Epidemiological and health economic implications of symptom propagation in respiratory pathogens: A mathematical modelling investigation.

BACKGROUND: Respiratory pathogens inflict a substantial burden on public health and the economy. Although the severity of symptoms caused by these pathogens can vary from asymptomatic to fatal, the factors that determine symptom severity are not fully understood. Correlations in symptoms between infector-infectee pairs, for which evidence is accumulating, can generate large-scale clusters of severe infections that could be devastating to those most at risk, whilst also conceivably leading to chains of mild or asymptomatic infections that generate widespread immunity with minimal cost to public health. Although this effect could be harnessed to amplify the impact of interventions that reduce symptom severity, the mechanistic representation of symptom propagation within mathematical and health economic modelling of respiratory diseases is understudied. METHODS AND FINDINGS: We propose a novel framework for incorporating different levels of symptom propagation into models of infectious disease transmission via a single parameter, α. Varying α tunes the model from having no symptom propagation (α = 0, as typically assumed) to one where symptoms always propagate (α = 1). For parameters corresponding to three respiratory pathogens-seasonal influenza, pandemic influenza and SARS-CoV-2-we explored how symptom propagation impacted the relative epidemiological and health-economic performance of three interventions, conceptualised as vaccines with different actions: symptom-attenuating (labelled SA), infection-blocking (IB) and infection-blocking admitting only mild breakthrough infections (IB_MB). In the absence of interventions, with fixed underlying epidemiological parameters, stronger symptom propagation increased the proportion of cases that were severe. For SA and IB_MB, interventions were more effective at reducing prevalence (all infections and severe cases) for higher strengths of symptom propagation. For IB, symptom propagation had no impact on effectiveness, and for seasonal influenza this intervention type was more effective than SA at reducing severe infections for all strengths of symptom propagation. For pandemic influenza and SARS-CoV-2, at low intervention uptake, SA was more effective than IB for all levels of symptom propagation; for high uptake, SA only became more effective under strong symptom propagation. Health economic assessments found that, for SA-type interventions, the amount one could spend on control whilst maintaining a cost-effective intervention (termed threshold unit intervention cost) was very sensitive to the strength of symptom propagation. CONCLUSIONS: Overall, the preferred intervention type depended on the combination of the strength of symptom propagation and uptake. Given the importance of determining robust public health responses, we highlight the need to gather further data on symptom propagation, with our modelling framework acting as a template for future analysis.

Global burden of influenza-associated lower respiratory tract infections and hospitalizations among adults: A systematic review and meta-analysis.

BACKGROUND: Influenza illness burden is substantial, particularly among young children, older adults, and those with underlying conditions. Initiatives are underway to develop better global estimates for influenza-associated hospitalizations and deaths. Knowledge gaps remain regarding the role of influenza viruses in severe respiratory disease and hospitalizations among adults, particularly in lower-income settings. METHODS AND FINDINGS: We aggregated published data from a systematic review and unpublished data from surveillance platforms to generate global meta-analytic estimates for the proportion of acute respiratory hospitalizations associated with influenza viruses among adults. We searched 9 online databases (Medline, Embase, CINAHL, Cochrane Library, Scopus, Global Health, LILACS, WHOLIS, and CNKI; 1 January 1996-31 December 2016) to identify observational studies of influenza-associated hospitalizations in adults, and assessed eligible papers for bias using a simplified Newcastle-Ottawa scale for observational data. We applied meta-analytic proportions to global estimates of lower respiratory infections (LRIs) and hospitalizations from the Global Burden of Disease study in adults ≥20 years and by age groups (20-64 years and ≥65 years) to obtain the number of influenza-associated LRI episodes and hospitalizations for 2016. Data from 63 sources showed that influenza was associated with 14.1% (95% CI 12.1%-16.5%) of acute respiratory hospitalizations among all adults, with no significant differences by age group. The 63 data sources represent published observational studies (n = 28) and unpublished surveillance data (n = 35), from all World Health Organization regions (Africa, n = 8; Americas, n = 11; Eastern Mediterranean, n = 7; Europe, n = 8; Southeast Asia, n = 11; Western Pacific, n = 18). Data quality for published data sources was predominantly moderate or high (75%, n = 56/75). We estimate 32,126,000 (95% CI 20,484,000-46,129,000) influenza-associated LRI episodes and 5,678,000 (95% CI 3,205,000-9,432,000) LRI hospitalizations occur each year among adults. While adults <65 years contribute most influenza-associated LRI hospitalizations and episodes (3,464,000 [95% CI 1,885,000-5,978,000] LRI hospitalizations and 31,087,000 [95% CI 19,987,000-44,444,000] LRI episodes), hospitalization rates were highest in those ≥65 years (437/100,000 person-years [95% CI 265-612/100,000 person-years]). For this analysis, published articles were limited in their inclusion of stratified testing data by year and age group. Lack of information regarding influenza vaccination of the study population was also a limitation across both types of data sources. CONCLUSIONS: In this meta-analysis, we estimated that influenza viruses are associated with over 5 million hospitalizations worldwide per year. Inclusion of both published and unpublished findings allowed for increased power to generate stratified estimates, and improved representation from lower-income countries. Together, the available data demonstrate the importance of influenza viruses as a cause of severe disease and hospitalizations in younger and older adults worldwide.

