COVID-19 vaccination in Sindh Province, Pakistan: a modelling study of health impact and cost-effectiveness
Authors: Pearson Carl A B , Bozzani Fiammetta , Procter Simon R , Davies Nicholas G , Huda Maryam , Jensen Henning Tarp , Keogh-Brown Marcus , Khalid Muhammad , Sweeney Sedona , Torres-Rueda Sergio ,   CHiL COVID-19 Working Group,   CMMID COVID-19 Working Group, Eggo Rosalind M , Vassall Anna , Jit Mark 
Published: February 2021

AbstractBackgroundMultiple 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 SummaryWhy Was This Study Done?-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.