Correction: COVID-19 vaccination in Sindh Province, Pakistan: A modelling study of health impact and cost-effectiveness.

[This corrects the article DOI: 10.1371/journal.pmed.1003815.].

COVID-19 vaccination in Sindh Province, Pakistan: A modelling study of health impact and cost-effectiveness.

BACKGROUND: Multiple Coronavirus Disease 2019 (COVID-19) vaccines appear to be safe and efficacious, but only high-income countries have the resources to procure sufficient vaccine doses for most of their eligible populations. The World Health Organization has published guidelines for vaccine prioritisation, but most vaccine impact projections have focused on high-income countries, and few incorporate economic considerations. To address this evidence gap, we projected the health and economic impact of different vaccination scenarios in Sindh Province, Pakistan (population: 48 million). METHODS AND FINDINGS: We fitted a compartmental transmission model to COVID-19 cases and deaths in Sindh from 30 April to 15 September 2020. We then projected cases, deaths, and hospitalisation outcomes over 10 years under different vaccine scenarios. Finally, we combined these projections with a detailed economic model to estimate incremental costs (from healthcare and partial societal perspectives), disability-adjusted life years (DALYs), and incremental cost-effectiveness ratio (ICER) for each scenario. We project that 1 year of vaccine distribution, at delivery rates consistent with COVAX projections, using an infection-blocking vaccine at $3/dose with 70% efficacy and 2.5-year duration of protection is likely to avert around 0.9 (95% credible interval (CrI): 0.9, 1.0) million cases, 10.1 (95% CrI: 10.1, 10.3) thousand deaths, and 70.1 (95% CrI: 69.9, 70.6) thousand DALYs, with an ICER of $27.9 per DALY averted from the health system perspective. Under a broad range of alternative scenarios, we find that initially prioritising the older (65+) population generally prevents more deaths. However, unprioritised distribution has almost the same cost-effectiveness when considering all outcomes, and both prioritised and unprioritised programmes can be cost-effective for low per-dose costs. High vaccine prices ($10/dose), however, may not be cost-effective, depending on the specifics of vaccine performance, distribution programme, and future pandemic trends. The principal drivers of the health outcomes are the fitted values for the overall transmission scaling parameter and disease natural history parameters from other studies, particularly age-specific probabilities of infection and symptomatic disease, as well as social contact rates. Other parameters are investigated in sensitivity analyses. This study is limited by model approximations, available data, and future uncertainty. Because the model is a single-population compartmental model, detailed impacts of nonpharmaceutical interventions (NPIs) such as household isolation cannot be practically represented or evaluated in combination with vaccine programmes. Similarly, the model cannot consider prioritising groups like healthcare or other essential workers. The model is only fitted to the reported case and death data, which are incomplete and not disaggregated by, e.g., age. Finally, because the future impact and implementation cost of NPIs are uncertain, how these would interact with vaccination remains an open question. CONCLUSIONS: COVID-19 vaccination can have a considerable health impact and is likely to be cost-effective if more optimistic vaccine scenarios apply. Preventing severe disease is an important contributor to this impact. However, the advantage of prioritising older, high-risk populations is smaller in generally younger populations. This reduction is especially true in populations with more past transmission, and if the vaccine is likely to further impede transmission rather than just disease. Those conditions are typical of many low- and middle-income countries.

Evidence on the magnitude of the economic, health and population effects of palm cooking oil consumption: an integrated modelling approach with Thailand as a case study.

