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Objectives: The exact characteristics of a coronavirus disease 2019 (COVID-19) outbreak that trigger public health interventions are poorly defined. The aim of this study was to assess the critical timing and extent of public health interventions to contain COVID-19 outbreaks in Australia. Methods: A practical model was developed using existing epidemic data in Australia. The effective combinations of public health interventions and the critical number of daily cases for intervention commencement under various scenarios of changes in transmissibility of new variants and vaccination coverage were quantified. Results: 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 wildtype-dominant epidemic to a low level (≤10 cases/day) would require effective combinations of social distancing and face mask use interventions to be commenced before the number of daily reported cases reaches six. Containing an Alpha-dominant epidemic would require more stringent interventions that commence earlier. For the Delta variant, public health interventions alone would not contain the epidemic unless the vaccination coverage was ≥70%. Conclusions: This study highlights the importance of early and decisive action in the initial phase of an outbreak. Vaccination is essential for containing variants.

Financial incentives may reduce opportunity costs associated with people who become lost to follow-up in hepatitis C treatment programs. We estimated the impact that different financial incentive amounts would need to have on retention in care to maintain the same unit cost per (1) RNA-positive person completing testing (defined as awareness of RNA status) and (2) RNA diagnosed person initiating treatment. Costing data were obtained from a 2019 community-based testing campaign focused on engaging people who inject drugs. For different financial incentive amounts, we modelled the corresponding improvements in retention in care that would be needed to maintain the same overall (1) unit cost per testing completion and (2) unit cost per treatment initiation. In the testing campaign, the unit cost per RNA-positive person completing testing was A$3215 and the unit cost per RNA diagnosed person initiating treatment was A$1055. Modelling found that an incentive of A$500 per RNA-positive person completing testing would result in more people completing testing for the same unit cost if the percentage of attendees receiving their test results increased from 63% to 74%. An incentive of A$200 per RNA diagnosed person initiating treatment would result in more people initiating treatment for the same unit cost if the percentage initiating treatment increased from 67% to 83%. Monetary incentives for completing testing and initiating treatment may be an effective way to increase retention in care without increasing the overall unit cost of completing testing/initiating treatment.

The economic crisis and food and health system disruptions related to the COVID-19 pandemic threaten to exacerbate undernutrition in low- and middle-income countries (LMICs). We developed pessimistic, moderate and optimistic scenarios for 2020–2022 and used three modelling tools (MIRAGRODEP, the Lives Saved Tool and Optima Nutrition) to estimate the impacts of pandemic-induced disruptions on child stunting, wasting and mortality, maternal anaemia and children born to women with a low body mass index (BMI) in 118 LMICs. We estimated the cost of six nutrition interventions to mitigate excess stunting and child mortality due to the pandemic and to maximize alive and non-stunted children, and used the human capital approach to estimate future productivity losses. By 2022, COVID-19-related disruptions could result in an additional 9.3 million wasted children and 2.6 million stunted children, 168,000 additional child deaths, 2.1 million maternal anaemia cases, 2.1 million children born to women with a low BMI and US$29.7 billion in future productivity losses due to excess stunting and child mortality. An additional US$1.2 billion per year will be needed to mitigate these effects by scaling up nutrition interventions. Governments and donors must maintain nutrition as a priority, continue to support resilient systems and ensure the efficient use of new and existing resources. Impacts of the COVID-19 crisis on maternal and child nutrition outcomes, and productivity losses due to childhood stunting and mortality, in 118 low- and middle-income countries are projected under optimistic, moderate and pessimistic scenarios. Six nutrition interventions to mitigate excess stunting and child mortality are financially costed.

Background Postpartum hemorrhage (PPH) is responsible for nearly one quarter of maternal deaths. A 2017 multicountry trial found that incorporating tranexamic acid (TXA) into the PPH management package was effective in reducing maternal death due to bleeding. Objective To systematically review studies assessing the cost‐effectiveness of tranexamic acid for PPH treatment. Search strategy Nine databases were searched using variations of keywords ‘tranexamic acid’, ‘postpartum hemorrhage’ and ‘cost effectiveness’. Selection criteria Eligible studies were any type of economic or effectiveness evaluation studies on tranexamic acid for treating women with PPH. Data collection and analysis Two reviewers independently screened citations and extracted data on cost effectiveness measures. Quality was assessed using the Consensus on Health Economic Criteria list. Main results Four studies were included, of which two were abstracts. Three studies concluded that early administration of TXA was cost‐saving or cost‐effective. One abstract reported TXA was not cost‐effective in the USA unless the probability of death due to hemorrhage is higher. Conclusion Available evidence (four studies in three countries) suggests that this life‐saving intervention may be below willingness to pay thresholds (cost‐effective) or cost saving. Further studies conducted in different populations and settings are needed to inform health policy decision‐making to reduce PPH‐associated morbidity and mortality., Synopsis Tranexamic acid for treating women with postpartum hemorrhage may be cost effective, but further research is needed in different countries and settings.

Background and Aims More than 292 million people are living with hepatitis B worldwide and are at risk of death from liver cirrhosis and liver cancer. The World Health Organization (WHO) has set global targets for the elimination of viral hepatitis as a public health threat by 2030. However, current levels of global investment in viral hepatitis elimination programmes are insufficient to achieve these goals. Methods To catalyse political commitment and to encourage domestic- and international-financing, we used published modelling data and key stakeholder interviews to develop an investment framework to demonstrate the return on investment for viral hepatitis elimination. Results The framework utilizes a public health approach to identify evidence-based national activities that reduce viral hepatitis-related morbidity and mortality, as well as international activities and critical enablers that allow countries to achieve maximum impact on health outcomes from investment to achieve WHO 2030 elimination targets. Conclusion Focusing on hepatitis B, this health policy paper employs the investment framework to estimate the substantial economic benefits of investing in the elimination of hepatitis B and demonstrates how such investments could be cost-saving by 2030., Graphical abstract, Highlights • The WHO has set global targets for elimination of hepatitis B by 2030 • To date, global investment in hepatitis B elimination activities has been limited • We have developed a global investment framework for the elimination of hepatitis B to guide domestic and international investment • This Health Policy paper outlines evidence to support the financial returns on investment in hepatitis B elimination, identifies national and international activities to achieve hepatitis B elimination targets and identifies potential funding sources • The goal of this investment framework is to pave the way for countries to build the economic case for investment in national hepatitis B elimination programmes.

Summary Background By adulthood, gender inequalities in health and wellbeing are apparent. Yet, the timing and nature of gender inequalities during childhood and adolescence are less clear. We describe the emergence of gender inequalities in health and wellbeing across the first two decades of life. Methods We focused on the 40 low-income and middle-income countries in Asia and the Pacific. A measurement framework was developed around four key domains of wellbeing across the first two decades: health, education and transition to employment, protection, and a safe environment. Specific measurement constructs were then defined by considering gender indicator frameworks, the Sustainable Development Goals, indicator frameworks for child and adolescent health and wellbeing, and key stakeholder input. Available data were then mapped to define 87 indicators, subsequently populated using databases (UN agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study) and nationally representative surveys. Where possible, estimates in girls were compared with boys to report relative risks. Findings Although son preference is evident in some settings—as shown by higher than expected male-to-female sex ratios at birth in India, Vietnam, and China (all >1·10 compared with an expected ratio of 1·05) and excess mortality of girl children in some South Asian and Pacific nations—it is during early adolescence where marked gender inequalities consistently emerged. Adolescent girls face considerable disadvantage in relation to sexual and reproductive health (notably in South Asia and the Pacific), with high rates of child marriage (≥30% of women aged 20–24 years married before 18 years in Bangladesh, Nepal, and Afghanistan), fertility (≥65 livebirths per 1000 girls in Nauru, Laos, Afghanistan, Nepal, Marshall Islands, Bangladesh, Vanuatu, and Papua New Guinea), and intimate partner violence (>20% in Timor Leste, Afghanistan, Pakistan, and Myanmar). Despite educational parity in many countries, females aged 15–24 years were less likely than males to be in education, employment, or training in 17 of 19 countries for which data were available. Compared with girls, adolescent boys experienced excess all-cause mortality and substantially higher mortality due to unintentional injury, interpersonal violence, alcohol and other drugs, and suicide, and higher prevalence of harmful drinking and tobacco smoking. Interpretation These findings call for a focus on gender policy and programming in later childhood and early adolescence before gender inequalities become embedded. Funding UNICEF.

