IntroductionBy 2022, high levels of past COVID-19 infections, combined with substantial levels of vaccination and the development of Omicron have shifted country strategies toward burden reduction policies. SARS-CoV-2 rapid antigen tests (RDTs) could contribute to these policies by helping rapidly detect, isolate and/or treat infections in different settings. However, the evidence to inform RDT policy choices in LMICs is limited. MethodWe provide an overview of the potential impact of several RDT use cases (surveillance; testing, tracing and isolation without and with surveillance; hospital-based screening to reduce nosocomial COVID; and testing to enable earlier/expanded treatment) for a range of country settings. We use conceptual models and literature review to identify which use cases are likely to bring benefits and how these may change with outbreak characteristics. Impacts are measured through multiple outcomes related to gaining time, reducing the burden on the health system, and reducing deaths. ResultsIn an optimal scenario in terms of resources and capacity and with baseline parameters, we find marginal time gains of at least a week through surveillance and testing tracing and isolation with surveillance, a reduction in peak ICU or ICU admissions by 6% or more (hospital-based screening; testing, tracing and isolation), and reductions in COVID deaths by over 6% (hospital-based screening; test and treat). Time gains may be used to strengthen ICU capacity and/or boost vulnerable individuals, though only a small minority of at-risk individuals could be reached in the time available. The impact of RDTs declines with lower country resources and capacity, more transmissible or immune-escaping variants and reduced test sensitivity. ConclusionRDTs alone are unlikely to dramatically reduce the burden of COVID-19 in LMICs, though they may have an important role alongside other interventions such as vaccination, therapeutic drugs, improved healthcare capacity and non-pharmaceutical measures. KEY MESSAGESO_LIWhat is already known: Important shifts in the way COVID is addressed, from efforts to reduce COVID transmission toward burden reduction, have led to question the role of testing, in particular SARS-CoV-2 rapid antigen tests (RDTs), both in countries that used them extensively and in those in which RDTs were never scaled-up, but the evidence to inform RDT policy choices in LMICs is particularly limited. C_LIO_LIWhat this study adds: This study provides an overview of multiple RDT use cases and their potential impacts to gain time, reduce health system burdens and reduce deaths. It shows the contrast between high- and low-resource and capacity settings, and how some use cases (surveillance, hospital-based screening, and testing associated with early/expanded treatment) may retain higher benefits, at least with regard to early warning and hospital burden, than the use of RDTs for testing, tracing and isolation. C_LIO_LIHow this study might affect research, practice or policy: The study highlights that RDTs alone are unlikely to dramatically reduce the burden of COVID-19 in LMICs, and that their role may be best understood as complementary to other interventions. C_LI
BackgroundThe COVID-19 vaccine supply shortage in 2021 constrained rollout efforts in Africa while populations experienced waves of epidemics. As supply picks up, a key question becomes if vaccination remains an impactful and cost-effective strategy given changes in the timing of implementation. MethodsWe assessed the impact of timing using an epidemiological and economic model. We fitted our mathematical epidemiological model to reported COVID-19 deaths in 27 African countries to estimate the existing immunity (resulting from infection) before substantial vaccine rollout. We then projected health outcomes for different programme start dates (2021-01-01 to 2021-12-01, n = 12) and roll-out rates (slow, medium, fast; 275, 826, and 2066 doses/ million population-day, respectively) for viral vector and mRNA vaccines. Rollout rates used were derived from observed uptake trajectories. We collected data on vaccine delivery costs by country income group. Lastly, we calculated incremental cost-effectiveness ratios and relative affordability. FindingsVaccination programmes with early start dates incur the most health benefits and are most cost-effective. While incurring the most health benefits, fast vaccine roll-outs are not always the most cost-effective. At a willingness-to-pay threshold of 0.5xGDP per capita, vaccine programmes starting in August 2021 using mRNA and viral vector vaccines were cost-effective in 6-10 and 17-18 of 27 countries, respectively. InterpretationAfrican countries with large proportions of their populations unvaccinated by late 2021 may find vaccination programmes less cost-effective than they could have been earlier in 2021. Lower vaccine purchasing costs and/or the emergence of new variants may improve cost-effectiveness. FundingBill and Melinda Gates Foundation, World Health Organization, National Institute of Health Research (UK), Health Data Research (UK)
BackgroundHow best to prioritise COVID-19 vaccination within and between countries has been a public health and an ethical challenge for decision-makers globally. We systematically reviewed epidemiological and economic modelling evidence on population priority groups to minimise COVID-19 mortality, transmission and morbidity outcomes. MethodsWe searched the National Institute of Health iSearch COVID-19 Portfolio (a database of peer-reviewed and pre-print articles), Econlit, the Centre for Economic Policy Research and the National Bureau of Economic Research for mathematical modelling studies evaluating the impact of prioritising COVID-19 vaccination to population target groups. We narratively synthesised the main study conclusions on prioritisation and the conditions under which the conclusions changed. FindingsThe search identified 1820 studies. 36 studies met the inclusion criteria and were narratively synthesised. 83% of studies described outcomes in high-income countries. We found that for countries seeking to minimise deaths, prioritising vaccination of senior adults was the optimal strategy and for countries seeking to minimise cases the young were prioritised. There were several exceptions to the main conclusion, notably reductions in deaths could be increased, if groups at high risk of both transmission and death could be further identified. Findings were also sensitive to the level of vaccine coverage. InterpretationThe evidence supports WHO SAGE recommendations on COVID-19 vaccine prioritisation. There is however an evidence gap on optimal prioritisation for low- and middle-income countries, studies that included an economic evaluation, and studies that explore prioritisation strategies if the aim is to reduce overall health burden including morbidity.
