Achievement of therapeutic antibiotic exposures using Bayesian dosing software in critically unwell children and adults with sepsis.

PURPOSE: Early recognition and effective treatment of sepsis improves outcomes in critically ill patients. However, antibiotic exposures are frequently suboptimal in the intensive care unit (ICU) setting. We describe the feasibility of the Bayesian dosing software Individually Designed Optimum Dosing Strategies (ID-ODS™), to reduce time to effective antibiotic exposure in children and adults with sepsis in ICU. METHODS: A multi-centre prospective, non-randomised interventional trial in three adult ICUs and one paediatric ICU. In a pre-intervention Phase 1, we measured the time to target antibiotic exposure in participants. In Phase 2, antibiotic dosing recommendations were made using ID-ODS™, and time to target antibiotic concentrations were compared to patients in Phase 1 (a pre-post-design). RESULTS: 175 antibiotic courses (Phase 1 = 123, Phase 2 = 52) were analysed from 156 participants. Across all patients, there was no difference in the time to achieve target exposures (8.7 h vs 14.3 h in Phase 1 and Phase 2, respectively, p = 0.45). Sixty-one courses in 54 participants failed to achieve target exposures within 24 h of antibiotic commencement (n = 36 in Phase 1, n = 18 in Phase 2). In these participants, ID-ODS™ was associated with a reduction in time to target antibiotic exposure (96 vs 36.4 h in Phase 1 and Phase 2, respectively, p < 0.01). These patients were less likely to exhibit subtherapeutic antibiotic exposures at 96 h (hazard ratio (HR) 0.02, 95% confidence interval (CI) 0.01-0.05, p < 0.01). There was no difference observed in in-hospital mortality. CONCLUSIONS: Dosing software may reduce the time to achieve target antibiotic exposures. It should be evaluated further in trials to establish its impact on clinical outcomes.

Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis.

OBJECTIVES: The structured, clinically supervised withdrawal of medicines, known as deprescribing, is one strategy to address inappropriate polypharmacy. This study aimed to evaluate the costs and consequences of deprescribing in frail older people living in residential aged care facilities (RACFs) in Australia. DESIGN: A within-trial cost-consequence analysis of a deprescribing intervention-Opti-Med. The Opti-Med double-blind randomized controlled trial of deprescribing included 3 groups: blinded control, blinded intervention, and an open intervention group. SETTING AND PARTICIPANTS: Seventeen RACFs in Western Australia and New South Wales. Participants were 303 older people living in participating RACFs from March 2014 to February 2019. METHODS: Analysis was conducted from the health sector perspective. Health economic outcomes assessed include cost saved from deprescribed medicines and the incremental quality-adjusted life-years. Costs were presented in 2022 Australian dollars. RESULTS: The total cost of the Opti-Med intervention was $239.13 per participant. The costs saved through deprescribed medicines over 12 months after adjusting for mortality within the trial period was $328.90 per participant in the blinded intervention group and $164.00 per participant in the open intervention group. On average, the cost of the intervention was more than offset by the cost saved from deprescribed medicines. Extrapolating these findings to the Australian population suggests a potential net cost saving of about $1 to $16 million per annum for the health system nationally. The incremental quality-adjusted life-years were very similar across the 3 groups within the trial period. CONCLUSIONS AND IMPLICATIONS: Deprescribing for frail older people living in RACFs can be a cost-saving intervention without reducing the quality of life. Systemwide implementation of deprescribing across RACFs in Australia has the potential to improve health care delivery through the cost savings, which could be reapplied to further optimize care within RACFs.

The impact of COVID-19 on the birth rate in Nigeria: a report from population-based registries.

