BackgroundWe compared the health and economic consequences for the State of Victoria, Australia, of four COVID-19 strategies: aggressive and moderate elimination, tight suppression (aiming for 1 to 5 cases per million per day) and loose suppression (5 to 25 cases per million per day). The strategies shifted up and down through five levels of policy stringency based on the number of cases per day, for one year.MethodsAn agent-based model (ABM) generated 100 runs of daily SARS-CoV-2 case numbers, that then fed into a proportional multistate lifetable to estimate health adjusted life years (HALYs) and costs. We used a net monetary benefit approach to estimate the optimal strategy.FindingsAggressive elimination resulted in the highest percentage of days with the lowest level of restrictions (median 31.7%, 90% simulation interval 6.6% to 64.4%). However, days in hard lockdown were similar across all four strategies (medians 27.5% to 36.1%).HALY losses (compared to a no-COVID-19 scenario) were similar for moderate elimination (286, 219 to 389) and moderate elimination (314, 228 to 413), and nearly eight and 40-times higher for tight and loose suppression. The median GDP loss was least for moderate elimination ($US41.7 billion, $29.0 to $63.6 billion), but there was substantial overlap in simulation intervals between the four strategies.From a health system perspective aggressive elimination was optimal in 64% of simulations above a willingness to pay of $15,000 per HALY, followed by moderate elimination in 35% of simulations. Moderate elimination was optimal from a partial societal perspective in half the simulations followed by aggressive elimination in a quarter.Shortening the pandemic duration to 6 months saw loose suppression become preferable under a partial societal perspective.InterpretationFor this single high-income jurisdiction, elimination strategies were preferable over a 1-year pandemic duration.FundingAnonymous philanthropic donation to the University of Melbourne.Research in contextEvidence before this studyThere have been varying approaches across countries and jurisdictions as to how to manage the COVID-19 pandemic, ranging from elimination of community transmission (e.g. Australasia, Taiwan and other East Asian and Pacific Island countries) to loose suppression or mitigation that attempts to keep the case numbers within health services capacity (e.g. Sweden, USA, India, UK and some continental European countries). The best or optimal approach is unknown, and involves an invidious balancing of health, social and economic consequences of the pandemic. But it has become apparent that in high income countries using loose suppression that one still has to use lock-downs from time to time to keep case numbers within health service capacity, raising the question as to what is the best for the economy – attempting elimination, tight suppression or loose suppression?One approach to integrating the health and economic consequences is cost effectiveness analysis, but to date such approaches have mainly been focused on SARS-CoV-2 treatments rather than societal intervention, and have not incorporated a counterfactual approach to compare the same jurisdiction across the many (stochastically varying) realizations for different policy options.Added value of this studyThis study uses one high-income jurisdiction, the state of Victoria in Australia as it exited its second wave, to estimate the health and economic consequences of four policy options: aggressive and moderate elimination strategies, and tight and loose suppression strategies. The modeling is done in two steps: first, an agent-based model to simulate 100 possible trajectories of daily SARS-CoV-2 infections over one year for each of the four policy options; and second, an integrated epidemiological and economic model that estimates health and economic costs. Whilst there is considerable uncertainty in outcomes for all of the four policy options, the two elimination options are usually optimal from both a health system and a partial societal (health expenditure plus GDP cost) perspective. However, if the remaining duration of the pandemic is lessened from 1 year to half a year (as may be the case with vaccine roll-outs), loose suppression becomes more favorable – suggesting countries with already high infection rates ‘ride it out’ till vaccination coverage is adequate.

This economic evaluation determines the optimal policy response to the COVID-19 pandemic in Victoria, Australia, using a net monetary benefit approach for policies ranging from aggressive elimination and moderate elimination to tight suppression and loose suppression.

BackgroundCost-effectiveness analysis (CEA) is frequently used as an input for guiding priority setting in health. However, CEA seldom incorporates information about trade-offs between total health gains and equity impacts of interventions. This study investigates to what extent equity considerations have been taken into account in CEA in low- and middle-income countries (LMICs), using rotavirus vaccination as a case study.MethodsSpecific equity-related indicators for vaccination were first mapped to the Guidance on Priority Setting in Health Care (GPS-Health) checklist criteria. Economic evaluations of rotavirus vaccine in LMICs identified via a systematic review of the literature were assessed to explore the extent to which equity was considered in the research objectives and analysis, and whether it was reflected in the evaluation results.ResultsThe mapping process resulted in 18 unique indicators. Under the ‘disease and intervention’ criteria, severity of illness was incorporated in 75% of the articles, age distribution of the disease in 70%, and presence of comorbidities in 5%. For the ‘social groups’ criteria, relative coverage reflecting wealth-based coverage inequality was taken into account in 30% of the articles, geographic location in 27%, household income level in 8%, and sex at birth in 5%. For the criteria of ‘protection against the financial and social effects of ill health’, age weighting was incorporated in 43% of the articles, societal perspective in 58%, caregiver’s loss of productivity in 45%, and financial risk protection in 5%. Overall, some articles incorporated the indicators in their model inputs (20%) while the majority (80%) presented results (costs, health outcomes, or incremental cost-effectiveness ratios) differentiated according to the indicators. Critically, less than a fifth (17%) of articles incorporating indicators did so due to an explicit study objective related to capturing equity considerations. Most indicators were increasingly incorporated over time, with a notable exception of age-weighting of DALYs.ConclusionIntegrating equity criteria in CEA can help policy-makers better understand the distributional impact of health interventions. This study illustrates how equity considerations are currently being incorporated within CEA of rotavirus vaccination and highlights the components of equity that have been used in studies in LMICs. Areas for further improvement are identified.Electronic supplementary materialThe online version of this article (10.1186/s12962-018-0102-2) contains supplementary material, which is available to authorized users.

Background: Pectin is a heterogeneous polysaccharide mainly present in citrus fruits and has different biological activities.Objective: High molecular weight Citrus Pectin and modified citrus pectin (MCP) were tested for their cytotoxic, anti-proliferative, and anti-oxidant activity.Methods: The cytotoxicity of pectin was studied against HaCaT cell line (human keratinocyte cell line) using Trypan blue method and LDH-cytotoxicity assay. Anti-proliferative activity was assayed using a WST-1 proliferation kit. Antioxidant activity was determined using the DPPH scavenging assay.Results: MCP and Pectin both reduced the viability of HaCaT cells in a dose dependent manner; however MCP was found to be more cytotoxic than high molecular weight citrus pectin since it had a lower IC50 (300ug/ul). At non-cytotoxic concentrations, the viability of cells decreased with increase of concentration of MCP as determined by the WST-1. MCP exhibited a higher antioxidant effect than pectin (SC50 at a concentration range between 2 and 4mg/ml).Conclusion: This study suggests that MCP exhibits a stronger cytotoxic and anti-proliferative effect on HaCaT cell line than pectin. The most probable explanation of this observation is the different effect due to the variable molecular weight and exposed side-chains of MCP and high molecular weight citrus pectin. Keywords: Cytotoxic, Anti-proliferative, Pectin, MCP, HaCaT cell line

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