Routine immunization against Streptococcus pneumoniae and Haemophilus influenzae type B and antibiotic consumption in India: a dynamic modeling analysis.

Background: Childhood vaccinations can reduce disease burden and associated antibiotic use, in turn reducing the risk of antimicrobial resistance (AMR). We retrospectively estimated the population-level reductions in antibiotic use in India following the introduction of vaccines against Streptococcus pneumoniae and Haemophilius influenzae type B in the national immunization program for children in the mid-2010s and projected future gains to 2028 if vaccination coverage were to be increased. Methods: Using IndiaSim, a dynamic agent-based microsimulation model (ABM) for India, we simulated the spread of Streptococcus pneumoniae and Haemophilius influenzae type B (Hib) among children to estimate reductions in antibiotic use under the scenarios of: (i) pneumococcal and Hib vaccine coverage levels equivalent to the national coverage of pentavalent diphtheria-pertussis-tetanus third dose (DPT3) compared to a baseline of no vaccination, and (ii) near-universal (90%) coverage of the vaccines compared to pre-COVID national DPT3-level coverage. Model parameters, including national DPT3 coverage rates, were based on data from the National Family Household Survey 2015-2016 and other published sources. We quantified reductions in antibiotic consumption nationally and by state and wealth quintiles. Findings: We estimate that coverage of S. pneumoniae and Hib vaccines at the same level as DPT3 in India would translate to a 61.4% [95% UI: 43.8-69.5] reduction in attributable antibiotic use compared to a baseline of zero vaccination coverage. Increases in childhood vaccination coverage between 2004 and 2016 have likely reduced attributable antibiotic demand by as much as 93.4% among the poorest quintile. Increasing vaccination coverage by an additional 11 percentage points from 2016 levels results in mortality and antibiotic use across wealth quintiles becoming increasingly similar (p < 0.05), reducing in health inquities. We project that near-universal vaccine coverage would further reduce inequities in antibiotic demand and may eliminate of outbreak-associated antibiotic use from S. pneumoniae and Hib. Interpretation: Though vaccination has a complex relationship with antibiotic use because both are modulated by socioeconomic factors, increasing vaccinations for S. pneumoniae and Hib may have a significant impact on reducing antibiotic use and improving health outcomes among the poorest individuals. Funding: The Bill & Melinda Gates Foundation (grant numbers OPP1158136 and OPP1190803).

"Undoubtedly a race, but they are not human": Immuno-politics and the Recognition of the Jew as Pathogenic Nonself in Art Spiegelman's Maus.

This article engages with the immuno-political juxtaposition of the healthy self and the pathogenic other to critically examine the representation of Nazis and Jews in Art Spiegelman's Pulitzer Prize-winning graphic novel Maus (1996). Written as a postmemory narrative, Maus recounts the horrors experienced by the author's father Vladek Spiegelman as a survivor of the Holocaust that claimed an approximate six million Jewish lives. Beginning with the years leading up to World War II, Spiegelman's novel reimagines the discrimination, dislocation, and dehumanization suffered by Vladek and his family at various prison camps in Nazi-occupied Poland before being transferred to Auschwitz. Deploying an immuno-political reading of Maus, this article investigates how the Third Reich undertook a systematic extermination of the Jewish race by construing them as immunological nonself or pathogenic others. It further argues that Nazism's fantasy of constructing a racially aseptic German identity by eradicating the Jews as vermin or parasites was reinforced by the late nineteenth-century eugenicist ideologies of racial hygiene. This article finally considers how policies of excessive immunization that was deployed by Nazi biopolitics against the Jewish community, as well as exercised by the Jews to survive the Holocaust, eventually assumed the form of an autoimmune pathology that culminated with the attempted destruction of the entire medico-juridical infrastructure of the German Reich on the one hand and the fostering of suicidal tendencies by the Jewish survivors on the other.

Effect of rotavirus vaccination on the burden of rotavirus disease and associated antibiotic use in India: A dynamic agent-based simulation analysis.