Background: Uterine tamponade is widely promoted for treating refractory postpartum hemorrhage (PPH); however, its cost‐effectiveness may vary depending on unit costs and setting. Objective: To review available data on cost‐effectiveness of uterine tamponade devices when used for PPH treatment. Search strategy: PubMed and EMBASE were searched (1980 to January 2020), as well as the National Health Services Economic Evaluation database from inception (1995) to March 2015. Selection criteria: Eligible studies were any type of economic evaluation, or effective‐ ness studies that provided cost or economic data. Data collection and analysis: Two reviewers independently screened studies, extracted data, and assessed quality. Main results: Eleven studies using a range of devices (condom catheter, uterine suc‐ tion devices, Bakri, Inpress, Ellavi) were identified. Cost of condom catheter devices or kits ranged from US$0.64 to US$6, whereas purpose‐designed device costs were up to US$400. Two studies that took a health system perspective assessed the cost‐ effectiveness of using uterine balloon tamponade and suggested that it was highly cost‐ effective because of the low cost per disability‐adjusted life‐year averted, although both used effect estimates from case series. Conclusions: Evidence on the cost‐effectiveness of uterine tamponade devices was limited and not generalizable. Rigorous economic evaluations based on updated effect estimates are needed. Fil: Vogel, Joshua P.. Monash University; Australia Fil: Wilson, Alyce N.. Burnet Institute; Australia Fil: Scott, Nick. Monash University; Australia. Burnet Institute; Australia Fil: Widmer, Mariana. Organizacion Mundial de la Salud; Argentina Fil: Althabe, Fernando. Organizacion Mundial de la Salud; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Oladapo, Olufemi T.. Organizacion Mundial de la Salud; Argentina

WHO has set global targets for the elimination of hepatitis B and hepatitis C as a public health threat by 2030. However, investment in elimination programmes remains low. To help drive political commitment and catalyse domestic and international financing, we have developed a global investment framework for the elimination of hepatitis B and hepatitis C. The global investment framework presented in this Health Policy paper outlines national and international activities that will enable reductions in hepatitis C incidence and mortality, and identifies potential sources of funding and tools to help countries build the economic case for investing in national elimination activities. The goal of this framework is to provide a way for countries, particularly those with minimal resources, to gain the substantial economic benefit and cost savings that come from investing in hepatitis C elimination.

Major gains in reducing the burden of hepatitis C are now possible because of the discovery of a cure. The prevention of premature deaths and increased workforce participation among people who are cured are likely to provide substantial indirect economic benefits. We developed an investment case for hepatitis C for the six WHO world regions, which, to our knowledge, is the first to consider both indirect and direct economic benefits in this context. Scaling up of testing and treatment to reach the 2030 WHO hepatitis C elimination targets was estimated to prevent 2·1 million (95% credible interval 1·3-3·2 million) hepatitis C-related deaths and 10 million (4-14 million) new hepatitis C virus infections globally between 2018 and 2030. This elimination strategy was estimated to cost US$41·5 billion (33·1-48·7 billion) in testing, treatment, and health care between 2018 and 2030 ($23·4 billion more than the status quo scenario of no testing or treatment scale up), with a global average of $885 (654-1189) per disability-adjusted life-year averted at 2030. Compared with the status quo scenario, the elimination scenario generated $46·1 billion (35·9-53·8 billion) in cumulative productivity gains by 2030. These indirect costs made elimination cost-saving by 2027, with a net economic benefit of $22·7 billion (17·1-27·9 billion) by 2030. This model shows that countries might be underestimating the true burden of hepatitis C and will benefit from investing in elimination.

AIMS To estimate the prevalence of and risk factors associated with concurrent injection of multiple substances (co-injection) among a community-recruited cohort of people who inject drugs. DESIGN Cross-sectional study. SETTING Melbourne, Australia. PARTICIPANTS A sample of 720 actively injecting participants from the Melbourne Injecting Drug User Cohort Study (33% female) was extracted. MEASUREMENTS We constructed two statistical models: a logistic regression model analysing correlates of co-injection of any substance combination in the past month and a multinomial logistic regression model analysing correlates of three mutually exclusive groups: heroin-diphenhydramine co-injection only, co-injection of other substances and no co-injection. Risk factors examined included drug use characteristics, demographic characteristics, health service use, hepatitis C status, injection risk behaviours and previous experience of non-fatal overdose. FINDINGS One-third [n = 226, 31%; 95% confidence interval (CI): 28-34%] of participants reported co-injecting substances within the past month, with equal numbers of participants reporting injecting combinations of heroin-diphenhydramine (n = 121, 54%; 95% CI = 48-60%) and heroin-methamphetamine (n = 121, 54%; 95% CI = 48-60%). In logistic regression analyses, reporting co-injection of any substance combination was associated with male sex [adjusted odds ratio (aOR) = 1.80, 95% CI = 1.18-2.74, P = 0.006] and injecting daily or more frequently (aOR = 2.04, 95% CI = 1.31-3.18, P = 0.002). In multinomial logistic regression analyses, participants reporting heroin-diphenhydramine co-injection only were significantly more likely to report groin injecting [adjusted relative risk ratio (aRRR) = 6.16, 95% CI = 2.80-13.56, P

Aims We report on motivations for crystal methamphetamine-opioid co-use/co-injection through narratives of people who inject drugs during a period of increased crystal methamphetamine use reporting in Australia. Methods Fourteen in-depth interviews were undertaken with selected participants (12 male, 2 female) from the Melbourne Injecting Drug User Cohort Study, including those in and out of opioid substitution therapy (OST). Results The main motivations for co-use reported by participants were as follows: (1) that heroin could be used to reduce the negative side effects of heavy crystal methamphetamine use, particularly during the ‘comedown’ phase; (2) that small quantities of crystal methamphetamine used with heroin could prolong the intoxication effect of heroin, and hence the time before opioid withdrawal; (3) that co-injection of crystal methamphetamine and heroin produced a more desirable intoxication effect than using either substance on its own and; (4) that crystal methamphetamine provided a substitute ‘high’ for heroin after commencing OST treatment. Conclusions Co-use of methamphetamine and opioids has been used by people who inject drugs to facilitate intoxication, sometimes as the result of ineffective opioid substitution therapy (OST) treatment and perceived lack of pleasure after stabilisation on OST treatment.

Objectives Testing and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups. Methods We modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination). Results Compared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and –$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results. Conclusions Scaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices.

Background Compared to other countries in sub-Saharan Africa, Tanzania has a relatively progressive illicit drug harm reduction (HR) policy, through a predominantly opioid substitution therapy-based programme. However, access to hepatitis C virus (HCV) diagnosis and curative direct acting antiviral therapy remains elusive. We developed a cost-effectiveness model to evaluate a simplified HCV screening-and-treatment intervention amongst PWID in Dar-es-Salaam, Tanzania. Methods A decision tree and Markov state transition model compared existing practice (no access to HCV viral confirmation and treatment) with the integration of point-of-care HCV screening and treatment within (1) existing HR services and (2) expansion to include PWID not currently engaged in HR. Outcome measures were screening, treatment, HR and disease-related costs per PWID, quality-adjusted life years (QALY) and disability adjusted life years (DALY). Cost-effectiveness was evaluated from a healthcare payer's perspective over a 30-year time horizon over a range of willingness-to-pay thresholds (USD$273 to USD$1,050). Both deterministic and probabilistic sensitivity analyses have been conducted. Results Assuming a chronic HCV prevalence of 18.8%, screening-and-treatment in existing HR settings resulted in an ICER per QALY-gained and DALY averted of USD$633 and USD$1,161, respectively. Expanding to include an outreach programme for unengaged PWID yielded an ICER per QALY-gained and DALY-averted of USD$4,091 and USD$10,288. Factors affecting the sensitivity of the ICER value included the cost of HR and the health utility of non-cirrhotic disease states. Conclusion Simplified HCV screening and treatment of PWID has the potential to be cost-effective in Dar-es-Salaam, Tanzania. In practice, synergism of human and financial resources with established health programmes may offer a pragmatic solution to minimise operational costs.

Background Modelling suggests that achieving the WHO incidence target for hepatitis C virus (HCV) elimination in Pakistan could cost US$3.87 billion over 2018 to 2030. However, the economic benefits from integrating services or improving productivity were not included. Methods and findings We adapt a HCV transmission model for Pakistan to estimate the impact, costs, and cost-effectiveness of achieving HCV elimination (reducing annual HCV incidence by 80% by 2030) with stand-alone service delivery, or partially integrating one-third of initial HCV testing into existing healthcare services. We estimate the net economic benefits by comparing the required investment in screening, treatment, and healthcare management to the economic productivity gains from reduced HCV-attributable absenteeism, presenteeism, and premature deaths. We also calculate the incremental cost-effectiveness ratio (ICER) per disability-adjusted life year (DALY) averted for HCV elimination versus maintaining current levels of HCV treatment. This is compared to an opportunity cost-based willingness-to-pay threshold for Pakistan (US$148 to US$198/DALY). Compared to existing levels of treatment, scaling up screening and treatment to achieve HCV elimination in Pakistan averts 5.57 (95% uncertainty interval (UI) 3.80 to 8.22) million DALYs and 333,000 (219,000 to 509,000) HCV-related deaths over 2018 to 2030. If HCV testing is partially integrated, this scale-up requires an investment of US$1.45 (1.32 to 1.60) billion but will result in US$1.30 (0.94 to 1.72) billion in improved economic productivity over 2018 to 2030. This elimination strategy is highly cost-effective (ICER = US$29 per DALY averted) by 2030, with it becoming cost-saving by 2031 and having a net economic benefit of US$9.10 (95% UI 6.54 to 11.99) billion by 2050. Limitations include uncertainty around what level of integration is possible within existing primary healthcare services as well as a lack of Pakistan-specific data on disease-related healthcare management costs or productivity losses due to HCV. Conclusions Investment in HCV elimination can bring about substantial societal health and economic benefits for Pakistan., Aaron G Lim and colleagues model the health and economic benefits of eliminating hepatitis C in Pakistan., Author summary Why was this study done? The World Health Organization (WHO) has set targets for the elimination of hepatitis C virus (HCV) as a public health problem by 2030. Pakistan is believed to have the highest HCV burden globally and so is a priority country for achieving HCV elimination. We have previously estimated that a direct investment of US$3.87 billion is required for HCV elimination in Pakistan, but the cost-effectiveness, as well as the economic benefits from integrating services and improvements to productivity, are unknown. Understanding these wider societal implications is important for informing decision-making. What did the researchers do and find? 4. We modelled the costs and cost-effectiveness of achieving HCV elimination in Pakistan through scaled-up service delivery, either stand-alone or with one-third of HCV testing integrated into existing healthcare infrastructure. Both scenarios were compared to status quo levels of HCV treatment. 5. The model found that HCV elimination averts substantial morbidity (5.57 million disability-adjusted life years or DALYs) and mortality (333,000 HCV-related deaths) over 2018 to 2030. 6. The HCV elimination strategy with partial integration is predicted to be highly cost-effective by 2030 (US$29 per DALY averted) and cost-saving by 2031 with a net economic benefit of US$9.10 billion by 2050. What do these findings mean? 7. Investment in HCV elimination by Pakistan is worthwhile as it brings substantial societal health and economic benefits; however, there is a trade-off between needing to invest early and the return on investment occurring later on. 8. Integrating HCV testing services into existing healthcare can reduce overall costs, although further studies are needed to quantify what level of integration is possible.