Respiratory tract infection-induced asthma exacerbations in adults with asthma: assessing predictors and outcomes.

Objective: To evaluate clinical and economic burden associated with respiratory tract infection (RTI)-induced asthma exacerbations and to identify risk factors associated with these exacerbations. Factors associated with these exacerbations are understudied and little information is available about consequent expenditures. Methods: In this retrospective case-control study, medical records and pharmacy data in King Abdullah University Hospital in Northern Jordan were reviewed for adults with asthma aged 40 years and older, over the period 2013-2016. Cases of RTI-induced asthma exacerbations were identified, and controls were selected randomly from asthmatic adults who did not experience any RTI-induced asthma exacerbation during the same period. Independent-samples t-tests and chi-square tests were conducted to compare patient characteristics of cases and controls. Predictors of RTI-induced asthma exacerbations and the resultant complications were evaluated using multivariable logistic regression. Multivariable regression on log-transformed charges was used to predict expenditures of these exacerbations. Results: A total of 137 cases and 548 controls were identified. Using inhaled corticosteroid + long-acting beta-agonists (ICS + LABA) was significantly associated with lower odds of RTI-induced asthma exacerbations (OR = 0.4; 95% CI, 0.21-0.77; p = 0.006), and lower odds of resultant serious complications (OR = 0.23; 95% CI, 0.07-0.69; p = 0.009), compared to being untreated with any asthma maintenance treatment. Asthma severity and co-morbidities were associated with increased susceptibility to these exacerbations. The average charges of RTI-induced asthma admissions and outpatient exacerbations were 1042.9 JD ($1471.0) and 81.1 JD ($114.4), respectively. Conclusions: ICS + LABA, asthma severity and co-morbidities appeared to affect the clinical and economic burden associated with RTI-induced asthma exacerbations. Efforts to prevent these exacerbations in patients with risk factors are warranted.

The impact of budesonide inhalation suspension for asthma hospitalization: In terms of length of stay, recovery time from symptoms, and hospitalization costs.

BACKGROUND: Hospitalization is a major cause of medical expenditure for asthma. Budesonide inhalation suspension (BIS) may assist in reducing asthma-related symptoms in severe asthma exacerbation. However, its effectiveness for hospitalized patients remains poorly known. The objective of this study is to determine associations of BIS with asthma hospitalization. METHODS: We retrospectively analyzed 98 patients who were admitted to our hospital due to severe asthma exacerbation (24 treated with BIS in combination with procaterol) from April 2014 to January 2019. Length of stay, recovery time from symptoms (wheezes), and hospitalization costs were compared between the 2 groups according to clinical factors including the use of BIS and sings of respiratory infections (i.e. C-reactive protein, the presence of phlegm, and the use of antibiotics). Multivariate logistic regression analysis was performed to determine factors contributing to hospitalization outcomes. RESULTS: The use of BIS was associated with shorter length of stay, faster recovery time from symptoms, and more reduced hospitalization costs (6.0 vs 8.5 days, 2.5 vs 5.0 days, and 258,260 vs 343,350 JPY). Signs of respiratory infection were also associated with hospitalization outcomes. On a multivariate regression analysis, the use of BIS was a determinant of shortened length of stay and reduced symptoms and medical costs for asthma hospitalization along with signs of respiratory infection. CONCLUSIONS: BIS may contribute to shorten length of hospital stay and to reduce symptoms and medical expenditure irrespective of the presence or absence of respiratory infection.