BACKGROUND: Rotavirus is a leading cause of diarrhea in infants and young children in many low- and middle-income countries. India launched a childhood immunization program for rotavirus in 2016, starting with four states and expanding it to cover all states by 2019. The objective of this study was to estimate the effects of the rotavirus vaccination program in India on disease burden and antibiotic misuse. METHODS: We built a dynamic agent-based model of rotavirus progression in children under five within each district in India. Simulations were run for various scenarios of vaccination coverage in the context of India's Universal Immunization Programme. Population data were obtained from the National Family Household Surveys and used to calibrate the models. Disease parameters were obtained from published studies. We estimated past and projected future reduction of disease burden and antibiotic misuse due to full vaccination nationwide, by state, and by wealth quintile. RESULTS: We estimate that rotavirus vaccination in India has reduced the prevalence of rotavirus cases by 33.7% (prediction interval: 30.7-36.0%), total antibiotic misuse due to rotavirus by 21.8% (18.6-25.1%), and total deaths due to rotavirus by 38.3% (31.3-44.4%) for children under five. We estimate total antibiotic misuse due to rotavirus infection to be 7.6% (7.5-7.9%) of total antibiotic consumption in this demographic versus 9.6% (9.4-9.9%) in the absence of vaccination. We project rotaviral prevalence to drop to below one case for every 100,000 individuals in those below five if vaccination coverage is increased by 50.3% (45.2-58.5%) to 68.1% (63.1-76.4) nationwide. CONCLUSION: Universal coverage of childhood rotavirus vaccination can substantially reduce inappropriate antibiotic use in India.

The global macroeconomic burden of Alzheimer's disease and other dementias: estimates and projections for 152 countries or territories.

BACKGROUND: Alzheimer's disease and other dementias (ADODs) severely threaten the wellbeing of older people, their families, and communities, especially with projected exponential growth. Understanding the macroeconomic implications of ADODs for policy making is essential but under-researched. METHODS: We used a health-augmented macroeconomic model to calculate the macroeconomic burden of ADODs for 152 countries or territories, accounting for: the effect on labour supply of reduced working hours of informal caregivers; the effect on labour supply of ADODs-related mortality and morbidity; age-sex-specific differences in education, work experience, labour market participations, and informal caregivers; and treatment and formal care costs diverting from savings and investments. FINDINGS: ADODs will cost the world economy 14 513 billion international dollars (INT$, measured in the base year 2020; 95% uncertainty interval [UI] 12 106-17 778) from 2020 to 2050, equivalent to 0·421% (95% UI 0·351-0·515) of annual global GDP. Japan incurs the largest annual GDP loss at 1·463% (1·225-1·790). China (INT$2961 billion [2507-3564]), the USA (INT$2331 billion [1989-2829]), and Japan (INT$1758 billion [1471-2150]) face the largest absolute economic burdens. The economic burden of informal care ranges from 60·97% in high-income countries to 85·45% in lower-middle-income countries, and treatment and formal care costs range from 10·50% in lower-middle-income countries to 30·80% in high-income countries. INTERPRETATION: The macroeconomic burden of ADODs is substantial and unequally distributed across countries and regions. Global efforts to reduce the burden, especially with regard to informal care, are urgently needed. FUNDING: National Institute on Aging, National Institutes of Health; Chinese Academy of Engineering; Chinese Academy of Medical Sciences; Bill & Melinda Gates Foundation; Davos Alzheimer's Collaborative through Data for Decisions.

Analysis of anthropometric outcomes in Indian children during the COVID-19 pandemic using National Family Health Survey data.

BACKGROUND: Disruptions in food, health, and economic systems during the COVID-19 pandemic may have adversely affected child health. There is currently limited research on the potential effects of the COVID-19 pandemic on stunting, wasting, and underweight status of young children. METHODS: We examine the short-term associations between the pandemic and anthropometric outcomes of under-5 children (n = 232,920) in India, using data from the National Family Health Survey (2019-2021). Children surveyed after March 2020 are considered as the post-COVID group, while those surveyed earlier are considered as pre-COVID. Potential biases arising from differences in socioeconomic characteristics of the two groups are mitigated using propensity score matching methods. RESULTS: Post-COVID children surveyed in 2020 and 2021 have 1.2% higher underweight rates, 1.2% lower wasting rates, 0.1 lower height-for-age z-scores (HAZ), and 0.04 lower weight-for-height z-scores as compared with matched pre-COVID children. Post-COVID children surveyed in 2020 have 1.6%, 4.6%, and 2.4% higher stunting, underweight, and wasting rates, respectively, and 0.07 lower HAZ, as compared with matched pre-COVID children. Reductions in nutritional status are largest among children from households in the poorest wealth quintiles. CONCLUSIONS: These findings indicate a trend towards a recovery in child anthropometric outcomes in 2021 after the initial post-pandemic reductions. The resilience of health and food systems to shocks such as COVID-19 should be strengthened while immediate investments are required to decrease child malnutrition and improve broader child health outcomes.