Background: Community reintegration from prison is typically stressful, with several health and social outcomes impacting psychiatric well-being during this time, often exacerbated among individuals with histories of drug use. Longitudinal data was used to assess change in psychiatric well-being over 2 years following release from prison among men who reported a recent history of injecting drug use. Methods: Data for this study come from the Prison and Transition Health cohort study of 400 men recruited in prison prior to release and followed up over three time points. Psychiatric well-being was assessed using the 12-item General Health Questionnaire. We calculated change in individual General Health Questionnaire scores between interviews and identified covariates associated with General Health Questionnaire score using linear mixed-effects regression. Results: Data from 690 follow-up interviews among 326 participants were included in analyses. There was considerable variation in individuals’ General Health Questionnaire scores. Moving accommodation frequently and frequent illicit drug injections were associated with an increase in General Health Questionnaire score (i.e. decline in psychiatric well-being). Two or more prior adult imprisonment episodes, social supports and past month primary healthcare attendance were associated with a decrease in General Health Questionnaire score. Conclusion: Our findings identify health, social and structural influences on psychiatric well-being after release from prison that can inform re-entry programmes to support community reintegration.

IntroductionIn the Greater Mekong Subregion, community health workers, known as malaria volunteers, have played a key role in reducing malaria in the control phase, providing essential malaria services in areas with limited formal healthcare. However, the motivation and social role of malaria volunteers, and testing rates, have declined with decreasing malaria burden and reorientation of malaria programmes from control to elimination. Provision of additional interventions for common health concerns could help sustain the effectiveness of volunteers and maintain malaria testing rates required for malaria elimination accreditation by the WHO.Methods and analysisThe Community-delivered Integrated Malaria Elimination (CIME) volunteer model, integrating interventions for malaria, dengue, tuberculosis, childhood diarrhoea and malaria Rapid Diagnostic Test (RDT)-negative fever, was developed based on global evidence and extensive stakeholder consultations. An open stepped-wedge cluster-randomised controlled trial, randomised at the volunteer level, will be conducted over 6 months to evaluate the effectiveness of the CIME model in Myanmar. One hundred and forty Integrated Community Malaria Volunteers (ICMVs, current model of care) providing malaria services in 140 villages will be retrained as CIME volunteers (intervention). These 140 ICMVs/villages will be grouped into 10 blocks of 14 villages, with blocks transitioned from control (ICMV) to intervention states (CIME), fortnightly, in random order, following a 1-week training and transition period. The primary outcome of the trial is blood examination rate determined by the number of malaria RDTs performed weekly. Difference in rates will be estimated across village intervention and control states using a generalised linear mixed modelling analytical approach with maximum likelihood estimation.Ethics and disseminationThe study was approved by Institutional Review Board, Myanmar Department of Medical Research (Ethics/DMR/2020/111) and Alfred Hospital Ethics Review Committee, Australia (241/20). Findings will be disseminated in peer-review journals, conferences and regional, national and local stakeholder meetings.Trial registration numberNCT04695886

SummaryTo prevent the catastrophic health and economic consequences from COVID-19 epidemics, some nations have aimed for no community transmission outside of quarantine. To achieve this, governments have had to respond rapidly to outbreaks with public health interventions. But the exact characteristics of an outbreak that trigger these measures differ and are poorly defined. We used existing data from epidemics in Australia to establish a practical model to assist stakeholders in making decisions about the optimal timing and extent of interventions. We found that the number of reported cases on the day that interventions commenced strongly predicted the size of the outbreaks. We quantified how effective interventions were at containing outbreaks in relation to the number of cases at the time the interventions commenced. We also found that containing epidemics from novel variants that had higher transmissibility would require more stringent interventions that commenced earlier. In contrast, increasing vaccination coverage would enable more relaxed interventions. Our model highlights the importance of early and decisive action in the early phase of an outbreak if governments aimed for zero community transmission, although new variants and vaccination coverage may change this.

Summary Background Hepatitis C elimination may be possible with broad uptake of direct-acting antiviral treatments (DAAs). In 2016 the Australian government committed A$1.2 billion for five years of unlimited DAAs (March 2016 to February 2021) in a risk-sharing agreement with pharmaceutical companies. We assess the impact, cost-effectiveness and net economic benefits likely to be realised from this investment. Methods Mathematical modelling to project outcomes for 2016-2030 included: (S1) a counter-factual scenario (testing/treatment maintained at pre-2016 levels); (S2) the current status-quo (testing/treatment as actually occurred 2016-2019, with trends maintained to 2030); and (S3) elimination scenario (S2 plus testing/treatment rates increased between 2021-2030 to achieve the WHO elimination targets). Findings S1 resulted in 68,800 new hepatitis C infections and 18,540 hepatitis C-related deaths over 2016-2030. The total health system cost (HCV testing, treatment, disease management) was A$3.01 billion and the cost of lost productivity due to absenteeism, presenteeism and premature deaths was A$26.14 billion. S2 averted 15,700 (23%) new infections and 8,500 (46%) deaths by 2030, with a total health system cost of A$3.48 billion, A$472 million more than S1 (A$1.65 billion more in testing/treatment but A$1.20 billion less in disease costs; A$5,752 per QALY gained from a health systems perspective). Productivity loss over 2016-2030 was A$19.96 billion, A$6.17 less than S1, making S2 cost-saving from a societal perspective by 2022 with a net economic benefit of A$5.70 billion by 2030. S3 averted an additional 10,000 infections and 930 deaths compared with S2 and increased the longer-term economic benefit. Interpretation Five years of unrestricted access to DAAs in Australia has led to significant health benefits and is likely to become cost-saving from a societal perspective by 2022. Funding Burnet Institute

BACKGROUND AND AIMS Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids. DESIGN Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME). SETTING Australia. PARTICIPANTS People who are prescribed opioids. MEASUREMENTS Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up. FINDINGS Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400). CONCLUSION In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.

Viral hepatitis is a leading cause of morbidity and mortality worldwide, but has long been neglected by national and international policymakers. Recent modelling studies suggest that investing in the global elimination of viral hepatitis is feasible and cost‐effective. In 2016, all 194 member states of the World Health Organization endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, but complex systemic and social realities hamper implementation efforts. This paper presents eight case studies from a diverse range of countries that have invested in responses to viral hepatitis and adopted innovative approaches to tackle their respective epidemics. Based on an investment framework developed to build a global investment case for the elimination of viral hepatitis by 2030, national activities and key enablers are highlighted that showcase the feasibility and impact of concerted hepatitis responses across a range of settings, with different levels of available resources and infrastructural development. These case studies demonstrate the utility of taking a multipronged, public health approach to: (a) evidence‐gathering and planning; (b) implementation; and (c) integration of viral hepatitis services into the Agenda for Sustainable Development. They provide models for planning, investment and implementation strategies for other countries facing similar challenges and resource constraints.

