Optimal pandemic control strategies and cost-effectiveness of COVID-19 non-pharmaceutical interventions in the United States.

backgroundNon-pharmaceutical interventions (NPIs) in response to the COVID-19 pandemic necessitated a trade-off between the health impacts of viral spread and the social and economic costs of restrictions. Navigating this trade-off proved consequential, contentious, and challenging for decision-makers.

methodsWe conduct a cost-effectiveness analysis of NPIs enacted at the state level in the United States (US) in 2020. We combine data on COVID-19 cases, deaths, policies, and the social, economic, and health consequences of infections and interventions within an epidemiological model. We estimate SARS-CoV-2 prevalence, transmission rates, effects of interventions, and costs associated to infections and NPIs in each US state. We use these estimates to quantitatively evaluate the efficacy and gross impacts of the policy schedules implemented during the pandemic. We also derive optimal cost-effective strategies that minimize aggregate costs to society.

resultsWe find that NPIs were effective in substantially reducing SARS-CoV-2 transmission, averting 860,000 (95% CI: 560,000-1,190,000) COVID-19 deaths in the US in 2020. Although school closures reduced transmission, their social impact in terms of student learning loss was too costly, depriving the nation of $2 trillion in 2020 US dollars (USD2020), conservatively, in future Gross Domestic Product (GDP). Moreover, this marginal trade-off between school closure and COVID-19 deaths was not inescapable: a combination of other measures would have been enough to maintain similar or lower mortality rates without incurring such profound learning loss. Optimal policies involve consistent implementation of mask mandates, public test availability, contact tracing, social distancing orders, and reactive workplace closures, with no closure of schools. Their use would have reduced the gross impact of the pandemic in the US in 2020 from $4.6 trillion to $1.9 trillion and, with high probability, saved over 100,000 lives.

conclusionsUS COVID-19 school closure was not cost-effective, but other measures were. While our study focuses on COVID-19 in the US prior to vaccines, our methodological contributions and findings about the cost-effectiveness and optimal structure of NPI policies have implications for the response to future epidemics and in other countries. Our results also highlight the need to address the substantial global learning deficit incurred during the pandemic.