This study examined how the COVID-19 pandemic affected the health of children under five years of age in India. We compared children surveyed before and after the pandemic. We find that children surveyed after the pandemic began in 2020 had decreased height and weight when compared to pre-pandemic measurements. In 2021, these outcomes improved but some outcomes, primarily weight, did not recover completely. These effects were most pronounced in the poorest households. Overall, our findings suggest that some of the effects of the pandemic may be short-term, but these require further study. Investments are required to reduce child malnutrition and improve the resilience of health and foods systems to shocks.

Vaccination for healthy aging.

As the world's population grows older, vaccination is becoming a key strategy for promoting healthy aging. Despite scientific progress in adult vaccine development, obstacles such as immunosenescence and vaccine hesitancy remain. To unlock the potential of adult vaccines fully, we must enhance immunization programs, dispel misinformation, and invest in research that deepens our understanding of aging and immunity.

Estimates of hospitalisations and deaths in patients with COVID-19 associated with undiagnosed diabetes during the first phase of the pandemic in eight low-income and middle-income countries: a modelling study.

Background: Patients with COVID-19 that had diagnosed chronic diseases - including diabetes - may experience higher rates of hospitalisation and mortality relative to the general population. However, the burden of undiagnosed co-morbidities during the pandemic has not been adequately studied. Methods: We developed a model to estimate the hospitalisation and mortality burden of patients with COVID-19 that had undiagnosed type 1 and type 2 diabetes (UD). The retrospective analytical modelling framework was informed by country-level demographic, epidemiological and COVID-19 data and parameters. Eight low-and middle-income countries (LMICs) were studied: Brazil, China, India, Indonesia, Mexico, Nigeria, Pakistan, and South Africa. The modelling period consisted of the first phase of the pandemic - starting from the date when a country identified its first COVID case to the date when the country reached 1% coverage with one dose of a COVID-19 vaccine. The end date ranged from Jan 20, 2021 for China to June 2, 2021 for Nigeria. Additionally, we estimated the change in burden under a scenario in which all individuals with UD had been diagnosed prior to the pandemic. Findings: Based on our modelling estimates, across the eight countries, 6.7 (95% uncertainty interval: 3.4-11.3) million COVID-19 hospitalised patients had UD of which 1.9 (0.9-3.4) million died. These represented 21.1% (13.4%-30.1%) of all COVID-19 hospitalisations and 30.5% (14.3%-55.5%) of all COVID-19 deaths in these countries. Based on modelling estimates, if these populations had been diagnosed for diabetes prior to the COVID-19 pandemic, 1.7% (-3.0% to 5.9%) of COVID-19 hospitalisations and 5.0% (-0.9% to 14.1%) of COVID-19 deaths could have been prevented, and 1.8 (-0.3 to 5.0) million quality-adjusted life years gained. Interpretation: Our findings suggest that undiagnosed diabetes contributed substantially to COVID-19 hospitalisations and deaths in many LMICs. Funding: This work was supported, in part, by the Bill & Melinda Gates Foundation [INV-029062] and FIND.

Cost of care for Alzheimer's disease and related dementias in the United States: 2016 to 2060.

Medical and long-term care for Alzheimer's disease and related dementias (ADRDs) can impose a large economic burden on individuals and societies. We estimated the per capita cost of ADRDs care in the in the United States in 2016 and projected future aggregate care costs during 2020-2060. Based on a previously published methodology, we used U.S. Health and Retirement Survey (2010-2016) longitudinal data to estimate formal and informal care costs. In 2016, the estimated per patient cost of formal care was $28,078 (95% confidence interval [CI]: $25,893-$30,433), and informal care cost valued in terms of replacement cost and forgone wages was $36,667 ($34,025-$39,473) and $15,792 ($12,980-$18,713), respectively. Aggregate formal care cost and formal plus informal care cost using replacement cost and forgone wage methods were $196 billion (95% uncertainty range [UR]: $179-$213 billion), $450 billion ($424-$478 billion), and $305 billion ($278-$333 billion), respectively, in 2020. These were projected to increase to $1.4 trillion ($837 billion-$2.2 trillion), $3.3 trillion ($1.9-$5.1 trillion), and $2.2 trillion ($1.3-$3.5 trillion), respectively, in 2060.

