Background At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. Methods The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. Results Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. Conclusions The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.
IntroductionThe arrival of COVID-19 vaccines in Thailand has supported the fight against the COVID-19 pandemic. This study examined COVID-19 vaccine acceptance among health care workers (HCWs) in Thailand before and after vaccines' availability and investigated factors (both enablers and barriers) affecting their decisions.MethodsTwo online self-administered questionnaires were distributed to HCWs in two time-periods: (1) the pre-vaccine arrival period (prior to COVID-19 vaccines' arrival in Thailand, January 28 to February 16, 2021); and (2) the post-vaccine arrival period (April 21 to May 9, 2021). Descriptive analyses and multinomial logistic regression were conducted to examine factors associated with vaccine hesitancy.ResultsThere were 55,068 respondents in the pre-vaccine arrival period and 27,319 respondents in the post-vaccine arrival period. In the pre-vaccine arrival period, 55.0% of respondents were willing to accept the vaccines, 35.4% were uncertain, and 9.6% declined. In the post-vaccine arrival period, ~16% already received two doses of either the Sinovac or AstraZeneca vaccine, and 43% were administered one dose. Approximately 12% of those who had received the first dose were uncertain or not willing to accept the second dose. Demographic and socio-demographic factors of participants, including their sex, place of residence, and whether they were frontline COVID-19 workers, were found to be the significant factors explaining vaccination hesitancy. Moreover, when comparing the pre-vaccine arrival and post-vaccine arrival periods, it was found that older HCWs were more likely to decline a COVID-19 vaccine in the pre-vaccine arrival period; on the other hand, older HCWs were less likely to decline or be uncertain to receive a COVID-19 vaccine in the post-vaccine arrival period.ConclusionInformation on HCWs' acceptance of COVID-19 vaccines, including who is more likely to accept the vaccines, could assist in planning vaccine allocation to both HCWs and the general public, who often believe HCWs' recommendations. This study's findings set out how policies can be addressed to reduce vaccine hesitancy. This study also highlights HCWs' characteristics (including gender, work region, occupation, and history of receiving influenza vaccination) and the reasons they cited for their vaccine acceptance or hesitance.
The Thai government implemented COVID-19 booster vaccines to prevent morbidity and mortality during the spreading of the Omicron variant. However, little is known about which types of vaccine should be invested in as the booster dose for the Thai population. This study aims to investigate the most cost-effective COVID-19 vaccine for a booster shot as empirical evidence for Thai policymakers. This study applied a stochastic simulation based on a compartmental susceptible-exposed-infectious-recovered model and included system dynamics in the model. We evaluated three scenarios: (1) No booster, (2) A viral vector vaccine as the booster dose, (3) An mRNA vaccine as the booster dose. The incremental cost-effectiveness ratio (ICER) was calculated based on provider perspectives. We found the number of cases in scenarios with viral vector and mRNA booster doses to be lower than in the non-booster group. Likewise, the number of deaths in the viral vector and the mRNA booster scenarios was threefold lower than in the no-booster scenario. Moreover, the estimated grand cost for the no-booster scenario was over 100 billion baht, while viral vector and mRNA scenario costs were 70 and 64.7 billion baht, respectively. ICER shows that viral vector and mRNA scenarios are more cost-effective than the no-booster scenario. Viral vector booster shot appeared to be slightly more cost-effective than mRNA booster shot in terms of death aversion. However, being boosted by an mRNA vaccine seemed slightly more cost-effective than a viral vector vaccine concerning case aversion. In conclusion, policies to promote COVID-19 booster shots in the Thai population by either mRNA or viral vector vaccines are likely to be worthwhile for both economic and public health reasons.
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