BackgroundEven with good progress on vaccination, SARS-CoV-2 infections in the UK may continue to impose a high burden of disease and therefore pose substantial challenges for health policy decision makers. Stringent government-mandated physical distancing measures (lockdown) have been demonstrated to be epidemiologically effective, but can have both positive and negative economic consequences. The duration and frequency of any intervention policy could, in theory, could be optimised to maximise economic benefits while achieving substantial reductions in disease. MethodsHere we use a pre-existing SARS-CoV-2 transmission model to assess the health and economic implications of different strengths of control through time in order to identify optimal approaches to non-pharmaceutical intervention stringency in the UK, considering the role of vaccination in reducing the need for future physical distancing measures. The model is calibrated to the COVID-19 epidemic in England and we carry out retrospective analysis of the optimal timing of precautionary breaks in 2020 and the optimal relaxation policy from the January 2021 lockdown, considering the willingness to pay for health improvement. ResultsWe find that the precise timing and intensity of interventions is highly dependent upon the objective of control. As intervention measures are relaxed, we predict a resurgence in cases, but the optimal intervention policy can be established dependent upon the willingness to pay (WTP) per QALY loss avoided. Our results show that establishing an optimal level of control can result in a reduction in net monetary loss of billions of pounds, dependent upon the precise WTP value. ConclusionsIt is vital, as the UK emerges from lockdown, but continues to face an on-going pandemic, to accurately establish the overall health and economic costs when making policy decisions. We demonstrate how some of these can be quantified, employing mechanistic infectious disease transmission models to establish optimal levels of control for the ongoing COVID-19 pandemic.
BackgroundMultiple 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 FindingsWe 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 hospitalization 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 one-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: 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. Varying these assumptions, we generally find that prioritizing the older (65+) population prevents more deaths, but broad distribution from the outset is economically comparable in many scenarios, and either scheme can be cost-effective for low per-dose costs. However, high vaccine prices ($10/dose) may not be cost-effective. 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. These projections are limited by the mechanisms present in the model. Because the model is a single-population compartmental model, detailed impacts of non-pharmaceutical interventions (NPIs) such as household isolation cannot be practically represented or evaluated in combination with vaccine programmes. Similarly, the model cannot consider prioritizing groups like healthcare or other essential workers. Additionally, because the future impact and implementation cost of NPIs is uncertain, how these would interact with vaccination remains an open question. ConclusionsCOVID-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, but the advantage of focusing initially on older, high-risk populations may be smaller in generally younger populations where many people have already been infected, typical of many low- and -middle income countries, as long as vaccination gives good protection against infection as well as disease. Author SummaryO_ST_ABSWhy Was This Study Done?C_ST_ABS- The evidence base for health and economic impact of COVID-19 vaccination in low- and middle-income settings is limited. - Searching PubMed, medRxiv, and econLit using the search term ("coronavirus" OR "covid" OR "ncov") AND ("vaccination" OR "immunisation") AND ("model" OR "cost" OR "economic") for full text articles published in any language between 1 January 2020 and 20 January 2021, returned 29 (PubMed), 1,167 (medRxiv) and 0 (econLit) studies: 20 overall were relevant, with only 4 exclusively focused on low- or middle-income countries (India, China, Mexico), while 3 multi-country analyses also included low- or middle-income settings, - However only three of these studies are considered economic outcomes, all of them comparing the costs of vaccination to the costs of non-pharmaceutical interventions and concluding that both are necessary to reduce infections and maximise economic benefit. - The majority of studies are set in high-income settings and conclude that targeting COVID-19 vaccination to older age groups is the preferred strategy to minimise mortality, particularly when vaccine supplies are constrained, while other age- or occupational risk groups should be priorities when vaccine availability increases or when other policy objectives are pursued. What Did the Researchers Do and Find?- We combined epidemiological and economic analysis of COVID-19 vaccination based on real-world disease and programmatic information in the Sindh province of Pakistan. - We found vaccination in this setting is likely to be highly cost-effective, and even cost saving, as long as the vaccine is reasonably priced and efficacy is high. - Unlike studies in high-income settings, we also found that vaccination programmes targeting all adults may have almost as much benefit as those initially targeted at older populations, likely reflecting the higher previous infection rates and different demography in these settings. What Do These Findings Mean?- Lower- and middle-income countries (LMICs) and international bodies providing guidance for LMICs need to consider evidence specific to these settings when making recommendations about COVID-19 vaccination. - Further data and model-based analyses in such settings are urgently needed in order to ensure that vaccination decisions are appropriate to these contexts.
