The Cost-Effectiveness of Outbreak Responses: Considerations in the COVID-19 Era

This piece was published first on the Tufts Medical Center's Center for the Evaluation of Value and Risk in Health's (CEVR) website. See the original here.

The drumbeat of advice seems constant: countries must focus all efforts on suppressing the current COVID-19 coronavirus pandemic, regardless of expense or impact on the broader economy. Ineffectual or incomplete suppression will have drastic effects on any health system’s ability to treat affected patients, with even more catastrophic consequences.

But no country, no matter how wealthy, has unlimited resources to throw at this crisis. Omitted from most reports are analyses of the tradeoffs that must be made between the benefits and economic costs of different containment and mitigation strategies, which are especially and painfully clear in low- and middle-income settings. Furthermore, evaluations should include immediate consequences as well as potential contributions toward preventing or mitigating future pandemics.

We evaluated how frequently the cost-effectiveness of disease outbreak control and/or prevention strategies has been assessed in the published literature. We queried the Tufts-CEVR CEA Registry, which contains information on over 8,000 cost-per-quality-adjusted-life-year (QALY) studies with over 20,000 cost-effectiveness ratios. We identified only 38 published studies (0.5 percent) that addressed this question. Of the 143 intervention-specific cost-effectiveness ratios reported in these studies, nearly 70 percent focused on vaccine or pharmaceutical strategies, with the remainder spread across broader approaches, such as screening or testing strategies, school closures, or stockpiling of supplies. The incremental cost-effectiveness ratios ranged from $440 USD/QALY (intravenous antiviral agents to treat hospitalized patients with influenza-like (HINI) illness) to $15,000,000 USD/QALY (universal meningococcal serotype B vaccination), with a median of $49,000 USD/QALY, while 37 interventions were “cost-saving” (lower costs and higher QALYs relative to an alternative policy or no intervention) (e.g., one-dose varicella vaccination).

We also examined similar data from the Tufts-CEVR Global Health CEA Registry, which contains information from more than 700 cost-per-disability-adjusted life year (DALY)-averted studies with nearly 6,000 ratios that focus primarily on LMICs. We found only 11 studies of outbreak or epidemic control (1.6 percent), seven of which described broad-based control strategies (i.e., beyond single vaccine or treatment programs). Six of the seven interventions were found to be highly cost-effective, ranging from $40 (integrated HIV and malnutrition control in Malawi) to $720 (insecticide-based prevention strategies for Dengue fever in Brazil) per DALY averted (median $169), all below a common threshold of GDP per capita in the relevant country. (The seventh study, with an estimate of $54,000 per DALY averted, was conducted in a high-income setting, and would still be considered cost-effective by most standards). However only two of the seven studies included estimates of the cost of implementing and maintaining the intervention over time; one of these studies was the high-income study mentioned above, and the other focused on an isolated refugee encampment in Pakistan. In other cases, costs of implementation or future surveillance were unavailable; in one, the full costs of the intervention were estimated, but services could not be consistently delivered due to budgetary issues.

Cost-effectiveness analysis can inform decisions about the most efficient, comprehensive, and feasible strategies to combat pandemic situations. Ideally, such analyses would be conducted before an outbreak occurs, although even amid of our current pandemic, augmenting public health intervention assessments—like the simulations run by Imperial College in the UK and Columbia University in the US—to include cost-effectiveness analysis can help to inform decision-making by integrating information on the societal costs and health benefits, and implementation challenges associated with different control strategies. To date, few cost-effectiveness analyses of pandemic responses have been published, and funding and conducting such analyses should be a priority for the future. Without such information, countries and health systems may be allocating resources unwisely, resulting in fewer health gains during an ongoing epidemic, and reducing their ability to effectively respond to the next one.