Systematic review and evidence synthesis of non-cervical human papillomavirus-related disease health system costs and quality of life estimates.

BACKGROUND: Many economic evaluations of human papillomavirus vaccination should ideally consider multiple disease outcomes, including anogenital warts, respiratory papillomatosis and non-cervical cancers (eg, anal, oropharyngeal, penile, vulvar and vaginal cancers). However, published economic evaluations largely relied on estimates from single studies or informal rapid literature reviews. METHODS: We conducted a systematic review of articles up to June 2016 to identify costs and utility estimates admissible for an economic evaluation from a single-payer healthcare provider's perspective. Meta-analyses were performed for studies that used same utility elicitation tools for similar diseases. Costs were adjusted to 2016/2017 US$. RESULTS: Sixty-one papers (35 costs; 24 utilities; 2 costs and utilities) were selected from 10 742 initial records. Cost per case ranges were US$124-US$883 (anogenital warts), US$6912-US$52 579 (head and neck cancers), US$12 936-US$51 571 (anal cancer), US$17 524-34 258 (vaginal cancer), US$14 686-US$28 502 (vulvar cancer) and US$9975-US$27 629 (penile cancer). The total cost for 14 adult patients with recurrent respiratory papillomatosis was US$137 601 (one paper).Utility per warts episode ranged from 0.651 to 1 (12 papers, various utility elicitation methods), with pooled mean EQ-5D and EQ-VAS of 0.86 (95% CI 0.85 to 0.87) and 0.74 (95% CI 0.74 to 0.75), respectively. Fifteen papers reported utilities in head and neck cancers with range 0.29 (95% CI 0.0 to 0.76) to 0.94 (95% CI 0.3 to 1.0). Mean utility reported ranged from 0.5 (95% CI 0.4 to 0.61) to 0.65 (95% CI 0.45 to 0.75) (anal cancer), 0.59 (95% CI 0.54 to 0.64) (vaginal cancer), 0.65 (95% CI 0.60 to 0.70) (vulvar cancer) and 0.79 (95% CI 0.74 to 0.84) (penile cancer). CONCLUSIONS: Differences in values reported from each paper reflect variations in cancer site, disease stages, study population, treatment modality/setting and utility elicitation methods used. As patient management changes over time, corresponding effects on both costs and utility need to be considered to ensure health economic assumptions are up-to-date and closely reflect the case mix of patients.

Behavioral Economics Interventions to Improve Outpatient Antibiotic Prescribing for Acute Respiratory Infections: a Cost-Effectiveness Analysis.

BACKGROUND: Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs). OBJECTIVE: To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs. DESIGN: Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data. SUBJECTS: Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider. INTERVENTIONS: (1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues. MAIN MEASURES: Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. KEY RESULTS: Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events. CONCLUSIONS: Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.

Respiratory Tract Infections in Children in the Community: Prospective Online Inception Cohort Study.

PURPOSE: Describe the duration of symptoms, proportion of parents seeking primary care consultations, and costs for respiratory tract infections (RTIs) of children in the community. METHODS: Community-based, online, prospective inception cohort study. General practitioners from socioeconomically diverse practices posted study invitations to parents of 10,310 children aged ≥3 months and <15 years. RESULTS: One parent of 485 (4.7%) children in 331 families consented, completed baseline data and symptom diaries, and agreed to medical record review. Compared with nonresponders, responding parent's children were younger (aged 4 vs 6 years) and less socioeconomically deprived. Between February and July 2016, 206 parents reported 346 new RTIs in 259 children. Among the 197 first RTIs reported per family, it took 23 days for 90% (95% CI, 85%-94%) of children to recover. Median symptom duration was longer: in children with primary care consultations (9 days) vs those without consultations (6 days, P = 0.06); children aged <3 years (11 days) vs >3 years (7 days, P <.01); and among children with reported lower RTI symptoms (12 days) vs those with only upper RTI symptoms (8 days, P <.001). Sixteen (8.1%; 95% CI, 4.7%-12.8%) of 197 children had primary care consultations at least once (total 19 consultations), and a similar proportion had time off school or nursery. Sixty of 188 (32%; 95% CI, 25%-39%) parents reported paying for medications for their child's illness. CONCLUSIONS: Parents can be advised that RTI symptoms last up to 3 weeks. Policy makers should be aware that parents may seek primary care support in at least 1 in 12 illnesses.