Background and objectives: Coronavirus disease 2019 (COVID-19) is a pandemic that has become a major source of morbidity and mortality worldwide, affecting the physical and mental health of individuals influencing reproduction. Despite the threat, it poses to maternal health in sub-Saharan Africa and Nigeria, there is little or no data on the impact it has on fertility, conception, gestation and birth. To compare the birth rate between pre-COVID and COVID times using selected months of the year. Materials and methods: This was a secondary analysis of cross-sectional analytical study data from the birth registries of three tertiary hospitals, comparing two years [2019 (Pre-COVID)] versus [2020 (COVID era)] using three months of the year (October to December). The data relied upon was obtained from birth registries in three busy maternity clinics all within tertiary hospitals in South-East Nigeria and we aimed at discussing the potential impacts of COVID-19 on fertility in Nigeria. The secondary outcome measures were; mode of delivery, booking status of the participants, maternal age and occupation. Results: There was a significant decrease in tertiary-hospital based birth rate by 92 births (P = 0.0009; 95% CI: -16.0519 to -4.1481) among mothers in all the three hospitals in 2020 during the COVID period (post lockdown months) of October to December. There was a significant difference in the mode of delivery for mothers (P = 0.0096) with a 95% confidence interval of 1.0664 to 1.5916, as more gave birth through vaginal delivery during the 2020 COVID-19 period than pre-COVID-19. Conclusion: Tertiary-hospital based birth rates were reduced during the pandemic. Our multi-centre study extrapolated on possible factors that may have played a role in this decline in their birth rate, which includes but is not limited to; decreased access to hospital care due to the total lockdowns/curfews and worsening inflation and economic recession in the country.

Combating the zoonotic trio of Ebola virus disease, Lassa fever, and COVID-19 in Nigeria: a retrospection of the challenges and lessons.

Various infectious disease outbreaks linked to zoonotic sources have been recorded over the years, some of which have resulted in epidemics on a national, regional, or global scale. In Africa, a number of such outbreaks occur intermittently, especially in countries like Nigeria with a high-risk of epidemiological transmission. Three viral outbreaks with zoonotic links have hit the Nigerian healthcare system hardest, which are the Ebola virus disease, Lassa fever and Coronavirus disease 2019. Due to the fragile nature of the Nigerian health system, several challenges were encountered in the process of responding to these viral outbreaks, some of which included inadequate healthcare infrastructure, limited diagnostic capacity, unfledged nature of emergency response, unsatisfactory remuneration of health workers, misinformation trends, amongst others. By reminiscing on the challenges and lessons learnt from these viral disease outbreaks, the Nigerian government and policymakers will be able to adopt more effective approaches towards emergency preparedness for future outbreaks of infectious diseases.

Cost Effectiveness of Strategies to Manage Atrial Fibrillation in Middle- and High-Income Countries: A Systematic Review.

BACKGROUND: Atrial fibrillation (AF) remains the most common form of cardiac arrhythmia. Management of AF aims to reduce the risk of stroke, heart failure and premature mortality via rate or rhythm control. This study aimed to review the literature on the cost effectiveness of treatment strategies to manage AF among adults living in low-, middle- and high-income countries. METHODS: We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit and Google Scholar for relevant studies between September 2022 and November 2022. The search strategy involved medical subject headings or related text words. Data management and selection was performed using EndNote library. The titles and abstracts were screened followed by eligibility assessment of full texts. Selection, assessment of the risk of bias within the studies, and data extraction were conducted by two independent reviewers. The cost-effectiveness results were synthesised narratively. The analysis was performed using Microsoft Excel 365. The incremental cost effectiveness ratio for each study was adjusted to 2021 USD values. RESULTS: Fifty studies were included in the analysis after selection and risk of bias assessment. In high-income countries, apixaban was predominantly cost effective for stroke prevention in patients at low and moderate risk of stroke, while left atrial appendage closure (LAAC) was cost effective in patients at high risk of stroke. Propranolol was the cost-effective choice for rate control, while catheter ablation and the convergent procedure were cost-effective strategies in patients with paroxysmal and persistent AF, respectively. Among the anti-arrhythmic drugs, sotalol was the cost-effective strategy for rhythm control. In middle-income countries, apixaban was the cost-effective choice for stroke prevention in patients at low and moderate risk of stroke while high-dose edoxaban was cost effective in patients at high risk of stroke. Radiofrequency catheter ablation was the cost-effective option in rhythm control. No data were available for low-income countries. CONCLUSION: This systematic review has shown that there are several cost-effective strategies to manage AF in different resource settings. However, the decision to use any strategy should be guided by objective clinical and economic evidence supported by sound clinical judgement. REGISTRATION: CRD42022360590.