"And Then It Spreads": contagion and disease as metaphors of sociomoral contamination in Charles Burns' graphic novel Black Hole.

This article attempts to demonstrate how Charles Burns' graphic novel Black Hole (1995) construes the prevalence of contagion and pathological transformation(s) as metaphors of social contamination operating within a biopolitics of segregation. Through a study of plague, infection and strange mutations in Burns' novel, this article offers a critical evaluation of the monstrous body and investigates how Black Hole portrays the social reception of a sexually contagious virus through conditions of sickness and exclusion, which become biopolitical in quality. It examines, through close reading, how Burns' novel uses metaphors of contagion, abjection and desire, often fusing those in order to foreground the complex intercorporeal state of the segregated subject and in the process dramatises the urgent need to revaluate conventional strategies of isolation and otherisation through a reconsideration of the biopolitical notions around engagement, community and immunity.

The gendered effects of the COVID-19 pandemic on adolescent literacy and schooling outcomes in India.

The COVID-19 pandemic disrupted education delivery around the world, with school closures affecting over 1.6 billion students worldwide. In India, schools were closed for over 18 months, affecting 248 million students. This study estimates the effect of the pandemic on adolescent literacy and schooling outcomes in India. We used data from the National Family Health Survey. (NFHS-5) which covered 636,699 households across all districts of India from June 2019 to April 2021. We considered 15-17 year old adolescents who were surveyed after March 2020 as the post-COVID group while those surveyed earlier were included in the pre-COVID group. We used propensity score matching and inverse propensity score weighted regression methods to account for differences in socioeconomic characteristics between the two groups. Rates of literacy (ability to read a complete sentence) were 1.5-1.6% lower among post-COVID girls as compared with similar pre-COVID girls. Among post-COVID girls in the lowest wealth quintile, rates of literacy were 3.1-3.8% lower than similar pre-COVID girls. There was no loss in literacy among post-COVID girls in the highest wealth quintile. COVID-induced loss in literacy among girls was twice in rural areas as compared to urban areas, and substantially higher among socioeconomically disadvantaged caste groups as compared with privileged caste groups. Post-COVID girls also had 0.08-0.1 lower years of schooling completed than similar pre-COVID girls but there was no difference in out-of-school rates. In a smaller subsample of 15-17 year old boys, the post-COVID group had 2% lower out-of-school rates and there was no difference in literacy or years of schooling completed as compared with matched pre-COVID boys. While markers of vulnerability such as residence, caste, and poverty further amplified the risk of learning. loss for girls, they did not have the same effect on boys.

Vaccines for a sustainable planet.

The health of the planet is one objective of the United Nations' Sustainable Development Goals. Vaccines can affect not only human health but also planet health by reducing poverty, preserving microbial diversity, reducing antimicrobial resistance, and preventing an increase in pandemics that is fueled partly by climate change.

Growth failure among children of adolescent mothers at ages 0-5 and 6-12 years in India.

Adolescent motherhood has been linked with poor health outcomes at birth for children, including high neonatal mortality, low birthweight, and small-for-gestational-age rates. However, longer-term growth outcomes in the children of adolescent mothers in low-resource settings remain inadequately studied. We used longitudinal data from the India Human Development Surveys, 2004-2005 and 2011-2012 (n = 12,182) and employed regression and propensity score matching analysis to compare the following growth indicators of children born to adolescent mothers (ages 19 years or below) with those born to older mothers. Growth indicators included height and weight during ages 0-5 years and 6-12 years and change in height and weight between the two periods. In regression-based estimates, children born to adolescent mothers were 0.01 m shorter and weighed 0.2 kg less than children of older mothers at ages 0-5 years. At ages 6-12 years, those born to adolescent mothers were 0.02 m shorter and weighed 0.97 kg less. The height difference between the two groups increased by 0.01 m and the weight difference grew by 0.77 kg over time. Height and weight difference between the two groups worsened among boys over time, while for girls, only the weight gap worsened. The results were similar when using propensity score matching methods. Public policies for reducing child marriage, combined with targeted health, nutrition, and well-being programs for adolescent mothers, are essential for both preventing adolescent childbearing and reducing its impact on growth failure among children in India.