Strong effect of Ecuador's conditional cash transfer program on childhood mortality from poverty-related diseases: a nationwide analysis.

BACKGROUND: The mortality rate in children under 5 years old (U5MR) has decreased considerably in Ecuador in the last decade; however, thousands of children continue to die from causes related to poverty. A social program known as Bono de Desarrollo Humano (BDH) was created to guarantee a minimum level of consumption for families and to reduce chronic malnutrition and preventable childhood diseases. We sought to evaluate the effect of the BDH program on mortality of children younger than 5 years, particularly from malnutrition, diarrheal diseases, and lower respiratory tract infections. METHODS: Mortality rates and BDH coverage from 2009 to 2014 were evaluated from the 144 (of 222) Ecuadorian counties with intermediate and high quality of vital information. A multivariable regression analyses for panel data was conducted by using a negative binomial regression model with fixed effects, adjusted for all relevant demographic and socioeconomic covariates. RESULTS: Our research shows that for each 1% increase in BDH county coverage there would be a decrease in U5MR from malnutrition of 3% (RR 0.971, 95% CI 0.953-0.989). An effect of BDH county coverage on mortality resulting from respiratory infections was also observed (RR 0.992, 95% CI 0.984-0.999). The BDH also reduced hospitalization rates in children younger than 5 years, overall and for diarrhea. CONCLUSIONS: A conditional cash transfer program such as BDH could contribute to the reduction of mortality due to causes related to poverty, such as malnutrition and respiratory infections. The coverage should be maintained -or increased in a period of economic crisis- and its implementation strengthened.

Hospital and economic burden of influenza-like illness and lower respiratory tract infection in adults ≥50 years-old.

BACKGROUND: Influenza-like illnesses (ILIs) and lower respiratory tract infections (LRTIs) cause substantial morbidity and mortality worldwide. The study assessed the health and economic burden of ILI and LRTI according to age and comorbidities, since available evidence is limited and heterogeneous. METHOD: The prevalence of comorbidities, the seasonal incidence rates and the mean and per capita direct costs of ED accesses for ILI/LRTI, whether followed by hospitalization or not, recorded in adults aged ≥50 years over the last 6 years, in the referral hospitals located in the Genoese metropolitan area (Liguria, Italy) where the syndromic surveillance system is active, were evaluated through a retrospective observational study. Comorbidities were estimated through the Chronic Condition Data Warehouse that integrates multiple Medicare data sources. A comparison with the administrative healthcare International Classification of Diseases-9th revision-Clinical Modification (ICD-9-CM)-based data was also conducted. RESULTS: The prevalence of subjects with ≥1 comorbidity ranged from 23.49 to 59.92%. The most prevalent all-age comorbidities were cardiovascular diseases and cancer. The overall ILI/LRTI incidence rate was 6.73/1000 person-years, almost double the value derived from routine data, and increased with age. The highest rates were observed in patients with renal failure and bronchopneumopathies. The mean cost of ED accesses/hospitalization for ILI/LRTI was €3353 and was almost twice as high in the ≥85 years as in the youngest age-group. The highest mean costs were observed in patients with renal failure and cancer. The per capita costs increased from €4 to €71 with age, and were highest in patients with renal failure and bronchopneumopathy. CONCLUSION: The burden of ILIs/LRTIs in terms of ED accesses and hospitalizations in adults aged ≥50 years is heavy, and is related to increasing age and, especially, to specific comorbidities. These results could contribute to revising age- and risk-based anti-influenza and -pneumococcus immunization strategies.

Cost-effectiveness analysis of a multi-dimensional intervention to reduce inappropriate antibiotic prescribing for children with upper respiratory tract infections in China.

