ABSTRACT
BackgroundDecision-makers in middle-income countries need evidence on the cost-effectiveness of COVID-19 booster doses and oral antivirals to appropriately prioritise these healthcare interventions. MethodsWe used a dynamic transmission model to assess the cost-effectiveness of COVID-19 booster doses and oral antivirals in Fiji, Indonesia, Papua New Guinea, and Timor-Leste. We conducted cost-effectiveness analysis from both healthcare and societal perspectives using 3% discounting for ongoing costs and health benefits. We developed an interactive R Shiny which allows the user to vary key model assumptions, such as the choice of discounting rate, and view how these assumptions affect model results. FindingsBooster doses were cost saving and therefore cost-effective in all four middle-income settings from both healthcare and societal perspectives using 3% discounting. Providing oral antivirals was cost-effective from a healthcare perspective if procured at a low generic ($25 United States Dollars) or middle-income reference price ($250 United States Dollars); however, their cost-effectiveness was strongly influenced by rates of wastage or misuse, and the ongoing costs of care for patients hospitalised with COVID-19. Interestingly, the cost or wastage of rapid antigen tests did not appear strongly influential over the cost-effectiveness of oral antivirals in any of the four study settings. ConclusionsOur results support that government funded COVID-19 booster programs continue to be cost-effective in middle-income settings. Oral antivirals demonstrate the potential to be cost-effective if procured at or below a middle-income reference price of $250 USD per schedule. Further research should quantify the rates of wastage or misuse of oral COVID-19 antivirals in middle-income settings.
Subject(s)
COVID-19ABSTRACT
Background COVID-19 vaccine coverage in low- and middle-income countries continues to be challenging. As supplies increase, coverage is increasingly becoming determined by rollout capacity.Methods We developed a deterministic compartmental model of COVID-19 transmission to explore how age-, risk-, and dose-specific vaccine prioritisation strategies can minimise severe outcomes of COVID-19 in Sierra Leone.Results Prioritising booster doses to older adults and adults with comorbidities could reduce the incidence of severe disease by 21% and deaths by 32% compared to the use of these doses as primary doses for all adults. Providing a booster dose to pregnant women who present to antenatal care could prevent 39% of neonatal deaths associated with COVID-19 infection during pregnancy. The vaccination of children is not justified unless there is sufficient supply to not affect doses delivered to adults.Conclusions Our paper supports current WHO SAGE vaccine prioritisation guidelines (released January 2022). Individuals who are at the highest risk of developing severe outcomes should be prioritised, and opportunistic vaccination strategies considered in settings with limited rollout capacity.
Subject(s)
COVID-19 , Perinatal DeathABSTRACT
BackgroundOngoing management of COVID-19 requires an evidence-based understanding of the performance of public health measures to date, and application of this evidence to evolving response objectives. This paper aims to define system requirements for COVID-19 management under future transmission and response scenarios, based on surveillance system performance to date. MethodsFrom 1st November 2020 to 30th June 2021 community transmission was eliminated in Australia, allowing investigation of system performance in detecting novel outbreaks, including against variants of concern (VoCs). We characterised surveillance systems in place from peer-reviewed and publicly available data, analysed the epidemiological characteristics of novel outbreaks over this period, and assessed surveillance system sensitivity and timeliness in outbreak detection. These findings were integrated with analysis of other critical COVID-19 public health measures to establish requirements for future COVID-19 management. FindingsAustralia reported 25 epidemiologically distinct outbreaks and 5 distinct clusters of cases in the study period, all linked through genomic sequencing to breaches in quarantine facilities housing international travellers. Most (21/30, 70%) were detected through testing of those with acute respiratory illness in the community, and 9 through quarantine screening. For the 21 detected in the community, the testing rate (percent of the total State population tested in the week preceding detection) was 2.07% on average, was higher for those detected while prior outbreaks were ongoing. For 17/30 with data, the delay from the primary case to detection of the index case was, on average 4.9 days, with 10 of the 17 outbreaks detected within 5 days and 3 detected after > 7days. One outbreak was preceded by an unexpected positive wastewater detection. Of the 24 outbreaks in 2021, 20 had publicly available sequencing data, all of which were VoCs. Surveillance for future VoCs using a similar strategy to that used for detecting SARS-CoV-2 to date would necessitate a 100-1,000-fold increase in capacity for genomic sequencing. InterpretationAustralias surveillance systems performed well in detecting novel introduction of SARS-CoV-2 in a period when community transmission was eliminated, introductions were infrequent and case numbers were low. Detection relied on community surveillance in symptomatic members of the general population and quarantine screening, supported by comprehensive genomic sequencing. Once vaccine coverage is maximised, the priority for future COVID-19 control will shift to detection of SARS-CoV-2 Vos associated with increased severity of disease in the vaccinated and vaccine ineligible. This will require ongoing investment in maintaining surveillance systems and testing of all international arrivals, alongside greatly increased genomic sequencing capacity. Other essential requirements for managing voices are maintaining outbreak response capacity and developing capacity to rapidly engineer, manufacture, and distribute variant vaccines at scale. The most important factor in management of COVID-19 now and into the future will continue to be how effectively governments support all sectors of the community to engage in control measures.