BACKGROUND: Palm oil's high yields, consequent low cost and highly versatile properties as a cooking oil and food ingredient have resulted in its thorough infiltration of the food sector in some countries. Longitudinal studies have associated palm oil's high saturated fatty acid content with non-communicable disease, but neither the economic or disease burdens have been assessed previously. METHODS: This novel palm oil-focussed disease burden assessment employs a fully integrated health, macroeconomic and demographic Computable General Equilibrium Model for Thailand with nine regional (urban/rural) households. Nutritional changes from food consumption are endogenously translated into health (myocardial infarction (MI) and stroke) and population outcomes and are fed back into the macroeconomic model as health and caregiver-related productive labour supply effects and healthcare costs to generate holistic 2016-2035 burden estimates. Model scenarios mirror the replacement of palm cooking oil with other dietary oils and are compared with simulated total Thai health and macroeconomic burdens for MI and stroke. RESULTS: Replacing consumption of palm cooking oil with other dietary oils could reduce MI/stroke incident cases by 8280/2639 and cumulative deaths by 4683/894 over 20 years, removing approximately 0.5% of the total Thai burden of MI/stroke. This palm cooking oil replacement would reduce consumption shares of saturated/monounsaturated fatty acids in Thai household consumption by 6.5%/3% and increase polyunsaturated fatty acid consumption shares by 14%, yielding a 1.74% decrease in the population-wide total-to-HDL cholesterol ratio after 20 years. The macroeconomic burden that would be removed is US$308mn, approximately 0.44% of the total burden of MI/stroke on Thailand's economy or 0.003% of cumulative 20-year GDP. Bangkok and Central region households benefit most from removal of disease burdens. CONCLUSIONS: Simulations indicate that consumption of palm cooking oil, rather than other dietary oils, imposes a negative health burden (MI and stroke) and associated economic burden on a high consuming country, such as Thailand. Integrated sectoral model frameworks to assess these burdens are possible, and burden estimates from our simulated direct replacement of palm cooking oil indicate that using these frameworks both for broader analyses of dietary palm oil use and total burden analyses of other diseases may also be beneficial.

Palm oil and dietary change: Application of an integrated macroeconomic, environmental, demographic, and health modelling framework for Thailand.

Palm oil is a cooking oil and food ingredient in widespread use in the global food system. However, as a highly saturated fat, palm oil consumption has been associated with negative effects on cardiovascular health, while large scale oil palm production has been linked to deforestation. We construct an innovative fully integrated Macroeconomic-Environmental-Demographic-health (MED-health) model to undertake integrated health, environmental, and economic analyses of palm oil consumption and oil palm production in Thailand over the coming 20 years (2016-2035). In order to put a health and fiscal food policy perspective on policy priorities of future palm oil consumption growth, we model the implications of a 54% product-specific sales tax to achieve a halving of future energy intakes from palm cooking oil consumption. Total patient incidence and premature mortality from myocardial infarction and stroke decline by 0.03-0.16% and rural-urban equity in health and welfare improves in most regions. However, contrary to accepted wisdom, reduced oil palm production would not be environmentally beneficial in the Thailand case, since, once established, oil palms have favourable carbon sequestration characteristics compared to alternative uses of Thai cropland. The increased sales tax also provokes mixed economic impacts: While real GDP increases in a second-best Thai tax policy environment, relative consumption-to-investment price changes may reduce household welfare over extended periods unless accompanied by non-distortionary government compensation payments. Overall, our holistic approach demonstrates that product-specific fiscal food policy taxes may involve important trade-offs between nutrition, health, the economy, and the environment.

Stark choices: exploring health sector costs of policy responses to COVID-19 in low-income and middle-income countries.

OBJECTIVES: COVID-19 has altered health sector capacity in low-income and middle-income countries (LMICs). Cost data to inform evidence-based priority setting are urgently needed. Consequently, in this paper, we calculate the full economic health sector costs of COVID-19 clinical management in 79 LMICs under different epidemiological scenarios. METHODS: We used country-specific epidemiological projections from a dynamic transmission model to determine number of cases, hospitalisations and deaths over 1 year under four mitigation scenarios. We defined the health sector response for three base LMICs through guidelines and expert opinion. We calculated costs through local resource use and price data and extrapolated costs across 79 LMICs. Lastly, we compared cost estimates against gross domestic product (GDP) and total annual health expenditure in 76 LMICs. RESULTS: COVID-19 clinical management costs vary greatly by country, ranging between <0.1%-12% of GDP and 0.4%-223% of total annual health expenditure (excluding out-of-pocket payments). Without mitigation policies, COVID-19 clinical management costs per capita range from US$43.39 to US$75.57; in 22 of 76 LMICs, these costs would surpass total annual health expenditure. In a scenario of stringent social distancing, costs per capita fall to US$1.10-US$1.32. CONCLUSIONS: We present the first dataset of COVID-19 clinical management costs across LMICs. These costs can be used to inform decision-making on priority setting. Our results show that COVID-19 clinical management costs in LMICs are substantial, even in scenarios of moderate social distancing. Low-income countries are particularly vulnerable and some will struggle to cope with almost any epidemiological scenario. The choices facing LMICs are likely to remain stark and emergency financial support will be needed.