BACKGROUND: We developed a multifaceted intervention to reduce antibiotic prescription rate for children with upper respiratory tract infections (URTIs) among primary care doctors in township hospitals in China. The intervention achieved a 29% (95% CI 16-42) absolute risk reduction in antibiotic prescribing. This study was to assess the cost-effectiveness of our intervention at reducing antibiotic prescribing in rural primary care facilities as measured by the intervention's effect on the antibiotic prescription rates for childhood URTIs. METHODS: We took a healthcare provider perspective, measuring costs of consultation (time cost of doctor), prescription monitoring process and peer-review meetings (time cost of participants) and medication costs. Costs on provider side were collected through a bespoke questionnaire from all 25 township hospitals in December 2016, while medication costs were collected prospectively in the trial. Incremental cost-effectiveness ratios were calculated by dividing the mean difference in cost of the two trial arms by the mean difference in antibiotic prescribing rate. RESULTS: This showed an incremental cost of $0.03 per percentage point reduction in antibiotic prescribing. In addition to this incremental cost, the cost of implementing the intervention, including training and materials delivered by township hospitals, was $390.65 (SD $145.68) per healthcare facility. CONCLUSIONS: This study shows that a multifaceted intervention programme, when embedded into routine practice, is very cost-effective at reducing antibiotic prescribing in primary care facilities and has the potential of scale up in similar resource limited settings.

The Effect of Hospital Isolation Precautions on Patient Outcomes and Cost of Care: A Multi-Site, Retrospective, Propensity Score-Matched Cohort Study.

BACKGROUND: Isolation precautions have negative effects on patient safety, psychological well-being, and healthcare worker contact. However, it is not known whether isolation precautions affect certain hospital-related outcomes. OBJECTIVE: To examine the effect of isolation precautions on hospital-related outcomes and cost of care. DESIGN: Retrospective, propensity-score matched cohort study of inpatients admitted to general internal medicine (GIM) services at three academic hospitals in Toronto, Ontario, Canada between January 2010 and December 2012. PARTICIPANTS: Adult (≥18 years of age) patients on isolation precautions for respiratory illnesses and methicillin-resistant Staphylococcus aureus (MRSA) were matched to controls based on propensity scores derived from nine covariates: age, sex, Resource Intensity Weight, number of hospital readmissions within 90 days, total length of stay for hospital admissions within 90 days, site of admission, month of isolation, year of isolation, and Case Mix Group. MAIN MEASURES: Thirty-day readmission rates and emergency department visits, hospital length of stay, expected length of stay, adverse events, in-hospital mortality, patient complaints, and cost of care in Canadian doll ars (CAD). KEY RESULTS: A total of 17,649 non-isolated patients were admitted to the participating hospitals during the study period. We identified 1506 patients isolated for respiratory illnesses and 745 patients isolated for MRSA. Compared to non-isolated individuals, those on isolation precautions for respiratory illnesses stayed 17 % longer (95 % CI: 9 %, 25 %), stayed 9 % longer than expected (95 % CI: 3 %, 15 %), and had 23 % higher cost of care (95 % CI: 14 %, 32 %). Patients isolated for MRSA had similar outcomes, but they also had a 4.4 % higher (95 % CI: 1.4 %, 7.3 %) rate of readmission to hospital within 30 days. CONCLUSIONS: Isolation precautions are associated with adverse effects which may result in poorer hospital outcomes. Balancing the benefits for the many with the harms to the few will be a future challenge.

Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China.

OBJECTIVE: To estimate the national costs relating to diarrhoea and acute respiratory infections from not handwashing with soap after contact with excreta and the costs and benefits of handwashing behaviour change programmes in India and China. METHODS: Data on the reduction in risk of diarrhoea and acute respiratory infection attributable to handwashing with soap were used, together with World Health Organization (WHO) estimates of disability-adjusted life years (DALYs) due to diarrhoea and acute respiratory infection, to estimate DALYs due to not handwashing in India and China. Costs and benefits of behaviour change handwashing programmes and the potential returns to investment are estimated valuing DALYs at per capita GDP for each country. RESULTS: Annual net costs to India from not handwashing are estimated at US$ 23 billion (16-35) and to China at US$ 12 billion (7-23). Expected net returns to national behaviour change handwashing programmes would be US$ 5.6 billion (3.4-8.6) for India at US$ 23 (16-35) per DALY avoided, which represents a 92-fold return to investment, and US$ 2.64 billion (2.08-5.57) for China at US$ 22 (14-31) per DALY avoided - a 35-fold return on investment. CONCLUSION: Our results suggest large economic gains relating to decreases in diarrhoea and acute respiratory infection for both India and China from behaviour change programmes to increase handwashing with soap in households.