Global antibiotic use during the COVID-19 pandemic: analysis of pharmaceutical sales data from 71 countries, 2020-2022.

Background: Despite bacterial coinfection rates of less than 10%, antibiotics are prescribed to an estimated 75% of patients with COVID-19, potentially exacerbating antimicrobial resistance. We estimated the associations of COVID-19 cases and vaccinations with global antibiotic sales during the first two years of the COVID-19 pandemic. Methods: We obtained monthly data on broad-spectrum antibiotic sales volumes (cephalosporins, penicillins, macrolides, and tetracyclines) in 71 countries during March 2020-May 2022 from the IQVIA MIDAS® database. These data were combined with country-month-level COVID-19 case and vaccination data from Our World in Data. We used least squares (pooled) and fixed-effects panel data regression models, accounting for country characteristics, to estimate the associations between antibiotic sales volumes and COVID-19 cases and vaccinations per 1000 people. Findings: Sales of all four antibiotics fell sharply during April and May 2020, followed by a gradual rise to near pre-pandemic levels through May 2022. In fixed-effects regression models, a 10% increase in monthly COVID-19 cases was associated with 0.2%-0.3% higher sales of cephalosporins, 0.2%-0.3% higher sales of penicillins, 0.4%-0.6% higher sales of macrolides, and 0.3% higher sales of all four antibiotics combined per 1000 people. Across continents, a 10% increase in monthly COVID-19 cases was associated with 0.8%, 1.3%, and 1.5% higher macrolides sales in Europe, North America, and Africa respectively. Sales of other antibiotics across continent were also positively associated with COVID-19 cases, although the estimated associations were smaller in magnitude. No consistent associations were observed between antibiotic sales and COVID-19 vaccinations. Results from pooled regression analysis were similar to those from the fixed-effects models. Interpretation: Antibiotic sales were positively associated with COVID-19 cases globally during 2020-2022. Our findings underline that antibiotic stewardship in the context of COVID-19 remains essential. Funding: Bill & Melinda Gates Foundation.

The effect of the COVID-19 pandemic on routine childhood immunization coverage and timeliness in India: retrospective analysis of the National Family Health Survey of 2019-2021 data.

Background: The COVID-19 pandemic has disrupted health systems globally. We estimated the effect of the pandemic on the coverage and timeliness of routine childhood immunization in India through April 2021. Methods: We used data from India's National Family Health Survey 2019-2021 (NFHS-5), a cross-sectional survey which collected immunization information of under-five children from a nationally representative sample of households between June 2019 and April 2021. We used a mother fixed-effects regression model - accounting for secular trends and confounding factors - to compare COVID-affected children with their COVID-unaffected siblings (n = 59,144). Children who were eligible for a vaccine after January 30, 2020 (date of the first COVID case in India) were considered as the COVID-affected group and those eligible for a vaccine before this date were included in the COVID-unaffected group. Coverage of the following vaccine doses was considered-Bacillus Calmette-Guérin (BCG), hepatitis B birth dose (hepB0), DPT1 (diphtheria, pertussis, and tetanus, first dose), DPT2, DPT3, polio1, polio2, polio3, and measles first dose (MCV1). Indicators of vaccine coverage and vaccine timeliness (defined as receiving a dose within 45 days of minimum eligibility age) were separately examined. Findings: Immunization coverage was lower in COVID-affected children as compared with unaffected children, ranging from 2% lower for BCG and hepB0 to 9% for DPT3 and 10% for polio3. There was no significant difference in MCV1 coverage. Coverage reduction was greater for vaccines doses given in later age groups. The rate of timely receipt of polio and DPT vaccine doses was 3%-5% lower among COVID-affected children relative to unaffected children. Among population subgroups, COVID-affected male children and those from rural areas experienced the highest reduction in vaccine coverage. Interpretation: Children in India experienced lower routine immunization coverage and greater delays in immunization during the COVID-19 pandemic. Funding: The Bill & Melinda Gates Foundation.