The impact of Covid-19, associated behaviours and policies on the UK economy: A computable general equilibrium model.

We estimate the potential impact of COVID-19 on the United Kingdom economy, including direct disease effects, preventive public actions and associated policies. A sectoral, whole-economy macroeconomic model was linked to a population-wide epidemiological demographic model to assess the potential macroeconomic impact of COVID-19, together with policies to mitigate or suppress the pandemic by means of home quarantine, school closures, social distancing and accompanying business closures. Our simulations indicate that, assuming a clinical attack rate of 48% and a case fatality ratio of 1.5%, COVID-19 alone would impose a direct health-related economic burden of £39.6bn (1.73% of GDP) on the UK economy. Mitigation strategies imposed for 12 weeks reduce case fatalities by 29%, but the total cost to the economy is £308bn (13.5% of GDP); £66bn (2.9% of GDP) of which is attributable to labour lost from working parents during school closures, and £201bn (8.8% of GDP) of which is attributable to business closures. Suppressing the pandemic over a longer period of time may reduce deaths by 95%, but the total cost to the UK economy also increases to £668bn (29.2% of GDP), where £166bn (7.3% of GDP) is attributable to school closures and 502bn (21.9% of GDP) to business closures. Our analyses suggest Covid-19 has the potential to impose unprecedented economic costs on the UK economy, and whilst public actions are necessary to minimise mortality, the duration of school and business closures are key to determining the economic cost. The initial economic support package promised by the UK government may be proportionate to the costs of mitigating Covid-19, but without alternative measures to reduce the scale and duration of school and business closures, the economic support may be insufficient to compensate for longer term suppression of the pandemic which could generate an even greater health impact through major recession.

Will More of the Same Achieve Malaria Elimination? Results from an Integrated Macroeconomic Epidemiological Demographic Model.

Historic levels of funding have reduced the global burden of malaria in recent years. Questions remain, however, as to whether scaling up interventions, in parallel with economic growth, has made malaria elimination more likely today than previously. The consequences of "trying but failing" to eliminate malaria are also uncertain. Reduced malaria exposure decreases the acquisition of semi-immunity during childhood, a necessary phase of the immunological transition that occurs on the pathway to malaria elimination. During this transitional period, the risk of malaria resurgence increases as proportionately more individuals across all age-groups are less able to manage infections by immune response alone. We developed a robust model that integrates the effects of malaria transmission, demography, and macroeconomics in the context of Plasmodium falciparum malaria within a hyperendemic environment. We analyzed the potential for existing interventions, alongside economic development, to achieve malaria elimination. Simulation results indicate that a 2% increase in future economic growth will increase the US$5.1 billion cumulative economic burden of malaria in Ghana to US$7.2 billion, although increasing regional insecticide-treated net coverage rates by 25% will lower malaria reproduction numbers by just 9%, reduce population-wide morbidity by -0.1%, and reduce prevalence from 54% to 46% by 2034. As scaling up current malaria control tools, combined with economic growth, will be insufficient to interrupt malaria transmission in Ghana, high levels of malaria control should be maintained and investment in research and development should be increased to maintain the gains of the past decade and to minimize the risk of resurgence, as transmission drops.

International trade, dietary change, and cardiovascular disease health outcomes: Import tariff reform using an integrated macroeconomic, environmental and health modelling framework for Thailand.

