Health impact and cost-effectiveness of COVID-19 vaccination in Sindh Province, Pakistan

Pearson, C. A.; Bozzani, F.; Procter, S. R.; Davies, N. G.; Huda, M.; Jensen, H. T.; Keogh-Brown, M.; Khalid, M.; Sweeney, S.; Torres-Rueda, S.; CHiL COVID-19 Working Group,; CMMID COVID-19 Working Group,; Eggo, R. M.; Vassall, A.; Jit, M.

Background Multiple 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 We fitted a compartmental transmission model to COVID-19 cases and deaths in Sindh from 30 April to 15 September 2020 using varying assumptions about the timing of the first case and the duration of infection-induced immunity. We then projected cases and deaths 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 cost-effectiveness for each scenario. Findings A one-year vaccination campaign using an infection-blocking vaccine at $3/dose with 70% efficacy and 2.5 year duration of protection is projected to avert around 0.93 (95% Credible Interval: 0.91, 1.0) million cases, 7.3 (95% CrI: 7.2, 7.4) thousand deaths and 85.1 (95% CrI: 84.6, 86.8) thousand DALYs, and be net cost saving from the health system perspective. However, paying a high price for vaccination ($10/dose) may not be cost-effective. Vaccinating the older (65+) population first would prevent slightly more deaths and a similar number of cases as vaccinating everyone aged 15+ at the same time, at similar cost-effectiveness. Interpretation 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, 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.