Global and regional projections of the economic burden of Alzheimer's disease and related dementias from 2019 to 2050: A value of statistical life approach.

Background: The burden of Alzheimer's disease and related dementias (ADRDs) is expected to grow rapidly with population aging, especially in low- and middle-income countries, in the next few decades. We used a willingness-to-pay approach to project the global, regional, and national economic burden of ADRDs from 2019 to 2050 under status quo. Methods: We projected age group and country-specific disability-adjusted life years (DALYs) lost to ADRDs in future years based on historical growth in disease burden and available population projections. We used country-specific extrapolations of the value of a statistical life (VSL) year and its future projections based on historical income growth to estimate the economic burden - measured in terms of the value of lost DALYs - of ADRDs. A probabilistic uncertainty analysis was used to calculate point estimates and 95% uncertainty bounds of the economic burden. Findings: In 2019, the global VSL-based economic burden of ADRDs was an estimated $2.8 trillion. The burden was projected to increase to $4.7 trillion (95% uncertainty bound: $4 trillion-$5.5 trillion) in 2030, $8.5 trillion ($6.8 trillion-$10.8 trillion) in 2040, and $16.9 trillion ($11.3 trillion-$27.3 trillion) in 2050. Low- and middle-income countries (LMICs) would account for 65% of the global VSL-based economic burden in 2050, as compared with only 18% in 2019. Within LMICs, upper-middle income countries would carry the largest VSL-based economic burden by 2050 (92% of LMICs burden and 60% of global burden). Interpretation: ADRDs have a large and inequitable projected future VSL-based economic burden. Funding: The Davos Alzheimer's Collaborative.

Public health facility quality and child immunization outcomes in rural India: A decomposition analysis.

Universal coverage of routine childhood vaccines remains a challenge in many low- and middle-income countries (LMICs). In India, vaccination campaigns have increased full immunization coverage among 12-23 month old children from an estimated 62% in 2015-2016 to 76% in 2019-2020. Long-term improvements in coverage will likely require systemic changes to both the supply and demand sides of immunization programs. However, the effect of health system inputs on child vaccination outcomes remains poorly quantified in India. We examined the association between the quality of public health facilities and child vaccination outcomes in rural India using data from the nationally representative Integrated Child Health and Immunization Survey (2015-2016) which covered 1,346 public primary health sub-centers and 44,571 households. We constructed two indices of sub-center quality using multiple correspondence analysis: one related to the general health infrastructure quality and the other measuring vaccine service delivery. Using probit regression, we analyzed the relationship between vaccination outcomes in children under 2 years of age and sub-center quality, controlling for household socioeconomic characteristics. Additionally, we conducted Fairlie decomposition analysis by wealth group - bottom wealth quintile relative to the top four wealth quintiles- to examine factors contributing to gaps in immunization between rich and poor households. Infrastructure quality index was positively associated with completion of seven vaccination outcomes: full immunization, DPT-1 (first dose of diphtheria, pertussis, and tetanus), DPT-2, DPT-3, Bacillus Calmette-Guérin (BCG), hepatitis B (birth dose), and on-time vaccination (OTV). Vaccine service delivery index was positively associated with completion of measles vaccination. The distribution of infrastructure quality contributed to increased gaps in full immunization and OTV between rich and poor households, while greater proximity to vaccination site for poorer households reduced these gaps. Improved quality of health facilities, particularly facilities used by low-income households, may improve vaccination outcomes.

Public finance of universal routine childhood immunization in India: district-level cost estimates.