United Nations (UN) member states have, since 2011, worked to address the emerging global NCD crisis, but progress has, so far, been insufficient. Food trade policy is recognised to have the potential to impact certain major diet-related health and environmental outcomes. We study the potential for using import tariff protection as a health and environmental policy instrument. Specifically, we apply a rigorous and consistent Macroeconomic-Environmental-Demographic-health (MED-health) simulation model framework to study fiscal food policy import tariffs and dietary change in Thailand over the future 20 year period 2016-2035. We find that the existing Thai tariff structure, by lowering imports, lowers agricultural Land Use Change (LUC)-related GHG emissions and protects against cholesterol-related cardiovascular disease (CVD). This confirms previous evidence that food trade, measured by import shares of food expenditures and caloric intakes, is correlated with unhealthy eating and adverse health outcomes among importing country populations. A continued drive towards tariff liberalization and economic efficiency in Thailand may therefore come at the expense of reduced health and environmental sustainability of food consumption and production systems. Due to large efficiency losses, the existing tariff structure is, however, not cost-effective as an environmental or health policy instrument. However, additional simulations confirm that stylized 30% food sector import tariffs generally improve nutritional, clinical health, demographic, and environmental indicators across the board. We also find that diet-related health improvements can go hand-in-hand with increased Saturated Fatty Acid (SFA) intakes. Despite limited cost-effectiveness, policy makers from Thailand and abroad, including WHO, would therefore be well advised to consider targeted fiscal food policy tariffs as a potential intervention to maintain combined health and environmental sustainability, and to reconsider the specification of WHO dietary guidelines with their focus on SFA intake (rather than composition of fatty acid intake) targets.

The Impact of Alzheimer's Disease on the Chinese Economy.

BACKGROUND: Recent increases in life expectancy may greatly expand future Alzheimer's Disease (AD) burdens. China's demographic profile, aging workforce and predicted increasing burden of AD-related care make its economy vulnerable to AD impacts. Previous economic estimates of AD predominantly focus on health system burdens and omit wider whole-economy effects, potentially underestimating the full economic benefit of effective treatment. METHODS: AD-related prevalence, morbidity and mortality for 2011-2050 were simulated and were, together with associated caregiver time and costs, imposed on a dynamic Computable General Equilibrium model of the Chinese economy. Both economic and non-economic outcomes were analyzed. FINDINGS: Simulated Chinese AD prevalence quadrupled during 2011-50 from 6-28 million. The cumulative discounted value of eliminating AD equates to China's 2012 GDP (US$8 trillion), and the annual predicted real value approaches US AD cost-of-illness (COI) estimates, exceeding US$1 trillion by 2050 (2011-prices). Lost labor contributes 62% of macroeconomic impacts. Only 10% derives from informal care, challenging previous COI-estimates of 56%. INTERPRETATION: Health and macroeconomic models predict an unfolding 2011-2050 Chinese AD epidemic with serious macroeconomic consequences. Significant investment in research and development (medical and non-medical) is warranted and international researchers and national authorities should therefore target development of effective AD treatment and prevention strategies.

The importance of health co-benefits in macroeconomic assessments of UK Greenhouse Gas emission reduction strategies.

We employ a single-country dynamically-recursive Computable General Equilibrium model to make health-focussed macroeconomic assessments of three contingent UK Greenhouse Gas (GHG) mitigation strategies, designed to achieve 2030 emission targets as suggested by the UK Committee on Climate Change. In contrast to previous assessment studies, our main focus is on health co-benefits additional to those from reduced local air pollution. We employ a conservative cost-effectiveness methodology with a zero net cost threshold. Our urban transport strategy (with cleaner vehicles and increased active travel) brings important health co-benefits and is likely to be strongly cost-effective; our food and agriculture strategy (based on abatement technologies and reduction in livestock production) brings worthwhile health co-benefits, but is unlikely to eliminate net costs unless new technological measures are included; our household energy efficiency strategy is likely to breakeven only over the long term after the investment programme has ceased (beyond our 20 year time horizon). We conclude that UK policy makers will, most likely, have to adopt elements which involve initial net societal costs in order to achieve future emission targets and longer-term benefits from GHG reduction. Cost-effectiveness of GHG strategies is likely to require technological mitigation interventions and/or demand-constraining interventions with important health co-benefits and other efficiency-enhancing policies that promote internalization of externalities. Health co-benefits can play a crucial role in bringing down net costs, but our results also suggest the need for adopting holistic assessment methodologies which give proper consideration to welfare-improving health co-benefits with potentially negative economic repercussions (such as increased longevity).