Summary Background The World Health Assembly calls for elimination of viral hepatitis as a public health threat by 2030 (ie, −90% incidence and −65% mortality). However, WHO's 2017 cost projections to achieve health-related Sustainable Development Goals did not include the resources needed for hepatitis testing and treatment. We aimed to estimate the incremental commodity cost of adding scaled up interventions for testing and treatment of hepatitis to WHO's investment scenarios. Methods We added modelled costs for implementing WHO recommended hepatitis testing and treatment to the 2017 WHO cost projections. We quantified additional requirements for diagnostic tests, medicines, health workers' time, and programme support across 67 low-income and middle-income countries, from 2016–30. A progress scenario scaled up interventions and a more ambitious scenario was modelled to reach elimination by 2030. We used 2018 best available prices of diagnostics and generic medicines. We estimated total costs and the additional investment needed over the projection of the 2016 baseline cost. Findings The 67 countries considered included 230 million people living with hepatitis B virus (HBV) and 52 million people living with hepatitis C virus (HCV; 90% and 73% of the world's total, respectively). Under the progress scenario, 3250 million people (2400 million for HBV and 850 million for HCV) would be tested and 58·2 million people (24·1 million for HBV and 34·1 million for HCV) would be treated (total additional cost US$ 27·1 billion). Under the ambitious scenario, 11 631 million people (5502 million for HBV and 6129 million for HCV) would be tested and 93·8 million people (32·2 million for HBV and 61·6 million for HCV) would be treated (total additional cost $58·7 billion), averting 4·5 million premature deaths and leading to a gain of 51·5 million healthy life-years by 2030. However, if affordable HCV medicines remained inaccessible in 13 countries where medicine patents are protected, the additional cost of the ambitious scenario would increase to $118 billion. Hepatitis elimination would account for a 1·5% increase to the WHO ambitious health-care strengthening scenario costs, avert an additional 4·6% premature deaths, and add an additional 9·6% healthy life-years from 2016–30. Interpretation Access to affordable medicines in all countries will be key to reach hepatitis elimination. This study suggests that elimination is feasible in the context of universal health coverage. It points to commodities as key determinants for the overall price tag and to options for cost reduction strategies. Funding WHO, United States Centers for Disease Control and Prevention, Unitaid.

Background The introduction of highly effective direct-acting antiviral (DAA) therapy for hepatitis C has led to calls to eliminate it as a public health threat through treatment-as-prevention. Recent studies suggest it is possible to develop a vaccine to prevent hepatitis C. Using a mathematical model, we examined the potential impact of a hepatitis C vaccine on the feasibility and cost of achieving the global WHO elimination target of an 80% reduction in incidence by 2030 in the era of DAA treatment. Methods The model was calibrated to 167 countries and included two population groups (people who inject drugs (PWID) and the general community), features of the care cascade, and the coverage of health systems to deliver services. Projections were made for 2018–2030. Results The optimal incidence reduction strategy was to implement test and treat programmes among PWID, and in settings with high levels of community transmission undertake screening and treatment of the general population. With a vaccine available, the optimal strategy was to include vaccination within test and treat programmes, in addition to vaccinating adolescents in settings with high levels of community transmission. Of the 167 countries modelled, between 0 and 48 could achieve an 80% reduction in incidence without a vaccine. This increased to 15–113 countries if a 75% efficacious vaccine with a 10-year duration of protection were available. If a vaccination course cost US$200, vaccine use reduced the cost of elimination for 66 countries (40%) by an aggregate of US$7.4 (US$6.6–8.2) billion. For a US$50 per course vaccine, this increased to a US$9.8 (US$8.7–10.8) billion cost reduction across 78 countries (47%). Conclusions These findings strongly support the case for hepatitis C vaccine development as an urgent public health need, to ensure hepatitis C elimination is achievable and at substantially reduced costs for a majority of countries.

Background To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to direct-acting antivirals (DAAs), especially among people who inject drugs (PWID). We aimed to determine the effectiveness of providing DAAs in primary care, compared with hospital-based specialist care. Methods We randomized PWID with HCV attending primary care sites in Australia or New Zealand to receive DAAs at their primary care site or local hospital (standard of care [SOC]). The primary outcome was to determine whether people treated in primary care had a noninferior rate of sustained virologic response at Week 12 (SVR12), compared to historical controls (consistent with DAA trials at the time of the study design); secondary outcomes included comparisons of treatment initiation, SVR12 rates, and the care cascade by study arm. Results We recruited 140 participants and randomized 136: 70 to the primary care arm and 66 to the SOC arm. The SVR12 rate (100%, 95% confidence interval [CI] 87.7–100) of people treated in primary care was noninferior when compared to historical controls (85% assumed). An intention-to-treat analysis revealed that the proportion of participants commencing treatment in the primary care arm (75%, 43/57) was significantly higher than in the SOC arm (34%, 18/53; P < .001; relative risk [RR] 2.48, 95% CI 1.54–3.95), and the proportion of participants with SVR12 was significantly higher in the primary care arm, compared to in the SOC arm (49% [28/57] and 30% [16/53], respectively; P = .043; RR 1.63, 95% CI 1.0–2.65). Conclusions Providing HCV treatment in primary care increases treatment uptake and cure rates. Approaches that increase treatment uptake among PWID will accelerate elimination strategies. Clinical Trials Registration NCT02555475.

Background & Aims Treatment programs for people who inject drugs (PWID), including prisoners, are important for achieving hepatitis C elimination targets. There are multiple barriers to treatment of hepatitis C in prisons, including access to specialist physicians, testing and antiviral therapy, short prison sentences, and frequent inter-prison transfer. We aimed to assess the effectiveness of a nurse-led model of care for the treatment of prisoners with hepatitis C. Methods A statewide program for assessment and management of hepatitis C was developed in Victoria, Australia to improve access to care for prisoners. This nurse-led model of care is supported by telemedicine to provide decentralized care within all prisons in the state. We prospectively evaluated the feasibility and efficacy of this nurse-led model of care for hepatitis C within the 14 adult prisons over a 13-month period. The primary endpoint was sustained virological response at post-treatment week 12 (SVR12) using per protocol analysis. Results There were 416 prisoners included in the analysis. The median age was 41 years, 90% were male, 50% had genotype 3 and 44% genotype 1 hepatitis C and 21% had cirrhosis. Injecting drug use was reported by 68% in the month prior to prison entry, 54% were receiving opioid substitution therapy, and 86% reported never previously engaging with specialist HCV care. Treatment duration was 8 weeks in 24%, 12 weeks in 59%, and 24 weeks in 17% of treatment courses. The SVR12 rate was 96% (301/313) per protocol. Inter-prison transfer occurred during 26% of treatment courses but was not associated with lower SVR12 rates. No treatment-related serious adverse events occurred. Conclusion Hepatitis C treatment using a decentralized, nurse-led model of care is highly effective and can reach large numbers of prisoners. Large scale prison treatment programs should be considered to support hepatitis C elimination efforts. Lay summary There is a high burden of hepatitis C infection among prisoners worldwide. Prisoners who continue to inject drugs are also at risk of developing new infections. For this reason, the prison setting provides an opportunity to treat those people at greatest risk of infection and to stop transmission to others. We developed a new method of providing hepatitis C treatment to prisoners, in which nurses rather than doctors assessed prisoners locally at each prison site. Treatment was safe and most prisoners were cured. Such programs will contribute greatly to achieving the World Health Organization’s hepatitis C elimination goals.

Background Myanmar has set national hepatitis C (HCV) targets to achieve 50% of people diagnosed and 50% treated by 2030. The WHO has additional targets of reducing incidence by 80% and mortality by 65% by 2030. We aimed to estimate the impact, cost, cost-effectiveness and net economic benefit of achieving these targets. Methods Mathematical models of HCV transmission, disease progression and the care cascade were calibrated to 15 administrative regions of Myanmar. Cost data were collected from a community testing and treatment program in Yangon. Three scenarios were projected for 2020–2030: (1) baseline (current levels of testing/treatment); and testing/treatment scaled up sufficiently to reach (2) the national strategy targets; and (3) the WHO targets. Findings Without treatment scale-up, 333,000 new HCV infections and 97,000 HCV-related deaths were estimated to occur in Myanmar 2020–2030, with HCV costing a total $100 million in direct costs (testing, treatment, disease management) and $10.4 billion in lost productivity. In the model, treating 55,000 people each year was sufficient to reach the national strategy targets and prevented a cumulative 40,000 new infections (12%) and 25,000 HCV-related deaths (25%) 2020–2030. This was estimated to cost a total $189 million in direct costs ($243 per DALY averted compared to no treatment scale-up), but only $9.8 billion in lost productivity, making it cost-saving from a societal perspective by 2024 with an estimated net economic benefit of $553 million by 2030. Reaching the WHO targets required further treatment scale-up and additional direct costs but resulted in greater longer-term benefits. Interpretation Current levels of HCV testing and treatment in Myanmar are insufficient to reach the national strategy targets. Scaling up HCV testing and treatment in Myanmar to reach the national strategy targets is estimated to generate significant health and economic benefits. Funding Gilead Sciences.