Impact of China's essential medicines scheme and zero-mark-up policy on antibiotic prescriptions in county hospitals: a mixed methods study.

OBJECTIVE: To evaluate the impact of the national essential medicines scheme and zero-mark-up policy on antibiotic prescribing behaviour. METHODS: In rural Guangxi, a natural experiment compared one county hospital which implemented the policy with a comparison hospital which did not. All outpatient and inpatient records in 2011 and 2014 were extracted from the two hospitals. Primary outcome indicator was antibiotic prescribing rate (APR) among children aged 2-14 presenting in outpatients with a primary diagnosis of upper respiratory tract infection (URTI). We organised independent physician reviews to determine inappropriate prescribing for inpatients. Difference-in-difference analyses based on multivariate regressions were used to compare APR over time after adjusting potential confounders. We conducted 12 in-depth interviews with paediatricians, hospital directors and health officials. RESULTS: A total of 8219 and 4142 outpatient prescriptions of childhood URTIs were included in the intervention and comparison hospitals, respectively. In 2011, APR was 30% in the intervention and 88% in the comparison hospital. In 2014, the intervention hospital significantly reduced outpatient APR by 21% (95% CI:-23%, -18%), intravenous infusion by 58% (95% CI: -64%, -52%) and prescription cost by 31 USD (95% CI: -35, -28), compared with the controls. We collected 251 inpatient records, but did not find reductions in inappropriate antibiotic use. Interviews revealed that the intervention hospital implemented a thorough antibiotics stewardship programme containing training, peer review of prescriptions and restrictions for overprescribing. CONCLUSION: The national essential medicines scheme and zero-mark-up policy, when implemented with an antimicrobial stewardship programme, may be associated with reductions in outpatient antibiotic prescribing and intravenous infusions.

Cost-effectiveness analysis of N95 respirators and medical masks to protect healthcare workers in China from respiratory infections.

BACKGROUND: There are substantial differences between the costs of medical masks and N95 respirators. Cost-effectiveness analysis is required to assist decision-makers evaluating alternative healthcare worker (HCW) mask/respirator strategies. This study aims to compare the cost-effectiveness of N95 respirators and medical masks for protecting HCWs in Beijing, China. METHODS: We developed a cost-effectiveness analysis model utilising efficacy and resource use data from two cluster randomised clinical trials assessing various mask/respirator strategies conducted in HCWs in Level 2 and 3 Beijing hospitals for the 2008-09 and 2009-10 influenza seasons. The main outcome measure was the incremental cost-effectiveness ratio (ICER) per clinical respiratory illness (CRI) case prevented. We used a societal perspective which included intervention costs, the healthcare costs of CRI in HCWs and absenteeism costs. RESULTS: The incremental cost to prevent a CRI case with continuous use of N95 respirators when compared to medical masks ranged from US $490-$1230 (approx. 3000-7600 RMB). One-way sensitivity analysis indicated that the CRI attack rate and intervention effectiveness had the greatest impact on cost-effectiveness. CONCLUSIONS: The determination of cost-effectiveness for mask/respirator strategies will depend on the willingness to pay to prevent a CRI case in a HCW, which will vary between countries. In the case of a highly pathogenic pandemic, respirator use in HCWs would likely be a cost-effective intervention.

Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a Chinese hospital system perspective.

