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Summary Background China has the highest prevalence of hepatitis B virus (HBV) infection worldwide. Universal HBV screening might enable China to reach the WHO 2030 target of 90% diagnostics, 80% treatment, and 65% HBV-related death reduction, and eventually elimination of viral hepatitis. We evaluated the cost-effectiveness of implementing universal HBV screening in China and identified optimal screening strategies. Methods We used a Markov cohort model, inputting parameters based on data from previous studies and public databases, to assess the cost-effectiveness of four HBV serological screening strategies in China in different screening scenarios. We simulated universal screening scenarios in 15 adult age groups between 18 and 70 years, with different years of screening implementation (2021, 2026, and 2031) and compared to the status quo (ie, no universal screening); in total, we investigated 180 different screening scenarios. We calculated the incremental cost-effectiveness ratio (ICER) between the different screening strategies and the status quo (current screening strategy). We performed probabilistic and one-way deterministic sensitivity analyses to assess the robustness of our findings. Findings With a willingness-to-pay level of three times the Chinese gross domestic product (GDP) per capita (US$30 828), all universal screening scenarios in 2021 were cost-effective compared with the status quo. The serum HBsAg/HBsAb/HBeAg/HBeAb/HBcAb (five-test) screening strategy in people aged 18–70 years was the most cost-effective strategy in 2021 (ICER $18 295/quality-adjusted life-years [QALY] gained). This strategy remained the most cost-effective, when the willingness-to-pay threshold was reduced to 2 times GDP per capita. The two-test strategy for people aged 18–70 years became more cost-effective at lower willingness-to-pay levels. The five-test strategy could prevent 3·46 million liver-related deaths in China over the lifetime of the cohort. It remained the most cost-effective strategy when implementation was delayed until 2026 (ICER $20 183/QALY) and 2031 (ICER $23 123/QALY). Screening young people (18–30 years) will no longer be cost-effective in delayed scenarios. Interpretation The five-test universal screening strategy in people aged 18–70 years, implemented within the next 10 years, is the optimal HBV screening strategy for China. Other screening strategies could be cost-effective alternatives, if budget is limited in rural areas. Delaying strategy implementation reduces overall cost-effectiveness. Early screening initiation will aid global efforts in achieving viral hepatitis elimination. Funding National Natural Science Foundation of China.

BACKGROUNDCOVID-19 and diabetes both contribute to large global disease burdens.PURPOSETo quantify the prevalence of diabetes in various COVID-19 disease stages and calculate the population attributable fraction (PAF) of diabetes to COVID-19–related severity and mortality.DATA SOURCESSystematic review identified 729 studies with 29,874,938 COVID-19 patients.STUDY SELECTIONStudies detailed the prevalence of diabetes in subjects with known COVID-19 diagnosis and severity.DATA EXTRACTIONStudy information, COVID-19 disease stages, and diabetes prevalence were extracted.DATA SYNTHESISThe pooled prevalence of diabetes in stratified COVID-19 groups was 14.7% (95% CI 12.5–16.9) among confirmed cases, 10.4% (7.6–13.6) among nonhospitalized cases, 21.4% (20.4–22.5) among hospitalized cases, 11.9% (10.2–13.7) among nonsevere cases, 28.9% (27.0–30.8) among severe cases, and 34.6% (32.8–36.5) among deceased individuals, respectively. Multivariate metaregression analysis explained 53–83% heterogeneity of the pooled prevalence. Based on a modified version of the comparative risk assessment model, we estimated that the overall PAF of diabetes was 9.5% (7.3–11.7) for the presence of severe disease in COVID-19–infected individuals and 16.8% (14.8–18.8) for COVID-19–related deaths. Subgroup analyses demonstrated that countries with high income levels, high health care access and quality index, and low diabetes disease burden had lower PAF of diabetes contributing to COVID-19 severity and death.LIMITATIONSMost studies had a high risk of bias.CONCLUSIONSThe prevalence of diabetes increases with COVID-19 severity, and diabetes accounts for 9.5% of severe COVID-19 cases and 16.8% of deaths, with disparities according to country income, health care access and quality index, and diabetes disease burden.