ObjectivesThe early stages of the COVID-19 pandemic illustrated that SARS-CoV-2, the virus that causes the disease, has the potential to spread exponentially. Therefore, as long as a substantial proportion of the population remains susceptible to infection, the potential for new epidemic waves persists even in settings with low numbers of active COVID-19 infections, unless sufficient countermeasures are in place. We aim to quantify vulnerability to resurgences in COVID-19 transmission under variations in the levels of testing, tracing and mask usage.SettingThe Australian state of New South Wales (NSW), a setting with prolonged low transmission, high mobility, non-universal mask usage and a well-functioning test-and-trace system.ParticipantsNone (simulation study).ResultsWe find that the relative impact of masks is greatest when testing and tracing rates are lower and vice versa. Scenarios with very high testing rates (90% of people with symptoms, plus 90% of people with a known history of contact with a confirmed case) were estimated to lead to a robustly controlled epidemic. However, across comparable levels of mask uptake and contact tracing, the number of infections over this period was projected to be 2–3 times higher if the testing rate was 80% instead of 90%, 8–12 times higher if the testing rate was 65% or 30–50 times higher with a 50% testing rate. In reality, NSW diagnosed 254 locally acquired cases over this period, an outcome that had a moderate probability in the model (10%–18%) assuming low mask uptake (0%–25%), even in the presence of extremely high testing (90%) and near-perfect community contact tracing (75%–100%), and a considerably higher probability if testing or tracing were at lower levels.ConclusionsOur work suggests that testing, tracing and masks can all be effective means of controlling transmission. A multifaceted strategy that combines all three, alongside continued hygiene and distancing protocols, is likely to be the most robust means of controlling transmission of SARS-CoV-2.

Background To achieve malaria elimination in the Greater Mekong Subregion, including Myanmar, it is necessary to ensure all malaria cases are detected, treated, and reported in a timely manner. Mobile phone-based applications for malaria reporting, case management, and surveillance implemented at a community-level may overcome reporting limitations associated with current paper-based reporting (PBR), but their effectiveness in this context is unknown. Methods A mixed methods evaluation study was undertaken to determine the effectiveness of a national Malaria Case-Based Reporting (MCBR) mobile phone application in improving malaria case reporting compared to the existing PBR reporting system in Myanmar. Methods included secondary analysis of malaria case report data, questionnaires, focus group discussions and field observations of community volunteers, interviews and direct observations of malaria programme stakeholders, and cost analysis. Using a combination of these approaches the following areas were investigated: data quality and completeness, data access and usage, capacity for timely reporting, the acceptability, functionality, and ease of use of the application and facilitators and barriers to its use, and the relative cost of MCBR compared to the PBR system. Results Compared to PBR, MCBR enabled more accurate and complete data to be reported in a much timelier manner, with 63% of MCBR users reporting they transmit rapid diagnostic test outcomes within 24 h, compared to 0% of PBR users. MCBR was favoured by integrated community malaria volunteers and their supervisors because of its efficiency. However, several technical and operational challenges associated with internet coverage, data transmission, and e-literacy were identified and stakeholders reported not being confident to rely solely on MCBR data for programmatic decision-making. Conclusions Implementation of MCBR provided timely and accurate data for malaria surveillance. Findings from this evaluation study will enable the optimization of an application-based reporting system for malaria monitoring and surveillance in the Greater Mekong Subregion and advance systems to track progress towards, and certify, the achievement of malaria elimination targets.

BackgroundIn clinical trials two vaccinations with mRNA vaccines have shown high efficacy in preventing COVID-19. However, in the context of a pandemic, the time to generation of protective immunity, the need for and timing of a second vaccination are matters of legitimate debate. This manuscript explores the efficacy and timing of the second dose COVID-19 vaccines, including a reanalysis of data from the Pfizer mRNA BNT162b2 mRNA SARS-CoV-2 vaccine phase 3 study.Methods and findingsA non-weighted three-segment, two knot linear regression was fitted to the published cumulative infection incidence from the Pfizer BNT162b2 vaccine Phase III trial using the lspine routine in R. The optimal knot days were estimated through sensitivity analysis and the confidence limits for efficacy estimates were determined by Monte Carlo Simulations. This analysis showed the vaccine was effective from day 11 post first vaccination. The estimated efficacy over the period 11 to 28 days post first vaccination was 0.94 and there was no detectable increase in efficacy following the second vaccination. The efficacy post first vaccination substantially preceded the development of detectable serum neutralizing antibody.ConclusionsStrongly protective immunity develops rapidly following a single vaccination and at least in the short period covered by the timetable of the Phase III trial, there was no additional benefit from a second vaccination. This increases options for use of this vaccine, e.g., for ring fence vaccination, for use in travelers and for mass vaccination rollout. It highlights the need for further research into duration of immunity following a single vaccination and for understanding mechanisms of protection.

In settings with zero community transmission, any new SARS-CoV-2 outbreaks are likely to be the result of random incursions. The level of restrictions in place at the time of the incursion is likely to considerably affect possible outbreak trajectories. We used an agent-based model to investigate the relationship between ongoing restrictions and behavioural factors, and the probability of an incursion causing an outbreak and the resulting growth rate. We applied our model to the state of Victoria, Australia, which has reached zero community transmission as of November 2020.We found that a future incursion has a 45% probability of causing an outbreak (defined as a 7-day average of >5 new cases per day within 60 days) if no restrictions were in place, decreasing to 23% with a mandatory masks policy, density restrictions on venues such as restaurants, and if employees worked from home where possible. A drop in community symptomatic testing rates was associated with up to a 10-percentage point increase in outbreak probability, highlighting the importance of maintaining high testing rates as part of a suppression strategy.Because the chance of an incursion occurring is closely related to border controls, outbreak risk management strategies require an integrated approaching spanning border controls, ongoing restrictions, and plans for response. Each individual restriction or control strategy reduces the risk of an outbreak. They can be traded off against each other, but if too many are removed there is a danger of accumulating an unsafe level of risk. The outbreak probabilities estimated in this study are of particular relevance in assessing the downstream risks associated with increased international travel.

Background Sustainable Development Goal (SDG) 2.2 calls for an end to all forms of malnutrition, with 2025 targets of a 40% reduction in stunting (relative to 2012), for wasting to occur in less than 5% of children, and for a 50% reduction in anaemia in women (15–49 years). We assessed the likelihood of countries reaching these targets by scaling up proven interventions and identified priority interventions, based on cost-effectiveness. Methods For 129 countries, the Optima Nutrition model was used to compare 2019–2030 nutrition outcomes between a status quo (maintained intervention coverage) scenario and a scenario where outcome-specific interventions were scaled up to 95% coverage over 5 years. The average cost-effectiveness of each intervention was calculated as it was added to an expanding package of interventions. Results Of the 129 countries modelled, 46 (36%), 66 (51%) and 0 (0%) were on track to achieve the stunting, wasting and anaemia targets respectively. Scaling up 18 nutrition interventions increased the number of countries reaching the SDG 2.2 targets to 50 (39%), 83 (64%) and 7 (5%) respectively. Intermittent preventative treatment of malaria during pregnancy (IPTp), infant and young child feeding education, vitamin A supplementation and lipid-based nutrition supplements for children produced 88% of the total impact on stunting, with average costs per case averted of US$103, US$267, US$556 and US$1795 when interventions were consecutively scaled up, respectively. Vitamin A supplementation and cash transfers produced 100% of the total global impact on prevention of wasting, with average costs per case averted of US$1989 and US$19,427, respectively. IPTp, iron and folic acid supplementation for non-pregnant women, and multiple micronutrient supplementation for pregnant women produced 85% of the total impact on anaemia prevalence, with average costs per case averted of US$9, US$35 and US$47, respectively. Conclusions Prioritising nutrition investment to the most cost-effective interventions within the country context can maximise the impact of funding. A greater focus on complementing nutrition-specific interventions with nutrition-sensitive ones that address the social determinants of health is critical to reach the SDG targets.

Background Hepatitis C is highly prevalent among prisoners. The simplicity of direct-acting antiviral (DAA) treatment for hepatitis C makes it possible to use novel models of care to increase treatment uptake within prisons. We estimate the average non-drug cost of initiating a prisoner on treatment using real world data from the State-wide Hepatitis Program (SHP) in Victoria, Australia – a coordinated nurse-led model of care. Methods Data were considered from prisoners presenting to the SHP (following antibody-positive diagnosis) during the evaluation period, November 2015 to December 2016. All costs associated with the SHP were estimated, including staffing salaries, medical tests, pharmacy costs and overhead costs. DAA costs were excluded as in Australia an unlimited number are available, covered by a federal government risk-sharing agreement with pharmaceutical companies. The average non-drug cost of treatment initiation through the SHP was compared to equivalent costs from primary and hospital-based models of care in the community. Results The total non-drug cost accumulated by prisoners in the SHP was AUD$749,470 (uncertainty range: AUD$728,905-794,111). 659/803 were PCR positive, 424/659 had sentences long enough to be eligible for treatment, and 416/424 were initiated on treatment, resulting in an average non-drug cost of AUD$1,802 (95% CI: AUD$1799-1841) per prisoner initiated. A protocol change allowing prisoners with short sentences to start treatment reduced the average non-drug cost to AUD$1263 (95% CI: AUD$1263-1287) per prisoner initiating treatment – 11% and 56% cheaper than estimated equivalent costs in primary (AUD$1654) and hospital-based (AUD$2847) models of care in the community, respectively. Conclusion Delivering hepatitis C treatment in prison using a nurse-led model of care is cheaper than delivering treatment in the community. These findings provide an economic rationale for implementing coordinated prison-based hepatitis C treatment programs.

