual discounting, using disability-adjusted life-years (DALYs) averted. Costs included procurement, delivery, cold-chain investment and treatment savings. Incremental cost-effectiveness ratios (ICERs) and probabilistic sensitivity analyses (10 000 simulations) were benchmarked against Zambia's US$500/DALY willingness-to-pay threshold. Equity was assessed via ICER distributions and concentration indices.
Results:
Over the 5-year analytic horizon, malaria vaccination substantially reduced transmission intensity and disease burden relative to a no-vaccination baseline, with marked heterogeneity across provinces. Nationally, deployment of the RTS,S vaccine was estimated to avert a median of 9.80 × 105 malaria cases (95% uncertainty interval (UI): 8.88×105-1.08×106), while the higher-efficacy R21 vaccine averted 1.09×106 cases (95% UI: 9.91×105-1.21×106). These reductions corresponded to approximately 1960 deaths averted under RTS,S and 2188 deaths averted under R21 over 5 years. Vaccine impact varied across provinces in line with baseline transmission intensity and climate-driven differences in malaria risk, influencing both health outcomes and cost-effectiveness.
Conclusions:
Provincial stratification highlights the need for targeted vaccine roll-out and infrastructure strengthening. RTS,S is borderline cost-effective at current prices, while R21 is highly cost-effective and potentially dominant. Findings support phased provincial deployment with equity weighting, budget integration and climate-adaptive investment to maximise health gains.