Background: To prevent the catastrophic health and economic consequences from COVID-19 epidemics, nations had to respond with swift public health interventions to achieve no community transmission outside of quarantine. However, the exact characteristics of an outbreak that trigger these measures are poorly defined. We aimed to assess the critical timing and extent of interventions in Australia. Methods: We developed a practical model using existing epidemics data in Australia. We quantified the effective combinations of public health interventions and the critical number of daily cases for intervention commencement. We assessed the impact of increasing transmissibility from new variants and the effect of vaccination coverage on the critical timing and extent of interventions. Findings: We found that in the past COVID-19 outbreaks in four Australian states, the number of reported cases on the day that interventions commenced strongly predicted the size and duration of the outbreaks. In the early phase of an outbreak, containing a wild-type dominant epidemic to a low level (≤10 cases/day) required effective combinations of social distancing and face mask use interventions to be commenced before the number of daily reported cases reaches 6 cases. Containing epidemics from alpha variant would require more stringent interventions that commenced earlier. For delta variant, public health interventions alone will not contain the epidemic, unless with a moderate vaccination coverage (≥50%). Interpretation: Our study highlights the importance of early and decisive action in the initial phase of an outbreak if governments aimed for zero community transmission. Vaccination is essential for containing variants. Funding Information: LZ is supported by the National Natural Science Foundation of China (grant number: 8191101420), Thousand Talents Plan Professorship for Young Scholars (Grant number: 3111500001); Xi’an Jiaotong University Basic Research and Profession Grant (Grant number: xtr022019003) and Xi’an Jiaotong University Young Talent Support Program (Grant number: YX6J004). The study is supported by Bill and Melinda Gates Foundation. Declaration of Interests: The authors declare no competing interests.

Background: With the largest hepatitis B virus (HBV) infected population worldwide, universal HBV screening in China may significantly contribute to the World Health Organization (WHO) 2030 goals in eliminating viral hepatitis. We evaluated the cost-effectiveness of universal HBV screening in China and identified optimal screening strategies. Methods: We conducted a cost-effectiveness analysis using a Markov cohort model based on four HBV serological screening methods in China. We simulated these universal screening in 15 different adult age groups with different initiation time (year 2021, 2026 and 2031). We performed probabilistic and one-way deterministic sensitivity analyses to assess the robustness of our findings. Results: With a willingness-to-pay level of 3x Chinese gross domestic product (GDP) per capita (US$30,828), HBsAg/HBsAb/HBeAg/HBeAb/HBcAb (five-test) screening among 18-70 years was the most cost-effective strategy in 2021 (incremental cost-effectiveness ratio [ICER] US$18,295/quality-adjusted life-year [QALY] gained). This remained the most cost-effective strategy, even when the willingness-to-pay threshold reduced to US$17,778; other strategies became more cost-effective at lower willingness-to-pay levels. This strategy would potentially prevent 3.46 million liver-related deaths over the lifetime of the cohort. It remained the most cost-effective even when the implementation was delayed to 2026 and 2031, but with greater ICERs (US$20,183/QALY and US$23,123/QALY, respectively). The screening will no longer be cost-effective in younger age groups in delayed scenarios. Conclusion: Five-test universal screening among 18-70 years implemented in 2021 is the optimal HBV screening strategy in China. Delaying strategy implementation reduces overall cost-effectiveness. Early screening initiation will aid global efforts in achieving viral hepatitis elimination. Funding: LZ is supported by the National Natural Science Foundation of China (grant number 8191101420); Outstanding Young Scholars Funding (3111500001); Xi'an Jiaotong University Basic Research and Profession Grant (xtr022019003); and Xi'an Jiaotong University Young Talent Support Program (YX6J004). WKS is supported by the Outstanding Young Researcher Award, the University of Hong Kong. JJO is supported by the Australian National Health and Medical Research Council Emerging Leadership Fellowship (GNT11953955). This project is funded by The University of Hong Kong Common Core Course. Declaration of Interest: PC is a staff member of the World Health Organization; the author alone is responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the World Health Organization. MFY is an advisory board member and/or received research funding from AbbVie, Arbutus Biopharma, Assembly Biosciences, Bristol Myer Squibb, Dicerna Pharmaceuticals, GlaxoSmithKline, Gilead Sciences, Janssen, Merck Sharp and Dohme, Clear B Therapeutics, Springbank Pharmaceuticals; and received research funding from Arrowhead Pharmaceuticals, Fujirebio Incorporation and Sysmex Corporation. WKS received speaker's fees from AstraZeneca and Mylan, is an advisory board member of CSL Behring, is an advisory board member and received speaker's fees from AbbVie, and is an advisory board member, received speaker's fees and researching funding from Gilead Sciences. The remaining authors have no conflict of interests.