One-stage revision versus debridement, antibiotics, and implant retention (DAIR) for acute prosthetic knee infection: an exploratory cohort study.

INTRODUCTION: Studies have shown that debridement, antibiotics, and implant retention (DAIR) is an effective procedure for acute infection of total knee arthroplasty (TKA). This study aimed to explore DAIR and one-stage revision for homogenous cohorts with acute postoperative and acute hematogenous infection of TKA, without compelling indications to perform a staged revision. MATERIALS AND METHODS: This study was an exploratory analysis that used retrospective data from Queensland Health, Australia, for DAIR and one-stage revision of TKA between June 2010 and May 2017 (3-year average follow-up). The re-revision burden, mortality rate, and the cost of the interventions were explored. Costs were expressed in 2020 Australian dollars. RESULTS: There were 15 (DAIR) and 142 (one-stage) patients with homogenous characteristics in the sample. The re-revision burden for DAIR was 20%, while for one-stage revision it was 12.68%. Two deaths were associated with a one-stage revision and no death was associated with DAIR. The total cost since the index revision of DAIR, $162,939, was higher than for one-stage revision $130,924 (p value = 0.501), due to higher re-revision burden. CONCLUSIONS: This study would suggest the use of one-stage revision over DAIR for acute postoperative and acute hematogenous infection of TKA. It suggests that there could be other potential criteria which have not been ascertained that need to be considered for optimal DAIR selection. The study indicates the need for more research and, of note, high-quality randomized controlled trials to provide a well-defined treatment protocol with high level of evidence to guide patient selection for DAIR.

Interventions to increase mammography screening uptake among women living in low-income and middle-income countries: a systematic review.

OBJECTIVE: To systematically identify interventions that increase the use of mammography screening in women living in low-income and middle-income countries (LMICs). DESIGN: Systematic review. DATA SOURCES: MEDLINE, Embase, Global Health, CINAHL, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials, Google Scholar and African regional databases. ELIGIBILITY CRITERIA: Studies conducted in LMICs, published between 1 January 1990 and 30 June 2021, in the English language. Studies whose population included asymptomatic women eligible for mammography screening. Studies with a reported outcome of using mammography by either self-report or medical records. No restrictions were set on the study design. DATA EXTRACTION AND SYNTHESIS: Screening, data extraction and risk-of-bias assessment were conducted by two independent reviewers. A narrative synthesis of the included studies was conducted. RESULTS: Five studies met the inclusion criteria consisting of two randomised controlled trials, one quasi-experiment and two cross-sectional studies. All included studies employed client-oriented intervention strategies including one-on-one education, group education, mass and small media, reducing client out-of-pocket costs, reducing structural barriers, client reminders and engagement of community health workers (CHWs). Most studies used multicomponent interventions, resulting in increases in the rate of use of mammography than those that employed a single strategy. CONCLUSION: Mass and small media, group education, reduction of economic and structural barriers, client reminders and engagement of CHWs can increase use of mammography among women in LMICs. Promoting the adoption of these interventions should be considered, especially the multicomponent interventions, which were significantly effective relative to a single strategy in increasing use of mammography. PROSPERO REGISTRATION NUMBER: CRD42021269556.

Are joint replacement registries associated with burden of revision changes? A real-world panel data regression analysis.