An increasing number of countries are committing to meet the World Health Organization (WHO) targets to eliminate hepatitis C virus (HCV) as a public health threat by 2030. These include service coverage targets (90% diagnosed and 80% of diagnosed patients treated) and impact targets (80% and 65% reductions in incidence and mortality, respectively, compared to 2015 levels). Currently, a dozen countries are on track to reach 2030 WHO HCV targets. However, while striving for the WHO targets is important, it should be recognized that progress on impact targets is derived from mathematical models projecting decreases in incidence and mortality on a global scale. Despite HCV treatment access in many counties for a number of years, limited empirical data are available to evaluate progress towards elimination. In some countries, substantial incidence and mortality reductions based on reaching the WHO service coverage targets may be unachievable. For example, in countries with ageing hepatitis C–infected populations, even if they have a quality hepatitis C response, high hepatitis C–related morbidity at baseline may not be reversible even with increased HCV treatment uptake and diagnosis. Finally, WHO targets are not necessarily easily or reliably measurable. Measuring relative impact targets requires high-quality data at baseline (ie 2015) and longitudinal data to assess temporal trends. In this commentary, we propose alternative additional measures to track progress on reducing the HCV burden, offer examples where the WHO targets may not be informative or achievable, and potential practical solutions.

Background and Objectives: Pre-donation screening of potential blood donors is critical for ensuring the safety of the donor blood supply, and donor deferral as a result of risk factors is practised worldwide. This systematic review was conducted in the context of an expert review convened by the Australian Red Cross Lifeblood in 2013 to consider Lifeblood’s injecting drug use (IDU)-related policies and aimed to identify studies assessing interventions to improve compliance with deferral criteria in blood donation settings. Materials and Methods: MEDLINE/PubMed, OVID Medline, OVID Embase, LILACS, and the Cochrane Library (CENTRAL and DARE) databases were searched for studies conducted within blood donation settings that examined interventions to increase blood donor compliance with deferral criteria. Observational and experimental studies from all geographical areas were considered. Results: Ten studies were identified that tested at least one intervention to improve blood donor compliance with deferral criteria, including computerized interviews or questionnaires, direct and indirect oral questioning, educational materials, and a combination of a tickbox questionnaire and a personal donor interview. High-quality evidence from a single study was provided for the effectiveness of a computerized interview in improving detection of HIV risk behaviour. Low-quality evidence for the effectiveness of computerized interviews was provided by 3 additional studies. Two studies reported a moderate effect of direct questioning in increasing donor deferral, but the quality of the evidence was low. Conclusion: This review identified several interventions to improve donor compliance that have been tested in blood donation settings and provided evidence for the effectiveness of computerized interviews in improving detection of risk factors.

Background A simplified cascade-of-care may improve screening and treatment uptake among incarcerated individuals. We assessed the cost-effectiveness of traditional and simplified screening and treatment in a London remand prison. Methods Using empirical data from Her Majesty's Prison (HMP) Wormwood Scrubs, London, we designed a decision tree and Markov transition state model using national average data for HCV screening and treatment for the base-case scenario. This compared two alternative strategies; (a) general prison population screening and treatment and (b) prioritising screening and treatment among people who inject drugs (PWID) combined with general prison population screening and treatment. Strategies varied the rates of screening (47%-90%), linkage-to-care (60%-86%) and treatment (21%-85%). Cost, utility and disease transition rates were obtained from existing literature. Outcome measures were as follows: screening, treatment and disease-related costs per admitted individual, quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICERs) were calculated for each intervention. All costs and utilities were discounted at a rate of 3.5% per annum. Both univariate and probabilistic sensitivity analyses have been conducted. Results In our cohort of 5239 incarcerated individuals with an estimated chronic HCV prevalence of 2.6%, all strategy ICER values (£3565-10 300) fell below the national willingness to pay threshold (£30 000). Increased successful treatment (7%-54%) was observed by an optimising cascade-of-care. A robust sensitivity analysis identified treatment cost of, QALY for mild liver disease and probability of completing treatment as important factors that impact the ICER value. Conclusion In our remand setting, optimising adherence to the cascade-of-care is cost-effective. Where universal screening is not practical, a stratified approach focused on intensive screening and treatment of PWID also results in increased treatment uptake and is highly cost-effective.

BACKGROUND Increases in sexually transmitted infections among gay and bisexual men (GBM) over the past decade have coincided with declines in condom use and rapid uptake of HIV preexposure prophylaxis (PrEP). We explored the impact of an antimicrobial gel-based point-of-sex intervention (gel-PSI) with a lower efficacy for reducing gonorrhea transmission risk than condoms on population-level gonorrhea incidence among GBM in Victoria, Australia. METHODS A deterministic compartmental model of HIV and gonorrhea transmission was used to project annual gonorrhea incidence from 2020 to 2025. Individuals were classified as HIV-negative (PrEP or non-PrEP users) or HIV-positive, and further stratified by gonorrhoea risk (high/low). All possible scenarios where between 0% and 100% of GBM using condoms transitioned to gel-PSI (considered a downgrade in protection) and 0% and 100% of GBM not using condoms transitioned to gel-PSI (considered an upgrade in protection), with gel-PSI efficacy ranging from 20% to 50%, were run. RESULTS The baseline scenario of no gel-PSI uptake (status quo) projected 94,367 gonorrhea infections between 2020 and 2025, with an exponentially increasing trend in annual infections. For a gel-PSI efficacy of 30%, a net reduction in cumulative gonorrhea incidence was projected, relative to the status quo, for any ratio of proportion of condom users "downgrading" to proportion of noncondom users "upgrading" to gel-PSI use of less than 2.6. Under the supposition of equal proportions of condom users and noncondom users switching to gel-PSI, a relative reduction was projected for any gel-PSI efficacy greater than 16%. CONCLUSIONS Our model suggests that the introduction of a gel-PSI could have benefits for controlling gonorrhea transmission among GBM, even in scenarios where the gel-PSI is considerably less efficacious than condoms and when gel-PSI uptake leads to consequent reductions in consistent condom use.

ObjectivesTo assess the risks associated with relaxing coronavirus disease 2019 (COVID-19)-related physical distancing restrictions and lockdown policies during a period of low viral transmission.DesignNetwork-based viral transmission risks in households, schools, workplaces, and a variety of community spaces and activities were simulated in an agent-based model, Covasim.SettingThe model was calibrated for a baseline scenario reflecting the epidemiological and policy environment in Victoria during March–May 2020, a period of low community viral transmission.InterventionPolicy changes for easing COVID-19-related restrictions from May 2020 were simulated in the context of interventions that included testing, contact tracing (including with a smartphone app), and quarantine.Main outcome measureIncrease in detected COVID-19 cases following relaxation of restrictions.ResultsPolicy changes that facilitate contact of individuals with large numbers of unknown people (eg, opening bars, increased public transport use) were associated with the greatest risk of COVID-19 case numbers increasing; changes leading to smaller, structured gatherings with known contacts (eg, small social gatherings, opening schools) were associated with lower risks. In our model, the rise in case numbers following some policy changes was notable only two months after their implementation.ConclusionsRemoving several COVID-19-related restrictions within a short period of time should be undertaken with care, as the consequences may not be apparent for more than two months. Our findings support continuation of work from home policies (to reduce public transport use) and strategies that mitigate the risk associated with re-opening of social venues.

AimsWe assessed COVID-19 epidemic risks associated with relaxing a set of physical distancing restrictions in the state of Victoria, Australia – a setting with low community transmission – in line with a national framework that aims to balance sequential policy relaxations with longer-term public health and economic need.MethodsAn agent-based model, Covasim, was calibrated to the local COVID-19 epidemiological and policy environment. Contact networks were modelled to capture transmission risks in households, schools and workplaces, and a variety of community spaces (e.g. public transport, parks, bars, cafes/restaurants) and activities (e.g. community or professional sports, large events). Policy changes that could prevent or reduce transmission in specific locations (e.g. opening/closing businesses) were modelled in the context of interventions that included testing, contact tracing (including via a smartphone app), and quarantine.ResultsPolicy changes leading to the gathering of large, unstructured groups with unknown individuals (e.g. bars opening, increased public transport use) posed the greatest risk, while policy changes leading to smaller, structured gatherings with known individuals (e.g. small social gatherings) posed least risk. In the model, epidemic impact following some policy changes took more than two months to occur. Model outcomes support continuation of working from home policies to reduce public transport use, and risk mitigation strategies in the context of social venues opening, such as >30% population-uptake of a contact-tracing app, physical distancing policies within venues reducing transmissibility by >40%, or patron identification records being kept to enable >60% contact tracing.ConclusionsIn a low transmission setting, care should be taken to avoid lifting sequential COVID-19 policy restrictions within short time periods, as it could take more than two months to detect the consequences of any changes. These findings have implications for other settings with low community transmission where governments are beginning to lift restrictions.

Organ transplant guidelines in many settings recommend that people with potential hepatitis C virus (HCV) exposure or infection are deemed ineligible to donate. The recent availability of highly-effective treatments for HCV means that this may no longer be necessary. We used a mathematical model to estimate the expected difference in healthcare costs, difference in disability-adjusted life years (DALYs) and cost-effectiveness of removing HCV restrictions for lung and kidney donations in Australia. Our model suggests that allowing organ donations from people who inject drugs, people with a history of incarceration and people who are HCV antibody-positive could lead to an estimated 10% increase in organ supply, population-level improvements in health (reduction in DALYs), and on average save AU$2,399 (95%CI AU$1,155-3,352) and AU$2,611 (95%CI AU$1,835-3,869) per person requiring a lung and kidney transplant respectively. These findings are likely to hold for international settings, since this policy change remained cost saving with positive health gains regardless of HCV prevalence, HCV treatment cost and waiting list survival probabilities. This study suggests that guidelines on organ donation should be revisited in light of recent changes to clinical outcomes for people with HCV.

