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.
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.