OBJECTIVES: To evaluate the cost-effectiveness of a booster strategy in the United States. METHODS: We developed a decision-analytic Markov model of COVID-19 to evaluate the cost-effectiveness of a booster strategy of the Pfizer-BioNTech BNT162b2 (administered 6 months after the second dose) among older adults from a healthcare system perspective. RESULTS: Compared with 2 doses of BNT162b2 without a booster, the booster strategy in a 100,000 cohort of older adults would incur an additional cost of $3.4 million in vaccination cost but save $6.7 million in direct medical cost and gain 3.7 quality-adjusted life-years in 180 days. This corresponds to a benefit-cost ratio of 1.95 and a net monetary benefit of $3.4 million. Probabilistic sensitivity analysis indicates that a booster strategy has a high chance (67%) of being cost-effective. Notably, the cost-effectiveness of the booster strategy is highly sensitive to the population incidence of COVID-19, with a cost-effectiveness threshold of 8.1/100,000 person-day. If vaccine efficacies reduce by 10%, 30%, and 50%, this threshold will increase to 9.7/100,000, 13.9/100,000, and 21.9/100,000 person-day, respectively. CONCLUSION: Offering the BNT162b2 booster to older adults aged ≥65 years in the United States is likely to be cost-effective. Less efficacious vaccines and boosters may still be cost-effective in settings of high SARS-CoV-2 transmission.

Background: The Chinese government implemented a metropolitan-wide quarantine of Wuhan city on 23 rd January 2020 to curb the epidemic of the coronavirus COVID-19. Lifting of this quarantine is imminent. We modelled the effects of two key health interventions on the epidemic when the quarantine is lifted. Method: We constructed a compartmental dynamic model to forecast the trend of the COVID-19 epidemic at different quarantine lifting dates and investigated the impact of different rates of public contact and facial mask usage on the epidemic. Results: We projected a declining trend of the COVID-19 epidemic if the current quarantine strategy continues, and Wuhan would record the last new confirmed cases on 25 th April 2020. At the end of the epidemic, 65,572 (46,156-95,264) individuals would be infected by the virus, among which 16,144 (14,422-23,447, 24.6%) were through public contacts, 45,795 (32,390-66,395, 69.7%) through household contact, and 3,633 (2,344-5,865, 5.5%) through hospital contacts (including 783 (553-1,134) non-COVID-19 patients and 2,850 (1,801-4,981) medical staff). A total of 3,262 (1,592-6,470) would die of COVID-19 related pneumonia in Wuhan. Early quarantine lifting on 21 st March is viable only if Wuhan residents sustain a high facial mask usage of ≥85% and a pre-quarantine level public contact rate. Delaying city resumption to mid/late April would relax the requirement of facial mask usage to ≥75% at the same contact rate. Conclusion: The prevention of a second epidemic is viable after the metropolitan-wide quarantine is lifted but requires a sustaining high facial mask usage and a low public contact rate. Funding Statement: This work is supported by a Research Grant from the Bill & Melinda Gates Foundation. Declaration of Interests: None.

Background: Coinciding with the first and soon-to-be released Chinese domestic human papillomavirus (HPV) vaccine, Innovax, and the substantial advancements in cervical cancer screening technology, we evaluated the cost-effectiveness of universal schoolgirls vaccination with Innovax and several cervical cancer screening programmes and identified the cost-effectiveness threshold for the vaccination cost in China. Methods: We developed a Markov model of cervical cancer to evaluate the incremental cost-effectiveness ratios (ICERs) of sixty-one intervention strategies, including a combination of various screening methods at different frequencies with and without vaccination, and also vaccination alone, from a healthcare system perspective. We conducted univariate and probabilistic sensitivity analyses to assess the robustness of the model findings. Findings: Compared with ‘no intervention’, all intervention strategies resulted in an ICER less than 3-time Chinese per-capita gross domestic product (GDP) (ranging from cost-saving to US$24,302/quality-adjusted-life-year (QALY)), except 3-yearly liquid-based cytology+Hybrid Capture-2 screening. With a willingness-to-pay (WTP) threshold of 3-time per-capita GDP, 5-yearly careHPV screening alone would be the most cost-effective strategy with an ICER of US$16,447/QALY compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier, and the probability of it being optimal (42%) outperformed other strategies. Strategies that combined screening and vaccination were only more cost-effective than screening alone strategies when the vaccination cost was below US$100/3 doses at the current WTP. Interpretation: Five-yearly careHPV screening is the most cost-effective strategy. Reduction in domestic HPV vaccine price is necessary to ascertain a good economic return for the future vaccination programme. Funding Statement: LZ is supported by Xi’An Jiaotong University Young Talent Support Program, with project title ‘Innovative approaches for risk prediction and prevention of HIV and sexually transmitted infections in China’. KC is co-PI of an unrelated investigator-initiated trial of cervical cytology and primary HPV screening in Australia (‘Compass’), which is conducted and funded by the VCS foundation, a government-funded health promotion charity. The VCS foundation has received equipment and a funding contribution for the Compass trial from Roche Molecular Systems and Ventana Inc USA. However neither she nor her institution on her behalf (Cancer Council NSW) receives direct funding from industry Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Not required.