Summary Background Hepatitis B causes more than 800 000 deaths globally each year. Perinatal infections are a major driver of this burden but can be prevented by vaccination within 24 h of birth. Currently, only 44% of newborn babies in low-income and middle-income countries (LMICs) receive a timely birth dose. We investigated the effects and cost-effectiveness of implementing ambient storage of hepatitis B vaccines under a controlled temperature chain (CTC) protocol and the use of compact prefilled auto-disable (CPAD) devices for community births. Methods In this mathematical modelling study of perinatal hepatitis B transmission and disease progression, we estimated the coverage impact and cost-effectiveness of implementing CTC and CPAD interventions in the six Global Burden of Disease (GBD) regions containing LMICs. Combinations of four different scenarios of birth dose delivery strategies (cold chain, CTC) and interventions (needle and syringe, CPAD) were modelled across facility or community birth locations. We also estimated the minimum cost and most cost-effective strategy to achieve the WHO 90% hepatitis B birth dose coverage target in GBD regions and in 46 LMICs with a reported coverage of less than 90%. Findings Current delivery protocols achieved a maximum coverage of 65% (IQR 64–65) across GBD regions. Reaching 90% hepatitis B birth dose coverage across all GBD regions was estimated to cost a minimum of US$687·5 million per annum ($494·0 million more than the estimated current expenditure), of which $516·5 million (75%) was required for CTC and CPAD interventions. Reaching 90% coverage in this way was estimated to be cost saving in five of the six regions (and in 40 of 46 LMICs individually assessed) due to the disease costs averted, with the cost per disability-adjusted life-years averted being less than $83·27 otherwise. Interpretation Hepatitis B birth dose coverage of 90% is unlikely to be reached under current protocols. CTC and CPAD vaccine strategies present cost-effective solutions to overcome coverage barriers. Funding The Burnet Institute.

Background: Whilst evidence of face masks’ effectiveness in reducing COVID-19 cases is increasing, the impact of mandatory use across a large population has been difficult to assess. Introduction of mandatory mask use on July 22, 2020 during a resurgence of COVID-19 in Melbourne, Australia created a natural experiment to assess the impact of the policy on the epidemic growth rate as its introduction occurred in the absence of other changes to restrictions. Methods: Exponential epidemic growth or decay rates in daily COVID-19 diagnoses were estimated using a non-weighted linear regression of the natural logarithm of the daily cases against time, using a linear spline model with one knot (lspline package in R v 3.6.3). The model’s two linear segments straddle the hinge day, determined from the model fit, on which the mask policy began to take effect. We used two forms of data to assess change in mask usage: population-based survey data and images of people wearing masks in public places obtained from a major media outlet. Potential confounding factors (including daily COVID-19 tests, number of COVID-19 cases among population subsets affected differentially by the mask policy – e.g. healthcare workers) were examined for their impact on the results. Findings: Introduction of a mandatory mask policy was associated with an estimated 23% reduction in the effective reproduction ratio, from 1.18 to 0.91. The hinge day in the linear spline model occurred eight days after the policy was introduced on July 23, 2020. Daily cases grew exponentially in the first log-linear segment (k = +0.042, s.e. = 0.007), and decayed exponentially in the second (k = -0.023, s.e. = 0.017). Analysis of images of people in public spaces showed mask usage rose from approximately 43% to 97%. Analysis of survey data found that on the third day before policy introduction, 44% of participants reported “often” or “always” wearing a mask; on the fourth day after, 100% reported “always” doing so. No potentially confounding factors were associated with the observed change in growth rates. Interpretation: The mandatory mask use policy substantially increased public use of masks and was associated with a significant decline in COVID-19 transmission after introduction of the policy. The hinge date (where the shift in epidemic growth was observed) occurred eight days after policy introduction, consistent with the incubation time of COVID-19 and the time needed to test and report new cases. Although studies emphasise the importance of masks in a clinical setting, to our knowledge no previous peer reviewed publications measured the role of masks for controlling epidemics in the broader community. Funding Statement: This work was funded from Burnet Institute resources. Declaration of Interests: BC serves on the National COVID-19 Health Research Advisory Committee that provides guidance to the Federal Government’s COVID-19 response. NS, MH, A Saeri, EG and LS provide guidance to the Victorian Government’s COVID-19 response. MH and NS receive funding from the Victorian Government for the Optimise Study and modelling work. A Saeri and EG receive funding from the Victorian Government for the SCRUB project. CRM serves on the National COVID-19 Health Research Advisory Committee that provides guidance to the Federal Government’s COVID-19 response. She currently receives funding from the National Health and Medical Research Council and Medical Research Futures Fund, Office of Health Protection, Department of Health, Sanofi and from the Defence Intelligence Organisation. All authors have nothing to declare.

Background: Latent tuberculosis infection (LTBI) is a critical driver of the global burden of active TB, and therefore LTBI treatment is key for TB elimination. Treatment regimens for LTBI include self-administered daily isoniazid for 6 (6H) or 9 (9H) months, self-administered daily rifampicin plus isoniazid for 3 months (3RH), self-administered daily rifampicin for 4 months (4R) and weekly rifapentine plus isoniazid for 3 months self-administered (3HP-SAT) or administered by a healthcare worker as directly observed therapy (3HP-DOT). Data on the relative cost-effectiveness of these regimens are needed to assist policymakers and clinicians in selecting an LTBI regimen. Objectives: To evaluate the cost-effectiveness of all regimens for treating LTBI. Methods: We developed a Markov model to investigate the cost-effectiveness of 3HP-DOT, 3HP-SAT, 4R, 3RH, 9H and 6H for LTBI treatment in a cohort of 10000 adults with LTBI. Cost-effectiveness was evaluated from a health system perspective over a 20 year time horizon. Results: Compared with no preventive treatment, 3HP-DOT, 3HP-SAT, 4R, 3RH, 9H and 6H prevented 496, 470, 442, 418, 370 and 276 additional cases of active TB per 10000 patients, respectively. All regimens reduced costs and increased QALYs compared with no preventive treatment. 3HP was more cost-effective under DOT than under SAT at a cost of US$27948 per QALY gained. Conclusions: Three months of weekly rifapentine plus isoniazid is more cost-effective than other regimens. Greater recognition of the benefits of short-course regimens can contribute to the scale-up of prevention and achieving the ‘End TB’ targets.

Background Restricted needle and syringe program (NSP) operating hours in Australia have been reported as a barrier to access for people who inject drugs (PWID). We explored the prevalence of drug use occurring outside NSP operating hours with a particular focus on its impacts on individual-level needle and syringe coverage. Methods Using data from 584 participants in a cohort of PWID in Melbourne, Australia, we analyzed time and day of drug use for heroin, methamphetamine and pharmaceutical opioids. We related this drug use to the typical operating times of Melbourne’s fixed-site NSPs, categorizing drug use as either “in-hours” or “out-of-hours”. We explored associations with out-of-hours drug use using a generalized linear mixed model of pooled longitudinal data. Results 23% of heroin use and 50% of methamphetamine use occurred out-of-hours. In regression analysis, males and those injecting in public locations had significantly reduced odds of out-of-hours drug use. Those currently employed and those using methamphetamine (compared to heroin) had significantly increased odds of out-of-hours drug use. There was no significant association between individual-level needle and syringe coverage and hours of drug use. Conclusions Deficiencies in individual-level needle and syringe coverage may not be due to restricted NSP operating hours. Instead, insufficient coverage may be the result of other factors in the lives of PWID or other NSP access difficulties. These preliminary results suggest improvements to coverage in Australia may not result from increased hours of NSP operation, but instead via improvements to client targeting.

Background & Aims Heroin use is associated with a disproportionately high level of morbidity and mortality with most deaths attributable to drug overdose. Aggregate heroin purity data has been used to examine the relationship between overdose and variability in street-level heroin, however heroin purity data alone may not be the most appropriate nor a sensitive enough measurement tool for this assessment. The aim of this study was to measure the variability in effective dose of street-level heroin seizures, accounting for variation in both purity and mass, and determine the proportion of samples with higher than expected effective dose that would not be detected using a purity-only measure. Methods Data on Victorian heroin seizures ≤150 mg in mass made between 01/01/2012 and 31/12/2013 were obtained from the Victoria Police Forensic Services Department. The effective dose of heroin in each sample was determined by multiplying the mass and purity variables. Effective dose outlier samples were considered as those containing either greater than 1.5–2 times or >2 times the median effective dose of heroin for the sample data. Results The 983 street-level heroin samples of ≤150 mg had a median mass of 92 mg (IQR of 43 mg), a median purity of 13% (range 3.6%–80.9%) and a median effective dose of 12.0 mg of heroin (IQR 6.6 mg; range 0.4 mg–111 mg). Approximately one in 13 samples (8%) and one in 17 samples (6%) contained between 1.5–2 times and >2 times the median effective dose of heroin respectively. Conclusion The effective dose of heroin is a more appropriate measure than purity to identify outlier samples that containing larger than expected doses of heroin compared to typical doses that may be expected by users. Together with other identified risk factors, fluctuation in the effective dose of heroin contained in street-level samples may contribute to the potential for overdose.