BACKGROUND: Cost-impact models have indicated that in the USA, the use of antibiotic stewardship protocols based on procalcitonin (PCT) levels for patients with suspected acute respiratory tract infection results in cost savings. Our objective was to assess the cost impact of adopting PCT testing among patients with acute respiratory infections (ARI) from the perspective of a typical hospital system in urban China. METHODS: To conduct an economic evaluation of PCT testing versus usual care we built a cost-impact model based on a previously published patient-level meta-analysis data of randomized trials including Chinese sites. The data were adapted to the China setting by applying the results to mean lengths of stay, costs, and practice patterns typically found in China. We estimated the annual ARI visit rate for the typical hospital system (assumed to be 1650 beds) and ARI diagnosis. RESULTS: In the inpatient setting, the costs of PCT-guided care compared to usual care for a cohort of 16,405 confirmed ARI patients was almost 1.1 million Chinese yuan (CNY), compared to almost 1.8 million CNY for usual care, resulting in net savings of 721,563 CNY to a typical urban Chinese hospital system for 2015. In the ICU and outpatient settings, savings were 250,699 CNY and 2.4 million CNY, respectively. The overall annual net savings of PCT-guided care was nearly 3.4 million CNY. CONCLUSIONS: Substantial savings are associated with PCT protocols of ARI across common China hospital treatment settings mainly by direct reduction in unnecessary antibiotic utilization.

Biotech innovations in the prevention of respiratory infectious diseases.

Acute respiratory infections place a huge burden on society in terms of disability, premature mortality, and also direct health service costs (drugs prescriptions) and the indirect costs related to lost production. Therefore, prevention of respiratory infections is an important goal for public health interventions. In this context, silver nanoparticles (AgNPs) represent an interesting perspective for research and development by virtue of their favorable antimicrobial activity against many respiratory pathogens. One of the latest innovations in the biotech field discussed in this review is the creation of a biocompatible, biogel-based nasal filter enriched with AgNPs. Compared to traditional personal protective equipment (PPE), this type of nasal filter has the advantage of combining the antibacterial and antiviral activity of AgNPs with the common filtration capacity shared by other PPEs. This dual mechanism means that AgNP-enriched nasal filters serve to reduce the infecting microbial-load and protect the lower airways, without interfering with the normal respiratory capacity (airflow-resistance <5%). Given their antimicrobial characteristics and performance, AgNP-enriched nasal filters can meet many community and occupational currently unmet needs in the prevention of airborne infectious diseases, by ensuring an excellent respiratory-comfort and a continuous day-use.

Assessing the burden of medical impoverishment by cause: a systematic breakdown by disease in Ethiopia.

BACKGROUND: Out-of-pocket (OOP) medical expenses often lead to catastrophic expenditure and impoverishment in low- and middle-income countries. Yet, there has been no systematic examination of which specific diseases and conditions (e.g., tuberculosis, cardiovascular disease) drive medical impoverishment, defined as OOP direct medical costs pushing households into poverty. METHODS: We used a cost and epidemiological model to propose an assessment of the burden of medical impoverishment in Ethiopia, i.e., the number of households crossing a poverty line due to excessive OOP direct medical expenses. We utilized disease-specific mortality estimates from the Global Burden of Disease study, epidemiological and cost inputs from surveys, and secondary data from the literature to produce a count of poverty cases due to OOP direct medical costs per specific condition. RESULTS: In Ethiopia, in 2013, and among 20 leading causes of mortality, we estimated the burden of impoverishment due to OOP direct medical costs to be of about 350,000 poverty cases. The top three causes of medical impoverishment were diarrhea, lower respiratory infections, and road injury, accounting for 75 % of all poverty cases. CONCLUSIONS: We present a preliminary attempt for the estimation of the burden of medical impoverishment by cause for high mortality conditions. In Ethiopia, medical impoverishment was notably associated with illness occurrence and health services utilization. Although currently used estimates are sensitive to health services utilization, a systematic breakdown of impoverishment due to OOP direct medical costs by cause can provide important information for the promotion of financial risk protection and equity, and subsequent design of health policies toward universal health coverage, reduction of direct OOP payments, and poverty alleviation.

Have Changing Palivizumab Administration Policies Led to More Respiratory Morbidity in Infants Born at 32-35 Weeks?