OBJECTIVES: The association of joint replacement registries with outcomes such as revision burden is uncertain. This study aimed to evaluate whether joint replacement registries are associated with the burden of revision changes while controlling for confounders that could affect the association. DESIGN: A longitudinal study involving a combination of cross-sectional and time series data from 1980 to 2018. The study was a panel regression analysis using the difference-in-difference method. SETTING: Data from countries with joint replacement registries and countries without joint replacement registries were used. Registry data were obtained from joint replacement registries' annual reports, while non-registry data were obtained from each included country's pooled hospitals' annual revision burden reported in the literature. OUTCOME MEASURES: Changes in revision burden from 1980 to 2018 was the outcome measure. The revision burden in the registry periods of registry countries was compared with the non-registry periods of registry and non-registry countries. RESULTS: Data were obtained from 12 registry periods and 8 non-registry periods. The average difference in revision burden in the registry periods of registry countries relative to the non-registry periods of registry and non-registry countries was statistically significant for hip, -3.80 (95% CI (-2.50 to -5.10); p<0.001) percentage points and knee, -1.63 (95% CI (-1.00 to -2.30); p<0.001) percentage points. This translates to a 19.30%, and 21.85% reduction in revision burden for hip and knee registries, for the whole sampling period. CONCLUSION: Joint replacement registries are associated with a significant reduction in the burden of revision. Although revision burden reduces over time even without the registries, the establishment of joint replacement registries is associated with an increased reduction. The establishment of joint replacement registries in non-registry countries would be a worthwhile decision as it will further improve the outcomes of arthroplasty surgeries.

Is 2-Stage Septic Revision Worth the Money? A Cost-Utility Analysis of a 1-Stage Versus 2-Stage Septic Revision of Total Knee Arthroplasty.

BACKGROUND: Two-stage exchange arthroplasty remains the gold standard for the management of prosthetic joint infection (PJI) of the knee, but several studies have demonstrated that 1-stage exchange is as effective as 2-stage exchange. This study aimed to support decision-making via an economic evaluation of 1-stage compared to 2-stage exchange for total knee arthroplasty septic revision in patients who did not have compelling indication PJI (ie, Methicillin-resistant Staphylococcus aureus, multiorganism, systemic sepsis, comorbidities, culture negative, resistant organism, and immunocompromised) to undergo a 2-stage exchange. METHODS: A cost-utility analysis was performed using a Markov cohort model from the health care provider perspective using Australia data. One-stage septic knee revisions were compared with 2-stage exchange procedures for chronic PJI using a patient-lifetime horizon. Health outcomes were expressed as quality-adjusted life-years (QALY), whereas costs were presented in 2020 Australian dollars. Sensitivity analyses, population expected values of perfect information, and the perfect information for parameters (EVPPI) were assessed to estimate the opportunity costs surrounding the decision made at a willingness-to-pay threshold of $50,000 per QALY. RESULTS: The incremental cost-effectiveness ratio of 2-stage exchange compared with 1-stage exchange was $231,000 per QALY, with 98.5% of the probabilistic sensitivity simulations above the willingness-to-pay threshold. The population expected value of perfect information was $882,000, whereas the expected value of perfect information for parameters for the "cost parameters" was $207,000. CONCLUSION: The adoption of 1-stage septic knee revision is the optimal choice for patients who have a PJI and who do not have a compelling need for a 2-stage exchange arthroplasty. One-stage exchange for PJI should be advocated in patients who meet the eligibility criteria.

Interventions to increase mammography screening uptake among women living in low-income and middle-income countries: a protocol for a systematic review.

