OBJECTIVES: The aim of this evaluation was to analyze and classify the economic evidence (EE) requirements and processes for a dengue vaccine in the US, Mexico, Brazil and Malaysia in order to better characterize and compare the decision-making drivers in key endemic and non-endemic healthcare systems. METHODS: Countries were classified as endemic or non-endemic based on dengue epidemiology. A standardized extraction grid covering health technology assessment (HTA) organizational overview, HTA methodology and criteria evaluated was developed for the US, Mexico, Brazil and Malaysia. A targeted search from official HTA, NITAG and public health sources was carried out from January 2017 -February 2018. An additional ad-hoc search was also performed for relevant articles on the ISPOR abstracts database and Google scholar. RESULTS: The US was categorized as a non-endemic setting while Brazil, Mexico and Malaysia were categorized as endemic settings. Published guidelines were identified which outline guidance for EE in the US, Mexico, Brazil and Malaysia. The technical requirements and processes across countries vary. In Brazil and Malaysia vaccines undergo the same requirements for incorporation as other health technologies; however the role of HTA in vaccine recommendations in Mexico is less defined. Guidelines highlighting economic evidence requirements for immunizations in non-endemic (US) settings were not identified. Key variables in HTA methodology which vary in endemic settings include the perspective adopted, the preferred outcome measures, the method to derive utility and the discounting rate of costs and outcomes. CONCLUSIONS: The same vaccine has different evidence requirements depending on the population and country. Cost-effectiveness is a factor in the development of immunization recommendations in endemic settings, however there are no clear guidelines on the weight given to EE in non-endemic settings such as the US. Early engagement with HTA authorities would be valuable in providing key insights into the country specific evidence requirements of different HTA bodies.