Optimising the deployment of vector control tools against malaria: a data-informed modelling study.

BACKGROUND: Concern that insecticide resistant mosquitoes are threatening malaria control has driven the development of new types of insecticide treated nets (ITNs) and indoor residual spraying (IRS) of insecticide. Malaria control programmes have a choice of vector control interventions although it is unclear which controls should be used to combat the disease. The study aimed at producing a framework to easily compare the public health impact and cost-effectiveness of different malaria prevention measures currently in widespread use. METHODS: We used published data from experimental hut trials conducted across Africa to characterise the entomological effect of pyrethroid-only ITNs versus ITNs combining a pyrethroid insecticide with the synergist piperonyl butoxide (PBO). We use these estimates to parameterise a dynamic mathematical model of Plasmodium falciparum malaria which is validated for two sites by comparing simulated results to empirical data from randomised control trials (RCTs) in Tanzania and Uganda. We extrapolated model simulations for a series of potential scenarios likely across the sub-Saharan African region and include results in an online tool (Malaria INtervention Tool [MINT]) that aims to identify optimum vector control intervention packages for scenarios with varying budget, price, entomological and epidemiological factors. FINDINGS: Our model indicates that switching from pyrethroid-only to pyrethroid-PBO ITNs could averted up to twice as many cases, although the additional benefit is highly variable and depends on the setting conditions. We project that annual delivery of long-lasting, non-pyrethroid IRS would prevent substantially more cases over 3-years, while pyrethroid-PBO ITNs tend to be the most cost-effective intervention per case averted. The model was able to predict prevalence and efficacy against prevalence in both RCTs for the intervention types tested. MINT is applicable to regions of sub-Saharan Africa with endemic malaria and provides users with a method of designing intervention packages given their setting and budget. INTERPRETATION: The most cost-effective vector control package will vary locally. Models able to recreate results of RCTs can be used to extrapolate outcomes elsewhere to support evidence-based decision making for investment in vector control. FUNDING: Medical Research Council, IVCC, Wellcome Trust. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Understanding the Economic Burden of Treating Low-Grade Upper Tract Urothelial Cancer in the United States.

INTRODUCTION: Low grade upper tract urothelial cancer is an uncommon urothelial tumor for which treatment involves multiple ureteroscopic interventions and potentially radical nephroureterectomy. Given the burden of these procedures, there is growing interest in determining how the utilization, complications and morbidities associated with treatment contribute to the burden of care for upper tract urothelial cancer. The aim of this study was to conduct a systematic literature review to understand the economic burden of treating low grade upper tract urothelial cancer. METHODS: The systematic literature review captured publications from January 1, 2009 to March 11, 2019 in MEDLINE®, Embase®, Evidence-Based Medicine Reviews, PsycINFO and EconLit. Conference proceedings from 7 different conferences were also searched. RESULTS: We identified 15 studies that reported on the economic burden associated with treatment interventions in upper tract urothelial cancer. Treatment costs associated with radical nephroureterectomy were the greatest cost component contributing to expenditures including initial procedural costs (ranging from $11,793 to $23,235 per patient), readmission/retreatment costs ($31,697 per patient) and long-terms costs up to 5 years associated with end stage renal disease and chronic kidney disease ($41,474 to $385,464 per patient). Kidney-sparing management was identified as a cost saving alternative to radical nephroureterectomy, with $252,272 per patient saved through 5 years. CONCLUSIONS: The economic burden of low grade upper tract urothelial cancer is high due to costs incurred by patient comorbidities, multiple episodes of care and complications associated with radical nephroureterectomy. Therefore, there is a need for a paradigm shift towards cost-effective, minimally invasive, kidney-sparing treatments.

Framework for rapid assessment and adoption of new vector control tools.

Evidence-informed health policy making is reliant on systematic access to, and appraisal of, the best available research evidence. This review suggests a strategy to improve the speed at which evidence is gathered on new vector control tools (VCTs) using a framework based on measurements of the vectorial capacity of an insect population to transmit disease. We explore links between indicators of VCT efficacy measurable in small-scale experiments that are relevant to entomological and epidemiological parameters measurable only in large-scale proof-of-concept randomised control trials (RCTs). We hypothesise that once RCTs establish links between entomological and epidemiological indicators then rapid evaluation of new products within the same product category may be conducted through smaller scale experiments without repetition of lengthy and expensive RCTs.