INTRODUCTION: Breast cancer is the most prevalent cancer and the second leading cause of cancer-related deaths among women in low and middle-income countries (LMICs), including sub-Saharan Africa. Mammography screening is the most effective screening method for the early detection of breast cancers in asymptomatic individuals and the only screening test that decreases the risk of breast cancer mortality. Despite the perceived benefits, it has a low utilisation rate in comparison with breast self-examination and clinical breast examination. Several interventions to increase the uptake of mammography have been assessed as well as systematic reviews on mammography uptake. Nonetheless, none of the published systematic reviews focused on women living in LMICs. The review aims to identify interventions that increase mammography screening uptake among women living in LMICs. METHODS AND ANALYSIS: Relevant electronic databases will be systematically searched from 1 January 1990 to 30 June 2021 for published and grey literature, including citation and reference list tracking, on studies focusing on interventions to increase mammography screening uptake carried out in LMICs and written in the English language. The search will incorporate the key terms: mammography, interventions, low- and middle-income countries and their associated synonyms. Randomised controlled trials, observational studies and qualitative and mixed methods studies of interventions (carried out with and without comparison groups) reporting interventions to increase mammography screening uptake in LMICs will be identified, data extracted and assessed for methodological quality by two independent reviewers with disagreements to be resolved by consensus or by a third author. We will use narrative synthesis and/or meta-analysis depending on the characteristics of the data. ETHICS AND DISSEMINATION: Ethical approval is not required as it is a protocol for a systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021269556.

Current practice of family planning among teachers in public secondary school in Enugu East Senatorial District, Nigeria.

Background: The aim of this study is to determine the current practice level of family planning and the associated factors among public secondary school teachers in Enugu East Senatorial District. Method: A cross-sectional study was carried out among public secondary school teachers, aged 18 - 60 years, in Enugu East Senatorial District, using probability proportional to size sampling and systematic random sampling to select 1000 participants. Binary and multiple logistic regression analyses were used to determine association. An odds ratio with a 95% confidence interval (CI) was computed to determine the level of significance. Results: The current practice level of family planning is 26.5%. Respondents with bachelor in education were 2 times more likely to be a current user of family planning (AOR=2.39; 95% CI: 1.25-4.55). However, respondents in age group 38 years and above were less likely to be a current user of family planning (AOR=0.64; 95% CI: 0.43-0.95), likewise female respondents (AOR=0.66; 95% CI: 0.44-0.98). Additionally, respondents who mentioned radio (AOR=0.64; 95%CI: 0.44-0.93), social media (AOR=0.73; 95% CI: 0.53-0.99) and healthcare (AOR=0.61; 95%CI: 0.43-0.88) as source of information were less likely to be current user of family planning. Whereas, partner who encouraged the use of family planning (AOR=2.54; 95% CI: 1.71-3.78) span style="font-family:'Times New Roman'; font-weight:bold">, partner who allow each other to decide on family planning methods (AOR=4.47; 95% CI: 2.67-7.48) and those who had good knowledge of family planning (AOR=1.96; 95% CI: 1.40-2.67) were more likely to be current user of family planning. Conclusion: The level of current practice of family planning is low and a significant number of factors predict the current practice of family planning. A family planning educational workshop among teachers is needed to improve teacher's knowledge on family planning to address the issue of adolescent sexual reproduction as teachers are vessels of knowledge impartation to students.

Cost of septic and aseptic revision total knee arthroplasty: a systematic review.

BACKGROUND: The increasing incidence of primary total knee arthroplasty (TKA) has led to an increase in both the incidence and the cost burden of revision TKA procedures. This study aimed to review the literature on the cost of revision TKA for septic and aseptic causes and to identify the major cost components contributing to the cost burden. METHODS: We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit, and Google Scholar to identify relevant studies. Selection, data extraction and assessment of the risk of bias and cost transparency within the studies were conducted by two independent reviewers, after which the cost data were analysed narratively for 1- or 2-stage septic revision without re-revision; 2-stage septic revision with re-revision; and aseptic revision with and without re-revision, respectively. The major cost components identified in the respective studies were also reported. RESULTS: The direct medical cost from the healthcare provider perspective for high-income countries for 2-stage septic revision with re-revision ranged from US$66,629 to US$81,938, which can be about 2.5 times the cost of 1- or 2-stage septic revision without re-revision, (range: US$24,027 - US$38,109), which can be about double the cost of aseptic revision without re-revision (range: US$13,910 - US$29,213). The major cost components were the perioperative cost (33%), prosthesis cost (28%), and hospital ward stay cost (22%). CONCLUSIONS: Septic TKA revision with re-revision for periprosthetic joint infection (PJI) increases the cost burden of revision TKA by 4 times when compared to aseptic single-stage revision and by 2.5 times when compared to septic TKA revision that does not undergo re-revision. Cost reductions can be achieved by reducing the number of primary TKA that develop PJI, avoidance of re-revisions for PJI, and reduction in the length of stay after revision. TRIAL REGISTRATION: PROSPERO; CRD42020171988 .