India's Universal Immunization Programme (UIP) is among the largest routine childhood vaccination programmes in the world. However, only an estimated 65% of Indian children under the age 2 years were fully vaccinated in 2019. We estimated the cost of raising childhood vaccination coverage to a minimum of 90% in each district in India. We obtained vaccine price data from India's comprehensive multi-year strategic plan for immunization. Cost of vaccine delivery by district was derived from a 2018 field study in 24 districts. We used propensity score matching methods to match the remaining Indian districts with these 24, based on indicators from the National Family Health Survey (2015-16). We assumed the same unit cost of vaccine delivery in matched pair districts and estimated the total and incremental cost of providing routine vaccines to 90% of the current cohort of children in each district. The estimated national cost of providing basic vaccinations-one dose each of Bacillus Calmette-Guerin (BCG) and measles vaccines, and three doses each of oral polio (OPV) and diphtheria, pertussis and tetanus vaccines-was $784.91 million (2020 US$). Considering all childhood vaccines included in UIP during 2018-22 (one dose each of BCG, hepatitis B and measles-rubella; four doses of OPV; two doses of inactivated polio; and three doses each of rotavirus, pneumococcal and pentavalent vaccines), the estimated national cost of vaccines and delivery to 90% of target children in each district was $1.73 billion. The 2018 UIP budget for vaccinating children, pregnant women and adults was $1.17 billion (2020 US$). In comparison, $1.73 billion would be needed to vaccinate 90% of children in all Indian districts with the recommended schedule of routine childhood vaccines. Additional costs for infrastructural investments and communication activities, not incorporated in this study, may also be necessary.

Timing of non-pharmaceutical interventions to mitigate COVID-19 transmission and their effects on mobility: a cross-country analysis.

In the early stages of a pandemic, non-pharmaceutical interventions (NPIs) that encourage physical distancing and reduce contact can decrease and delay disease transmission. Although NPIs have been implemented globally during the COVID-19 pandemic, their intensity and timing have varied widely. This paper analyzed the country-level determinants and effects of NPIs during the early stages of the pandemic (January 1st to April 29th, 2020). We examined countries that had implemented NPIs within 30 or 45 days since first case detection, as well as countries in which 30 or 45 days had passed since first case detection. The health and socioeconomic factors associated with delay in implementation of three NPIs-national school closure, national lockdown, and global travel ban-were analyzed using fractional logit and probit models, and beta regression models. The probability of implementation of national school closure, national lockdown, and strict national lockdown by a country was analyzed using a probit model. The effects of these three interventions on mobility changes were analyzed with propensity score matching methods using Google's social mobility reports. Countries with larger populations and better health preparedness measures had greater delays in implementation. Countries with greater population density, higher income, more democratic political systems, and later arrival of first cases were more likely to implement NPIs within 30 or 45 days of first case detection. Implementation of lockdowns significantly reduced physical mobility. Mobility was further reduced when lockdowns were enforced with curfews or fines, or when they were more strictly defined. National school closures did not significantly change mobility.

Engaging with the private healthcare sector for the control of tuberculosis in India: cost and cost-effectiveness.

BACKGROUND: The control of tuberculosis (TB) in India is complicated by the presence of a large, disorganised private sector where most patients first seek care. Following pilots in Mumbai and Patna (two major cities in India), an initiative known as the 'Public-Private Interface Agency' (PPIA) is now being expanded across the country. We aimed to estimate the cost-effectiveness of scaling up PPIA operations, in line with India's National Strategic Plan for TB control. METHODS: Focusing on Mumbai and Patna, we collected cost data from implementing organisations in both cities and combined this data with models of TB transmission dynamics. Estimating the cost per disability adjusted life years (DALY) averted between 2014 (the start of PPIA scale-up) and 2025, we assessed cost-effectiveness using two willingness-to-pay approaches: a WHO-CHOICE threshold based on per-capita economic productivity, and a more stringent threshold incorporating opportunity costs in the health system. FINDINGS: A PPIA scaled up to ultimately reach 50% of privately treated TB patients in Mumbai and Patna would cost, respectively, US$228 (95% uncertainty interval (UI): 159 to 320) per DALY averted and US$564 (95% uncertainty interval (UI): 409 to 775) per DALY averted. In Mumbai, the PPIA would be cost-effective relative to all thresholds considered. In Patna, if focusing on adherence support, rather than on improved diagnosis, the PPIA would be cost-effective relative to all thresholds considered. These differences between sites arise from variations in the burden of drug resistance: among the services of a PPIA, improved diagnosis (including rapid tests with genotypic drug sensitivity testing) has greatest value in settings such as Mumbai, with a high burden of drug-resistant TB. CONCLUSIONS: To accelerate decline in TB incidence, it is critical first to engage effectively with the private sector in India. Mechanisms such as the PPIA offer cost-effective ways of doing so, particularly when tailored to local settings.