OBJECTIVES: To determine differences in the incidence of respiratory morbidity during the first year of life among infants born 32(0/7)-34(6/7) weeks' gestational age (GA) before and after the administration policy for palivizumab, as written by the American Academy of Pediatrics, was updated in 2009. STUDY DESIGN: Secondary analysis of the dataset collected for the Gastrointestinal Risk Factors for Wheezing in Premature Infants study, which enrolled preterm infants without bronchopulmonary dysplasia and followed them by parental questionnaires at 3, 6, 9, and 12 months adjusted age for prematurity. Participants were included if they were enrolled in Gastrointestinal Risk Factors for Wheezing in Premature Infants, born 32(0/7)-34(6/7) weeks' GA, and completed the 12-month questionnaire. We compared rates of recurrent wheezing, respiratory medication use, and health care use before (Epoch 1) and after (Epoch 2) the 2009 administration policy change. RESULTS: A total of 165 infants met inclusion criteria. There was a significant increase in recurrent wheezing in Epoch 2 (46.2%) vs Epoch 1 (28.8%) (OR 2.22 [95% CI 1.08-4.53], P = .03). There was a nonsignificant increase in visits to the emergency department in Epoch 2 (27.4%) vs Epoch 1 (15.3%) (OR 2.12 [95% CI 0.91-4.96], P = .08). There were no differences in hospital admissions or respiratory medication use. CONCLUSIONS: Infants born 32(0/7)-34(6/7) weeks' GA treated after the American Academy of Pediatrics administration policy change in 2009 had a greater incidence of recurrent wheezing than those treated according to the previous policy. It will be important to track rates of recurrent wheezing after the 2014 administration policy, because it may be an important factor in future cost-effectiveness analyses.

Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a US health system perspective.

BACKGROUND: Whether or not antibiotic stewardship protocols based on procalcitonin levels results in cost savings remains unclear. Herein, our objective was to assess the economic impact of adopting procalcitonin testing among patients with suspected acute respiratory tract infection (ARI) from the perspective of a typical US integrated delivery network (IDN) with a 1,000,000 member catchment area or enrollment. METHODS: To conduct an economic evaluation of procalcitonin testing versus usual care we built a cost-impact model based on patient-level meta-analysis data of randomized trials. The meta-analytic data was adapted to the US setting by applying the meta-analytic results to US lengths of stay, costs, and practice patterns. We estimated the annual ARI visit rate for the one million member cohort, by setting (inpatient, ICU, outpatient) and ARI diagnosis. RESULTS: In the inpatient setting, the costs of procalcitonin-guided compared to usual care for the one million member cohort was $2,083,545, compared to $2,780,322, resulting in net savings of nearly $700,000 to the IDN for 2014. In the ICU and outpatient settings, savings were $73,326 and $5,329,824, respectively, summing up to overall net savings of $6,099,927 for the cohort. RESULTS were robust for all ARI diagnoses. For the whole US insured population, procalcitonin-guided care would result in $1.6 billion in savings annually. CONCLUSIONS: Our results show substantial savings associated with procalcitonin protocols of ARI across common US treatment settings mainly by direct reduction in unnecessary antibiotic utilization. These results are robust to changes in key parameters, and the savings can be achieved without any negative impact on treatment outcomes.

Viral lower respiratory tract infections and preterm infants' healthcare utilisation.

UNLABELLED: The aim of this study was to determine whether respiratory syncytial virus (RSV) and other viral lower respiratory tract infections (LRTI) in prematurely born infants were associated with similar effects on healthcare utilisation and related cost of care in the second compared to the first year after birth. Thirteen infants who had RSV LRTIs (RSV), 21 who had other viral LRTIs (other viral) and 25 had no viral LRTIs (no LRTI) were prospectively followed. Nasopharyngeal aspirates were collected whenever an infant had an LRTI regardless of whether it was in the hospital or in the community. Healthcare utilisation and the health-related cost of care were determined. Only the RSV group compared to the no LRTI group had higher overall respiratory costs in both year 1 (mean, £3,917 versus £24; p < 0.041) and year 2 (mean, £1,164 versus £61; p = 0.012). Only the RSV group required respiratory admissions; the RSV admission rate in year 2 was 3.4 % (number needed to treat 59). CONCLUSION: RSV LRTIs are associated with increased healthcare utilisation and cost of care in the first and second year; nevertheless, if prophylaxis is to be cost-effective in the second year, a high risk group needs to be identified.