Cost-effectiveness and feasibility of conditional economic incentives and motivational interviewing to improve HIV health outcomes of adolescents living with HIV in Anambra State, Nigeria.

BACKGROUND: In sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). This is a result of limited adolescent-centred service delivery interventions. This cost-effectiveness and feasibility study were piggybacked on a cluster-randomized trial that assessed the impact of an adolescent-centred service delivery intervention. The service delivery intervention examined the impact of an incentive scheme consisting of conditional economic incentives and motivational interviewing on the health outcomes of adolescents living with HIV in Nigeria. METHOD: A cost-effectiveness analysis from the healthcare provider's perspective was performed to assess the cost per additional patient achieving undetected viral load through the proposed intervention. The cost-effectiveness of the incentive scheme over routine care was estimated using the incremental cost-effectiveness ratio (ICER), expressed as cost/patient who achieved an undetectable viral load. We performed a univariate sensitivity analysis to examine the effect of key parameters on the ICER. An in-depth interview was conducted on the healthcare personnel in the intervention arm to explore the feasibility of implementing the service delivery intervention in HIV treatment hospitals in Nigeria. RESULT: The ICER of the Incentive Scheme intervention compared to routine care was US$1419 per additional patient with undetectable viral load. Going by the cost-effectiveness threshold of US$1137 per quality-adjusted life-years suggested by Woods et al., 2016, the intervention was not cost-effective. The sensitivity test showed that the intervention will be cost-effective if the frequency of CD4 count and viral load tests are reduced from quarterly to triannually. Healthcare professionals reported that patients' acceptance of the intervention was very high. CONCLUSION: The conditional economic incentives and motivational interviewing was not cost-effective, but can become cost-effective if the frequency of HIV quality of life indicator tests are performed 1-3 times per annum. Patients' acceptance of the intervention was very high. However, healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed. TRIAL REGISTRATION: This trial is registered in the WHO International Clinical Trials Registry through the WHO International Registry Network ( PACTR201806003040425 ).

Introducing rotavirus vaccine in eight sub-Saharan African countries: a cost-benefit analysis.