Subject(s)
COVID-19 , Respiratory InsufficiencyABSTRACT
In 2020 many countries are struggling to respond to a ‘second wave’ of COVID-19 infections through: mandatory and voluntary social distancing (SD) measures; testing, contact tracing and isolation; border controls; and economic incentives and stimulus measures. A second wave of infections began in the Australian state of Victoria from the end of May and in Western Europe from July. Following a series of Victorian state government measures beginning in June 2020, new daily cases and daily COVID-19 fatalities, respectively, peaked on 5 August and 4 September and there have been no new COVID-19 cases and fatalities for more than 30 days as of 30 November 2020. We contrast the Victorian government’s responses to its second wave to those of Western Europe, compare the economy and public health costs and provide six key policy findings.
Subject(s)
COVID-19 , Headache DisordersABSTRACT
Objective(s): Australia requires high quality evidence to optimise likely health and economy outcomes to effectively manage the current resurgence of COVID-19. We hypothesise that the most stringent social distancing (SD) measures (100% of level in Australia in April 2020) deliver better public health and economy outcomes. Design: Fit-for-purpose (individual-based and compartment) models were used to simulate the effects of different SD and detection strategies on Australian COVID-19 infections and the economy from March to July 2020. Public reported COVID-19 data were used to estimate model parameters. Main outcome measures: Public health and economy outcomes for multiple social distancing levels were evaluated, assessing hard versus soft lockdowns, and for early versus later relaxation of social distancing. Outcomes included costs and the timing and magnitude of observed COVID-19 cases and cumulative deaths in Australia from March to June 2020. Results: Higher levels of social distancing achieve zero community transmission with 100% probability and lower economy cost while low levels of social distancing result in uncontrolled outbreaks and higher economy costs. High social distancing total economy costs were $17.4B versus $41.2B for 0.7 social distancing. Early relaxation of suppression results in worse public health outcomes and higher economy costs. Conclusion(s): Better public health outcomes (reduced COVID-19 fatalities) are positively associated with lower economy costs and higher levels of social distancing; achieving zero community transmission lowers both public health and economy costs compared to allowing community transmission to continue; and early relaxation of social distancing increases both public health and economy costs.
Subject(s)
COVID-19ABSTRACT
BackgroundFollowing successful implementation of strong containment measures by the community, Australia is now close to the point of eliminating detectable community transmission of COVID-19. We aimed to develop an efficient, rapid and scalable surveillance strategy for detecting all remaining COVID-19 community transmission through exhaustive identification of every active transmission chain. We also identified measures to enable early detection and effective management of any reintroduction of transmission once containment measures are lifted to ensure strong containment measures do not need to be reinstated. MethodsWe compared efficiency and sensitivity to detect community transmission chains through testing of: hospital cases; primary care fever and cough patients; or asymptomatic community members, using surveillance evaluation methods and mathematical modelling, varying testing capacities and prevalence of COVID-19 and non-COVID-19 fever and cough, and the reproduction number. System requirements for increasing testing to allow exhaustive identification of all transmission chains, and then enable complete follow-up of all cases and contacts within each chain, were assessed per million population. FindingsAssuming 20% of cases are asymptomatic and all symptomatic COVID-19 cases present to primary care, with high transmission (R=2.2) there are a median of 13 unrecognised community cases (5 infectious) when a transmission chain is identified through hospital surveillance versus 3 unrecognised cases (1 infectious) through primary care surveillance. 3 unrecognised community upstream community cases themselves are estimated to generate a further 22-33 contacts requiring follow-up. The unrecognised community cases rise to 5 if only 50% of symptomatic cases present to primary care. Screening for asymptomatic disease in the community cannot exhaustively identify all transmission under any of the scenarios assessed. The additional capacity required to screen all fever and cough primary care patients would be approximately 2,000 tests/million population per week using 1/16 pooling of samples. InterpretationScreening all syndromic fever and cough primary care presentations, in combination with exhaustive and meticulous case and contact identification and management, enables appropriate early detection and elimination of community transmission of COVID-19. If testing capacity is limited, interventions such as pooling allow increased case detection, even given reduced test sensitivity. Wider identification and testing of all upstream contacts, (i.e. potential sources of infection for identified cases, and their related transmission chains) is critical, and to be done exhaustively requires more resources than downstream contact tracing. The most important factor in determining the performance of such a surveillance system is community participation in screening and follow up, and as such, appropriate community engagement, messaging and support to encourage presentation and compliance is essential. We provide operational guidance on implementing such a system. FundingNo specific funding was received for this project, beyond the salary support the authors receive from their institutions and elsewhere. Professor Banks is supported by the National Health and Medical Research Council of Australia (Principal Research Fellowship 1136128).