To increase access to treatment, the Australian government enabled general practitioners (GPs) to prescribe direct-acting antivirals (DAAs) to treat hepatitis C virus (HCV)-in consultation with a specialist if inexperienced in HCV management. This study describes the establishment and outcomes of a remote consultation pathway supporting GPs to treat HCV. Key stakeholders from primary and tertiary healthcare services in the Barwon South Western region developed and implemented an HCV remote consultation pathway. Pharmaceutical Benefits Schedule prescription data were used to evaluate GP DAA prescription 12 months pre-and post- pathway implementation. A retrospective review of patients referred for remote consultation for 12 months post- pathway inception was undertaken to determine the care cascade. HCV treatment initiation by GPs increased after implementation of the remote consultation pathway. In the 12-month study period, 74 GPs referred 169 people for remote consultation; 114 (67%) were approved for GP DAA treatment; 48 (28%) were referred for specialist assessment. In total, 119 (71%) patients commenced DAA; 69 were eligible for SVR12 assessment. Post-treatment HCV RNA data were available for 52 (75%) people; 37 achieved SVR12; 15 achieved SVR ranging from week 5 to 11 post-treatment. No treatment failure was detected. Collaborative development and implementation of a remote consultation pathway has engaged regional GPs in managing HCV. Follow-up post-treatment could be improved; however, no treatment failure has been documented. To eliminate HCV as a public health threat, it is vital that specialists support GPs to prescribe DAA.

Background and aim Direct-acting antiviral (DAA) treatments became available for all people living with hepatitis C virus (HCV) in Australia in March 2016. We assess variations in treatment rates and prescribing patterns across Australia's 338 Statistical Area 3 (SA3) geographical units. Methods Geocoded DAA treatment initiation data were analysed for the period 1 March 2016 to 30 June 2017. Regression models tested associations between the population demographics and healthcare service coverage of geographical areas and (a) their treatment rates; and (b) the proportion of prescriptions written by specialists compared to non-specialists. Results Across the 320 areas (95%) recording treatments, a median 76 (interquartile range [IQR] 35–207, range 4–3834) per 100,000 were initiated, corresponding to an estimated median 7.9% (IQR 2.9–23.6%, range 0–100%) treatment uptake. Major cities, areas of socioeconomic advantage and areas with lower proportions of the population born overseas had the highest per capita treatment rates. Non-specialists prescribed 46% (20,323/44,382) of treatment initiations. Prescriptions were written by non-specialists only in 163 areas (51%), while in other areas a median 40.0% (IQR 21.8–62.5%) of prescriptions were written by non-specialists. Non-specialist prescribing was higher in regional areas, as well as areas that had greater proportions of Indigenous Australians. Conclusions High national-level treatment uptake of 20% in Australia masks underlying health system limitations; more than half of geographical areas may have treated less than 8% of people living with HCV. Areas of socioeconomic disadvantage and areas with a higher proportion of the population born overseas may need targeting with interventions to improve treatment uptake.

The COVID-19 pandemic has created an urgent need for models that can project epidemic trends, explore intervention scenarios, and estimate resource needs. Here we describe the methodology of Covasim (COVID-19 Agent-based Simulator), an open-source model developed to help address these questions. Covasim includes country-specific demographic information on age structure and population size; realistic transmission networks in different social layers, including households, schools, workplaces, long-term care facilities, and communities; age-specific disease outcomes; and intrahost viral dynamics, including viral-load-based transmissibility. Covasim also supports an extensive set of interventions, including non-pharmaceutical interventions, such as physical distancing and protective equipment; pharmaceutical interventions, including vaccination; and testing interventions, such as symptomatic and asymptomatic testing, isolation, contact tracing, and quarantine. These interventions can incorporate the effects of delays, loss-to-follow-up, micro-targeting, and other factors. Implemented in pure Python, Covasim has been designed with equal emphasis on performance, ease of use, and flexibility: realistic and highly customized scenarios can be run on a standard laptop in under a minute. In collaboration with local health agencies and policymakers, Covasim has already been applied to examine epidemic dynamics and inform policy decisions in more than a dozen countries in Africa, Asia-Pacific, Europe, and North America., Author summary Mathematical models have played an important role in helping countries around the world decide how to best tackle the COVID-19 pandemic. In this paper, we describe a COVID-19 model, called Covasim (COVID-19 Agent-based Simulator), that we developed to help answer these questions. Covasim can be tailored to the local context by using detailed data on the population (such as the population age distribution and number of contacts between people) and the epidemic (such as diagnosed cases and reported deaths). While Covasim can be used to explore theoretical research questions or to make projections, its main purpose is to evaluate the effect of different interventions on the epidemic. These interventions include physical interventions (mobility restrictions and masks), diagnostic interventions (testing, contact tracing, and quarantine), and pharmaceutical interventions (vaccination). Covasim is open-source, written in Python, and comes with extensive documentation, tutorials, and a webapp to ensure it can be used as easily and broadly as possible. In partnership with local stakeholders, Covasim has been used to answer policy and research questions in more than a dozen countries, including India, the United States, Vietnam, and Australia.

Background The high burden of malaria and limited funding means there is a necessity to maximize the allocative efficiency of malaria control programmes. Quantitative tools are urgently needed to guide budget allocation decisions. Methods A geospatial epidemic model was coupled with costing data and an optimization algorithm to estimate the optimal allocation of budgeted and projected funds across all malaria intervention approaches. Interventions included long-lasting insecticide-treated nets (LLINs), indoor residual spraying (IRS), intermittent presumptive treatment during pregnancy (IPTp), seasonal mass chemoprevention in children (SMC), larval source management (LSM), mass drug administration (MDA), and behavioural change communication (BCC). The model was applied to six geopolitical regions of Nigeria in isolation and also the nation as a whole to minimize incidence and malaria-attributable mortality. Results Allocative efficiency gains could avert approximately 84,000 deaths or 15.7 million cases of malaria in Nigeria over 5 years. With an additional US$300 million available, approximately 134,000 deaths or 37.3 million cases of malaria could be prevented over 5 years. Priority funding should go to LLINs, IPTp and BCC programmes, and SMC should be expanded in seasonal areas. To minimize mortality, treatment expansion is critical and prioritized over some LLIN funding, while to minimize incidence, LLIN funding remained a priority. For areas with lower rainfall, LSM is prioritized over IRS but MDA is not recommended unless all other programmes are established. Conclusions Substantial reductions in malaria morbidity and mortality can be made by optimal targeting of investments to the right malaria interventions in the right areas. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-2019-1) contains supplementary material, which is available to authorized users.

Objective: Many variations of venue lockout and last-drink policies have been introduced in attempts to reduce drinking-related harms. We estimate the public health gains and licensee costs of these policies using a computer simulated population of young adults engaging in heavy drinking. Method: Using an agent-based model we implemented 1 am/2 am/3 am venue lockouts in conjunction with last drinks zero/one/two hours later, or at current closing times. Outcomes included: the number of incidents of verbal aggression in public drinking venues, private venues or on the street; and changed revenue to public venues. Results: The most effective policy in reducing verbal aggression among agents was 1 am lockouts with current closing times. All policies produced substantial reductions in street-based incidents of verbal aggression among agents (33–81%) due to the smoothing of transport demand. Direct revenue losses were 1–9% for simulated licensees, with later lockout times and longer periods between lockout and last drinks producing smaller revenue losses. Conclusion: Simulation models are useful for exploring consequences of policy change. Our simulation suggests that additional hours between lockout and last drinks could reduce aggression by easing transport demand, while minimising revenue loss to venue owners. Implications for public health: Direct policies to reduce late-night transport-related disputes should be considered.

Objective: To determine what percentage of Victorians with a history of notified hepatitis C exposure received appropriate follow-up diagnostic services between 2001 and 2012. Methods: Individual notification data and aggregate Medicare and supplementary testing data were entered into a compartmental transition model, which was used to estimate the percentage of people with a hepatitis C notification who were yet to receive either a negative diagnostic test for viral nucleic acid, or a test for viral genotype, at the end of 2012. Results: We estimate that 58.2% (uncertainty interval: 42.2%, 72.4%) of Victorians with a hepatitis C notification between 2001 and 2012 did not receive either a negative test for viral nucleic acid or a viral genotyping test during the study period. At the end of 2012, we estimate there were approximately 20,400 Victorians living with hepatitis C antibodies who were yet to receive testing, of which approximately 9,300 would have been aged 45 years or older. Conclusions: A majority of people living with HCV antibodies in Victoria had not received appropriate secondary diagnostic services as of the end of 2012. Implications: As improved therapeutic options become available for people living with chronic hepatitis C, measures to support appropriate follow-up of people with suspected or confirmed chronic infections via primary care services will be required.