BACKGROUND: Stimulated by the economic challenges faced by many sub-Saharan African countries and the changes in the rotavirus burden across these countries, this study aimed to inform the decision of health policy makers of eight sub-Saharan countries, who are yet to introduce the rotavirus vaccine as of Dec 31, 2020, on the health economic consequences of the introduction of the vaccine in terms of the costs and benefits. METHODS: We did a cost-benefit analysis using a simulation-based decision-analytic model for children aged younger than 1 year, who were followed up to 259 weeks, in the Central African Republic, Chad, Comoros, Equatorial Guinea, Gabon, Guinea, Somalia, and South Sudan. Data were collected and analysed between Jan 13, 2020, and Dec 11, 2020. Cost-effectiveness analysis and budget impact analysis were done as secondary analyses. Four rotavirus vaccinations (Rotarix, Rotateq, Rotavac, and Rotasiil) were compared with no vaccination. The primary outcome was disability-adjusted life-years averted, converted to monetary terms. The secondary outcomes include rotavirus gastroenteritis averted, and rotavirus vaccine-associated intussusception. The primary economic evaluation measure was the benefit-cost ratio (BCR). FINDINGS: For the modelling period, Jan 1, 2021, to Dec 31, 2030, we found that the benefits of introducing the rotavirus vaccine outweighed the costs in all eight countries, with Chad and the Central African Republic having the highest BCR of 19·42 and 11·36, respectively. Guinea had the lowest BCR of 3·26 amongst the Gavi-eligible countries. Equatorial Guinea and Gabon had a narrow BCR of 1·86 and 2·06, respectively. Rotarix was the optimal choice for all the Gavi-eligible countries; Rotasiil and Rotavac were the optimal choices for Equatorial Guinea and Gabon, respectively. INTERPRETATION: Introducing the rotavirus vaccine in all eight countries, but with caution in Equatorial Guinea and Gabon, would be worthwhile. With the narrow BCR for Equatorial Guinea and Gabon, cautious, pragmatic, and stringent measures need to be employed to ensure optimal health benefits and cost minimisation of the vaccine introduction. The final decision to introduce the rotavirus vaccine should be preceded by comparing its BCR to the BCRs of other health-care projects. FUNDING: Copenhagen Consensus Center and the Bill & Melinda Gates Foundation.

Promoting the integrated community case management of pneumonia in children under 5 years in Nigeria through the proprietary and patent medicine vendors: a cost-effectiveness analysis.

BACKGROUND: While evidence-based recommendations for the management pneumonia in under-5-year-olds at the community level with amoxicillin dispersible tablets (DT) were made by the World Health Organisation, initiatives to promote the integrated community case management (iCCM) of pneumonia through the proprietary and patent medicine vendors (PPMVs) have been poorly utilized in Nigeria, possibly due to low financial support and perceived benefit. This study provides costs, benefits and cost-effectiveness estimates and implications of promoting the iCCM through the PPMVs' education and support. The outcome of this study will help inform healthcare decisions in Nigeria. METHODS: This study was a cost-effectiveness analysis using a simulation-based Markov model. Two approaches were compared, the 'no promotion' and the 'promotion' scenarios. The health outcomes include disability-adjusted life years averted and severe pneumonia hospitalisation cost averted. The costs were expressed in 2019 US dollars. RESULTS: The promotion of iCCM through the PPMVs was very cost effective with an incremental cost-effectiveness ratio of US$143.77 (95% CI US$137.42-150.50)/DALY averted. The promotion will prevent 28,359 cases of severe pneumonia hospitalisation with an estimated healthcare cost of US$390,578. It will also avert 900 deaths in a year. CONCLUSION: Promoting the iCCM for the treatment of pneumonia in children under 5 years through education and support of the PPMVs holds promise to harness the benefits of amoxicillin DT and provide a high return on investment. A nationwide promotion exercise should be considered especially in remote areas of the country.

Introducing Rotavirus Vaccination in Nigeria: Economic Evaluation and Implications.

BACKGROUND: As Nigeria prepares to introduce a rotavirus vaccine, the Gavi board has approved the extension of the transition period for the country until 2028. The current position of the country on Gavi's funding profile calls for a pragmatic step in planning and implementation so that sustainability at the fully self-financing phase will be feasible. OBJECTIVE: This study aimed to inform the decisions of the country's health policymakers on the costs, benefits, and implications of the introduction of rotavirus vaccine. METHODS: This study was an economic evaluation using a simulation-based Markov model. It compared four approaches: 'no vaccination' and vaccination with ROTARIX, ROTAVAC, or ROTASIIL. Ten cohorts from the year 2021 to 2030 were used in the analysis. Primary measures were the benefit-cost ratio (BCR) and the incremental cost-effectiveness ratio (ICER). Future costs and outcomes were discounted to 2019 values. RESULTS: The adjusted vaccine cost of ROTARIX was the highest, followed by ROTAVAC and ROTASIIL, whereas the immunization delivery cost was in the reverse order. All the vaccines were very cost effective, with ROTARIX being the optimal choice for the 10-year period, having a BCR of 27 and an ICER of $US100 (95% confidence interval [CI] 71-130)/disability-adjusted life-year averted. Adopting ROTARIX was the optimal choice from 2021 to 2027, whereas ROTAVAC was optimal from 2028 to 2030. The net budget impact of the programme was $US76.9 million for the 10-year period. The opportunity cost of a late introduction was about $US8 million per annum from 2021 to 2028. CONCLUSIONS: The rotavirus vaccine ROTARIX should be implemented in Nigeria at the earliest opportunity. A switch to ROTAVAC should be considered from the year 2028. Cost-minimization measures are imperative to ensure the sustainability of the programme after the transition out of Gavi support.