BackgroundIn response to the coronavirus disease 2019 (COVID-19), the UK adopted mandatory physical distancing measures in March 2020. Vaccines against the newly emerged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may become available as early as late 2020. We explored the health and economic value of introducing SARS-CoV-2 immunisation alongside physical distancing scenarios in the UK. MethodsWe used an age-structured dynamic-transmission and economic model to explore different scenarios of immunisation programmes over ten years. Assuming vaccines are effective in 5-64 year olds, we compared vaccinating 90% of individuals in this age group to no vaccination. We assumed either vaccine effectiveness of 25% and 1-year protection and 90% re-vaccinated annually, or 75% vaccine effectiveness and 10-year protection and 10% re-vaccinated annually. Natural immunity was assumed to last 45 weeks in the base case. We also explored the additional impact of physical distancing. We considered benefits from disease prevented in terms of quality-adjusted life-years (QALYs), and costs to the healthcare payer versus the national economy. We discounted at 3.5% annually and monetised health impact at {pound}20,000 per QALY to obtain the net monetary value, which we explored in sensitivity analyses. FindingsWithout vaccination and physical distancing, we estimated 147.9 million COVID-19 cases (95% uncertainty interval: 48.5 million, 198.7 million) and 2.8 million (770,000, 4.2 million) deaths in the UK over ten years. Vaccination with 75% vaccine effectiveness and 10-year protection may stop community transmission entirely for several years, whereas SARS-CoV-2 becomes endemic without highly effective vaccines. Introducing vaccination compared to no vaccination leads to economic gains (positive net monetary value) of {pound}0.37 billion to +{pound}1.33 billion across all physical distancing and vaccine effectiveness scenarios from the healthcare perspective, but net monetary values of physical distancing scenarios may be negative from societal perspective if the daily national economy losses are persistent and large. InterpretationOur model findings highlight the substantial health and economic value of introducing SARS-CoV-2 vaccination. Given uncertainty around both characteristics of the eventually licensed vaccines and long-term COVID-19 epidemiology, our study provides early insights about possible future scenarios in a post-vaccination era from an economic and epidemiological perspective. Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed and medRxiv for economic evaluations of SARS-CoV-2 vaccines with the search string (coronavirus OR COVID OR SARS-CoV-2) AND (vaccin* OR immunisation) AND ((economic evaluation) OR (cost effectiveness analysis)) AND 2020[dp] on September 21, 2020, with no language restrictions. We found one pre-print that valued health outcomes in monetary terms and explored the additional impact of vaccines in a cost-benefit analysis of physical distancing for the USA; no study focused on vaccines in a full economic evaluation. Added value of this studyWith a growing number of vaccine candidates under development and having entered clinical trials, our study is to our knowledge the first to explore the health and economic value of introducing a national SARS-CoV-2 immunisation programme. A programme with high vaccine effectiveness and long-lasting protection may stop the community transmission entirely for a couple of years, but even a vaccine with 25% vaccine effectiveness is worthwhile to use; even at short-lived natural and vaccine-induced protections. After an initial lockdown, voluntary physical distancing as a sole strategy risks a large second epidemic peak, unless accompanied by highly effective immunisation. Compared to no vaccination, introducing vaccination leads to positive net monetary value across physical distancing scenarios from the healthcare perspective, subject to the long-run vaccine price and cost-effectiveness of other treatments (e.g. new drugs). The net monetary value of immunisation decreases if vaccine introduction is delayed, natural immunity is long or vaccine-induced protection is short. Intermittent physical distancing leads to negative net benefits from the perspective of the wider economy if the daily national income losses are persistent and large. Implications of all the available evidenceOur model findings highlight the health and economic value of introducing SARS-CoV-2 vaccination to control the COVID-19 epidemic. Despite the many uncertainties, continued physical distancing may be needed to reduce community transmission until vaccines with sufficiently high vaccine effectiveness and long-lasting protection are available. Our study provides first broad health-economic insights rather than precise quantitative projections given the many uncertainties and unknown characteristics of the vaccine candidates and aspects of the long-term COVID-19 epidemiology, and the value of vaccines will ultimately depend on other socioeconomic and health-related policies and population behaviours.
