Assessing the potential impact of COVID-19 booster doses and oral antivirals: A mathematical modelling study of selected middle-income countries in the Indo-Pacific.

Continued efforts to reduce the burden of COVID-19 require the consideration of additional booster doses and emerging oral antivirals. This study explored the individual- and population-level impacts of booster dose and oral antivirals in Indonesia, Fiji, Papua New Guinea, and Timor-Leste. Our mathematical model included age structure, vaccine coverage, prevalence of comorbidities, and immunity from prior infection fit to incidence data from our study settings. We explored a range of eligibility criteria and found that boosters had the largest impact per dose when prioritised to high-risk adults and adults who had not previously received a booster. Antivirals were most effective in settings with low vaccine-derived immunity. In general, fewer antivirals than booster doses were required to prevent a hospitalisation or death. Only in settings with very high vaccine uptake was the impact per dose of providing booster doses to high-risk adults comparable to providing oral antivirals to high-risk adults. Together, booster doses and oral antivirals could prevent 80%, 64%, 49%, and 65% of deaths, and 38%, 37%, 16%, and 34% of hospitalisations in Fiji, Indonesia, Papua New Guinea, and Timor-Leste respectively. Therefore, our findings support the continued provision of COVID-19 booster doses to high-risk adults in 2023, and advocate for increased access to oral antivirals, especially in settings with low vaccine coverage such as Papua New Guinea. Future work should consider the threshold at which self-financing of COVID-19 oral antivirals would be viable for middle-income countries in South-East Asia and the Pacific.