Management of Chest Indrawing Pneumonia in Children Under Five Years at the Outpatient Health Facilities in Nigeria: An Economic Evaluation.

BACKGROUND: The recommendation of the World Health Organization (WHO) for the management of children aged < 5 years with chest indrawing pneumonia with oral amoxicillin dispersible tablets (DT) at the outpatient health facilities is imperative, especially in a high pneumonia mortality and low-resource setting like Nigeria. However, this recommendation has not been widely adopted in Nigeria due to poor access to healthcare and sub-optimal outpatient management and follow-up system to ensure patients' safety and management effectiveness. This study aimed to evaluate the cost effectiveness and the cost benefit of the WHO recommendation relative to usual practices in Nigeria. The outcome of this study will provide supporting evidence to healthcare providers and inform their management decisions. METHODS: A cost-effectiveness and cost-benefit analyses of this study used a Markov cohort model from the healthcare provider perspective for a time horizon of five years. Three approaches were compared: a conventional approach (base-comparator); the amoxicillin DT (WHO) approach; and a parenteral approach. Bottom-up costing method was used. Health outcome was expressed as disability-adjusted life years averted and converted to monetary terms (benefit). RESULTS: The incremental cost-effectiveness ratio (ICER) and the benefit-cost ratio (BCR) of the amoxicillin DT approach dominate the conventional approach. The parenteral approach was more effective and more beneficial than the amoxicillin DT approach but the ICER and BCR were $75,655/DALY averted and 0.035, respectively. CONCLUSIONS: The use of amoxicillin DT proves to be the optimal choice with high benefit and low cost. The opportunity cost of not adopting an approach more effective than amoxicillin DT will be offset by the cost saved. Its use in chest indrawing pneumonia management needs to be scaled up.

Cost of Revision Total Knee Replacement: A Protocol for Systematic Review and Meta-Analysis.

BACKGROUND: A major limitation of total knee replacement (TKR), as with other joint replacements, is the risk of revision. Revision TKR is associated with high risk and economic burden to patients, healthcare providers, and societies. It will be worthwhile to assess the economic burden of revision TKR across countries or different study settings. This study aims to review the literature on the cost of revision TKR to assess costs across countries and studies, estimate a pooled cost estimate for homogenous data, and identify major cost components that contribute to the cost burden. METHODS: We will conduct a search of the MEDLINE (OvidSp), EMBASE, Web of Science, Cochrane Library, EconLit, and Google Scholar databases to identify relevant studies, and will use an optimally designed search approach to search for relevant studies. EndNote library will be used to manage the searched studies. Selection will be undertaken in two phases-screening and eligibility. Study selection, data extraction, and assessment of the risk of bias will be performed in duplicate, after which the data will be analysed narratively and a meta-analysis performed for homogenous studies, if possible. DISCUSSION: This protocol provides a proposed stepwise plan for conducting a systematic review and meta-analysis of the cost of revision TKR. Findings from this systematic review will provide information about the cost across settings and identify the major cost drivers of revision TKR, which will, in turn, stimulate efforts to minimize the cost. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020171988.