Much attention has focussed in recent months on the impact that COVID-19 has on health sector capacity, including critical care bed capacity and resources such as personal protective equipment. However, much less attention has focussed on the overall cost to health sectors, including the full human resource costs and the health system costs to address the pandemic. Here we present estimates of the total costs of COVID-19 response in low- and middle-income countries for different scenarios of COVID-19 mitigation over a one year period. We find costs vary substantially by setting, but in some settings even mitigation scenarios place a substantial fiscal impact on the health system. We conclude that the choices facing many low- and middle-income countries, without further rapid emergency financial support, are stark, between fully funding an effective COVID-19 reponse or other core essential health services. O_TEXTBOXThis is preliminary report that has not yet been peer reviewed. These estimates should not yet guide policy in specific countries nor be reported as established information. We are placing these in the public domain to inform those who are estimaing Covid costs in low- and middle-income countries about the methods and assumptions required; higlight the broad level of fiscal impact and to invite comments for others working in this field, prior to submission to peer review publication. These estimates have been subjected to a detailed validation and error checking process internally. Nevertheless, given the dearth of data to inform Covid cost estimates at this time, our results depend on a range of assumptions. Comments and suggestions to improve this work are welcomed and can be sent to the authors below C_TEXTBOX
BackgroundCoronavirus disease 2019 (COVID-19) epidemics strain health systems and households. Health systems in Africa and South Asia may be particularly at risk due to potential high prevalence of risk factors for severe disease, large household sizes and limited healthcare capacity. MethodsWe investigated the impact of an unmitigated COVID-19 epidemic on health system resources and costs, and household costs, in Karachi, Delhi, Nairobi, Addis Ababa and Johannesburg. We adapted a dynamic model of SARS-CoV-2 transmission and disease to capture country-specific demography and contact patterns. The epidemiological model was then integrated into an economic framework that captured city-specific health systems and household resource use. FindingsThe cities severely lack intensive care beds, healthcare workers and financial resources to meet demand during an unmitigated COVID-19 epidemic. A highly mitigated COVID-19 epidemic, under optimistic assumptions, may avoid overwhelming hospital bed capacity in some cities, but not critical care capacity. InterpretationViable mitigation strategies encompassing a mix of responses need to be established to expand healthcare capacity, reduce peak demand for healthcare resources, minimise progression to critical care and shield those at greatest risk of severe disease. FundingBill & Melinda Gates Foundation, European Commission, National Institute for Health Research, Department for International Development, Wellcome Trust, Royal Society, Research Councils UK. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe conducted a PubMed search on May 5, 2020, with no language restrictions, for studies published since inception, combining the terms ("cost" OR "economic") AND "covid". Our search yielded 331 articles, only two of which reported estimates of health system costs of COVID-19. The first study estimated resource use and medical costs for COVID-19 in the United States using a static model of COVID 19. The second study estimated the costs of polymerase chain reaction tests in the United States. We found no studies examining the economic implications of COVID-19 in low- or middle-income settings. Added value of this studyThis is the first study to use locally collected data in five cities (Karachi, Delhi, Nairobi, Addis Ababa and Johannesburg) to project the healthcare resource and health economic implications of an unmitigated COVID-19 epidemic. Besides the use of local data, our study moves beyond existing work to (i) consider the capacity of health systems in key cities to cope with this demand, (ii) consider healthcare staff resources needed, since these fall short of demand by greater margins than hospital beds, and (iii) consider economic costs to health services and households. Implications of all the evidenceDemand for ICU beds and healthcare workers will exceed current capacity by orders of magnitude, but the capacity gap for general hospital beds is narrower. With optimistic assumptions about disease severity, the gap between demand and capacity for general hospital beds can be closed in some, but not all the cities. Efforts to bridge the economic burden of disease to households are needed.
